Every finding on record at South Heritage Health & Rehabilitation Center

Based on interview and record review, the facility failed to protect the resident's right to seek medical services outside the facility, resulting in delayed emergent care and services for one resident (#5) of two residents sampled.Findings included: During a follow-up telephone interview on 4/25/26 at 2:50 p.m. with Resident #5's family member, the family member revealed being upset and frustrated with the facility because they did not want to send Resident #5 out to the ER (emergency room). The family member stated the resident had requested to go to the hospital following discomfort after laparoscopic surgery. The family member stated Resident #5 had symptoms of pain, bloating and had been vomiting all night. He stated a nurse said the inhouse doctor would assess Resident #5 first. He stated she was given nausea medication and continued to have diarrhea all night through the next day. The family stated having begged the nurse to send the resident out. He stated he eventually called non-emergency police to do a wellness check and request Resident #5 to be sent out. The family member said, no one was helping her. she had not been checked on all night and had a pail of vomit at bedside. I begged the nurse to send her out and she would not. The family member stated eventually he advised the resident to call 911 herself and that was when she went out. The family member said, The sad thing was that the hospital actually found that she had fluid build-up, and yet she was ignored and yet she not well.Review of the admission record revealed Resident #5 was admitted to the facility with diagnoses to include other specified diseases of pancreas, disorder involving the immune mechanism, anemia, muscle wasting and atrophy.Review of Resident #5's progress notes revealed a change in condition as follows:On 3/26/26 at 2:25 p.m. Writer called and left a message for MD (Medical Doctor) to call facility back regarding resident condition. Writer informed desk nurse of call being placed. On 3/26/26 at 11:49 p.m. Resident complained of pains and vomiting by 7p.m. MD was notified, pain medication was changed from every six hours to every four hours, and MD ordered milk of magnesium to be given and same was offered to Resident #5 with good results. Note please call MD to get an order for intravenous (IV) infusion normal saline for resident to prevent dehydration per family request (MD was called but no response).On 3/27/26 12:20 p.m. Patient complains of stomach pain and is insisting on going to hospital. VITALS: 97.3-104-18 173/99 97%. Paged doctor to advise.On 3/27/26 4:11 p.m. writer returned from lunch and saw paramedics at patient's room and writer was advised that the patient had called the paramedics to be taken to the hospital.On 3/28/26 at 8:19 a.m. Resident admitted to hospital.Review of Resident #5's hospital records dated 3/27/2026, revealed: chief complaint sepsis, suspended pseudocyst.comes to the ED secondary to abdominal pain and discomfort. Patient was previously admitted 12/25 and underwent Magnetic Resonance Imaging (MRI), secondary to similar symptoms, which revealed stricture at the pancreatic body-tail junction involving the main pancreatic duct with upstream pancreatic duct dilation and parenchymal atrophy. Patient underwent laparoscopic distal pancreatomy with sphincterotomy and en bloc partial gastrectomy on January 26, 2026. Postoperatively, patient had to be treated with IV antibiotics secondary to blood cultures positive for Serratia bacteremia with suspected source being urine versus abdomen. Patient was discharge on additional seven days of oral antibiotics with drain still in place after undergoing procedure. Patient underwent removal of surgical drain on 03/18, but reports she gradually had increased distention and pain at the site of drain removal. Patient reports in the last 24 hours she began to have significant increase in abdominal pain, swelling and discomfort. Patient reporting fevers at home, chills, abdominal pain, and inability to tolerate oral intake. The physical exam, Vitals & Measurements revealed T: 97.8 F (Oral) HR: 59 (Pulse) RR: 15 BP: 106/63 SpO2: 100% HT: 149.86 cm HT: 59-inch(es) WT: 60.8 kg BMI: 27.1. The assessment plan revealed .presents with worsening abdominal pain, swelling, and systemic symptoms following removal of the drain. Evaluation revealed leukocytosis with left shift and Computed Tomography (CT) imaging showing gastritis with inflammation near the prior drain site as well as two postoperative fluid collections or possible pseudocysts. Given her symptoms and imaging findings, concern is raised for postoperative complications such as infected fluid collections versus recurrent pancreatitis-related issues. Further review of the assessment plan showed abdominal pain, with evidence of a fluid collection and differential of pseudocyst versus surgical collection, chronic pancreatitis post Whipple's procedure and splenectomy.An interview was conducted with Staff B, Registered Nurse (RN)/Unit Manager on 4/25/26 at 12:42 p.m. Staff B said Resident #5 was here for recovery after laparoscopic. She stated the resident had complications and had been discharged from the hospital to home. Resident #5 had complications at home and was readmitted to the hospital, needing a drain, the drain was subsequently removed, without complications. Resident #5 developed pain afterwards. Staff B said there was an order for dressing which came off and she was fine. Staff B stated if a resident has a change, and they want to go to the ER, We assess first, we look at the entire picture and review vital signs, we look if we can treat the issue here at the facility. Staff B said, Resident #5 was given pain and nausea medication. Staff B said Resident #5 ended up going to the hospital, having called 911 herself. Staff B stated usually the nurse would call. She said, I don't know what happened. Staff B stated she did not know Resident #5's condition upon admission to the hospital. She said the Director of Nursing (DON) calls after they leave to check on them.An interview with Staff D, Licensed Practical Nurse (LPN) revealed Resident #5 stayed in her room but would come out for smoking. She stated she heard the resident was sick and was throwing up, she does not remember the timeline, and whether she was sent out immediately or not.An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 4/25/2026 at 11:20 a.m. She stated she remembered Resident #5 and said, She was ambulatory. She was getting sick towards the end, . she was too sickly, like throwing up all the time. On 4/25/26 at 11:38 a.m. an interview was conducted with Staff C, CNA. Staff C said Resident #5 was independent with care. Staff C said, Resident #5 got sick, throwing up. An interview was conducted with the Director of Nursing (DON) on 4/25/26 at 3:24 p.m. The DON stated if the doctor would have ordered for Resident #5 to go to the hospital, they would have documented. She stated she heard about her being sick. She said, I did hear about it. I heard the police were here for Resident #5, I did not get any details. The DON confirmed if someone wanted to go to the hospital, the nurse would assess and notify the physician. She stated there should be notes showing the assessment and monitoring following a change in condition. The DON stated the nurses should have documented the monitoring and vitals obtained during the period of the change. The DON said, I agree, if it is not documented it did not happen. The nurse should have documented vitals, if the resident wanted to be sent out, assess, call the doctor and send them out. the DON confirmed the resident has a right to seek medical care and should be assisted if they choose to do so.Review of a facility policy titled, Resident Rights, effective August 2025, revealed a policy: The facility strives to ensure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising bis or her rights and to be supported by the facility in the exercise of his or her rights.Procedure: 5. Assist the resident with such things including, but not limited to, the following: b. Maintaining communication with outside agencies.

Based on observation, record review and interviews, the facility failed to ensure nail care was provided to one resident (#4) out of three resident reviewed for total assistance with activities of daily living (ADLs).Findings included: A review of Resident #4's admission record showed an admission date of 1/20/26. Further review of the admission record showed diagnoses to include quadriplegia, unspecified, muscle wasting and atrophy, not elsewhere classified, multiple sites, and other lack of coordination.On 4/25/26 at 9:19 a.m., an interview and observation occurred with Resident #4. Resident #4's nails were observed approximately one to one and a half inches long. During the interview, he stated he wanted his nails cut, and he had been asking the assigned certified nursing assistant (CNA) for the last three days. Resident #4 said the assigned CNA would tell him, No, not yet I'm on break. He said one of the days the assigned CNA assisted with soaking his nails for 30 minutes. Resident #4 said when she came back, she said he had to wait for them to be trimmed because it was the change of shift. He said his family member cut his nails approximately six weeks ago. He said the Director of Nursing (DON) was told about his request for nail trimming by the psychiatry provider. On 4/25/26 at 10:40 a.m., a telephone interview was conducted with Resident #4's family member. She said the resident's nails were cut by a family member approximately six weeks ago.On 4/25/26 11:00 a.m., an interview was conducted with Staff A, CNA. She said she typically was assigned to Resident #4. She stated, He likes stuff done a certain way. A lot of CNAs are scared to go in there because he reports people who don't do their job. She said nail care for residents was supposed to be completed every weekend or as needed. Staff A, CNA said whenever a resident asked to cut their nails, staff should do it. She said the facility did not always have enough staff which prolonged them being able to cut the residents' nails. She said nail care is an as needed (PRN) task and documented in the Kardex. She said his nails were cut approximately a month ago when his family member had visited and cut his nails. Staff A, CNA said she was going to cut Resident #4's nails today because he asked her to do it.A review of Resident #4's nail care task, dated 3/28/26 to 4/23/26, showed, No Nail Care, was documented. On 3/30/26, Resident Refused, was documented. Review of the nail task documentation showed no nail care was provided for the last 30 days. A review of Resident #4's care plan revealed the following: PREFERENCE/CHOICE: [Resident #4] has indicated the following preferences and/or has made the following choic [sic] heir [sic] health care: Resident chooses to decline recommended or ordered health care interventions of: -refusing medications, weights, personal care, incontinence care, bathing/showers -turned and positioned, refusing to allow staff to roll him side to side for care -Requests for staff to wear gloves when they feed him -refusing to get OOB [out of bed]. Date Initiated: 02/09/2026 Revision on: 04/22/2026. [Resident #4] has an ADL [Activity Daily Living] Self Care Performance Deficit r/t [related to] quadriplegia . Date Initiated: 01/22/2026 Revision on: 02/16/2026. BEHAVIORAL: [Resident #4] has a behavior problem r/t psychosocial well-being -alleging extended amount of time between care, staff handling roughly -confabulates regarding care being given, staff not feeding him, no water being offered (has adaptable water bottle at bedside) -c/o [complains of] pain but refuses pain medication -threatens to call DCF [department of children and families] -requesting fitted sheet on air mattress, explained those are not used, family threatening to call DCF -allegations of dietary spiking his food -refuses wound care photos Date Initiated: 02/16/2026 Revision on: 04/08/2026. QUADRIPLEGIA: [Resident #4] has Quadriplegia r/t Spinal injury, Trauma Date Initiated: 01/28/2026 Revision on: 01/28/2026, with interventions to include, Assist with ADLs and locomotion as required. Encourage resident to perform as much as possible of these activities. Date Initiated: 01/28/2026. RANGE OF MOTION: [Resident #4] has an actual limitations in Range of Motion as evidence by impaired ROM [range of motion] to BUE [bilateral upper extremities] and BLE [bilateral lower extremities], quadriplegia. Date Initiated: 01/28/2026 Revision on: 01/28/2026.On 4/25/26 at 3:33 p.m., an interview was conducted with the Director of Nursing (DON) and Staff B, Registered Nurse (RN)/Unit Manager (UM). The DON said the CNAs or nurses provided nail care depending on the diagnosis of the resident. The DON said nail care is provided as needed. She stated staff would observe the resident's nails upon assessment and, See how long they are getting. The DON said nail care should be completed if the resident asked the staff to do it. The DON and Staff B, RN/UM were not aware where completion of nail care was documented. The DON stated if a resident refused nail care a nursing note should be completed or, The same spot it's supposed to be documented. She stated nail care was, Part of hygiene and infection control. She said she had attempted to assist with cutting Resident #4's nails but he would not let staff. She said she could not confirm if that was documented. Staff B, RN/UM said she thought the resident refusing nail care was in his care plan. The facility did not provide a policy related to ADLs or nail care.

Based on observations, record review, and interviews, the facility failed to ensure diet-related physician orders were implemented for one resident (#4) out of three resident reviewed. Findings included: On 4/25/26 at 12:30 p.m., an observation of Resident #4's lunch meal revealed the meal ticket did not show large or double portions was documented. A review of Resident #4's admission record showed an admission date of 1/20/26. Further review of the admission record showed diagnoses to include quadriplegia, unspecified, muscle wasting and atrophy, not elsewhere classified, multiple sites, and other lack of coordination. A review of Resident #4's physician orders revealed the following: House diet Regular texture, Regular(Thin) consistency, No pork, lactose intolerant, no dairy (milk or cheese), with a start date of 1/26/26. Resident may have double portions for all meals six times a day, with a start date of 3/7/26. A review of Resident #4's care plan revealed the following: NUTRITIONAL: [Resident #4] has a potential nutritional problem r/t [related to] Diagnoses - Quadriplegia, Spinal Stenosis, HTN [hypertension], Hyperlipidemia, Hypotension. Weight - Elevated BMI [body mass index] - IBW [ideal body weight] adjusted for quadriplegia - Resident requests large entree portions at meals. Medications - Duloxetine, may impact appetite. Date Initiated: 01/22/2026 Revision on: 01/26/2026. A review of Resident #4's nutrition evaluation, dated 1/26/26, revealed the following: New admit [admission] 1/21. CBW [current body weight] 249.8 lbs [pounds] (1/21). BMI 34.8. IBW adjusted for quadriplegia. Resident reports his UBW [usual body weight] prior to his recent hospitalization was 270 lbs. House diet, regular textures, thin liquids. Resident requests large entree portions at meals. No problems chewing/swallowing reported. Dependent with meals. On duloxetine, which may impact appetite. Continue with diet as ordered. Large entree portions provided, per resident request. Resident denied the need for additional snacks/supplements at this time. Tray ticket updated with food preferences. Will monitor weights weekly, per new admit.On 4/25/26 at 2:30 p.m., an interview was conducted with the Food Service Manager (FSM). He said Resident #4 received large portions for breakfast, but not with the other meals. The FSM provided today's meal tickets which showed, Large Portion, for breakfast. A review of Resident #4's lunch and dinner meal ticket did not show large portions was documented.On 4/25/26 at 2:48 p.m., a follow-up interview was conducted with the FSM. He said all dietary orders are placed in the electronic medical record and automatically transferred to the food service meal tracker system. He said the meal tracker system printed the meal tickets. The FSM said he was not able to adjust the orders. He said the orders needed to be placed in the electronic medical record by the nursing staff or the registered dietitian (RD). He said he received a notification everyday if there was a change to the resident's diet order. The FSM said he did not see the order for double portions for all meals as it was categorized as, other, not under dietary. On 4/25/26 at 3:33 p.m., an interview was conducted with the Director of Nursing (DON). She said the DON, nurse, or unit manager (UM) would put in a resident's diet order. She said the order is documented on a dietary slip and provided to the dietary personnel. She said the FSM has a list of the residents' diet orders. The DON said whoever put in Resident #4's order for double portions for all meals, put it under the other, category. She stated, Other orders floats in the nursing space. The DON confirmed the order for double portions for all meals should have been put under the dietary category. She said the diet slip should have been written and handed off to the dietary personnel as well. The facility did not provide a policy related to physician orders or dietary orders.

Based on observations, record reviews, and interviews the facility failed to to ensure the medication error rate was less than 5.00%. Twenty-two medication administration opportunities were observed, and fifteen errors were identified for two residents (#3 and #2) of two residents observed. These errors constituted a 68.18% medication error rate. Failure to ensure the accurate administration of medications has the potential to greatly affect the effectiveness of the medication and jeopardize the health and safety of the resident. Findings included:1.On 10/15/25 at 10:06 a.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #3. The resident's medication profile was colored red, showing medications were late. The staff member removed an insulin pen and insulin syringe lying both on top of the medication cart then dispensed the following medications:- saccharomyces boulardii over-the-counter (otc) 500 milligram (mg) tablet- haloperidol 2 mg tablet- 4 gabapentin 100 mg capsules- fluoxetine 10 mg capsule- benztropine 2 mg tablet- aspirin 81 mg chewable otc tablet- meloxicam 15 mg tablet- metformin 1000 mg tablet- insulin degludec pen 24 unitsThe staff member uncapped and used an alcohol pad to wipe the rubber stopper of the insulin cartridge before inserting the needle from an insulin syringe into the pens cartridge, and drawing up 24 units. The staff member did not engage the safety sheath of the syringe leaving the needle exposed. Staff A laid the insulin syringe onto the mouse pad atop the medication cart to confirm the dispensation of 11 tablets. The staff member proceeded to pick up the syringe then laid it back down on an empty blister card of atorvastatin, picked up a cup of water, the syringe, and a glucometer with the syringe resting upon the glucometer. Staff A entered Resident #3's room, lying the insulin syringe with the exposed needle directly onto the resident's over bed table proceeding to open an alcohol pad package. The staff member was asked to stop the administration and return to the hallway. Staff A stated they were not to draw up insulin from the pen but when they order pen needles pharmacy does not send them. The infection control issues were discussed with Staff A and the staff member returned to the medication cart, discarding the insulin syringe. The staff member again used an insulin syringe to draw up insulin degludec from the pen, returned to the resident's room, injected the insulin, and obtained blood glucose level of 117 acknowledging the resident did not require short-acting insulin. Review of Resident #3s Medication Administration Record (MAR) revealed the following medications were to be dispensed and included the times in which the medications were scheduled to be administered:- acidophilus (lactobacillus) tablet - one time a day for prophylaxis otc. Medication provided by facility, pharmacy do not send.- haloperidol 2 mg oral tablet- give 2 mg by mouth two times a day for schizoaffective disorder bipolar type. The medication was scheduled for 9:00 a.m. and 5:00 p.m.- gabapentin 100 mg - give 400 mg by mouth three times a day for neuropathic pain, give 4 capsules of 100 mg. The medication was scheduled for 9:00 a.m., 1:00 p.m., and 5:00 p.m.- benztropine mesylate oral 2 mg tablet - give 2 mg by mouth two times a day for EPS (Extrapyramidal symptoms). The medication was scheduled for 9:00 a.m. and 5:00 p.m.- metformin 1000 mg - give 1000 mg by mouth two times a day related to type 2 diabetes mellitus without complications, give with breakfast and dinner. The medication was scheduled for 9:00 a.m. and 5:00 p.m.- insulin degludec subcutaneous solution pen-injector 100 unit/milliliter (mL) - inject 24 uit subcutaneously every morning and at bedtime for diabetes. The medication was scheduled for 8:00 a.m. and 9:00 p.m. Review of the administered medications and the MAR showed the resident received the probiotic yeast (fungus), saccharomyces boulardii instead of the ordered bacteria probiotic, acidophillus (lactobacillus acidophillus). Review of Resident #3s progress notes, conducted on 10/15/25 at 3:32 p.m. did not reveal the physician had been notified and instructions were received for the next dose(s) of the late medications of haloperidol, gabapentin, benztropine or metformin. Review of insulin degludec's manufacturers prescribing information (https://www.novo-pi.com/tresiba.pdf) included Dosage and Administration - Important Administration Instructions: DO NOT transfer (brand name) insulin degludec from insulin degludec FlexTouch pen into a syringe for administration (see Warnings and Precautions (5.4)). The warnings and precautions (5.4) instructed users To avoid dosing errors and potential overdose, never use a syringe to remove (brand name - insulin degludec) from the (insulin degludec) flex touch disposable insulin prefilled pen (see Dosage and administration (2.1) and Warnings and Precautions (5.3)). An interview was conducted with Staff A on 10/15/25 immediately following the medication administration observation. The staff member stated the facility has not had insulin pen needles since switching over from vials to pens. 2.An observation was made of Staff B, Licensed Practical Nurse (LPN) in room with the medication cart parked in front of door and the electronic medication profile of a resident visible. The staff member returned to the cart, moved it near to Resident #2's doorway (across the hall), moving a wheelchair out of the way before parking the cart directly in front of the doorway. The observation showed on 10/15/25 at 10:30 a.m. revealed the resident's medication profile was red showing medications were late when the staff member dispensed the following medications for Resident #2:- amiodarone 100 mg tablet- duloxetine delayed release (DR) 20 mg tablet- furosemide 20 mg tablet- jardiance 10 mg tablet- eliquis 5 mg tablet- artificial tears otc drops- fluticasone propionate nasal spray- Trelegy 100 microgram (mcg)/62.5 mcg/25 mcg inhaler- senna 8.6 mg (sennosides) otc tablet- docusate sodium 100 mg otc tablet- 3 guaifenesin 400 mg otc tabletStaff B confirmed dispensing 10 oral tablets, an inhaler, a nasal spray, and an eye drop. The staff member handed the nasal spray to the resident who administered it, then a medication cup was given to the resident, the resident refused guaifenesin requesting liquid form, and the resident administered one inhale of trelegy. Staff B opened the bottle of eye drops and without hand hygiene or donning gloves the staff member administered one drop of artificial tears in each eye. Staff B returned to the cart as the resident asked writer to not blame the nurse for the pills as the resident hadn't told anyone (changing to liquid guaifenesin). Review of Resident #3s Medication Administration Record (MAR) revealed the following medications were to be dispensed and included the times in which the medications were scheduled to be administered:- duloxetine delayed release particles 20 mg - give 1 capsule by mouth two times a day for depression. This medication was scheduled to be administered at 9:00 a.m. and 5:00 p.m.- furosemide 20 mg tablet - give 20 mg by mouth two times a day for diuretics. This medication was scheduled to be administered at 9:00 a.m. and 9:00 p.m.- apixaban (Eliquis) 5 mg tablet - give 5 mg by mouth two times a day for anticoagulant. This medication was scheduled to be administered at 9:00 a.m. and 9:00 p.m.- artificial tears solution - instil 1 drop in both eyes two times a day for dry eyes. OTC medication provided by facility, pharmacy do not send. This medication was scheduled to be administered at 9:00 a.m. and 5:00 p.m.- Senokot 8.6 mg (sennosides) - give 1 tablet by mouth two times a day for laxatives. This medication was scheduled to be administered at 9:00 a.m. and 9:00 p.m.- Docusate 100 mg - give 100 mg by mouth two times a day for laxative. This medication was scheduled to be administered at 9:00 a.m. and 9:00 p.m.- Guaifenesin 400 mg - give 1200 mg by mouth two times a day for cough, do not crush, chew or split medication. This medication was scheduled to be administered at 9:00 a.m. and 9:00 p.m. Review of Resident #2s MAR showed the resident was to receive Ipratropium/Albuterol inhalation solution 0.5-2.5- (3) mg/3mL - inhale orally four times a day for antiasthmatic, document minutes administered. The MAR printed on 10/15/25 at 1:21 p.m. did not reveal the resident had received the 9:00 a.m. dose of Ipratropium/Albuterol which was also not witnessed as administered at the time of other scheduled medications. The MAR showed Staff B had documented the resident had received the 3 tablets of guaifenesin that was observed as being refused. Review of Resident #2s Treatment Administration Record (TAR) showed Nystatin powder was to be applied topically twice daily to resident's groin and abdominal folds. The observation did not reveal the powder had been applied. Review of Resident #2s Medication Admin Audit Report, printed on 10/15/25 at 2:33 p.m. revealed:- Nystatin had not been applied on 10/15/25 as of 2:33 p.m.- the first of two daily doses of artificial tear solution, sennosides, and trelegy inhaler were administered on 10/15 at 10:34 a.m. (1.5 hours after scheduled time)- the first of two daily doses of duloxetine, apixaban, furosemide were administered at 10:31 a.m. (1.5 hours after scheduled time)The Audit report showed both the 9:00 a.m. dose and the 1:00 p.m. dose of Ipratropium/Albuterol were administered at 1:43 p.m. showing the 9:00 a.m. dose was given at the same time as the 1:00 p.m. dose and 4.75 hours after the scheduled time. Review of Resident #2s progress notes on 10/15/25 at 3:30 p.m. revealed the physician was not notified of the late medication administration and staff had received instructions regarding the administration of the next doses. An interview was conducted with Resident #2 on 10/15/25 at 1:22 p.m. The resident reported medications are usually late and had not received either one of nebulizers yet because the nurse hadn't had time. The resident also reported not having Nystatin powder applied either. An interview was conducted with Staff B on 10/15/25 at 2:33 p.m. The staff member stated late medications were due to a resident with a tracheostomy and a resident who was a readmission from an involuntary transfer, and medications were not usually late. An interview was conducted with Staff A on 10/15/25 at 3:08 p.m. The staff member stated medications were seldom late and this morning was due to a mandatory meeting that went past the scheduled time. An interview was conducted with Staff C, Unit Manager (UM) on 10/25/25 at 3:39 p.m. The staff member reported being with the facility since March and knew staff were not allowed to draw insulin from pens but only received insulin pen needles about 2 hours ago, and its been the first time since March the facility has had pen needles. The staff member reported informing the them in March the facility was [NAME] to be tagged for not having the needles. An interview was conducted with the Director of Nursing (DON) on 10/15/25 at 4:14 p.m. The DON reported not knowing if saccharomyces boulardii and acidophillus were the same medication and would have to look it up. A continued interview was conducted with the Director of Nursing (DON) on 10/15/25 at approximately 4:30 p.m. The DON stated medications are to be given one hour before and one hour after (scheduled time). The DON reported staff have had to extract insulin from the pens due to a shortage of screwed on needles for a couple of months, has called a sister facility and they didn't have any, was able to receive from pharmacy today 2 boxes. The DON stated she was not aware of missing needles until working the cart approximately one month ago. The DON reported she had not spoken with pharmacy regarding the pen needles but had been informed of it by a nurse (she did not identify the nurse), had called a sister facility who informed her they didn't have any either. An interview was conducted with a pharmacy representative on 10/15/25 at 4:42 p.m. The representative stated there had been a crazy one shortage of insulin pen needles for approximately 3 weeks. Review of the policy - Medication Administration General Guidelines, dated 9/18, revealed Medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they are familiarized themselves with the medication.3. Medication administration timing parameters include the following: b. Medications to be given with meals are to be scheduled for administration at the resident's meal times.9. Verify medication is correct three (3) tiems before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered11. Hands are washed With soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Anti micro micro sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy.14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times period unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at meal times or in the dining room unless specifically ordered with meal.The policy revealed documentation should be completed immediately following the medication being given and if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for as needed (PRN) documentation. Review of the policy - Medication Administration Subcutaneous Insulin, dated 5/16 revealed the policy was To administer subcutaneous insulin as ordered and in a safe, accurate, and effective manner. The policy did not show staff were allowed to extract insulin with a syringe from the pen. Review of the policy - Medication Administration Eye Drops, dated 5/16 showed the purpose was To administer ophthalmic solution into eye in a safe and accurate manner. The procedure included the instructions:3. Perform hand hygiene.8. With a gloved finger, gently pull down lower eyelid to form pouch while instructing resident to look up.9. Instruct resident to close eyes slowly to allow for even distribution over surface of the eye. The resident should also refrain from blinking or squeezing eyes shut.10. While the eye is closed, use one finger to compress the tear duct in the inner corner (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately 3 minutes.13. If administering medications to both eyes, use a different gloved finger to apply pressure to the inner tear duct.16. Remove and dispose of gloves. Discard any barrier used for carrying or storing the medication and supplies. Wash hands thoroughly with antimicrobial soap and water or facility-approved hand sanitizer.

Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to ensuring one of one observed needle attached to an insulin syringe was appropriately sheathed, staff failed to provide a barrier between an insulin syringe and an over bed table, failed to clean hands in between residents and handling random resident equipment stored in hallway, failed to don gloves prior to the administration of eye drops for one (#2) of one resident receiving this type of medication, and failed to ensure two (B & C) of three direct care nurses fingernails had the ability to be cleaned thoroughly and adequately to prevent the transmission of microbes. Failure to not implement and educate staff regarding infection control measures could cause serious harm to residents by not ensuring cross contamination between environmental and residents. Findings included:On 10/15/25 at 10:06 a.m. Staff A was observed during Resident #3's administration of medications. The observation showed Staff B extract 24 units from an insulin degludec insulin pen with a safety sheath insulin syringe, after the extraction the staff member placed the syringe without sliding safety sheath onto the mouse pad lying on the medication cart before picking it back up. Staff A placed the uncapped/unsheathed syringe on an empty blister card of atorvastatin with the needle lying next to/on a blister to confirm the number of dispensed oral tablets. The staff member picked up a cup of water in one hand and with other picked up insulin syringe and glucometer with the unsheathed needle resting against the back of meter. The staff member entered Resident #2s room and placed water, glucometer, and syringe on the resident's over bed table without placing a barrier. The observation was stopped and the staff member was asked to exit the room. The infection control issues with the uncapped needle being unsheathed and eedle touching multiple surfaces were discussed and the staff member confirmed the observations. On 10/15/25 at 10:29 a.m. an observation revealed a medication cart parked in front of an unknown resident room. Staff B was observed exiting the room and move the medication cart to the other side of the hallway, moving a wheelchair out of the way. The staff member was observed with green square cut fingernails extending approximately a half inch (1/2) past fingertips. The staff member confirmed dispensing 10 oral tablets, inhaler, nasal spray, and (bottle) of eye drops. Staff B entered Resident #2s room, the resident squirted one spray of nasal spray into each nostril, swallowed oral medications refusing the guaifenesin, and administered one inhalation of the inhaler, gargling with water and spitting out. The staff member, without hand hygiene and gloving, administered one drop into the left eye then the right eye. Staff B left the resident room. Immediately following the observation, at the medication cart, the staff member stated I didn't put my hands on some sanitizer, thought I did and should have worn gloves when putting eye drops in. Staff B reported the fingernails were real. On 10/15/25 at 3:39 p.m. Staff C, Unit Manager, was observed with square cut fingernails painted pink with sparkles extending approximately 1/2 past end of fingertips. An interview on 10/15/25 at approximately 4:30 p.m. the Director of Nursing (DON) stated hand hygiene should almost every time, (during) casual touch, when you provide before and after putting on gloves, and supposed to do hand hygiene with hand sanitizer during medication administration. The DON stated she would have to check the handbook regarding fingernail length but normally says if you turn and look at palm should not see fingernails, would have to check. Review of the Facility Employee Handbook 2025 showed under Personnel Hygiene Fingernails should be kept neat, clean, and nails short so not to create safety or infection control issues. No artificial nails, appliques, or studs on nails may be worn at any time. Review of policy - Infection Prevention and Control Program, effective October 2021, showed The infection Prevention and Control Program is comprehensive program that addresses detection, prevention and control of infections and communicable disease among residents, visitors, volunteers, those individuals providing services under contractual agreement and personnel. The Infection Prevention and Control Program, in addition, will facilitate activities to imprvove antibiotic use to reduce adverse events, prevent emergence of antibiotic resistance, and promote better outcomes for residents. The goals of the Infection Prevention and Control Program are to: a. Provision of a safe sanitary, and comfortable environmentb. Decrease the risk of infection and communicable disease development and transmission to residents, volunteers, visitors, individuals providing services under a contractual arrangement and personnel.Review of the Centers of Disease Control and Prevention guidance, Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, included the following: Protect yourself and your patients from deadly germs by cleaning your hands.All healthcare personnel should understand how to care for and clean their handThe CDC explained the importance of proper and adequate hand hygiene was:Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with:Handwashing with water and soap (e.g., plain soap or with an antiseptic).Antiseptic hand rub (alcohol-based foam or gel hand sanitizer).Surgical hand antisepsis.Cleaning your hands reduces:The potential spread of deadly germs to patients.The spread of germs, including those resistant to antibiotics.The risk of healthcare personnel colonization or infection caused by germs received from the patient.Some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep themselves, patients and staff safe. A common challenge is keeping the skin on your hands healthy and clean.The CDC recommended the following regarding fingernails for healthcare workers:Natural nails should not extend past the fingertip.Do not wear artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive-care units or operating rooms.Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing.

Based on observations, interviews and review of the facility policy, the facility did not ensure a sanitary and home-like environment was provided in the main shower room and in two shared bathrooms (100/102 and 129/131) out of thirteen rooms with shared bathrooms.Findings included: On 10/15/25 at 9:43 a.m., an observation of the main shower room revealed clumps of hair and debris in the drain. Further observations of the main shower revealed a white shower chair, by the door, which had a clear cup with a green colored substance and multiple black particles on the left leg and arm handle. On 10/15/25 at 9:45 a.m., an observation of the shower area in room [ROOM NUMBER] and 102 revealed a bedpan on the shower chair with black debris and particles inside. Further observation of the floor revealed multiple strands of dark colored hair as well as multiple areas of black bio-growth. On 10/15/25 at 10:08 a.m., an observation of the shower area in room [ROOM NUMBER] and 131 revealed multiple areas of green and black colored bio-growth along the tiles and edges of the floor. On 10/15/25 at 10:11 a.m., an interview with Staff D, Housekeeping was conducted. He stated, I don't do anything in the showers. Staff D, Housekeeping said he only cleaned the toilet and mirrors and replaced the paper towels and toilet paper. He stated he was currently filling in the housekeeping position and was cleaning up from the previous night.On 10/15/25 at 10:22 a.m., an interview with Staff E, Housekeeping was conducted. He said cleaned the toilet and mirrors, sweeps and mops the floor, and replaced paper towels and soap. Staff E, Housekeeping said he cleaned the main shower room in the mornings, and the certified nursing assistants (CNAs) were responsible for cleaning after each resident. He said he would clean the main shower room throughout the day if staff brought it to his attention. He said there are two rooms, that he knows of in his assignment, with showers. Staff E, Housekeeping stated he kept the showers clean by picking up items off the floor but does not, Deep clean, because, Residents don't use them. He said there are housekeeping staff from 7:00 a.m. to 3:00 p.m. Staff E, Housekeeping said nursing staff are responsible for cleaning when housekeeping is not there. On 10/15/25 at 1:12 p.m., an interview was conducted with the housekeeping supervisor. He said some showers are not in use by residents. The housekeeping supervisor reviewed a facility map and counted 8 to 9 showers with water running into them. The housekeeping supervisor said he expected staff to clean the toilets and showers, as well as sweep up trash. He stated if there was bio-growth the housekeeping staff is expected to let him know and, Get something stronger to clean. He said the housekeeping staff are expected to use disinfectant to clean. The housekeeping supervisor confirmed the housekeeping staff should be cleaning the showers whether a resident uses it or not. He said for shower chairs, the housekeeping staff are supposed to clean them, including wiping them down. Photographic evidence was shown to the housekeeping supervisor of the main shower room and the showers in rooms 100/102 and 129/131. He confirmed the bio growth observed would not have happened overnight. The housekeeping supervisor said he thought the shower in room [ROOM NUMBER]/131 is going to be re-done and confirmed it should still be cleaned. A review of the facility's policy titled, Physical Environment, effective August 2024, revealed the following, A safe, clean, comfortable, and home-life environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment and dining, health services, recreation, and program areas are provided to enable staff to provide residents with needed services. 4. Assure resident care equipment is clean, properly stored, and identified.(Photographic Evidence Obtained).

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for one resident (#1) out of seven sampled residents. Resident #1 sustained an unwitnessed fall on 08/21/25 and was not assessed after the fall. Resident #1 complained of hip pain on 08/23/25, an X-ray was obtained on 08/24/25 and Resident #1 was transferred to a higher level of care due to a right hip fracture on 08/24/25 and required surgical intervention.Findings included: An interview was conducted with Resident #2 on 09/02/2025 at 10:08a.m. Resident #2 was the roommate of Resident #1 and recalled the events of 08/21/2025 when Resident #1 had a fall. She stated the night of her roommate's fall; she was starting to fall asleep when she heard a loud sound and heard her roommate grunting ouch. Resident #2 said she remembered seeing her roommate in her wheelchair near the door shortly before the fall, but she was unsure as to what she was doing when the actual fall occurred. After she heard her roommate grunting ouch she immediately pushed her call light to get help and began yelling out for help. Resident #2 said it took ten minutes for staff to respond. Resident #2 stated she heard someone come into the room and then call for a second person to assist. She assumed the facility was following their protocol and taking care of the roommate until two days later when other staff members asked her if Resident #1 had fallen. Resident #2 said after the fall she had mentioned to staff, more than once, that her roommate seemed to be in pain and then she later found out she had broken her hip.An interview was attempted with Resident #1 on 09/02/25 at 9:25 AM, 1:30 PM, and 2:45 PM. Resident #1 was in bed with eyes closed for all three interview attempts.Review of Resident #1's admission Record revealed an admission date of 01/14/25 and readmitted on [DATE]. Resident #1's diagnoses included fracture of unspecified part of the neck of right femur with an onset date of 08/27/25. Other diagnoses included muscle weakness, reactive arthropathies, unspecified site., dementia without behavioral disturbances, osteoarthritis, anxiety disorder, arthritis, abnormalities of gait and mobility, lack of coordination, and metabolic encephalopathy. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. Review of Resident #1's medical record did not reveal any documentation or assessments related to a fall on 08/21/25.Review of Resident #1's progress notes revealed the following:On 08/23/25 at 10:10 AM a late entry note revealed, Resident's [family] was called at 10:07AM. I informed [family] that [Resident #1's] hip was broken and asked him what hospital he wanted her sent out to, .said [Hospital].On 08/23/25 at 5:00 PM revealed The Change In Condition/s reported on this CIC [change in condition] are/were: Falls.On 08/23/25 at 5:12 PM revealed Resident has a fall in room according to roommate. Resident is c/o [complaint of] Right hip/pelvis pain when leg is moved. MD [Medical Doctor] called and X-Ray ordered.On 08/23/25 at 5:20 PM a late entry note revealed Resident's [family] was called also and made aware that X-ray was being done due to possible fall with injuries. Pain medication was given Tylenol 500mg [milligrams] two tabs for pain with effective results. Resident stopped crying out and was lying in bed quietly.On 08/24/25 at 10:17 AM revealed Resident is being sent out to [Hospital] due to fracture of right hip.On 8/27/25 at 7:15 PM revealed patient returned from hospital via stretcher accompanied by EMS [Emergency medical Service] team.On 8/28/25 at 3:38 AM revealed, Resident status post right hip hemiarthroplasty with multiple sutures on right hip clean dry dressing intact. Abdominal binder in place due to replacement of peg tube that was dislodged while in hospital. Resident in bed at this time wither periods of moaning. PRN [as needed] medication administered for pain. Will continue to monitor.A review of Resident #1's hospital records revealed the following Assessment/Plan: Patient presented to hospital initially after sustaining a hip fracture after ground-level fall, underwent repair on 8/25/2025. Indication for surgery: Right displaced femoral neck fracture. Scheduled Procedure: 8/25/25 12:30 PM right hip hemiarthroplasty.Fortunately her PEG tube has become dislodged.will plan for EGD [esophagogastroduodenoscopy] with PEG [percutaneous endoscopic gastrostomy] insertion today, 8/26/2025.Risks, benefits and alternatives of endoscopic procedure discussed.including but not limited to infection, bleeding, perforation and need for surgery or repeat procedures or blood transfusion or hospitalization. Other risks include complications related to sedation. Death is a rare event.An interview was conducted on 09/02/2025 at 1:20 PM with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Risk Manager. The NHA stated around 11:20 p.m. on Sunday 08/23/2025 she received a phone call notifying her that Resident #1 had fallen a few days prior and had been experiencing pain. Orders for an x-ray had been put in and the next morning the x-ray showed the resident to have a hip fracture. The NHA stated at that point they immediately began an investigation, filed an injury of unknown origin report was filed. Their investigation revealed the resident did have a fall, but the nurse who was assigned to Resident #1, Staff F, Registered Nurse (RN), put the resident back in bed with the assistance of the Certified Nursing Assistant (CNA), but never completed the post-fall assessment as was required by the facilities protocol. No documentation about the fall was made and the nurse did not notify anyone after the fall. The Risk Manager stated all fall precautions were in place prior to the resident falling, however they recognized room for improvement on what happened after the fall. The NHA stated Resident #1 went to the hospital, had hip surgery, came back to the facility and had been kept comfortable with pain medication.An interview was conducted with the DON on 09/02/2025 at 2:35 PM. The DON stated her expectation for the staff after finding a resident on the floor after an unwitnessed fall would be a full post-fall assessment be performed with neuro checks and range of motion to the extremities before ever moving that resident back into bed. The DON said if Resident #1 was complaining of any pain or if there was any suspected injury they should have immediately called 911 and not moved the resident at all. The DON said in the instance of Resident #1's fall on 08/21/25, the DON should have been notified as well as the NHA, the doctor, and family or responsible party. The DON said she knew the ball was definitely dropped in Resident #1's situation and unfortunately, they had to let go of three nurses because of it. An attempt was made on 09/02/25 to interview Resident #1's physician as well as Staff F, RN via phone. Neither the Physician nor Staff F, RN, returned the call. Review of the facility's Fall and Injury Reduction Policy, with an effective date of March 2023 revealed: The facility has designated and implemented processes, which strive to reduce the risk for falls and injuries.This policy guides the identification, implementation of appropriate interventions, and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such occurrence.Guidelines.Status Post witnessed/unwitnessed Fall or observed on floor eventNurse will evaluate the resident for signs/symptoms of injury.Do no[sic] move the resident from the floor until a nurse has evaluated.If no signs/symptoms of injury assist resident from floor using a Mechanical lift unless resident is can actively assist in getting off the floor.Notification of Resident/patient Change in ConditionNurses will notify the resident/residents representative., if there is a crucial/significant change in the resident condition. If the change in the resident's condition is not crucial or significant, the resident's Physician, resident representative or legal representative will be notified at the earliest convenient time during regular business hours.Procedure1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day.a. If the nurse responsible for the care of the resident is remaining with the resident and is unable to place the telephone calls, another nurse will place the calls.2. Document the Nurses' Notes, the time notification was made and the names of the person(s) to whom you spoke.Serious Injury1. If there are signs/symptoms of serious injury,Signs/symptoms of a serious injury, may include, but not limited to:a. fracture/broken/displaced bone,b. head injury identified by change in mental status, change in neuro checks such as one pupil larger than the other, experience weakness, numbness, decreased coordination, convulsions, or seizure, have slurred speech or unusual behavior have a headache that gets worse and does not go away or vomit repeatedly.c. Skin or tissue injury with blood loss greater than that of a skin tear or minor injury, etc.Provide first aide if needed.2. Ask the resident and/or witnesses what happened.3. Obtain vital signs and document in the medical record.4. Start neurological checks.5. Notify Supervisor6. Notify physician with evaluation and request further instruction.7. Notify the resident representative of the fall, new intervention, and/or care given, or location transferred.8. Update the care plan with new intervention, communicate to the care staff to the oncoming nurses and C.N. A's during shift-to-shift report.9. Verify the newly determined interventions have been implemented10. Educate resident/resident representative/ family, as appropriate.11. Document the event in the medical record. Review of the facility's Clinical Guidelines Manual, with an effective date of October 2021 revealed, Notification of Resident/Patient Change in ConditionPolicyNurses will notify the resident/resident representative, if there is a crucial/significant change in the resident condition. If the change in the resident's condition is not crucial or significant, the resident's Physician, resident representative or legal representative will be notified at the earliest convenient time during regular business hours.Procedure1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day.a. If the nurse responsible for the care of the resident is remaining with the resident and is unable to place the telephone calls, another nurse will place the calls.2. Document the Nurses' Notes, the time notification was made and the names of the person(s) to whom you spoke.

Based on observations, record reviews, and interviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of three sampled residents, was provided transfer assistance in accordance with the resident's ability, care plan, facility policy, and/or the mechanical lifts manufacturer's recommendation, resulting in harm to Resident #1. Findings included: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. The electronic medical record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, subsequent encounter for closed fracture with routine healing (created 3/1/23), and displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing (created 3/28/25). Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 15/15, indicating an intact cognition. The resident had Range of Motion (ROM) impairment on one upper extremity and bilateral lower extremities. The resident utilized a wheelchair for mobility, requiring substantial/maximum assistance for bed mobility, and was dependent upon staff for sitting to lying, lying to sitting, and for bed-to-chair transferring. The resident did not ambulate and the sit-to-stand ability was not applicable. The comprehensive assessment revealed the resident had frequent pain requiring scheduled and as needed pain medication. The resident was shown to have had a fall in the last month prior to admission/entry or reentry, no falls in the last 2-6 months, and had a fracture related to a fall in the 6 months prior to admission/entry or reentry. Review of Resident #1's care plan showed the resident had an Activities of Daily Living self-care performance deficit due to a cerebrovascular accident (CVA), weakness, unsteady gait, impaired mobility, decreased strength, recent fracture, and reduced mobility. The included interventions showed the resident was a total mechanical lift to chair of 2 assist with a large sling size (revised on 3/27/25). The history of the original care plan, created 6/7/23, showed the resident was a mechanical lift to chair of 2 without specifying a sling size, on 6/3/24 the resident was a mechanical lift to chair with 2 assist, revised on 2/12/25 to dependent, without mention of type of transfer to be utilized. Review of the facility Incident Log revealed Resident #1 had a fall incident on 3/23/25. A Change in Condition Evaluation, effective 3/23/25 at 7:40 p.m., revealed the resident had a fall and complained of left leg pain. The pain was chronic, intermittent, and needed either an x-ray or ultrasound for evaluation. The physician recommended the resident be sent to hospital for further evaluation and treatment. Review of the Situation, Background, Appearance, and Review and Notify, dated 3/23/25, revealed Resident #1 had a fall with worsening of chronic pain in the front left thigh and front left knee and rated the intensity of pain 7 of 10. The summary of staff observation and evaluation revealed the resident was complaining of left leg pain, pain condition was chronic, it was intermittent, and a need for x-ray or ultrasound for evaluation. The primary care clinician recommended at 7:30 p.m. to send patient to hospital for further evaluation and treatment. Review of a Progress Note, effective 3/23/25 at 8:18 p.m., revealed Resident #1 complained of left leg pain after sliding from the chair to the floor. The nurse did not find any neurological abnormalities other than pain and after 30 minutes the resident continued to have a 9 out of 10 rating of pain and around 8:15 p.m. the resident was sent to hospital for evaluation. Review of the acute care facility's physician attestation signed on 3/24/25 at 5:51 a.m., date of service on 3/23/25 at 10:23 p.m., revealed a trauma consultation for Resident #1 with a significant past medical history of hypertension, cerebrovascular accident (CVA) with left-sided deficits who presented with left-sided leg pain after falling off of her lift and onto her knees. The note revealed the resident did not walk at baseline and was unable to inform the physician on how long it had been since last walked. The workup in the Emergency Department (ED) included x-rays of the left ankle, femur, knee, and tibia/fibula with hip and pelvis x-rays. The results showed an acute fracture of the mid to distal femoral shaft with intra-articular extension to the knee joint with a large knee effusion. The resident was stable enough to be admitted to the trauma surgery floor and placed in 15-pound traction to the left lower extremity. The trauma consults History & Physical, dated 3/23/25 at 10:23 p.m. showed the resident presented status post (s/p) fall from mechanical lift, complaining of left leg pain with obvious deformity. The patient reported having not walked in several years since having a stroke. Review of an acute care facility's Orthopedic Surgery Daily Progress Note dated 3/25/25 at 8:28 a.m. revealed Resident #1 was seen and examined at bedside. The note showed the orthopedic injury was a left closed femoral shaft fracture with a left femur retrograde intramedullary nailing on 3/24/25. The assessment showed the surgical dressing was to stay on operative sites until postoperative day 7 and the resident was essentially bedbound at baseline, was non-ambulatory, and utilized a mechanical lift for transfers at baseline Review of the acute care facility's Geriatric consult on 3/26/25 at 9:10 a.m. noted the resident was seen status post (s/p) fall from mechanical lift when getting out of wheelchair with left femur fracture and extension into the knee joint and possible posterior left calcaneous fracture. Review of Resident #1s Psychiatric Periodic Evaluation note dated 4/2/25 showed Social Services reported the resident recently had a fall which resulted in a hospitalization . The resident was found lying in bed watching television and when asked about the recent fall the resident informed the provider of being dropped from the mechanical lift while she was being transferred from her bed to her wheelchair. She reported that she broke her left femur and had to have surgery. The resident reported having a lot of pain since the fall and believed current pain medication was effective. The resident voiced frustration about her recent fall and broken femur but said she was happy to know the aide who dropped her was fired, voiced confidence with other staff, and denied anxiety or fear of having to use mechanical lift. An interview was conducted with Resident #1 on 4/23/25 at 10:40 a.m. The resident voiced her leg was hurting and began rubbing top of her left leg. The resident reported recently having surgery on left leg due to the girl decided to pivot her from the bed to wheelchair, then dropped her. The resident reported staff did not use the mechanical lift. The resident reported having rod in her leg. Resident #1 stated, I swear she didn't [use the mechanical lift]. If she had, I wouldn't be sitting in pain. The resident reported the CNA always used the mechanical lift with two people prior to the event. The resident stated the CNA picked her up to put her in the chair and dropped her. The resident stated to the staff, oh my leg, oh my leg, and informed the staff member of having to go to the hospital, before the nurse and CNA picked her up floor. After the staff members left, the resident reported propelling herself to the nursing station and informed the nurse of needing to go to the hospital. A telephone interview was conducted on 4/23/25 at 1:39 p.m. with the facility's Risk Manager Consultant (RMC). The RMC reported at the time of Resident #1s fall with resulting injury on 3/23/25, the previous Director of Nursing, Staff C, Registered Nurse (RN) was the Risk Manager. The RMC reported receiving a call on Tuesday 3/25/25 notifying her of a fall with fracture occurring over the weekend. Staff C, RN was asked where the investigation was and shared with RMC the statements gathered included the resident was transferred to her wheelchair and fell out of the chair after the Staff B, CNA was making the resident's bed. The RMC stated out of precaution, Staff C, RN was informed to do more additional investigation. The RMC stated Staff B, CNA completed a reenactment with Staff C, RN how the resident was transferred and exactly when the resident fell . Staff B, CNA confirmed during the reenactment of transferring the resident by herself. Staff B, CNA said after the resident transfer, Resident #1 slipped out of the chair and fell . The CNA was suspended for not following facility protocol for a 2-person mechanical lift transfer. The RMC directed someone from the facility to speak with the resident. The Admission Director spoke to Resident #1 and reported the resident confirmed Staff B, CNA did everything right and the resident slipped from chair, not the lift. The facility received Resident #1's hospital records, which revealed the resident fell from the mechanical lift, at which time an immediate reporting was initiated. The resident informed the RMC, during a hospital interview she was almost to the chair and had fallen from the lift sling and confirmed Staff B, CNA, was the only aide present. The nurse, Staff A, RN, was interviewed and confirmed the lift was in the room, but did not see the transfer. An interview was conducted on 4/23/25 at 2:44 p.m. with Staff A, RN. The staff member confirmed being the nurse assigned to Resident #1 on the evening of 3/23/25 and was at the nursing station. Staff A, RN reported Staff B, CNA tried to pull the resident up with the mechanical lift. The CNA informed Staff A, RN of the fall and Staff A, RN observed the resident on the floor next to the bed and the mechanical lift was present. Resident #1 told Staff A, RN, It's not her fault and she slid and fell . Staff A, RN confirmed the resident, after returning from hospital, lied and was trying to protect Staff B, CNA. Staff A, RN stated he heard the mechanical lift may have messed up and the resident fell from the lift. The staff member re-enacted the positioning of the resident and confirmed the resident was sitting on crossed ankles, however, when describing the position, he said the right leg was bent in front of the resident and the left leg was bent back. Staff A, RN, said when the resident was on the floor, he and Staff B, CNA lifted the resident up off floor without the use of a mechanical lift. Staff B, CNA informed Staff A, RN the resident slid from the wheelchair and he informed the primary doctor and Director of Nursing (DON) of the fall, telling the DON the resident said she slid from the wheelchair and did not want to blame the CNA. Staff A, RN confirmed Staff B, CNA did not ask for assistance with the mechanical lift prior to the incident. An interview was conducted on 4/23/25 at 4:24 p.m. with the Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). The NHA reported not being at the facility for Resident #1's fall with injury. The NHA stated Staff B, CNA was supposed to have another person to assist with the transfer of Resident #1 but did the transfer by herself. The resident fell , the resident heard a pop, the nurse assessed the resident, and the resident went to the hospital. The incident happened on 3/23/25 at 7:00 p.m. and on 3/24/25 the facility was notified the resident suffered a fracture, however, the resident expressed falling out of the wheelchair. On 3/26/25, through the facility Quality Assurance Assessment and Compliance review of the fall to include review of hospital records, it was determined Resident #1 fell from the mechanical lift onto her knees. The NHA stated the resident said something different in the hospital when interviewed by staff. On 3/25/25, a return demonstration of the incident was completed by Staff B, CNA for Staff C, RN, who was the previous Director of Nursing (DON). The re-enactment showed Staff B, CNA did not transfer the resident with a second person. The review of the facility's investigation revealed the following staff member statements: - 3/27/25 unknown time: Resident #1 reported I was going from chair to bed, I was almost in bed, when I slipped out of [mechanical lift] sling She said the CNA thought she was playing as they goof around. Nurse came in and helped pick her up. Per the statement, she picked me up then nurse came and picked me up. The statement was written by the Risk Management Consultant (RMC) - 3/23/25: Staff B, CNA wrote two statements, reporting the staff member was putting Resident #1 in chair with mechanical lift and the resident did not have footrests, so they slowly slid out of the wheelchair. - 3/23/25: Staff A, RN reported Staff B, CNA called out to him and witnessed Resident #1 next to her wheelchair. Resident #1 described to him that while the CNA was transferring, the resident slipped from the chair. Staff A, RN assessed the resident's pain, her injury, and received orders to send the resident to the hospital. - 3/26/25: A second interview of Staff A, RN conducted by RMC. The staff member confirmed the mechanical lift was in the resident's room on 3/23/25. Staff A, RN informed the RMC Resident #1 reported slipping from the wheelchair and it was not the CNA's fault. No one else was in the room, the mechanical lift was next to the bed, the wheelchair was next to bed, and the bed was in the lowest position. Staff B, CNA reported transferring the resident to the wheelchair and the resident slid out of the chair. The staff member reported he and Staff B, CNA put the resident in bed, put pain cream on her leg, and the resident stated she thought something popped. Staff A, RN and Staff B, CNA physically lifted the resident to bed after the assessment. The staff member reported the resident was wearing long silky pants and t-shirt and the resident resisted pulling up her pant leg because it hurt. During an interview on 4/23/25 at 12:10 p.m., the DON stated she was told Resident #1 slid out of the mechanical lift and both the resident and CNA informed the facility investigator of being transferred with one-person. During an interview on 4/23/25 at 12:19 p.m., Staff E, Registered Nurse/Unit Manager (RN/UM) reported not being at the facility on 3/23/25 but returned on 3/24/25. She stated based on many different stories, the CNA transferred Resident #1 and the resident ended up getting injured. The staff member reported the resident required a mechanical lift prior to the incident. Staff E, RN/UM stated everybody gets education regarding transferring during orientation and the CNA documentation system, which every CNA has access to, allowed staff to know how to transfer a resident. During an interview on 4/23/25 at 5:02 p.m., the Nursing Home Administrator (NHA) stated Staff A, RN and Staff B, CNA should have used a mechanical lift to get Resident #1 off the floor following the resident's fall. During an interview on 4/23/25 at 5:13 p.m., the Registered Nurse Consultant (RNC) confirmed Staff B, CNA was suspended on 3/25/25 after it was identified there was not a second person assisting with the transfer of Resident #1. An interview was conducted on 4/24/25 at 9:44 a.m. with Staff G, Physical Therapist (PT). The staff member stated Resident #1 was receiving both physical and occupational therapy. The resident used to be able to transfer years ago but declined due to motivation and wanting to use the mechanical lift. Staff G, PT reported Resident #1has been totally dependent on transfers for over a year and had a stroke on the left side and developed a contracture in the leg. Staff G, PT stated since Resident #1's injury from her fall, She's in so much pain, she can't stretch [her leg] like she used to. The resident was scheduled for 8 weeks of therapy but, most likely will extend care because of more that needs to be done. Review of the facility policy titled Abuse Prevention Program, last changed November 2024, revealed under Policy, the facility has designated implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, expectation, and misappropriation of residence property through education of staff and residents, as well as earlier identification of staff burnout, or resident behavior which may increase the likelihood of such events. The policy defined neglect as Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the policy titled Safe Operation of Resident Lifts Policy and Procedure, effective March 2022, revealed Facility is a low-lift environment. Use of Mechanical Lifts occur per the resident's care plan and otherwise indicated. . 1. Operation of mechanical lift: a. Refer to manufacturer lift manual. . 3. Training on use of mechanical lift a. Staff will be trained at orientation and annually with the competency and skills check off on the proper use of mechanical lifts. Review of the manufacturer manual for the mechanical lift revealed BEFORE using this product, this manual MUST be read and saved for future reference. The procedures in this manual MUST be performed by a qualified technician. The manual showed: . 7. Patient Lifting: - 7.1 Preparing the Lift for Use. -- Although [Brand Name] recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case. Review of the policy titled Fall and Injury Reduction Policy, effective March 2023, revealed under Policy, the facility has designated and implemented processes, which drive to reduce the risk for falls and injuries. This policy guides the identification, implementation of appropriate interventions and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such an occurrence. The policy revealed the following Guidelines: . Status Post witnessed/unwitnessed Fall or observed on floor event. 1. Nurse will evaluate the resident for signs/ symptoms of injury. 2. Do not move the resident from the floor until a nurse has evaluated. 3. If no signs/ symptoms of injury assist resident from floor using a Mechanical lift unless resident is can actively assist in getting off the floor.

Based on record review and interviews, the facility did not ensure a Registered Nurse (RN) was providing services for eight consecutive hours a day, seven days a week, for the period of 4/6/25 to 4/12/25. Findings included: A review of the staff schedule dated 4/5/25 - 4/6/25 revealed the nursing staff on each shift (10:45 p.m. - 7:15 a.m., 6:45 a.m. - 3:15 p.m., and 2:45 p.m. - 11:15 p.m.) were all Licensed Practical Nurses (LPNs) and RN was indicated next to a staff name that was crossed out. On 4/24/25 at 3:34 p.m., an interview was conducted with the Director of Nursing (DON). She said the facility completed their staffing based on census to determine how many Certified Nursing Assistants (CNAs) and nurses they need per day. She said between calling and requesting off, they haven't had enough staff on certain days and she finds out afterwards when staff do not come in, After the fact. She confirmed the facility is supposed to have an RN on duty and, Maybe the RN called off that day. She said she doesn't know because she was out of town. The DON said when she was out of town, a DON from another building came to assist with coverage. A review of the facility's policy titled Staffing, effective August 2024, revealed the following: Policy: The Administrator and Director of Nursing are responsible to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental and psychosocial well-being of each resident, as required by federal law and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). Staffing is monitored on an ongoing basis through reviews conducted by the Facility. The facility Administrator and Director of Nursing should evaluate staffing on a daily basis. Procedure: . 1. Monitor the census and resident special care needs daily. 4. Develop daily staffing patterns that allocate positions per unit, per shift, and by assignment. Ongoing Monitoring: 1. Monitor open positions and call offs throughout the day and respond to staffing needs as needed.

Based on observations, record reviews, and interviews the facility failed to provide nursing staff with the competencies and skills to provide appropriate nursing services to one resident (#1) of three sampled residents related to 1.) not providing a safe mechanical lift transfer which resulted in a severe bodily injury, 2.) not accurately documenting the administrations of controlled medications, and 3.) failed to notify the emergency contact of the resident requiring a transfer to an acute care facility following a fall. Findings included: 1. Review of the facility's reportable log showed an event involving Resident #1 occurred on 3/23/25. The event resulted in Fracture/Dislocation/transfer outside. Review of the Situation, Background, Appearance, and Review and Notify, dated 3/23/25, revealed Resident #1 had a fall with worsening of chronic pain in the front left thigh and front left knee and rated the intensity of pain 7 of 10. The summary of staff observation and evaluation revealed the resident was complaining of left leg pain, pain condition was chronic, it was intermittent, and a need for x-ray or ultrasound for evaluation. The primary care clinician recommended at 7:30 p.m. to send patient to hospital for further evaluation and treatment. Review of a Progress Note, effective 3/23/25 at 8:18 p.m., revealed Resident #1 complained of left leg pain after sliding from the chair to the floor. The nurse did not find any neurological abnormalities other than pain and after 30 minutes the resident continued to have a 9 out of 10 rating of pain and around 8:15 p.m. the resident was sent to hospital for evaluation. Review of the acute care facility's physician attestation signed on 3/24/25 at 5:51 a.m., date of service on 3/23/25 at 10:23 p.m., revealed a trauma consultation for Resident #1 with a significant past medical history of hypertension, cerebrovascular accident (CVA) with left-sided deficits who presented with left-sided leg pain after falling off of her lift and onto her knees. The note revealed the resident did not walk at baseline and was unable to inform the physician on how long it had been since last walked. The workup in the Emergency Department (ED) included x-rays of the left ankle, femur, knee, and tibia/fibula with hip and pelvis x-rays. The results showed an acute fracture of the mid to distal femoral shaft with intra-articular extension to the knee joint with a large knee effusion. The resident was stable enough to be admitted to the trauma surgery floor and placed in 15-pound traction to the left lower extremity. The trauma consults History & Physical, dated 3/23/25 at 10:23 p.m. showed the resident presented status post (s/p) fall from mechanical lift, complaining of left leg pain with obvious deformity. The patient reported having not walked in several years since having a stroke. Review of an acute care facility's Orthopedic Surgery Daily Progress Note dated 3/25/25 at 8:28 a.m. revealed Resident #1 was seen and examined at bedside. The note showed the orthopedic injury was a left closed femoral shaft fracture with a left femur retrograde intramedullary nailing on 3/24/25. The assessment showed the surgical dressing was to stay on operative sites until postoperative day 7 and the resident was essentially bedbound at baseline, was non-ambulatory, and utilized a mechanical lift for transfers at baseline. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. The electronic medical record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, subsequent encounter for closed fracture with routine healing (created 3/1/23), and displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing (created 3/28/25). Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 15/15, indicating an intact cognition. The resident had Range of Motion (ROM) impairment on one upper extremity and bilateral lower extremities. The resident utilized a wheelchair for mobility, requiring substantial/maximum assistance for bed mobility, and was dependent upon staff for sitting to lying, lying to sitting, and for bed-to-chair transferring. The resident did not ambulate and the sit-to-stand ability was not applicable. The comprehensive assessment revealed the resident had frequent pain requiring scheduled and as needed pain medication. The resident was shown to have had a fall in the last month prior to admission/entry or reentry, no falls in the last 2-6 months, and had a fracture related to a fall in the 6 months prior to admission/entry or reentry. Review of Resident #1's care plan showed the resident had an Activities of Daily Living self-care performance deficit due to a cerebrovascular accident (CVA), weakness, unsteady gait, impaired mobility, decreased strength, recent fracture, and reduced mobility. The included interventions showed the resident was a total mechanical lift to chair of 2 assist with a large sling size (revised on 3/27/25). The history of the original care plan, created 6/7/23, showed the resident was a mechanical lift to chair of 2 without specifying a sling size, on 6/3/24 the resident was a mechanical lift to chair with 2 assist, revised on 2/12/25 to dependent, without mention of type of transfer to be utilized. An interview was conducted with Resident #1 on 4/23/25 at 10:40 a.m. The resident voiced her leg was hurting and began rubbing top of her left leg. The resident reported recently having surgery on left leg due to the girl decided to pivot her from the bed to wheelchair, then dropped her. The resident reported staff did not use the mechanical lift. The resident reported having rod in her leg. Resident #1 stated, I swear she didn't [use the mechanical lift]. If she had, I wouldn't be sitting in pain. The resident reported the CNA always used the mechanical lift with two people prior to the event. The resident stated the CNA picked her up to put her in the chair and dropped her. The resident stated to the staff, oh my leg, oh my leg, and informed the staff member of having to go to the hospital, before the nurse and CNA picked her up floor. After the staff members left, the resident reported propelling herself to the nursing station and informed the nurse of needing to go to the hospital. A telephone interview was conducted on 4/23/25 at 1:39 p.m. with the facility's Risk Manager Consultant (RMC). The RMC reported at the time of Resident #1s fall with resulting injury on 3/23/25, the previous Director of Nursing, Staff C, Registered Nurse (RN) was the Risk Manager. The RMC reported receiving a call on Tuesday 3/25/25 notifying her of a fall with fracture occurring over the weekend. Staff C, RN was asked where the investigation was and shared with RMC the statements gathered included the resident was transferred to her wheelchair and fell out of the chair after the Staff B, CNA was making the resident's bed. The RMC stated out of precaution, Staff C, RN was informed to do more additional investigation. The RMC stated Staff B, CNA completed a reenactment with Staff C, RN how the resident was transferred and exactly when the resident fell . Staff B, CNA confirmed during the reenactment of transferring the resident by herself. Staff B, CNA said after the resident transfer, Resident #1 slipped out of the chair and fell . The CNA was suspended for not following facility protocol for a 2-person mechanical lift transfer. The RMC directed someone from the facility to speak with the resident. The Admission Director spoke to Resident #1 and reported the resident confirmed Staff B, CNA did everything right and the resident slipped from chair, not the lift. The facility received Resident #1's hospital records, which revealed the resident fell from the mechanical lift, at which time an immediate reporting was initiated. The resident informed the RMC, during a hospital interview she was almost to the chair and had fallen from the lift sling and confirmed Staff B, CNA, was the only aide present. The nurse, Staff A, RN, was interviewed and confirmed the lift was in the room, but did not see the transfer. An interview was conducted on 4/23/25 at 2:44 p.m. with Staff A, RN. The staff member confirmed being the nurse assigned to Resident #1 on the evening of 3/23/25 and was at the nursing station. Staff A, RN reported Staff B, CNA tried to pull the resident up with the mechanical lift. The CNA informed Staff A, RN of the fall and Staff A, RN observed the resident on the floor next to the bed and the mechanical lift was present. Resident #1 told Staff A, RN, It's not her fault and she slid and fell . Staff A, RN confirmed the resident, after returning from hospital, lied and was trying to protect Staff B, CNA. Staff A, RN stated he heard the mechanical lift may have messed up and the resident fell from the lift. The staff member re-enacted the positioning of the resident and confirmed the resident was sitting on crossed ankles, however, when describing the position, he said the right leg was bent in front of the resident and the left leg was bent back. Staff A, RN, said when the resident was on the floor, he and Staff B, CNA lifted the resident up off floor without the use of a mechanical lift. Staff B, CNA informed Staff A, RN the resident slid from the wheelchair and he informed the primary doctor and DON of the fall, telling the DON the resident said she slid from the wheelchair and did not want to blame the CNA. Staff A, RN confirmed Staff B, CNA did not ask for assistance with the mechanical lift prior to the incident. Review of the policy titled Fall and Injury Reduction Policy, effective March 2023, revealed under Policy, the facility has designated and implemented processes, which drive to reduce the risk for falls and injuries. This policy guides the identification, implementation of appropriate interventions and management. It is expected that this policy will assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behavior which may increase the likelihood of such an occurrence. Review of the policy titled Safe Operation of Resident Lifts Policy and Procedure, effective March 2022, revealed Facility is a low-lift environment. Use of Mechanical Lifts occur per the resident's care plan and otherwise indicated. . 1. Operation of mechanical lift: a. Refer to manufacturer lift manual. . 3. Training on use of mechanical lift a. Staff will be trained at orientation and annually with the competency and skills check off on the proper use of mechanical lifts. Review of the manufacturer manual for the mechanical lift revealed BEFORE using this product, this manual MUST be read and saved for future reference. The procedures in this manual MUST be performed by a qualified technician. The manual showed: . 7. Patient Lifting: - 7.1 Preparing the Lift for Use. -- Although [Brand Name] recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case. 2. Review of Resident #1s April Medication Administration Record (MAR) revealed the following orders: - Ordered 3/28/25: Oxycodone oral tablet 5 milligram (mg) - Give 1 tablet by mouth every 4 hours as needed for pain. Discontinued on 4/7/25. - Ordered 4/7/25: Oxycodone oral tablet 10 mg - Give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone Immediate Release (IR) 5 mg tablets revealed 40 tablets were received on 4/1/25 and 24 tablets were to be disposed of on 4/7/25, showing the resident received 16 tablets between 4/1/25 and 4/7/25. A review of Resident #1s April MAR showed the resident received 12 doses of 5 mg Oxycodone. A comparison of the residents' MAR and inventory sheet revealed staff documented the resident received doses of oxycodone on 4/5/25 at 10:25 a.m., 2:30 p.m., and 7:00 p.m. and a dose on 4/6/25 at 10:00 a.m., which were not recorded on the MAR. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone 10 mg tablets revealed 42 tablets was received on 4/7/25 with one tablet remaining for disposal on 4/24/25, showing the resident received 41 doses of the medication. The resident's April MAR showed the resident received 32 doses of Oxycodone 10 mg, revealing a discrepancy of 9 doses. Review of the inventory sheet showed staff documented the resident received a dose on the following days and times, which were not recorded on the MAR: 4/8/25 at 8:00 p.m., 4/12/25 at 10:00 a.m., 4/14/25 at 8:32 a.m., 4/16/25 at 2:00 p.m., 4/17/25 at 9:30 a.m., 4/19/25 at 10:00 a.m. and 4:00 p.m., 4/20/25 at 4:08 p.m., and a third dose on 4/23/25 (unreadable time). The following doses recorded discrepancies in the times of administration when compared with MAR and inventory sheet: - 4/11/25 per MAR administered at 6:00 a.m., inventory sheet recorded time of 7:30 a.m. - 4/13/25 per MAR administered at 9:41 a.m., inventory sheet recorded time as 9:00 a.m. - 4/14/25 per MAR administered at 4:25 p.m., inventory sheet recorded time as 5:00 p.m. The inventory sheet revealed a disclosure reading: For every dose of a drug listed under the Controlled Substances Act, the information required below must be given in full. The information must be filled in at the time the drug is administered and not at some future date. Failure to do so is punishable under law by fine or imprisonment or both. Ink or indelible pencil must be used. An interview was conducted on 4/25/25 at 12:11 p.m. with the Director of Nursing (DON). The DON stated staff are to document in the electronic record and the inventory sheet when the medication was administered. She reviewed Resident #1s April MAR and the 5 mg and 10 mg Oxycodone inventory sheets and confirmed the discrepancies between the documentation on MAR and the inventory sheets. Review of the policy titled Medication Administration - Controlled Substances dated 11/17 revealed under Policy, Controlled Medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependency. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The policy revealed under Procedures: . 2. The Director of Nursing and the Consultant Pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and determine that drug records are in order and then an account of all controlled drugs that's maintained and periodically reconciled. . 4. When in controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and removing dust from controlled storage: (Note: refer to state regulations for particulars regarding scheduled classes and proper storage.) a. Date and time of administration. b. Amount administered c. Signature of the nurse administering the dose 5. Administer the controlled medication and document dose administration on the MAR. 50570 3. A review of Resident #1's skilled nursing facility (SNF)/nursing facility (NF) to hospital transfer form, dated 3/23/25, revealed the resident is documented as the resident representative and was notified of the transfer/aware of clinical situation. Further review of the form revealed no documentation of a family member being notified of the transfer to the hospital. A review of Resident #1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form dated 3/23/25 and completed by Staff A, Registered Nurse (RN), did not reveal documentation under name of family/health care agent notified. A review of Resident #1's Progress Notes dated 3/23/25 at 8:18 p.m. revealed the resident was discharge to the hospital after she sustained a fall and was complaining of pain. The Progress Notes did not reveal documentation the family member/emergency contact was notified or contacted related to the resident's change in condition. On 4/23/25 at 10:40 a.m., an interview with Resident #1 and her family member revealed the family member did not find out, until a week later, Resident #1 was in the hospital. The family member stated, no one knew. He said he called the facility the day she was in the hospital and was told she was at a doctor's appointment. The family member said he called the facility again to see if Resident #1 was back from the doctor's appointment, and was told they didn't know where she was and someone signed her out. On 4/23/25 at 2:44 p.m., an interview was conducted with Staff A, RN. He said he was assigned to Resident #1 the day she fell and went to the hospital on 3/23/25. He confirmed he communicated with the Director of Nursing (DON) immediately about the change in condition and also notified the physician who gave orders to discharge the resident to the hospital. On 4/24/25 at 2:29 p.m., a phone interview was conducted with Resident #1's family member, who is her emergency contact (EC). She stated, I was made aware of the fall later. She said Resident #1 called her to tell her she was in the hospital, but the facility did not call her. She said Resident #1 called her on 3/24/25, while she was in the hospital, and told her she had fallen. The EC said the facility normally called her when there was an issue, but this time they did not. She stated, I'm supposed to be her first call when she goes to the hospital or if she has an emergency. She said when she initially talked to Resident #1, she didn't specify which hospital because, She was out of it. The EC stated, I had to call around and find out which hospital. The EC said she called another resident at the facility to find out where Resident #1 was. She confirmed she called the facility and was told Resident #1 was at [Hospital name], but she wasn't there. She found out Resident #1 was at another hospital. On 4/25/25 at 11:39 a.m., an interview was conducted with the Director of Nursing (DON). She said staff are supposed to call the family when there is a change in condition and complete a risk event note, where they are supposed to call the family, and doctor, and document. The DON said risk events are reviewed the next morning at the clinical meeting. They review the event note to see if the family was notified. She stated, They should be documenting in the medical record about that notification. A review of Resident #1's risk event note was conducted with the DON on her computer. She said usually under action is where staff is supposed to document the family notification. She confirmed she did not see notification to the family when Resident #1 went to the hospital. A review of the facility's policy titled Notification of Resident/Patient Change in Condition, effective October 2021, revealed the following under Policy: Nurses will notify the resident/resident representative, if there is a crucial/significant change in the resident condition. The policy revealed under Procedure: 1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. 2. Document the Nurses' Notes, the time notification was made and the names of the person(s) to whom you spoke.

Based on record review and interviews, the facility did not ensure the designated representative/emergency contact was notified regarding a change in condition, related to an accident resulting in hospitalization , for one resident (#1) of three residents sampled. Findings included: A review of Resident #1's Admission Record revealed an original admitted [DATE] and a re-admitted [DATE]. Review of the Admission Record revealed diagnoses to include displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with routine healing, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other lack of coordination, weakness, unsteadiness on feet, need for assistance with personal care, contracture, left knee, unspecified fracture of left lower leg, and subsequent encounter for closed fracture with routine healing. A review of Resident #1's Admission Record revealed her family member (EC) is the emergency contact/recipient for verbal patient health information (PHI). A review of Resident #1's skilled nursing facility (SNF)/nursing facility (NF) to hospital transfer form, dated 3/23/25, revealed the resident is documented as the resident representative and was notified of the transfer/aware of clinical situation. Further review of the form revealed no documentation of a family member being notified of the transfer to the hospital. A review of Resident #1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form dated 3/23/25 and completed by Staff A, Registered Nurse (RN), did not reveal documentation under name of family/health care agent notified. A review of Resident #1's Progress Notes dated 3/23/25 at 8:18 p.m. revealed the resident was discharge to the hospital after she sustained a fall and was complaining of pain. The Progress Notes did not reveal documentation the family member/emergency contact was notified or contacted related to the resident's change in condition. On 4/23/25 at 10:40 a.m., an interview with Resident #1 and her family member revealed the family member did not find out, until a week later, Resident #1 was in the hospital. The family member stated, no one knew. He said he called the facility the day she was in the hospital and was told she was at a doctor's appointment. The family member said he called the facility again to see if Resident #1 was back from the doctor's appointment, and was told they didn't know where she was and someone signed her out. On 4/23/25 at 2:44 p.m., an interview was conducted with Staff A, RN. He said he was assigned to Resident #1 the day she fell and went to the hospital on 3/23/25. He confirmed he communicated with the Director of Nursing (DON) immediately about the change in condition and also notified the physician who gave orders to discharge the resident to the hospital. On 4/24/25 at 2:29 p.m., a phone interview was conducted with Resident #1's family member, who is her emergency contact (EC). She stated, I was made aware of the fall later. She said Resident #1 called her to tell her she was in the hospital, but the facility did not call her. She said Resident #1 called her on 3/24/25, while she was in the hospital, and told her she had fallen. The EC said the facility normally called her when there was an issue, but this time they did not. She stated, I'm supposed to be her first call when she goes to the hospital or if she has an emergency. She said when she initially talked to Resident #1, she didn't specify which hospital because, She was out of it. The EC stated, I had to call around and find out which hospital. The EC said she called another resident at the facility to find out where Resident #1 was. She confirmed she called the facility and was told Resident #1 was at [Hospital name], but she wasn't there. She found out Resident #1 was at another hospital. On 4/25/25 at 11:39 a.m., an interview was conducted with the Director of Nursing (DON). She said staff are supposed to call the family when there is a change in condition and complete a risk event note, where they are supposed to call the family, and doctor, and document. The DON said risk events are reviewed the next morning at the clinical meeting. They review the event note to see if the family was notified. She stated, They should be documenting in the medical record about that notification. A review of Resident #1's risk event note was conducted with the DON on her computer. She said usually under action is where staff is supposed to document the family notification. She confirmed she did not see notification to the family when Resident #1 went to the hospital. A review of the facility's policy titled Notification of Resident/Patient Change in Condition, effective October 2021, revealed the following under Policy: Nurses will notify the resident/resident representative, if there is a crucial/significant change in the resident condition. The policy revealed under Procedure: 1. Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. 2. Document the Nurses' Notes, the time notification was made and the names of the person(s) to whom you spoke.

Based on observations, record reviews, and interviews, the facility failed to maintain an accurate accounting of narcotic medication for one resident (#1) of one resident sampled for the administration of pain medication. Findings included: On 4/23/25 at 10:40 a.m. Resident #1 was observed sitting in the Dining Room with a family member. The resident reported her legs and hands were hurting while rubbing the top of left leg and the oxy was not working. The resident reported a recent surgery to the left leg due to a staff member pivoting her to transfer. Review of Resident #1s quarterly Minimum Data Set (MDS) assessment, dated1/8/25, revealed a Brief Interview of Mental Status score of 15 of 15, indicating the resident was cognitively intact. The assessment revealed Resident #1 was dependent upon staff for sit to lying, lying to sit, and bed to chair transferring. The assessment showed the resident received scheduled and as needed pain medication for occasional pain. Review of Resident #1s April Medication Administration Record (MAR) revealed the following orders: - Ordered 3/28/25: Oxycodone oral tablet 5 milligram (mg) - Give 1 tablet by mouth every 4 hours as needed for pain. Discontinued on 4/7/25. - Ordered 4/7/25: Oxycodone oral tablet 10 mg - Give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone Immediate Release (IR) 5 mg tablets revealed 40 tablets were received on 4/1/25 and 24 tablets were to be disposed of on 4/7/25, showing the resident received 16 tablets between 4/1/25 and 4/7/25. A review of Resident #1s April MAR showed the resident received 12 doses of 5 mg Oxycodone. A comparison of the residents' MAR and inventory sheet revealed staff documented the resident received doses of oxycodone on 4/5/25 at 10:25 a.m., 2:30 p.m., and 7:00 p.m. and a dose on 4/6/25 at 10:00 a.m., which were not recorded on the MAR. Review of Resident #1s Controlled Drug Declining Inventory Sheet for Oxycodone 10 mg tablets revealed 42 tablets was received on 4/7/25 with one tablet remaining for disposal on 4/24/25, showing the resident received 41 doses of the medication. The resident's April MAR showed the resident received 32 doses of Oxycodone 10 mg, revealing a discrepancy of 9 doses. Review of the inventory sheet showed staff documented the resident received a dose on the following days and times, which were not recorded on the MAR: 4/8/25 at 8:00 p.m., 4/12/25 at 10:00 a.m., 4/14/25 at 8:32 a.m., 4/16/25 at 2:00 p.m., 4/17/25 at 9:30 a.m., 4/19/25 at 10:00 a.m. and 4:00 p.m., 4/20/25 at 4:08 p.m., and a third dose on 4/23/25 (unreadable time). The following doses recorded discrepancies in the times of administration when compared with MAR and inventory sheet: - 4/11/25 per MAR administered at 6:00 a.m., inventory sheet recorded time of 7:30 a.m. - 4/13/25 per MAR administered at 9:41 a.m., inventory sheet recorded time as 9:00 a.m. - 4/14/25 per MAR administered at 4:25 p.m., inventory sheet recorded time as 5:00 p.m. The inventory sheet revealed a disclosure reading: For every dose of a drug listed under the Controlled Substances Act, the information required below must be given in full. The information must be filled in at the time the drug is administered and not at some future date. Failure to do so is punishable under law by fine or imprisonment or both. Ink or indelible pencil must be used. An interview was conducted on 4/25/25 at 12:11 p.m. with the Director of Nursing (DON). The DON stated staff are to document in the electronic record and the inventory sheet when the medication was administered. She reviewed Resident #1s April MAR and the 5 mg and 10 mg Oxycodone inventory sheets and confirmed the discrepancies between the documentation on MAR and the inventory sheets. Review of the policy titled Medication Administration - Controlled Substances dated 11/17 revealed under Policy, Controlled Medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependency. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The policy revealed under Procedures: . 2. The Director of Nursing and the Consultant Pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and determine that drug records are in order and then an account of all controlled drugs that's maintained and periodically reconciled. . 4. When in controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and removing dust from controlled storage: (Note: refer to state regulations for particulars regarding scheduled classes and proper storage.) a. Date and time of administration. b. Amount administered c. Signature of the nurse administering the dose 5. Administer the controlled medication and document dose administration on the MAR.

Based on observation staff interview and facility record review, the facility failed to ensure the kitchen dish washing machine was operating at optimum levels, to include excessive concentration with the chemical sanitizer delivery, in one of one facility kitchen, during one (2/11/25) of three days observed. Findings included: On 2/11/2025 at 9:08 a.m. the facility's kitchen was toured with the Dietary Manager, Staff A. Staff A, the only staff member in the kitchen demonstrated on how the dish washing machine is used. He revealed he had primed the machine for operation just minutes before. Staff A revealed the dish washing machine was a Low Temperature operation and indicated the wash temperature was to reach 120 degrees F. (Fahrenheit), and the final rinse was to reach 120 degrees F. Staff A continued to say the machine has a chemical chlorine agent delivery system and the chemical chlorine sanitizer should be measured between 50 - 100 Parts Per Million (PPM), via litmus testing strip. Review of the dish machine's specification plate attached to the bottom frame revealed the machine is operated at Low Temperature/Chemical Sanitizer and with Wash temperature to reach 120 degrees F., the Rinse temperature to reach 120 degrees F., and the Chemical Sanitizer to be at a range of 50 ppm. The machine did not identify a range, but revealed ppm must be at least 50. On 2/11/2025 at 9:15 a.m. Staff A ran a rack of soiled bowls through the dirty side of the dish machine and through to the inside. The machine wash temperature reached 120 + degrees F., and the rinse temperature reached 120 + degrees F., After the machine had ran it's cycle, the rack of cleaned bowls was pulled out from the clean side of the machine. Staff A had a bottle of litmus test strips and used a clean, unused white test strip. He mentioned the ppm should be within a range of 50 and 100. He was able to show the test strip bottle with a color legend, showing light purple in color less ppm, and very dark purple in color more ppm. Staff A then placed the clean unused test strip on a clean bowl that had some puddling of water on, and it immediately turned very dark purple. He revealed he had a problem with the test strip and asked if he could do another demonstration. On 2/11/2025 at 9:19 a.m. Staff A ran another rack of bowls and immediately when the test strip touched the water, it turned from white to a very dark purple. Staff A held the test strip bottle showing the color ranges and placed the tested strip on the bottle which revealed the test strip chemical chlorine sanitizer was a very dark purple, well over the range of 100 ppm. Staff A confirmed this observation. Photographic evidence Obtained. At the time, Staff A did not say what he and his dietary staff would do with the dishes that had already been ran through the dish machine the morning of 2/11/2025. The dishes were not rewashed through the three-compartment sink, nor was there plastic eating ware used until the dish machine was evaluated by the machine's maintenance technician. Staff A and dietary staff operated and used the machine after the lunch meal service, after the dinner meal service on 2/11/2025, as well as again after the breakfast meal service on 2/12/2025. Staff A revealed he had tested the chemical chlorine sanitizer prior to each use on 2/11/2025 and 2/12/2025, and the test strip still read the chemical chlorine sanitizer delivery system was still too concentrated and still above 100 ppm. The Dietary Manager, Staff A revealed the facility's county Department of Health inspection occurred on 1/24/2025. The report revealed a violation to include chlorine sanitizer in dish machine not at proper minimum strength of 50-100 ppm. Use manual sanitation until dish machine is repaired. Staff A confirmed the machine technician came out and repaired the machine about two days later. Staff A was not aware the dish machine's chemical chlorine sanitizer delivery system was not overconcentrating, until it was observed on 2/11/2025. Also, he did not have any documentation of in-services/education to his staff related to dish washing machine operation since the health department inspection. On 2/13/2025 at 1:00 p.m. an interview with the Dietary Manager, Staff A, and upon request, revealed he did not have the facility's dish washing machine operations manual, nor did he have a policy with relation to the dish washing machine's operating procedure.

Based on observations, interviews and facility record review, the facility failed to ensure resident spaces and equipment were maintained in a sanitary manner in two of two units (Main, West), during three of three days observed (2/11/2025, 2/12/2025, and 2/13/2025). Findings included: On 2/11/2025 at 10:55 a.m. 2/12/2025 at 8:30 a.m. and 2/3/2025 at 11:00 a.m. the following was observed: 1. Resident room [ROOM NUMBER] bathroom was observed with a recent wall repair between the sink and the toilet. It was further observed a white panel approximately two feet by two feet covering a hole in the wall. The panel was observed torn off the wall. The bathroom was also observed without a trash can, and the toilet tank was observed without a lid. Photographic evidence was taken. 2. Resident room [ROOM NUMBER] shared bathroom was observed with a metal glove box holder affixed to the wall on the left side of the sink wall. The metal box was observed heavily rusting and with paint chipped and peeling, leaving a non-cleanable surface; The bathroom door (inside) was observed with heavy chipping, peeling and leaving injury hazard and non-cleanable surface. On 2/13/2025 at 2:00 p.m. an interview with the Director of Maintenance (DOM) and the housekeeping director. Both confirmed they were not aware of the above listed areas of concern. They both confirmed the concerns and revealed they should have been made aware by either nursing staff who are in the rooms, as well as housekeeping staff who clean the spaces. (Photographic Evidence Obtained) 48223 On 2/11/2025 at 10:10 a.m. room [ROOM NUMBER]'s bathroom was observed with a brown substance surrounding the toilet base on the floor. The substance was on both sides of the toilet and the base of the toilet did not appear to be sealed. On 2/11/2025 at 9:52 a.m. room [ROOM NUMBER]'s toilet base was observed not to be sealed at the base and a brown substance surrounded the toilet. On 2/11/2025 at 10:02 a.m. the shower room on Main Unit was observed with door not closing, the shower chair had pink/brown bio-growth on all four of the legs of the shower chair. Under the seat of the chair, there was a brown substance. The shower stall had pink/brown bio-growth in the grout of the shower. On 2/11/2025 at 10:14 a.m. the bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] (shared bathroom of 4 residents) was observed with the following: the light did not function properly, the toilet paper roll holder was not available. The toilet paper was observed sitting on the back of the toilet and the shower had brownish bio-growth on the shower tiles. On 2/12/2025 at 11:50 a.m. the bathroom of room [ROOM NUMBER] had an uncovered toilet plunger sitting next to the toilet. The above observations above were still observed on 2/13/2025 at 9:00 a.m. (Photographic Evidence Obtained) 46234 3-An observation was conducted on 2/11/25 at 10:18 a.m. in room [ROOM NUMBER]. The cove base was coming off the wall behind the bed. There was a plastic glove box holder hanging on the wall that was broken with pieces missing. A resident in the room said the box had been broken for over a month. An observation was conducted on 2/11/25 at 10:26 a.m. in room [ROOM NUMBER]. There was a large patch on the wall under the window that had been repaired but not painted. The windowsill had a broken tile with a piece missing. The room also contained an armchair with the top of the covering material rubbed off, creating a non-cleanable surface. An observation and interview was conducted on 2/13/25 at 2:06 p.m. with the Regional [NAME] President. She was observed going to room [ROOM NUMBER] and looking at the broken glove box. She said it should be removed and not be on the wall broken. She also confirmed the cove base should not be coming off the wall. She was then observed entering room [ROOM NUMBER] and inspecting the room. She said the patch on the wall should have been painted and the broken tile repaired. She also confirmed the armchair was a non-cleanable surface and should be removed. 50570 4. On 2/11/25 at 10:14 a.m., an observation of the privacy curtain in room [ROOM NUMBER] revealed multiple dark orange stains along the middle and bottom part of the curtain. An observation of the bathroom in room [ROOM NUMBER] revealed the light fixture in the ceiling had multiple black spots/debris. Further observations of the bathroom revealed the lining of the bathroom floor had cracked tiles and black particles/debris in between the tiles. On 2/11/25 at 10:59 a.m., an observation of room [ROOM NUMBER] revealed the handrail of the B-bed was detached and resting on the wall. Observations of the floor by the B-bed revealed a large black hole with cracked/missing tile. An observation of the bathroom in room [ROOM NUMBER] revealed the shower head was detached and laying in a bed pan on a shower chair. Further observations of the bathroom revealed a bed pan, which contained water and the end of the shower hose inside the pan. Observations of the soap and toilet paper holder revealed it was rusted and oxidized as evidenced by green and white residue/spots, (Photographic Evidence Obtained). On 2/12/25 at 9:48 a.m., observations of room [ROOM NUMBER] and 134 had the same concerns observed on 2/11/25. An interview with Resident #16 revealed the handrail detached from the bed had been like that, For a couple of days. On 2/13/25 at 12:20 p.m., an interview and review of work orders was conducted with the Director of Maintenance (DOM). A review of work orders from 11/1/24 to 2/11/25 revealed room [ROOM NUMBER]'s work orders were not related to the floor, the detached bed handrail or bathroom concerns. The DOM stated he was not aware of the observations in room [ROOM NUMBER]. He stated the hole in the floor and detached handrail could have occurred when the previous bed was replaced with the current hospice bed. He stated an outside company brought and installed the hospice bed for Resident #16. The DOM stated he expected staff to put a work order in regarding the observations in room [ROOM NUMBER]. He stated he completed rounds every Friday and picked a few rooms to round. He could not confirm when the last time room [ROOM NUMBER] was included in his rounds. The DOM stated he was not aware of the environment concerns in room [ROOM NUMBER]. He stated he looked at bathrooms during rounds. He stated all staff had access to the work order system, with an automatic log-in. The DOM stated when staff communicate to him about an environment concern, he encouraged them to put a work order in. On 2/13/25 at 1:25 p.m., an interview with the Housekeeping Manager revealed each housekeeping staff had their own section of the facility they were responsible for. He stated the housekeeping team was considered fully staffed. An observation of the privacy curtain in room [ROOM NUMBER] was conducted with the Housekeeping Manager. He stated he could replace the curtain today. The Housekeeping Manager stated he wasn't aware of the stained privacy curtain. A review of the facility's policy titled, Physical Environment, effective date August 2024, revealed the following, Policy - A safe, clean, comfortable, and home-like environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible . (Photographic Evidence Obtained)

Based on observation interview and record review, the facility did not ensure prompt efforts were made to resolve grievances for two (#33 and #13) of six residents sampled. Findings included: During an interview on 2/12/2025 at 9:20 a.m. Resident #33 stated during the hurricane evacuation their wheelchair was lost. Resident #33 stated speaking to the Social Service Director (SSD) upon returning from the evacuation, as the chair given is not as wide as the prior chair. Resident #33 stated notifying the SSD that someone else was in the chair (as Resident #33's name was on the chair). Resident #33 stated not having any resolution as Resident #33 is still in this chair that was too small and preferred the wider chair. Review of the grievance log from September 2024 to January 2025 showed an absence of grievances for Resident #33. 50570 2.On 2/11/25 at 10:44 a.m., an observation of Resident #13 revealed he was sitting in his wheelchair to the left of the bed, by the door. He expressed concerns related to his wheelchair bearings that needed to be fixed. He stated he goes out every day and sometimes his wheelchair gets stuck, and he had difficulty rolling. Resident #13 stated he had been telling staff, for a couple of months. He stated he was offered a new wheelchair, but that's not what he wanted. Resident #13 stated purchasing a new wheelchair, Is it not fixing the problem. Resident #13 stated, The bearings just need to be fixed, that's all I want. He stated he asked for the, [NAME] of sale, for the new wheelchair, and it was not provided to him. During the interview, Resident #13 called for his nurse Staff E, Registered Nurse (RN) who confirmed staff were aware of his concerns. Review of Resident #13's admission record revealed an original admitted [DATE] and re-admitted [DATE] with diagnoses to include other lack of coordination, unsteadiness on feet, other abnormalities of gait and mobility, unspecified lack of coordination, and generalized muscle weakness. Review of Resident #13's quarterly Minimum Data Set (MDS), Section C - Cognitive Patterns, dated 1/1/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Review of the grievance/concern log for January 2025 revealed a grievance for Resident #13, on 1/14/25, related to environment. Further review of the log revealed Resident #13's grievance was resolved on 1/14/25. The grievance did not show documented concerns relate to the wheelchair. Review of Resident #13's progress notes on 1/29/25 revealed the following, Resident was given a new wheelchair which was personally ordered for him, which he decline to use. resident stated that he does not want a new chair. Review of work orders from 1/1/24 to 2/11/25, provided by the Director of Maintenance (DOM), revealed the following, Wheelchair Bearing . Resident [room number] Wheelchair . Assigned To DOM. Further review of this work order revealed no documentation of the date it was submitted or a completion date. On 2/13/25 at 12:20 p.m., an interview and review of work orders was conducted with the DOM. He stated the work order for Resident #13's wheelchair bearing was communicated to him on 1/10/25. The DOM stated the resident told him his wheelchair bearing, Was going out. He stated a new wheelchair was ordered, but Resident #13 refused. The DOM stated, We don't mess with personal items. He stated he could order the part needed, if the serial number on the wheelchair was legible. The DOM stated he could order the part through direct supply and an, outside company, could possibly fix it. He stated he had not tried to order a replacement part for the wheelchair, but confirmed the facility could do it. On 2/13/25 at 2:44 p.m., an interview was conducted with the Social Services Director (SSD) related to Resident #13's grievance on 1/14/25. She stated the Resident said the wheels were loose on his wheelchair, making it hard to ambulate down the hallway. The SSD stated herself, the business office and the NHA were aware of and were involved with the related grievance. She stated they offered him a new wheelchair, with his permission, and it was ordered. The SSD stated, He wants his own wheelchair to be fixed. She stated maintenance was looking into purchasing the part to see if his wheelchair can be fixed. The SSD stated, I'm not sure what happened, but I will have to get with maintenance on that. Regarding resolution of the grievance, the SSD confirmed, It isn't what he wanted. Review of the facility policy titled Grievance/ Concern Management, effective February 2021, revealed the following, Policy . These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents. Further review of the policy revealed the following, .5. The Social Services Representatives/Grievance Official in collaboration with the NHA [Nursing Home Administrator] will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion. 6. The department involved will document the concern and record the resident/resident representative's satisfaction with the resolution to the concern. 13. Social Services staff will provide information regarding compliance line information for unresolved concerns.

Based on observation interview and policy review, facility did not ensure medication was stored appropriately on three out of three units in the facility related to medication in resident rooms on the north and main units, unsecured medication is an office on the central unit, and improperly stored medication in two medication carts on the north and central units. Findings included: An audit of the central medication cart and interview was conducted on [DATE] at 3:34 p.m. with Staff H, Licensed Practical Nurse (LPN). The cart contained a bottle of Sodium Bicarbonate 10 gr (grain) that had been opened on [DATE] and expired on ,d+[DATE]. The drawers of the cart had dirt, debris, pieces of packaging, rubber bands, and glucose test strips in them. Staff H said the night shift is supposed to clean the medication cart and check them for expired medication. She agreed the cart was dirty and said night shift obviously hadn't cleaned it. An audit of the north medication cart and interview was conducted on [DATE] at 3:48 p.m. with Staff E, Registered Nurse (RN). The medication cart contained a box of Bisacodyl suppositories that expired ,d+[DATE]. There was one loose pill in the medication cart. The narcotics drawer contained a box of medical gloves being stored with the medication. Another drawer contained medication being stored in the same compartments as plastic bags, syringes, and lancets. Staff E confirmed the box of Bisacodyl suppositories was expired and said she would dispose of them. She confirmed there should be no loose medication in the cart, but she was unaware the medication could not be stored in the same compartment as other items. An observation was conducted on [DATE] at 3:00 p.m. of a medication cart on the central hall unlocked with no staff in sight. Residents were ambulating and self-propelling in the hall. 20536 2. On [DATE] at 11:00 a.m. the Main unit was observed with a long hallway with resident rooms and other unidentified rooms. An unidentified room between resident rooms [ROOM NUMBERS] was observed with the door closed. There was no signage indicating what the space was. The door was unlocked. Upon entrance, the room was noted very small, and it appeared to be an employee's office. Further observations revealed there was no staff in the room. Upon glancing at the floor to the right of the door when it was opened, revealed a cardboard box with many cards of medications. The box was not labeled as to what the medications were. There was no nursing staff in, at, nor around this unlocked space. Further observations revealed residents ambulate or self-propel while seated in a wheelchair past this room which was in a high traffic area. Some residents who reside on this hallway were noted with confusion and dementia and ambulate at and near this unlocked space. There were observations of two residents who were seated in wheelchairs, and who were with cognition deficits, going in and out from rooms that were not theirs. Photographic evidence was taken of the room and unsecured medications. On [DATE] at 12:00 p.m. the unlocked room with unsecured medications was observed unlocked, unsupervised and the box of cards of medications were still accessible to anyone walking by the space. An interview with the West/Main Unit Manager Staff D, RN on [DATE] at 12:11 p.m. revealed the space/office between resident rooms [ROOM NUMBERS] was her personal office. Staff D stated the office door is usually locked and monitored and a key was needed to access it. When asked about the room being unlocked with open box of medications on the ground yesterday, she stated that the box of medications were go backs and they have a process for how they return them. Staff D, RN stated that yesterday she was right in the middle of getting that form completed before moving the box to the medication room where it usually stays secured until the pharmacy picks up. She explained that there were no narcotics in the box but stated she understands the potential issues that could arise from having the medications in her office unlocked and accessible by any foot traffic in that hall, specifically several cognitively impaired residents near the office. 50570 3.On [DATE] at 11:05 a.m. an observation of Resident #65's bedside table revealed a clear, plastic medicine cup with medicine inside. The plastic medicine cup appeared to have approximately six different colored pills. During the interview Resident #65 said, I was supposed to take the medications. He stated he would take them now. Review of Resident #65's admission record revealed the following diagnoses: multiple sclerosis, other lack of coordination, weakness, vitamin deficiency, unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, and depression, unspecified. Review of Resident #65's Active Orders revealed the following under pharmacy, Baclofen Oral Tablet 5 MG [milligrams] (Baclofen) Give 1 tablet by mouth every 12 hours for musculoskeletal therapy Celebrex Oral Capsule 200 MG (Celecoxib) Give 1 capsule by mouth one time a day for DJD [Degenerative Joint Disease] Cyanocobalamin Oral Tablet (Cyanocobalamin) Give 1000 mcg [micrograms] by mouth one time a day for hematopoietic therapy Ergocalciferol Oral Capsule 1.25 MG (50000 UT [upper-level intake]) (Ergocalciferol) Give 1 capsule by mouth one time a day every 7 day(s) for vitamin supplement Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 mg by mouth one time a day for preventive measures Glatiramer Acetate Subcutaneous Solution Prefilled Syringe 40 MG/ML [milliliters] (Glatiramer Acetate) Inject 40 mg subcutaneously one time a day every Wed related to MULTIPLE SCLEROSIS (G35) Lyrica Oral Capsule 100 MG (Pregabalin) *Controlled Drug* Give 1 capsule by mouth three times a day for nerve pain for 30 Days Tamsulosin HCl [hydrochloride] Oral Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth one time a day for prostate Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 50 mg by mouth four times a day for Acute Pain Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen)Give 2 tablet by mouth every 6 hours as needed for Pain, headache or fever (Temp GREATER than 100.4F [Fahrenheit]). Review of Resident #65's physician orders did not reveal an order for self-administration order. Review of a care plan for Resident #65 initiated on ,d+[DATE] did not shower a focus related to self-administration of medications. 48223 3. On [DATE] at 10:12 a.m. and [DATE] 10:21 a.m. an observation occurred of Resident #221's inhaler on the over the bed table and later on the nightstand. Review of Resident #221's physician orders did not reveal an order for self-administration order. On [DATE] at 9:54 a.m. and [DATE] at 10:22 a.m. an observation occurred of Resident #54's over the bed table, in front of the resident, an inhaler (with the prescription label affixed) and a bottle of anti-diarrheal medication. Review of Resident #54's physician orders did not reveal an order for self-administration. (Photographic Evidence Obtained) During an interview on [DATE] at 1:34 p.m. the Director of Nursing (DON) stated no residents in the facility have an order for self-administration of medications. DON stated no residents in the facility should have any medications on the bedside, over the bed table or in their rooms in general. The expectation would be that the staff member who notes the medication would alert the nurse, and the nurse would educate, remove the medication from the bedside, and notify the physician for orders if necessary. Review of the facility's policy and procedures titled: Medication Storage - Storage of Medication dated ,d+[DATE] showed: 4.1 Storage of Medication Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 1. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 2. Controlled medications must be stored separately from non-controlled medications. The access system (key, security codes) used to lock Schedule IJ medications and other medications subject to abuse, cannot be the same access system used to obtain the nonscheduled medications. Schedule Il medications and preparations must be stored in a separately locked permanently affixed compartment. (See Section 4.2 - Controlled Medication Storage.) 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 4. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories. 5. Intravenously administered medications are stored separately from orally administered medications, under appropriate temperature and sterility conditions, and following the manufacturer's recommendations. 6. Eye medications are stored separately from ear medications and inhalers, etc. 7. Medications for oral inhalation are stored in the dispensed containers following manufacturer guidelines for positioning and priming. 8. Medications for nasal inhalation are stored in dispensed containers following manufacturer guidelines for positioning and priming. The following information is provided as general guidelines for proper storage of specific nasal inhaler products and is not meant to be all inclusive. 9. Potentially harmful substances (such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in an area separate from medications. 10. Medications requiring storage at room temperature are kept at temperatures ranging from 15 C (59 F) to 30 C (86 F). Controlled room temperature is defined as 20 C (68 F to 25 C (77 F). 11.Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label as cool temperatures are those between 8 C (46 F) and 15 C (59 F). A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. 12. Insulin products should be stored in the refrigerator until they are opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Opened insulin pens must be stored at room temperature. Do not freeze insulin. If insulin has been frozen, do not use. (Refer to Section 9.10 - Medications with Shortened Expiration Dates) 13. Refrigerated medications should be kept in closed and labeled containers, with internal medications separated from external medications and all medications segregated from fruit juices, applesauce, and other foods used in administering medications. Any other foods such as employee lunches and activity department refreshments should not be stored in this refrigerator. The refrigerator should be kept clean and frost-free. To protect refrigerated medications from freezing, store them away from the freezer section. 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal (Refer to Section 5 - Disposal of Medications, Syringes and Needles), and reordered from the pharmacy (Refer to Section 3.2 - Ordering and Receiving Non-Controlled Medications), if a current order exists. 15. Medication storage should be kept clean, well lit, organized and free of clutter. 16. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken.

Based on record review and interviews the facility did not ensure Preadmission Screening and Resident Review (PASARR) Level I screens were completed accurately for three residents (#64, #65, and #40) out of sixteen sampled residents. Findings included: Review of Admission Records showed Resident #64 was admitted on [DATE] with diagnoses including post-traumatic stress disorder. Review of Resident #64's physician orders showed an order for Bupropion HCL ER 150mg for depression. Review of Resident #64's Care plans revealed a focus area of Psychotropic medication use related to antidepressant to manage depression, dated 12/9/24. Review of Resident #64's PASARR Level I screen, dated 11/8/24, did not indicate the resident had any mental illness or suspected mental illness. An interview was conducted on 2/12/25 at 5:15 p.m. with the Director of Nursing (DON). She reviewed resident #64's PASARR Level 1 screen and confirmed it was not correct and should have been updated. An interview was conducted on 2/12/25 at 5:24 p.m. with the Admission Director. She stated upon admission she ensured every resident had a PASARR Level 1 screen but did not check for accuracy. The Admission Director said nursing should check for accuracy of the diagnoses and information, she had not had any training to do that. 50570 2. Review of Resident #65's admission record revealed an original admitted [DATE], and a re-admitted [DATE]. With diagnoses to include multiple sclerosis, other lack of coordination, weakness, vitamin deficiency, unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, and depression, unspecified. Review of Resident #65's Level I PASARR, dated 12/5/24, under Section I-Part A MI (Mental Illness) or suspected MI, revealed the diagnosis of depression was not indicated. Review of Resident #65's current care plan revealed the following, Psychotropic med [Medication]: [Resident name] uses psychotropic medications r/t [related to] Antidepressant to manage: depression Anticonvulsant for neuropathic pain, with an initiated/revision date of 12/13/2024. Review of Resident #65's Comprehensive Minimum Data Set (MDS) dated [DATE], Section I - Active Diagnoses, revealed depression was indicated under psychiatric/mood disorder. Section N - Medications revealed antidepressant was indicated. Review of Resident #40's Admission Record revealed an admitted [DATE] with diagnoses to include cerebral infarction, unspecified, weakness, anxiety disorder, unspecified, polyneuropathy, unspecified, and chronic pain syndrome. Review of Resident #40's Level I PASARR, dated 2/24/23, under Section I-Part A MI or suspected MI, revealed the diagnosis of anxiety was not indicated. Review of Resident #40's Comprehensive MDS dated [DATE], Section I - Active Diagnoses, revealed anxiety disorder was indicated under psychiatric/mood disorder. Section N - Medications - revealed antianxiety was indicated. On 2/12/25 at 5:15 p.m., an interview and review of Resident #65 and #40's PASSARs was conducted with the Director of Nursing (DON). She stated she was responsible for PASSAR review and updating if needed. The DON stated the Level I PASSAR is reviewed upon admission. She stated for newly admitted resident's, the admissions staff member should verify their Level I PASSAR is accurate. The DON stated she updated Level I PASSAR's based on the resident's diagnoses and medication. She stated when the MDS assessment is completed, she initiates the resident review. The DON stated if the resident is not a new admission, she would update the Level I PASSAR and/or submit for a Level II PASSAR if there is a new diagnosis, medication, or if the resident's behavior changed. Review of Resident #65's Level I PASSAR, with the DON, revealed it should have been checked on admission. She stated the diagnosis of depression should have been indicated on the Level I PASSAR and she confirmed it needed to be updated. Review of Resident #40's Level I PASSAR, with the DON, revealed it should have been checked on admission. She stated the diagnosis of anxiety should have been indicated on the Level I PASSAR and she confirmed it needed to be updated. Review of a facility policy and procedure titled PASARR Requirement Level I & Level II revealed the following, Policy . Preadmission screening will be conducted prior to admission as the PASARR process is a federally mandated pre-admission screening program required to be performed on all individuals prior to admission to a Nursing Home. The screening is reviewed by Admission for suspicion of serious mental illness & intellectual disability to ensure appropriate placement in the least restrictive environment & to identify the need to provide applicants with needed specialized services. Further review of the policy revealed the following, Procedure . 2. Determine if a serious mental illness &/or intellectual disability or a related condition exists while reviewing the PASARR form completed by the Acute Care Facility. (Trigger for Level II completion).

Based on observation interview and record review, the facility failed to develop a contracture management splinting care plan with goals and interventions for one (#45) of thirty-two sampled residents. Findings included: Review of the current care plan for Resident #45 with next review date of 5/27/2025 revealed an ADL focus - [Resident #45] has an ADL Self Care Performance Deficit r/t (related to) weakness, impaired mobility, activity intolerance, multiple comorbidities, with interventions in place as reviewed. The review showed there was no care plan problem area with goals and interventions related to contracture management and use of a Right-hand splint/orthotic. Further, there were no other assessments, progress notes, Medication Administration Record and Treatment Administration Record for months 1/2025 and 2/205 revealing treatment for contracture management with use of Right-hand splint/orthotic. On 2/11/2025 at 9:45 a.m. Resident #45 was noted in his room and seated in a wheelchair next to his bed. On top of the dresser was observed with a blue color hand splint/orthotic. Observation of Resident #45 revealed he was not wearing any splint/orthotic on either of his hands. The resident revealed he was knowledgeable of the hand splint/orthotic and that he has worn it at times. He could not explain why staff had not assisted him with the splint/orthotic on his Right hand. His right hand was observed with the last two-digit fingers contracted. He was observed to use his Left-hand fingers to stretch out the two fingers on his Right hand due to lack of movement. Continued interview with Resident #45 confirmed the splint/orthotic was his and it was to help with the pain. He could not remember when he first started wearing the splint/orthotic, but he did say staff have to put it on for him. On 2/11/2025 at 1:45 p.m. Resident #45 was observed in his room and seated in his wheelchair. He was observed not wearing any splints/orthotics on either of his hands, and the blue splint/orthotic was still placed on top of the dresser under the television. On 2/11/2025 at 2:20 p.m. Resident #45 was noted self-propelling while in his wheelchair down the hall to the outside courtyard. He was noted using both hands and feet to propel himself. He was again noted not wearing a hand splint/orthotic on either of his hands. Observation in his room revealed the hand splint/orthotic was still on top of the dresser. The resident was not offered or assisted with the orthotic during the entire 7 a.m.-3 p.m. On 2/12/2025 at 7:30 a.m. and 8:17 a.m. Resident #45 was noted in his room, lying in bed and not wearing any splints/orthotics on either of his hands. The orthotic hand splint was observed in the same place on top of the dresser in his room. On 2/12/2025 at 10:07 a.m. Resident #45 self-propelled out of his room while seated in his wheelchair. He was observed not wearing any splints/orthotics on either of his hands. The room was observed with his splint/orthotic placed on the over the bed table. A Certified Nursing Assistant (CNA) Staff B was in the room cleaning and changing linen. She was not observed assisting the resident with the splint before he left the room. On 2/12/2025 at 10:00 a.m. and at 11:45 a.m. Resident #45 was not wearing an orthotic on either of his hands. Observations in the room revealed a blue hand splint/orthotic placed on the over the bed table, on top of a closed container of food. Resident #45 was again observed in his room seated in his wheelchair next to his bed on 2/12/25 at 1:30 p.m., 2:00 p.m. and at 2:45 p.m. and not wearing a hand splint/orthotic on his Right hand. The splint was still observed placed on top of the dresser. Resident #45 was asked about the splint, and he said, they don't put that thing on me anymore. On 2/12/2025 at 2:45 a.m. an interview with Staff B, CNA confirmed she had remembered seeing the hand splint in the room on the dresser. She stated it was not the responsibility of nursing staff to put it on and or take it off. She revealed it was the responsibility of Occupational Therapy (OT) staff to do that. She again could not say where the hand splint/orthotic went, and that it was no longer in the room. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to muscle wasting, unsteady on feet, muscle wasting atrophy. Review of the most current modification significant change Minimum Data Set (MDS) dated [DATE], revealed - Cognition - a Brief Interview Mental Status (BIMS) score of 13 of 15, which indicated the resident was able to be interviewed related to his medical care and services. Behaviors - none documented as exhibited during this timeframe. ADL (Activities of Daily Living) showed - Upper Extremity documented as Impairment on both sides and use of wheelchair. The resident required substantial/maximal staff assistance for showering/bathing, personal hygiene and upper body dressing. The resident was dependent for putting shoes/socks. Active Diagnosis - CVA (Cerebrovascular accident)/Stroke. Review of the current POS (point of service) for the month of 2/2025 for OT (Occupational Therapy) and PT (Physical Therapy) revealed there were no orders related to use of an orthotic or hand splint for Resident #45 to use on his Right hand. Review of the Occupational Therapy Recertification and Updated Plan of Treatment for certification period 2/12/2025 - 3/13/2025, revealed admission diagnosis to include Muscle wasting and Atrophy, and Lack of Coordination. The Summary revealed LTG (long term goal) LTC goal #7.0 - Continue with patient will wear Right hand grip splint to prevent worsening risk of contractures for 5-6 hours as tolerated with skin checks to be provided, with a baseline start date/order date of 11/14/2024 and updated previous 1/29/2025 date with 3-4 hours wear as tolerated. Review of the progress summary of the assessment revealed; Maximum improvement is yet to be attained and patient is compliant with POT. On 2/12/2025 at 12:52 p.m. an interview with the Occupational Therapist Staff C revealed she is currently seeing the resident on OT caseload. Staff C revealed OT picked the resident up for caseload regarding wearing of Right-hand grip splint to prevent worsening risk of contractures for 5-6 hours as tolerated with skin checks to be provided. Staff C revealed this intervention baseline started on 1/14/2025 and it was the responsibility of therapy staff to don and doff the splint daily at this point. She revealed they did not actually receive the Right-hand splint until 1/22/2025. Staff C revealed this splint was ordered and OT is monitoring the use of, application of, participation from resident on a daily basis. On 2/13/2025 at 2:00 p.m., the Director of Nursing (DON) and Nursing Home Administrator (NHA) provided for review a delivery ticket showing the Right-hand splint was delivered and started for resident use on 1/22/2025. The NHA, and Staff C, Occupational Therapist could not show documentation to support application of, offering of, use of the Right-hand splint/orthotic use since 1/22/2025. Review of the facility policy titled Care plan, effective February 2024 showed the facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but not limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives, and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end-of-life situation, coordination with Hospice plan of care). Managing risk factors to the extent possible or indicating the limits of such interventions. a. Addressing ways to try to preserve and build upon a resident's strengths, needs, personal, and cultured preferences. b. Applying current standards of practice in the care planning process. c. Evaluating treatment of measurable objectives, timetables, and outcomes of care. d. Respecting the resident's right to choose to decline treatment, request treatment, or discontinue treatment. e. Offering alternative treatments, as applicable. 2. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. a. Involving the resident to have a role in care planning even if adjudged incompetent, and the resident's family and / or other resident representatives as appropriate to participate in the development and implementation of his or her person-centered plan of care. b. Assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs. d . Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. Procedure revealed: 2. Update to Care Plans a. Ongoing updates to care plans are added by a member of the IDT, as needed. 3. Dates and documentation on the care plan a. New, revised, or discontinued problems, goals, or interventions are dated for the date the documentation was made. 5. Comprehensive Plan of Care a. The comprehensive care plan is developed by members of the IDT and the resident, resident's family , or representative, as appropriate, in conjunction with completion of the Admission, Annual, Significant Change in Assessment or other comprehensive assessment, and the associated Care Area Assessments. b. The comprehensive care plan describes or includes: i. The services that are to be furnished and goals that reflect the Resident's wishes, choices, and exercise of rights. vi. Adequate information provided to make informed choices regarding treatment.

Based on observation interviews and record review, the facility failed to ensure nail care was provided to a resident who needed assistance for one (#55) of three residents reviewed for activities of daily living (ADL). Findings included: On 2/11/25 at 10:06 a.m. an observation of Resident #55 revealed he was laying down in bed, facing the window. The resident's hands were observed and revealed long, untrimmed fingernails on both hands with dark brown/black debris underneath three of his nails. Resident #55 stated he could not recall when he last received nail care. He stated he wanted his nails trimmed. On 2/12/25 at 9:42 a.m., an observation of Resident #55 revealed the same concerns observed on 2/11/25. (Photographic Evidence Obtained) Review of Resident #55's admission record revealed an admitted [DATE] with diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple sites, type 2 diabetes mellitus without complications, other lack of coordination, other abnormalities of gait and mobility, unsteadiness on feet, schizoaffective disorder, unspecified, and major depressive disorder, single episode, unspecified. Review of Resident #55's current care plan revealed the following, [Resident name] has an ADL Self Care Performance Deficit r/t [related to] recent hosp. [hospital] stay, with an initiated date of 6/28/24 and revision date of 8/9/24. Interventions to include, Personal hygiene - assist of 1 Date Initiated: 10/02/2024. Further review of Resident #55's record revealed there was no documentation related to refusing nail care. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment, Section GG - Functional Abilities, dated 12/18/24, indicated the following, Personal Hygiene . Supervision or touching assistance. A progress note dated 10/30/24 showed, Resident agreed to take a shower today, nail care and shave also completed at that time. Resident stated he sometimes refuses showers because staff comes too early to give showers, he prefers to have his showers after lunch. Further review of Resident #55's progress notes from 1/21/25 to current revealed there was no documentation related to nail care to include providing or refusing nail care. Review of Resident #55's tasks related to nail care, dated 1/15/25 to 2/2/25, revealed no documentation that nail care was provided. Further review of the tasks related to nail care revealed documentation showing - No Nail Care, or a few times it was documented, Resident Refused. There was no other documentation related to nail care from 2/2/25 to 2/13/25. Review of the facility's shower schedule revealed the following, When showering residents the C.N.A. [Certified Nursing Assistant] is responsible for providing assistance with all grooming including shaving and nail care. Further review of the shower schedule revealed Resident #55's scheduled days are Tuesday and Friday. Review of the facility's weekly grooming schedule revealed the following, . Wednesday - Nail care - All resident's nails should be clean and trimmed. On 2/13/25 at 10:05 a.m., an interview was conducted with Staff I, CNA. She stated CNAs provided nail care to include cleaning and trimming. She stated if the resident has diabetes the nurse completed nail care. Staff I, CNA stated nail care is documented on the kiosk for daily ADL tasks. She stated if the resident refused, CNAs are expected to report to the nurse and document in their tasks. She stated documentation of, No Nail Care, on the tasks means it wasn't done or the resident completed it themselves and the CNA didn't assist. Staff I, CNA stated completing Resident #55's nail care, Is a challenge. She stated when she offered to assist with nail care, Resident #55 will tell her no. Staff I, CNA stated she tells the nurse when the resident refuses. On 2/13/25 at 10:57 a.m., an interview was conducted with the Director of Nursing (DON). She stated if a resident refused ADL care, she expected the CNA to tell the nurse, and the nurse should be documenting in the electronic Medication Administration Record (eMAR) or progress notes. She stated if the resident is refusing care, to include nail care, That should be care planned. The DON stated, No Nail Care, indicated in the tasks means the resident refused and no nail care was provided. She stated she did not know why Resident #55 did not have a care plan related to nail care refusal as they've known about the refusals since October 2024, due to a grievance. She stated she hasn't observed Resident #55's nails recently. On 2/13/25 at 11:03 a.m., an interview with the DON revealed she couldn't locate current shower sheets for Resident #55. The shower sheets observed were from 11/2024. On 2/13/25 at 2:34 p.m., an interview was conducted with the Social Services Director (SSD) related to a grievance dated 9/22/24 from Resident #55. She stated the resident wanted his fingernails cut. She stated she communicated with the nursing department and asked a staff member to cut his fingernails. Another grievance was reviewed with the SSD, dated 10/30/24, related to Resident #55's nails, skin and shaving. She stated the grievance was initiated by the resident's family member. The SSD stated Resident #55 refused care at times. She stated they figured out it was the timing of when nail care, and other ADL assistance, was being provided. The SSD stated part of the resolution was the DON educated the resident on the shower schedule. She stated the grievance was resolved and Resident #55's nails were cut. The SSD confirmed he should have a care plan for refusing ADL's, to include nail care, and could not confirm if he has one. On 2/13/25 at 2:01 p.m., the DON stated the facility does not have an ADL policy and she expected staff to follow the resident's care plan. Review of a facility policy and procedure titled, Care Plan - Interdisciplinary Plan of Care Interim to Meeting, dated February 2024, revealed the following, Policy . The care is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Further review of the policy revealed the following, . 2. Update to Care Plans a. Ongoing updates to care plans are added by a member of the IDT (interdisciplinary team), as needed.

Based on interviews, observations, and record reviews the facility failed to provide enteral nutrition per physician orders for one (#220) out of five residents with enteral nutrition orders. Findings included: An interview and observation was conducted with Resident #220 on 2/11/2025 at 10:25 a.m. Resident #220 was lying in bed, looking out the window. Resident #220 said his enteral feeding had not been on for a while. Upon observation of the enteral feeding pump, it was noted it was not running, the [brand name] 1.5 calorie bottle was observed with approximately 450 ml (milliliters) of enteral feeding remaining of the 1000 ml bottle. The date 2/10/25 was the only other piece of information seen written on the label that was not from the manufacturer. An interview and observation was conducted with Resident #220 on 2/11/2025 at 4:10 p.m. Resident #220 was lying in bed, listening to the TV. Resident #220 said the enteral pump had not been running. Observation of the enteral feeding pump confirmed it was not running, the [brand name] 1.5 calorie bottle was observed with approximately 450 ml of enteral feeding remaining of the 1000 ml bottle. The date 2/10/25 appearing as the same 2/10/25 seen at the 10:25 a.m. visit, the bottle was observed with the following information written on the label: Resident #220 name, 2/11/2025, 12:10 a.m., and 65 ml/hour. An interview and observation was conducted with Resident #220 on 2/12/2025 at 9:37 a.m. and 11:50 a.m. Resident #220's enteral feeding pump was not powered on and not running. The enteral feeding formula was observed hanging with approximately 875 ml of formula in the bottle. The bottle label was observed with the following writing: Resident #220 name, date: 2/12/25 at 5 AM, 65 ml. Resident #220 stated the pump has not been running. An interview and observations was conducted with Resident #220 on 2/13/2025 at 10:10 a.m. Resident #220 stated the bottle was taken down earlier in the morning. Upon observation no bottle was observed on the enteral pump and the pump was powered off. During an interview on 2/13/2025 at 10:15 a.m. Staff J, Registered Nurse (RN) stated Resident #220 had an order for continuous feeding at 65 ml/hr. (milliliter/hour) and flushes every 6 hours of 250 ml of water. Staff J, RN confirmed removing Resident #220's enteral feed bottle earlier in the shift, while passing medications to the room. Staff J, RN stated she needed to replace the bottle and was waiting to finish the medication pass. Staff J, RN stated she would be finished with the medication pass in about an hour. On 2/13/2025 at 11:50 a.m. Resident #220's enteral pump was noted off and no formula was hanging. On 2/13/2025 at 2:20 p.m. Resident #220's enteral pump was noted to be on and running. The label of the bottle showed: Resident #220's name, Room number, Date: 2/13, product name, rate: 65 ml/hr., volume:1300 Time:1400. During an interview on 2/13/2025 at 11:22 a.m. the Registered Dietitian (RD) stated the order is for 65 ml/hr. to be infusing for a total of 1300 ml. The calculation for the needs of the resident are based on the formula running for 20 hours, 4 hours is given for care/services to be completed when the formula is not running. The RD stated the review of the information above is concerning as the resident missed nutrition. She said, We will need to contact the physician. During an interview on 2/13/2025 at 2:05 p.m. the Director of Nursing (DON) stated being concerned about how the tube feeding was being handled, stating, would need to investigate the handling of Resident #220's orders. The DON's expectation is that the nurses follows the physician's orders. Review of Resident #220's admission record revealed an original admitted [DATE] with diagnoses to include malignant neoplasm of larynx, chronic obstructive pulmonary disease, and other co-morbidities. Review of Resident #220's physician orders revealed an order dated 2/10/2025 for enteral feed: Jevity 1.5 Cal continuous via tube to infuse at a rate of 65 ml/hr. for a total volume of 1300 ml infused in 24 hours. Review of Resident #220's physician orders revealed an order dated 2/10/2025 to flush enteral tube with 250 ML of water every 6 hours for hydration. Review of Resident #220's progress notes from 2/10/2025 to 2/13/2025 revealed an absence of entries regarding the enteral feeding. Review of the facility's policy and procedures titled: nutrition - enteral/parental nutrition & hydration dated effective October 2021 revealed under overview - Enteral/Parental nutrition and hydration palliative care will focus on the resident/patient's enjoyment, relief of symptoms, and maintenance of energy and strength. Optimizing nutritional status to delay decline will be an appropriate goal only if in accordance with resident/patient or legal guardian's wish.

Based on observation, interview of staff, review of resident record, review of hospital records, and local police department photographic evidence the facility failed to provide assessment and treatment to prevent the worsening of pressure ulcers for two (#4, #2) of two residents reviewed for pressure ulcer care in regards to a resident admitted to the facility with a Stage II pressure ulcer that was not noted on an admission assessment, the pressure ulcer went untreated and the resident was subsequently assessed to have multiple pressure ulcers documented in an emergency room final nursing report and by photograph in a police report and a resident whose pressure ulcer dressing was found to be three days overdue to be changed, was not covering the wound, and the record reflected that it had been changed. Findings included: 1) Resident #4 was readmitted to the facility on [DATE] after a hospital admission that occurred from 8/10/18 to 8/13/18. Review of Resident #4's record from the nursing home showed a Hospital Patient Transfer Form, AHCA5000-3008 dated and signed by an ARNP (Advanced Registered Nurse Practitioner) on 8/13/18. The Skin Care/Pressure Ulcers section showed a circle on the resident's sacral area and a note Stage II. The resident's nursing home record also showed discharge paperwork from the hospital that included a History and Physical for admitted [DATE], the plan of care included wound care, the discharge instructions [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] 3. [MEDICAL CONDITIONS] 4. [MEDICAL CONDITION] 5. obstructive sleep apnea 6. hypoventilatio[DIAGNOSES REDACTED] 7. esophagitis, cbc (complete blood count),cmp (comprehensive medical panel), mag (magnesium), in one week, offloading/wound care, encourage PO (by mouth) intake, hold insulin if refusing to eat, pain management follow up 1 - 2 weeks. The nursing home's admission paperwork for Resident #4 included a Readmission/return from leave Data Collection form dated 8/13/18 at 7:45 pm, and signed by Staff member A, LPN (Licensed Practical Nurse). It showed that the resident arrived via stretcher from the hospital and weighed 326 pounds. The skin integrity section showed color normal, temperature: warm, equal, dry, turgor: normal, resident admitted with the following skin issues: blank. Level of consciousness: alert, Oriented to person, place, time, situation. Speech: clear. There was no documentation found in the record of an assessment of ulcers to the resident's skin or doctor's order for treatment of [REDACTED]. Review of the progress notes showed: 8/13/18 at 5:30 p.m. revealed the resident returned to the facility from Hospital A alert and oriented. She was placed back on her bi-pap (bi-level positive airway pressure) mask with oxygen at 3 liters. Her vitals 110/72 pulse 98, respirations, 20, temperature 98.6. spoke to the ARNP and faxed the orders to the pharmacy. 8/14/18 at 11:53 p.m. revealed the resident refused dinner and the alternative, fluids were encouraged. 8/15/18 at 1:30 p.m. revealed the resident alert and oriented with incontinence of bowel and bladder. The resident is total care and requested pain meds at 11:06 a.m. which were given. The resident stated the pain was general and noted at her base line. The resident did not express any concerns to staff. 8/15/18 at 15:15 at 2:50 pm noticed a visitor to (Resident #4) visibly upset being escorted out of the facility being loud and making threats .moments later the Police and EMS arrived to the facility. Review of the resident's FINAL REPORT' from the emergency room (ER) visit on 8/15/18 showed Pt (patient) arrived to ER @ 1537 via ems on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) with c/o (complaints of) AMS (altered mental status)/[MEDICAL CONDITION]. EMS(emergency medical services) reports Pt's daughter called 911 because she seemed altered. EMS reports on their arrival to the facility pt was found to be on [MEDICAL CONDITION] with O2 Saturation 81% and unresponsive/obtunded to them. EMS also reports no staff was in room on their arrival. On arrival to ER PT (patient) seemed lethargic, opens eyes to pain and withdrawal to painful stimuli. (Physician) at bedside for eval/orders on pt arrival to ER. Pt recently admitted to (this hospital) for [MEDICAL CONDITION]/[DIAGNOSES REDACTED] per report. Post initial eval [MEDICAL CONDITION] was removed by RT (respiratory therapist) and placed on nasal cannula. Oral care was provided. Pt noted to have significant dried mucous/oral secretions, preventing pt from communicating/opening mouth. Post mouth care pt communicating appropriately and answering questions appropriately. Pt with c/o generalized pain but especially her buttock and mouth. Pt also noted to have scattered bruising to her LUE (left upper extremity) and ABD (abdomen). Pt does report getting shots in her ABD during hospital stay. Pt transferred from ER stretcher to hospital bed for comfort. Upon turning pt noted to have multiple pressure ulcers (Stage II) to her buttocks, Stage 3 to sacrum. Mepiplex heart from 8/10/18 removed and 2 new Mepiplex applied. foley changed from previous facility, strong urinary odor noted during catheter change PD (local police department) at bedside for evaluation and pictures. Performed and signed by the RN (registered nurse) Charge for 8/15/2018. Review of an Incident/Investigation Report from a local Law Enforcement Agency, Report type: Adult abuse, The report narrative included: The daughter advised she came to the nursing home and saw her mother covered in bruises and was unresponsive. Fire/Rescue advised that they waited over 10 minutes for nursing staff to provide any paperwork to them so they could ensure the victim was not allergic to anything they would provide. There were fresh bruises on the victim's face, on and underneath her left arm and all the way to her arm pit. The victim also had bed sores that were covered with an old bandage on her bottom and had bruising along her belly. There were also sores and severe redness and pain on the interior of the victim's thighs. The victim could barely talk and her lips had been caked shut from dehydration according to Fire/Rescue. The victim was transported to the hospital and wishes to press charges at this time. Review of an Incident/Investigation Report from a local Law Enforcement Agency, Report type: Adult abuse, Supplemental Narrative, On 8/15/18, at 1613 hours I arrived at the hospital and met with the Officer in reference to an Adult Abuse. Total photographs 16. I took photographs of Resident #4 and her injuries. Review of the police photograph of the resident's buttocks showed more than 5 open areas in the skin of varying sizes on the left buttock and upper thigh and at least 3 open areas in the skin on the right buttock and upper thigh. It is difficult to visualize the sacral area in the photograph. Blood tinged drainage from most of the open areas was present on the pad where the resident had been lying. During an interview with the Director of Nursing (DON) on 8/28/18 at 11:23 a.m. to review the closed record for Resident #4 the DON stated, the nurse would use the 3008 and hospital documentation to complete the readmission. During an interview with Staff member B, Unit Manager and the DON, they stated, when we have an admission, we review the chart during the morning meeting. Review of this chart for whatever reason did not match up with the documentation from the hospital. We would also have received an order for [REDACTED]. We do not recall this resident coming back with a pressure ulcer as the 3008 stated. The DON and Staff member B, confirmed after the review of the resident nursing assessment on admission and nurses progress note, the resident was documented without skin issues. The DON and Staff member B stated that this chart was not reviewed for accuracy in the stand up meeting the next morning. During a phone interview on 8/28/18 at 11:02 a.m. with Staff member A, LPN, she stated that when the resident was readmitted to the facility she would have looked at the 3008 and any other physician orders [REDACTED]. She does not remember the resident having any wounds on her back or coccyx area, she stated the resident did get rashes under her breast, abdominal folds and peri area and was receiving a cream. She stated the resident had always been on her [MEDICAL CONDITION] as long as she worked with her. She stated that the resident used it while awake and asleep. During an interview with Staff C, CNA (Certified Nursing Assistant) on 8/28/18 at 11:59 a.m., she stated she was taking care of Resident #4 on 8/13/18 and 8/14/18 when she came back from the hospital. I assisted with morning care and had another CNA assist to turn her. We washed her up and lotioned her feet. The skin was dead and falling off. I used the thick lotion like A&D on her feet and her bottom was really red and stuff so I tried to keep it from getting worse. I told the nurse her bottom was red. Her bottom was clear when she left here but when she returned it was very red. I put the thick lotion on her groin, her legs were red as well, and I put the lotion there too. She was unable to assist us this time so the other CNA helped me and she turned easily. She used to be able to turn on her own but that has been a while. She would whisper and talk low. I would have to put my ear down there and she would shake her head to answer. Her appetite had been decreasing. I would try to feed her. She would decline it and I would offer anything. She would say fruit and she would eat it good. However, her tray food she decreased eating. She had been declining in her fluids also. She would drink her sodas and her juice with three to four cups of ice. I would come back in 15 minutes and ask her to drink. I would give it to her and offer her the liquid, and she would decline. I took care of her for a long time. Everyone knew that she was declining in eating and drinking. 2) During observation and interview with Resident #2 at 9:15 a.m. on 8/27/18 the resident was complaining of heel pain, yelling out when Staff F, CNA tried to remove his sock. The bed was noted with brown stains in eight to ten places around the right heel area. After Staff member F, CNA removed the right sock, a dressing was noted on the posterior upper portion of the heel with a date of 8/22/18. Observation of the right heel revealed a round draining wound that was uncovered with serous sanguineous drainage, a scab and raw peeling skin. The resident was yelling out to be careful kept saying that area is very sore. Staff F,CNA stated the resident's CNA was doing something else so he was helping. At 9:50 a.m. staff member G,CNA entered the room and asked if she could help with the resident. She stated that he was her resident and that she was assigned today to work in fine dining from approximately 8:00 a.m. to 8:30 or 8:45 a.m. then take the smokers outside from 9:00 a.m. to 9:30 a.m Staff member F, stated that is why he was helping with these residents since she was off the floor. Staff member F, CNA confirmed the dressing date on the right heel. During an interview with staff member H, LPN on 8/27/18 at 10:09 a.m. she stated that it is the nurse's job to change dressings daily. During an interview with Staff B, Unit Manager on 8/27/18 at 10:08 a.m., she confirmed the dressing on the right heel was not where it should be and the wound was exposed with the date of 8/22/18 on the dressing. The Unit Manager stated that the dressing was documented as changed on 8/25/18 and confirmed the documentation was inaccurate and the dressing was not changed on that day. Resident #2 was admitted on [DATE], readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the skin grid for pressure ulcers dated 8/11/18 revealed the right heel measuring 3.0 x 3.0 x utd (undetermined), 8/14/18 measuring 3.0 x 3.0 x utd, 8/21/18 measuring 2.5 x 3.0 x utd. Review of the resident's Medication Administration Record [REDACTED]. Apply therahoney gel and cover with foam. Every 3 days and as needed. Dated 8/15/18 with documented changes completed on 8/16/18, 8/19/18, 8/22/18 and 8/25/18. Review of the progress notes dated 8/27/18 revealed right heel dressing changed on 8/27/18 at 10:57 a.m. Review of the progress note dated 8/22/18 at 3:52 p.m. revealed the resident seen during wound rounds, new treatment order in place for skin tear. Review of the resident care plans revealed the resident has an actual wound right heel DTI (deep tissue injury) dated 8/7/18 with revision on 8/9/18 with intervention to treat as ordered, premeditated as indicated dated 8/7/18. Monitor wound weekly of location, highest stage and visual stage. Measure length, width and depth, color of drainage, color of wound bed, presence of odor, tunneling or undermining. Review for improvements, report declines to MD dated 8/7/18, observe that dressing is covering and adhering. Report lose dressing to nurse dated 8/7/18 Review of the policy and procedure for Wound Prevent & Treatment Overview from Clinical Policy & Procedure Manual W1.1 Page 1 of 2 revised on (MONTH) 2011 revealed: The facility has developed prevention & treatment protocols based on National Pressure Ulcer Advisory Panel (NPUAP), & Wound, Ostomy & Continence Nurses Society (W[NAME]N). A resident with ulcers will receive continued preventative interventions & necessary treatment & services to promote healing & prevent infection. Wound characteristics will be documented by measuring length, width, depth in centimeters. Additional documentation shall also include color or drainage, wound bed color.

Based on review of resident ' s medical records, review of event logs, review of reference materials for staff guidance related to resident specific dietary requirements, review of inservice and attendance documents, and confirmed through interviews with facility staff and residents, the facility failed to provide goods and services necessary to avoid physical harm to four of four sampled residents (#1,2,3,4) related to the lack of a system that would consistently and accurately identify residents with food allergies, ensure residents received only those foods that were not harmful to them, and to ensure that staff were able to implement a new system to prevent residents from receiving foods to which they were allergic. Additionally the facility failed to ensure that nutritional assessments reflected the residents ' food allergies and dislikes, and provided a modified menu to ensure that residents received meals and snacks that provided a nutritionally adequate, varied diet that reflected the omitted foods, and was acceptable to the resident. These practices resulted in the determination of on-going Immediate Jeopardy. Findings include: 1.On 09/14/11, per review of an immediate report filed with the state agency on 09/27/11, a " resident (#4) with an allergy to tuna fish was given a tuna fish sandwich, then experienced chest pain. " When asked how this happened, the Administrator, on 10/11/11 beginning at 10:40 a.m. , revealed that he didn ' t think the aide checked the cardex prior to providing the sandwich. Interview with resident #4, on 10/11/11 beginning at 9:00 a.m. , confirmed he asked for the sandwich, even though he knew it was tuna fish and he knew he was allergic to tuna fish. The resident stated, " I did wrong. " When asked about the aide who provided the sandwich, the resident stated, " She did wrong too . " Interview with the aide who provided the sandwich to resident #4, on 10/11/11 beginning at 2:30 p.m., revealed she had just provided the roommate with a sandwich after he asked what type of sandwiches she had. The aide said when resident #4 asked for a sandwich , she assumed he wouldn ' t ask for a sandwich that he was allergic to, so she gave him one. The aide said that she is familiar with the resident and thinks he is alert and oriented and aware of the foods he was allergic to. She reported that when she heard he went out to the hospital later that same night, she didn ' t think of it as being related to the sandwich he had eaten. The aide said that she would ask the nurse about a resident if she didn ' t know the resident, otherwise , for residents that she was familiar with, she didn ' t need to ask the nurse. Interview with the Dietary Manager (DM) , on 10/11/11 beginning at 10:20 a.m., revealed resident #4 did not have a labeled HS (bedtime) snack. The DM reported that HS snacks are delivered to the nursing units for delivery to the residents before bedtime. Both resident labeled snacks and bulk snacks (snacks for residents who want something to eat, but have not made a special request for a snack or do not have either a doctor or dietitian planned ' labeled ' snack) are provided to the residents by the nurses aides about 7 or 8:00 p.m. A review of nutrition assessments and follow up notes, written by the facility ' s Registered Dietitian, and located under the Dietary tab in the resident ' s medical record was made. Five notes were reviewed, which had been written by a Registered Dietitian (RD) , in the last year: 11/02/10, 02/11/11, 04/14/11, 05/13/11, and 08/12/11. Four of the five notes documented the resident as having " No Known Food Allergies " (NKFA). Despite the fact that resident #4 is allergic to milk/dairy, eggs, fish, and peanuts, (per the face sheet) only one of the five notes documented that the resident was " lactose intolerant " and had an " allergy to eggs to eat. " This one note, dated 04/14/11, had been written due to the resident ' s weight loss over the past year, per RD #1, who wrote the note in an interview on 10/14/11 beginning at 2:20 p.m. This note addressed the resident ' s lactose intolerance by documenting that she discussed it with him, and then recommended to the physician, a calcium with vitamin D supplement. The reference to the egg allergy was not further investigated or addressed by modifying the breakfast menu for the resident. Review of the facility ' s planned menu revealed that out of the four week cycle menu, eggs as the main breakfast entree were served from four to six times each week. Observation of the resident at breakfast on 10/13/11 at approximately 8:30 a.m. revealed the resident had received two slices of dry toast, ground sausage, and orange juice. The resident reported that this was his usual breakfast. Also through interview , which occurred on 10/14/11 beginning at 2:20 p.m., with the RDs who confirmed that they assessed and documented the resident ' s nutritional status, it was confirmed that this resident ' s annual comprehensive nutritional assessment had not been completed when the MDS (Minimum Data Set ) Annual Assessment had been completed in February 2011. RD #2 reported that , " I missed it " referring to completing the annual assessment. (The two RDs explained that RD #1 is a corporate Dietitian that covers for RD #2 when she is on vacation.) The Food Preference Record , signed and dated by the Dietary Manager on 01/17/11, had been completed for the Annual MDS. This form documented the resident ' s multiple food allergies ( fish, milk, eggs, peanuts) and multiple food dislikes (ham, turkey, hot cereal, spaghetti, beets, broccoli, Brussels Sprouts, and all dairy foods.) Further review of this resident ' s dietary history, through review of the diet slip that guides dietary aides during the tray line while preparing resident ' s meals, revealed additional dislikes: chicken, ham, cabbage, cauliflower, carrots, green beans, peas, peaches, corn bread , gravy and margarine. None of the five notes written by the RDs referenced the many foods that the resident disliked , as well as all of the food allergies that the resident had. There was no indication that the planned menu had been adjusted to reflect the food allergies and the food dislikes of this resident, as well as no indication that the HS snack had been planned to provide a ' labeled ' snack to this resident, despite his multiple, potentially serious food allergies. Because of the lack of a comprehensive nutrition assessment which should have led to the RD reviewing and revising the planned menu, including an HS snack, this resident was able to receive a sandwich to which he was allergic and was hospitalized for [REDACTED]. Further review of the resident ' s medical record revealed a History and Physical (H&P) dated 09/15/11 from the resident ' s hospital admission. This H&P documented the resident as having a history of Down ' s Syndrome with the chief complaint that led to the hospital admission being " facial, lip, and throat swelling after eating a tuna fish sandwich. " The Physician documented the resident ' s admission (on 09/14/11) as due to needing " monitoring of the airway. " The Assessment noted that there was " facial, tongue, and throat [MEDICAL CONDITION] secondary to most likely an allergic reaction. " The [DIAGNOSES REDACTED]. " (Per Wikipedia, Angio [MEDICAL CONDITION] is the rapid swelling of the skin and mucous membranes, such as around the mouth, inside the mouth, and the tongue. It is usually caused by an allergic reaction and can be itchy or painful. In severe cases the airway can be blocked by the swollen tongue or throat requiring intubation.) 2.Further interview with the DON, on 10/11/11 beginning at 10:45 a.m. , revealed she provided an inservice (along with the immediate past DON) to all staff on 09/28/11, 14 days after the 09/14/11 incident, on the topic of Drug & Food Awareness. The objective listed on the Inservice Training Record indicated, " staff members will be aware of food allergies of residents prior to giving food and where to find information. " Review of the sign in sheet with the DON on 10/13/11 at 12:30 p.m. revealed 18 of the 71 facility ' s employees had not received the inservice. Facility from all departments had attended the inservice. 3.Despite the inservicing of three quarters of the employees, observation of the lunch meal on 10/13/11 beginning at 1:00 p.m. revealed two (residents # 2 and 3) of the four of the residents with documented food allergies received foods to which they were allergic. Resident # 3 was observed in the restorative dining room, on 10/13/11 at approximately 1:00 p.m. , dozing in a geri chair. Her lunch was in front of her on the table which included a small tulip cup with what appeared to be milk (a white liquid) poured over the scoop of food. The aide who was assisting a resident sitting next to resident #3, confirmed that the small cup with the white liquid had been served to resident #3. Interview with dietary staff , after the observation, confirmed that milk had been poured over the pureed pie and it was an error to serve it to resident #3 , who was allergic to milk. Resident #2 was observed lying in her bed, on 10/13/11 at approximately 1:20 p.m. She confirmed that she had just finished her lunch in her room and agreed that she had eaten some of the peanut butter pie that was still sitting on the resident ' s bedside table. When asked if she was allergic to peanut butter, the resident confirmed that she was, and reported that she could eat just a little bit, but not too much as it interfered with her [MEDICATION NAME] receptors. The resident confirmed that the aide left the pie so she could eat more of it, if she wanted. Interview with dietary staff, after the observation, confirmed that they had served peanut butter pie to the resident, even though there was a list of residents with allergies posted on the refrigerator adjacent to the tray line. The dietary staff member who placed the pie on her meal tray reported that he was concentrating on not serving peanut butter for resident #4 and forgot about resident #2 ' s allergy to peanut butter. 4.An interview with the activities director occurred on 10/11/11 at approximately 3:15 p.m to inquire how activities staff are aware of which residents have food or beverage restrictions when they attend an activity at which food is served. The Activities Director (AD) reported that the new system to identify resident ' s food allergies (as of 09/28/11) was a list of those residents and their allergies which would be kept in notebooks in which aides document resident specific information. Review of this list noted that it had been " updated 09/28/11 " . The AD also explained that at the main nursing station across from the restorative dining room was a file that aides (and activity staff) could refer to that listed resident specific food restrictions, such as modified diets, thickened liquids, and resident allergies. The file was reviewed and it was noted that all lists of residents were dated 04/22/11 and were not current. 5. Per the Florida Dietetic Association, Manual of Medical Nutrition Therapy, 2009 Edition, version 22, the nutritional adequacy of the diet of a resident with allergies depends on the food(s) that are omitted. The effect of each food that is omitted from the diet must be evaluated , and if needed, a replacement for the lost nutrients must be found. Per the Mayo Clinic and the Asthma and Allergy Foundation of America (AAFA), " It is extremely important for people who have true food allergies to identify them and prevent allergic reactions to food(s) because these reactions can cause devastating illness, and in some cases, be fatal. " AAFA documents indicate that both tuna fish and peanuts can cause a life threatening reaction called [MEDICATION NAME]. Symptoms can develop right away or within the hour after eating the food, and can include difficulty breathing, wheezing, and chest tightness. Hives can develop , which are red, swollen itchy welts on the skin. The lips, tongue, and throat can swell, causing blockage of the airway. 6. Resident #1 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the nutrition assessments and follow up notes revealed the Annual Comprehensive Nutrition Assessment had been completed on 08/12/11 by RD #2. The Data Collection section of the assessment contained an area to identify Food allergy or Food Intolerance. Next to Food allergy RD #2 had written in NKFA (No known food allergy). Next to Food Intolerance RD #2 had written in No. Page two of the assessment contained the analysis of the data collected and did not reveal any discussion of the resident ' s documented allergy to orange sherbet. The Food Preference Record, dated 08/12/11, and completed by RD #2 , documented the resident ' s Food Allergies as orange sherbet and jello. Interview with RD #2 who had completed the assessment, on 10/14/11 beginning at 2:20 p.m., revealed that food allergies or intolerances would be investigated, included in a comprehensive nutrition assessment , and addressed in the plan of care. When questioned about this resident's allergies, referring to the Food Preference Record that she had completed, she responded during the interview that the resident ' s mother directed much of this resident's care, including what foods and beverages to provide during meals and at snack times. However, she was not able to identify documentation related to a discussion she had had with the mother or an investigation into this resident's documented allergy . 7. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive initial nutrition assessment which had been completed on 11/08/10 by RD #3, did not reveal documentation of the peanut butter allergy. The Data Collection section of the assessment contained an area to identify Food allergy or Food Intolerances, which had been left blank, indicating it didn't apply to the resident. Page two of the assessment contained the analysis of the data and included a statement made by RD #3 which indicated she had " discussed with resident food preferences. " There was no reference to the need to eliminate peanuts or peanut butter from the resident's diet or investigation into the severity or type of reaction if the resident was exposed to peanut butter. Review of the Food Preference Record, which was completed and signed by the Dietary Manager on 11/04/10 revealed the documentation of "peanut" for the Food Allergies. This resident was observed receiving, and eating, peanut butter pie at lunch on 10/13/11 at approximately 1:20 p.m., even though the resident's diet slip indicated she was allergic to peanut butter and staff had recently received an inservice on residents and food allergies. 8. Resident #3 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of nutrition notes revealed an annual comprehensive nutrition assessment had been completed by RD #2 on 06/03/11. The Data Collection section of the assessment did not identify the resident as having a 'food intolerance and allergy.' The Assessment section of the form did not refer to the allergy and the need to eliminate milk from the resident's diet. There was no discussion referring to an investigation that the entire dairy food group needed to be eliminated from the resident's diet, or if it was just the beverage 'milk' that the resident was allergic to. A follow up note written by RD #2 on 09/09/11 contained a phrase "history of milk allergy ?, Plan continue with current POC (plan of care). Add calcium supplement with (vitamin) D3." Review of the September telephone orders and the October Physician order [REDACTED]. There was no indication in either the nurses notes or a follow up RD note indicating what had happened with the recommendation for the calcium supplement made to the physician. This was the resident who was observed to receive milk poured over a pureed dessert at lunch on 10/13/11 at 1:00 p.m., even though facility staff had received an inservice on 09/28/11 on identifying foods that residents are allergic to prior to serving them any food or beverages.

Based on medical record review, review of event logs, review of resource files for staff to access to identify resident specific eating and meal requirements, and review of the facility policy for preventing neglect of all residents , and confirmed through interview with facility staff and the Administrator, the facility jeopardized the health and well being of four residents (residents #1,#2, #3, #4) of four sampled residents, with documented allergies by not immediately reporting to the appropriate State Agencies an incident in which a resident ingested a food he was allergic to and was transferred to the hospital for monitoring for airway blockage, and timely investigation of the facility ' s process of identifying residents with allergies and their food delivery systems, during meals, snacks, activities, and therapy; did not assess the severity or reaction caused by an allergic food; and did not implement the care plan related to foods that caused allergies. The facility failed to identify and assess how residents with allergies would be protected from receiving foods that may cause anguish from sustaining a potentially life threatening reaction to a food for which they have a documented allergy. These practices resulted in the findings of Immediate Jeopardy , which are on-going. Findings include: 1. Review of the facility ' s event log revealed a listing for an " allergic reaction " suffered by resident #4 on 09/14/11. Review of nurses notes for 09/14/11 revealed at 2150 resident #4 " notified nursing staff that he ate a tuna fish sandwich for his evening snack, he stated he is allergic to tunafish. 97.7, 88, 20, 110/70, a+ox3 (alert and oriented x 3), lungs clear, Doctor notified and [MEDICATION NAME] 50 mg po given. " At 2300 a nurses note documented, " complained of chest pains, 98.4 62, 22, 113/69 lungs clear, a+o x 3, abdomen soft with bowel sounds. Doctor notified and wanted him to be evaluated and treated in the ER (emergency room ). " There were no physician ' s notes discussing this event until 10/13/11. The 3008 form for transfer from the hospital to the nursing home, dated 09/18/11, revealed the resident ' s Principal [DIAGNOSES REDACTED]. (Per Wikipedia, [MEDICAL CONDITION] is the rapid swelling of the skin and mucous membranes, such as around the mouth, inside the mouth and the tongue. It is usually caused by an allergic reaction and can be itchy or painful. In severe cases the airway can be blocked by the swollen tongue or throat requiring intubation.) The Secondary [DIAGNOSES REDACTED]. The Discharge [DIAGNOSES REDACTED]. Indicated on the form was the past [DIAGNOSES REDACTED]. The form described the resident as having fair vision, hearing, and speech. Also, the resident was documented as being able to transmit messages and receive information, and he was alert. The History and Physical (H&P) from the hospital, dated 09/15/11, documented the resident as " having a history of Down ' s Syndrome, with the chief complaint of facial, lip, and throat swelling after eating a tuna fish sandwich. Patient does have a history of many multiple food allergies in the past. Solu-[MEDICATION NAME] and [MEDICATION NAME] were given in the emergency room with mild improvement of the symptoms. Patient was admitted for monitoring of the airway. " " The H&P listed the resident ' s Food Allergies as Eggs, Milk, Peanuts, Tuna, Shellfish, and Lactose. The Physical Exam listed the HEENT (head, ears, eyes, neck throat) as " swelling noted of the tongue and neck area. " The first item under Assessment was noted to describe " Facial, tongue, and throat [MEDICAL CONDITION] secondary to most likely an allergic reaction. " Item #2 was noted to describe " Acute Respiratory insufficiency secondary to #1. " Item #3 was noted as " History of Down ' s Syndrome. " Item #4 was noted as " Dysphagia (difficulty swallowing) secondary to #1. " Interview with resident #4 on 10/11/11 beginning at 9:00 a.m. revealed he was aware of which foods that he was allergic to. When asked about the incident, the resident confirmed he ate the sandwich and reported, " I did wrong. " When asked about the aide ' s response to his asking for a tuna sandwich, he reported that " she did wrong too. " Interview with the aide who provided the tuna sandwich to the resident, on 10/11/11 beginning at 2:30 p.m., revealed that the resident knew what kind of sandwich it was since he had heard her tell his roommate . She said he never said he was allergic to tuna, but just accepted the sandwich and ate it. She said that she is familiar with the resident and thinks he is alert and oriented and able to say what his allergies were. She reported that she often delivered HS snacks to residents and either knew a resident was alert and oriented and could tell her their allergies, or knew the resident wasn ' t alert and oriented and she would have to ask the nurse . She said that resident #4 usually took something from the snack cart. The aide confirmed that there was not a labeled snack for this resident. She reported that she heard later that he had been transferred to the hospital with chest pains but did not think it could have been due to the tuna sandwich that she provided to him. The facility ' s medical record for resident #4 documented that he had been a resident since admission on 04/30/2002 with a readmission on 09/18/11. [DIAGNOSES REDACTED]. The face sheet also listed the resident ' s allergies as lactose, egg, dairy, tunafish, peanut. The resident was documented as a competent adult on an assessment completed on 03/11/2003. A physician ' s note dated 04/08, without the year, but located between notes dated in March 2011 and May 2011, contained the impression , " seen and examined, not competent to make decisions. Appropriate documents signed. " The Minimum Data Set (MDS) Quarterly Assessment, which was completed on 08/04/11, described the resident as having clear speech, usually being able to be understood, and sometimes able to understand others. The resident was described as having difficulty focusing attention. The Interdisciplinary Plan of Care, dated 08/11/11 revealed the resident had no DPOA (Durable Power of Attorney) and that he used antipsychotic and antidepressant medications. The Care Plan included a Maintenance ADL & Safety & Communication Tool, updated on 08/11/11, which described the resident as alert , confused. This care plan documented the resident ' s allergies on the bottom of the form under " Additonal Information " . The Care Plan for Cognitive Loss, updated on 08/11/11, described the resident as having impaired cognitive skills, as seen by a decision making problem because of down ' s syndrome, depression, and [MEDICAL CONDITION]. 2. Interview with the Administrator, on 10/11/11 beginning at 10:40 a.m. , about the event log ' s listing of the allergic reaction revealed he had filed a report with the state agency, but could not recall why it had taken until 09/27/11 to file the immediate report. Review of documents that the Administrator maintained on this issue revealed that the administrator had been made aware of the incident on 09/14/11, but had not filed the report with the agency until 09/27/11 when he also reported the incident to the abuse hot line. Review of the Resident Concern Log, maintained by the Social Services Director, who had also been identified as the Abuse Coordinator, did not reveal an entry for resident #4 and the allergic reaction suffered on 09/14/11. When asked about the incident, the Social Services Director, on 10/11/11 at 11:45 a.m. revealed that she had heard about the allergic reaction and that the resident had been sent to the hospital. She reported that it happened at night and it was a nursing issue. She said that she knows her policy and procedure and it directs her to report allegations of abuse, neglect, and exploitation to the Director of Nursing and the Administrator right away. She confirmed that she had not been involved in either the reporting of nor the investigation of the incident involving the resident receiving a food that he was allergic to. Based on interview with the Administrator (10/11/11 beginning at 10:40 a.m.) and review of the time line of the events that had taken place, it was apparent that for a two week period, from when the resident returned to the facility from the hospitalization for the allergic reaction (09/18/11) until the report to the State Agency and the Abuse Hotline had been made (09/27/11), no investigation of how the resident had been provided with a snack that was made with a food that he was allergic to had happened. Interviews with facility staff that had been present the night the incident occurred did not happen until the report was filed on 09/27/11, approximately two weeks after the incident. Inservicing of staff related to residents ' with allergies were not provided until 09/28/11, two weeks after the event. Chart audits by Nursing staff and a review of allergies on file conducted by the Pharmacy did not occur until 09/28/11, two weeks after the event. Updating of reference material located in the aide ' s documentation notebooks did not occur until 09/28/11, two weeks after the event. No documentation could be found that any of the four residents with food allergies had been reassessed after the event on 09/14/11, to determine the extent of their allergy , whether it was a true allergy or food intolerance, and no recognition had been made of the need for a planned menu specifically for resident #4 based on his food allergies and multiple food dislikes - predominately of protein rich foods. This was confirmed by interview with the Registered Dietitians in an interview on 10/14/11 beginning at 2:20 p.m. No documentation, prompted by the event that occurred on 09/14/11, by the physicians could be found for any of the four residents with food allergies, related to a review of their allergies. Per the Administrator, (on 10/11/11 at approximately 1:00 p.m.) the facility had developed an action plan to address this event which included resident medical record audits, an audit of all resident records by the Pharmacy and inservicing the staff on Food and Drug Allergy Awareness. However , there was no documentation of a review of the process to monitor meal tray preparation in the main kitchen or delivery of meal trays to residents, and despite inservicing staff on which residents had food allergies, observation on 10/13/11 during the lunch meal confirmed that the facility had not completely investigated the systems in place to ensure that residents who were allergic to foods would not be served them at meals. 3. Review of the facility ' s policy for Prevention & Reporting: Suspected Resident/Patient Abuse &/or Misappropriation of Property (policy A&E 1 effective January 2006), revealed the facility acknowledged definition of Neglect : failure to provide goods and services necessary to avoid physical harm , mental anguish, or mental illness. The policy indicates that the responsible facility staff will: Notify the appropriate state agency immediately by fax or telephone after identification of alleged/suspected event. 4. Policy review also revealed that implementation and ongoing monitoring of Training would occur to prevent neglect of residents. Interview with the Administrator , on 10/11/11 beginning at 10:40 a.m. revealed that an inservice was provided to staff , related to the incident that occurred on 09/14/11, dated 09/28/11, on the topic of " Drug & Food Allergy Awareness. " The objective listed on the Inservice Training Record indicated, " staff members will be aware of food allergies of residents prior to giving food and where to find information. " Review of the sign in sheet for this inservice, with the Director of Nurses , at 12:30 p.m. on 10/13/11, revealed of the 71 employees listed, 18 had not received the inservice. Facility staff from all departments had attended the inservice, including aides, nurses, dietary staff, and department heads. Random interviews with facility staff occurred on 10/11/11 beginning at 10:00 a.m. . and continuing through out the day confirmed that an inservice related to resident food allergies and where to find the list of which residents and which foods, had been given. Nursing aides confirmed that their notebooks where they document resident information contained a list of residents and their allergies, and the cardexes that were kept on the medical record rack also listed resident allergies. Most staff were able to report who the four residents were and which foods they were allergic to. On 10/11/11 (mid afternoon) Dietary staff referred to a list posted on their tray line refrigerator that would be an easy reference for them while preparing meal trays for residents. This list contained the four residents and their food allergies. A dietary aide, at that time, also confirmed that the diet slips listed each residents food allergies as well. Despite the training that occurred on 09/28/11 beginning at 8:30 a.m., presented by the immediate past Director of Nurses and the current Director of Nurses, staff were not able to implement (operationalize) that information during meal service and compare items on the meal tray to the diet slips, recognizing when an item should not be served to a resident. Dietary staff did not demonstrate that they were able to identify all forms of a food, identified as an allergy producing food, when they prepared the meal tray. Despite staff training, observation of the lunch meal, on 10/13/11 beginning at 1:00 p.m. , revealed two of the four residents who had documented food allergies , receiving foods to which they were allergic. On 10/13/11 beginning at 1:00 p.m. revealed resident # 3 who was seated in the main dining room with her meal in front of her. The resident was dozing in her geri chair and had yet to be assisted with her meal. She had been served a pureed lunch and a small tulip cup containing dessert. The small cup contained pureed pie that had milk poured over it. Resident #3 was one of the four residents who had been identified as having a food allergy, which was to milk. An aide who was assisting a resident with his lunch at the table with resident #4 was asked about the dessert. She confirmed that it was resident #4 ' s dessert and agreed that milk had been poured over the pureed pie and that resident #4 was allergic to milk. A second aide was called over, who removed the dessert with the milk and provided resident #4 with pureed fruit. Observation and interview with resident # 2, on 10/13/11 at 1:20 p.m. , who had been identified as being allergic to peanut butter, occurred in the resident ' s room, after the resident had eaten her lunch. There was a piece of peanut butter pie on the resident ' s over bed table. The resident, at that time, confirmed that she had just eaten her lunch sitting in her room, had had a few bites of the pie, but wasn ' t sure if she would eat more of it. She reported that she couldn ' t eat much peanut butter, due to an allergy to it, because it interfered with her [MEDICATION NAME] receptors. The resident confirmed that the aide had left the pie on the over bed table in case she wanted to eat more of it. Interview with a dietary staff member, on 10/13/11 at approximately 1:25 p.m. , confirmed that resident #2 could have received the peanut butter pie, as he was concentrating on not serving resident #4 the peanut butter pie. (Resident #4 was documented as being allergic to peanuts.) The dietary aide did not remember serving the pureed pie with the milk to resident # 3, but confirmed that the pie was the dessert that most of the residents received. 5. A staff member who provided activities to residents was interviewed on 10/11/11 at approximately 3:20 p.m. When asked how the activities department knows which residents have restrictions on foods they can be offered at activities, she responded that the aides ' documentation notebooks have a list of the four residents who have allergies and what they are. She also said that there was a file at the main nursing station that listed information about meals. The file was reviewed and noted to contain a Roster by Name of all residents , their diets and consistencies, and allergies. This list was dated 04/22/2011. The file also contained a list of residents on thickened liquids and residents who used assistive devices at meals. These lists also were dated 04/22/11 and were not current. 6. Review of care plans for residents # 2,3,and 4 revealed documentation on the Maintenance ADL & Safety Care Plan & Communication Tool (the Tool) , under Additional Information, the specific foods to which each resident was allergic. Resident #2 , per the Tool, had been assessed and the care plan had been reviewed on 08/11/11. The Tool listed peanut butter as the food item to which the resident was allergic. Observation of the resident at lunch on 10/13/11 at approximately 1:15 p.m. revealed the resident received peanut butter pie. The resident confirmed at that time that she had eaten some of it and maybe would eat some more of it. The Tool documented the resident as alert and oriented. Resident #3 , per the Tool, had been assessed and the care plan had been reviewed on 06/23/11. The Tool listed milk as the food item to which the resident was allergic. Observation of the resident at lunch on 10/13/11 at approximately 1:00 p.m .revealed the resident had been served a pureed dessert which had milk poured over the top of it. The aide feeding the resident sitting next to resident #3 confirmed that the dessert had been served to resident #3 and had another aide replace the milk topped dessert with a pureed fruit dessert. The Tool documented this resident as being alert and confused . This resident was also described on the Tool as a dependent diner. Resident #4 , per the Tool had been assessed and the care plan had been reviewed on 08/11/11. The Tool listed an allergy to eggs, tuna, peanut butter, all dairy, and milk. The Tool described the resident as alert and confused, and only needing set up at meals. Resident #4 was provided a sandwich on 09/14/11 of tuna, to which he was allergic. 7. Per the Florida Dietetic Association, Manual of Medical Nutrition Therapy, 2009 Edition , version 22, the nutritional adequacy of the diet of a resident with allergies depends on the food (s) that are omitted. The effect of each food that is omitted from the diet must be evaluated, and if needed a replacement for the lost nutrients must be found. Per the Mayo Clinic and the Asthma and Allergy Foundation of America , " It is extremely important for people who have true food allergies to identify them and prevent allergic reactions to food(s) because these reactions can cause devastating illness, and in some cases, be fatal. " Both tuna fish and peanuts can cause a life threatening reaction called [MEDICATION NAME]. Symptoms can develop right away or within the hour after eating the food, and can include difficulty breathing ,wheezing, and chest tightness. Hives can develop, which are red, swollen itchy welts on the skin. The lips , tongue, and throat can swell, causing blockage of the airway. Review of the nutrition notes for residents #1,#2,#3,and #4 revealed the assessments completed by the Registered Dietitians did not identify the nutritional adequacy of the residents diets based on the omitted foods due to allergy. There was no documentation in the medical records of these four residents that indicated that the foods labeled as allergy inducing were investigated. a. Review of Nutrition notes written by Registered Dietitians, (dated 1102/1010, 02/11/2011, 04/14/2011, 05/13/2011 and 08/12/2011) for resident #4 did not reveal that a complete evaluation with planned intervention of the foods that the resident was allergic to had been made. Review of four of the five notes revealed documentation that indicated that there were NKFA (no known food allergies) for this resident. The note written on 04/14/11 reviewed weight loss for the resident and listed under [DIAGNOSES REDACTED]. The progress note referenced a discussion with the resident and the plan to supplement the resident ' s diet with calcium with vitamin D , related to the resident ' s intolerance to lactose. There was no reference to the allergy to eating eggs and no plan as to what the resident would eat every morning at breakfast. In addition, on 01/ 17/11, a Food Preference Record had been updated. It listed additional protein foods that the resident disliked (fish, ham, turkey) and three vegetables that the resident disliked. Resident meal trays are accompanied by a diet slip which directs the dietary aide in preparing each resident ' s meal tray. Review of the diet slip for resident #4 revealed an additional meat product that the resident disliked (chicken), one fruit that he didn ' t like (peaches) and five additional vegetables that he disliked. The diet slip also listed corn bread, butter and gravy as dislikes. Interview with the Registered Dietitians (RDs) that had written notes on the resident (10/14/11 beginning at 2:20 p.m.) confirmed that any nutrition assessment that they made would include an evaluation with intervention on food items that the resident was allergic to, as well as food dislikes documented by other dietary staff. However, they were not able to identify in their notes (except for the calcium supplement related to the lactose intolerance) any evaluation or investigation as to the severity of the reaction to the allergic foods, or how they would ensure that the resident was receiving a nutritionally adequate diet due to his multiple allergies to protein foods and his many food dislikes. The RDs confirmed that they had not planned a menu for this resident around his many food allergies and dislikes which would ensure that the diet met the resident ' s needs. b.Review of Nutrition notes, written by the Registered Dietitian, on 04/13/11, 05/27/11, and 08/12/11, for resident #1, revealed no discussion of a food allergy, even though the Food Preference Record, dated 08/12/11 listed that the resident was allergic to orange sherbet and jello. Review of care plans dated 06/02/11 with a new revision date of 09/01/11 listed the resident as having an allergy to orange sherbet and jello. The RD note dated 08/12/11 corresponded with the annual MDS assessment and the Food Preference Record. The Data Collection section of the assessment form did not reference the resident ' s allergy and review of the form revealed the abbreviation " NKFA " (no known food allergy) and the word " NO " written in next to the trigger " Food Intolerance " . Interview with the RDs who wrote the notes, on 10/14/11 beginning at 2:20 p.m. revealed food allergies or intolerances would be investigated as part of an annual assessment. The RDs confirmed that the resident ' s mother was very involved in this resident ' s care and directed the facility to provide certain foods to her son. The RDs were not able to identify in their notes discussions they had with the mother in reference to the resident ' s allergy to orange sherbet and jello. There was no documentation that a discussion had taken place with the mother related to type of allergic reaction and severity, which would assist facility staff in providing the resident with the best care. c. Review of Nutrition notes for resident #3, written on 12/07/2010, 03/17/11, and 09/09/11, revealed documentation that the resident had an allergy to milk. This information was not included in the annual assessment written on 06/03/11. The Care Area Assessment of the MDS Annual assessment , completed on 06/16/11, did not reflect that the resident had a food allergy or intolerance. It was not until the 09/09/11 note that the RD questioned the milk allergy ( " Hx of milk allergies? " ) and recommended to " add calcium supplement with D3 " . There was no documentation in the September 2011 note, or follow up notes that an investigation was made into the history of the milk allergy. However, there was no confirmation in a review of nurses notes in September referring to the recommendation made by the RD. A review of the October Physician ' s Order Sheet, did not reveal that the physician ordered the supplement and the resident received the calcium with vitamin D supplement. d. Review of Dietary and Nutrition notes for resident #2 , found under the Dietary tab in the resident ' s medical record, revealed the Food Preference Record dated 11/08/10 and signed by the Certified Dietary Manager indicated that the resident had an allergy to " peanut " (sic). Review of the Initial Assessment completed on 11/08/10 by the RD did not reflect an allergy to peanuts. There was no reference to an allergy or intolerance made in the data collection section of the assessment form and no reference made in the assessment section of the form. Additional nutrition assessments , completed by the RDs , dated 02/11/11, 04/13/11, 05/13/11, 06/12/11 and 08/12/11 made no reference to a peanut allergy . Review of the resident ' s intial MDS Care Area Assessment , dated 11/12/10 did not include that the resident was allergic to peanuts. The Maintenance ADL & Safety Care Plan and Communication Tool, located in the resident ' s cardex, initiated on 11/03/10 and reviewed and updated on 08/11/11, listed an allergy to peanut butter. Interview with the resident on 10/11/11 during the evening meal, revealed she doesn ' t eat peanut butter because it effects her [MEDICATION NAME].

Based on observation, interview, and record review of the requirement to complete a comprehensive assessment of the resident's needs related to dietary habits, preferences, and restrictions, it was determined through a review of Dietary and Nutrition Notes, and the Minimum Data Set, that the facility failed to assess completely, accurately and timely, four of four sampled residents (#1,2,3,4) nutritional status due to the residents ' food allergies which required eliminating specific foods from their diets. The lack of a comprehensive , accurate, assessment which evaluated the effect of the eliminated foods on the resident ' s total diet, led to not providing a substitute for the eliminated foods for residents #1,2,and 3; and led to not planning a menu, that would also include an adequate bedtime snack, based on the multiple food allergies and food dislikes for resident #4. An incomplete assessment did not allow for those findings to be integrated into the meal and snack planning and meal tray preparation, which ultimately led to resident #4 receiving a HS snack made with a food to which he had a documented food allergy resulting in the need to transfer resident #4 to the hospital. Additionally two (#2,#3) of four residents were observed to receive foods that they had a documented food allergy to. These actions by the facility resulted in a determination of on-going Immediate Jeopardy. Findings include: 1. Resident #4 was admitted to the facility on [DATE], per the face sheet which also listed [DIAGNOSES REDACTED]. The face sheet listed allergies, which included lactose, egg, dairy, tunafish, and peanuts. An Annual MDS (Minimum Data Set) Assessment was completed on 02/11/11 which documented the resident in Section K Nutrition as having no swallow disorders, as being 60 " tall and weighing 207 pounds, having no weight loss and no nutritional approaches. The Care Area Assessment (CAA) Nutritional Status Worksheet, (used to further investigate any nutritional indicators triggered by the MDS) dated 02/14/11, was reviewed and noted to not include any checks at any of the items describing the resident, including the item " Resident has allergies or food intolerances. " The analysis of findings documented by the Dietary Manager on the CAA included, resident " is on a regular diet which he tolerates well. His weight is stable. Resident is also able to feed himself. Resident does not ambulate and is up in the wheelchair when out of bed. He does self propel. Resident is overweight. Will not care plan as having a problem with nutrition at this time. " The Food Preference Record, updated on 01/17/11, revealed the resident ' s food allergies as " fish , milk, eggs, peanuts. " This record also included two additional protein foods as dislikes (ham, turkey), two starchy foods as dislikes (hot cereal and spaghetti), and three vegetables as dislikes (beets, broccoli, and Brussels sprouts). All dairy foods on the list were circled as " dislikes ' . In an interview on 10/14/11 beginning at 2:20 p.m with two Registered Dietitians that confirmed they had been assessing and charting on the facility ' s residents ' nutritional status, the Food Preference Record was explained as a form that was initiated when the resident was admitted , and was updated annually, or when residents indicated they had additional food preferences. Record review did not locate the Annual Nutrition Assessment performed by the Registered Dietitian (RD) which would have corresponded to the MDS Annual Assessment and completed during the first two weeks of February 2011. Confirmed through interview with the RDs (on 10/14/11 at 2:20 p.m) , there had been no comprehensive annual assessment completed for resident #4. RD #2 stated, " I missed it. " There had been a quarterly progress note written by the RD in February, but it was not comprehensive. Additional record review of notes written by the RDs and located in the resident ' s medical record revealed notes written on 11/02/10, 02/11/11, 05/13/11, and 08/12/11 which were all identified as Quarterly Notes. All four of these notes identified the resident as having NKFA (no known food allergies), except for an inclusion of " lactose intolerance " under the [DIAGNOSES REDACTED]. or the addition of a calcium supplement related to the lactose intolerance. There was no reference to the multiple food dislikes of the resident, and no discussion of how the resident ' s nutritional needs were being met due to the food allergies and dislikes. A more comprehensive note was reviewed, which was entitled " High Risk Nutrition Assessment " , dated 04/14/11, and identified (by the RDs) as being written based on a weight loss the resident had sustained over the prior year. It was in this April 2011 note that two of the food s that the resident was allergic to were referenced - milk and eggs. An assessment related to the elimination of milk and dairy foods from the resident ' s diet had been made and to compensate, RD #1 recommended a calcium supplement, which the physician ordered. There was nothing more than the phrase, " allergy to eggs to eat " however. RD #1 did not investigate or document whether the resident tolerated eggs mixed into products, for example, French toast, or baked goods, or quiche. Also, RD #1 did not modify the resident ' s breakfast meal to address the eliminated food - eggs. Review of the facility ' s planned menu revealed that in the four week cycle of menus, eggs as the breakfast entree appeared from four to six times a week. The Food Preference Record documented that the resident wanted sausage at breakfast, which the resident reported he usually received (in an interview on 10/13/11 at approximately 8:40 a.m.) , but no assessment of the use of a high fat breakfast meat substituting for eggs had been made. Confirmed through interview with the RDs on 10/14/11 beginning at 2:20 p.m., the facility ' s planned menu had not been adjusted for resident #4 , based on his multiple food allergies and food dislikes. The RDs didn ' t seem to be aware of the number of foods that had been eliminated from the resident ' s diet when the Food Preference Record and resident ' s diet slip were merged to show that only beef and pork were accepted by the resident, no dairy was accepted, and the list of vegetables that the resident wouldn ' t accept numbered seven. Both RDs confirmed they had not planned a menu and had not assessed the nutritional adequacy of the current menu based on the many foods that the resident wouldn ' t accept. It was confirmed that due to the resident ' s multiple allergies and food dislikes, and without a planned menu to guide dietary staff, the resident probably ate hot dogs or a cold cut sandwich several times a week for lunch and dinner. The RDs also confirmed that the resident did not have a labeled HS (bedtime) snack and would be offered any of the snacks from the snack cart at bedtime. Review of the facility ' s event log revealed on 09/14/11 resident #4 sustained an allergic reaction and was transferred to the hospital. Review of the History and Physical (H&P) , dated 09/15/11, and obtained from the hospital stay revealed the resident ' s chief complaint was " facial, lip and throat swelling after eating a tuna fish sandwich. " The H&P documented the resident ' s history of multiple food allergies and listed them. The resident was transferred back to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Interview with the Administrator on 10/11/11 beginning at 10:40 a.m. revealed an aide provided a tuna sandwich to the resident as a bedtime snack and must not have checked with the nurse whether he could have it. Interview with the Dietary Manager (DM) on 10/11/11 beginning at 10:30 a.m. revealed that the resident ' s diet slip documented his allergies as well as his multiple food dislikes, but diet slips only accompany meals, not HS snacks. The DM reported that the resident did not have a labeled HS snack in place which was part of the reason he received the tuna sandwich, which caused the allergic reaction. The DM explained the process of HS snacks as both resident-specific labeled and unlabeled snacks were sent to the nursing stations for delivery by the nurses aides to the residents at bedtime. Unlabeled snacks were available to any resident and it was up to the aide to determine if the resident could have that particular food or beverage. Interview , on 10/11/11 at 2:45 p.m with the aide who provided the resident with the tuna sandwich which caused the allergic reaction, revealed that the resident ' s roommate had accepted a tuna sandwich. The aide reported that she had said what kind of sandwiches she had and when resident #4 said he wanted a sandwich, she figured he wouldn ' t ask for a sandwich to which he was allergic. The aide confirmed that she knew the resident and had worked with him in the past. She said she thinks resident #4 is alert and oriented and aware of his allergies and wouldn ' t accept one made with a food to which he was allergic. The aide confirmed that she knew she could ask the nurse about a resident ' s dietary restrictions, but since she said she knew the resident knew what foods he was allergic to, she relied on him to not accept a food to which he was allergic. 2. Per the Florida Dietetic Association, Manual of Medical Nutrition Therapy, 2009 Edition , version 22, the nutritional adequacy of the diet of a resident with allergies depends on the food (s) that are omitted. The effect of each food that is omitted from the diet must be evaluated, and if needed a replacement for the lost nutrients must be found. Per the Mayo Clinic and the Asthma and Allergy Foundation of America , " It is extremely important for people who have true food allergies to identify them and prevent allergic reactions to food(s) because these reactions can cause devastating illness, and in some cases, be fatal. " Both tuna fish and peanuts can cause a life threatening reaction called [MEDICATION NAME]. Symptoms can develop right away or within the hour after eating the food, and can include difficulty breathing ,wheezing, and chest tightness. Hives can develop, which are red, swollen itchy welts on the skin. The lips , tongue, and throat can swell, causing blockage of the airway. An interview with two Registered Dietitians (RD) that confirmed they had been assessing and following the nutritional status of residents in the facility for at least the past year occurred on 10/14/11 beginning at 2:20 p.m. Both RDs confirmed that they completed comprehensive initial and follow up assessments that corresponded to the MDS assessments, and would interview residents as to their food likes and dislikes if the Dietary Manager had not done so. Both RDs confirmed that investigating a food allergy would be part of their comprehensive assessment and they would determine the form of the food that would cause the allergy, the amount needed to be ingested, and the type of reaction, including the severity , of any food allergy. However, review of the other residents ' with documented food allergies did not reveal that the RDs had completed comprehensive nutrition assessments that included the eliminated foods and integrated their assessments into the food delivery system. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet listed allergies to orange sherbet. The resident ' s annual MDS assessment was completed on 08/29/11. Review of the Nutrition section revealed he was identified as having no swallow disorders, being 61 " tall and weighing 112 lbs, sustaining weight loss,, but not being on a physician ordered weight loss regimen, and receiving a mechanically altered and therapeutic diet. The CAA Nutritional Status Worksheet, dated 08/21/11, did not include any additional information about the resident, including not identifying ' Resident has allergies or food intolerances. " The Food Preference Record, dated 08/12/11, signed by RD #2 , documented the resident ' s allergy to orange sherbet and also listed " jello." The Nutrition Assessment form was completed on 08/12/11 by RD #2 and the assessment type was indicated as Annual. On the front side of the form is a data collection section where Food allergy or Food intolerance can be indicated. Written in next to Food allergy were the initials NKFA (no known food allergy) and written in next to Food Intolerance was the word NO. Review of the assessment of the information collected did not reveal any reference to the resident ' s listed allergy of orange sherbet of jello from the Food Preference Record that had been filled in the same day. Interview with RD #2 on 10/14/11 beginning at 2:20 p.m. revealed that this resident ' s mother is involved in the resident ' s care and directs the facility as to foods and beverages that she thinks he should have. RD #2 could not report, nor could she locate, information that had been received from the mother as to this resident ' s documented food allergy to orange sherbet or jello. 4. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Also listed on the face sheet under allergies was ' peanut butter ' . The Food Preference Record, dated 11/04/10 and signed by the Certified Dietary Manager documented the resident ' s allergy to peanuts. An initial MDS assessment was completed on 11/12/10 and section K, related to Swallowing/Nutrition Status documented the resident as having no swallowing disorders, standing 63 " tall and weighing 100 pounds, weight loss but not on a physician -prescribed weight loss regimen, and receiving a mechanically altered diet. Review of the CAA for Nutritional Status, revealed comments had been made in reference to the items to describe the resident, but the statement " Resident has allergies or food intolerance " had not been marked as applying to the resident. The CAA did not have an ' analysis of findings ' documented where all indicators and supporting documentation could be reviewed . However the CAA was marked that a care plan would be developed. Review of the care plan that was developed with the initial MDS assessment did not reflect that the resident had an allergy to peanut butter. Review of the Nutrition Risk Data Collection and Assessment form, completed by the RD #3 on 11/08/10 , revealed it had been identified as an Initial assessment. The data collection section for food intolerances and allergies had not been identified as an area of concern for this resident. The assessment summary referred to discussing the resident ' s food preferences with her, but did not reflect the concern of an allergy to peanut butter. Interview with this resident on 10/11/11 during dinner, which the resident ate in her room, revealed she can eat some peanut butter , but not too much because it interferes with her [MEDICATION NAME] receptors. 5. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet also listed milk as an allergy. An Annual MDS assessment was completed on 06/16/11. Review of section K Swallowing/Nutritional Status revealed the resident had no swallowing disorders , was 53 " tall and weighed 99 lbs, had had no weight loss and received a mechanically altered diet. Review of the CAA for Nutritional Status revealed the resident ' s communication problems and disease conditions had been identified, as well as functional problems and cognitive, mental status and behavioral problems. But the resident ' s current eating problems had not been identified, even though that included " Resident has allergies or food intolerance " . An analysis of findings was documented with the decision to develop a care plan, but there was no reference to the milk allergy. Review of the care plan for Nutrition, updated on 06/29/11, did not include the resident ' s allergy to milk. The Maintenance ADL & Safety Care Plan & Communication Tool, reviewed and updated on 06/23/11 included as ' additional information ' " allergy to milk " . Review of the Nutrition Risk Data Collection and Assessment , completed by RD #2 on 06/03/11, and identified as the Annual assessment did not include the resident ' s allergy to milk in either the data collection section of the form or in the assessment section of the form. Review of the Medications : Nutrition related (section listed on the data collection side of the form) did not reveal that the resident was receiving a calcium supplement as a replacement for the milk. No documentation could be located that indicated whether the resident ' s allergy to milk extended to all dairy products, or only the beverage, milk. There was no documentation as to the quantity that was tolerated or what the reaction would be should milk be consumed. There was no documentation whether a food with milk was tolerated. Even though in the interview with the RDs , on 10/14/11 beginning at 2:20p.m. , it was confirmed that an allergy to a food product would be investigated, there was no documentation that an investigation into this resident ' s allergy had been conducted. 6. Review of the RDs nutrition assessments for residents #1, 2, 3,and 4 revealed the foods that would be omitted from the diet due to allergies, had not been evaluated for the effect on the nutritional adequacy of the diet. The lack of investigation to identify the severity of the allergic reaction downplayed the importance of consistently omitting the food from resident ' s meal trays. The lack of RD involvement in menu planning, food distribution and oversight was a contributing factor in observations made during the lunch meal on 10/13/11 beginning at 1:00 p.m for residents #2 and #3. These two residents were observed to receive foods to which they had documented allergies. a. Resident #2 was observed in her room on 10/13/11 at approximately 1:20 p.m. This resident confirmed that she had just finished lunch in her room and had eaten some of the peanut butter pie that had been served for lunch. The peanut butter pie was sitting on the over bed table with obvious bites missing. The resident reported that the aide had left the pie for her to finish. The resident confirmed that she had an allergy to peanut butter, but reported that she can eat a little bit of peanut butter, but too much affects her [MEDICATION NAME] receptors. b. Resident #3 was observed dozing in her geri chair at a table in the restorative dining room on 10/13/11 at approximately 1:00 p.m.. The resident ' s pureed lunch had been served and a small tulip cup of a scoop of pureed food was noted to have a white liquid poured over it. The aide feeding another resident at the table reported that the small tulip cup was resident #3 ' s dessert. Questioning the dessert and the white liquid, another aide removed the dessert and returned from the kitchen with a cup of pureed fruit. Dietary staff reported, after this observation, that the pureed dessert was peanut butter pie with milk poured over it. They confirmed that the resident had an allergy to milk and should not have received the dessert with the milk.

Based on observations, interviews and record review, the facility failed to ensure that dietary services consistently met professional standards of practice for four (# 1-4) of four sampled residents who were identified with food allergies. The lack of a comprehensive, accurate, assessment which evaluated the effect of eliminated foods, due to food allergies, on the resident ' s total diet, led to not providing a substitute for the eliminated foods for residents #1, 2,and 3. The lack of a comprehensive, accurate assessment led to not planning a menu, that would also include an adequate bedtime snack, based on the multiple food allergies and food dislikes for resident #4. An incomplete assessment did not allow for those findings to be integrated into the meal and snack planning and meal tray preparation, which ultimately led to resident #4 receiving a HS snack made with a food to which he had a documented food allergy resulting in the need to transfer resident #4 to the hospital due to a life threatening reaction. Additionally, two (#2,#3) of four residents were observed to receive foods for which they had a documented allergy. These actions by the facility resulted in a determination of on-going Immediate Jeopardy. Findings include: 1. " Dietetics and nutrition practice " shall include assessing nutrition needs and status using appropriate data; recommending appropriate dietary regimens, nutrition support, and nutrient intake; improving health status through nutrition research, counseling, and education; and developing, implementing, and managing nutrition care systems, which includes, but is not limited to, evaluating, modifying, and maintaining appropriate standards of high quality in food and nutrition care services. 2. . Per the Florida Dietetic Association, Manual of Medical Nutrition Therapy, 2009 Edition , version 22, the nutritional adequacy of the diet of a resident with allergies depends on the food (s) that are omitted. The effect of each food that is omitted from the diet must be evaluated, and if needed a replacement for the lost nutrients must be found. Per the Mayo Clinic and the Asthma and Allergy Foundation of America , " It is extremely important for people who have true food allergies to identify them and prevent allergic reactions to food(s) because these reactions can cause devastating illness, and in some cases, be fatal. " 3. An Annual MDS (Minimum Data Set) Assessment was completed on 02/11/11 for Resident #4 (admitted on [DATE]) which documented the resident in Section K Nutrition as having no swallow disorders, as being 60 " tall and weighing 207 pounds, having no weight loss and no nutritional approaches. The facesheet listed [DIAGNOSES REDACTED]. Also listed were allergies including lactose, egg, dairy, tunafish, and peanuts. The Care Area Assessment (CAA) Nutritional Status Worksheet, (used to further investigate any nutritional indicators triggered by the MDS) dated 02/14/11, was reviewed and noted to not include any checks at any of the items describing the resident, including the item " Resident has allergies or food intolerances. " The analysis of findings documented by the Dietary Manager on the CAA included, resident " is on a regular diet which he tolerates well. His weight is stable. Resident is also able to feed himself. Resident does not ambulate and is up in the wheelchair when out of bed. He does self propel. Resident is overweight. Will not care plan as having a problem with nutrition at this time. " The Food Preference Record, updated on 01/17/11, revealed the resident ' s food allergies as " fish , milk, eggs, peanuts. " This record also included two additional protein foods as dislikes (ham, turkey), two starchy foods as dislikes (hot cereal and spaghetti), and three vegetables as dislikes (beets, broccoli, and Brussels sprouts). All dairy foods on the list were circled as " dislikes ' . In an interview on 10/14/11 beginning at 2:20 p.m with two Registered Dietitians that confirmed they had been assessing and charting on the facility ' s residents ' nutritional status, the Food Preference Record was explained as a form that was initiated when the resident was admitted , and was updated annually, or when residents indicated they had additional food preferences. Record review did not locate the Annual Nutrition Assessment performed by the Registered Dietitian (RD) which would have corresponded to the MDS Annual Assessment and completed during the first two weeks of February 2011. Confirmed through interview with the RDs (on 10/14/11 at 2:20 p.m) , there had been no comprehensive annual assessment completed for resident #4. RD #2 stated, " I missed it. " There had been a quarterly progress note written by the RD in February, but it was not comprehensive. Additional record review of notes written by the RDs and located in the resident ' s medical record revealed notes written on 11/02/10, 02/11/11, 05/13/11, and 08/12/11 which were all identified as Quarterly Notes. All four of these notes identified the resident as having NKFA (no known food allergies), except for an inclusion of " lactose intolerance " under the [DIAGNOSES REDACTED]. or the addition of a calcium supplement related to the lactose intolerance. There was no reference to the multiple food dislikes of the resident, and no discussion of how the resident ' s nutritional needs were being met due to the food allergies and dislikes. A more comprehensive note was reviewed, which was entitled " High Risk Nutrition Assessment " , dated 04/14/11, and identified (by the RDs) as being written based on a weight loss the resident had sustained over the prior year. It was in this April 2011 note that two of the food s that the resident was allergic to were referenced - milk and eggs. An assessment related to the elimination of milk and dairy foods from the resident ' s diet had been made and to compensate, RD #1 recommended a calcium supplement, which the physician ordered. There was nothing more than the phrase, " allergy to eggs to eat " however. RD #1 did not investigate or document whether the resident tolerated eggs mixed into products, for example, French toast, or baked goods, or quiche. Also, RD #1 did not modify the resident ' s breakfast meal to address the eliminated food - eggs. Review of the facility ' s planned menu revealed that in the four week cycle of menus, eggs as the breakfast entree appeared from four to six times a week. The Food Preference Record documented that the resident wanted sausage at breakfast, which the resident reported he usually received (in an interview on 10/13/11 at approximately 8:40 a.m.) , but no assessment of the use of a high fat breakfast meat substituting for eggs had been made. Confirmed through interview with the RDs on 10/14/11 beginning at 2:20 p.m., the facility ' s planned menu had not been adjusted for resident #4 , based on his multiple food allergies and food dislikes. The RDs didn ' t seem to be aware of the number of foods that had been eliminated from the resident ' s diet when the Food Preference Record and resident ' s diet slip were merged to show that only beef and pork were accepted by the resident, no dairy was accepted, and the list of vegetables that the resident wouldn ' t accept numbered seven. Both RDs confirmed they had not planned a menu and had not assessed the nutritional adequacy of the current menu based on the many foods that the resident wouldn ' t accept. It was confirmed that due to the resident ' s multiple allergies and food dislikes, and without a planned menu to guide dietary staff, the resident probably ate hot dogs or a cold cut sandwich several times a week for lunch and dinner. The RDs also confirmed that the resident did not have a labeled HS (bedtime) snack and would be offered any of the snacks from the snack cart at bedtime. Review of the facility ' s event log revealed on 09/14/11 resident #4 sustained an allergic reaction and was transferred to the hospital. Review of the History and Physical (H&P) , dated 09/15/11, and obtained from the hospital stay revealed the resident ' s chief complaint was " facial, lip and throat swelling after eating a tuna fish sandwich. " The H&P documented the resident ' s history of multiple food allergies and listed them. The resident was transferred back to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Interview with the Administrator on 10/11/11 beginning at 10:40 a.m. revealed an aide provided a tuna sandwich to the resident as a bedtime snack and must not have checked with the nurse whether he could have it. Interview with the Dietary Manager (DM) on 10/11/11 beginning at 10:30 a.m. revealed that the resident ' s diet slip documented his allergies as well as his multiple food dislikes, but diet slips only accompany meals, not HS snacks. The DM reported that the resident did not have a labeled HS snack in place which was part of the reason he received the tuna sandwich, which caused the allergic reaction. The DM explained the process of HS snacks as both resident-specific labeled and unlabeled snacks were sent to the nursing stations for delivery by the nurses aides to the residents at bedtime. Unlabeled snacks were available to any resident and it was up to the aide to determine if the resident could have that particular food or beverage. Interview , on 10/11/11 at 2:45 p.m with the aide who provided the resident with the tuna sandwich which caused the allergic reaction, revealed that the resident ' s roommate had accepted a tuna sandwich. The aide reported that she had said what kind of sandwiches she had and when resident #4 said he wanted a sandwich, she figured he wouldn ' t ask for a sandwich to which he was allergic. The aide confirmed that she knew the resident and had worked with him in the past. She said she thinks resident #4 is alert and oriented and aware of his allergies and wouldn ' t accept one made with a food to which he was allergic. The aide confirmed that she knew she could ask the nurse about a resident ' s dietary restrictions, but since she said she knew the resident knew what foods he was allergic to, she relied on him to not accept a food to which he was allergic. Both tuna fish and peanuts can cause a life threatening reaction called [MEDICATION NAME]. Symptoms can develop right away or within the hour after eating the food, and can include difficulty breathing ,wheezing, and chest tightness. Hives can develop, which are red, swollen itchy welts on the skin. The lips , tongue, and throat can swell, causing blockage of the airway. An interview with two Registered Dietitians (RD) that confirmed they had been assessing and following the nutritional status of residents in the facility for at least the past year occurred on 10/14/11 beginning at 2:20 p.m. Both RDs confirmed that they completed comprehensive initial and follow up assessments that corresponded to the MDS assessments, and would interview residents as to their food likes and dislikes if the Dietary Manager had not done so. Both RDs confirmed that investigating a food allergy would be part of their comprehensive assessment and they would determine the form of the food that would cause the allergy, the amount needed to be ingested, and the type of reaction, including the severity , of any food allergy. However, review of the other residents with documented food allergies did not reveal that the RDs had completed comprehensive nutrition assessments that included the eliminated foods and integrated their assessments into the food delivery system. 4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet listed allergies to orange sherbet. The resident ' s annual MDS assessment was completed on 08/29/11. Review of the Nutrition section revealed he was identified as having no swallow disorders, being 61 " tall and weighing 112 lbs, sustaining weight loss,, but not being on a physician ordered weight loss regimen, and receiving a mechanically altered and therapeutic diet. The CAA Nutritional Status Worksheet, dated 08/21/11, did not include any additional information about the resident, including not identifying ' Resident has allergies or food intolerances. " The Food Preference Record, dated 08/12/11, signed by RD #2 , documented the resident ' s allergy to orange sherbet and also listed " jello." The Nutrition Assessment form was completed on 08/12/11 by RD #2 and the assessment type was indicated as Annual. On the front side of the form is a data collection section where Food allergy or Food intolerance can be indicated. Written in next to Food allergy were the initials NKFA (no known food allergy) and written in next to Food Intolerance was the word NO. Review of the assessment of the information collected did not reveal any reference to the resident ' s listed allergy of orange sherbet of jello from the Food Preference Record that had been filled in the same day. Interview with RD #2 on 10/14/11 beginning at 2:20 p.m. revealed that this resident ' s mother is involved in the resident ' s care and directs the facility as to foods and beverages that she thinks he should have. RD #2 could not report, nor could she locate, information that had been received from the mother as to this resident ' s documented food allergy to orange sherbet or jello. 5. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Also listed on the face sheet under allergies was ' peanut butter ' . The Food Preference Record, dated 11/04/10 and signed by the Certified Dietary Manager documented the resident ' s allergy to peanuts. An initial MDS assessment was completed on 11/12/10 and section K, related to Swallowing/Nutrition Status documented the resident as having no swallowing disorders, standing 63 " tall and weighing 100 pounds, weight loss but not on a physician -prescribed weight loss regimen, and receiving a mechanically altered diet. Review of the CAA for Nutritional Status, revealed comments had been made in reference to the items to describe the resident, but the statement " Resident has allergies or food intolerance " had not been marked as applying to the resident. The CAA did not have an ' analysis of findings ' documented where all indicators and supporting documentation could be reviewed . However the CAA was marked that a care plan would be developed. Review of the care plan that was developed with the initial MDS assessment did not reflect that the resident had an allergy to peanut butter. Review of the Nutrition Risk Data Collection and Assessment form, completed by the RD #3 on 11/08/10 , revealed it had been identified as an Initial assessment. The data collection section for food intolerances and allergies had not been identified as an area of concern for this resident. The assessment summary referred to discussing the resident ' s food preferences with her, but did not reflect the concern of an allergy to peanut butter. Interview with this resident on 10/11/11 during dinner, which the resident ate in her room, revealed she can eat some peanut butter , but not too much because it interferes with her [MEDICATION NAME] receptors. 6. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet also listed milk as an allergy. An Annual MDS assessment was completed on 06/16/11. Review of section K Swallowing/Nutritional Status revealed the resident had no swallowing disorders , was 53 " tall and weighed 99 lbs, had had no weight loss and received a mechanically altered diet. Review of the CAA for Nutritional Status revealed the resident ' s communication problems and disease conditions had been identified, as well as functional problems and cognitive, mental status and behavioral problems. But the resident ' s current eating problems had not been identified, even though that included " Resident has allergies or food intolerance " . An analysis of findings was documented with the decision to develop a care plan, but there was no reference to the milk allergy. Review of the care plan for Nutrition, updated on 06/29/11, did not include the resident ' s allergy to milk. The Maintenance ADL & Safety Care Plan & Communication Tool, reviewed and updated on 06/23/11 included as ' additional information ' " allergy to milk " . Review of the Nutrition Risk Data Collection and Assessment , completed by RD #2 on 06/03/11, and identified as the Annual assessment did not include the resident ' s allergy to milk in either the data collection section of the form or in the assessment section of the form. Review of the Medications : Nutrition related (section listed on the data collection side of the form) did not reveal that the resident was receiving a calcium supplement as a replacement for the milk. No documentation could be located that indicated whether the resident ' s allergy to milk extended to all dairy products, or only the beverage, milk. There was no documentation as to the quantity that was tolerated or what the reaction would be should milk be consumed. There was no documentation whether a food with milk was tolerated. Even though in the interview with the RDs , on 10/14/11 beginning at 2:20p.m. , it was confirmed that an allergy to a food product would be investigated, there was no documentation that an investigation into this resident ' s allergy had been conducted. 7. Review of the RDs nutrition assessments for residents #1, 2, 3,and 4 revealed the foods that would be omitted from the diet due to allergies, had not been evaluated for the effect on the nutritional adequacy of the diet. The lack of investigation to identify the severity of the allergic reaction downplayed the importance of consistently omitting the food from resident ' s meal trays. The lack of RD involvement in menu planning, food distribution and oversight was a contributing factor in observations made during the lunch meal on 10/13/11 beginning at 1:00 p.m for residents #2 and #3. These two residents were observed to receive foods to which they had documented allergies. a. Resident #2 was observed in her room on 10/13/11 at approximately 1:20 p.m. This resident confirmed that she had just finished lunch in her room and had eaten some of the peanut butter pie that had been served for lunch. The peanut butter pie was sitting on the over bed table with obvious bites missing. The resident reported that the aide had left the pie for her to finish. The resident confirmed that she had an allergy to peanut butter, but reported that she can eat a little bit of peanut butter, but too much affects her [MEDICATION NAME] receptors. b. Resident #3 was observed dozing in her geri chair at a table in the restorative dining room on 10/13/11 at approximately 1:00 p.m.. The resident ' s pureed lunch had been served and a small tulip cup of a scoop of pureed food was noted to have a white liquid poured over it. The aide feeding another resident at the table reported that the small tulip cup was resident #3 ' s dessert. Questioning the dessert and the white liquid, another aide removed the dessert and returned from the kitchen with a cup of pureed fruit. Dietary staff reported, after this observation, that the pureed dessert was peanut butter pie with milk poured over it. They confirmed that the resident had an allergy to milk and should not have received the dessert with the milk.

Based on review of resident medical records, including their care plans, interview with facility staff, and observation of the residents ' meals, the facility failed to ensure that for three (#2,3,4) of four sampled residents with food allergies, their care plans were implemented. Observations of resident #2 and 3 during a meal captured that those residents received a food listed as causing an allergic reaction and resident #4 received a food known to cause an allergic reaction and was transferred to the hospital with a life threatening reaction. Without implementing the care plan, the facility put the residents at risk for sustaining a potentially severe, life threatening allergic reaction, resulting in a determination of Immediate Jeopardy which is on-going. Findings include: 1. Record review for resident #4 revealed a care plan entitled Maintenance ADL (activities of daily living) & Safety Care Plan & Communication Tool which was documented as being reviewed and updated on 08/11/11. This care plan listed under Additional Information " Allergies to eggs, tuna, peanut butter, all dairy , shellfish, milk, and lactose. " Review of the facility event log revealed that on 09/14/11 the resident had an allergic reaction. Interview with the Administrator on 10/11/11 at 10:40 a.m. revealed that an aide had given the resident a tuna sandwich as a bedtime snack and the resident complained of chest pain and was sent to the hospital. The Administrator reported that he thought maybe the aide didn ' t know to check the cardex for information on what the resident could eat. Interview with the Dietary Manager on 10/11/11 at 10:30 a.m. revealed that the resident did not have a labeled snack and could ask for anything off of the snack cart. Interview ( on 10/11/11 at 2:30 p.m.) with the aide who provided the sandwich to the resident said that she had just told the resident ' s roommate what type of sandwiches she had , and when resident #4 asked for the sandwich she figured he was alert and oriented and aware of his allergies and wouldn ' t have asked for something that he was allergic to. She reported that for residents that she knows are alert and oriented she doesn ' t ask the nurse, but for those that she isn ' t sure, she asks the nurse if they have restrictions. She reported that she considers resident #4 alert and oriented and aware of his allergies. Review of the notes from the emergency room , dated 09/14/11 at 23:42 (11:45 p.m.) revealed the resident presented with a chief complaint of " face and throat swelling that was mild to moderate, with mild wheezing. " Associated symptoms were " skin rash, itching , with mild shortness of breath, and mild trouble swallowing. " The physical exam confirmed facial, tongue, and uvula [MEDICAL CONDITION] with a skin rash and [DIAGNOSES REDACTED] on the lower arms. The resident was admitted for monitoring of the airway. (Per Wikipedia, [MEDICAL CONDITION] is the rapid swelling of the skin and mucous membranes, such as around the mouth, inside the mouth, and the tongue. It is usually caused by an allergic reaction and can be itchy or painful. In severe cases the airway can be blocked by the swollen tongue or throat requiring intubation.) Review of the 3008 transfer document dated 09/18/11 revealed the admitting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. A Psychological exam, conducted on 09/21/10, answered " NO " to " Can Resident make appropriate medical decisions at this time? " A progress note with the date of 4/8, without a year but located between notes in the resident ' s medical record from March 2011 and May 2011, had been written by a Physician and indicated, " Seen and examined; not competent to make decisions. Appropriate documents signed. " Interview with the Social Services Director on 10/14/11 at 2:15 p.m. revealed she was not aware of this note in the chart, but confirmed they had gotten a Health Care Proxy signature on 10/13/11 for resident #4. She confirmed that the resident had no family and no guardian. 2. Interview with the Director of Nurses(DON) on 10/11/11 beginning at 10:45 a.m , revealed all staff members had received inservicing (on 09/28/11 beginning at 8:30 a.m.) on the topic of Drug and Food Allergy Awareness related to resident #4 receiving a food as a bedtime snack to which he was allergic. Presented by the immediate past DON and the current DON, the objectives of the training included, " staff members will be aware of food allergies of residents prior to giving food and where to find information. Nurses will also be aware of drug allergies prior to medication administration. " The DON explained that the information about food allergies was posted on the inside of each of the notebooks that the aides document their resident ADL information in. The Dietary Manager explained , on 10/11/11 at 10:30 a.m that dietary staff have a list of the four residents with food allergies and what foods they are allergic to posted adjacent to their tray line for easy reference. On 10/13/11 at 12:30 p.m. the DON confirmed that 18 of 71 employees listed on the Personnel List had not been inserviced. However, despite the inservicing, facility staff demonstrated at lunch that same day (10/13/11 beginning at 1:00 p.m.) that they were not able to implement the information received in the inservice, and two (residents #2, 3) of the four residents with food allergies received foods that they were allergic to. 3. Resident # 2 had been documented upon admission to the facility by the Certified Dietary Manager (CDM) as reporting that she was allergic to peanut butter. A review of the Food Preference Record, completed by the CDM on 11/04/10, revealed this information, which was then included on the Maintenance ADL & Safety Care Plan & Communication Tool, was dated as reviewed and updated on 08/11/11. Observation of the resident at lunch on 10/13/11 at approximately 1:20 p.m. revealed the resident had eaten her lunch in her room and was lying in bed. There was a piece of peanut butter pie on the over bed table, which was next to the bed. The slice of pie had obvious bites missing from it and a fork was observed lying on the plate. The resident reported at that time that she doesn ' t eat much peanut butter as it affects her [MEDICATION NAME] receptors, but she did confirm that she had had a few bites of the pie. The resident also said that the aide had left the pie on the table in case she wanted to eat some more of it. 4. Resident #3 was a long term resident of the facility. Review of the Nutrition Assessments completed by the RDs, dated 12/07/10, 03/17/11 and 09/09/11 all documented that the resident had an allergy to milk. Review of the Maintenance ADL & Safety Care Plan & Communication Tool , dated as reviewed and updated on 06/23/11 , included under " Additional Information: Allergy to Milk " . Observation of the resident at lunch in the restorative dining room on 10/13/11 at approximately 1:00 p.m. revealed she was dozing in her geri chair while another resident at the table was being assisted with his meal. The resident ' s meal was in front of her with a small tulip cup containing a pureed food with what looked like milk poured over it. The aide assisting the other resident was asked about the small cup and it was reported that it contained resident # 3 ' s dessert. The question was asked about the resident receiving a milk product and another aide removed the dessert and provided the resident with a pureed fruit dessert. 5. At approximately 1:25 p.m on 10/13/11, dietary staff were questioned about the two residents receiving the foods to which they were allergic and staff confirmed that they have a list to refer to , but they missed these two residents today. One aide reported that he was concentrating on not providing the peanut butter pie to resident #4 that he forgot about resident #2 and her allergy to peanut butter. And it was confirmed that the pureed dessert with the milk poured over it had been given to the resident in error.

Based on review of Nutrition Assessments and Progress Notes, review of the planned menu, and interview with the resident and facility staff, the facility failed to ensure the maintenance of acceptable parameters of nutritional status for four (#1, 2, 3, 4) of four sampled residents through failure to accurately assess four of four sampled residents (#1, #2, #3, #4) related to resident ' s #4 ' s food allergies and multiple food dislikes, and residents #1, 2, and 3 food allergies. This lack of comprehensive, accurate assessment put resident #4 at risk for sustaining a potentially life threatening allergic reaction, by not investigating the severity, type of reaction and form of the specific food(s) to which the resident was allergic, and then not integrating that information into a planned menu for meals and snacks. The facility failed to ensure that dietary aides implemented the planned menu and nursing aides were aware of the food allergies to prevent them from providing harmful foods to resident #4. The lack of a comprehensive , accurate assessment for residents #1,2,and 3 put those residents at risk when there was no full investigation into the foods to which the residents were allergic and no plan to ensure nutritional adequacy due to food(s) that were eliminated from their diets due to the allergies. There was no plan for substitutes of the allergic foods by the Registered Dietitian after the assessment and no monitoring of meal trays prior to service to the residents to ensure that they had not been served a food to which they were allergic. The facility ' s practice resulted in on-going Immediate Jeopardy. Findings include: 1. Per the Florida Dietetic Association, Manual of Medical Nutrition Therapy, 2009 Edition , version 22, the nutritional adequacy of the diet of a resident with allergies depends on the food (s) that are omitted. The effect of each food that is omitted from the diet must be evaluated, and if needed a replacement for the lost nutrients must be found. Per the Mayo Clinic and the Asthma and Allergy Foundation of America (AAFA) , " It is extremely important for people who have true food allergies to identify them and prevent allergic reactions to food(s) because these reactions can cause devastating illness, and in some cases, be fatal. " Both tuna fish and peanuts can cause a life threatening reaction called [MEDICATION NAME]. Symptoms can develop right away or within the hour after eating the food, and can include difficulty breathing ,wheezing, and chest tightness. Hives can develop, which are red, swollen itchy welts on the skin. The lips , tongue, and throat can swell, causing blockage of the airway. (Per the AAFA) Upon developing any symptoms after eating a food that has been documented as an allergy, medical attention should be sought immediately. 2. Resident #4 was originally admitted to the facility per the face sheet located in the resident ' s medical record on 04/30/2002. [DIAGNOSES REDACTED]. The face sheet listed the resident ' s allergies as lactose , egg, dairy, tuna fish and peanut (sic). Review of the Food Preference Record, located under the Dietary tab in the resident ' s medical record, dated 01/17/11, revealed the resident ' s allergies as " fish, milk, eggs, peanuts. " This form also listed the resident food dislikes to include two other meats, as well as tuna; two starchy foods; and three vegetables. The diet slip for this resident listed additional dislikes that included one other protein food, four other vegetables, one fruit, one starch, and two fats. Review of nurses notes, dated 09/14/11 at 2150, revealed resident " notified nursing staff that he ate a tuna fish sandwich for his evening snack. He stated he is allergic to tuna fish. Doctor notified and [MEDICATION NAME] 50 mg po given. " The next nurses note, dated 09/14/11 at 2300 , indicated, " complained of chest pains lungs clear, alert and oriented x 3, doctor notified and wanted him to be evaluated and treated in the emergency room . " Review of the History and Physical (H&P) written in the hospital and dated 09/15/11 revealed the resident was admitted with the chief complaint of facial, lip and throat swelling after eating a tuna fish sandwich yesterday. Patient has a history of multiple food allergies in the past. Solu-[MEDICATION NAME] and [MEDICATION NAME] were given in the ER with mild improvement of the symptoms. Patient was admitted for monitoring of airway. " The H&P listed the resident ' s Food Allergies as Eggs, Milk, Peanuts, Tuna, Shellfish, and Lactose. The Physical Exam listed the HEENT (head, ears, eyes, neck throat) as " swelling noted of the tongue and neck area. " The first item under Assessment was noted to describe "Facial, tongue, and throat [MEDICAL CONDITION] secondary to most likely an allergic reaction. "Item #2" was noted to describe "Acute Respiratory insufficiency secondary to #1." Item #3 was noted as "History of Down ' s Syndrome." Item #4 was noted as "Dysphagia (difficulty swallowing) secondary to #1." The resident was readmitted to the facility on [DATE] with a 3008 (transfer form) that listed the Discharge [DIAGNOSES REDACTED]. Review of the Nutrition Section (Section K) of the MDS (Minimum Data Set) Significant Change Assessment, completed on 02/11/11 revealed the resident was documented as having no swallowing concerns, 60 " tall and weighing 207 pounds, no significant weight loss, and no nutritional approaches. The CAA (Care Area Assessment ) Review of Indicators of Nutritional Status completed on 02/14/11 contained no checkmarks on the four pages of items that could describe the resident. (The CAA is a worksheet used to further evaluate an area that due to answers in the MDS assessment pointed to a possible problem.) The first section of the CAA includes indicators of the resident ' s Current Eating Pattern with opportunities to document whether " food offered or available is not consistent with the resident ' s food choices/needs." This section included the statement to indicate: "Resident has allergies or food intolerance, " but it was not checked as describing resident #4. Page two of the CAA included under the heading Cognitive, mental status, and behavior problems, the item " Mental [MEDICAL CONDITION] " was available, but it was not checked as describing resident #4. The last page of the CAA provided an opportunity to analyze the findings of the prior four pages, and the following documentation was noted: resident #4 " is on a regular diet which he tolerates well. His weight is stable. Resident is also able to feed himself. Resident does not ambulate and is up in the wheelchair when out of bed. He does self propel. Resident is overweight . Will not care plan as having a problem with nutrition at this time. " A care plan had been developed and was reviewed by the facility on 02/15/11. Foods to which the resident was allergic were listed as a problem, with the intervention " Nursing to monitor tolerance to diet " and " monitor allergic reactions " . There was no reference to specify the many foods that had been listed on the resident ' s Food Preference Record. Review of the Nutrition Progress Notes, completed by the Registered Dietitian (RD) , revealed notes written on 11/02/10, 02/11/2011, 04/14/11, 05/13/11, and 08/12/11. The 02/11/11 note, which corresponded to the February Annual MDS assessment was titled as a Quarterly Note. Data collection included the entry NKFA (no known food allergies ). Summary, or analysis , of the data collection revealed: " resident weight has been stable 30, 90,180 days. Good appetite/appropriate intake @ 100% of meals. Resident stated that he enjoys his meals. Continue with current plan of care. Check cmp (labs) followup prn (as necessary). " Interview on 10/14/11 beginning at 2:20 p.m. with the RD who wrote the note , confirmed that there hadn ' t been an annual assessment that corresponded with the annual MDS completed for this resident. Also stated in this interview was that food allergies documented in the record would be investigated as to severity of reaction and type of food that caused the allergy. Food preferences, collected by the dietary manager would also be included in the assessment. This information would be addressed in the assessment and the plan of care for the resident. The RD confirmed that neither an investigation of the allergies or multiple food dislikes were addressed and planned for in the assessment. The RD confirmed that the planned menu had not been adjusted to reflect this resident ' s food allergies and many food dislikes, and it would be the cook who would make the decision about what the resident would eat when the planned menu included a food that the resident either was allergic to or disliked. It was confirmed that due to the resident ' s multiple allergies and food dislikes, and without a planned menu to guide dietary staff, the resident probably ate hot dogs or a cold cut sandwich several times a week for lunch and dinner. On 10/11/11 the dinner menu was noted to be tuna salad sandwiches and the alternate meal was egg salad sandwiches, both of which resident #4 has listed as foods that he is allergic to. In an interview with the dietary manager on 10/11/11 at approximately 4:30 p.m. , she reported that he would probably receive either a hot dog or a cold cut sandwich, both of which they always had on hand and the resident enjoyed. In an interview with the dietary manager on 10/11/11 at approximately 10:30 a.m., it was confirmed that the resident did not have a labeled HS (before bedtime) snack. The dietary manager reported that labeled snacks are sent for distribution before bedtime to residents as well as other snack foods and sandwiches for residents to choose from that do not have a labeled snack. It would be up to the aide who distributed them to ensure that residents make the right choice based on their diet restrictions. Interview with the Director of Nurses (DON) , on 10/11/11 beginning at 10:45 a.m. , revealed that prior to 09/14/11, information related to resident ' s food allergies was maintained and could be referenced by the aides in the resident cardexes. These were kept on top of the rack of medical records in the main nursing station. However, the DON reported that she had learned that aides thought they couldn ' t access the cardex, similar to their not having access to the resident ' s medical record. Interview with nurses, nurses aides, and dietary aides, on 10/11/11 beginning at 11:00 a.m and continuing throughout the day, revealed that nurses knew they could find resident ' s allergies listed on the bottom of the Physician order [REDACTED]. The nurses aides reported that they could ask the nurses about food allergies, or go to their ADL books as there was a list of the four residents and the foods they were allergic to in each of the books. Aides also reported that the resident cardex, kept on the top of the medical record rack in the main nursing station, was a resource for foods that residents were allergic to. Dietary aides reported that a list with the four residents and the foods they were allergic to was taped to the refrigerator adjacent to the tray line for easy access. Also the diet slips listed resident food allergies. The Activities Director, on 10/11/11 at 3:20 p.m. , reported , as a reference for aides, there was a Restorative Dining file kept at the main nursing station that listed specific information about residents ' meals and dining needs. The file was discovered to contain lists of residents ' diet modifications, allergies, and assistive equipment needs, which was all dated 04/22/11. The list had not been kept current, and had not been reviewed and updated once the investigation into the resident sustaining an allergic reaction occurred. A High Risk Nutrition Assessment note, dated 04/14/11, was reviewed. Per interview on 10/14/11 at 2:20 p.m. the note was written to address the residents weight loss over the past year. This note referred to two of the four foods to which the resident was allergic. The note reflected that the resident was lactose intolerant and he had agreed to take a calcium/vitamin D supplement to replace calcium that he wasn ' t ingesting by omitting dairy foods from his diet. The note also listed " allergy to eggs to eat " , but there was no intervention to address omitting eggs from the diet, even though a review of the planned menu included eggs as a breakfast protein from four to six days a week, depending on the week of the four week cycle . Due to one aide not asking either the resident or his nurse about food allergies , resident #4 received an HS snack containing a food to which he was allergic. Due to an incomplete nutrition assessment, which did not reflect resident #4 ' s multiple food allergies and many food dislikes, the RD did not review and revise the planned menu to ensure that resident #4 received a nutritionally adequate, varied diet. This extended to the HS snack. When there is a variation away from the planned regular menu, such as a Physician ordered Therapeutic or Modified consistency diet, or when a resident has multiple allergies and food dislikes, the RD is responsible for reviewing and revising the menu to ensure the nutritional adequacy and resident tolerance and acceptance. Relying on aides, either dietary or nursing, to make the decision as to what to provide a resident when he refuses what is on the planned menu, based on his allergies or dislikes, is not providing care to help that resident attain the highest practicable level. 3. Resident # 1 had been a resident of the facility since 10/10/95 per the face sheet located in the resident ' s medical record, which also listed [DIAGNOSES REDACTED]. Also listed on the face sheet was an allergy to orange sherbet. Review of the diet slip that accompanied the meal trays revealed listed under allergies was " orange sherbet " . Review of the Nutrition Section (Section K) of the Annual MDS Assessment, completed on 08/29/11 , revealed the resident had no swallowing disorders, was 61 " tall and weighed 112 pounds, had had weight loss but was not on a physician ordered weight loss program, and received a mechanically altered, therapeutic diet. The Nutritional Status Worksheet of the CAA, completed on 08/21/11, had not been marked for the resident ' s allergies or food intolerances. A Nutrition care plan had been developed on 06/03/11 and reviewed on 09/01/11. It identified the resident as having a swallowing problem, and receiving a mechanically altered diet, with the goal of eating more than 75% of most meals daily. Interventions included providing the diet as ordered with thickened liquids and the supplement as ordered. The resident ' s allergy to orange sherbet was listed under the intervention without any reference to the reaction that should staff should be alert to, or what the resident would receive instead. Review of the nutrition notes in the resident ' s medical record revealed an annual assessment completed by the RD on 08/12/11. Under the data collection section of the assessment was an area to document the resident ' s Diet History which included both Food Allergy and Food Intolerance. The source of the information was the family and the RD had documented NKFA and ' no ' to food intolerance. The summary and/or analysis of the data collection did not refer to an allergy or food intolerance, even though it was the same RD who had completed the Food Preference Record on 08/12/11 which listed the resident ' s Food Allergies as orange sherbet and jello. Interview with this RD on 10/14/11 beginning at 2:20 p.m. revealed that this resident ' s mother was very involved in his care and the facility took direction from the mother as to what the son was to be served at meals and snacks. The RD confirmed that an investigation into a food identified as one that the resident was allergic to would be made so there would be an understanding of the severity or type of reaction that might occur. The RD confirmed that this information would be incorporated into the assessment and care plan to ensure that the resident ' s nutritional needs were being met. However, the RD was not able to identify in her notes any discussion of the allergy to either orange sherbet or jello that she had documented. 4. Resident #3 had been a resident of the facility since 07/06/07 per the face sheet located in the resident ' s medical record. The face sheet listed the resident ' s [DIAGNOSES REDACTED]. The face sheet also listed an allergy to milk. Review of the resident ' s diet slip listed the Allergy to Milk Products. Review of the Annual MDS Nutrition Assessment (section K) revealed the resident had no swallowing disorders, was 53 " tall and weighed 99 pounds, and received a mechanically altered diet. Review of the Care Area Assessment, Nutritional Status Worksheet, dated 06/16/2011, revealed under Current Eating Pattern, the item " Resident has allergies or food intolerance " was not identified as describing this resident. The analysis of findings did not reflect that the resident was not to be provided with milk at her meals related to an allergy. Review of the RD ' s Annual assessment, dated 06/03/11 , revealed data collection that did not identify ' food intolerances and allergies.' The Nutrition Assessment summary completed by the RD concluded that the resident " continues to take meals in restorative/assisted dining , total feed, with appropriate intake of 75 - 100% meals. Weight has been stable @ 30, 90, 180 days. Labs reviewed were within normal range. Repeated skin tear , on mvi (multivitamin) daily. Diet order appropriate (has teeth) due to [DIAGNOSES REDACTED]. " There was no reference to the milk allergy or whether it had been addressed in the plan of care. A follow up note was reviewed, written on 09/09/11 which listed the resident ' s food allergies/intolerance to milk in the data collection section. The summary of the data collection included the phrase, " history of milk allergy?, continue with current plan of care. Add calcium supplement with D3. Follow up prn. " There had been no investigation related to the question of the history of milk allergy and whether the use of a milk replacement, such as [MEDICATION NAME] Milk, would be tolerated by the resident. The October 2011 Physician order [REDACTED]. There was no follow up note by the RD as to what happened to the recommendation for the calcium supplement. 5. Resident #2 was admitted to the facility on [DATE] per the face sheet located in the resident ' s medical record. The face sheet listed [DIAGNOSES REDACTED]. Review of notes located under the Dietary tab in the resident ' s medical record revealed a Food Preference Record, dated 11/04/11, signed by Certified Dietary Manager documenting the resident ' s allergy to " peanut " (sic). Review of the RD ' s Initial Nutrition Assessment, dated 11/08/10 did not include in the data collection section of the form the residents ' food intolerance and allergies ' . Review of the Assessment section of the form did not reveal any reference to the peanut allergy specifically, however there was reference to discussing with the resident her preferences. Review of the Nutrition Section of the Initial MDS Assessment , completed on 11/12/10, revealed the resident had no swallowing disorders, was 63 " tall and weighed 100 pounds, had had a significant weight loss, and was on a mechanically altered diet. The Care Area Assessment did not include that the resident had a food allergy or intolerance. Review of care plans for resident #2 revealed the Maintenance ADL & Safety Care Plan & Communication tool, reviewed and revised on 08/11/11 listed the peanut butter allergy. The Individualized Care Plan for Nutrition, Hydration, Electrolyte Imbalance & Elimination, initiated in November 2010 (date illegible), and revised most recently on 08/11/11, did not include the peanut butter allergy. Follow up notes written by the RDs, dated 02/11/11 , 04/13/11, 05/13/11, 06/10/11 and 08/12/11, did not refer to a peanut allergy. Interview with the RDs on 10/14/11 beginning at 2:20 p.m. revealed that an investigation would be made if a resident had a documented food allergy. There was no documentation that the RDs had investigated this resident ' s food allergy, including the severity of it or the type or amount of the food or the reaction that would occur.

Based on review of resident medical records, review of the planned menu, interview with residents and facility staff, and observation at meals, the Administrator failed to ensure that staff were knowledgeable about food allergies for four (#1,2,3,4) of four residents, or aware of how to obtain information related to food allergies prior to providing a food or beverage. Administrator failed to ensure that the meal delivery system was effective in preventing residents with food allergies from receiving those foods, based on accurate, comprehensive nutrition assessments that had been integrated into the food delivery system with a planned menu, that included the bedtime snack for one resident (#4) with multiple food allergies and food dislikes. Administrator failed to ensure that one resident (#4) had been assessed for the need for a guardian to assist with medical decision making. These practices resulted in the determination of Immediate Jeopardy which was on-going. Findings include: 1. Review of the POS [REDACTED] " Summary of Position: the Nursing Home Administrator is responsible for maintaining appropriate guidelines and regulations to assure the highest degree of attention and care is provided to all residents. Essential Duties and Responsibilities: Plans, develops , organizes, implements, and directs the facility ' s programs and activities. Ensures that each resident ' s right to fair and equitable treatment, self-determination, individuality , privacy, property, and civil rights, including the right to lodge a complaint, are strictly enforced. 2. Interview with the Administrator on 10/11/11 beginning at 10:30 a.m. revealed that a nurses aide provided a bedtime sandwich to a resident that contained a food to which he was allergic. Within the hour, per nurses notes dated 09/14/11 at 2150, the resident reported that he had eaten the sandwich to which he was allergic. At 2300, that same night, the nurse documented that the resident reported that he was having chest pains. A physician's order [REDACTED]. Interview with resident #4 on 10/11/11 beginning at 9:00 a.m. revealed he was aware of which foods that he was allergic to. When asked about the incident, the resident confirmed he ate the sandwich and reported, " I did wrong. " When asked about the aide ' s response to his asking for a tuna sandwich, he reported that " she did wrong too. " Interview with the aide who provided the tuna sandwich to the resident, on 10/11/11 beginning at 2:30 p.m., revealed that the resident knew what kind of sandwich it was since he had heard her tell his roommate . She said he never said he was allergic to tuna, but just accepted the sandwich and ate it. She said that she is familiar with the resident and thinks he is alert and oriented and able to say what his allergies were. She reported that she often delivered HS snacks to residents and either knew a resident was alert and oriented and could tell her their allergies, or knew the resident wasn ' t alert and oriented and she would have to ask the nurse . She said that resident #4 usually took something from the snack cart. The aide confirmed that there was not a labeled snack for this resident. She reported that she heard later that he had been transferred to the hospital with chest pains but did not think it could have been due to the tuna sandwich that she provided to him. Based on interview with the Administrator (10/11/11 beginning at 10:40 a.m.) and review of the time line of the events that had taken place, it was apparent that for a two week period, from when the resident returned to the facilty from the hospitalization for the allergic reaction (09/18/11) until the report to the State Agency and the Abuse Hotline had been made (09/27/11), no investigation of how the resident had been provided with a snack that was made with a food that he was allergic to had happened. Interviews with facility staff that had been present the night the incident occurred did not happen until the report was filed on 09/27/11, approximately two weeks after the incident. Inservicing of staff related to residents ' with allergies were not provided until 09/28/11, two weeks after the event. Chart audits by Nursing staff and a review of allergies on file conducted by the Pharmacy did not occur until 09/28/11, two weeks after the event. Updating of reference material located in the aide ' s documentation notebooks did not occur until 09/28/11, two weeks after the event. No documentation could be found that any of the four residents with food allergies had been reassessed after the event on 09/14/11, to determine the extent of their allergy , whether it was a true allergy or food intolerance, and no recognition had been made of the need for a planned menu specifically for resident #4 based on his food allergies and multiple food dislikes - predominately of protein rich foods. This was confirmed by interview with the Registered Dietitians in an interview on 10/14/11 beginning at 2:20 p.m. No documentation, prompted by the event that occurred on 09/14/11, by the physicians could be found for any of the four residents with food allergies, related to a review of their allergies. Per the Administrator, (on 10/11/11 at approximately 1:00 p.m.) the facility had developed an action plan to address this event which included resident medical record audits, an audit of all resident records by the Pharmacy and inservicing the staff on Food and Drug Allergy Awareness. However , there was no documentation of a review of the process to monitor meal tray preparation in the main kitchen or delivery of meal trays to residents, and despite inservicing staff on which residents had food allergies, observation on 10/13/11 during the lunch meal confirmed that the facility had not completely investigated the systems in place to ensure that residents who were allergic to foods would not be served them at meals. 3. Administration failed to ensure that Residents were appropriately assessed related to foods that were eliminated from their diets due to food allergies, and failed to ensure that a menu was planned to replace the eliminated foods which would meet their nutritional needs. Nutrition notes written by the Registered Dietitian on 02/11/11, 04/14/11, 05/13/11, and 08/12/11 did not address the resident ' s food allergies in the assessment and did not evaluate the effect that the foods that were eliminated (tuna fish, dairy/milk, eggs, peanut butter) would have on the nutritional adequacy of the diet. Also, the nutrition assessment did not reflect the many foods that the resident reported he disliked. Interview with the RD who had assessed the resident ' s nutritional status, in interview on 10/14/11 beginning at 2:20 p.m. confirmed that there had been no revision made to the resident ' s menus to reflect the many food allergies and food dislikes. Interview with the Dietary Manager on 10/11/11 at approximately 4:30 p.m. revealed that due to the planned menu for that night ' s dinner, which was two foods that the resident disliked or was allergic to, the resident would have either hot dogs or a cold cut sandwich. Review of the planned menu revealed that for the four week cycle menu, between four and seven meals a week would not be tolerated by the resident and he would need to receive an alternate meal, which without the planned menu would fall onto the dietary aide to determine . Review of residents # 1, 2, and 3, all had documented food allergies, per record reviews of their face sheets which listed the food to which they were allergic. Review of Review of Nutrition notes, written by the Registered Dietitian, on 04/13/11, 05/27/11, and 08/12/11, for resident #1, revealed no discussion of a food allergy, even though the Food Preference Record, dated 08/12/11 listed that the resident was allergic to orange sherbet and jello. Review of care plans dated 06/02/11 with a new revision date of 09/01/11 listed the resident as having an allergy to orange sherbet and jello. The RD note dated 08/12/11 corresponded with the annual MDS assessment and the Food Preference Record. The Data Collection section of the assessment form did not reference the resident ' s allergy and review of the form revealed the abbreviation " NKFA " (no known food allergy) and the word " NO " written in next to the trigger " Food Intolerance " . Interview with the RDs who wrote the notes, on 10/14/11 beginning at 2:20 p.m. revealed food allergies or intolerances would be investigated as part of an annual assessment. The RDs confirmed that the resident ' s mother was very involved in this resident ' s care and directed the facility to provide certain foods to her son. The RDs were not able to identify in their notes discussions they had with the mother in reference to the resident ' s allergy to orange sherbet and jello. There was no documentation that a discussion had taken place with the mother related to type of allergic reaction and severity, which would assist facility staff in providing the resident with the best care. Review of Nutrition notes for resident #3, written on 12/07/2010, 03/17/11, and 09/09/11, revealed documentation that the resident had an allergy to milk. This information was not included in the annual assessment written on 06/03/11. The Care Area Assessment of the MDS Annual assessment , completed on 06/16/11, did not reflect that the resident had a food allergy or intolerance. It was not until the 09/09/11 note that the RD questioned the milk allergy ( " Hx of milk allergies? " ) and recommended to " add calcium supplement with D3 " . There was no documentation in the September 2011 note, or follow up notes that an investigation was made into the history of the milk allergy. However, there was no confirmation in a review of nurses notes in September referring to the recommendation made by the RD. A review of the October physician's order [REDACTED]. Review of Dietary and Nutrition notes for resident #2 , found under the Dietary tab in the resident ' s medical record, revealed the Food Preference Record dated 11/08/10 and signed by the Certified Dietary Manager indicated that the resident had an allergy to " peanut " (sic). Review of the Initial Assessment completed on 11/08/10 by the RD did not reflect an allergy to peanuts. There was no reference to an allergy or intolerance made in the data collection section of the assessment form and no reference made in the assessment section of the form. Additional nutrition assessments , completed by the RDs , dated 02/11/11, 04/13/11, 05/13/11, 06/12/11 and 08/12/11 made no reference to a peanut allergy . Review of the resident ' s intial MDS Care Area Assessment , dated 11/12/10 did not include that the resident was allergic to peanuts. The Maintenance ADL & Safety Care Plan and Communication Tool, located in the resident ' s cardex, initiated on 11/03/10 and reviewed and updated on 08/11/11, listed an allergy to peanut butter. Interview with the resident on 10/11/11 during the evening meal, revealed she doesn ' t eat peanut butter because it effects her [MEDICATION NAME]. 4. Administration failed to ensure that the meal delivery system provided meals or bedtime snacks to residents that did not include foods to which they were allergic. No monitoring system was found during the visit of the meal delivery system that ensured that dietary aides provided the correct foods, or staff that were assisting residents with their meals or serving meal trays knew to review the dietary slip to ensure that the correct foods were being served. No monitoring system was found during the visit that ensured that bedtime snacks were provided by aides who knew to confirm with nursing staff, or who knew where to access information about food allergies, allowing one resident with multiple food allergies to receive a food to which he was allergic. On 10/13/11 beginning at 1:00 p.m. revealed resident # 3 who was seated in the main dining room with her meal in front of her. The resident was dozing in her geri chair and had yet to be assisted with her meal. She had been served a pureed lunch and a small tulip cup containing dessert. The small cup contained pureed pie that had milk poured over it. Resident #3 was one of the four residents who had been identified as having a food allergy, which was to milk. An aide who was assisting a resident with his lunch at the table with resident #4 was asked about the dessert. She confirmed that it was resident #4 ' s dessert and agreed that milk had been poured over the pureed pie and that resident #4 was allergic to milk. A second aide was called over, who removed the dessert with the milk and provided resident #4 with pureed fruit. Observation and interview with resident # 2, on 10/13/11 at 1:20 p.m. , who had been identified as being allergic to peanut butter, occurred in the resident ' s room, after the resident had eaten her lunch. There was a piece of peanut butter pie on the resident ' s over bed table. The resident, at that time, confirmed that she had just eaten her lunch sitting in her room, had had a few bites of the pie, but wasn ' t sure if she would eat more of it. She reported that she couldn ' t eat much peanut butter, due to an allergy to it, because it interfered with her [MEDICATION NAME] receptors. The resident confirmed that the aide had left the pie on the over bed table in case she wanted to eat more of it. Interview with a dietary staff member, on 10/13/11 at approximately 1:25 p.m. , confirmed that resident #2 could have received the peanut butter pie, as he was concentrating on not serving resident #4 the peanut butter pie. (Resident #4 was documented as being allergic to peanuts.) The dietary aide did not remember serving the pureed pie with the milk to resident # 3, but confirmed that the pie was the dessert that most of the residents received. 5. Administration failed to ensure the rights of resident #4 who had been judged not competent to make decisions, by not ensuring that a guardian be named to assist with decision making. Review of the medical record for resident #4 revealed the face sheet, located in the resident ' s medical record, indicated that [DIAGNOSES REDACTED]. The face sheet also did not indicate that there were any contacts for this resident. Review of Progress notes in the medical record revealed a note written by a Physician with the date " 4/8 " but no year. The note read, " Imp (impression) Seen and examined, not competent to make decisions. Appropriate documents signed. " No other notes referenced this note. Review of a Psychological Services note dated 09/21/10 revealed the No was circled in response to the question on the form " Can Resident make appropriate medical decisions at this time. " Review of the Social Service(SS) notes did not reflect that she was aware of this physician ' s note. The SS notes did not reflect that the resident had any family or responsible party. Interview with the Social Services Director (SSD) on 10/14/11 beginning at 2:15 p.m. confirmed that she was not aware of the note from " 4/8 " indicating the resident was not competent to make decisions. The SSD confirmed that the resident had neither family nor a responsible party and that she had not been working on obtaining one for this resident. The Immediate Jeopardy was on-going based on observation made at lunch on 10/13/11 beginning at 1:00 p.m. when resident #2 was observed to be served peanut butter pie, even though the diet slip that accompanied the meal indicated that she was allergic to peanut butter. The resident confirmed that she had eaten some of the pie. Resident #3 was observed to receive a milk topped pureed dessert, even though the diet slip that accompanied the meal indicated she was allergic to milk.