Every finding on record at Stuart Rehabilitation and Healthcare

Based on observation, interview and record review, the facility failed to timely submit resident data, within 14 days as required, for 4 of 4 sampled residents reviewed for Minimum Data Set (MDS) submissions, Residents #2, #30, #67 and #75. The findings included:a. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included Paroxysmal Atrial Fibrillation, Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side and Chronic Obstructive Pulmonary Disease. Record review of the annual Minimum Data Set (MDS) assessment revealed it was accepted to Centers for Medicare and Medicaid Services (CMS) on 07/01/25. It was completed on 06/16/25. The assessment was submitted on day 15.b. Record review revealed Resident #30 was admitted to the facility on [DATE] with a diagnosis of Congestive Heart Failure. Record review revealed the quarterly MDS was completed on 05/12/25 and submitted on 05/29/25, 17 days after completion.c. Record review revealed Resident #67 was admitted to the facility on [DATE] with a diagnosis of post Cerebral Infarction. An interview was conducted with the MDS coordinator on 09/17/25 at 12:08 PM revealed an entry assessment was submitted on 09/02/25 which was more than 14 days after the Assessment Reference Date (ARD).d. Recor review revealed Resident #75 was admitted to the facility on [DATE] with a diagnosis of Atherosclerotic Heart Disease of native coronary artery without angina pectoris. A quarterly MDS was completed on 08/18/25 and submitted on 09/09/25, which was on day 22.An interview was conducted with the MDS coordinator on 09/17/25 at 2:30 PM regarding the 4 late MDS submissions reviewed. The MDS coordinator stated they were all late submissions. She stated she tries to submit weekly but sometimes she gets busy, and she does it every 2 weeks and that is how she got behind.

Based on record review and interview, it was determined, the facility failed to appropriately assess 1 of 2 sampled residents experiencing changes in condition, Resident #1, as evidenced by the lack of monitoring signs and symptoms of a bowel obstruction, that included vomiting, diarrhea, bradycardia / tachycardia and fever. The findings included: Clinical record review conducted on 04/10/25 revealed Resident #1 has been a long-term care resident at the facility since 08/29/22. Review of the Minimum Data Set (MDS) quarterly assessment, with reference date 01/16/25, documents Resident #1 was assessed as severely impaired for skills of daily decision making; is always incontinent of bladder and bowel; has active diagnoses of dementia; and is dependent on staff for activities of daily living (ADLs). Revie of the Care plan titled, At risk for constipation related to decrease self-mobility, last revised 01/22/25, documents interventions as: observe for and report to medical doctor complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, bradycardia, abdominal, distension, vomiting, small loose stools, fecal smearing, decreased bowel sounds, diaphoresis, abdominal tenderness, guarding, rigidity and fecal compaction. The electronic record revealed a nurse's note communicating to the physician via fax dated 03/04/25. The nurse advised the physician that Resident #1 was vomiting, and the nurse requested antiemetic medication. The physician replied with an order for Zofran 4 milligrams every six hours as needed. Review of the Progress notes dated 03/05/25 documents, Resident remains in bed at this time and will not allow staff to get her up. Resident did not eat breakfast this morning and would not allow staff to feed her. Vital signs stable. Resident fought this nurse when the blood pressure cuff was applied but ultimately allowed vitals to be obtained. Afebrile. Resident continues to sleep but is responsive and easily roused. Review of the Advance Practitioner Registered Nurse (APRN) notes dated 03/05/25 documents, Seen in bed lethargy, vital signs stable. Patient not eating, won't get out of bed which is not her norm. Patient did vomit one episode yesterday. Review of the APRN notes dated 03/10/25 documents, the resident was seen in the hallway, lethargy has resolved, chest x-ray and urine tests were negative. The resident refused intravenous fluids and laboratory studies. Review of the Progress notes dated 03/11/25 documents as follows: Resident noted to be choking while swallowing thin liquids. APRN notified and new orders for speech consult. APRN notified of resident's abdomen is distended and causing her discomfort. New orders to give a rectal enema and a KUB (abdominal x-rays, kidney, ureter and bladder) stat. APRN was notified of resident produced a large stool post enema. APRN was notified of KUB results. Review of the Abdominal x-rays results dated 03/11/25 documents, mild to moderate ileus, follow up x-ray is needed. Review of the vital signs report and progress notes indicated the last documented vital signs for Resident #1 were dated 03/05/25. Review of the Progress notes dated 03/12/25 documents the resident noted with no bowel sounds in any quadrant. Emergency services were called to send the resident out. APRN aware. Family notified. The record failed to document Resident#1's condition or vital signs prior to transfer. Review of the Hospital records indicate Resident #1 arrived at the emergency department via ambulance, with complaints of diarrhea and abdominal distention for two days. Rescue states, as per nursing staff, the patient had ileus found two days ago. The patient has dementia and is oriented to person. The record indicates the resident arrived with unstable vital signs, blood pressure 77/45, pulse 100, and oxygen level 90 percent on room air. Laboratory studies indicate increased white blood cell count, decreased potassium levels, and abnormal kidney function. Ct scan of the abdomen revealed the following: 1. Constipation with severe fecal impaction that extends out through the sigmoid colon to the upper abdomen. The rectum measures 11 cm in diameter and the sigmoid colon measures 12 cm in diameter and is distended with dense appearing stool. Constipation extends through the splenic flexure. There is wall thickening of the descending colon, sigmoid colon and rectum likely reflecting stercoral colitis. 2. Bowel perforation. Large amount of pneumoperitoneum from bowel perforation, likely related to the severe fecal impaction/stercoral colitis. Recommend General Surgery consultation. The emergency department notes documents, Patient with peritoneal signs on exam. Lab studies consistent with leukocytosis. Discussed with general surgery. Awaiting imaging.After imaging patient with pneumoperitoneum in the setting of severe constipation and would require colostomy. Plan for hospice care with [Name provided] hospice. Patient to be admitted . An interview was conducted with the Director of Nursing (DON) on 04/10/25 at 12:34 PM who revealed the facility reviewed the care provided to Resident #1 after she learned the resident had a bowel obstruction and the staff reviewed the bowel protocols, and no deviations of care were identified. A phone interview was conducted with Staff A, Licensed Practical Nurse (LPN), on 04/10/25 at approximately 1:40 PM who revealed the staff worked on 03/11/25, the resident told her she had pain and pointed to her belly, she reported it to the practitioner and x-rays were ordered. The staff recalls the resident was at baseline, wheeling self around the building, she had an enema with good results and ate dinner. The staff stated she does not recall getting prior reports that the resident was vomiting but recalls reports of diarrhea. The staff is not sure when the episodes of diarrhea occurred two or three days prior to her shift on 03/11/25 as she did not have her notes available and does not recall if vital signs were taken as the resident was at baseline. An interview was conducted with the DON on 04/10/25 at approximately 1:50 PM who confirmed the fax addressing complaints of vomiting and the physician response prescribing Zofran did not make it to the clinical record, there were no orders written, and she would complete an incident report. A follow-up interview with the DON on 04/11/25 at 2:16 PM confirmed there are no documented vital signs after 03/05/25, there is no evidence the staff re-approached and attempted to obtain the prescribed blood work after the resident refusal, and confirmed the nursing staff did not document the resident had vomiting or diarrhea. The investigation determined the nursing staff did not assess Resident #1 to monitor for continued changes in condition. There was no evidence that the staff monitored vital signs from 03/05/25 through 03/12/25. There is no documentation of Resident #1 refusing vital signs. The record validates the resident started to exhibit signs of gastrointestinal complaints on 03/04/25. The nurse failed to document the resident was vomiting and how often it occurred and failed to document and implement the physician's orders to treat the vomiting with Zofran. The nurse failed to document episodes of diarrhea and how often it occurred, as it was reported by Staff A during her interview. The nurse documented the blood work was completed on the Treatment Administration Record (TAR) dated 03/06/25. The investigation determined the resident refused it and there was no evidence that any further attempts were made to complete the laboratory studies or to initiate the intravenous fluids. Resident #1 had dementia and was well known to the staff. There was no evidence the staff tried to reapproach the resident at a later time to complete the testing and treatment.

Based on record review and staff interview, the facility failed to implement a baseline care plan within 48 hours of admission for 2 of 17 newly admitted sampled residents, Resident #202 and Resident #71. The findings included: 1. Record review documented Resident #71 was admitted to the facility on [DATE] with diagnoses which included Parkinsonism, Obstructive and Reflux Uropathy, Alzheimer's Disease, and Dementia. A review of Resident #71's electronic health record (EHR) contained no evidence of a Baseline Care Plan completed within 48 hours of Resident #71's admission. 2. Record review documented Resident #202 was admitted to the facility on [DATE] with diagnoses that included Dementia, Frontotemporal neurocognitive Disorder, and Anxiety. A review of Resident #202's EHR contained no evidence of a Baseline Care Plan completed within 48 hours of Resident #71's admission. On 05/22/24 at 1:50 PM, the Director of Nursing (DON) was asked where the Baseline Care Plans could be found within the electronic health records. She stated that the Baseline Care Plans are scanned into the resident's electronic record under the Observation section of the record. The DON looked with the surveyor through the EHR for Resident #202 baseline care plan. She acknowledged that the Baseline Care Plan was not in the resident's file. On 05/23/24 at approximately 1:30 PM, the DON was notified that the Baseline Care Plan for Resident #71 was also missing from the Observation section of the resident's EHR and could not be found in any other section of the EHR that was made available to the surveyor for review. The DON acknowledged that the Baseline Care Plan was not in the Resident #71's electronic file.

Based on record review and interview, the facility failed to ensure residents were invited to participate in care plan meetings for 1 of 19 sampled residents reviewed, Resident #61. The findings included: On 05/20/24 at 12:50 PM, and interview was conducted with Resident #61, The resident was asked if she attends her care plan meetings. She stated she didn't know what I was talking about and had never been to a care plan meeting. Review of Resident #61's medical records revealed the resident was admitted to the facility on [DATE]. A review of her quarterly MDS (Minimum Data Set) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition. A review of the resident's Care Plan meetings document showed the facility has had a care plan meeting every 3 months. The document showed who attended the care plan meetings that included the resident's son attending the care plan meetings via telephone. There is only one date of 07/27/23, when the resident attended. The following dates documented care plan meetings were held but did not have the resident in attendance and did not give a reason why the resident did not attend: 04/15/24, 01/17/24, 10/19/24, 05/10/23, and 02/21/23. During an interview on 05/23/24 at 9:52 AM with the Director of Social Service, the surveyor asked if Resident #61 attends the care plan meetings. He stated, 'it was established to call the son to give him updates, we just ask her how she is doing.' The Director of Social Service stated he has worked for the facility for almost a year, and it has always been established to call the son. When the surveyor asked if they invited the resident to the care plan meetings, he did not have an answer. He just kept saying it was established to have the son called. During an interview on 05/23/24 at 10:00 AM with the DON (Director of Nursing), she stated that the resident's son is involved in her care plan meetings. The surveyor asked why she was not invited, and the DON stated that she wouldn't want to go, if she saw a group of people she would get upset and think she did something wrong. She said we can talk to her in her room. The DON stated, 'I talk to her every day, and she is aware of her care.' The surveyor stated there is no documentation stating that she had talked to or invited Resident #61 to the Care Plan meetings. During a follow-up interview on 05/23/24 at 10:30 AM with Resident #61, she was advised that her son has been attending the care plan meetings by telephone. She was asked if she wanted to attend and stated, he can just do it but then stated she 'wants to go to the care plan meetings'.

Based on observation, record review, interview, and policy review, the facility failed to ensure respiratory care and services for 3 of 3 sampled residents, as evidenced by staff failed to store and change oxygen and nebulizer (a device for administering a medication by spraying a fine mist) tubing for Resident #36; failed to remain with Resident #36 during a nebulizer treatment, then failed to complete a post treatment assessment as per policy; failed to assess Resident #306 before and after a nebulizer treatment; and failed to obtain a physician order for oxygen use for Resident #9. The findings included: Review of the policy, titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, documented, in part, the process for preparing and setting up the nebulizer for administration of a medication, followed by, . 6. Obtain baseline pulse, respiratory rate and lung sounds. 17. Remain with the resident for the treatment. 26. Obtain post-treatment pulse, respiratory rate and lung sounds. This policy then described the process for cleaning followed by, 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. Change equipment and tubing every seven days, or according to facility protocol. Documentation: The following information should be recorded in the resident's medical record. 5. Pulse, respiratory rate and lung sounds before and after the treatment. 6. Pulse during treatment. 7 Amount and characteristics of sputum production. 8. The resident's tolerance of the treatment. 9. Any adverse effects of the medication and/or treatment and physician notification, if applicable. Reporting: . 3. Notify the Physician if the resident experiences adverse effects from the medication. Review of the policy, titled, Medication Orders, revised November 2014, documented, in part, . Supervision by a Physician . 2. A current list of orders must be maintained in the clinical record of each resident. Recording Orders: . 3. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale. 1. Review of the record revealed Resident #36 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score was not completed as the resident was rarely or never understood. This MDS documented the resident received oxygen therapy. Review of the current care plan initiated on 10/25/18 documented Resident #36 had a diagnosis of COPD and staff were to give oxygen therapy as ordered by the physician. Further review of the record revealed an order dated 11/18/19 for staff to change the oxygen and nebulizer tubing every week on Wednesdays. Another order dated 01/19/24 documented the resident was to receive oxygen at 2 liters per minute. Review of the current Medication Administration Record (MAR) for May 2024 revealed Resident #36 received DuoNeb (a respiratory medication) via the nebulizer twice daily, and received Pulmicort (another respiratory medication) twice daily. Both of these medications revealed documentation on the MAR that the treatments were for 15 minutes. The documentation lacked any type of assessment, tolerance, or effects. During an observation on 05/20/24 at 11:25 AM, Resident #36 was in bed wearing a nasal cannula for the administration of oxygen, but the nasal cannula was on top of the resident's nose instead of in the nares. The tubing on the oxygen had a label dated 5/8 (Photographic Evidence Obtained). A nebulizer was noted on top of the bedside table with the tubing going into a nearly closed drawer. On 05/20/24 at 1:55 PM, while passing by the nurse's station on the way to Resident #36's room, Staff A, Registered Nurse (RN), was noted sitting at the desk and working on the computer. Upon entering the room of Resident #36, the nebulizer was noted to be running and Resident #36 was receiving a nebulizer treatment through a respiratory mask. At 2:00 PM, Staff A, RN, entered the room and took the mask off of Resident #36. The RN started to put the nebulizer mask back into the drawer, and then stated he would change it because there was no bag to store the mask. An observation of the mask revealed it was soiled with light tan spots inside the mask and the tubing lacked any date. The RN failed to do any type of post treatment assessment. A subsequent observation on 05/20/24 at 2:03 PM revealed Resident #36 wearing the oxygen and the tubing on the oxygen concentrator was still dated 05/08/24. An observation on 05/21/24 at 1:59 PM revealed the oxygen tubing on the concentrator was still dated 05/08/24, and the nebulizer mask was now in a storage bag on top of the bedside nightstand, but it was not dated. Resident #36 was in bed, the oxygen concentrator was running, and the nasal cannula was on her left cheek instead of in her nares. On 05/22/24 in the afternoon, the photograph of oxygen tubing dated 05/08/24 was shown to the Director of Nursing (DON), and the observations with Staff A were shared with the DON. The DON agreed with the concerns. 39167 2. Record review revealed Resident #306 was admitted to the facility on [DATE], with diagnoses that included Cardiorespiratory Conditions, Heart Failure, Pneumonia, and COPD. Review of the Physician order dated 05/22/24, documented for ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL special instruction Listen to lung sounds before and after treatment. On 05/22/24 beginning at 8:49 AM, observation of medication administration was conducted with Staff G, Registered Nurse (RN). Before the process of the nebulizer treatment (of Ipratropium-albuterol), Staff G failed to listen to Resident #306's lung sounds. After the treatment, Resident #306 removed the nasal canula (oxygen tubing) from her nose. Subsequently, she began to experience desaturation (low blood oxygen concentration). The pulse oximeter read, 60, which is considered low. Normal pulse oximeter is between 95% and 100%. After the treatment, Staff G stayed with Resident #306 for about 5-8 minutes, and instructed her to take deep breaths, purse lip breathing and kept checking the pulse oximeter, gradually the pulse oximeter was increasing, and eventually went up to 94%. Staff G failed to listen to Resident #306's lungs after completing the treatment. Staff G left the room, went to the medication cart, said he was done and proceeded to withdraw medications for other residents. On 05/22/24, at 9:20 AM, the surveyor asked Staff G if he should have listened to Resident #306's lungs sounds. especially since Resident #306 experienced de-saturation. Staff G voiced that's a good idea, but it didn't come up as an order for him to check her lungs sounds. He then asked the Assistant Director of Nursing (ADON) who was standing near them, about listening to lungs sound before and after treatment. The ADON asked him to look in the policy as she did not remember offhand. Staff G, ADON and the 500-unit Manager looked up the policy. They revealed that lungs should have been listened to before and after the treatment. During this time, the surveyor asked to see the nebulizer treatment policy and procedure. They immediately provided it. The policy, titled, administering medications through a small volume handheld nebulizer, dated October 2010, indicated that the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The steps in the procedures included, #6 obtain baseline pulse, respiratory rate and lungs sounds. #26 obtain post-treatment pulse, respiratory rate, and lung sounds. 33103 3. Record review revealed Resident #9 admitted to the facility on [DATE], with diagnosis that included Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, Insomnia, Atrial Fibrillation, Severe Protein Calorie Malnutrition, Hypertension, Major Depressive Disorder, Transient Ischemic Attack (TIA), and Chronic Pain Syndrome. Review of quarterly MDS assessment dated [DATE] documented the resident has a BIMS score of 15, indicating the resident was cognitively intact. Section O documented the resident was receiving oxygen. A review of Resident #9's physician orders revealed no order in place for oxygen. Observations on 05/20/24 to 05/22/24 revealed the resident to be wearing an oxygen nasal cannula in her nose running at 2.5 liters per minute. During an interview on 05/22/24 at 9:52 AM with Staff F, Registered Nurse (RN), she was asked if resident is on oxygen, she stated yes. The surveyor asked if the nurse would look up Resident #9's physician order for oxygen. The nurse looked in the record and stated that she did not see an order. She then went back to discharge orders from 01/01/24-05/22/24, and stated the resident had an oxygen order on 03/07/24 but it was discontinued when she was sent to hospital on 03/25/24. She stated the oxygen order was not put in place when she came back on 03/27/24. She stated she uses the oxygen as needed (PRN). The nurse then went into the resident's room and took her O2 saturation, which was 96%. She took the oxygen off the resident and told her she didn't need it. The nurse said she would call the physician to get an order for oxygen as needed.

Based on observation, record review, interview, and policy review, the facility failed to ensure accurate labeling of medications for 2 of 8 sampled residents, Resident #5 and #9, who had medication ordered for bedtime, with a change in scheduled administration time, and failed to identify the change on the medication packaging. The findings included: Review of the policy, titled, Medication Ordering and Receiving from Pharmacy, dated May 2022 documented, in part, Policy: Medication are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy / registered pharmacist can modify, change, or attach prescription labels. Procedures: . G. Medication labels are not altered, modified, or marked in any way by nursing personnel. 1) If the physician's directions for use change or the label is inaccurate, the nurse may place a change of order - check chart label on the container indicating there is a change in directions for use, taking care not to cover important label information. 2) When such a label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. 3) Old order is discontinued and a new order is sent to the dispensing pharmacy. 1. A medication administration observation for Resident #5 was made on 05/22/24 beginning at 4:11 PM with Staff C, Registered Nurse (RN). The RN pulled the bubble pack (medication card containing individual doses of a medication) for Atorvastatin 10 mg (milligrams) and popped a pill into the medication cup. Review of the label documented the medication was to be administered at bedtime, with no change of order sticker. Photographic Evidence Obtained. The facility's scheduled time for bedtime medications was 9:00 PM. This label also documented the bubble pack contained 30 pills and was dispensed on 05/04/24. Review of the physician's orders revealed the Atorvastatin was originally ordered on 03/24/20 to be given at bedtime and was scheduled for 9:00 PM. Review of the April 2024 MAR documented the medication was administered at 5:00 PM daily. Review of the May 2024 MAR documented the Atorvastatin was administered at 5:00 PM daily. The nursing staff failed to utilize the change direction sticker and failed to discontinue the previous order to administer at bedtime and or send the new order to the pharmacy for the administration at 5:00 PM. 2. A medication administration observation for Resident #9 was made on 05/22/24 beginning at 4:30 PM with Staff D, Licensed Practical Nurse (LPN). The LPN pulled the bubble pack for amitriptyline, an anti-depressant, and stated, Why is this coming up now at 5 (on the electronic medication administration record) when it's an HS (bedtime) medication. An observation of the label revealed the medication was to be administered at bedtime, with no change of order sticker. Photographic Evidence Obtained. Review of the physician orders revealed the amitriptyline was originally ordered on 11/03/23 to be administered at bedtime and was scheduled for 9:00 PM. Review of the April 2024 MAR documented the medication was administered at 9:00 PM. Review of the May 2024 MAR revealed the medication was administered at 9:00 PM until 05/11/24, when staff began administering the medication at 5:00 PM. During an interview on 05/22/24 at approximately 5 PM, a side-by-side review of the record and observation of the medication labels, the Director of Nursing (DON) agreed the labels documented the medication was to be administered at HS, yet the medications had been given during the evening at 5:00 PM. The DON explained that it was changed as per the resident's choice, and stated the Change Direction labels are on each medication cart and should be utilized for clarity.

Based on record review and interview, the facility failed to document when showers or bed baths were provided for 3 of 3 sampled residents, Resident #49, #252 and #61. This has the potential to affect all residents related to system documentation. The census at the time of survey was 108. The findings Included: Review of the Policy and Procedure for shower/tub baths documented, in part, under Documentation, the following: The following information should be recorded on the resident's ADL [Activities of Daily Living] record and/or in the resident's medical record: 1. The date and time of the shower/tub was performed 2. The name and title of the individual who assisted the resident with the shower/tub bath 3. All assessment data (e.g. any reddened areas, sores, etc on the resident's skin) obtained during the shower/tub bath 4. How the resident tolerate3d the shower/tub bath 5. If the resident refused the shower/tub bath, the reason why the intervention taken 6. The signature and title of the person recording the data. Under Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath 2. Notify the physician of any skin areas that may need to be treated 3. Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #61's medical records revealed Resident #61 was admitted to the facility on [DATE]. The resident's diagnosis included Intervertebral Disc Degeneration, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease, Osteoporosis, Osteoarthritis, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease: Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, and Hypertension. Review of the Physician Order documented, showers 3 times a week on Monday, Wednesday, and Friday on the 7:00 AM-3:00 PM shift. Review of the shower schedule showed days of Tuesday, Thursday, and Saturday on the 3-11 shift. Review of the care plan documented, requires staff assistance for bathing. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) of 15, indicating cognition is intact. During an interview on 05/20/24 at 12:37 PM, Resident #61 was asked if she gets showers as per her schedule. She stated, I do not get showers except once a week. Supposed to get them Tuesday, Thursday, and Saturday. She stated she has not told them or asked them for showers but feels that she shouldn't have to. She stated that they just walk by her room and do not say anything to her. During an interview on 05/23/24 at 10:30 AM with Resident #61, she was asked if she got a shower this week. She stated no, but the RN [Registered Nurse] stated to her she did get one on Tuesday by [name]. She stated, unfortunately, cannot show evidence of it, as the state is in the building, we were flustered and didn't get stuff done. The resident stated she didn't get one but then stated she doesn't know when her last shower was. 2. Review of Resident #49's medical records revealed Resident #49 was admitted to the facility 03/12/20. The resident's diagnosis included Dissection of Abdominal Aorta; Rheumatoid Arthritis; Cachexia, Moderate Protein-Calorie Malnutrition, Mild Cognitive Impairment; Dysphagia, Idiopathic Scoliosis, and Glaucoma. Review of the physician's order documented the resident's shower days are Tuesday, Thursday, and Saturday on the 3:00 PM-11:00 PM shift. Review of the care plan documented the resident requires one to two staff assistance with bathing / showering. Review of the resident's quarterly MDS dated [DATE] documented the resident's BIMS score is a 14, indicating cognition is intact. Review of the document called Point Care History documented that showers are given 3 times a week on Monday, Wednesday, and Friday. This was the resident's old schedule when she was in a different room. The document had a date, time, shift and whether it was done and who did it. Under the date, it documented multiple days of having showers two to three times, and the word 'done'. During an interview on 05/20/24 at 1:19 PM, Resident #49 was asked if she gets her showers as scheduled. She stated she is not getting showers because it is hard for her to stand up. The surveyor asked if she wanted them, and she said yes but she didn't know her shower days. During an observation and interview on 05/23/24 at 10:45 AM, Resident #49 was still observed in a hospital gown. She stated she has been asking to get dressed since 8:00 AM and she wants a shower, Staff J, Certified Nursing Assistant (CNA) walked by and was asked to come into room. She asked the resident about a shower. Resident #49 told the CNA that she wanted a shower this morning even though her schedule is this afternoon. The CNA told her that she is getting ready to give another resident a shower but will give her a shower when she gets done. The surveyor went back into room on 05/23/24 at 12:30 PM, and the resident was asked if she received a shower. She was so excited and stated, it was [NAME]. 3. Review of Resident #252's medical records revealed Resident #252 was admitted to the facility on [DATE] with a diagnosis to include Diverticulum of Esophagus: Spondylolisthesis, Cardiomyopathy, Hypertension, Subluxation of C2/C3 [cervical] and C7/T1 [thoracic], Epilepsy and Hospice Care. A review of the physician's order documents shows his shower days are 3 times a week on Monday, Wednesday, and Fridays on the 7:00 AM-3:00 PM shift. The resident's care plan documents need staff assistance with bathing. His admission MDS dated [DATE] documents he has a BIMS of 8. His cognition is moderately impaired. During an interview on 05/20/24 at 12:55 PM with Resident #252, the resident was asked if he gets showers per his schedule. He stated he has asked for showers, but they don't give them. He has no idea when his showers are scheduled. During an interview on 05/22/24 at 9:48 AM with Staff H, CNA, she was asked about the shower schedule for Resident #252 and how they document it. She took the surveyor to the computer and stated that we click on the section that shows tub/shower and clicks what the care needs are. It does not have a section for bed bath. On 05/22/24 at 10:12 AM, with the DON (Director of Nursing), she stated the Point of Care documentation is not correct. She was asked about shower schedule. She stated that the residents do not get showers every day and multiple times in a day. When we went to section GG in the MDS system and went from [NAME] to Keys, the documentation changed. She stated that they have shower sheets that are supposed to get filled out. The RN puts the name and room number on the document and the CNAs will fill it out after a shower. It is then given back to the nurse to review to see if there are any skin issues. It then gets put in a box for the DON to review and given to the wound care nurse. The problem is after the wound care nurse reviews them and when she is done, she put them in the shred box. She acknowledged that they do not have any documentation of when residents had a bed bath versus a shower.

Based on observation, record review, interview, and policy review, staff failed to wear Personal Protective Equipment (PPE) during direct care for 1 of 1 sampled resident who was on Enhanced Barrier Precautions (EBPs), as evidenced by Resident #21 had an indwelling urinary catheter and Staff E, Certified Nursing Assistant (CNA), provided care and failed to don PPE. The facility also failed to ensure hand hygiene between residents during two observed meals on 1 of 4 units (100 Unit), that affected Residents #62, #5, and #35. The findings included: Review of the policy, titled, MDRO'S [multidrug-resistant organisms] and Enhanced Barrier Precautions [EBP], (not dated), documented, in part: Enhanced Barrier Precautions require the use of gowns and gloves only for high-contact resident care activities (unless otherwise indicated as part of Standard Precautions). With EBP, the use of PPE is expanded for everyone's protection. Staff are required to use gowns and gloves during high-contact resident care activities that might result in the transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high-contact activities, such as: dressing, bathing and showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line, IUC [indwelling urinary catheter], feeding tube, tracheostomy / ventilator; and wound care: any skin opening requiring a dressing. 1. Review of the record revealed Resident #21 was admitted to the facility on [DATE] with an indwelling urinary catheter. Review of the current care plan initiated on 04/01/24 documented Resident #21 was placed on Enhanced Barrier Precautions (EBP) due to the use of an indwelling urinary catheter, to minimize the risk of MDRO infections. An approach included the use of PPE during high contact care such as dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care. An observation of personal care, to include indwelling urinary catheter care for Resident #21, was made on 05/23/24 beginning at 9:07 AM with Staff E, Certified Nursing Assistant (CNA). The CNA obtained water in a basin and set up her supplies. The CNA opened the drawer containing the gowns worn as PPE, while stating she was looking for lotion, but did not obtain or don a gown. The CNA began to assist Resident #21 with bathing, handing the resident washcloths and towel for her face and torso, leaning against the resident's bed during care. The CNA proceeded to provide personal care and care for the indwelling urinary catheter. During the bath and care, the CNA failed to don a gown. During an interview outside of the resident's room shortly after the provision of care, when asked what the purpose of the EBP or Enhanced Barrier Precautions was, Staff E did not understand the terminology. While pointing to the EBP sign at the door and asking why the sign was there, Staff E stated, So we put on gowns. The CNA went back into the room and showed the surveyor the drawer with gowns. When asked when she should put on the gown and or why she would put on a gown, the CNA could not answer. During a side-by-side review of the EBP sign, the CNA stated she understood. When asked why she did not put on a gown during the care for Resident #21, Staff E stated, Because it's new to me. 2. An observation of the 100 Unit lunch meal was made on 05/20/24 beginning at 11:57 AM. Staff I, Personal Care Assistant (PCA), went into a resident room, and set up the resident's meal tray. The PCA then went into the common area and moved a resident in her wheelchair from the dining room, was going to take her to the main dining room, but was told she would eat on the unit so wheeled her back to the table. The PCA did not perform hand hygiene. Staff I went back to the food cart and obtained the lunch for Resident #62, and delivered it to the resident. The PCA touched the resident's bed and adjusted it, moved the pillows, repositioned the resident, removed the stuffed animals, and set up Resident #62's food. The PCA did not perform any hand hygiene, but returned to the food cart and delivered a lunch tray to Resident #5. While in the room of Resident #5, the PCA touched her face, gave the resident her drink, went back to the food cart, touching it, then went into the nourishment room to get a cup of ice chips for Resident #5. Upon return to the room, the PCA poured a drink into the cup for Resident #5, then went to the resident's dresser and pulled out clean clothing and placed it on top of the dresser. The PCA then returned to the common area and was done with the lunch delivery but failed to perform hand hygiene at any time. 3. A second meal observation was made on 05/21/24 beginning at 8:13 AM. Staff I, PCA, went into a resident room, moved the over the bed table, set up a breakfast tray, and adjusted the bed. The PCA did not perform hand hygiene, but went to the clean linen cart to obtain a clothing protector and returned it to the resident. The PCA then went to the food cart and obtained a breakfast tray for Resident #35, moving the over-the-bed table and setting up the food. The PCA returned to the food cart placing the tray on top of the cart, then went to the nourishment room for a straw, grabbed the tray back at the cart, and delivered it to Resident #5. Staff I moved the resident's table, opened the blinds, and then left to assist another staff member with positioning of another resident. The PCA failed to perform hand hygiene between residents while assisting with the delivery of food trays.

Based on record review and interview, the facility failed to ensure that the MDS (Minimum Data Set) Assessment, death assessment, was completed and transmitted within 14 days after completion for 3 of 6 sampled residents, Residents #27, #37 and #59, reviewed for closed records. The findings included: During the survey, the Risk Assessment for the Minimum Data Set (MDS) assessments was triggered for MDS records being over 120 days old for Resident #27, #37 and #59. 1. Record review of Resident #27 revealed the resident was admitted to the facility on [DATE] and expired in the facility on [DATE]. A review of the resident's MDS assessment documented the latest MDS completed was the 5-day Medicare on [DATE]. There was no death / discharge MDS assessment. 2. Record review of Resident #37 revealed the resident was admitted to the facility on [DATE] and expired in the facility on [DATE]. A review of the resident's latest MDS assessment documented it was completed on [DATE]. There is no death / discharge MDS assessment. 3. Record review of Resident #59 revealed the resident was admitted to the facility on [DATE] and expired on [DATE]. A review of the resident's latest MDS asssesment documented it was completed for admission on [DATE]. There is no death / discharge MDS assessment. During an interview on [DATE] at 9:30 AM with the MDS Coordinator, she stated that they have ,d+[DATE] days to complete an assessment, but it depends on what assessment it is. The surveyor asked her to pull up the MDS assessments for Residents #27, #37 and #59. The MDS Coordinator acknowledged that she had not completed the death assessments and had missed it. She stated, I am human, what can I say.

Based on record review and staff interview, the facility failed to ensure nursing staff followed the facility protocol regarding unavailable medications for 1 of 6 sampled residents reviewed for medications, resulting in the resident not receiving physician-ordered medications as prescribed (Resident #72). The findings included: A review of the facility's policy regarding Medication Errors (Reference #6084) documents: Definition: A Medication Error is any preventable event that may cause or lead to inappropriate medication use or resident harm . Types of medication errors include: Omission (not administered before next scheduled dose due . Procedure: When a medication error occurs, the following shall occur in this order: Notify the physician and evaluate the resident. Notify resident/responsible party. Perform any necessary clinical interventions, within the resident care provider's scope of practice to reduce negative effects of the identified error. Record the medication as given in the medical record if applicable. Record the observed and assessed outcome of the resident in the medical record. Record notification of physician in the medical record with any resultant orders. Record any actions and clinical interventions taken and the resident's response to same. Report the error in detail on a medication error incident report. The practitioner who identifies an error shall document all relevant particulars on the medication error report form. All medication error reports shall be reviewed by the physician, pharmacist and DON/designee and categorized according to severity, type, cause and drug class involved. All medication error reports evaluated as significant (Level 4 or above) shall be referred to the Pharmacy and Physician. Reports of actions taken and appropriate follow-up shall be made by the DON/designee to the Pharmacy and Physician. Resident #72 was admitted to the facility with diagnoses that included Parkinson's Disease, Hypertension, and Allergic Rhinitis. A review of the February and March 2023 electronic Medication Administration Record (eMAR) for Resident #72 revealed the following medication administration concerns: 1) Selegiline HCI 5 mg, was prescribed to treat Resident 72's Parkinson's symptoms, and was to be administered twice a day (9:00 AM and 9:00 PM). It was documented on the eMAR as Not administered / Item unavailable on the following dates and times: 02/25/23 at 9:00 AM; 02/26/23 at 9:00 AM and 9:00 PM; 02/28/23 at 9:00 PM; 03/02/23 at 9:00 AM and 9:00 PM; 03/03/23 at 9:00 AM and 9:00 PM; and 03/04/23 at 9:00 AM and 9:00 PM. 2) Spironolactone 50 mg was prescribed for treatment of high blood pressure and was to be administered once daily. It was documented on the eMAR as Not administered / Item unavailable on the following dates and times: 02/15/23; 02/25/23; 02/26/23; 03/02/23; 03/03/23; 03/04/23, and 03/05/23. 3) Ipratropium Bromide Nasal Spray 42 mcg for the treatment of allergic rhinitis was to be administered as 2 sprays twice daily (9:00 AM and 5:00 PM). It was documented on the eMAR as Not administered / Item unavailable on the following dates and times: 02/10/23 at 9:00 AM and 5 PM; 02/21/23 at 5 PM; and 02/23/23 at 5 PM. A review of February and March 2023 Nursing / Progress Notes showed only one note made by nursing staff documenting steps taken to address one of the unavailable medications for Resident #72: On 03/04/23 at 3:14 PM, Called pharmacy to inquire when Selegiline HCI would be sent out. Pharmacy state that order was discontinued on their end and not showing up in their system. Pharmacy said medication will have to be discontinued and then re-entered. This writer discontinued and re-entered medication. On 03/07/23 at 3:52 PM, the Director of Nursing (DON) was advised of the concerns with the unavailable medications and lack of documentation by nursing staff addressing the medication availability. On 03/08/23 at 11:48 AM, the DON stated she had not been made aware that Resident #72's medication was unavailable prior to the surveyor notifying her of the issue. She stated, I immediately notified pharmacy and the physician. I completed a Medication Error Analysis Report for each of the medications. The Physician did discontinue the nasal spray, and I am having the nurses take the resident's vital signs daily to make sure he has no ill effects. A review of his vitals showed there have been no issues with his blood pressure, and the resident stated he has not had any issues with fine motor tremors as a result of the missing medications. On 03/08/23 at 11:50 AM, the DON notified Resident #72's ARNP (Advanced Registered Nurse Practitioner) while the ARNP was in the facility, and the ARNP stated she would visit Resident #72 that day. On 03/08/23 at 11:58 AM, the Administrator confirmed that according to policy, the nurses are to call the pharmacy to find out why a resident doesn't have their medication(s) available, look for missing medications in the E-kit, and if none of the medications are in the E-kit, notify the doctor. The DON stated, None of the nurses followed this protocol, except for [Staff D] when he called the pharmacy on 03/04/23. He did what he was supposed to do. I will be doing an in-service with the nursing staff on following this protocol.

Based on observation, interview, record review and policy review, the facility failed to ensure proper indwelling urinary catheter care and services for 3 of 3 sampled residents, as evidenced failure to maintain Resident #81's urinary catheter tubing and drainage bag off the floor and failure to ensure proper urinary catheter anchoring for Residents #24, #43, and #81. All three residents had a history of Urinary Tract Infections (UTIs). The findings included: Review of the policy, titled, Indwelling Urinary Catheter Insertion and Maintenance - Female Resident, revised 10/2017, documented the process for placing the catheter followed by the instructions to keep the collection bag below the level of the bladder at all times, but do not rest the bag on the floor. This policy further instructed the staff to apply a catheter strap to the leg to prevent it from pulling. The Director of Nursing (DON) was unable to locate a policy that included these directions for the male resident but agreed it would be applicable to both. 1. Review of the record revealed Resident #81 was admitted to the facility on [DATE] and moved to his current room on 10/25/22. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #81 did have an indwelling catheter. Resident #81 had UTIs on 10/17/22 and 11/11/22 with subsequent antibiotic use. During an observation on 03/05/23 at 12:34 PM, Resident #81 was observed lying in a low bed. An indwelling urinary catheter bag was noted lying flat on the floor, with the wheel of an over-the-bed table on top of the bag. Photographic Evidence Obtained. At 12:47 PM, Staff A, Certified Nursing Assistant (CNA), delivered a lunch tray to Resident #81. While trying to position the over-the-bed table within reach of the resident, the CNA moved the table off the catheter bag, used her shoe to move the bag out of the way, and positioned the table for Resident #81. The CNA left the room with the urinary catheter bag still lying directly on the floor. During a subsequent observation on 03/05/23 at 2:31 PM, Resident #81 was sitting up in bed. The urinary catheter bag was now hooked to the bed frame, but the bottom of the catheter bag and part of the catheter tubing remained on the floor. Photographic Evidence Obtained. An observation of personal care for Resident #81 was made on 03/07/23 at 9:20 AM, with Staff A, CNA. The urinary catheter bag and tubing were noted off the floor and positioned properly. When Staff A removed the resident's adult brief, the catheter tubing was noted to be pulled taunt, and the tubing lacked any type of anchoring device. After the CNA completed the care, when asked if they use any type of anchoring device for the catheter tubing, the CNA stated yes, and that it must have fallen off. During an observation on 03/07/23 at 1:35 PM with Staff B, Registered Nurse (RN), the urinary catheter bag for Resident #81 was off the floor, but the catheter tubing was lying directly on the floor. The RN agreed the bag and tubing should not be on the floor. The RN was made aware of the above observations. An observation on 03/08/23 at 11:41 AM revealed the urinary catheter bag and tubing were again noted lying directly on the floor. Photographic Evidence Obtained. Review of the current care plan for the resident's indwelling catheter lacked any intervention for anchoring or securing the tubing, which helps in the prevention of UTIs. Further review of the record revealed a current physician order dated 10/16/22 to anchor (urinary) drainage tubing to the resident's leg. 2. Review of the record revealed Resident #24 was admitted to the facility on [DATE] with an indwelling catheter, and UTI. Resident #24 had subsequent UTIs on 02/03/23 and 02/27/23, with the provision of an antibiotic each time. An observation on 03/07/23 at 11:29 AM revealed Resident #24 sitting up in her wheelchair, with a urinary catheter bag noted hanging from the wheelchair frame. When asked if there was any type of anchoring or device to secure the catheter tubing to her thigh, Resident #24 felt her thigh and stated there was nothing there. The resident then proceeded to pull up her shorts to reveal her left thigh, the catheter tubing, and a lack of anchoring device. Review of the current care plans lacked any intervention for anchoring or securing the urinary catheter tubing. Further review of the record revealed a current physician order dated 01/02/23 to anchor (urinary) drainage tubing to the resident's leg. During an interview on 03/08/23 at 12:39 PM, Staff C, RN, when asked about any anchoring device for Resident #24, stated she was told to put one on the resident before she left work the previous day (03/07/23). 3. Review of the record revealed Resident #43 was admitted to the facility on [DATE] with an indwelling urinary catheter. Resident #43 had a subsequent UTI on 12/31/22, with the provision of an antibiotic. A physician's order dated 12/23/22 documented to anchor the (urinary) drainage tubing to the resident's leg. During an observation on 03/07/23 at 11:47 AM, Resident #43 was sitting in a wheelchair and an urinary drainage bag was noted, with no anchoring device. At 11:52 AM, Staff E, Licensed Practical Nurse (LPN), was asked if the facility utilized anchoring devices for urinary catheters, and the LPN confirmed the use of the anchors. During a subsequent observation at this time, the LPN agreed to the lack of an anchoring device for the urinary catheter tubing of Resident #43.

Based on interview and record review, the facility failed to develop care plans to accurately reflect their Do Not Resuscitate (DNR) status for 1 of 22 sampled residents, Resident #42, reviewed for DNR status. The findings included: On 12/01/21 at 10:54 AM, record review for Resident #42 revealed a physician order, dated 05/26/21, for Advanced Directives that indicated - 'Do Not Resuscitate (DNR)'. Further review of Resident #42's records lacked evidence of a care plan to reflect the DNR status. On 12/01/21 at 11:43 AM, an interview was held with the Social Worker (SW). She reviewed Resident #42's records in the presence of the surveyor and revealed she could not find a care plan for the DNR. The SW then confirmed that there was no care plan but that there should have been a care plan for DNR status. After surveyor intervention, she voiced she would generate a DNR care plan today (12/01/21).

Based on observation, interviews and record review, the facility failed to provide fingernail care for 4 of 4 sampled residents, observed for activities of daily living, Residents #20, #33, #28, and #58. The findings included: Review of facility policy, titled, Care of Fingernails / Toenails, with a revision date of October 2020, revealed the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Steps in the procedure included gently, remove the dirt from around and under each nail with an orange stick, do not trim nails below the skin line or cut the skin, trim fingernails in an oval shape and toenails straight across. Documentation included the following information should be recorded in the resident's record: the date and time that nail care was given, the name and title of the individual(s) who administered the nail care, any difficulties in cutting the resident's nails, any problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure, if the resident refused the treatment, the reason(s) why and the intervention taken, the signature and title of the person recording the data. Reporting included notify the supervisor if the resident refuses the care. 1. Record review for Resident #20 revealed the resident was admitted on [DATE]with diagnoses, in part, that included: [CONDITION(S)] Spondylopathy Cervical Region, [CONDITION(S)], Spondylosis Lumbar Region, [CONDITION(S)] Heart Disease, Impingement Syndrome of Right Shoulder, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Diabetic Retinopathy, Mild Cognitive Impairment, Muscle Weakness and Need for Assistance with Personal Care. Review of the Quarterly Minimum Data Set assessment (MDS), dated [DATE], revealed: in section C, a brief interview for mental status (BIMS) score of 12, indicating moderate impairment, in section G, Toilet use / Self-Performance is total dependence on staff of two plus persons, Personal hygiene / Self-Performance is total dependence on staff with two persons assistance. Record review for Resident #20's care plan reviewed and/or revised on 09/15/21 revealed a focus on the resident having a self-care deficit and is unable to perform activities of daily living (ADL's) without assistance due to decline in function related to hospital stay with a goal of the resident being able to perform ADL's with task segmentation and cueing as evidenced by improvement in functional ability status by next review date. Interventions on the care plan included: encourage to care for personal needs to promote as much independence as possible for level of function, involve in decision making process, praise all efforts, provide assistance with hygiene and grooming, assist with toileting dressing and bathing as needed, provide materials and assistance needed to preform ADLs, physical therapy, occupational therapy, speech therapy (PT/OT/ST) as ordered, report any deterioration in status to physician, and transfer with assist of staff. Record review for Resident #20 revealed no documentation or evidence of fingernail care (clipping and/or cleaning) being completed or refused by the resident from 08/01/21 to 12/01/21. On/11/29/21 at 10:05 AM, an observation was made of Resident #20's dirty, long, jagged edged fingernails and were with a brownish substance under the fingernails. During an interview conducted on 11/29/21 at 10:07 AM with Resident # 20 when asked about his fingernails, he stated, of course I want them cut, nobody here will do it, so my wife must do it, or I try to do them myself and it is very hard for me. He stated that sometimes the staff dress him but mostly he must do it himself. He stated he has no plan of action; he wants to get up and walk again. During an interview conducted on 11/30/21 at 10:16 AM with Resident #20 's spouse, who was visiting with the spouse, when asked about the resident's fingernail care, she stated, he cannot do his fingernails so I trim his fingernails, but the staff should keep his nails clean. 2. Record review for Resident #28 revealed an admission of 02/18/21 with the most recent re-admission on 11/15/21, with diagnoses, in part, that included: Type 2 Diabetes Mellitus with Diabetic [CONDITION(S)], Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Chronic Pain Syndrome, [CONDITION(S)], and Dementia with behavioral disturbance. The significant change MDS, dated [DATE], revealed: in section C, a brief interview for mental status score of 10, indicating moderate impairment, In section E, revealed under, Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being, the behavior occurred 1 to 3 days, In section G, for Bed mobility / Self-Performance the resident required total dependence with support of 2 plus persons from staff; Dressing / Self-Performance documented total dependence with support of two plus persons; Eating / Self-Performance was total dependence with support of one-person; and Personal hygiene / Self-Performance was total dependence with support of two plus persons. Review of the care plan, dated 03/05/21 for Resident #28 revealed a focus on the resident requiring staff assistance with bathing, dressing, toileting, hygiene, and mobility needs r/t (related to) increased weakness; the ADL skills may fluctuate related to behaviors and mood; and a goal that the resident would maintain her current level of function in bed mobility, transfers, dressing, toilet use and personal hygiene through the review date as evidenced by nursing documentation. Interventions on the care plan included: Resident requires staff assistance with bathing / showering; Resident requires staff assistance to reposition and turn in bed; Resident requires staff assistance to dress; Resident requires staff assistance with personal hygiene and oral care; Physical therapy, occupational therapy (PT/OT) evaluation and treatment as per MD orders; Resident requires staff assistance to use toilet; and Resident requires staff assistance with transfers. Record review for Resident #28 revealed a progress note, dated 09/07/21, that the resident returned from MD (physician) appointment with new orders to increase frequency of treatment (tx) to fingers from daily to twice a day; and Staff to cut resident's nails shorter. A progress note, dated 09/09/21, revealed the resident refused to have her fingers clipped at this time and insisted to be helped back to bed; the resident was assisted back to bed and fluids were provided. Another progress note, dated 09/09/21, revealed: 'Nails were carefully cut short, cleaned, and filed. Resident tolerated it well. Tx (treatment) applied to affected nails.' There were no progress notes that documented if the resident had received fingernail care or had been offered and refused fingernail care from 09/10/21 to 11/06/21 or from 11/15/21 to 12/01/21. On 11/29/21 at 10:40 AM, an observation made of Resident #28's fingernails revealed them to be long with blackish / brown substance under the nails. Photographic evidence obtained. During an interview on 11/29/21 at 10:40 AM with Resident #28, she stated she does not like her nails that long and said they are very dirty. When asked if anyone cleans her fingernails, she said occasionally. 3. Record review for Resident #33 revealed an admission of 03/30/82 with no re-admissions. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS, dated [DATE], revealed: In section C, a BIMS score of 0, indicating severe cognitive impairment; In section G, Eating/Self-Performance required supervision and set up. Resident #33's care plan with a reviewed / revised date of 09/28/21, revealed a focus on the resident required staff assistance with bathing, dressing, toileting, hygiene, and mobility needs, r/t to multiple contractures and [CONDITION(S)] due to (d/t) [CONDITION(S)] ([CONDITION(S)]). The resident's ADL performance fluctuated at times related to the [CONDITION(S)] with a goal of the resident's needs being anticipated and met daily through the review date by nursing / CNA documentation and being well groomed. Interventions on this care plan included the resident required staff assistance with bathing / showering three times weekly and as needed (PRN); the resident required staff assistance to reposition and turn in bed; the resident required staff assistance to dress; the resident was independent with eating, after set up assistance was provided; encourage to participate with self-care to the best of resident's ability; the resident required staff assistance with personal hygiene and oral care; evaluation and treatment as per MD orders; restorative nursing program as ordered, splints as tolerated; the resident required staff assistance for incontinence care; and the resident required staff assistance with transfers, may require mechanical lift and assist of 2 at times. Record review for Resident #33's progress note, dated 09/27/21, revealed a Quarterly Review that included: care plan was reviewed and updated today; remains severely impaired for cognition; needs are anticipated and met by staff; is out of bed (OOB) daily; dressed and as well-groomed as she will allow; will refuse specific care tasks at times, and will, at times, refuse to wear shoes or socks; refuses to allow hair to be cut but will allow staff to brush hair and secure it off of face or trim the ends at times; has a history of hallucinations but not experiencing any hallucinations currently; and they (family) visit when they can and provide personal needs, as does staff. Review of the notes from 08/02/21 to 12/01/21, except for progress note date 09/27/21, revealed there was no documentation about fingernails being cleaned / trimmed or that the resident refused to have her fingernails cleaned / trimmed. On 11/29/21 at 10:30 AM, an observation was made of Resident # 33's fingernails being long and with brownish/black substance under the fingernails. 4. During an attempted interview with Resident #58 on 11//29/21 at 10:30 AM, it was discovered that the resident was non-verbal. The record revealed Resident #58 was admitted [DATE] with a most recent re-admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], revealed: In section C, a brief interview of mental status score of 13, indicating intact cognitive response; In section F, Dressing / Self-Performance required total dependence on staff, Dressing / Support required one person assistance and personal hygiene / Self-Performance required total dependence of one person assist. The care plan, with a reviewed / revised date of 10/26/21, had a focus on: Resident has a self-care deficit and is unable to perform activities of daily living (ADL's) without assistance due to decline in function related to hospital stay a goal of Resident will be able to perform ADLs with task segmentation and cueing as evidenced by (AEB) improvement in functional ability status by next review date. The care plan interventions included: encourage to care for personal needs to promote as much independence as possible for level of function, involve in decision making process, praise all efforts, provide assistance with hygiene and grooming, assist with toileting dressing and bathing as needed; Provide materials and assistance needed to preform activities of daily living; physical therapy, occupational therapy, speech therapy (PT/OT/ST) as ordered; Report any deterioration in status to physician; and Transfer with assist of one staff. Review of Resident #58's progress notes of 10/08/21 revealed, in part: 'Resident is sitting up in her wheelchair with a pleasant affect and propels self on the unit. Cognition remains the same, alert, and oriented x3 with encouragement needed for all meals. Resident's needs are being met by the facility and mood is stable. Resident has delusional episodes, Is kind and cooperative. Resident's skin turgor is good with no signs or symptoms of dehydration noted. PO (oral) supplements given and taken well. ROM (range of motion) in RUE (right upper extremity) is limited. Therapy referral has been issued. Brisk cap refill is present in all fingers and toes. Fingers to left hand/both feet are deformed due to arthritis. Review of the record revealed there were no other progress notes that documented fingernail care provided, or documented fingernail care was refused from 08/01/21 to 12/01/21. On 11/29/21 at 10:20 AM, an observation of Resident #58 revealed the fingernails were long, jagged and with a brownish substance underneath the fingernails. The left hand was contracted. During an interview conducted on 11/29/21 at 10:22 AM with Resident # 58 when asked about her fingernails, she stated that she does not like them that long, she likes them just past the flesh of her finger and they need to be cut. When asked if staff cut and clean her nails, she stated nobody does them and she stated she cannot do them herself. During an interview conducted 11/30/21 at 3:20 PM with Staff D-CNA (certified nursing assistant), she stated the CNAs are also responsible for inspecting the fingernails and if the fingernails are not clean as some residents put their nails in their food, the CNAs clean under the nails with a cuticle stick and/or brush. Throughout the day, we check the residents' fingernails to see if they are dirty, if they are dirty, we offer to clean their hands and nails. During an interview conducted on 12/01/21 at 9:05 AM with Staff E-CNA when asked who is responsible for clipping and cleaning the residents' fingernails, he stated that it is the CNAs who are responsible for clipping and cleaning the residents' fingernails. He also stated that if the resident needs their fingernails washed, he just does it with a washcloth; and if they need to be cut, he cuts them so that just a little of the white part of the fingernail shows. He also stated that you must be careful if the resident is diabetic. During an interview conducted on 12/01/21 at 9:25 AM with Staff F-CNA when asked who is responsible for fingernail care, she stated the CNAs are responsible for the fingernail care, cutting them and cleaning them. Sometimes residents make an appointment with the activities department and the activities department will do the cutting and cleaning and polishing the fingernails.

Based on facility policy review, observation, record review and interview, the facility failed to obtain physicians orders prior to administering medication to 1 of 1 sampled resident, Resident # 417. The finding included: Review of the facility policy, titled, Subject: Telephone, verbal, and written orders for medication, reference #6029, effective 03/01/21, stated orders given for medications and their administration shall be filled only when given by a qualified physician, surgeon, dentist, podiatrist, or other person duly licensed or authorized to prescribe by the State of Florida and who has been approved as a member of the medical staff of this facility. Per Florida Statute 464, An RN [registered nurse] must be licensed as an Advanced Practice Registered Nurse (APRN) to prescribe medications. Facility Policy, titled, 11B1: Administration Procedures for all Medications C. 1) Prior to removing the medication package from the cart; a) Check the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the record for Resident 417 revealed an admission of 11/01/21. The record documented a Brief Interview for Mental Status (BIMS) score that indicated the resident was cognitively intact. Resident 417 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the resident on 11/30/21 at 2:30 PM, revealed Resident 417 appeared tired and pale. Resident #417 stated he was up all night with horrible diarrhea and said it poured out like water. When asked if the nurses were aware Resident 417 stated, yes, they all knew. He stated he got two doses of [MEDICATION(S)] and that it had helped some. On 11/30/21 at 3:00 PM, Resident 417 was noted walking around in his room unassisted and confirmed again that he got [MEDICATION(S)] earlier this morning and again this afternoon for diarrhea. Record reviews revealed: On 11/30/21 at 2:45 PM, there was no documentation of the resident's diarrhea, no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/30/21 at 3:31 PM, Resident 417's progress note by Staff A-RN (registered nurse) documented the resident received [MEDICATION(S)] at 7:30 AM and 13:30 PM for loose stools On 12/01/21 at 9:00 AM, the record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The new order was documented as received via telephone on 11/30/21 at 3:41 PM. Interviews were conducted as follows: On 11/30/21 at 3:05 PM, Staff A-RN, when asked by surveyor if [MEDICATION(S)] was given today to Resident #417 for diarrhea, stated yes but it has not been charted yet. Staff A-RN said they have a facility standing order and she notified the doctor of the diarrhea. On 11/30/21 at 3:30 PM, the Director Of Nurses (DON) was asked to provide the policy for facility standing orders for medications. On 12/01/21 at 9:15 AM, the DON stated they 'did not have standing orders for [MEDICATION(S)], the nurse gave it without an order'. She said she re-educated the nurse on medication administration policies and obtaining physicians orders. She stated nurses receive medication administration training when hired. On 12/01/21 at 9:45 AM, Staff A-RN stated, to be honest with you, I did not call the doctor about the diarrhea until after you spoke to me yesterday at 3:05 PM. I had given him two doses of [MEDICATION(S)], one at 7:30 AM and 1:30 PM. I know I need a doctor's order for all medications. I am new. I thought there was a standing order, that was my mistake.

Based on observation, interview and record review, the facility failed to ensure a palm guard was applied to a resident's right hand for 1 of 1 sampled resident, Resident #47, to prevent further contracture of the right hand. The findings included: Record review revealed Resident #47 was admitted to the facility on [DATE]. The admission minimum data set (MDS) assessment reference date 10/19/21 indicated a BIMS score 15 indicating Resident #47 was cognitively intact. Observations conducted of Resident #47 on 11/29/21 at 11:44 AM, 11/30/21 at 9:10 AM, 12/01/21 at 8:45 AM and 12/01/21 at 2:03 PM, revealed that on the mentioned dates and times, Resident #47 was noted with right hand contracture but was without any splint. On 12/01/21 at 1:41 PM, an interview was held with the Rehabilitation (Rehab) Director, who revealed Resident #47 was on physical therapy (PT) and occupational therapy (OT) services that had started on 10/14/21 through 11/02/21. The Rehab Director stated that OT had ordered a 'palm guard' for Resident #47, and showed that Nursing had been trained on proper donning of the palm guard. During the interview, the Rehab Director presented a document, dated 10/15/21, that documented, patient trial right hand palm guard to prevent further contracture; patient stated she was comfortable with palm guard. Nursing staff informed on proper donning and skin checks. The Rehab Director presented another document, dated 10/18/21, that documented, the resident has right hand contracture, tolerate wear of right hand palm guard, staff training on proper donning of palm guard to prevent further contracture. On 12/01/21 at 1:58 PM, a side by side review of Resident #47's records and interview was conducted with the Director of nursing (DON). She confirmed there was no evidence of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, honestly, I 've never seen her (Resident #47) with a palm guard. On 12/01/21 at 2:03 PM, an interview was held with Resident #47, and when asked about the right hand contracture, she voiced she has a disease called [CONDITION(S)] (CBD) which causes her hand to be contracted. When asked about the palm guard, she voiced she hasn't worn the palm guard in weeks. When asked if there was a reason, she did not wear the palm guard, she voiced she doesn't know. The resident stated, please get the palm guard for me, and apply it to my hand. The surveyor verbalized she would inform the facility staff. On 12/01/21 at 2:06 PM, an interview was conducted with Staff B-CNA, who was the attending aide, and when asked about Resident #47's right hand contracture, she stated she was aware of the resident's contracture. She voiced she was not sure what the facility was doing about the contracture. When asked whether the resident had interventions in place for the contracture and whether the resident had palm guard available, the aide said, 'she has never seen Resident #47 wear a palm guard'. When asked what she was supposed to do for the resident in regard to the contracture, she voiced she was not sure what she was supposed to do for the resident. Staff B-CNA was made aware that the resident was requesting for the palm guard. A review of the care plan, dated 10/27/21, indicated Resident #47 has DDD of the lumbar region. The goal was Resident #47 will remain free of complications related to DDD ([CONDITION(S)] Disc Disease / joint stiffness or decline in mobility) through the review date AEB nursing documentation. The care plan interventions included: observe for and report to MD (physician) complications related to DDD: Joint pain, Joint stiffness, usually worse on wakening, swelling, decline in mobility, decline in self-care ability, contracture formation/joint shape changes, crepitus (creaking or clicking with joint movement), and pain after exercise or weight bearing. A review of the progress note, dated 10/12/21 at 10:31 AM, documented Resident #47 had right hand fingers contraction. A review of another progress note, dated 10/13/21 at 8:14 PM, documented, 'Patient seen and examined on 10/13/21, Patient presents with [CONDITION(S)], [CONDITION(S)] disease, Weakness and Fatigue. She has CBD disease which has caused profound increased weakness and has affected her ability to ambulate and complete ADLs including dressing and meals. She has ongoing numbness and tingling in her bilateral hands and feet.'

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Urinary Tract Infections [MEDICAL CONDITION] and Resident behavior related to the infection for 1 of 21 sampled residents, reviewed for UTIs, Resident #17. The findings included: Review of the clinical record revealed Resident #17 was admitted on [DATE]. On 10/19/20 the rsident was diagnosed with [REDACTED]. Further review of the care plans in the record revealed there was no care plan to reflect the risk for UTIs and care for the acquired UTI. There were no documented interventions in attempt to prevent or care for the UTI. During an interview and peri care observation conducted by the AHCA Registered Nurse (RN) for Resident #17 on 10/22/20 at 9:18 AM, Staff C was asked how Resident #17 developed a urinary tract infection [MEDICAL CONDITION]. Staff C said the resident has a tendency to put her hand in her private area, then put her hands in her mouth. She voiced the facility is aware of that. On 10/22/20, at 11:32 AM, an interview conducted with the Minimum Data Set (MDS) RN revealed that she was informed of the resident's UTI on the morning of 10/22/20, after the observation of Resident #17 by the surveyor. She said she then immediately developed a Care Plan for Resident #17, and provided a copy of 2 care plans to the survyeor and each was dated 10/22/20 at 10:56AM.

Based on observation, staff interview and record review, the facility failed to identify and treat a rash on the left foot for 1 of 3 sampled residents (Resident #7), reviewed for non-pressure related skin conditions. The findings included: During an observation on 10/19/20 at 11:00 AM, Resident #7 was in the POD (Dining/Activity area for wing 400) sitting in her wheelchair dressed in clothes with shoes and no socks on. A red patchy rash was noted to be exposed on the top surface of her left foot outside the lining of the shoe tongue. During an interview with CNA (certified nursing assistant), Staff A, on 10/21/20 at 11:18 AM when asked does the resident have a red rash on her foot? She replied yes. When asked what she does for the rash, the Staff A stated I asked the Central supply lady for grease because she has dry feet. The lotion doesn't work as good as the grease lotion. Staff A indicated that Resident #7 has had the rash for 2 weeks, and I use body lotion now for her feet. Staff A was asked to show the surveyor the lotion. The lotion was in the resident's drawer and the bottle's name was called (brand name) body lotion. When asked if she told the nurse about Resident #7's foot rash, she said No. Staff A indicated I asked for the grease lotion and that works for her dry feet. During an interview with Staff Nurse B on 10/21/20 at 2:30 PM when asked about Resident #7's rash on her feet, Staff B replied, I did not notice anything about her feet, Lets go see. At 2:40 PM on 10/21/20, the surveyor accompanied Staff Nurse B to resident's bedside. During the bedside observation on 10/21/20 at 2:40 PM, of Resident #7 with Staff B, it was confirmed that Resident #7 had a rash on her left foot. With gloved hands, Staff B performed a skin assessment of the resident's feet. The resident was resting in bed with shoes off. Staff B confirmed the rash on top of the left foot with a dry scaly rash on bottom heel of left foot. There was no rash on right foot. The surveyor observed red/white patchy scattered rash on the top of left foot in alternating round patterns. The resident's toenails were dark and thick on the left foot. The heel of the left foot has a small amount of dry scaly skin. Review of the record for Resident #17 revealed a BIMS (Brief interview for Mental Status) score of 3, indicating severe cognitive impairment. Record review of the weekly skin and Braden Scale dated 10/16/20 was as follows: weekly skin assessment indicates no skin issues or rash, a Braden Scale (quarterly) indicated no impairment, with a score of 16 indicating (at risk). Further review of the Resident's Skin Care Plan (Start Date: 06/12/20; Last Reviewed/Revised 10/20/20 at 8:58 AM) indicates an APPROACH: Observe skin during daily ADL care. Notify the Nurse of any abnormalities. A review of the nurse notes for August, September and October 2020 indicated there was no skin rash. An interview with the Director of Nursing on 10/22/20 at 4:00 PM indicated there might be something in the record about the skin rash and she would do further investigate. At the time of the survey exit, no record was provided was provided to the surveyor.

Based on observation, record review and interview, the facility failed to provide a mechanical soft diet to 1 of 27 residents on a Mechanical Soft diet that was prescribed by the resident's attending physician, Resident #52. The finding included: On 10/19/20 at 12:35 PM, during dining observation, Resident #52 was observed in her room. It was noted that Resident #52's diet order was Mechanical Soft. Observation of resident's lunch tray revealed that the resident had a whole fresh orange on her tray for dessert. The resident attempted to chew the whole orange but ws unable. The resident placed it back on her tray with a slice of the orange hanging from the whole orange. A review of the dietary progress notes had no documentation that the resident was allowed to eat fresh fruit. The resident's diet order was for altered texture; and she should only be served canned fruit. On 10/21/20 at 10:53 AM, in an interview with Registered Dietitian (RD) and Certified Dietary Manager (CDM), they were informed that Resident #52, lunch tray on 10/19/20 included a whole orange for dessert but the resident's diet order was for Mechanical Soft, which restricts fresh fruit or vegetables. The CDM stated that the resident requests fruit, but the resident did not order the whole orange. The CDM said the resident should have been served canned fruit.

Based on record review and interviews, the facility failed to maintain complete medical records as evidenced by: 1) not consistently charting hydration intake as ordered by a physician for 1 of 3 sampled residents reviewed for nutrition (Resident #18); and 2) failure to ensure quarterly fall risk assessment forms were completed for 3 of 3 sampled residents (Resident #5, Resident #16, and Resident #66) reviewed for fall incidents. The findings included: 1. Review of Resident #18's clinical records revealed the resident was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. She has a history of urinary tract infection. The 08/11/20 Minimum Data Set (MDS) health assessment documented she required extensive assistance with moving around in bed and supervision for eating. The record had a written physician's orders [REDACTED]. A written physician's orders [REDACTED]. On 10/19/20, the facility's Registered Dietitian (RD) status update documented she had altered laboratory values and that staff were offering 240 CCs of fluid each shift. The RD's 09/21/20 update documented she was treated for [REDACTED]. Review of Resident #18's October 2020 Medication Administration Record [REDACTED] 1. 10/20/20, 240 ML received at 10:03 AM and 12:51 PM - There was no documentation for the third shift. 2. 10/19/20, 240 ML received at 10:50 AM. There was no documentation for the second (3 PM - 11 PM) and third (11 PM - 7 AM) shifts. 3. 10/18/20, 120 ML received at 10:12 AM and 2:09 PM. There was no documentation for the third shift. 4. 10/17/20, 200 ML received at 9:04 PM. There was no documentation for the second and third shifts. 5. 10/16/20, 200 ML received at 10:50 AM and 200 ML received at 1:56 PM. There was no documentation for the second and third shifts. 6. 10/15/20, 240 ML received at 2:00 PM. There was no documentation for the for the second and third shifts. 7. 10/14/20, 640 ML received at 2:55 PM. There was no documentation for the second and third shifts. 8. 10/13/20, 560 ML received at 2:18 PM and 240 ML received at 10:15 PM. There was no documentation for the third shift. 9. 10/12/20, 200 ML at 10:20 AM. There was no documentation for the second and third shifts. 10. 10/11/20, 620 ML received at 11:45 AM. There was no documentation for the second and third shifts. 11. 10/10/20, there was no documentation for all three shifts. 12. 10/09/20, 240 ML received at 11:02 AM. There was no documentation for the second and third shifts. 13. 10/08/20, 240 ML received at 2:06 PM. There was no documentation for the second and third shifts. 14. 10/07/20, 80 ML at 5:44 AM and 340 ML at 12:51 PM. There was no documentation for the second shift. 15. 10/06/20, 200 ML received at 10:55 AM and 1:10 PM. There was no documentation for the second and third shifts. 16. 10/05/20, 200 ML received at 10:13 AM. There was no documentation for the second and third shifts. 17. 10/04/20, 200 ML received at 10:51 AM, 360 ML received at 2:16 PM, 460 ML received at 8:03 PM. There was no documentation for the third shift. 18. 10/03/20, 240 ML received at 7:03 PM. There was no documentation for the first and third shifts. 19. 10/02/20, 240 ML received at 11:09 AM and 9:24 PM. There was no documentation for the third shift. 20. 10/01/20, 240 ML received at 10:58 AM and 200 ML received at 1:25 PM. There was no documentation for the second and third shifts. This was brought to the attention of the Director of Nursing's (DON) on 10/21/20 at 2:10 PM. In an interview conducted on 10/22/20 at 8:48 AM, the DON stated Resident #18 receives plenty of fluids, and she needs to rewrite the order in the system so all amounts are charted. 2. A review of Resident #5's clinical record beginning on 10/20/20 documented Resident #5 had recent fall incidents on 10/14/20, 10/8/20, and 09/12/20 with no injuries. Further review of Resident #5's clinical record showed Resident #5 had an annual fall risk assessment completed on 05/05/20 and a quarterly fall risk assessment completed on 10/14/20. There was no quarterly fall risk assessment found for 08/2020. An interview was conducted with the DON on 10/21/20 at 12:06 PM. The DON reviewed Resident #5's clinical record and was unable to find a quarterly fall risk assessment for 08/2020. She explained that the Restorative Nurse is the staff member assigned to complete quarterly fall risk assessments for residents, but her routine tasks were divided amongst other staff members. The DON stated the quarterly fall risk assessments were probably missed during the reassignment of the Restorative Nurse's tasks. The DON stated they should have been completed. 3. Resident #16 was selected for fall review as the nursing note, dated 08/20/20 at 2:40 PM, indicated Resident #16 had a fall with injuries that included: Bump on the head and scratch on the left leg. Another nursing note, dated 08/20/20 at 8:24 PM, indicated observed dark bruising of inner eye down around under the eyes. This note revealed the attending Nurse Practitioner (NP) was notified, and the NP ordered Resident #16 to be sent to the Hospital for a computerized tomography scan (CR scan: series of X-ray images from different angles). Resident # 16's records revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#16 was cognitively intact. The care plans, dated 12/02/19, Last Reviewed/Revised 08/21/20, indicated Resident #16 was at risk for falls related to mobility impairments and medications. The goal was Resident #16 will not sustain a serious fall related injury. The approaches included: Complete a fall evaluation to determine fall risk score on admission and as needed as determined by interdisciplinary team (IDT), and Follow facility fall protocol. The records had no evidence of quarterly fall risk assessment in August 2020 to determine fall risk score to define interventions for the prevention of falls. There was no evidence of a fall risk assessment after the fall that occurred on 08/20/20. A review of the facility's policy for Fall prevention & management program, indicated: the purpose for a fall prevention program was used to provide a safe environment for resident of the facility. This program is designed to identify residents at risk of falls; define interventions for the prevention of falls; implement quality assurance measures to monitor progress; and provide ongoing staff education. The policy further indicated all residents will be assessed for risk of falling during the first 72 hours of admission, the assessment will be completed quarterly, annually, and/or if a change in condition requiring completion of a new MDS occurs. On 10/21/20 at 10:24 AM, an interview process started with the DON, and an inquiry was made regarding the facility's protocol of fall risk assessment. The DON revealed fall risk assessment should be done on admission, quarterly and any time after a fall. During this time, a side by side review of Resident #16's records was conducted with the DON. She confirmed that the records lacked evidence of the quarterly fall risk assessment in August 2020 and lacked evidence of fall risk assessment after the fall on 08/20/20. She agreed that there should have been fall risk assessments in the records. She further revealed that the restorative nurse, who was assigned to do this task (to do fall risk assessments), was not available, evidently she was responsible to do this task, and she forgot to complete the fall risk assessments for Resident #16. 4. Review of the closed medical record for Resident #66 revealed an admission date of [DATE] and a discharge date of [DATE]. The documented BIMS score for Cognition was 09, indicating moderate cognitive impairment. Review of the Progress notes revealed Resident #66 had 2 falls from 09/25/20 to 10/18/20. The progress notes on 09/25/20 revealed the resident had an unwitnessed fall. He was admitted to an acute care hospital for evaluation. The resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 10/18/20 at 7:16 PM, the resident was found on the floor. On 10/19/20, per his physician orders, the resident was sent to the hospital's emergency room for evaluation of right [MEDICAL CONDITION]. Further review of the chart revealed 1 of the 4 quarterly fall risk assessments were not completed. The completed dates for the (Quarterly) fall risk assessments were noted on 02/05/20, 04/27/20 and 09/30/20. The Medical Record lacked a Fall Risk Assessment for July 2020. Interview with the DON on 10/22/20 confirmed the medical record lacked a Quarterly Fall Risk assessment for July 2020.

Based on observation, interview, and record review, the facility failed to ensure the facility had sufficient staff to aeduately and appropriately care for residents, affecting 3 of 4 units (100, 200, and 400 halls) reviewed for staffing. The findings included: Upon entry to the facility on [DATE] at 6:00 AM, interviews were conducted with staff on the night shift (11:00 PM to 7:00 AM). At 6:10 AM, a random confidential interview was conducted with Staff [NAME] This interview revealed Staff A was covering the 100 hall with a census of 16 and the 200 hall with a census of 24. Staff A, a licensed practical nurse, stated that she has been assigned over 40 residents before, but tonight, she has 40. She stated it is difficult to get to everyone (new staff), since they have so many residents and the facility wants them to help the Certified Nursing Assistants (CNA's) when needed. Staff A further stated that they (management) hire staff for the 11 PM - 7 AM shift but they do not stay after seeing how it is here. Staff A has worked for the facility for many years and stated that it has not always been this way. The facility is under new management. Staff A referred the surveyor to the Monday night's schedule (08/19/19), where there is one nurse and one CNA on each hallway and stated This happens often. They want the nurses to help the aides but with 40 residents, that is not always possible. The residents in both halls (100 and 200 halls) all need assistance for transfers and mobility and many are Hoyer lift only, which requires two people. In an interview at 6:20 AM with Staff B and C, both CNA's, it was revealed that they have only worked in the facility a short time. They both stated it was difficult to get all the work done, but they work together and do their best. They were assigned to the 200 hall but stated they do go over to the 100 hall if the CNA there needs help. Most of the residents on these hallways are there for long term care, and many require a Hoyer lift. In an interview at 6:35 AM with Staff D, a registered nurse (RN), it was revealed that this unit had a census of 26 residents. There was 1 nurse and 1 CNA assigned to this unit. Staff D, who was also the charge nurse for the facility, stated they (management) do the scheduling of the CNA's based on the entire census of the facility and that CNA's will come from other units to assist when needed. A review of the schedules did not reflect this (CNAs assigned to other units also). At 6:45 AM, a second interview with Staff B revealed sometimes they will go over to other units, but the aide that is there today does not want help and prefers to do everything herself. A confidential interview with Staff [NAME] at 6:50 AM, revealed the staff member was assigned the 16 residents on hall-1 to take care of. Staff [NAME] stated they hire people, but they quit after a couple days because of the workload. Staff [NAME] said, They work you like a slave here. Last Saturday night, I had 24 residents by myself. All these residents require incontinent care and need help moving. I do my best to get to everyone, but I can only do so much. After working 3 days in a row, sometimes I have to call off because my back is hurting. Staff [NAME] further stated that, 'this staff member has gone over to the 400 unit to help, but then it leaves the unit they are working empty. This staff member comes back to call lights going off and no one to answers them.' Staff [NAME] stated, 'many times the nurse will work both the 100 and 200 hallways. It is very bad.' In an interview with Resident #1 at 8:34 AM, it was revealed that she feels the CNA's have a hard time getting around to caring for all the residents. They have four CNA's today, but many times, they only have three. They must get everyone up, cleaned up, dressed, and fed. All the residents here do not move on their own and need help. Many need to be fed. It is a lot of work for them and they do the best with what they have. The place is okay, but they have a staffing problem and staff do not stay. The call lights are sometimes answered slow, taking more than 20 minutes. A review of Resident #1's record revealed she was admitted to the facility on [DATE]. Her last quarterly assessment MDS (Minimum Data Set) was conducted on 05/22/19 revealed the resident has a BIMS of 15, which shows the resident is cognitively intact. This resident is always incontinent of bladder and frequently incontinent of bowel. The resident is an extensive assist of one for personal hygiene. In an interview with Resident #2 at 8:52 AM, it was revealed that this is her second time being in the facility. She stated two years ago and it was very nice. After this visit, I do not think I would come back here. They have changed ownership and it has gone downhill. There is not enough staff. The resident care is okay for what they have, but the staff always appear rushed and overworked. This resident said the worst shift is evenings (3 PM to 11 PM), they are snarky and lazy. The resident stated she feels bad for the residents here who cannot say anything for themselves. Any complaint you have falls on deaf ears, and they are only worried about the money. They need to do something about the staffing here. She stated she feels bad for the staff that are there. A record review for Resident #2 revealed the resident was admitted to the facility on [DATE] for rehab related to a fractured upper left tibia. The MDS was not completed at the time of the survey, but the resident appeared to be cognitively intact. The care plans revealed the resident is a two person assist with transfers and is continent of bowel and bladder. She is a high risk for falls. In an interview with Resident #3 at 9:05 AM, it was revealed that she has been in the facility for about 3 years. Resident #3 said, The care before the change of ownership was much better than it is now. The care here is terrible. They do not have enough staff, and the 3 PM - 11 PM staff are rude. It can take over a half hour to get help / changed after ringing a call light. The aides and nurses treat you 'like dirt'. A review of Resident #3's record revealed the resident was admitted on [DATE] for LTC (long term care). The last MDS conducted was an annual assessment on 06/03/19, that revealed a BIMS of 10 of 15, indicating moderate impaired cognition. The resident needs limited assistance of one for toileting and is frequently incontinent of bladder and continent of bowel. She is a limited assist of one for transfers. In an interview with Resident #4 at 11:15 AM, it was revealed that the resident has resided at the facility for a couple years. The resident stated they do eventually answer the call light, but it can be 15 minutes or longer. The resident stated I don't like to complain. They only have a couple people to take care of so many. A review of the incident log revealed this resident sustained [REDACTED]. The report indicated the call light was not utilized by the resident. In an interview with Resident #5 at 11:20 AM, it was revealed that it can take over 20 minutes at times to get help in getting to the bathroom, and sometimes that is too long. The resident stated the worst time is the 3 PM - 11 PM shift. At 11:25 AM, upon walking into the room of Resident #6, the resident was observed attempting to pick up his nebulizer off the floor. He had been given a breathing treatment and the medication was still present, and the nurse was not present. The resident picked it up off the floor and started to use. The surveyor had him put it down until a nurse came in the room. Staff G, an Registered Nurse (RN), walked in approximately two minutes later, and Staff G was made aware of what had happened, and she stated that she would get the resident a new one. A review of the facility log from 05/01/19 through 08/19/19 revealed the following: There were two elopements from the facility, one in (MONTH) and one in August, neither one resulted in injury. These occurred on the 7 AM - 3 PM shift. During the month of May, there were a total of 20 falls. During the month of June, there were 23 falls. During the month of July, there were 19 falls. So far in the month of (MONTH) 2019, there have been 10 falls. The falls are occurring at all times of the day and night. During the time reviewed, there were 23 falls on the 7 AM-3 PM shift, 28 falls of the 3 PM-11 PM shift, and 20 falls on the 11 PM-7 AM shift. The facility had conducted investigations, which resulted in no adverse events. In an interview with the Director of Nursing (DON) at approximately 1:00 PM, she stated they have met all of the staffing ratios with the exception of one day. The DON further stated that she has not received any complaints about staffing. A review of the staff schedules from 07/15/19 through 08/19/19 revealed the following staff shortages: 07/15/19 - Hall 4 census 22: 11PM - 7AM shift had 1 CNA 07/16/19 - Hall 4 census 22: 11PM - 7AM shift had 1 CNA 07/17/19 - Hall 2 census 23: 11PM - 7AM shift had 1 CNA, and Hall 4 census 22: 11PM - 7AM shift had 1 CNA 07/18/19 - Hall 4 census 22: 11PM - 7AM shift had 1 CNA 07/19/19 - Hall 4 census 23: 11PM - 7AM shift had 1 CNA 07/20/19 - Hall 4 census 21: 11PM - 7AM shift had 1 CNA 07/21/19 - Hall 2 census 23: 11PM - 7AM shift had 1 CNA, and Hall 4 census 23: 11PM - 7AM shift had 1 CNA 07/22/19 - Hall 2 census 23: 11PM - 7AM shift had 1 CNA, and Hall 4 census 23: 11PM - 7AM shift had 1 CNA 07/23/19 - Hall 2 census 23: 11PM - 7AM shift had 1 CNA, and Hall 4 census 21: 11PM - 7AM shift had 1 CNA 07/24/19 - Hall 2 census 25: 11PM - 7AM shift had 1 CNA, and Hall 4 census 24: 11PM - 7AM shift had 1 CNA 07/25/19 - Hall 4 census 21: 11 PM - 7 AM shift had 1 CNA 07/26/19 - Hall 2 census 21: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 23: 11 PM - 7 AM shift had 1 CNA 07/27/19 - Hall 2 census 22: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 21: 11 PM - 7 AM shift had 1 CNA 07/28/19 - Hall 2 census 22: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 21: 11 PM - 7 AM shift had 1 CNA 07/29/19 - Hall 4 census 21: 11PM - 7 AM shift had 1 CNA 07/30/19 - Hall 2 census 23: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 22: 11 PM - 7 AM shift had 1 CNA 07/31/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 22: 11 PM - 7 AM shift had 1 CNA 08/01/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 24: 11 PM - 7 AM shift had 1 CNA 08/02/19 - Hall 5 census 27: 11 PM - 7 AM shift had 1 CNA 08/03/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 23: 11 PM - 7 AM shift had 1 CNA 08/04/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 23: 11 PM - 7 AM shift had 1 CNA 08/05/19 - Hall 2 census 23: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 23: 11 PM - 7 AM shift had 1 CNA 08/06/19 - Hall 4 census 21: 11 PM - 7 AM shift had 1 CNA 08/07/19 - Hall 1 & 2 had combined census of 41 with one LPN covering both hallways 08/07/19 - Hall 2 census 25: 11 PM - 7 AM shift had 1 CNA; and Hall 4 census 24: 11 PM - 7 AM shift had 1 CNA 08/08/19 - Hall 4 census 21: 11 PM - 7 AM shift had 1 CNA 08/09/19 - Hall 4 census 23: 11 PM - 7 AM shift had 1 CNA 08/10/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA/with orientee, and Hall 4 census 25: 11 PM - 7 AM shift had 1 CNA/with orientee 08/11/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA/with orientee, and Hall 4 census 25: 11 PM - 7 AM shift had 1 CNA/with orientee 08/12/19 - 08/09/19 - Hall 4 census 26: 11 PM - 7 AM shift had 1 CNA 08/13/19 - Hall 2 census 25 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 25 11 PM - 7 AM shift had 1 CNA 08/14/19 - Hall 1 & 2 had combined census of 41 with one LPN covering both hallways 08/14/19 - Hall 2 census 25: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 26 11 PM - 7 AM shift had 1 CNA 08/15/19 - Hall 4 census 25: 11 PM - 7 AM shift had 1 CNA 08/17/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA 08/18/19 - Hall 4 census 26: 11 PM - 7 AM shift had 1 CNA 08/19/19 - Hall 2 census 24: 11 PM - 7 AM shift had 1 CNA, and Hall 4 census 26: 11 PM - 7 AM shift had 1 CN[NAME] The staffing schedule review revealed the nurses on Hall 1 and Hall 2 are frequently combined giving that one nurse up to 40 residents nightly with the expectation of assisting the CNAs in their care of residents. On two occasions, the census was 41 residents for the reviewed time period above, with only one nurse.