Every finding on record at Sunrise Health & Rehabilitation Center

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 2 of 2 visits conducted in the Main Kitchen. The findings included: On 02/23/26 at 8:47 AM, a tour of the facility's kitchen was conducted. Upon entering the kitchen, several male staff were observed with facial hair, none of which were wearing beard covers (Staff V, W, X, Y). Once the staff were alerted by the surveyor, Staff X donned a beard cover but did not cover his mustache. The surveyor had to explain to all the male staff that beard covers were to cover all facial hair, not just beards. The following was also observed: a. Two plates in the plate warmer were found to have food particles and the food contact surface of the plates showed signs of wear and excessive use. b. Two 50-ounce cans of Tomato Soup were noted with dents on the bottom of the cans in the dry stock room. c. The dishwashing machine was a high temperature model. During the observation, it was run 3 times, but it did not meet the required temperatures. The rinse cycle reached 175 degrees Fahrenheit, not the required temperature of 180 degrees. The wash cycle reached 125 degrees Fahrenheit and was also below the requirement of 150-165 degrees. Without reaching the proper temperatures, the dishes were not properly sanitized. In an interview conducted on 02/26/26 at 3:30 PM with the Administrator, she was informed of the findings.

Based on review of policy and procedure, observation, record review and interview, the facility failed to provide care and services and change the dressings for residents' Midline Intravenous (IV) catheter dressing in a timely manner, for 1 of 1 sampled resident observed, on the Locked Memory Care, G-wing, with a Midline catheter in place, Resident #23.The findings included:Review of the facility policy title, Midline.Dressing Change, provided by the Director of Nursing (DON), revised on 01/2026 documented in the Policy Statement: It is the policy of this facility to change.Midline.dressing weekly, or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: g. Open sterile dressing kit.6. Inspect the catheter-skin junction and surrounding area, palpating through the intact dressing for redness, tenderness, swelling and drainage. Be attentive to any reports of pain, paresthesia's, numbness, or tingling. 7. Remove old dressing beginning at the device hub and gently pull the dressing perpendicular to the skin toward the insertion site.14. Clean the insertion site with an antiseptic following manufacturer's instructions.16. If applicable, apply skin barrier solution and follow manufacturer's directions for use. 17. Secure the catheter with an engineered stabilization device, if available. 18. Apply a transparent semipermeable dressing to the insertion site. 21. Label the dressing with the date and time and your initials.24. Document the procedure.Record review revealed Resident #23 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease, Systolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Adult Failure to Thrive, Chronic Kidney Disease, Chronic Pulmonary Edema, Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Parkinson's Disease with Dyskinesia, with Fluctuations. The record documented a Brief Interview Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment.On 02/18/26, the physician's order documented, Midline Intravenous (IV): Change Transparent Dressing Weekly on every night shift every Monday and as often as needed (PRN).Record review of Resident #23's IV Medications care plan initiated 01/26/26 and revised 02/19/26 indicated Focus: Related to Pneumonia and Sepsis. Interventions: Administer IV medications as ordered. IV dressing: Transparent dressing. Observe dressing (PRN). Change dressing and record observations of site (as scheduled and PRN). Monitor/document/report PRN signs and symptoms of infection at the site: Drainage, inflammation, swelling, redness, warmth. Monitor/document/report PRN signs/symptoms of leaking at the IV site: Edema at the insertion site, taut, shiny or stretched skin, whitening/blanching or coolness of the skin, slowing or stopping of the infusion, leaking of I.V. fluid out of the insertion site.Goal: The resident will not have any complications related to IV Therapy through the review date.Record review of Resident #23's Antibiotic Therapy Care plan initiated 01/26/26 and revised 02/19/26 indicated Focus: .Related to Pneumonia and Sepsis. Interventions: Administer medication as ordered Goal: Manage symptoms without complications and will have current infection treated.On 02/23/26 at 1:05 PM, observation of Resident #23 in the Locked Memory Care Unit G-wing, revealed his Midline Intravenous (IV) was dated on the outside of the transparent IV dressing as: Wednesday 02/11 @ 9 AM. The dressing was observed with a small amount of old, dried blood noted in the base of the tubing.On 02/23/26 at 4:21 PM, during a second observation, Resident #23 was observed with his Midline Intravenous (IV) dated on the outside of the transparent IV dressing as: Wednesday 02/11 @ 9 AM. The dressing was observed with a small amount of old, dried blood noted in the base of the tubing.Record review of the Medication Administration Record (MAR) documented that Resident #23 had been ordered the following three (3) IV medications: 1) Anti-fungal - Mycamine Intravenous Solution Reconstituted 100 mg (Micafungin Sodium) Use 100 mg intravenously one time a day for sepsis/Pneumonia. 2) Antibiotic - Vancomycin Hydrochloride (HCl) Intravenous Solution (Vancomycin HCl) initially 1250 mg intravenously one time a day for Methicillin Resistant Staphylococcus Aureus (MRSA). Subsequently, Vancomycin HCl Intravenous Solution (Vancomycin HCl) 750 mg intravenously in the morning for Sepsis. And 3) Antibiotic -Cefepime HCl Intravenous Solution Reconstituted 2 GM (Cefepime HCl) two (2) gram intravenously every twelve (12) hours for Complicated Urinary Tract Infection (UTI).Record review of the facility's nursing progress note dated 02/11/26 revealed that, Midline re-inserted to left upper arm, by IV access. IV line in place patent, flushed as indicated.Review of the nursing progress note dated 02/14/26 documented, .patient reported. having chest pain. 911 called, patient was assisted out of facility via stretcher transported to [hospital name] .admitted with diagnosis of Sepsis, Pneumonia and COPD exacerbation.Record review of the February 2026, 3008 Transfer Form documented Resident #23 had been returned to the facility from the hospital, with his original Midline IV catheter site and dressing to his left arm in place, for Antibiotic infusions.On 02/19/26, the progress notes documented, Resident is re-admitted to facility, with diagnosis of Sepsis, Methicillin Resistant Staphylococcus Aureus (MRSA), Complicated Urinary Tract Infection (UTI). Patient is.be continued on IV antibiotic.Further record review of Resident #23's MAR, the nurses' progress notes and of the Treatment Administration Record (TAR), did not show, nor document whether or not the Resident #23's original Midline IV transparent dressing had been changed since Wednesday 02/11 @ 9 AM; remaining in place for thirteen (13) days, after the original re-insertion date in the facility. An interview was conducted on 02/24/26 at 11:28 AM with Staff E, Licensed Practical Nurse (LPN), regarding Resident #23's outdated Midline IV transparency dressing site, in which she acknowledged that the resident had a Midline IV re-inserted on 02/11/26, by an outside company. Staff E acknowledged the resident had been transferred out of the facility on Saturday 02/14/26 on day shift to the hospital for Chest Pain, and was re-admitted last week on Wednesday 02/18/26, with the same Midline IV transparent dressing still remaining in place and not changed, until 02/23/26, the first day of survey after surveyor intervention.A side-by-side record review and interview was conducted on 02/24/26 at 11:38 AM with Staff Q, Registered Nurse (RN)/Unit Manager of the G-wing, regarding Resident #23's outdated Midline IV transparency dressing site, in which she acknowledged the resident had a Midline IV re-inserted on 02/11/26 by an outside company. She acknowledged the resident had been transferred out of the facility on Saturday 02/14/26 on day shift to the hospital, and was re-admitted on Wednesday 02/18/26, with the same Midline IV transparent dressing remaining in place and not changed until 02/23/26, the first day of this survey after surveyor intervention.The Director Of Nursing acknowledged on 02/24/26 at 4:30 PM that Resident #23's Midline IV transparent dressing should have been changed in a timely manner, and according to the physician's written orders.

Based on observation, interview and record review, the facility failed to correctly complete Minimum Data Set (MDS) assessments for 2 of 35 sampled residents, Resident #54 and Resident #98. The findings included:1. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section C revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating the resident had moderate cognitive impairment. Section P-Restraints and Alarms of the same MDS revealed the MDS was coded as the resident using Bed Rails. An interview was conducted with Staff B, Licensed Practical Nurse (LPN), MDS Coordinator on 02/24/26 at 10:56 AM. She stated it was an error as they do not use restraints. 2. Record review revealed Resident #98 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Acquired Absence of Left Leg Above Knee, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Record review of the quarterly MDS assessment dated [DATE] under Section C revealed the resident had a BIMS score of 6 indicating the resident had severe cognitive impairment. Section K of the same MDS revealed the MDS was coded as receiving intravenous (IV) fluids during the 7-day lookback period. In an interview with Staff B, LPN, on 02/24/26 at 10:56 AM, she stated hydration was triggered because the MDS was coded as the resident receiving IV fluids, but she did not have during that look back period.

Based on observation, interviews, and record review, the facility failed to provide splints / protectors to assist in preventing contractures for 1 of 3 sampled residents reviewed for position and mobility, Resident #15. The findings included: Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia, depression, and right-hand contracture. The [NAME] Data Set (MDS) dated [DATE] showed Resident #15's cognitive status to be severely impaired. A review of the physician's orders showed a Bilateral hand palm protector order every shift for skin integrity, dated 12/17/25. Review of the care plan dated 01/16/26 revealed contracture prevention and management, including split-type palm protectors for bilateral hands, refer to therapy as needed, and apply splints and remove them as scheduled. Review of the Occupational Therapy Evaluation and plan of treatment dated 12/12/25 revealed Resident #15 presents with Bilateral upper extremity hand contractures and recommended the use of splints in place. In an observation conducted on 02/24/26 at 10:20 AM, Resident #15 was noted in bed with no bilateral palm hand protectors on each hand. Resident #15's hands were noted to be very contracted. Closer observation revealed the palm protectors were located in Resident #15's top drawer of her dresser. No staff were noted at the time of this observation. In an observation conducted on 02/24/26 at 10:50 AM, Resident #15 was noted in bed with no bilateral palm hand protectors on each hand. Closer observation revealed the palm protectors were in Resident #15's top drawer of her dresser. No staff were noted at the time of this observation. In an observation conducted on 02/24/26 at 12:05 PM, Resident #15 was noted in bed with no bilateral palm protectors on each hand. Closer observation revealed the palm protectors in Resident #15's top drawer of her dresser. No staff were noted at the time of this observation. In an observation conducted on 02/24/26 at 12:50 PM, Resident #15 was noted in bed with no bilateral palm hand protectors on each hand. Closer observation revealed the palm protectors in Resident #15's top drawer of her dresser. No staff were noted at the time of this observation. In an interview conducted on 02/24/26 at 2:45 PM with the Assistant Director of Rehab, she stated Resident #15 has an order for bilateral palm protectors to help prevent pain and skin breakdown. It is the daily staff who are responsible for placing the splints on the residents, and they conduct audit visits to ensure that other staff members place them. In an interview conducted on 02/24/26 at 3:08 PM with Staff H, Certified Nursing Assistant / CNA, who has been working in the facility for the last 33 years, she stated that Rehab or she is responsible for placing the palm protectors on Resident #15. She further said that the palm protectors are on Resident #15 all the time and, when asked whether they were on today, said no.

Based on observations, interviews, record reviews, and policy review, the facility failed to follow physicians' oxygen orders for 4 of 5 sampled residents reviewed for oxygen therapy and has the potential to affect 49 residents on oxygen therapy, Resident #38, Resident #229, Resident #108, Resident #228; failed to obtain physicians order for oxygen therapy administration for 1 of 5 sampled residents reviewed for oxygen therapy, Resident #49; and failed to follow the professional standards of practice during medication administration via an oral inhalation for 1 of 8 sampled residents for medication administration observation, Resident #54. The findings included:Review of the facility policy titled, Oxygen Therapy, provided by the Director of Nursing (DON) revised in 01/26, documented in the Policy Statement: To administer Oxygen when insufficient Oxygen is carried by the blood to the tissue.Procedure:.Place signs Oxygen in use and No Smoking signs outside room.Adjust rate of flow according to doctor's orders.Record oxygen therapy on treatment record; time, rate of flow concentration, tolerance. 1. Record review showed Resident #38 was admitted on [DATE] with diagnosis of critical illness Myopathy and Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation. Review of the Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 14, which indicates no cognitive impairment. A review of section O (Special treatments, Procedures and Programs) of the MDS indicated that Resident #38 was admitted with oxygen therapy to the facility. Review of the Physician's Orders indicated that on 01/06/26 an order for an oxygen concentrator with humidifier was placed for 2 liters per minute. Review of the care plan dated 01/08/26 documented Resident #38 has altered respiratory status and difficulty breathing. Goals are to maintain normal breathing pattern and have no complications related to shortness of breath. The interventions included setting oxygen with humidifier via nasal cannula at 2 liters as ordered. In an observation conducted on 02/23/26 at 10:45 AM, Resident #38 was seen lying in bed with the oxygen in placed and functioning. The oxygen was set at 1.5 liter per minute. In an observation conducted on 02/23/26 at 3:25 PM, Resident #38 was seen lying in bed with oxygen functioning at 1.5 liter per minute. 2. Record review showed that Resident #229 was admitted on [DATE] and readmitted [DATE] on with diagnosis of Pulmonary Candidiasis and COPD with acute exacerbation. Review of the Medicare 5-Day MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Review of section O (Special treatments, Procedures and Programs) of the MDS indicated Resident #229 was admitted with oxygen therapy to the facility. Review of the Physician's Orders indicated that on 02/11/26 an order for supplemental oxygen concentrator with humidifier was placed for 3 liters per minute. Review of the care plan dated 02/23/26 documented Resident #229 has altered respiratory status and difficulty breathing. Goal is to maintain normal breathing pattern. The interventions included setting oxygen with humidifier via nasal cannula at 3 liters as ordered. In an observation conducted on 02/24/26 at 12:09 PM, Resident #229 was seen seating on a wheelchair in her room with oxygen functioning at 2.5 liters per minute. In an interview conducted on 02/24/26 at 12:10 PM, Resident #229 stated that her oxygen is always set at 2 liters per minute. 3. Record review documented Resident #108 was admitted on [DATE] with diagnosis of Respiratory Failure with hypoxia and other sequelae of other cerebrovascular disease. The Medicare 5-Day MDS assessment dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Review of section O (Special treatments, Procedures and Programs) of the MDS indicated Resident #229 started receiving oxygen therapy while being a resident in the facility. Review of the Physician's Orders indicated that on 02/24/26 an order for oxygen concentrator with humidifier was placed in for 2 liters per minute. Review of the care plan dated 01/29/26 documented Resident #108 has altered respiratory status and difficulty breathing. Goals are to maintain normal breathing pattern and have no complications related to shortness of breath. The interventions included setting oxygen with humidifier via nasal cannula at 2 liters as ordered. In an observation conducted on 02/23/26 at 12:35 PM, Resident #108 was seen lying in bed, sleeping with the bed placed in a low position and fall mattresses placed on each side of bed. Resident #108 was receiving 3 liters per minute of oxygen. In an observation conducted on 02/23/26 at 3:30 PM, Resident #108 was seen lying in bed, sleeping and receiving 3 liters per minute of oxygen. In an interview conducted on 02/26/26 at 11:00 AM, the Infection Control Preventionist stated that he has been working for the facility for about 2 years. He stated the staff were educated on oxygen and that they should always follow the order. He stated when setting the oxygen machine, it should be to eye level to put the right amount of liter. In an interview conducted on 02/26/26 at 11:15 AM with Registered Nurse (RN), Staff T, the nurse stated she has been working for the facility for about 2 years now. She stated you would go to the computer to check the order the oxygen should be on; then you go to the room at eye level and position it the ball of the machine on the line of the liters were supposed to be. She was made aware of the findings. In an interview conducted on 02/26/26 at 11:20 AM with Registered Nurse (RN) Unit Manager, Staff U stated he has been working in the facility for 1 year. He further stated the residents that come from the hospital come with their orders but residents that have a change in condition in the facility are seen by the doctor and reevaluate the resident. Staff U explained that he always checks the oxygen machines at eye level during his rounds, but the issue is that the unit is short-term, which means that the resident is manipulated by staff from different departments and the oxygen is constantly changed. 4. Record review for Resident #228 revealed the resident was admitted to the facility on [DATE]. Resident #228's diagnoses upon admission included: COPD, Respiratory disorders, Immunodeficiency, Obstructive sleep apnea, Acute maxillary sinusitis, Atherosclerotic heart disease, Dementia, Shortness of breath, and Atrial fibrillation. Review of Resident #228's physician orders included: Oxygen/concentrator with humidifier at 3 Liters per minute (LPM) via nasal cannula - every shift for shortness of breath – 02/24/26 Review of Resident #228's care plan for altered respiratory status documented: Resident has altered respiratory status/difficulty breathing r/t [related to] COPD, Respiratory disorder, SOB [shortness of breath], Obstructive Sleep Apnea, Pleural effusion, Atelectasis; Date Initiated: 02/24/2026, Revision on: 02/24/2026. The goal of the care plan was documented as: The resident will have no complications related to SOB through the review date. Date Initiated: 02/24/2026 Target Date: 05/21/2026. Interventions to the care plan included: OXYGEN SETTINGS: O2 with humidifier via (nasal cannula) (3)L as ordered Date Initiated: 02/24/2026. Review of the Plan of Care Note dated 02/24/26, documented: Note Text: Resident was admitted with diagnoses of polyneuropathy, psoriatic arthritis mutilans, chronic obstructive pulmonary disease (COPD), respiratory disorder, pleural effusion, immunodeficiency, and protein-calorie malnutrition. During assessment, he was noted to experience shortness of breath (SOB) when lying flat. The head of the bed is maintained in an elevated position to promote comfort and ease breathing. Respiratory status is being closely monitored due to underlying COPD. Oxygen therapy is administered as ordered, and nebulizer treatments are provided per orders. Physical and occupational therapy are actively involved to support recovery, address weakness and functional limitations associated with polyneuropathy and chronic illness and improve overall functional independence. On 02/23/26 at 3:49 AM, Resident #228 was observed in bed and was receiving oxygen (O2) at 2 LPM via nasal canula from an oxygen concentrator. When asked Resident #228 voiced no shortness of breath and no concerns. On 02/25/2026 at 8:34 AM, Resident #228 was observed in bed and was receiving O2 at 2.5 LPM via nasal canula from a concentrator. Photographic Evidence Obtained. During an interview, on 02/25/26 at 2:49 PM, with Staff O, RN, when the RN was shown the photographic evidence of the oxygen concentrator being set at 2.0 and 2.5 LPM, the RN stated, sometimes when you are looking at it, it only looks like it is not at 3 LPM. On 02/26/2026 at 9:28 AM, Resident #228 was observed in bed receiving O2 at 2.5 LPM. During an interview, on 02/26/26 9:49 AM, with Staff P, RN, the RN confirmed the order for oxygen at 3 LPM. When the RN was shown the photographic evidence of the resident not receiving the O2 as ordered, the RN acknowledged that the findings were accurate. Staff P stated, sometimes he takes it off and we have to educate him on it. He will titrate it. I switched it back to 3. During an interview, on 02/26/26 at 11:11 AM, when asked about changing the settings on the concentrator, Resident #228 stated, I can't reach it and I don't touch it. 5. Record review revealed Resident #49 was admitted to the facility on [DATE] and he was readmitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Atherosclerotic Heart Disease, and Epilepsy. The record documented a BIMS score of 3, indicative of severe cognitive impairment. During an observation conducted on 02/23/26 at 10:05 AM, Resident #49 was observed with Oxygen infusing at two (2) liters via Oxygen tank. There was no signage noted outside of the resident's doorway, signifying Oxygen Therapy in use. Record review of the Form 3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 02/19/26, did not document Oxygen usage for this resident, prior to readmission to the facility, following an episode of Chest Pain. Record review of Resident #49's Oxygen Saturation Levels dating from Monday 02/16/26 until Monday 02/23/26 revealed that the range was 96-98%; either on room air (RA), or on Oxygen via nasal cannula. There were readings for Oxygen Therapy dating as far back as 01/15/26, with an Oxygen saturation level of 96% at two (2) liters via nasal cannula. Record review of 4 nursing facility progress notes dated from 02/20/26 through 02/23/26, revealed the following, with regards to the Resident #49's respiratory status, after readmission to the facility, .Resident returned to the facility from.Hospital. Respiration even and unlabored. No acute respiratory distress noted. Lungs clear throughout bilaterally. No difficulty breathing. No cough noted. Right lung clear. Left lung clear. No shortness of breath noted. Right lung clear. Left lung clear. Humidification: Yes. Oxygen via nasal cannula. Further record review revealed there was no physician's order in place for Oxygen Therapy Administration for Resident #49. Record review of the Resident #49's Respiratory care plan initiated 01/19/26 and revised 01/19/26 indicated: Focus: Resident has altered respiratory status/difficulty breathing related to Shortness of Breath and Cough. Interventions: Administer medication as ordered.Monitor for s/sx of respiratory distress and report to MD PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Goal: The resident will have no complications related to shortness of breath through the review date. An interview was conducted on 02/23/26 at 1:31 PM with Staff R, Certified Nursing Assistant (CNA), regarding Resident #49's Oxygen use. Staff R revealed the resident had been on Oxygen since her first admission and the readmission to the facility. The CNA stated she had seen the resident on the Oxygen concentrator, when in bed and whenever the resident comes out of the room, she will use the Oxygen tank. An interview was conducted on 02/23/26 at 1:46 PM with Staff E, Licensed Practical Nurse (LPN), regarding Resident #49's Oxygen use. She acknowledged the resident had been having Oxygen infusing at two (2) liters since she was transferred to this unit from the E-wing, prior to February 2026. Staff E stated the resident had to be put back on continuous Oxygen, after she failed a trial without it. Staff E acknowledged there had been no physician's order for the Oxygen therapy in place. A side-by-side record review and interview was conducted on 02/23/26 at 1:56 PM with Staff Q, Registered Nurse (RN), Unit Manager, regarding the Resident# 49's Oxygen use. Staff Q acknowledged the resident had currently been on Oxygen at two (2) liters. Prior to her transfer to the G-wing Memory Care Unit, Staff Q stated Resident #49 had been on the E-wing and acknowledged there had never been a physician's order in place for Oxygen therapy, to include the liters and parameters for care. The Director of Nursing (DON) acknowledged on 02/23/26 at 4:30 PM that Resident #49 had been receiving Oxygen therapy for her entire facility stay, and a physician's order should have been obtained for its use. Review of the policy titled, Medication Administration, implemented on 02/01/23 and revised on 01/26, documented the following: To obtain and record vital signs, when applicable, or per physician orders. If other than per Orem (po) route, administer in accordance with facility policy for the relevant route of administration. Review of the policy titled, Nebulizer Therapy, implemented on 02/01/23, and revised on 02/26, documented the following: Obtain vital signs, and respiratory assessment to establish baseline. Disassemble and rinse the nebulizer with sterile or distilled water and allow air to dry. Records review documented Resident #54 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction due to unspecified Occlusions or Stenosis of the Right Cerebellar Artery, Respiratory Disorders in Diseases Classified Elsewhere, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, and Chronic Respiratory Failure, Unspecified Whether Hypoxia or Hypercapnia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] under Section C documented a Brief Interview for Mental Status (B IMS) score of 11 indicating Resident #54 had moderate cognitive impairment. Review of the physician order dated 07/30/25 documented for: Ipratropium-Albuterol Solution 0.5-2.5 (3 milligram[mg]/3 milliliter[m]), inhale orally four times a day for shortness of breath (SOB)/wheezing. Review of the documented vital signs including respiratory rate, blood pressure and oxygen saturation for Resident #54 revealed that they are usually taken during the 3 PM to 11 PM shift by Staff F, Licensed Practical Nurse (LPN). Review of the vital signs revealed no documentations after 02/24/26. The documentation below revealed no consistency in vital signs monitoring and recording. Below is the latest documentation of recorded respiratory rates: 02/24/2026 20:11 18 Breaths/min Staff F, LPN, (Manual) 02/17/2026 17:04 18 Breaths/min Staff F, LPN (Manual) 02/16/2026 17:07 18 Breaths/min Staff F, LPN (Manual) Below are the latest blood pressure readings: 02/24/26 20:11 135/63 mmHg lying l/arm Staff F, LPN 02/17/26 17:04 106/63 mmHg lying r/arm Staff F, LPN 02/16/26 17:07 122/74 mmHg sitting r/arm Staff F, LPN Below are the latest oxygen saturation readings: 02/24/26 20:11 97% oxygen via nasal cannula Staff F, LPN 02/21/26 01:47 97% oxygen via nasal cannula another Staff 02/17/26 17:04 94% oxygen via nasal cannula Staff F, LPN Review of recent nursing progress notes did not reveal any documentation of lung auscultations before and after oral inhalation therapy. There was no documentation of vital signs such as respiratory rate, heart rate, blood pressure and oxygen saturation before and after oral inhalation therapy for Resident #54. Review of Medication Administration Records (MAR) for 02/2026 revealed no documentation of vital signs before and after oral inhalation therapy for Resident #54. During a medication observation for an oral inhalation treatment on 02/24/26 at 4:35 PM for Resident #54, with Staff F, LPN, the following were observed: Staff F entered Resident #54's room on 02/24/26 at 4:40 PM, with the oral inhalation medication, disinfecting wipes, and a plastic cup with approximately 8 ounces water. Staff F did not bring the oximeter to check for oxygen saturation, a sphygmomanometer to check the blood pressure, and a stethoscope to check for lung sounds. Staff F placed the inhalation mask onto the resident's face. Staff F proceeded with providing the oral inhalation therapy without lung auscultation, and did not obtain the respiratory rate, blood pressure and oxygen saturation of Resident #54 on 02/24/26 at 4:43 PM. After the procedure on 02/24/26 at 4:56 PM, Staff F immediately left the room after hearing an interview with Resident #54's roommate asking her if staff checked her lung sounds before and after a nebulizing treatment. Staff F returned to the room on 02/24/26 at 4:58 PM with a stethoscope and an oximeter. He stated the oxygen saturation was 99% on 02/24/26 at 4:59 PM. He started auscultating for lung sounds after obtaining Resident #54's oxygen saturation level. When Staff F was asked if they check Resident #54's vital signs, and lung sounds before and after oral inhalation treatment, he responded, yes. He stated they record them in progress notes and in vital signs section on their computer. When asked if they record them somewhere else, he responded, no, only in those areas. When asked if they record the time when vital signs were checked, he responded yes. In an interview conducted with Staff D, LPN on 02/25/26 at 11:30 AM, when she was asked her process of providing oral inhalation treatment to a resident, stated the following: Assist the resident in sitting position; Check both lungs, upper and lower back, to ensure they are clear, using a stethoscope; Check the pulse oximeter for measurement of oxygen saturation; Explain to the patient what she is going to do; Put the mask on to the resident, ensure it is not too tight or lose; Start the treatment. Stay with the patient; When finished, remove the mask, ask if patient is ok; Check oximeter for oxygen saturation, and check the lung sounds, starting at the back. She then added that it is the end. In an interview conducted with Staff A, LPN on 02/26/26 at 8:48 AM, when she was asked her process when providing oral inhalation treatment for a resident responded: Identify herself to the resident and check the resident's identification wrist band; Check both lungs for lung sounds after explaining to resident what she is going to do; Put resident's mask on, check proper fit, and stay with the resident for 15 minutes or until the medication is completed; Listen again to lung sounds. Document in progress notes. Interviews with facility staff revealed they do not monitor respiratory rate before and after oral inhalation and nebulizing treatment. In an interview conducted with the Nurse Educator on 02/24/26 at 5:21 PM, when he was asked where they document vital signs before and after inhalation treatment, responded, in the progress notes and on the Medication Administration Record (MAR). During another interview with the Nurse Educator on 02/26/26 at 9:45 AM, he was informed that staff assess lung sounds but do not monitor respiratory rates before and after oral inhalation and nebulizing treatment as evidenced by no progress notes and no Medication Administration Record (MAR) documentations.

Based on observation, interview and record review, the facility failed to document the code status in the physician's orders for 1 of 35 sampled residents, Resident #6. The findings included:Review of the facility's policy titled, Communication of Code Status, date implemented 4/2022 and date revised 1/2025, revealed When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical records. Examples of directions to be documented include, but are not limited to:a. Full Codeb. Do Not Resuscitatec. Do Not Intubated. Do Not HospitalizeThe designated sections of the medical record are: Order Section of Point Click Care.On 02/24/26 at 10:22 AM a review was conducted of the Physician Orders for Resident # 6. The orders did not reveal a code status order.On 02/25/26 at 9:50 AM an interview was conducted with Staff A, a Licensed Practical Nurse (LPN) and Unit Manager. She stated to find the code status they check the Electronic Health Record (EHR) and care plan. The code status should be in the Physician's Orders. If it is not in the Physician's Orders, they check the care plan. Record review reveled Resident #6 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Other Idiopathic Peripheral Autonomic Neuropathy, and Peripheral Vascular Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. On 02/24/26 at 10:22 AM, a review was conducted of the Physician Orders for Resident # 6. The orders did not reveal a code status order. On 02/25/26 at 9:50 AM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN) and Unit Manager. She stated to find the code status they check the Electronic Health Record (EHR) and the care plan. The code status should be in the Physician's Orders. If it is not in the Physician's Orders, they check the care plan. The order was added after surveyor intervention.

Based on observations, interviews and record reviews, the facility failed to maintain residents' call lights in a working manner for 2 of 35 residents in the final sample, Residents #112 and 225. The findings included:1. Record review revealed that Resident #112 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 02/02/26, Resident #112 had a Brief Interview for Mental Status (BIMS) score of 09, indicating the resident was moderately cognitively impaired. The assessment documented that the resident required partial/moderate assistance for transfers and was able to walk short distances independently and up to 150 feet with assistance and was frequently incontinent of bowel and blader. Resident #112's diagnoses at the time of the assessment included: Anemia, Hypertension, Heart failure, Renal insufficiency, DM, Hyperlipidemia, Hip fracture, Malnutrition, Chronic lung disease, refractory anemia, Pulmonary fibrosis, Immunodeficiency, Muscle wasting and atrophy, Muscle weakness, Dependence on renal dialysis, Adjustment disorder with depressed mood, Pleural effusion. Review of Resident #112's care plan for falls documented: Resident is at risk for falls r/t [related to] Gait/balance problems, Impaired mobility r/t left femur fx,[fracture] Thoracolumbar Spondylopathy and Disc degeneration Date Initiated: 10/29/2025 Revision on: 10/29/2025.The goal of the care plan was documented as: The resident will be free of falls through the review date. Date Initiated: 10/29/2025 Revision on: 11/10/2025 Target Date: 04/21/2026. Interventions in the care plan included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 10/29/2025; and The resident needs a safe environment with: (Such as: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach) Date Initiated: 10/29/2025. On 02/24/26 at 10:34 AM, the call light in the resident's bathroom was noted to be tied around the grab bar to the resident's right side of the commode. During an interview, on 02/26/26 at 9:38 AM, with the Activities Director, the Activities Director confirmed that Resident #112 was physically and mentally able to use the call light, we remind her to use it when she needs helpDuring an interview, on 02/26/2026 at 9:41 AM, with Staff N, Registered Nurse (RN)/Unit Manager, the RN confirmed that Resident #112 was physically and mentally able to use the call light. 2. Record review revealed that Resident #225 was admitted to the facility on [DATE]. According to the resident's baseline care plan, with a reference date of 02/23/26, Resident #225 was 'cognitively impaired' with confusion. The baseline care plan documented that the resident required limited assistance with bed mobility, transfers, locomotion and toileting. Review of Resident #225's care plan for Activities of Daily Living (ADLs) documented: Resident has an ADL self-care performance deficit related to Activity Intolerance, Limited Mobility, Musculoskeletal impairment, Sequelae of Cerebrovascular Accident (CVA), Cerebral ischemia Date Initiated: 02/23/2026 Revision on: 02/23/2026. Interventions to the care plan included: Encourage the resident to use bell to call for assistance. Date Initiated: 02/23/2026. Review of Resident #225's care plan for falls documented: Resident is at risk for falls related to Gait/balance problems, Impaired mobility, Sequelae of CVA, Cerebral ischemia, Muscle wasting and atrophy and End Stage Renal Disease (ESRD) Date Initiated: 02/23/2026 Revision on: 02/23/2026. Interventions to the care plan included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 02/23/2026 The resident needs a safe environment with: (Such as: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach) Date Initiated: 02/23/2026. On 02/24/26 at 9:01 AM, the call light in the resident's bathroom was noted to be tied around the grab bar to the resident's left side of the commode.On 02/26/2026 at 9:05 AM, the call light in the resident's bathroom was noted to be tied around the grab bar to the resident's left side of the commode. During an interview, on 02/26/26 at 9:43 AM, with Staff N, the RN stated, he can use the call light, but he can't use the bathroom by himself. He is 1 person assistance to the toilet. We tell him to use the call light. We check on him time to time before he finishes.

Based on observations, interviews, and record review, the facility failed to address weight loss in a timely manner and provide nutritional interventions for 3 of 5 sampled residents reviewed for nutrition, Resident #193, Resident #7, and Resident #59. The findings included: 1. Record review showed Resident #193 was admitted to the facility on [DATE] with diagnoses of Anemia and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #193 has a Brief Interview of Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. In an interview conducted on 02/24/26 at 9:10 AM with Resident #193, he stated that he was in so much pain and could not eat his breakfast. Closer observation showed that the breakfast meal was untouched. In an interview conducted on 02/24/26 at 11:39 AM, Resident #193 was in the room with his lunch, consisting of marinated pork cubes, fluffy rice, carrots, and vanilla ice cream. Resident #193 stated that he is not very hungry, but he loves ice cream and would eat it on his tray. He further said that he would drink shakes if they were offered to him. Review of the Weights Log for Resident #193 revealed the following: 02/13/2026, a weight of 130.2 pounds. 02/12/2026, a weight of 130.2 pounds. 02/6/2026, a weight of 130.4 pounds. 01/12/2026, a weight of 142.0 pounds. 12/29/2025, a weight of 142. 0 pounds. 12/4/2025, a weight of 144.6 pounds. This showed a weight decrease noted from 01/12/26 to 02/6/26, going from 142 pounds to 130.4 pounds in one month, which was 8.1% weight loss. A nutrition assessment dated [DATE], 10 days later, noted the following: Resident #193 had 8.5% weight loss in 30 days, 50% of tray consumed, and presented with significant weight loss. In this assessment, a house supplement of 120 milliliters (ml) was recommended twice a day. Review of the physician's orders dated 02/17/26 showed an order for house nutritional supplements, 120 ml, two times a week for nutritional support, with a record amount consumed. Further review of the Medication Administration Record (MAR) revealed the House Supplements were never given to Resident #193, nor was the amount consumed documented. Review of the care plan dated 02/09/26 revealed Resident #193 had significant weight loss expected related to poor intake, as evidenced by the use of an appetite stimulant; and Resident #193 will maintain adequate nutritional status as evidenced by maintaining weight, no signs and symptoms of malnutrition, and consuming at least 75% of at least 2 meals daily through the review date. In an interview conducted on 02/24/26 at 12:45 PM, Staff A, Unit Manager, stated that a house nutritional supplement is a Med Pass provided to residents by nursing and documented in the MAR. In an interview conducted on 02/25/26 at 9:26 AM, Staff K, Registered Nurse, stated that when an order is written for house supplements, he will provide ''Med Pass and document in the MAR as given. When asked if Resident #193 was receiving house supplements, he said no. He checked the electronic system to verify the order and acknowledged that there was no record of a house supplement. In an interview conducted on 02/25/26 at 9:51 AM with Staff M, Registered Dietitian, he stated that a significant weight change is defined as a 5% change in one month. As soon as the weight loss is identified, the Dietitians will write an order for nutritional supplements if feasible. The Med Pass is calorie-dense and considered a good nutritional supplement, widely accepted. When entering the order for house supplements in the electronic system, the staff member must ensure the order type is changed to reflect the MAR. 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Cirrhosis of Liver, Protein-Calorie Malnutrition, Pressure Ulcer, Muscle Wasting and Atrophy, End Stage Renal Disease on Dialysis, Ascites, and Fluid Overload. Review of the 5 Day Minimum Data Set (MDS) for Resident #7 dated 02/24/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. Review of the physician's orders revealed a Fluid Restriction order dated 02/20/26 which included: 7:00-3:00 PM: 240 mL Juven (+30 mL Liquid Protein), 140 mL water 3:00-11:00 PM: 240 mL Juven (+30 mL Liquid Protein), 180 mL water 11:00 PM-7:00 AM 110 mL water (at bedside). On 02/26/26 the Physician's Orders for Resident #7 did not include any orders for nutritional supplements. Review of the care plan for Resident #7 dated 01/09/26 with a focus on Nutrition included interventions that the Registered Dietitian (RD) evaluated and made diet change recommendations and the facility provided supplements as ordered. Review of a Nutrition note dated 02/20/26 stated the resident agreed to Juven and liquid protein. Review of the readmission assessment dated [DATE] documented the resident was willing to try a Vanilla Flavored Magic Cup; Recommend Magic Cup daily (qd). On 02/26/26 at 10:48 AM, an interview was conducted with Resident #7 who recalled he had tried a magic cup once and thought it was ok. He stated he did not receive it again. He also denied ever receiving or trying Juven. He expressed concern over his weight because he was eating well and still losing weight. On 02/26/26 at 12:37 PM, Staff M, RD, who had been employed by the facility for 2.5 years, stated the Magic Cup was ordered by a temporary RD and was unable to explain what happened to the order. On 02/26/26 at 1:15 PM, the Dietetic Technician, who had been employed by the facility for 8 months, was interviewed. She stated Resident #7 was prescribed a generic wound supplement packet since Juven was not available. The resident went to hospital and upon return, it was not restarted although his Fluid Restriction included the supplement. She stated it was an oversight. She confirmed the Magic Cup was ordered for one time only and was never followed up by the RD who ordered it to determine if the resident wanted it daily. 2. Record review for Resident #59 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Diabetes, End Stage Renal Disease on Dialysis, and Protein-Calorie Malnutrition. Review of the admission MDS for Resident #59 dated 02/01/26 revealed the resident had a BIMS score of 10, indicating the resident had moderate cognitive impairment. Resident #59 had a care plan dated 01/28/67 that focused on Nutrition which had a goal stating the resident would have gradual weight loss. Significant weight loss is 5% or more during a 30-day period. Review of Resident #59's weights reflected a significant weight loss of 15.9 pounds (lbs), 7.2% in 16 days (01/28/26 – 02/13/26) and 20.3 lbs, 9.2% in 21 days (01/28/26 – 02/18/26). Review of the Nutrition admission assessment dated [DATE] stated the goal was for gradual weight loss and the RD was to monitor dry weight. The last nutrition note as of 02/25/26, was dated 02/16/26, and the RD addressed other issues but there was no documentation regarding the resident's significant weight loss. On 02/25/26 at 10:04 AM, an interview was conducted with Staff M, RD. He stated residents on dialysis are initially assessed upon admission and then monthly or as needed. The documentation was in the progress notes. Staff M stated Dietary Staff usually have weights the same day they are taken thus a significant weight loss is addressed within a day or two and the system would provide an alert as well. The weights and dietary notes were reviewed with Staff M, and he acknowledged there was no documentation of the significant weight loss.

Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure communication sheets were filled out accurately and completely for 2 of 3 sampled residents reviewed for dialysis, Resident #59 and Resident 105. The findings included: Review of the policy, titled, Weight Monitoring, dated 09/01/22, documented, weights should be recorded at the time obtained. Review of the facility's contract with an outside dialysis company, effective 02/14/25, page 6, documented, communication between the Facility and the Dialysis Center was via a communication form that must contain the most recent vital signs and current weights. The Dialysis Center was to enter the total amount of fluid removed. Review of the communication form revealed a notation stating the floor nurse was to report post weight promptly to dialysis. 1. Record review revealed Resident #59 was admitted to the facility on [DATE]. The following diagnoses were included: Diabetes, End Stage Renal Disease on Dialysis, and Left Leg Below Knee Amputation. Review of the admission Minimum Data Set (MDS) for Resident #59 dated 02/01/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Review of the care plan for Resident #59 dated 01/28/26 with a focus on Dialysis had interventions stating to document vital signs before leaving and upon returning to the facility and to weigh before and after dialysis. On 02/24/26, review of Resident #59's weights revealed the following: -No pre weight entered on 02/04/26, 02/13/26, 02/16/26, 02/18/26, 02/20/26, and 02/23/26. -No post weight entered on 01/30/26, 02/06/26, 02/09/26, 02/11/26, 02/20/26, and 02/23/26. Review of Resident #59's dialysis communication forms for the months of January 2026, and February 2026 revealed the following: -No blood sugar results documented on 01/28/26, 01/30/26, 02/16/26, and 02/18/26. -No pre weights documented on 02/13/26 and 02/23/26. -No total fluids removed documented on 02/02/26 and 02/16/26. Further review of the dialysis communication sheets showed the following discrepancies between the weights and the amount of fluids removed: -On 02/06/26 - 12.1-kilogram (kg) weight difference per pre and post weights, 3.0 kg was documented. -On 02/04/26 - 3.8 kg weight difference per pre and post weights, 2.7 kg was documented. -On 02/11/26 - 4.4 kg weight difference per pre and post weights, 2.4 kg was documented. -On 02/16/26 - 12.8 kg weight difference per pre and post weights, amount of fluids removed was not documented. -On 02/25/26 - 4.2 kg weight gained per pre and post weights, 2.7 kg loss was documented. 2. Record review revealed Resident #105 was admitted to the facility on [DATE]. The following diagnoses were included: End Stage Renal Disease on Dialysis, Anorexia, and Protein-Calorie Malnutrition. Review of the 5 Day Minimum Data Set (MDS) assessment for Resident #105 dated 02/07/26 revealed the resident had a BIMS score of 13, indicating the resident had intact cognition. Review of the care plan for Resident #105 dated 01/16/26 with a focus on Dialysis had interventions stating to document vital signs before leaving and upon returning to the facility and to weigh before and after dialysis. On 02/24/26, a review of Resident #105's weights in the record revealed the following: -No pre weight entered on 01/19/26, 01/21/26, 02/02/26, 02/11/26, 02/13/26, 02/16/26, and 02/18/26. -No post weights entered on 01/30/26 and 02/06/26. Review of Resident #105's communication forms revealed the following: -No pre weights were documented on 01/19/26, 01/26/26, 01/30/26, 02/02/26, 02/04/26, 02/06/26, and 02/09/26. Discrepancies between weights and amount of fluid removed: -On 01/23/26 - 1.5 kg weight difference per pre and post weights, 0.8 kg was documented -On 01/28/26 - 2.5 kg gained per pre and post weights, 1.7 kg loss was documented. -On 02/18/26 - 1.6 kg weight difference per pre and post weights, 0.8 kg was documented. On 02/25/26 at 10:26 AM, an interview was conducted with Staff Z, Registered Nurse (RN) and Unit Manager (UM), who had been employed by the facility for 23 years. She stated before and after dialysis weights were taken by the Certified Nursing Assistants (CNAs) who then provided the results to the nurses. The nurses entered them into the system the day the weights were taken. If there was a notable difference with the weights, they would notify the Registered Dietitian. Staff Z was then alerted to missing pre and post weights in the electronic health records of Residents #59 and #105. On 02/26/26 at 12:10 PM, an interview was conducted with Staff Z during which dialysis communication forms for Residents #59 and #105 were presented to her. She was alerted to the missing blood sugar results, pre weights, and post weights, as well as the discrepancies in fluid removal amounts. She acknowledged the missing documentation. On 02/26/26 at approximately 12:15 PM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN) and UM, who confirmed the pre and post weights were taken at both the facility and dialysis center. Discrepancies were then communicated to the dialysis center and residents were reweighed. On 02/26/26 at 12:37 PM an interview was conducted with Staff M, Registered Dietitian (RD), who had been employed by the facility for 2.5 years. He stated when weights were entered into residents' records, it would alert him of significant weight changes and agreed that entering weights accurately and timely was important for him to do his job. On 02/26/26 at approximately 12:30 PM, an interview was conducted with Staff CC, CNA, who had been employed by the facility for 1 year. She stated she had residents who were on dialysis and she weighed them before and after treatment. She then passed the weight information to the nurse to input them into the records.

Based on interview, observation, and record review the facility failed to effectively communicate, and educate Staff regarding fluid restriction, failed to ensure supervision, communication, and education of a resident about the allowable amount of liquids for fluid restriction, and failed to document the amount of provided liquid per shift based on the guidelines of a medically prescribed order for fluid restriction for 1 of 1 sampled resident (Resident # 172). The Findings included: Resident #172 was readmitted to the facility on [DATE] with the diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease, Kidney Transplant Failure, Unspecified Protein-Calorie Malnutrition and Acute Pulmonary Edema. His initial admission was on 01/27/2024 with diagnoses of Muscle wasting, Acute Respiratory Distress Syndrome, Pleural Effusion, Atherosclerotic Heart Disease, and Dependence on Renal Dialysis. Record review of MDS (Minimum Data Set) Section C revealed a BIMS (Brief Interview of Mental Status ) score of 12 indicating good cognitive function. Resident #172 speaks Spanish. He does not read English but has minimal understanding of spoken English. Review of orders dated 05/26/2204 showed fluid restriction of 1000 ml (milliliters) for 24 hours for Resident #172. It elaborated that Nursing Staff must provide 360 ml for 24 hours to be divided as follows: 150 ml for the 7 AM to 3 PM shift; 150 ml for the 3 PM to 11 PM shift; and 60 ml for the 11 PM to 7 AM shift. In addition, dietary fluid allowance is 640 ml for 24 hours. Record review of facility's Fluid Restriction Policy, reviewed on 04/2023, showed facility ensures that fluid restrictions will be followed in accordance with physician's orders. This policy's compliance guidelines # 4 states that water will not be provided at the bedside unless calculated into the daily total fluid restriction; #5 states that risks and benefits of the fluid restriction will be explained to the resident and or representative. A review of a paper titled Diet Type Report provided by Staff Q , Director of Activities, showed that Resident #172 has the following data: Diet Type is Renal, Diet Texture is Regular, Fluid Consistency is Regular/Thin, with blank spaces under Diet Supplements and Additional Directions columns. There were no comments or notes regarding fluid restrictions. Further record review of Physician's Quarterly Progress Notes dated 08/07/2024 section J revealed Resident #172 is on moderate nutritional risk related to comorbidities, advanced age, dependence to hemodialysis, history of fluid overload, status post ( after) thoracentesis ( a surgical procedure of draining extra fluids from the pulmonary system), therapeutic diet and 1 (one )Liter fluid restriction per hemodialysis. Additional comments on section K showed to continue 1 (one) Liter Fluid Restriction per hemodialysis. Additional record review of Dietary Notes dated 07/30/2024, 06/30/2024, 05/31/2024, and 03/29/2024 revealed Resident #172 was to remain on a fluid restriction of 1000 ml per day. Further Dietary Notes record review dated 03/04/2024 showed notes by Staff F suggesting Resident #172 to have fluid restriction of 1000 ml daily- 640ml by dietary, and 360 ml from nursing, distributed as follows: 7 AM to 3 PM shift to give 150 ml, 3 PM to 11 PM shift to give 150 ml, and 11 PM to 7 AM to give 60 ml. Review of Facility's Policy titled Communicating with Persons with Limited English Proficiency stated that facility staff will identify the language and communication needs of the LEP ( Limited English Proficiency)person during the pre-screening and admission process. Further record review of fluid restriction on the MAR (Medication Administration Record) and TAR ( Treatment Administration Record) during the whole month of July 2024 (totaling 31 days) , and the beginning dates of August 2024 ( 8 days), revealed X symbols under all dated columns, with no Nurses initials or recorded amount of fluid provided to Resident # 172 per shift. Additional record review of a paper titled Nursing Point Click Care Emar dated 3/22, stated that the symbol X on e-mar means that the day selected was prior to the start date of the order start date, this can be due to a new order, and it was not started until a certain effective date. PCC ( Point Click Care ) automatically populates with an X for all dates that have passed from the start of a new order. In an observation conducted on 08/05/24 at 5:49 PM, Resident #172 was not in the room. The dinner tray was noted on the side table with the following:2 pieces of stuffed green peppers, fruit salad, 4 ounces of juice, mashed potatoes, and blended veggies. The meal ticket revealed the following: Regular texture renal diet, large servings, fluid restrictions 1000ml, and one serving of 4 ounces juice. Closer observation revealed 12 ounces of water in a Styrofoam cup, 4 ounces of bottled water and 4 ounces can of coke (which showed a total of 20 ounces of liquids, equals 600ml of fluids). In another observation conducted on 08/06/24 at 10:00 AM, 4 ounces can of coke and 4 ounces of juice noted at the bed side (which showed a total of 8 ounces, equals 240ml of fluids). During an interview conducted on 08/06/24 at 12:30 PM with Resident #172, he stated that he was not educated on fluid restrictions and did not know how much liquids he is allowed daily. Additional interview and observation on 08/06/2024 at 3:50 PM, showed Resident# 172 was filling up a cup with red colored liquid from a jug at the front entrance of the facility. This surveyor observed him throwing the empty container after drinking the total amount ( 4 ounces or 120 ml of fluids). In an interview with Resident # 172 on 08/06/2024 at 4:00 PM, he stated no Staff had informed him of any fluid restrictions. When asked if somebody communicated to him the allowable amount of fluids to drink during each shift, he seemed confused and said, I only drink from this cup while pointing at a plastic container ( 8 ounces or 240 ml ) during mealtimes. He added that the facility Staff must have told him, but he does not understand English. When asked about a menu for the week, he pointed at the activity calendar on the wall. An hour later, this surveyor observed Resident #172 had an opened can of coke ( 4 ounces or 120 ml of fluids) on his table. In an interview with Staff F, an RD (Registered Dietitian) on 08/06/ 2024 at 4:19 PM, she stated that when a resident is admitted or readmitted , she will go over diets, likes and dislikes and any food preferences based on the MD's( Medical Doctor's) orders as well. Staff F added that the food preferences and likes are sometimes documented in the nutrition assessment if there are any that are reported by the residents. It may also be documented under the dietary profile. The choices and preferences are then updated in the nutrition management system for the main kitchen. When asked if she went over preferences and menus with the Resident, she said she did not think so. When asked about the nutrition assessment she said that it is limited to the sections and did not have a section for food preferences. She added that she speaks Spanish and can effectively communicate with Resident #172. When asked if she spoke to the Resident regarding fluid restrictions or educated the Resident on fluid restrictions, she said No. During an observation and an interview with Staff S, a CNA ( Certified Nursing Assistant), who clarified to this surveyor that she speaks Spanish on 08/08/2024 at 08:28 AM, she stated that Resident #172 does not have any fluid restrictions. She asked Resident # 172 if he wishes to fill up his empty cup on the meal tray with more water. Resident #172 refused, and Staff S left the room. During an interview with the DON (Director of Nursing) on 08/08/2024 at 10:20 AM, when this surveyor pointed out that Fluid restriction column was marked with several X's on July 2024 ( 31 days), and August 2024 (8 days), she stated that all the X's on Resident #172's MAR and TAR mean that the order has not yet started. In an interview with Staff R, a CNA, on 08/08/2024 at 11:50 AM she stated that Resident #172 can get extra water to drink from his bathroom. When asked if Staff R tells the Nurse the amount of fluids Resident # 172 consumes , she replied No She was not aware that Resident # 172 is on fluid restrictions. She picked up and read Resident #172's meal card , stepped out of the room and talked to the Nurse outside. During another interview with Staff S, a CNA, on 08/08/2024 at 11:53 AM , she stated Resident #172 takes water from the bathroom sink to fill up his empty cup. During this interview, Resident # 172 was observed with 2 cups( 8 ounces each) of water about 3/4 full next to his lunch tray on the table. When asked if Resident # 172 is allowed to drink all the liquids inside the meal tray and the 2 cups next to the meal tray, Staff S stated, It is fine. In an interview with Staff P, an Activities Assistant on 08/08/2024 at 11:00 AM, she stated that she does not know Resident #172 is on Fluid Restriction. When asked if she provides fluids to Resident #172 during activities, she stated she gives him coffee. She added that she ensures the correct diets and preferences are provided to the residents based on a dietary paper. When asked to show this surveyor the dietary paper where she checks Resident #172's prescribed diet and preferences, she stated she will copy it. An hour later, she came back with Staff Q, and both stated that they give a maximum amount of 4 ounces of fluids everytime Resident #172 asks for refreshments or drinks. When asked if they can show this surveyor where they documented the amount of liquids given to Resident #172, they stated they did not document anything. During an interview with the Staff Q, Director of Activities on 08/08/2024 at 12:00 PM, she stated that she does not know Resident # 172 is on fluid restriction, since she provides morning coffee pass to all residents who attended activities, or when she performs room visits, and no Nurse told her about fluid restriction order for Resident #172. She verifies diet information from a paper titled Dietary Notes, where she checks Facility residents' prescribed diet, preferences, and other dietary comments. Resident # 172 does not have fluid restriction notes under the additional directions column of the Dietary Notes according to her. In another interview with the new Clinical Educator on 08/08/2024 at 11:15 AM, when asked about the fluid restriction order on the MAR and TAR, he explained that the X symbols signified the task has not started. He added that fluid restriction was not a Physician order, so Nurses do not need to put their initial on the dated columns. When asked how would Staff communicate the acknowledgement of fluid restriction and the total amount of fluids provided to Resident # 172 for each shift according to the prescribed fluid restriction guidelines, he stressed that fluid restriction for Resident #172 was not a Physician order, so Nurses do not need to document the exact amount of fluids per shift or put their initials. In an interview with the DON on 08/08/2024 at 3:30 PM, the above information was shared.

Based on observations, interviews, and record review, the facility failed to provide food that accommodates resident preferences and appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 2 of 8 residents sampled for nutrition (Resident #88 and Resident #172). The findings included: A review of the facility ' s policy titled Nutritional Management, revised on 09/2022, revealed the following: Interviewing the Resident and Resident representative to determine if their personal goals and preferences are being met. ii. Directly observing the Resident. iii. Interviewing the direct care staff to gain information about the Resident, the interventions currently in place, their responsibilities for reporting on these interventions, and possible suggestions for changes if necessary. 1. A record review revealed that Resident #88 was admitted to the facility on [DATE] with diagnoses of Underweight, Muscle Wasting, and Depression. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11, which was normal to low cognitive impairment. In an observation conducted on 08/05/24 at 4:45 PM, Resident #88 received her dinner tray in her room. The dinner tray consisted of navy bean soup, egg salad with two slices of bread, cucumber tomato salad, apple crisp, and apple juice. In this observation, Resident #88 was heard saying, I don't want to eat this; every day, it is an egg salad. When asked by this Surveyor, Resident #88 said, I don't like the food on this dinner tray, and refused to answer any more questions. In an observation conducted on 08/06/24 at 12:35 PM, Staff were setting up Resident #88's lunch tray in her room. Resident #88 meal tray consisted of: roast turkey, stuffing and green beans. Resident #88 did not want to eat the choices on her lunch plate and asked for a tuna sandwich and fruit instead. Continued observations showed that Resident #88 ate the tuna sandwich and the grapes which she requested instead of the regular food items that were served for the lunch meal. The initial nutrition assessment dated [DATE] revealed that Resident #88 was at nutritional risk related to poor appetite and intake of meals. Patient reports poor appetite with an average meal intake of 25% to 50% of meals. In an interview conducted on 08/07/24 at 11:00 AM with Staff F, Registered Dietitian, she stated that she assessed Resident #88 when she was admitted on [DATE], and Resident #88 only reported that she did not like eggs. Staff F attempted to call Resident #88's husband to obtain food likes and preferences but was not able to speak to Resident #88's husband. When asked regarding the menu choices that were provided to Resident #88, Staff F said the Resident was not picking her menu choices but was provided with options for the day that were provided on the menu. Staff F reported that Resident #88 was confused when she tried to obtain food choices and preferences in the past. Staff did not tell her anything about Resident #88's disliking the food choices she was receiving. The findings were to explained to her in an interview with the nursing home administrator on 08/08/24 at 2:30 PM. 50370 2. Resident #172 was readmitted to the facility on [DATE] with diagnoses of Muscle Weakness, Type 2 Diabetes Mellitus, Anemia, Chronic Kidney Disease, Intermittent Claudication bilateral legs, Renal Disease, Kidney Transplant Failure, and unspecified Protein-Calorie Malnutrition. His initial admission was on 01/27/2024 with diagnoses of Muscle wasting, Acute Respiratory Distress Syndrome, Pleural Effusion, Atherosclerotic Heart Disease, and Dependence on Renal Dialysis. Record review of MDS (Minimum Data Set) Section C revealed a BIMS (Brief Interview for Mental Status ) score of 12 indicating good cognitive function. Resident #172 speaks Spanish. He does not read English but has minimal understanding of spoken English. Review of Facility's Policy titled Communicating with Persons with LEP (Limited English Proficiency) copyrighted in 2022, states that facility is to take reasonable steps to ensure that persons with LEP have meaningful access and an equal opportunity to participate in facility's services. Policy explanation and Compliance Guidelines # 1 states that facility staff will identify the language and communication needs of the LEP person during the pre-screening and admission process; #4 states that notification of the availability of language assistance services will also be provided through one or more of the following : outreach documents, telephone voice mail menu, and/ or the facility's website. Nutrition and Dietary Progress Notes record review dated 07/30/2024, and 06/30/2024, showed Staff F, a Registered Dietitian reviewed the menu with Resident # 172. In an observation on 08/05 2026 at 5:30 PM, a meal tray was seen on top of a table with a meal ticket written in English. The meal ticket showed the following: Resident #172's name , ticket #404, date= 08/05/2024, meal period -week 3 Mon Lunch, P 11. Additional notes included large servings, fluid restriction 1000 ml, 1 (one) juice (116 ml); Expo items showed 1 Rice, 1 Fruit Salad (1/2 cup), 1 Cranberry Juice ( 4 fluid oz {ounces}); Hot showed 1 stuffed green pepper, 1 California blend (SHC)( 4 oz); Diet: regular texture, RG7, renal, fluids-thin; DR -eats in room. During another observation on 08/06/2024 at 4:45 PM, Resident #172 was not in his room, but a meal tray was observed on top of a table. The meal ticket was written in English. The meal ticket revealed the following: Resident#172's name, ticket #332 , date-08/06/2024, meal period -week 3 Tuesday lunch , P11; notes-large servings, fluid restrictions 1000ml, and one juice (116 ml); expo items- 1 French style green beans (1/2 cup), 1 sherbet (1/2 cup), 1 cranberry juice ( 4 fluid oz); hot-1 roast turkey ( 3 oz), 1 cornbread stuffing ( 4 oz), 1 dinner ( 1 each with margarine); diet - regular texture RG7, renal, fluids-thin. Above the meal table was a calendar of activities written in English. During interview and observation of Resident # 172 on 08/06/2024 at 4:00 PM, he stated that he did not like the food offered to him at lunch time today and at other mealtimes, because they were not his food preferences. He was offered American style dishes, but he likes Hispanic dishes. When asked if any Staff spoke with him regarding his food preferences , choices, likes and dislikes, he stated No When asked if someone explained the menu to him, he added that the facility Staff must have told him, but he does not understand English. When asked about a menu for the week, he pointed to the activity calendar posted on the wall. In an interview with the Staff F, a Registered Dietitian on 08/06/ 2024 at 4:19 PM, she stated that when a resident is admitted or readmitted , she will go over diets, likes and dislikes and any food preferences based on the MD's ( Medical Doctor's) orders as well. Staff F stated that the food preferences and likes are sometimes documented in the nutrition assessment if there are any that are reported by the residents. It may also be documented under the dietary profile. The choices and preferences are then updated in the nutrition management system for the main kitchen. When asked if she went over preferences and menus with Resident #172, she said she did not think so. When asked about the nutrition assessment, she said that it is limited to the sections and did not have a section for food preferences. She added that she speaks Spanish and can communicate effectively with Resident #172. When asked if she talked to this resident regarding his preferences for Hispanic foods, she stated No, I do not think so. She added Resident #172 is on dialysis which makes selection of food very limited, and she has not heard Resident #172 complained about his food. In another interview with Staff S on 08/08/2024 at 12:20 PM, she stated Resident #172 ate 10 % of his lunch. She added that she asked if he wanted a sandwich instead, to which Resident #172 refused. She added that she will tell the Nurse. During an interview with the DON on 08/08/2024 at 3:30 PM the above information was shared.

Based on observations, interviews and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice for 1 of 1 resident reviewed for pain (Resident #358). The findings included: A review of the facility's policy titled Pain Management, revised on 09/01/2022, revealed the following: facility staff will observe for nonverbal indications that may indicate the presence of pain. These indicators include but are not limited to, the impact of pain on quality of life (sleeping, appetite, and mood), currently prescribed pain medications, dosage and frequency, and the resident's goals for pain management and satisfaction with the current level of pain control. Resident #358 was admitted on [DATE] with diagnoses of Muscle Wasting, Type 2 Diabetes, and Muscle Weakness. The 5-day Minimum Data Set, dated dated dated [DATE] revealed that Resident #358 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. A review of the Physician's orders showed the following: Oxycodone (pain medication) oral tablet, 10 milligrams to give one tablet by mouth every 12 hours for chronic pain, which was discontinued on 08/5/24. Oxycodone (pain medication) oral tablet, 10 milligrams to give one tablet by mouth every 8 hours for chronic pain dated 08/5/24. In an interview conducted on 08/05/24 at 11:00 AM, Resident #358 stated that he spoke to the facility's Social Worker two days ago regarding the issue with his pain medication not being given on time. He said that his pain medications are given later, and at times, it is 2-3 hours past the scheduled medication time. Resident #358 reported that he asked for his pain medication this morning at 7:30 AM, which was only given to him around 10:00 AM this morning. In an interview conducted on 08/07/24 at 11:00 AM, Resident #358 stated that he could not sleep well last night because he was in pain, and Staff are still not giving him his pain medication on time. In an interview with Staff G, a Registered Nurse (RN), on 08/07/24 at 11:10 AM, the RN stated that Resident #358 is getting his pain medication every 8 hours. He received his pain medication this morning at 6:00 AM, and his next one is due at 2:00 PM today. A review of the Care Plan for Pain showed that Resident #358 has the potential for acute/chronic pain and that he is on routine pain medication. Anticipate the resident's need for pain relief, respond immediately to any complaint of pain, and administer pain medication as per orders. A review of the medication administration audit report showed the following: On 08/02/24, Oxycodone was scheduled for 8:00 AM and was given at 9:20 AM, an hour and a half later. On 08/03/24, Oxycodone was scheduled for 8:00 AM and was actually presented at 10:49 AM, which was almost 3 hours later; on 08/05/24, Oxycodone was scheduled for 8:00 AM and was actually given at 10:47 AM, which was nearly 3 hours later, and on 08/05/24, Oxycodone was scheduled for 10:00 PM and was actually given at 11:50 PM which was almost 2 hours later. In an interview conducted on 08/07/24 at 3:30 PM with the Director of Nursing, she stated that pain medication is usually given either an hour before or an hour after the scheduled medication time.

Based on observations, interviews, and record review, the facility failed to monitor weights, provide appropriate nutritional interventions, and ensure that dietary interventions were followed as ordered for 2 of 8 sampled residents for nutrition (Resident #162 and Resident #98). The findings included: A review of the facility's policy titled Nutritional Management, revised on 09/2022, revealed the following: A systematic approach is used to optimize each Resident's nutritional status: a. Identifying and assessing each Resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. A review of the facility's policy titled Weight Monitoring: revised on 09/01/2022 revealed the following: Based on the Resident's comprehensive assessment, the Center will ensure that all residents maintain acceptable parameters of nutritional statuses, such as usual body weight or desirable body weight range and electrolyte balance unless the Resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a helpful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period) may indicate a nutritional problem. 1. Resident #162 was admitted on [DATE] with diagnoses of protein-calorie malnutrition, Type 2 diabetes, and muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 02, which indicates severe cognitive impairment. In an observation conducted on 08/06/24 at 12:21 PM, Resident #162's lunch tray arrived in the room. At 12:25 PM, Staff I, a Speech-Language Pathologist, noted near the Resident helping her with the lunch meal. She stated that Resident #162 initially needed total assistance with her meals, but at this point, she needs supervision. Some days, she needs more than supervision and encouragement, depending on her mood. In an observation conducted on 08/07/24 at 8:00 AM, Resident #162 was noted in her bed, with Staff D, an Occupational Therapist, sitting near her assisting her with the breakfast meal. Staff D said that at times, Resident #162 can eat on her own, and at other times, she needs more assistance and encouragement. According to Staff D, Resident #162 eats between 75% and 100%, and some days, she eats less than that. A review of the weight log showed the following weights for Resident #162: 130 pounds on 06/14/24, 123 pounds on 07/01/24, 122.5 pounds on 07/5/24, and 122.5 pounds on 08/01/24. This showed a significant weight loss of 5.7% from 06/14/24 to 08/01/24. A new weight requested by this Surveyor on 08/06/24 revealed Resident #162 at 119.5 lbs, which showed an additional weight loss of 3 pounds in 5 days. A review of the physician's orders showed an order for House Nutritional Supplement as needed for poor meal intake, to pour 6 ounces and encourage intake if less than 50% of meals were consumed, dated 05/19/24. A review of the Medication Administration Records for July 2024 showed Resident #162 did not receive any House Nutritional Supplements for the entire month. The Nutrition Assessment completed on 05/15/24 revealed Resident #162 was at a moderate nutritional risk, meal intake between 51% to 75%, 128.2 pounds admission weight, and no height documented on Resident #162. In this assessment, Staff E, the Registered Dietitian, needed to document the estimated calories and estimated protein needs for Resident #162. The nutrition progress note dated 05/17/24 documented a height of 64 inches on Resident #162 and a Body Max Index (BMI) greater than 21 and less than 23 (within normal ranges). In this note, Staff E stated that Resident #162 was coded as malnourished. In the nutrition progress note dated 07/10/24 (9 days after the identified significant weight loss), Staff E documented that Resident #162 is experiencing sudden weight loss despite reports of good meal intake. The Resident appeared to have lost a significant amount of weight, and this is her usual appearance. In this note, Staff E did not make any additional nutritional recommendations or changes despite the significant weight loss noted. The nutrition care plan revealed that Resident #162 will maintain adequate nutritional status, as evidenced by maintaining weight within 3-5% of 128.2 pounds. It further showed that the individual weight loss of 3 pounds in one week or over 5% of weight loss in one month should be monitored. In an interview conducted on 08/07/24 at 8:30 AM with Staff E, he stated that a weight loss of 5% or more in one month will trigger in the electronic system and notify him of any significant weight loss. He will run a daily weight report to identify residents with significant weight changes. Staff E will intervene when the weight loss is noted and reevaluate the resident ' s nutritional status. When asked about the House Supplements ordered for Resident #162, Staff E said it is either Boost (nutritional supplement) or Ensure (nutritional supplement). He validated that Resident #162 had a severe weight loss in one month from 06/14/24 to 08/01/24. Staff E said that because Resident #162 ate between 75% and 100% of her meals, there was no indication that she would need additional calories for her daily meals. He said a significant weight loss paired with documented poor intake for an extended period would indicate a criterion for diagnosing malnutrition. Staff E stated that he could not calculate the estimated caloric and protein needs for Resident #162 on her initial nutrition assessment because he did not have the height of Resident #162. According to Staff E, a current weight of 119.5 showed that Resident #162 ' s BMI dropped from 21.9 to 20.4, placing her at borderline underweight. 41837 2. Record review for Resident #98 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Protein-Calorie Malnutrition and Unspecified Dementia. Review of the Minimum Data Set (MDS) for Resident #98 dated 06/30/24 documented in Section C a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. Review of the weights for Resident #98 revealed the following: On 6/26/2024 the resident weighed 196.0 pounds From 06/30/24 to 07/06/24 there was no weight documented for the resident. From 07/07/24 to 07/13/24 there was no weight documented for the resident. From 07/14/24 to 07/20/24 there was no weight documented for the resident. From 07/21/24 to 07/27/24 there was no weight documented for the resident. On 7/31/2024 the resident weighed 170.0 pounds This indicated the resident had lost 26 pounds (13.27%) in 1 month which is a significant weight loss after 4 weeks of no weights. Review of the Physician's Orders for Resident #98 revealed an order dated 06/26/24 to weigh weekly one time a day every Wednesday. Review of the Physician's Orders for Resident #98 revealed an order dated 06/27/24 NAS (No Added Salt) diet Regular texture, Regular/Thin consistency. Review of the Physician's Orders for Resident #98 revealed an order dated 08/02/24 House Nutritional Supplement one time a day for nutrition support 120 ml (milliliters) document % consumed. Review of the Nutrition/Dietary Note for Resident #98 dated 08/05/24 documented the following: Weight Review: Weight taken 7/31 of 170 pounds with a BMI (Body Mass Index) of 30.1, indicative of obesity. Weight is down 26 pounds/15% in comparison to admission weight of 196 lbs. She has a hx (history) diuretic use, weight/fluid shifts anticipated. Estimated needs remain consistent to admission assessment based on adjusted BW (Body Weight). On a NAS diet with intake of 0-50%. NP notified of weight loss and suboptimal intake. Mirtazapine and Eldertonic were ordered as well as House supplement QD (daily). Pt has a history of behavioral disturbances, she has refused to be weighed at times. Attempted to contact her Emergency contact however, unavailable. Will continue on weekly weights to further assess weight trends and adjust POC (plan of care) as needed. Review of the Care Plan for Resident #98 dated 06/27/24 with a focus on the resident is at nutritional risk r/t comorbidities, advanced age, hx edema, dentures, obesity, hx PU (pressure ulcer), and therapeutic diet with supplements as ordered. Refuses weights at times. The goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition, and consuming meals daily through review date. The interventions included: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve diet as ordered. Provide, serve diet as ordered. Monitor intake and record q meal. RD to evaluate and make diet change recommendations PRN. The resident needs a calm, quiet setting at meal times with adequate eating time. Encourage the resident's socialization and interaction with table mates during meals. Weigh per facility protocol During an interview conducted on 08/07/24 at 9:15 AM with Staff E Registered Dietitian (RD) who stated he has worked at the facility since June 2023. When asked how often residents are weighed, he said on admission, then weekly for 4 weeks, if weight is stable then monthly. He said if the resident has a significant weight loss they would be on weekly weights and the duration of time would be determined by the RD. When asked what is considered a significant weight loss, he stated it would be 5% or greater in 30 days, 7.5% or greater in 90 days, and 10% or greater in 180 days. When asked if the significant weight loss and interventions are entered into the resident's care plan he said yes. During an interview conducted on 08/07/24 at 10:15 AM with Staff F Registered Dietitian (RD) who stated she has worked at the facility for over 1 year. When asked about Resident #98, she said she is following the resident. When asked if the resident had significant weight loss, she said the resident lost 26 pounds (15%) in 30 days from 6/26/24 to 7/31/24. When asked if the resident was weighed weekly following admission on 06/26/24, she said no, the resident had refused, or nursing never gave her the weights. When asked if there was any documentation of resident refusing weights, she said she put it in her notes on 08/05/24. When asked if she addressed the no weights or resident refusing weights with nursing, she said yes but could not provide name of who she spoke to. She said she just did not document the resident refusing the weights until 8/05/24. She acknowledged the significant weight loss was not addressed timely. When asked about the care plan for the resident she acknowledged she did not update the care plan until 08/05/24.

Based on review of policy and procedure, interview and record review, the facility failed to assess skin in a timely manner, to identify a pressure ulcer for 1 of 7 sampled residents reviewed for facility acquired pressure ulcers, Resident #408. The findings included: Review of the facility policy and procedure on 08/08/24 at 3:10 PM titled Pressure Injury Prevention and Management provided by the Director of Nursing (DON) revised 10/2022 documented in the Policy Statement: This facility is committed to the prevention of avoidable pressure injuries .and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries Policy Explanation and Compliance Guidelines: .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury assessment, using the Braden Scale, on all residents upon admission/re-admission, weekly x four (4) weeks, then quarterly or whenever the resident's condition changes significantly .c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Finding will be documented in the medical record. d. Assessments of pressure injuries will be performed by a licensed nurse, and documented in Point Click Care. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task .Monitoring a. The Unit Manager or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. b. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, or lack of healing, or any pressure injuries weekly .6. Modifications of Interventions a. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: .ii New onset or recurrent pressure injury development . Review of the facility policy and procedure on 08/08/24 at 3:15 PM titled Notification of Changes provided by the DON revised 11/29/22 documented in the Policy Statement: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Compliance Guidelines: .Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status iii. Exacerbation of a chronic condition. Resident #408 was admitted to the facility on [DATE] with diagnoses which included Unspecified Displaced Fracture of Seventh Cervical Vertebra, Paraplegia Incomplete, Spondylopathy, Muscle Wasting, Dysphagia, Neuromuscular Dysfunction of Bladder, Anemia, Depression, Adjustment Disorder, Quadriplegia Hypertension, Atherosclerotic Heart Disease, Gastroesophageal Reflux Disease, Ileus, Fusion of Spine and Edema. He had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact). A telephone interview was conducted on 08/07/24 at 2:04 PM with Resident #408's family member, who is the Power of Attorney (POA). Resident #408's Niece stated that she was on her way, at the time, to visit her Uncle, who was currently in the Hospital again for the same wounds which are infected, in addition to being diagnosed with Pneumonia. Resident #408's Niece went on to say that the resident had to have another debridement for his level four (4) sacral wound; which she said that she had subsequently learned had actually been worse, than she was originally told to her by facility nursing staff members. She ended by saying that the resident has no history of any sacral wounds. On 05/30/24 the 3008 Agency for Healthcare Administration (AHCA) Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form did not document any pressure ulcers, lesions or wounds, at the time, for this resident. Record review revealed that on 05/30/24, Staff U, a Licensed Practical Nurse (LPN), documented in the following admission nursing progress note, Patient arrived at the facility on stretcher accompanied by two (2) attendants and family member. admitted to room B-26-B, alert and oriented able to make needs known to staff. Skin warm to touch, scar to the neck, open area to right shin, dried blister to left heel, swelling to bilateral feet. Patient has neck brace. Patient not able to move arms and legs, very immobile, fingers are stiff. Denies any pain. No acute distress noted. Vital signs 134/60, O2 sat 100%, T97.7 P74. Will continue to monitor; with no mention of the status of Resident #408's sacral skin region. Record review of Resident #408's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 05/30/24 indicated that the resident had a score of 13 which indicated that he was at Moderate risk. An interview was conducted on 08/08/24 at 9:47 AM with Staff X, a Certified Nursing Assistant, (CNA), in which she stated that Resident #408 was totally dependent for care. She said that she fed him, washed and cleaned his entire body and dressed him, with staff member assistance. She stated that she worked with this resident on day shift for five (5) days from Tuesday 06/04/24 until Saturday 06/08/24. Staff X said that Resident #408 did not come into the facility with any open areas on his sacral/bottom area during this time, and she added that if she had seen any redness, open areas, abrasions, rash or anything of this kind, she would have reported it to the nurse. Staff X went on to say that she repositioned this resident every 2 hours on her shift, she said that she cleaned and checked the resident's sacral area on a daily basis and entered the information in the mounted computerized CNA tablet, located in the hallway of the B-wing, which documented how the resident ate, if he was continent or incontinent, if he had a bowel movement or not, the presence of a Foley catheter and the skin condition. Staff X stated and documented, that on Tuesday June 4th at 1:16 PM, she showered, Resident #408, while still in bed and on Thursday June 6th at 1:28 PM, Resident #408 had a small bowel movement, and she cleaned and changed him. Finally, Staff X stated that from Wednesday 06/05/24 until Tuesday 06/11/24 for two (2) hours daily, that both she and Staff Y, the facility Physical Therapist, who also corroborated this to the Surveyor on 08/08/24 at 11:25 AM, would get Resident #408 out of bed utilizing the Hoyer lift into a recliner wheelchair. According to record review of the CNA Task list form, Staff Z, documented, that she showered, Resident #408, while still in bed and on Friday June 7th at 10 PM it was also documented that the resident had a medium bowel movement, and she cleaned and changed him on that day. Staff W, a Licensed Practical Nurse (LPN) Wound Care Nurse, who recorded the Tuesday 06/11/24 Sacral Wound Physician treatment order, and who was primarily responsible for Resident #408's sacral wound care during his short, facility stay, was out of the facility and unavailable for telephone interview, during the survey. A subsequent side-by-side record review was conducted of the Wound Care Doctor's progress notes, completed by the Advanced Registered Nurse Practitioner (A.R.N.P.) along with the facility's current Wound Care Director on 08/08/24 at 11:24 AM in which it was noted that, The initial sacral Stage III wound measurements were: 10.0 x 10.0 x 0.1 cm and the surface area was 100.00 sq.cm. on 06/11/24; no tunneling or undermining, moderate amount of serosanguinous drainage with no odor, pain level 01/10, 60% granulation, 10% epithelization; no eschar present. The Physician's order for wound care were: Normal saline, skin prep, Hydrogel, bordered dressing daily and PRN. The sacral wound measurements vs. wound presentation were: 10.0 x 10.0 x 0.1 cm and the surface area was 100.00 cm. on: 06/18/24; no tunneling or undermining, moderate amount of serous drainage with no odor, pain level 01/10, 20% granulation, 0% epithelization; no eschar present with no change in wound progression. The Physician's order for wound care were: Normal saline, skin prep, Hydrogel, bordered dressing daily and PRN. Wound evaluation done by ReNew 6/25/24 shows sacral wound remains 'Un-stageable and measures 10 x 8 x 0.4, no significant change since last week, moderate serous exudate, 80% Slough, 20% Granular, mild odor, denies pain. The sacral wound measurements vs. wound presentation (Post-debridement) were: 10.0 x 8.0 x 3.8 cm and the surface area was 80.00 cm. on: 06/25/24; no tunneling or undermining, moderate amount of serous drainage with no odor, pain level 01/10, 20% granulation, 0% epithelization; no eschar present with no change in wound progression. The Physician's order for wound care: treatment changed to 1/4 strength Dakin's moistened gauze packing and cover with bordered dressing daily and PRN; family and attending physician made aware. For the month of May and June 2024, the Medication Administration Record (MAR) documented a physician's order for a blood thinner medication for Resident #408: Enoxaparin Sodium Solution 40 mg/0.4ml Inject 40 mg subcutaneously (SQ) every twelve (12) hours for blood clotting prevention for ten (10) Days that were initialed by licensed nursing staff as being provided to this resident, and for Aspirin Enteric Coated (EC) Tablet Delayed Release 325 MG (Aspirin) Give one (1) tablet by mouth one (1) time a day for Coronary Artery Disease (CAD) with breakfast. For the month of May and June 2024, the Treatment Administration Record (TAR) documented two (2) physician's orders, beginning prior to Tuesday 06/11/24 for the following: 1) Cleanse right and left buttocks with soap and water. Apply Lantiseptic cream after each brief change every shift for prophylaxis - start date Thursday 06/06/24, and 2) Turn and re position frequently as tolerated every shift for preventative measure - start date Wednesday 06/05/24. During an interview conducted on 08/08/24 at 10:22 AM with Staff AA, RN, she stated that she was part of the nursing staff who cared, for this resident, at bedside, prior to Tuesday June 11th on the following seven (7) days: Friday 05/31/24, Tuesday June 4th, Wednesday June 5th, Friday June 7th , Saturday June 8th, Sunday June 9th and Monday June 10th , for the entire week on day shift. Staff AA stated that on: Friday 05/31/24, she noticed immediately upon entering Resident #408's room, that he was, sweaty, smelling badly with his beard looking overgrown and unkempt. As a result, Staff AA stated that she asked Resident #408 if he was ok, with her giving him a shave, a good, full entire bath and nail trimming; which he agreed. Staff AA stated that on that same day, she and another aide proceeded to provide this care for him, but Staff AA also said that she saw no open skin areas on his sacrum. Staff AA added that she had not gone back at any other time during that week to see Resident #408's sacral area. Staff AA also became emotional and tearful, during the interview, indicating that when she had learned later about the resident's wound being found on his sacral, she added that, when she saw the Resident #408's skin it was just shiny and black to her, and she added that she, felt so bad about it once she was aware of and realized what had happened. On 08/08/24 at 12:25 PM an interview was conducted with, the Advanced Registered Nurse Practitioner (A.R.N.P.) for Wound Care working with Renew Wound Care Consultants, regarding the on-set of Resident #408's facility-acquired sacral wound. The A.R.N.P. stated that she had not seen Resident #408 prior to Tuesday June 11th. She said that she did not see or assess the resident until Tuesday June 11th and she saw him again one (1) week later on Tuesday June 18th and again on Tuesday June 25th. She acknowledged that all necessary preventative skin measures/interventions, should have been put into place, for this resident, to maintain skin integrity, beginning upon admission to the facility. On 08/08/24 at 1:06 PM a telephone interview was conducted with, Resident #408's Primary Care Physician (PCP)'s regarding the on-set of the resident's facility-acquired sacral wound. Resident #408's PCP stated and documented that either he or his A.R.N.P., had been in the facility to see this resident on Friday 05/31/24, Tuesday 06/04/24 and again Friday Tuesday 06/07/24. The Doctor stated that he believed that Resident #408 developed a Deep Tissue Injury (DTI) to that area, and he had very dark skin hyperpigmentation making it almost impossible to detect changes in his skin in addition to his other co-morbidities and he stated that, it would have happened anyway. Resident #408's PCP said that he personally saw and assessed Resident #408's sacral skin area with his A.R.N.P. He added that he was not aware of Resident #408's current status or condition. Resident #408's PCP also acknowledged that all necessary preventative skin measures/interventions, should have been put into place, for this resident, to maintain skin integrity, beginning upon admission to the facility. Record review of Resident # 408's CNA ADL (Activities of Daily Living) Task Flowsheet Record dated Thursday 05/30/24 thru Tuesday 06/11/24 revealed that for at least three (3) of the facility's CNA staff working with this resident on both the day and evening shifts documented that they had actually provided the following (ADL)'s of: Bathing support, Shower in bed, and Bowel elimination for the resident. Record review of Resident #408's Baseline care plan dated Friday 05/31/24 indicated that the resident was alert and cognitively intact and required extensive assistance for bed mobility, dressing, hygiene and bathing. He was also totally dependent for transfers, locomotion and toileting. Resident #408's only skin tegrity issues, at that time, were Cellulitis and Edema to leg. Resident #408's subsequent Care plans initiated on 05/31/24 for ADL self-care performance deficit and on 06/02/24 for potential and actual impairment to skin integrity was relative to the resident's disease process, impaired balance/mobility and fragile skin. The following interventions were listed: resident is totally dependent on two (2) staff to provide bath/shower resident is totally dependent on one (1) staff for personal hygiene and oral care follow facility protocols for treatment of injury, keep skin clean and dry, weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The goals noted for Resident #408 were to improve current level of functioning through the review date and to maintain or develop clean and intact skin by the review date. A side-by-side record review was also conducted with the DON of the facility's progress notes, at that time, of the resident's skin status. However, the documentation reviewed in the progress notes, weekly Skin Only Evaluation and in the daily Skilled Evaluations forms dated Friday 05/31/24 up until Tuesday 06/11/24) only documented the general condition or status of the resident's skin area as: warm and dry, skin color within normal limits (wnl) and Turgor is normal, no edema or pitting edema present to lower extremities, and turgor normal, warm to touch, circulation check; extremities are warm and pink, Capillary Refill: Brisk < 3 seconds, skin negative for rash or bruising, no skin lesions or rashes appreciated in exposed bilateral upper extremities or bilateral lower extremities., patient has high risk for developing .ulcers and for skin breakdown which can progress to sepsis ., but with no documentation to specifically describe the resident's sacral area, as having been assessed by facility staff. In Summary, Resident #408 had been residing in the facility, seen and cared for by several different nursing staff members, for eleven (11) days, before the resident's sacral wound was discovered at a stage III; with subsequent treatment then being initiated by facility nursing staff, with no timely notification made to the resident's representative of such. The DON recognized and acknowledged during interview on 08/08/24 at 3:47 PM, that Resident #408's sacral skin wound was not discovered, identified nor documented on by the facility's nursing staff until Tuesday 06/11/24; eleven (11) days after admission to the facility.

Based on observations, interviews, and record review, the facility failed to provide the necessary services to maintain good nutrition (assist with feeding) for a resident who is unable to carry out activities of daily living for 1 of 8 sampled residents reviewed for nutrition (Resident #121). The findings included: Resident #121 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, Heart Failure, and Muscle Wasting. The Significant Change Minimum Data Set (MDS) dated [DATE] revealed that Resident #121 has a Brief Interview of Mental Status (BIMS) score of 04, which is severe cognitive impairment. Section GG (eating) on the above MDS showed that Resident #121 needs set-up and clean-up assistance with her eating. The Care plan dated 07/19/24 showed Resident #121 has a self-care performance deficit related to impaired cognition. Resident #121 has impaired visual function related to blurred vision. In an observation conducted on 08/05/24 at 5:40 PM, Resident #121 was noted in her room with the dinner tray. The dinner tray was observed with two scoops of egg salad, 2 ounces of pureed bread, vegetable salad, and 4 ounces of juice. No staff was noted in the room at the time of this observation. The continued observation on 08/05/24 at 6:05 PM (25 minutes later) showed that Resident #121 did not eat anything on her tray and was noted as 100% untouched. At 6:10 PM, the tray was still untouched, which was 30 minutes later after the first observation. At 6:30 PM, the tray remained untouched, and no staff member came into the room from 5:40 PM to 6:30 PM. Staff K, a Certified Nursing Assistant, entered the room at 6:32 PM and sat near the Resident to feed her dinner. She left the room [ROOM NUMBER] minutes later with the tray. In an observation conducted on 08/06/24 at 11:50 AM, the lunch tray came into Resident #121 ' s room and was set up for the Resident. At 12:10 PM, no staff was noted in the room, and the lunch tray was 100% untouched. The observation continued at 12:15 PM, and the tray was still 100% untouched, with no staff in the room. Staff J, a Certified Nursing Assistant, came into the room at 12:17 PM and left the room with Resident #121 ' s lunch tray in her hands. A review of the Activities of Daily Living (ADL) task for eating (documented by the Certified Nursing Assistants) showed that from 07/08/24 to 08/06/24, Resident #121 needed the following assistance: 107 meals with total dependence and full staff performance, six meals with extensive assistance with staff providing weight-bearing support, four meals with limited assistance and staff providing non-weight bearing assistance, 16 meals with supervision and staff encouraging and cuing and 15 meals independently with no help from staff or oversight at any time. In an interview conducted on 08/06/24 at 3:10 PM with Staff B, Certified Nursing Assistants (CNA), who stated that Resident #121 needs assistance with all her meals. In an interview conducted on 08/06/24 at 3:20 PM with Staff A, the MDS Coordinator stated the following: for section GG, eatingm, a resident is coded by reviewing therapy evaluations, interviewing staff, and looking at the CNAs documentation under tasks for eating to see what type of assistance is needed for each meal. This is done by looking at the 7-day look-back period. Staff A said that she would also observe residents during dining times. Section GG for eating is coded depending on how often the same assistance is needed for each meal. When asked about Resident #121 ' s eating task, Staff A confirmed that she requires total assistance with most meals.

Based on observations, interviews and record review the facility failed to treat residents in a dignified manner during dining observations for 5 out of 44 sampled residents (Residents #176, #101, #412, #162 and #135). The findings included: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes with a revised date of 03/2023 included in part the following: 5. All staff will be seated, if possible, while feeding a resident. 8. Ensure the resident receives the proper tray. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity with a revised date of 05/2023 included in part the following: 10. Speak respectfully to residents; avoid discussions about residents that may be overheard. 1. Record review for Resident #101 revealed the resident was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia. Review of the Minimum Data Set (MDS) for Resident #101 dated 05/24/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #101 revealed the resident was not currently on isolation. On 08/06/24 at 8:45 AM an observation was made of Resident #101 sitting in wheelchair and on the overbed table in her room was partially eaten breakfast that was served in a divided Styrofoam cover dish, with Styrofoam cups, and plastic utensils on a Styrofoam tray. On 08/06/24 at 12:33 PM an observation was made of Resident #101 in the Atrium dining room on G unit, the resident was served lunch in a Styrofoam container, with Styrofoam cup, plastic utensils on a Styrofoam tray. 2. Record review for Resident #176 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Protein-Calorie Malnutrition and Dementia. Review of the Minimum Data Set (MDS) dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #176 revealed an order dated 04/30/24 for Regular diet Regular texture, Regular/Thin consistency, PAPER PLATES. Review of the Physician's Orders for Resident #176 revealed the resident was not currently on isolation. On 08/06/24 at 8:35 AM an observation was made of Resident # 176 sitting up in bed eating breakfast that was served in a divided Styrofoam cover dish, with Styrofoam cups and plastic utensils on a Styrofoam tray. On 08/06/24 at 12:30 PM an observation was made of Resident # 176 in the Atrium dining room on G unit, the resident was served lunch in a Styrofoam container, with Styrofoam cup and plastic utensils on a Styrofoam tray. 3. Record review for Resident #412 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Covid-19 and Dementia. Review of the Minimum Data Set (MDS) for Resident #412 dated 07/24/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #412 revealed the resident was not currently on isolation. On 08/06/24 at 8:40 AM an observation was made of Resident #412 sitting on edge of bed eating breakfast that was served in a divided Styrofoam cover dish, with Styrofoam cups and plastic utensils on a Styrofoam tray. On 08/06/24 12:35 PM an observation was made of Resident # 412 in the Atrium dining room on G unit, the resident was served lunch in a Styrofoam container, with Styrofoam cup and plastic utensils on a Styrofoam tray. During an interview conducted on 08/06/24 at 9:50 AM with Staff M Certified Nursing Assistant (CNA) who stated she has worked at the facility for about 3 months. When asked why Residents #412, #101, and #176, were served breakfast on Styrofoam, she said they were on isolation, and I think the kitchen forgot to stop using the Styrofoam when they came off of isolation. When asked when the residents came off of isolation, she said she did not remember. During an interview conducted on 08/06/24 at 12:30 PM with Staff N, Certified Nursing Assistant (CNA), who stated she has worked at the facility for [AGE] years. When asked why some of the residents are served lunch with disposable items like Styrofoam container and cups and plastic utensils, she said the residents used to have Covid and probably the kitchen forgot to take them off. During an interview conducted on 08/06/24 at 12:43 PM with Staff O, Registered Nurse/Unit Manager (RN/UM), who stated she has worked at the facility for 8 years. When asked why some residents are served lunch in the dining room with disposable items like Styrofoam container and cups and plastic utensils, she said they were on Covid, and the kitchen forgot to take them off. When asked how long the residents in the dining room had been off of isolation for Covid, she said about a week. She said she will call the kitchen. 40153 4. Resident #162 was admitted on [DATE] with diagnoses of protein-calorie malnutrition, Type 2 diabetes, and muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 02, which indicated severe cognitive impairment. In an observation conducted on 08/05/24 at 6:25 PM, Resident #162 received her dinner tray, which was placed at the side table. At 6:55 PM (30 minutes later), Staff C, Certified Nursing Assistant, was noted standing over the Resident feeding her the dinner soup. A chair was noted near Staff C, which had enough space to pull the chair near Resident #162's bed. Staff C stopped when this Surveyor walked into the room and said, She is a feeder, in front of Resident #162. In an interview conducted on 08/07/24 at 3:40 PM, Staff H, a Certified Nursing Assistant, stated that she was educated on treating the residents with dignity while assisting with dining. She needs to make sure that she sits near the residents at eye level while feeding them. Staff H further reported putting less food in the residents' mouths at one time and assisting the residents in eating their meals. 50370 5. Resident #135 was admitted to the facility on [DATE] with diagnoses of bilateral primary osteoarthritis of knees, acute kidney failure, hypertension, dysphagia, peripheral vascular disease, atrial fibrillation, asthma, respiratory disorders unspecified protein-calorie malnutrition, pleural effusion, and elevated white blood cell count. She was readmitted as hospice care on 06/14/2024. Review of MDS (Minimum Data Set) section C on 06/21/2024 showed an updated BIMS (Brief Interview for Mental Status) score of 11 indicating good cognitive function. Previous BIMS score of 9 was obtained on 06/08/2024 indicating less cognitive function. Section GG of MDS revealed the following: 1. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear- required substantial maximal assistance; 2. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower showed -partial moderate assistance; 3. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement showed - partial moderate assistance. Record review of care plan's goals and interventions dated 06/13/2024 showed to maintain resident's dignity and comfort at the highest level; keep the environment quiet and calm, lighting low, and familiar objects near. Additional review of care plan and interventions revealed to monitor resident for signs and symptoms of respiratory distress and report to MD( Medical Doctor) prn ( as needed). In an interview with Resident # 135 on 08/05/2024 at 2:00 PM, she stated there were less Staff at night. She added only one nurse was available to take vitals signs. Resident #135 stressed that she sat on her feces and urine for eight hours, and they occured more than several times. When she pressed her call lights multiple times at night, a Staff wanted to get the call light away from her. She did not remember the name of the Staff, since Staff was a floater. Resident # 135 added that Staff are not respectful. She rememebered an incident when she pressed the call light because she was experiencing difficulty of breathing, when a floater Staff came and asked her What do you want?. This incident shocked her because of the disrespect from Staff's tone and attitude. In another interview with Resident # 135 on 08/05/0224 at 6:37 PM, she stated there was no Staff available to help her get to her wheelchair. She added Staff don't come back when I pressed the call light, and when I needed help to use my wheelchair, she was talking while pointing her finger to a Staff who came in to answer her call light. Staff T, a CNA (Certified Nursing Assistant) reminded Resident #135 that she helped her move from bed to wheelchair whenever the resident asked. Resident # 135 showed a frown on her face, mouth turned downwards and moved head side to side indicating disagreement from what she heard. Resident # 135 added that Facility Staff do not listen to her whenever she requests a different type of meal. She does not like to eat eggs morning, noon, and night, and no Staff told her or informed her why she cannot have another type of meal. She asked this surveyor, how is she able to eat a cucumber salad? In another interview with Resident # 135 on 08/08/2024 at 08:18 AM , she stated that she does not like that any Facility Staff enters her room and moves her stuff without asking her permission first. She added that she is losing her dignity and respect because Staff does not communicate with her. One Staff enters her room, gets objects like her expensive Pepto Bismol without asking permission from her first. She said that a Staff uses a rough paper to wipe her body and when she asked for a linen face cloth at night, Staff tells her residents are allowed one face cloth, one bath towel and one bed blanket. Resident #135 showed and let this surveyor feel a folded brownish paper ( similar to a rough kitchen paper towel) which she said Staff uses to wipe her back, chest, and bottom. During an interview with Staff E, a Registered Dietician on 08/06/2024 at 10 :00 AM, he stated that he listened to the dietary requests of Resident #135, and tried to accommodate her preferences and likes. In an interview with the Unit Manager of E Wing on 08/08/2024 at 11:00 AM, when asked his ways of showing respect and dignity to residents, he stated that he knocks on the door, and asks permission before going inside resident's room. He added that he did not remember taking any medication out of Resident #135's room.

Based on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods in a safe and proper form for 7 of 31 sampled residents on puree diets (Residents #83, #110, #114, #120, #132, 135, and #248) and failed to provided thickened liquids as per physician order for Resident #120. The findings included: 1) Observation of the approved menu for the lunch meal of 05/16/23 noted Pureed Diet (PU4) were to receive 4 oz Pureed Rice (PU4) and 4 oz of Pureed Vegetables (PU4) . During the observation of the lunch meal in the main kitchen on 5/16/23 at 11:45 AM , it was noted that the Pureed Rice and Pureed Vegetable to be sticky, grainy, and to have pieces of food that were visible to the naked eye. At the request of the surveyor the pureed rice and vegetables were tasted to ensure a smooth consistency. The test revealed that there were large pieces of the rice grain and vegetables in the pureed mixture. Interview with key staff noted that the cook (Staff H) failed to taste pureed foods on a daily basis to ensure that the pureed mixture was smooth and free of piece of foods. Further interview with Staff H on 05/16/23 noted that he was unaware that the all pureed foods are required to be smooth in consistency for residents with diagnoses of Dysphagia. Further stated no training on the preparation of pureed foods. The surveyor requested that the Pureed Rice and vegetables be further pureed until the proper consistency was obtained prior to serving. Following the observation the surveyor requested a copy of the Pureed PU4 Diet from the facility's approved diet manual from the Director of Skilled Therapy and the Speech Therapist. On 05/17/23 the Director of Skilled Therapy submitted a copy of the Pureed Level 4 Diet form the Eat Right -Nutrition Care Manual that had been designated for use by the facility. A review of the Pureed Level 4 Diet noted documentation that the diet is prescribed for residents with chewing or swallowing of food. The diet requires a texture of foods that are smooth and lump free and should not be firm or sticky. A review of the Food Group - Grains, documented that Rice is not recommended for Pureed PU4 Diet. Further interview with the Director noted that she and the Speech Therapist was unaware that pureed rice was being served to residents with physician ordered Pureed PU4 Diet. A review of the facility's Diet Census for 05/16/23 noted that there were currently 31 residents with physician ordered Pureed PU4 Diet. Of the 31 residents it was noted that it included Sampled Residents #83, #110, #114, #120 , #132, #135 , and #248. 2) During the observation of the breakfast meal on 05/16/23 at 8:45 AM, it was noted that the meal tray was delivered to the room of Resident #120. A review of the resident's meal tray ticket at the time of the observation noted : Pureed Diet (PU4), Honey Thickened Liquids. Observation of the meal noted regular orange juice (4 ounces) , whole milk (8 ounces) , and coffee (8 ounces). Continued observation noted that none of the fluids were thickened to Honey consistency and the CNA in the room stated that the fluids are required to come from dietary pre-thickened except for the coffee. The CNA stated that she will have to thicken the liquids with powdered packaged thickener. Further observation noted that the resident thickened the 3 beverages with 2 packages of the powdered thickener. A review of the Thick & Easy Beverage Thickening Powder noted directions that a whole package of thickener needs to be added to 4 ounces of liquid. Following the observation it was discussed with the D Wing Charge Nurse that an insufficient amount of thickener was used for the beverages of Resident #120. It was discussed that a total of 5 packets of the thickener need to be used that included; juice (1 packet), milk (2 packets), and coffee (2 packets). The Charge Nurse stated that all beverages on meal tray were to come from dietary department pre-thickened to their respective thickening order. It was also discussed that the resident's personal refrigerator contained 4 -8 ounce containers of juice that were not thickened to Honey consistency. During a meeting with the facility's Registered Dietitian, Diet Technician, and Corporate Food Manager on 05/16/23 at 11 AM, it was noted that all beverages should have been purchased pre-thickened and powdered thickener should not be utilized. A review of the facility's policy for Thickened Liquids (Implemented, 10/15/22 and Revised 03/10/23) noted the following: Policy - The facility provides commercially-prepared thickened liquids , as prescribed, to residents who require them. #7 (a) - Do not thicken liquids in the facility, even with products designed for this purpose. Use only pre-thickened commercially prepared liquids in the desired consistency. Interview with the Director of Skilled Therapy on 05/15/23 noted that she was unaware that nursing staff was thickening liquids within the facility and further stated that the facility requires only the use of commercially prepared thickened liquids. Review of clinical record of Resident #120 on 05/16/23 noted the following: Date of Admission : re-admission 11/16/22 Diagnoses: Dysphagia, Alzheimer's Disease Current Physician Orders: 3/31/23: Pureed Diet - Honey Thick Consistency 10/25/22 - Resource 2. 0 120 ml TID 11/11/22 - Health Shake BID 3/13/23 - Fortified Foods Q Monday/Wed/Fri 3/12/23 - Fortified Cereal Every Day * Review of resident's breakfast meal tray card on 05/16/23 noted no documentation of the Fortified Cereal and was not included on the resident's meal tray. Current MDS: 2/21/23 Sec B: Sometimes Understood/Understands Sec C: NO BIMS-resident does not understand Sec K: 69/102 #-Weight Loss - not prescribed Mechanically Altered Diet Weight History: 5/5/23 = 107 4/5/23 = 107 2/28/23 = 105 2/7/23 = 108 BMI= 15.9 Height = 69 Nutrition Note : 3/11/23: Progressive decline. Pureed diet with Honey Thick Liquids and Fortified Cereal every morning. Review of Current Care Plan * High Risk for Nutritional Decline > Provided as order liquids to Honey < Fortified Cereal Every Day 40153 3. A record review showed that Resident #149 was admitted to the facility on [DATE] with diagnoses of Dementia, Anxiety, and Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #149 is severely cognitively impaired. Section G for eating showed supervision with set up only. A diet order was noted for Soft & Bite-Sized SB6 texture, Regular/Thin consistency, dated 03/31/23. In an observation conducted on 05/15/23 at 9:52 AM, Resident #149 was in Unit G's dining room, eating her breakfast tray independently. Closer observation showed a meal tray with scrambled eggs, a cut-up bite-size biscuit, and a large piece of hashbrown that was not cut into bite-size pieces. 4) A record review showed that Resident #144 was readmitted to the facility on [DATE] with diagnoses of Pulmonary Disease and Diabetes. The annual MDS dated [DATE] showed that Resident #144 has a Brief Interview of Mental Status (BIMS) score of 03, which is severe cognitive impaired. Section G for the MDS showed for eating, Resident #144 is with supervison and set up only. A diet order was noted for Soft & Bite-Sized SB6 texture, Regular/Thin consistency, dated 03/31/23. In an observation conducted on 05/15/23 at 9:38 AM, Resident #144 was in Unit G's dining room, eating her breakfast tray independently. Closer observation showed a meal tray with scrambled eggs, a cut-up bite-size biscuit, and a large piece of hashbrown that was not cut into bite-size pieces. In an interview conducted on 05/17/23 at 10:09 AM with Staff C, Speech Language pathologist, she was asked by the Surveyor to explain the Soft & Bite-Sized SB6 texture, Regular diet. She stated that this is a level 6 diet that has a soft bite-size consistency. Everything on the plate needs to be cut up to bite size pieces. Staff C reported that the meals should come out of the kitchen cut up already, especially the bread and the vegetables. In an interview conducted on 05/17/23 at 3:30 PM, with the facility's Director of Nursing, she was informed of the findings.

Based on interview and record review the facility failed to conduct appropriate infection surveillance testing of staff for Covid-19 in accordance with national standards and facility's policy during current outbreak of Covid-19. The findings included: Review of the facility's policy titled Coronavirus Testing with a revised date of 03/06/23 included the following: The facility will implement testing of facility residents and staff, including individuals providing services under arrangement and volunteers, for Covid-19. Individuals with signs and symptoms of Covid-19 should be prioritized first when tested , then perform testing triggered by an outbreak investigation as follows: Testing Trigger - Newly identified Covid-19 positive staff or resident in a facility that is unable to identify close contacts. Staff - Test all staff, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g., unit, floor, or other specific area(s) of the facility). Under the heading of Testing of Staff and Residents in Response to an Outbreak Investigation , it included: Upon identification of a single new case of Covid-19 infection in any staff or residents, testing will begin immediately (but not earlier than 24 hours after the exposure, if known). Outbreak testing will be performed either through contact tracing or broad-based (e.g., facility-wide) testing. The facility may choose to conduct focused testing based on known close contacts if they can identify close contacts of the individual with Covid-19, but if the facility does not have the expertise, resources, or ability to identify all close contacts, the facility should investigate the outbreak at a facility-wide or group-level. If an expanded testing approach is taken and testing identifies additional infections, testing should be expanded more broadly. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. Review of the Covid Testing Sign In Sheets for the week of 05/07/23 to 05/17/23 revealed 163 out of 339 employees were tested , and of the 163 employees tested on ly 35 were tested twice. During an interview conducted on 05/17/23 at 9:25 AM with the Director of Nursing/Infection Preventionist (DON/IP) and the Staff Developer/Infection Preventionist in Training (SD/IP in training), they stated they both work full-time. The SD/IP in training stated they are currently in an outbreak of Covid-19 status as of 05/04/23 when a resident had symptoms of fever and aches and tested positive for Covid, and the roommate also tested positive for Covid on 05/04/22 as well. The DON/IP stated that on 05/04/23 they tested the entire F-wing (where the 2 positive residents were) and they notified the Epidemiologist at the Department of Health, who agreed with their plan to test all staff/residents for Covid twice a week. On 05/05/23, all staff and all residents in the facility were supposed to be tested . The DON/IP stated they conduct Covid testing per guidelines, and outbreak mode includes testing all residents and testing all staff members twice a week (Sunday to Saturday) and the testing continues until there is no positive residents/staff members for 14 days. Each staff member is supposed to be tested twice a week (Tuesdays and Thursdays). The night shift tests themselves and have been trained to do so. The DON/IP stated that sometimes we do not test all staff, some are PRN (as needed) or on vacation, and then they need to show a negative test result before returning to work. The DON/IP also stated the staff members who have not been tested are tested by the unit managers who have been trained on how to perform covid test. When asked how they ensure that all staff members are tested twice a week, they both stated we have the assignment sheet for the day of testing, and we test all those staff members. When asked again how they ensure they are testing all staff members twice a week the SD/IP in training stated they could compare the assignment sheets to the employee roster. When asked if they think the system they are using is working effectively, the DON/IP stated it could be a little more precise to ensure they capture all the staff including the PRN and staff who may be out for various reasons. She then went on to say we have a large building and a lot of staff. When asked who is responsible for making sure all the staff are tested twice a week during outbreak testing, she said she is the DON/IP and ultimately, she is responsible.

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for 2 of 4 residential wings (D and E Wing), and maintain comfortable sound levels (Resident #2, and #96). The findings included: 1) During the environmental tours conducted during resident screenings on 05/14/23 and environment tour on 05/15/23 at 1:30 PM accompanied with the Director of Maintenance, the following were noted: D- Wing: D#1: The bathroom floor grout and tiles were heavily stained and in disrepair, razor located on bathroom sink, room floors soiled and stained, and bathroom door exterior in disrepair. D#2: Room floors soiled with areas of black stains , and numerous black scuff marks to room walls. D#3: Bathroom floor grout and tiles heavily stained, room baseboards exterior were soiled and in disrepair, and room couch exterior has several stained areas. D#6: Bathroom floor grout and tiles heavily stained, overbed light cord missing (B Bed), and window blinds were in disrepair. D#7: Entry door exterior in disrepair, room baseboards in disrepair and stained, and room walls in disrepair and peeling paint. D#8: Bathroom floor grout and tiles were heavily stained. D#11: Room base boards were cracked and in disrepair. D#13: Bathroom floor grout and tiles heavily stained, and exterior of over-bed table (Bed A) was cracked and rusted. D#14: Bathroom floor grout and tiles were heavily stained, room base boards in disrepair, and exteriors of overbed tables (X 2) were rusted and in disrepair. D#18: Bathroom floor grout and tiles were heavily stained. D#22: Bathroom floor grout and tiles were heavily stained. Soiled Utility Room: The exterior of the entry door was heavily worn and peeling paint. Kitchen Pantry: The room floor was stained and heavily soiled. E Wing: E#14: Bathroom toilet continuously running. E#19: Bathroom floor grout and tiles heavily stained and worn, room dresser missing drawer handles. E#20: Bathroom floor grout and tiles heavily stained and worn. Over-bed table exterior disrepair with sharp edges. E#21: Bathroom floor grout and tiles heavily stained and worn. E#22: Bathroom floor grout and tiles heavily stained and worn. Hallway Handrails: The wall hand rail next to room [ROOM NUMBER] was loose and separating from the wall. Following the enviroment tour the findings were confimed with the Director of Mainteance who stated the issues would be discussed with the administration team. 41837 2. Record review for Resident #96 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Diabetes, Major Depressive Disorder, and Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #96 dated 05/06/23 revealed in Section C the resident had a Brief Interview of Mental Status (BIMS) score of 15 indicated the resident had an intact cognitive response. During an observation conducted on 05/14/23 between 11:00 AM to 1:00 PM the exterior door located at the East end of E-wing unit was opened 15 times with a very loud alarm sounding each time the door was opened. An interview was conducted on 05/14/23 at 12:59 PM with Resident #96 who was awake and lying in her bed. When asked if the East E-wing exterior door alarm disturbs her, she said sometimes it does at night. It happens so often that I do not jump every time it goes off like I used to. 3. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Insomnia, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Diabetes and Major Depressive Disorder. Review of the Minimum Data Set (MDS) for Resident #2 dated 03/10/23 revealed in Section C the resident had a Brief Interview of Mental Status (BIMS) score of 14 indicated the resident had an intact cognitive response. An interview was conducted on 05/14/23 at 1:06 PM with Resident #2, who was sitting in her wheelchair in her room. When asked if the East E-wing exterior door alarm disturbs her, she stated yes it goes off all the time. When asked if it goes off during the night, she stated it is all through the day and several times in the night, it even wakes her up in the middle of the night. An interview was conducted on 05/17/23 at 8:10 AM with the Administrator who stated she has been with the facility for 3 years. When asked which staff enter the building through the East E-wing exterior door, she stated it is only the staff from the maintenance department, the housekeeping department and the laundry department who enter through the East E-wing exterior door. When asked how often those staff members enter through the East E-wing exterior door, she stated all through the day and sometimes at night. When asked if the loud alarm sound that goes off when entering the East exterior E-wing door disturb the residents, she stated, We have to have the alarm to keep the residents safe so they cannot get out. When asked again if the East E-wing exterior door alarm disturbed any of the residents, she did not answer the question.

Based on observations, interviews, and record reviews, the facility failed to provide dining in a dignified manner during multiple observations conducted on Unit G (lockdown unit). The findings included: In an observation conducted on 05/14/23 at 1:50 PM, in Unit G (lockdown), in the Atrium,15 residents were sitting waiting on their lunch trays. The first table had 4 residents with 1 resident eating; the second table had 4 residents with only 1 resident eating, the third table had 4 residents with 2 residents eating, and the fourth table had 3 residents with 3 residents eating. At 2:02 PM (12 minutes later), the first table had 3 residents waiting on their lunch trays, the second had 2 residents still waiting on their lunch meal, and the third had 3 residents still waiting on their lunch meal. Continued observation at 2:10 PM, 20 minutes later, showed that the first table had 3 residents still waiting on their lunch meal, the second table had 1 resident eating and 2 residents waiting on their lunch meal. The third table had 2 residents eating and 1 waiting for their lunch. In an observation conducted on 05/15/23 at 9:30 AM on Unit G, 14 residents were seated in the Dining room waiting on their breakfast trays. There were 5 tables with the following residents: table 1 had 2 residents, table 2 had 4 residents, table 3 had 3 residents, table 4 had 2 residents and table 5 had 2 residents. One resident in table 2 received their breakfast meal at 9:38 AM; the second resident received their breakfast tray at 9:48 AM; the 3rd resident received their breakfast tray at 9:50 AM, 12 minutes after the first resident received their breakfast tray. Continued observation at 9:55 AM showed that Resident #165 (4th resident at table 2) still needs their breakfast tray. In this observation, Resident #165 turned around and said to Surveyor, I am so hungry and still waiting for my breakfast tray. A record review showed Resident #165 was readmitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #165 Brief Interview of Mental Status (BIMS) score is severely impaired. In an interview conducted on 05/17/23 at 8:53 AM with Staff G, Licensed Practical Nurse (LPN), it was stated that when she passes the meal trays during dining on the G unit, she will reach for the trays in the meal cart and will grab whichever tray she has and place it in front of the resident. It is not done in any specific order. She further said that she knows that she is supposed to provide the trays to residents one table at a time, but it is not done. In an interview conducted on 05/17/23 at 9:00 AM, Staff B, Nurse Manager, reported that she knows that the meal trays need to be passed out one table at a time but that it is not done. She further said that the trays on the meal cart arrive sporadically with no specific order. In an interview conducted on 05/17/23 at 3:30 PM, with the facility's Director of Nursing, she was informed of the findings.

Based on observation, interview, record review and review of policies and procedures, the facility failed to provide adequate supervision to 1 of 3 sampled residents, at risk for elopement, Resident #1. The deficient practice allowed Resident #1 to exit the facility on 08/27/21 at approximately 12:30 AM, and after an unlicensed staff member left the resident on an unsecured patio. Resident #1 was observed walking towards the emergency exit to the facility's designated Covid-19 unit, where the resident sat on furniture that was on a patio just outside of the emergency exit door on this unit. The emergency exit door was not secured and did not have an alarm on it to indicate that the door was opened. Staff E, Clerical (staffing agency staff with no responsibility for providing care to the residents) joined the resident on the patio and when Staff E failed to redirect the resident back inside, left the resident alone on the patio, where there was no security (fence, gate). There were 11 residents in the facility's designated Covid-19 unit at the time of the elopement. At the time of the survey, there were 9 residents on this unit. Based on review of police reports, provided by the local law enforcement, documented that the resident was found by K9 unit, on 08/27/21 at 5:51 AM, where Resident #1 was assessed by local Fire Rescue. Resident #1 was returned to the facility by local Fire Rescue on 08/27/21 at 6:30 AM, more than 5 hours after the resident was first seen independently ambulating towards an emergency exit that was not armed with an alarm and left alone on the unsecure patio area. The findings included: The facility's policy for the subject of Elopement Protocol, dated 01/2002 and revised most recently 05/2014, provided to this surveyor on 10/25/21, documented: * Residents are reviewed and evaluated for elopement risk by Social Services and Nursing staff. Elopement risk is based on past history and/or medical diagnosis at the time of pre-admission screening or immediately upon admission, as well as interview with family members and the resident. * When appropriate, residents will be placed on the Alzheimer's Unit to allow independent mobility within a secured environment. * Those residents who are considered to be an elopement risk but are inappropriate for the secured unit will be monitored by the least restrictive method allowing for resident safety as determined by the Interdisciplinary team. The facility's policy for the subject of Elopement Protocol, dated 01/2002 and most recently revised on 08/2021, and provided to this surveyor on 10/27/21 at approximately 5:30 PM, documented: * Any staff member observing a resident attempting to leave the premises shall attempt to prevent such departure. Should the attempt fail, the staff member shall obtain the assistance of another staff in the immediate vicinity. If none are available, staff member should remain with the resident until help arrives. Resident #1 was admitted on [DATE]. The resident's Admission Minimum Data Set (MDS), dated [DATE], documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99, indicating that Resident #1 was unable to complete the assessment. The assessment documented that the Resident #1 was 'independent' with indoor mobility without the use of assistive devices. Resident #1's diagnoses at the time of the assessment included: Coronary Artery Disease; Hypertension; Dementia; and Anxiety Disorder. An 'Elopement Risk Assessment, dated 08/25/21 (date of admission) documented that Resident #1 was not at risk for elopement based on abilities and behaviors. In a section of the assessment for 'Mobility, the assessment documented that the resident 'Propels self/some assist'. In the section of the assessment for 'Mental Stability' the assessment documented the resident as being 'Alert and oriented x3'. In the section of the assessment for 'Medications (meds) (antipsychotic, mood altering) the assessment documented '1 of these meds. In the section of the assessment for Disease's (dementia any type mental illness)' the assessment documented '1 present'. During an observation of the facility's designated Covid-19 isolation unit (F Unit), as part of the initial tour, on 10/25/21 and beginning at 9:20 AM, this surveyor, after donning Personal Protective Equipment (PPE), opened the F-unit emergency door from the outside as the door was not locked. Upon opening the door, there was no alarm that sounded to alert staff on the unit that the door had opened. During an interview, on 10/25/21 at 1:46 PM, with the Director of Nursing (DON) and the Executive Director (ED), the DON provided a facility investigation report regarding Resident #1's elopement. The report documented the incident (elopement) occurred 08/27/21. The DON quoted from the report, Resident left the Covid-19 unit to the patio area and sat down for a while with the CNA [certified nursing assistant], the CNA sat with him while trying to redirect him back inside and he did not want to come in. He [the CNA] said that he sat there for a while, then when he tried to redirect him [Resident #1] in again he refused so that was when he went inside to get the nurse to assist. When the CNA made it back to the patio, the resident was no longer there. Both him [CNA] and the nurse looked around the surroundings to see if they could find him and when they couldn't, they came back in and notified the supervisor, and the supervisor called the 'code blue' [elopement risk code that we call when we are unable to locate a patient]. The supervisor called me [DON] and I called the Administrator and the ED on [MEDICATION(S)] in and we all arrived to the building. I conducted a search of the Covid-19 unit, each room. Even though the nurses toured the other units, I toured the inside of the facility. After we weren't able to locate him, I called 911 and the resident's son and physician. [Local] Police showed up to the facility and toured the facility and the grounds. They asked for a description of him and checked his room. We continued to search, some of them branched out to the outside of the facility, while some remained in the facility to search. A couple of hours later the police called and said that the resident was found. They checked the cameras. He was found in the shrubs, that is what the staff told me. During an interview with the local Police Department (the law enforcement agency that found the resident), on 10/25/21 at 3:53 PM, the representative from the law enforcement agency stated, He [Resident #1] was found at NW 50th St, approximately 0.1 miles from the facility, with no time documented to when the resident was found and appeared to be un-injured and did not need any other medical attention. (Police report obtained). Observation of the patio and area where Resident #1 had left the facility revealed that Resident #1 had to step down from the patio and onto terrain with multiple hazards, including trees roots that protruded from the ground and uneven terrain, to a sidewalk that had a 2-4 inch drop to the facility's parking lot, to another area of terrain with hazards (tree roots, uneven terrain), across a four-lane road with an elevated concrete and grass median, and to a local business that was approximately 0.1 miles from the facility. Photographic evidence obtained. During an interview, on 10/25/21 at 4:05 PM, with Staff C, Registered Nurse/RN (Staffing agency's DON), when asked about Resident #1's elopement, Staff C replied, I was the RN on the shift. We were working the shift and I was doing rounds and I had questions for the supervisor and because of Infection Control, I couldn't break the barrier and I needed the supplies, I was standing by the door that separated the Covid side from the clean side of the wing. I saw the resident [Resident #1] walk by from his room by the nurse's station in a shirt and an adult brief. I saw him headed toward the exit and I called another staff member and said that I saw the resident heading to the exit and the other staff member [Staff D, an agency CNA] headed after the resident. He had seen that the resident actually exited the building and was sitting in a chair just outside of the door. [Staff D, agency CNA] had another staff member [Staff E, agency clerical staff] sit with him [Resident #1] outside to try to convince him to come back inside, he refused to come in. They [Staff E / clerical staff and Resident #1] were out there over 30 minutes. When I came back to the nurse's station after taking care of patients, he [Staff E, agency clerical staff] came to the nurse's station to ask me for help. He [Staff E, agency clerical staff] just came back into the door for about 30 seconds. He [Resident #1] is ambulatory without any assistive device. He had no injuries. He was found in the bushes in the parking lot. When asked what the staff did when the resident was gone from the patio, Staff C (agency RN) replied, When we walked out and didn't see him, we headed the other way from where he was. He was talking about leaving and that he wasn't staying and was always talking about the circular driveway and that was where we started looking. During an interview, on 10/25/21 at 4:50 PM, with Staff E, Clerical, when asked about the resident elopement, Staff E replied, I was working at the desk. A resident went outside I stayed with him while he was on the chair, I sat with him for 10-15 minutes. I tried to get him inside, but he didn't want to go back inside. I went inside for about 1-2 minutes to get the nurse. When I go back out with the nurse, he wasn't there. I don't know exactly where he was found. The agency had a meeting with me about leaving someone by himself for even a minute. It was late at night, and I didn't want him to stay outside by himself. He had a shirt and did not have pants. That was the only time that I have worked at the facility. When asked about his job duties while at the facility, Staff E replied, I do filing, I do not do any patient care at all. Staff E further stated that the resident was not injured and that the incident happened starting between 12:30 AM (00:30 AM) and 1:00 AM. On 10/26/21 at 8:49 AM, Staff F (RN) and this surveyor attempted to open the door that the resident walked out of. Staff F opened the door with minimal effort and there was no alarm. Staff F (RN) had instructed the staff at the nurse's station on the unit to reset the lock on the door and secure it, and the door was then secured. Upon attempting to open the door again after being secured, the door opened with application of significant amount of force, and an alarm sounded at the nurse's station indicating that someone was attempting to open the door. During the observation, the Maintenance Director was observed cleaning the patio where the resident exited the facility. Staff F(RN) was unable to determine if the Maintenance Director exited through the door to get to the patio and when asked about the door being unsecured and unarmed, did not know why the door was unsecured and unarmed. This was the same door that Resident #1 exited through as the unit was part of the facility's designated Covid-19 isolation unit while the resident was at the facility. During an interview, on 10/26/21 at 9:37 AM, with the Maintenance Director and the Assistant Maintenance Director, when asked how he got to the outside patio, the Maintenance Director stated, When I am cleaning outside, I do not enter the facility. I go from the Maintenance Office that is outside and clean around the outside. The Maintenance Director confirmed that he did not unlock and disarm the alarm to the door to get to the patio. During an interview, on 10/26/21 at 10:55 AM, with the ADON and DON, when asked about documentation of bed, chair and door alarms being monitored, the DON replied that the facility did not use Wanderguards. When asked about the resident's behaviors prior to the elopement, the DON stated that there was no documentation that the resident exhibited exit-seeking behaviors prior to the incident. The DON stated, The aide was gone for 2 minutes. When he returned to the patio, within two minutes, he [Resident #1] was gone. They searched the immediate area and initiated a 'Code Blue' [Resident Elopement] immediately. During an interview, on 10/26/21 at 12:08 PM, with the DON, ADON (Assistant DON), ED and Administrator, when asked about the unit being used for the COVID unit and the door not being secured from the outside or having an alarm, the Administrator stated that the emergency exit had been designated as the entrance and exit to the COVID unit and where staff would don and doff Personal Protective Equipment (PPE). During an interview with Staff F, RN, when asked about Resident #1, Staff F replied, He was a patient here, he had COVID. When asked about exit seeking behaviors exhibited by Resident #1, Staff F replied, Not to my knowledge. He walked very well. His cognition was intact, he would tell me about his son and that he was an engineer. During an interview, on 10/27/21 at 4:47 PM, Staff C (agency RN) confirmed that she was the DON for the staffing agency and was the person in charge when Resident #1 eloped. Staff C further stated, I caught a glimpse of him exiting his room [Room #9]. I yelled to both of them [Staff D/agency CNA and Staff F/RN] to go after him then he was going out the door. They went after him. I continued with the patient that I was with and saw him in my line of vision. It was a while before he [Staff E] came in to get me and tell me 'I have been out there with him for over a half an hour, could you come out and help me.' I thought that when they went after him that they already brought him back in. I walked out to the door where they were sitting, and he [Resident #1] wasn't there. Because we are on a COVID unit, it was preferable that we do not use electronic devices. I don't know if he had his phone with him. I did not hear a bed alarm go off, there were 2 residents that I saw out of bed. We walk around room to room. We document once a shift if there were any safety issues, if they were up out of bed at night. Staff C further said, He did not go out to the resident. He was closer to the resident, and when I saw that the resident was walking in the direction of the door, I yelled to him to go get the resident. From my point of view, I could see the resident and they could not see him. Both the CNA and the clerical staff member went after him [Resident #1]. During an interview, on 10/28/21 at 11:19 AM, with Staff D, CNA, when asked what happened, Staff D replied, It was my first day in the facility, while providing care, the other nurse saw the patient going out. She asked me and the other guy [Staff E] to go and pick up the guy. By the time that I went there, the guy was sitting on the little porch at the front, and I asked what's up and he said he feels uncomfortable with the mask. I was the first person to sit with the patient for 15-20 minutes. I went back and left the patient with the other guy [Staff E] and went back to check with the other patients - we had 11 patients or something like that. When Staff D was asked what he was doing while Resident #1 and Staff E (agency clerical staff) were outside on the patio, Staff D replied, I was going around counting the patients and residents because there was no alarm on the door, and I had to be sure who it was that was outside of the door. I was with the nurse helping to do an assessment of the other patients, because there were two sides to the unit. When asked how Staff E (agency clerical staff) would have been able to get the attention of the Staff C (agency RN) and Staff D (agency CNA) for assistance, Staff D replied, There was no other way for Staff E [clerical staff] to get help, he had no choice but to leave the resident to get help. It took less than two minutes for me to get to the door and see that he was not there. I said to Staff E [clerical staff], 'in two minutes, he couldn't have gotten too far', I called the other nurse and yelled, she came and we went around the facility. The nurse called the facility supervisor. I don't know who the supervisor for the facility was, it was my first day and my first time at the facility. I am an RN but was working as a CNA because that was what was needed. On 10/29/21 at 6:44 AM, this surveyor arrived to the facility and went to the emergency exit door of the COVID unit. It was noted that there was no staff visible on the unit and that this surveyor had to wait for staff to enter the unit from residents' rooms to answer the door. When staff arrived to answer the door, Staff D opened the door, with minimal effort, and there was no alarm that sounded to indicate that the door was opened. During an interview, on 10/29/21 at 6:45 AM, with Staff D, RN, when asked if it would be possible to know when a resident exited the unit to the outside, through the exit door that did not have an alarm on it, Staff D replied that they would not be able to know if the door opened and a resident walked out. During an interview, on 10/29/21 at 6:52 AM, with Staff Q, CNA (agency staff), when asked if it would be possible to know when a resident exited the unit to the outside, through the exit door that did not have an alarm on it, Staff Q replied that there would be no way to know if the door opened and a resident walked out. Staff Q further stated that if both staff members were providing care to the residents, they would not be able to know if the door opens and a resident walked out. On 10/29/21 at 9:10 AM, the ED and the Administrator accompanied this surveyor to the exit door from the outside of the facility. The door was locked, and no staff were visible on the unit. When Staff H and Staff R, LPN (agency staff) arrived at the door and opened the door, there was no alarm, indicating that the door had been opened. The Administrator instructed Staff H and Staff R to lock the door and make sure that it was armed, the staff members struggled to lock and secure the door and were unable to. On 10/29/21 at 9:16 AM, the Assistant Maintenance Director arrived at the door and taught the staff members how to lock the door and informed this surveyor that the alarm did not work as one of the magnetic pieces was missing from the door. During an interview, on 10/29/21 at 9:26 AM, with Staff S, Unit Manager (agency staff), when asked about the exit door being locked from the outside and the alarm that did not sound, Staff S stated that the door was never locked from the outside and there had never been an alarm when she worked. During an interview, on 10/29/21 at 9:31 AM, with the Maintenance Director, when asked about the alarm not working on the emergency exit to the COVID unit, the Maintenance Director replied, He [the Assistant Maintenance Director] told me this morning that the magnet was missing so we are getting one and putting it on right now. It was working yesterday. During an interview, on 10/29/21 at 9:34 AM, with Staff H, when asked about the emergency door to the COVID unit being secured from the outside and having an alarm, Staff H replied that the door was not locked when she came in, was never locked, and that she had never heard the alarm go off. Staff H further stated that all of the residents currently on the unit were non-ambulatory. During an interview, on 10/29/21 at 9:37 AM, with Staff R, when asked about the emergency door on the COVID unit being secured from the outside and armed with an alarm, she replied, I work Fridays 7AM-3PM, Saturday double and Sunday double. The door has never been locked. The alarm has never gone off. When asked about the door being secured from the outside and armed when she arrived, Staff R replied, the door was not locked when I got here. On 10/29/21 at 9:40 AM, the Maintenance Director and the assistant Maintenance Director arrived to the door with the necessary parts and stated that the mechanism will be installed that will secure the door from the outside and initiate an alarm when opened. On 10/29/21 at 11:45 AM, this surveyor verified that the door alarm and lock on the emergency exit to the COVID unit had been repaired via the Assistant Maintenance Director was inside of the door and when attempting to open did not open for 15 seconds. After 15 seconds, the door was opened, and an alarm sounded that was able to be heard across the entire unit. A tour of the facility was conducted on 10/29/21 at 11:50 AM, for the purpose of checking the 23 exterior doors of the facility with the Maintenance Director and the Assistant Maintenance. During the tour, in the Dining Room at the F and G unit (G is a secured dementia unit, the COVID unit is part of the F unit), the emergency doors in the dining room between the G and F units, both with signs that read Emergency Exit Only Alarm Will Sound were opened with minimal effort, and no alarm sounded, as the doors had no alarm and were not secured. The Maintenance Director stated that the dining room had been closed since the beginning of the COVID-19 pandemic (March 2020). The Maintenance Director, the Assistant Maintenance Director and this surveyor walked through the door to the outside of the facility. The door opened to an area where there was a 60-yard dumpster just to the left of the door, and there was no fencing or means of securing the property, where Nob Hill Road could be accessed, and a residential area, business park (the same business park that Resident #1 was found) as well as a canal of unknown depth, approximately 30 feet wide. It was noted that the doors at the entrance to the dining room from the hallway were in closed position and that Dietary staff frequently passed through the doors, as did nursing staff that were using the Dining Room as a place for taking breaks. The Assistant Maintenance Director stated, those doors haven't worked for as long as I have worked here. The Assistant Maintenance Director stated that he had been working at the facility, since 2009 or 2010. Also, during the tour, an emergency door that was by the Activity Room and the Recreation Room, between the D and E units, with a red sign that read Emergency Exit Only Alarm Will Sound, was opened, with a moderate amount of force, and no alarm sounded. The door opened to a small courtyard that had no fencing or means to secure the property, where Nob Hill Road could be accessed as well as a residential area and the business park that Resident #1 was found. When asked about the documentation of all of the audits that were conducted regarding the emergency door that documented there were no concerns, the Maintenance Director stated that the audits were done on the emergency doors that were at the ends of each unit and not the dining room doors or the emergency doors that connected the units. When it was brought to the attention of the Maintenance Director and the Assistant Maintenance Director that the audits showed that all of the emergency doors were operational, when it was noted that the one that was on the COVD-19 unit did not work, the Maintenance Director and the Assistant Maintenance Director did not reply. At the conclusion of the tour, the Maintenance Director informed this surveyor that the facility had received 9 door alarms earlier in the week, to be installed at the emergency exits. This surveyor accompanied the Maintenance Director to the Maintenance Office where there was a box that contained the items to be installed. An invoice that accompanied the alarms documented that the alarms were delivered to the facility on [DATE]. On 10/29/21 at 1:18 PM, the Assistant Maintenance Director stated that the Maintenance Director had to call an electrician to install and rewire the censors for the door alarms and that the electrician will be at the facility later today or Monday. On 10/29/21 at 1:31 PM, the Administrator phoned the company providing the electrician, in the presence of this surveyor, and reported that the electrician was enroute and approximately 20-30 minutes from arriving to the facility. On 10/29/21 at 1:49 PM, the Maintenance Director reported that the electrician was 'on his way' with no knowledge of when the electrician would be on site. The Maintenance Director stated that it would take 'only two hours to fix' after the electrician gets here. The facility's Removal of IJ Plan included: On 08/27/21, Resident #1 was placed on 1:1 supervision for the duration of his stay at the facility after he had been returned to the facility, which was confirmed by interviews with 3 staff members that were familiar with the resident and record review of progress notes. On 08/27/21 and ongoing, the exit doors at the ends of each unit were checked by the maintenance department to ensure that they were alarmed. Confirmed via documentation and interviews with the Maintenance Director and the Assistant Maintenance Director facility conducted weekly audits and documented on Exit Door - hallway Check Log. According to the Maintenance Director and the Assistant Maintenance Director, the audits did not include the dining room emergency exit doors or the emergency exits in the hallways connecting the units. On 08/27/21, bed and chair alarms were checked by Maintenance. Confirmed monthly audits of all bed and chair alarms that were being used on a monthly basis, including ongoing, via record review and interviews with the Maintenance Department. On 08/27/21, 207 total staff were in-serviced, including 102 of the facility's 135 nursing staff. Confirmed via record review and interviews with 10 staff members of varying disciplines, departments and shifts. On 09/07/21 and 09/17/21, elopement drills were conducted. One hundred and eighty one (181) total staff members participated in the elopement drills, including 99 of the facility's 135 nursing staff. This was confirmed via record review and interviews with 8 staff members of varying disciplines, departments, and shifts. The alarm mechanisms were received from supplier on 10/27/21, according to the invoice that accompanied them. On 10/29/21 at 11:45 AM, the emergency exit on the COVID unit was repaired and confirmed to be working by observation of the Assistant Maintenance Director opening the door and triggering an alarm that was audible in every part of the unit. On 10/29/21 at 2:17 PM, the facility provided a temporary solution to secure and have alarmed the two dining room emergency exit doors and the emergency exit door in the hallway between the D and E unit in the form of placing a bed alarm pad inside of the door frame, as the door is opened, pressure is taken off of the mattress pad and an alarm would sound. The bed alarm on the emergency exit in the hallway connecting the units was audible to all points of the D and E units. The bed alarm on the emergency doors in the Dining Room were audible to the entrance of the F and G units, as well as through the hallway and main lobby. The elopement was reviewed by QAPI (Quality Assurance and Performance Improvement) on 09/10/21 as confirmed by record of the meeting. On 11/01/21 at 3:21 PM, the Administrator provided pictures, via email to this surveyor, of the alarm mechanisms that had been placed on the doors.