Every finding on record at Tamarac Center for Rehabilitation and Healing

Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP), during a perineal care observation for I of 1 sampled resident, Resident #7, reviewed for perineal care, for 1 of 4 sampled residents reviewed for PEG tube, Resident #7, during a percutaneous endoscopic gastrostomy (PEG) tube care observation; failed to perform hand hygiene, and failed to change damaged PPE gloves during a bolus feeding observation for 1 of 4 sampled residents reviewed for tube feeding, Resident #9; failed to follow their policy for hand hygiene during a medication administration for 1 of 6 medication administration observations, Resident # 16; failed to initiate an EBP nursing care plan for 1 of 6 sampled residents for medication administration, Resident #16; and failed to ensure laundry staff handled clean linen in a sanitary manner. The findings included: Review of the Center for Disease Control (CDC), Enhanced Barrier Precautions (EBP) guidelines revealed the following: Everyone must clean their hands, including when both entering and leaving the room. Providers and Staff must also wear gloves and a gown for the following: high-contact care resident care activities, dressing, bathing-showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use; central line, urinary catheter, feeding tube, tracheostomy. Wound care with any skin opening requiring a dressing. The website is: https://www.cdc.gov/long-term-care facilities/media/pdfs/ Review of the facility's policy titled, Enhanced Barrier Precautions, implemented on 1/25, documented the following: An order for EBP will be obtained for residents with any of the following: wounds (e.g. chronic wounds such as pressure ulcers, unhealed surgical wounds.) even if the resident is not known to be infected or colonized with Multiple Drug-Resistant Organism (MDRO) (2.b). EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound. (10). Review of the facility's policy titled, Hand Hygiene, revised 8/25, documented the following: o All staff will perform proper hand hygiene procedures to prevent the spread of Infection to other personnel, residents and visitors. o Staff will perform hand hygiene when indicated, using proper technique consistent with the accepted standards of practice. o Hand hygiene technique when using soap and water (5)-use clean towel to turn off faucet (f). 1. Record review documented Resident #7 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with Hypoxia, Traumatic Subdural Hemorrhage with loss of consciousness, and Gastrostomy Status. Review of recent Minimum Data Set (MDS) assessment under Section C of the Brief Interview of Mental Status (BIMS), revealed a score of 0, indicating Resident #7 had severe cognitive impairment. During an observation conducted on 09/16/25 at 3:06 PM with Staff U, Licensed Practical Nurse (LPN), she stated she would check the resident's gastronomy tube and briefs, upon hearing Resident #7's loud voice. Staff U went inside the room without performing hand hygiene and immediately went to resident's bedside, turned off the PEG tube pump, and checked the resident's brief, after donning a pair of personal protective equipment (PPE) gloves and closed the privacy curtain. She did not don on PPE gown. When she noted that the brief was wet, she closed the Velcro on one side of the brief and covered the resident. She removed her gloves and left the room, without performing hand hygiene. When Staff U returned to the resident's room, she was accompanied by Staff D, Licensed Practical Nurse (LPN). Both staff performed hand washing before donning on gloves. Staff U donned on Personal Protective Equipment (PPE) of a short-sleeved, non-disposable, cloth gown, exposing her white laboratory coat's sleeves during the entire perineal care and gastrostomy observation, while Staff D did not don on a PPE gown. When they approached the resident's bedside, they turned the resident on her left side up, with the resident's back facing Staff D. Staff D, without a PPE gown, started to un-Velcro the brief and performed perineal care on that side. While she was assisting with stabilizing Resident #7's position, Staff U's PPE short sleeved cloth gown was falling down her chest and her middle abdominal area. It was observed that she did not tie the neck area of her PPE gown. With the gloved hands she was using for touching the resident's left shoulder and lateral left thigh, she used the same gloves to put back her PPE short sleeved cloth gown up on her chest area. The PPE cloth gown's top part kept falling onto Staff U's chest and middle abdomen, while she was bent down and stabilizing Resident #7's lateral position. Both her upper and lower white laboratory coat sleeves were exposed during the procedure since the PPE gown she was wearing was short-sleeved. When Resident #7's first lateral side was completed, both staff put the resident in a supine position. Staff U checked the PEG tube dressing by un-velcroing the abdominal binder. With the same gloves she was using for adjusting her PPE gown, she touched the abdominal dressing around PEG tube, and stated it was dated, dry and intact. She then put the abdominal binder back on with help from Staff D who also did not change her gloves after performing perineal care on one side. Staff D performed perineal care on the anterior and front area of the perineum, then both staff turned the resident facing up. Staff D was touching the resident's right shoulder, and right lateral thigh, for position stabilization using the same gloves she used for perineal care. Staff U's PPE gown fell down to her chest again and with the same gloves, she adjusted the PPE gown to put it towards her neck area. She then performed adjustment of the brief after performing perineal care on the remaining side, while her PPE gown kept going down to her chest and abdominal area. Staff U readjusted her gown several times while using the same gloves and while performing the back perineal care. When Staff U was asked why she did not don on a long sleeve PPE gown, to make sure her laboratory coat's white sleeves were covered during the gastrostomy and perineal care observation, she did not respond. When asked why she did not tie the neck part of the gown to keep it from falling down to her chest and middle abdominal area while providing the perineal care and gastrostomy check care, she did not respond. When Staff D was asked why she did not don on PPE gown during the gastrostomy check and perineal care, she responded, It was too hot. 2. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included Fracture of the neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Malignant Neoplasm of Right Breast. the Review of admission MDS, dated [DATE], under Section C, for BIMS revealed a score of 15 indicating Resident #16 had no cognitive impairment. Electronic review of physician orders dated 08/26/25 did not include an EBP order, but documented the following: Levothyroxine Sodium tablet 75 mcg (microgram); Give 1 tablet by mouth in the evening for low thyroid hormone. [NAME] Wound Consult for sacrum stage 1 versus moisture associated damage (MASD,) Left Hip, status post Open Reduction Internal Fixation (ORIF), with Acticoat dressing. Do not remove, however re-enforce if site is draining, notify surgeon for orders, every shift. Electronic record review of the nursing care plan did not include focus and interventions for post-surgical wound regarding the left hip wound and for EBP. During a medication administration observation on 09/15/25 at 4:02 PM, Staff L, Registered Nurse (RN), stated she would administer the medication to Resident #16. Upon entering resident's room, when this staff was about to perform hand washing, there were pillows on top of the sink inside the resident's room, and there were no paper towels. She stated she must wash her hands in the resident's bathroom. When Staff L performed hand washing inside Resident #16's bathroom, she was observed to use the same paper towel for drying her hands and for turning off the faucet on 09/15/25 at 4:08 PM. Staff L administered the medication to Resident #16, and then performed hand washing using soap and water inside the resident's room (a housekeeping staff had filled the paper towel dispenser) but turned off the faucet using the same paper towel she used to dry her hands. 3. Review of the facility policy titled Infection Prevention and Control Program revised on 05/2025 documented .Linens: laundry and direct care staff shall handle, store, process and transport linens to prevent spread of infection . On 09/16/25 at 4:05 PM, a tour to the facility's laundry started. Observation revealed Staff J, Laundry Aide, in the clean area removing clean linens and gowns from the dryer without wearing a gown. Further observation revealed clean linens were hanging outside a full bin. An interview was conducted with Staff J who stated she picks up the laundry from the resident's units, puts a gown on when sorting the dirty clothes, puts them in a washer and when done she removes the gown and leave it in the dirty room. Staff J stated she removes the clean linens from the dryer and places them in a bin and brings them to the folding area. On 09/17/25 at 2:18 PM, a second observation to the laundry was conducted. A joint interview was conducted in the clean area with Staff K, Laundry Aide, and the Housekeeping Supervisor. Staff K was observed wearing a gown and stated she had to use a gown when folding because the linens are clean and did not want to touch them with her uniform. The Housekeeping Supervisor was apprised that Staff J was not wearing a gown while removing clean linens from the dryer and that the clean linens were observed hanging down from a full bin. The Housekeeping Supervisor stated they (staff) all know that they have to wear a gown when removing and folding clean linens and clothes. Staff K stated all clean linens had to be inside the bin and not touching the outside. 5. Review of the facility's policy, 'Hand Hygiene', with an implementation date of 01/2025 and a revision date of 08/2025, documented, in part: 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review for Resident #9 revealed an admission date of 06/25/24. According to the resident's most recent complete assessment, a Medicare 5-day Minimum Data Set (MDS), Resident #9 had a BIMS score of 07, indicating a severe cognitive impairment. Resident #9's diagnoses at the time of the admission included: Parkinsonism, Hypertension, Neurogenic bladder, Hyperlipidemia, Hip fracture, Chronic Lung Disease, Respiratory Failure, Metabolic Encephalopathy, Lack of coordination, displacement of gastrointestinal prosthesis, Chronic respiratory failure with hypoxia, and Muscle weakness. Resident #9's orders included: Enteral Feed - five times a day JEVITY CARTON 1.5, 237ml, VIA PEG TUBE - 07/10/25 It was determined that Resident #9 could not be interviewed as resident did not respond to being greeted by name, despite multiple attempts to interact with the resident. During an observation of Resident #9 being provided a bolus feeding via Peg Tube, on 0916/25 at 11:14 AM, by Staff A, LPN, Staff A donned a pair of clean single use gloves and elevated the resident's head of the bed and then retrieved supplies from a drawer in the nightstand. Staff A then removed the gloves and donned a new pair of single use gloves and did not perform hand hygiene while changing the gloves. It was noted that the glove on the right hand of the LPN was torn up to the palm of the hand. Staff A continued the bolus feeding and did not change the gloves or perform hand hygiene During an interview with Staff A, on 09/17/25 8:16 AM, the LPN acknowledged that the glove was torn and that she should not have continued without removing the gloves, performing hand hygiene and donning a new pair of single use gloves

Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 of 60 rooms (room [ROOM NUMBER]-B, #102-B, 105-B, #110, #116, #120, #206, #210, #212, and #214). The findings included:The findings included: 1. On 09/15/25 at 10:25 AM, observation revealed a telephone on top of the nightstand of an occupied resident room [ROOM NUMBER]-B with accumulation of residue on the dialing pad and the handset. 2. On 09/15/25 at 10:40 AM, observation revealed a telephone on top of the nightstand of an occupied resident room [ROOM NUMBER]-B with accumulation of residue on the dialing pad and a loose Air Conditioning cover. 3. On 09/15/25 at 10:42 AM, observation revealed a telephone on top of the nightstand of an occupied resident room [ROOM NUMBER]-B with accumulation of residue on the handset. 4. On 09/15/25 at 11:26 AM, observation revealed a resident's bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] with a missing emergency cord/string for the residents to pull and call for help. The bathroom was used by 3 of 4 residents in room [ROOM NUMBER] and #112. 5. On 09/15/25 at 11:26 AM, observation revealed resident's room [ROOM NUMBER]'s bathroom bedside commode with a rusted part near the toilet seat. 6. On 09/15/25 at 10:56 AM, observation revealed residents' room [ROOM NUMBER] with a loose Air Conditioning cover. On 09/16/25 at 2:41 PM, a tour to the East wing with the Director of Maintenance (DOM) was conducted. The DOM stated they replaced room [ROOM NUMBER] bedside commode after the surveyor tour and that he did not know about the missing emergency call light cord. The DOM stated the Air Conditioning (AC) covers are removable and they clip on top but not on the bottom. A side-by-side observation of room [ROOM NUMBER]'s AC cover was conducted with the DOM who stated the cover left top clip was broken and he would replace it. On 09/16/25 at 4:49 PM, a joint interview was conducted with the Housekeeping Supervisor, the Administrator and the DOM. The Housekeeping supervisor and the DOM stated the staff are supposed to clean the resident's phone every day. 7. On 09/15/25 at 5:08 PM, an observation revealed residents' room [ROOM NUMBER] had black and white residue on the slats of the vents and inside the vents of wall mounted air conditioner (AC) units. Photographic Evidence Obtained. 8. On 09/15/25 at 4:18 PM, an observation revealed residents' room [ROOM NUMBER] had black and white residue on the slats of the vents and inside the vents of wall mounted air conditioner (AC) units. Photographic Evidence Obtained. 9. On 09/15/25 at 3:50 PM, an observation revealed residents' room [ROOM NUMBER] had black and white residue on the slats of the vents and inside the vents of wall mounted air conditioner (AC) units. Photographic Evidence Obtained. 10. On 09/15/25 at 4:03 PM, an observation revealed residents' room [ROOM NUMBER] had black and white residue on the slats of the vents and inside the vents of wall mounted air conditioner (AC) units. Photographic Evidence Obtained.

Based on observations, interviews, record review and the review of the facility policy, the facility failed to report a resident's unwitnessed fall with an injury of unknown source for 1 of 1 sAMPLED resident reviewed for Falls, Resident #77.The findings included:Review of the facility's policy titled Fall Prevention Program revised on 05/2025 documented .when any resident experience a fall, the facility will:.obtain witness statements in the case of injury.Review of the facility's policy titled Unexplained Injures revised on 05/2025 documented all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated.if the injury is of unknown source, reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. An injury should be classified as an injury of unknown source when both the following conditions are met: the source of injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of: the extent of the injury or the location of the injury.Review of the facility's policy titled Abuse, Neglect and Exploitation revised on 10/23/2024 documented .Identification of Abuse, Neglect and Exploitation.possible indicators of abuse include, but are not limited to:.physical injury of a resident, of unknown source.Investigation of Alleged Abuse, Neglect and Exploitation: provide complete and through documentation of the investigation.Reporting/Response:.reporting of alleged violations to .state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific time frame. Review of Resident #77's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's primary diagnosis on admission included Fracture of Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Syncope and Collapse, Dementia, Muscle Weakness, History of Falling, Anxiety Disorder, and Depression. The resident diagnosis of Fracture of Left Clavicle, Initial Encounter for Closed Fracture, was added to the diagnoses list on 08/15/25.Review of Resident #77's Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a Brief Interview for Mental State (BIMS) score of 3 indicating the resident had severe cognition impairment; and that he was dependent on staff for most of his activities of daily living.Review of Resident #77's Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a BIMS score of 4 indicating the resident had severe cognition impairment; and that he was dependent on staff for most of his activities of daily living. The assessment documented the resident had a major injury (bone fractures, joint dislocation.).Review of Resident #77's radiology results dated 08/11/25 of Portable Left shoulder X-rays documented Significant Findings Portable LEFT SHOULDER X-Ray Complete 2 or more views; Impression: Acute Distal Clavicle Fracture.Review of Resident #77's physician orders dated 08/19/25 documented Adaptive Equipment: Sling to Left Upper Arm when out of Bed every shift.Review of Resident #77's September 2025 Treatment Administration Record (TAR) documented Adaptive Equipment: Sling to Left Upper Arm when out of Bed every shift initialed as administered every shift from 09/01/25 thru 09/17/25.Review of Resident #77's care plan titled (Resident name) has impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia, Difficulty making decisions, Impaired decision making initiated on 08/18/25, revised on 08/26/25, included interventions in part as Observe / document/report any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.Review of the resident's care plan titled Resident is at risk for falls secondary to decreased mobility, functional decline, generalized weakness, use of assistive device, side effects of medications, DX (diagnosis) of Dementia, initiated on 07/14/25 had interventions to include in part to Instruct in use of call bell, two half side rails may be up for enhanced mobility, keep bed in low position.Review of the resident's care plan titled The resident has no injury, @ [at] risk for further falls d/t (due to) Unsteady gait, dementia, was initiated on 07/25/25 and revised on 09/02/25, as follows:07/14/25, Observed on floor in bedroom, no visible in juries.07/22/25, Observed sitting on floor next to bed- no injury.07/22/25, Observed next to bed on floor - no injuries.08/10/25, Observed sitting on floor next to bed- Left distal clavicle FX [fracture].08/31/25, Observed on Lt. [left] Side on floor by sink - No injury.The care plan interventions included in part to continue interventions on the at-risk plan, floor mat as ordered, for no apparent acute injury, determine and address causative factors of the fall, hipsters at all times, maintain NWB (no weight bearing) status as ordered.scoop mattress, sling to left arm as ordered. Review of Resident #77's nurse's note dated 08/10/25 timed 8:45 PM documented, During hourly rounds pt [patient] observed sitting on the floor mat near the wheelchair facing forward. Pt reports shoulder pain 3/10. When asked what happened pt stated I don't know I messed up.Skin tear noted to LT elbow, site cleansed with NS [normal saline] and Island dressing applied. MD [physician] notified and new orders received. The review revealed no other nursing notes documenting hourly rounds. Review of Resident #77's nurse's note dated 08/11/25 timed 2:08 PM documented, Patient is being sent to [local hospital name] due to X-Ray imaging reveals a left clavicle fracture post fall.Review of the Certified Nursing Assistant (CNA) tasks record for Resident #77 from 08/20/25 to 08/22/25 documented the resident had behaviors of physically aggressive, kicking other, grabbing others .Review of Resident #77's local hospital report dated 08/11/25 revealed reason for treatment: Syncope, Non Displaced Fracture of L.the patient is oriented to person. He is unable to provide history.He does complain of pain in the left shoulder. Per ED (emergency department) notes, he does not recall the circumstances of his fall but believes that he did hit his head.Assessment: past medical history of dementia.presenting to ED.for evaluation after an unwitnessed fall earlier today.he is unable to provide history.patient unable to quantify pain but was observed touching his L shoulder and saying ouch. Patient with increased confusion.X-Ray interpretation: X-rays reviewed shows a left distal clavicle minimally displaced.left upper extremity in sling. Tenderness to palpation distal clavicle. Pain with range of motion left shoulder passively.On 09/15/25 at 10:50 AM, observation revealed Resident #77 sitting in a wheelchair and wearing a left arm sling. Attempted to interview the resident but he had difficulty finding words.On 09/17/25 at 11:32 AM, an interview was conducted with the Director of Nursing / Risk Manager (DON) who stated Resident #77 had an unwitnessed fall on 08/10/25 at 8:45 PM. The DON stated the resident had a BIMS score of 4 and was originally admitted for a Right hip fracture after a fall. The DON stated the resident was admitted to a room closest to the nurse station due to a history of falls. The DON stated on the day of the fall, the resident had a scoop mattress and floor mats in place, on rounds the resident was observed sitting on floor mats next to his bed, complained left shoulder pain, the nurse asked what happened and he responded he did not know, skin tear to his left elbow was observed, was and medicated with Tylenol for pain, notified the physician who ordered a stat X-rays of left shoulder and left wrist. The DON stated on 08/11/25 results of the X-rays were non-displaced fracture of left clavicle; the physician was notified and ordered the resident to be transferred to hospital for evaluation. The DON stated the hospital results read suspected non-displayed fracture of the left distal clavicle and he was admitted for syncope, swallowing issues and non-displaced fracture. The DON stated the interventions in place did not cause the fall and added the bed was in low position, the call light was within reach and floor mats in place. The DON was asked if the resident had any behaviors and stated the resident gets frustrated when he can't get words out, has a good appetite, and no swallowing issues. The DON added the resident keeps removing the sling from his left arm and had no complaints of pain. The DON stated another X-rays of left shoulder was made on 08/31/25 and showed no acute fracture or dislocation of left shoulder. The DON was asked if a report was submitted to the Agency of Health Care Administration (AHCA) for this unwitnessed fall and fracture of unknown source and replied she did not report it to AHCA because it did not meet criteria for reporting. The DON was asked to submit the reporting criteria. On 09/17/25 at 12:14 PM, the DON stated that the criteria were that they have rounding, and as soon as they noticed Resident #77 was in the floor, they notified the provider, added the facility was following the POC (plan of care) that is why it was not reported. The DON was asked if she had completed an investigation and stated she did. The DON was asked to submit staff statements and stated she reviewed the nurse progress note and spoke with the nurse and her statement matched her progress note. The DON added she spoke to the resident's roommate at the time, and he was not interviewable. The DON was asked if she interviewed any other staff and stated she did not interview any other staff on duty the day of the fall. The DON stated she ruled out abuse because the staff was rounding on the resident and there was not any type of abuse. On 09/17/25 at 3:10 PM, a joint interview was conducted with the DON and the Administrator. The Administrator stated that they had interventions in place, and the staff was rounding and supervising every 1 hour, and the fall did not require reporting. The Administrator was asked to submit hourly documentation and replied it is documented on her note. The DON stated Resident #77 complained of pain to his shoulder status post the fall event, and added the pain was not there before. The DON stated the resident was not to get out of bed by himself and complained of pain after been observed on the floor. The DON was asked where Resident #77 was prior to the fall and stated 'in bed'. On 09/17/25 at 3:45 PM, an interview was conducted with Staff T, Licensed Practical Nurse (LPN) who stated Resident #77 was pleasantly confused and tries to get out of bed. The LPN stated the resident had a fall in the facility and had a left clavicle fracture.On 09/17/25 at 4:19 PM, observation revealed Resident #77 wearing a left arm sling, sitting in wheelchair in the facility's activities / recreation room. The resident was asked what he was doing and was not able to respond. An interview was conducted with Staff V, Activity Assistant, who stated Resident #77 was watching the TV, added he loves music, he attends activities likes coffee, trivia, loves rock and roll and stands up to dance. Staff V stated the resident gets angry, agitated and swing at the staff, they redirected him and if not able to, they call nursing. On 09/18/25 at 8:37 AM, a telephone call interview was conducted with Staff I, Certified Nursing Assistant (CNA), who stated she works 3 PM to 11:00 PM (3-11 shift) and was assigned to Resident #77 on 08/10/25. Staff I stated she left the resident sitting in the wheelchair, when on a break and informed Staff H, LPN so she could keep an eye on him. Staff I stated on her returned from break was told by Staff H that the resident fell. Staff I stated Resident #77 likes to stand up, added she checked on him and found no bruises, and he was not complaining of pain to her after the fall. Staff I stated the resident was not able to use the call light. On 09/18/25 at 9:13 AM, a telephone call interview was made to Staff H, LPN, who stated she was familiar with Resident #77 and was assigned to him on 08/10/25. Staff H stated when she was rounding, the resident was facing forward sitting between the wheelchair and the floor mat and had assisted the resident back to bed with other staff help. Staff H stated the resident was telling her that his shoulder hurt, and he never complained of pain. Staff H added it was a new onset of pain and after a fall, the policy was to notify the doctor, the doctor ordered X-rays that were done the following day and results revealed he had a fracture. Staff H stated the fall was unwitnessed, and the resident told her he did not know what happened, that he got messed up. Staff H stated Resident #77 had periods of confusion, some type of aphasia, but when he really needs something, they were able to understand his needs at time. Staff H stated she was not sure what the DON does with the report, but she reported the resident's fall on the 24-hour report.

Based on observation, interviews and the facility policy review, the facility failed to initiate and conduct a complete and thorough investigation to an unwitnessed fall resulting in an injury of unknown source of origin for 1 of 1 sampled resident for Falls (Resident #77). The findings included:Review of the facility's policy titled Fall Prevention Program revised on 05/2025 documented .when any resident experiences a fall, the facility will.obtain witness statements in the case of injury.Review of the facility's policy titled Unexplained Injures revised on 05/2025 documented all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated.if the injury is of unknown source, reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. An injury should be classified as an injury of unknown source when both the following conditions are met: the source of injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of . the extent of the injury or the location of the injury.Review of the facility's policy titled Abuse, Neglect and Exploitation revised on 10/23/2024 documented .Identification of Abuse, Neglect and Exploitation.possible indicators of abuse include, but are not limited to:.physical injury of a resident, of unknown source.Investigation of Alleged Abuse, Neglect and Exploitation: provide complete and through documentation of the investigation.Reporting/Response:.reporting of alleged violations to .state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific time frame.Review of Resident #77's clinical record documented an admission on [DATE] with a readmission on [DATE]. Resident's primary diagnosis on admission Fracture of Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; other diagnoses included in part, Syncope and Collapse, Unspecified Dementia, Muscle Weakness, History of Falling, Anxiety Disorder, and Depression. Resident diagnosis of Fracture of Unspecified Part of Left Clavicle, Initial Encounter for Closed Fracture added to the diagnoses list on 08/15/25.Review of Resident #77's Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a BIMS score of 3 indicating the resident had severe cognition impairment and that he was dependent on staff for most of his activities of daily living.Review of Resident #77's Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a BIMS score of 4 indicating the resident had severe cognition impairment and that he was dependent on staff for most of his activities of daily living. The assessment documented the resident had a major injury (bone fractures, joint dislocation.). Review of Resident #77's radiology results dated 08/11/25 of Portable Left shoulder X-rays documented SIGNIFICANT FINDINGS Portable LEFT SHOULDER X-Ray Complete 2 or more views; Impression: Acute Distal Clavicle Fracture.Review of Resident #77's physician orders dated 08/19/25 documented Adaptive Equipment: Sling to Left Upper Arm when out of Bed every shift.Review of Resident #77's September 2025 Treatment Administration Record (TAR) documented Adaptive Equipment: Sling to Left Upper Arm when out of Bed every shift initialed as administered every shift from 09/01/25 thru 09/17/25.Review of Resident #77's care plan titled (Resident name) has impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia, Difficulty making decisions, Impaired decision making initiated on 08/18/25 revised on 08/26/25 included interventions in part as Observe/document/report any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.*Resident care plan titled Resident is at risk for falls secondary to decreased mobility, functional decline, generalized weakness, use of assistive device, side effects of medications, DX (diagnosis) of Dementia initiated on 07/14/25 with interventions to include in part as to Instruct in use of call bell, two half side rails may be up for enhanced mobility, keep bed in low position.* Resident care plan titled The resident has no injury, @ risk for further falls d/t (due to) Unsteady gait, dementia initiated on 07/25/25 revised on 09/02/25.7/14/25 Observed on floor in bedroom, no visible in juries.7/22/25- Observed sitting on floor next to bed- no injury7/22/25- Observed next to bed on floor- no injuries8/10/25- Observed sitting on floor next to bed- Left distal clavicle FX.8/31/25- Observed on Lt. Side on floor by sink- No injuryThe care plan interventions included in part continue interventions on the at-risk plan, floor mat as ordered, for no apparent acute injury, determine and address causative factors of the fall, hipsters at all times, maintain NWB (no weight bearing) status as ordered.scoop mattress, sling to left arm as ordered. Review of Resident #77's nurse note dated 08/10/25 timed 8:45 PM documented During hourly rounds pt observed sitting on the floor mat near the wheelchair facing forward. Pt reports shoulder pain 3/10. When asked what happened pt stated I don't know I messed up.Skin tear noted to LT elbow, site cleansed with NS and Island dressing applied. MD notified and new orders received. The review revealed no other nursing notes documenting hourly rounds. Review of Resident #77's nurse note dated 08/11/25 timed 2:08 PM documented Patient is being sent to (local hospital name) due to X-Ray imaging reveals a left clavicle fracture post fall.Review of Resident #77's local hospital report dated 08/11/25 revealed reason for treatment: Syncope, Non-Displaced Fracture of L .the patient is oriented to person. He is unable to provide history.He does complain of pain in the left shoulder.Per ED (emergency department), he does not recall the circumstances of his fall but believes that he did hit his head.Assessment: past medical history of dementia.presenting to ED.for evaluation after an unwitnessed fall earlier today.he is unable to provide history.patient unable to quantify pain but was observed touching his L shoulder and saying ouch. Patient with increased confusion.X-Ray interpretation: X-rays reviewed shows a left distal clavicle minimally displaced.left upper extremity in sling. Tenderness to palpation distal clavicle. Pain with range of motion left shoulder passively.On 09/15/25 at 10:50 AM, observation revealed Resident #77 sitting in a wheelchair and wearing a left arm sling. Attempted to interview the resident but he had difficulty finding words.On 09/17/25 at 11:32 AM, an interview was conducted with the Director of Nursing/Risk Manager (DON) who stated Resident #77 had an unwitnessed fall on 08/10/25 at 8:45 PM, added the resident had a BIMS score of 4, and was originally admitted for a Right hip fracture after a fall. The DON stated the resident was admitted to a room closest to the nurse station due to a history of falls. The DON stated on the day of the fall the resident had a scoop mattress and floor mats in place, on rounds the resident was observed sitting on floor mats next to his bed, complained left shoulder pain, place, the nurse asked what happened and he responded he did not know, skin tear to his left elbow was observed, was medicated with Tylenol for pain, notified the physician who ordered a stat X-rays of left shoulder and left wrist. The DON stated on 08/11/25 results of the X-rays were non-displaced fracture of left clavicle; the physician was notified and ordered to transfer to hospital for evaluation. The DON stated the hospital results read suspected non-displayed fracture of the left distal clavicle and was admitted for syncope, swallowing issues and non-displaced fracture. The DON stated the interventions in place did not cause the fall and added the bed was in low position, the call light withing reach and floor mats in place. The DON was asked if she completed a thorough investigation of Resident #77's unwitnessed fall with a fracture of unknow source origin and replied she did. The DON was asked to submit staff statements and stated she reviewed the nurse progress note and spoke with the nurse and her statement matched her progress note. The DON added she spoke to the resident's roommate at the time, and he was not interviewable. The DON was asked if she interviewed the resident's CNA assigned and stated she did not interview any other staff on duty the day of the fall. The DON stated she ruled out abuse because the staff was rounding on the resident and there was not any type of abuse.On 09/18/25 at 8:37 AM, a telephone call interview was conducted with Staff I, CNA, who stated she works 3-11:00 PM shift and was assigned to Resident #77 on 08/10/25. Staff I stated she left the resident sitting in the wheelchair, when on a break and informed Staff H, LPN so she could keep an eye on him. Staff I stated on her returned from break was told by Staff H that the resident fell. Staff I stated Resident #77 likes to stand up, added she checked on him and found no bruises, and he was not complaining of pain to her after the fall. Staff I the resident was not able to use the call light. On 09/18/25 at 9:13 AM, a telephone call interview was made to Staff H, LPN, who stated she was familiar with Resident #77 and was assigned to him on 08/10/25. Staff H stated when she was rounding, the resident was facing forward sitting between the wheelchair and the floor mat, assisted the resident back to bed with other staff help. Staff H stated the resident was telling her that his shoulder hurt, and he never complained of pain. Staff H added it was a new onset of pain and after a fall, the policy was to notify the doctor, the doctor ordered X-rays that were done the following day and results revealed he had a fracture. Staff H stated the fall was unwitnessed, and the resident told her he did not know what happened, that he got messed up. Staff H stated Resident #77 had periods of confusion, some type of aphasia.

Based on observations, interviews and record reviews, the facility failed to follow physician orders for weekly weight monitoring for 1 of 5 sampled residents reviewed for respiratory care, Resident #34. Based on observations, interviews, and record reviews, the facility failed to follow the professional standards of nursing practice for not following physician orders by ensuring that blood pressure and heart rate were monitored before the administration of a beta blocker medication for 1 of 6 medication administration reviews, affecting Resident #100; and failed to follow their own policy by ensuring the right dosage and right route based on the six rights of medication administration were followed for 1 of 5 unnecessary medication reviews, affecting Resident #7. The findings included: 1. Review of the American Heart Association, individuals with heart failure monitor their daily weight to assess fluid retention and manage edema effectively. Here are the guidelines for daily weight measurement: Weigh daily: Take weight at the same time each day, preferably after waking up, after using the restroom, and before consuming any food or beverage. Dry weight measurement: Ensure wearing the same clothes to get an accurate dry weight. Weight tracking: Track weight changes over time, as even a small increase can indicate fluid retention Record review documented Resident #34 was admitted to the facility with diagnoses that included Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Generalized Edema, Primary Hypertension, Malignant Neoplasm of the Colon, Acute Kidney Failure and Congestive Heart Failure. An electronic review of recent Minimum Data Set (MDS) assessment, under Section C of the Brief Interview for Mental Status (BIMS), revealed a score of 14, indicating Resident #34 had no cognitive impairment. Review of physician orders revealed the following: On 08/13/25, it documented, house diabetic, no added salt, regular texture and thin consistency diet, weekly weight, encourage to elevate head of bed while in bed to assist with breathing and prevent episodes of shortness of breath when lying flat, and furosemide oral tablet, 80 mg (milligram), two (2) times a day, for Congestive Heart Failure.On 09/02/25, it documented to measure abdominal girth daily. An interview was conducted with Resident #34 on 09/16/25 at 11:52AM, who stated he does not want to have a bigger stomach because it makes his breathing harder, thus he did not want to eat more lunch. An electronic review of September 2025 Medication Administration Record (MAR) revealed that on 09/09/25, on 09/11/25, 09/15/25, and 09/16/25, there was no recorded measurement of the abdominal girth, indicating the physician order was not followed. An additional electronic review of weights documented that Resident #34's weights were recorded on 07/30/25, 08/06/25, 08/21/25 and 09/05/25, revealing the physician order for weekly weights was not followed, as evidenced by missing weights on weeks of 08/13/25, 08/27/25, 09/03/25, and 09/10/25. An interview was conducted with the Director of Nursing (DON) on 09/18/25 at 1:30 PM, who was asked if nurses follow the physician orders regarding medications, oxygen therapy and weights, she responded, Nurses follow the physician orders. If they are not clear, the physician is notified, and verification is obtained. An interview was conducted with Staff X, Registered Nurse (RN), on 09/17/25 at 11: 45 AM, who stated that Nurses always follow the physician orders regarding resident's medication and treatment. Nurses also follow the physician order regarding measuring vital signs, daily weights monitoring, and behavior monitoring. If we have questions and orders are not clear, we call the physician to verify the correct order. 2. Record review of facility policy titled, Medication Administration, implemented on 1/2025, documented the following: Obtain and record vital signs, when applicable (8) . Ensure the two rights of the six rights of medications administration are followed (10): b. right drug d. right routeRecord review documented Resident #100 was admitted to the facility on [DATE] with diagnoses that included Essential Primary Hypertension, Sepsis, Cellulitis of the Groin, and Chronic Obstructive Pulmonary Disease. Review of most recent Minimum Data Set (MDS) assessment under Section C of the Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating Resident #100 had no cognitive impairment. Electronic record review of physician orders dated 08/02/25 documented vital signs (skilled) every shift. Another physician orders dated 08/03/25 documented Losartan Potassium oral tablet, 100 mg (milligram) for Hypertension (HTN), give 1 (one) tablet by mouth in the morning. A medication administration observation was conducted on 09/16/25 at 8:45 AM with Staff D, Licensed Practical Nurse (LPN), who stated she would administer Losartan Potassium for Resident #100. Staff D did not state that she took the resident's vital signs such as the blood pressure and the heart rate (HR). Staff D administered Losartan Potassium 100 mg by mouth without first obtaining the resident's BP and HR. Electronic record review of the blood pressures (BP) in Point Click Care (PCC) did not include any documentation of the morning blood pressure for this resident on 09/16/25 at 8:28 AM. The last documented blood pressure was on 09/15/25 at 9:00 PM.An interview was conducted with Staff T, LPN, on 09/17/25 at 9:35 AM, who when asked why she needed to take and monitor the resident's vital signs before administering BP medications, responded that it is standard practice. She added that she takes the vital signs 10 minutes before administering BP medications and she would take it again after the BP medication was administered. An interview conducted with Staff N, Registered Nurse (RN) on 09/17/25 at 4:00 PM, who when asked what the nursing professional standards were before administering Losartan Potassium, responded, Vital signs must be monitored first. The vital signs must include the residents' BP and HR. The vital signs must be monitored before and after Losartan Potassium administration. She added that she usually takes the vital signs 30 minutes before and thirty minutes after Losartan Potassium and any beta blockers medications. 3. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with Hypoxia, Traumatic Subdural Hemorrhage with Loss of Consciousness, Diverticulosis of the Large Intestine without Perforation or Abscess, and Dementia. Review of the most recent MDS under Section C revealed a BIMS score of 00, indicating severely impaired cognitive function.Electronic review of the physician order dated 03/09/25 at 7:52 PM revealed an order for Quetiapine Fumarate tablet 25 mg, give 0.5 tablet via PEG tube at bedtime for psychosis (give 12.5 mg).Additional review of an order created by a Speech Therapist on 04/15/25 and signed by a physician on 04/19/25 revealed nothing by mouth [NPO] texture, and NPO consistency, pleasure food diet type. Electronic review of orders dated 09/12/25 at 9:05 PM revealed an order for enteral feed two times a day through enteral pump feeding: Administer Glucerna 1.2 via PEG (percutaneous endoscopic gastrostomy) pump, rate: 55 ml (milliliter)/per hour for 21 hours per day to provide 1155 ml and 1386 calories for 24 hours. Pump is on at 10:00 AM and off at 7:00 PM.Further review of the physician orders dated 09/12/25 documented Quetiapine Fumarate oral tablet 25 mg (Quetiapine Fumarate); Give 1 tablet by mouth at bedtime for restlessness and agitation.Review of Medication Administration Record (MAR) for September 2025 revealed that on 09/12/25 Quetiapine Fumarate 25 mg by mouth was administered by Staff N, LPN, at 9 PM; and that Seroquel 25 mg was also administered via PEG on 09/12/25 at 9 PM by Staff N.An interview was conducted with Staff X, RN, on 09/18/25 at 11:50 AM, who was asked how she would verifies that medications were administered to Resident #7 in the MAR. She responded that there would be a check mark and nurses' initials parallel to the medication box aligned with the date. When she was shown the September 2025 MAR to verify the administration of Quetiapine Fumarate and Seroquel at the same time by Staff N, she responded, Yes, the Quetiapine Fumarate was administered orally at 9:00 PM by Staff N, and the Seroquel was also administered through the PEG, at the same time by the same LPN. When she was asked about Quetiapine Fumarate and Seroquel, she responded, Seroquel is the brand name, while Quetiapine [Fumarate] is a generic name for Seroquel, but they have the same actions. She added that Resident #7 has been receiving medications through the PEG tube, and it was an error if a medication was administered by mouth and it would also be an error if both medications were administered at the same time.An interview was conducted with the Medical Director on 09/18/25 at 1:05 PM, who stated that since the resident is a new re-admission, he would continue to assess the resident. He stated that Resident #7 only receives medication by PEG, is on NPO diet status, and is receiving enteral feedings. When asked about his orders for Quetiapine 25 mg to be administered by mouth, and Seroquel 25 mg to be administered by PEG both at bedtime, he responded that Seroquel is the brand name for Quetiapine, and only one must be administered. It should be Quetiapine or Seroquel but not both of them at the same time. He added that no facility nurse called him to clarify the orders for Seroquel and Quetiapine. When asked if any nurse informed him that both medications were administered at the same time on 09/12/25 at bedtime, he responded, No, no nurse has informed me that both medications were received at the same time. He stated that since the resident had a PEG tube since before hospitalization, the oral route is not a valid order, and the staff should have informed him. The order was written in early September, and no one had clarified it with him. The Director of Nursing (DON) upon hearing this conversation, immediately discontinued the oral Quetiapine order in front of this surveyor on 09/18/2025 at 1:10 PM. An interview was conducted with the Director of Nursing (DON) on 09/18/25 at 1:10 PM, who was asked why there was an order for Quetiapine Fumarate 25 mg by mouth, when the resident had been on enteral feeding and on NPO status since March 2025. The DON did not initially respond but later added that she would change the order as soon as possible. When she was asked if the nurse had reported this incident regarding double dose medication administration by mouth and by PEG on 09/12/25, of the same type of medication, she did not respond. When she was asked if any nurse had written a progress note about monitoring Resident #7 after the double dose administration, and administration of medication by mouth, she did not respond.Review of the physician orders for 09/18/25 at 1:10 PM, documented Quetiapine Fumarate oral tablet 25 mg, give 1 tablet via PEG-tube at bedtime for restlessness and agitation. Further review of this order revealed it was created by the DON on 09/18/25 at 1:11 PM and was revised on 09/18/25 at 4:45 PM. Review of nursing progress notes from 09/12/25 until 09/13/25 revealed it did not document any nurse's monitoring of Resident #7 after the medication administration of Quetiapine 25 mg by mouth, together with the medication administration of Seroquel 25mg by PEG at the same time. ,

Based on observations, record reviews, policy reviews, and interviews, the facility failed to weigh a newly admitted resident weekly for 4 weeks in a row, for 1 of 4 sampled residents, Resident #105, reviewed for nutrition; and failed to implement interventions and monitoring to ensure adequate nutrition for 1 of 4 residents sampled residents, Resident #125, reviewed for Tube Feeding. The findings included: Review of the facility's policy on Weight Monitoring, last revised on 05/2025, documented, all new admissions were to be weighed weekly for the first 4 weeks post admission. Well known standards of protocol for long term care facilities include recording weekly weights for the first 4 weeks for all new admissions except when there is a medical order to weigh the resident more or less frequently. Record review revealed Resident #105 was admitted to the facility on [DATE]., with diagnoses that included Sequelae of Cerebral Infarction, Muscle Weakness, Oropharyngeal Dysphagia, Dementia, Anxiety Disorder, and Mild Protein-Calorie Malnutrition. The first recorded weight of Resident #105 entered into the medical records was 109 pounds (#), entered on 01/06/25. The second weight entered for Resident #105 was 82.4 pounds and entered on 01/24/25 at 10:49 AM. On 01/24/25 at 10:49 AM, 18 days after the initial weight was recorded, the Registered Dietician (RD) who entered the weight crossed out the weight entry 109 pounds (01/06/25), and added documentation that said, incorrect documentation. A progress note written by the RD on 01/24/25 at 10:50 AM noted that Resident #105 was to continue on weekly weights. The third recorded weight, 85 pounds on 02/12/25 was taken 19 days after the RD's progress note was posted. Resident #105 was not weighed on the second or the fourth week post her admission to the facility. An interview was conducted with the Licensed Dietitian (LD) on 09/17/25 at approximately 3:30 PM, who was asked how often new admission residents should be weighed, who stated ' new admissions should be weighed weekly for 4 weeks', and explained that if there was a significant change in the resident's weight he would request weekly weights, and if the weight was stable, he would request monthly weights for the resident. When the LD was asked to look at the recorded weights for Resident #105, he confirmed that Resident #105 wasn't weighed weekly on admission. Record review revealed that the first completed admission / Medicare – 5-Day assessment dated [DATE] showed that Resident #105 weighed 109 pounds. The Modification of admission / Medicare – 5-Day assessment dated [DATE] displayed the weight 82 pounds. An interview was conducted with the Minimum Data Set (MDS) Coordinator, Staff Y, who was asked to review the completed admission / Medicare-5 Day assessment dated [DATE]. When Staff Y was asked what weight was entered, she revealed that she submitted a second, Modification of Admission/Medicare – 5-Day assessment that was also dated 01/10/25. When asked what weight was entered on the modified MDS assessment, she answered 82 pounds was entered (that was rounded down from 82.4 pounds entered on 01/24/25). When asked if it was ok to enter a weight from 01/24/25 on an assessment dated [DATE], Staff Y answered no. According to the MDS 3.0 Resident Assessment Instrument Manual, the weight must be the most recent measure taken within the last 30 days. 2. Record review for Resident #125 revealed an admission date of 09/06/25. According to the resident's most recent assessment, a Nursing admission Assessment with a reference date of 09/06/25, Resident #125 was alert and oriented with cognition documented as 'intact'. Resident #125's diagnoses upon admission included: Hemiplegia and hemiparesis following cerebral infarction, Occlusion and stenosis of the right middle cerebral artery, hemiplegia affecting the left nondominant side, Facial weakness following cerebral infarction, Muscle weakness, Lack of coordination, Metabolic encephalopathy, Long term use of anticoagulants, Hyperlipidemia, Dysphagia, Gastro-Esophageal disease (GERD), chronic obstructive pulmonary disease (COPD), and Anemia. Review of Resident #125's physician orders included: a. House Diabetic, NAS diet, Minced & Moist (mechanical soft/ground) texture, thin consistency - for dysphagia – 09/08/25. b. Enteral Feed - two times a day JEVITY 1.5 CAL AT 75 ML/HR X 10 HOURS (1900-0500) VIA G-TUBE VIA KANGAROO OMNI PUMP – 09/06/25. It was noted that there was no order for the amount of the supplement that Resident #125 is to receive via the enteral feeding and no orders for monitoring the resident's weights. Review of Resident #125's Care plan for tube feeding documented :the resident requires tube feeding related to Dysphagia, Swallowing problem Date Initiated: 09/08/2025 Created on: 09/08/2025 The goals of the care plan were documented as: The resident will be free of aspiration through the review date. Date Initiated: 09/08/2025 Created on: 09/08/2025 Target Date: 12/07/2025. The resident will maintain adequate nutritional and hydration status aeb (as evidenced by) weight stable, no signs/symptoms of malnutrition or dehydration through review date. Date Initiated: 09/08/2025 Created on: 09/08/2025 Target Date: 12/07/2025 An admission Assessment, with a reference date of 09/06/25 documented in Section M, ADLs (Activities of Daily Living) / Functional devices, that the resident was independent for eating. A revision to the admission Assessment documented that Resident #125 required Partial / moderate assistance for eating. A Nutrition Assessment with a reference date of 09/15/25 documented, under: 4. Current appetite as fair. 5. Current food intake as fair 50-75%. 7. Impaired Swallowing/chewing difficulties – related to dysphagia diagnosis. 9. Meal Assistance – Extensive Assistance. Section C of the assessment documented that the resident was at risk for malnutrition – health related factors included: 6. Physical and Mental Functioning: - bedridden, inactive, total dependence, extensive or total assistance while eating, aspirates, tube feeding, TPN, mouth pain. 7. Risk for malnutrition – health related factors * Poor PO intake * Chronic disease 8. Risk for malnutrition – other contributing factors * Dependent with eating. A Nutrition / Dietary Note, dated 09/15/25 at 10:38, documented, Dietitian admission Assessment: . with a history of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, occlusion and stenosis of Right Middle cerebral artery, encounter for attention to gastrostomy, metabolic encephalopathy, long term (current) use of anticoagulants, Hyperlipidemia, dysphasia, GERD, COPD, Hypertension. Feeding ability: extensive assistance Diet: NAS/CCD, mech soft, thin consistency PO (oral) Intake: Mosty >50% PO intake per CNA documentation, sporadically documented between the ranges of 50-75% and >75%. Resident also receives Enteral feeding via G-tube: Jevity 1.5 @ 75 mL/hr (milliliters per hour) x10hrs. Summary: Resident is at risk for malnutrition related to dysphagia and extensive assistance needed with feeding as evidenced by MNA score of 8, history of cerebral infarction with hemiplegia/hemiparesis, and need for supplemental enteral nutrition to support adequate intake. Resident admitted s/p hospitalization r/t hemiplegia and hemiparesis following cerebral infarction. BMI WNL. No new nutrition intervention at this time. Goals: Maintain wt +/-4%, PO intake >75%, tolerance of tube feeding Recommend: Continue current POC (Plan of Care). RD/DTR available PRN (as needed) to monitor weight, skin, labs, PO intake. Review of Resident #125's ADL task worksheets since admission documented the following: - Resident #125 typically ate 51% to 100% of all meals. - Resident #125 required setup or cleanup assistance for meals. - Saff only documented 1-2 meals most days. An interview was conducted on 09/17/25 at 9:20 AM with Staff C, CNA, who when asked about the resident's ability to feed himself, Staff C replied, he feeds himself, I have to set it for him – open everything for him. Has not voiced that the tube feeding makes him nauseous. Staff C stated that Resident #125 typically ate Most of the food. An interview was conducted on 09/17/25 at 3:48 PM with the Licensed Dietitian (LD), who when asked about monitoring the resident for oral intake, the LD replied, I have requested them to record every meal (referred to ADL task worksheet). When asked about the discrepancies in the assessments that documented Resident #125's varying ability to feed himself, the LD replied, Based on tasks for eating that said setup assistance. It entails bringing the tray to the table and opening the containers. For the dependence and the enteral feeds, I was going by the orders for tube feeding to determine ability to feed himself. When asked about monitoring Resident #125's weights, the LD stated that Resident #125 should have been weighed within a couple of days of admission and weekly for the next four weeks. The LD acknowledged that the resident was not weighed until 6 days after being admitted and had not been weighed since. During a follow up interview, on 09/18/25 at 7:55 AM with Staff C, when asked about documenting Resident #125's oral intake, Staff C replied, most of the time he eats everything. I work with him 2-3 times a week. For breakfast and lunch, I document how much eaten. Documentation is based on the entire tray – fluids and supplements are separate.

Based on observations, interviews, and record reviews, the facility failed to follow their policy regarding oxygen therapy for 2 of 5 sampled residents reviewed for respiratory care, Resident #34 and Resident #37; failed to follow the professional standards of nursing practice by allowing a Certified Nurse Assistant (CNA) to administer and change the sterile water bottles use for oxygen humidification of oxygen concentrators for 3 of 5 sampled residents reviewed for respiratory care, Resident #34, Resident #109, Resident 107; and failed to ensure proper care and management of oxygen therapy equipment for 3 of 5 sampled residents reviewed for respiratory care, Resident #34, Resident #37, and Resident #109. The findings included: Review of a facility policy titled, Oxygen Administration, revised 04/09/25, documented the following: Oxygen is administered to residents who need it, consistent with professional standards of practice . Oxygen is administered under the orders of a physician . The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessments and orders .o Type of oxygen delivery systemo When to administer, such as continuous or intermittent and when to discontinueo Equipment setting for the prescribed flow rates Other infection control measures includeo Change oxygen tubing and mask/cannula weekly and as needed .o Change humidifier bottle when empty, every 72 hours . Use sterile water for humidification.o Keep delivery services covered in plastic bag when not in use. 1 1. Record review documented Resident #34 was admitted to the facility on [DATE] with diagnoses that included Pneumonia, Chronic Respiratory Failure with Hypercapnia, Pleural Effusion, and Chronic Kidney Disease Stage 3.Electronic review of recent Minimum Data Set (MDS) assessment, under Section C,, documented the Brief Interview for Mental Status (BIMS) revealed a score of 14, indicating Resident #34 had no cognitive impairment. Electronic review of the current and discontinued physician orders did not document oxygen therapy orders for Resident #34. Review of the Medication Administration Record (MAR) from 07/2025 until 09/2025 did not reveal any oxygen therapy documentation for Resident #34.An observation was conducted on 09/15/25 at 10:05 AM, of the oxygen concentrator beside Resident #34's bed. The concentrator was producing gurgling sounds. A closer observation revealed the oxygen concentrator was on, but Resident #34 was not present inside the room. A date of 09/12/25 was written on a hanging Ziploc bag. There was a square shaped sterile water bottle on the right side of the cylinder with a black ink date of 06/27/25 written on the top part. An observation conducted on 09/16/25 at 9:56 AM of the same oxygen concentrator revealed it remained located at the same location inside Resident #34's room. A closer observation revealed the sterile water solution bottle top was dated 06/27/25, indicating the assigned nurse for the resident did not check the date of the sterile water for humidification. An observation on 09/18/25 at 12:50 PM revealed the sterile water was still dated 06/27/25, indicating the resident had an oxygen concentrator complete with sterile water solution which was almost 3 months old, but with no physician order for oxygen therapy. An interview was conducted with Resident #34 on 09/15/25 at 12:45 PM, who was asked how often he uses the oxygen, and responded that he uses oxygen at night. When he was asked if he receives nebulizing treatment, he responded, I get them during the day and during the night. An interview was conducted with Staff S, Restorative Certified Nursing Assistant, on 09/16/25 at 11:45 AM, who stated she is responsible for changing all the oxygen concentrator's tubing, and nebulizing masks and tubing. She stated she is also responsible for changing all the sterile water solutions weekly for oxygen humidification for oxygen concentrators. She added that sterile water solution is changed weekly, and when the bottle is empty. An interview was conducted with Staff D, Licensed Practical Nurse (LPN) on 09/16/25 at 2:31 PM, who was providing a nebulizing treatment to Resident #34. She stated Resident #34 receives oxygen by nasal cannula when needed. She added, I do not remember the last time I provided oxygen to this resident during my morning shift, but the oxygen concentrator is kept inside the resident's room in case he needs it. When she was informed that the oxygen concentrator was turned on yesterday, even though the resident was not inside the room, she stated she did not know who left the oxygen on when the resident was not in the room. When she was asked if there was an order for oxygen for this resident, she responded, Yes. An interview was conducted with the Maintenance Director on 09/17/25 at 12:45 PM, who was asked how often he checks the oxygen concentrator and nebulizing equipment, and responded, The maintenance staff checks them monthly, but the nursing staff performs a weekly check. He added that the Maintenance staff ensures that both the external and the internal filters are clean, the electrical safety inspection is current with the posted and dated sticker on top of the of both the oxygen concentrator and the nebulizing equipment. He also stated that a clean filter has a black color and when it turned gray it is considered dirty. When he was asked if all the oxygen concentrators being used by all residents who needed oxygen have clean filters, he responded, I am sure. An interview was conducted with the Director of Nursing (DON) on 09/18/25 at 1:30 PM, who was asked about oxygen therapy, and responded All residents in this facility who have oxygen therapy must have physician orders. When she was asked if oxygen is used without a doctor's order, she responded, No.The DON added that the oxygen equipment and the nebulizing tubing, mask and accessories are changed weekly, and every Friday. She added that only one Restorative staff is responsible for changing all the oxygen therapy equipment and accessories inside the facility. She added that this staff also put sterile water bottle on all the oxygen concentrators that need them. She added that the facility does not have a policy to put an open date or any date tag on top of the sterile water. The DON stated that Staff S, Restorative CNA, changes the sterile water for humidification used for some oxygen concentrators in the facility. An interview was conducted with Staff N, Registered Nurse (RN), on 09/17/25 at 4:00 PM, who stated the nurse who is assigned to the resident is responsible for checking the oxygen and other nebulizing equipment and accessories. There is only one staff who checks them regularly, Staff S. She stated Staff S checks and changes the sterile water bottle for humidification and checks and changes the tubing and all accessories for both the oxygen concentrators and the nebulizing treatment machines. An interview was conducted with Staff U, Licensed Practical Nurse (LPN), on 09/18/25 at 11:08 AM, who stated Staff S, Restorative CNA, is responsible for weekly changing the sterile water used for humidification for oxygen concentrators, the nebulizing tubing, mask, other accessories and oxygen equipment, but the nurses must check them daily. 2. A record review documented Resident #37 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), and Atherosclerotic Heart Disease. Electronic record review of recent MDS dated [DATE], under Section C, revealed a BIMS score of 15, indicating Resident #37 had no cognitive impairment. Section O revealed this resident was receiving oxygen via nasal cannula at 2 liters, continuously every shift. Review of the September 2025 Medication Administration Record (MAR) revealed that oxygen was administered by staff nurses via nasal cannula at 2 liters per minute, with the documentation of oxygen saturation values every shift. The MAR revealed that the orders were carried as evidenced by the documented nurses' initials and check marks in the same line of oxygen therapy and date column. An interview was conducted with Staff X, RN, on 09/18/25 at 11:08 AM, who was asked how they verify that an order was carried out in MAR, and responded, Nurse's initials, and check marks are present in line with the date column, and the physician order. When asked if a physician order is needed for oxygen therapy, she responded, Yes, all treatment and therapy provided to residents must have physician orders.An observation was conducted on 09/15/25 at 10:50 AM, but the resident was not inside the room. On top of the bedside table was a nebulizing treatment machine, and on the floor was an oxygen concentrator. During another observation conducted on 09/16/25 at 3:00 PM, Resident #37 was sitting on a wheelchair with nasal cannula in both nares. The oxygen flow meter was on level 4, indicating Resident #37 was receiving oxygen at 4 liters per minute, which was 2 liters per minute above the physician order. When Resident #37 was asked about the oxygen at 4 liters per minute, she responded, she always gets 4 liters per minute because that level makes her breath easier. She added that the nurses keep the oxygen level at 4. 3. Records review documented Resident #109 was admitted to the facility on [DATE] with diagnoses that included COPD, Hypothyroidism, Displaced Bimalleolar Fracture of the Right Lower Leg, and Acute Embolism and Thrombosis of the Deep Veins of Lower Extremity. Electronic review of the quarterly MDS dated [DATE] under Section C, documented a BIMS score of 15 indicating Resident # 109 had no cognitive impairment. Section O documented a yes response to continuous oxygen therapy.Review of physician orders dated 02/12/25 documented oxygen via nasal canula at 2 liters, continuously every shift. Electronic record review of September 2025 MAR documented oxygen at 2 liters per minute, via nasal cannula, continuously. The oxygen saturation value was also documented every shift with the oxygen administration. An observation was conducted on 09/15/25 at 10:52 AM of oxygen concentrator-8 with inspected due date of 11/25, and with a clear plastic tubing, dated 09/12/25, and was located on the floor, on the left side of Resident #109's bed. The observation revealed that a filter was missing on the left side of oxygen concentrator. There was dark gray colored filter on the right side of the concentrator, indicating it was dirty. An observation on 09/16/25 at 10:35 AM revealed the oxygen concentrator was still missing a filter on the left side. During a second observation on 09/16/25 at 2:56 PM, the resident was not in the room, but the oxygen was turned on and was still with a missing filter on the left side, indicating the assigned nurses to the resident did not check the filter daily.An interview was conducted with the Director of Nursing (DON) on 09/18/25 at 1:08 PM, who was asked who is responsible for checking all the oxygen concentrators and nebulizing treatment machines in the facility, she responded, Nurses check them daily, but the responsibility of changing the oxygen tubing, and sterile water solution weekly, on Fridays, is done by Staff S, Restorative CNA. She added that this staff does not write dates on sterile water for oxygen concentrators, but only writes dates on the oxygen tubing, and also on plastic bags holding the oxygen tubing for oxygen concentrators and nebulizing machines. She added that Staff S writes the dates on plastic bags containing masks and accessories for all nebulizing treatment machines. 4. Record review documented Resident #107 was admitted to the facility on [DATE] with diagnoses that included Endocarditis, Chronic Respiratory Failure with Hypoxia, Metabolic Encephalopathy, and Bacteremia. Electronic review of the most recent MDS, dated [DATE] documented under Section C the BIMS score was 14 indicating Resident #107 had no cognitive impairment. Review of the MAR documented to change the suction tubing and Yankeur [part of the suction apparatus] every Wednesday, during 11 AM-7PM shift. It revealed that on 09/10/25 and 09/17/25, this order was carried through as indicated by check marks and nurse's initials. An observation was conducted on 09/15/25 at 9:53 AM of the suction machine located on top of the bedside table close to the resident bed and not enclosed in a plastic bag. There was also a nebulizing machine that was not contained in a plastic bag or protective covering. The resident stated the suction machine, close to her bed, occupied most of the top part of the bedside table, providing no rooms for the books she wants to read. An observation on 09/16/25 at 2:08 PM revealed the suction machine and the nebulizing machine were still on top of the bedside table. They were not enclosed in plastic bags or a container. The resident stated again that the suction machine, closer to her bed, occupied most of the top part of the bedside table, providing no rooms for the books she wants to read. An observation and interview on 09/17/25 at 10:00 AM revealed Resident #107 was still complaining about the machines, the lack of accessibility to her drawers and the lack of space on top of the bedside table. She stated that she told another staff, but the staff did not listen. An interview was conducted with Resident #107 on 09/15/25 at 2:53 PM, who stated the suction machine and the nebulizing machine occupied most of the spaces on top of the bedside table, making it impossible for her to put the books she wants to read. She added that she told staff, but no staff wanted to help her arrange the machines to make room for her books. The oxygen concentrator located directly in front of the bedside table drawers was observed to have a sterile water solution with a written date of 09/12/25. There was a plastic Ziploc bag hanging on a black dial above the flowmeter and written on it was Room [resident room #] and 09/12/25. The resident voiced she is unable to open the drawers because the oxygen concentrator was located directly in front of them. She added, I told staff several times, but they do not want to help me. I do not remember their names. An interview was conducted with Staff S, Restorative CNA, on 09/16/25 at 12:30 PM, who stated that she changes the sterile water for oxygen concentrators for Resident #34, Resident #37, Resident #109 and Resident #107. She added that she writes the date on top of the sterile water solution for oxygen humidification, indicating that the facility allows a CNA instead of a Nurse to change the sterile water for the humidification of oxygen flow from the concentrator. The CNA's statement also contradicted the DON statement that the facility does not write dates on the sterile water bottles or any medication used in the facility.

Based on observations, interviews, policy review, and record review, the facility failed to provide foods consistent with dietary orders for 2 of 11 residents who had physician orders for puree texture diets. The findings included: Review of the International Dysphagia Diet Standardization Initiative (IDDSI) described the pureed diet as food that falls off the spoon when tilted, requires no chewing, and has no lumps or stickiness. The IDDSI list of foods to avoid on the pureed diet included lumps in pureed food and crust that forms on food during cooking or after heating. Photographic Evidence Obtained. 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, and GERD (Gastroesophageal Reflux Disease) with Esophagitis. Review of the Minimum Data Set (MDS) assessment of 06/17/25, revealed the Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS assessment also showed that Resident #20 was dependent on assistance with feeding. Her diet order since 06/12/25 was for a regular diet with pureed texture foods, and thin consistency fluids.During an observation of the dinner meal on 09/16/25 at 5:19 PM, Resident #20 received assistance with feeding to eat her meal. The meal was observed to be lumpy stuffing. Photographic Evidence Obtained.2. Record review of Resident #10 revealed that she was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Aphasia, and Cerebral Infarction. Review of Section C of the MDS dated [DATE] revealed Resident #10 had a BIMS score of 12 indicating moderate cognitive impairment. The physician ordered diet order since 02/27/25 was for a regular diet with pureed texture foods, and honey thickened consistency fluids. During an observation of the dinner meal on 09/16/25 at 5:25 PM, Resident #10 fed herself from a meal plate that contained a scoop of lumpy stuffing. The color of the stuffing was medium brown with dark brown patches and a dark brown flat edge of crusty stuffing. Photographic Evidence Obtained. During an interview with the Director of Dietary Manager (DM) on 09/16/2025 at 5:53 PM in Resident #10's room, the DM stated the stuffing could have been improved if the cook added more gravy to make the stuffing moister. She said that the cook could have made the stuffing smoother. She also said that the texture was not uniform. She acknowledged the 2 different colors on the stuffing. The DM pointed to the dark brown, flat side of the stuffing and explained that the darker color resulted from the heat of the pan. The darker edge may have been closer to the pan.

Based on observations, interviews, and record review, the facility failed to provide showers per resident preferences for 2 of 2 sampled residents reviewed for showers (Resident #62 and 80). The findings included: Review of the facility policy, titled, Resident Showers, dated 04/22, revealed the following compliance guideline - Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 1. Resident #62 was admitted to the facility on [DATE]. Resident #62 had a medical history significant for a right femur fracture, high blood pressure, asthma, Parkinson's disease, prostate cancer, falls, depression, and dementia. An Admission Minimum Data Set (MDS), dated [DATE], documented Resident #62 had a Brief Interview of Mental Status (BIMS) score of 12, which indicates he had mild mental impairment. This MDS documented Resident #62 required extensive assistance of one staff member for personal hygiene (i.e., showering); and documented Resident #62 told the staff it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. Review of Resident #62's care plans, physician orders, and progress notes revealed there was no documentation for why Resident #62 had not received regular showers since his admission. During the initial tour of the facility and initial interview conducted on 02/27/23 at 9:35 AM, Resident #62 stated he had not received a shower since he had been at the facility. A review was conducted of the Certified Nursing Assistant (CNA) Task for Bathing for a 30-day look back period. It was documented on this task that Resident #62 received a shower on 02/10/23. This indicated Resident #62 had only received one shower in 21 days. A second interview was conducted with Resident #62 on 03/01/23 at 1:00 PM, who stated he had not received a shower since the initial discussion on 02/27/23. When asked if he remembered the staff asking on admission what his shower preferences were, he said he was pretty out of it when he was admitted and did not remember the staff asking about his shower preferences. He said since his admission to the facility, he had received one shower. 2. Resident #80 was admitted to the facility on [DATE]. Resident #80 had a medical history significant for a leg fracture, high blood pressure, heart failure, kidney failure, and diabetes. An Admission Minimum Data Set (MDS) was done on 02/18/23. This MDS documented Resident #80 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he was cognitively intact. This MDS documented Resident #80 required extensive assistance of one staff member for personal hygiene (i.e., showering); and that Resident #80 told the staff it was somewhat important for him to choose between a tub bath, shower, bed bath, or sponge bath. During the initial tour of the facility and initial interview conducted on 02/27/23 at 9:35 AM, Resident #80 stated he had not received a shower since he had been at the facility. Review of Resident #80's Care Plans, Physician Orders, and Progress Notes revealed there was no documentation for why Resident #80 had not received showers since his admission. A review was conducted of the Certified Nursing Assistant (CNA) Task for Bathing for a 30-day look back period. It was documented on this task that Resident #80 received a shower on 02/17/23 and 02/22/23. This indicated Resident #80 had only received two showers in 19 days. A second interview was conducted with Resident #80 on 03/01/23 at 1:00 PM, who stated he had not received a shower since the initial discussion on 02/27/23. When asked if he remembered the staff asking on admission what his shower preferences were, he said he was awake and oriented when he was admitted and did not remember the staff asking about his shower preferences. Resident #80 stated again that, since his admission to the facility, he had not received any showers. When told the staff had documented two showers, he stated he did not receive any showers. An interview was conducted with Staff A, CNA on 03/01/23 at 1:10 PM. When asked how the CNAs know which days each resident is supposed to receive a shower, Staff A showed the surveyor a Staffing Binder and stated the shower schedules are kept in there. She showed the surveyor a page which indicated each of the resident rooms and what days and times each resident is to receive a shower. Further review of this paper revealed Resident #80 was supposed to receive a shower on Wednesdays and Saturdays on the 7:00 AM to 3:00 PM shift. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 03/02/23 at 9:28 AM. When asked how the CNAs know when each resident is supposed to be showered, she stated it is pre-populated on the daily assignment sheets that are given to each CNA at the start of the shift. When asked if this means a resident receives a bed bath on the assigned day, she stated no, the residents receive a shower on the assigned days, not a bed bath.

Based on observations, interviews and record review, the facility failed to ensure the physician's orders were followed as ordered for 1 of 10 sampled residents (Resident #16) during medication administration observation review as evidenced by performing Resident #16's blood glucose test and administering insulin after a meal instead of before meal as per physician order. The findings included: Review of the facility's policy, titled, Blood Glucose Monitoring implemented on 04/22 documented, The facility will perform blood glucose monitoring as per physician's order . Review of Resident #16's clinical record documented an initial admission to the facility on [DATE] and a readmission on 12/27/21. The resident diagnoses included Acute Kidney Failure, Heart Failure, Anorexia and Type 2 Diabetes Mellitus. Review of Resident #16's Minimum Data Set (MDS) quarterly assessment, dated 12/31/22, documented a Brief Interview of the Mental Status (BIMS) score of 8, indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the nursing staff to complete her activities of daily living. Review of Resident #16's care plan, initiated on 01/23/19 with a revision date on 01/16/23, titled, Resident has Diabetes Mellitus, documented, 'Resident has Potential for signs and symptoms of hypoglycemia (low blood sugar level) /hyperglycemia (high blood sugar level). The care plan interventions included: Accu-checks (blood glucose testing) as ordered initiated on 01/23/19 .Administer medication as per order initiated on 01/23/19 .'. Review of Resident #16's physician order, dated 08/22/22, documented, Humalog KwikPen 100 unit/ML Solution pen-injector. Inject subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus .Inject as per sliding scale: if 201- 250 = 3 units; 251- 300 = 6 units; 301- 350 = 9 units; 351- 400 = 12 units, greater than 400 give 12 units and call MD. On 02/28/23 at 12:38 PM, observation revealed Resident #16 complained of pain and asked for a pain pill while Staff B, Licensed Practical, was in the resident's room administering Resident #16's roommate's medication. Observation revealed Resident #16 had her lunch tray on the table in front of her and stated she was done with lunch. Further observation revealed the resident ate two cups of yogurt and ate a small amount of mashed potatoes and a piece small of meat. Staff B, LPN stated she would check to see if the resident had an order for pain medication. Staff B proceeded to review Resident #16's electronic medication administration record. During the review, Staff B stated the resident was due for Insulin at 11:30 AM and added that she could give it one hour before or one hour after a meal. Staff B stated she was only 10 minutes behind the scheduled time. On 02/28/23 at 12:42 PM, observation revealed Staff B, LPN performed Resident #16's blood sugar/glucose testing. Staff B stated the resident blood sugar/glucose test results was 229 [mg/Dl] and needed 3 units of Insulin. At 12:43 PM, observation revealed Staff B administered 3 units of Humalog Pen Insulin to Resident #16 and two (2) Tylenol 325 milligrams for pain. On 02/28/23 at 2:10 PM, an interview was conducted with the facility's Consultant Pharmacist (CP). The CP was apprised Resident #16 had her 11:30 AM blood glucose test done and insulin administration during lunch time rather than before meals as per physician order. A side-by-side review of Resident #16's physician order, dated 08/22/22, for Humalog Insulin Pen with sliding scale coverage was conducted with the CP. The CP stated the blood glucose test should have been done before meals as ordered. On 02/28/23 3:20 PM, an interview was conducted with Staff B, LPN who stated that she got report that Resident #16 had BG (blood glucose) checks/test to be done. Staff B stated it was her second time coming to the facility and forgot that the resident needed a blood sugar test at 11:30 AM. On 03/01/23 at 9:16 AM, an interview was conducted with Staff C, LPN who acknowledged that Resident #16, blood sugar/glucose checks should have been done and the insulin administration before meals as per physician order. Staff C acknowledged Staff B did not follow physician's orders. On 03/02/23 at 11:21 AM, an interview was conducted with the facility's Director of Nursing (DON). The DON was apprised of Staff B not following physician orders for Resident #16's blood sugar/glucose testing. The DON stated Staff B did not do it intentionally and that it was an isolated incident. The DON was apprised that Staff B noticed that Resident #16 was due for a blood sugar check when she logged in into the resident's electronic medication administration record to check for pain medication as requested by the resident. On 03/02/23 at 12:20 PM, an interview was conducted with Staff D, LPN who stated residents' blood glucose testing are to be done before meals as per physician orders.

Based on observation, interview and record review, the facility failed to provide dignity during dining for 1 of 8 residents reviewed for dignity, Resident #57. Findings included: The facility's policy titled Promoting/Maintaining Resident dignity during Mealtimes, implemented 11/2017, documented, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. Under the heading titled Policy Explanation and Compliance Guidelines the policy documented: 1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes 5. All staff will be seated, if possible, while feeding a resident. Resident #57 was admitted on [DATE] and most recently readmitted on [DATE]. According to the resident's most recent complete assessment, a Significant Change Minimum Data Set (MDS), dated [DATE], Resident #57 had a Brief Interview for Mental Status (BIMS) score of 10, indicating that the resident's cognition was 'moderately impaired'. The MDS documented that the resident required 'Limited assistance' and 'one person physical assist' for eating and that the resident had 'impairment on one side' of upper extremity. Resident #57's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57's care plan, initiated on 01/13/21 and most recently revised on 11/05/21, documented, Resident requires assistance with all ALD's task performance R/T hx (related to history of ) hospitalization , weakness, abnormalities of gait and mobility. [CONDITION(S)], [CONDITION(S)], hx of [CONDITION(S)], dementia, [CONDITION(S)], s/o falls, [CONDITION(S)] reflux, [CONDITION(S)], [CONDITION(S)] , hx [CONDITION(S)], hx functional decline, diabetes, [CONDITION(S)], adjustment disorder with depressed mood. The goal of the care plan was documented as, Resident will be dressed, clean, dry, odor free and well groomed daily through the next review date with a target date of 01/01/22. Interventions to the care plan were documented as: * Assist resident with eating as needed. Monitor and documented % taken at each meal time. Encourage completion of meals. * Assist with all ADL tasks as needed. * Encourage resident to participate as much as tolerated. On 11/07/21 at 12:20 PM Staff A, CNA was observed standing over resident to the resident's left side of bed while feeding Resident #57. It was noted that there was a chair in the room next to the resident's left side of the head of bed and directly behind Staff A, that was not being used for any purpose during the observation. On 11/07/21 at 12:26 PM, Staff A was observed sitting in the chair at resident's left side of bed while feeding Resident #57. On 11/07/21 at 12:34 PM, Staff A was observed standing over Resident #57 while feeding and providing fluid, with the room chair directly behind Staff A. On 11/09/21 at 8:26 AM, Resident #57 was observed in bed with the head of bed elevated, drinking coffee with breakfast on over bed table in front of the resident, with no staff in room to provide assistance or cueing. Resident #57 was noted to have food particles on outer clothing and blanket. During an interview on 11/09/21 at 8:45 AM with the Rehab Manager, when asked for clarification of the MDS that documented that Resident #57 required 'limited assistance' and 'one person physical assist', the Rehab Manager replied that the need for 'limited assistance' and 'one person physical assist' was based on behaviors and that sometimes the resident would do very well with feeding himself. On 11/09/21 at 12:35 PM, Staff B, CNA, was observed standing to resident's right side of bed and feeding the resident lunch from the over bed table that was positioned on the same side of the bed, while standing over the resident. It was noted that the room chair was on the resident's left side of bed and was not being used for any other purpose. During an interview, on 11/09/21 at 12:50 PM, with Staff B, when asked about the facility's policy for feeding a resident, Staff B replied, We take the tray to them and we set them up and we feed them. The ones that can't eat, we feed them. We set up the tray, we put the tray across the table so that we are able to feed them. We sit. He is the way he is, we put the tray across and he said that he didn't want to eat, he ate everything. He loves his food. Resident #57 was not interviewable.

Based on observations, interviews, and record review, the facility failed to provide fingernail care for 1 of 1 resident reviewed for Activities of Daily Living (Resident #1). The findings included: Review of the facility's policy titled, Nail Care, dated October 2019, documented the following: Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. Review of the Duties & Responsibilities section of the Certified Nursing Aide Job Description documented the following: Gives hygienic care: bathing, assisting with cleaning teeth, back rubs, providing water to wash hands and face, nail care, combing hair. Review of the record showed that Resident #1 was readmitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status score of 15, which indicated that she was cognitively intact. Review of Section G of the MDS dated [DATE] documented that Resident #1 required extensive assistance with one-person physical assist for personal hygiene. Review of the Care Plan dated 09/28/21 documented that Resident #1 had an ADL self-care performance deficit. Interventions were to check nail length and trim and clean on bath day and as necessary. Review of the Certified Nursing Assistant (CNA) Tasks for Nail Care dated 11/07/21 - 11/08/21 documented that nail care was done daily. During an observation conducted on 11/07/21 at 12:16 PM, Resident#1's fingernails were past her fingertips. Closer observation showed Resident #1's fingernails had a noticeable black discoloration under her nails. Resident #1 stated, They haven't cut my nails since I've been here. I don't like them long. When asked if she would like them trimmed, she said Yes. During an interview conducted on 11/08/21 at 3:20 PM, Resident #1 stated no one came in to do her nails. She further stated, They're the same as yesterday. It was noted that Resident #1's fingernails were still past her fingertips and still had a noticeable black discoloration underneath. During an interview conducted on 11/09/21 at 9:14 AM, Staff C, CNA, stated that CNAs were responsible for cleaning and cutting residents' fingernails. When asked how often fingernails were cleaned and cut, she stated, Whenever we see that they're long or dirty when we're doing care. According to her, nail care was documented under CNA Tasks for Nail Care. She stated that if it was marked yes, that would mean that the nails were cleaned. When asked about Resident #1, she stated, I know Staff D, Registered Nurse, was cutting nails last week. During an interview conducted on 11/09/21 at 9:17 AM, Staff D stated that CNAs are normally responsible for cutting and cleaning residents' fingernails, and that it was part of their tasks. She stated she does trim residents' fingernails sometimes, and when she does she informs the CNA. She further stated that if a resident refused nail care, she would document it in the progress notes. When asked about Resident #1, she stated, I think I cut her nails 2 weeks ago. During an observation conducted on 11/09/21 at 9:24 AM, accompanied by Staff C, Resident #1's fingernails were still past her fingertips and still had a noticeable black discoloration underneath. Staff C stated, They didn't look like that on Saturday. She further stated Resident #1's fingernails might be dirty because she might get food under them when she eats. She then acknowledged Resident #1's nails were long, dirty, and said that she would clean and cut her nails.

Based on observation, interview and record review, the facility failed to provide services to prevent further decrease in range of motion for 1 of 1 resident reviewed for limited range of motion, Resident #33. The findings included: The facility's policy titled, Prevention of Decline in Rang of Motion, implemented 11/2014, documented:, Section 3, Appropriate Care Planning b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but Is not limited to: ii. Appropriate equipment e. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record. Section 4 Preventive Care b. Staff will be educated on basic, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include but is not limited to: iv. Assisting residents in adjustment to their disabilities and use of any assistive devices. Resident #33 was admitted on [DATE]. According to Resident #33's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #33 had a Brief Interview for Mental Status score of 13, indicating 'cognitively intact'. The MDS documented that the resident was dependent upon staff for Activities of Daily Living (ADLs). The assessment documented that the resident used an indwelling catheter and was 'frequently incontinent' of bowel'. Resident #33's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33's orders included: Left hand roll on at all times remove for hygiene only every shift related to [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left dominant side - 10/12/21. Review of Resident #33's electronic and paper-based health record revealed no documentation of Resident #33 being noncompliant with the use of a splint/device to the left hand. During an interview with Resident #33, on 11/07/21 at 1:21 PM it was noted that the resident's left hand was contracted with a device on the left lower arm at the wrist. The resident stated, it's not supposed to be like that, it's supposed to be under my fingers. On 11/08/21 at approximately 12:15 PM, Resident #33 was observed in bed with the splint around the resident's left lower arm/wrist. On 11/09/21 at 8:38 AM, Resident #33 was observed in bed with breakfast on over bed table, eating independently. It was noted that the resident's splint was around the left lower arm/wrist. During an interview, on 11/09/21 at 8:38 AM, with the Rehab Manager, when asked about Resident #33's splint to the left hand, the Rehab Manager replied, they (CNAs) take it off during any kind of AM care and should be taken off at night. She had another splint that she refused so we discharged that. It is supposed to be around her hand and under her fingers to keep her fingernails from digging in. She (Resident #33) fidgets a lot and moves the splint there. On 11/09/21 at 10:50 AM, Resident #33 was observed in bed and was asked if the staff had placed the splint properly, Resident #33 replied, they were supposed to come back after I finished eating and he never came back. Resident #33 held up the left hand and the brace was at the resident's left lower arm/wrist. When the resident was asked of the ability to move and place the splint independently, Resident #33 stated she was not able to. During a follow up interview, on 11/09/21 at 10:57 AM, with the Rehab Manager, the Rehab Manager stated, the CNAs and whoever is in the room should recognize the splint and replace it as needed. The ADON helped place it on Sunday, she (Resident #33) gets agitated and fidgets with it. During an interview, on 11/10/21 at 10:36 AM, with Staff B, CNA, when asked about maintaining Resident #33's splint device, Staff B replied, we are supposed to get a new one and put it on her hand. We get her a new one so that she has a clean one. She moves around in bed a lot and sometimes it gets moved around and out of place. During an interview, on 11/10/21 at 11:35 AM, with Staff C, LPN, when asked about the facility's policy for maintaining a resident's range of motion and devices, Staff C replied, Just as far as making sure that the CNAs provide care to that hand and clean inside of it, they are supposed to do that every shift. They are supposed to check every 3 hours and clean underneath if it (splint, device) needs to be, shifts are 8 hours. If it is fine when they check, they can leave it off for thirty minutes and go back to put it back on after they have cleaned it and the hand.

Based on observations, interviews, and record review, the facility failed to obtain daily weights as per Physician's Orders for 3 of 7 residents reviewed for nutrition (Resident #280, Resident #283, Resident #330). The findings included: Review of the facility's policy titled, Weight Assessment/Evaluation and Intervention, dated August 2018, documented the following: The nursing staff will obtain weights on the newly admitted resident for 3 days, beginning the [MEDICATION(S)] admission, and weekly for 4 weeks. Weight will be recorded in the individual's medical record/electronic medical record. 1. Review of the record showed that Resident #280 was readmitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders showed that Resident #280 had an order with a start date of 11/06/21 for daily weights for 3 days on every day shift. Review of the weights for Resident #280 showed that there were no weights documented on 11/06/21 or 11/07/21. Review of all progress notes dated 11/06/21 - 11/07/21 for Resident #280 showed that there were no notes regarding refusal of daily weights. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 11/06/21 documented that Resident #280 had the potential for further weight loss, skin breakdown, and further alteration in nutrition/hydration status. During an observation conducted on 11/07/21 at 10:45 AM, Resident #280 was observed laying in her bed. Resident #280 appeared thin with sunken cheeks and hollow orbital regions. When asked if she had lost any weight, she stated, I would imagine so. I don't eat very much. During an observation conducted on 11/08/21 at 8:38 AM, Resident #280's breakfast tray contained a muffin, sausage links, a cup of coffee, a cup of orange juice, and a container of Raisin Bran cereal. It was noted that Resident #280 had only taken a few small bites of her muffin, showing that she had consumed less than 25% of her meal. When asked if she was still hungry, Resident #280 stated that she was done with her breakfast. During an observation conducted on 11/09/21 at 8:22 AM, Resident #280 was observed in her bed with her breakfast meal untouched on her overbed table. When asked about her meal, Resident #280 stated that she did not want to eat breakfast. During an interview conducted on 11/10/21 at 9:02 AM, Staff E, Registered Dietitian, stated that upon admission, weights were taken daily for 3 days, weekly until stable, and then monthly thereafter. According to her, nursing was responsible for taking weights. She further stated that the nurse assigned to the resident was responsible for taking their daily admission weights. When asked, Staff E stated that weights were documented in PointClickCare (electronic charting system) and that nurses were responsible for entering the daily admission weights into PointClickCare. She further stated that nursing would know if a resident required daily weights because it would be placed as an order and would appear in their MAR. According to her, residents with a low body mass index, abnormal [MEDICATION(S)], poor intake, elevated blood urea [MEDICATION(S)], and skin alterations were at high nutritional risk. When asked about Resident #280, Staff E reviewed her chart and confirmed that there was no documentation showing that she refused to be weighed on 11/06/21 or 11/07/21. Upon further review of Resident #280's chart, Staff E confirmed that there was no documentation for daily weights on 11/06/21 or 11/07/21. This showed that the Physician's Order for daily weights for three days was not followed. 2. Review of the record showed that Resident #283 was readmitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders showed that Resident #283 had an order with a start date of 11/05/21 for daily weights for 3 days on every day shift. Review of the weights for Resident #283 showed that there were no weights documented on 11/05/21, 11/06/21, or 11/07/21. Review of all progress notes dated 11/05/21 - 11/07/21 for Resident #283 showed that there were no notes regarding refusal of daily weights. Review of the MAR for November 2021 for Resident #283 showed that there was no documentation regarding daily weights for 11/05/21 - 11/07/21. Review of the Baseline Care Plan dated 11/04/21 documented that Resident #283 was at risk for dehydration and potential for weight loss. During an observation conducted on 11/07/21 at 10:14 AM, Resident #283 was observed sleeping in his bed. Resident #283 appeared thin with sunken cheeks and hollow orbital regions. During an interview conducted on 11/10/21 at 9:02 AM, Staff E reviewed Resident #283's chart and confirmed that there was no documentation showing that he refused to be weighed on 11/05/21, 11/06/21, or 11/07/21. Upon further review of Resident #283's chart, Staff E confirmed that there was no documentation for daily weights on 11/05/21, 11/06/21, or 1/07/21. This showed that the Physician's Order for daily weights for three days was not followed. 3.Review of the record showed that Resident #330 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Physician's Orders showed that Resident #330 had an order with a start date of 11/06/21 for daily weights for 3 days. Review of the Care Plan dated 11/05/21 documented that Resident #330 has potential for weight loss, skin breakdown and alteration in nutrition/hydration status. Goals were to meet Nutrition and hydration needs as evidenced by no significant weight loss, labs maintained within acceptable range and no skin breakdown by next review date. Review of the weights for Resident #330 showed that there were no weights for 11/06/21, 11/07/21, and 11/08/21. Review of all progress notes dated 11/06/21 - 11/08/21 showed there was no documentation showing Resident #330 refused daily weights. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/10/21 at 9:02 AM, Staff E, Registered Dietician, was asked about the daily weights for Resident #330. Upon further review of the chart, she confirmed that there was no documentation for daily weights on 11/06/21, and 11/07/21 for Resident #330. This showed that the physician's order for daily weights for three days were not followed.

Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety, as evidenced by failure to maintain equipment in safe working conditions, failure to maintain adequate holding temperatures, and failure to maintain sanitary conditions. The findings included: A. During the initial tour of the kitchen, on 10/19/20 at 9:00 AM accompanied by the Food Service Director (FSD), the following were noted: 1. The hand washing sink located on the wall between the mechanical ware washing machine and the three-compartment for manual ware washing was not secured to the wall and water could not properly drain from the hand washing sink. 2. The exhaust hood over the stove top, the exhaust hood over the mechanical ware washing machine, and the underside of the soiled dishes table were observed with cracked, chipped, black paint. These paint chips can fall into prepared food / clean dishes and put food at risk of physical contamination. 3. The frame of the drop ceiling over the food preparation tables was damaged in a manner that created an opening in the ceiling over the food equipment. This puts food at risk of physical contamination. 4. Forty pieces of bacon stored in a metal quarter gallon insert were uncovered on the stove top and were stored next to a red bucket with sanitizing solution and a green bucket with soap and water. This puts food at risk of chemical contamination. The surveyors requested that FSD (Food Service Manager) remove the chemicals and store them in a lower area away from the food. 5. Food preparation and serving equipment (one whisk, one spatula and two ladles) were noted to be stored in a metal bucket of stagnant water on the stove top. The surveyors informed the FSD that this was an inappropriate storage of equipment and that they must be stored in the food product only. 6. The followig temperatures were noted: The internal temperature of a metal half gallon insert of mashed potatoes was 126 degrees Fahrenheit (F), the internal temperature of a metal quarter gallon inset of ground sausage was 113 degrees F, the internal temperature of a metal quarter gallon insert of pureed sausage was 110 degrees F, and the internal temperature of a metal quarter gallon insert containing 40 pieces of bacon was 117 degrees F. It was noted that the pans were resting on the range with no heat source to keep them at a safe temperature. All temperatures were taken using the facilities metal stem probe thermometer. Hot food must be held at the regulatory temperature of 135 degrees F or above. The surveyors requested the FSD to discard these food products and not serve them. 7. Observation of the walk-in refrigerator noted that three 5-pound containers of sour cream had an expiration date of 10/12/20. The surveyor requested that the FSD discard these containers of sour cream. 8. Four of the bottom racks in the walk-in refrigerator were less than the required regulatory 6 inches above the floor. The surveyor informed the FSD that 6 inches is needed for proper cleaning under the shelving. 9. One 5-pound jar of peanut butter near the food preparation sink had an expiration date of 10/15/20. The surveyor requested that the FSD discard this container of peanut butter. 10. Staff C, Diet Aide, was observed touching the heads of clean utensils with her bare hands as she rolled them into napkins. This revealed that clean utensils were being contaminated. Staff C was also observed wearing hoop earrings while handling food items. The surveyors informed the FSD that silverware was not being handled in a sanitary manner and to re-wash utensils. 11. Aprons were observed on top of boxes of paperwork in the back storage room. Interview with FSD at the time of observation revealed she could not determine if the aprons were clean or dirty. 12. Two boxes of 150 count single use foam hinged lid containers and one box of 100 single use vented lids were stored next to cleaning chemicals in a back storage room designated for cleaning chemicals and equipment. This puts food items at risk of chemical contamination. B. During a subsequent observation of the kitchen on 10/20/20 at 7:30 AM, accompanied by the FSD, the following were noted: 13. Observation of the mechanical ware washing machine noted that 4 of the 5 internal separation curtains were encrusted with food residues. Interview with FSD at this time revealed that the dish washing machine was not properly cleaned from the evening meal from the day before. The FSD agreed that the machine should be thoroughly cleaned and sanitized after every meal. The surveyors requested that the curtains be cleaned and sanitized before use on 10/20/20. 14. Observation of the breakfast meal noted that the internal temperature of a metal quarter gallon of hard boiled eggs on the stove was 97 degrees F. It was noted that the container of eggs was resting on the stove with no heat source to keep them at a safe temperature. At the request of the surveyor, the FSD checked the temperature of the eggs with the facility's calibrated metal stemmed probe thermometer. The temperature test revealed that the eggs were not being held at the regulatory temperature of 135 degrees F or above. The temperature of the eggs was 97 degrees F. The surveyors requested that the eggs be discarded and not served. Photographic evidence was obtained.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment in resident rooms and laundry area. The findings included: 1. During the laundry tour conducted on 10/19/20 at 10:05 AM, accompanied by the Director of Environmental Services, the following were noted: a. During the tour, it was noted that the exterior cover of two of two clean linen storage carts were ripped, torn, worn and in disrepair. b. Observation of the Soiled Utility Room located on the West Wing noted that personal protective equipment (disposable gloves) were not properly bagged and were noted to be loose in the laundry cart. The disposable gloves were not placed inside of a garbage bag inside of the cart that was designated for trash. c. The Access hall to the laundry area was noted to have numerous rolls (40 rolls) of toilet tissue and paper towels that were stored with caustic chemicals and soiled clothing that was touching the toilet tissue. d. The walls and ceiling area of the Access hall to the laundry area were dust laden. The entire ceiling area was covered in dust. One of the walls was covered in dust. e. The exterior coverings of the folding tables (2) located in the clean folding area were torn, soiled, and in disrepair. Both tables were located in the clean folding area. One table was against the wall on the left side of this room. The other table was against the wall on the right side of this room. Photographic evidence obtained. 2. During the environment observation conducted on 10/20/20 at 12:27 PM, accompanied by the Director of Environmental Services and the Regional Director of Environmental Services, the following were noted: f. In room [ROOM NUMBER], a small portion of the privacy curtain was stained. It looked like something brown may have splattered on it. The dresser by the bed closest to the door was broken and in disrepair. The drawer was broken and falling out of the dresser. g. In room [ROOM NUMBER], the floor near the window was in disrepair and covered in debris. The bed's string for the overhead bed light of the bed closest to the door was broken and was out of the resident's reach. The string was cut off and too short. It was also noted that the gasket in the personal refrigerator nearest this bed had a buildup of dust. The top of the gasket on the opening side (door side) of the personal refrigerator was covered in approximately 1/8th inch of dust. h. The front of the vanity was dirty and in disrepair in room [ROOM NUMBER]. It had a black substance in the crevices of the front of the vanity and was worn and tattered. i. The privacy curtain was stained in room [ROOM NUMBER]. A small portion of the privacy curtain was stained and looked like something brown had splattered on it. j. In the Community Shower Room located on the West Wing, it was noted that the call light in shower room [ROOM NUMBER] was tied up in a knot. The string of the call light was tied up in a knot. The call light string was higher off the ground, making the call light string out of reach to anyone who fell . k. The gasket of the freezer door had residue buildup in the Nourishment Room located on the West Wing. The residue lined the whole top of the gasket and looked like brown crumbs. l. In an observation of the Nursing Station located on the West Wing, soiled gowns and shoe coverings were not properly bagged and were stored in an opened box. The soiled gowns and shoe coverings were not labeled as soiled and were not stored in a covered box/bag. m. In room [ROOM NUMBER], the overbed commode seat was observed with rust. A white bar, which was part of the frame of the commode, between the lid and seat was observed with rust. The baseboard near the window was also in disrepair. n. A random chair near room [ROOM NUMBER] was observed with torn arm rests. o. The hand sanitizer dispenser between rooms #226 and #228 and the hand sanitizer dispenser in room [ROOM NUMBER] were not functioning. It was noted that both dispensers were filled with hand sanitizer but neither were able to dispense the hand sanitizer. p. Following the observation tour, the findings were again confirmed with the facility staff. It was further revealed that the facility has a TELS system, but that housekeeping is not able to access the system. q. In room [ROOM NUMBER], an office chair was observed heavily worn and in disrepair. The armrests, seat of the chair, and back of the chair were ripped and tattered. A high back Geri chair was also observed with the arm rests torn, ripped and in disrepair. The chair rail/wall behind the window bed was in disrepair. There was black crown molding on the wall behind the bed, referred to as the chair rail, which was scuffed and had chipped paint. r. The air conditioning unit under the window was observed with dust in room [ROOM NUMBER]. The air conditioning unit had approximately 1/8 inch of dust coming out of each vent. Photographic evidence obtained.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 2 sampled residents, Resident #36, received restorative nursing service to maintain Range of Motion and Ambulation. The findings included: During an observation and interview with Resident #36 on 10/19/20 at 11:45 AM, it was noted that the resident stated that he was admitted to the facility to receive skilled therapy services which were discontinued approximately 1 week ago. At the request of the surveyor, restorative nursing services provided a hard copy of residents receiving restorative range of motion and restorative ambulation. Upon receiving the list, it was noted that Resident #36 was listed as enrolled into restorative range of motion (ROM) and restorative ambulation. During an interview on 10/21/20 at 9:56 AM, Staff B, Restorative Licensed Practical Nurse, confirmed that Resident #36 was enrolled in restorative ROM and restorative ambulation. Staff B further stated that Resident #36 came off of physical therapy 10 days ago. Staff B stated that communication between therapy and restorative nursing is completed through the Therapy Communication to Nursing screen. Staff B stated that the restorative ambulation and restorative ROM are each conducted 3 times per week. The surveyor requested evidenced to show that Resident #36 received restorative nursing services. A second interview with Staff B was conducted on 10/22/20 at 9:22 AM, and it was noted that Staff B did not have documentation to show that Resident #36 had been in restorative nursing services. When asked about documentation for Resident #36, Staff B did not respond. During an interview on 10/22/20 at 9:33 AM, Staff A, Restorative Certified Nursing Assistant (CNA), stated that Resident #36 was not on her list of residents for restorative nursing services at that time. Staff A stated that Resident #36 was only placed on her list for restorative ambulation yesterday. During an interview on 10/22/20 at 9:52 AM, the Rehab Manager stated that when residents are discharged from physical therapy, the physical therapists will enter an order for [REDACTED]. During an interview on 10/22/20 at 10:26 AM, Resident #36 stated that he was discharged from physical therapy last week. Resident #36 further stated that he did not begin walking with restorative nursing therapy until one week later. Review of the Physical Therapy Notes revealed a start of care, date of 08/26/20 with a [DIAGNOSES REDACTED]. Further review of the Therapy Communication to Nursing, dated 10/12/20, noted to remove the resident from physical therapy and enroll in restorative nursing with programs for ambulation and range of motion, which included receiving a four wheeled rolling walker for 100-200 feet and active range of motion for bilateral lower extremities in all planes of motion for 1 set of 10 repetitions. Review of the clinical record noted an admission date of [DATE] with [DIAGNOSES REDACTED].

Based on observation, interview and facility policy review, the facility failed to implement an infection prevention and control program for screening staff for fever and signs and symptoms of COVID-19. The findings included: Review of the CDC guidance, updated June 26, 2020, located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html documents: Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. o Actively take their temperature* and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. o *Fever is either measured temperature >100.0oF or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. o HCP who work in multiple locations may pose higher risk and should be encouraged to tell facilities if they have had exposure to other facilities with recognized COVID-19 cases. Review of the facility policy and procedure for Novel Coronavirus Prevention and Response, dated 03/20/20 and updated 10/15/20 documented in part: 6.e Staff will enter/exit from a designated door - upon entrance will have temperature checked - and answer required questionnaire . On 10/20/20 at 8:03 AM, the surveyor was let in the facility by the Maintenance Director. Upon entering, Staff D, Registered Nurse (RN), was observed taking her own temperature and completing a questionnaire in using an I-Pad. After Staff D finished screening, she immediately left the entrance/screening area. During an interview, on 10/22/20 at 11:09 AM, with Staff D, RN, when asked how often she conducts her own screening, including taking her own temperature, she replied that it happens every once in a while. During an interview with the Administrator, on 10/20/20 at 9:00 AM, the above concern regarding staff self-screening was brought to her attention. During an interview with the Infection Preventionist, on 10/20/20 at 9:22 AM, when the concern regarding staff self-screening were brought to her attention, she stated, (Nurse Manager) is supposed to be there (at the entrance) to screen staff when they come in. On 10/21/20 at 7:30 AM, the Assistant Business Office Manager was observed entering the facility from a secondary entrance and going into an office area without being screened. The Business Office Manager then went through the corridors / units, where the main dining room, kitchen, therapy and therapy room were located, and residents were observed participating in therapy next to the designated entrance that was being used as the main entrance for screening. It was noted that the Business Office Manager was wearing a mask, as were all staff that were observed on the unit(s). On 10/21/20 at 8:22 AM, during an interview with the Rehab / OT (occupational therapy) Manager, when the concerns regarding staff screening were brought to his attention, he replied, I come in around 6:30 and the DON and I take care of screening visitors and staff until 8:00 AM when the AP (Accounts Payable) Receptionist comes in and takes over the responsibility of screening everybody. On 10/20/20 at approximately 8:30 AM, when being screened, the staff member responsible for screening gave the surveyor a choice of the staff member conducting the screening, or she would have the option of doing it herself and taking her own temperature. During an interview, on 10/21/20 at 8:25 AM, with the AP Receptionist, she stated that she is responsible for screening the staff when the OT/Rehab Manager was away from the entrance. Documentation provided by the Administrator showed that the Assistant Business Office Manager and the Business Office Manager were not screened until 10:42 AM and 10:23 AM, respectively, approximately 3.25 hours after being observed entering the facility.

Based on record review, observation, and interview, the facility failed to provide appropriate care and services to prevent and treat pressure ulcers for 2 of 3 sampled residents reviewed for pressure ulcers. This affected Residents #1 and #4. The findings included: 1. Resident #4's record documented the resident was admitted to the facility on [DATE] for rehabilitation after a distal left femur fracture. The Nursing Admission Screening, dated 07/31/19 at 5:20 PM, documents she had unstageable redness to her sacrum and an unstageable ulcer on the left heel. Resident #4's Physician Order, dated 08/01/19, documented left knee immobilizer at all times remove for hygiene and dressing change only. Patient #4's Physician Order, dated 08/02/19, documented for a Low Air Loss Mattress for pressure relief. Patient #4's (MONTH) 2019 Treatment Administration Record documented the low air loss mattress as administered each shift for 38 of 40 shifts, from night shift on 08/03/19 to evening shift on 08/26/19, the date of survey. A wound care physician's Initial Evaluation & Management Summary for Resident #4 dated 08/05/19 documented recommendations for low air loss mattress, reposition per facility protocol, off-load heel wound, and float heels in bed. The wound physician's Initial Evaluation & Management Summary, dated 08/05/19, documented Patient #4's plan of care was discussed with Wound Care Nurse that included the need to turn and reposition the patient per facility protocol, the need to float/offload the heels when the patient is sitting or in bed, and the need for low air loss mattress on the correct setting for the resident's weight. A facility report, dated 08/15/19, at 7:25 PM, documented Aide brought to nurse's attention that resident was noted with wound and swelling to left lower foot. Upon assessment, the resident was noted with an unstageable wound L (length) 4.4 cm (centimeters) X (by) W (width) 3.5 cm to the left lateral calf, also +2 [MEDICAL CONDITION] (swelling) noted to foot. A Skin and Wound Evaluation, dated 08/15/19 at 6:17 PM, documented an unstageable wound to the left calf, in-house acquired and identified on 08/15/19, measuring 4.4 cm by 3.5 cm; that the wound bed was 70% slough and had light purulent drainage; that evidence of infection included redness/inflammation, and the surrounding area had [DIAGNOSES REDACTED] (redness) and [MEDICAL CONDITION] less than 4 cm from the wound A wound care physician's Wound Evaluation & Management Summary for Resident #4, dated 08/20/19, documented the presence of a new wound, Site 3, as unstageable (due to necrosis (dead tissue)) to the left lower lateral ankle, likely secondary to brace. Resident #4's Physician Order, dated 08/21/19, documented to remove the left brace and examine the skin for any abnormalities every shift. Resident #4's (MONTH) 2019 Treatment Administration Record documents for the assigned task beginning 08/21/19 evening shift Remove brace and examine skin q (every) shift for any abnormalities, that the site was intact for 11 shifts, ok for 3 shifts, no entry for evening shift on 08/24/19, and Ip (abbreviation not defined) for night shift on 08/26/19. During observation on 08/27/19, beginning at 11:48 AM, Resident #4 was observed on a pressure relief mattress and to have a left posterior calf wound with necrosis that extended approximately 1/3 the length of the calf, and had been covered by the brace before it was removed for observation. During interview with the Wound Care Nurse on 08/27/19 at 12:10 PM, she reported she started removing the brace daily, checks the skin and charts intact or ok, and has been doing this since about last week. The Wound Care Nurse stated she would not chart intact today because she is waiting on a order to place padding over the wound because the brace keeps pressing on it. The Wound Care Nurse stated the wound started as a blister on 08/16/19 and has progressed since then, but wasn't as black yesterday as it was today. The Wound Care Nurse denied that staff should have been checking under the brace daily before this wound's discovery because she said it's an immobilizer and they don't want her knee to pop, and they don't want Resident #4 bending that knee. The Wound Care Nurse denied that the wound care physician stated the calf wound was unavoidable but that he said to pad it to keep the pressure of the brace off the wound. During interview on 08/27/19 at 12:45 PM, the Director of Nursing looked at Resident #4's mattress and stated it was not a low air loss mattress, but a pressure relief mattress. During interview with the Director of Nursing on 08/27/19 at 3:10 PM, she stated the calf wound was unavoidable because it was caused by the brace, that the brace was hard and had a piece of iron that put pressure on the skin. Upon inquiry to whether nurses should have been checking under the brace daily for skin integrity before the calf wound was discovered as an unstageable wound, the Director of Nursing said they were doing it but just didn't have an order. Upon inquiry how she knew that since this was not documented, she replied I hope that they would do it. When asked how the facility ensures staff turn bed-bound residents to help prevent pressure ulcers, the Director of Nursing replied I have to believe the CNAs (certified nursing assistants) are doing what they should be. Upon inquiry to the low air loss mattress, the Director of Nursing said it was up to the treatment nurse to make sure that was done, and that for this patient's insurance, the facility provides the air mattress from their own stock so maintenance can bring it the same day. During interview with the wound care nurse, on 08/27/19 at 5:09 PM, the nurse stated she works with Resident #4 about every couple of weeks, is aware of her pressure ulcers, denied awareness she had an order for [REDACTED]. Further review of Resident #4's (MONTH) 2019 Treatment Administration Record revealed the sound care nurse had documented the low air loss mattress as administered on 08/03/19, 08/04/19, 08/08/19, 08/13/19, 08/17/19, 08/23/19, and 08/26/19. 2. Resident #1's record documented he was admitted to the facility on [DATE] after heart surgery. Resident #1's hospital transfer form documented incisions and that his right toes were amputated but no presence of pressure ulcers. Resident #1's Nursing Admission Screening/History, effective date 06/19/19, documented right toes 'all amputated', chest incision, and bilateral thigh scars, but no presence of pressure ulcers. Resident #1's Skin/Wound note, dated 06/20/19, documented the left toes on left foot are amputated, surgical incisions related to heart surgery, and no indication of any pressure ulcers. The Physician Orders, dated 06/26/19, documented treatments for a fluid filled blister on the left heel and a pressure ulcer on the right heel. Review of the record revealed no evidence of measurements or further description of these wounds until 07/02/19. Without the benefit of an assessment, progress towards healing could not be determined until after 07/02/19. Resident #1's Skin & Wound Evaluations, dated 07/02/19, documented an in-house acquired right heel pressure deep tissue injury measuring 4.2 cm by 5.3 cm, and an in-house acquired unstageable left heel pressure ulcer measuring 5.4 cm by 4.0 cm with light serous drainage. A Wound Care Physician's Initial Wound Evaluation & Management Summary for Resident #1, dated 07/02/19, documented surgical debridement of the left heel at the bedside and recommendations to elevate legs, float heels in bed, off-load the wound, reposition per facility protocol; and discussion with the staff, patient, and his wife that included strict adherence to offloading/positional recommendations while in chair/bed. The Wound Care Physician's Wound Evaluation and Management Summary, dated 07/09/19, documented surgical debridement of the left heel was performed and the repeated recommendations to elevate legs, float heels in bed, off-load the wound, and reposition per facility protocol. Review of nursing documentation revealed no evidence of efforts to offload Resident #1's heels since identification of the new heel ulcers on 06/26/19, until an order dated 07/10/19 documented to offload Resident #1's heels while in bed with a rolled pillow. Resident #1's Skin and Wound Evaluation, dated 07/16/19, documented new wounds to the lateral (side of) right foot and right lateral malleolus (ankle), that surgical debridement of both heels was performed, and the recommendations to elevate legs, float heels in bed, off-load the wound, and reposition per facility protocol. Review of Certified Nurse's Assistants' (CNAs) documentation for turning and positioning of Resident #1 revealed they documented no or not applicable to the question Did you turn and reposition for 37 of 78 (8-hour) shifts. During interview on 08/26/19 at 3:27 PM, Certified Nurse's Assistant, Staff A explained that when she documents not applicable to a task, including for turning and repositioning, it means that it is not relevant to that resident because they don't need that done, so she did not do it for that reason. Review of Resident #1's documentation for turning and positioning reveals Staff A answered not applicable to turning and positioning for 2 of 2 shifts she worked with him. Resident #1's Follow Up Questions Report for (MONTH) and (MONTH) 2019 documented Staff A responded to his bed mobility as follows: self performance as Not Applicable and as Extensive Assistance - Resident involved in activity, staff provided weight-bearing support; and for the question of how Resident #1 moves to and from lying position, turns side to side, and positions himself in bed (how much help he needed), responded as One person physical assist. During interview on 08/26/19 at 3:30 PM, Certified Nurse's Assistant, Staff B, explained sometimes everybody is busy with their own assignment and she can't get the help she needs to turn a particular resident, but that she doesn't want them to get pressure ulcers so she would try to do it herself. Staff B stated if she answered no, she could not do the task. Review of Resident #1's documentation for turning and positioning reveals Staff B answered no to turning and positioning for 5 of 5 shifts she worked with him. Resident #1's Follow Up Questions Report for (MONTH) and (MONTH) 2019 documents Staff B responded to each query of his bed mobility: self performance as Limited Assistance - Resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight-bearing assistance; and for the question of how Resident #1 changed position in bed, responded as One person physical assist.

Based on interview, record review and review of policy and procedure, it was determined that the facility failed to provide a requested copy of medical records, in a timely manner, for 1 of 3 sampled residents, Resident #2. The findings included: Review of facility policy and procedure on 04/01/19 at 12:44 PM was conducted of the policy for resident medical record requests/release, dated 02/23/16, which indicates that ' .Upon receipt of a request for medical record copies, the facility should notify the requesting party of the cost for obtaining records within a reasonable time frame and that the records are available for .a former resident, within 10 working days after receipt of payment. Copies should not be released prior to the receipt of payment for copying charges .Once a request for records is received, all records for that resident should be gathered and secured in a place inaccessible to anyone except the Administrator, Director of Nursing or designee. The facility must ensure that information is provided to each resident in a form and manner the resident can access and understand ' Record review revealed Resident #2 was admitted to the facility on [DATE] at approximately 8:30 PM. The record reveals that Resident #2 left the facility against medical advice on 03/09/19 at approximatley 11:44 PM. During an interview with Resident #2 on 03/31/19 at 12:57 PM, the resident stated that she went back to the facility on [DATE] and completed a written request for her medical records. She was told that they would charge her $1 per page for the records. She said that she is still waiting on the records and had not heard anything back from the facility. There was documentation provided that a request was made on 03/11/19. Record review revealed that on 04/01/19 at 12:01 PM, the existence of Resident#2's written request Consent for Release of Medical Information for her medical records, dated 03/11/19, indicated that the resident was also requesting specific portions of the record to include nurse comments / chart. This form was completed with the resident's information and signed by the resident on 03/11/19. An interview was conducted with Staff A, Medical Records Coordinator, in which she revealed that Resident #2 and spouse had come back to the facility to complete a written request for her medical records. Staff A said that she told Resident #2 that she would be charged $1.00 per page for the records. Staff A told Resident #2 that this would take approximately two weeks. Staff A said she had last spoken with the resident on: 03/11/19, in person; with no other contact made since that time. There was no evidence the facility provided to the resident a total cost of copying the medical record. An interview was conducted with both Staff C and Staff D on 04/01/19 at 11:45 AM. They both indicated that they were not made aware by the medical records department that a medical record request was made by Resident #2. Both Staff C and Staff D also said that if they had known about the medical records request, they would have been able to complete the assessment much quicker. Record review indicated that on 04/01/19 at 12:09 PM that the facility's blank Invoice for Medical Records indicated that there would be a charge of $1 per page for the first 25 pages, then 0.25 cents for each page thereafter with the facility's Federal Identification number included. There was no documentation or evidence the resident was notified of the total cost to copy the medical record.