Every finding on record at VI at Lakeside Village

Based on observations and interviews, the facility failed to maintain food in a safe and sanitary method. This had the potential to affect 49 residents on oral diets. The findings included:An initial tour of the kitchen was conducted on 02/23/26 at 9:05 AM. The surveyor was accompanied by the Registered Dietician (RD) and the Kitchen Manager. The following was observed:1. Unwrapped tongs with brown residue was on a low shelf located to the right of the salad area. A metal bin with 2 bags of chicken broth powder and a pastry cloth were also on the shelf. A rag for cleaning and 2 empty red buckets were on the same shelf. Cleaning items should not be in the same area as food and food handling items. The Kitchen Manager agreed with this finding. 2. The Southbend oven had an accumulation of dark brown residue on the inside of the oven's doors. A frayed mesh material that was visible when the oven door was open, revealed broken off pieces of the mesh that rested on silver metal. Dark black residue covered the bottom of the oven. The RD agreed with this finding. 3. Yellow/orange and brown/black residue was on the knobs that were used to set the timer and temperature on the Southbend oven. The RD agreed with this finding. 4. The Vitamix-Drink Machine Two-Speed blender had white colored particles on top of the base of the machine. A yellow-white batter-like substance was splattered on the machine. The Kitchen Manager agreed with this finding. 5. The food processor (used to mix ingredients or to make them smoother) had tan colored residue on its' center tube. The Kitchen Manager agreed with this finding. 6. A 2 Gallon plastic container of shredded Kraut had dried on bright yellow residue on the exterior top of the container. Clusters of green residue was on the exterior of the container below the lid.Photographic Evidence Obtained

Based on observation and interview, the facility failed to ensure proper labeling of pill dispensing packets for 2 of 27 reviewed during medication administration for 2 of 4 sampled residents, Resident #7 and Resident #58.The findings included: Review of the facility's policy titled, Medication Management Protocol, dated November 2004 and revised June 2011, included the following: Administration of Medications 3. Prior to administering the medication, the label on the container is matched to the Medical Administration Record (MAR).Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated March 2019, included the following: Only the dispensing pharmacy / registered pharmacist can modify, change, or attach prescription labels. Procedures G. 1) If the physician's directions for use change or the label is inaccurate, the nurse may place a change of order-check chart label on the container indicating there is a change in directions for use, taking care not to cover important label information.Review of the facility's policy titled, Preparation and General Guidelines, dated March 2019, included the following: Procedures: A. Preparation 5) .If the label and the Medical Administration Record (MAR) are different and the container has not already been flagged, indicating a change in directions, .the physician's orders are checked for the correct dosage.and the order change communicated to the provider pharmacy so that the next supply of the medication is labeled with the current directions. 1. Record review revealed Resident #7 was admitted to the facility on [DATE] with the following diagnosis: Generalized anxiety disorder.Review of the Physician's Orders showed that Resident # 7 had an order dated 02/13/26 for Clonazepam 1mg tablet to be given twice a day for anxiety.During a medication administration observation conducted on 02/25/26 at 8:58 AM with Staff B, Registered Nurse (RN), for Clonazepam 1 mg tablet, the pill pack description stated, blue round logo 2531. During a side-by-side comparison of the pill, Staff B agreed that the pill color was green and did not have a logo. Photographic evidence obtained ([NAME]). When asked how she knows if this is the correct medication, Staff B stated that she would look in the pill description guide. Staff B notified the Director Of Nursing (DON) and confirmed the medication prior to administration. 2. Record review revealed Resident #58 was admitted to the facility on [DATE] with the following diagnosis: Hypotension (low blood pressure).Review of the Physician's Orders showed that Resident #58 had an order dated 11/03/25 for Midodrine tablet 5 mg, one tablet to be given three times a day. Special instructions Orthostatic Hypotension. Hold for Systolic Blood Pressure (SBP) greater than 140.During a medication administration observation conducted on 02/25/26 9:14 AM with Staff C, RN, and during the side-by-side comparison of the electronic medical record (EMR) and the pill dispensing packet for Midodrine 5mg 1 tablet three times per day, the EMR read Hold for SBP greater than 140. The pill pack description stated, Hold for SBP less than 140. Staff C noted the difference and stated that she is aware of the SBP parameters for the medication, follows the orders in the EMR but will clarify with the provider prior administration. Photographic Evidence Obtained.During a follow up interview on 02/25/26 at 11:58AM, Staff C informed this surveyor that after speaking with the provider and verifying that the EMR order was correct, the pill pack label was covered with new instructions that read Directions changed, refer to chart per pharmacy. During an interview conducted on 02/26/26 at 3:00PM, the DON stated that she was immediately notified of the pill pack labeling issues for Resident #7 and Resident #58. She stated that she reached out to the pharmacy to confirm that the correct medication was dispensed for Resident #7 and was informed that the medication was correct and that she was instructed to place a new description label on the pill pack. When asked about the process for reconciling medication received from the pharmacy, she stated that any nurse can receive the medication from the courier, verifying the count with the inventory sheet and give the medication to the unit nurse to restock the cart.

Based on observation, interview and record review, the facility failed to provide food in a puree form to meet the individual needs of residents for 1 of 6 residents, Resident #57, who were on puree diets; and failed to provide honey thickened fluids to 1 (one) of 7 residents, Resident #61, who were on a diet with thickened fluids. This had the potential to affect 7 residents who were on diets with thickened fluids that included 6 residents were on nectar thickened fluids and 1 resident on honey thickened fluids. The findings included: 1. Record review revealed Resident #57 was admitted to the facility on [DATE], with diagnoses that included: Muscle Weakness and Oropharyngeal Dysphagia (swallowing difficulty). Review of the physician orders documented a medical diet order was for a Regular diet with puree texture foods, and thin consistency fluids. An observation on 02/23/26 at 1:16 PM revealed Resident #57 received a plate with pureed Chicken Alfredo. The resident ate approximately 1 bite of the food. Small rectangular and square pieces of a green vegetable were on top of the pureed chicken alfredo. A square piece of a green vegetable was in the sauce on the plate. The pureed food should have been a homogenous mixture of smooth food with no distinguishable pieces or lumps in it. The Registered Dietician (RD) was made aware. Photographic Evidence Obtained. On 02/23/26 at 1:55 PM, an interview was conducted with the RD and the Kitchen Manager in the kitchen. When asked what the green pieces were, the RD showed the surveyor that the alfredo sauce had small pieces of celery in it. She said the sauce was pureed and that the puree process didn't work. Photographic Evidence Obtained. 2. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses that included: Pneumonia, Unspecified Protein Calorie Malnutrition, and Oropharyngeal Dysphagia (swallowing problem). Resident #61's physician's diet order specified a regular diet with mechanical soft ground texture foods, and honey thickened fluids consistency since 01/20/26. Review of the Minimum Data Set (MDS) assessment dated [DATE] showed the resident was able to understand others sometimes, and she was able to make herself understood sometimes. An observation on 02/23/26 at 12:50 PM revealed Resident #61 was served a glass of regular consistency cranberry juice. The resident should have been served honey thickened cranberry juice. The RD agreed with this finding. Photographic Evidence Obtained. An interview on 02/03/26 at 1:00 PM with the RD revealed she could just look at the juice and see that it was thin. She confirmed that the cranberry juice served to Resident #61 was not honey thickened.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and services for respiratory services for 2 of 2 sampled residents as evidenced by the failure to ensure oxygen orders and a clean oxygen filter for Resident #63, and failure to ensure a clean oxygen filter for Resident #9.The findings included:1. Review of the record revealed Resident #63 was admitted to the facility on [DATE], transferred to the hospital on [DATE], and returned to the facility on [DATE]. The resident's diagnoses included congestive heart failure (CHF), and acute respiratory failure with hypoxia (a lack of oxygen).Review of the physician orders revealed Resident #63 had orders to administer oxygen continuously at 3 liters per minute from 02/06/26 though 02/16/26. The record lacked any current physician orders for oxygen use. There was also an order for staff to clean the concentrator filter weekly from 02/06/26 through 02/16/26. The record lacked any current order for filter maintenance.A current care plan initiated on 02/09/26 documented the resident had the potential for respiratory distress related to CHF and history of acute respiratory failure with hypoxia. Interventions included the use of oxygen as ordered, but lacked anything related to the filter maintenance.During an observation on 02/24/26 at 12:02 PM, the concentrator's oxygen filter was noted to be dust laden, with approximately 1/4 inch of gray dust on the black filter. Photographic Evidence Obtained.During an interview on 02/25/26 at 2:24 PM, when asked the process for maintaining oxygen equipment, the RN (Registered Nurse) Supervisor explained all oxygen equipment was changed out and cleaned by the night nurses once weekly. When asked specifically about Resident #63, the RN Supervisor stated she had heard there was an issue. The RN Supervisor was shown the photograph of the filter and agreed with the findings. During this interview a side-by-side review of the record confirmed the lack of current oxygen orders. 2. Review of the record revealed Resident #9 was admitted to the facility on [DATE] with a diagnosis of acute respiratory disease. Review of the orders revealed the resident had received oxygen since 10/12/25. The record also documented the orders to clean the concentrator filter with soap and water weekly since that date.An observation on 02/24/26 at 12:09 PM revealed the oxygen filter was dust laden. Photographic Evidence Obtained.On 02/25/26 at 2:24 PM, the RN Supervisor agreed with the findings.

50895 Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. The findings included: 1. During the initial tour of the Main Kitchen on 08/12/24 at 9:05 AM, and accompanied by Staff B, the facility's [NAME] Supervisor, and Staff C, the Registered Dietitian (RD), the following was observed: a. A used serving spoon for the breakfast sweet potatoes rested on top of the plastic wrap that partially covered the sweet potatoes. There were plastic spoons observed in an uncovered metal tin, and placed on top of the steam table used on the tray line. The surveyor informed Staff B about the concerns of contaminated serving utensils and contaminated plastic utensils. b. Staff B was observed taking temperatures of foods on the steam table and did not sanitize the thermometer prior to taking the temperature of the sweet potatoes. Staff B was made aware of some possible risks associated with cross contamination. c. Staff C, RD, placed test strips for sanitizer into bucket #1 and bucket #2. The sanitizing solution in bucket #1 and bucket #2 did not meet the requirement for Ammonium compound to be 150 - 200 parts per million. The result of bucket #1 was a yellow color on the test strip, which indicated that there was no sanitizer (O parts per million) mixed into the solution. The result of bucket #2 was a light green color (100 parts per million) on the test strip, which indicated the sanitizing solution was too weak. d. The plastic container of thickener powder had no date written on the container nor on a label on the container. The container of thickener had dried food stuck to the exterior of the container. e. A metal screen like fixture with tiny holes, approximately 18 inches from the ceiling, and located in between the steam table and the oven exhaust, had many dark spots all over the surface. Staff B was made aware that this fixture needed to be clean to maintain sanitary conditions for food service. f. The walk-in refrigerator #8 had no thermometer inside the refrigerator. An empty thermometer clip was observed affixed to the wall inside the refrigerator close to the door. When surveyor questioned Staff B about where the thermometer was, Staff B said that there used to be a thermometer right here. Staff B pointed to the empty clip to the left of the entry door of the refrigerator. g. The cottage cheese best if used by date was 08/3/24. The Hummus use by date was 07/09/24. h. The fan covers on the upper back wall were dusty. Groupings of black specs were observed on the walls located between and around the fans. A concentration of black speck-like debris was observed sprinkled on the ceiling of the refrigerator in the area located on the rear walls near the fans. i. A cycle run of the dishwasher was performed. This dishwasher was a low temperature dishwasher and depended on the regulated sanitizer concentration of 50 parts per million (ppm) of chlorine to sanitize the dishes, glasses, and utensils adequately. The RD used a test strip to test the sanitizing solution. The test strip turned a pale lavender color which indicated a concentration between 0-10 ppm chlorine. The measured amount of sanitizing solution failed to meet the required 50 ppm chlorine. The RD used a second test strip and placed it on a cup that was wet from the dishwasher. The test strip turned a pale lavender color which indicated a concentration between 0-10 ppm chlorine. The test strip again failed to show the required amount of sanitizing solution. j. The clean side of the dishwasher run had residual pieces of food. k. The garbage pail was filthy with splattered food on top of garbage lid and on the exterior of the garbage pail. One half of plastic lid was missing. l. The Southbend oven had a build-up of grease on the interior and exterior surfaces. The top of the oven had food crumbs, dust, and stuck on residue. The oven drip trays were ladened with burned grease. m. The Hoshizaki reach-in refrigerator #5 had a puddle of water on the floor close to and under the unit. The surveyor made Staff B aware that this indicated a functional problem with this refrigerator. n. A drawer of knives and a drawer containing cooking spoons, spatulas, scoops, and whisks was dirty. The knives were removed from the drawer by the RD and they were sent to be washed. The empty drawer revealed a dirty paper with debris that lined the drawer. o. The [NAME] boiler was observed in use boiling soup. It was filthy with residual dried on food on exterior sides of the boiler. p. The ice machine was located in an area for dirty containers, bowls, pans, and garbage. q. A dirty, used apron hung in an area, located near the ice machine and the garbage. r. The food mixer was dirty with residual flour and dried on batter. s. The soda dispenser was rusty. t. A rack of uncovered trays was in the hallway next to the entry door of the kitchen. Photographic Eveidence Obtained of above findings. The findings were reviewed with Staff B and Staff C who agreed with these findings and communicated findings with sanitation of kitchen to the administrator. 2. During a follow-up visit to the kitchen on 08/12/24 at 11:30 AM, Staff B, the [NAME] Supervisor, was asked to take the temperatures of the foods prepared for lunch. The temperature of the broccoli did not meet the regulatory required temperature of 135'F (degrees Fahrenheit) or above. The temperature of approximately 20 portions of cooked broccoli was 122'F. The temperatures of 2 cold foods: cottage cheese, and shrimp salad, were not held at the required temperature of 41'F or below. The temperature of the cottage cheese in the fruit and cottage cheese plate measured 49'F. The shrimp salad measured 75'F. Photographic Eveidence Obtained of above findings. 3. During a follow-up visit to the kitchen on 08/14/24 at 11:36 AM, an interview with the RD revealed she thought the problem with the concentration of the dishwasher's sanitizing solution was because of a clogged tube that ran from the bucket of the sanitizer solution to the dishwashing machine. The RD showed the surveyors the bucket and the connecting tube to the dishwasher. The RD ran the dishwasher twice, and then she performed testing for adequate sanitizer strength. She touched three separate test strips to wet spots on cups that had gone through the dishwashing machine. All three test strips produced a pale lavender color which indicated a concentration between 0-10 ppm chlorine. The sanitizing solution failed to meet the requirement of 50 parts per million of chlorine. Photographic Eveidence Obtained of above findings.

Based on observation, interview, and record review, the facility failed to provided housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 12 of 32 resident rooms, 1 of 1 dining room, 1 of 1 community shower room, main entrance area, and 1 of 1 soiled utility room. The findings included: 1. During the initial resident screenings conducted on 08//12-13/24 conducted by the surveyors and the environment observation tour conducted on 08/14/24 at 10:00 AM with the Administrator and Director of Maintenance, the following observations were noted: a. Main Lobby Area: Floor carpeting was noted to have numerous large black stains. b. room [ROOM NUMBER]: The room Formica flooring was noted to have a large tear (15 inches) and was a potential trip hazard for the room residents, and the portable commode seat was noted to be rust laden. c. room [ROOM NUMBER]: bathroom floor heavily stained throughout, 1 of 4 bathroom lights not working, live ants noted in and around the wall air-conditioner unit (W-bed), air-conditioning unit noted to not be attached properly to the room wall. d. room [ROOM NUMBER]: Room walls (2) noted to be damaged and in disrepair, dresser drawers not closing (W-bed), and fall mat soiled (W-bed). e. room [ROOM NUMBER]: Bathroom floor noted to soiled and stained throughout, room floor soiled and stained throughout, wall air-conditioning unit not properly attached to the wall, and 1 of 4 bathroom lights not working. f. room [ROOM NUMBER]: Room floor stained throughout, no over-bed light pull cord (W-bed), large hole in wall (behind W-bed). g. room [ROOM NUMBER]: Bathroom toilet requires re-caulking to the floor, over bed light cord too short (W-bed), and dresser drawers not closing properly. h. room [ROOM NUMBER]: Bathroom emergency nurse call bell cord wrapped around the bathroom wall handrail. i. room [ROOM NUMBER]: Bathroom toilet requires re-caulking to the floor, room walls (3) damaged and in disrepair. And no over-bed light cord (W-bed). j. room [ROOM NUMBER]: Bathroom toilet required re-caulking to the floor, room floor stained throughout, bathroom toilet seat loose, and room walls damaged and in disrepair. k. room [ROOM NUMBER]: Room floor stained throughout, bathroom floor stained, and toilet required re-caulking to the floor. l. room [ROOM NUMBER]: Bathroom floor stained and soiled throughout, air-conditioning unit not properly attached to the room walls, and toilet requires re-caulking to the floor. m. room [ROOM NUMBER]: Bathroom floor stained throughout, and toilet requires re-caulking to the floor. Community Shower Room: Room entry door damaged and in disrepair, and discolored/stained wall tiles (Shower Stall #1). n. Soiled Utility Room: Interior of Specimen Refrigerator was soiled. o. Housekeeping Storage Room: Soiled equipment and chemicals stored with clean resident toilet and paper towel rolls. p. Hallway Hand Rails: the wall mounted handrails between Rooms #13-21 were noted to have large areas of peeling paint and exposed bare wood surfaces. Following the tour, the environment findings were again confirmed with the Administrator who stated that facility staff are not reporting housekeeping and maintenance issues with the receptionist who is responsible for contacting the housekeeping and maintenance department for their attention to the specific issues. 2. Observation of the main dining room on 08/13/24 at 8:00 AM accompanied with the Administrator and Director of Housekeeping, the following observations were noted: a. Three of six dining room chairs were noted to be soiled and stained with a white substance. b. The exterior of the [NAME] cupboard was soiled and stained. c. Dining room walls (4) were noted to have large black markings in numerous areas of the room. d. Accumulation of dust and dirt on window sills and furniture. e. Floor areas around the dining room tables were noted to have numerous pieces of food debris and were not cleaned following the dinner meal of 08/12/24. f. Numerous room windows (20) were heavily soiled and were not being cleaned on a regular basis. g. The exterior of the suctioning machine located on a back table was noted to be dirt and dust laden. h. Base boards throughout the dining room were soiled and stained. i. Five of 10 light fixture were noted to be heavily soiled and had evidence of dead insects. j. The exteriors of 4 of 4 food tray tray stands were rust laden and required to discarded . k. Soiled resident food trays were carried individually by staff uncovered through the dining room through the clean serving area, and into the kitchen. It was discussed with the Registered Dietitian that exposed soiled food trays are required to be covered at all times and not exposed to clean food preparation and serving areas. l. Observation of the dining room preparation area noted that soiled resident table linens (tabled cloths and napkins) are stored in uncovered barrels (2). m.) Observation of drinking glasses noted that the interiors of the glasses was covered with a white film (26 of 26 glasses). Following the tour, an interview was conducted with the Director of Maintenance who stated he only cleans the dining room floor and has no responsibility for the rest of the dining room issues. The Administrator confirmed all the surveyor findings.

Based on observations, record review, and interviews, the facility failed to prepare food in a form designed to meet the resident's individual need for 1 of 1 sampled resident who had a physician ordered mechanical soft ground diet, Resident #23. The findings included: Record review revealed Resident #23 was admitted to the facility on [DATE], was recently hospitalized on [DATE], and was readmitted to the facility on [DATE], with a diagnosis of Pneumonia. The record revealed Resident #23 had other diagnoses that included Dysphagia (difficulty swallowing), muscle weakness, Dementia, and a history of Covid-19 and obesity. Review of the Minimum Data Set (MDS) significant change assessment, dated 06/15/24, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. This MDS assessment revealed Resident #23 had swallowing problems specified as holding foods in mouth / cheeks or residual food in mouth after meals. Review of Resident #23's care plan, last reviewed on 08/05/24, revealed the resident was at nutritional risk related to Dysphagia. The approach in the care plan noted that the resident's diet was upgraded from a pureed diet to a mechanical soft diet with ground meat. Review of Resident #23's physician diet order dated 07/04/24 listed the current diet order consistency was Mechanical Soft Ground. This diet order was signed by the physician on 07/05/24. Photographic Evidence Obtained. Observation in the main dining room on 08/13/24 at 1:36 PM revealed Resident #23 was served shredded pork. The meat had stringy pieces that were mostly 1/4-1/2 inches long. Resident #23 was observed with prolonged chewing. Photographic Evidence Obtained. The surveyor then went to the kitchen and requested a portion of ground meat from the cook, Staff D. Staff D explained that each plate was prepared to order. Staff D then used a chopping knife and chopped up the meat finely. He gave the plate to the surveyor to observe. This plate remained in the kitchen. Observation at this time revealed Staff B, the Food Service Manager (FSM), entered the food preparation area and he was made aware of the concern about the food texture. The surveyor then requested Staff B to go to the dining room to observe Resident #23's plate. In an interview at the dining room table on 08/13/24, at 1:50 PM, Staff B was asked to describe the prepared pork entree that was on the resident's plate. Staff B stated the pork on Resident #23's plate was of a chopped texture, and clarified that it was not ground. In an interview in the dining room on 08/13/24 at 2:05 PM, the Registered Dietitian (RD), verified that Resident #23's diet order was for foods to be prepared with a mechanical soft ground texture. The RD explained, They don't do therapeutic (ground) diets here. They do regular, salt free pack, the chopped consistency or what we are calling mechanical soft, and we also do puree. The surveyor requested that the RD provide a copy of the diet manual that included a description of foods served on a mechanical soft ground diet. The RD provided a sheet of paper that listed Food items not allowed on mechanical soft diet. Specific breads, cereals, desserts, vegetables, potatoes, and fruits were listed. There was no mention of any meat items. This sheet had no identifying headings that referred to the name of a diet manual or the source of this listing. Photographic Evidence Obtained.

Based on observation, interview, and record review, the facility failed to provide adequate catheter care for a resident with recurrent Urinary Tract Infections (UTI) for 1 of 1 sampled resident reviewed for catheter care, Resident #5. The findings included: A review of the Skills Checklist for Catheter Care documented, in part, for procedure: Use the first washcloth with soap and water to carefully wash around the catheter where it exits the urethra (opening on the penis). Hold the catheter where it exits the urethra with one hand. While holding the catheter, clean 3-4 inches down the catheter tube. Clean with strokes moving away from the urethra. Use a clean portion of the washcloth for each stroke. Resident #5 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive to total two-person assistance with activities of daily living. The assessment further documented Resident #5 had an indwelling catheter (for urinary drainage) and had received antibiotics. Record review revealed Resident #5 was care planned for an indwelling urinary catheter, with an intervention to provide catheter care every shift and as needed, and anchor as ordered. A review of resident #5's physician orders revealed an order dated 05/23/23 for the indwelling catheter to be secured and anchored at all times and catheter care every shift as per protocol. An observation of catheter care for Resident #5 was conducted on 06/14/23 at 12:20 PM with Staff D, a Certified Nurse Assistant (CNA), and assisted by Staff E, a CNA. Staff D was observed cleaning / wiping the catheter going towards the urethra (opening of the penis) three times with separate wipes. Further observation revealed Resident #5's catheter was not secured or anchored. Staff D proceeded to pull back the resident's foreskin to clean the penis shaft. A heavy layer of thick white substance was observed under the resident's foreskin and around the penis. Staff D used approximately 10 wipes to remove the substance, to enable the completion of catheter care. An interview was conducted with the Director of Nursing (DON) on 06/14/23 at 2:00 PM. The DON was made aware of the above.

Based on interview and record review, the facility failed to accommodate a resident's choice or preference for showers, for 1 of 12 sampled residents, Resident # 291. The findings included: Resident #291 was admitted to the facility on [DATE], for short term rehabilitation. Review of the MDS (Minimum Data Set) assessment dated [DATE] indicated it was very important to the resident to choose between a shower, bed bath, or sponge bath. It indicated she required partial assist with bathing with one-person assist. The Brief Interview for Mental Status (BIMS) score was 15 of 15, indicating she was cognitively intact. Review of the care plan, dated 06/07/23, stated she is able to verbalize personal preferences regarding activities of daily living (ADLs) as well as leisure activities. The goal was that the resident will confirm her personal preferences which will be honored to the extent possible daily. The approach included to assist in the resident's preference for bathing which is to be offered showers and choose to accept or not. On 06/12/23 at 10:30 AM, an interview was conducted with Resident #291 regarding choices and preferences. She stated she has not had a shower since she was admitted . She stated she didn't want it in the morning because she goes to therapy at 10:00 AM, and prefers to have a shower in the afternoon. On 06/14/23 at 9:00 AM, the resident stated she was offered a shower this morning but had told the staff she didn't want it because she had therapy at 10 o'clock. She told staff she prefers showers in the afternoon. No showers had been received yet. On 06/14/23 at 11:00 AM, an interview was conducted with the Certified Nursing Assistant, CNA B, who was assigned to the resident. She stated she asked the resident if she wanted a shower this morning but she said no. She stated she had not given the resident a shower this week. When asked if she asked the resident what time she would prefer to have a shower, she said no. On 06/14/23 at 1:30 PM, CNA B, reported to the surveyor that she gave the resident a shower today before lunch. On 06/14/23 at 2:00 PM, Resident #291 confirmed she received her first shower today. On 06/14/23 at 11:15 AM, the Staff Developer printed the bathing information for Resident #291 from 06/05/23-06/13/23. It noted 3 showers were given to the resident, on 06/05/23 by CNA D, and on 06/07/23 and 06/09/23 by CNA C. On 06/14/23 at 2:35 PM, an interview with CNA C was conducted, regarding the two showers she had marked for the resident last week (on 06/07/23 and 06/09/23). She confirmed she did not give the resident any showers, and she must of documented them in error. On 06/14/23 at 3:30 PM, an interview was conducted with Staff A, Registered Nurse, who was assigned to resident. She stated she did see the aide bring the resident back to her room after receiving a shower today.

Based on record review and interview, the facility failed to provide the Binding Arbitration Agreement in writing and failed to have evidence that a resident and/or the resident's representative acknowledged understanding of the Binding Arbitration Agreement. The census at the time of the survey was 47 residents with 17 of the residents being new admissions. The findings included: Review of the facility's admission packet documented, in part, Optional Arbitration Clause (If the parties to this Agreement do not wish to include the following arbitration provision, please indicate so by marking an X through this clause. Other parties shall also initial that X to signify their agreement to refuse arbitration). Any controversy or claim arising out of or relating to the Agreement, or the breach thereof, shall be settled by arbitration in accordance with the provisions of the Florida Arbitration Code found at Chapter 682, Florida Statutes, and judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction. During an interview, on 06/14/23 at 9:14 AM with the Outreach Manager (Admissions and Marketing), when asked about the Binding Arbitration Agreement, the Outreach Manager replied, upon admission, the agreement is explained to the resident or the representative. When asked how the resident or representative acknowledges understanding of the agreement, the Outreach Manager replied, The entirety of the admission packet is good for thirty days and signing the admission packet acknowledges understanding of all of the packet. The Outreach Manager confirmed that the one paragraph in the admission packet was the only reference to the Binding Arbitration Agreement in the entirety of the admission packet. On 06/14/23 at approximately 1:30 PM, the Outreach Manager provided a copy of the facility's Binding Arbitration Agreement. The Outreach Manager stated that she had only had the entire written agreement for about a week. The Outreach Manager was not able to provide documentation of resident or representative acknowledging understanding the Binding Arbitration Agreement upon agreeing to or declining the agreement.

Based on observation, interview, and record review, the facility failed to have a person-centered comprehensive care plan developed and implemented to meet residents preferences and needs related to her [CONDITION(S)] for 1 of 14 sampled residents (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment further documented the resident had highly impaired vision, object identification in question, but appears to follow objects. Resident #29 was care planned for [CONDITION(S)], chronic [CONDITION(S)], dry eyes, unable to participate in visual testing, and legally blind in both eyes, dated 06/17/20. Interventions included: apply cool compress to resident's left eye as ordered, eye medication as ordered, arrange ophthalmologist/optometrist consult as needed, notify physician of any changes, and clean from inner to outer eyelid, and eyelid scrub as ordered. Resident #29's care plan did not address any interventions for the resident's legal [CONDITION(S)]. An interview was conducted with Resident #29's Power of Attorney (POA) on 02/14/22 at 3:50 PM. The POA stated the aides (Certified Nurse Assistants) used to call before breakfast, to go over menu selection that she makes a week in advance. The aides have to ask the resident if the coffee is too hot. It is important to have aides familiar to the resident, as she is blind. An interview was conducted with the Director of Nursing (DON) on 02/16/21 at 4:15 PM. The DON was questioned how new employees are oriented to Resident #29's needs. The DON stated new employees shadow an employee for about a week. They learn all units (3). The DON further stated for Resident #29, there is an instruction pamphlet on how to provide care to the resident, that the resident's POA provides. The pamphlet is kept in a binder at the nursing station, and is pinned on the wall in the resident's room. The POA updates the pamphlet as needed. A review of the pamphlet provided by the DON was dated [DATE]. The first line under communication on the first page documented: Because she (Resident #29) is legally blind, you must verbalize to ensure she knows what is going on. The DON stated her staff knows that Resident #29 is legally blind. An interview was conducted with Staff A, a Certified Nurse Assistant (CNA), on 02/16/22 at 4:30 PM, in the presence of the DON. Staff A-CNA stated she had been working at the facility for 6 months. Staff A-CNA stated she has provided care for Resident #29 about 3 times with another CNA. Resident #29 always has 2 CNAs assigned to her due to the resident's POA special requests for the resident, and they rotate assignments. Staff A-CNA stated she always presents herself to a resident when she enters a room, even if they are blind. Staff A-CNA stated Resident #29 can hear her and see her. Surveyor questioned Staff A how she knows what to do for the resident. Staff A replied The POA tells her what to do. An interview was conducted with Staff B, a CNA, on 02/16/22 at 4:41 PM, in the presence of the DON. Staff B stated she had been working at the facility for 9 years. Staff B stated she is assigned to Resident #29 about 3-4 times a week, with another CNA. Staff B-CNA stated she was assigned to Resident #29 yesterday, but not today. They rotate assignments to avoid burnout. Staff B stated the resident requires total care. You have to know how to position the resident per the resident's POA request. Staff B-CNA stated she traines new CNA staff. You knock on the door, and introduce yourself. You ask the resident if it is okay to stay. The resident indicates it is okay when she opens her eyes, at times. Sometimes there is no response. Staff B-CNA stated she trained an agency CNA yesterday, she only observed. Surveyor questioned if there was anything someone new would need to know about the resident prior to entering the resident's room? Staff B-CNA shrugged her shoulders. The DON asked Staff B-CNA What does to POA always say? Staff B-CNA stated, Oh, her POA says she is blind. Surveyor questioned Staff B-CNA how someone new would find out how to care for Resident #29. Staff B stated they would look at her Plan of Care (POC) in the computer for the CNAs. The DON stated CNA's POC is pulled from the resident's care plan. Staff B-CNA, along with the DON, pulled up Resident #29's POC. The POC did not have any documentation or plan of care for Resident #29 being legally blind. An interview was conducted with the DON on 02/17/21 at 12:00 PM. The DON acknowledged Resident #29's care plan needed to be revised to address the resident's legally [CONDITION(S)].

Based on record review and interview, the facility failed to follow a physician order [REDACTED]. The findings included: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a comprehensive assessment dated [DATE] for Resident #36 that documented the resident had mild cognitive impairment, required extensive two-person assist with activities of daily living, and had an indwelling catheter. Resident #36 was care planned for an indwelling urinary catheter related to having [MEDICAL CONDITION] and is at risk for UTI (urinary tract infection has enlarged prostate .01/13/21 [MEDICAL CONDITION] .01/26/21--has a fever Start Date: 01/26/2021. An intervention included to administer antibiotics as ordered. A review of Resident #36's physician orders [REDACTED]. Further review of the resident's orders revealed a physician order [REDACTED]. Resident #36's physician ordered [MEDICATION NAME] (antibiotic) intravenously dated 01/27/21 once a day until 02/01/21 for a [DIAGNOSES REDACTED]. A review of Resident #36's progress notes revealed a note dated 01/11/21 at 2:00 PM documented Resident #36 had a distended, hard abdomen. Physician was notified. A progress note dated 01/11/21 at 6:34 PM documented: Portable ultrasound of kidney and bladder received with significant findings. Results faxed to Physician. New order received. A progress note dated 01/11/21 at 7:23 PM documented: Resident straight cathed (catherization) as per physician order [REDACTED]. Will maintain Foley. A progress note dated 01/26/21 at 3:15 PM documented Resident #36 reported being tired and fatigued. The resident had a fever of 100.3 Fahrenheit (F). Physician was notified, and orders were received for blood work, urinalysis culture and sensitivity and a stat chest x-ray. A review of the facility's Laboratory Specimen Log Book revealed an entry for Resident #36 for a CBC, Chem 21, BNP, and Blood Cultures x 2. There was no evidence a UA/C&S was not logged into the specimen book. An interview was conducted with Staff A, Nurse Supervisor / desk Registered Nurse, on 01/28/21 at 1:00 PM. Staff A acknowledged the order for Resident #36 for UA/C&S. Staff A further acknowledged the urine sample had been checked off as received on Resident #36's Medication / Treatment Administration Record on 01/26/21. Staff A acknowledged a UA/C&S was not documented on the Laboratory Specimen Log Book. Staff A called the lab, and confirmed they did not have a urine specimen for Resident #36.

Based on observation and interview, the facility failed to maintain the kitchen environment in a sanitary manner, as evidenced by staff not wearing hair covering. The findings Included: On 05/01/19 at 12:00 PM, a second kitchen observation was conducted of the lunch food temperatures and portion sizes. At 12:20 PM, while observing the dishwashing machine and the three compartment sink accompanied by the Registered Dietitian / Consultant, Employee A, the dishwasher / diet aide, was observed not wearing a hair net or covering. The Registered Dietitian / Consultant asked Employee A to get a hairnet. On 05/01/19 at 12:30 PM, in an interview with the Registered Dietitian / Consultant, who had witnessed this observation with the surveyor, confirmed the finding.

Based on interview and record review, the facility failed to provide written notice of residents' transfer and the reason for the transfer in writing to the residents' representatives, and the Ombudsman for 2 of 2 sampled residents, Residents #44 and #54. The findings Included: 1. On 05/01/19 at 2:00 PM while conducting a record review it revealed that Resident# 44 was transferred to the hospital on [DATE] because the resident was unresponsive. did not respond with sternal rubs and tactile stimuli. The Resident, once awake, had left side weakness noted but was unable to follow command. The physician (MD) was notified. The MD ordered to transfer the resident to the hospital for evaluation and treatment. Further review of the resident chart lacked evidence of documentation that a written notice, upon transfer or soon after the transfer, was provided to the resident or the resident's representative. There was also no evidence that a notice was sent to the Ombudsman or that they had been notified. The resident was readmitted to the facility on [DATE]. 2. On 05/01/19 at 2:00 PM, record review revealed that Resident #54 was transferred to the hospital on [DATE] at 12:00 PM, due to abnormal lab results (elevated white cell count/WBC) and a history of [MEDICAL CONDITION] but the resident was without signs and symptoms of the infection. The physician (MD) ordered the resident be transferred to a hospital for further evaluation. Further review of the resident's record lacked evidence, upon transfer or as soon after transfer, that the resident's representative was provided written notice or was notified. There was also no evidence of documentation that the Ombudsman was notified. There was no evidence that this resident returned to the facility. On 05/01/19 at 3:40 PM, an interview was conducted with the administrator who confirmed the findings that the facility did not provide the written notice of Transfer / Discharge to the residents, the resident's representatives, or the Ombudsman's office. There was evidence the facility sent the Transfer / Discharge form to the hospital with EMS (emergency medical services). Further interview with the administrator revealed that they was not aware that the residents' representative and the Ombudsman were to be notified in writing of a transfer or discharge.

Based on record review and interview, the facility failed to provide written information of the bed-hold policy to residents and the residents' representative for 2 of 2 sampled residents, Residents #44 and #54, upon transfer or discharge. The findings included: 1. On 05/01/19 at 2:00 PM, record review of Resident #44 record revealed that Resident# 44 was transferred to the hospital on [DATE] due to the resident being unresponsive. Further review of the resident chart revealed that the chart lacked written evidence that the resident and the resident's representative was provided a copy of the Bed-Hold Policy and information. 2. On 05/01/19 at 2:00 PM, record review revealed that Resident #54 was transferred to the hospital on [DATE] at 12:00 PM, due to abnormal lab results (elevated white blood cells/WBCs) but the resident was without signs and symptoms of the infection. The physician (MD) ordered the resident to be transferred to the hospital. Further review of the resident's medical record lacked evidence of documentation that, upon transfer, a copy of the bed-hold policy and information was provided in writing to the resident and the resident's representative. On 05/01/19 at 3:40 PM, an interview was conducted with the administrator who confirmed the findings that the facility did not provide a written copy of the bed-hold policy and information to the resident and the resident's representative. Further interview with the administrator revealed that they was not aware that the resident and the resident's representative were to be notified in writing.

Based on observation and interview, the facility failed to maintain in good condition a wheelchair pressure relieving cushion for 1 of 50 residents observed during the initial screening process, Resident #35. The findings included: On 04/30/19 at 9:29 AM, Resident #35 was observed in the activities room sitting on his wheelchair. At the time of the observation, it was noted that the pressure relieving cushion in the wheelchair was worn out, split, and not supplying appropriate support for Resident #35. It was noted that the split/tear was at the front right corner of the cushion, was approximately 2 inches long, and the yellow stuffing inside the cushion was exposed. This resident's cushion was observed in the same condition during the entire 4-day survey period. On 05/02/19 at 10:45 AM, the surveyor brought this concern to the attention of the Assistant Director of Nursing (ADON), who was stationed at the Nurse's Station. The ADON had not been aware of the issue with the cushion until the surveyor showed her specifically where to look. The ADON agreed that the cushion should be replaced and brought the resident in his wheelchair to the Rehabilitation Department, who is responsible for the mobility devices and pressure relieving devices. The surveyor accompanied the ADON to the rehab department where a Therapist replaced the seat cushion. The old cushion was again observed to be worn and thin. After the cushion was removed from the wheelchair, the seat of the cushion did not rise to return to former shape, indicating that there was reduced support being provided. The ADON agreed that the cushion should have been checked and replaced prior to this time. The ADON was unsure who was responsible for the maintenance of the wheelchair and the seat cushion. The finding was brought to the attention of the Director of Nursing (DON), who stated that the Rehabilitation (Rehab) Department is responsible for the inspection and care of the wheelchairs and pressure relieving cushions. At this time, the Rehab Director joined the meeting at the request of the DON. The Director of Rehab explained that facility-wide inspections of the cushions and wheelchairs were done quarterly in conjunction with the wheelchair supplier. The Director of Rehab said these inspections included inspections of the arm rests, leg rests, seat cushions, brake grips and brakes. The Director of Rehab then explained that he just implemented a plan with the wheelchair provider to make these inspections monthly. The Rehab Director could not provide written evidence of this plan. The Director of Rehab stated he could put together a formal in-service for of the staff to proactively look for key signs of wear in mobility devices and pressure relieving devises, and this was verbally supported by the DON.

Based on interview and record review, it was determined that the facility failed to provide immediate access to a resident by a family member, subject to the resident's right to to deny or withdraw consent at any time, for 1 of 3 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. A review of the resident's most recent quarterly Minimum Date Set (MDS) assessment, dated 10/15/2018, revealed the resident's Brief Interview for Mental Status (BIMS) score was 06 out of 15, indicating severe cognitive impairment. Interview with the admininstrator, on 10/29/18, during the review of the facility files and documentation, it was revealed a family member of Resident #1 was denied admittance and vistation rights. The facility documented the justification for their denial of vistation, however there was no legal documentation of a restraining report obtained by the facility to deny access and vistation to Resident #1. Accoring to facility records and documentation, the family member's right to access the resident for vistation was denied beginning on 09/23/18 and was still in place on the date of the complaint survey, 10/29/18. Resident #1 was contacted briefly during the facility tour on 10/29/18 at 11:30 AM, however she would not respond to interview questions.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food service safety. These include: holding hot food at regulatory temperatures, maintenance of refrigeration units, and ensure that canned foods are safe for use and are removed from food storage areas. The findings included: 1. The entrance to the walk-in refrigerator was noted to have a heavy build-up of condensation around the upper door frame. Further observation noted that the condensation was so heavy that it was dripping down over the entrance to the unit. There was a potential that this soiled condensation could drip onto foods and staff that enter and exit the refrigeration unit. The surveyor requested that the issues be corrected immediately and the facility contacted an outside refrigeration vendor on 03/26/18. An interview conducted with the vendor technician on 03/26/18 revealed that the build-up of condensation was due to leaving the entry door open for long periods of time. 2. The entrance to the walk-in freezer was noted to have a heavy ice build-up around the entrance way and entrance door. Further observation noted that the entrance door would not shut tight and seal when shut. There was a potential of ice crystals developing on foods stored within the unit and loss of temperature. The surveyor requested that the issues be corrected immediately and the facility an outside refrigeration vendor on 03/26/18. An interview conducted with the refrigeration technician on 03/26/18 revealed that the entrance door to the freezer unit is warped and will not seal when shut which cause the ice build-up. 3. During the tour it was noted that there was a pan of cooked BBQ pork (40 portions) located in the Autos hot holding unit. Interviews with the 2 preparation cooks (Staff A and Staff B) at the time of the observation noted that the pork was put into the unit to reheat the pork for the 03/26/18 lunch service. The staff were informed by the surveyor that this type of re-heating or cooking of perishable cannot be used due to time and temperature, specifically that the time for the pork would take to long to reach the minimum holding temperature of 135 degrees F. An internal temperature of the pork was taken by the surveyor utilizing the facility's calibrated digital thermometer and was recorded at 95 degrees F. The surveyor requested that the pork not be served to the facility residents. 4. During the observation of the dry goods / canned goods storage room, it was noted there were canned foods that were heavily dented that were stored on the canned food storage rack. The dented canned foods included: 3 - #10 Cheddar Cheese Sauce, 1 - #10 Mandarin Oranges, and 1 - #10 Pitted Prunes. The Food Service Manager stated that all canned foods are required to be inspected for dents / damage prior to being put into the storage shelves, and any dented / damaged cans should be put in the main office.

Based on observation, interview, and record review, it was determined that the facility failed to served the portion size of entrees that was documented on the approved menu. The findings included: 1. During the review of the approved menu for the week of 03/25/18 and the lunch meal of 03/26/18, it was noted that the portion size to be served for the Salmon Cake was 5 ounces. Further review of the approved menu noted that a 4 ounce protein entrée was the standard minimum size portion to be served to the residents. An interview with the facility's Consultant Dietitian, at the time of the menu review, confirmed that the standard minimum entree protein portion was 4 ounces. A review of the Standardized recipe for Salmon Cake was reviewed on 03/26/18. The review revealed that 20 pounds of salmon were to be utilized for yield 80, 5 ounce portions. Interview with the the lunch cooks (Staff C and Staff D) revealed that only 11 pounds of Salmon were utilized to yield approximately 40, 3 ounce portions of Salmon Cakes. During the observation of the lunch steam table line on 03/26/18 at 12 PM, at the request of the surveyor, two portions of Salmon Cakes were weighed using the facility's calibrated portion weighing scale. It was noted that both Salmon cake portions were recorded at 3 ounces. It was confirmed with the Consultant Dietitian at the times of the weighing that an insufficient portion of Salmon was being served and the approved menu was not being followed for the lunch meal. 2. During the review of the approved menu for the lunch meal of 03/28/18, it was noted that a 4 ounce protein portion of catfish was to be served as a standard portion size. A review of the Standardized recipe for Fried Catfish documented only to utilize a 4 ounce breaded catfish fillet. It was discussed with the Consultant Dietitian at the time of the review that after cooking the catfish, it would weigh only approximately 3 ounces and would not be the portion that the approved menu documents. During the observation of the steam table serving line on 03/28/18 at 12:10 PM, the surveyor requested that 3 portions of the Fired Breaded catfish to be weighed on the facility calibrated portion scale. The portions were recorded as follows: #1=3.25 ounces, #2=2.5 ounces, and #3=2.75 ounces. It was confirmed with the Dietitian following the weighing, that a 4 ounce protein portion of of the catfish was not being served and that the approved menu for the lunch meal entree was not being followed. 3. A review of the diet census for 03/26/18 and 03/28/18 was reviewed on 03/29/18. The review indicated that there were 37 residents with physician ordered regular diet. There was potential that the insufficient protein entree portion could effect all 37 residents.

Based on observation and interview, the facility failed to label and store food in a proper, safe and sanitary condition. The findings included: The requirement was not met as evidenced by the following: On 02/20/2017 at 07:45 AM, a tour of the dry storage area in the kitchen was conducted with the Food Service Manager. The following was revealed: Two female kitchen Servers (Staff A and Staff B), were noted to serve breakfast plates to the residents without wearing hair nets. They were observed entering the kitchen to pick up food and returning with plates to serve. A large bag of opened walnuts were not dated to reveal when the items were received or opened by the facility. An open 4 oz. can of powdered Hollandaise sauce with an egg base was not properly dated. The date shown on the top of the can revealed 05/03. The year was not included to reflect when the can was received into the facility. There was no open date on the can. A large aluminum baking tray was observed with sprinkled spices stuck on the base of the tray. On the second shelf in the dry storage closet a 16 oz. container of honey had dripped down on the following 12 oz. spice containers. The outside of the containers were sticky and stained: Garlic powder, Black Pepper, and Bay Leaves. The Bay leaves were dated good for use from 06/29/16-08/11/16, which were expired, but possibly still being used by staff. Approximately 3 pounds of sliced Turkey was observed in an opened zip locked bag on the refrigerator shelf. It did not contain a date. Two pounds of opened Mozzarella cheese were not dated. One half pound of opened unsalted butter was not dated. Four ounces of opened Mild American Cheese slices were not dated. On the same day at the time of the discovery, these issues were discussed with the Food Service Manager and the Dietitian. It was confirmed that the findings were correct.