Every finding on record at Washington Rehabilitation and Nursing Center

Based on record reviews and interviews, the facility failed to ensure allegations of neglect were reported timely for 2 of 2 sampled residents. (Residents #3 and #8) The findings include:Resident #8 On 11/24/25, a record review was conducted for Resident #8. The review revealed the resident sustained a fracture of the right knee during a 1 person assist transfer from their bed to a wheelchair. On 11/24/25 at 11:00 AM, an interview was conducted with Staff B, a licensed practical nurse (LPN), who performed the transfer. The LPN stated he broke protocol when getting the resident up for a medical appointment. He stated that the resident needs a mechanical lift for all transfers but the lift could not be found, so he asked the resident if she could pivot and she agreed. He was the one who got the resident up and used a pivot turn to transfer the resident from the bed to the wheelchair. There did not seem to be any issues after the transfer so he did not think to say anything. It was not until later that the resident complained of knee pain. On 11/25/25 at 9:52 AM an interview was conducted with the Administrator, who stated she did file a state Adverse report for the fracture due to failure to follow the plan of care, but did not start an investigation into neglect as she believed the issue was limited to not following the plan of care. Resident #3 An interview was conducted with the Social Services Director (SSD) and Director of Nursing (DON) on 11/24/25 at 2:30 PM concerning an issue where Resident #3 had an undetected broken hip which eventually led to hospitalization on 9/5/25 The SSD got a call on Labor Day that Resident #3 was at the hospital and had a fractured hip. The Risk Manager had a statement that another resident had rolled up to Resident #3 to speak to her and rolled too close to her leg, and the wheel of the wheelchair came between her legs, which caused Resident #3 to yell out. The next day the facility found a bruise in the same area. The DON stated they did not think it was hard enough to cause any injury. Further interview was conducted with the SSD and the Administrator on 11/24/25 at 2:45 PM. The Administrator was asked why the facility did not file a federal report with the state agency regarding the allegation of neglect for Resident #3; she stated they did not feel the incident rose to the level of neglect. Review of the undated facility policy for Abuse, Neglect, Exploitation, Misappropriation of Property, and Injury of Unknown Source revealed a definition of Neglect: Neglect means the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish or emotional distress. Federal reporting requirements: immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, report to the Agency for Health Care Administration's Complaint Administration Unit.

Resident #116 An observation of Resident #116 was conducted on 6/16/25 at 1:18 PM. Contact precautions signage was observed to be on the resident's room door. (Photographic evidence was obtained.) The signage instructed everyone to clean their hands before entering the room, and providers and staff to put on gown and gloves before entering the room. Employee A (Laundry Aide) was observed to enter the room and deliver Resident #116's laundry. Employee A did not apply a gown or gloves prior to entering the room. Employee A was observed to touch Resident #116's bare hand with her bare hand and then left the room. An interview was conducted with Employee A on 6/16/25 at 2:30 PM. She stated she recalled touching Resident #116's hand when she delivered her laundry. She observed the signage on the door but she did not know she had to apply a gown and gloves before entering the room. She was not sure if she had training regarding isolation procedures. A review of Resident #116's electronic medical record revealed a physician's order dated 6/16/25 for contact isolation precautions every shift due to her urine testing positive with a multi-drug resistant organism. A review of the undated facility policy for Standard and Transmission-based Precautions revealed that contact precautions are implemented most often for residents who have an infection due to an epidemiologically important organism such as multi-drug resistant organism (MDRO). Staff are to put on gowns and gloves upon entry and remove gowns and gloves upon exit of the resident room. Based on observation, record review, staff interview, and policy review, the facility failed to ensure staff followed appropriate infection control practices during wound care for 1 of 1 resident sampled with a pressure ulcer (Resident #95) and 1 of 1 residents reviewed for contact isolation precautions (Resident #116). The findings include: Resident #95 A wound care observation was conducted concerning Resident #95 on 6/18/25 at approximately 8:50 AM. Staff B (Wound Care Nurse) put on gloves upon entering the resident's room. The nurse set up the wound care dressing supplies on the draped bedside table and repositioned the resident to her left side for access to the wound sites. It was observed that the resident's adult brief contained urine. The brief was rolled and tucked underneath the resident and the old dressings from resident's right hip and coccyx pressure ulcer wounds were removed. At this point, wound care was performed, and new dressings were placed. At no time while performing the wound care was Staff B observed to perform hand hygiene and change her gloves. An interview was conducted with Staff B after this wound care was completed. She was asked about the infection control practice of changing gloves and if she should have changed her gloves before performing wound care and placing new dressings. She stated that Yes, I know that I know should have changed my gloves, I don't know how I missed that. An interview was conducted at approximately 9:05 AM with the Director of Nursing (DON). She was asked about her expectations regarding infection control practices for nurses when performing wound care and dressing changes. She stated that she expected that nurses will follow infection control practices and change their gloves as trained while performing wound care and dressing changes. The facility's undated wound care policy and procedure entitled Infection Control- Clean Dressing Change stated, 9. Position the resident for comfort 10. Perform hand hygiene 11. Put on clean gloves 12. Remove dressing and place in the resident's trash can 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Cleanse wound . 16.pat wound dry. 17. Remove gloves and perform hand hygiene. 18. Put on clean gloves. 19. Apply clean dressing as ordered and ensure dressing is dated.

Based on interviews and record review, the facility failed to implement the care plan for 1 of 3 residents sampled for wound care. (Resident #308) The findings include: On 3/5/24 at 8:35 AM, an interview was conducted with Resident # 308's representative. During the telephone interview, she indicated Resident #308's wound care treatments were not being done. A review of Resident # 308's record was conducted. The record revealed that Resident #308 was discharged from the facility on 2/16/24 and could not be observed or interviewed. Therefore, a review of the closed record was performed. The medical record revealed the resident was admitted to facility on 11/5/23 from a hospital related to brain mass that resulted in the resident having a partial right frontal lobectomy (a surgical removal). A review of the physician's orders revealed an order to apply skin prep to a blister on the right side of her forehead daily and as needed one time a day, starting on 11/7/23 and discontinued on 11/28/23. A review of the Treatment Administration Record (TAR) revealed there was missing documentation on 11/10/23. Another physician's order stated Right side of forehead denude blister: cleanse with NS, pat dry, apply a piece of collagen sheet to area and cover with a dry dressing daily, to start 11/28/23 and discontinued on 1/16/24. The TAR review revealed there was missing documentation on 12/3/23, 12/6/23, 12/19/23, 12/21/23, 12/22/23, 12/25/23, 1/4/24, 1/11/24, and 1/16/24. Another physician's order stated, Cleanse wound to right temporal lobe with normal saline, pat dry, apply calcium alginate to open area and cover with dry dressing every day shift for wound care with a start date 1/17/24 to be discontinued on 2/18/24. The TAR here had missing documentation on 1/18/24, 1/25/24, 2/1/24, and 2/8/24. The plan of care included the goal of wound care as ordered. On 3/07/24 at 9:51 AM, an interview was conducted with the Director of Nursing (DON). She reviewed Resident #308's medical record and confirmed the TARs were not completed related to wound care. She further stated there was no reason for the documentation to not be completed.

Based on observation, resident interviews, staff interviews and record review, the facility failed to provide a palatable diet that took resident preferences and feedback into consideration for 9 of 20 residents sampled who consume meals from the facility (#s 6, 7, 8, 10, 27, 34, 55, 66, and 109). The findings include: On 11/28/22 at approximately 12:01 PM, an interview was conducted with Resident #7 who stated, the food is horrible. An observation was made of the resident eating beans and macaroni and cheese from a plastic container. Resident #7 revealed her family brings food to her because the food at the facility is so horrible. On 11/29/22 at approximately 11:44 AM, Resident #7 revealed to the surveyor that she went to the kitchen and ordered a salad for lunch and further stated the salad consists of lettuce and tomatoes. On 11/29/22 at approximately 12:34 PM an observation was made of Staff B, Registered Nurse (RN) supervisor serve resident #7 lunch tray. The tray included the regular menu of meat balls and noodles. The resident refused the lunch tray and stated, I went to the kitchen and told the kitchen staff I wanted a salad for lunch. Observed Staff B remove the meal ticket from the tray and notified Resident #7 she would go to the kitchen to get her a salad, after she finished serving the trays to the other residents. On 11/28/22 at approximately 2:26 PM, resident #6 was interviewed regarding requesting alternate food choices. He indicated sometimes when he asks for an alternate the kitchen staff have an attitude. On 11/29/22 at approximately 8:44 AM, an interview was conducted with Resident #109 who stated, the food is horrible, it's like prison food. On 11/29/22 at approximately 12:22 PM, an observation was made of staff B, RN Supervisor, serving Resident #109 lunch tray. The resident stated when asked if that was what he wanted for lunch, there's nothing I can do about it. Staff B offered to get Resident #109 an alternative food choice, the resident stated, it doesn't matter. On 11/30/22 at approximately 9:21 AM, an follow-up interview was conducted with Resident #109 who stated breakfast was the same as always, with powdered eggs and blah. Resident #109 stated the staff do not offer him a choice of meals before the meal is served, and then stated he did not know there was an option for an alternate meal choice. Resident #109 then stated the food is not fit to eat, but he has to eat it. A review of Resident #109 record revealed the resident has a medical diagnosis to include Type II diabetes with an order for carbohydrate-controlled diet. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status, (BIMS) score of 10 which indicates moderate impairment. The care plan, with a problem start date of 7/1/22 indicated the resident is at risk for malnutrition related to the resident's disease processes. On 11/28/22 at approximately 3:28 PM, an interview was conducted with resident #10 who stated the food is not good. On 11/29/22 at approximately 12:28 PM an observation was made of Resident #10 sitting in her wheelchair in her room who stated she did not want to eat her lunch. The lunch tray was observed to be meatballs with noodles and carrots. On 11/30/22 at approximately 9:33 AM an observation was made of Resident #10 breakfast tray which was partially eaten. Resident #10 stated the food is not fit to eat and stated the staff do not offer an alternate meal. A review of Resident #10 record revealed the annual MDS dated [DATE] with a BIMS of 08 which indicates moderate impairment. The Care plan with a problem start date of 4/16/19 indicated the resident is at risk of malnutrition related to intake of less than 75% for most meals. On 11/28/22 at approximately 11:59 AM, an interview was conducted with Resident #8 who stated the food is terrible, but she just accepts the meals and either eats it or leaves it. On 11/30/22 at approximately 9:17 AM, a follow-up interview was conducted with Resident #8 who stated the staff do not ask for meal preference prior to serving the meal, they just bring the meal in. Resident #8 stated if she doesn't like the meal, she will pick what she can tolerate and leave the rest. The resident revealed the meals are getting worse and provided an example of Thanksgiving Day meal. The resident stated the lima beans were so hard she could not eat them. Resident #8 stated she has a refrigerator in her room, so she can keep food, condiments, etc. On 11/28/22 at approximately 2:00 PM, an interview was conducted with Resident #34, who's roommate stated the food is not very good. Resident #34 was asked if she liked the food, and the resident shook her head no. Review of the resident's medical record revealed the resident was non-verbal, but communicated by shaking her head yes or no. On 11/28/22 at approximately 10:16 AM, an observation was made of the menus posted on 3 North nursing unit, located across from the nurse's station. The menus posted were for Sunday breakfast, lunch, and dinner. An additional observation was made on 11/29/22 at approximately 11:44 AM, the menus posted were for Sunday breakfast, lunch, and dinner. Photographic evidence obtained. On 11/28/22 at approximately 03:27 PM, Resident #55 indicated that she was unsatisfied with the food served at the facility. She explained that residents had met and repeatedly requested fried chicken, they have not been served fried chicken. She explained that for the Thanksgiving meal they were served turkey with lima beans. She described the lima beans as being undercooked and hard. She also said that vegetables served were often either undercooked and hard or overcooked and mushy. She indicated that alternates served were often left overs from the last meal. She explained the residents have met and complained on numerous occasions; but have seen no improvement in food quality. On 11/29/22 at approximately 11:55 AM, an interview was conducted with Resident #66. He said: The food is never palatable. The food is either over cooked or under cooked. He had a case of canned food and a refrigerator in his room. He said: I have to stay stocked with my own food because I cannot eat the food here. It has gotten worse in recent months. We have complained but the food does not get any better. He was asked to specifically describe the issues with the food. He said: The food has a poor consistency and a poor temperature. On 11/29/22 at approximately 11:55 AM, Resident #27 said he also wanted to talk about the food. He had eaten cheerios, milk, and a banana provided by the facility for lunch. He said: I ask for cheerios all the time because I do not like the food here. I can eat cheerios. He was asked if he has requested food choices from the alternate menu. Resident #27 explained that the problem with the food is the way that it is cooked. He explained that alternate food choices were just as poorly cooked as the main menu items . On 11/29/22 at approximately 12:22 PM, an interview was conducted with Staff B, RN Supervisor who stated residents who get up can review the posted menus and then request an alternate food choice. She stated if the residents do not get up or go outside of their room the staff will review what is on the menu and will then notify the kitchen of the request. She confirmed she gets a lot of complaints related to food and stated she tells the dietary department when a resident complains or will notify the administrator depending on the complaints. She stated she was not aware the menus had not been changed since Sunday. On 11/30/22 at approximately 9:00 AM, an interview was conducted with Staff A, CNA who stated residents who get up can review the menus and tell the staff what they want for lunch. Staff A revealed the requests must be to the dietary department by 10:00 AM so the dietary department can prepare the appropriate tray. She stated for the residents that do not get up, or leave their rooms, the staff will go to the resident and let them know what is on the menu, then will submit the request to the kitchen. Staff A, CNA stated, the kitchen does not always respond, and the residents don't always get the requested tray. Staff A, CNA revealed the kitchen staff is usually the problem with getting the correct trays to the resident. A follow up interview was conducted on 11/30/22 at approximately 12:48 PM, with Staff A who stated, the kitchen sucks, and stated the kitchen staff are rude and get mad if the CNA's go to the kitchen for alternates. Staff A, CNA stated residents don't always get silverware or the right specialized plates, such as a lip plate. Staff A revealed there are a lot of food complaints and stated, the food is so bad, I wouldn't feed it to a dog. On 11/30/22 at approximately 11:29 AM, an interview was conducted with the Registered Dietician, (RD) who revealed she splits management of the kitchen with the Certified Dietary Manager (CDM). She revealed she is typically at the facility 3 days per week, and the CDM comes in 2 days per week. The RD stated the menus are on a 4-week rotation cycle and the menu is changed every 6 months. The RD revealed the facility has a resident food council, and the residents voice what they like and don't like. The RD stated meal preferences are obtained on admission and quarterly and are entered in the meal tracker system and further stated preferences change more frequently for residents who are alert and oriented. The RD stated the process for the residents to get an alternate meal is for the resident to tell the CNA and the CNA would go to the kitchen and ask for a tray. She stated the kitchen staff may need to finish a tray line prior to fixing the requested tray, and then the dietary staff would send it to the floor. The RD stated the kitchen manager and herself follow up on the grievances, and indicated if the resident grievance is not specific, such as a complaint that the food sucks she can't do much with the complaint and stated, I eat the food and it doesn't suck. She stated if the grievance can be fixed, it will be fixed on the spot. She stated if it is fixed immediately, she does not complete a grievance or document the complaint and stated if it is a complaint such as I always get what is on my dislike list, she will write a grievance and will work to resolve the complaint. The RD stated the dialysis patients have a liberalized diet which is supported by the literature for residents in a long-term setting, and she tries to teach them it is ok to eat the diet provided. She stated she coordinates with the dietician at the dialysis center. The RD was told the residents had complaints of food not cooked well, and she stated, I don't doubt there are complaints of food. She was told the beans were hard, and not fully cooked on Thanksgiving and the biscuit was so hard the resident could not eat it. She stated when there is a complaint of how the food is cooked if it is reported when it happens, she would look at trays and remove items that were not good and substitute for something else and stated they would just fix it on the spot and keep the line moving. She stated they do try to accommodate the requests and stated the kitchen staff try to accommodate the residents and stated she really advocates for the kitchen staff because they try hard. She confirmed the menus on the units are changed daily and confirmed the menus on 3 North were not changed. A follow up interview was conducted with the RD on 12/1/22 at approximately 10:13 AM who stated she is at the facility most of the time and primarily runs the kitchen and indicated the CDM is at the facility 1-2 days per week. The RD stated she is part of the QAPI team and discusses weights primarily and confirmed she follows up with each complaint. The RD stated the facility has had a hard time getting a CDM and stated they have had 3 in the last year. The RD stated the kitchen staff can be gruff with the staff and stated she might be gruff sometimes as well. On 11/30/22 at approximately 10:45 AM, staff member C, LPN, was interviewed. She indicated nursing staff advocate for the residents and their choices of alternate meals, however the dietary staff can be difficult to deal with. On 12/1/22 at approximately 10:26 AM, a telephone interview was conducted with the facility CDM who confirmed he is at the facility 2 times per week and stated he covers 4 other facilities. The CDM confirmed the RD focuses more on clinical issues and the CDM is more operational and confirmed the facility has a dietary manager. The CDM revealed the residents give suggestions for menu items, but the kitchen staff follow the agreed upon 4-week menu cycle and stated they will work to give what the residents want as long as the RD signs off and it meets nutritional standards. The CDM revealed the residents prefer fried chicken over baked and stated fried chicken was on the menu for today. The CDM stated the residents will notify the CNA's when they want the alternate meal, the CNA would then go to the kitchen to get the meal. The CDM stated the dietary manager follows up on the food/dietary grievances and will then give the completed grievance to social services. The CDM confirmed that the dietary department does not track or trend grievances. On 12/1/22 at approximately 10:46 AM, an interview was conducted with Staff H, dietary manager who stated she is required to follow the menus and must stick to the budget and can only use the substitute menu if items do not come in on the truck. She stated the residents like fried chicken, but baked chicken is usually on the menu. She revealed she has discussed with the RD and CDM the requests made by the residents, but she is told she must follow the menus and confirmed the residents are not happy, but she must go by the menus. The dietary manager confirmed she follows up on the grievances by talking with the residents, then discusses with the social worker, who completes the grievance form, she then signs the form. A review of the Resident Council Minutes was completed, for the time period of January 2022 to October 2022, which revealed complaints related to food on 1/11/22, 2/3/22, 3/3/22, 4/7/22, 6/7/22, 8/4/22, and 10/16/22. A review of grievances from January 2022 to November 2022 revealed continued food complaints throughout the period. Two grievances were generated through the resident Council meeting on 1/11/22 and 8/4/22. Resident #79 filed a grievance related to food on 1/17/22, 5/2/22, 6/6/22. Resident #46 filed a grievance related to food on 5/2/22. Resident # 6 filed a grievance related to food on 5/2/22 and on 10/26/22. Resident #55 filed a grievance on 11/6/22. Additional grievances related to food were completed on 2/3/22, 4/7/22, 3 additional grievances on 5/2/22, 6/6/22, 6/7/22, 8/16/22, 8/29/22. All of the grievances reviewed were documented as resolved. 14762 42756 44767

Based on observation, interview, and record review the facility failed to offer adequate language assistance to residents who have limited English proficiency for 1 of 1 resident sampled for communication (#61). The findings include: On 11/28/22 at approximately 1:17 PM, a family interview was conducted with the family of residents #61. During the interview the family member explained that her mother does not speak English and the facility does not provide adequate language assistance when it comes to interpretation. On 11/30/ 22 at approximately 8:20 AM, Staff F Certified Nursing Assistant (CNA) and Staff G, CNA were observed as they assisted Resident #61 with turning and repositioning in the bed. The two staff members did not verbally interact with Resident #61 before or during care. The CNA' s did not explain the care that would be performed prior to assisting the resident. As the CNA's finished repositioning Resident #61. She repeated the same phrase several times to each of the CNA's in Spanish. Staff G, CNA and Staff F, CNA made no effort to understand the phrase the resident was repeating. The surveyor asked how they communicate with the resident. Staff F, CNA explained that they have a sheet posted at the head of her bed with some Spanish words. She also explained that the resident's son was a resident at the facility. He is available to interpret when needed. They were asked what they do when the son in not available. Staff F, CNA explained that there had been a Spanish speaking nurse on day shift previously. That nurse had been moved to another unit a few months ago. The CNA's were asked if they had access to a Spanish translator service. Staff G, CNA and Staff F, CNA indicated that they were not aware of any translator service. Staff F, CNA explained that if the son was not available then they can call her daughter to translate. Both CNA's were asked if they had been trained or knew how to use a translator service in the event that Resident #61's son or daughter were unavailable. They both indicated that they had no knowledge about how to utilize a translator. On 11/30/22 at approximately 10:14 AM, an interview was conducted with Nurse J, Licensed Practical Nurse (LPN) who supervises the MDS (Minimum Data Set) office. She was asked how the verbal portion of the Brief Interview Of Mental Status (BIMS) was conducted for residents who do not speak English. She indicated that Speech Therapy and Social Services complete the BIMS part of the assessment. Nurse K, LPN was in the room during the interview and stated: I don't know if we have ever had a resident that needed an interpreter. It Depends on what language. 11/30/22 at approximately 10:30 AM, interviews were conducted with Nurse L, Registered Nurse (RN), Nurse C, LPN, and Staff E, CNA. They were asked to explain how they communicate with Resident #61. Nurse L, RN explained that they utilize her son and daughter to interpret when necessary. The surveyor asked how they communicate with the resident when the son and daughter are unavailable. Nurse L, RN indicated there was a nurse that worked in another part of the facility that spoke Spanish. They were asked if there was an interpreter service available at the facility for times when family might not be available or if they knew how to utilize an interpreter service. Each of the staff members indicated that they did not know if an interpreter service was available and that they had not been trained how to use one if it was available. 11/30/22 at approximately 11:00 AM, an interview was conducted with the Social Services Director. She was asked to explain how they communicate with Resident #61. The Social Services Director indicated that she utilizes the resident's daughter and son to translate when needed. The Social Services Director mentioned communication words posed on the wall above the bed and indicated that the resident she can point to specific things to communicate. The director indicated that an interpreter service was previously available through the previous management company but she did not have information on what interpreter service was currently available. 1/30/22 at approximately 10:30 AM, an interview was conducted with the Director of Nursing (DON). She was asked to explain how staff adequately communicate with Resident #61. She explained that there is a communication board posted in the room. She also indicated that there had previously been a Spanish speaking nurse who worked with the resident. She explained that staff members utilize the Residents' family members to interpret. The surveyor notified the DON that observations revealed concerns in how some of the staff were communicating with the resident. Several nurses and staff had been asked how to communicate with Resident #61 if family members were not available. All of the staff members except social services were unable to explain the process for contacting or utilizing an interpreter service. The DON indicated that she would obtain the number for the interpreter service, get it posted and complete in-services for the nurses. A review of the facility's policy titled Translation and or Interpretation was conducted. The policy states when a staff member fluent in the patient's language is not available. Written and verbal translation is available 24 hours an day 7 days a week.

Based on observation, interview and recorded review the facility failed to comply with the facility's infection control policy and procedure for instilling eye medications for 1 of 1 sampled residents. (Resident # 89) The findings include: On 11/30/22 at approximately 2:11 PM, staff member D, Licensed Practical Nurse (LPN) was observed administering medications to resident # 89. The staff member proceeded to instill 1 drop of Prednisolone AC 1% eye medication into the resident's right and left eyes without wearing gloves. On 11/30/22 at approximately 4:00 PM, an interview was conducted with staff member D, LPN. She indicated she was aware she was to put on gloves before instilling eye drops but just forgot. A review of the facility's policy and procedure for Eye Drops dated 11/2001 revealed staff were to put on gloves prior to instilling eye drop medications.

Based on observation, interview, and policy review staff in the kitchen failed to consistently serve food that is appetizing in taste and temperature for 5 of 6 residents sampled for food concerns (#65, 79, 54, 36, 59 The findings include: On 7/19/21 at 11:34 AM, an interview was conducted with Resident #54. When asked about meals they stated, Food, sucks, sucks, sucks, and keeps getting worse. Everything about the food is bad. It is bad. I have talked to them about it. I have told the Nursing Assistants and the Dietary Manager about it. On 7/19/21 at approximately 11:45 AM, an interview was conducted with Resident #59. The surveyor inquired about the satisfaction with (or quality of) the food, to which the resident responded, Well, it looks ok, but it just tastes blah. On 7/19/21 at 12:42 PM, an interview was conducted with Resident #79. When asked about meal times at the facility they responded that, The food is terrible. On 7/19/21 at approximately 1:00 PM, an interview was conducted with Resident #65. She was asked about food quality. Resident #65 stated The food is always cold. On 07/21/21 at 8:30 AM, an observation of Resident #36's breakfast tray revealed that only several bites of breakfast had been taken. The surveyor inquired about the satisfaction with the meal and Resident #36 stated, I tried to eat the pancakes, but they were tough, and the sausage was not done. Upon further observation of the tray, the sausage appeared translucent in the middle. (Photographic evidence obtained) On 07/21/21 at approximately 8:50 AM, an observation of Resident #59's breakfast tray revealed that only a few bites of breakfast had been taken, and the resident was drinking a Glucerna (a meal replacement shake). The surveyor inquired about why more of the meal had not been consumed, to which Resident #59 replied, I just don't think the food tastes good. They don't season it enough for me. The resident continued that, I will just drink my Glucerna, and if I get hungry later, I will eat some of the snacks my daughter brought me. On 07/21/21 at approximately 12:00 PM, an observation of Resident #59's lunch tray revealed that she was not served the tater tots that were listed on the meal ticket. The surveyor inquired about the taste and temperature of the meal. The resident stated that it was warm, not hot, and that the fried okra was ok, but bland. On 7/21/21 at approximately 1:11 PM, a sample tray was checked with Staff Member F, Certified Dietary Manager (CDM). The tray had barbequed pork in a bun, ½ cup of tater tots, and ½ cup of seasoned okra. Staff Member F CDM placed the thermometer into the pork in a Bun first. The thermometer read 111 degrees Fahrenheit. She placed the thermometer into two of the tater tots next the thermometer read 111 degrees Fahrenheit. Staff Member F, CDM then placed the thermometer into two of the seasoned okra the thermometer read 111 degrees Fahrenheit. Staff Member F, CDM was asked if the temperature was adequate. She explained that the temperatures should be higher but would need to check policy to be sure. On 7/22/21 at approximately 11:45 AM, the dietician provided a copy of the test tray check sheet. This form stated hot food on a test tray should have a temp equal to or above 120 degrees Fahrenheit. On 7/21/2021 a review of resident grievances revealed that three residents had complained and initiated facility grievances regarding the temperatures of food served on trays at mealtimes on 07/01/2021. A review of the Food Quality and Palpability Policy (Policy #HSCG 006 last reviewed 9/2017) was conducted. The policy stated that food will served at an appetizing temperature.

Based on observation, interview, and policy review the facility failed to maintain a safe and sanitary environment to prevent the transmission of communicable diseases by failing to ensure that kitchen staff wore facial masks covering their nose and mouth for 3 of 3 kitchen staff observed. (staff members A, B, and C) The findings include: On 07/19/21 at approximately 10:55 AM, Staff Member A, a Cook, was observed working in the kitchen. She was standing at the steam table with her face mask pulled down below her nose and mouth. Staff Member A was observed for approximately 5 minutes. During the 5 minute time-period she did not pull her mask up. After the 5 minute observation, she was asked to identify herself at which time she pulled her mask up. On 07/19/21 at approximately 11:00 AM, Staff Member C, a Cook, was observed working in the kitchen area preparing food without a face mask on. The staff member was asked for her name. During the 2-to-3-minute conversation with the surveyor, Staff Member C did not secure a face mask and properly apply it to her face at any time. On 07/20/21 at approximately 3:28 PM, Staff Member B, a Cook, was observed working in the kitchen. She had her face mask pulled below her nose and mouth. Staff Member B, was observed for approximately 5 min. During the observation she did not pull her mask up over her nose and mouth. On 07/21/21 at approximately 9:00 AM, Staff member C, a Cook, was observed in the kitchen with her mask pulled below her nose and mouth. On 07/22/21 at approximately 10:52 AM, an interview was conducted with Staff Member D, Certified Dietary Manager (CDM). She was notified that kitchen employees were observed in the food preparation area without face covering on three occasions. Staff Member D, CDM was asked if staff should have had face masks in place. She explained that they should have had masks on. She further explained that a retraining session for staff was initiated for all dietary staff members yesterday. She was asked to provide a copy of the training session and sign in sheet. A review of the facilities' Novel Coronavirus (COVID-19) Policy that was last revised 06/2/2021 was conducted. Page 2 item 6 states During the pandemic a facility should require that all direct care stakeholders wear a mask while in the facility in coordination with the Center for Disease Control (CDC), state and federal guidelines.

Based on observation, staff interview and record review the facility failed to maintain 1 of 18 (resident # 3) oxygen concentrator in sanitary condition and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 88 rooms observed (rooms [ROOM NUMBERS]). The findings include: Resident #3 During the initial tour of residents on 1/27/20 at 10:34 AM, resident #3 was observed to be recieving oxygen per nasal cannula. The outside of the oxygen concentrator was dirty and the filter was dusty. A follow up observation of the concentrator was conducted on 1/28/20 at 8:54 AM, while a certified nursing assistant (CNA) was in the room it was in the same condition as the day before. (Photographic evidence obtained) On 1/28/20 at 1:12 PM, Employee F Registered Nurse (RN) Unit Manager 200 hallway was taken to Resident #3's room to see the oxygen concentrator. She was asked if the concentrator should look the way it did. She stated, It is totally embarrassing and not right. It should look better than that. Respiratory Therapy (RT) comes in three times weekly and they assess patients on oxygen. They also change all the tubing weekly. She was asked who was responsible for cleaning the concentrators and keeping the filters clean. She stated, I guess we are. I guess she (RT) is supposed to help us. She was asked to look at the concentrator filter and said, Yes that is dusty . An interview was conducted with the Director of Nursing (DON) on 01/28/20 02:52 PM. She stated that From this day forward RT will be responsible for the outside cleaning of the concentrator as well as changing the tubing and checking the filters. The humidifiers that are rented with filters are required to have filters changed by the company that owns them. A follow up interview was conducted at 4:05 PM, on 1/28/20 with the DON, during which she provided a copy of the policy titled (Departmental Respiratory Therapy) Prevention of Infection: Steps in procedure include #9 wash filters from oxygen concentrators every 7 days with soap and water. Rinse and squeeze dry. She then stated that the RT does not have a check sheet showing she cleaned the filter last week, but she will from now on. room [ROOM NUMBER] & 308 On 01/27/20 at approximately 11:30 AM, during observation of the restroom of room [ROOM NUMBER] the shower curtain was found to have along the bottom 1-inch to 2-inch portion there was a black residue. On the side of the shower curtain that faced the interior of the shower, there was a section approximately 10 inches in diameter with black splotches and residue. On 01/27/20 at approximately 1:36 PM, during observation of room [ROOM NUMBER], it was noted that the bedding for bed A was covered in black specks, and there was a peppered colored dust along the frame of the bed. In the room, on a portion of wall next to the doorway into the restroom it was observed that the baseboard was swollen and partially separated from the wall with an approximately ¼ inch to ½ inch separation that had a black residue along the separation line. There were stains along the wall and fluid trail marks leading to the baseboard. (Photographic evidence obtained) On 01/29/20 at approximately 9:57 AM, during observation and interview with the facility Administrator and Director of Housekeeping, in the restroom of room [ROOM NUMBER] the shower curtain was observed in the same condition as observed on 1/27/20, large sections and the bottom 1 inch to 2 inch portion of the curtain was noted to have black residue. The facility Administrator and Director of Housekeeping services stated that a resident's shower curtain should never be in that condition and stated it needed to be replaced. Immediately following was observation of room [ROOM NUMBER] where it was confirmed that the wall next to the doorway entering the restroom was swollen and had black residue along the wall junction and both confirmed that it should not look like that, and that it needed to be cleaned and repaired. During observation of bed A's bedding the staff confirmed that the resident had tobacco from smokeless tobacco scattered around the bedding including the bed frame and it was additionally noted that the pillow case was yellowed, both the Administrator and Director of Housekeeping Services confirmed it should not look like that, it was not to their expectation, and that it should be addressed.

Based on observation, record review, and interview the facility failed to make prompt efforts to resolve a grievance the resident brought to staff attention for 1 of 4 residents sampled for activities of daily living care (resident #89). The findings include: On 01/29/20 at approximately 8:30 AM, during observation and interview with resident #89 and staff member B, Certified Nursing Assistant (CNA), the resident stated that she wanted to file a grievance to staff B, CNA, for concerns regarding staff not assisting the resident to change incontinence briefs frequently enough, stating she had to sit in her feces all night and she was very unhappy about it, and that she was concerned about staff not emptying her urinary catheter bag frequently enough. The resident continued to express that other staff have not listened to her and she has voiced the concerns to them. On 01/29/20 at approximately 4:43 PM during interview with the facility Social Services Director, whose responsibility it was to process grievances, stated that the expectation for direct care staff to report grievances immediately and stated that she had not received a grievance regarding resident #89. On 1/29/20 at approximately 4:50 PM, during interview with staff C, Social Services Assistant, expressed that she had not received a grievance regarding resident #89 from staff. On 01/29/20 at approximately 5:05 PM, during interview with staff D, Registered Nurse Supervisor on the unit resident #89 resided, expressed that she had not a grievance regarding resident #89 from staff. On 01/29/20 at approximately 5:12 PM, the grievance concerns resident #89 made were brought to the Social Services Director's attention by surveyor and it was made known that the concerns were brought to the attention of a direct care staff. The Social Services Director stated that if a staff person heard a grievance, they should have assisted the resident to file a grievance. And additionally stated, that is not to standards, they should come to us and report that immediately if not before the end of the shift. On 01/30/20 at approximately 12:43 PM, during interview with staff B, CNA, confirmed that she heard resident #89's concerns on 01/29/20 at approximately 8:30 AM, and stated that she did not know the resident wanted her to report it and had not reported it to anyone else. Review of the facility policy titled Investigating a Resident Grievance or Complaint identified that all grievances were to be investigated by the appropriate staff and that the Social Services Department was responsible for such investigations.

Based on observations, record reviews, policy review and interviews, the facility failed to provide proper medication storage for 2 of 6 residents observed for medication administration and storage (#52, 24). The findings include: Resident #52 On 1/29/20 at approximately 4:20 PM, the spouse of resident #52 stated the nurse left the residents medications at the bedside and was concerned because she has asked them before not to do that because a dementia patient can come in his room and take his medications. At this time the the surveyor went to the resident room with the spouse, there were 2 medicine cups with pills and two vials of nebulizer medications on the bedside table. Staff K, a licensed practical nurse (LPN) entered the room at approximately 4:25 PM, and stated she pulled the medications for the resident and documented the medications was administered but the resident was not in the room she left them there and was watching out for the resident to return to his room. When nurse and surveyor returned to cart (med cart 1), the nurse unlocked the cart and opened the top drawer, it was observed there were 5 more medicine cups filled with medications. The nurse stated they were for 5 more residents on the hall and she did document the medication had been given but she had not yet given it to the resident and she knew she was not supposed to give it like that. (Photographic evidence was obtained). Medications left at bedside were for resident #52 were [MEDICATION NAME] 0.5/2ml (milliliters) l vial, [MEDICATION NAME] sodium delayed release 75mg (milligrams), Eliquis 5mg, Misoprostol 200 mcg (micrograms), omeprozole 20mg, Potassium chloride 20 meq (milliequivalent) 2 tabs and Tamsulosin 0.4mg. On 1/29/20 at approximately 4:45 PM, an interview was conducted with the Director of Nursing (DON). The DON was informed of the observation of the medications left at the bedside and responded the nurse should not have done that and it was not their policy to leave medications at the bedside or to document them as given if they have not been given. A review of the facility policy Medication Administration General Guidelines, 2007 page 3 number 4 stated Medications are to be given at the time they are prepared. Resident #24 On 01/27/20 at approximately 12:49 PM, during observation and interview with resident # 24 it was noted that a sore throat spray containing [MEDICATION NAME] 1.4% was on the resident's overbed table, the resident stated the nurse left it in the room. Also noted was [MEDICATION NAME] 8% and zinc oxide 8% lotion in a bag with resident's name on it on the resident's dresser and an external [MEDICATION NAME] containing [MEDICATION NAME] 0.5% on a separate dresser in the resident's room. On 01/29/20 at 12:10 PM, during record review of resident #24's active orders no orders for an over-the-counter throat spray or [MEDICATION NAME] lotion were noted. On 01/29/20 12:10 PM, during review of facility policy review titled Over-the-counter (OTC) Medications last reviewed dated 6/26/2018 stated the facility must store drugs and biologics in locked compartments and that over-the-counter medications are not to be administered without a current order from the resident's prescriber. On 01/29/20 at approximately 12:38 PM, during interview and observation with the facility Director of Nursing, observation of resident #24's room showed the [MEDICATION NAME] lotion on the dresser and the [MEDICATION NAME] lotion on the separate dresser. It was brought to the DON's attention at that time of the observation on 01/27/20 at approximately 12:49 PM, that included the sore throat spray. The DON confirmed that any OTC medication should be stored in a locked compartment regardless if they were assessed for self-administration or not.

Based on observations, record review and staff interview, the facility failed to implement the plan of care for 1 of 4 residents (#151) reviewed for nutrition services. The findings include: Review of the residents medical record revealed a current physician order [REDACTED]. Observations of resident #151 were conducted on 2/12/19 at 1:15 PM & 3:23 PM, on 2/13/19 at 8:41 AM & 2:33 PM. During these observations, the physician ordered tube feeding was not attached to the resident or infusing. The medical nutrition review notes, dated 1/11/19, revealed the resident had lost 10 pounds since admission to the facility on [DATE]. The resident's weight on 2/1/19 was 84 pounds. The current care plan for risk of altered nutritional status revealed the resident had a low body mass index and significant weight loss of 5% or more over 30 days. The interventions of the care plan included administering nutritional support as ordered. Review of the documented daily totals revealed the following amount of tube feeding was received each day: 2/1/19- 1374 cc 2/4/19- 1245 cc 2/5/19- 1161 cc 2/6/19- 1201 cc 2/7/19- 1323 cc 2/8/19- 1132 cc 2/9/19- 1454 cc 2/10/19- 1107 cc 2/11/19- 1333 cc 2/12/19- 977 cc An interview was conducted with employee C (licensed practical nurse) on 2/13/19 at 3:20 PM. He stated he did not know if anyone reviewed the documented tube feeding to ensure the total volume was infused. An interview was conducted with employee D (registered nurse unit manager) on 2/13/19 at 3:22 PM. She stated the dietician monitored the total tube feeding administered and she was not aware of any process in place to ensure the resident received the full prescribed amount of tube feeding ordered each day. An interview was conducted with the dietician on 2/13/19 at 3:27 PM. The dietician stated nursing had a protocol where they cleared the total infused and recorded the total fluids and she would review the documentation every month, but stated she just reviewed an average, not daily totals. She stated she had not reviewed this for the current month, but she had increased the resident's tube feeding in January.

Based on observations, record review and staff interview, the facility failed to provide appropriate amounts of tube feeding, in accordance with physician orders, for 1 of 4 residents (#151) reviewed for nutrition services. The findings include: Review of the residents medical record revealed a current physician order [REDACTED]. Observations of resident #151 were conducted on 2/12/19 at 1:15 PM & 3:23 PM, on 2/13/19 at 8:41 AM & 2:33 PM. During these observations, the physician ordered tube feeding was not attached to the resident or infusing. The medical nutrition review notes, dated 1/11/19, revealed the resident had lost 10 pounds since admission to the facility on [DATE]. The resident's weight on 2/1/19 was 84 pounds. The current care plan for risk of altered nutritional status revealed the resident had a low body mass index and significant weight loss of 5% or more over 30 days. The interventions of the care plan included administering nutritional support as ordered. Review of the documented daily totals revealed the following amount of tube feeding was received each day: 2/1/19- 1374 cc 2/4/19- 1245 cc 2/5/19- 1161 cc 2/6/19- 1201 cc 2/7/19- 1323 cc 2/8/19- 1132 cc 2/9/19- 1454 cc 2/10/19- 1107 cc 2/11/19- 1333 cc 2/12/19- 977 cc An interview was conducted with employee C (licensed practical nurse) on 2/13/19 at 3:20 PM. He stated he did not know if anyone reviewed the documented tube feeding to ensure the total volume was infused. An interview was conducted with employee D (registered nurse unit manager) on 2/13/19 at 3:22 PM. She stated the dietician monitored the total tube feeding administered and she was not aware of any process in place to ensure the resident received the full prescribed amount of tube feeding ordered each day. An interview was conducted with the dietician on 2/13/19 at 3:27 PM. The dietician stated nursing had a protocol where they cleared the total infused and recorded the total fluids and she would review the documentation every month, but stated she just reviewed an average, not daily totals. She stated she had not reviewed this for the current month, but she had increased the resident's tube feeding in January.

Based on observation, staff interview, facility competency checklist review and policy review, the facility failed to ensure staff implemented appropriate infection control procedures to prevent cross contamination of wounds for 2 of 2 residents (#59 and #147)during wound care observations. The findings include: An observation of wound care for resident #147 was conducted with employee E (licensed practical nurse) on 2/13/19 at 9:27 AM. Employee E washed her hands, applied clean gloves, changed the dressing on the resident's coccyx as ordered, then cleansed her scissors and marker with alcohol using her soiled, gloved hands. An observation of wound care for resident #59 was conducted with employee E on 2/13/19 at 10:21 AM. Employee E washed her hands, applied clean gloves, changed the dressing on the resident's heel as ordered, then cleansed her scissors and marker with alcohol using her soiled, gloved hands. An interview was conducted with employee E on 2/13/19 at 11:34 AM. She confirmed she cleaned the marker and scissors with the same gloves she used to apply the dressings to the residents. She stated she should have removed her gloves, washed her hands and applied new gloves before cleaning the marker and scissors. Review of the facility competency checklist revealed the nurse should wash hands, position to expose area for treatment, put on non-sterile gloves, remove soiled dressing and discard in appropriate receptacle, remove gloves and discard them, wash and dry hands, establish a clean field, date dressing or label tape. Review of the facility policy for standard precautions revealed staff should ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded.

Based on observations, interviews and resident council responses, the facility failed to post clearly readable staffing information in a prominent place readily accessible to residents and visitors. Findings included: On 2/13/2019 at approximately 9:28am, an observation of staff posting was made on the 100 hallway. The typed information included the current date and names of nurses and certified nursing assistants (CNAs) assigned to the hall and the number of hours worked by each. The information was typed and fit in the top half of an 8 x 11 sheet of paper which was folded in half and taped at the nurses' station on the 100 hallway (photo evidence obtained). On 2/13/2019 at approximately 1:30pm, in a meeting with the resident council, a concern was raised regarding not knowing which staff were assigned to them each day. On 02/14/19 at 08:52 AM, observations of nurse staffing postings on each hall consisted of 8 x 11 forms posted in the hallways near the nurses' stations on each hall. The first names of CNAs were handwritten on the typed form to indicate which room assignments each CNA had for the current shift. The first names of the nurses were handwritten in the top corner of the form. The names were not printed clearly and some were difficult to read (photo evidence obtained.) On 02/14/19 at approximately 09:59 AM, in an interview, the director of nursing and administrator confirmed the posting would be difficult for residents to read from a wheelchair and agreed that the handwritten names were also difficult to read.

Based on observations, staff and resident interviews, and review of resident council meeting minutes, the facility failed to provide adequate housekeeping services to maintain a comfortable and sanitary environment for 2 of 3 units within the facility (Units #1 and #2). The findings include: On 11/06/2017 at approximately 1:00pm, an observation was conducted of the room of resident #114. The wall over the bed for resident #114 was observed with flecks of a dried tan-brown colored substance staining the wall. The walls were scuffed and in need of painting, and there was a chair with a torn seat cushion (photo documentation obtained). Observation of the resident's bathroom showed a brown/black colored stain in the toilet, and the floor felt gritty. On 11/06/2017 at 1:17pm an interview was conducted with resident #71, who stated, sometimes they clean and sometimes they don't. The aides are asked to do too much here. They aren't given stuff to clean with at all, and they use water. The CNAs are overworked, and there is not enough of them. She stated that she had asked for her blinds to be cleaned, but the aides were too busy. On 11/06/2017 at approximately 1:30pm observation of the room for resident #35 showed an empty urinal on the resident's bedside table. The lip of the urinal had a brown discoloration, and the urinal was not labeled with the resident's name or room number. The stainless steel shelves in the resident's room and bathroom were rusted and contained an open box of razor blades. There were dried spots of a brownish-red colored substance on the floor next to the toilet (photo documentation obtained), and the bedroom and bathroom had a musty odor. An additional observation was conducted on 11/07/2017 at 10:10am, and showed that no cleaning had been done since the previous observation on 11/6/17. The bathroom remained unclean, and there was rust on the shelf over the sink. The open box of razor blades remained on the shelf, and the toilet was noted to have a black/brown substance around the hinges of the toilet seat. There were several dark brown/red colored spots on the bathroom floor near the toilet (photo documentation obtained). On 11/06/2017 at approximately 2:00pm, observation of the room for resident #196 showed there to be a strong odor of urine in the resident's room, and it appeared to be coming from a bedside commode that had not been emptied. Observation of the room for resident #78 was conducted on 11/06/2017 at 2:20pm. The resident's bed linens appeared dirty, and the room was cluttered and appeared unkempt with stains observed on the walls. This room was again observed on 11/07/2017 at 08:40am. The room remained unkept and cluttered. The bed linens were thin, discolored, and pulled away from the bed. There was staining on the wall and on the air conditioning unit. The floor was dirty with crumbs, debris and dried spills, and the window blinds had a brown/black substance on them. The room had a musty odor and smelled strongly of cigarettes. On 11/06/2017 at approximately 2:55pm residents #12 and #65, both in the same room on Unit 1, were interviewed. Both residents complained about not having housekeeping and that the room was not cleaned daily. The residents complained of odors in the hall and in their room. Both stated they had each complained, but nothing was done about the issue. They complained that their bathroom was often dirty and that the overall housekeeping within the facility was not good. The residents indicated that their bathroom had been mopped that day, by a Certified Nursing Assistant (CNA), but still wasn't clean. Observation made of the residents' bathroom at that time showed debris on the bathroom floor, a small amount of feces on the rim of the toilet, and a brown/black ring stain inside the toilet bowl. The stainless steel shelf over the sink was observed not to be clean, and contained unlabeled resident personal care supplies. On 11/06/2017 at approximately 3:15pm an interview was conducted with CNA staff Y. Staff Y indicated her duties included mopping, sweeping, cleaning bathrooms, blinds and emptying the trash daily in all her residents' rooms along with the provision of personal care for the residents. She stated she had between six and eight residents assigned to her daily, and normally spent 20-30 minutes in each room daily cleaning. She stated she did not have to document room cleaning anywhere, unless a deep cleaning was done. Staff Y stated the CNAs were expected to complete deep cleanings as well. On 11/07/2017 at approximately 10:00am an interview was conducted with resident #164, who asked can you do anything about the smell in here and in the hall? The resident stated he had complained about the smell and nothing had been done. He stated he purchased his own air freshener and sprays his room. He also complained that his room was not being cleaned and stated, there are feces on the bathroom floor from the other day that still have not been cleaned. He stated that when the CNAs do clean, they use the same mop they used in the bathroom to mop his bedroom floor, and stated he had complained about that practice as well. On 11/07/2017 at approximately 11:15am an interview was conducted with resident #72. Resident #72 shared a bathroom with residents #12 and #65. Resident #72 complained that the bathroom was not clean, stating, The CNAs do the best they can. The shared bathroom, originally observed on 11/6/17 was again observed at the time of this interview. The inside of the toilet continued to have a black/brown colored ring stain and there was feces around the rim of the toilet. The bathroom floor had debris, and there were unlabeled personal care items observed on a shelf above the sink. On 11/07/2017 at approximately 11:25am an interview was conducted with resident #132. Resident #132 stated he would give the facility a C minus for housekeeping. He stated that the CNAs working had been there for the past four days, and that nothing had been cleaned in his room. He stated the trash had not been emptied for two days and he had to call have someone come in to empty it. Observation of the resident's room and bathroom were made at the time of the interview. There was debris on the bedroom floor, numerous urinals around the resident's bedside, and the room appeared cluttered and unkempt. There were personal care items observed in the bathroom that had not been labeled. Resident #129 was interviewed on 11/07/17 at approximately 9:33 am, and stated that staff are not always helpful with hanging clothes up and cleaning up the room. Resident #129 stated there were not enough CNAs working to handle all the residents' needs and clean all the rooms. He stated that complaints had been made to administration regarding the lack of cleanliness and the shortage of staffing. On 11/08/2017 at approximately 09:00am, housekeeping was observed on unit 3. A brief interview was conducted with the housekeeper, who stated housekeeping only works on unit 3. When asked why they don't work on other units she stated she thought it was because they were on holistic care. She stated her duties included mopping, sweeping, cleaning the bathrooms, emptying the trash, and cleaning the blinds, and stated she spent about 30 minutes in each room. Unit 3 was observed to be well maintained, clean and there are no observed concerns with sanitation on that unit. On 11/08/2017 at approximately 12:00pm an interview was conducted with Staff U. Staff U stated the duties performed for providing resident care and also stated housekeeping duties that were expected to be performed, which included sweeping, cleaning toilet, restocking paper towels, wiping down tables and emptying the trash. Staff U stated the time it took to clean a room varied, depending on how dirty the room was. Staff U confirmed that she was assigned eight residents in four rooms that day, and stated that many residents had complained about their rooms not being clean to administration, but nothing had been done. On 11/08/2017 at approximately 1:30pm an interview was conducted with Staff T, who stated that CNAs were expected to provide personal care to the residents as well as maintain the cleanliness of the residents' rooms. Staff T stated that at times, they have to choose between providing care and performing cleaning duties because there is just not enough time to do both. Staff T stated that the CNAs normally have about eight residents each that they are assigned to care for on each shift, and can have up to five rooms that have to be cleaned as well. Staff T stated that residents complain about the rooms not being clean, but stated that focusing on the cleaning could really compromise resident care. On 11/09/2017 at approximately 8:50am an interview was conducted with Staff R. Staff R confirmed that CNAs at the facility provided resident care as well as cleaning services, and stated that normally each CNA is assigned about eight residents and four or five rooms to clean. Staff R stated she spent about two hours a day cleaning resident rooms and at times has not been able to provide resident care because of cleaning. Staff R stated that several CNAs have complained to administration, but were told to do the best they could. Staff R also stated that it was not unusual for residents to complain about the sanitation of their rooms. With the permission of the resident council president, the monthly resident council meeting minutes were reviewed. There were numerous concerns and formal complaints submitted by residents related to sanitation and housekeeping. The minutes from 10/20/17 noted concerns that CNAs were not answering call lights, not cleaning and not changing trash with one resident complaint that their room had not been cleaned in five days. Minutes from the meeting held on 08/11/17 identified housekeeping concerns listed under old business, and stated that housekeeping in resident rooms still had not improved. The meeting minutes on 07/14/17 indicated housekeeping was not good on halls 1 and 2, and stated shower rooms were not being cleaned, there was dust hanging from the vents, and a bad smell. There was no indication that the facility had formally addressed any of the concerns presented by the residents during these meetings.

Based on observations, staff and resident interviews, and review of resident council meeting minutes, the facility failed to ensure adequate staffing to meet the needs of the residents by failing to maintain a comfortable and sanitary environment for residents on 2 of 3 units in the facility (units 1 and 2). The findings include: On 11/06/2017 at approximately 1:00pm, an observation was conducted of the room of resident #114. The wall over the bed for resident #114 was observed with flecks of a dried tan-brown colored substance staining the wall. The walls were scuffed and in need of painting, and there was a chair with a torn seat cushion (photo documentation obtained). Observation of the resident's bathroom showed a brown/black colored stain in the toilet, and the floor felt gritty. On 11/06/2017 at 1:17pm an interview was conducted with resident #71, who stated, sometimes they clean and sometimes they don't. The aides are asked to do too much here. They aren't given stuff to clean with at all, and they use water. The CNAs are overworked, and there is not enough of them. She stated that she had asked for her blinds to be cleaned, but the aides were too busy. On 11/06/2017 at approximately 1:30pm observation of the room for resident #35 showed an empty urinal on the resident's bedside table. The lip of the urinal had a brown discoloration, and the urinal was not labeled with the resident's name or room number. The stainless steel shelves in the resident's room and bathroom were rusted and contained an open box of razor blades. There were dried spots of a brownish-red colored substance on the floor next to the toilet (photo documentation obtained), and the bedroom and bathroom had a musty odor. An additional observation was conducted on 11/07/2017 at 10:10am, and showed that no cleaning had been done since the previous observation on 11/6/17. The bathroom remained unclean, and there was rust on the shelf over the sink. The open box of razor blades remained on the shelf, and the toilet was noted to have a black/brown substance around the hinges of the toilet seat. There were several dark brown/red colored spots on the bathroom floor near the toilet (photo documentation obtained). On 11/06/2017 at approximately 2:00pm, observation of the room for resident #196 showed there to be a strong odor of urine in the resident's room, and it appeared to be coming from a bedside commode that had not been emptied. At the time of the observation, resident #196 was also interviewed and stated, I haven't gotten assistance at all today. These CNAs are just too busy. The resident was observed to be in a hospital type gown at the time, but stated that she usually gets dressed. Observation of the room for resident #78 was conducted on 11/06/2017 at 2:20pm. The resident's bed linens appeared dirty, and the room was cluttered and appeared unkempt with stains observed on the walls. This room was again observed on 11/07/2017 at 08:40am. The room remained unkept and cluttered. The bed linens were thin, discolored, and pulled away from the bed. There was staining on the wall and on the air conditioning unit. The floor was dirty with crumbs, debris and dried spills, and the window blinds had a brown/black substance on them. The room had a musty odor and smelled strongly of cigarettes. On 11/06/2017 at approximately 2:55pm residents #12 and #65, both in the same room on Unit 1, were interviewed. Both residents complained about not having housekeeping and that the room was not cleaned daily. The residents complained of odors in the hall and in their room. Both stated they had each complained, but nothing was done about the issue. They complained that their bathroom was often dirty and that the overall housekeeping within the facility was not good. The residents indicated that their bathroom had been mopped that day, by a Certified Nursing Assistant (CNA), but still wasn't clean. Observation made of the residents' bathroom at that time showed debris on the bathroom floor, a small amount of feces on the rim of the toilet, and a brown/black ring stain inside the toilet bowl. The stainless steel shelf over the sink was observed not to be clean, and contained unlabeled resident personal care supplies. On 11/6/17 at approximately 3:00pm an interview was conducted with resident #51 who stated that the normal wait time for a CNA to answer their call light was 45 minutes, and stated there had been a lot of complaints about this. On 11/06/2017 at approximately 3:15pm an interview was conducted with CNA staff Y. Staff Y indicated her duties included mopping, sweeping, cleaning bathrooms, blinds and emptying the trash daily in all her residents' rooms along with the provision of personal care for the residents. She stated she had between six and eight residents assigned to her daily, and normally spent 20-30 minutes in each room daily cleaning. She stated she did not have to document room cleaning anywhere, unless a deep cleaning was done. Staff Y stated the CNAs were expected to complete deep cleanings as well. On 11/07/2017 at approximately 10:00am an interview was conducted with resident #164, who asked can you do anything about the smell in here and in the hall? The resident stated he had complained about the smell and nothing had been done. He stated he purchased his own air freshener and sprays his room. He also complained that his room was not being cleaned and stated, there are feces on the bathroom floor from the other day that still have not been cleaned. He stated that when the CNAs do clean, they use the same mop they used in the bathroom to mop his bedroom floor, and stated he had complained about that practice as well. He also stated that the CNAs never come to see what he needs. He stated that he will put his call light on, and the CNAs either never come, or they come by and turn the light off, telling him they will return, but they never do. He stated that sometimes you can see the CNAs in the hall and holler for them, but they will just keep walking. He stated that this scared him because he has breathing problems. On 11/07/2017 at approximately 11:15am an interview was conducted with resident #72. Resident #72 shared a bathroom with residents #12 and #65. Resident #72 complained that the bathroom was not clean, stating, The CNAs do the best they can. The shared bathroom, originally observed on 11/6/17 was again observed at the time of this interview. The inside of the toilet continued to have a black/brown colored ring stain and there was feces around the rim of the toilet. The bathroom floor had debris, and there were unlabeled personal care items observed on a shelf above the sink. On 11/07/2017 at approximately 11:25am an interview was conducted with resident #132. Resident #132 stated he would give the facility a C minus for housekeeping. He stated that the CNAs working that day had been there for the past four days, and that nothing had been cleaned in his room. He stated the trash had not been emptied for two days and he had to call to have someone come in to empty it. Observation of the resident's room and bathroom were made at the time of the interview. There was debris on the bedroom floor, numerous urinals around the resident's bedside, and the room appeared cluttered and unkempt. There were personal care items observed in the bathroom that had not been labeled. Resident #129 was interviewed on 11/07/17 at approximately 9:33 am, and stated that staff are not always helpful with hanging clothes up and cleaning up the room. Resident #129 stated there were not enough CNAs working to handle all the residents' needs and clean all the rooms. He stated that complaints had been made to administration regarding the lack of cleanliness and the shortage of staffing. He stated that at times he has had to wait 45 minutes or more to get assistance to use the restroom, and has often soiled himself while waiting. He also stated that many times his roommate is left in pajamas all day and he thought this was due to not having enough staff as well. On 11/08/2017 at approximately 09:00am, housekeeping was observed on unit 3. A brief interview was conducted with the housekeeper, who stated housekeeping only works on unit 3. When asked why they don't work on other units she stated she thought it was because they were on holistic care. She stated her duties included mopping, sweeping, cleaning the bathrooms, emptying the trash, and cleaning the blinds, and stated she spent about 30 minutes in each room. Unit 3 was observed to be well maintained, clean and there are no observed concerns with sanitation on that unit. On 11/08/2017 at approximately 12:00pm an interview was conducted with Staff U. Staff U stated the duties performed for providing resident care and also stated housekeeping duties that were expected to be performed, which included sweeping, cleaning toilet, restocking paper towels, wiping down tables and emptying the trash. Staff U stated the time it took to clean a room varied, depending on how dirty the room was. Staff U confirmed that she was assigned eight residents in four rooms that day, and stated that many residents had complained about their rooms not being clean to administration, but nothing had been done. On 11/08/2017 at approximately 1:30pm an interview was conducted with Staff T, who stated that CNAs were expected to provide personal care to the residents as well as maintain the cleanliness of the residents' rooms. Staff T stated that at times, they have to choose between providing care and performing cleaning duties because there is just not enough time to do both. Staff T stated that the CNAs normally have about eight residents each that they are assigned to care for on each shift, and can have up to five rooms that have to be cleaned as well. Staff T stated that residents complain about the rooms not being clean, but stated that focusing on the cleaning could really compromise resident care. On 11/09/2017 at approximately 8:50am an interview was conducted with Staff R. Staff R confirmed that CNAs at the facility provided resident care as well as cleaning services, and stated that normally each CNA is assigned about eight residents and four or five rooms to clean. Staff R stated she spent about two hours a day cleaning resident rooms and at times has not been able to provide resident care because of cleaning. Staff R stated that several CNAs have complained to administration, but were told to do the best they could. Staff R also stated that it was not unusual for residents to complain about the sanitation of their rooms. With the permission of the resident council president, the monthly resident council meeting minutes were reviewed. There were numerous concerns and formal complaints submitted by residents related to sanitation and housekeeping. The minutes from 10/20/17 noted concerns that CNAs were not answering call lights, not cleaning and not changing trash with one resident complaint that their room had not been cleaned in five days. Minutes from the meeting held on 08/11/17 identified housekeeping concerns listed under old business, and stated that housekeeping in resident rooms still had not improved. The meeting minutes on 07/14/17 indicated housekeeping was not good on halls 1 and 2, and stated shower rooms were not being cleaned, there was dust hanging from the vents, and a bad smell. There was no indication that the facility had formally addressed any of the concerns presented by the residents during these meetings.

Based on observation, interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good oral hygiene for 1 of 3 residents sampled for activities of daily living (Resident #195). Findings include: On 11/07/2017 at 12:37 PM resident #195 was observed in her bed. The resident was noted to have dry skin on her lips and a white coating on her tongue. The resident's spouse was at her bedside, and stated that he feared staff were not cleaning his wife's mouth when he was not present. He stated that he has requested staff keep the resident's mouth clean, but everyday when he arrives at the facility, he finds his wife with debris in her mouth. He stated she often has old food particles, secretions, or a film over her teeth when he arrives, and he has to provide his wife with oral care to ensure it gets done. Further observations of resident #195 showed that on 11/07/2017 at 2:38 PM and at 3:15 PM resident #195 had dry, cracked lips and a yellow/white substance on her tongue. On 11/08/2017 at 8:34 AM resident #195 was observed to be clean from a recent bed bath; however, her mouth had a thick yellow substance covering her tongue and the front of her teeth. He husband stated that he had cleaned the resident's mouth before leaving the facility on 11/7/17, but stated the staff were not good about cleaning her mouth. The plan of care for resident #195, dated 11/2/17, showed an intervention for staff to cue, assist, and provide oral care to the resident as needed. On 11/8/2017 at approximately 10:00 AM, an interview was conducted with staff CNA J. She stated that she was responsible for providing activities of daily living to resident #195, and revealed that while she has provided oral care to the resident, it was the husband who primarily provided the resident's oral care. She stated that she is required to document the performance of oral care for the resident in the facility's electronic documentation system, and will document the care as having been completed whether it was her or the husband who provided the care.

Based on observation, interview and record review, the facility failed to ensure that residents and/or their representatives were fully informed of their treatment options to include skilled nursing care, palliative care and hospice services for 1 of 1 resident sampled (Resident #195). Findings include: Resident #195 was admitted to the nursing facility on [DATE] and a Florida Do Not Resuscitate was signed on [DATE]. The plan of care for resident #195, dated [DATE], was reviewed, and stated: resident has a terminal condition and has not elected hospice or palliative care at this time but husband has voiced that it is resident's wishes for the disease to run its natural course and states as well that he understands what that means. On [DATE] at approximately 10:15 AM an interview was conducted with the spouse of resident #195. During this interview the family member stated that the resident had been a pervious hospice patient in another state, but had been discharged from hospice services when she was admitted to the hospital, prior to coming to the facility. He stated that he was aware that his wife was not doing well and was not going to recover. He stated that upon admission to the facility in October, he had expressed a desire for comfort measures only and had signed a Do Not Resuscitate (DNR), provided a copy of his power of attorney for resident #195, and expressed to the facility that he did not want a feeding tube placed for his wife. He said the facility explained to him that he had 100 days remaining of skilled nursing care, but they did not discuss, or offer palliative care or hospice services during the admission process. He also stated he was not aware resident #195 could receive hospice services while in the facility. On [DATE] at approximately 1:00 PM, an interview was conducted with the Social Services Director (SSD) who stated that when the resident was admitted the spouse requested therapy to help her get stronger and did not request hospice services. When asked if she had documented this conversation with the spouse, she stated that she had, but failed to be able to produce this documented conversation by [DATE] at 4:30 PM. When asked if she was aware that the resident had previously been a hospice patient and had a terminal diagnosis, she stated, yes, but that the family had revoked their hospice benefit when the resident was in the hospital. She stated that the husband was aware that the resident was terminal, but had not requested hospice services. When asked why hospice was not discussed with the family when the resident was admitted to the facility, she again stated the family had not requested it. The SSD was asked if families were required to request hospice services before these services or treatment options could be discussed with the residents or their families, to which the SSD replied, no. On [DATE] at approximately 8:00 AM a follow-up interview was conducted with the spouse of resident #195. During this interview the spouse stated that he had received a call at 6:45 AM that morning ([DATE]) stating the resident had been made Nothing by Mouth (NPO) and that she was being placed on palliative care. He stated that he was waiting for the facility staff to speak to him and have him sign the forms. On [DATE] at approximately 9:30 AM a follow-up interview with the SSD was conducted in the presence of the Director of Nursing (DON). They stated that anytime a resident was admitted to the facility they were reviewed for the appropriate level of care. The SSD stated that while she was aware that resident #195 had previously had hospice and was not going to improve, she was not aware that the spouse wanted hospice services or palliative care until [DATE] when she spoke to him and he elected palliative care. On [DATE] at approximately 9:45 AM, upon entering the SSD's office, this surveyor observed the spouse of resident #195 sitting in a chair with the SSD standing over him, the Minimum Data Set (MDS) Coordinator leaning on a table, arms crossed, and another employee sitting at the desk in front of the family member. The SSD was handing the resident's spouse a pen, and on the desk in front of him was a form titled Palliative Care Informed Consent - Washington Rehabilitation and Nursing Center. Upon inspection of the form, it was noted to have the date [DATE] noted beside the spouse's printed name, as well as the physicians signature. When asked about the date of the form, the SSD stated that she had made an error in the dating of the form and corrected the date to [DATE]. A chart review for resident #195 revealed that the resident was previously receiving hospice services in another state. She was admitted to an acute care hospital and was discharged from hospice services at that time. Physician notes from the hospital stay of resident #195, dated [DATE], stated palliative care has spoken with the husband who said he understands the course of the supranuclear palsy and wants to allow its natural course and does not want CPR, resuscitation involving intubation or feeding tubes. Further review revealed a physician note dated [DATE] which stated again that the husband wished to allow its natural course and does not want CPR, resuscitation involving intubation or feeding tubes.

Based on observation and staff interview, the facility failed to serve resident meal trays in a manner that maintained each resident's dignity for 2 of 19 residents observed eating lunch in the Camellia Diningroom. (#215 and #18) On 10/10/2016 at 11:39 AM entrance was made to the Camellia Diningroom. There were several residents observed to already be in the dining room waiting on their meal trays to arrive and be served. At 11:49 AM the first cart containing resident trays arrived in dining area. By 11:57 AM all trays from the cart had been served, but there were five residents observed to be without trays and were watching the other residents eat. At that time, resident #215) asked a staff member when she would get her food. She was seated at table with two other residents who had already been eating for about 4 minutes. She was told by the staff member that her tray would be on a second cart that would be arriving in the dining area shortly. At 11:58 AM another cart was wheeled into the diningroom and all residents were served except for two, residents #215 and #18. After the second cart had been unloaded, it was observed that residents #215 and #18 still did not havea tray. Resident #215 was observed at 12:02 PM taping her hand on the table and looking at one of the staff members who responded by telling the resident that someone had gone to get her tray to which she replied: If you say so. At 12:03 PM one of the residents at the table had already finished eating and left the table. Resident #215 told the remaining resident at the table that she didnt think she was going to get any lunch. At 12:08 PM the resident's tray arrived. Resident #18 was seated at a large table in the center of the room with multiple other residents at the table who were observed eating their meal. She did not receive her meal tray from the first cart, nor was her tray on the second cart that was brought into the diningroom. A staff member approached the resident and told her that the kitchen was making her tray and it would be there in just a minute. The staff member told the resident that there had been a mishap, but that her tray was it was being made. The rsident's tray arrived at 12:09 PM. Each resident waited approximately 19 minutes after tray service bagan to receive their meal while other residents were observed eating. Interview with one of the staff members in the dining room revealed that resident #215 was a new admission and had just arrived at the facility the prior day. She stated that the resident had eaten in her room the previous day and they had not been expecting her to come to the dining room so they had to find her tray on another cart to bring it to the diningroom. She stated that she was not sure why the tray for the other resident (#18) had been late, and that resident #18 did normally eat in the dining room.