Every finding on record at Wilton Manors Healthcare & Rehabilitation Center

Based on review of policy and procedure, record review and interview, the facility failed to ensure that residents received appropriate care and treatment to prevent an evolving change in condition and status for 1 of 1 sampled resident reviewed, Resident #113. The findings included: Review of the facility policy, titled, Change in a Resident's Condition or Status, provided the Director of Nursing (DON), revised May 2017, documented in the Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and the representative (sponsor) of changes in the resident's medical / mental condition and/or status (e.g. changes in level of care, billing / payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. significant change in the resident's condition . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than two areas of the resident's health status . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. There is a significant change in the resident's physical, mental, or psychological status . 8. The nurse will record in the resident's record information relative to changes in the resident's medical/mental condition or status . Record review revealed Resident #113 was originally admitted to the facility on [DATE] with diagnoses that included Paraplegia, Urinary Tract Infection, Iron Deficiency Anemia, Acute Pyelonephritis and Neuromuscular Dysfunction of the Bladder. The record documented a Brief Interview Mental Status (BIMS) score of 15, indicative of intact cognition. Resident #113 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE] with a medical diagnosis of Sepsis. Record review of the facility's computerized progress notes (prior to hospital transfer on 03/30/25) revealed that during the previous four (4) day time-span, in the facility dating from Thursday March 27th to Sunday March 30th (2025), Resident #113 had a documented episode of an elevated temperature, and several subsequent documented on-going episodes of elevated heart rate, abdominal pain complaints, as well as other associated signs and symptoms, during that time. Computerized record of the subsequent Hospital's Infectious Disease (IF) Doctor's and of the Hospital's History and Physical reports dated 04/01/25 revealed that, resident admitted to the hospital with fever, chills, intractable nausea / vomiting, abdominal pain and severe sepsis Resident was tachycardic with Leukocytosis .On exam, he was seen by Urology, who drained and packed a draining scrotal abscess .urinalysis revealed Pyuria. Microbiology collected on 03/30/25---specimen from urine clean catch revealed the presence of Escherichia Coli (ESBL) and Enterococcus faecalis. On 03/31/25---specimen from Scrotal swab revealed the presence of Escherichia Coli Extended-Spectrum Beta-Lactamases (ESBL), Morganella Morganii SSP Morgani (a species of Gram-negative bacteria) and Enterococcus faecalis. Blood, urinalysis---extra turbid, significant for large leucocyte esterase, proteinuria and moderate [NAME] Blood Count (WBC), and urine cultures were obtained, and the resident was started on intravenous (IV) Vancomycin, Clindamycin and Meropenem since Monday 03/31/25. Infectious Disease was asked to assist in evaluation and antibiotic management Complete Blood Count (CBC) with differential complete with WBC's on Sunday 03/30/25 was 15.43 (high), Monday 03/31/25 the WBC was 13.65 (high) and Tuesday 04/01/25 the WBC was 16.11 (high). Record review of the Resident #113's care plan initiated 01/03/25 indicated Focus: Resident has potential for complications Infection .Interventions: Labs as ordered; report findings to physician .Observe site of infection for increased swelling, inflammation, tenderness, drainage, or necrosis; update physician if noted. Observe for signs and symptoms of recurring infection; notify physician if noted. Goal: Resident will be free of infection . Record review of Resident 113's care plan initiated 01/03/25 indicated Focus: Resident has potential for pain and/or alteration in comfort related to diagnosis and conditions .Interventions: .Administer medication for discomfort as ordered .; observe for effectiveness and for side effects .Encourage resident to voice discomfort at onset as needed. Observe for nonverbal signs and symptoms of discomfort: i.e. grimacing, restlessness, irritability, pulling away, moaning, crying. Assess pain level as needed. Report changes in comfort level to physician as needed. Goal: Resident [#113] will exhibit signs and symptoms that pain is at an acceptable level of comfort thru next review date. Resident will voice acceptable level of comfort thru the next review date. A computerized record review of the nursing progress notes dated 03/27/25 at 17:32 (5:32 PM) and again on 03/27/25 at 18:45 PM (6:45 PM) by Staff C, RN, revealed she had documented, Upon hourly rounding, resident complained of headache with slight abdominal discomfort Vitals assessed as blood pressure (BP) 92/51, heart rate: 148, respiratory rate 19, temperature 103F (Fahrenheit . Call placed to the resident's attending physician's service and awaiting call back ; .still awaiting physician to call back, oncoming nurse made aware to continue monitoring the resident and follow up. There was no documented evidence to indicate the doctor had been notified or made aware of Resident 113's elevated temperature and heart rate, or of his abdominal discomfort, at the time. There was no documented evidence of the physician's call back response with any new written orders obtained. Further computerized record review of the 03/27/25 at 20:26 (8:26 PM) evening nurses' note by Staff O, documented, .the resident had been complaining of abdominal pain at 2 AM in the morning, doctor's office was notified, (but no exact time was given, as to when this had been done). Staff O did not document whether or not the doctor ever received the message or called back with any new orders. Review of the record and computerized Medication Administration Record (MAR) dated 03/27/25 documented Resident #113 had a temperature of 103 Fahrenheit and a heart rate 148 at 17:34 (5:34 PM) in the evening. There was no documentation in the record to indicate that the doctor had been notified and responded back with any new orders. Further review of the computerized record showed that Resident #113's attending physician was not in the facility to examine this resident until 03/28/25 at 11:58 AM (over 15 hours later the next day). There was no evidence to show that the physician was directly made aware of the resident's change in condition and status and there were no new orders written for this resident regarding the resident's recent complaints of abdominal pain, elevated temperature and elevated heart rate. There was no evidence to show there was any lab work, urinalysis, or urine culture tests ordered for this resident, prior to his transfer from the facility. Computerized record review of the Medication Administration Record (MAR) documented that Resident #113 was only administered Tylenol oral tablet 325 mg to give two (2) tablets by mouth every four (4) hours as needed for pain. Resident complained of stomach and throat pain level five (5)/ten (10), as documented on Sunday 03/30/25 at 12:16 AM by Staff P, LPN. Further computerized record review of the MAR documented that on Sunday 03/30/25 at 2:29 AM, Resident #113's condition had worsened or deteriorated in that his pain level had advanced to a level of six (6)/ten (10); with again only two (2) Tylenol tablets having been administered to him by Staff P. There was no evidence to show that Resident #113's doctor was notified, nor made aware of the resident's elevated temperature and heart rate, nor of his increasing pain level from 5 to 6/10, at the time; with no notation indicating the resident's physician was called to increase the resident's pain medication, as previously requested by the resident. A subsequent computerized nurses' progress note dated 03/30/25 at 2:45 PM (over 48 hours later) by Staff P, documented, Resident #113 had complained of generalized pain, two (2) 325mg tablets of Tylenol were administered as ordered (orally) PO. About 30 minutes later, the resident called and asked to see the doctor for a sleeping medication and for a stronger pain medication and the nurse informed the resident that pain management consult would be needed. The oncoming nurse was made aware to follow-up. Staff P didn't document whether or not the doctor was notified of this request by the resident, nor did she document any information regarding the pain management consult. Record review of the nursing progress note by Staff Q, revealed documentation for 03/30/25 at 18:47 PM (6:47 PM) (4 hours later) on The Change In Condition form that the resident had . Nausea / Vomiting and Pain (uncontrolled) .Call place to medical doctor's on call service. Still awaiting call back. Resident is requesting to go out to the Hospital. Record review of the nursing progress notes by Staff Q revealed that on 03/30/25 at 19:20 (7:20 PM), it was documented that, Resident complained of uncontrollable pain in abdominal area, unable to swallow, feeling malaise, vomiting and nauseated, stating he just does not feel like himself for the past five (5) days, and he would like to be transferred to the hospital to be evaluated. Call placed out to the doctor's call service at 5:30 PM, message left for the resident's physician, at 7:30 PM, still no call back. Resident insisted on being transferred out because he's really not feeling great. Resident's aunt also notified because resident had been telling her, he's not feeling well . There was no documented evidence showing the resident's physician had been made aware of the resident's additional deteriorating and worsening symptoms of uncontrollable pain in abdominal area, unable to swallow, feeling malaise, vomiting and nauseated, and stating he just does not feel like himself for the past five (5) days, most occurring almost three (3) hours prior to transfer to the hospital. An interview was conducted on Monday 06/16/25 at 4:57 PM with Resident #113 regarding the past date of Sunday March 03/30/25, who stated that he recalled that he was not feeling well, and he stated that he had vomited at least two to three (2-3) times during the four (4) days prior to this, was not able to eat anything, but that he had been hungry and he was trying to eat, and had been in a lot of pain. Resident #113 also stated he had not thought about it,, but that the nurses were aware of this. Resident #113 stated he had felt hot and had a fever on the second (2nd) or third (3rd) day. Resident #113 said that he was given something for the nausea, but it did not work; and was given Tylenol. Resident #113 indicated that a doctor came to see him around that time, but the doctor provided no additional information to him. Resident #113 stated that prior to his last few days in the facility in March 2025, he had not had any episodes of nausea and vomiting; he indicated that he did become concerned and then wanted to go the hospital. On 06/18/25 at 1:35 PM, during an interview and side-by-side record review conducted of the nursing progress notes dated from 03/27/25 at 17:32 PM to 03/30/25 at 2:45 PM, with the Registered Nurse (RN) / Infection Control (IC) Nurse, it was revealed that Resident #113 had been first admitted to this facility on 01/03/25 with a UTI from the hospital in which he was given the ordered oral antibiotics. The computerized record review revealed there had been no subsequent lab work ordered and collected from the resident since 01/06/25. The IC Nurse emphasized there had been no other lab work, urinalysis, or urine cultures ordered for this resident, prior to his transfer from the facility to the hospital on [DATE]. During a subsequent interview conducted with Resident #133 on 06/19/25 at 10:42 AM, regarding Sunday 03/30/25, he recalled that he had smelled some odor to his urine prior to his hospitalization, just the day before. The resident said that he thought nothing of it, but stated the abdominal pain got worse and he learned later that it was a Urinary Tract Infection (UTI). He said that he had a UTI in the past with the same smell. An interview was conducted 06/19/25 at 12:59 PM with Staff C, who was aware that on 03/27/25 at 17:32 PM and on 03/27/25 at 18:45 PM, Resident #113 had a fever of 103 F, indicative of some type of infection. She stated his blood pressure was low at 95/51, and that his heart rate was high at 148. She stated she had placed a call to the attending physician's service and was awaiting a call back. Staff C acknowledged she had not made any other documented attempts to contact the doctor's service again regarding the resident's headache, abdominal pain level, elevated temperature and elevated heart rate. She had not documented any contact made to the resident's family to notify them of the resident's current status at that time. A telephone interview was conducted on 06/19/25 at 1:35 PM with Staff P, Licensed Practical Nurse ( LPN), who verbalized that on 03/30/25 at 2:45 AM (2 days later), around 12:15 AM, the resident was alert and oriented, complained of generalized pain. Two (2) 325 mg tabs Tylenol administered as ordered oral (PO). About thirty (30) minutes later, the resident called and asked to see the doctor for sleeping medication and a stronger pain medication, the nurse informed the resident that that a pain management consult was needed; on-coming nurse made aware to follow-up (F/U). Staff P stated she had not made any other documented attempts to contact the doctor again regarding the resident's continued generalized pain complaints and elevated heart rate. A telephone interview was conducted on 06/19/25 at 1:51 PM with Staff O, LPN, who stated the following on 03/27/25, around 2 AM, Resident #113 had been complaining of abdominal pain his heart rate was 131 (high) on assessment Call placed to Dr. [name provided] office, Spoke to [name] to report the situation Resident had one episode of vomiting around 7:32 AM. Waiting for Dr. [name] to call back. Report given to the oncoming nurse to follow up. Staff O acknowledged she had not made any other attempts to contact the doctor again regarding the resident's continued abdominal pain concerns, vomiting and elevated heart rate after the 3 AM call earlier or again at 7 AM. A telephone interview was conducted on 06/19/25 at 2:09 PM with Staff Q, RN, Daytime Supervisor, who stated on Sunday 03/30/25 at 18:47 PM (6:47 PM), she documented in the resident's record that, The Change In Condition .: Nausea/Vomiting, Pain (uncontrolled), at the time of evaluation .Call place to MD on call service. Still awaiting call back. Resident is requesting to go out to the Hospital, at 5:30 PM with still no return call back from the doctor at 7:30 PM. Staff Q stated that she had been called in by the resident's assigned nurse because the resident had said that he had not been feeling well and was complaining of abdominal pain for five (5) days. Staff Q stated she had been assisting the assigned nurse with paperwork to send Resident #113 out to the hospital due to his continued complaints of pain and because the resident had told her that he was not able to keep anything down. Staff Q acknowledged she had not called the doctor again and was not aware if the assigned nurse had called the doctor. Staff Q stated that the calls to the doctor's office had not been returned. An interview was conducted on 06/19/25 at 2:35 PM with Staff R, Certified Nursing Assistant (CNA), who stated she did recall that between the days of Thursday 03/27/25 through Sunday 03/30/25, in the morning while she was caring for Resident #113, that the resident was eating and then told her that he felt like he was going to throw up. Staff R said that she reported this episode to his nurse. An interview was conducted on 06/19/25 at 3:05 PM with Staff N, LPN Supervisor South wing, who revealed that none of her staff, nor the resident, told her anything of the resident's change in condition or status. Staff N stated she did not find out about any of the above until she returned to work on the following Monday, 03/31/25. A telephone interview was conducted on 06/19/25 at 4:00 PM with Staff S LPN, who stated that on 03/28/25 at 11:08 AM the following day, Resident #113 still complained of pain in the abdomen .heart rate was now up to 145 and a call was placed to the resident's physician. Waiting for him to call back. Staff S stated that specific orders obtained from the doctor and pertaining to the resident had not been recorded and documented in the resident's record. A telephone interview was conducted on 06/19/25 at 4:17 PM, with Resident #113's attending physician, who was asked if he had been routinely, consistently and specifically notified and made aware by the facility staff of all of the Resident #113's symptoms of having a temperature of 103 F, during the resident's entire 4-day time span from Thursday 03/27/25 through Sunday 03/30/25, of the elevated heart rate, of the uncontrolled abdominal pain, inability to swallow, feeling of malaise, vomiting and nausea and of the resident stating that he just did not feel like himself for the past five (5) days. The doctor did not respond to this information specifically. The physician indicated that the resident did not have any signs and symptoms of UTI, had no lab work, no urinalysis and no urine culture ordered at the time. In summary, both record review and interviews revealed that Resident #113 had been suffering from continued, documented, abdominal and generalized pain, at a level of six (6) out of ten (10) during a four (4) day-time frame, and having only Tylenol administered with unresolved results. Resident #113 spiked a fever of 103 F. on Thursday 03/27/25, as well as having exhibited, at least two (2) episodes of an elevated heart rate of 148 on Thursday 03/27/25, and an elevated heart rate of 145 on Friday 03/28/25 at 11:08 AM; with no documented physician response, nor any new written physician's orders documented, at the time, to address the resident's change in condition or status. Resident #113 had not been transferred to the hospital until three (3) days after his symptoms had begun, on March the 30th, by the staff. On 06/19/25 at 5 PM, the DON acknowledged the nursing staff should be contacting a resident's physician for notification, promptly following up to ensure a response, and documenting the actions in the resident's record.

3. Review of the American Dietetic Association titled National Dysphagia Level 2: Mechanically Altered Nutrition Therapy showed the following: for vegetables, it is recommended to be soft, well cooked, should be less than 1/2 inch, and easily mashed with a fork. 3a. Record review revealed Resident #230 was admitted to the facility on [DATE] with diagnoses of Unspecific Protein-Calorie Malnutrition, Unspecific Dementia, and Muscle Weakness. On 06/16/25 at 12:44 PM, an observation was conducted, during which Resident #230 was noted in her room eating her lunch meal, being assisted by staff. The meal ticket listed the following: a mechanically altered ground diet with pureed fruits and vegetables, collard greens, macaroni and cheese, a dinner roll, ground ham, and banana pudding. Closer observation of the food on the tray revealed that the pureed collard greens lacked a smooth consistency and were lumpy. 3b. Record review revealed Resident #106 was readmitted to the facility on [DATE] with diagnoses of Unspecific Protein-Calorie Malnutrition, Dysphagia and Muscle Weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #106 with a Brief Interview of Mental Status (BIMS) score of 12, indicting moderate cognitive impairment. In an observation conducted on 06/16/25 at 12:40 PM, Resident #106 was in his room eating the lunch meal. The meal ticket was noted as follows: mechanically altered ground diet, collard greens, macaroni and cheese, and a dinner roll. Closer observation of the collard greens on the plate showed that they did not have ground consistency. It was noted with large pieces (bigger than 1/2 inch) and stamp pieces that were hard to touch and not easily cut with a fork. 3c. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses to include Dementia, Adult Failure to Thrive, and Anxiety. The Quarterly MDS assessment dated [DATE] showed Resident #22 with a BIMS score of 13, indicating slight cognitive impairment. In an observation conducted on 06/16/25 at 12:41 PM for the lunch observation, Resident #22 was eating her lunch meal. The meal ticket was noted with the following: mechanically altered ground diet, collard greens, macaroni and cheese, and a dinner roll. Closer observation of the collard greens on the plate showed that they did not have a ground consistency. It was noted with large pieces (bigger than 1/2 inch) and stamp pieces that were hard to touch and not easily cut with a fork. An interview was conducted on 06/19/25 at 10:49 AM with Staff D, Speech-Language Pathologist (SLP) who stated that for a mechanically altered ground diet, it is up to the company to determine the consistency of the diet. They will define for themselves how to prepare the consistency of the altered ground diet. Staff D stated the diet would typically have a taco-like meat consistency, and some vegetables will be pureed. A further interview was conducted on 06/19/25 at 11:10 AM with Staff D who stated that for the ground consistency national guidelines that they follow the National Dysphagia Mechanically Altered Nutrition Therapy. Based on observations, interviews and record reviews, the facility failed to provide the correct diet consistency for the Pureed diet for 2 of 3 sampled residents, Resident #1 and Resident #34, and which has the potential to affect 7 residents on pureed diet; and failed to provide the correct diet consistency for altered ground diet for 3 of 3 sampled residents, Resident #22, Resident #106, and Resident #230, and which has the potential to affect 22 residents on a ground diet. The findings included: Review of the facility's policy titled Review current texture-modified diet terminology and definitions at your facility and compare to IDDSI showed the following: The Dysphagia Level 1: Pureed consistency is smooth, lump free; not firm or sticky; does not require chewing or bolus formation. Falls off spoon as intact spoonful and holds shape. No mixed consistency. For liquids at this level: cannot be poured or drunk from a cup; nor sucked through a straw. No chewing or biting required nor ability to form bolus. 1. Record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnosis to include Malignant Neoplasm of brain and Urinary Tract Infection (UTI). The Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 04, indicating severe cognitive impairment. During an observation conducted 06/16/25 at 12:40 PM, Resident #1's meal ticket consisted of: #10 Scoop (Scp) Pureed Baked Ham, 1 ounce of sauce, #8 Scp. of Puree [NAME] Peas, #6 Scp. of Puree Macaroni & cheese, 3 oz. of Pureed Buttered Corn Bread, #10 Scp. of Puree Banana Pudding Dessert, 1 Puree Sandwich, 4 oz. of Juice of choice. Observation of Resident #35's tray consisted of a lumpy, grainy baked ham, and a yellow grainy textured of buttered corn bread. 2. Record review revealed Resident #34 was admitted on [DATE] with diagnosis to include Chronic Systolic (Congestive) Heart Failure and Dysphagia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. During an observation conducted on 06/17/25 at 8:25 AM, Resident #34's meal ticket consisted of: #8 scoop of Puree Scrambled Eggs, #10 Scp. of Puree toast, 1 Ea. Margarine, 4 oz. of Orange juice, 6 oz. of Hot Coffee or Hot tea, 8 oz. of Whole Milk, 1 Ea. of syrup, 6 oz. of puree yogurt, #16 Scp. of puree banana, #6 Scp. of Puree of Oatmeal and may have banana when requested. Observation of Resident #35's tray consisted of yellow lumpy scrambled eggs, grainy oatmeal, orange juice, yogurt, jelly, hot coffee, a whole banana, margarine, and sugar. An interview was conducted on 06/18/25 at 1:20 PM with the Speech Therapist, Staff D, who stated she has been working at this facility since September. She stated that a pureed consistency should be like a baby food consistency somewhere between apple sauce and mashed potatoes, and the right term is blenderized. She stated the consistency is defined by the company's kitchen not by her. A pureed consistency is company defined, like in this facility, oatmeal is allowed on pureed diet. An interview was conducted on 06/19/25 at 3:15 PM with the Registered Dietitian (RD) who stated that she has been working in this facility for 4 years. The RD stated that pureed texture is like a blenderized diet like a baby food consistency, and some cereals and vegetables may have a little bit of texture which is fine. She stated they follow the NDDS (National Dysphagia Diet) guideline. The RD further stated that mechanical ground diet is like ground meat and some vegetables like asparagus are pureed.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses during two of the two visits to the main kitchen. The findings included: Review of the US Food and Drug Administration's (FDA) report, dated March 2022, showed the following: raw hamburger, ground for 1-2 days, and fresh poultry, stored for 1-2 days, in the refrigerator. Website: https://www.fda.gov/food/people-risk-foodborne-illness/refrigerator-freezer-chart-food-safety-moms-be. On 06/16/25 at 8:55 AM, during tour and observation in the kitchen, the following were noted: a. The Hydron strip was used to check 1 of 3 red sanitation buckets for the appropriate sanitation solution. It showed 0, indicating that no sanitation solution was noted in the bucket. b. The reach-in freezer was marked by visible water droplets and ice buildup on the top and bottom of the freezer. c. The walk-in refrigerator was noted to contain a box of raw chicken thighs dated 06/12/25. In this observation, the Food Manager said it was used for the alternate menu as needed. This showed that the raw chicken thighs were in the walk-in refrigerator for 4 days. d. The walk-in refrigerator was stocked with three rolls (each weighing 10 pounds) of raw ground beef dated 06/12/25. The Food Manager said that it was placed in the refrigerator on 06/12/25. She was unsure when they had ground beef on the menu and said she would have to check. This revealed that the three rolls of raw ground beef had been stored in the walk-in refrigerator for 4 days. In a tour of the kitchen conducted on 06/19/25 at 11:31 AM, Staff A, Dietary Aide, was asked to calibrate a facility's thermometer to take the temperatures of food of the lunch tray-line. She was observed taking a cup of ice and overflowing it with water before placing the thermometer inside the cup. The temperature of the iced water did not go down to the necessary range of 32 degrees F. Staff A did not ensure that the ice in the cup was mostly ice with just enough water to fill the gaps; too much water would raise the temperature above 32 degrees F (0 degrees C). The surveyor intervened to ensure that the correct method of calibration was used. In an interview conducted on 06/19/25 at 6:00 PM with the facility's Administrator, she was informed of the findings.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were treated in a dignified manner while providing dining assistance during 1 of 3 dining observations conducted, affecting Resident #285. The findings included: Review of the facility's policy titled, Quality of Life - Dignity, dated August 2009, included the following: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed. Record review for Resident #285 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia, Generalized Anxiety Disorder, Depressive Disorder and Type 2 Diabetes Mellitus without Complications. Review of the baseline care plan documented Resident #285 has decreased strength on upper extremities and decreased feeding ability related to generalized weakness. During the lunch dining observation conducted on 06/16/25 at 12:12 PM, Resident #285 was observed in bed, with her meal tray on the overbed table and in front of her. Staff L, Certified Nursing Assistant (CNA), was observed standing over Resident #285 while assisting her to eat. Resident #285's family member was in the room. The surveyor left the room at 12:19 PM and Staff L was still standing over the Resident #285 assisting her with lunch. An interview was conducted on 06/18/25 at 3:07 PM with Staff L, CNA, who stated she has worked at the facility for 11 years. She stated she has two residents on her schedule that require assistance during dining. Staff L stated she does encourage the residents to eat independently but she is there if they need her assistance. Staff L was asked about the day (06/16/25) when she was assisting Resident #285 during lunch time. She acknowledged that she was standing over Resident #285 while assisting her with lunch. Staff L stated she is aware that she is supposed to sit, and it is a dignity concern. An interview was conducted on 06/18/25 at 3:20 PM with Director of Nursing (DON), who stated the CNA is aware of the dining assisting protocol and was surprised that this occurred. An interview was conducted on 06/19/25 at 12:07 PM with the family members of Resident #285. The family member stated the CNA (Staff L) does stand often to assist his mom with the meals.

Based on observations, interviews and record review, the facility failed to ensure call light devices were within reach of 4 of 93 rooms, room numbers 23, 25, 29 and 104. The findings included: 1. On 06/16/25 at 9:53 AM, an observation was made of room [ROOM NUMBER] and both residents were in bed. Upon further observation of the bed near the window, it was observed the call light cord was wrapped around the bed rail with the call light push button dangling towards the back of the bed and not within reach. Photographic Evidence Obtained. At this time the resident was asked if he knew how to call the nurse if he needs assistance and he stated yes. Then it was observed that the resident was looking for the call light push button, stating he could not find it and was unable to reach the cord that was wrapped around the bed rail and not within reach. 2. On 06/16/25 at 10:14 AM, an observation of room [ROOM NUMBER] was conducted and both residents were sleeping in bed. During this observation, it was observed that the call light cord was wrapped around the bed rail with the call light push button dangling towards the back of the bed. Photographic Evidence Obtained. 3. Observation of room [ROOM NUMBER] conducted on 06/16/25 at 11:10 AM noted the room's bathroom red emergency call light cord was wrapped neatly around the call light activating box. Photographic Evidence Obtained. During another observation of room [ROOM NUMBER]'s bathroom conducted on 06/17/25 at 9:30 AM, it was observed that the red emergency call light cord was still neatly wrapped around the call light activating box. Photographic Evidence Obtained. On 06/18/25 at 9:23 AM, another observation of room [ROOM NUMBER]'s bathroom emergency call light cord was conducted in which half of the red call light cord was now dangling from the call light activating box. Photographic Evidence Obtained. At this time, an interview was conducted with both residents, who stated that one of them does use the bathroom on a regular basis. 4. On 06/16/25 at 11:41 AM during an observation of the rooms, it was observed that in room [ROOM NUMBER]'s bathroom that the emergency call light cord was missing from the call light activating box near the shower by the bathroom door. At this time, the resident was asked if he uses the bathroom and he stated yes. An environment tour of the facility was conducted on 06/19/25 at 4:09 PM with the Director of Maintenance (DOM), who stated he has worked at the facility for 6 months. The Administrator joined the tour. The DOM stated that the call lights are checked daily and monthly for any concerns. At this time, the call light concerns in the above rooms were discussed with the DOM and the Administrator who stated that they must have missed a few of the call lights. The Administrator stated that further training will be conducted regarding the call lights. They both confirmed that the building will soon be going through renovations.

Based on observations, interviews and record reviews, the facility failed to initiate a care plan for Enhanced Barrier Precautions (EBP) for 1 of 29 sampled residents, Resident #328. The findings included: 1. Record review documented Resident #328 was admitted on [DATE] with diagnosis of encounter for other orthopedic aftercare and displaced trimalleolar fracture of left lower leg, encounter for closed fracture with routine healing. The Medicare - 5 Day Minimum Data Set (MDS) dated [DATE]documented the Brief Interview of Mental Status (BIMS) score is 15, indicating no cognitive impairment. Review of the Physician's Orders showed Resident #328 had an order dated 05/20/25 for Enhanced Barrier Precautions: Surgical wound. Review of the care plan dated 05/31/25 documented Resident #328 had skin impairment localized in the left ankle and left foot. Goals were the healing of wounds without complications by the next review date. The interventions did not include Enhanced Barrier Precautions. In an interview conducted on 06/28/25 at 3:30 PM with Minimum Data Set (MDS) coordinator, Staff J stated she has been working in this facility since 2015 and explained that she is one of the persons in her department that is responsible of elaborating care plans. She further explained that the process starts as soon as she gets the orders, she initiates the care plan the next day and for new residents within 48 hours upon admission. Regarding Resident #328, Staff J acknowledged there was no care plan for EBP put in place.

Based on observations, interviews and record reviews, the facility failed to provide assistance during dining for 1 of 1 sampled resident, reviewed for activities of daily living (ADLs), Resident #330. The findings included: 1. Record review documented Resident #330 was admitted on [DATE] and discharged on 06/16/25 with diagnoses that included Sepsis and Urinary Tract Infection (UTI). The Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 13, indicating mild cognitive impaired. Section GG of the MDS showed that Resident #330 needs Substantial / Maximal Assistance during dining. Review of Resident #330 care plan dated 05/14/25 documented Resident #330 was at risk for an alteration in nutrition and/or hydration. The interventions put in place included providing hands on assist with eating at meals and as needed and provide cues / encouragement during meals. During an observation conducted on 06/16/25 at 12:15 PM, Resident #330 was seen in bed seating and trying to eat alone. Fifteen (15) minutes later, at 12:30 PM, Resident #330 was seen in the same position with a pudding like food dripping on his clothes and struggling to eat. The resident looked desperate and annoyed. At 12:45 PM, the surveyor asked a Certified Nursing Assistant (CNA) if she could assist the resident. In an interview conducted on 06/18/25 at 2:30 PM with MDS coordinator, Staff J stated she has been working in this facility since 2015 and further explained that Substantial / Maximal assistance means the staff is doing more than 50% of the work. Staff J explained she would expect the staff to be doing the activity and the patient to participate in it but would not expect the staff to be helping the resident throughout the whole meal and staff could be going in and out of residents' room. In an interview conducted on 06/18/25 at 4:30 PM, the Director Of Nursing (DON) stated she has been working for this facility for 2 years. She explained that the nurse is responsible for conducting the initial assessment and starting the baseline care plan, therapy assesses the residents, the MDS department does their assessment to determine the level of assistance that the residents need. The DON stated some residents fluctuate from needing maximal assistance to not needing assistance. She further stated that for a resident on substantial / maximal assistance, she would expect the staff to do the setup, help the residents eat and encourage the residents to feed themselves. The DON stated that as far as whether staff are to stay in the room during the whole process, sometimes yes, sometimes no; but staff must stay in the room if residents do not want to be helped to encourage the residents.

Based on interviews, observations, and record review, the facility facility failed to ensure that services and treatment were provided to increase or maintain range of motion (ROM) and to prevent potential decrease in ROM, as ordered by physicians, for 2 of 2 sampled residents, reviewed for ROM, Residents #51 and #62. The findings included: Review of the facility's policy titled, Splints and Braces, undated, included the following: Procedures: 3. After therapy discharges the patient, the splints will be monitored by Assistant Director of Nursing (ADON) or designee, Director of Rehab Services (DOR) and/or designee. A new T.O will be obtained to indicate the wearing schedule and the responsible department with updated care plan. 5. If a patient is issued a splint / brace and cannot be located, go to the ADON or DOR and get the correct or replacement of splint/brace. 8. Report to nurse any adverse observations. Review of the facility's policy titled, Contracture Management, undated, included the following: 3. Treatment plans will be geared towards minimizing or possibly alleviating resident of noted contractures. 1. Record review revealed Resident #51 was admitted to the facility on [DATE] with a readmission date of 03/14/25, with diagnoses that included: Cerebral Infarction, Contracture (Unspecified Elbow dated: 10/11/23) and Vascular Dementia. A physician's order dated 04/11/25 revealed the following: Bilateral elbow splints, on daily after AM care and off at bedtime, as tolerated with skin check upon donning and doffing. The order was documented as discontinued on 06/11/25. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 99, indicating he was rarely understood and had severe cognitive impairment. In an observation conducted on 06/16/25 at 10:55 AM, Resident #51 was observed in bed with contractures on both elbows (bent to center of chest) and hands (fingers curled and pulled towards the palm), and no splint was observed in place. In observations conducted on 06/17/25 at 12:35 PM, at 2:30 PM and 5:00 PM, Resident #51 was observed in bed with contractures on bilateral elbows and hands, and no splint was observed in place. An interview was conducted on 06/18/25 at 3:34 PM with the Director of Rehab (DOR), who stated she has worked at the facility for 2 years. She stated Resident #51 had splints when he went to the hospital and splints when he returned to the facility. The DOR noted that the splints were ordered as a foam type due to Resident #51's delicate skin, but these splints were still providing too much pressure on the elbows (bony area) that the splints were discontinued due to high risk of pressure injury. She then stated that they are looking into other splints for Resident #51. (Splints were documented as being discontinued on 06/11/25). An interview was conducted on 06/19/25 at 9:06 AM with Assistant Director of Nursing (ADON). She stated she oversees the restorative program which is composed of 3 Restorative Certified Nursing Assistants (CNAs), but all CNAs are educated by Rehab on how to properly put on splints and braces. An interview was conducted on 06/19/25 at 11:50 AM with Staff M, Restorative CNA, who stated she has worked at the facility for 8 years. She stated she puts on the splint on the resident and regularly checks the skin to ensure the resident can tolerate the splint. Staff M noted that she documents for each resident when splints are put on and removed. She also pointed out that the documentation is on the computer (Point Click Care (PCC)) under Restorative Weekly Documentation Record. Review of the Restorative Weekly Documentation Record in PCC for Resident #51revealed only one week was listed, dated 04/17/25, in which no documentation was found of Resident #51 ever wearing the splint. On 06/19/25 at 12:07 PM, a side-by-side review of Resident #51's May and June 2025 Treatment Administration Record (TAR) was conducted with the ADON. During this review, the ADON was made aware that for Resident #51, it was never documented that the resident wore the bilateral splints as per the physician's orders. The ADON acknowledged not seeing the documentation and stated the staff will receive proper education. 2. Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses that included: Muscle Wasting and Atrophy (Right Hand 08/02/24), Contracture (Right Elbow) and Hemiplegia. A physician order dated 08/13/24 revealed the following: Right elbow orthosis and Right Wrist Hand orthosis on after lunch, off at bedtime (HS) as tolerated, skin check upon donning and doffing device. Review of Section C of the MDS assessment dated [DATE] revealed Resident #62 had a BIMS score of 15 indicating he was cognitively intact. In an observation conducted on 06/16/25 at 9:38 AM, Resident #62 was observed in bed with a contracture (fingers curled and pulled towards the palm) on his right hand, and no right-hand splint was in place. In this observation, Resident #62 stated he is supposed to have a splint on but the staff told him they cannot find it. In an observation conducted on 06/17/25 at 1:40 PM, Resident #62 was observed in bed with a contracture to his right hand, and no splint was in place. An interview was conducted on 06/17/25 at 5:13 PM with Resident #62, who stated he used to have a splint for his right hand, but it got lost or he's not sure where it is and neither does the staff. He noted that since the splint is missing, the staff has not put it on him. Resident #62 stated he would like to wear it because it was helpful. In an observation conducted on 06/18/25 at 3:13 PM, it was observed that Resident #62 was in bed with a contracture to his right hand, and no splint was in place. An interview was conducted on 06/18/25 at 3:34 PM with DOR who she stated at one point Resident #62 had a splint and he would often refuse to wear it. The DOR stated she was not aware of the splint missing and would check with the occupational therapist (OT) regarding the splint. Review of the progress notes for the months of May and June 2025 revealed no documentation of Resident #62 refusing to wear the splint. Review of the CNA Tasks dated 06/01/25 to 06/18/25 revealed Resident #62 was wearing the splint except on 06/14/25 and 06/15/25. This contradicted the 06/16/25 to 06/18/25 observations of Resident #62 noted to not be wearing the splint. In an observation conducted on 06/19/25 at 10:07 AM, Resident #62 was observed in bed with no right-hand splint on. When asked about the splint, he stated that one of the staff just had it and they walked away with it. At this time, the OT entered the room with a splint which appeared clean and new. She stated they had mentioned to her that there was equipment missing for Resident #62 and came to inquire about it. She then stated the splint was in his closet all this time, but maybe the CNAs did not know the splint was there. She stated that sometimes splints are sent out to laundry to get cleaned and they can get lost.

Based on review of policy and procedure, observation, interview and record review, the facility failed to follow proper technique and infection control practices during catheter care observation for 1 of 1 sampled resident observed, Resident #113. The findings included: Review of the facility policy, titled, Urinary Catheter Care, provided by the Director of Nursing (DON), revised September 2014, documented in the Policy Statement: Purpose: the purpose of this procedure is to prevent catheter-associated urinary tract infections (UTI). Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: .Maintain Unobstructed Urine Flow: .3. The urinary drainage bag must be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder Record review revealed Resident #113 was admitted to the facility on [DATE] with diagnoses that included Paraplegia, Urinary Tract Infection, Iron Deficiency Anemia, Acute Pyelonephritis, Neurogenic Bladder and Neuromuscular Dysfunction of the Bladder. The documented Brief Interview Mental Status (BIMS) score was 15, indicating intact cognition. Review of Resident #113's care plan initiated 01/03/25 indicated Focus: Resident [#113] has an alteration in elimination as evidenced by: .he has a Foley catheter related to Neurogenic Bladder. Interventions: Provide catheter care and peri-care every shift and as needed. Maintain closed drainage system and keep drainage bag below level of the bladder .Goal: Resident [#113] will continue with a patent indwelling catheter and remain free from signs and symptoms of UTI thru next review date. Resident will have adequate bladder function thru catheter and will remain from complications related to use of device thru the next review date On 04/10/25, the Physician's Orders documented, Indwelling Foley Catheter care every shift, as needed for soiling or leakage. During a Foley / Peri-care observation performed by Staff K, Certified Nursing Assistant (CNA), on 06/19/25 10:53 AM, it was noted that Resident #113's Foley catheter was observed to be properly secured in place with both a Foley catheter strap and anchor per physician's written order. Resident #113's privacy curtain was pulled closed by Staff K. Staff K washed her hands, and donned a PPE, including a clean pair of gloves. Prior to performance of the resident's peri-Foley care, Staff K was observed lifting and raising the resident's Foley catheter bag with the tubing and placing it on top of the resident's bed at or above the level of his bladder. The resident's Foley bag with tubing remained on the bed throughout and the procedure. Photographic Evidence Obtained. On 06/19/25 at 11:13 AM after the Foley catheter care, an interview was conducted with Staff K, who was asked whether or not this was something that she routinely does with the catheter bag and tubing. Staff K responded that she had made a mistake placing the Foley catheter bag on the bed next to the resident. She said she was aware that she should not have lifted and raised the resident's Foley up unto the bed. On 06/19/25 at 11:34 AM, an interview was conducted with Staff N, Licensed Practical Nurse (LPN) and Unit Manager South wing, who acknowledged the Foley catheter bag should have been kept below the level of the resident's bladder. An interview was then conducted on 06/19/25 at 2:38 PM with the Registered Nurse (RN)/Infection Control Nurse, who acknowledged that the Foley catheter bag should have been kept below the level of the bladder. The Director Of Nursing acknowledged on 06/19/25 at 2:45 PM that the resident's Foley catheter bag should not have been raised unto the bed and should have been kept below the level of the resident's bladder.

Based on observations, interviews, and record review, the facility failed to complete a nutrition assessment in a timely manner for 1 of 3 sampled residents reviewed for nutrition, Resident #231. The findings included: Review of the facility's policy titled Nutrition Assessment, revised in October 2017, showed the following: as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for residents at risk for or with impaired nutrition. Review of the facility's policy titled Weight Assessment and Interventions, revised September 2008, showed the following: The nursing staff will measure resident weights on admission, times 2, then monthly thereafter, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Record review revealed Resident #231 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Diabetes and Anemia. The 5-day Minimum Data Set (MDS) assessment, dated June 12, 2025, showed that Resident #231 had a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Resident #231 is dependent on Hemodialysis and is receiving dialysis 3 times a week in the facility. Review of the physician's orders, dated 06/06/25, showed an order for weights to be done at the Dialysis Center. Review of the weights log for Resident #231 showed the following: On 06/09/25, Resident #231's weight was 189.6 pounds. On 06/11/25, the resident's weight was 181 pounds. This revealed a 4.5% weight loss in 3 days. The care plan for nutrition revealed the following: Resident #231 is at risk for alteration in nutrition and hydration related to dialysis dependence and pressure ulcers on admission. It further showed to follow weights as ordered and as needed. The dialysis communication sheet dated 06/09/25 showed that a pre-dialysis weight was documented for Resident #231, and a post-dialysis weight was documented for Resident #231. Review of the Initial Nutrition Assessment, which was created on 06/10/25 and locked on 06/13/25, revealed the following: Resident #231's current weight was documented at 181 pounds and not at 189.6 pounds, which was noted on 06/09/25. Resident #231 has a history of 20 pounds weight loss in about two months and stage 3 pressure ulcers. Under the section Estimated Nutrition Needs of this assessment, the facility's Registered Dietitian did not calculate the caloric needs, protein needs, or fluids needs for Resident #231. An interview was conducted on 06/18/25 at 9:45 AM with the facility's Registered Dietitian (RD), who stated that initial nutritional assessments are done within 3 days of admission. According to the facility's policy, they have up to 14 days to complete the evaluation. Residents on dialysis are considered at high nutritional risk, and it is important to calculate and estimate nutrition needs (calories, protein, and fluids). The RD indicated works closely with the dialysis's RD regarding dialysis weights, fluid restrictions, and nutritional needs. When asked about the facility's weight policy, she stated weights are taken on admission, second weight is taken after one week, and monthly thereafter. According to the RD, weights are taken before and after each dialysis treatment and are documented in the dialysis communication sheets. The communication sheets are then given to nursing. She will review the weights from the communication sheets and record them under the Weight section in the electronic system. The RD said that for any missing communications sheets, she would contact the dialysis's RD to obtain the weights. When asked about the Initial Nutrition Assessment, which she completed on 06/10/25, she stated that she was waiting for the dialysis RD to provide her with Resident #231's weights to complete the assessment. She was waiting on the Assessment Reference Date (ARD) with the most current data, which would have been on 06/11/25. The RD placed the weight into the assessment on 06/11/25 but did not calculate estimated nutritional needs because she was still waiting for the dialysis RD to provide her with additional weights. She indicated she probably went into the assessment and placed the weight of 181 pounds on 06/13/25, but she was not sure. Since Resident #231 was a long-term care resident, she may not have recorded the weights in the system after each dialysis treatment and may only have done so once a week.

Based on observations, interviews, and record review, the facility failed to have dialysis communication sheets readily available for the continuation of care for 1 of 2 sampled residents reviewed for dialysis, Resident #231. The findings included: Review of the facility's dialysis contract dated 05/27/21 revealed the following: Access to Records-provider will ensure that the Facility has any and all records of supplies and services provided to, and any flow sheets, progress notes, physician orders, incident reports, and other documentation which reflect the quality of treatments received by the Covered Patients. Providers and Caregivers will communicate information necessary to the Facility and/or Physician for continuing care of each Covered Patient, including medication administration for maximum therapeutic effect. Record review revealed Resident #231 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Diabetes and Anemia. The 5-day Minimum Data Set (MDS) assessment dated [DATE] showed Resident #231 had a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of the physician's order, dated 06/17/25, showed an order for a dialysis center on Mondays, Wednesdays, and Fridays. The dialysis care plan for Resident #231 documented to complete the dialysis communication tool on dialysis days and to review it upon return from dialysis. Review of the dialysis communication sheets in the electronic system revealed a dialysis communication sheet dated 06/09/25, as well as an incomplete communication sheet for 06/11/25. The dialysis communication sheets for 06/13/25 and 06/16/25 were missing. An interview was conducted on 06/17/25 at 10:50 AM with Staff F, Licensed Practical Nurse (LPN), who stated the dialysis communication sheets are completed in the dialysis center after each treatment and taken back to the unit to be uploaded into the electronic system. An interview was conducted on 06/17/25 at 12:40 PM with Staff G, LPN, who stated the communication sheets are first completed by the nurse who oversees the residents. It is then completed by the dialysis center after the treatment, and the dialysis technician will bring the filled form to the assigned nurse. The form is then brought to medical records to be scanned into the electronic system. An interview was conducted with the Director of Nursing (DON) on 06/18/25 at 12:08 PM, who stated the assigned nurse would start the communication sheet before Resident #231 went to dialysis. The form is given to the resident to take with him to dialysis. The Dialysis team will complete their part of the form and return it to the resident to take back to the unit. The nurse takes the communication sheet from the resident and brings it to the medical record staff so they can scan the form into the system. The DON stated many dialysis communication sheets are stored in medical records before being loaded into the electronic system. The DON stated the communication sheets are vital for the continuation of care and are an essential communication tool between the nursing staff and the dialysis staff. In an interview conducted on 6/18/25 at 4:17 PM with Staff H, a Dialysis Registered Nurse stated that when a resident comes to dialysis, they come in with the communication sheet, which is given to them to fill out during the treatment. The sheet is then given to the staff who comes to pick up the Resident from dialysis. They always fill out the form during each treatment.

Based on observations, interviews, and record review, the facility failed to accurately assess a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and establish triggers for PTSD for 1 of 1 sampled resident reviewed for PTSD, Resident #58. The findings included: Record review revealed Resident #58 was admitted to the facility with diagnoses of Chronic Post Traumatic Stress Disorder, Anxiety, and Major Depressive Disorder. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #58 had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. Review of the physician's order showed the following: Sertraline (psychotropic medication) 150 milligrams at bedtime for Major Depressive Disorder dated 03/14/24. Aripiprazole (antipsychotic medication) tablet 2 milligrams one time a day for Schizoaffective Disorder, dated 09/23/23. An interview was conducted on 06/17/25 at 4:36 PM with Resident #58, who stated he had served in the [name] War and that he has PTSD. He sometimes has disagreements with staff due to his triggers, and different things bother him. He is sensitive to loud noises, family walking in and out of his room and disagreements. Review of the Social Services OBRA Evaluation dated 06/17/25 and dated 01/30/25 showed that under the section on Psychotropic medications, the following questions were filled: *Is the Resident currently receiving psychotropic medication? The answer was no. *Is the Resident currently being followed by the psychologist/psychiatrist? The answer was no. Review of the care plan initiated on 02/05/24 showed the following: Resident [#58] is at risk for re-traumatizing and mental health problems related to PTSD and combat war exposure. The Resident will display minimal signs and symptoms of health problems. Further review of the care plan did not show any triggers for PTSD that were part of the interventions. An interview conducted on 06/17/25 at 4:47 PM with Staff E, Licensed Practical Nurse, who stated Resident #58 has a history of PTSD. She was not aware of any triggers for PTSD and reported that Resident #58 had not exhibited any symptoms or behaviors. He is pleasant with her and talks about his military life and his family. She has not seen him be argumentative, combative, or any behaviors that are vindictive of PTSD. An interview was conducted on 06/18/25 at 8:11 AM with the Director of Nursing (DON) who stated Resident #58 had not exhibited any symptoms of PTSD except for the usual symptoms that he has which were care planned for. When asked about the Trauma-informed assessment, she said that it is embedded in the Social Worker's Initial Assessment. An interview was conducted on 06/18/25 at 8:44 AM with the Social Service Director who stated that Trauma-informed care is part of her assessment, and she would assess for any triggers and would discuss them in the care plans. She stated that she started to work in the facility only a few weeks ago. In this interview, the surveyor stated understanding and identifying PTSD triggers is important because it enables individuals to anticipate situations or stimuli that may provoke intense emotional and physiological reactions linked to their trauma. An interview was conducted on 06/18/25 at 12:54 PM with the Corporate Social Worker who stated that in their initial evaluation, they have a section that asks questions about trauma-informed care. They begin their initial evaluation, which is called the Social Services Initial Evaluation, which addresses trauma-informed care for residents. The above resident was admitted with the older system of documentation, and another type of assessment was completed on 01/28/20 by another Social Worker who was here. An interview was conducted on 06/19/25 at 10:08 AM with the Corporate Social Worker, who stated the care plan for Resident #58 should have had triggers in place so the staff would know what to do and what to look for related to PTSD triggers. She further stated that the current Social Worker Director, who has started working recently, identified the missing triggers in the care plan and plans to update the care plan in the next quarterly review to include these triggers. An interview was conducted on 06/19/25 at 10:20 AM with Staff C, Registered Nurse, who stated that she has been working in the facility for one year. She is familiar with Resident #58, and he has a history of PTSD. When asked if she knew of any triggers for PTSD, she said, I am not aware of any triggers or what may be some of the triggers for PTSD. Staff C stated Resident #58 may behave differently with the staff and may yell or scream at times or refuse to answer questions when asked. An interview was conducted on 06/19/25 at 1:00 PM with Staff K, Certified Nursing Assistant, who reported not knowing Resident #58 had a history of PTSD. She was not aware of any triggers of PTSD or if Resident #58 had any triggers for his PTSD. An interview was conducted on 06/19/25 at 12:50 PM with Resident #58 who stated he has a history of PTSD with some triggers. He stated that some of his triggers may be loud noises or another resident who always yells and repeats the same words in the hallway.

4. Record review revealed Resident #231 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Diabetes, and Anemia. The 5-day MDS dated [DATE], showed that Resident #231 had a BIMS score of 9, indicating moderate cognitive impairment. The Initial Nutrition assessment, dated 06/10/25, showed that Resident #231 was at increased risk for altered nutritional status, and it was recommended to provide double protein with meals. In an observation conducted on 06/16/25 at 12:37 PM, Resident #231 was eating his lunch meal. The closer observation showed the meal ticket with the following: Controlled Carbohydrates Renal diet, double protein, baked pork chops, buttered green, buttered pasta, and cornbread. The lunch plate was observed with the following: 3 ounces of grilled chicken, 4 ounces of buttered green, 4 ounces of buttered pasta, and one piece of cornbread. This showed that Resident #231 did not get the double portion of the protein for lunch. Based on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, for 4 of 29 sampled residents observed during dining, Resident #50, Resident #1, Resident #6, Resident #231. The findings included: 1. Record review revealed Resident #50 was admitted on [DATE] with diagnosis to include Acute Embolism and Thrombosis of unspecified deep veins of right lower extremity and Dysphagia Oropharyngeal phase. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #50's care plan dated 12/30/24 indicated Resident #50 is at risk for an alteration in nutrition and/or hydration. The interventions put in place included double meat with meals and honoring food preferences to prevent resident from losing weight. During an observation conducted on 06/16/25 at 1:00 PM in the main dining room, Resident #50 was seen irritated. An interview was conducted with Resident #50 who explained that on multiple occasions when he is dining in his room, he only gets soup and crackers, and today they served him his food without meat. Staff members had explained to Resident #50 that his wife said that he does not eat pork. Resident #50 explained that his wife passed a long time ago. Review of the residents' meal ticket consisted of: 1/2 cup of collard greens, 4 oz. (ounces) of macaroni & cheese, 6 oz. of soup of the day, 2 packages of crackers, 1/2 cup of banana pudding dessert, and 4 oz. of punch. Resident meal ticket or tray did not consist of meat. 2. Record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnosis to include malignant neoplasm of brain and urinary tract infection. The Medicare - 5 Day MDS assessment dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. During an observation conducted 06/16/25 at 12:40 PM, Resident #1's meal ticket consisted of: #10 Scoop (Scp) Pureed Baked Ham, 1 ounce of sauce, #8 Scp. of Puree [NAME] Peas, #6 Scp. of Puree Macaroni & cheese, 3 oz. of Pureed Buttered Corn Bread, #10 Scp. of Puree Banana Pudding Dessert, 1 Puree Sandwich, 4 oz. of Juice of choice. Resident #35 tray consisted of puree baked ham, puree green peas, puree macaroni & cheese, pureed buttered corn bread, pureed banana pudding, juice of choice. The tray did not have the sauce or the pureed sandwich. 3. Record review revealed Resident #6 was admitted on [DATE] with diagnosis of senile degeneration of brain and other specified persistent mood disorders. The Modification of Quarterly MDS dated [DATE] revealed a BIMS score of 99 indicating they were unable to conduct the interview / severe cognitive impairment. During an observation conducted on 06/16/25 at 12:45 PM, Resident #6's meal ticket consisted of: 3oz. (ounces) of glazed ham, 1 peanut butter & jelly sandwich, 1/2 cup of collard greens, 4 oz. of macaroni & cheese, 1 piece of cornbread, 1/2 cup of banana pudding dessert, 8 oz. of whole milk, 4 oz. of punch. Resident #6's tray did not have the peanut butter & jelly sandwich. During an observation conducted on 06/17/25 at 8:30 AM, Resident #6's meal ticket consisted of: 1 Ea. (each) Breakfast Biscuit Sandwich, 4 oz. of Orange Juice, 8 oz. of Coffee, 8 oz. of Whole Milk, 8 oz. of 2% Milk, 6 oz. of Yogurt and 3/4 cup of Grits. Resident #6's tray did not have the orange juice and only had 1 cup of milk instead of two. An interview was conducted on 06/18/25 at 2:15 PM with the Food Service Manager (FSM) who stated she has been working at this facility for over 2 years. The FSM stated that when a resident is newly admitted she visits the resident and records their food preferences within 48 hours; and the residents have a weekly preference menu to fill out and some residents prefer to call to put in their preferences. The FSM explained that the tray line has two employees that are dedicated to making sure that the meal ticket matches the tray; one at the start and one at the end. If there is a change in portions size, the Food Manager is made aware by the nurse through communications slips. The Food Manager was made aware of the findings and agreed the meal ticket should always match what is on the tray. The Food Manager stated Resident #50 should have gotten a double portion of meat or two sandwiches. An interview was conducted on 06/19/25 at 3:20 PM with Licensed Practical Nurse (LPN), Staff I, who stated she has been working at this facility for 15 years. She stated that when the food gets on the floor (delivered to the unit) before bringing the food to the resident, they check that the meal ticket matches the tray and they touch under the plate to check the food temperature, the food should be hot.

4. Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder and Unspecific opened wound. An order was noted for Enhanced Barrier Precautions-wound every shift, which was dated 05/20/25. An observation was conducted on 06/16/25 at 11:30 PM of Staff B, Occupation Therapist, who was noted coming out of Resident #38's room with a gown. She was observed walking over to a Personal Protective Equipment (PPE) box located on the wall in the hallway. She grabbed a surgical mask with her bare hands and continued to put on gloves without practicing hand hygiene first. Staff B took a Hoyer lift and walked into Resident #38's room to assist him from the bed to the wheelchair with another staff member who was already in the room. Based on observations, interviews, and record review, the facility failed to implement Center for Disease Control and Prevention (CDC) guidelines and recommendations for Enhanced Barrier Precautions (EBP) for 4 of 45 sampled residents reviewed for EBP, Residents #111, # 51, #328 and #38. The findings included: According to CDC, Enhanced Barrier Precautions revealed the following: Everyone must clean their hands including when both entering and leaving the room. Providers and Staff must also; wear gloves and a gown for the following high-contact resident care activities: dressing; bathing-showering; transferring; changing linens; providing hygiene; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy; Wound Care any skin opening requiring a dressing. Website: https://www.cdc.gov/long-term-care-facilities/medi a/pdfs/EBP-KeepResidentsSafe Poster-508.pdf. 1. Record review revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included: Quadriplegia, Major Depressive Disorder and Local Infection of the Skin and Subcutaneous Tissue (03/27/25). Review of the physician order dated 05/30/25 with an end date of 07/11/25 revealed the following: Meropenem Intravenous (IV) Solution Reconstituted 2 GM, use 2 gram IV every 8 hours for Infected Sacral Wound Site (Possible Osteomyelitis) for 6 Weeks; and Monitor Midline site for signs and symptoms of infection, infiltration, and/or extravasation every shift for Infection Prevention. On 06/18/25 at 2:02 PM, an IV antibiotic administration observation was conducted with Staff G, Licensed Practical Nurse (LPN), for Resident #111. Staff G entered the resident's room with all the supplies which included the antibiotic: Meropenem 2 gram IV Solution and 2 saline syringes. Staff G stated he had already primed and dated the tubing and placed them on clean napkins on top of the overbed table. Staff G then went to the sink and washed his hands, donned on clean gloves. Staff G did not don on a gown. Staff G then returned to hang and connected the medication to Resident #111's midline. An interview was conducted on 06/18/25 at 2:12 PM with Staff G, LPN, who stated that he thought EBP would apply just when providing care and did not realize that he needed to don on a gown for administering IV medication. At this time, the surveyor pointed out the EBP sign by the door and Staff G acknowledged that a gown is required for IV medication administration. An interview was conducted on 06/18/25 at 2:34 PM with the Director of Nursing (DON). She stated she was surprised that Staff G did not don on a gown. She acknowledged that EBP education is needed. 2. Record review for Resident #51 revealed an admission to the facility on [DATE] with readmission date on 03/14/25 with diagnoses that included: Cerebral Infarction, Encounter for Surgical Aftercare Following Surgery on the Digestive System, Adult Failure to Thrive and Vascular Dementia. Review of the physician order dated 06/16/25 revealed the following: Enteral Feed, every shift Jevity 1.5 at 60 milliliters (ml) per hour via feeding tube for 20 hours with auto flush at 60 ml/hour for 20 hours. On at 1400 (2:00 PM) and off at 10:00 AM. On 06/19/25 at 10:14 AM, a Percutaneous Endoscopic Gastrostomy (PEG) tube feeding disconnection observation for Resident #51 was conducted with Staff G, LPN, who gathered the following supplies: cup with water, small medication cup, and 2 large syringes. He then placed clean paper towels on the overbed table and placed the foam tray with all the supplies. He washed his hands, donned on a clean gown and only donned a glove on his right hand, held the other glove in the right hand and stated that he was going to close the window blinds for privacy. At this time, Staff G went to the window and using his left bare hand (which he had previously washed and had no glove on) closed the blinds and then pulled the privacy curtain. Staff G then without washing his hands, donned on the glove on the left hand and moved to the pump and turned it off. Without changing his gloves or performing hand hygiene, Staff G moved to disconnect Resident #51's PEG tube. Throughout the entire procedure, Staff G never changed gloves or performed hand hygiene. Once finished, he removed his gloves and gown, discarded them, washed his hands and left the room. At this time, an interview was conducted with Staff G regarding hand hygiene during the procedure. Staff G looked confused and stated that he did not use the gloved hand to close the blinds or the loose glove in his hand. He was asked if hand washing is required after touching the blinds, he again appeared confused and then realized that he needed to wash his hands more often. 3. Record review revealed Resident #328 was admitted on [DATE] with diagnosis of encounter for other orthopedic aftercare and displaced trimalleolar fracture of left lower leg, encounter for closed fracture with routine healing. Review of the Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 15, indicating no cognitive impairment. Review of the physician's orders showed that Resident #328 had an order dated 05/20/25 for Enhanced Barrier Precautions: Surgical wound. Review of the care plan dated 05/31/25 documented Resident #328 had skin impairment localized in the left ankle and left foot. Goals were the healing of wounds without complications by the next review date. The interventions did not include enhanced barrier precautions. During an observation conducted on 06/16/25 at 9:25 AM, Resident #328 was seen lying in bed and Staff I , Licensed Practical Nurse (LPN), entered the room without a gown or surgical mask and put on some gloves without washing her hands and injected the resident in the abdomen area without disinfecting it. In an interview conducted on 06/18/25 at 4:45 PM, Director Of Nursing (DON) stated that she has been working for this facility for 2 years. She stated her expectations when a resident is on EBP is for staff to wear the adequate EBP elements which are gown, surgical mask and gloves. She stated they put a little pink heart by the resident's name and also put an EBP sign at the door. The DON stated that they reinforce it as much as possible and that the expectations when a nurse is going to inject a resident is to wear the EBP. In an interview conducted on 06/19/25 at 3:20 PM, Staff I, LPN, stated that if a resident is on EBP, she has to wear gowns and gloves before entering the room. She stated what they usually do is that they wash their hands in the bathroom outside and put the gown on and gloves at the residents door.

Based on observations, interviews, and record review, the facility failed to treat a resident with a left-hand contracture for 1 of 1 sampled resident reviewed for a range of motion (ROM), Resident #108. The findings included: Review of the facility's policy, titled, Splints and Braces, revised on January 2, 2024, revealed the following: Donn patient splint / brace according to positioning / splinting instructions. Allow the patient to wear a splint / brace per the therapist's recommended wearing schedule and tolerated. Review of the facility's policy, titled, Contracture Management, revised on January 2, 2024, revealed that treatment plans will be geared towards minimizing or possibly alleviating residents noted contractures. Record review revealed Resident #108 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, repeated Falls, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/19/24, revealed a Brief Interview of Mental Status (BIMS) score of 09, indicating mild cognitive impairment. In an observation conducted on 03/18/24 at 10:00 AM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/18/24 at 1:34 PM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/18/24 at 2:30 PM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/19/24 at 9:03 AM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/19/24 at 12:10 PM, Resident #108 was noted in a chair. Continued observation revealed a splint that was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. Review of the Physician's orders showed an order dated 02/16/24 for a left-hand splint after AM [morning] care and off HS [hour of sleep]. Review of the Occupational Therapy Evaluation dated 01/25/24 to 02/23/24 revealed that Resident #108 will tolerate a left-hand orthotic for up to hours to improve skin and joint integrity. An interview was conducted on 03/20/24 at 2:07 PM with Staff E, Occupation Therapist Assistant who stated Resident #108 has a resting hand splint that needs to be placed on the Resident's left hand at AM after morning care and off at PM. She further stated Resident #108 has a left-hand contracture, and the splints will prevent skin breakdown and hygiene. Staff E accompanied the surveyor to Resident #108's room. The surveyor pointed at the resting hand splint at the side table and asked if it needed to be placed on Resident #108, and she said yes. Staff E reported that it is the responsibility of the Certified Nursing Assistants (CNAs) who are taking care of Resident #108 to place the splint on the left hand after morning care. An interview was conducted on 03/20/24 at 2:14 PM, Staff D, Certified Nursing Assistant (CNA), who stated that hand splints are placed on residents by the restorative team and sometimes by the Certified Nursing Assistants. She usually places it on residents after morning care. Staff D was asked if Resident #108 had a hand splint, and she said, I do not know. She was then asked to accompany the surveyor to Resident #108's room. When asked why the left-hand splint was not placed on Resident #108, she said that the restorative staff put it on this morning and must have removed it. An interview was conducted on 03/20/24 at 2:24 PM with Resident #108, who stated the staff has yet to place his left-hand splint on him all week. An interview was conducted on 03/20/24 at 2:50 PM with Staff F, Restorative Certified Nursing Assistant, who stated that she is assigned to some residents on the floor who have orders for hand splints and the designated Certified Nursing Assistant (CNA) assigned for the day. The splints are usually placed after morning care and taken off before she leaves, which is around 3:30 PM to 4:00 PM. She further said that since Resident #108 is on a maintenance program, it is the responsibility of his assigned CNA to place the hand splints on him. When asked if it was placed on Resident #108 this morning, she said that his CNA (Staff D) was assigned to him this morning.

Based on observations, interviews and record review, the facility failed to provide nutritional interventions in a timely manner to prevent further weight loss for 1 of 5 sampled residents reviewed for nutrition, Resident #101. The findings included: Review of the facility policy, titled, Nutrition Assessment, revised in October 2017, revealed the following: Any weight change of 5% or more since the last weight assessment will be verified, and nursing will contact the Dietitian for further evaluation. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends. Negative trends will be evaluated by the treatment team to determine whether or not the criteria for significant weight change has been met. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria where the percentage of body weight loss == (usual weight actual weight) (usual weight) - 100]: a. month 5% weight loss is significant; greater than 5% is severe. b. - 3 months -7.5% weight loss is significant; greater than 7.5% is severe. C. months - 10% weight loss is significant; greater than 10% is severe. Record review documented Resident #101 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia, Dysphagia, and Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/25/24, documented Resident #101 has a Brief Interview of Mental Status (BIMS) score of 14, indicating cognition was intact. Section B on the MDS revealed Resident #101's speech was unclear. Review of the Physician's orders, which started on 02/26/24 and discontinued on 03/05/24, revealed an order for a med pass (nutritional supplement) of 120 milliliters (ml) three times a day. It further revealed another order for a med pass written on 03/05/24. A phone interview was conducted on 03/18/24 at 4:00 PM, with Resident #101's Fiance who stated she spoke to the facility's Dietitian a few weeks ago regarding her concerns with Resident #101's continued weight loss. The Dietitian told her she would review updating Resident #101's food preferences but had not heard back from her. In an observation conducted on 03/19/24 at 9:05 AM, Resident #101 was noted in his bed. Staff P, Certified Nursing Assistant (CNA), was noted setting up the breakfast tray for Resident #101 at the bedside. She then proceeded to feed Resident #101 his breakfast meal. The breakfast tray was observed with a regular puree diet and 4 ounces of a mighty shake (nutritional supplement). Continued observation revealed Resident #101 ate 50% of his breakfast tray but did not drink any of the mighty shakes on his tray. In an observation conducted on 03/20/24 at 8:47 AM, Resident #101 was eating his breakfast tray in his room. Staff D, CNA, was sitting near the resident, assisting him with his breakfast tray. The breakfast tray was noted to have a mighty shake (nutritional supplement). Staff D stated that when the resident is done eating, she will document the total amount consumed for the entire meal but will not document the percentage consumed from the nutritional supplement. Review of the Weight Log revealed Resident #101 had dropped from 11/03/24 to 02/07/24 from 148.2 pounds to 136.4 pounds, which was 8.3% severe weight loss in 3 months. Review of a quarterly dietary profile note dated 02/26/24 noted it was written 19 days after Resident #101 had the significant weight loss. In this note, the facility's Dietitian recommended adding an additional nutritional supplement with med pass 120 ml three times a day. The Dietitian noted that Resident #101's Usual Body Weight was 150 pounds, and that Resident #101 had a weight loss of 8% in 2 months. The care plan dated 02/24/24 revealed Resident #101 was at risk for alteration in nutrition. It included Resident #101 will remain free from significant weight loss and to notify the Physician of significant weight changes if noted. Review of the Medication Administration Record (MAR) for March 2024 showed that the med pass nutritional supplement was not documented as given to Resident #101 after 03/05/24. An interview was conducted on 03/20/24 at 3:25 PM with the Dietitian who stated the mighty shakes are placed on the meal trays from the kitchen and that the nurses provide the med pass. The nursing aides will include the percent intake of the resident's meals in their documentation, but it is overall and not specific for the nutritional supplements. When asked how she knows if a resident is drinking any of the nutritional supplements that are placed on the meal tray, she stated that the nursing staff will let her know verbally. The Dietitian reported that she would run the Weight and Vital reports daily to review any severe weight loss triggered for all residents. When asked as to why she only addressed Resident #101 with a severe weight loss of 8.3% 19 days later, she did not know. She stated the electronic system would usually pop up with a significant weight loss when identified but was unsure why it did not for Resident #101. The Dietitian said she placed the order for a med pass on 02/26/24 but was wondering why it was not given after 03/05/24.

Based on observations, interviews, and record review, the facility failed to provide the correct food consistency for 3 of 3 sampled residents who were on a mechanical soft / chopped, who were observed during dining, Resident #34, Resident #87, and Resident #230. This has the potential to affect 30 residents on a mechanical soft/chopped diet. The census at the time of the survey was 138 residents. The findings included: Review of the facility's diet manual dated 2019, provided by the facility's Dietitian, showed the following foods that were allowed on the mechanical soft diet: canned fruits, cooked or steamed fruit desserts, ripe banana, diced watermelon, diced ripe melon, diced ripe strawberries, and smooth fruit sauces. It further showed that all other fresh fruits were not allowed. Review of the International Dysphagia Diet Standardization Initiative dated 2019, provided by Staff C, Speech Therapist, revealed the following: Level 5 minces and moist diet, to provide fruits served minced or chopped or mashed for level 6 soft bite-sized diet, to provide fruits that are soft enough to be cut into small pieces and not use the white part of an orange. 1a. Record review documented Resident #34 was admitted to the facility on [DATE] with diagnoses to include Dysphagia and Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 05, indicating severe cognitive impairment. In an observation conducted on 03/18/24 at 1:04 PM, Resident #34 was noted eating her lunch in the Emerald dining room. Closer observation revealed a meal ticket with the following: Regular mechanically altered ground pork. Mechanically altered ground orange twist. Mechanically altered ground black-eyed peas. Closer observation of the meal plate revealed a fresh 1/2 slice of an orange a quarter of an inch thick. Photographic Evidence Obtained. 1b. Record review documented Resident #87 was admitted to the facility on [DATE] with diagnoses to include Dysphagia and Dementia. The annual MDS assessment dated [DATE] showed a BIMS score of 06, indicating severe cognitive impairment. In an observation conducted on 03/18/24 at 1:04 PM, Resident #87 was noted eating his lunch in the Emerald dining room. Closer observation revealed a meal ticket with the following: regular mechanically altered ground pork, mechanically altered ground orange twist, and mechanically altered ground black-eyed peas. Closer observation of the meal plate revealed a fresh 1/2 slice of an orange that was a quarter of an inch thick. The mechanically altered ground pork was observed in chunks and not ground. An interview was conducted on 03/19/24 at 3:30 PM with Staff C, Speech Therapist, who stated the facility only has one type of mechanical soft diet. Fresh fruits are not part of a mechanical soft diet but are often used as a garnish. When asked if a mechanical soft / ground diet should have fresh fruit on the plate, she said no. Staff C stated she did not know why the mechanical soft diets on the meal tickets had altered ground noted. An interview was conducted on 03/19/24 at 4:17 AM with the Culinary Service Manager, who stated they have a mechanical soft diet in the facility and that the food provided on this diet is altered ground meat. She further stated they follow the 2019 diet manual and that soft, fresh foods are allowed on mechanical soft diets. 39026 2. Record review documented Resident #230 was admitted to the facility on [DATE], with diagnoses to include Dependence on Renal Dialysis, Peripheral Vascular Disease, and Acquired absence of right leg below knee. On the 02/27/24, the Comprehensive Nursing Evaluation documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On 03/19/24 at 9:20 AM, Resident #230 was observed eating his breakfast during medication administration. Resident #230 was observed with 2 fried eggs on his plate, a slice of toast and a half slice of an orange. Photographic evidence obtained. An observation of his meal ticket revealed the resident was on a renal diet, mechanically altered / ground diet. An interview was conducted with the resident at this time that revealed he was not happy with the breakfast and requested a ham sandwich. He had spoken to Staff O, Licensed Practical Nurse (LPN), and had requested a ham sandwich. Staff O asked Staff G, Certified Nursing Assistant, to bring him a ham sandwich. Shortly after that Staff G came back with a ham sandwich on white bread and the resident began eating it. On 03/19/24 at 3:33 PM, an interview was conducted with Staff C, Speech Therapist. Staff C was asked if fresh fruit, specifically an orange slice, was part of a mechanical soft diet and she stated it was not. On 03/19/24 at 4:09 PM, an interview was conducted with the Registered Dietician (RD) regarding Resident #230's diet order. It was explained to the RD that a ham sandwich was given to the resident and the RD stated that the nurse should have referred the resident to the dietician before giving the ham sandwich since a ham sandwich is not part of a mechanical soft diet.

Based on observations, interviews, and record review, the facility failed to maintain a proper sanitizing solution in the central kitchen for 2 of 3 red buckets observed during the initial tour of the kitchen; and failed to offer or encourage hand hygiene prior to dining for 5 of 5 sampled residents observed during dining, Residents #10, #24, #381, #99, and #69. The findings included: 1. The first visit to the central kitchen was conducted on 03/18/24 at 8:50 AM, accompanied by the Culinary Food Manager. The following issues were observed: a. The Culinary Food Manager used a testing strip taken from the (Hydrion quaternary sanitizer test tape) to check the concentration of the solution from the first red bucket. Further observation showed the test strip read 500 ppm (parts per million). This revealed that the concentration solution in the 1st red bucket was too high. In this observation, the Culinary Food Manager stated that the reading of 500 ppm was too high. b. The Culinary Food Manager used a testing strip taken from the (Hydrion quaternary sanitizer test tape) to check the concentration of the solution from the 3rd red bucket. Further observation showed that the test strip read 500 ppm (parts per million). This revealed that the concentration solution in the 3rd red bucket was too high. In this observation, the Culinary Food Manager stated that the reading of 500 ppm was too high. c. The Artic Air commercial refrigerator reach-in had an unidentified container of food that needed to be dated and labeled. d. The walk-in freezer was noted to have debris all around the floor. Photographic Evidence Obtained. e. The dry storage area was noted to have a 6-pound, 10-ounce can of tropical fruit salad can that was dented. 2. Record review documented Resident #10 was admitted to the facility on [DATE] with diagnoses to include Dysphagia, Dementia, and Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #10 has severe cognitive impairment. In an observation conducted on 03/20/24 at 8:42 AM, Staff B, Certified Nursing Assistant, brought the breakfast tray into Resident #10's room and placed it on the side table. Staff B helped Resident #10 to a sitting position and set up the tray in front of the resident. Resident #10 started eating her breakfast food using her fingers. Staff B did not wash or use hand sanitizer to clean Resident #10's hands before she started eating. 50370 3. During dining observation of Resident #24 on 03/19/24 at 8:45 AM, the surveyor asked Staff M, CNA, if she performs handwashing to residents who were unable to get up. She stated that she encourages residents to wash their hands and she just completed giving hand wipes to the resident. She further added that she tossed the wipes in the trash bin. When the surveyor requested Staff M to show her where the discarded wipes were, Staff M divulged that she did not wash the hands of the resident or offered him hand wipes today. 4. Resident #83 was observed in the dining hall on 03/19/24 at 12:03 PM. Staff were observed washing their hands before touching the contents of the food cart, but the surveyor did not observe staff encouraging Resident #83 to wash her hands or offer hand sanitizer to her. 5. Resident #381 was observed in his room receiving a snack post dialysis on 03/18/24 at 10:45 AM. There was no bottle of sanitizer or hand wipes observed when snacks were placed on the resident's overbed table. 6. Resident #99 was observed in his room receiving lunch on 03/19/24 at 1:10 PM. The facility failed to provide the resident with hand wipes or hand sanitizer prior to eating his lunch meal.

Based on observations, interviews, and record reviews, the facility failed to provide restorative rehabilitation services in a manner that promotes the highest practicable level of functioning for 1 of 5 sampled residents receiving restorative services during dining (Resident #10). The findings included: Review of the facility policy, titled, Restorative Nursing Services,, revised in July 2017, revealed that Residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may start on restorative nursing programs upon admission, during stay or when discharged from rehabilitative care. Restorative goals may include: Supporting and assisting the Resident in adjusting or adapting to changing abilities. Maintaining dignity, independence, and self-esteem. Developing and strengthening physiological and psychological resources. Resident #10 was admitted to the facility on [DATE] with diagnoses of Dysphagia, dementia, and anxiety disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident has severe cognitive impairment. Review of the Physician's orders, dated 10/30/23, revealed an order for all food to be served in bowls and beverages in coffee cups with each meal to assist with safe self-feeding. The care plan dated 01/02/24 revealed Resident #10 would participate in the Restorative Nursing Programs: Dining will improve / maintain current self-care abilities related to participation in specified restorative programs as ordered by the next review. Allow adequate time to eat and provide interventions as needed. In an observation conducted on 03/19/24 at 9:00 AM, Resident #10 was noted in her room with Staff B, Certified Nursing Assistant (CNA), standing near Resident #10, feeding her the breakfast meal. Resident #10 attempted to take the spoon from Staff B, who gently pushed Resident #10's hand away. In this observation, Staff B stated that Resident #10 likes to eat independently, but she makes a mess, and it is easier to feed the resident. Staff B continued feeding Resident #10, and at 9:10 AM (10 minutes later) took the breakfast tray out of the room. In an observation conducted on 03/19/24 at 12:15 PM, Resident #10 was noted in the Emerald dining room (Restorative Dining Room) eating her lunch meal with Staff A, Occupational Therapist (OT), sitting near the resident. Resident #10 was observed eating a peanut butter sandwich with no issues. She then picked up a mug/bowl with food inside and used a spoon to scoop the food towards her mouth. In this observation, Staff A stated that Resident #10 can handle a cup and use a spoon for eating, which is why the food is placed in cups and not on plates. She further said that Resident #10 needs supervision, so she sometimes does not pick up the food with her hands and needs reminding. Resident #10 eats in the Restorative dining room on weekdays from Mondays to Fridays. Staff A stated Resident #10 eats breakfasts and dinners in her room. The staff has been educated on the setup and feeding techniques for Resident #10 and said that, hopefully, they are following the same things she is doing with Resident #10 in the restorative dining room. Review of the OT evaluation from 02/8/24 to 03/13/24 showed that Resident #10's Puree food will come in cups. Present cup handle to left hand and give teaspoon to Right hand with voice commend to use her spoon. [Resident #10] is with appropriate self-feeds utilizing her spoon with occasional reminders for use of the spoon. She completes 100% of intake with supervision. In an observation conducted on 03/20/24 at 8:42 AM, Staff B brought the breakfast tray into Resident #10's room and placed it on the side table. Staff B helped Resident #10 to a sitting position and set up the tray in front of the resident. Resident #10 started eating her breakfast food using her fingers. Staff B did not wash or use hand sanitizer to clean Resident #10 hands before she started eating. Continued observation showed Staff B encouraging Resident #10 to use the spoon to eat her meal. After a few minutes, Resident #10 used her fingers to scoop up the food and then started using the spoon to pick up the food. In this observation, Staff B was asked why she fed Resident #10 her entire breakfast meal yesterday and why she let Resident #10 eat independently with cueing today. Staff B said, I like her to be independent, and so I am letting her eat on her own.

Based on observation and interview, it was determined the facility failed to treat 3 of 3 sampled residents, Resident's #95, #105,and #281, and potentially 132 facility residents, with respect and dignity in a manner that promotes enhancement of quality of life that includes providing drinking cups and glasses with meals. The findings included: During the observation of the lunch meal of 12/05/22, breakfast meal of 12/06/22, and lunch meal of 12/06/22, it was observed that all residents who received beverages in disposable cartons, including milk, thickened milk, juice and supplements, did not receive a drinking cup for the cartons' beverages. Specifically, the facility residents were required to drink straight from the disposable cartons. The facility residents were noted to receive 1 - 3 beverages on the meal trays. Interviews conducted with sampled Residents' #95, #105, and #281 at this time voiced their displeasure to be required to drink from disposable cartons. Both residents' #105 and #281 stated they have stopped drinking whole milk and thickened milk due to having difficulty drinking straight from the carton. Interview conducted with the Certified Dietary Manager on 12/06/22 revealed that she was aware that residents should be receiving a drinking cup for all beverages served via carton, however staff failed to include the drinking cups on the residents' meal trays. Documentation review and observation of Resident #95 was noted to receive up to 6 beverage cartons without a drinking cup per day. Documentation review and observation of Resident #105 was noted to receive up to 10 beverages in cartons without a drinking cup per day. Documentation review and observation of Resident #281 was noted to receive up to 6 beverage cartons per day without a drinking cup per day. Review of clinical records noted the following: Resident #95: Minimum Data Set (MDS) of 09/23/22 -Section C: BIMS Score = 14 (Cognitively Intact). Resident 105: MDS of 11/03/22 - Section C: BIMS Score = 13 (Cognitively Intact). Resident #281: MDS of 12/05/22 - Section C: BIMS Score = 15 (Cognitively Intact).

Based on observation, interview and record review, the facility failed to obtain physician orders and to provide care and services to prevent the development of a pressure wound. This was evidenced by the failure to assess and evaluate the resident's response to preventative efforts resulting in the development of an unstageable pressure wound and failure to report changes to the physician and obtain orders to meet the needs to prevent worsening of the wound for 1 of 3 sampled residents (Resident #334) who deveoped an unstaegable wound within 4-6 days of admission out of 18 residents identified by the facility on the Resident Census and Condition Report (CMS 672) as having pressure ulcers (excluding Stage 1). The findings included: Review of Resident #334's medical record indicated that the resident was admitted to the facility on [DATE] from the hospital after undergoing surgical intervention for a spinal cord mass with spinal compression. Review of the record indicated the resident has medical [DIAGNOSES REDACTED]. In an observation of Resident #334 on 5/12/2015 at 4:30 PM, the resident was lying in bed on her side, with a pillow placed behind her back. The resident was alert and oriented and stated that she had recently had surgery to remove a spinal tumor from her back which had left her paralyzed and unable to move her lower extremities. Resident #334 stated that she had a pressure wound on her bottom and was scheduled to see the wound care physician for follow-up on the following day. She stated that the pressure wound had developed since she was admitted to the facility and she did not feel any pain below her chest area but could feel touch only. She stated that she relied on the facility staff to provide all her care since she was unable to turn and move herself. Review of the nursing admission data review form dated on 4/17/2015 indicated that Resident #334 was alert and oriented, able to follow directions and react to painful stimuli. The resident was assessed to be totally dependent for transfers, bathing, toileting, bathing and dressing. Review of the form indicated there was no level of mobility documented for the resident. Further record review indicated the resident was admitted with an indwelling urinary catheter and was noted to have redness on her buttocks. Resident #334 was assessed to have a Braden score of 17 or low risk for development of a pressure wound and as having " no sensory impairment " which would limit her ability to feel pain. Review of the facility policy "Skin Risk Analysis and Interventions Form "dated on 8/2003 indicated any resident with a score 18 or less is considered "at risk" for the development of pressure wounds. The policy indicated that the form is designed to be the "Interim Care Plan for Skin Risk" which identified recommendations for resident skin care. Review of the Skin Risk Analysis and Interventions Form dated on 4/17/2015 indicated recommendations for Resident #334 which included inspecting the resident's skin daily during routine care and repositioning the resident at least every 2 hours. Review of the nursing progress notes for Resident #334 dated from 4/17/2015 through 4/21/2015 indicated no documentation of overall ongoing skin assessment of the identified sacral area. The first documentation related to the wound was a nursing note dated on 4/22/2015 that indicated that wound care was completed for a sacral wound on that date. Review of the facility policy titled "Admission/readmission skin and wound care program" dated 3/2010 indicated that the nurse will obtain a physician order for [REDACTED]. Review of the April 2015 Treatment Administration Record (TAR) indicated Resident #334 was prescribed barrier cream to the lumbar sacral region, every shift, for redness and thie cream was documented as being administered starting on 4/17/2015 as ordered. Review of a physician order with a questionable date of either 4/20/2015 or 4/22/2015 revealed wound care orders for a sacral wound to cleanse the sacral wound with normal saline, apply [MEDICATION NAME] antibiotic ointment and cover the wound with dry dressing daily and as needed and a request for a wound care consultation. Further review of the April TAR for Resident #334 indicated the wound care order to cleanse the sacral wound with normal saline, apply [MEDICATION NAME] antibiotic ointment and cover the wound with dry dressing daily and as needed; no date for this order was indicated on the TAR. There was a note next to this entry reading DC (discontinue) 4/23/15. There were no initials for this entry indicating this wound care was done at any time in April. A new physician order dated 4/23/15 noted to DC the prior treatment to the sacral wound and to cleanse the wound with NS (normal saline), apply acetic acid 0.2550, moisten gauze, cover with a dry 4X4 (dressing) and secure with tape daily and prn (as needed). There is no documentation on the TAR to indicate this treatment was done on 4/23/15 or 4/24/15. Additionally, the physician order dated 4/23/15 documented to obtain consent for debridement. In an interview with a licensed practical nurse (LPN) on 5/13/2015 at 4:30 PM, she stated that she recalled that on 4/20/2015, she had observed that Resident #334 had developed a sacral pressure wound and she phoned the physician to obtain wound care orders. The nurse stated that she had completed the prescribed sacral wound care treatments on 4/20, 4/21 and 4/22 but failed to document the treatments she had provided or any observation/inspection of the wound. She stated that she did not recall if she had informed the Director of Nursing (DON) regarding the worsening of the sacral wound. The nurse stated that she did not notify the wound care nurse practitioner (NP) of the wound deterioration since she knew the nurse would be coming to the facility later in the week to assess the wound. Review of the wound care nurse practitioner ' s initial assessment dated on 4/23/2015 indicated that Resident #334 was assessed to have an unstageable sacral pressure wound, measuring 11.1 x 7 x 0.3 cm with 100% excessive necrotic tissue and moderate amount of malodorous serous drainage. In an interview with the wound care nurse practitioner on 5/13/2015 at 2:00 PM, she stated that she conducts consultations weekly and is also available when needed. She stated that Resident #334 was admitted with multiple comorbidities, including paralysis and at a high risk for the development of a pressure wound. She stated the Resident #334 was unable to reposition herself and required staff to assist her to turn at least every 2 hours. She stated that the resident was admitted with sacral redness, which rapidly developed in a few days, into an unstageable wound with necrotic tissue. The nurse practitioner stated that in her opinion, when the nursing staff initially identified the resident's sacral redness and progressed into an open wound, more aggressive wound care interventions could have been attempted to reduce the progression and severity of the wound. She stated that she could have assessed the resident immediately instead of waiting for 3 days when the wound had severe deterioration. In an interview with the DON on 5/13/2015 at 5:00 PM she stated that Resident #334 had been identified on admission as " at risk " for pressure wound development. She stated that preventative interventions recommended for the resident would include, turning and reposition the resident every 2 hours and inspect the resident's skin daily during routine care. She reviewed the medical record and could not provide documentation that the resident had been turned and repositioned and that the resident's sacral area was observed/inspected for redness. The DON stated that the nursing staff should have documented the observations of the wound development and any additional interventions that were taken to reduce the resident's risk. After further review of Resident #334 ' s medical record, the DON stated that the nursing staff was to document the completed wound care on the TAR and also to notify nursing management to conduct a reassessment of a worsening wound.

Based on interview and record review, it was determined the facility failed to follow the plan of care for [MEDICAL TREATMENT] treatments for 1 of 3 sampled residents (Resident #1), as evidenced by Resident #1 not receiving [MEDICAL TREATMENT] according to a Physician prescribed schedule. The findings include: A review of Resident #1 ' s clinical record indicated he was admitted to the skilled nursing facility on 6/6/12 for rehabilitative services. His admission [DIAGNOSES REDACTED]. Resident # 1 was transferred to an acute care hospital on [DATE] at 3:05 PM. During the interview on 6/13/12 at 12:15 PM with the Rapid Recovery Unit (RRU) manager and the Regional Director of Clinical Operations (RDCO), they were given Resident #1 ' s record to review with the surveyor. This record review reveals transfer orders from the hospital on the 3008 form, and the nursing home's physician's orders [REDACTED]. The nursing home's physician's orders [REDACTED]. Further review of the clinical record indicated a Nephrologist's [MEDICAL TREATMENT] (HD) orders, on "Physicians [MEDICAL TREATMENT]" letterhead, dated 6/6/12 at 2:20 PM indicates [MEDICAL TREATMENT] (HD) is to be conducted on TTS (Tuesday, Thursday, and Saturday). The RRU manager stated the specific Nephrologist orders written on 6/6/12 at 2:20 PM for HD for TTS (Tues, Thru, and Saturday) were to be followed. Review of this form indicates it was faxed to the nursing home on Friday 6/8/12. The Rapid Recovery Unit (RRU) manager and the Regional Director of Clinical Operations (RDCO) both reviewed Resident #1 ' s clinical record and acknowledged [MEDICAL TREATMENT] was not given on Thursday (6/7/12), or Saturday (6/9/12) as the Nephrologist's order indicated. Neither was [MEDICAL TREATMENT] given on Friday (6/8/12) according to the attending physician's orders [REDACTED]. Further review of the clinical record indicates Resident #1 was transferred to an acute care hospital on [DATE] at 3:05 PM with a transfer [DIAGNOSES REDACTED]. The nursing notes dated 6/9/12 at 2:45 PM and 3:05 PM indicate a respiratory rate at 22 per minute to uneven and labored, and an oxygen level of 66% (normal range is 92-100%). Resident #1's clinical record was obtained by the surveyor from the acute care hospital. This record was reviewed and indicates Resident #1 was admitted for "[MEDICAL CONDITION]" to the acute care hospital on [DATE] at 3:32 PM. Review of the acute care hospital ' s emergency department record indicates in the Physician's notes dated 6/9/12, Resident # 1 was transported to the emergency room by emergency medical services (EMS) 911. Further review of this note indicates the resident is a longstanding [MEDICAL TREATMENT] patient, and was due for a [MEDICAL TREATMENT] treatment "yesterday, on Friday", and that the facility canceled this treatment and informed the resident's Son that this [MEDICAL TREATMENT] treatment would be rescheduled for the morning of 6/9/12. The Physician's emergency department note further indicates the emergency department Physician "immediately" called a Nephrologist consultant, and [MEDICAL TREATMENT] orders were given to the nurse. The record continues to indicate Resident #1's potassium is elevated at 7.4 (normal range is 3.5-5.1), with a heart rate of 39-40. The resident was admitted to the intensive care unit (ICU), and a STAT [MEDICAL TREATMENT] treatment was provided by the acute care hospital. The hospital emergency summary report dated 6/9/12 indicates "[MEDICAL CONDITION]" as the reason for admission. The DON stated upon inquiry that the arrangements for in-house [MEDICAL TREATMENT] at the nursing home are made by the hospital discharge planner or case manager. They arrange for this [MEDICAL TREATMENT] service prior to the admission to the nursing home. The nursing home's in-house [MEDICAL TREATMENT] service is provided by "Physicians [MEDICAL TREATMENT]", which was formerly call "Orion". An interview was conducted on 6/13/12 at 9:35 AM with the [MEDICAL TREATMENT] Certified [MEDICAL TREATMENT] Technician (CHT) that is providing in-house [MEDICAL TREATMENT] care for Resident # 3. She confirms that in-house [MEDICAL TREATMENT] is provided by "Physicians [MEDICAL TREATMENT]" group. The CHT stated upon inquiry that if a [MEDICAL TREATMENT] treatment is missed or if an immediate [MEDICAL TREATMENT] treatment is needed the skilled nursing facility staff or Nurse would notify the Physician [MEDICAL TREATMENT] group and the STAT [MEDICAL TREATMENT] treatment would then be scheduled and provided. The Regional Director of Clinical Operations (RDCO) provided the surveyor with the skilled nursing facility (SNF) [MEDICAL TREATMENT] (HD) policy and procedures (P&P) that indicates residents HD treatments at a [MEDICAL TREATMENT] center, this P&P does not mention in-house [MEDICAL TREATMENT]. Upon inquiry the RDCO stated: "There is not a specific P&P for in-house [MEDICAL TREATMENT], the P&P that indicates [MEDICAL TREATMENT] centers is understood to include the in-house [MEDICAL TREATMENT], and the intent is the same thing" . The [MEDICAL TREATMENT] P&P indicates admission coordinator or the nurse liaison will obtain specific orders for type of [MEDICAL TREATMENT], location where the resident is to be hemodialyzed and the number of times per week the resident is to transported. The P&P further indicates: upon admission, the facility will verify orders for [MEDICAL TREATMENT], location, and times per week in order to secure transportation to the [MEDICAL TREATMENT] center and avoid disruption in service. The RRU manager and the RDCO state Resident #1 would have received their Saturday (6/9/12) HD treatment, but he was transferred to an acute care hospital due to respiratory distress at 3:05 PM before HD could be given. The RDCO stated she does not know the Saturday scheduled time for HD. The RDCO and the RRU manager states to the surveyor that Resident # 1 missing a HD would not cause his respiratory distress, she did acknowledge that Resident #1 did not receive a [MEDICAL TREATMENT] treatment at this facility during the 3 days since admission on Wednesday, 6/6/12 at 5:50 PM and his transfer to the acute care hospital on [DATE] at 3:05 PM. The resident had last received [MEDICAL TREATMENT] on 6/6/12 at 11:44 AM at the hospital prior to the nursing home admission.