**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a Level II Preadmission Screening and Resident Review (PASRR) evaluation was completed after a Level 1 screening suggested the possibility of a serious mental illness for one (Resident #6) of one resident reviewed for PASRR, out of 30 residents in the total survey sample. The findings include: A review of Resident #6's medical record revealed an initial admission date of 11/19/2017 with the most recent readmission on [DATE]. The resident's diagnoses included hereditary and idiopathic neuropathy, hyperlipidemia, dysphagia, pneumonia, fracture of left femur, acquired absence of kidney, sacrococcygeal disorders, gout, anemia, muscle weakness (generalized, history of falling), unspecified intellectual disabilities, not an acceptable Primary Diagnosis, 08/14/2023, Secondary Diagnosis During Stay, 10/4/2023, dementia in other diseases classified elsewhere, unspecified severity with agitation, secondary diagnosis and present on admission [DATE]), schizophrenia, unspecified secondary diagnosis, present on admission, 4/17/2024, cognitive communication deficit, dysphagia, chronic pain syndrome, major depressive disorder, recurrent, moderate, secondary diagnosis, present on Admission, 8/25/2023, and essential (primary) hypertension. A review of the care plan initiated 04/19/2019 and revised on 07/02/2024, revealed that Resident #6 had behavior symptoms related to cognitive impairment, refusing to get out of bed, refusing care, and calling staff names. She was noted with combative and aggressive behavior. Care plan interventions included: Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for resident's disruptive behaviors by offering tasks which divert attention, such as a calm approach, no changes in routine (any change, any routine upsets her). If reasonable, discuss resident's behavior. Explain and reinforce to the resident why behavior is inappropriate and/or unacceptable. Provide a calm, quiet atmosphere; loud, crowded areas appear to be overstimulating. Minimize the potential for resident behavior problems by modifying environmental factors and daily routine. A review of the resident's PASRR, completed by a Social Worker (MSW - Master of Social Work) and dated 07/17/2024, revealed in Section I A. Depressive disorder, schizoaffective disorder and schizophrenia. Related conditions were noted as cognitive/communication deficit. Substantial functional limitations in three or more major life activities were noted as: Capacity for independent living, learning, self-care and self-direction. Findings were based on documented history, individual and medication. Section II: Other indications for PASRR Screen Decision-Making documented that there was an indication that the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage. It further documented the concentration, persistence, and pace: The individual has serious difficulty in sustaining focused attention for long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks. The form documented that the resident had a related neurocognitive disorder. And finally, the form, dated and signed on 07/17/2024 at 1:30 PM, documented that the MSW spoke to Resident #6's legal guardian, who consented to the information being shared. On 04/02/2025 at 2:25 PM, the Administrator provided a copy of the resident's Florida PASRR Level II Receipt of Referral Packet Notice of Missing Required Documentation sent to the facility and dated 07/31/2024. The letter read, We have received a referral to complete a PASRR Level II Review on [Resident #6]. In order to complete the PASRR Level II evaluation and determination, we ask that you send a copy of the following required documents: - Informed Consent - Minimum Data Set (MDS) - Patient Transfer/Continuity of Care (3008) - Relevant Case Notes/Records of Treatment The letter further noted, This information should be sent to us within five business days from the date of this notice. If the information is not submitted within the requested timeframe, we will close the request. During an interview with the Administrator on 04/02/2025 at 2:25 PM, he stated, I couldn't find anything in our system other than the copy of the Florida PASRR Level II Receipt of Referral Packet Notice of Missing Required Documentation, dated 07/31/2024. He explained that he was not aware of whether or not any of the requested documentation for a Level II PASRR for Resident #6 was submitted, and he would need to check with the Director of Social Services when the employee returned from leave. The Administrator also noted that the facility did not have a policy and procedure for PASRR. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop comprehensive care plans that included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for four (Residents #1, #40, #24 and #31) of 30 residents reviewed for care planning from a total survey sample of 30 residents. The findings include: 1. On 3/30/25 at 11:30 AM, Resident #1 was observed in bed with a pressure relieving mattress, catheter bag hanging at bedside, bilateral boots to prevent pressure wounds, and a peripherally inserted central catheter (PICC) line in the left upper arm. A review of the medical record revealed that Resident #1 was initially admitted on [DATE]. On 2/21/25, he had an unplanned discharge to an acute care hospital with return anticipated. On 3/1/25, he was readmitted from the hospital. Resident #1's diagnoses included multiple sclerosis, contractures of both knees, pressure ulcer of the left buttocks-Stage 4, chronic pain, hydronephrosis, dementia, history of transient ischemic attack (TIA), extended spectrum beta lactamase (ESBL) resistance and sepsis. A review of the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/4/25 revealed that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. No behaviors were noted including refusal of care. The resident required a mechanical lift and two-person assistance with care activities. A review of the physician's orders dated 3/1/25 revealed: Methocarbamol Oral Tablet 500 milligrams (mg), 2 tablets four times a day (QID) (muscle relaxant) Rivaroxaban Oral Tablet 20 milligrams (mg), 1 tablet daily (QD) (anticoagulant) Primidone Oral Tablet 50 milligrams (mg), 1 tablet daily (QD) (anticonvulsant) Lasix (anti-diuretic) Oral Tablet 40 milligrams (mg), 1 tablet every other day (QOD) (diuretic) Occupational Therapy (OT) clarification order: OT evaluation and treatment 5 x week for self -care. ADLs (activities of daily living), therapeutic activities, neuromuscular re-education in order to return to prior level of function (PLOF). Suprapubic catheter care every shift, cleanse site and replace t-sponge. Flush PICC Line: Flush lumens every 12 hours with 10 ml (milliliters) normal saline. Catheter: Suprapubic catheter 18 FR (French) with 10 cc (cubic centimeter) balloon to dependent drainage. Change catheter monthly, PRN (as needed) if dislodged or plugged and unable to clear with irrigation. Scrotum MASD (moisture-associated skin damage) wound treatment as follows: Clean with NS (normal saline). Pat apply silver sulfadiazine 1% cream. Leave open to air. IV - Dressing Change - PICC transparent dressing change every week and as needed (PRN). A review of the resident's care plan (start date 3/4/25, target completion date 3/11/25) revealed no focus area, goals, or interventions for prescribed diuretic or anticoagulant medication. There were no focus areas, goals, or interventions for a PICC line, urinary catheter care, or MASD. In a 4/2/25 interview at 12:05 p.m. with Licensed Practical Nurse (LPN) A/Minimum Data Set (MDS) Coordinator, she explained that the care plan goals were derived from diagnoses, physicians' orders, and any pertinent information obtained from residents' records. She stated the purpose of the care plan was to enhance resident-centered care. She was asked to review Resident #1's care plan for anticoagulants, diuretics, PICC line , catheter and MASD. After opening the resident's record she said, Oh, this is incomplete; it should be more than two pages. There are goals that are missing interventions. She confirmed that there was no care plan in the resident's record for a PICC line, urinary catheter, diuretic, anticoagulant, or MASD. She stated she would expect all those issues and medications to be care planned. During a 4/2/25 interview at 12:39 p.m. with LPN E/Unit Manager, she stated during daily clinical meetings, all new admissions' records were reviewed to ensure the documentation was complete. She further stated the clinical team also reviewed order listings for new orders, risk management notes, and updated the care plan. 2. A review of Resident #40's medical record revealed an admission date of 2/18/24. The resident's medical diagnoses included Parkinson's disease without dyskinesia (involuntary, uncontrolled muscle movements), without mention of fluctuations and depression. A review of the 5-day MDS assessment, dated 3/3/25, revealed a BIMS score of 15/15, indicating intact cognition. Medications included injections on one of seven days, as well as antianxiety, antidepressant, anticoagulant, and antibiotic medications received during the assessment period. A review of Resident #40's active physician's orders revealed: Hydrocodone-acetaminophen (combination opioid-over-the-counter analgesic pain medication) oral tab 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for moderate pain (2/18/2025) Document pain on scale 0-10 every shift for monitoring. Provide pain medication and/or non-pharmaceutical pain relief per order as needed (2/19/2025) Apixaban (anticoagulant) oral tab 5 mg, give 1 tablet by mouth two times per day for deep vein thrombosis prophylaxis (2/19/2025) Behavior monitoring: daytime sleepiness; difficulty concentrating; fatigue; irritability; aggressiveness every shift behavior monitoring due to use of hypnotic medication (2/19/2025) Mirtazapine (antidepressant) oral 1 tablet 15 mg by mouth at bedtime related to depression, unspecified (2/21/2025) Lorazepam (benzodiazepine) oral tablet 0.5 mg, give 1 tablet by mouth every 24 hours as needed at bedtime for anxiety and insomnia (3/7/2025) DNR (do not resuscitate) (3/3/2025) A review of the resident's care plan (revision date 3/11/25) revealed no focus areas, goals or interventions for the resident's use of anticoagulant, opioid, antidepressant, or benzodiazepine medications. (Copy obtained) A review of the March 2025 and April 2025 medication administration records (MARs) and treatment administration records (TARs) revealed that medications were provided as ordered; however, no behavior monitoring was located in the records. During an interview on 4/2/25 at 11:50 a.m. with LPN A/MDS Coordinator, she stated she updated care plans by reviewing the residents' hospital records or medical records, through resident and family meetings, and by reviewing the physicians' orders. Nursing completed the initial baseline care plan. The MDS department scheduled care plan meetings. They usually occurred at three weeks. When the resident's MDS assessment was completed, the care plan opened up and was subsequently completed in the resident's record. The baseline care plan was completed on paper. When asked how she ensured that all care plans were complete, LPN A replied that was accomplished through audits. There was a review date and target complete date that she monitored. She also monitored input from other departments. She signed off the completion of the care plan during the care plan meeting with the families and/or residents. Care plan meetings were held on Tuesdays. Residents were added to the care plan schedule. The purpose of the care plan was to ensure that all staff were on the same page and understood the residents' needs. The care plan was due for completion seven days after the MDS assessment was closed. Staff knew specific interventions that should be implemented related to a resident's care and services by either the baseline care plan or the care plan or kardex system. LPN A was asked to identify where Resident #40's care plan addressed specific care, services, and interventions for his use of anticoagulant, opioid, antidepressant, and benzodiazepine medications, as well as for pain management. LPN A confirmed there were no care plans for these medications or for pain management. When asked who reviewed the MDS assessments, LPN A stated the Director of Nursing (DON) reviewed and signed off on them. The MDS department would let the Director of Nursing know that the MDS assessments were ready to be reviewed and signed. During a 4/2/25 interview with LPN B at 12:05 p.m., she stated she was responsible for monitoring her residents' behavior. Certified Nursing Assistants (CNAs) reported anything they saw/heard, and nursing documented what was reported, then observed the resident, placed interventions, and notified the physician or members of the interdisciplinary team. Nursing was able to find a resident's specific care, services and interventions on the resident's MAR/TAR. Resident behaviors were documented in the electronic medical record (EMR) on a progress note or in the 24-hour report. When she was asked to point out where Resident #40's behavior monitoring was being documented, she stated there was no supplementary information added to the order, so no information was showing on the TAR for behavior monitoring. When she was asked how she knew a resident's behavior was being monitored, she replied that if Resident #40 had a behavior issue reported, it would have been documented in the progress notes. 3. On 3/30/25 at 2:00 p.m., Resident #24 was observed lying in bed. When she was greeted and asked how she was doing, she stated, I'm feeling better after a few days of vomiting and not feeling well. She was asked if she had eaten her lunch. She replied, No, I haven't had much of an appetite, but I was able to eat some of my breakfast. She was asked if she was currently taking antibiotics. She replied, Yes, I am taking antibiotics after being so sick the other day. On 3/31/25 at 12:38 p.m, a record review revealed that Resident #24 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus - type II. The resident had a documented fever on 3/28/25, and experienced nausea and vomiting with symptoms that started on 3/27/25. A review of the quarterly MDS assessment, dated 12/27/24, revealed the resident had a BIMS score of 10/15, indicating moderate cogniitve impairment, and received insulin injections, antidepressant, diuretic, and antibiotic medications during the assessment period. On 3/31/25 at 12:46 p.m., a review of the resident's care plan revealed the following focus areas: Focus: Impaired cognitive function/dementia or impaired thought processes related to current health status (initiated 3/27/24, revised 3/13/25) Focus: Diabetes mellitus (initiated 4/1/24, revised 10/2/24) Focus: Altered respiratory status - requires oxygen (initiated 5/30/24, revised 3/13/25) There was no care plan related to the new onset symptoms of nausea/vomiting or fever (102.1 on 3/28/25), or initiation of antibiotic use for indication of fever. On 3/31/25 at 12:55 p.m., a review of the resident's active physician's orders revealed: Does the resident have nausea, vomiting, loss of appetite, or diarrhea? Conduct temperature check after meals and at bedtime for Infection Control (3/31/25) RSV (Respiratory Syncytial Virus), UA (Urinalysis) with reflex to C&S (culture and sensitivity), Sent uncollected 3/31/25 3:57 PM, one time only related to muscle weakness, generalized (3/28/25) CBC w/diff (Complete Blood Count with differential), CMP (Comprehensive Metabolic Panel), Waiting to be sent, one time only related to muscle weakness, generalized (3/28/25) Ceftriaxone Sodium Injection Solution Reconstituted 1 gram, inject 1 gram intramuscularly one time a day for fever for four days (3/29/25 - 4/2/25). On 3/31/25 at 1:00 p.m., a review of the resident's progress notes revealed that the resident vomited on 3/27/25, and was seen by the APRN (Advanced Practice Registered Nurse) on 3/28/25 for symptoms of fever 102.1 F (Fahrenheit), vomiting, risk for dehydration, suspected infection, and was given new orders for IV (intravascular) fluid bolus for 1 day, a urinalysis, culture & sensitivity, comprehensive metabolic panel, and a complete blood count. (No results were available for any of the lab tests ordered.) Ceftriaxone Sodium Injection Solution Reconstituted 1 Gram IM (intramuscularly) was ordered daily for four days for fever. On 4/1/25 at 11:43 a.m., an interview was conducted with LPN C. She was asked the following: Have you received training/education for how to identify and prevent abuse and neglect? Of course. Do you believe you have enough staff to give your residents the care they need? We do. Who is responsible for transcribing lab orders? Sometimes the nurses do it and sometimes the doctors or the nurse practitioners have access to the medical record, and they put in their own lab orders. How long does it take for the faclity to receive lab results? It depends on which lab test is ordered, usually it's pretty quick. What is the typical wait time to receive lab results? I would say within a day or so. Who is responsible for collecting urine samples from the residents? The nurses. Are urine samples collected on any particular shift? No, whenever a STAT (immediate) urine is ordered, we go ahead and collect the sample right then and put it in the refrigerator for the lab to pick it up. What do you do with the lab results when you receive them? Report to the doctor. On 4/2/25 at 11:54 a.m., an interview was conducted with LPN A. She was asked the following: Who is responsible for initiating the resident care plan on admission? I look for their diagnoses in the hospital records to start the care plan. I talk to the CNAs (certified nursing assistants) and family to get more information about the resident, and review the physician orders. We have up to 14 days to complete the comprehensive care plan. Each department adds their own parts of the comprehensive care plan. I monitor all the departments' input and make sure everything is completed before it is signed off as completed. Is the initial baseline resident care plan documented on paper? Yes. What is the purpose of the resident care plan? The care plan itself is so everybody is on the same page on how to take care of the resident. What are some of the medication categories that should be addressed in a resident's care plan? I personally care plan antibiotics, antidepressants, antianxiety, psychotropics, diuretics, hypnotics, anticoagulants, antiplatelets, and IV medication. When there is a change in condition, who is responsible for updating the resident care plan? That is nursing and myself would do that, and it's based on the order summary that the Unit Manager runs in the mornings. We review it, but the nurses can update the care plan anytime they initiate an order. LPN A was asked to access the care plan for Resident #31 in the EMR. She was asked to find a care plan that addressed her recent antibiotic use or any indication for infection. LPN A stated, I don't see a care plan for any indication of infection or current antibiotic use. On 4/2/25 at 12:48 p.m., an interview was conducted with LPN E. She was asked the following: When she was asked who was responsible for updating a resident care plan, she stated she ran a summary of new orders every morning and reviewed those orders with the clinical team to ensure that everything had been addressed. She named the MDS nurses as staff who would actually access a resident's care plan in the EMR and update the care plan intervention, or goals, with pertinent input from the clinical team during the morning clinical meeting. What is the purpose of the resident care plan? It's a plan to tell us how to take care of the resident. She was asked to access Resident #24's current care plan in the EMR and find a care plan focus for the current order for antibiotic use and the indication. I can't find anything. Who is responsible for transcribing lab orders? Whoever receives the order. How long does it take for the facility to receive lab results? It's based on the lab; if it's STAT it's taken to the hospital, and it usually reports in 5-6 hours or sometimes before that, and if it's not ordered STAT, the lab technicians usually come in the morning to draw the lab, and the results come back by that afternoon. Who receives the results? They come into [EMR] and some lab results come by fax. All nurses are responsible for looking out for lab results. I usually check first thing in the morning as part of my routine and bring the results to the morning clinical meeting. Who is responsible for collecting urine samples from the residents? The nurses. Are urine samples collected on any particular shift? Not really. What is the facility's process for making sure lab specimens are collected in a timely manner? If you have a urinalysis that is not a STAT order, the night shift will collect it and the lab picks it up in the morning. If it's a STAT order, the nurse collects it right then. What is the facility's process for making sure lab orders are followed through on in a timely manner? We have a list that the lab technician uses to note what labs were drawn, and which specimens were collected or picked up. We can also check in [EMR] to review them with the clinical team in the morning meeting to determine if labs were collected or not. How many days a week does the facility have lab services? Monday through Sunday but on the weekends they only come if we have STAT orders. She was asked to access the EMR for Resident #24 and review the lab orders. She confirmed that the resident had labs for RSV, urinalysis with reflex culture, and CMP & CBC with differential orders on 3/28/2025. She was asked to provide the results. She stated, I'm not sure why these results have not come back yet. I will contact the lab and get back with you on what I find out. On 4/2/25 at 4:00 p.m., LPN E returned to provide an update on the lab results. She stated, The new nurse documented that the labs had been collected when really they had not. She wasn't aware of how that should have been documented. 4. On 3/30/25 at 1:58 p.m., Resident #31 was observed with a large, purple-colored bruise on her left forearm. When she was asked about the area, Resident #31 stated, It was worse; it's gotten better. On 4/1/25 at 12:16 p.m., a record review revealed that Resident #31 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, Type II diabetes mellitus with diabetic peripheral angiopathy without gangrene/with hyperglycemia, mood [affective] disorder, anxiety disorder, wedge compression fracture of first, second, fourth and fifth lumbar vertebra, heart failure, chronic obstructive pulmonary disease, atrial fibrillation and a diagnosis of dementia documented on the psychiatric evaluation dated 2/11/25. On 4/1/25 at 12:16 p.m., a review of the quarterly MDS assessment, dated 1/25/25, revealed a BIMS score of 14/15, indicating intact cognition. MDS documentation also indicated that the resident received insulin injections, antidepressant, anticoagulant, and diuretic medications during the assessment period. On 4/1/25 at 12:16 p.m., a review of the resident's current care plan revealed the following focus areas: Focus: The resident uses antidepressant medication related to Depression (Initiated: 10/31/2024, Revision on: 10/31/2024) Focus: The resident has pain/discomfort related to multiple back fractures, compression fractures, neuropathy. (Initiated: 10/31/2024, Revision on: 01/10/2025) There were no care plans available that addressed resident care for anticoagulant use, diuretic use, insulin use or Advanced Directives/DNR (Do Not Resuscitate). On 4/1/25 at 12:16 p.m., a review of the resident's active physician's orders revealed: Furosemide (diuretic) oral tablet 40 mg, Give 1 tablet by mouth in the morning related to Heart Failure (10/24/2024) Humalog Injection Solution 100 unit/ml (units per milliliter) (Insulin Lispro), inject as per sliding scale subcutaneously before meals and at bedtime related to type II DM (diabetes mellitus) (10/25/2024) Eliquis (anticoagulant) oral tablet 2.5 mg, give 1 tablet by mouth two times a day related to Atrial fibrillation (12/4/2024 ) Lantus Solo Star Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), inject 20 units subcutaneously in the morning related to type II DM with hyperglycemia (1/10/25) Trazodone (antidepressant) Oral tablet 50 mg, give 1 tablet by mouth one time a day for sleep (1/7/25) Sertraline (selective serotonin reuptake inhibitor - can be used to treat depression or anxiety) Oral Tablet 25 mg (2/12/25) Hydrocodone-Acetaminophen (combination opioid-over-the-counter analgesic pain medication) Oral Tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed for pain (2/18/25) Antidepressant Medication - Observe for behavior (specify) every shift, (11/14/24) Antidepressant Medication - Side Effects monitor every shift (11/14/24) Donepezil (acetylcholinesterase inhibitor) 10 mg by mouth at bedtime for dementia (10/24/24) DNR (Do not resuscitate) (1/6/25). On 4/2/25 at 11:54 a.m., an interview was conducted with LPN A/MDS Coordinator. She was asked to access the initial care plan for Resident #31 and find a focus area that addressed anticoagulant use. I do not see one. She was asked to find a care plan focus area that addressed diuretic use. There is indication for diuretic use under her care plan for falls, for nutrition and for incontinence. She was asked to find a care plan focus area that addressed the resident's Advanced Directive status for DNR. I do not see one. She was asked to find a care plan focus area that addressed Diabetes Mellitus and insulin use. I do not see one. On 4/2/25 at 12:48 p.m., an interview was conducted with LPN E/Unit Manager. She was asked to access the current care plan for Resident #31 in the EMR and find a care plan focus area that addressed anticoagulant use. I don't see it. She was asked to find a care plan focus that addressed the resident's Advanced Directive status for DNR. I don't see it. She was asked to find a care plan focus area that addressed Diabetes Mellitus and insulin use. It's not there. A review of the facility's policy and procedure for Comprehensive Care Plans, (implemented 3/20/25, revised 2/27/25, reviewed [NAME] President of Operations), revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychological needs, and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated. 2. The comprehensive care plan will be developed within seven days after completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rational for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two (Residents #304 and #305) of 30 residents in the total survey sample. Resident #304 was not provided adequate care for a Jackson Pratt (JP) drain, and the facility failed to obtain a timely hospice consult per physician's orders for Resident #305, who was admitted on [DATE], with a physician's order for Consult [provider name] Hospice dated 3/12/25 at 12:55 PM. As of 4/2/25, three weeks after the order was written and on the last day of the survey, there was no documented evidence that a hospice consult had been obtained. The findings include: 1. A review of Resident #304's medical record revealed an admission date of 3/7/25 with a re- entry on 3/26/25. Diagnoses included encounter for surgical aftercare following surgery, non-pressure chronic ulcer of lower leg with unspecified severity, diabetes mellitus type II, pressure ulcer of the sacral region stage III, need for assistance with personal care, calculus of gall bladder and bile duct with acute and chronic cholecystitis with obstruction, cellulitis, and dementia. A review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA form 5000-3008), dated 3/26/25, revealed that the resident had a JP drain at the abdomen upon transfer from the hospital to the facility on 3/26/25. (Copy obtained) A review of the resident's progress notes revealed a physician's progress note dated 3/28/25, indicating that the resident was seen for follow-up after a recent hospital re-admission. During her hospitalization, she was initially scheduled for a computed tomography (CT) of her chest to rule out pulmonary embolism (PE); however, an incidental finding of gallstones was noted and she underwent a cholecystectomy (gall bladder removal). Currently, she had two laparoscopic sites (incision sites) covered with 2x2 gauze and Tegaderm, as well as a JP drain in her right upper quadrant draining serosanguinous fluid. Plan: Post-cholecystectomy status: - Keep surgical sites clean and dry. Do not remove dressings unless instructed by your healthcare provider. - Monitor JP drain output and report any significant changes in color, amount, or consistency of drainage. - Report any signs of infection such as increased redness, swelling, warmth, or fever. - Gradually increase activity as tolerated, but avoid strenuous activities for at least 4-6 weeks. - Follow up with surgeon as scheduled for drain removal and wound check. (Copy obtained) A review of the active physician's orders revealed a physician order dated 3/26/25 for Flagyl (antibiotic) 500 milligrams (mg) two times a day (BID) related to surgical aftercare following surgery on the digestive system. There were no orders for care of the JP drain care or monitoring for signs and symptoms of infection. (Copies obtained) 2. A review of Resident #305's medical record revealed an admission date of 3/11/25 with diagnoses including non-displaced intertrochanteric fracture of the right femur, anorexia, dementia, muscle wasting and atrophy, cognitive communication deficit, depression, anemia, and cardiomyopathy. A review of the active physician's orders revealed: 3/11/25 - Eliquis (anticoagulant) 2.5 mg BID (twice daily) for deep vein thrombosis (DVT). 3/12/25 - Furosemide (diuretic) 40 mg (milligrams) daily for congestive heart failure (CHF). 3/12/25 - Trazadone (serotonin antagonist and reuptake inhibitor - can be used for depression or as a sedative) 50 mg at bedtime (HS) for depression. 3/12/25 - Consult hospice related to dementia. A review of the resident's progress notes revealed a nursing progress note dated 3/12/25, indicating that Resident #305 was moved from 206B to 101A, closer to the nursing station, due to restlessness/irritability. A psychiatric consult was ordered. A new order was received for Trazodone at HS. The resident's family member was made aware of the room change and the resident's status, and a new order was received for a hospice consultation. A review of all of the resident's progress notes with Licensed Practical Nurse (LPN) E/Unit Manager from the date of admission [DATE]) through 4/2/25, revealed no information indicating that the physician's 3/12/25 hospice order was followed through on. LPN E confirmed there was no documentation indicating follow through A review of the Social Worker's notes revealed no information indicating that the physician's 3/12/25 hospice order was followed through on. A review of the physician's progress note dated 3/18/25 revealed that the reason for the visit was a follow-up due to dementia, insomnia, CHF, and muscle weakness. It was noted that the resident was observed being wheeled around the facility in her wheelchair by her family member, and was seen being fed lunch by her family member during rounds. She exhibited behavioral issues, including biting staff members and spitting out her pills. Concerns were raised by both the resident's family member and the staff regarding her memory issues and tendency to wander, as well as her getting up out of her wheelchair. The resident's family member had scheduled an appointment with hospice for Thursday. A review of the resident's current care plan (initiated on 3/11/25) revealed that there was no indication for hospice. No hospice certification paperwork was provided upon request. A review of the admission 5-day Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/17/25, revealed that the resident's brief interview for mental status (BIMS) score was left blank. The assessment documented that resident exhibited hallucinations, delusions, and wandering behaviors that interfered with her participation in activities or social interactions. In an interview on 4/2/25 at 12:38 PM, Licensed Practical Nurse (LPN) E/Unit Manager, stated she had worked at the facility for about a year. When asked how she was notified of new orders, she explained that during the daily clinical meeting, all new admissions' records were reviewed to ensure that the documentation was complete. She stated the clinical team also reviewed the order listing for new orders and risk management noted and updated the care plan. When asked about Resident #305's functional status, LPN E stated the resident was confused and dependent on staff for all activities of daily living (ADL). When asked if the resident was receiving hospice services, LPN E said, The consult was placed on 3/12/25 and the Social Services Director (SSD) was to arrange for the services. She stated the SSD was not in the facility; therefore, she could not tell what the progress was on the consult. She reviewed the resident's record and said, There is no certification paperwork. Normally, when a resident is picked up by hospice, the nursing department is left with admission paperwork. Additionally, the nurses complete a progress note on the same. When asked about Resident #304's care, she stated that resident was sent to the emergency room on 3/19/25 for elevated temperature, decreased breath sounds on the left side, and decreased oxygen saturation. Resident #304 returned to the facility on 3/26/25 after gastrointestinal (GI) surgery. She had for flagyl for surgical after care. When asked if the resident had any indwelling devices, LPN E stated she was not aware. She reviewed the resident's record and confirmed she had a JP drain and there was no order for care of the drain. She added that if there was no order, the nurses should document under the progress notes. She confirmed that there were no progress notes related to JP care and monitoring of the output. She said,If it's not documented it's not done. She also confirmed that the Flagyl antibiotic did not have a stop date. A review of the facility's policy titled Provision of Physician Ordered Services (reviewed 7/21/24), revealed that the purpose of the policy was to provide a reliable process for the proper and consistent provision of physician-ordered services according to professional standards of quality. Definition: Professional Standards of Quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Policy Explanation and Compliance Guidelines: 1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physicians' orders. No diagnostic tests or consultation requests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialists' orders in accordance with State law, including scope of practice laws. 2. Qualified nursing personnel will submit timely requests for physician-ordered services (laboratory, radiology, consultations) to the appropriate entity. 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering physician, physician's assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering provider will be notified of results upon receipt if deemed critical and/or require immediate attention. 4. Documentation of consultations, diagnostic tests, the results, and date/time of physician notification will be maintained in the resident's clinical record. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish an infection prevention and control program (IPCP) that included a system for preventing, identifying, reporting, investigating, and controlling infections, specifically, the spread of a gastrointestinal infection (GI) affecting 15 (Residents #208, #32, #42, #36, #22, #207, #21, #24, #35, #51, #40, #1, #8, #14 and #20) of 50 residents living in the facility. Failure to control the spread of infection can result in serious harm to residents, staff, volunteers, visitors, and other individuals providing services to the facility. Facility staff also failed to implement enhanced barrier precautions (EBP) for two (Residents #1 and #304) of two residents with indwelling devices from a total survey sample of 30 residents. The findings include: On 3/30/25 at 11:00 AM, upon entrance to the facility, Licensed Practical Nurse (LPN) G notified the survey team that there was a gastrointestinal (GI) outbreak and stated approximately 50% of the residents were symptomatic with vomiting and diarrhea. She recommended the use of surgical masks while in the facility. Staff were observed with surgical masks. No personal protective equipment (PPE) was observed outside residents' rooms or signs notifying staff and visitors of illness. In an telephone interview on 03/30/25 at 11:30 AM, the Director of Nursing (DON)/Infection Control Preventionist was asked to provide more information related to resident status and how the symptoms began. She said, The symptoms started on Friday (3/28) morning. Residents reported that the pizza they ate the previous night might have upset their stomachs. She said residents were provided with hydration. At this time, I'm not sure how many residents have symptoms. I was unwell yesterday. The DON added that she was enroute to the facility and would provide more information upon arrival. In an interview on 03/30/25 at 11:45 AM, LPN F stated there were eight residents on her unit (West Wing) that were symptomatic. Three residents started exhibiting symptoms on Friday and five other residents started exhibiting symptoms on Saturday (3/29). She stated resident vital signs were within normal limits (WNL). She confirmed that there were no residents on any type of isolation precautions including enhanced barrier precautions. She provided a list indicating that 13 residents had symptoms. (Residents #208, #32, #42, #36, #22, #207, #21, #24, #35, #51, #40, #1, and #8) In a follow-up interview on 03/30/25 at 12:00 PM, LPN G stated there were 11 residents on her unit (East Wing) that were symptomatic. She mentioned that five residents started having diarrhea and vomiting on Friday, and six additional residents started experiencing symptoms on Saturday. She confirmed that there were no residents on any type of isolation precautions including enhanced barrier precautions. On 03/30/25 at 12:30 PM, the DON stated four residents started showing signs and symptoms on Friday morning. These residents stated that whatever they ate on Thursday night may have upset their stomachs. Of the four residents, three were prescribed IV (intravenous) fluids and one resident who was alert oriented was encouraged to drink fluids. The DON added that there were two employees who also had symptoms. As of last night, three more residents started having symptoms, and the Medical Director ordered stool for Oval and Parasite (O&P) for salmonella, shigella, norovirus and requested an Enzyme Immunoassay (EIA) immediately (STAT). When asked to describe the precautions currently in place, the DON stated the facility was utilizing universal precautions until they had confirmed results. She stated she had not contacted the Department of Health (DOH) for guidance, but would do so by the end of the day and initiate a line listing ( method of tracking infections). During a tour on 03/30/25 at 2:00 PM, Resident #24 was observed lying in bed. She stated she was feeling better after a few days of vomiting and not feeling well. A review of her medical record revealed that the resident stated she vomited on 3/27/25. She was visited by the APRN (advanced practice registered nurse) on 3/28/25 (Friday) for symptoms of a fever at 102.1 degrees Fahrenheit (F) and vomiting, with a risk for dehydration and infection suspected. She was prescribed new orders for Rocephin (antibiotic) 1gram (gm) intramuscularly (IM) x 4 days and an intravenous (IV) fluid bolus x1 day. In an interview on 03/31/25 (Monday) at 9:29 AM, the DON stated she had initiated the line listing. (Copy obtained) She stated as of last night (Sunday) all of the residents' symptoms had resolved. When she was asked for the laboratory results, she stated she had not received the results yet. On 03/31/25 at 10:38 AM, Resident #40 stated he was not doing great. He stated he felt nauseated. On 03/31/25 at 11:00 AM, Resident #207 stated she had diarrhea this morning. She further stated she had been nauseated with vomiting and diarrhea for the last three days. A review of the line listing, dated 3/30/25, and provided on 3/31/25 at 9:30 AM, revealed that Residents #40 and #207's symptoms had resolved as of 3/30/25. (Copy obtained) A joint interview was conducted on 03/31/25 at 3:26 PM with the DON and the Administrator. The DON stated she had not yet received the laboratory results. She was asked if there were any other residents that exhibited symptoms today. The DON replied, no. After three inquiries, the DON repeated that all residents' symptoms had resolved. She stated she conducted rounds in the morning with the Unit Manager and no symptoms were noted. She stated there had been no symptoms as far as she was aware of up to the time of this interview. She stated she was waiting for the lab results. She confirmed that there were no residents who had symptoms reported. When asked the names of the residents who had samples obtained, she replied that Residents #36 and #207 had samples obtained. When she was asked when the samples were obtained, she replied, this morning. She was again asked if there were residents that still had symptoms. She said, Just those two and it was one time in the morning. When she was asked to review the line listing she provided in the morning dated 3/30/25, she confirmed that Resident #36 was not added and the list indicated that Resident #207's symptoms were resolved as of 3/30/25. She added Resident #36 to the line listing in the presence of the surveyor. Residents #14 and #20 were added to the list on 4/1/25 making 16 the total number of residents listed on the report. In a follow-up interview on 4/1/25 at 1:55 PM, the DON confirmed that there were two new residents with loss of appetite or vomiting. She added that she reached out to the Department of Health (DOH) on 3/31/25 and was advised to put the residents with symptoms on contact isolation until they were symptom-free for 48 hours. She stated she was also advised to discontinue communal dining and group activities until after 48 hours of no symptoms in the facility. 2. On 3/30/25, Resident #1 was observed in bed with a pressure relieving mattress, a catheter bag hanging at bedside, boots to prevent pressure wounds bilaterally, and a peripherally inserted central catheter (PICC) line in the left upper arm. There was no door sign or PPE (personal protective equipment) for enhanced barrier precautions. A review of the resident's medical record revealed that Resident #1 was admitted on [DATE] with a re-entry on 3/1/25. Diagnoses included multiple sclerosis, contractures of both knees, a pressure ulcer at the left buttocks - Stage IV, chronic pain, hydronephrosis, dementia, a history of Transient Ischemic Attack (TIA), extended spectrum beta lactamase (ESBL) resistance and sepsis. A review of the physician's orders dated 3/1/25 revealed: Suprapubic catheter care every shift, cleanse site and replace t- sponge. Flush PICC Line: Flush lumens every 12 hours with 10 ml (milliliters) normal saline. Catheter: Suprapubic catheter 18 FR (French) with 10 cc (cubic centimeter) balloon to dependent drainage. Change catheter monthly, PRN (as needed) if dislodged or plugged and unable to clear with irrigation. Scrotum MASD (moisture-associated skin damage) wound treatment as follows: Clean with NS (normal saline). Pat apply silver sulfadiazine 1% cream. Leave open to air. IV Dressing Change - PICC transparent dressing change every week and as needed (PRN). 3. Resident #304 was admitted to the facility on [DATE] with a re-entry on 3/26/25. Diagnoses included: Encounter for surgical aftercare following surgery. Non-pressure chronic ulcer of lower leg with unspecified severity, diabetes mellitus type II, pressure ulcer of the sacral region stage III, need for assistance with personal care, calculus of gall bladder, and bile duct with acute and chronic cholecystitis with obstruction, cellulitis, and dementia. A review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA form 5000-3008), dated 3/28/25, revealed that the resident had JP (Jackson Pratt) drain to the abdomen. (Copy obtained) A physician's progress note dated 3/28/25 revealed that the resident was seen for follow-up after a recent hospital readmission. During her hospitalization, she was initially scheduled for a computed tomography (CT) of her chest to rule out pulmonary embolism (PE); however, an incidental finding of gallstones was noted and she underwent a cholecystectomy (gallbladder removal). Currently, she had two laparoscopic sites covered with 2x2 gauze and Tegaderm, as well as a JP drain in her right upper quadrant draining serosanguinous fluid. There was no door sign or PPE (personal protective equipment) for enhanced barrier precautions. In a follow-up interview on 4/1/25 at 1:55 PM, the DON was asked if there were any current residents on enhanced barrier precautions. She said, no. She was then asked which residents should be on enhanced barrier precautions and she said she was not sure. A review of the facility's policy and procedure titled Infection Outbreak Response and Investigation (reviewed on 5/1/2024), revealed: Policy: It is the policy of the facility to respond to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections following standards of practice and CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control and Prevention) guidelines. Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. Policy Explanation and Compliance Guidelines: 1. Recognition of outbreak: a. Changes in condition and/or signs and symptoms of infection shall be reported according to procedures for infection reporting. b. The following triggers shall prompt an investigation as to whether an outbreak exists: - An increase over baseline infection rate (i.e. ten percent or more increase). ii. A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases). - A single case of a rare or serious infection (i.e. invasive group A Strep, foodborne pathogens, active TB, acute hepatitis, Legionella, chicken pox, measles, COVID-19). - An outbreak will be defined according to current definitions used by local and state health departments. - An outbreak will be reported to the local and/or state health department in accordance with the state's reportable diseases website. 3. Outbreak investigations. - When the existence of an outbreak has been established, an investigation will begin. - The Infection Preventionist/designee shall be responsible for coordinating investigation. The Infection Preventionist will be the liaison between the health department and the facility. - A line list about each person affected by the outbreak will be maintained. - The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved. - A summary of the investigation will be documented and reported to QAPI committee and health department, if indicated. A review of the facility's policy and procedure titled Enhanced Barrier Precautions (reviewed on 2/28/25), revealed: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a) All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b) All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. c) The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. 2. Initiation of Enhanced Barrier Precautions: a) The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an Multidrug resistant organism (MDRO) that is not currently targeted by Centers for Disease Control and Prevention (CDC) but may be considered epidemiologically important. b) An order for enhanced barrier precautions will be obtained for residents with any of the following: I. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) II. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #11) of 13 residents receiving oxygen therapy, from a total sample of 21 residents, received the correct oxygen flow rate as ordered by the physician. The findings include: On 6/19/23 at 2:11 p.m., Resident #11 was observed lying in bed wearing a nasal cannula. Her oxygen concentrator, located at bedside, was observed with a flow rate set at 3.5 L/min. (liters per minute) (Photographic evidence obtained) On 6/20/23 at 11:11 a.m., another observation was made of Resident #11 lying in bed wearing her nasal cannula. Her oxygen concentrator was running and the flow rate was set at 3.5 L/min. (Photographic evidence obtained) A review of Resident #11's physician's order, dated 12/8/2020, revealed she was to receive oxygen at 3 L/min via nasal cannula as needed for an oxygen saturation <90%. On 6/21/23 at 10:29 a.m., another observation of Resident #11's oxygen concentrator revealed it was set at 3.5 L/min. (Photographic evidence obtained) A review of the resident's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dependence on supplemental oxygen, dementia - unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the resident's June 2023 Medication Administration Record (MAR), revealed an order for oxygen at 3 L/min via nasal cannula as needed for an oxygen saturation <90%. It was blank. There were no nursing initials documented to indicate that this resident was provided oxygen as per the order at anytime during the month of June 2023. (Photographic evidence obtained) A review of the quarterly Minimum Data Set (MDS) assessment, dated 6/12/2023, revealed that Resident #11 had a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 points, indicating severe cognitive impairment. The assessment also documented that she was receiving oxygen therapy. A review of Resident #11's vital signs for May 2023 revealed that from 5/1/2023 through 5/29/2023, the resident received oxygen via nasal cannula with saturations of 91-100% and on 5/18/2023, her blood oxygen saturation was 96% on room air. A review of a Provider/Practioner note, dated 6/14/2023 at 5:48 p.m., revealed the resident's oxygen saturation was 91% with the use of supplemental oxygen. On 06/21/23 at 10:00 a.m., an interview was conducted with Certified Nursing Assistant (CNA) E, who confirmed that nursing provided ongoing monitoring of Resident #11's oxygen therapy. The nurse was responsible for ensuring that the resident was receiving oxygen at the flow rate ordered by the physician. She stated Resident #11 did not refuse her oxygen therapy. CNA E was not sure if the resident had ever changed her own oxygen flow rate. On 06/21/23 at 10:12 a.m., accompanied by Licensed Practical Nurse (LPN) F, Resident #11's oxygen concentrator was observed to be set to administer oxygen at 3.5 L/min. (Photographic evidence obtained) LPN F confirmed that Resident #11's physician's order was for a flow rate of 3 L/min. Changes in Resident #11's condition regarding her respiratory care was communicated to the Unit Manager, Director of Nursing (DON), family and physician. Correct oxygen settings were identified on the MAR and communicated from one staff person to another verbally during shift reports. Resident #11 did not refuse oxygen or change her own oxygen flow rate settings. On 06/21/23 at 2:14 a.m., the DON confirmed that the correct oxygen settings were identified by reviewing the resident's physician's orders. A review of the facility's policy and procedure for Oxygen Administration (revised October 2010), revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to complete temperature logs for the dish machine and ice cream box, properly clean and sanitize the kitchen ice machine, fryer, upper and lower-level of convection oven, can opener, oven tray lines, and grill; date mark numerous open food packages in the dry storage room, on the bread rack, under the food prep table, in the refrigerator, and in the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 6/19/2023 at 11:20 a.m. During the tour, no temperature log for June 2023 was displayed for the ice cream box, and incomplete temperature logs for June 2023 were displayed for the dish machine and sanitizing sink. The bread rack next to the reach-in cooler had several open bundles of bread with no date markings. The prep table on the opposite side of the reach-in cooler had one open bin with onions and one open bin with potatoes, and two open boxes of bananas with no date markings. Expired milk was observed in the walk-in refrigerator along with no date marking on one open box of squash and one aluminum pan of tomatoes. No date markings were observed on one open package of veggie burgers, hamburgers, and a bag of french fries in the walk-in freezer. No date marking was observed on one open aluminum pan of hotdogs in the reach-in cooler next to the bread rack. In the dry storage room, there were no date markings observed on one bag of pecans, one bag of macaroni, or one jar of barbecue sauce. The ice machine located next to the serving line had black biological growth spots and a pink, slimy substance that were in close proximity to the internal chute of the ice machine. These same observations of the pecans, bread, and squash, were made again on 6/20/2023 at 10:14 a.m., 10:17 a.m., 10:19 a.m., and 10:32 a.m. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 6/21/2023 at 10:55 a.m. The can opener pixel holder was greasy and filled with food debris. The inside, left and right door area of the top and bottom convection oven next to the grill was covered with grease buildup. The grill grate was filled with food debris and grease buildup, the grill tray was filled with ashes, the oven burners were filled with grease buildup, the oven tray and fryer tray were filled with food debris and grease, and another oven tray was filled with food debris and a liquid substance. Inside another oven, grime buildup was observed, the fryer next to the grill was covered with food debris and grease, and the oven side next to the fryer was filled with grease buildup. Observations were made of bread left torn open and bread with no date markings on the bread rack. Tubing on the drink machine was covered with black biological growth spots. (Photographic evidence obtained) An interview was conducted on 06/22/23 at 10:13 a.m. with Dietary Aide A. When asked who was responsible for documenting temperature logs in the dish room, she replied, the cook. When asked who was responsible for documenting temperature logs for the ice cream box, she replied, There is no specific staff, it is whoever is assigned to do it. When asked who was responsible for stocking the dry storeroom, she replied that she was not sure but sometimes the lead manager. When asked who was responsible for stocking the refrigerator and freezer, she replied, The staff that receives the delivery and puts up the food. She confirmed that the facility's policy for date marking was to date and use opened products within 2-3 days. When asked what happened when a food item was opened, used, and placed back in the refrigerator or freezer, she replied, Opened food is sealed, labeled with the date opened and the expiration date. When asked what happened when bread was opened, used, and placed back on the bread rack, she replied that staff should check the expiration date. Once the bread was opened, staff were to label the package with the date opened and an expiration date. She stated she was unsure of the exact date. Opened bread is used fast. Dietary Aide A reported all staff were assigned cleaning tasks that were identified on a chore list. The can opener should be cleaned daily, and the cooks clean the kitchen equipment every 2-3 days or weekly. Sometimes Maintenance or the [NAME] would clean and sanitize the ice machine. She stated since her employment with the facility over the last nine months, she observed the ice machine being cleaned two times. An interview was conducted on 06/22/23 at 10:52 a.m. with [NAME] B, who stated the dishwasher was responsible for documenting temperature logs in the dish room. The Dietary Aide assigned was responsible for documenting temperature logs for the ice cream box. The Lead Manager or the staff assigned was responsible for stocking the dry storeroom and the refrigerator and freezer. He confirmed that the facility's policy for date marking was to label food items with the date opened and an expiration date. When a food item was opened, used, and placed back in the refrigerator or freezer it was labeled and dated. When bread was opened, used, and placed back on the bread rack, the bread was labeled and discarded after three days. The [NAME] cleaned kitchen and food service equipment every 3-4 days, and the grill was brushed daily. He stated the facility had an outside vendor who came to deep clean the kitchen equipment, but since the new ownership took over, there was currently no one scheduled to provide the deep cleaning. When asked how often the ice machine was cleaned, he replied, I don't remember how often it is cleaned or who cleans it. No one is really assigned to clean it. An interview was conducted on 06/22/23 at 11:11 a.m. with Dietary Aide C, who stated the staff member completing the task was responsible for documenting on the temperature logs. The prep staff was responsible for documenting on the temperature logs for the ice cream box. The staff assigned to put the truck delivery away was responsible for stocking the dry storeroom and refrigerator/freezer. She confirmed that the facility policy for date marking was to seal the food item, label the food item with the date received, date opened, and expiration date. Bread was to be wrapped, dated with the open and expiration date, and used by the 10th day. The cook was responsible for cleaning kitchen and food service equipment. When asked how often kitchen equipment was cleaned, she replied, They try to clean every night after dinner and deep clean weekly. She was unable to report when or how often the ice machine was cleaned, and stated any staff member could clean it. An interview was conducted on 06/22/23 at 11:31 a.m. with the Lead Food Service Assistant, who confirmed that the morning [NAME] was responsible for documenting on the temperature logs. Dietary Aides were responsible for documenting on the temperature logs for the ice cream box. Dietary Aides were responsible for stocking the dry storeroom and the refrigerator/freezer. She confirmed that the facility's policy for date marking was to date mark the item with a received date, opened date, and expiration date. When a food item was opened, used, and placed back in the refrigerator or freezer, the item was date marked with the day opened, the expiration date, and was discarded after seven days. The [NAME] was responsible for cleaning kitchen and food service equipment. Kitchen equipment was cleaned usually every night and Dietary Aides cleaned the ice machine two times per week. A review of the facility's policy and procedure for Cleaning and Sanitizing Dietary Areas and Equipment (Undated) revealed: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary foodservice that meets state and federal regulations. A review of the facility's policy and procedure for Sanitation of Ice Machine (Undated) revealed: It is the policy of this facility that the ice machine shall be sanitized twice monthly by dietary. A review of the facility's policy and procedure for Food Receiving and Storage (dated July 2014) revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). According to the FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. Chapter 4. Equipment, Utensils, and Linens. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 4-20. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility policy and procedure, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two (Resident #11 and Resident #13) of two residents sampled for review of range of motion services, from a total sample of 20 residents. The findings include: 1. On 9/20/21 at 12:33 PM, Resident #11 was observed sitting in her wheelchair. She had a contracture of her left hand. Resident #11 stated, I don't get any therapy to help me walk, they said my torso isn't stable. When she was asked if she uses a splint for her left hand and arm. She stated, Yes, but I don't know where it is. On 9/21/21 at 10:32 AM, Resident #11 was observed sitting in her wheelchair in the living room area of the facility. Her left arm did not have a splint in place. On 9/22/21 at 12:30 PM, Resident #11 was observed in her wheelchair in the living room area of the facility sitting at a table for lunch. Her left arm did not have a splint in place. On 9/22/21 at 2:30 PM, Employee E, Licensed Practical Nurse (LPN) was asked if Resident #11 wears a left-hand splint. She stated, She wanted to wear a splint, I think a family member brought it in a while ago, so we got an order so she could wear it. She wears it when she wants to, it's not really doing anything. On 9/22/21 at 3:00 PM, the Director of Therapy, was asked about the restorative program for Resident #11. She stated, She was discharged from PT yesterday and picked up by restorative. She produced a restorative functional maintenance plan with an objective: Maintain and possibly increase strength in bilateral LE and core muscles. Approach: PROM to AROM to bilat LE in all planes 2 X 15. Patient reaching for objects using cone 3 x 10, muscles to come forward. Plan is dated 8/26/2021. On 9/22/21 at 3:15 PM, Resident #11 was observed once again in her wheelchair in the living room area of the facility talking with another resident. Her left arm did not have a splint in place. A review of Resident #11's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included intercranial injury, seizures, major depressive disorder, hydrocephalus, and contracture of muscle (left hand). A review of her annual minimum data set (MDS) assessment, dated 7/7/21, revealed the resident had a brief interview for mental status score of 14, indicating cognitively intact. She also required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. A review of Resident #11's current physician orders revealed the following: 5/16/2021: resting left hand splint- remove at hs.; 7/30/2021: PT (Physical Therapy) to eval and treat. (Physical Therapy Discharge summary dated [DATE]; 9/1/2021: ST (Speech Therapy) to eval and treat; 9/13/2021: Resident to wear left resting splint for 12 hours daily as tolerated, may remove for hygiene. Apply in am and off in 12 hours. (Copy obtained) A review of the resident's care plan with revision date of 8/11/21, revealed the following focus area: Resident has an ADL self-care performance deficit r/t activity impaired mobility, left side hemiplegia, left hand contracture, traumatic brain injury. Interventions included assistance with splint or brace PRN. Resident to wear left resting hand splint for 12 hours as tolerated may remove splint for hygiene, apply in am and off in 12 hrs. (Copy obtained) On 9/23/21 at 9:45 AM, Resident #11 was observed lying in her bed, dressed in day clothes. She stated, she was waiting for someone to come back to get her up. Her left arm did not have a splint in place. When she was asked if she would be wearing her left-hand splint today. She stated, I'd like to, but I don't know where it is. A visual sweep of her room did not reveal a splint in sight. Resident stated she hasn't seen or used her splint since she moved to this unit from the [NAME] unit, about a month ago. She stated when she was on the [NAME] Unit, her splint was kept on her bedside table, and she wore it daily. During the interview with Resident #11, Employee C, Certified Nursing Assistant (CNA)/Restorative Aide entered the room. When she was asked if she was caring for resident #11 today. She stated, I'm working with her for restorative this morning. When she was asked if she would be applying the resident's left-hand splint this morning. She stated, No, I don't think she has a splint, I haven't seen her wear one since I've been working with her. I think, I did see her wearing one when she was on the [NAME] unit, but that was before she was on the restorative program. Employee C stated that she works with Resident #11 Monday thru Friday, each day. When she was asked how long she had been performing restorative therapy with Resident #11. She stated, I started her restorative therapy on August 26 of this year. When she was asked who would apply the splint if she had one ordered. She stated, Usually the CNA would but if I see a splint isn't on when I am doing restorative, then I would apply it. When she was asked if she uses a [NAME] to guide the care the resident receives. She stated, Yes. A review of the [NAME] information for Resident #11 with Employee C revealed, Assistance with splint or brace PRN; resident to wear left resting hand splint for 12 hours daily as tolerated, may remove splint for hygiene- apply in am and off in 12 hours. Employee C confirmed that Resident #11 had not been wearing the hand splint and she should be. (Copy obtained) 2. A review of Resident #13's medical record revealed that he was admitted on [DATE]. His diagnoses included cellulitis of lower limbs, and osteoarthritis. A review of his quarterly MDS assessment, dated 7/7/21 revealed the resident had a BIMS score of 13, indicating cognitively intact. With limitation in range of motion on one side of upper and lower extremity. A review of resident's care plan revised on 9/6/21 revealed a need for restorative intervention to prevent physical and functional decline with interventions for active range of motion to bilateral lower extremities all planes x 10-20 repetitions x 2 sets as tolerated. The functional maintenance plan for Resident #13 was reviewed and noted services for therapy ended on 8/3/21 with a recommendation for active range of motion on both lower extremities, all planes x 10-20 reps x 2 sets or as tolerated and the objective is for resident to maintain joint integrity on both lower extremities/range of motion on both lower extremities and maximum strength of both lower extremities. The physical therapy plan of care dated 8/2/21 was signed by the physician, and the discharge plan noted to remain in long term care with updated restorative nursing program. A review of the documentation for restorative revealed resident received services twice weekly on 9/7, 9/9, 9/15, 9/16, 9/20 and 9/22/21. On 9/21/21 at 9:22 AM, an interview and observation with Resident #13 was conducted in his room. He reported that therapy had finished, and he was receiving restorative for range of motion for both legs and it is hit and miss. He stated, the restorative CNA gets pulled to the floor to work an assignment, so he does not get the services. He reported the range of motion should be five days a week and he has never refused the restorative services. On 9/22/21 at 11:47 AM, an interview was conducted with Employee C, CNA/Restorative Aide. She reported that Resident #13 receives bilateral lower reps with 2 sets of 20 range of motion. She stated, It is ordered 5 times a week, but if I am working on the floor and have been assigned to resident care, I am unable to perform restorative duties. She reported she works Monday-Friday and once a week she is pulled from restorative to be a CNA on the floor. When she was asked what happens if a resident refuses, she replied If a patient refuses, I document and tell the nurse. If the resident refuses, I will go back in afternoon and try again, then report it. When she was asked if Resident #13 refuses restorative services, she replied, He never refuses restorative services but will refuse showers. On 9/22/21 at 3:12 PM, an interview was conducted with Employee D, MDS coordinator. After reviewing Resident #13's documentation for restorative services from 9/7-9/22/21, she confirmed, he only received the services twice a week instead of the 5 days as ordered. The documentation reviewed revealed services were provided on 9/7, 9/9, 9/15, 9/16, 9/20 and 9/22. On 9/23/21 at 10:00 AM, an interview was conducted with the interim DON. The DON stated, she had been at the facility for 1 week and was acclimating to the restorative program. The DON stated, she spoke to the CNA restorative aide, who confirmed she gets pulled to the floor at least once a week for resident care. When she was asked if there was a backup plan or if another CNA was available to provide the services. She replied, There is no back up plan, we only have 1 CNA on restorative that works Monday through Friday. The DON confirmed Resident #13 had received services 9/7, 9/9, 9/15, 9/16, 9/20 and 9/22 and not 5 days a week. The DON was asked about having a written physician order for the services and she stated, As a nurse, I like to have physician orders. The policy states we do not need a physician order. The time frame is 5 times a week for everyone on services. The policy says 7 days a week. I will be changing the restorative program. On 9/23/21 at 11:06 AM, an interview with Resident #13 was conducted in his room. He reported receiving restorative yesterday and stated, I really need the stretching, it helps with my pain. I hope, I can stay on restorative, and they do it five times a week like they are supposed to, I need it. A review of the facility policy and procedure titled, Restorative Nursing Care Policy and Procedure revised 4/21/21 revealed the goal of restorative nursing care is to attain and maintain the maximum possible independence and or prevent rapid declines through the interventions for each resident. Under procedure it is noted restorative services should be seven days a week. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to monitor resident behaviors and potential side effects related to the use of psychotropic medication for one (Resident #25) of five residents reviewed for unnecessary medications from a total of 20 residents in the sample. The findings include: A record review for Resident #25 revealed she was admitted on [DATE], with the following diagnoses: urinary tract infection (UTI); unspecified dementia without behavioral disturbance; syncope and collapse; anxiety disorder; major depressive disorder; adjustment disorder with mixed anxiety and depressed mood. A review of physician orders on 6/11/21, revealed an order for Seroquel 25 mg (milligram) by mouth every 12 hours for dementia, depression, and delusional ideation. A review of Resident #25's medication administration records (MAR) for July through September 2021 revealed no behavior monitoring documentation and/or side effect monitoring documentation for the antipsychotic medication, Seroquel. A review of the medication record review (MRR) in August 2021 and September 2021 revealed a pharmacy recommendation to start antipsychotic monitoring on the MAR for Seroquel. On 9/22/21 at 2:52 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She confirmed that Resident #25 had an order for Seroquel 25 mg every 12 hours. She added that the resident has displayed some behaviors, including excessive sadness, tearful, outbursts and anxiety. When she was asked about behavior monitoring, she stated it was in place, but she was unable to provide any documentation to show it was happening. On 9/22/21 at 3:54 PM, an interview was conducted with the Director of Nursing (DON). She verified there was no documented behavior monitoring for Resident #25 related to the use of Seroquel, and could not explain why the behavior monitoring was not a part of the MAR. On 9/23/21 at 11:32 AM, a follow up interview was conducted with the DON. The DON confirmed the pharmacist recommendation in August 2021 and September 2021 to add behavior monitoring for Resident #25 related to the use of Seroquel. She stated that the previous DON initialed that it was implemented in 8/2021, however, it was not. She added that all pharmacy recommendations are to be reviewed by the DON to ensure they are implemented. She once again confirmed there was no documented behavior monitoring for Resident #25. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and facility policy and procedure review, the facility failed to properly store medication in locked compartments, allowing only authorized personnel access to them for one (Resident #10) of 20 sampled residents, by leaving a medication cup with pills in it and a bottle of artificial tears on the resident's bedside table and failing to ensure the resident took the medications. The findings include: An interview was conducted with Resident #10 on 9/20/21 at 1:04 PM. During the interview, a clear pill cup containing one white oblong shaped tablet was observed on the resident's overbed table. Resident #10 stated it was a pain pill which she gets every four hours. She stated the nurse brings it to her, and then she takes it on her own as needed. On 9/21/21 at 2:29 PM, a second interview was conducted with Resident #10. During the interview, and a clear bottle of artificial tears was observed on the resident's overbed table. Resident #10 stated, she used the eye drops for her dry eyes. On 9/22/21 at 9:32 AM, the bottle of artificial tears was still at the bedside along with two (one black and one orange) unidentified round tablets. Resident #10 stated the pills were from the morning medications and were her iron and stool softener pill. She then stated, I'll take them later. A medical record review for Resident #10 revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses that included specified fracture of unspecified pubis, acute kidney failure, non-pressure chronic ulcer of unspecified part of right lower leg and essential hypertension. A review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #10 scored a 14 out of 15 on the brief interview for mental status (BIMS), indicating cognitively intact. A review of physician's orders for Resident #10 revealed Tylenol extra strength 500 mg by mouth three times a day, Methadone HCI tablet 2.5 mg by mouth every 12 hours, Mirtazapine 7.5 mg by mouth at bedtime, Artificial tears 1.4% instill 1 drop every four hours as needed, Acetaminophen extra strength 500 mg by mouth every four hours as needed. A review of Resident #10's medication administration record (MAR) for September 1st- 21st, 2021 revealed no documentation eye drops were given during this time. A review of the care plan for Resident #10, last revised on 8/31/21 revealed no documentation related to self-administration of medication. Further medical record review revealed no documentation an assessment for self-administration of medication was conducted for Resident #10. During an interview on 9/22/21 at 9:37 AM with Employee A, a Licensed Practical Nurse (LPN), she stated there are no residents currently in the facility who have been assessed and approved for self-administration of medication. When asked about Resident #10, she stated she leaves medication at her bedside because she takes her medications at her leisure. During the interview, Employee A reviewed the September 2021 MAR for Resident #10. It reflected all medications scheduled for 9:00 AM on 9/22/21 had been administered. When questioned if the resident had taken the medications, the LPN replied, she did not know and proceeded to the resident's room. Upon entering the room, the LPN observed medications and eye drops at bedside. Employee A questioned Resident #10 on why she had not taken the medications. When the resident replied that she would take them later, Employee A advised the resident that she would have to take the medications, or they would be discarded. When the resident refused to take the medications, Employee A discarded them in the sharp's container inside of the resident's room, leaving the eye drops on the over bed table. When asked if the eye drops were supposed to remain in the resident's room for self-administration, Employee A stated she didn't know if there was an order for the eyes drops. The nurse returned to the cart and verified there was an as needed order for the eye drops and stated they shouldn't be at bedside. During an interview on 9/23/21 at 10:32 AM with Employee B, the Clinical Learning Development Specialist, she stated that the MAR should not be updated prior to the medication administration. She also stated unless there is an order and/or an assessment for self-administration of medications, residents should not be allowed to administer their own medications and under no circumstances should medications be left at bedside. She stated that residents who self-administer medications must store their medications in a locked box provided by the facility. A review of the facility's policy and procedures on Resident Self-Administration of Medication with reviewed/revised date of 11/18/2020 revealed: Per procedures, The Resident Self-Administration of Medications user defined assessment (UDA) must be completed to determine if the resident can safely administer medications and to create a plan to assist the resident to be successful in this process. .