**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, interview and record review, the facility failed to 1) accurately document, assess and report a resident's change in skin condition and; 2) ensure appropriate notification of the resident's representative of a change in the resident's condition for 1 of 2 sampled residents reviewed, Resident #1.The findings included: 1) Review of the facility policy titled Skin Management provided by the Director of Nursing (DON) reviewed effective 04/23/12 documented .Ongoing Skin Checks Daily C.N.A. and/or other direct care giver skin checks: 1. The Certified Nursing Assistant (C.N.A.)/other direct care giver will conduct an inspection of the resident's skin daily when providing care, assisting with or providing bath/shower. 2. The Certified Nursing Assistant (C.N.A.)/other direct care giver will report to the Licensed Nurse any findings/concerns daily. Weekly Licensed Nurse skin checks: 1. The Licensed Nurse will complete full body inspection of the resident, and either: a. document on weekly skin sheet, or: b. document in the resident's electronic health record. 2. Any new concerns/risk factor will be addressed and the care plan reviewed and revised as appropriate. As appropriate, the resident's physician and primary contact will be notified of any new skin concerns. Resident #1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Diabetes Mellitus II, Hypertension, End Stage Renal Disease, Cerebral infarction, Dysphagia, Parkinson's Disease, Seizure, Depression, Anemia, Gastrostomy, Dependence on Renal Dialysis (with AV fistula/shunt to left upper extremity), contracture of the left hand, contracture of right elbow, Osteomyelitis ankle and foot. He had a Brief Interview Mental Status (BIM) score of 1, indicative of severe cognitive impairment.On 05/27/25 at 05:32 AM, Resident #1 was transferred to the hospital for lethargy, shortness of breath, and labored breathing. Vital signs were Blood Pressure 124/52, Temperature 98.3F, Pulse 61, Respiratory rate 28; and Oxygen saturation 90%.During a telephone interview conducted on 07/01/25 at 12:33 PM, with the son, who is the Power of Attorney (POA) and Healthcare Surrogate (HCS), he explained how he had received a call from the Hospital informing him that Resident #1 had been admitted to the Emergency Room, from the facility. The son stated that no one from the facility called to notify him and he said that no call was ever received. The son also stated that when he arrived at the hospital, he discovered that Resident #1 had bruises and swelling on his forehead and chin and he was on a ventilator. The son said that he could not understand how the bruises and swelling got there and why he had not been informed about this, especially since his Dad was bed bound and unable to move. The son went on to say that he was not given any information from the facility regarding Resident #1's being transferred to the hospital, nor the reason why and what happened, when he went back there several days later to gather his Father's belongings. He said that the facility only referred him to speak with the Risk Manager (RM) and with the Social Worker (SW), neither of which was able to provide any further plausible explanation to him.For the dates of 05/08/25 through 05/27/25 the Physician's Order documented, Weekly skin checks once a day on Wednesday.During a computerized record review of the nurses' note dated 05/26/25 at 11:29 PM by Staff D, Licensed Practical Nurse (LPN) she documented and revealed, Resident resting in bed no sign of distress noted . Resident face has redness On 07/02/25 at 4:28 PM an interview was conducted with Staff B, Certified Nurse Assistant CNA (assigned to the resident at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM in which she was working on the 11 PM - 7:30 AM shift), in which she revealed that when she came in that night and did her rounds, after 11 PM that night, both she and the nurse, Staff C, LPN, saw a little red rash on one of the resident's cheeks and on his chin. On 07/02/25 at 4:24 PM a telephone call was attempted, but the message stated that, this number cannot take calls, at this time, Staff A, CNA (was assigned to Resident #1 just before the event occurring on Tuesday 05/27/25 at 4:30 AM, in which she was working on the 3 PM - 11:30 PM shift), was unavailable for interview, during this survey, in order to discuss Resident #1's skin condition, at the time.On 07/02/25 at 4:26 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system, and it is not available to leave a message, Staff D, (was assigned to Resident #1 just before the event occurring on Tuesday 05/27/25 at 4:30 AM and who had been working on the 3 PM - 11:30 PM shift), was unavailable for interview, during this survey, in order to discuss Resident #1's skin condition, at the time.An interview was conducted on 07/02/25 at 4:58 PM with the Facility Registered Nurse (RN)/Risk Manager, in which she acknowledged that Resident #1 did have some type of redness, bruising and swelling on his forehead and chin, to her knowledge, however, she indicated that she did not learn about this until it was brought to her attention (when she was informed) by the resident's son, after Resident #1 had already been transferred out of the facility and to the hospital, after the date of: Thursday 05/29/25 at 6:33 PM---2 days later. She stated that she was not informed of this by the assigned nurse for the resident, at the time in which it had been documented, on Tuesday 05/27/25. The Risk Manager also acknowledged that there had been no further description nor details documented regarding Resident #1's skin condition, in the facility's progress notes. Moreover, the Facility Risk Manager revealed that she had documented, Hospital staff informed the resident's son that the resident was admitted with the above bruises, as documented in the report provided to Agency for Healthcare Administration (AHCA), by the facility's Risk Manager, dated 06/03/25 6:01:45 PM. The Risk Manager also indicated in the AHCA report that, On May 26, 2025, the 3 PM - 11 PM staff stated that upon their initial rounding on the resident, they observed him with redness on the left chin, the redness appeared recent And, the Risk Manager further documented in this same report that, during the interview process, the 11 PM- 7 AM staff expressed that they saw a bruise on the left side of the resident's cheek. And documented this on the resident's transportation form before he was transported to the Hospital. The Risk Manager subsequently described, as documented, the resident's skin abrasions after hospital transfer as: The first skin abrasion was visible approximately an inch above the resident's right brow line approximately the size of a nickel, with pinpoint red bumps visibly around the area, no swelling or rise was observed; the second skin abrasion was visible under the resident's lip towards the left corner of his mouth, the skin abrasion was blotchy/irregular shaped and approximately 2 inches, also with no swelling or skin elevation> The Risk Manager further acknowledged that both of these notations were also in the report that she submitted to AHCA. Record review of the Resident #1's Skin Care plan initiated 10/30/20 and revised 05/08/25 indicated Focus: Status/post Hospitalization on 05/08/25 . Interventions: Dermatology consult as needed . Topical treatments as ordered Goal: Resident #1 will be free of skin breakdown by next review date.There had been no mention or documentation in the record, prior to this time referencing a redness to the resident's face from Thursday 05/01/25 at 6:23 AM, in which Resident #1 was sent out to the hospital, returned to the facility on Thursday 05/08/25 at 9:25 PM until the nurses' notation on Monday 05/26/25 at 11:29 PM. Neither was there any further information describing the exact location on the resident's face that this was noted, whether the skin was intact, bruising, swollen, clean and dry. Furthermore, there was no notation in the record that this had been reported to either the Supervisor or Unit Manager on duty, nor whether any further facial skin assessment or follow-up had been done, for this resident, at the time.2) Review of the facility policy titled Change of Condition provided by the DON effective 05/12/25 documented in the Policy Statement: . II Standard: Identify, report, document and respond to a resident's change of condition to ensure timely and appropriate care. III. Definitions: A. Change of Condition: A new, worsening, or unexpected clinical development that: Threatens life or may lead to hospitalization, or Requires starting, stopping, or adjusting treatment, or Alters the residents' physical, mental, or psychological status. IV. Procedures: A. Detect the Change: All direct-care staff continuously observe deviations from baseline such as but not limited to: New or worsening pain, New changes in vital signs, Acute mental-status change, New skin discoloration or breakdown, New onset/change of mobility or functional decline, Abnormal event or occurrence. B. Notification: Relay observations to LPN/RN/Supervisor/DON to assist as necessary. Contact the primary or on-call MD/NP/PA promptly, for potentially life-threatening situations (e.g. possible Sepsis, Stroke, Uncontrolled pain). a. Provide concise information: vitals, assessment and observation findings, labs, code status, and recommended actions. b. Initiate treatments, diagnostic tests, or transfers as prescribed. Inform the resident (as able) and the designated representative of the change and provider orders. C. Document in the HER, create a comprehensive progress note on the same shift that includes: Assessment details and clinical findings, Provider notification (name, time, information shared), Interventions carried out and resident's response and Follow-up evaluation results.Computerized record review of the nurses' progress note dated Tuesday 05/27/25 at 5:16 AM by Staff C, LPN, on the 11 PM - 7:30 AM shift, revealed that she documented, Call placed to resident family member. Message left on answering machine informing of resident transfer to the hospital. Resident #1 was transferred to the hospital due to lethargy, shortness of breath, and labored breathing.On 07/02/25 at 4:47 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system and it is not available leave a message. Staff F, RN, Part-time Night Supervisor of the entire building (was assigned to Resident #1's unit at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM she will often either work on the 7 AM - 3:30 PM shift or on the 11 PM - 7:30 AM shift), was unavailable for interview, during this survey, in order to discuss whether or not the resident's representative had been contacted.On 07/02/25 at 4:43 PM a telephone call was attempted, but the message stated that, your call has been forwarded to an automatic voice messaging system, and it is not available to leave a message, Staff C, (was assigned to Resident #1 at the time of the event occurring on Tuesday 05/27/25 at 4:30 AM in which she was working on the 11 PM - 7:30 AM shift), was unavailable for interview, during this survey, in order to discuss whether or not the resident's representative had been contacted.During an interview conducted on 07/02/25 at 2:38 PM, with Staff E, RN, (who was assigned to Resident #1 just the time after the event had occurred earlier on Tuesday 05/27/25 at 4:30 AM, in which she was working on the 7 AM to 3:30 PM day shift) she revealed that she had not made any phone calls, at any time during her shift, to Resident #1's family in order to ensure that they had been informed of the resident's hospital transfer.During a subsequent side-by-side record review and interview with the Risk Manager on 07/02/25 at 5:20 PM, it was revealed, according to the progress notes in the facility record, that there was only one (1) note regarding Resident #1's family being notified via voice message only. Subsequently, the Risk Manager acknowledged that there was no additional notation to show that the resident's family ever actually received this information from the facility, nor that the facility made any other attempts to contact and notify the resident's family of the resident's transfer out of the facility to the hospital.There were no other documented follow-up phone call attempts made by the facility to verbally inform the resident's representative of the resident's changed in condition or status, nor of his transfer to the hospital. And, there was no evidence to show that the facility had actually spoken to and informed the son. The DON further recognized and acknowledged on 07/02/25 at 5:45 PM that, Resident #1's facility identified 'face with redness and rash on one of his cheeks and on his chin,' should have been documented in detail to include whether or not the skin was intact, bruising, swollen, clean and dry, size and include a description and exact location on the resident's face along with any further facial skin assessment or follow-ups, reported to the Supervisor, to her and to the Doctor notified, as applicable or as warranted. The DON also acknowledged that the resident's representative should have been notified and ensured that documented attempts or efforts were made to contact them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide residents' choices consistent with their interest assessments and care plan. Facility failed to honor resident choices regarding scheduled bedtime for 1 of 1 resident (Resident #114). The findings included: A record review showed that Resident #114 was admitted on [DATE] with Quadriplegia, C1-C4 incomplete. The Minimum Data Set (MDS) quarterly dated 12/18/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicated no cognitive impairment. A review of the admission MDS dated [DATE] section E showed that Resident #114 answered that it was very important for him to choose his bedtime. In an observation conducted on 01/06/2025 at 11:35 AM Resident #114 was still lying in his bed undressed. In an observation conducted on 01/08/2025 at 12:05 PM Resident #114 was seen in bed underneath the covers. In this observation Resident #114 said that he was waiting to get dressed and get out of bed. In an interview conducted on 01/09/2025 at 1:15 PM Resident #114 stated that he wished to be out of bed earlier than 12:00 PM. An ideal time for him would be at 10:00 AM. Resident #114 further stated that he talked to the staff regarding getting out of bed at 10:00 AM and not after 12:00 PM, but nothing changed. In his last attempt to address the issue he was answered that they have to do what is best for the nursing staff. In an interview conducted on 01/09/2025 at 1:05 PM with Staff O, Certified Nurse Assistant (CNA) Staff O, stated that Resident #114 did mention wanting to be out of bed earlier than 12:00 PM, but she did not have the power to change that. In an interview conducted on 01/09/25 at 2:00 PM, with the Director of Nursing (DON), she was informed of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to address a grievance regarding hearing aids for 1 of 1 sampled resident (Resident #17). The findings included: A review of facility's policy titled, State of Florida, Department of Veteran's Affairs, Resident Grievances dated 08/04/2009, revised 10/18/2027, revealed the resident has the right to voice grievances to the facility. Number 1under the filing grievances section revealed that any resident, family member, or appointed resident representative may file a grievance concerning care, treatment, behavior of other staff members, theft of property or any other concerns regarding his or her stay in the facility. Number 3 revealed that grievance may be submitted orally or in writing and may be filed anonymously. Number 6 under the investigation and resolution of grievances section revealed that the resident and or resident's representative filing the grievance on behalf of the resident, will be informed of the findings of the investigation within 10 working days of receiving the grievance, and actions taken to correct any identified concerns. Record review revealed Resident #17 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder. Review of quarterly Minimum Data Set (MDS) assessment, dated 11/12/24, revealed a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. Section B revealed hearing aids were used by Resident #17 during the assessment. A review of nursing care plan dated 08/15/23, quarterly reviewed on 11/15/23, 02/14/24, 05/15/24; annually reviewed on 08/14/24 and 11/13/24, revealed to continue the plan of care for communication problem with the Nursing approaches of assisting with hearing aid placement and maintenance prn (pro re nata), or as needed. Additional nursing interventions revealed to check Resident #17's ears for cerumen build up prn, and to refer to Audiologist as indicated. Additional review of Social Worker's notes dated 11/20/24, revealed impaired hearing, bilateral hearing aid used, potential for decline in understanding. A further review of care plan edited on 11/21/24 regarding mood and state problem revealed interventions by Nursing and Social Services to involve Resident #17's family in his care. In an interview on 01/07/25 at 11:19 AM, Resident #17 reported he lost his hearing aids two weeks ago. When asked if he told Staff, he pointed to his right ear and asked this Surveyor to repeat the question. He then responded No! Resident stated he was having a hard time understanding and asked the surveyor to talk louder. When asked how he lost the pair of hearing aids, he responded with a smile, pointed at his right ear and asked to repeat the question. After the surveyor asked the question in a louder voice, Resident #17 responded, I put them in my right short pocket, then my laundry was taken out of my room with the pair of hearing aids. In an interview with Staff Q, a Certified Nursing Assistant (CNA), on 01/07/25 at 11:30 AM, when asked if she had observed Resident #17 was not wearing both hearing aids for the past few weeks, she responded No. When asked if she is aware resident lost his hearing aids, she responded, she was not. She added she will tell the Charge Nurse right away. In an interview with Staff E, a Charge Licensed Practical Nurses (LPN) on 01/08/25 at 11:46 AM , she stated she has never heard of any resident who lost hearing aids. In an interview with Resident #17's daughter on 01/07/25 at 12:16 PM, she revealed she reported the loss of hearing aids two weeks ago to both laundry and nursing staff but failed to get their names. When asked if any of the facility staff had given her an update regarding the hearing aid search, she responded, No, no one called me back and I want to get an update as soon as possible. She was worried that her father might be having difficulty in communicating and expressing his needs. In another interview on 01/07/25 at 2:30 PM, when asked about his lunch, Resident #17 answered with a smile that he is having hearing difficulty. He kept pointing at his right ear and asking the surveyor to repeat the questions. In an interview with Staff S, a Licensed Social Worker (LSW) on 01/08/25 11:56 AM, when asked who can report the loss of personal property in the facility, she responded, Anybody, including staff, visitors and residents may report a loss or missing personal item. She added that there is no time limit for reporting the loss or missing items. When a resident reports the lost or missing items to a facility staff, the staff completes a Care and Concern form. Once filled, the form is submitted to the Social Services department, which initiates the investigation, and discusses the search event during the next day staff meeting. When the entire facility staff is aware, they all participate in the investigation by searching for the lost or missing item. When asked why there was no completed Care and Concern form and investigation started for Resident #17's hearing aids, she responded, I never heard of anybody who lost a pair of hearing aid!. Staff S, a LSW was made aware that Resident #17 told Staff Q, a CNA yesterday about the lost hearing aids. Furthermore, she was informed that Resident #17's daughter reported the loss to the laundry and the nursing staff a few weeks ago. Staff S responded that there is a break in reporting, but she will talk to the Nurse Supervisor and will personally fill out the report. In another interview on 01/09/25 at 9:02 AM, Resident #17 stated no one has updated him about the hearing aids. In an interview with Staff S on 01/09/25 at 10:23 AM, she stated the hearing aids investigation started, and Resident #17's daughter was updated regarding the search.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) At the resident council meeting held on 01/08/2024 at 2:30 pm, Resident #34 complained that at a prior resident council meeting he reported the problem that he waits too long for assistance with toileting. He and two other residents agreed that reported problems are not resolved. When asked to describe what happened in the bathroom, Resident #34 said that he waited on the toilet for one and a half hours before he received assistance. At first, he pulled the call bell, and no one came. When he got too tired of waiting, he phoned the front desk and asked for someone to request that a nursing staff member to go to his room and to provide him with assistance in the bathroom. When the surveyor asked how many times this has happened, Resident #34 stated every day of the week. A record review showed that Resident #34 was admitted to the facility on [DATE] with Other Sequelae of Cerebral Infarction, and Diabetes Mellitus Type 2. This resident's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) assessment dated [DATE], was 15. This indicated that Resident #34 was cognitively intact. 3) At the resident council meeting held on 01/08/2024 at 2:30 pm Resident #104, said that he waited half of an hour to receive assistance when he was on the toilet. He stated that when he called someone to help, a CNA answered that she was unable to assist him because she was assigned to a different section of residents on the unit. Per record review, Resident #104 was admitted on [DATE] with diagnoses that included Hemiplegia/Hemiparesis following Cerebral Infarction affecting left dominant side, and Spinal stenosis. This resident's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) assessment dated [DATE], was 14. This indicated that Resident #104 was cognitively intact. In an Interview with Staff J, on 01/06/25 at 3:00 PM, the CNA said that she worked at the facility for almost 8 years. When asked how many residents she provided care for on that day, the CNA responded that each CNA on her unit provided care for 7 residents. When asked if she felt like they could provide adequate care for the residents, she answered that with love and cooperation, they could manage it. In a follow-up interview with Staff J on 01/08/25 at 10:00 AM, the surveyor asked if there was enough nursing staff to take care of all of the residents on the unit on that day, Staff J answered, we manage. Based on observations, interviews and record reviews, the facility failed to provide treatment and care, in accordance with professional standards for practice for 3 of 25 sampled residents (Resident #114, Resident #34, Resident #104). The findings included: 1) Record review showed that Resident #114 was admitted to the facility on [DATE] with Quadriplegia, C1-C4 incomplete. The Minimum Data Set (MDS) quarterly dated 12/18/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairment. A review of section GG indicated that Resident #114 needs partial to moderate assistance to roll left and right. In an interview conducted on 01/09/2025 at 1:30 PM Resident #114 stated that 3 weeks ago he was left on his bed for 2 hours in fetal position waiting for a suppository to help with defecation. He further stated Staff O, Certified Nurse Assistant (CNA), who starts her shift at 3:00 PM and came into his room and found him in fetal position on his bed sweating with his heart rushing. The CNA obtained the Hoyer lift from the room across, got him in his wheelchair, pushed him into the bathroom and made the necessary arrangement for him to evacuate. In an interview conducted on 01/09/2025 at 4:05 PM with Staff O, she stated that the incident happened 3 weeks ago. She came in at 3:00PM and started rounding when she found Resident #114 lying on one side sweating saying that he needed to use the bathroom, she ran and went to get the Hoyer lift from the opposite room, got him on the chair and pushed him to the bathroom. She further stated that Resident #114 told her that he had spent two hours waiting for the suppository which never got administrated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a left hand splint as per Physician's order for 1 of 1 resident reviewed for Limited Range of Motion (Resident #19). The findings included: Record review revealed that Resident #19 was readmitted to the facility on [DATE] with diagnoses of Hypertension and Muscle Weakness. An order dated 11/30/23 revealed the following: apply left hand splint and left elbow protector for 8 hours (as needed) during AM hours and check skin before and after removal. The Quarterly Minimum Data Set( MDS) dated [DATE], showed that Resident #19 has a Brief Interview of Mental Status (BIMS) score of 13, which is low to moderate cognitive impaired. In an observation conducted on 01/06/25 at 11:00 AM, Resident #19 was observed in bed with a contracture (fingers curled and pulled towards the palm) on his left hand, and no left-hand splint in place. In this observation, Resident #19 stated that the left hand splint has not been placed on his left hand and that the staff will get around to do so when they can. In observations conducted on 01/06/25 at 12:35 PM, at 2:00 PM and 3:00 PM, Resident #19 was observed in bed with a contracture on his left hand, and no left-hand splint in place. In an observation conducted on 01/07/24 at 8:30 AM, Resident noted in bed with a contracture to his left hand, and no left-handed splint in place. In an interview conducted on 01/07/24 at 2:35 PM with the facility's Rehab Director, he said that Resident #19 had an order for left hand splint which was dated 11/30/24. He further stated that Restorative oversees making sure that the splints are placed on Resident #19 on a daily basis. In an interview conducted on 01/07/25 at 2:38 PM with Staff D, Registered Nurse, she stated that the Restorative team, oversees the Restorative program. The Restorative treatment is documented in a Restorative binder located in the nurse's station. If a resident has a splint in place, it will be documented in the electronic system indicating whether the splints are on or off. Staff D said that it will also be documented in the progress notes if a resident has splint in place. If a resident has an order for splint that is not placed as per Physicians' order, she will question the Restorative staff as to why it is not followed. In an interview conducted on 01/07/25 at 2:53 PM, with Staff C, Restorative Certified Nursing Assistant, she stated that she is given a list of residents who have orders for splints by the Restorative Nurse. She follows Physicians orders for splints and documents in the electronic system. Staff C oversees the placement of splints on her unit and will ask for help from other Restorative staff if needed. When asked about the order for splints for Resident #19, she said that he has knee braces every day between 4-8 hours and was not aware of any other orders for splints. She then said Resident #19 has no more splints that I am aware of. In an interview conducted on 01/07/25at 3:30 PM, with the Staff F, Registered Nurse, she stated that Resident #19 is receiving hip and knee splints that are placed by Restorative staff. She further said that she will document in the electronic system for on and off when the splints are placed on the resident or taken off the resident. A review of the last 14-days Administration History in the electronic system did not show any on or off documented for Resident #19. In an interview conducted on 01/09/25 at 3:00 PM with the facility's Director of Nursing, she was informed of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the facility's policy titled, Oxygen Concentrators/Oxygen Tanks-Maintenance and Inspection with a revised date of 07/19/23 included in part the following: All portable oxygen tanks that are not in use are to be properly secured and stored in the designated oxygen storage room within the appropriate tank holder. Not in use (empty) portable oxygen carts and hand trucks stored within the stored room are also to have appropriate securing mechanism attached. Record review for Resident #44 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE]. Diagnoses included in part the following: Acute Respiratory Failure with Hypoxia, Respiratory Syncytial Virus Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Other Asthma, Unspecified Dementia Moderate with Anxiety. Review of the Minimum Data Set for Resident #44 dated 11/20/24 documented in Section C a Brief Interview of Mental Score of 15, indicating a cognitive response. Documented in Section O for Respiratory Treatments included oxygen therapy. Review of the Physician's Orders for Resident #44 revealed an order dated 08/13/24 to check O2 (oxygen) saturation every shift, give oxygen at 3 L/min (Liters per minute) via n/c (nasal cannula) continuous. Review of the Care Plan for Resident #44 dated 08/07/23 with a problem of resident has diagnosis of COPD with continuous oxygen as ordered via nasal cannula and is susceptible to shortness of breath, labored respirations, URI (Upper Respiratory Infection), and increased congestion. The goals were for the resident to breathe comfortably with intervention thru NRD (next review date), and episodes of congestion and URI will be minimized with interventions in place thru NRD. The Approaches included in part the following: Administer medications, respiratory treatments and oxygen as ordered. Pulmonary consult as ordered. On 01/06/25 at 11:18 AM, an observation was made of Resident #44 sitting up in bed with oxygen on via nasal cannula. Next to the bed was a wheelchair with an oxygen tank in the holder on the wheelchair, behind the wheelchair was an additional oxygen tank standing up next to an empty oxygen holder (Photographic Evidence Obtained). On 01/06/25 at 3:30 PM, an observation was made of Resident #44 sitting up in bed with oxygen on via nasal cannula and an additional oxygen tank standing up next to an empty oxygen holder in same spot as previously observed earlier today. On 01/07/25 at 9:00 AM, an observation was made of Resident #44 sitting up in bed wearing oxygen via nasal cannula. Next to the bed was a wheelchair with an oxygen tank in holder on the wheelchair, behind the wheelchair continued to be an additional oxygen tank standing up next to an empty oxygen holder. During an interview conducted on 01/06/25 at 11:25 AM with Staff A, Registered Nurse (RN) who was asked about the oxygen tanks for the resident, she stated he has an oxygen tank on his wheelchair for when he goes out of his room, she said he also has an additional oxygen tank behind the wheelchair just in case he needs it. Staff A checked both oxygen tanks with a penlight and said yes they both have oxygen in them. During an interview conducted on 01/07/25 at 3:15 PM with Staff B, Certified Nursing Assistant (CNA) who stated she has worked at the facility for 3 years. When asked about oxygen tanks at the bedside, she stated they do not keep additional oxygen tanks at the bedside, if the tank on the back of the wheelchair becomes empty, they take the empty one back to the oxygen room to store it and will get a replacement tank. The oxygen tank is kept in the back of the wheelchair. When asked if there was an additional oxygen tank how it would be stored, she said they are in stored in the holder. During an interview conducted on 01/07/25 at 3:18 PM with Staff C, CNA who stated she has worked at the facility since 2008. When asked about oxygen tanks at the bedside, she stated oxygen tanks are kept in the back of the resident's wheelchair, they do not have extra oxygen tanks at the bedside. She stated that if the oxygen tank becomes empty, they return it to the oxygen room and obtain a full tank. During an interview conducted on 01/08/25 at 8:51 AM with Staff D, RN who stated she has worked at the facility for 7.75 years. When asked about oxygen tanks at the bedside, she said they are not supposed to have extra oxygen tanks in the resident's room, if the tank becomes depleted they return the tank to the oxygen room and obtain a new tank. When asked how oxygen tanks are stored, she said in the holder attached to the back of the wheelchair. If there was an extra oxygen tank it would be stored in a roller (stand). Based on observations, interviews, record reviews, and policy reviews, the facility failed to provide adequate supervision during a Hoyer lift transfer for 1 of 1 sampled resident (Resident #45). This had the potential to affect 50 residents who used Hoyer lifts. The facility failed to ensure that the oxygen tank was secured for 1 of 1 sampled resident (Resident #44). The findings included: 1) According to the facility's policy and procedure on Safe Resident Handling and Lifting, revised 05/09/2018, employees will use mechanical lifting devices and/or other approved resident handling assistive devices in accordance with instructions and training. At least two people will be present to assist the resident during the use of mechanical lift equipment. Staff should refer to and comply with the resident's care plan prior to transferring or lifting residents. Review of the clinical record for Resident #44 revealed an admission date of 08/12/19. This resident's diagnoses included Unspecified Dementia, Unspecified Psychosis, Chronic Kidney Disease, Muscle Weakness, Other Lack of Coordination, and Senile Degeneration of the Brain. According to the Minimum Data Set assessment dated [DATE], Resident #44 was rarely/never understood. His functional abilities were coded dependent for chair/bed-to chair transfers. Review of the care plan for Resident #44 showed that he was at increased risk for falls. The care plan revised 12/26/24 listed a goal was to be free of fall related injuries. An intervention listed in the care plan specified the requirement for dependent assistance to be provided with bed/chair to chair transfer. On 01/06/25 at 1:10 PM, Staff J, Certified Nursing Assistant (CNA), was observed using the mechanical lift to lower Resident #45 into his bed. No other nursing staff members were present in the room. Staff J detached the Hoyer pad from the mechanical lift and then she proceeded to answer questions. In an interview with Staff J, on 01/06/25 at 3:00 PM, she stated that she worked at this facility for almost 8 years. When asked how a resident gets transferred from a bed to a wheelchair, Staff J said some residents used a lift and other residents ambulated during the transfer. She explained that nursing and therapy departments communicated about how the resident was to be transferred. When asked how she knew if the resident's transfer required 1 person or 2 people to assist, she answered that when a mechanical lift was used, two people were needed to assist the resident. Staff J was asked if it was easy to find another staff member to provide assistance with mechanical lift transfers. She responded that it was not easy to find someone to help provide assistance, for instance in the morning, at breakfast time, everyone is busy. So, you have to wait. An interview was conducted on 01/06/25 at 2:30 PM, with Staff K, Registered Nurse (RN), who oversees the care planning for residents. She was asked what dependent in transfers meant. Staff K answered that dependent meant the resident depended totally on the staff for transfers. When asked to describe examples of total dependence, the RN said it usually means a mechanical lift. Staff K explained that each resident was screened by the therapy department to determine their needs for transfers and mobility. When asked how the nurses know when to use a mechanical lift, the RN said that it's listed on each resident's care plan. Both of the RNs in the room, Staff K, and Staff L, voiced that always, at least two person assistance is needed for mechanical lift transfers. In an interview with Staff K on 01/09/25 at 12:00 PM, the surveyor requested to know how many people were using mechanical lifts. Staff K said she was unable to print out a list of the residents. She said she would ask each charge nurse how many residents used mechanical lifts on 01/09/25 on their unit. At 1:10 PM, Staff K reported that 50 residents were using mechanical lifts for transfers on that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 01/09/25 at 10:15 AM, a review of the medication cart 1 on Alpha Yellow with Staff D, Registered Nurse (RN) this included a review of the Controlled Drug Record for Resident # 44 for Oxycodone HCl 5mg. The count was 18, and Staff D acknowledged count was correct and matched the count of 18 on the Controlled Drug Record. Record review for Resident #44 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE], diagnoses included in part the following: Other Fracture of Lower End of Left Tibia Subsequent Encounter for Closed Fracture with Routine Healing, Acute Respiratory Failure with Hypoxia, Respiratory Syncytial Virus Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Other Asthma, Unspecified Dementia Moderate with Anxiety. Review of the Minimum Data Set for Resident #44 dated 11/20/24 documented in Section C a Brief Interview of Mental score of 15, indicating a cognitive response. Review of the Physician's Orders for Resident #44 revealed an order dated 10/15/24 for Oxycodone 5mg 1 tab oral every 4 hours as needed for pain. Review of the Controlled Drug Record for Resident #44 for the Oxycodone 5mg every 4 hours as needed documented on 01/06/25 6:00 PM the drug was signed out and given. Review of the Medication Administration Record for Resident #44 for 01/06/25 did not have any documentation for Oxycodone 5mg being administered on 01/06/25 at or around 6:00 PM. During the interview conducted on 01/09/25 at 11:20 AM with the Director of Nursing (DON), who was asked when a controlled medication is being administered, where is the nurse to document this, she stated they document the medication on the Controlled Drug Record and in the resident's chart in the Medication Administration Record. During the interview conducted on 01/09/25 at 11:30 AM with Staff H, Registered Nurse (RN), who was asked when a controlled medication is being administered, how do they document, she said you document the medication on the Controlled Drug Record and in the resident's chart in the Medication Administration Record. During the interview conducted on 01/09/25 at 11:28 AM with Staff D, RN, who was asked when a controlled medication is being administered, how do they document, she said you document the medication on the Controlled Drug Record and in the resident's chart in the Medication Administration Record. Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 2 of 9 sampled residents reviewed during the controlled substance record review on the facility's Delta and Alpha wings, for Residents #38 and #44. The findings included: 1) Review of Resident #38's clinical record documented admission on [DATE] and readmission on [DATE], and had diagnoses that included: Dementia, Anxiety Disorder, Restlessness and Agitation, Unspecified Psychosis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #38 had a Brief Interview for Mental Status (BIMS) of 04, indicating severe cognitive impairment. Review of the Physician's Orders showed that Resident #38 had an order dated 12/19/24 for Alprazolam 0.5 mg tablet, give 1 tablet oral every 12 hours for 30 days for Psychosis/Agitation/Anxiety. On 01/09/25 at 11:00 AM, a review of Resident #38's Controlled Drug Record sheet received by the facility from the pharmacy on 01/02/25 for Alprazolam 0.5 mg (30 tablets), give one tablet every 12 hours for 30 days for Psychosis-Agitation, was conducted. The inventory sheet documented that one tablet of Alprazolam 0.5 mg was removed from the controlled substances box at 9:00 AM and 9:00 PM on the following days: 01/06/25, 01/07/25, and 01/08/25. Further review revealed that a total of 6 tablets were removed from the controlled substances box. Review of Resident #38's January 2025 electronic Medication Administration Record (eMAR) documented Alprazolam 0.5 mg was initialed as administered on 01/09/25 at 9:00 AM. The medication was not documented on the resident's controlled drug record sheet as removed from the box. The resident's controlled drug was not reconciled. On 01/09/25 at 12:25 PM, an interview was conducted with Staff E, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 10 years. She stated she first retrieves the controlled drug from the locked box, dispenses it, administers it to the resident and then she documents the medication as administered in the Controlled Drug binder and in the eMAR. A side-by-side review of Resident #38's controlled drug record sheet dated 01/02/25 for Alprazolam was conducted with Staff E. She stated she believed she did administer the medication to Resident #38 because she signed the eMAR. When Staff E reviewed the controlled drug record for Resident #38 she stated she missed it. When asked why she documented prior to administering the Alprazolam, she stated she just missed it. Staff E acknowledged that Resident #38's Alprazolam count (24 tablets) was correct in the controlled substance box. An interview was conducted 01/09/25 at 11:45 AM with Staff N, Delta Nurse Supervisor. She stated the controlled drugs count is done on every change of shift by the nurses. Staff N stated the protocol for controlled drug administration is to first dispense the medication, administer it to the resident, return to the medication cart and document as given in the Controlled Drug Binder and in the eMAR. An interview was conducted on 01/09/25 at 1:57 PM with the Director of Nursing (DON), who stated she is confused as to why the nurse signed the eMAR and not the controlled drug binder and why the nurse did not dispense the medication accordingly.

Based on observations, interviews and record review, the facility failed to ensure a treatment cart was locked while unattended during facility tour; failed to ensure medication cart and medications were secured during medication administration observation; and failed to dispose of expired over the counter medications (OTC) during medication storage review. The findings included: Review of the facility's policy titled, Storage of Drugs and Biologicals, dated 05/04/16, included the following: In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments/containers Containers/compartments containing drugs and biologicals will be locked when not in use, including medication carts. Review of the facility's policy titled, Medication Administration, dated 12/31/21, included the following: During administration of medications, the medication cart will be kept closed and locked when out of sight of the personnel administering medication. No medications are kept on top of the cart. 1) During the initial tour of the facility conducted on 01/06/25 at 09:25 AM, the surveyor noted an unlocked, unattended treatment cart in the Delta [NAME] unit, in which some of the residents' diagnoses include Dementia, Psychosis, Anxiety and Depression. Further observation revealed in the top-drawer treatment medications labeled with residents' names, and a pair of scissors stored in the second drawer of the treatment cart, photographic evidence obtained. During this observation, multiple staff members and residents were noted walking past the unlocked treatment cart. An additional observation was conducted on 01/06/25 at 10:14 AM which revealed the treatment cart was still unlocked and a few moments later observed the floor nurse lock the cart. 2) A medication administration observation was conducted in the Delta [NAME] unit on 01/07/25 at 9:02 AM with Staff M, Licensed Practical Nurse (LPN) for Resident #96. While dispensing the prescribed medications, Staff M noticed one resident wheeled his wheelchair close to another resident and both residents started to argue. Staff M stated, they are going to fight and walked approximately 25 meters away from the medication cart to where the two residents were arguing. However, she left the medication cart unlocked and the dispensed medication for Resident #96 on top of the medication cart. During this observation, Staff M was away from the unlocked, unattended medication cart and medications for approximately 7 minutes. Staff M returned to the medication cart and continued preparing the medications for Resident #96. 3) On 01/09/25 at 10:58 AM a medication cart storage review in the Delta Yellow unit was conducted with Staff E, Senior LPN, who worked at the facility for 10 years. Review of the over-the-counter medication (OTC) drawer in the medication cart revealed the following two expired medication bottles: Almacone double strength Antacid 355 mL bottle with an expiration date of 08/2024 and opened date of 01/07/24. Cough Syrup, Cough and Chest Congestion DM: Dextromethorphan HBr, USP 20mg and Guaifenesin, USP 200mg, 118 mL bottle with an expiration date of 11/2024 and opened date of 10/24/24. An interview was conducted at this time with Staff E, LPN, who stated that the pharmacist and the unit nurse supervisor check the medication carts regularly. She was surprised that there were expired medications in the cart. An interview was conducted on 01/09/25 at 11:45 AM with Staff N, Delta Unit Nurse Supervisor. She stated that all the supervisors do random medication cart checks as well as the pharmacist. She also stated the floor nurses are to check expiration on the medications prior to administering it and any medication that has expired, they are to remove it from the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement CDC (Center for Disease Control and Prevention) guidelines and recommendations for Enhanced Barrier Precautions for 2 residents with wounds (Resident #61, and Resident #101). 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. https://www.cdc.gov/long-term-care-facilities/media/pdfs/EBP-KeepResidentsSafe-Poster-508.pdf. 1). Record review revealed Resident #61 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including status post Open Reduction Internal Fixation of Left Femur, Closed Fracture with Routine Healing, Acute Respiratory Failure, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. A record review of Minimum Data Set (MDS) assessment, Section C, dated 11/11/24, revealed a Brief Interview for Mental Status score of 12, indicating moderately good cognition. A review of orders dated 11/05/24 revealed directions to dress the right heel wounds. Additional review of physician orders dated 12/30/24, were in place for resident's wound. Review of nursing care plan dated 11/11/24 revealed no EBP guidelines were included for Resident #61's interventions. During observation on 01/06/25, 01/07/25, and 01/08/25, revealed no EBP signpost on resident's door. There was a metal shelf containing Personal Protective Equipment (PPE) gowns, and gloves. During an observation on 01/09/25 at 10:30 AM, no EBP signpost was observed, and a hanging metal shelf did not contain PPE gowns, and gloves. The only item present was a plastic bottle of a hand sanitizer. During observation and interview on 01/09/25 at 09:28 AM, two Certified Nursing Assistants (CNAs) were inside the bathroom and assisting resident #61with toileting. Staff R, a CNA stated the resident had a bowel movement, before they could transfer him from wheelchair to toilet. Both CNAs were wearing gloves, but not wearing gowns. When asked why they were not wearing gowns, Staff P, a CNA stated, There were no gowns on the metal shelf, and they were in a hurry to assist Resident #61with toileting. When asked who was responsible for replenishing PPE on the metal shelf, she did not respond. In an interview with Staff A, a wound care Registered Nurse (RN) on 01/08/25 10:27 AM, she stated the resident was re- admitted to facility from hospital on [DATE]. During skin assessment she observed right and left heel wounds, left hip surgical wounds with 21 staples, skin scab on left arm was healing, and dark sacral area with sheering (approximately 6x6 cm in size). In an interview with Staff K, an MDS Director, when asked about the absence of EBP guidelines on Resident #61's care plan approach for wounds, she responded, she did not include it. 2). Record review revealed Resident #101 was admitted on [DATE] with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, and Pressure Ulcer of Sacral Region (unspecified stage). A record review of quarterly MDS assessment Section C, dated 11/12/24, revealed a BIMS score of 12 indicating moderately good cognition. A review of orders dated 12/30/24, revealed internal tunneled catheter on the right chest area. Additional review of orders initiated on 12/31/24 revealed processes to address the sacral wounds. A further review of orders dated 01/08/25, revealed updated processes to dress the sacral wounds. Additional review of orders from 12/30/24 until 01/08/25, revealed no EBP guidelines related to sacral wounds. During observations on 01/06/25, 01/07/25, and 01/08/25, no EBP signpost and PPE metal shelf were observed on Resident #101's door as compared to other facility doors with different types of skin wounds. During another observation on 01/08/25 at 11:25 AM, Staff A, a wound care RN was asking Staff E, a Licensed Practical Nurse for a PPE gown before entering Resident #101's room. In an interview with Staff A, a wound care RN on 01/08/25 at 09:23AM, she stated Resident #101 came back to the facility on [DATE] with hospital acquired sacral wounds. During an interview with Staff E, an LPN on 01/08/25 at 11:40 AM, when asked who put the PPE metal cart containing gowns and gloves on Resident #101's door today, she responded, The wound care RN did. When asked why there is no EBP signpost on resident's door, she did not respond. When asked how Staff would know EBP guidelines must be followed during resident's care, she responded During report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure it was adequately equipped with functioning emergency call device in 2 of 12 bathrooms on the Alpha Unit. The findings included: On 01/06/25 10:25 AM, an observation was made of the emergency call device pull cord in the bathroom for room [ROOM NUMBER], which was wrapped around grab bar (Photographic Evidence Obtained). On 01/06/25 11:38 AM, an observation was made of the emergency call device pull cord in the bathroom for room [ROOM NUMBER], which was wrapped around the grab bar and dragging on the floor (Photographic Evidence Obtained). During an interview conducted on 01/07/25 at 3:15 PM with Staff B, Certified Nursing Assistant (CNA) who stated she has worked at the facility for 3 years. When asked about call devices, she said each resident has one by their bed and there is one in each bathroom. When asked if the emergency call device pull cord in the bathroom should be wrapped around the grab bar she said no. During an interview conducted on 01/07/25 at 3:18 PM with Staff C, CNA who stated she has worked at the facility since 2008. When asked about emergency call devices, she said there is one for each bed and one in each bathroom. When asked if the emergency call device pull cord should be wrapped around the grab bar, she said no. During an interview conducted on 01/08/25 at 8:51 AM with Staff D, Registered Nurse (RN) who stated she has worked at the facility for 7.75 years. When asked about the emergency call devices, she said each resident has a call bell with their bed and there is a pull cord in each bathroom. When asked if the emergency call device pull cord in the bathroom should be wrapped around the grab bar, she said no. During an interview conducted on 01/08/25 at 10:25 AM with Staff I, Registered Nurse Supervisor 7:00 AM-3:00 PM who did a side by side observation with the surveyor of the emergency call device in the bathroom for room [ROOM NUMBER] and she acknowledged the emergency call device was wrapped around the grab bar and was non-functional in this manner. The Registered Nurse Supervisor unwrapped the emergency call device cord and the cord was long and laid on the floor. A second side by side observation was made with the Registered Nurse Supervisor of the emergency call device in the bathroom for room [ROOM NUMBER]. During an interview conducted on 01/09/25 at 1:10 PM with the Director of Nursing (DON) who was asked for a policy on call devices, she said they have no policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to follow their own menu for fresh fruit, for 8 of 8 residents observed during dining (Resident #104, Resident #42, Resident #14, Resident #8, Resident #86, Resident #12, Resident #60, and Resident #35). The findings included: 1. Record review revealed that Resident #104 was admitted on [DATE] with diagnoses of Hypokalemia and Hemiplegia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an interview conducted on 01/07/25 at 8:24 AM in the main dining room, Resident #104 was eating his breakfast meal. Resident #104 stated that they only get bananas twice a week if any, and that the rest of the week they do not get any fresh fruits. He then picked up his meal ticket and said, it says here that we are supposed to get fresh fruit for breakfast. 2. Record review revealed that Resident #42 was readmitted to the facility on [DATE] with diagnoses of Depression and Dysphagia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 01/07/25 at 8:32 AM in the main dining room, Resident #42 stated that they only get fresh fruits twice a week and that is usually a fresh banana which they do not have today. 3. Record review showed that Resident #14 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, and Muscle Weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 01/07/25 at 8:32 AM in the main dining room, Resident #14 stated that they are supposed to get a fresh fruit every day for breakfast and that they do not. 4. Record review revealed that Resident #8 was readmitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, and Hypertension. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 01/07/25 at 8:32 AM in the main dining room, Resident #8 stated that they only get bananas but not every day and that it is only given once or twice a week. 5. Record review revealed that Resident #86 was admitted on [DATE] with diagnoses of Muscle Weakness and Depressive Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an observation conducted on 01/07/24 at 8:41 AM, Resident #86 was in his room with the breakfast tray. The breakfast meal ticket dated 01/07/25 showed fresh fruit. The breakfast meal plate provided to Resident #86 did not have fresh fruit. 6. Record review showed that Resident #12 was readmitted to the facility on [DATE] with diagnoses of Muscle Weakness and Dysphagia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an interview conducted on 01/07/24 at 8:50 AM, Resident #12 stated that they do not get fresh fruit for breakfast every day. 7. Resident #60 was readmitted on [DATE] with diagnoses of Parkinson, Dysphagia and Depression. An order dated 12/20/24 for Mechanical Soft (Pureed fruits and vegetables with nectar thick liquids. The Significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #60 is rarely or never understood. In an observation conducted on 01/07/24 at 8:54AM, Resident #60 was in his room with the breakfast tray. The breakfast meal ticket dated 01/07/25 showed fresh fruit. The breakfast meal plate provided to Resident #60 did not have fresh fruit. 8. Record review showed that Resident #35 was readmitted to the facility on [DATE] with diagnoses of Hemiplegia and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an observation conducted on 01/07/24 at 8:39AM, Resident #35 was in his room with the breakfast tray. The breakfast meal ticket dated 01/07/25 showed fresh fruit. The breakfast meal plate provided to Resident #35 did not have fresh fruit. In an interview conducted on 01/09/24 at 11:00 AM with the facility's Diet Technician, she stated that they have bananas coming in on a weekly basis and that they also substitute other fresh fruits. When asked as to why the fresh fruit was not provided to all residents on 01/7/24 for the breakfast meal she did not have an answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide palatable, appetizing and flavorful food for 8 of 8 residents (Resident# 58, Resident# 43, Resident# 59, Resident# 73, Resident# 88, Resident# 17, Resident# 32, Resident# 70). The findings included: 1. A record review showed that Resident #58 was admitted on [DATE] with chronic kidney disease stage 3. The Minimum Data Set (MDS) quarterly dated 11/20/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 13, which indicates mild cognitive impairment. In an interview conducted on 01/06/2025 at 11:45 AM, this surveyor was stopped in the hallway by Resident # 58 who said that the food in the facility is disgusting. He stated that the food did not look appetizing, that he usually asks for his eggs over easy but one day he gets it and the next day he does not. This is because they alternate between pasteurized and unpasteurized eggs. Resident #58 further stated that the unpasteurized eggs are overcooked and have a pancakes texture. The resident said that he doesn't understand what is going on in the kitchen, but the food is terrible. 2. A record review showed that Resident #43 was admitted on [DATE] and readmitted on [DATE] with Amyotrophic lateral sclerosis and muscle wasting and atrophy. The Minimum Data Set (MDS) quarterly dated 10/16/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 12, which indicates moderate cognitive impairment. In an interview conducted on 01/06/2025 at 10:01 AM Resident # 43 stated that his meals are incomplete, and that he never gets what he asks for. 3. A record review showed that Resident #59 was admitted on [DATE]with low vision, atherosclerotic heart disease, and unspecified angina pectoris. The Minimum Data Set (MDS) quarterly dated 12/18/24 revealed that the Brief Interview of Mental Status (BIMS) score is 08, which indicates severe cognitive impairment. In an interview conducted on 01/06/2025 at 10:05 AM Resident # 59 stated that the food is horrible. 4. A record review showed that Resident #73 was admitted on [DATE] and readmitted on [DATE] with cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery and chronic arterial fibrillation. The Minimum Data Set (MDS) quarterly dated10/09/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairment. In an interview conducted on 01/06/2025 at 12:30 PM in the main dining room Resident # 73 stated that breakfast is okay, but lunch and dinner are terrible. Sometimes they serve popcorn shrimp with a very thick coating and some pieces don't have any shrimp under the coating. Resident #73 further stated that when he says he doesn't like the food the staff gets mad and takes his plate away. 5. A record review showed that Resident #88 was admitted on [DATE] with polymyalgia rheumatica and muscle wasting and atrophy. The Minimum Data Set (MDS) quarterly dated 10/16/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 14, which indicates mild cognitive impairment. In an interview conducted on 01/06/2025 at 12:37 PM in the main dining room Resident # 88 stated that the main issue of this facility is that the food is not appetizing and that he does not get what's on the menu even when he orders it. A review of the Fall/Winter week 4, Day 4, lunch showed the following: 3 ounces of baked chicken, sage bread dressing, Harvard beets and black forest cake. At test tray on a Regular consistency diet was conducted on 01/08/24 at 12:10 PM. The following were noted: the baked chicken appeared small and tasted bland with no seasoning. The sage bread stuffing was colorless, with no taste and a dough like texture. The beets had a thick glaze with no taste and tasted like canned beets. The overall lunch plate had a beige and reddish color with no other color variation and lacked any type of colorful garnish. The black forest cake was dry to taste and was served in a plastic throw away container. The lunch meal did no have an appetizing appearance or taste. 9) During an interview with the Food Service Director (FSD) on 01/08/25 at 3:50 PM, in the Dietary Manager's office, the FSD mentioned that she eats the foods served at the facility and that she thinks they taste good. She also said that there were many residents on the No Added Salt diet, and for that reason many of the foods tasted bland. The requested test tray was for the lunch meal served to residents on a Regular diet (with no restrictions). 6) Record review revealed Resident #17 was admitted on [DATE] with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness, Muscle Weakness, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Major Depressive Disorder, and Malignant Neoplasm of the Prostate. A review of quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C revealed a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. A review of dietary care plan dated 08/29/24, revealed Resident #17's risk for nutritional status decline, with interventions to monitor and document the intake of food, and to offer food preferences. During an interview on 01/07/25 at 11:25 AM, Resident #17 was sitting in a wheelchair, and waiting for a staff to take him to activities. When asked regarding breakfast, he prompted the surveyor to speak louder, while pointing at his left ear. He stated he barely ate the breakfast served him because of bad food taste. He added he had to eat some of it because he had no other choices. When asked if he requested an alternate meal, he seemed confused, pointing at his right ear, then asked this surveyor to repeat the question. When the surveyor explained that he could ask for a different meal in a louder voice volume, he smiled and stated he did not know that. When asked regarding other previous meals served in the facility, he added all foods had bad taste and not good to eat. 7) Record review revealed Resident # 32 was initially admitted on [DATE], and re-admitted on [DATE] with diagnoses including Bullous Pemphigoid (a rare skin condition causing large, fluid-filled blisters), Hemiplegia and Hemiparesis following Cerebrovascular Disease (affecting left non-dominant side), Muscle Weakness, Dementia with Agitation and Diabetes Mellitus. A quarterly MDS dated [DATE], revealed a BIMS score of 12, indicating a moderately good cognition. A review of baseline care plan dated 03/02/23, revealed Resident #32 was at risk for nutritional deficit, with the following interventions: dietician to evaluate as needed, provide diet as ordered, assist with meals as needed, and obtain food preferences. Additional review of a quarterly nutrition progress notes dated 09/03/24, revealed the following: Basal metabolic index (BMI) of 27.12, weight of 121 Lbs. (pounds), fluctuating food intake, and known food preferences. During an interview with resident on 01/06/25 at 10:10 AM, when asked regarding meals and food serve by the facility, she responded, Terrible food. When asked to explain what terrible means, she stated, Food does not match menu, and food does not taste good. When asked if she requested a tastier food, she responded All of the foods served here have no flavor. In another interview with Resident #32 on 01/08/25 at 03:49 PM, when asked regarding lunch, she responded, Lunch was tasteless. 8) Record review revealed Resident #70 was admitted on [DATE] with diagnoses including Complete Traumatic Amputation of 2 or more toes, Type 2 Diabetes Mellitus, Essential Hypertension and Depression. A review of quarterly MDS dated [DATE], revealed a BIMS score of 09, indicating moderately impaired mental cognition. Section K revealed no swallowing disorder, while Section L revealed no broken teeth, loose teeth and mouth or facial pain. Additional review of nutrition care plan dated 09/19/24, revealed resident was at risk for nutritional status decline. A quarterly MDS review notes dated 10/29/24, revealed to assist resident with meals as needed, diet as ordered, and monitor food intake. Further review of dietary notes dated 01/08/25 revealed no food intolerances, and resident was at continued nutritional risk. During an interview with Resident #70 on 01/06/25 at 10:36 AM, when asked regarding the meals and food served by the facility, he responded, The food was not flavorful. In another interview on 01/07/25 at 9:30 AM, when asked about his breakfast, he responded, Food was not good. When asked why it was not good, he responded, It had crappy taste. During another interview with resident on 01/08/25 at 9:10 AM, when asked if he is losing weight, because he stated he does not like the taste of food in the facility, he responded his wife brings him food, he is not bothered if he is losing weight but would like to have tasty and flavorful food from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8) Resident #60 was readmitted on [DATE] with diagnoses of Parkinson's, Dysphagia, and Depression. An order dated 12/20/24 for Mechanical Soft (Pureed fruits and vegetables) with nectar thick liquids. The Significant Change Minimum Data Set (MDS) dated [DATE] revealed that Resident #60 is rarely or never understood. In an observation conducted on 01/06/25 at 12:09 PM, Resident #60 was in his room with his lunch meal. Closer observation showed a meal ticket: regular mechanical soft diet with pureed fruits and vegetables, mechanical soft baked ham, creamed corn, soy milk, bread, and thick nectar liquids. The lunch plate was noted with mechanical soft ham and pureed corn that was lumpy, with visible pieces of corn that did not have a uniform consistency. 9) Resident #22 was readmitted on [DATE] with diagnoses of Dysphagia and Psychotic disorder. The diet order dated 08/12/24 was for a pureed thin liquids diet. The Quarterly MDS dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 09, which was moderate cognitive impairment. In an observation conducted on 01/06/25 at 12:40 PM, Resident #22 was in his room eating his lunch tray. A closer observation showed a meal ticket noted with the following: pureed diet with pureed ham and pureed buttered corn. The lunch plate was noted with pureed corn that was lumpy, with visible pieces of corn that did not have a uniform consistency. Based on observations, record reviews, interviews, and policy review, the facility failed to provide the correct diet consistency for 9 residents on the Pureed consistency diet (Residents #41, #65, #25, #53, #11, #16, #45, #60 and #22). This had the potential to affect 14 residents that were prescribed the pureed consistency diet. The findings included: 1) During an observation of residents eating lunch in the Delta Blue dining area, on 01/06/25 at 12:10 PM, Resident #16, Resident #45, and Resident #11 were served the pureed entrée consisting of ham, brussel sprouts, and corn. The food appeared lumpy. 2) In an observation and interview with the FSD on 01/06/25 at 12:25 PM, the surveyor approached the Food Service Director (FSD) who was behind the steam table in the main dining room. Concerns about the pureed consistency were voiced by the surveyor. The surveyor requested a sample of the pureed lunch meal and the FSD asked a dietary aide to prepare a pureed meal plate. The FSD carried the pureed meal tray to her office accompanied by the surveyor. At the Food Service Director's desk, the surveyor tasted the pureed meal and observed that the pureed corn, the pureed ham, and the pureed brussel sprouts had small pieces in them that required chewing. They were not smooth. The FSD agreed that the consistency of the pureed foods was not smooth. 3) During an observation of residents eating lunch in the Delta Blue dining area on 01/07/25 at 12:14 PM, Resident #16, Resident #45, and Resident #11, received the pureed entrée consisting of pureed Goulash, pureed mixed vegetables, and pureed white bread. The Goulash, mixed vegetables, and bread appeared lumpy. The surveyor approached the FSD and expressed concern about the pureed meal plates and requested a written description of the mechanically altered diets that the cooks follow. 4) Observation of the lunch meal served on the Delta [NAME] unit 01/08/25 at 12:03 PM showed that the pureed diet was served to Resident #41, Resident #65, Resident #25, and Resident #53. The pureed chicken had visible strands of chicken. It was not a uniform consistency. 5) A review of the facility's diet roster printed on 01/06/2025 showed that Resident #16, Resident #45, Resident #11, Resident #41, Resident #65, Resident #25, and Resident #53, were on pureed consistency diets. 6) A review of the State of Florida Department of Veteran's Affairs policy on Facility Diets-Food Consistencies, revised 11/07/2017, described the pureed food consistency. The pureed consistency is designed to provide soft smooth foods. The pureed diet is indicated for individuals with chewing or swallowing problems. 7) In an interview conducted on 01/08/25 at 3:39 PM with Staff G, the Speech Language Pathologist (SLP), she stated that for the pureed consistency, the food needs to be cooked in a way that is it not too liquid and that it should have no solids particles. Sometimes when they process the food in the blender it may have some food particles in it. The Pureed food should have a smooth consistency, with one solid uniform consistency. When the Speech Language Pathologist was shown a picture of the strand of chicken on the spoon from the pureed lunch meal served on 01/08/25, she said that if she saw that pureed chicken served to the residents, she would have sent it back to the kitchen and requested that it be pureed until it was smooth. Photographic evidence obtained

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, sanitary conditions, and to ensure the prevention of foodborne illnesses for 106 of 112 residents. The findings included: During the initial tour of the kitchen on 01/06/25 at 9:30 AM, accompanied by the Food Services Director (FSD): 1. The walk-in refrigerator had a black plastic bag with a knot in it located on a shelf. When asked what was in the bag the FSD opened the bag and revealed that it was someone's personal food. It looked like it was chicken and vegetables in a plastic container. On the shelf below that there was transparent, white plastic wrap crumpled up into a ball. 2. The Arctic walk-in freezer had pieces of rubber on the floor. When asked what it was, a food service employee said that it fell off a pipe. 3. The metal backsplash connected to the Vulcan oven had streaks of black and brown debris on the area rising approximately 14 above the level of the stove top. 4. A clear plastic bin had white dried on residue on the interior walls of the bin. The FSD said it must be cleaning solution. 5. Two frying pans had burned on black debris. 6. A large stock pot had black debris surrounding the areas where both handles were connected. 7. The meat slicer had rusty colored markings and brown residue on the blade and the surrounding areas. A follow-up tour of the kitchen on 01/08/25 at 12:00 PM was conducted. The following was observed: 1. The temperature of chocolate pudding that was taken out of the reach in refrigerator was 48' F. The temperature of the puree Black Forest Cake was 54' F. The temperature should have been 41' F or below to meet professional standards for food safety. The FSD was present during this temperature reading and she agreed with the finding. She said that she didn't know why the temperature was so high. During a tour of the nourishment rooms on 01/08/25 at 4:00 PM, accompanied by the FSD, the following was observed: 1. The Alpha nourishment room refrigerator had brown residue on the highest plastic shelf on the inside of the refrigerator door. Drops of brown colored dried on liquid was on the inside of the freezer close to where the ice packs were stored. There was brown residue on the door handle. 2. The microwave had brown residue on the interior surfaces of the microwave, including the lower and the upper sides of the interior. 3. The temperature of the refrigerator in the Delta Yellow nourishment room was 44' F. The temperature should have been 41' F or below to meet professional standards for food safety. 4. An interview with the nurse supervisor for the Delta Yellow unit, Staff I, on 01/08/25 at 4:32 PM, revealed that to the best of her knowledge, housekeeping does not clean inside the refrigerator. If someone uses the microwave and spills something they should clean it up right then. She added that if someone spills something in the refrigerator, they should clean it up. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow the Physician's orders for wound treatment (Resident #4), and failed to obtain a physician order for wound care (Resident #5), for 2 of 3 sampled residents reviewed for wound care (Residents #4 and #5). The findings included: 1) Review of Resident #4's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The residents diagnoses included Non-Traumatic Intracerebral Hemorrhage, Encephalopathy, Unsteadiness on Feet, Diabetes Mellitus and Unspecified Open Wound, Lower Leg. Review of Resident #4's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most the activities of daily living except eating. Review of the resident's care plan titled (Resident name) has impaired skin integrity. Potential for further breakdown . initiated on 05/19/22 and revised on 05/25/23 documented an intervention that read .wound treatment as ordered . Review of Resident #4's physician order dated 01/19/24 documents cleanse with normal saline open area to left lower leg shin, apply Xeroform dressing every other day. On 04/23/24 at 9:13 AM, observation revealed Resident #4 in his room sitting in a motorized wheelchair. An interview was conducted with the resident who voiced no concerns and that his leg dressing was changed daily. Observations revealed a dressing on the resident's left lower leg, partial covered by a splint. On 04/23/24 at 9:16 AM, a side by side observation of Resident #4's left lower leg dressing was conducted with Staff A, Certified Nursing Assistant (CNA). The observation revealed the resident's dressing was dated 04/18/24. Photographic evidence obtained. On 04/23/24, at 10:50 AM, a side by side observation of Resident #4's left lower leg dressing was conducted with the Wound Care Nurse (WCN). The observation revealed the resident's dressing was dated 04/23/24. The WCN stated the floor nurse were responsible to do Resident #4's left lower leg dressing changes. Subsequently, the photographic evidence was presented to the WCN. On 04/23/24 at 10:57 AM, an interview was conducted with Staff B, Registered Nurse (RN) who stated she changed Resident #4's left lower leg dressing today. Staff B stated he had a scab on his left shin and she cleansed with normal saline and applied a xeroform dressing. Staff B acknowledged the resident's dressing was dated 04/18/24. Subsequently, a side by side review of the resident's physician order for the left lower leg dressing change was conducted with Staff B who stated the dressing was supposed to be changed every other day on the evening shift. On 04/23/24 at 11:30 AM, during an interview, the Director of Nursing (DON) was apprised of Resident #4's left lower leg dressing change not done as per physician orders. A side by side review with the DON of the resident's Treatment Administration Record (TAR) revealed that it was documented that the resident's dressing was changed on 04/20/24 and on 04/22/24. Photographic evidence of Resident #4's dressing dated 04/18/24 was presented to the DON. 2) Review of Resident #5's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Atrial Fibrillation (A-Fib), Diabetes Mellitus, Venous Insufficiency (Peripheral), Cellulitis of Left Toe, Localized Swelling, Acute Osteomyelitis, and Open Wound of Left Foot. Review of Resident #5's MDS quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most of the activities of daily living. Review of Resident #5's care plan titled (resident's name) risk for skin breakdown initiated on 02/21/20 and revised on 04/17/24 documented an approach start date 02/21/20 as to monitor skin for signs and symptoms of further breakdown or changes .topical treatment as ordered .wound/skin treatment as ordered, monitor site for changes . Review of Resident #5's clinical record lacked evidence of a written physician order for the resident's left shin dressing. On 04/23/24 at 9:55 AM, a side by side observation of Resident #5's wound dressing was conducted with the Wound Care Nurse (WCN). Observation revealed the resident had a dry gauze over his left shin with no date printed. The WCN was asked to remove the dressing and revealed a Xeroform gauze underneath the dry gauze. The WCN stated that the resident had a skin tear to the shin and that the floor nurses are responsible to do skin tear care and dressing changes. The WCN added she was not aware of the resident's skin tear to the shin. The WCN was asked to submit Resident #5's physician order for the left shin skin tear Xeroform treatment and stated there was not a physician order for the skin tear. On 04/23/24 at 11:35 AM, during an interview, the DON was apprised of Resident #5's left shin skin tear with an undated dressing and without a physician order for treatment. On 04/23/24 at 2:39 PM, an interview was conducted with Staff C, RN who stated that she was not aware of Resident #5's skin tear dressing on his left shin. The RN stated an order for the left shin skin tear was obtained today.

Based on interview, observation, and record review, the facility failed to perform proper technique with catheter care for Resident #24 and failed to utilize a urinary catheter anchor for 3 of 14 residents identified with urinary catheters, Residents #24, #19, and #55. The findings included: 1. The facility's policy titled Urinary Catheter Indication and Maintenance (Urethral and Supra-pubic), revised 6/9/17, has a section titled Maintenance/Care of Indwelling Urinary Catheters that has 6 steps. Step 5 states: Minimize the pull of catheter tubing by securing catheter to resident's body. 2. A procedure manual document from www.nursegroups.com, titled Indwelling Catheter Care, has numbered steps describing indwelling catheter care. Step 10 instructs: Perform perineal care with washcloths, soap, and warm water. Remember to clean front-to-back on female residents and under the foreskin of uncircumcised males. 3. On 09/13/23 at 9:35 AM, an observation was made of Staff A, a Certified Nursing Assistant (CNA), performing perineal care with catheter care on Resident #24. The CNA had all her equipment laid out on a barrier pad. The CNA washed her hands and put on gloves. The CNA filled a wash basin 1/2 full of warm water. The CNA repositioned the resident and removed his brief. The CNA used the warm water with disposable wash cloths and liquid soap to clean the tubing of the catheter from the urinary meatus outward. The CNA then used the same water and a clean disposable washcloth to provide perineal care. The CNA washed around the scrotum and the body of the penis up to the glans. The CNA then retracted the foreskin to wash the glans in a circular motion up to the meatus. The CNA took a disposable washcloth and wet it in the soapy water. The CNA squeezed the water over the penis. The CNA then used a dry towel to pat dry the resident's penis and scrotum. The CNA emptied the basin in the toilet, removed her gloves and put on new gloves. The CNA then refilled the basin with warm water, and washed the resident's buttocks from front to back. The CNA patted the resident dry and placed a new brief on the resident. The CNA did not place any device to secure the catheter tubing to the resident's body as documented in the catheter care policy. When asked about washing her hands between glove changes, Staff A admitted she did not wash her hands when she changed the water in the basin, and put on new gloves. 4. On 09/13/23 at 11:40 AM, after observing Resident #24 without an anchoring device for his catheter tubing, this surveyor used the facility matrix to determine all residents with an indwelling catheter. These residents were observed for the presence of an anchoring device for their indwelling catheter tubing. There was a total of 3 residents out of 14, who had indwelling catheters, who did not have an anchoring device, Resident #24, #19, and #55. 5. On 09/13/23 at 11:59 AM, a meeting was conducted with the ADON and the Program Administrator of Clinical Services present. They were informed of the observations made of perineal care with an indwelling catheter. They agreed Staff A should have washed her hands between glove changes. They agreed Staff A should not have wrung out the washcloth above the groin because the water was dirty, and the technique did not ensure the groin had been rinsed clean properly. They agreed Staff A washed the perinium and Indwelling catheter in the incorrect order which could lead to a Catheter Acquired Urinary Tract Infection (CAUTI). The ADON and the Program Administrator of Clinical Services were also informed of the 3 residents who did not have an anchoring device for their indwelling catheter tubing.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5 percent, as evidenced by three medication errors in 25 opportunities which resulted in a medication error rate of 12 percent, for 2 of 5 sampled residents (Resident #83 and #34). The findings included: Review of the facility's policy titled Medication Administration, dated 12/31/21 revealed that The individual administering the medication must check the label to verify the . right dosage . of administration prior to giving the medication. 1) A medication administration observation was conducted on 09/13/23 at 8:46 AM with Staff B, Licensed Practical Nurse (LPN) for Resident #83. Staff B stated she had taken Resident #83's vital signs previously-Blood Pressure (BP) 142/79 and Heart Rate (HR) 76. Staff B then prepared the following medications: 1) Aspirin 81 milligram (mg) 1 tablet 2) Multivitamin with Minerals 1 tablet 3) Duloxetine 20mg 2 capsules 4) Lisinopril 5mg-Staff B discussed this medication and that based on the blood pressure parameters ordered by the physician, Resident #83 was due to receive the medication, however she failed to remove the medication from the medication cart. 5) Lithium Carbonate 300mg 1 tablet 6) Lorazepam 0.5 mg 1 tablet 7) Metformin 500mg 2 tablets 8) Simbrinza 1%-0.2% eye drops- 1 drop to each eye Staff B administered the above medications and then returned to her medication cart. The surveyor then asked Staff B to show her the package for the Lorazepam tablet that was given. Staff B retrieved the Lorazepam medication cards from the narcotic drawer and the surveyor confirmed that the medication cards contained 0.5mg tablets, but the zipper bag, medication order on the computer, and medication sticker in the narcotic book each documented 1mg tablets were ordered by the physician. Staff C, Nursing Program Specialist presented to the medication cart at this time to assist Staff B. The surveyor showed Staff C the observed error and she confirmed that this was not the correct dose of Lorazepam based on the physician order. Staff C then asked Staff D, Pharmacist to come to the medication cart for further advisement. Staff D also confirmed that these 0.5mg tablets were not the correct dose of Lorazepam based on the physician order. Staff D stated it was her covering pharmacist who dispensed this medication. At this time, the surveyor noted in the narcotic book that there had been 30 tablets dispensed on 09/07/23. It was noted during this observation, Staff B administered tablet #20 of the 30 that were dispensed. Staff D then told Staff B that she recommended giving a second 0.5mg Lorazepam tablet so Resident #83 received his full dosage and that she would contact the physician to alert him of the error. Staff D further stated she would dispense new 1mg Lorazepam tablets. Staff D also stated she would put a one-time order into the computer for Lorazepam 0.5mg give 2 tablets so Staff B could properly sign off this administration. Following this interaction, the surveyor then alerted Staff B of the missed Lisinopril tablet during the medication administration. Staff B dispensed the missed Lisinopril and additional Lorazepam tablet and administered them to Resident #83 at 9:18 AM. 2) A medication administration observation was conducted on 09/13/23 at 9:22 AM with Staff E, Registered Nurse (RN) for Resident #34. Staff E stated she had taken Resident #34's vital signs previously-BP 133/78 and HR 72. Staff E then prepared the following medications: 1) Hydrochlorothiazide 12.5mg 1 cap given 2) Allopurinol 100mg 1 tab given 3) Aspirin 81mg 1 tab given 4) Citalopram 20mg 1 tab given 5) Methenamine Hippurate 1 gram 1 tab given 6) Amlodipine 2.5mg-Staff E discussed this medication and that there were no blood pressure parameters ordered by the physician, however she failed to remove the medication from the medication cart. Staff E administered the above medications and then returned to her medication cart. The surveyor then alerted Staff E to the missed Amlodipine tablet during the medication administration. Staff E dispensed the missed Amlodipine and administered it to Resident #34 at 9:32 AM.

Based on observation, interview and record review, the facility failed to post daily nurse staffing information, in a timely manner, prior to the beginning of the shift for two of three shifts and three of four days, during the Re-certification survey. The findings included: Review of policy titled Nurse Staff Information for Posting effective date 03/01/06, included: The facility must document compliance with staffing standards and post daily staffing information based on State and Federal regulatory standards. Federal Requirement for Nurse Staff posting: The facility must post the following information related to Nurse staffing on a daily basis: 1. Facility name; 2. The current date; 3. Total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a. Registered Nurses b. Licensed Practical Nurses c. Certified Nurse Aides; and 4. Resident Census. The data must be posted in a clear and readable format and be displayed in a prominent place readily accessible to residents and visitors. On 05/02/22 at 4:30 PM, the posted Nurse Staff schedule for the 3-11 PM shift was still noted to be Blank. On 05/03/22 at 8:37 AM, the posted Nurse Staff schedule for the 7-3 PM shift was noted to be Blank. On 05/03/22 at 9:32 AM, the posted Nurse Staff schedule for the 7-3 PM shift was still noted to be Blank. On 05/04/22 at 9:35 AM, it was noted that the Nurse Staff schedule dated 05/03/22 was still posted on today's date of 05/04/22. Photographic evidence obtained. During an interview conducted on 05/04/22 at 9:54 AM with the Director of Nursing (DON) she was made aware of the nurse staffing posting not being properly recorded on the form, in a timely manner, before the beginning of both the evening and day shifts on 05/02/22, 05/03/22 and 05/04/22, in the main facility entryway corridor. She stated that the nurse staffing posting should be posted by the Staffing Coordinator or by the day or evening shift Supervisors before the beginning of each shift; this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to assure that psychotropic drugs are limited for 14 days unless the prescribing physician document their rationale for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #69). The findings included: Review of the facility's policy titled Psychotropic Medication Clinical Guidelines revised on 10/06/2017 showed the following: PRN (as needed) orders for psychotropic drugs are limited to 14 days, except when the attending Physician, or prescribing practitioner believes that it is appropriate for the PRN orders to be extended beyond 14 days. Then he/or she should document the rational in the resident's medial chart and indicate the duration of the PRN order. It further showed that the Pharmacist should contact the attending physician regarding any concerns with psychotropic medications. A review of the medical chart showed that Resident #69 was admitted [DATE] and readmitted on [DATE]. Diagnoses included Dementia, Dysphagia, and abnormal weight loss. Further review of the Physicians orders showed an order for Lorazepam 0.5 mg by mouth every 12 hours PRN for anxiety disorder which was dated 02/24/22. Review of the PRN Medication Administration History from 03/01/22 to 03/31/22 showed that Resident #69 was given Lorazepam PRN on the following 12 dates: 03/01/22, 03/03/22, 03/05/22, 03/08/22, 0310/22, 03/15/22, 03/18/22, 03/19/22, 03/25/22, 03/26/22, 03/29/22 and 03/31/22. This showed that the order for Lorazepam PRN continued passed 14 days. Review of the PRN Medication Administration History from 04/01/22 to 04/30/22 showed that Resident #69 was given Lorazepam PRN on the following 10 dates: 04/01/22, 04/04/22, 04/06/22, 04/07/22. 04/08/22, 04/09/22, 04/12/22, 04/13/22, 04/14/22 and 04/15/22. Further review of the electronic chart did not contain any documentation that the facility's Pharmacist contacted the prescribing physician regarding the use of PRN medication beyond 14 days. In an interview conducted on 05/03/22 at 2:50 PM, with the facility's Pharmacist, she stated that any psychotropic medication that are passed the 14 days she will contact the prescribing physician and will rewrite a new order for another 14 days if needed. When asked if she knew that Resident #69 continued receiving a psychotropic medication that was given passed the 14 days limit, she said no. When asked if she contacted the prescribing physician regarding Resident #69's PRN order that went beyond the 14 days, she said no. In an interview conducted on 05/05/22 at 11:55 AM, with the facility's Director of Nursing, she stated that PRN psychotropic medication are limited to 14 days unless the prescribing physician wants it for a longer period. In this case, the facility's Pharmacist keeps an updated list and will contact the prescribing physicians when needed. She also stated that the facility's supervisors are the back up when the Pharmacist is not able.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that menu foods were served palatable, at an appetizing temperature, and attractive during dining observations for 1 of 1 resident (Resident #5). The findings include: In an interview conducted on 05/03/22 at 12:05 PM with Resident #5's roommate's family, they stated Resident #5 needs full assistance with all his meals and cannot eat on his own. At times, the facility does not have enough staff assisting during mealtime, and they place the meals in the room and walk out. The family further said they told Resident #5's family member what was happening when she was not in the facility. A chart review showed that Resident #5 was admitted on [DATE] and is with swallowing problems related to dysphagia. He is at a potential risk for aspiration and weight loss. It further showed that Resident #5 is at cognitive impairment related to his diagnoses of Alzheimer's disease. In a phone interview conducted on 05/03/22 at 9:11 AM with Resident #5's family member, she stated that she was concerned with the facility staff feeding him his meals and liquids too fast. She reported that her brother had aspiration pneumonia in the past and was worried that it may happen again. She further stated that a family member who comes in daily told her that she often sees Resident #5 fed too fast and that on the days that she is not in the facility, her brother is the last Resident to get his meal tray. The lunch tray arrived on the unit in an observation conducted on 05/03/22 at 11:38 AM. At 12:02 PM, 24 minutes later, the lunch tray was taken out of the meal cart in the hallway and brought into Resident #5's room. The meal was placed on the side table. In this observation, Resident #5's family member arrived at 12:10 PM and started assisting Resident #5 with his lunch meal (which was 32 minutes later). In an observation conducted on 05/04/22 at 7:45 AM, the breakfast meal cart arrived at the Delta-Green Unit. At 8:15 AM, 30 minutes later, the breakfast tray was taken from the meal cart and brought into Resident #5's room. Staff A, Certified Nursing Assistant (CNA), was at the bedside. Staff A was told by Staff C, a Licensed Practical Nurse, to wait for the breakfast meal because she needed to go into the kitchen and get the honey thickened liquids for Resident #5. At 8:21 am, about 36 minutes later, Staff B, Certified Nursing Assistant, started assisting Resident #5 with his breakfast tray. She was done helping the Resident at 8:32 am, 11 minutes later. In an interview conducted on 05/05/22 at 2:00 PM, with the facility's Director of Nursing, she was informed of the findings.

Based on observation, interview, and record review the facility failed to provide food items that accommodate preferences for 4 of 4 sampled residents (Residentd #4, #46, #5 and #50). Findings included: In an observation conducted on 05/03/22 at 11:25 AM, in the Delta-Green Unit, Resident #50 was observed eating his lunch meal in the dining room. Closer observation showed a meal ticket with the following: extra 2 soups and extra 2 margarines. His lunch meal consisted of only 1 soup (instead of 2) and no margarines (Photographic evidence obtained). In an observation conducted on 05/04/22 at 7:52 AM, in the Delta-Green Unit, Resident #46 was observed in the dining room eating his breakfast meal. Closer observation showed a meal ticket with the following: No added salt, breakfast with 2 extra margarines. Resident #46's plate showed eggs, toast, bacon and 1 pack of margarine (Photographic evidence obtained). In this observation, Resident #46's stated I do not have enough margarine. In an observation conducted on 05/04/22 at 7:52 AM, in the Delta-Green Unit, Resident #4 was observed in the dining room eating his breakfast meal. Closer observation showed a meal ticket with the following: extra yogurt and extra prune juice. The breakfast meal did not have the extra yogurt, or the extra prune juice as requested (Photographic evidence obtained). In an observation conducted on 05/04/22 at 11:25 AM, in the Delta-Green Unit, Resident #50 was observed in the dining room eating his lunch meal. Closer observation showed a meal ticket with extra double portion of meat. His lunch plate showed a fruit salad with only 1 serving of cottage cheese (Photographic evidence obtained). In an interview conducted on 05/03/22 at 12:10 PM, Resident #5's family member, stated that when she comes into the facility 3 times a week to help her brother with his lunch meal it takes her about 1 hour to feed him and he usually consumes 100% of his meals. She also said that in the past, she was not provided with meal choice options and only recently after complaining she received a menu to make the choices for Resident #5. According to her, they often do no place soups on the meal tray even when requested. In an interview conducted on 05/05/22 at 11:18 AM, the facility's Food Service Director stated that upon admission, the resident's food preferences and food likes are placed into the system and generated on the meal tickets. If residents cannot say what they like, they would speak to the residents' families. She further reported that the kitchen supervisors would check for the accuracy of the meal tickets in the morning shift and the evening shift. She does random checks on the tray line to ensure that the right foods are placed on the meal tickets. According to the Food Service Director, any updated food preferences are changed in the electronic system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to provide appropriate fluids to a dialysis resident who was prescribed by the physician to have fluid restriction for 1 of 1 sampled resident (Resident #7). The findings included: A record review showed that Resident #7 was admitted on [DATE] with the following diagnoses: End stage renal disease, cognitive deficit and cerebral infarction. Further review of the physician orders showed an order for fluid restriction with meals: Breakfast 240 ml (milliliters), Lunch 240 ml, Dinner 240 ml, for a subtotal of 720 ml, which was dated on 04/02/21. In an observation conducted on 05/03/22 at 12:30 PM, Resident #7 was noted in his room. He was observed drinking 8 ounces (240 ml) of coffee, and 12 ounces (360 ml) of water in a Styrofoam cup was noted on the side table. In this observation, Resident #7 was asked by Surveyor if he was on a fluid restriction and he could not give any clear answers. In an observation conducted on 05/04/22 at 8:25 AM, Resident #7 was eating his breakfast meal with staff in the room. Closer observation showed a meal ticket with the following: Regular, liberalized ml fluid restriction, with small portion of starch. It further showed Miscellaneous 240 ml fluids with meals and no other liquids with meals. Closer observation of the breakfast meal showed the following: 12 ounces (360 ml) of water in a Styrofoam cup, 8 ounces (240 ml) of water in a second cup, 8 ounces (240 ml) of juice and 8 ounces (240 ml) of coffee. This accumulated to 1080 milliliters of liquids at one meal which exceeded the 240 ml of fluids for breakfast. In an interview conducted on 05/05/22 at 10:30 AM, with Staff D, Certified Nursing Assistant, she stated Resident #7 is always asking for a cup of coffee after he comes back from dialysis and will usually drink it all. She further said Resident #7 already has 8 ounces (240 ml) of water at the bedside, and he gets an additional 8 ounces of water with his meal trays. Staff D also said Resident #7 does not always drink his extra water, but she puts it at the bedside just in case. She further stated that extra water needs to be placed for all residents. When asked by Surveyor if she knew that Resident #7 was on a fluid restriction she said yes. She was also asked what being on a fluid restriction means. She said the following: not giving residents too much water or too much juice.