Every finding on record at Bay Village of Sarasota

Based on observations, record review, facility policy review, resident and staff interviews, the facility failed to ensure the safe storage of medications for 1 (Resident #62) of 2 residents observed with unsecured and unattended medications at bedside. The facility failed to ensure prescribed medications were consumed and not left at bedside for 1 (Resident #55) of 2 residents observed with unattended medications at bedside.The findings included:Review of the undated facility policy titled Medication Labeling and Storage revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.Review of the clinical record for Resident #62 revealed an admission date of 11/15/2023. Diagnoses included Parkinson's Disease, unspecified Dementia, Cerebral Infarction (type of stroke), and depressive episodes. Review of the Quarterly Minimum Data Set (MDS) assessment completed on 4/14/26 revealed Resident #62 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.On 6/16/26 at 9:13 a.m., observation of Resident #62's room revealed the following medications stored unsecured, in a basket on the resident's nightstand: One bottle of dry mouth moisturizing spray, one bottle of ultra lubricant eye drops, one bottle of antifungal cream, one bottle of bio-active silver hydrosol dietary supplement. In an interview, Resident #62 verified that he uses the antifungal medications and stores them on the bedside table, in the basket. On 6/18/26 at 10:40 a.m., the bottle of dry mouth moisturizing spray, the bottle of ultra lubricant eye drops, the bottle of antifungal cream, the bottle of bio-active silver hydrosol, and a tube of cortisone ointment remained stored in a basked on Resident #62's bedside table. Resident #62 was not in the room at the time of the observation. The medications were unattended and potentially available to others.Review of the clinical record for Resident #55 revealed an admission date of 2/20/24. Diagnoses included Type 2 Diabetes, Heart Failure, Chronic Kidney Disease and Cerebral Infarction.The Quarterly MDS completed on 5/19/26 revealed that Resident #55 scored 15 of 15 on the BIMS, indicating the resident's cognitive skills for daily decision making were intact.On 6/16/26 at 11:03 a.m., observation of Resident #55's room revealed multiple unidentifiable pills in an open cup of pudding on Resident #55's over the bed table. Resident #55 was not in the room at the time of the observation. Photographic evidence obtainedOn 6/16/26 at approximately 11:10 a.m., Registered Nurse (RN) Staff A verified the observation of the pills on the surface of the open cup of pudding. RN Staff A said that he administered the medications to Resident #55 at approximately 9:30 a.m. that morning and thought he observed the resident swallow each pill. RN Staff A left the room, returned and stated that he could not identify the pills and marked all the medications administered at 9:30 a.m., as refused. On 6/18/26 at 11:30 a.m., the observations of the unattended and unsecured medications at Residents #62's bedside on 6/16/26 and 6/18/26, and #55's bedside table on 6/16/26 were shared with the Director of Health Services, along with the photographic evidence obtained. In an interview, the Director of Health Services stated that she would not expect a resident to have medications at bedside and would not expect a nurse to leave medications at a resident's bedside to take/use later.

The facility failed to prepare, and store food in a sanitary manner by failing to cover and date food in 2 walk-in coolers and 1 refrigerator. The facility failed to ensure staff used the three compartment sink appropriately including use of the proper sanitizing agent. The facility failed to ensure staff wear hair restraints during preparation of food. The facililty failed to service and maintain ice machines in the main dining room and three of three nourishment rooms. The findings included: 1. The facility policy and procedure for Walking Cooler, documented to protect and ensure that food is free from foodborne illness, contamination, and hazards. All foods stored in coolers are labeled and dated. During an initial tour of the kitchen with the Certified Dietary Manager (CDM) and the Director of Dining (DOD) on [DATE] at 9:20 a.m., the following was observed: a.) In the line reach in refrigerator was a box of muffins without a date and sitting on top of the muffins was another box containing empty plastic cups. The observation was confirmed the CDM. Photographic evidence obtained. b.) In the walk-in cooler #1 there were two tray's with uncooked broccoli that were uncovered on pans with no date. There were 2 trays of uncovered and undated calzones on a cart. The findings were verified by the DOD. Photographic evidence obtained. c.) In the walk-in cooler #2 there was an uncovered tray of small pie shells and a tray of unknown food items that were uncooked and uncovered on trays. The tray of pie shells was resting on top of the unknown food item. There were 3 trays of an uncooked food item the DOD identified as chicken. The top tray of the chicken was sitting on top of the tray beneath it. The findings were verified by the DOD. Photographic evidence obtained. 2. The facility policy Dish Machine and 3 Compartment Sink Procedures documented Three compartment sink operator requirements: a. The three-compartment sink should be drained, cleaned and refilled with fresh water/solutions after each meal period or when water becomes dirty using the 3 compartment sink instructions on the wall chart. b. Sanitation solution levels should be logged before each meal period. This log should be kept on the log board or filed for reference. The wall chart for the 3-compartment sink located above the sink, specified Sanitizer Tips: Test sanitizer solution in sinks and trigger sprayers often to verify 200 parts per million (PPM). Do not test directly from the dispenser. Fill the sink to the proper level then test from the sink. Be sure to use only authorized test strips. Do not hold the test strip in the solution for more then 1 second. Use only 200 PPM solution sanitizer. On [DATE] at 1:00 p.m., during a second tour of the kitchen in the second sink dedicated for rinsing, the pots and pans were piled and stacked above the water line and not in contact with the rinsing solution. The CDM confirmed the cooking utensils should be fully submerged in the sink. Photographic evidence obtained. The CDM was asked to test the sanitizer in the third compartment of the sink. The CDM had a bottle of test strips, took one out and dipped it into the sanitizing sink. The test strip failed to turn the green color indicated on the bottle to assure 200 PPM of sanitizing agent. The test strip failed to turn any color indicating there was no sanitizing agent in the sink. The CDM tested the water in the sanitizing sink for a second time with the test strip in the water for 5 seconds. The test strip remained yellow indicating no sanitizing agent. The CDM confirmed there was no sanitizing agent in the sink. A review of the test strip container showed an expiration date of ,d+[DATE]. The CDM said she was unaware the test strips had expired and said, we have more, I will get another bottle The CDM returned with several test strips in her hand, not in a test strip container. The CDM dipped several test strips in the sanitizing water, moving them back and forth for a few seconds. The test strips failed to identify any sanitizing agent in the sink. On ,d+[DATE]/ 24 at 1:15 p.m., Dishwasher Staff O removed 2 sheet pans from the rinse sink and placed them into the sanitizing sink. The pans were only partially submerged in the sink. Staff O removed the trays and placed them on the clean rack to dry. The CDM said she would educate Staff O on the use of the 3 compartment sink and the need for the dishes and cooking utensils to be sanitized to prevent food borne illness. Surveyor informed the CDM the sheet pans would need to be removed from the drying rack and to be cleaned and sanitized. The CDM said the Executive Chef was responsible to provide education to the dietary staff on the use of the 3-compartment sink. The CDM said I do audits to make sure they are following instructions and I test the sanitizer solution level in the third sink. The CDM confirmed she did not keep any records of her audits of the 3-compartment sink and had no logs to indicate when the sanitizing sink was last tested . On [DATE] at 11:04 a.m., during a third tour of the kitchen the DOD said the dispensing line for the sanitizer in the 3-compartment sink had been clogged so no solution was being dispensed. The DOM said, we had the clogged line replaced yesterday and the sink and chemicals were all inspected. He said it was unknown when the sanitizing dispensing line had become clogged and was not dispensing the sanitizer. On [DATE] at 11:10 a.m., Dishwasher Staff M was observed washing cooking utensils and pots in the 3-compartment sink. The third sanitizing sink was noted to have pots and cooking utensils stacked above the water line and not submerged in the sanitizing agent. The DOD confirmed the observation. On at [DATE] 12:07 p.m., in an interview with the DOD said the 3-compartment sink was operating before I left for vacation and when I returned it was not functioning. I went on vacation on the [DATE] so it has been a week or so but not longer then that. I was testing the sanitizing agent before I left. He confirmed there was no way to know when the sanitizing dispenser for the sanitation sink had stopped dispensing the sanitizer. He said the staff are to check the sanitizing level in the sink several times a day and the water is changed hourly so they are supposed to check the level then. He confirmed he had no documentation he or the dietary staff were checking the sanitizer levels to ensure the dishes were sanitized. 3. The facility Policy and Procedure for Hair Restraints and Beard Guards documented, To ensure that food is free from contamination, food service staff are required to wear protective gear. According to food safety guidelines any employee working in a food production establishment must wear a hair restraint that prevents hair from coming into contact with food products. Allowed hair restraints include hair nets, hats, beard and mustache nets and clothing that covers body hair. Food handlers with facial hair such as overgrown sideburns, mustaches and beards required protective gear. On [DATE] at 11:15 p.m., Chef N was observed preparing mashed potatoes and other foods. Staff N had a mustache and beard that were not covered when he was preparing the food. The DOD was present during the observation and did not instruct Staff N to cover his facial hair. There was a total of 4 male staff in the kitchen with some sort of facial hair and only 1 had a facial cover over his beard. 4. The manufacturers guideline for the facility ice machines, Cleaning and Sanitizing Instructions documented, The appliance must be cleaned and sanitized at least twice a year. More frequent cleaning and sanitizing may be required in some condition. On [DATE] at 8:30 a.m., an observation of the second-floor ice machines revealed the following: The main dining room ice machine revealed a layer of dust and grime on the front doors of the ice machine. On the left side of the machine there was a white substance. The lower front of the machine had brown splatters of unknown origin. The inside of the ice machine had grime around the edges of the door. On the left side was a brown unknown substance. Photographic evidence obtained. In the Citrus Unit nourishment room water/ice dispenser, in the catch tray on the bottom of the machine there was a white biofilm, dust and grime. The area surrounding the dispensing spout where the water and ice comes out had a rust-colored substance. The findings were verified by the Assisted Director of Nursing (DON). Photographic evidence obtained. In the Magnolia Unit nourishment room, the ice machine had a white film on the front of the machine and on the spout where the ice comes out. The tray had dust and grime on the right side. The surrounding pad where the ice machine was sitting was rusted and had debris and grime. The findings were verified by Registered Nurse Staff R. Photographic evidence obtained. In the Hibiscus Unit nourishment room the ice machine had a white substance on the front of the machine and on the overflow tray. The surrounding area of the spout where the ice is released had a black substance on it. There was rust colored and brown unknown substances on the machine. Photographic evidence obtained. On [DATE] at 8:59 a.m., on a walking tour with the ADON the condition of the ice machines was verified. The ADON said Housekeeping was to clean the machines but she was not certain. On [DATE] at 10:00 a.m., in an interview the Director of Nursing (DON) said she had put a work order in a week or so ago to have the machines looked at. She said she was aware of the condition of the machines and would find out when they were serviced last. On [DATE] at 11:36 a.m., in an interview the DON she said she was not able to locate any documentation of when the ice machines were serviced. She said the dietary staff was responsible for cleaning the ice machines. She said there was no service log of who was responsible to do the cleaning and when they were to be cleaned and serviced.

Based observation on interview record review and policy the facility failed to provide supervision to prevent the elopement of one resident (Resident #162) of one resident surveyed for elopement and failed to ensure four of four residents assessed as an elopement risk currently residing at the facility had appropriate interventions to prevent the potential for an elopement. Findings included: Resident #162 is a [AGE] year-old female who was admitted to the facility on [DATE] with a history of cognitive communication deficit, abnormal gait, lack of coordination, and hypertensive heart disease. Review of the Elopement/Wander Risk Screen dated 12/21/23 shows Resident #162 was assessed with being a risk for elopement. The intervention listed as being initiated on 12/21/23 was a wanderguard was put in place at that time. According to the timeline provided in the facility's investigation, on 12/24/23 at approximately 9:30 a.m., Resident #162 was last seen in her room by staff who were attempting to administer her morning medication. On 12/24/23 at 10:15 a.m, a facility camera captured Resident #162 eloping from the facility through the front guarded gate. According to the timeline, Resident #162 was not seen again by facility staff until 12:45 p.m. when the resident was brought back to the facility by Resident #162's daughter. Resident #162 had traveled to an area in shopping mall approximately 0.4 miles from the facility. Resident #162 had provided contact information to the police and the police had notified Resident #162's daughter that she had left the facility. On 12/24/23 at 1:33 p.m., the staff nurse assigned to the resident documented Resident #162 had cut the wanderguard off her walker and was able to exit the building though the 2nd floor elevator without the wanderguard system alarming. The analysis of the facility's investigation was Resident #162 had become confused due to a visit from an estranged family member and a potential urinary tract infection. The facility policy was changed to include a silver alert with the room number announced over radio communication. The Guard shack was to also be provided with an updated elopement book weekly. The facility investigation showed Resident #162 was able to remove the Wanderguard device and enter into the second floor elevator without the Wanderguard system alarming, and then exit the building and the guarded gate at the facility without staff being aware the resident had left the premises. On 4/17/24 at 8:15 a.m., the Security Guard at the front gate said he was not aware of an elopement book. He stated he would have to find out about the elopement book from his supervisor. On 4/17/24 at 10:15 a.m., the Assistant Director of Nursing provided an example of the Wandergaurd device, and the plastic bracelet currently being used on 4 residents assessed as being an elopement risk by the facility. The plastic bracelet provided was observed to be easily snapped in two pieces by applying very little force at both ends. On 4/17/24 at 11:20 a.m., Resident #52 was observed in her room with the Wanderguard device attached to her wrist with the same type of plastic bracelet observed to be easily broken with very little force. On 4/17/24 at 11:25 a.m., Resident #18 was observed sitting in a recliner in his room with a Wanderguard device attached to his left ankle with the same type of plastic bracelet. On 4/17/24 at 12:15 a.m., Resident #29 was observed in the dining room with the Wanderguard device attached to her wrist with the same type of plastic bracelet. On 4/17/24 at 12:30 p.m., Resident #17 was observed in her room with the plastic bracelet attaching the wandergaurd device to her ankle. On 4/17/24 at 1:15 p.m., the Director of Nursing (DON) said she had the bracelets which had come with wandergaurd device. She said she was in the process of applying the wandergaurd devices to the residents who were assessed by the facility to be an elopement risk. The bracelets the DON provided at this time were grey in color and were observed to be stronger. They could not be broken by applying force at both ends of the bracelet. The DON could not explain why the appropriate bracelets were not being used to attach the wandergard devices. She said that from now on they would be and she had ordered more of the grey bracelets to be used in the future. On 4/17/24 at 1;20 p.m., the DON said she had not implemented putting a elopement book at the guard shack. She felt the issue had to due with communication, and by implementing a policy for announcing a Silver Alert when a resident eloped it would be communicated to staff. On 4/17/24 at 3:04 p.m., the Receptionist on the first floor of the facility in the front of the doors leading in and out of the building said she was not aware of who the residents were on the second floor who were at risk to elope from the building. The Receptionist said she did not know the code (Silver Alert) that would be called over the walkie talkie if a resident eloped from the second floor. She said she had had an email about elopement a while ago, but she was not aware of what the email had addressed. On 4/17/24 at 3:09 p.m., the Guard at the guard shack at the front gate of the building said he was not aware of what residents were at risk for elopement on the second floor of the facility. He verified he was stationed at the only open gate that residents could go through to get off the facility grounds. He said there was one other closed gate that could be opened by pushing a button and it was not a guarded gate. On 4/17/24 at 3:15 p.m., the Receptionist at the station directly in front of the elevators on the second-floor skilled nursing unit said she did not know the code (Silver Alert) that would be called on the walkie talkie if a resident had eloped and could not be found. On 4/17/24 at 3:35 p.m., Certified Nursing Assistant, Staff G said she did not know the Code ([NAME] Alert) that would be called over the walkie talkie if a resident could not be found on the second floor. Staff G said they use the telephone to communicate if residents could not be found. On 4/17/24 at 2:59 p.m., The DON verified Resident #162 had exited the second floor by removing her wandergaurd device. She said staff were not aware the resident had left the premises for over 2 hours when the resident's daughter returned the resident to the facility. The DON verified how resident #162 was able to remove the wandergaurd and go off the premises through the guarded gate had not been addressed.

Based on observation, staff interviews, resident interviews, and resident council meeting notes, the facility failed to serve food that was palatable and at the appropriate temperature for 4 (Residents Resident #23, #26, #259, and #261) of 4 residents interviewed and Resident Council concerns reviewed from 1/2023 through 12/2023 for food palatability and appropriate temperature. This had the potential of decline in health due to poor nutrition. The findings included: On 4/16/24 at 12:25 p.m., Resident #26 was observed with a sandwich and pot roast stew. She said the sandwich is warm today, and the pot roast stew needs heated. Her meal ticket has a tossed salad listed and there was no salad on Resident #26's tray. During an interview on 4/15/24 at 2:18 p.m., Resident #26 said the food is not good. The grilled cheese is cold. The bread does not look like it is grilled, and the cheese is not melted. The bun was ice cold on a sandwich. The mac and cheese was served cold. During an interview on 4/15/24 at 9:30 a.m., Resident #259 stated the food is up and down. The list they gave to circle likes and dislikes are not followed. The transition has not been good. Resident #259 made a diet plan out 3 times and it was not right. His daughter went down to the kitchen and had to speak to someone to finally get it corrected. During an interview on 4/16/24 at 9:39 a.m., Resident #259 said requested a grilled cheese sandwich, and it was not cooked. The grilled cheese came with lima beans and roasted tomato. Resident #259 said the side choices served with grilled cheese was not an appetizing combination. During an interview on 4/16/24 at 12:33 p.m., Resident #259 said staff brought the wrong tray to him. The staff corrected the wrong tray. Resident #259 said the beef was pretty good today. During an interview on 4/15/24 at 12:36 p.m. Resident #261 said the fish for lunch stunk so bad she couldn't eat it. Last night was salmon and it was good. For breakfast she gets 2 pancakes and poached eggs. She only had toast today. She had to ask staff to get a correct breakfast. During an interview on 4/15/24 at 12:54 p.m., Resident #23 said she hates fish and has had fish served to her several times. It is on Resident #23's meal ticket that she dislikes fish. During an interview on 4/16/24 at 10:14 a.m., Resident #23 said when she gets fish, she had to ask for a different meal. Staff will bring Resident #23 a sandwich that is cold and hard. Staff was brought spaghetti with no sauce on the noodles. During an interview on 4/17/24 at 9:47 a.m., Resident #23 said she gets toast and 2 slices of bacon every morning. Resident #23 filled out a breakfast likes paper. There is no variety for breakfast meals. Breakfast is the same every day. During an interview on 4/17/24 at 12:17 p.m., with the Certified Dietary Manager (CDM), she said if a resident does not fill out breakfast likes and dislikes paper, they get scrambled eggs and pancakes every day. If they do fill out a food likes and dislikes paper, they will get their choices every day. If the resident only circles 2 items, they will get those 2 items for every breakfast. During an interview on 4/17/24 at 1:09 p.m. with Registered Nurse (RN) Staff R, she said the CDM comes up and talks to the residents and gives them the form to fill out for food likes and dislikes. The CDM would revisit the likes and dislikes quarterly for long term care residents. During an interview on 4/18/24 at 1:34 p.m. with the CDM, she said the food concerns are brought to her by staff or residents. Resident Council gives her food concerns. The CDM gets emails and has not been asked to attend resident council meetings. The CDM has only received 1 meal complaint from Resident council dated 2/2/24. The CDM said just found out Resident #23 does not like fish. Review of the resident council meeting minutes from 1/2023 through 12/2023 revealed the following food concerns: 1/19/23: Residents would like a better variety of food. Sometimes the food isn't hot like it should be. 2/8/23: Residents would like more of a selection of food and drinks. Residents would like more sauce for their side dish on the side. Residents are not happy with the food. Residents said by the time they get their food it is cold when it should be hot. Some of the food isn't always cooked all the way. The ice cream gets to them melted. 3/8/23: Residents would like more of a variety of food. They would like pizza on the menu. The residents would like the meats to be easier to cut. They would like to have more sauce on their foods that need sauce. Food seems difficult to keep warm. 4/11/23: Residents would like to have breakfast menus to fill out. The food sometimes isn't cooked all the way. The coffee is cold. 5/9/23: Residents are saying they fill out their menus, but they don't get what they have selected. 6/13/23: The residents would like more sauce to put on the foods that require sauce. They would like the hot food to be hot and the cold food to be cold. 7/11/23: the residents would like more vegetarian meals. The residents would like more sauce on their food. The food isn't hot enough for the residents. 8/3/23: Meat is tough. Tickets are not what they ordered. 10/5/23: Not satisfied with menus-several residents agree. November 2023: Residents said food was often overcooked and not seasoned very well. 11/2/23; Food not warm and overcooked. More sauce on spaghetti. 12/6/23; Food is not warm when it arrives. Want more variety, hot when it's served. Beef is cooked too long. 12/6/23: Residents stated the food is not warm when it arrives to them, and the beef is usually overcooked. Other than that, they said the food is pretty good usually.

Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to maintain a urinary catheter in a safe and sanitary manner for 1 (Resident #5) of 1 resident reviewed with an indwelling urinary catheter. The findings included: The facility policy Catheter Care documented The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the clinical record documented Resident #5 had an admitted [DATE] with diagnoses including schizophrenia, type 2 diabetes mellitus, hypertensive heart disease. The record revealed the resident was receiving hospice services. The record showed a physician order dated 4/13/24 instructing staff to insert an indwelling urinary catheter to promote wound healing of a pressure wound on the resident's coccyx. On 4/16/24 at 9:33 a.m., Resident #5 was observed in her room in bed and was noted to have an indwelling urinary catheter. The catheter drainage bag was attached to the bed frame and the bed was in the lowest position. The catheter drainage bag and tubing was in contact with the floor. Photographic evidence obtained. On 4/16/24 at 10:44 a.m., during a walking tour with the Assistant Director of Nursing (ADON) confirmed the drainage bag was on the floor and should be off the floor. The ADON attempted to readjust the drainage bag and tubing and placed a towel and under the catheter drainage bag to prevent contact with the floor.

Based on observation, staff interviews, and record reviews, the facility failed to ensure its medication error rate remained below 5%. Five licensed nurses with 26 opportunities were observed. Two medication errors were identified resulting in a 7.69% error rate. The findings included: On 4/18/24 at 8:34 a.m., Licensed Practical Nurse (LPN) Staff Q was observed administering medications to Resident #261. LPN Staff Q administered 1 chewable 81 milligram (mg) aspirin to Resident #261. The physician's order was ordered for aspirin 81 mg delayed release. On 4/18/24 at 8:20 a.m., LPN Staff P was observed administering medications to Resident #23. LPN Staff P administered 1 tablet, vitamin D 25 micrograms (mcg,) for Resident #23. The physician's order was vitamin D3 25 mcg (1,000 unit) tablet, 6 tablets by mouth once daily for vitamin deficiency. An interview on 4/18/24 at 8:55 a.m., with LPN Staff Q, she confirmed she gave a chewable 81 mg aspirin to Resident #261 and the physician's order is aspirin 81 mg tablet, delayed release, 1 tablet by mouth once daily for cerebral infarction. An interview on 4/18/24 at 11:38 a.m. with LPN Staff P, she confirmed she gave 1 vitamin D 25 mcg tablet for Resident #23. LPN Staff P reviewed the order and confirmed the order is written to administer 6 tablets of vitamin D3, 25 mcg by mouth once daily.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure 1 (Resident #19) of 3 residents reviewed for dental services received appropriate care and services for broken teeth. The findings included: On 4/15/24 at 12:43 p.m., Resident #19 revealed she had missing upper and lower teeth. The resident said she lost several of her teeth several months ago, and because of the missing teeth, her diet was changed to mechanical soft so she could eat her food. She said she would like to eat regular food, but due to her missing teeth, she is unable to eat a regular diet. A review of Resident #19's medical record revealed her original admission to the facility was on 11/16/17 and a readmission on 11/5/20. The Nursing Admission assessment dated [DATE] stated Resident #19 had no broken or loosely fitting full or partial dentures, natural teeth or tooth fragments, or chewing or swallowing difficulty. A dietary progress note dated 10/24/22, said Resident #19 had lost three front teeth, and due to this, her diet would be changed to a mechanical soft diet/food. A care plan meeting progress note, dated 10/25/22, stated the meeting was attended by the facility's interdisciplinary team (IDT) and Resident #19's daughter, said Resident #19 recently lost teeth. The daughter will have to arrange an appointment with the resident's dentist and let the nursing department know the date of the dental appointment. The daughter was told transportation to the dental appointment would be at her expense. A dietary progress note dated 10/25/22 said Resident #19's daughter attended the care plan meeting and was aware her mother's diet was changed to a mechanical soft diet due to the loss of the three front teeth. The daughter was aware Resident #19's teeth need to be fixed. The care plan meeting progress note, dated 1/31/23, stated the meeting was attended by the IDT and Resident #19's daughter. The IDT wrote that Resident #19 was stable overall. The Social Worker (SW) asked the daughter if she had arranged for a funeral home in the event of Resident #19's death. The daughter said the funeral homes wanted prepayment, and she didn't have the money set aside to pay for the funeral home. She wanted any money she had for her mother's teeth replacement. A review of the facility's Dental Services policy noted that it was not dated. The policy stated that routine and emergency dental services were available to meet the residents' oral health needs in accordance with the resident's assessment and plan of care. The policy said oral health services were available to meet the resident's needs, and routine and emergency dental services were provided to their resident through referral to the resident's personal dentist, community dentist, or other health care organization that provides dental services. A list of community dentists available to provide dental services would be provided to the residents and was available from Social Services. Social Services personnel were responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. On 4/18/24 at 11:53 a.m., in an interview with the Social Service Director (SSD), she confirmed during the care plan meeting on 10/25/22 with the IDT and Resident #19's daughter, that Resident #19 had lost three front teeth, causing her diet to be changed to mechanical soft diet/food because of the missing teeth. She said Resident #19 was on Medicaid, and the IDT told Resident #19's daughter she was responsible for finding a dental service to fix Resident #19's broken teeth. The SSD said after reviewing Resident #19's medical record, she could not find documentation of the facility finding a dental service to fix Resident #19's broken teeth or documentation the facility had assisted Resident #19's daughter in finding dental services to fix Resident #19's broken teeth. The SSD said she would contact Resident #19's daughter to determine if Resident #19's daughter had found a dental service to fix Resident #19's broken teeth, as noted in the 10/25/22 care plan meeting. On 4/18/24 at 3:04 p.m., in an interview with the SSD, she said she had received an email from Resident #19's daughter stating this was a follow-up email to their previous conversation regarding Resident #19's dental care. Resident #19's daughter said she was unable to find a traveling dentist in the area, and due to her mother's physical condition, it would be a challenge to transport her to a dental office. She said the cost would be over $20,000 to fix her mother's broken teeth. Because neither her mother nor herself can afford the dental service, and because they do not have the money, her mother has to remain on a soft diet. The email ended with Resident #19's daughter asking the SSD if she is aware of any alternatives, and the daughter would be open to any suggestions. The SSD said she is unable to find any documentation that she and/or anyone in the facility had assisted Resident #19's daughter in finding dental service as required in their Dental Services policy and procedure to address Resident #19's broken teeth, which were identified and noted in the 10/25/22 care plan meeting.

Based on staff interview and record review, the facility failed to ensure 5 (Staff C, D, E, F and G) of 10 staff reviewed had the required education and training in abuse, neglect, and exploitation. Failure to provide staff with abuse, neglect, and exploitation training prior to working with facility residents could lead to staff not knowing how to prevent and report abuse, neglect, and exploitation. The findings included: On 6/21/22, review of Administrator (ADM) Staff C's employee record revealed her start date was 7/15/19. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/21/22, review of Dietary Aid (DA) Staff D's employee record revealed her start date was 5/2/22. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/21/22, review of Security Guard (SG) Staff E's employee record revealed her start date was 2/21/22. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/21/22, review of Renovation Maintenance Supervisor (RMS) Staff F's employee record revealed her start date was 12/20/21. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/21/22, review of Certified Nursing Assistant (CNA) Staff G's employee record revealed her start date was 3/30/22. Review of her employee training records revealed she did not receive education or training in abuse, neglect, and exploitation prior to working with the facility residents. On 6/21/22 at 2:01 p.m., interview with Human Resources Director, confirmed Staff C, was a current employee and had resident contact. She confirmed Staff C's hire date and confirmed as of 6/21/22 she had not had onboarding required training in abuse and neglect and exploitation as required for new hires. On 6/23/22 at 9:30 a.m., interview with the Infection Preventionist/Staff Development Coordinator, confirmed Staff D, E, F, and G were current employees and had resident contact. She confirmed Staff D's, E's, F's, and G's hire dates and confirmed as of 6/23/22 they had not had the onboarding required training in abuse and neglect and exploitation as required for new hires.

Based on record review, observation, staff and resident interview, the facility failed to ensure timely response to call lights to meet the needs of 2 (Resident #94 and #96) of 2 residents reviewed. The findings included: On 6/20/22 at 1:42 p.m., Resident #94 said staff did not respond to the call light at night in a timely manner. Resident #94 said it would take 10 to 15 minutes for staff to respond to his call light. He said it happened every night and it was worse on the weekends. On 6/21/22 at 9:01 a.m., the restroom call light for Resident #94 on the Magnolia hallway observed sounding and flashing rapidly from the nursing station. Registered Nurse Staff B was observed standing at a medication cart directly in front of the nursing station. At 9:06 a.m., Resident 94's restroom call light continued to flash and sound. Staff B continued to stand at the medication cart and did not respond to the call light. Licensed Practical Nurse Staff A was observed walking to the nursing station, converse, and wash her hands at a sink next to the nursing station. After several minutes Staff A walked to a room in the back of the magnolia nursing station as the call light continued to flash and sound. Another unknown staff member was heard down the Magnolia Hallway was knocking on doors and saying, Activities. On 6/21/22 at 9:16 a.m., Resident 94's room was observed. After knocking on the resident's door, and the resident responding, the resident was heard saying be careful. There was fecal material observed from the bed at the window of the room and leading into the restroom. Resident #94 was observed sitting of the bathroom toilet with the door open. The resident said, I have been waiting for someone to help me for about fifteen minutes. The resident continued to ask for assistance. No staff member was observed in the hallway near the resident at that time. There was an attempt to locate the Director of Nursing (DON). A staff member said the DON was in a morning meeting. At 9:18 a.m., the Administrator walked to the Magnolia hallway and the restroom call light was still flashing and sounding. Upon opening Resident #94's door a staff member was observed assisting the resident. The Administrator said the call light times were recorded, and she would be able to provide documentation of how long the light was initiated. Review of the Detailed Patient Activity Report provided by the DON showed the call light response time for Resident #94. The form shows Resident #94's call light was engaged on 6/21/22 at 8:55 a.m. and was completed and immediately reengaged on 16 minutes and 33 seconds later. The light was completed and reengaged 7 seconds later. After 19 minutes had passed the call light is completed and reengaged 2 seconds later. One second later the light is complete and reengaged one second later. The light is then completed the last time after 22 minutes and 29 seconds had elapsed. On 6/21/22 at 11:00 a.m., Resident #96 was observed with his spouse in his room. The resident's spouse complained the aides were shorthanded. Resident #96's spouse said there were times when the call light was not answered for 15 minutes or more. She said this usually occurred during mealtimes when staff are assisting residents with meals. She said the response time was worse on the weekend. Review the Patient Detailed Report for Resident #96's room showed on 6/20/22 Resident #94's call light was engaged at 6:15 p.m. and was not completed until 24 minutes and 45 seconds later. On 6/23/22 at approximately 11:00 a.m., the Director of Nursing (DON) said the light was going off and coming back on several times during the time Resident #94 was in the bathroom. The light was observed from 9:01 a. m., to 9:18 a.m., to continue to be engaged. The DON said Resident #94 was turning the call light on and off attempting to get assistance from staff. The DON said she had only been spot checking the call light response time. The DON said she was going to begin auditing the call light response time and initiate staff in-services to ensure all staff are aware the expectation of the facility is a call light response time of less than five minutes.

Based on record review, and interview the facility failed to complete a level one Pre Admission Screening and Resident Review (PASARR), and report significant mental illness changes to the appropriate state agencies (KEPRO) for 2 (Resident #10 and #25) of 3 residents reviewed with newly diagnosed psychiatric disorder. The findings included: Record review revealed Resident #10 was a [AGE] year-old female who was admitted to the facility on [DATE]. There was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10's cognition was moderately impaired. Resident #10 was taking an Antipsychotic medication six days a week. The active diagnoses listed included non Alzheimer's dementia, and anxiety disorder. On 2/23/22, the physician issued an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] revealed Resident #10 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/22/22 at 11:22 a.m., in an interview, Resident #10's nephew said he was never told his aunt had been diagnosed with [CONDITION(S)]. Resident #10's nephew said his aunt had had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's nephew said the facility had informed him that his aunt had a new antipsychotic medication because she was yelling out a lot. On 6/22/22, record review revealed no evidence a Level 1 PASARR was completed for Resident #10 when she was diagnosed with [CONDITION(S)]. On 6/22/22 at 10:52 a.m., the DON said all the residents in the facility are long term care and they usually have the same staff members working with them to identify if they have a new mental illness diagnosis. The DON said the Risk Manager would decide if a resident with a significant change in mental status was reported to the appropriate state agencies. The DON verified the facility did not have a system to identify residents with significant changes to their mental status and report the changes to the appropriate state agency. On 6/22/22 at 11:54 a.m., the Social Service Director said she could not complete a level one PASSAR because she was not a Registered Nurse (RN). The Social Worker said the only staff member who completed the Level one PASARR's was the Staff Developer who is a RN. On 6/22/22 at 12:05 p.m., the Staff Developer said the Director of Nursing (DON) would be responsible to refer any resident with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Staff Developer said she had never completed a level one PASARR for and resident who had been diagnosed with a new mental illness while residing at the facility. On 6/23/22 at 9:47 a.m., in a telephone interview the Supervisor of Keystone Peer Review Organization Inc. (KEPRO), which is the state agency responsible for reviewing changes to resident's mental health status, said if while residing at a nursing home facility a resident receives a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident Review Evaluation form dated 6/23/22 revealed Resident #10 had previously never had a level two PASARR determination. The Resident Review Documented Resident #10 had an increase in behavioral, psychiatric, or mood-related symptoms. The documentation revealed Resident #25 has had Behavioral, psychiatric, or mood related symptoms that have not responded adequately to on-going treatment. On 6/23/22 at 10:54 a.m., the DON and the Social Worker verified the facility currently did not have a system in place to report changes in mental health to KEPRO for residents after they are admitted to the facility. 2. Review of The Annual MDS assessment dated [DATE] revealed Resident #25 was rarely understood and is moderately cognitively impaired. Section I of the MDS shows Resident #25 was diagnosed with Non-Alzheimer's Dementia, Depression and [CONDITION(S)] Disorder. The MDS revealed Resident #25 was receiving an antipsychotic medication seven days a week. The Quarterly MDS assessment dated [DATE] revealed Resident #25 was rarely understood and moderately impaired mentally. Resident #25 was receiving an antipsychotic medication seven days a week. Resident #25 had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/22/22, record review revealed no evidence a Level 1 PASARR was completed for Resident #25 when he was diagnosed with [CONDITION(S)]. On 6/23/22 at 10:54 a.m., the DON and the Social Worker verified the facility currently did not have a system in place to report changes in mental health to KEPRO for residents after they were admitted to the facility.

Based on record review and interview the facility failed to ensure a [CONDITION(S)] (medication that affects brain activity) as needed medication (PRN) had a fixed duration of time for 1 (Resident #10) of 5 residents reviewed for unnecessary medications. The findings included: Review of the monthly pharmacy review for Resident #10 revealed a pharmacy recommendation printed on 4/12/22 to the physician that read, [MEDICATION(S)] 1 mg [milligram] by mouth every 4 hours as needed for severe anxiety. (Since 3/22/22). The new Mega Rule guidelines require PRN psychoactive orders to have a duration of 14 days for the initial order. Then the resident should be seen by the prescriber who may reorder the medication for a fixed duration after fully documenting the need for the medication by the resident. There was no documentation in Resident #10's medical record the as needed [MEDICATION(S)] was changed and no documentation from the physician of the benefit of the [MEDICATION(S)] or the set duration of the medication. The order for the PRN [MEDICATION(S)] remained in place. The monthly pharmacy recommendation printed on 6/7/22 read, [MEDICATION(S)] 1 mg [milligram] by mouth every 4 hours as needed for severe anxiety. (Since 3/22/22). The new Mega Rule guidelines require PRN psychoactive orders to have a duration of 14 days for the initial order. Then the resident should be seen by the prescriber who may reorder the medication for a fixed duration after fully documenting the need for the medication by the resident. The Practitioner documented on 6/16/2022 to continue the orders as the resident was under hospice care and continued to require the medication for anxiety. The prescriber's response did not document a set duration for the PRN medication. Another pharmacy recommendation for Resident #10 printed on 6/22/22 noted, [MEDICATION(S)] 1 mg by mouth every 4 hours as needed for severe anxiety. (Since 3/22/22). The new Mega Rule guidelines require PRN psychoactive orders to have a duration of 14 days for the initial order. Then the resident should be seen by the prescriber who may reorder the medication for a fixed duration after fully documenting the need for the medication by the resident. On 6/22/22 at 2:30 p.m., the Consultant Pharmacist said he had been making monthly referrals to the physician to write an order for changing the as needed [MEDICATION(S)] order for Resident #10 since April of 2022. The Pharmacist verified there had been no change to the as needed [MEDICATION(S)] order since March of 2022.

Based on record review, and interview, the facility failed to ensure an orderly hospital transfer by not including advance directives with the transfer documentation for 1 (Resident #1) of 3 Residents reviewed. The facility failed to include Resident #1's Do Not Resuscitate Order (DNRO) in the hospital transfer information. This resulted in Emergency Medical Services (EMS) resuscitating Resident #1 in the ambulance because they did not know the resident did not wish to be resuscitated. Resident #1 underwent lifesaving/prolonging medical procedures against the residents wishes before death. This resulted in a likelihood of serious psychosocial harm to Resident #1. This failure had the potential to affect all residents with Do Not Resuscitate Orders. On [DATE] at 9:11 a.m., the Administrator was informed of the Immediate Jeopardy (IJ) and provided with the IJ Template. The Immediate Jeopardy had started on [DATE]. The Immediate Jeopardy was removed on [DATE] and the scope and severity was lowered to a D. The facility's noncompliance at F624 was corrected on [DATE] and determined to be past noncompliance when the facility had fully implemented corrective actions, prior to the complaint survey. The findings included: Review of Resident #1's advance directives revealed on [DATE] the resident signed a Do Not Resuscitate Order (DNRO) form directing that CardioPulmonary Resuscitation (CPR) be withheld or withdrawn. The attending physician signed the DNRO form on [DATE] directing the withholding or withdrawing of CPR including artificial ventilation, cardiac compression, endotracheal intubation and defibrillation from the patient in the event of the patient's cardiac or respiratory arrest. Review of Resident #1's record revealed an original admission date of [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident needed limited assistance with all ADLs (Activities of Daily Living), including toileting and a BIMs (Brief Interview for Mental Status) score at 15 which indicated the resident was cognitively intact. The [DIAGNOSES REDACTED]. The resident was [AGE] years old. On [DATE] at 15:45, Licensed Practical Nurse (LPN) Staff A documented for Resident #1 documented, CNA (Certified Nursing Assistant Staff C) responded to bathroom call light. Found res (resident) sitting against commode, blood on left side of head and on neck/shirt collar. There was smeared blood on the underside of the porcelain sink, drops of blood on floor to the left of the sink. 911 called, arrived at 4:05 (p.m.), assessed res. (resident), placed him on monitor, HR (heart rate) drifted down from 59 to 33, radial pulse 33. Amb (ambulance) arrived 4:20 (p.m.), res (resident) agreed to go to (name of hospital), he got on the stretcher, EKG/monitor on, left floor @ 4:30 p.m. The resident's description documented, I fell and have been sitting here for an hour yelling for help. Pointing to his watch, I fell @ 3:45 & it's 4:45 now. (actual time (of the note) was 3:49.) The note showed EMS arrived at 4:20, but the Neurological Assessment Flow Sheet showed the resident was being attended to by EMTs (Emergency Medical Technicians) at 4:15 p.m. and on the heart monitor. Only 1 neuro-check was completed at 4:00 p.m. Review of EMS Prehospital Care report dated [DATE] specified, At contact the patient was sitting upright within a wheelchair. The patient was alert and a weak irregular radial pulse and displayed no acute respiratory distress . the patient was noted [MEDICAL CONDITION] (slow heart rate) with a 3rd degree heart block. Transcutaneous pacing was initiated (series of electrical shocks through the chest wall) . the patient went unresponsive and apneic (absence of breathing) . the resident was then intubated (breathing tube placed). Review of the hospital progress notes revealed on [DATE] the physician documented Resident #1 presented from the facility after a witnessed syncopal hitting his head. He was unconscious and in a bradycardic (slow heart rate) rhythm. On arrival EMS intubated him and paced (applied a cardiac pacer to pace the heart) pt. (patient). Once his daughter arrived at the emergency room , she was able to convey that he had a DNR request that the intubation and pacemaker be removed. Once removed patient has agonal rhythm (lack of electrical activity in the heart/flatline) with long periods of apnea (not breathing). He will be admitted for Hospice care. Re-Evaluation/Progress #1 note documented Patient's daughter/healthcare power-of-attorney is now present still upholding the DNR, . she expresses understanding and agreement to what CMO (Comfort Measures Only) means and that patient will likely die as a result of this which based on her accounting of the family history was his wish not to be put through pain at the end of his life . additional discharge routines: dc (discontinue) to hospice for comfort care measures. On [DATE] at 8:50 a.m., during a telephone interview with Resident #1's daughter said she saw Bay Village called and left a message that they sent her father to the hospital. When she got to the hospital, he had already been intubated by EMS. She went to Trauma 1 and told them to extubate him because he would not want it. She provided the Do Not Resuscitate (DNR), so they extubated him after sedating him. She had him sent to hospice where he lasted for 6 days so the family got to see him before he passed which was a blessing. She was a case manager at the hospital for many years but retired due to COVID (Coronavirus Disease 2019) concerns. She does believe he was right about the amount of time he was on the floor because he always wore his watch. A Review of LPN Staff A's written statement dated [DATE] documented, I don't recall pulling code status. On [DATE] at 3:48 p.m., during a telephone interview, LPN Staff A said she did not have anything else to add to her written statement except that her immediate supervisor and evening supervisor were there when the incident happened. She said she had sent many residents out to the hospital in the past and this time it was just an oversight. She said there was no official checklist to use or specific training process for what to include in the transfer packet. On [DATE] at 11:53 a.m., during an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) they confirmed that on [DATE], LPN Staff A gathered information to send with EMS. While he was in the ambulance, he became unresponsive and was intubated. On [DATE], the Assistant Director of Nursing (ADON) called the family to check on how the resident was doing. The daughter told the ADON that EMS had intubated him, and that EMS did not know he had a DNR (Do Not Resuscitate) order. On [DATE] at 1:47 p.m. during interview with the DON, she said the nurses were required to gather the appropriate paperwork when transferring a resident to the hospital including face sheet, transfer form, advance directives, MD orders, and COVID Transfer sheet. However, the information could have been pulled by one or multiple nurses and there was no checklist to ensure all required information was in the transfer packet. The facility's policy titled Transfer or Discharge, Emergency revised [DATE] noted Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident . The policy for Advance Directives revised [DATE] noted Advance directives will be respected in accordance with state law and facility policy. Informing Emergency Medical Personnel of Resident's Advance Directives . The Nurse in charge of resident will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. The facility submitted an acceptable IJ Removal Plan on [DATE]. The following immediate actions were verified onsite: · 100% audit of Advanced Directives on [DATE]. Information with no issues reported to Director of Health Services (DHS) on [DATE]. · Advanced Directive Policy reviewed and up dated to clarify the nurse responsible for the resident is the person to gather the transfer paperwork including the DNR/Advanced Directive paperwork. · Education for the nurse on the transfer process began on [DATE] by the DHS, Assistant Director of Health Services (ADHS) , and Nurse Educator from [DATE] to [DATE]. · Additional Advance Directive training for the nurses was completed from [DATE] to [DATE]. · The teachable moment, effective date: [DATE], from: DON, Topic: Advance Directives/Hospital transfers included the process for sending resident to hospital, it is important that advance directives are sent with resident. The steps should be taken for all transfers. It is important that all information is sent with resident, including advance directives, medication lists, and face sheet. Families must also be notified of transfer. A nurse's not stating the information you sent with EMS and the family member you spoke to. Only one person should be assigned to complete the paperwork task, this will prevent any confusion on responsibilities. Transfer form filed in with as much details possible, most recent vital signs Face Sheet Medication summary, make sure you highlight/document already taken medications 4. DNR if applicable 5. Advance Directives/living will 6. Most recent labs/x-rays/ultrasounds .if applicable 7. H & P if applicable or last MD note 8. COVID-19 transfer form. All staff (nurses) must complete the advance directive module in Realis (a computer-based training) by [DATE]. The facility took the following further corrective actions to put F624 into substantial compliance: · Newly hired nurses will be educated on the transfer process by the Nurse Educator and by the nurse they shadow on the floor. · Ongoing training will continue quarterly. · A plan of correction was initiated on [DATE]. · A Hospital Transfer Checklist was developed and implemented on [DATE]. The transfer list is included in each transfer packet and a copy of the form completed by the nurse will be provided to the DHS. · Audit of Transfer Checklists was begun on [DATE]. · Social Worker to continue audits of Advance Directives. Begun on [DATE] through [DATE] showed 100% completion. · Hospital Transfer Checklists given to the DHS are checked against the Hospital Transfer Log. Results are provided to Quality Assurance Committee Meeting (QACM). · Social Worker audits of Advanced Directives are logged on the Comprehensive Capacity Code Status Audit Tool and reported to QACM. · Non-compliance of any audit will initiate an ad hoc QACM to review an plan of action and root cause analysis. · The adverse event, plan of correction, education, hospital transfer checklist audits, new admission and advanced directive audits were discussed at the [DATE] QAC monthly meeting.

Based on record review, observation, and staff interview, the facility failed to follow physician orders, to promote healing of a pressure ulcer for 1 (Resident #30) of 3 residents reviewed for pressure ulcers. The findings included: Review of the facility's policy for Pressure Ulcers/Skin Breakdown (undated) read the physician . will order pertinent wound treatments, including pressure reduction surfaces . Review of the facility's policy and procedure on Skin Evaluations (effective date 6/10/19) read 3. Licensed wound care nurse, RN or ARNP will review to ensure necessary treatments are implemented. 5. Any resident with a prescribed positioning or medical device will have a CMS (Color, Movement, Sensation) tool initiated for further evaluation of skin to prevent potential impairment. Review of the Minimum Data Set (tool used to assess and plan care) dated 11/5/20 showed Resident #30 was at risk of pressure ulcers/injuries. Review of the clinical record showed on 11/19/20 Resident #30 developed a stage II pressure ulcer (ulcer that expands into deep layers of the skin). A physician order [REDACTED]. On 12/14/20 review of Resident #30's treatment administration record from 11/19/20 through 11/30/20 and from 12/1/20 through 12/14/20 showed daily documentation the Specialty Mattress for Bed Gel Overlay was in place. Review of the skin evaluation form dated 12/14/20 revealed documentation Wound to left posterior thigh resurfaced with [MEDICATION NAME] tissue, area closed, resolved, skin is dry, smal (sic) scab present. APRN (Advanced Practice Registered Nurse) informed . Will continue skin prep to area X 10 days preventative. On 12/14/20 at 10:02 a.m., Resident #30 was observed in his room, with no overlaying gel mattress on his bed. On 12/15/20 at 11:14 a.m., Resident #30 was observed in his room, with no overlaying gel mattress on his bed. On 12/15/20 at 11:19 a.m., during an interview Registered Nurse (RN) Staff K said Resident #30 was ordered a pressure relieving gel overlay. On 12/15/20 at 11:26 a.m., observed Resident #30's bed with RN Staff K. Staff K confirmed the gel overlay was not in place. On 12/15/20 at 11:36 a.m., during an interview RN Supervisor Staff L said Resident #30 was at risk for skin breakdown. RN Supervisor Staff L confirmed Resident #30 did not have the ordered gel overlay in place. On 12/15/20 at 1:30 p.m., observation of the resident's skin done with RN Staff K and RN Staff L revealed a dark red dime size spot with peri wound denuded.

Based on observation, record review, resident and staff interview the facility failed to provided care and treatment to prevent pressure ulcers for 1 (Resident #37) of 1 resident reviewed for pressure ulcers. Due to a delay of 9 days for an assessment by a qualified Registered Nurse (RN), appropriate assessments, preventive measures and monitoring were not put in place. This resulted in harm to the resident who developed three pressure ulcers, one of which required a higher level of care. The findings included: The policy for admission assessment dated 2001 (revised 2012) included: contain list of active medical diagnoses, especially those most related to the reasons for admission to the facility. Contact attending physician, communicate and review the findings, and obtain admission orders [REDACTED]. The policy for Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 2001 (revised (YEAR)) included: Assess and document significant risk factors for developing pressure ulcers including immobility and history of pressure ulcers. The staff and practitioner will examine the skin of newly admitted residents. On 5/20/19 at 1:46 p.m., Resident #37 was observed with a large air boot on her right lower leg. The resident said she got a big sore on her leg from a splint she had on her leg. Resident #37 said she had an area on her buttocks they were treating and also had an issue with her heel. Resident #37 was admitted to the facility from a hospital on [DATE]. The current [DIAGNOSES REDACTED]. The resident also had a recent history of vascular surgery on her right leg to improve flow of blood to her lower leg. Resident #37 then fell and fractured her right lower leg and was admitted to the facility for further care. Resident #37 was admitted with a full leg immobilizer to her right leg that was to be kept on at all times, but could be removed for care and services. Review of Resident #37's full body admission skin assessment done by a Licensed Practical Nurse (LPN) on 2/11/19 documented no pressure areas were identified at that time. Record review of skin evaluation form completed on 2/20/19, (nine days after admission) documented that LPN Staff J found scattered areas of deep dark purple skin on sacrum with areas of broken skin. The Advanced Registered Nurse Practitioner (ARNP) in the facility classified area on sacrum as a deep tissue injury (DTI) with scattered area on sacrum of deep dark purple nonblanchable skin. The ARNP documented Resident #37 had deep dark nonblanchable intact skin to right posterior lower leg from immobilizer and a DTI on right heel. In an interview on 5/22/19 at 12:03 p.m., the Director of Health Services acknowledged the resident did not have any pressure ulcers on admission. The Director of Health Services could not produce any documentation the facility was offloading resident's right heel, turning her, or checking her skin under the immobilizer from the time of admission until the Wound Nurse LPN Staff J did her first assessment on the resident (9 days after admission). On review of documentation of the resident's history and her severe [MEDICAL CONDITION], the Director of Health Services agreed the resident was at high risk for development of pressure ulcers on admission. She acknowledged the order said to remove immobilizer for care and services and acknowledged there was no RN assessment of the skin at the time of admission. In an interview on 5/23/19 at 10:39 a.m., LPN Staff J, said she was working as the wound care nurse in the facility when Resident #37 was admitted . She said she did not see Resident #37 until 9 days after she came in. She was not able to find any prior documentation of skin monitoring, offloading resident's right heel or a positioning schedule. Record review of the vascular specialist's follow-up visit on 2/22/19 documented post multiple angioplasties to right leg, the intervention appeared patent, her perfusion to the right leg was reasonable. The vascular specialist said he believed it was safe for her to wear a foot/ankle brace. Doctor noted resident now had a foot drop and her rehabilitation facility was not applying a foot/ankle brace. Doctor also noted resident had posterior right leg pain. No evidence of documentation that vascular specialist was made aware of the wound care nurse and ARNP's finding in regards to the deep tissue injuries found on the back of resident right leg and right heel. Record review of vascular specialist follow-up visit on 4/26/19 revealed no documentation he was notified the resident developed a wound on her right posterior calf. He wrote that this was a pressure issue from her previously placed immobilizer in her medical management of her tibia-fibular fracture. He documented the wound as approximately 5x3 centimeters (cm) on posterior calf with exposed muscle and tendon. He wrote the significant ulceration to her posterior calf, unfortunately, on review of her previous angiogram, she did not have any posterior tibial flow. Doctor said that he was concerned that this may be a wound that may not heal. He recommended a wound care center. He wrote I'm concerned that she is at high risk of limb loss. Record review of the wound care center note from the first visit dated 5/1/19 documented Resident #37 wound was currently classified as a category/Stage IV wound with etiology of pressure ulcer and was located on the right posterior lower leg. The wound measured 6.4 cm length x 2.4 cm width x 0.3 cm depth. There was fascia exposed. There was a medium amount of purulent drainage noted. The wound margin was thickened. Wound care ARNP then did debridement at this visit. No observation of wound during survey, all wound care done at wound care center. In a phone interview, on 5/23/19 at 2:05 p.m., Resident #37's vascular surgeon said he was unaware the facility was not removing the immobilizer to check the skin underneath. He said that if they would have then perhaps the pressure ulcer would not have gotten to the point it was now. He said he could not say the pressure ulcer was unavoidable. He was unaware that the facility did not have skin monitoring in place.

Based on observation, record review, policy review and staff interview, the facility failed to ensure appropriate alternatives were attempted prior to use of bed rails for 7 (Residents #13, #14, #23, #48, #305, #306, #309) of 18 residents reviewed for accidents. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: On 5/23/19, review of facility Policy titled Side Rails, Policy NO: 3.11 (FL) adopted 11/28/17 noted The facility will use appropriate alternatives prior to installing a side or bed rail. On 5/21/19 at 9:18 a.m., bilateral upper bed rails were noted in the up position on the bed of Resident #13. On 5/23/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #13. On 5/20/19 at 11:45 a.m., bilateral upper bed rails were noted in the up position on the bed of Resident #23. On 5/23/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #23. On 5/21/19 at 1:44 p.m., bilateral upper bed rails were noted in the up position on the bed of Resident #48. On 5/23/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #48. On 5/20/19, bilateral upper bed rails were noted in the upper position on the bed of Resident #14. Record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #14. On 5/20/19, bilateral upper bed rails were noted in the upper position on the bed of Resident #305. Record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #305. On 5/20/19, bilateral upper bed rails were noted in the upper position on the bed of Resident #306. Record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #306. On 5/20/19, bilateral upper bed rails were noted in the upper position on the bed of Resident #309. Record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #309. On 5/23/19 at 10:41a.m., the Director of Health Services was unable to show documented evidence alternatives were attempted prior to the installation and use of bed rails on the beds of Residents #13, #14, #23, #48, #305, #306, and #309.

Based on observation, staff interview and record review, the facility failed to implement an infection control program to maintain a sanitary environment in regards to cleaning and disinfecting shared resident-care equipment. Five assist to stand mechanical lifts were found to be in unsanitary condition. This had the potential for cross contamination and spreading of infections. The findings included: During observations of residents on 5/21/19 at 3:04 p.m., five mechanical assist to stand lifts (Sara lift) were found to be dirty with grimy debris and residue on the foot pads, knee pad and frame. (pictures) The lifts were parked against the wall at the end of the Magnolia corridor. An observation of the lifts was conducted on 5/21/19 at 3:14 p.m., with the acting Assistant Director of Health Services (ADHS) and the Housekeeping Supervisor. The Sara lifts were examined and found to be dirty with grimy debris and residue on the foot pads, knee pads and frames. The ADHS acknowledged the Sara lifts are not clean. He also concurred the lifts should be disinfected between uses. The Housekeeping Supervisor said he there is not a schedule for thoroughly cleaning the lifts. A review of the facility policies and procedures found there was no policy for the thorough cleaning of durable medical equipment. In an interview on 5/22/19 at 6:52 a.m., the Housekeeping Supervisor said staff cleaned all of the lift, however, there is no schedule for regular thorough cleaning of the lifts. He said he will involve the infection control nurse in developing a policy and schedule. In an interview on 5/22/19 at 8:20 a.m., the Director of Health Services said the facility has a policy to wipe down equipment with a disinfectant between uses but there is no policy for thorough cleaning.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 2 (Residents #55 and #37) of 7 residents MDS assessments reviewed. Inaccurate coding could lead to improper assessment and lack of appropriate care planning. The findings included: 1. On 5/23/19, a closed record for Resident #55 was reviewed for hospitalization . Review of progress notes revealed Resident 55 was admitted [DATE] following surgery to the left knee for short term rehabilitation and was subsequently discharged to home on 3/10/19. No hospitalization s occurred during this time. A review of the MDS completed on 3/10/19 was coded as resident discharged to hospital. On 5/23/19 at 9:50 a.m., the MDS Coordinator said Resident #55 was discharged to home and this was an error in coding. 2. On 5/22/19 at 3:02 p.m., MDS Coordinator coded the day 14 MDS assessment for Resident #37. She said the resident did not have any pressure ulcers on admission On review of the MDS documentation from 2/25/19, the resident was coded as having three areas of suspected deep tissue injury (DTI). She acknowledged she incorrectly coded the resident had one stage 1 and two DTI on admission. The MDS Coordinator confirmed there were no pressure ulcers on admission. She reviewed her next assessment on 3/12/19, which was also was coded incorrectly as one stage 2 pressure ulcer that was present on admission. The MDS assessment dated [DATE], coded Resident #37 as having two Venous and Arterial ulcers. This was inaccurate. The MDS coordinator agreed the coding was innaccurate. The MDS assessment dated [DATE], coded Resident #37 as having no pressure ulcers. The vascular surgeon documented on 4/26/19 Resident #37 had a pressure wound on her right posterior leg caused by the immobilizer. The MDS assessment dated [DATE], coded Resident #37 had no pressure ulcers. On 5/1/19, the vascular surgeon and the wound care Advanced Registered Nurse Practitioner note documented a stage 4 pressure ulcer on the posterior right leg.

Based on record review and staff interview, the facility failed to create an individualized care plan for behaviors for 1 (Resident #9) of 5 residents behavior care plans reviewed. This had the potential to lead to behaviors not being addressed in the proper manner. The findings included: On 5/22/19, review of the quarterly Minimum Data Set with an Assessment Reference Date of 2/27/19 for Resident #9 revealed a Brief Interview for Mental Status (BIMS) score of zero which meant the interview was not able to be conducted because Resident #9 was rarely/never understood. On 5/22/19, review of the behavior care plan for Resident #9 noted I have periods of confusion, frustration and I am resistant to care at times. I have a behavior of crying out and screaming. Some of the interventions included; Please educate me on the benefits from following my MD (Medical Director} orders, Please re-educate me about the use of the sling and broad chair for my comfort. Neither intervention was appropriate for a resident with a BIMS score of zero and was not individualized to assist in dealing with the identified behaviors of crying out and screaming. On 5/22/19 at approximately 1:30 p.m., the Director of Health Services confirmed some of the interventions on the behavior care plan for Resident #9 were not appropriate or individualized for assisting to deal with the identified behaviors.

Based on record review and staff interview, the facility failed to ensure a performance review of every Certified Nursing Assistant (CNA) was conducted every 12 months for 1 (Staff F) of 5 CNA's reviewed. This did not allow the facility to identify areas of weakness that needed to be addressed through in-service education. The findings included: On 5/22/19, record review of CNA Staff F revealed a date of hire of 4/15/15. There was no documented evidence a performance review was completed between 4/15/18 and 4/15/19. On 5/22/19 at 11:01 a.m., the Staff Development Coordinator confirmed a performance review had not been completed and said Staff F who worked PRN (worked on an as needed basis) and the facility did not complete performance reviews for PRN employees.

Based on observation and staff interview, the facility failed to ensure dignity was provided by not covering the urinary catheter bag for 1 (Resident #13) of 1 resident reviewed for dignity. The findings included: On 5/20/19 at 3:11 p.m., observation revealed Resident #13 lying in bed with an uncovered urinary drainage bag attached to the bed. On 5/21/19 at 9:15 a.m., observation revealed Resident #13 lying in bed with an uncovered urinary drainage bag attached to the bed. On 5/21/19 at 1:15 p.m., observation revealed Resident #13 lying in bed with an uncovered urinary drainage bag attached to the bed. On 5/21/19 at 2:46 p.m., Licensed Practical Nurse Staff A confirmed the urinary catheter bag for Resident #13 was not covered. ** Pictures on file **

Based on observation, record review, staff interview, and review of policy and procedures, the facility failed to comprehensively assess, develop a care plan for, and implement interventions to prevent the development of a pressure ulcer for 1 (Resident #176) of 2 residents with pressure ulcers of 24 stage 2 sampled residents. This failure caused the development of an unstageable pressure ulcer to the resident's coccyx. The findings included: 1. Review of the facility policy entitled Prevention of Pressure Ulcers, (revised 2013) included: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or decreased circulation (blood flow) to that area of subsequent destruction of tissue. 6. The facility should have system/procedures to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Intervention and Prevention Measures: General: 1. Identify risk factors for pressure ulcer development. 2. For a person in bed: a. Change positions at least every two hours or more frequently if needed. b. Determine if the resident needs a special mattress per bed selection algorithm. 3. For a person in a chair: a. Change position at least every hour: and b. Use a foam, gel, or air cushion as indicated to relieve pressure. Resident #176 was admitted to the facility on [DATE] from the hospital with a [DIAGNOSES REDACTED]. Review of the Admission - Initial Assessment + Plan showed Resident #176 needed assistance with ambulation and toileting and used a walker at the time of admission. A record review of form Braden Scale For Predicting Pressure Sore Risk completed on 2/1/17 by a Licensed Practical Nurse (LPN) showed Resident #176 with a score of 21. This score indicated the resident was not at risk for developing a pressure ulcer. The same form completed on 5/15/17 showed Resident #176 with the same score. Review of the Minimum Data Set (MDS) assessment dated [DATE] showed during the first eight days of Resident #176's stay at the facility, she needed extensive assistance of two people for bed mobility and extensive assistance of 1 person for transfers. When ambulating in her room, she required 2 people to assist her. During the first eight days of admission, Resident #176 did not ambulate outside of her room. Record review of the MDS dated [DATE] documented Resident #176's impaired mobility. The MDS failed to note Resident #176 was at risk for developing a pressure ulcer. The MDS showed there was no pressure-relieving device for the resident's chair, she was not on a turning and repositioning program, and there were no interventions for nutrition or hydration. On 5/17/17 at 3:17 p.m., the Director of Nursing (DON) said on 5/16/17 she had re-assessed Resident #176's Braden Scale and obtained a score of 17, which indicated the resident at risk for developing a pressure ulcer. The DON verified the initial Braden score was not accurate. The DON verified a care plan for being at risk for pressure ulcers should have been initiated on 2/8/17. Record review of the resident's MDS dated [DATE] had triggered the development of a care plan for pressure ulcer risk. Staff F and the MDS Coordinator documented, (Resident #176) has required extensive assistance for bed mobility. She has a fractured humerus. Will proceed to care plan for pressure ulcer risk. Record review of Resident # 176's care plan revealed no care plan had been initiated for risk of development of a pressure sore on 2/8/17. On 5/17/17 at 11:06 a.m., during an interview the MDS Coordinator/LPN Staff F said Resident #176 was only ambulating in her room with assistance from staff when she was going to the toilet. Staff F verified the resident spent most of her time in bed or in the chair. Staff F said Resident #176 would have been at risk for developing a pressure ulcer when she was assessed on 2/8/17. Staff F said she had documented on the 2/8/17 MDS Resident #176 was not at risk for developing pressure ulcers because she felt the resident would improve in her mobility since the resident was receiving physical therapy. Staff F verified a care plan for risk of pressure ulcers was not initiated for Resident #176 on 2/8/17. On 5/17/17 at 11:30 a.m., Resident #176 was observed in a recliner next to her bed with her legs elevated. Her ankles were swollen. Resident #176 said she developed a pressure ulcer after she was admitted to the facility on [DATE] because she was not moving a lot on her own. She said staff did not talk to her about the risk of developing a pressure sore or how the wound had developed. When asked about her pain, Resident #176 stated, (her butt) hurts from sitting. On 5/17/17 at 11:59 a.m., LPN Staff H said Resident #176 developed a pressure ulcer about a month after being admitted to the facility due to a lack of activity and sitting for too long. LPN Staff F said she did not remember any special interventions in place to prevent Resident #176 from developing a pressure ulcer. Record review of the weekly skin checks showed there were no weekly skin assessments completed for Resident #176 from 2/7/17 to 2/21/17. On 2/21/17, a skin assessment noted, Open area to coccyx, duoderm in place. Wound Dr. will address tomorrow. During an interview on 5/17/17 at 2:49 p.m., LPN Staff A said she would usually do skin checks on residents in the facility every Tuesday. LPN Staff A verified there were no skin checks documented from 2/7/17 to 2/20/17. On 2/22/17, the wound physician documented an unstageable pressure ulcer 1.2 inches in width x 0.7 inches in length x 0.2 centimeters in depth with 80% necrotic tissue. The documentation showed the wound was debrided on 2/22/17. On 5/18/17 at 11:30 a.m., observed a pressure ulcer directly over the coccyx area of Resident #176 approximately 1/2 centimeter in diameter. The wound had a yellow color in the center with granulated tissue on the edges. There was no drainage from the wound. There was partial erosion of the skin on the sacrum and both buttocks with redness and scabbing. The facility did not provide care to prevent the development of a pressure ulcer.