Every finding on record at Bayside Health and Rehabilitation Center

Based on observations and interviews, the facility failed to maintain dry food and disposable food supplies in the kitchen storage room in a clean, dry, and sanitary environment. On 08/06/26 at approximately 12:45 PM, a tour of the kitchen dry food storage room entrance area revealed an unknown black substance in the ceiling tiles and on the wall behind the door, with an unknown orange substance on the metal ceiling grid. Water was observed dripping from the ceiling. At 12:57 PM, while exiting the kitchen dry food storage, another area of water dripping from the ceiling was observed. An approximately 3x3 section of white plywood screwed into the ceiling was discolored with water pooling and dripping from the ceiling. On 08/06/26 at approximately 12:57 PM, an interview with the Dietary Manager regarding the dry food storage area revealed that they are always mopping in this area. On 08/06/26 at approximately 1:00 PM, an observation of two dry food storage areas outside behind the facility were conducted. The smaller storage area shed front doors were broken at the bottom of the door, leaving an approximately 2-inch gap exposing water bottles, water bladders, and disposable styrofoam boxes to weather and pests. The large storage shed has two sets of doors, with one set of barn wood doors with a crack approximately 12 inches long in height, exposing the contents to weather, rodents, or other pests. The back of this shed's ceiling has an area that was wet and was dark with an unknown black substance. Water was observed dripping from the area onto kitchen equipment, food trays, cases of bottled water, heat lamp and sealed disposable Styrofoam food bowls. On 08/06/26 at approximately 1:10 PM, an interview with the Dietary Manager was performed concerning these concerns. The manager was not aware of these issues but confirmed the ceiling is leaking with an unknown black substance, doors were broken, and a box of styrofoam bowls that were in a plastic bag were wet.

Based on observation, interview and policy review, the facility failed to ensure a functioning resident call light system was readily accessible to 2 of 4 sampled residents in a shared bathroom. The call light cord was missing, and the call system could not be activated from the floor, creating the potential for delayed assistance in the event of a fall or other need for staff assistance. (Residents #65 and #70)On 8/4/26 at approximately 9:20 AM an observation of the shared bathroom used by Resident #65 and #70 revealed the resident call light cord was missing from the area adjacent to the toilet. The call light could not be activated from the floor in the event a resident fell and was unable to reach the wall-mounted call light.On 8/4/26 at approximately 10:00 AM, an interview was conducted with Employee E, Certified Nursing Assistant (CNA). Employee E confirmed residents should have access to a call light cord while using the bathroom and stated, I will notify maintenance to repair the cord.On 8/4/26 at approximately 10:30 AM, an interview was conducted with Employee P, Licensed Practical Nurse (LPN). Employee P confirmed there should be a functioning call light in each bathroom for residents to summon staff assistance and stated I will contact maintenance to get a cord placed in the bathroom.On 8/6/26 at approximately 10:00 AM, an interview and walk-through were conducted with the Maintenance Director. The Maintenance Director confirmed there was no call light cord by the toilet in the shared bathroom and stated a replacement cord was required. The Maintenance Director stated staff are expected to submit maintenance requests through TELLS, the facility's electronic maintenance/work-order system, when repairs are needed. The Maintenance Director stated he had not been notified of the missing call light cord prior to staff just now bringing the concern to his attention. The call light cord remained unavailable at the time of the 8/6/26 observation. (Photographic Evidence Obtained)

Based on observations, interviews, and record reviews, the facility failed to ensure infection control standards were maintained for vascular access devices in 1 of 1 residents reviewed. (Resident #68) The findings include: On 08/03/2026 at 11:45 AM, an observation of Resident #68 was completed. Resident #68 had a transparent dressing over the midline intravenous catheter in the upper right arm. The dressing was not dated, the edges on two sides of the transparent dressing were loosened and rolling inward and no longer in contact with the skin. On 08/04/2026 at 09:45 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nurses change the dressings on midline intravenous catheters as ordered and are supposed to write the date on the dressing.08/05/2026 at 09:50 AM, an interview was conducted with the regional consultant nurse and interim Director of Nursing (DON). The DON stated the expectation is that dressings placed over intravenous catheters will be dated and initialed by the nurse completing the dressing change and dressings will be changed per order and policy.On 08/05/2026 at 2:45 PM, a review of Resident #68's electronic medical record was completed. The provider entered an order on 07/24/2026 to change the midline catheter dressing weekly on Sundays. An entry in Resident #68's care plan dated 07/24/2026 reads to label dressings as per policy.The policy IV Policies and Procedures Manual, Catheter Insertion and Care (effective on 01/17/2019) reads, Place label on one side of catheter (not over insertion site). Include the date and time of catheter insertion and initials.The Centers for Disease Control (CDC) guidelines for the prevention of intravascular catheter-relation infections recommend changing transparent dressings every seven days or immediately if the dressing becomes damp, loosened, or visibly soiled.

Based on observation and interview, the facility failed to maintain a safe functional, sanitary, and comfortable environment when multiple resident rooms, and resident-use areas were observed damaged, deteriorated, unsecured, or unsanitary conditions in 8 of 64 rooms observed. (Rooms 210, 214, 216, 101, 226, 221, 207, and 211) The findings include: 1. On 8/4/26 at approximately 9:30 AM, an observation of room [ROOM NUMBER] revealed the front panel of a drawer on the built-in wall cabinet was broken and hanging downward. Observation also revealed the wall behind the bed was scuffed, with areas of chipped and scraped paint. 2. On 8/4/26 at approximately 9:45 AM, observation of room [ROOM NUMBER] revealed the air return vent grill was rusted and a section of the trim adjacent to the grille was not secured. Rust was observed on the bedframe. Observation of the bathroom floor revealed a broken tile. 3. On 8/4/26 at approximately 10:15 AM, observation of room [ROOM NUMBER] revealed the wall behind the bed was scuffed, with chipped and scraped paint and the wall trim/chair rail behind the bed was missing, leaving an unfinished area of the wall. 4. On 08/03/2026 at approximately 1:00 PM, an environmental observation of room [ROOM NUMBER] revealed a gallon of Clorox in the bathroom. The metal air conditioning shelf was noted to have visible rust. 5. During the observation on 8/6/26 at approximately 10:00 AM, room [ROOM NUMBER]'s dresser was scratched, heavily exposing the wood underneath the paint. 6. On 08/06/26 at 10:10 AM, an observation of room [ROOM NUMBER] revealed the wall behind the bed was scuffed. 7. On 8/6/26 at approximately 10:15 AM, an observation of room [ROOM NUMBER] revealed the wall behind the bed was scuffed, with chipped and scraped paint and the wall trim/chair rail behind the bed was missing, leaving an exposed torn sheetrock to an unfinished area of the wall. 8. On 8/6/26 at approximately 10:18 AM, an observation of room [ROOM NUMBER] revealed the wall behind the bed was scuffed, with chipped and scraped paint, the wall trim/chair rail behind the bed was missing, leaving a exposed torn sheetrock to an unfinished area of the wall. Also, the area underneath the window had chipped and scraped paint. On 8/6/26 at approximately 10:00 AM, an interview and walkthrough was conducted with the Maintenance Director. During the walkthrough, the Maintenance Director acknowledged the identified environmental conditions requiring repair or correction. (Photographic Evidence obtained of all above issues)

Based on observations and interviews, the facility failed to ensure medications were appropriately stored and inaccessible to residents for 1 of 27 residents reviewed. (Resident #85)The findings include: On 8/3/2026 at 1:00 pm, during an observation of Resident #85's room, a bottle of Vicks VapoRub was observed. When interviewed, Resident #85 stated that he experiences difficulty breathing at night and uses the Vicks VapoRub to help relieve his symptoms. Upon additional observation, Neosporin ointment was also observed in the room. (Photographic evidence obtained) A review of the orders for Resident #85 revealed no orders allowing for self-administration of medications On 8/4/2026 at 10:00 am, during a follow up observations of Resident #85's room, the Neosporin ointment was still at the bedside. However, the Vicks VapoRub had been removed. Resident #85 stated that he wanted the Vicks VapoRub available at night because it helped him breath better. On 8/4/2026 at 12:07 pm, Staff B, Licensed Practical Nurse, acknowledged that Resident #85 did not have an order allowing self-medication but the facility was attempting to obtain provider orders so the resident could keep over-the- counter medications at the bedside. Staff B removed the Vicks VapoRub from Resident #85's room. On 8/5/2026 at 10:30 am, during an observation of Resident #85's room, Neosporin ointment remained accessible on the windowsill.

Based on observation, resident and staff interviews, the facility failed to provide housekeeping and maintenance services to maintain a clean and sanitary environment for 9 of 9 rooms sampled for environment. (Rooms 112, 114, 115, 203, 207, 220, 228, 229, 230, resident #31's room and resident #71's room) The findings include: Resident #31's room and room [ROOM NUMBER] An observation of Resident #31's room was conducted on 3/11/2024 at 11:38 AM. The blinds to the window were noted to be broken with exposed edges. An interview with Resident #31 could not determine how long the blinds had been broken. An observation of the shared bathroom noted broken and stained tiles at the base of the toilet. (photographic evidence obtained) An observation of room [ROOM NUMBER] was conducted on 3/11/2024 at 11:56 AM. An observation of the shared bathroom noted a dirty shower chair, a dirty shower floor, and the room had an intense odor of urine. A tour on 3/13/2024 at 8:37 AM noted the same shower chair and also that the shower had not been cleaned and the smell of urine remained. A tour on 3/14/2024 at 8:15 AM noted the shower chair had been cleaned, but the floor remained dirty, and the intense smell of urine remained. (photographic evidence obtained) In an interview with the Assistant Director of Nursing 3/14/2024 at 10:53 AM, she concurred that the urine smell was intense in the room and the floors needed cleaning. 47306 rooms [ROOM NUMBER] On 3/11/2024 at approximately 11:22 AM, an observation of room [ROOM NUMBER] was conducted . Bed A was empty and had a fitted sheet in place with a cloth pad on top of the fitted sheet. The fitted sheet had a brownish red stain and the cloth pad was yellow stained. On 3/11/2024 at approximately 1:50 PM an observation was made of Resident #71's room. The bed was noted to have red and yellowish stains on the fitted sheet. The entire fitted sheet appeared dirty. On 3/11/2024 at approximately 1:55 PM, an interview was conducted with Resident #71, who was alert and oriented. The resident was asked how often the staff change his bed sheets. The resident stated maybe once a week. The resident indicated the last time he was assisted with a bath, the staff did not change his sheets. On 3/12/2024 at approximately 10:02 AM, an observation was made of room [ROOM NUMBER]. Bed A was noted to have a several reddish stains on the fitted sheet. (photographic evidence obtained) 44730 Rooms 220, 228, 229, and 230 On 3/11/24 and 3/12/24 observations were made of rooms 220, 228, 229, and 230. The following issues were noted: 1. In room [ROOM NUMBER], the wall behind the bed had molding missing. 2. In room [ROOM NUMBER], there was a hole in the wall than sunlight could be seen through. 3. In room [ROOM NUMBER], the walls behind bed B were noted with missing paint. 4. In room [ROOM NUMBER], a hole was noted in the wall beside the window as well as a hole in the wall beside the vents. On 3/11/24 at approximately 11:30 am, an observation was conducted of the 2nd floor dining room, and again at approximately 1:52 pm, where it was observed that the dining room was being used as additional storage of beds, wheelchairs and boxes. (Photographic evidence obtained) On 3/12/24 at approximately 11:30 am, an interview was conducted with the Director of Clinical Services, who indicated that the facility has gone through a couple of maintenance workers, and have hired a new Maintenance Supervisor as well as brought in as needed maintenance staff to get the building maintenance caught back up. On 3/12/24 at approximately 3:29 pm, an interview was conducted with the Administrator and Director of Clinical Services. The Administrator indicated that, during the weekend, the staff does not have access to the outside storage area and they moved some beds and things around and placed them in the 2nd floor dining area until they were able to move them out to the storage locker yesterday afternoon. The Director of Clinical Services confirmed the beds stored in the dining area over the weekend does not make for a home like environment for dining. The policy titled Environmental Services (dated March 2022) states, Policy: It is the primary responsibility of the Housekeeping, Laundry and Maintenance Departments to ensure a safe, sanitary, orderly and comfortable environment. Under Policy Interpretation and Implementation: 6. A safe, clean, comfortable and homelike environment will be provided.

Based on observations, interviews, and policy review, the facility failed to follow proper hand hygiene and food handling practices during 1 of 5 observation of the kitchen. The findings include: On 3/13/2024 at approximately 11:21 AM, Dietary Staff B was wearing disposable gloves and placing frozen chicken contained in a plastic bag onto a metal baking sheet. Dietary Staff B placed the last piece of frozen chicken onto the baking sheet and walked to the garbage can to dispose of the empty plastic bag. Dietary Staff B did not use the hands-free foot pedal on the garbage can and lifted the garbage can lid with her gloved hands. Dietary Staff B returned to the prepping area and opened a new bag of frozen chicken and began placing the chicken on the baking sheet after touching two other baking sheets. Dietary Staff B did not change her gloves or wash her hands after touching the garbage can lid surface. During the observation an interview was attempted, but Dietary Staff B did not respond to questions. On 3/13/2024 at approximately 11:25 AM, an interview was conducted with the Dietary Manager. The Dietary Manager was asked about the process for hand hygiene when touching a contaminated surface with gloves hands during food preparation. The Dietary Manager indicated the process is to remove the disposable gloves, wash hands with soap and warm water, and apply new disposable gloves before returning to preparing food. On 3/13/2024 a review of the facility's policies titled Handwashing and Principle of Safe Food Handling (dated November 2017) indicated, Dietary Personnel must perform appropriate handwashing procedures under the following conditions: after handling soiled, contaminated equipment. The policies also indicated Dietary Personnel are to wash their hands with warm water and soap for 20 seconds before and after handling food.

Based on observation, resident interview, staff interview and facility policy review, the facility failed to ensure proper storage of medications for 1 of 21 sampled residents (Resident #71). The findings include: On 3/11/24 at approximately 1:50 PM, medications and medication supplies were observed on the bedside table of Resident #71. No staff members were in the room. There was a 1 pound jar of Triamcinolone Acetonide Cream 0.1% sitting on the bedside table. On top of the jar was a 30 milliliter medicine cup containing a white substance. Also observed on the bedside table was an emesis basin containing a prefilled saline syringe, a multidose bottle of Artificial Tears eye drops, and 8 alcohol impregnated port protectors (used to cap off ports used for intravenous infusions). During the observation, an interview was conducted with Resident #71 regarding the medications and supplies observed on the bedside table. Resident #71 stated the emesis basin with the supplies just stays on my table for the staff to utilize. Resident #71 stated the nurses told him that he could apply the cream himself. He thought the cream was for his groin area, but stated he was unsure exactly where to apply it. Resident #71 stated he was capable of applying the cream if properly instructed, but would prefer if the nursing staff applied it. On 3/11/24 at approximately 1:57 PM, Licensed Practical Nurse (LPN) D entered Resident #71's room, and an interview was conducted regarding the storage of the medications, eye drops, saline pre-filled syringes, and alcohol impregnated port protectors. LPN D indicated the medications and supplies should be kept on the medication cart and was unaware of who left the medications and supplies on the resident's bedside table. LPN D disposed of the eye drops in the resident's trash can and removed the medications and supplies from the bedside table. On 3/11/24 at approximately 2:04 PM, an interview was conducted with Assistant Director of Nursing E (ADON E) who was asked if prefilled saline syringes are normally kept at the bedside. ADON E stated that this occurs only when the nurse is returning in a few minutes to flush the line. ADON E was asked if the eye drops, alcohol impregnated port protectors, and the anti-fungal cream should be left at the bedside. The ADON E indicated those items should not be at any bedside and that they should be kept on the medication cart. A review of the facility's policy titled, Storage of Medications, indicated drugs and biologicals are to be locked up when not in use, and trays or carts used to transport such items are not left unattended. The policy also indicated drugs and biologicals are stored in the containers in which they were received.

Based on record review, staff interview and policy review, the facility failed to ensure complete and accurate documentation on the Medication Administration Records (MARs) for for 1 of 5 residents sampled for unnecessary medication review. The findings include: A record review was conducted of Resident #49's medical record, which revealed an order written for premethrin external cream 5% (a cream often used to treat scabies) on 3/1/24. A review of the Electronic Medication Administration Record (EMAR) revealed the premethrin cream was scheduled to be given for 4 days from 3/1/24 - 3/4/24. However, there was no documentation of this cream being applied. On 3/13/24, an interview was conducted with the Director of Nursing (DON) at approximately 3:11 PM. The DON stated that she would expect this order to be documented. Later, she stated that she had followed up with the supervisor and confirmed that the resident did receive the medication. On 3/14/24 at approximately 3:02 pm, a follow up interview was conducted with the Director of Clinical Services, who confirmed that all administered medications should be documented. Review of the policy titled:Administration of Drugs dated October 2019 revealed, Policy: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. Under Policy Interpretation and Implementation: 4. Topical drugs used in treatments should be recorded on the resident's treatment record. 10. The nurse administering the drugs must electronically sign the resident's EMAR. Further review of Resident #49's record revealed a current plan of care for Psychotropic Medications (medications used to help manage behaviors) which included an intervention to observe and document for adverse medication side effects every shift. Upon review of the electronic medication administration record, no documentation was noted for side effect monitoring on the following dates and shifts: 3/1/24 on the day shift (7:00 AM - 3:00 PM) or the evening shift (3:00 PM to 11:00 PM), 3/2/24 on the day shift, 3/4/24 on the evening shift, 3/5/24 on the evening or night shift(11:00 PM to 7:00 AM), 3/6/24 on the evening shift, 3/7/24 on the evening shift, 3/8/24 on the evening shift, 3/11/24 on the evening shift, or 3/13/24 on the evening shift. A review of the policy Charting Errors/Omissions, November 2001, item 4 Any hole or omitted documentation is considered an error/omission. An interview was conducted with the Director of Nursing (DON) on 3/13/24 at approximately 3:34 PM. The DON indicated that it was her expectation to document every time anything is done for our residents, like giving medications.

Based on observations, interviews, and record review, the facility failed to honor resident's right to dignity for 2 of 2 residents sampled. (Resident #63 and #70) The findings include: Resident #63 An observation on 3/11/2024 at 12:58 PM noted Staff A, a Certified Nursing Assistant (CNA), standing while assisting Resident #63 with breakfast. On 03/14/24 at 9:00 AM, Staff A was again observed standing while assisting with feeding Resident #61. When Staff A was asked if that is the way they feed the residents, Staff A stated she isn't always standing. She was aware they are to assist residents with feeding while sitting. In an interview on 3/13/2024 at 1:28 PM with the Assistant Director of Nursing (ADON), she was asked if the staff receive training on sitting while assisting residents with feeding. She stated they did. She was then advised that Staff A was observed standing while assisting Resident #63. The ADON agreed that it was a dignity concern for the resident. 44730 Resident # 70 On 3/11/24 at approximately 11:37 AM, Resident #70 was observed from the hallway lying in bed with the catheter bag attached to the bed railing uncovered and visible. On 3/12/24 at approximately 2:53 PM, another observation was made of the catheter bag uncovered and visible to other residents in the hallway. On 3/13/24 at approximately 10:20 AM, the resident was again observed lying in the bed with eyes closed, door open to the hallway, with the catheter bag attached to the bed rail and visible from the hallway. On 3/13/24 at approximately 10:22 AM, an interview was conducted with the Risk Manager Registered Nurse. The Risk Manager confirmed that the catheter bag was visible from the hallway and indicated that it should be covered for dignity with a dignity bag. The Risk Manager went on to state that she would get that fixed right away. A review of the facility policy titled Dignity (dated December 2017), revealed under Policy, The Center must treat each Resident with respect and dignity for each Resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Under Procedure- Treat each resident with respect and dignity with regards to the following: * Personal care.

Based on observation, resident interview, staff interview and record review, the facility failed to provide activities of daily living assistance with finger and toenail trimming for 2 of 3 residents sampled (Resident #31 and #47). The facility also failed to facilitate Restorative Nursing services as ordered for Resident #31. The findings include: Resident #31, Toenail Care On 03/11/24 at approximately 12:36 PM, Resident #31 was observed with no socks or shoes. An observation of Resident #31 toenails noted very long toenails to both big toes and the third toe on the right foot. Resident #31 stated that she wasn't aware of the last time she had her toenails cut. A second observation of Resident #31 toenails on 03/13/24 at approximately 12:53 PM noted that the toenails had not been cut since the previous observation. On 03/13/24 at 1:25 PM, the Assistant Director of Nursing (ADON) was asked what the process was for residents to have their toenails cut. She stated if the resident is a diabetic, the podiatrist must do it. If they are not, then the nurse does it. When asked if there was a schedule or a process to ensure that the resident's toes are evaluated for need of trimming, she stated it likely should be done on their shower day, but that they really don't have a process to ensure toes were evaluated. Resident #31, Restorative Therapy A review of the medical record on 3/13/2024 noted that Resident #31 had an order for Restorative Therapy dated 12/20/2023 to utilize the arm bike for 15 minutes on Level 2, three times a week for 12 weeks. A review of the monthly intervention and task reports noted that the resident did not receive active range of motion therapy as ordered for Restorative Nursing 2-3 times a week. A review of the January 2024 intervention and tasks noted that Resident #31 received Active Range of Motion (ROM) for only 1 of 31 days in January. A review of February 2024 intervention and tasks noted Resident #31 received Active ROM for only 4 of 29 days. In an interview on 3/14/2024 at approximately 3:26 PM, Staff G, a Restorative Nurse, stated that Resident #31 was ordered for the Omni Cycle bilateral upper extremities back in December. She stated the staff have been trying to get her to utilize the machine, but the resident has refused. She stated she should have documented attempts to utilize the machine, but she neglected to do that. On 03/14/24 at 04:00 PM, Staff G returned and stated she had reviewed the order again and realized that she had entered the order incorrectly. The order was entered as a PRN order which meant as needed, as opposed to three times a week. She stated that because of the error, the staff were probably not asking Resident #31 appropriately and as frequently. 47306 Resident #47, fingernails and toenails On 3/11/2024 at approximately 10:54 AM, an observation was made of Resident #47. Resident #47 was observed to have long fingernails on both hands and long toenails to the right foot. Resident #47's fingernails on the right hand appeared discolored and were noted to have a brown substance underneath each fingernail. Resident #47's toenails on the right foot appeared long and thick. On 3/11/2024 at approximately 10:57 AM, an interview was conducted with Resident #47, who was alert to person and place. Resident #47 was asked if he allows the staff to trim his fingernails and toenails. Resident #47 indicated he does allow the staff to trim his fingernails and toenails and indicated the staff have trimmed his fingernails on his left hand in the past, but not his fingernails on his right hand or his toenails on either foot. On 3/12/2024 at approximately 9:56 AM, another observation was made of Resident #47. Resident #47 who is alert and oriented to person and place gave verbal consent to take photographic evidence of his right hand and right foot. The resident was observed to have long fingernails on the right hand with a brown substance underneath each fingernail. The resident was also observed to have long toenails to the right foot. (photographic evidence obtained). On 3/12/2024 at approximately 2:10 PM, an interview was conducted with the ADON regarding the policy for trimming resident's fingernails and toenails. The ADON indicated the Certified Nursing Assistants (CNAs) should be trimming residents' fingernails and toenails on days the residents are given or assisted with a bath. The ADON indicated, if the resident is a known Diabetic, they are referred to podiatry for toenail trims. The ADON indicated the CNAs should be reporting to the Nurses if they are unable to trim the residents' fingernails and toenails or if the residents refuse care. On 3/13/2024, a record review was conducted for Resident #47. The record review confirmed that Resident #47 did not have a diagnosis of Diabetes Mellitus. The record review also confirmed that Resident #47 has not refused hygiene care.

Based on observations, staff interviews, policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain infection prevention standards when staff failed to change gowns worn with Coronavirus Disease 2019 (COVID-19) infected (positive) residents before entering rooms of COVID-19 negative residents to deliver meal trays, gowns which were reused and worn during care of COVID-19 infected residents were stored close together with gowns worn during the care of COVID-19 negative residents, and staff failed to wash hands between passing meal trays and donning gloves to provide resident care creating the potential for cross-contamination. The findings include: On March 1, 2020, The Office of the Governor issued Executive Order Number 20-51 directing the Florida Department of Health to issue a Public Health Emergency. The Executive Order documented, Coronavirus Disease 2019 (COVID-19) is a severe acute respiratory illness that can spread among humans through respiratory transmission and presents with symptoms similar to those of influenza. On March 9, 2020, The Office of the Governor issued Executive Order Number 20-52 declaring a state of emergency for the entire State of Florida as a result of COVID-19. On 5/26/20 at approximately 8:45 AM, the Director of Nursing (DON) explained that the first floor housed residents who were COVID-19 negative and had no known exposure to COVID-19 infection. The entire second floor was designated as an isolation unit. The second floor housed both COVID-19 infected (positive) residents on the B hall, and residents who had previously tested positive and were now negative or who had a known exposure to a COVID-19 infected resident on the A hall. On 5/26/20 starting at approximately 9:50am a tour was conducted of the 2nd floor isolation area. Upon entering the second-floor resident care area past an isolation barrier set up to prevent the spread of COVID 19, a covered rolling linen cart was observed to contain previously used disposable isolation gowns. The gowns were for all staff on the second floor to include both halls A (COVID-19 negative residents) and hall B (COVID-19 positive residents). On 5/26/20 at approximately 1:32 PM, an interview was conducted with the DON who stated that the linen cart was set up after the cloth PPE (Personal Protective Equipment) gowns began to disappear. At this time the facility started to use disposable gowns, write staff names on them and store them in the linen cart for reuse. The DON reported that staff wear the gowns for a few days until they become soiled or torn when they would get a new one. Gowns for the entire 2nd floor were stored in the linen cart. On 5/26/20 at approximately 10:15am, an interview was conducted with Certified Nursing Assistant (CNA) A and CNA B on the second-floor isolation unit. Both CNAs confirmed that residents on hall B are identified as COVID-19 positive and residents on hall A are confirmed as COVID-19 negative and explained that staff are dedicated to care only for residents on one hall or the other and do not go between the two areas except at mealtime. CNA A confirmed staff from both halls go into all rooms on the second floor during meal tray delivery. CNA C approached the desk and confirmed staff assigned to hall A deliver meal trays on hall B and vice versa. On 5/26/2020 at approximately 10:55AM, the Assistant Director of Nursing (ADON) for the COVID-19 isolation area on the 2nd floor described the set-up of the floor stating one side housed the residents that were positive for COVID-19 and the other side that was utilized for residents whom had transitioned from a positive to negative status or who had been exposed to a positive resident. The ADON described the nurses and CNA's being assigned to just positive or negative residents. One nurse/CNA would not be assigned both COVID-19 positive and negative residents. On 5/26/2020 at approximately 12:19 PM, an observation was made of staff members A & B, both CNAs delivering lunch trays on the 2nd floor of the facility. CNA A delivered a lunch tray to room [ROOM NUMBER] (A hall) and then room [ROOM NUMBER] (B hall) - the rooms were divided by a large Solarium which served as the divider between the two halls. The resident in room [ROOM NUMBER] was noted to be negative and the resident on 218 was documented as positive. The CNAs were observed to change gloves and wash hands between residents, but the CNA did not change or remove her gown. A review of CDC guidelines for extended use of personal protective equipment, isolation gowns, published 4/30/20 and retrieved on 5/28/20 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html indicated that isolation gowns may be reused for more than one patient known to be infected with the same infectious disease when these patients are housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). The CDC also recommended the isolation unit should be physically separated from other rooms or units housing residents without confirmed COVID-19 and recommended a separate floor, wing, or cluster of rooms when possible and to assign dedicated HCP (health care personnel) to work only on the COVID-19 care unit. Meal Tray Delivery - 1st floor On 5/26/20 at approximately 12:29pm, observations were made of lunch tray delivery on the first floor which housed only COVID-19 negative residents. CNA D was observed delivering a meal tray to room [ROOM NUMBER], upon exiting the room, CNA D did not perform hand hygiene. CNA D then obtained a meal tray from a cart in the hall and delivered the meal tray to room [ROOM NUMBER], bed B and exited the room again without performing hand hygiene. While leaving room [ROOM NUMBER], the resident in bed A requested assistance and CNA D returned to room [ROOM NUMBER] and donned gloves without performing hand hygiene and was observed to move her gloved hands toward the resident in bed A to assist in repositioning the resident. At this time, CNA D was asked to step out of the room by the surveyor and asked about expectations for hand hygiene when performing resident care and passing meal trays. CNA D said hand hygiene should be performed between each task and confirmed hand hygiene was not performed between passing trays in rooms [ROOM NUMBERS] or before donning gloves to assist a resident. Immediately following this observation, CNA E was observed to deliver a meal tray to room [ROOM NUMBER] and exit the room without performing hand hygiene. CNA E was interviewed after leaving the room and said hand hygiene should be performed after every 2-3 trays or rooms. Another staff member was present in the hall during the interview and CNA E asked the other staff member if hand hygiene should be performed after every tray and the other staff member said, yes. A review of Meals, Serving policy, Nutritional Services; Nursing Services Procedure dated on October 2019, on page 25 and 26 the manual indicated washing hands was required when finished serving the meal or if it becomes necessary to attend to the needs of another resident during meal service.

Based on observation and interview, the facility failed to post notice of the availability of state survey reports in areas of the facility that are prominent and accessible to the public. The findings include: On 2/05/20 at 1:00 PM, the state survey report was observed in a binder hanging in a wall holder outside the therapy department on the first floor hallway (photographic evidence obtained). The binder was labeled on the spine which faced the ceiling from the wall holder where it was located. The wall holder was not labeled, and it was approximately 4 feet from the floor and the title on the binder would not be visible to a resident in a wheelchair. During a resident council meeting on 2/5/20 which started at 1:35pm, resident #55 indicated not knowing where the results of the most recent state survey were located. On 2/05/20 at 3:49 PM, during an interview with the director of nursing (DON) and the corporate Risk Manager (RM), the DON could not immediately find the state survey binder. When the DON found the survey binder in the wall holder, both the DON and RM agreed the state survey binder was not easily identifiable and residents would not be able to identify it, especially from a wheelchair. They stated that a label could be added to the wall holder to identify the state survey results are in the wall holder.

Based on record review, staff interview and policy review the facility failed to demonstrate adequate control testing of the blood glucose monitoring system for 4 of 8 glucose monitoring devices. (4 devices 2nd floor) The findings include: Review of the narcotics books on the 2nd floor revealed no evidence of control testing of the blood glucose monitoring system. An interview was conducted with employee B (Licensed Practical Nurse) on 8/22/19 at 11:33 AM. Employee B stated the night shift checks the controls every night and the results are usually logged in the narcotics book; she was not able to locate the control testing. An interview was conducted with the Regional Nurse on 8/22/19 at 12:48 PM. He stated the facility instituted a form indicating the meter controls should be checked every day on 11-7, but the policy is to only check as stated in the policy. An interview was conducted with employee D (Registered Nurse) on 8/22/19 at 1:14 PM. Employee D stated there are 8 total blood glucose monitoring systems in the facility, two for each medication cart. Review of the facility policy (December (YEAR)) and manufacturer guidelines for the blood glucose monitoring system revealed the control test and check strip test will be performed when: using the meter for the first time, using a new bottle of blood glucose test strips, you left the test strip bottle cap open for a while, you dropped the meter, you suspect your meter and test strips are not working properly, the blood glucose test results do not reflect how you feel, or you want to practice the testing procedure.

Based on interview and record review the facility failed to accurately complete the resident assessment for 1 of 5 residents (#60) sampled for unnecessary medications and 1 of 2 residents (#47) sampled for Activities of Daily Living. The findings include: Resident #60 A review was conducted of Resident #60's Annual Minimum Dataset assessment, dated 7/11/2019. Under Section N, subsection N410, the facility listed that the resident had received antipsychotic medication all 7 days of the look back period. A review of current and past medication orders was conducted which failed to reveal any antipsychotic medications that would have been administered during that time period. On 8/21/19 at 9:54 AM an interview was conducted with employee A, a case manager. At that time she agreed that the resident was not on any antipsychotic medications during the lookback period and that she would submit a correction. Resident #47 A record review was conducted for resident #47 which revealed the resident received [MEDICATION NAME] 75 mg by mouth daily. [MEDICATION NAME] is an antiplatelet medication. The admission minimum data set (MDS) with an assessment reference date of 7/2/19 revealed he received an anticoagulant 6 days. On 8/21/19 at 2:57 PM an interview was conducted with employee A, a case manager. At this time she stated the MDS was not correct and she would submit a correction.

Based on observations, staff interview, record review and policy review the facility failed to obtain a physician order for [REDACTED].#260) The findings include: Observations of resident #260 were conducted on 8/20/19 at 1:54 PM and 4:39 PM and on 8/21/19 at 8:38 AM, 11:54 AM and 1:24 PM. During the observations the resident was in bed and had oxygen at 4 liters per minute via nasal cannula in place. Review of the resident's record revealed no physician orders for the use of oxygen. An interview was conducted with employee C (licensed practical nurse) on 8/21/19 at 1:24 PM. Employee C observed resident #260 and confirmed he had oxygen in place at 4 liters per minute. She stated the resident will adjust the flow rate himself and he had been using oxygen for about a week since he returned from the hospital. She reviewed the record and confirmed there was not a physician order for [REDACTED]. Review of the facility policy for Physician Order's (November (YEAR)) indicated resident medications, treatments, and services must be ordered by a licensed physician or licensed practitioner.

Based on closed record review and staff interviews, the facility failed to develop and implement an appropriate plan of action to identify and correct process failures following the death of a resident from inappropriate administration of enteral feeding for 1 of 1 residents sampled (#1). The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Director of Nursing, Risk Manager as well as the Regional Nurse Consultant were notified of the Immediate Jeopardy findings on (MONTH) 10, 2019 at 3:38 PM. Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:45 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included review and revision of the physician orders [REDACTED]. The scope and severity level of the deficient practice was reduced to a D. Cross reference F600, F656, F693, and F726. Findings include: Review of the medical record and facility incident documentation revealed that on [DATE], Resident #1, who received enteral nutrition via a Percutaneous Endoscopic Gastronomy (PEG) tube which provides food, liquids and medications directly into the stomach, erroneously received a 1000 milliliter (ml) bolus of tube feeding via his PEG tube over a 2 hour period. There was a physician's orders [REDACTED].#1 revealed a plan related to enteral nutrition that included the intervention of feedings and flushes per MD (physician) orders - [MEDICATION NAME] 1.5 via PEG at a rate of 70 milliliters per hour via feeding pump for 20 hours. Resident #1 subsequently expired in the facility. On [DATE] at 1:46 PM, an interview with the facility's Director of Nursing (DON) revealed she had been notified of the resident's passing by staff on duty at the time. She stated that after notification, the staff then called back to alert the DON that the resident's tube feeding had been administered via gravity and not through a pump. Stated tube feeding had been hung at 9:00 PM and that at 11:45 PM the resident was found in respiratory distress and the bag of feeding was noted to be empty at that time. Review of the facility's documentation related to the incident with Resident #1 was reviewed and showed a timeline of events developed from witness statements which detailed the following: [DATE] at 9:00 PM - Nurse X stated that a Certified Nursing Assistant (CNA) notified her that Resident #1 wanted his pain medication. Nurse X stated she gathered his medication, enteral feeding ([MEDICATION NAME]) and wound care supplies and went to the resident's room where she administered the resident's medication, hung a new bottle of [MEDICATION NAME] for the resident and conducted wound care while she was there. [DATE] at 10:15 PM - CNA GG performed her last rounds and assisted Resident #1 with the help of CNA II. CNA GG reported the resident was acting normal, had no complaints and was joking with her. CNA II stated she had observed the tubing for the resident's tube feeding not in the pump, but hanging by the bed with tube feeding running through it. (This observation was not documented as having been reported to the resident's nurse) [DATE] from 11:15 - 11:30 PM - CNAs GG and FF were conducting change of shift walking rounds and went into the room of Resident #1 due to his call light being on. They stated upon entering the resident's room, they observed Resident #1 with his oxygen off and he was sweating. They put his oxygen back on and notified the nurse that Resident #1 requested to see her. [DATE] at 11:45 PM - Registered nurse C entered the resident's room and observed the resident to be breathing rapidly and he was noted to have 'gurgling' sound on exhalation, which had not been present the previous night when this same nurse cared for Resident #1. At 11:50 PM the nurse requested assistance from registered nurse F who entered the room by 11:55 PM. At that time the two nurses observed that the resident's feeding tube was not connected to the pump, but was connected to Resident #1 and that the bottle of [MEDICATION NAME] hanging was empty. At 12:07 AM, Resident #1 was noted with coarse rales bilaterally to all lobes on auscultation. Oxygen saturation at that time was noted to be 65% and resident was less responsive. Nurse C went to call the physician and verify the resident's code status. At 12:12 AM, Resident #1 had an oxygen saturation at 48% and his eyes were noted to be rolled back and he was no longer responsive with 'bluish' color noted to resident's nail beds. Resident was noted to take an occasional breath. At 12:15 AM, nurse F was unable to obtain a blood pressure, respirations or a pulse for Resident #1 and the resident was pronounced deceased . As a result of this error the facility conducted an unscheduled Risk Management and QA (Quality Assurance) Committee Meeting on [DATE], which was attended by the DON, the Risk Manager (RM) and 5 other staff members. The sign-in sheet for this meeting, titled Sub Committee: Proper Administration of Tube Feeding, was not signed by the Medical Director; however, it was reported that the Medical Director had reviewed the information developed from the meeting. The committee prepared and approved a Performance Improvement Plan (PIP) for Proper Administration of Tube Feeding with a time frame of 120 days. Review of the PIP found no evidence of an implementation date that would serve as a starting point for the 120 day time frame. Further review of the PIP revealed a description of the problem/findings as Failure to administer tube feeding as ordered and Not following physician orders [REDACTED].#1 after identification of the error was not identified as an area of concern, nor was the failure of the Certified Nursing Assistants (CNAs) to report their observation of the tube feeding tubing for Resident #1 being outside of the administration pump, or the Registered Nurse's failure to conduct walking rounds of her patients at shift change. Further review of the PIP showed the facility's implemented changes in response to this incident as Tube feeding observations for return demonstration to verify proper technique is used in hanging of tubing and to ensure physician orders [REDACTED]. The Risk Manager (RM) presented copies of the audits that had been conducted as part of the facilty's PIP. The first sheet had the dates [DATE] and [DATE] on them with a list of 4 staff names next to each date and a Registered Nurse's signature at the top. The paper had no other identifiers listed to include staff titles, time of day, what was the purpose of the sheet or if it related to observation, demonstration, or education. Review of the next 4 sheets of paper presented to the surveyor revealed that on [DATE] at 1400, 1800, 2050 and 2120 and on [DATE] at 1400 staff member HH had observed four nurses properly administering a tube feeding. No identification of where the observations had occurred or what was actually observed beyond the words properly administering a tube feeding was noted. The final sheet of white copy paper was titled Tube feeding observations with consecutive dates starting on ,[DATE] through ,[DATE]. Each date had three, one word names, many repeated several times on the list. No last names, titles, times, or description of audit items were listed. Also presented as evidence of implementation of the PIP was a computer generated order sheet that listed the physician orders [REDACTED]. At the top of this sheet was the notation starting with a check mark All Funct. Properly with the date [DATE] at 2 AM. In-services which consisted of policy reviews conducted immediately after the incident on [DATE] included Proper Administration of Tube Feeding, Abuse and Walking Rounds and was attended by 100% of the nursing and direct care staff. On [DATE] at approximately 2:17 PM, an interview was conducted with the Administrator and the Director of Nursing (DON), during which the DON stated the resident's DNR status and lack of emergency treatment/care was not included or discussed when the PIP was initiated. She stated the PIP was initiated on [DATE], but verified the date was not noted on the PIP. When asked to explain the audit process to include who conducted the audits, what they looked at, or if they reviewed the residents' care plans and physician orders [REDACTED]. She could also not identify which nurse had conducted the audits with the exception of the papers signed by nurse HH. Review of the in-service used for the observations found it addressed setting up the feeding pump only with no indication that physician orders [REDACTED].

Based on closed record review, staff interviews and policy review, the facility failed to ensure 1 of 1 resident (#1) was free from neglect when facility staff erroneously administered 1000 milliliters of tube feeding via gravity, when it was supposed to be infused by a pump to the resident. The facility then failed to acquire emergency medical treatment for [REDACTED]. The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Director of Nursing, Risk Manager as well as the Regional Nurse Consultant were notified of the Immediate Jeopardy findings on (MONTH) 10, 2019 at 3:38 PM. Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:45 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included review and revision of the physician orders [REDACTED]. The scope and severity level of the deficient practice was reduced to a D. Cross reference F656, F693, F726 and F867. Findings include: Review of the medical record for Resident #1 revealed the resident had been originally admitted to the facility in (MONTH) of (YEAR) with a history of dysphagia, [MEDICAL CONDITION] Disease, [MEDICAL CONDITION], contractures and was at risk for aspiration pneumonia. Further review of the record revealed that the resident had signed a Do Not Resuscitate (DNR) form on [DATE] and was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube which provided food, liquids and medications directly into the resident's stomach. There was a physician's orders [REDACTED]. A nursing note, dated [DATE] at 1:00 AM, stated, resident appeared to be in respiratory distress upon entering his room around 11:45 PM. Respirations were labored and very audible at 36 (breaths per minute). Blood pressure was ,[DATE], heart rate was 120 and temperature was 98.7 orally. Eyes were open and skin was cool to the touch. Nasal cannula was repositioned with oxygen running at 2 liters per minute. Oxygen saturation reading was initially 93, gradually decreasing to 65 and then 48. Respirations began to diminish and eyes rolled back as he lost consciousness around 12:10 AM. By 12:15 AM there were no signs of cardiac activity and resident was pronounced deceased . On [DATE] at 1:46 PM, an interview with the facility's Director of Nursing (DON) revealed she had been notified of the resident's passing by staff on duty at the time. She stated that after notification, the staff then called back to alert the DON that the resident's tube feeding had been administered via gravity and not through a pump. Stated tube feeding had been hung at 9:00 PM and that at 11:45 PM the resident was found in respiratory distress and the bag of feeding was noted to be empty at that time. Review of the facility's documentation related to the incident with Resident #1 was reviewed and showed a timeline of events developed from witness statements which detailed the following: [DATE] at 9:00 PM - Nurse X stated that a Certified Nursing Assistant (CNA) notified her that Resident #1 wanted his pain medication. Nurse X stated she gathered his medication, enteral feeding ([MEDICATION NAME]) and wound care supplies and went to the resident's room where she administered the resident's medication, hung a new bottle of [MEDICATION NAME] for the resident and conducted wound care while she was there. [DATE] at 10:15 PM - CNA GG performed her last rounds and assisted Resident #1 with the help of CNA II. CNA GG reported the resident was acting normal, had no complaints and was joking with her. CNA II stated she had observed the tubing for the resident's tube feeding not in the pump, but hanging by the bed with tube feeding running through it. (This observation was not documented as having been reported to the resident's nurse) [DATE] from 11:15 - 11:30 PM - CNAs GG and FF were conducting change of shift walking rounds and went into the room of Resident #1 due to his call light being on. They stated upon entering the resident's room, they observed Resident #1 with his oxygen off and he was sweating. They put his oxygen back on and notified the nurse that Resident #1 requested to see her. [DATE] at 11:45 PM - Registered nurse C entered the resident's room and observed the resident to be breathing rapidly and he was noted to have 'gurgling' sound on exhalation, which had not been present the previous night when this same nurse cared for Resident #1. At 11:50 PM the nurse requested assistance from registered nurse F who entered the room by 11:55 PM. At that time the two nurses observed that the resident's feeding tube was not connected to the pump, but was connected to Resident #1 and that the bottle of [MEDICATION NAME] hanging was empty. At 12:07 AM, Resident #1 was noted with coarse rales bilaterally to all lobes on auscultation. Oxygen saturation at that time was noted to be 65% and resident was less responsive. Nurse C went to call the physician and verify the resident's code status. At 12:12 AM, Resident #1 had an oxygen saturation at 48% and his eyes were noted to be rolled back and he was no longer responsive with 'bluish' color noted to resident's nail beds. Resident was noted to take an occasional breath. At 12:15 AM, nurse F was unable to obtain a blood pressure, respirations or a pulse for Resident #1 and the resident was pronounced deceased . Review of a statement written by the Medical Director, dated [DATE], stated: I have reviewed the circumstances of Resident #1's death and find no evidence of negligent care. His 1000 milliliter (ml) bag of [MEDICATION NAME] 1.5 had been hooked up to a pump and infusion started at 9:00 PM. At 11:45 PM it was discovered to be empty and off the pump. Had it not been started on the pump and the entire 1000 ml had been delivered by gravity drip, the time for it to infuse completely would have been two hours (determined by replicating the scenario with a similar bag of tube feeding dripping into a waste can). The largest amount of fluid Resident #1 had scheduled in a three hour period was about 500 ml (70 ml/hr of tube feeding and 300mL of water). Resident #1 had frequent reoccurrence of pneumonia in recent months, presumed due to ongoing aspiration which he was susceptible. He likely had limited [MEDICAL CONDITION] reserve due to his recurrent and recent pneumonia and general debility and bedbound status from advanced dementia. I think he had a final episode of aspiration that simply overwhelmed his limited [MEDICAL CONDITION] reserve. On [DATE] at approximately 7:30 AM, an interview was conducted with Registered nurse C who confirmed she was the nurse who responded to Resident #1 on the night of the incident. She stated that she would have normally checked the resident's feeding during walking rounds, but reported that she was unable to do walking rounds because she had to count narcotics on two carts as the second nurse was running late. She stated that when the CNAs reported to her that the resident had requested assistance that she assumed that it was for pain medication, and went to his room within ,[DATE] minutes. She stated that when she entered the resident's room, she found him to be in respiratory distress. When asked if emergency services, such as 911, were considered when the resident was in distress, she stated: We were on the verge of calling 911, I don't know why we didn't. When asked what types of situations she would call 911 for, she stated: If the situation was out of our hands, like respiratory distress, excessive vomiting, vital signs out of control, [MEDICAL CONDITION], or elevated temperature and blood pressure. When asked about residents with DNR status, she stated, I get the feeling we are supposed to keep a DNR in the facility. When asked what DNR meant to her, she replied, if life threatening situation, do not resuscitate. On [DATE] at approximately 9:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who was asked if it was appropriate to call 911 for a resident who was a DNR and she stated, No. She further stated that if the resident had been full code she would have called 911 but the DNR status changes that. On [DATE] at 1:00 PM, Licensed Practical Nurse (LPN) J was asked if a resident received 1000 ml tube feed bolus in error, and you observed the resident in respiratory distress and the resident was a DNR, would you call 911? LPN J replied: No, the resident is a DNR. On [DATE] at 7:51 AM, an interview was conducted with registered nurse F. She stated that when she entered the room at the request of nurse C, both nurses found the feeding tube was not in the pump and was wide open and empty. She stated the resident looked panicky before his eyes rolled back in his head and confirmed she sent nurse C to call the nurse practitioner and stayed with Resident #1 who passed with her by his side. She also stated, He was a DNR so we are not going to call 911. The most appropriate thing was to notify the nurse practitioner. She reported there had never been a discussion about calling 911 because the resident was a DNR, and stated that if he had been a full code, they would have started compressions and called 911. She stated that after the resident passed, the CNAs who performed post mortem care reported that when they turned him, he had what appeared to be tube feeding coming out of his nose and mouth and it just kept coming. She also stated the nurse who had caused this had done it before with another resident and the Director of Nursing (DON) and Administrator were aware. On [DATE] at approximately 3:20 PM a group interview was conducted with the Director of Nursing (DON), Corporate Consultant and facility Administrator. When asked why 911 was not initiated for Resident #1, the DON stated that the incident had happened within 7 minutes and was sudden and quick. Review of the facility's undated policy Advance Directives stated that prior to or upon admission, residents and their families would be asked about the existence of advance directives and a copy would be obtained for inclusion in the resident's medical record. The policy defined advance directive options as (1) Do Not Resuscitate which the policy stated indicates that in the case of respiratory or cardiac failure, no cardio-pulmonary resuscitation or other lifesaving methods would be used. Review of the facility's undated policy Emergency/Alternative Physician Care stated that all residents shall be provided with emergency physician care and that should an emergency arise and the resident's attending physician is not available, the emergency physician, which could include the medical director or emergency medical services (EMS), may be notified.

Based on closed record review, staff interviews and policy review, the facility failed to follow the plan of care for appropriate administration of tube feeding via a gastrostomy tube for 1 of 1 resident (#1), which resulted in staff erroneously administering1000 milliliters (ml) of tube feeding (the entire container of tube feeding) via gravity in less than 3 hours, to the resident and the subsequent death of the resident. The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Director of Nursing, Risk Manager as well as the Regional Nurse Consultant were notified of the Immediate Jeopardy findings on (MONTH) 10, 2019 at 3:38 PM. Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:45 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included review and revision of the physician orders [REDACTED]. The scope and severity level of the deficient practice was reduced to a D. Cross reference F600, F693, F726 and F867. Findings included: Review of the medical record for Resident #1 revealed the resident was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube which provided food, liquids and medications directly into the resident's stomach. Review of physician order, dated [DATE], showed Resident #1 was to receive [MEDICATION NAME] 1.5 at 70ml/hr for 20 hours daily. The orders also stated the resident was to have the head of his bed elevated ,[DATE] degrees and staff were to check tube placement and residuals every shift and also record the amount of tube feeding the resident received every shift. Review of the plan of care for Resident #1 revealed a plan related to enteral nutrition that included the intervention of feedings and flushes per MD (physician) orders - [MEDICATION NAME] 1.5 via PEG at a rate of 70 milliliters per hour via feeding pump for 20 hours. A nursing note, dated [DATE] at 1:00 AM, stated, resident appeared to be in respiratory distress upon entering his room around 11:45 PM. Respirations were labored and very audible at 36 (breaths per minute). Blood pressure was ,[DATE], heart rate was 120 and temperature was 98.7 orally. Eyes were open and skin was cool to the touch. Nasal cannula was repositioned with oxygen running at 2 liters per minute. Oxygen saturation reading was initially 93, gradually decreasing to 65 and then 48. Respirations began to diminish and eyes rolled back as he lost consciousness around 12:10 AM. By 12:15 AM there were no signs of cardiac activity and resident was pronounced deceased . On [DATE] at 1:46 PM, an interview with the facility's Director of Nursing (DON) revealed she had been notified of the resident's passing by staff on duty at the time. She stated that after notification, the staff then called back to alert the DON that the resident's tube feeding had been administered via gravity and not through a pump. Stated tube feeding had been hung at 9:00 PM and that at 11:45 PM the resident was found in respiratory distress and the bag of feeding was noted to be empty at that time. Review of the job descriptions for both Registered Nurses and Licensed Practical Nurses revealed that review of care plans to ensure that appropriate care was being rendered was an essential duty and responsibility of those positions and also stated that staff in these positions were to ensure nursing documentation reflected that the care plan was being followed when administering nursing care or treatment. Review of the facility's undated and untitled policy on comprehensive care plans revealed a comprehensive care plan would be maintained on each resident and was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, prevent declines in the resident's functional status and to ensure the plan of care was individualized and reflected the resident's goals for desired outcomes.

Based on closed record review, staff interviews and policy review, the facility failed to safely administer the tube feeding for 1 of 4 residents (#1) by failing to follow physician orders [REDACTED]. The facility failed to safety administer resident #1's tube feeding, which resulted in the death of the resident. The facility erroneously administered 1000 milliliters (ml) of tube feeding via gravity, when it was supposed to be infused by a pump at 70 ml/hour. Based on the physician-ordered administration rate, the entire container of tube feeding would be empty after 14 hours. The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Director of Nursing, Risk Manager as well as the Regional Nurse Consultant were notified of the Immediate Jeopardy findings on (MONTH) 10, 2019 at 3:38 PM. Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:45 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included review and revision of the physician orders [REDACTED]. The scope and severity level of the deficient practice was reduced to a D. Cross reference F600, F656, F726 and F867. Findings include: Review of the medical record for Resident #1 revealed the resident had been originally admitted to the facility in (MONTH) of (YEAR) with a history of dysphagia, [MEDICAL CONDITION] Disease, [MEDICAL CONDITION], contractures and was at risk for aspiration pneumonia. Further review of the record revealed that the resident had signed a Do Not Resuscitate (DNR) form on [DATE] and was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube which provided food, liquids and medications directly into the resident's stomach. There was a physician's orders [REDACTED]. A nursing note, dated [DATE] at 1:00AM, stated, resident appeared to be in respiratory distress upon entering his room around 11:45 PM. Respirations were labored and very audible at 36 (breaths per minute). Blood pressure was ,[DATE] (mmHg), heart rate was 120 (beats pers minute) and temperature was 98.7 (degrees Fahrenheit) orally. Eyes were open and skin was cool to the touch. Nasal cannula was repositioned with oxygen running at 2 liters per minute. Oxygen saturation reading was initially 93%, gradually decreasing to 65 and then 48. Respirations began to diminish and eyes rolled back as he lost consciousness around 12:10 AM. By 12:15 AM there were no signs of cardiac activity and resident was pronounced deceased . Review of the plan of care for Resident #1 revealed a plan related to enteral nutrition that included the intervention of feedings and flushes per MD (physician) orders [MEDICATION NAME] 1.5 via PEG at a rate of 70 milliliters per hour via feeding pump for 20 hours. On [DATE] at 1:46 PM, an interview with the facility's Director of Nursing (DON) revealed she had been notified of the resident's passing by staff on duty at the time. She stated that after notification, the staff then called back to alert the DON that the resident's tube feeding had been administered via gravity and not through a pump. Stated tube feeding had been hung at 9:00 PM and that at 11:45 PM the resident was found in respiratory distress and the bag of feeding was noted to be empty at that time. Review of the facility's documentation related to the incident with Resident #1 was reviewed and showed a timeline of events developed from witness statements which detailed the following: [DATE] at 9:00 PM - Nurse X stated that a Certified Nursing Assistant (CNA) notified her that Resident #1 wanted his pain medication. Nurse X stated she gathered his medication, enteral feeding ([MEDICATION NAME]) and wound care supplies and went to the resident's room where she administered the resident's medication, hung a new bottle of [MEDICATION NAME] for the resident and conducted wound care while she was there. [DATE] at 10:15 PM - CNA GG performed her last rounds and assisted Resident #1 with the help of CNA II. CNA GG reported the resident was acting normal, had no complaints and was joking with her. CNA II stated she had observed the tubing for the resident's tube feeding not in the pump, but hanging by the bed with tube feeding running through it. (This observation was not documented as having been reported to the resident's nurse) [DATE] from 11:15 - 11:30 PM - CNAs GG and FF were conducting change of shift walking rounds and went into the room of Resident #1 due to his call light being on. They stated upon entering the resident's room, they observed Resident #1 with his oxygen off and he was sweating. They put his oxygen back on and notified the nurse that Resident #1 requested to see her. [DATE] at 11:45 PM - Registered nurse C entered the resident's room and observed the resident to be breathing rapidly and he was noted to have gurgling sound on exhalation, which had not been present the previous night when this same nurse cared for Resident #1. At 11:50 PM the nurse requested assistance from registered nurse F who entered the room by 11:55 PM. At that time the two nurses observed that the resident's feeding tube was not connected to the pump, but was connected to Resident #1 and that the bottle of [MEDICATION NAME] hanging was empty. At 12:07 AM, Resident #1 was noted with coarse rales bilaterally to all lobes on auscultation. Oxygen saturation at that time was noted to be 65% and resident was less responsive. Nurse C went to call the physician and verify the resident's code status. At 12:12 AM, Resident #1 had an oxygen saturation at 48% and his eyes were noted to be rolled back and he was no longer responsive with 'bluish' color noted to resident's nail beds. Resident was noted to take an occasional breath. At 12:15 AM, nurse F was unable to obtain a blood pressure, respirations or a pulse for Resident #1 and the resident was pronounced deceased . Review of a statement written by the Medical Director, dated [DATE], stated: I have reviewed the circumstances of Resident #1's death and find no evidence of negligent care. His 1000 milliliter (ml) bag of [MEDICATION NAME] 1.5 had been hooked up to a pump and infusion started at 9:00 PM. At 11:45 PM it was discovered to be empty and off the pump. Had it not been started on the pump and the entire 1000 ml had been delivered by gravity drip, the time for it to infuse completely would have been two hours (determined by replicating the scenario with a similar bag of tube feeding dripping into a waste can). The largest amount of fluid Resident #1 had scheduled in a three hour period was about 500 ml (70 ml/hr of tube feeding and 300mL of water). Resident #1 had frequent reoccurrence of pneumonia in recent months, presumed due to ongoing aspiration which he was susceptible. He likely had limited [MEDICAL CONDITION] reserve due to his recurrent and recent pneumonia and general debility and bedbound status from advanced dementia. I think he had a final episode of aspiration that simply overwhelmed his limited [MEDICAL CONDITION] reserve. On [DATE] at approximately 7:30 AM, an interview was conducted with registered nurses (RNs) C and D. RN C confirmed she was the nurse who responded to Resident #1 on the night of the incident, but stated she was not the nurse who hung the resident's tube feeding. She stated that she would have normally checked the resident's feeding during walking rounds, but reported that she was unable to do walking rounds because she had to count narcotics on two carts as the second nurse was running late. She stated that when the CNAs reported to her that the resident had requested assistance that she assumed that it was for pain medication, and went to his room within ,[DATE] minutes. She stated that when she entered the resident's room, she found him to be in respiratory distress. When asked about skills audits or competency evaluations, RN D stated that she received a competency evaluation annually on her employment anniversary and RN D stated she had not had a competency evaluation that she knew of. When asked if they had received any recent training on feeding tubes, they stated Yes, a piece of paper we had to review and sign. On [DATE] at 7:51 AM, an interview was conducted with registered nurse F. She stated that when she entered the room of Resident #1 at the request of nurse C, both nurses found the feeding tube was not in the pump and was wide open and empty. She stated the resident looked panicky before his eyes rolled back in his head and confirmed she sent nurse C to call the nurse practitioner and stayed with Resident #1 who passed with her by his side. She stated that after the resident passed, the CNAs who performed post mortem care reported that when they turned him, he had what appeared to be tube feeding coming out of his nose and mouth and it just kept coming. She also stated the nurse who had caused this had done it before with another resident and the Director of Nursing (DON) and Administrator were aware. She stated she had been in in-services over the past year, but none of them had been related to feeding tubes and further stated she had never been in-serviced on feeding tubes and had not had a skills competency review. On [DATE] at 8:15AM, interview with LPN J revealed she had received face-to-face training on feeding tubes recently and confirmed that she had received a skills competency review in (MONTH) of (YEAR). On [DATE] at 8:30AM, interview with Licensed Practical Nurse (LPN) I revealed she did have an annual skills review done by her peers and that it was probably due to be done again. She also confirmed that staff had been given a form to sign back in (MONTH) related to tube feeding procedures. On [DATE] at 11:39AM, interview with LPN K revealed she had just returned to work from a period of leave so she had not recently received any training. She stated she remembered having a skills competency review when she was new, but can't recall any other. Review of the job descriptions for both Registered Nurses and Licensed Practical Nurses revealed that review of care plans to ensure that appropriate care was being rendered was an essential duty and responsibility of those positions and also stated that staff in these positions were to ensure nursing documentation reflected that the care plan was being followed when administering nursing care or treatment. Review of the facility's undated and untitled policy on comprehensive care plans revealed a comprehensive care plan would be maintained on each resident and was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, prevent declines in the resident's functional status and to ensure the plan of care was individualized and reflected the resident's goals for desired outcomes.

Based on closed record review, employee record review and staff interview, the facility failed to ensure nursing staff had appropriate training and competency related to administration of enteral nutrition via a gastrostomy tube, failed to ensure Certified Nursing Assistants were knowledgeable about potential complications associated with tube feeding and knew when to report those complications to the nurse, and failed to ensure staff knew when it was appropriate to seek medical care for a resident with Do Not Resuscitate directives for 1 of 4 residents (#1) which resulted in the death of Resident #1. The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Director of Nursing, Risk Manager as well as the Regional Nurse Consultant were notified of the Immediate Jeopardy findings on (MONTH) 10, 2019 at 3:38 PM. Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:45 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included review and revision of the physician orders [REDACTED]. The scope and severity level of the deficient practice was reduced to a D. Cross reference F600, F656, F693 and F867. Findings included: Review of the medical record for Resident #1 revealed the resident was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube which provided food, liquids and medications directly into the resident's stomach. There was a physician's orders [REDACTED]. A nursing note, dated [DATE] at 1:00 AM, showed Resident #1 had expired in the facility around 12:15 AM. On [DATE] at 1:46PM, an interview with the facility's Director of Nursing (DON) revealed she had been notified of the resident's passing by staff on duty at the time. She stated that after notification, the staff then called back to alert the DON that the resident's tube feeding had been administered via gravity and not through a pump. Stated tube feeding had been hung at 9:00 PM and that at 11:45 PM the resident was found in respiratory distress and the bag of feeding was noted to be empty at that time. Review of the facility's documentation related to the incident with Resident #1 was reviewed and showed a timeline of events developed from witness statements which detailed the following: [DATE] at 9:00 PM - Nurse X stated that a Certified Nursing Assistant (CNA) notified her that Resident #1 wanted his pain medication. Nurse X stated she gathered his medication, enteral feeding ([MEDICATION NAME]) and wound care supplies and went to the resident's room where she administered the resident's medication, hung a new bottle of [MEDICATION NAME] for the resident and conducted wound care while she was there. [DATE] at 10:15 PM - CNA GG performed her last rounds and assisted Resident #1 with the help of CNA II. CNA GG reported the resident was acting normal, had no complaints and was joking with her. CNA II stated she had observed the tubing for the resident's tube feeding not in the pump, but hanging by the bed with tube feeding running through it. (This observation was not documented as having been reported to the resident's nurse) [DATE] from 11:15 - 11:30 PM - CNAs GG and FF were conducting change of shift walking rounds and went into the room of Resident #1 due to his call light being on. They stated upon entering the resident's room, they observed Resident #1 with his oxygen off and he was sweating. They put his oxygen back on and notified the nurse that Resident #1 requested to see her. [DATE] at 11:45 PM - Registered nurse C entered the resident's room and observed the resident to be breathing rapidly and he was noted to have 'gurgling' sound on exhalation. At 11:50 PM the nurse requested assistance from registered nurse F and the two nurses observed that the resident's feeding tube was not connected to the pump at that time, but was connected to Resident #1 and that the bottle of [MEDICATION NAME] hanging was empty. At 12:07 AM, Resident #1 was noted with coarse rales bilaterally to all lobes on auscultation. At 12:12 AM, Resident #1 was no longer responsive with 'bluish' color noted to resident's nail beds. At 12:15 AM, nurse F was unable to obtain a blood pressure, respirations or a pulse for Resident #1 and the resident was pronounced deceased . Review of a statement written by the Medical Director, dated [DATE], stated: I think he had a final episode of aspiration that simply overwhelmed his limited [MEDICAL CONDITION] reserve. On [DATE] at approximately 7:30 AM, an interview was conducted with registered nurses (RNs) C and D. RN C confirmed she was the nurse who responded to Resident #1 on the night of the incident, but stated she was not the nurse who hung the resident's tube feeding. When asked about skills audits or competency evaluations, RN D stated that she received a competency evaluation annually on her employment anniversary and RN C stated she had not had a competency evaluation that she knew of. When asked if they had received any recent training on feeding tubes, they stated Yes, a piece of paper we had to review and sign. On [DATE] at 7:51 AM, an interview was conducted with registered nurse F. She stated that when she entered the room of Resident #1 at the request of nurse C, both nurses found the feeding tube was not in the pump and was wide open and empty. She stated that after the resident passed, the CNAs who performed post mortem care reported that when they turned him, he had what appeared to be tube feeding coming out of his nose and mouth and it just kept coming. She also stated the nurse who had caused this had done it before with another resident and the Director of Nursing (DON) and Administrator were aware. She stated she had been in in-services over the past year, but none of them had been related to feeding tubes and further stated she had never been in-serviced on feeding tubes and had not had a skills competency review. On [DATE] at 8:15 AM, interview with LPN J revealed she had received face-to-face training on feeding tubes recently and confirmed that she had received a skills competency review in (MONTH) of (YEAR). On [DATE] at 8:30 AM, interview with Licensed Practical Nurse (LPN) I revealed she did have an annual skills review done by her peers and that it was probably due to be done again. She also confirmed that staff had been given a form to sign back in (MONTH) related to tube feeding procedures. On [DATE] at 11:39 AM, interview with LPN K revealed she had just returned to work from a period of leave so she had not recently received any training. She stated she remembered having a skills competency review when she was new, but can't recall any other. Review of the employee file for RN X, the staff member noted to have hung the resident's tube feeding at 9:00 PM the night the error occurred, found that she had not had a skills verification or validation since her orientation in (MONTH) (YEAR). Review of the Orientation In-Service Acknowledgement for this employee showed training the nurse had received during her orientation; however, there was no indication that tube feeding procedures were covered as part of her orientation. Review of the Nurse Skills Checklist in her file showed the following items were assessed for RN X related to tube feeding: (1) tube feeding care (2) site care (3) placement checks prior to medication or feeding administration. There was no evidence of annual skills verification or education listed within her employee file. Review of the in-services RN X attended after the passing of Resident #1 revealed she had attended trainings on tube feedings and abuse on [DATE]. Review of the employee file for RN C found she had not had a skills competency verification since her initial orientation in (MONTH) (YEAR). Review of her orientation paperwork revealed that she had not been verified/validated on use of feedings pumps as this area of the orientation check sheet was without a date, which would indicate that the nurse orienting her had not observed her completing this task. There was no evidence of annual skills verification or education listed within her employee file. Review of the in-services RN C attended after the passing of Resident #1 revealed she had attended trainings on tube feedings and abuse on [DATE]. Review of the employee filed for RN F revealed she had a Skills Validation Check completed in (MONTH) of (YEAR). There was no evidence of annual skills verification or education listed within her employee file. Review of the in-services RN F attended after the passing of Resident #1 revealed she had attended trainings on tube feedings and abuse on [DATE]. On [DATE] at approximately 3:20 PM, a group interview was conducted with the risk manager, director of nursing (DON), administrator and the regional nursing consultant. During this interview, they stated that a new staff development coordinator had recently been hired and would be responsible for annual skills validations, competencies and ensuring annual training classes were completed. The DON reported that staff were educated upon hire on Do Not Resuscitate (DNR); however, she was not able to state if additional training was offered after initial orientation. She also stated that annual skills verifications and training should coincide with the employee's anniversary date and that the staff developer would be responsible for ensuring this was completed. The DON further stated that the facility did education throughout the year on abuse, disasters, Accu-checks and change of condition, but stated that not all in-services were mandatory, and she could not verify whether each staff member had attended those trainings or which of the conducted in-services had been mandatory. The administrator stated that the facility had access to Gulf Coast University, and on-line training portal, but they had not been utilizing them He stated that the newly hired staff developer would also be responsible for this component. Review of the Facility Assessment for 2019 (pg. 8 under Staffing Plan - training/education and competencies) stated, We ensure our staff are licensed or certified as applicable for their positions. We also ensure new hire orientation as well as yearly mandatory education on various subjects. We perform regular in-services based on QAPI (Quality Assurance Performance Improvement) initiatives. Our staff have the ability for on-site training sessions as well as our on-line training portal for our training needs. Review of the facility's undated policy entitled Staff Development In-Service Training - General Policies revealed a primary purpose to provide the facility's associates with an in-depth review of established policies and procedures and to provide up-to-date information that would assist in providing quality care and stated all staff must attend and participate in regularly scheduled in-service training programs. The policy went on to state the primary objectives of the facility's in-service training programs was to plan and organize a system of training that began with an orientation program and continued throughout employment and to develop in each associate an awareness of his/her abilities and limitations in providing care for residents. Review of the job descriptions for both Registered Nurses and Licensed Practical Nurse revealed it was an essential duty and responsibility to attend and participate in all center in-service programs as required and to maintain professional competence through participation in continuing education programs, seminars and training programs.