Every finding on record at Blue Palms Health and Rehabilitation Center of del

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

Based on observations, interviews, and record review, the facility failed to develop comprehensive care plans that included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for four (Residents #1, #40, #24 and #31) of 30 residents reviewed for care planning from a total survey sample of 30 residents. The findings include: 1. On 3/30/25 at 11:30 AM, Resident #1 was observed in bed with a pressure relieving mattress, catheter bag hanging at bedside, bilateral boots to prevent pressure wounds, and a peripherally inserted central catheter (PICC) line in the left upper arm. A review of the medical record revealed that Resident #1 was initially admitted on [DATE]. On 2/21/25, he had an unplanned discharge to an acute care hospital with return anticipated. On 3/1/25, he was readmitted from the hospital. Resident #1's diagnoses included multiple sclerosis, contractures of both knees, pressure ulcer of the left buttocks-Stage 4, chronic pain, hydronephrosis, dementia, history of transient ischemic attack (TIA), extended spectrum beta lactamase (ESBL) resistance and sepsis. A review of the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/4/25 revealed that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. No behaviors were noted including refusal of care. The resident required a mechanical lift and two-person assistance with care activities. A review of the physician's orders dated 3/1/25 revealed: Methocarbamol Oral Tablet 500 milligrams (mg), 2 tablets four times a day (QID) (muscle relaxant) Rivaroxaban Oral Tablet 20 milligrams (mg), 1 tablet daily (QD) (anticoagulant) Primidone Oral Tablet 50 milligrams (mg), 1 tablet daily (QD) (anticonvulsant) Lasix (anti-diuretic) Oral Tablet 40 milligrams (mg), 1 tablet every other day (QOD) (diuretic) Occupational Therapy (OT) clarification order: OT evaluation and treatment 5 x week for self -care. ADLs (activities of daily living), therapeutic activities, neuromuscular re-education in order to return to prior level of function (PLOF). Suprapubic catheter care every shift, cleanse site and replace t-sponge. Flush PICC Line: Flush lumens every 12 hours with 10 ml (milliliters) normal saline. Catheter: Suprapubic catheter 18 FR (French) with 10 cc (cubic centimeter) balloon to dependent drainage. Change catheter monthly, PRN (as needed) if dislodged or plugged and unable to clear with irrigation. Scrotum MASD (moisture-associated skin damage) wound treatment as follows: Clean with NS (normal saline). Pat apply silver sulfadiazine 1% cream. Leave open to air. IV - Dressing Change - PICC transparent dressing change every week and as needed (PRN). A review of the resident's care plan (start date 3/4/25, target completion date 3/11/25) revealed no focus area, goals, or interventions for prescribed diuretic or anticoagulant medication. There were no focus areas, goals, or interventions for a PICC line, urinary catheter care, or MASD. In a 4/2/25 interview at 12:05 p.m. with Licensed Practical Nurse (LPN) A/Minimum Data Set (MDS) Coordinator, she explained that the care plan goals were derived from diagnoses, physicians' orders, and any pertinent information obtained from residents' records. She stated the purpose of the care plan was to enhance resident-centered care. She was asked to review Resident #1's care plan for anticoagulants, diuretics, PICC line , catheter and MASD. After opening the resident's record she said, Oh, this is incomplete; it should be more than two pages. There are goals that are missing interventions. She confirmed that there was no care plan in the resident's record for a PICC line, urinary catheter, diuretic, anticoagulant, or MASD. She stated she would expect all those issues and medications to be care planned. During a 4/2/25 interview at 12:39 p.m. with LPN E/Unit Manager, she stated during daily clinical meetings, all new admissions' records were reviewed to ensure the documentation was complete. She further stated the clinical team also reviewed order listings for new orders, risk management notes, and updated the care plan. 2. A review of Resident #40's medical record revealed an admitted [DATE]. The resident's medical diagnoses included Parkinson's disease without dyskinesia (involuntary, uncontrolled muscle movements), without mention of fluctuations and depression. A review of the 5-day MDS assessment, dated 3/3/25, revealed a BIMS score of 15/15, indicating intact cognition. Medications included injections on one of seven days, as well as antianxiety, antidepressant, anticoagulant, and antibiotic medications received during the assessment period. A review of Resident #40's active physician's orders revealed: Hydrocodone-acetaminophen (combination opioid-over-the-counter analgesic pain medication) oral tab 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for moderate pain (2/18/2025) Document pain on scale 0-10 every shift for monitoring. Provide pain medication and/or non-pharmaceutical pain relief per order as needed (2/19/2025) Apixaban (anticoagulant) oral tab 5 mg, give 1 tablet by mouth two times per day for deep vein thrombosis prophylaxis (2/19/2025) Behavior monitoring: daytime sleepiness; difficulty concentrating; fatigue; irritability; aggressiveness every shift behavior monitoring due to use of hypnotic medication (2/19/2025) Mirtazapine (antidepressant) oral 1 tablet 15 mg by mouth at bedtime related to depression, unspecified (2/21/2025) Lorazepam (benzodiazepine) oral tablet 0.5 mg, give 1 tablet by mouth every 24 hours as needed at bedtime for anxiety and insomnia (3/7/2025) DNR (do not resuscitate) (3/3/2025) A review of the resident's care plan (revision date 3/11/25) revealed no focus areas, goals or interventions for the resident's use of anticoagulant, opioid, antidepressant, or benzodiazepine medications. (Copy obtained) A review of the March 2025 and April 2025 medication administration records (MARs) and treatment administration records (TARs) revealed that medications were provided as ordered; however, no behavior monitoring was located in the records. During an interview on 4/2/25 at 11:50 a.m. with LPN A/MDS Coordinator, she stated she updated care plans by reviewing the residents' hospital records or medical records, through resident and family meetings, and by reviewing the physicians' orders. Nursing completed the initial baseline care plan. The MDS department scheduled care plan meetings. They usually occurred at three weeks. When the resident's MDS assessment was completed, the care plan opened up and was subsequently completed in the resident's record. The baseline care plan was completed on paper. When asked how she ensured that all care plans were complete, LPN A replied that was accomplished through audits. There was a review date and target complete date that she monitored. She also monitored input from other departments. She signed off the completion of the care plan during the care plan meeting with the families and/or residents. Care plan meetings were held on Tuesdays. Residents were added to the care plan schedule. The purpose of the care plan was to ensure that all staff were on the same page and understood the residents' needs. The care plan was due for completion seven days after the MDS assessment was closed. Staff knew specific interventions that should be implemented related to a resident's care and services by either the baseline care plan or the care plan or kardex system. LPN A was asked to identify where Resident #40's care plan addressed specific care, services, and interventions for his use of anticoagulant, opioid, antidepressant, and benzodiazepine medications, as well as for pain management. LPN A confirmed there were no care plans for these medications or for pain management. When asked who reviewed the MDS assessments, LPN A stated the Director of Nursing (DON) reviewed and signed off on them. The MDS department would let the Director of Nursing know that the MDS assessments were ready to be reviewed and signed. During a 4/2/25 interview with LPN B at 12:05 p.m., she stated she was responsible for monitoring her residents' behavior. Certified Nursing Assistants (CNAs) reported anything they saw/heard, and nursing documented what was reported, then observed the resident, placed interventions, and notified the physician or members of the interdisciplinary team. Nursing was able to find a resident's specific care, services and interventions on the resident's MAR/TAR. Resident behaviors were documented in the electronic medical record (EMR) on a progress note or in the 24-hour report. When she was asked to point out where Resident #40's behavior monitoring was being documented, she stated there was no supplementary information added to the order, so no information was showing on the TAR for behavior monitoring. When she was asked how she knew a resident's behavior was being monitored, she replied that if Resident #40 had a behavior issue reported, it would have been documented in the progress notes. 48947 3. On 3/30/25 at 2:00 p.m., Resident #24 was observed lying in bed. When she was greeted and asked how she was doing, she stated, I'm feeling better after a few days of vomiting and not feeling well. She was asked if she had eaten her lunch. She replied, No, I haven't had much of an appetite, but I was able to eat some of my breakfast. She was asked if she was currently taking antibiotics. She replied, Yes, I am taking antibiotics after being so sick the other day. On 3/31/25 at 12:38 p.m, a record review revealed that Resident #24 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus - type II. The resident had a documented fever on 3/28/25, and experienced nausea and vomiting with symptoms that started on 3/27/25. A review of the quarterly MDS assessment, dated 12/27/24, revealed the resident had a BIMS score of 10/15, indicating moderate cogniitve impairment, and received insulin injections, antidepressant, diuretic, and antibiotic medications during the assessment period. On 3/31/25 at 12:46 p.m., a review of the resident's care plan revealed the following focus areas: Focus: Impaired cognitive function/dementia or impaired thought processes related to current health status (initiated 3/27/24, revised 3/13/25) Focus: Diabetes mellitus (initiated 4/1/24, revised 10/2/24) Focus: Altered respiratory status - requires oxygen (initiated 5/30/24, revised 3/13/25) There was no care plan related to the new onset symptoms of nausea/vomiting or fever (102.1 on 3/28/25), or initiation of antibiotic use for indication of fever. On 3/31/25 at 12:55 p.m., a review of the resident's active physician's orders revealed: Does the resident have nausea, vomiting, loss of appetite, or diarrhea? Conduct temperature check after meals and at bedtime for Infection Control (3/31/25) RSV (Respiratory Syncytial Virus), UA (Urinalysis) with reflex to C&S (culture and sensitivity), Sent uncollected 3/31/25 3:57 PM, one time only related to muscle weakness, generalized (3/28/25) CBC w/diff (Complete Blood Count with differential), CMP (Comprehensive Metabolic Panel), Waiting to be sent, one time only related to muscle weakness, generalized (3/28/25) Ceftriaxone Sodium Injection Solution Reconstituted 1 gram, inject 1 gram intramuscularly one time a day for fever for four days (3/29/25 - 4/2/25). On 3/31/25 at 1:00 p.m., a review of the resident's progress notes revealed that the resident vomited on 3/27/25, and was seen by the APRN (Advanced Practice Registered Nurse) on 3/28/25 for symptoms of fever 102.1 F (Fahrenheit), vomiting, risk for dehydration, suspected infection, and was given new orders for IV (intravascular) fluid bolus for 1 day, a urinalysis, culture & sensitivity, comprehensive metabolic panel, and a complete blood count. (No results were available for any of the lab tests ordered.) Ceftriaxone Sodium Injection Solution Reconstituted 1 Gram IM (intramuscularly) was ordered daily for four days for fever. On 4/1/25 at 11:43 a.m., an interview was conducted with LPN C. She was asked the following: Have you received training/education for how to identify and prevent abuse and neglect? Of course. Do you believe you have enough staff to give your residents the care they need? We do. Who is responsible for transcribing lab orders? Sometimes the nurses do it and sometimes the doctors or the nurse practitioners have access to the medical record, and they put in their own lab orders. How long does it take for the faclity to receive lab results? It depends on which lab test is ordered, usually it's pretty quick. What is the typical wait time to receive lab results? I would say within a day or so. Who is responsible for collecting urine samples from the residents? The nurses. Are urine samples collected on any particular shift? No, whenever a STAT (immediate) urine is ordered, we go ahead and collect the sample right then and put it in the refrigerator for the lab to pick it up. What do you do with the lab results when you receive them? Report to the doctor. On 4/2/25 at 11:54 a.m., an interview was conducted with LPN A. She was asked the following: Who is responsible for initiating the resident care plan on admission? I look for their diagnoses in the hospital records to start the care plan. I talk to the CNAs (certified nursing assistants) and family to get more information about the resident, and review the physician orders. We have up to 14 days to complete the comprehensive care plan. Each department adds their own parts of the comprehensive care plan. I monitor all the departments' input and make sure everything is completed before it is signed off as completed. Is the initial baseline resident care plan documented on paper? Yes. What is the purpose of the resident care plan? The care plan itself is so everybody is on the same page on how to take care of the resident. What are some of the medication categories that should be addressed in a resident's care plan? I personally care plan antibiotics, antidepressants, antianxiety, psychotropics, diuretics, hypnotics, anticoagulants, antiplatelets, and IV medication. When there is a change in condition, who is responsible for updating the resident care plan? That is nursing and myself would do that, and it's based on the order summary that the Unit Manager runs in the mornings. We review it, but the nurses can update the care plan anytime they initiate an order. LPN A was asked to access the care plan for Resident #31 in the EMR. She was asked to find a care plan that addressed her recent antibiotic use or any indication for infection. LPN A stated, I don't see a care plan for any indication of infection or current antibiotic use. On 4/2/25 at 12:48 p.m., an interview was conducted with LPN E. She was asked the following: When she was asked who was responsible for updating a resident care plan, she stated she ran a summary of new orders every morning and reviewed those orders with the clinical team to ensure that everything had been addressed. She named the MDS nurses as staff who would actually access a resident's care plan in the EMR and update the care plan intervention, or goals, with pertinent input from the clinical team during the morning clinical meeting. What is the purpose of the resident care plan? It's a plan to tell us how to take care of the resident. She was asked to access Resident #24's current care plan in the EMR and find a care plan focus for the current order for antibiotic use and the indication. I can't find anything. Who is responsible for transcribing lab orders? Whoever receives the order. How long does it take for the facility to receive lab results? It's based on the lab; if it's STAT it's taken to the hospital, and it usually reports in 5-6 hours or sometimes before that, and if it's not ordered STAT, the lab technicians usually come in the morning to draw the lab, and the results come back by that afternoon. Who receives the results? They come into [EMR] and some lab results come by fax. All nurses are responsible for looking out for lab results. I usually check first thing in the morning as part of my routine and bring the results to the morning clinical meeting. Who is responsible for collecting urine samples from the residents? The nurses. Are urine samples collected on any particular shift? Not really. What is the facility's process for making sure lab specimens are collected in a timely manner? If you have a urinalysis that is not a STAT order, the night shift will collect it and the lab picks it up in the morning. If it's a STAT order, the nurse collects it right then. What is the facility's process for making sure lab orders are followed through on in a timely manner? We have a list that the lab technician uses to note what labs were drawn, and which specimens were collected or picked up. We can also check in [EMR] to review them with the clinical team in the morning meeting to determine if labs were collected or not. How many days a week does the facility have lab services? Monday through Sunday but on the weekends they only come if we have STAT orders. She was asked to access the EMR for Resident #24 and review the lab orders. She confirmed that the resident had labs for RSV, urinalysis with reflex culture, and CMP & CBC with differential orders on 3/28/2025. She was asked to provide the results. She stated, I'm not sure why these results have not come back yet. I will contact the lab and get back with you on what I find out. On 4/2/25 at 4:00 p.m., LPN E returned to provide an update on the lab results. She stated, The new nurse documented that the labs had been collected when really they had not. She wasn't aware of how that should have been documented. 4. On 3/30/25 at 1:58 p.m., Resident #31 was observed with a large, purple-colored bruise on her left forearm. When she was asked about the area, Resident #31 stated, It was worse; it's gotten better. On 4/1/25 at 12:16 p.m., a record review revealed that Resident #31 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, Type II diabetes mellitus with diabetic peripheral angiopathy without gangrene/with hyperglycemia, mood [affective] disorder, anxiety disorder, wedge compression fracture of first, second, fourth and fifth lumbar vertebra, heart failure, chronic obstructive pulmonary disease, atrial fibrillation and a diagnosis of dementia documented on the psychiatric evaluation dated 2/11/25. On 4/1/25 at 12:16 p.m., a review of the quarterly MDS assessment, dated 1/25/25, revealed a BIMS score of 14/15, indicating intact cognition. MDS documentation also indicated that the resident received insulin injections, antidepressant, anticoagulant, and diuretic medications during the assessment period. On 4/1/25 at 12:16 p.m., a review of the resident's current care plan revealed the following focus areas: Focus: The resident uses antidepressant medication related to Depression (Initiated: 10/31/2024, Revision on: 10/31/2024) Focus: The resident has pain/discomfort related to multiple back fractures, compression fractures, neuropathy. (Initiated: 10/31/2024, Revision on: 01/10/2025) There were no care plans available that addressed resident care for anticoagulant use, diuretic use, insulin use or Advanced Directives/DNR (Do Not Resuscitate). On 4/1/25 at 12:16 p.m., a review of the resident's active physician's orders revealed: Furosemide (diuretic) oral tablet 40 mg, Give 1 tablet by mouth in the morning related to Heart Failure (10/24/2024) Humalog Injection Solution 100 unit/ml (units per milliliter) (Insulin Lispro), inject as per sliding scale subcutaneously before meals and at bedtime related to type II DM (diabetes mellitus) (10/25/2024) Eliquis (anticoagulant) oral tablet 2.5 mg, give 1 tablet by mouth two times a day related to Atrial fibrillation (12/4/2024 ) Lantus Solo Star Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), inject 20 units subcutaneously in the morning related to type II DM with hyperglycemia (1/10/25) Trazodone (antidepressant) Oral tablet 50 mg, give 1 tablet by mouth one time a day for sleep (1/7/25) Sertraline (selective serotonin reuptake inhibitor - can be used to treat depression or anxiety) Oral Tablet 25 mg (2/12/25) Hydrocodone-Acetaminophen (combination opioid-over-the-counter analgesic pain medication) Oral Tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed for pain (2/18/25) Antidepressant Medication - Observe for behavior (specify) every shift, (11/14/24) Antidepressant Medication - Side Effects monitor every shift (11/14/24) Donepezil (acetylcholinesterase inhibitor) 10 mg by mouth at bedtime for dementia (10/24/24) DNR (Do not resuscitate) (1/6/25). On 4/2/25 at 11:54 a.m., an interview was conducted with LPN A/MDS Coordinator. She was asked to access the initial care plan for Resident #31 and find a focus area that addressed anticoagulant use. I do not see one. She was asked to find a care plan focus area that addressed diuretic use. There is indication for diuretic use under her care plan for falls, for nutrition and for incontinence. She was asked to find a care plan focus area that addressed the resident's Advanced Directive status for DNR. I do not see one. She was asked to find a care plan focus area that addressed Diabetes Mellitus and insulin use. I do not see one. On 4/2/25 at 12:48 p.m., an interview was conducted with LPN E/Unit Manager. She was asked to access the current care plan for Resident #31 in the EMR and find a care plan focus area that addressed anticoagulant use. I don't see it. She was asked to find a care plan focus that addressed the resident's Advanced Directive status for DNR. I don't see it. She was asked to find a care plan focus area that addressed Diabetes Mellitus and insulin use. It's not there. A review of the facility's policy and procedure for Comprehensive Care Plans, (implemented 3/20/25, revised 2/27/25, reviewed [NAME] President of Operations), revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychological needs, and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated. 2. The comprehensive care plan will be developed within seven days after completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rational for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure that a Level II Preadmission Screening and Resident Review (PASRR) evaluation was completed after a Level 1 screening suggested the possibility of a serious mental illness for one (Resident #6) of one resident reviewed for PASRR, out of 30 residents in the total survey sample. The findings include: A review of Resident #6's medical record revealed an initial admitted [DATE] with the most recent readmission on 4/25/2024. The resident's diagnoses included hereditary and idiopathic neuropathy, hyperlipidemia, dysphagia, pneumonia, fracture of left femur, acquired absence of kidney, sacrococcygeal disorders, gout, anemia, muscle weakness (generalized, history of falling), unspecified intellectual disabilities, not an acceptable Primary Diagnosis, 08/14/2023, Secondary Diagnosis During Stay, 10/4/2023, dementia in other diseases classified elsewhere, unspecified severity with agitation, secondary diagnosis and present on admission (02/24/2025), schizophrenia, unspecified secondary diagnosis, present on admission, 4/17/2024, cognitive communication deficit, dysphagia, chronic pain syndrome, major depressive disorder, recurrent, moderate, secondary diagnosis, present on Admission, 8/25/2023, and essential (primary) hypertension. A review of the care plan initiated 04/19/2019 and revised on 07/02/2024, revealed that Resident #6 had behavior symptoms related to cognitive impairment, refusing to get out of bed, refusing care, and calling staff names. She was noted with combative and aggressive behavior. Care plan interventions included: Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for resident's disruptive behaviors by offering tasks which divert attention, such as a calm approach, no changes in routine (any change, any routine upsets her). If reasonable, discuss resident's behavior. Explain and reinforce to the resident why behavior is inappropriate and/or unacceptable. Provide a calm, quiet atmosphere; loud, crowded areas appear to be overstimulating. Minimize the potential for resident behavior problems by modifying environmental factors and daily routine. A review of the resident's PASRR, completed by a Social Worker (MSW - Master of Social Work) and dated 07/17/2024, revealed in Section I A. Depressive disorder, schizoaffective disorder and schizophrenia. Related conditions were noted as cognitive/communication deficit. Substantial functional limitations in three or more major life activities were noted as: Capacity for independent living, learning, self-care and self-direction. Findings were based on documented history, individual and medication. Section II: Other indications for PASRR Screen Decision-Making documented that there was an indication that the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage. It further documented the concentration, persistence, and pace: The individual has serious difficulty in sustaining focused attention for long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks. The form documented that the resident had a related neurocognitive disorder. And finally, the form, dated and signed on 07/17/2024 at 1:30 PM, documented that the MSW spoke to Resident #6's legal guardian, who consented to the information being shared. On 04/02/2025 at 2:25 PM, the Administrator provided a copy of the resident's Florida PASRR Level II Receipt of Referral Packet Notice of Missing Required Documentation sent to the facility and dated 07/31/2024. The letter read, We have received a referral to complete a PASRR Level II Review on [Resident #6]. In order to complete the PASRR Level II evaluation and determination, we ask that you send a copy of the following required documents: - Informed Consent - Minimum Data Set (MDS) - Patient Transfer/Continuity of Care (3008) - Relevant Case Notes/Records of Treatment The letter further noted, This information should be sent to us within five business days from the date of this notice. If the information is not submitted within the requested timeframe, we will close the request. During an interview with the Administrator on 04/02/2025 at 2:25 PM, he stated, I couldn't find anything in our system other than the copy of the Florida PASRR Level II Receipt of Referral Packet Notice of Missing Required Documentation, dated 07/31/2024. He explained that he was not aware of whether or not any of the requested documentation for a Level II PASRR for Resident #6 was submitted, and he would need to check with the Director of Social Services when the employee returned from leave. The Administrator also noted that the facility did not have a policy and procedure for PASRR.

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

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

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

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

Based on record review and staff interviews, the facility failed to monitor resident behaviors and potential side effects related to the use of [CONDITION(S)] medication for one (Resident #25) of five residents reviewed for unnecessary medications from a total of 20 residents in the sample. The findings include: A record review for Resident #25 revealed she was admitted on [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's medication administration records (MAR) for July through September 2021 revealed no behavior monitoring documentation and/or side effect monitoring documentation for the antipsychotic medication, [MEDICATION(S)]. A review of the medication record review (MRR) in August 2021 and September 2021 revealed a pharmacy recommendation to start antipsychotic monitoring on the MAR for [MEDICATION(S)]. On 9/22/21 at 2:52 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She confirmed that Resident #25 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She added that the resident has displayed some behaviors, including excessive sadness, tearful, outbursts and anxiety. When she was asked about behavior monitoring, she stated it was in place, but she was unable to provide any documentation to show it was happening. On 9/22/21 at 3:54 PM, an interview was conducted with the Director of Nursing (DON). She verified there was no documented behavior monitoring for Resident #25 related to the use of [MEDICATION(S)], and could not explain why the behavior monitoring was not a part of the MAR. On 9/23/21 at 11:32 AM, a follow up interview was conducted with the DON. The DON confirmed the pharmacist recommendation in August 2021 and September 2021 to add behavior monitoring for Resident #25 related to the use of [MEDICATION(S)]. She stated that the previous DON initialed that it was implemented in 8/2021, however, it was not. She added that all pharmacy recommendations are to be reviewed by the DON to ensure they are implemented. She once again confirmed there was no documented behavior monitoring for Resident #25.

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

Based on observations, resident and staff interviews and resident and facility record reviews, the facility failed to provide the appropriate activity of daily living (ADL) care (bathing) for three dependent residents (#1, #2 and #5) of three residents whose bathing schedules were reviewed. The findings include: Observation during the facility tour commenced at 9:28 am on 4/29/19. There were two shower rooms, one on each of the two units. The east wing shower room was in use at the time of tour. The west wing shower room was observed with a sign on the inside of the door instructing, Document your (picture of a shower head with running water). 1. Resident #1 was interviewed on 4/29/19 at 9:45 am in her room. She was asked if she received showers according to her preference, and she responded that the facility was often too short-staffed to provide showers. She only received showers once a week instead of the two to three times weekly per her shower schedule. Resident #1 said she had complained to administration, but the staff still often told her they did not have the time or the staff to give her a shower on their shift. Record review for Resident #1 found a quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/18/19. She was assessed with [REDACTED]. She required extensive assistance with bed mobility, and was totally dependent on two staff members for transfers. She also required extensive assistance with personal hygiene and total dependence with bathing. She used a wheelchair as a mobility aid. [DIAGNOSES REDACTED]. Resident #1 was care planned on 4/22/19 for her self-care performance deficit related to activity intolerance, confusion, disease process, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A review of the certified nursing assistant (CNA) daily tasks revealed Resident #1 was to receive showers on Monday and Thursday evenings. The data for the last 30 days showed she received a shower on 4/1/19 and 4/10/19; only twice over the past 30 days. The CNAs documented they provided a bed bath on (MONTH) 9, 10, 11, 15, 18, 22, 23, and 25, 2019. (Photographic evidence obtained) 2. A record review for Resident #2 found a quarterly MDS assessment with an ARD of 3/20/19. She had a BIMS score of 4, indicative of severely impaired cognition. Resident #2 required extensive assistance with bed mobility, and she was totally dependent on staff for personal hygiene and bathing. She had upper and lower extremity impairment on both sides and used a wheelchair as a mobility aid. [DIAGNOSES REDACTED]. Resident #2 was care planned on 3/20/19 for her activities of daily living (ADL) self-care performance deficit related to her [DIAGNOSES REDACTED]. A review of the daily CNA task documentation for Resident #2 found she was to receive bathing each Monday and Thursday on the evening shift. A review of the data found there were no showers documented over the past 30 days. There were only 6 bed baths documented as having been given during the 30-day period. 3. A record review for Resident #5 found a significant change MDS assessment with an ARD of 4/4/19. She had a BIMS score of 4 (severely impaired cognition) an required extensive assistance for bed mobility and transfers, and personal hygiene. She was totally dependent on staff for bathing. Resident #5 used a wheelchair and walker as mobility aides. [DIAGNOSES REDACTED]. Resident #5 was care planned on 4/4/19 for impaired cognitive function, and resistiveness to care. She was care planned for her ADL self-care performance deficit evidenced by her inability to provide self-care. Approaches included one staff assist and cueing for bathing, and noted that showers were scheduled on Sundays during the 3:00 pm to 11:00 pm shift. A review of the facility's grievance log found that on 1/21/19, a concern was filed on behalf of Resident #1 by a family member. The concern involved her not receiving a shower for a week. The investigation revealed the shower schedule was reviewed with the family member, who was pleased with the schedule. The plan was to continue on the current schedule with bathing, and both the resident and the family member were agreeable to this plan as of 1/22/19. A grievance filed by Resident #6 on 1/24/19 found she had been in the facility for 11 days with no shower. She was told the day prior to filing that she was not on the schedule yet, as she was too new. As a result of the concern, Resident #6's chart was audited and confirmed no shower had been done. A CNA was assigned to give her a shower. The form also indicated more records for the 200 court were audited and revealed a few other residents were missing scheduled shower days. Updates were completed in response to resident care plan and the CNA tasks. An interview was conducted with CNA B at 2:30 pm on 4/29/19. She said that showers could be difficult to provide as scheduled, speaking honestly. There were supposed to be three aides on each unit, but sometimes there were only two if anyone called off. Resident #1 was a 2-person assist with showers, and it could take 20 minutes or more for her showers. She stated there simply was not always enough staff to provide a full shower. She would give a bed bath in that case to her residents and document this on the CNA tasks in the electronic records kiosk. CNA B said facility staff was trying to rearrange the shower schedules to make it easier, but residents didn't like being showered on the 3rd shift so that might not work. She said all baths, showers and refusals should be documented in the CNA tasks. An interview was conducted with the Quality Assurance Nurse at 3:35 pm on 4/29/19. She reviewed the grievances regarding no showers as well as the CNA tasks for Residents #1, #2 and #5. She acknowledged that showers, bed baths and sponge baths were not being documented as provided per the resident schedules, confirming it was not possible to determine if the bathing actually occurred. An interview with the Director of Nursing at 3:50 pm on 4/29/19 revealed the shower schedule was recently rearranged to make it more fair to the aides. Some residents took over one hour to shower. Some of the aides had complained that bathing and showering assignments were not fairly distributed. She stated each bath type was supposed to be documented each time provided, and acknowledged the lack of documentation which made it difficult to determine if residents were receiving bathing as scheduled.

Based on interviews with residents and staff, and resident record review, the facility failed to implement the comprehensive person-centered care plan for the use of a chair alarm for accident prevention for one (Resident #5) of three residents reviewed for falls out of a total of six residents in the sample. The findings include: An observation of Resident #5 was made on 4/29/19 at 9:28 am. She was seated at a table with two other residents. She had her head down, chin to chest, and appeared to be asleep in her wheelchair. Slippers were observed on her feet, and there was no personal alarm in place. She was observed again on 4/29/19 at 10:40 am in the dining area attending a church service. She was in her wheelchair and had a slice of a red foam pool noodle observed hanging off of the back of her chair. An interview was conducted at 10:55 am. She said she was well, and that she liked the church service very much. When asked how long she had resided here, she got a puzzled look on her face. She was not able to respond. During the conversation, she was asked if she had any recent falls. With a pensive expression, she replied that she had not. There was no personal alarm observed on the resident at this time. An observation of Resident #5 at 1:00 pm on 4/29/19 found her in her wheelchair at the dining table. Her chin was down, and she appeared to be dozing off. No personal alarm was in place. A room observation at 2:30 pm on 4/29/19 found there was an alarm observed on Resident #5's bed. Resident #5 was observed in her wheelchair in the living area at this time. She was awake and smiled. No alarm was in place on her chair. An interview was conducted with certified nursing assistant (CNA) A at 10:45 am on 4/29/19. She stated any residents identified at risk for falls were placed on a red ring program. A small red ring is cut from a pool noodle and placed on the wheelchair to visually identify residents at risk. An interview with CNA C at 2:38 pm on 4/29/19 found Resident #5 was able to bear weight for transfers. Fall precautions involved toileting every two hours. We also keep her out here for activities for closer supervision. She used to have a chair alarm but it was discontinued. A record review for Resident #5 found she was admitted to the facility on [DATE]. She had a significant change minimum data set (MDS) assessment with an assessment reference date of 4/4/19. Her brief interview for mental status (BIMS) score was 4, indicating severe cognitive impairment for daily decision making. She required extensive assistance of one person for bed mobility, transfers, and personal hygiene, and total dependence on one staff member for bathing. She used a wheelchair and walker as mobility aides. [DIAGNOSES REDACTED]. There had been one fall since last assessment with no injury. She received opioid medications on seven days during the assessment period. Bed and chair alarms were marked as being used daily. Resident #5 was care planned on 4/4/19 for her impaired cognitive function. She was care planned for a risk for falls related to her unsteady gait and impaired balance evidenced by a history of frequent falls. Approaches included a personal clip alarm when in her wheelchair. Check every shift for placement and function. Resident #5 was care planned for a controlled fall without injury with most recent fall on 3/3/19. Approaches included toilet upon rising, before and after meals, at bedtime and as needed. Monitor for significant changes, personal alarm clip alarm for wheelchair (4/10/18) and pad alarm for bed (added 3/3/19). Nursing progress notes reflected that on 3/4/19 Resident #5 was found at the foot of her bed. She complained of left hand pain with guarding. As a result of the fall, a scheduled toileting program was initiated. On 3/7/19 Resident #5 was noted with bruising to the left hand and swelling to her pinky and ring finger related to her fall. Resident #5 had physician's orders [REDACTED]. Review of the care plan note for Resident #5 dated 4/23/19 found it stated she still had a chair alarm in use. An interview was conducted with the director of nursing (DON) at 3:50 pm on 4/29/19. She reviewed the record for Resident #5 and did not know why the chair alarm was discontinued on 4/27/19. She reviewed the resident's recent falls risks assessment and score dated 4/27/19 with this surveyor and confirmed a score of 16 (high risk). She stated the alarm should still be implemented for that score. She had no explanation for why the alarm was discontinued.

Based on observations, interviews, and record reviews, the facility failed to ensure that the services provided by the facility met professional standards of quality by failing to ensure that a fall prevention care plan was implemented for 1 (Resident #6) of 2 high-risk residents who sustained falls with injuries at the facility, in a sample of 22 residents. Resident #6 sustained a subdural hematoma from a fall on 07/1/2017, requiring hospitalization . Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. Practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: During an interview with the Director of Nursing (DON) on 7/10/2017 at 12:41 PM, she was asked if Resident #6 sustained any falls at the facility within the last 30 days. She stated that Resident #6 fell attempting to get off of the commode. The resident hit her head on the wall, sustained a subdural hematoma, and was in the hospital for three days. The resident was observed on 7/10/2017 at 1:00 PM, and an attempt to interview her was made, but she was unable to answer any questions. A record review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 was assessed as having a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating a significant cognitive impairment. Bed mobility, transfers, dressing and toileting were coded as requiring extensive assistance of one person. A wheelchair was used for mobility. Section J indicated that there was a history of falls, indicating the resident was at risk at the time of the comprehensive assessment. A record review for Resident #6 revealed that she was admitted to the facility on [DATE] from an assisted living facility. She was assessed on admission as requiring the assistance of one person for transfers. Gait and balance was noted as unsteady. Resident #6 was discharged to an acute care hospital on [DATE] following a fall and hitting her head. She was re-admitted to the facility on [DATE]. Her readmission [DIAGNOSES REDACTED]. A record review of the hospital admission documents from the 7/1/2017 fall revealed that the diagnostic impression was advanced dementia, history of traumatic injury to the left frontal area, and small left subdural hematoma of 5 millimeters, with no midline shift. The nursing progress notes for Resident #6 revealed that she sustained falls at the facility on the following dates: On 6/7/2016, Resident #6 was observed falling out of her wheelchair. No injury noted. On 6/24/2016, Resident #6 was found on the floor in the room. No injury noted. On 7/10/2016, Resident #6 was found sitting on floor next to the bed. Small abrasion on head. Multiple skin tears on left forearm. On 8/12/2016, Resident #6 removed her personal alarm, and got out of bed to use the bathroom. By the time the certified nursing assistant (CNA) got to the room, the resident lost her balance and fell , hitting the left side of her head against the bed frame. She sustained a small abrasion to her head and complained of left knee pain. On 10/27/2016, Resident #6 was found on the floor. Some pain associated with left hip that was chronic. On 11/11/2016, Resident #6 was found on the floor in the room in between her bed and her husband's bed, lying on the fall mat. No injuries were noted. On 11/27/2016, Resident #6 was found on the floor in the room with a laceration to the right eye. On 11/28/2016, a progress note documented Resident #6's return from the emergency room with an impacted intra articular distal radial fracture and a small [MEDICAL CONDITION] of the ulna (wrist fracture). On 4/1/2017 at 11:22 PM, a progress note documented Resident #6 was on 8-hour neurological checks. There were no details related to the need for the neurological checks in the progress note. A 4/2/2017 note documented the resident was on follow-up from a fall the previous day with ecchymosis (discoloration/bruising) to the left forehead. On 5/17/2017 at 6:59 PM, the resident was observed lying on her left side with both legs bent at the knee and with her backside toward the couch on the 400 unit. No mention of injury. On 7/1/2017 at 2:46 PM, the resident was sent to the emergency room after a fall off of the toilet, hitting her head on the floor with an open head injury. During an interview with the Director of Nursing on 7/12/2017 at 2:00 PM, Resident #6's falls for November of 2016 to the present were reviewed. The DON reviewed the notes found in the computer and gave the following information: She stated a nurse made a note on 11/27/2016 at 11:39 PM that the resident was observed lying at the foot of her bed face down. She had removed her clip alarm. The resident was calling for assistance. She was evaluated for right wrist pain and had a laceration over right eye. The family and physician were notified. She was sent out to the hospital and returned on 11/28/2017 at 3:28 AM. She was diagnosed with [REDACTED]. The DON was asked if there were any new interventions as a result of the fall. She did not have any information to provide. The interview continued and the DON stated on 4/1/2017 that she learned Resident #6 sustained a fall. She stated Resident #6 needed assistance to get to the bathroom at that time. She stated Resident #6 fell off of the toilet, hit her head on the wall, and sustained a hematoma to the top of her head. She stated the resident's physician was notified and they monitored the resident. The DON was asked if there were any new precautions related to leaving the resident alone in the bathroom that were put in place. She stated, No. She stated it was already a precaution not to leave residents that had alarms alone in the bathroom. She was asked for the investigation and documentation of the staff training. She stated she would look for the training, but could not provide the investigation as it was part of their internal documents. The next fall reviewed occurred on 7/1/2017. Resident #6 was sent out to the hospital as a result. On 7/1/2017 at 4:58 PM, a Certified Nursing Assistant (CNA) assisted Resident #6 to the bathroom. The CNA stepped out of the room to get supplies, and heard the resident hit the wall. The DON stated that the CNA was educated on not leaving residents with personal alarms in the bathroom unattended. She stated the CNA should have been aware not to leave the resident alone. She again stated the facility policy was not to leave residents with alarms alone in rooms, and confirmed the precaution to not leave the resident alone was already on the care plan. Further interview was conducted with the DON on 7/12/2017 at 3:15 PM. She was asked again for evidence of employee training or any type of investigation into how to prevent falls for Resident #6. The DON once again stated that the investigations of the falls are internal documents that she could not give to the surveyor to review. She was asked to provide evidence of any training provided or new interventions put in place as a result of the falls. She once again stated that any resident with an alarm should not be left alone. She stated she had gone to Human Resources to look for training related to the 4/1/2017 fall, and could not find any training for the CNA involved or any staff in the facility. She also confirmed that she did not document the training she did with the employee involved in the resident's fall on 7/1/2017, and did not provide training to any staff in the facility related to the residents fall. Record review of Resident #6's care plans which were revised on 6/7/2017, revealed that the resident was care planned for risk of falls due to deconditioning, dizziness, unsteady gait, balance impairment, cognitive deficits, and a history of falls. The interventions included the directive: Do not leave alone in bathroom all in upper case letters. The intervention was added to the care plan on on 6/15/2016. Additional interventions included a Call Don't Fall sign on the closet door meant to encourage the resident to call for assistance. This was a resident with a BIMS score of 1 out of a possible 15. The staff was to monitor the resident for significant changes in gait, posture, balance, and lower extremity joint function. They were to monitor the resident's clip alarm and check placement every two hours. (Copy obtained)

Based on observations, interviews, and record reviews, the facility failed to ensure that a fall prevention care plan was implemented for 1 (Resident #6) of 2 high-risk residents who sustained falls with injuries at the facility, in a sample of 22 residents. Resident #6 sustained a subdural hematoma from a fall on 07/1/2017, requiring hospitalization . The findings include: During an interview with the Director of Nursing (DON) on 7/10/2017 at 12:41 PM, she was asked if Resident #6 sustained any falls at the facility within the last 30 days. She stated that Resident #6 fell attempting to get off of the commode. The resident hit her head on the wall, sustained a subdural hematoma, and was in the hospital for three days. The resident was observed on 7/10/2017 at 1:00 PM, and an attempt to interview her was made, but she was unable to answer any questions. A record review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 was assessed as having a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating a significant cognitive impairment. Bed mobility, transfers, dressing and toileting were coded as requiring extensive assistance of one person. A wheelchair was used for mobility. Section J indicated that there was a history of falls, indicating the resident was at risk at the time of the comprehensive assessment. A record review for Resident #6 revealed that she was admitted to the facility on [DATE] from an assisted living facility. She was assessed on admission as requiring the assistance of one person for transfers. Gait and balance was noted as unsteady. Resident #6 was discharged to an acute care hospital on [DATE] following a fall and hitting her head. She was re-admitted to the facility on [DATE]. Her readmission [DIAGNOSES REDACTED]. A record review of the hospital admission documents from the 7/1/2017 fall revealed that the diagnostic impression was advanced dementia, history of traumatic injury to the left frontal area, and small left subdural hematoma of 5 millimeters, with no midline shift. The nursing progress notes for Resident #6 revealed that she sustained falls at the facility on the following dates: On 6/7/2016, Resident #6 was observed falling out of her wheelchair. No injury noted. On 6/24/2016, Resident #6 was found on the floor in the room. No injury noted. On 7/10/2016, Resident #6 was found sitting on floor next to the bed. Small abrasion on head. Multiple skin tears on left forearm. On 8/12/2016, Resident #6 removed her personal alarm, and got out of bed to use the bathroom. By the time the certified nursing assistant (CNA) got to the room, the resident lost her balance and fell , hitting the left side of her head against the bed frame. She sustained a small abrasion to her head and complained of left knee pain. On 10/27/2016, Resident #6 was found on the floor. Some pain associated with left hip that was chronic. On 11/11/2016, Resident #6 was found on the floor in the room in between her bed and her husband's bed, lying on the fall mat. No injuries were noted. On 11/27/2016, Resident #6 was found on the floor in the room with a laceration to the right eye. On 11/28/2016, a progress note documented Resident #6's return from the emergency room with an impacted intra articular distal radial fracture and a small [MEDICAL CONDITION] of the ulna (wrist fracture). On 4/1/2017 at 11:22 PM, a progress note documented Resident #6 was on 8-hour neurological checks. There were no details related to the need for the neurological checks in the progress note. A 4/2/2017 note documented the resident was on follow-up from a fall the previous day with ecchymosis (discoloration/bruising) to the left forehead. On 5/17/2017 at 6:59 PM, the resident was observed lying on her left side with both legs bent at the knee and with her backside toward the couch on the 400 unit. No mention of injury. On 7/1/2017 at 2:46 PM, the resident was sent to the emergency room after a fall off of the toilet, hitting her head on the floor with an open head injury. During an interview with the Director of Nursing on 7/12/2017 at 2:00 PM, Resident #6's falls for November of 2016 to the present were reviewed. The DON reviewed the notes found in the computer and gave the following information: She stated a nurse made a note on 11/27/2016 at 11:39 PM that the resident was observed lying at the foot of her bed face down. She had removed her clip alarm. The resident was calling for assistance. She was evaluated for right wrist pain and had a laceration over right eye. The family and physician were notified. She was sent out to the hospital and returned on 11/28/2017 at 3:28 AM. She was diagnosed with [REDACTED]. The DON was asked if there were any new interventions as a result of the fall. She did not have any information to provide. The interview continued and the DON stated on 4/1/2017 that she learned Resident #6 sustained a fall. She stated Resident #6 needed assistance to get to the bathroom at that time. She stated Resident #6 fell off of the toilet, hit her head on the wall, and sustained a hematoma to the top of her head. She stated the resident's physician was notified and they monitored the resident. The DON was asked if there were any new precautions related to leaving the resident alone in the bathroom that were put in place. She stated, No. She stated it was already a precaution not to leave residents that had alarms alone in the bathroom. She was asked for the investigation and documentation of the staff training. She stated she would look for the training, but could not provide the investigation as it was part of their internal documents. The next fall reviewed occurred on 7/1/2017. Resident #6 was sent out to the hospital as a result. On 7/1/2017 at 4:58 PM, a Certified Nursing Assistant (CNA) assisted Resident #6 to the bathroom. The CNA stepped out of the room to get supplies, and heard the resident hit the wall. The DON stated that the CNA was educated on not leaving residents with personal alarms in the bathroom unattended. She stated the CNA should have been aware not to leave the resident alone. She again stated the facility policy was not to leave residents with alarms alone in rooms, and confirmed the precaution to not leave the resident alone was already on the care plan. Further interview was conducted with the DON on 7/12/2017 at 3:15 PM. She was asked again for evidence of employee training or any type of investigation into how to prevent falls for Resident #6. The DON once again stated that the investigations of the falls are internal documents that she could not give to the surveyor to review. She was asked to provide evidence of any training provided or new interventions put in place as a result of the falls. She once again stated that any resident with an alarm should not be left alone. She stated she had gone to Human Resources to look for training related to the 4/1/2017 fall, and could not find any training for the CNA involved or any staff in the facility. She also confirmed that she did not document the training she did with the employee involved in the resident's fall on 7/1/2017, and did not provide training to any staff in the facility related to the residents fall. Record review of Resident #6's care plans which were revised on 6/7/2017, revealed that the resident was care planned for risk of falls due to deconditioning, dizziness, unsteady gait, balance impairment, cognitive deficits, and a history of falls. The interventions included the directive: Do not leave alone in bathroom all in upper case letters. The intervention was added to the care plan on on 6/15/2016. Additional interventions included a Call Don't Fall sign on the closet door meant to encourage the resident to call for assistance. This was a resident with a BIMS score of 1 out of a possible 15. The staff was to monitor the resident for significant changes in gait, posture, balance, and lower extremity joint function. They were to monitor the resident's clip alarm and check placement every two hours. (Copy obtained)

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision that would have reduced the risk of falls with injury for 1 (Resident #6) of 2 residents reviewed for falls in a sample of 22 residents. Resident #6 sustained a subdural hematoma from a fall on 7/1/17, requiring hospitalization . The findings include: During an interview with the Director of Nursing (DON) on 7/10/2017 at 12:41 PM, she was asked if Resident #6 sustained any falls within the last 30 days. She stated Resident #6 fell attempting to get off of the commode. She hit her head on the wall, sustained a subdural hematoma, and was in the hospital for three days. Resident #6 was observed in the facility on 7/10/2017 at 1:00 PM, and an interview was attempted, but she was unable to answer any questions. A record review for Resident #6 revealed that she was admitted to the facility on [DATE], and was then discharged to the hospital on [DATE] following a fall. She was readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The hospital admission documents from the 7/1/2017 fall revealed a diagnostic impression of advanced dementia, traumatic injury to the left frontal area, and a small left subdural hematoma of 5 millimeters, with no midline shift. A review of the Falls Tool Assessment for Resident #6 dated 7/5/2017 revealed she was scored at a 13, placing her at a moderate risk for falls. An interview was conducted on 7/12/2017 at 4:15 PM with the nurse (Employee A) who completed the assessment. She confirmed the resident should be documented at a high risk for falls; not a moderate risk. The nurse stated she was not able to accurately assess the resident because the resident was groggy at the time of her return to the facility. She pulled up the assessment on the computer, and started checking risk factors that were previously left blank. Once she had revised the assessment, Resident #6 was marked as a fall risk of 20, indicating that she was at a high risk for falls. A record review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 was assessed as having a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15 points, indicating a significant cognitive impairment. She required extensive assistance with bed mobility, transfers, dressing and toileting. A wheelchair was used for mobility. Section J indicated that there was a history of falls, indicating the resident was at risk at the time of the comprehensive assessment. A record review of the care plans found the resident was care planned for risk of falls due to deconditioning, dizziness, unsteady gait, balance impairment, cognitive deficit, and a history of falls. The interventions included the directive: Do not leave alone in bathroom, all in upper case letters. The intervention was added on 6/15/2016. Additional interventions included a Call Don't Fall sign on the closet door meant to encourage the resident to call for assistance. This was a resident with a BIMS score of 1 out of a possible 15. The staff was to monitor the resident for significant changes in gait, posture, balance, and lower extremity joint function. They were to monitor the resident's clip alarm and check placement every two hours. (Copy obtained) During an interview with Resident # 6's Certified Nursing Assistant (CNA) (Employee B) on 7/12/2017 at 11:03 AM, she stated the residents' fall precautions were listed on the computer kiosk that the CNAs used for documentation. She stated the resident should not be left alone on the toilet. Record review of the nursing progress notes for Resident #6 found the resident sustained [REDACTED]. On 6/7/2016, Resident #6 was observed falling out of her wheelchair. No injury noted. On 6/24/2016, Resident #6 was found on the floor in her room. No injury noted. On 7/10/2016, Resident #6 was found sitting on the floor next to the bed. A small abrasion was noted on her head. Multiple skin tears were noted on her left forearm. On 8/12/2016, Resident #6 removed her personal alarm and got out of bed to use the bathroom. By the time the CNA got to the room, the resident lost her balance and fell , hitting the left side of her head against the bed frame. She sustained a small abrasion to her head and complained of left knee pain. On 10/27/2016, Resident #6 was found on the floor. Some pain associated with left hip. On 11/11/2016, Resident #6 was found on the floor in the room between her bed and her husband's bed lying on the fall mat. No injuries were noted. On 11/27/2016, Resident #6 was found on the floor in the room with a laceration to the right eye. On 11/28/2016, a progress note documented Resident #6's return from the emergency room with an impacted intra articular distal radial fracture and a small fracture the tip of the ulna. On 4/1/2017 at 11:22 PM, a progress note documented Resident #6 was on 8-hour neurological checks. A 4/2/2017 note documented the resident was on follow-up from a fall the previous day with ecchymosis (discoloration/bruising) to the left forehead. On 5/17/2017 at 6:59 PM, the resident was observed lying on the floor on her left side with both legs bent at the knee and her backside to the couch on the 400 unit. There was no mention of injury. On 7/1/2017 at 2:46 PM, the resident was sent to the emergency room due to a fall from the toilet, hitting her head on floor with an open head injury. During an interview with the Director of Nursing on 7/12/2017 at 2:00 PM, Resident #6's falls for November of 2016 to the present were reviewed. The DON reviewed the notes she found in the computer and gave the following information. She stated a nurse made a note on 11/27/2016 at 11:39 PM that Resident #6 was observed lying at the foot of the bed face down. She had removed her clip alarm. The resident was calling for assistance. Resident #6 was evaluated for right wrist pain and had a laceration over her right eye. She was sent out to the hospital and returned on 11/28/2017 at 3:28 AM. She was diagnosed with [REDACTED]. The DON was asked if there were any new interventions as a result of the fall. She did not have any information to provide. The interview continued and the DON stated that on 4/1/2017, she learned Resident #6 sustained a fall. She stated Resident #6 needed assistance to get to the bathroom at that time. She stated Resident #6 fell off of the toilet, hit her head on the wall, and sustained a hematoma to the top of her scalp. She stated the resident's physician was notified and they monitored the resident. The DON was asked if there were any new precautions put into place related to leaving the resident alone in the bathroom. She stated, No, it was already a precaution not to leave residents that had alarms alone in the bathroom. She was asked for the investigation and documentation of the staff training. She stated she would look for the training, but could not provide the investigation as it was part of their internal investigation. The next fall reviewed occurred on 7/1/2017. Resident #6 was sent out to the hospital. On 7/1/2017 at 4:58 PM, a CNA assisted Resident #6 to the bathroom. The CNA stepped out of the room to get supplies and heard the resident hit the wall. The DON stated that the CNA was educated on not leaving residents with personal alarms in the bathroom unattended. She stated the CNA should have been aware not to leave the resident alone. She again stated the facility policy was not to leave residents with alarms alone in rooms, and confirmed the precaution to not leave the resident alone was already in the care plan. Further interview was conducted with the DON on 7/12/2017 at 3:15 PM. She was asked again for evidence of employee training or any type of investigation into how to prevent falls for Resident #6. The DON once again stated that the investigations of the falls were internal documents that she could not give to the surveyor to review. She was asked to provide evidence of any training provided or new interventions put in place as a result of the falls. She once again stated that any resident with an alarm should not be left alone. She stated she had gone to Human Resources to look for training related to the 4/1/2017 fall, and could not find any training for the CNA involved or any staff in the facility. She also confirmed that she did not document the training she did with the employee involved in the resident's fall on 7/1/2017, and did not provide training to any staff in the facility related to the resident's fall. An interview with conducted with the Administrator on 7/13/2017 at 2:10 PM. He had reported to the survey team the same day that the facility had not had any Adverse Incidents as defined by Florida law since the last recertification survey. He was asked whether the facility initiated an investigation related to Resident #6's fall with injury on 7/1/2017 that required hospitalization . He was asked whether he thought the 7/1/2017 incident could have been prevented if the staff followed the care plan and did not leave the resident alone in the bathroom as per the care plan intervention. He stated if the resident was care planned and they did not use the intervention, the incident would be considered an Adverse Incident. He stated he would check to see if the Adverse Incident investigation had been initiated. The Fall Prevention policy was provided to the surveyor, along with a flow sheet of what to do when falls occurred. A record review of the policy and the flow sheet found that procedures of beginning a fall investigation and reviewing interventions for appropriateness were included in the protocol. It could not be determined definitively that procedures were followed, since record review of the care plans found no evidence of new precautions in place, and the facility was not willing to provide any written documentation to support that each fall was thoroughly investigated.

Based on resident medical record review, staff interviews, resident interview, and policy and procedure review, the facility failed to obtain written informed consent from five (Residents #45, #61, #30, #36, and #22) out of 5 sampled residents to receive or refuse vaccinations for influenza (flu) and pneumococcal immunization. The findings include: Medical record reviews for Residents #45, #61, #30, #36, and #22 revealed a physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) revealed each resident received the vaccine on 10/17/2016 or 10/18/2016 for the last influenza season (October 1, 2016 through March 31, 2017). The electronic medical record did not contain proof of informed consent or refusal for the vaccines for each of the residents. The software program being used contained a screen with boxes to be filled in by the nursing staff. The box that indicated consent was initialed by the nurse. There were no forms in the electronic medical records that were signed by the residents in acknowledgement of the education, the consent, or the refusal of the vaccines. During an interview with the Director of Nursing (DON) on 07/13/2017 at 11:20 a.m., she stated that she used the education forms from the Centers for Disease Control (CDC). The facility obtained consent from the resident or their representative upon admission; they obtained an order from the physician, and then they administered the vaccines at the beginning of the influenza season. Every resident in the facility was asked if they wanted the vaccine every season. She was asked to produce the consent forms for the vaccines. She left the interview. During an interview with Employee N, Health Information Director (HID), and the Social Services Director (SSD) on 07/13/2017 at 12:00 p.m., the HID stated, Oh yes, we have gone through this in the past. It doesn't say it in the statute that it has to be a written consent, or that the facility has to have a written consent in the chart. She produced a copy of the CDC education form and stated, This is the form we give them at admission and they give verbal consent. When asked where it is documented when a resident refuses, she shrugged her shoulders and did not answer. During a second interview with the DON at 12:41 p.m. on 07/13/2017, she stated she had called the Corporate Skilled Nursing Consultant for the facility, and was told that the State of Florida did not have a mandatory consent form for immunizations. She produced a copy of the admission agreement for Resident #61 in which she had highlighted parts of the form that she thought indicated informed consent if the resident or their representative signed it. Review of the admission agreement for Resident #61 revealed no verbiage regarding immunizations specifically. During an interview with Resident #30 on 07/13/2107 at 1:48 p.m., he stated that he chose to get a flu shot every year. He stated he did not sign a form consenting to the vaccine prior to receiving his influenza shot every year. He stated he could not remember whether he received education every year. He thought when he was admitted he was told about immunizations. He stated, Oh no, I don't sign anything. A review of Resident #30's Minimum Data Set assessment, dated 03/25/2017, revealed his Brief Interview of Mental Status score was 15 out of a possible 15, indicating no cognitive impairment. During an interview with Resident #36 on 07/13/2017 at 1:48 p.m., she stated that she received a flu shot every year. She stated her daughter takes care of it for her. She stated that she did want the flu shot every year. She could not remember if she ever signed a form for it. A review of Resident #36's Minimum Data Set assessment, dated 06/21/2017, the Brief Interview of Mental Status score was 12 out of a possible 15, indicating little to no cognitive impairment. During an interview with Employee M, Licensed Practical Nurse (LPN), on 07/13/2017 at 1:43 p.m., she stated she had not been working in the facility during the last influenza season. She was not involved in the process, and had not read the facility policy. She did not think there were forms for informed consent, and she did not know of any. She stated that the nurses documented in the electronic medical record after they received verbal consent. During an interview with the DON and Administrator on 07/13/2017 at 2:20 p.m. in the DON's office, it was explained that an informed consent would need to be in writing because otherwise, there was no proof that the resident had been educated on the current year's vaccine and had consented to receive the vaccines for immunization. They both stated that they understood. During an interview with the DON on 07/13/2017 at 3:10 p.m., she stated, There are no written consents in the charts. She stated that they used to use them, but then corporate told her to stop using them. A review of the policy and procedure entitled 'Immunizations For Residents', issued 06/2012 and last revised 11/2016, revealed: b. If the resident and/or the resident representative consent to vaccinations for pneumococcal and annual influenza follow procedures below. Obtain written consent if required by state regulations. Scan the signed consent into Resident Spaces using the indexing category of Consent for Immunizations. c. If the resident and/or resident's representative chooses not to be vaccinated after discussion of benefits, select Refused in the Consent Given field and document resident or the name of the family member/POA in the Notes section under the resident's immunization tab for the specific immunization. According to The Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD) https://www.cdc.gov/flu/protect/keyfacts.htm#benefits https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html Influenza is a serious disease that can lead to hospitalization and sometimes, even death. Every flu season is different, and influenza infection can affect people differently, but millions of people get the flu every year, hundreds of thousands of people are hospitalized , and thousands or tens of thousands of people die from flu-related causes every year. Flu vaccines cause antibodies to develop in the body about two weeks after vaccination. These antibodies provide protection against infection with [MEDICAL CONDITION] that are in the vaccine. The seasonal flu vaccine protects against the [MEDICAL CONDITION] that research indicates will be most common during the upcoming season. Some of the people who are at higher risk for complications from influenza include people with asthma, diabetes, [MEDICAL CONDITION], or history of a stroke; people age [AGE] years or older; people who have immunocompromising conditions and people who [MEDICAL CONDITION]. Everyone 6 months old and older is recommended for an annual flu vaccine with rare exception. A flu vaccine is needed every season for two reasons. First, the body's immune response from vaccination declines over time, so an annual vaccine is needed for optimal protection. Second, because flu viruses are constantly changing, the formulation of the flu vaccine is reviewed each year and sometimes updated to keep up with changing flu viruses. For the best protection, everyone 6 months and older should get vaccinated annually. Pneumococcal vaccines help protect against some of the more than 90 types of pneumococcal bacteria that contribute to the burden of pneumonia, meningitis, bacteremia, sinusitis, and otitis media. CDC recommends pneumococcal vaccination for all adults [AGE] years or older. According to https://www.hss.edu/conditions_understanding-informed-consent.asp, Signed consent forms are really the culmination of a dialogue required to help assure your informed participation in the clinical decision. According to Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved, Informed consent: consent of a patient or other recipient of services based on the principles of autonomy and privacy; this has become the requirement at the center of morally valid decision making in health care and research. Seven criteria define informed consent: (1) competence to understand and to decide, (2) voluntary decision making, (3) disclosure of material information, (4) recommendation of a plan, (5) comprehension of terms (3) and (4), (6) decision in favor of a plan, and (7) authorization of the plan. A person gives informed consent only if all of these criteria are met. If all of the criteria are met except that the person rejects the plan, that person makes an informed refusal. In non-emergency situations, written informed consent is generally required before many medical procedures, such as surgery, including biopsies, endoscopy, and radiographic procedures involving catheterization. The physician must explain to the patient the diagnosis, the nature of the procedure, including the risks involved and the chances of success, and the alternative methods of treatment that are available. Nurses or other members of the health care team may be involved in filling out the consent form and witnessing the signature of the patient or the parent or guardian, if the patient is a minor. In medical research, the patient must be informed that the procedure is experimental and that consent can be withdrawn at any time. In addition, the person signing the consent form must be informed of the risks and benefits of the experimental procedure and of alternative treatments.

Based on observations and staff interviews, the facility failed to ensure the kitchen and its equipment were maintained and sanitary during three of three days observed (7/10/2017, 7/12/2017 and 7/13/2017) related to: 1. Prevention of bacterial and biological contamination, 2. The handwashing sinks were not maintained in a sanitary fashion. 3. Freezer maintained at manufacturer's recommendations, 4. Food products securely wrapped and correctly labeled with expiration dates, 5. Employees and vendors wearing the proper attire, protective garments and displayed proper hand hygiene, and 6. The drying rack must not be in disrepair and must be sanitary. The findings include: During the comprehensive kitchen tour on 7/12/2017 at 7:20 a.m. and the follow up kitchen visit on 7/13/2017 at 7:05 am with the Registered Dietitian and Dietary Staff (Employee I), the following concerns were observed and confirmed. 1. A close examination of the stacked dishes adjacent to the steam table revealed dishes were wet and stacked on top of each other with water on the top of the three stacked lines of dishes (wet nesting). 2. The hand washing sink was observed with bio growth along the entire top area of the sink lining that attached to the wall and inside the unit were spots of a brown/gold substance. 3. The reach in freezer was observed with approximately two (2) inches of ice along the entire top, base and both sides of the unit. In addition, chucks of ice pieces were stuck to 5 of the ice cream cups. 4. The reach-in freezer was observed with unlabeled and undated pancakes and waffles. In addition, one 4-pack of open waffles was observed with pieces of ice and frost on the waffles. 5. The drying rack above the dishwasher was observed with five of five holding brackets that were covered in a brown/gold substance. The grill was also covered with the same substance.

Based on observations, staff interviews, and facility policy and procedure review, the facility failed to ensure the confidentiality of private health information (PHI) for all residents on the East Wing of the facility when the nurse working on the unit failed to close the laptop lid when she walked away from the medication cart. The findings include: The medication cart on the East Wing of the facility was observed on 07/11/2017 at 11:15 a.m. The laptop with the electronic Medication Administration Record [REDACTED]. The nurse, Employee M, was observed down the hallway at the Director of Nursing's (DON's) office standing in the threshold of the door speaking to someone not observed. (Photographic evidence obtained) The medication cart on the East Wing of the facility was observed on 07/12/2017 at 10:28 a.m. The laptop was open with 12 residents' faces and names showing. The nurse, Employee M, was not observed on the unit for three (3) minutes. When she came back to the unit, she did not close the laptop or lock the screen. (Photographic evidence obtained) The medication cart on the East Wing was observed on 07/13/2017 at 1:42 p.m. The laptop with the electronic MAR indicated [REDACTED]. The nurse was not observed on the unit. (Photographic evidence obtained) During an interview with Employee M, she was asked whether the electronic medical record on the laptop was supposed to be visible, if the screen was to be locked, or the laptop should be closed when she was away from the cart. She said, Yes, she should have closed and locked the competer screen before she walked away from the medication cart. During an interview with the Director of Nursing (DON) and the Administrator on 07/13/2017 at 2:20 p.m. in the DON's office, they were informed that Employee M had left the electronic medical record on the laptop open and visible for anyone passing by her cart three times during the survey. They both acknowledged that the nurse should have locked the screen before leaving the cart unattended. A review of the facility's policy and procedure entitled 'Safeguarding Protected Health Information', issued April, 2003 and last revised July, 2016, read: The Society will ensure, to the extent possible, that PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulation governing confidentiality and privacy of health information. The section entitled Safeguards for Written PHI Active Records read: 3. Active medical records will not be left opened or unattended on the nurse's station desk or other areas where residents/clients, visitor s and unauthorized individuals could easily view the records. 4. Medication Administration Records, Treatment Administration Records, report sheets and other documents containing PHI will not be left open and/or unattended. The section entitled Computer Monitors read: 1. Log off computers when not attended and between users. 3. Position computer monitors so they are not easily viewable by unauthorized people. If necessary, place a privacy filter over the computer's monitor.

Based on resident and staff interviews, the facility failed to ensure that mail delivered by the postal service on Saturdays was distributed to the 48 residents residing in the facility within 24 hours of receipt. The findings include: During an interview with Resident # 1 on 7/12/2017 at 11:40 AM, she stated she did not receive mail on Saturdays because the staff that delivered mail to the residents during the week did not work on Saturdays. During an interview with the Administrator and the Receptionist on 7/12/2017 at 11:55 AM, both confirmed that mail was not given out to residents at the facility on Saturdays. The Receptionist stated mail was delivered to the facility on Saturdays. She stated it went over to the Assisted Living Facility building, and those residents in the Assisted Living unit got their mail in their mailboxes. She stated over at the Assisted Living where the mail was delivered, there was no one on Saturdays to bring the mail over to the health center. The Administrator also confirmed the findings. He stated the post office delivered mail to a mailroom located in another building. He stated the mail was always delivered to the other building, as that was the address used by the facility and was where the mailroom was located. He stated he was not aware of the requirement for the mail to be brought over to the residents when it is delivered on a Saturday.

Based on observations, interviews, and record review, the facility failed to provide the texture consistency specifications of a pureed diet for two (Residents #1 and #17) of two residents with an order for [REDACTED]. The findings include: During the comprehensive kitchen tour on the East Wing on 7/12/17 at 7:20 a.m., this surveyor observed a breakfast meal tray that consisted of pureed sausage, pureed eggs, and the option of regular oatmeal or regular grits. A closer examination of the pureed sausage revealed various pieces of sausage not pureed. In addition, both oatmeal and grits were served in regular textured consistency. The oatmeal consisted large lumps of oats and the grits with large lumps of grains. A finger test confirmed the unsmooth texture of the pureed sausage, the regular consistency of the oatmeal, and regular consistency of the grits. An interview with the Registered Dietitian on 7/12/2017 at 7:30 a.m. confirmed the unacceptable texture of the pureed sausage, in addition to the regular consistency of the oatmeal and grits. A follow-up interview was conducted with the Registered Dietitian on 7/12/2017 at 1:35 p.m. She provided the facility's policy for pureed foods. A review of the policy and procedure, titled Texture Altered Diets revised 2/2016, revealed the purpose of the protocol was to ensure safe consumption of foods/fluids for those residents with chewing/swallowing problems. The section titled, Procedure number 1 and letter A stated, 'follow the national Dysphagia Diet Guidelines', and the facility's diet manual in conjunction with a speech therapy evaluation and physician ordered diets. Under the section titled, Dysphagia level 1 Pureed Texture, it read, 'Pureed foods will hold a mashed potato consistency and will be served on a regular plate.'

Based on observation, interview and record review, the facility failed to provide respiratory services and meet the continuous oxygen needs of 1 (Resident #103) of 17 sampled residents due to an inadequate supply of portable supplemental oxygen. The findings include: An initial observation of Resident #103 on 7/11/2017 at 1:15 p.m., revealed that she was in bed. She appeared fatigued. A review of the resident's face sheet revealed that Resident #103 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED].). A review of the discharge Minimum Data Set (MDS) assessment dated [DATE], section C - cognitive patterns, documented Resident #103's Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15, indicating that she was alert and oriented. A review of the nursing admission/readmission documentation dated 7/8/17 at 3:47 p.m., section A, titled initial admission information, number 2 under reason for admission, documented weakness, [MEDICAL CONDITION], was found to be in acute [MEDICAL CONDITION], and continues to be oxygen dependent. Section B titled, physical exam number 18, respiratory observations documented Resident on oxygen via nasal cannula at 3 liters per minute. A review of the Medication Administration Record [REDACTED]. A follow-up review of the MAR/TAR for July 2017 dated 7/11/17 at 11:00 p.m. documented oxygen at 2 liters. During an interview conducted with Resident #103 on 7/11/17 at 1:15 pm, she revealed she had returned from [MEDICAL TREATMENT] treatment early in the morning, and she did not have any oxygen with her. She stated, Since my admission I have to have oxygen all time. She revealed she did not have an oxygen canister with her at her [MEDICAL TREATMENT] treatment, and rode in the bus with no oxygen. She said she was connected to an oxygen concentrator at the [MEDICAL TREATMENT] center. During an interview conducted with Employee C, Nurse, on 7/11/17 at 1:20 p.m., she stated she did not see the resident leave this morning with oxygen, and confirmed that Resident #103 was on continuous oxygen. She stated that she did not check her, because she was still under the care of Employee F, Nurse. Employee C confirmed she did not take Resident #103's vital signs upon return from the [MEDICAL TREATMENT] center or check to see if she had oxygen. During an interview conducted with Employee F, Nurse, on 7/11/17 at 4:32 p.m., the nurse confirmed that Resident #103 did not leave for [MEDICAL TREATMENT] with oxygen. An interview conducted with the Director of Nursing (DON) on 7/11/17 at 1:53 p.m. confirmed there was no portable oxygen available. She stated that the oxygen canisters were all empty and there was none available. She also stated there were no residents with appointments that needed to leave the facility. She revealed that the oxygen vendor's driver called off sick, and she was told the oxygen would arrive the following day on 7/11/2017. An interview conducted with the Administrator on 7/12/17 at 10:15 a.m. revealed the facility did not have a contract with the oxygen provider. Oxygen was delivered on an as needed basis. A review of the facility policy and procedure, titled Oxygen administration with nasal cannula revised 7/2016, revealed that the purpose of the policy was to administer various levels of oxygen concentration in a safe manner. Under the section titled, procedure number 13, was noted to observe for signs that included [MEDICAL CONDITION].