Every finding on record at Bonifay Nursing and Rehab Center

Based on observation, interview, and record review, the facility failed to provide needed tracheostomy supplies for 1 of 1 residents reviewed for tracheostomy care. (Resident #28)The findings include:An observation of Resident #28 was conducted on 02/03/2026 at 09:00 AM. The resident was in bed with tracheostomy in place (tracheostomy is a surgical procedure creating an opening (stoma) in the neck into the trachea to establish an airway, facilitate mechanical ventilation, or remove lung secretions). No extra tracheostomy inner cannula and obturator was observed at bedside (tracheostomy inner cannula and obturator are components of a tracheostomy tube system). Additional observations were made on 02/03/2026 at 12:45 PM, on 02/03/2026 at 02:35 PM, and on 02/04/2026 at 09:00 AM. No extra tracheostomy inner cannula and obturator was at the bedside at any of these times.A review of Resident #28's current comprehensive care plan indicates that Resident #28 has tracheostomy and is at increased risk for infection/complications. The care plan's interventions included to keep extra trach tube and obturator at bedside if tube is coughed out.An interview was conducted with Staff A, a licensed practical nurse, on 02/04/2026 at 09:45 AM. Staff A stated that a spare tracheostomy inner cannula and obturator is usually at bedside. Staff A looked through the resident's room and verified that Resident #28 did not have the spare equipment. Staff A stated that residents with a tracheostomy should always have spare tracheostomy inner cannula and obturator at bedside.

Based on observations, interviews, medical record review and facility policy review, the facility failed to provide protective measures for 1 of 1 resident sampled for neutropenic precautions. (Resident #12)The findings include:On 2/03/2026 at 8:38 AM, Resident #12 was observed. Signage on the door stated, Neutropenic precautions: clean hands before entering and when leaving room. Avoid raw or undercooked fruits or vegetables: raw or undercooked eggs or shellfish. No live flowers or plants. Do not enter if you feel unwell. There was a second sign at door stating, Personal Protective Equipment: per standard precautions. Signage stated room cleaning: use facility policy for neutropenic precautions. However, there was no protective equipment (mask, gown, gloves) observed outside the room.On 2/03/2026 at 8:47 AM, Staff D, Certified Nurse Assistant (CNA), was observed exiting the resident's room with a tray. She was asked about the resident's signage. Staff D stated she was aware that Resident #12 was on neutropenic precautions. Staff D, CNA, was asked to explain what neutropenic precautions meant when entering the room. She explained it meant to wash hands before and after entering room. She stated she did not wear gloves, gowns or mask when she entered Resident #12's room. She further stated she had been instructed to wash hands but she did not have to wear a mask or any other protective equipment.On 2/03/2026 at 11:54 AM, an interview was conducted with the Director of Nursing (DON). She stated the facility did not have a policy for neutropenic precautions. She further stated the facility's protocol for a resident with neutropenic precautions was for staff to perform hand washing before having contact with patient, when touching resident, or when touching resident's belongings. The DON clarified that staff did not wear a mask because the resident was the one with a weakened immune system. The DON further stated if the resident came out the room, then the resident will wear a mask.A review of Resident #12's medical record was conducted. Resident #12 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including myelophthisis (a severe form of bone marrow failure), neutropenia (a condition with low levels of neutrophils, a type of white blood cell that fights infection), thrombocytopenia (a condition with an abnormally low number of platelets in the blood, leading to easy bruising and bleeding) and pancytopenia (a serious blood disorder characterized by a reduction in all three blood cell types -red cells white cells and platelets, leading to symptoms like fatigue, infections and easy bleeding). An active physician order dated 9/30/25 stated Neutropenic Precautions DX: Myelophthesis. A review of the facility provided in-service/education dated 2/2/26 was conducted. In-service education documentation titled Neutropenic precautions states Use standard precautions and wear a mask when entering the room. On 2/04/2026 at 9:05 AM, an interview was conducted with the DON. She was asked to explain the meaning of standard precautions. The DON stated standard precautions meant hand washing alone, did not involve any type of protective equipment. On 2/04/2026 at 2:20 PM, an interview was conducted with Staff C, Medical Doctor (MD) and Resident #12's primary doctor. He was asked to explain the meaning of neutropenic precautions. He stated neutropenic precautions were protective measures. He was asked the expectations in regards of neutropenic precautions for Resident #12. Staff C, MD stated he expected staff to wash their hands, and at minimum, to wear a mask when entering the room. He further stated a gown and gloves were very essential when providing care.A review of facility policy titled Standard Precautions, revised 8/2023, was conducted. The policy stated Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. All employees are to practice standard precautions to reduce the risk of transmitting infections and the likelihood of exposure. Use of standard precautions applies to all resident care contacts. Under procedures, policy stated masks, eye protection, face shields: mask and eye protection or a face shield are worn to protect mucous membranes of the eyes, nose and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.

Based on observation, interviews, medical record review, and facility policy review, the facility failed to develop a care plan with interventions for 1 of 1 resident sampled. (Resident #12)The findings include:On 2/03/2026 at 8:38 AM, an observation of Resident #12's room was made. Signage stated, Neutropenic precautions: clean hands before entering and when leaving room. Avoid raw or undercooked fruits or vegetables: raw or undercooked eggs or shellfish. No live flowers or plants. Do not enter if you feel unwell. A review of Resident #12's medical record was conducted. Resident #12 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including myelophthisis (a severe form of bone marrow failure), neutropenia (a condition with low levels of neutrophils, a type of white blood cell that fights infection), thrombocytopenia (a condition with an abnormally low number of platelets in the blood, leading to easy bruising and bleeding) and pancytopenia (a serious blood disorder characterized by a reduction in all three blood cell types -red cells white cells and platelets, leading to symptoms like fatigue, infections and easy bleeding). An active physician order dated 9/30/25 stated Neutropenic Precautions DX: Myelophthesis. The care plan included goals related to diagnoses including thrombocytopenia, Pancytopenia, Neutropenia, Myelofibrosis and Myelophthisis. The care plan did not have interventions related to neutropenic precautions.On 2/04/2026 at 9:17 AM, an interview was conducted with Staff F, a Registered Nurse (RN) and Minimum Data Set (MDS) coordinator. She reviewed Resident #12's care plan. She was asked to review the interventions related to resident's diagnoses of thrombocytopenia, pancytopenia, and Neutropenia. She confirmed the interventions should include neutropenic precautions and she stated she would add it into the care plan.

Based on record review and staff interview the facility failed to refer a resident with intellectual disability or related condition to the appropriate state-designated authority for a level II PASARR (preadmission screening and resident review) evaluation and determination for 1 of 1 residents sampled for PASARR. (Resident number 45) The findings include: Review of Resident number 45's electronic medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section 2- page 3 of the PASARR level I revealed there was indication the resident has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the resident's developmental age. Section IV- page 5 of the PASARR level I revealed the resident may not be admitted to a nursing facility. Use the PASARR level I and required documentation to request a level II PASARR because there is a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the DON on 3/16/2022 at 11:00 AM. She stated she completed resident number 45's level I PASARR and the resident should have had a level II evaluation. She stated the level I triggered for a level II, but the facility did not ensure a level II PASARR was completed for the resident.

Based on observations, record reviews and interview, the facility failed to ensure that residents with swallowing concerns followed recommendations from the Speech-Language Pathologist (SLP) related to consumption of thin liquids via rim of a cup for 1 of 4 residents sampled for nutrition (Resident #119). The findings include: On 2/15/2021 at 1:27 PM, Resident #119 was observed to have a drinking cup with a straw inserted inside. A meal ticket dated 2/15/2021 was on the table and read: No straws. (Photographic evidence obtained). On 2/16/2021 at 3:24 PM, Resident #119 was observed to have a straw inserted inside a drinking cup at the bedside. (Photographic evidence obtained). On 2/16/2021, record review of Resident #119's orders revealed an active diet order for no straws. A review of the resident's Quarterly Speech Therapy Rehabilitation Service Screening Form dated 5/18/2020 revealed: patient safely swallowing regular textures and thin liquids via rim of cup. The Nutritional Comprehensive assessment dated [DATE] revealed Resident #119 had a risk factor of a known swallowing disorder. On 2/17/2021 at 4:16 PM, an interview was conducted with Staff C, Speech-Language Pathologist (SLP), revealed that there was an active order for no straws issued by SLP for Resident #119 and that she was unaware Resident #119 had been receiving straws.

Based on observation and interview, the facility failed to safeguard resident's wellbeing by failing to follow current infection control standards related to Coronavirus Disease of 2019 (COVID-19) set forth by the Center for Disease Control and Prevention (CDC), the Department of Health (DOH), and the Agency for Health Care Administration in prevention of the transmission of Covid19. The findings include: The President declared a Nationwide emergency for COVID-19 on 03/13/2020 and approved a major disaster declaration for Florida on 03/27/2020. On March 1, 2020, The Office of the Governor issued Executive Order Number 20-51 directing the Florida Department of Health to issue a Public Health Emergency. The Executive Order documented, Coronavirus Disease 2019 (COVID-19) is a severe acute respiratory illness that can spread among humans through respiratory transmission and presents with symptoms similar to those of influenza. Section 1 directed the State Health Officer and Surgeon General to declare a public health emergency in the state of Florida pursuant to his authority in section 381XXX , Florida Statutes. Section 2 directed the State Health Officer to take any action necessary to protect the public health. Section 3 directed the State Health Officer to follow the guidelines established by the CDC (Centers for Disease Control and Prevention) in establishing protocols to control the spread of COVID-19. Section 4 designated the Florida Department of Health as the lead state agency to coordinate emergency response activities among the various state agencies and local governments. Section 5 specified that all actions taken by the State Health Officer with respect to this emergency before the issuance of this Executive Order are ratified. Section 6 stated The Florida Department of Health will actively monitor, at a minimum, all persons meeting the definition of a Person Under Investigation (PUI) as defined by the CDC for COVID-19 for a period of at least 14 days. Active monitoring by the Florida Department of Health will include at least the following: A. Risk Assessment with 24 hours of learning an individual meets the criteria for a PUI and B. Twice daily temperature checks. Section 7 directed the Florida Department of Health, pursuant to its authority in section 381XXX , Florida Statutes, will ensure that all individuals meeting the CDC's definition of a PUI are isolated or quarantined for a period of 14 days or until the person tests negative for COVID-19. Section 8 directed Florida Department of Health to make its own determinations as to quarantine, isolation and other necessary public health interventions as permitted under Florida Law. Section 9 directs all agencies under the direction of the Governor to fully cooperate with the Florida Department of Health, and any representative thereof in furtherance of this Order. On March 9, 2020, The Office of the Governor issued Executive Order Number 20-52 declaring a state of emergency for the entire State of Florida as a result of COVID-19. On March 15, 2020, the Division of Emergency Management (DEM) Emergency Order No. 20-006 restricting entrance into residential health care facilities including nursing homes. The Order limited persons who were allowed to enter the facility and directed screening of all individuals seeking entry. The order documented, Individuals seeking entry to the facility under the above section1 (includes staff) will not be allowed to enter if they meet any of the screening criteria listed below: a. Any person infected with COVID-19 who has not had 2 consecutive negative test results separated by 24 hours; b. Any person showing, presenting signs or symptoms of, or disclosing the presence of a respiratory infection, including cough, fever, shortness of breath or sore throat; c. Any person who has been in contact with any person(s) known to be infected with COVId-19, who has not yet tested negative for COVID-19 within the past 14 days; d. Any person who traveled through any airport within the past 14 days; or e. Any person who traveled on a cruise ship within the past 14 days. Part 5 of the Order stated, The following documentation must be kept for visitation within a facility: a. Individuals entering a facility subject to the screening criteria above may be screened using a standardized questionnaire or other form of documentation. b. The facility is required to maintain documentation of all non-resident individuals entering the facility. Documentation must include: 1. Name of the individual; 2. Date and time of entry; and 3. The documentation used by the facility to screen the individual showing the individual did not meet any of the enumerated screening criteria, including the screening employee's printed name and signature. On 3/18/20 the Agency for Health Care Administration (AHCA) issued an Alert entitled, Residential and Long Term Care Facilities to Implement Universal Use of Facial Masks. The directive stated, Effective immediately staff of residential and long term care facilities are to implement universal use of facial masks while in the facility. All staff, essential healthcare visitors and anyone entering the facility are to don a mask upon the start of their shift or visit and only change it once it becomes moist. It is important to keep hands away from the mask and only touch the straps of the mask. Gloves are to be worn when providing care to the resident. Continue to perform hand hygiene prior to donning gloves, after removing gloves, and anytime there is contact with the resident environment. Staff in a room with a patient with respiratory symptoms of unknown cause or a patient with known or suspected COVID-19 should adhere to Standard, Contact, and Droplet Precautions with eye protection. This includes wearing gown, gloves, N95 mask (as fitted and available - if not available, at least a facial mask), and eye protection such as face shields or goggles. In addition to securing more gowns, gloves, and masks, facilities will need to immediately order the appropriate eye protection (I.e. face shields) since many do not have this on hand. In the event you are unable to acquire the necessary PPE, please notify your local emergency management agency. Facilities will need to educate their staff on the proper donning (putting on), doffing (taking off), and disposal of any PPE. Information about the recommended duration of Transmission-Based Precautions is available in the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of hospitalized Patients with COVID-19. CDC The review of the website for the Centers for Disease Control and Prevention found information entitled Strategies to Optimize the Supply of PPE and Equipment dated April 3, 2020 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html . The guidance acknowledges current PPE shortages and offers some optimization strategies. Guidance included: The implementation of extended use of facemasks. Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters. The facemask should be removed and discarded if soiled, damaged, or hard to breathe through. HCP must take care not to touch their facemask. If they touch or adjust their facemask, they must immediately perform hand hygiene. HCP should leave the patient care area if they need to remove the facemask. Under the page, Interim Guidance for Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#interim-guidance the CDC documented, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, residents are at increased risk of serious illness. Visitors and HCP continue to be sources of introduction of COVID-19 into nursing homes. To protect the vulnerable nursing home population, aggressive efforts toward visitor restrictions and implementing sick leave policies for ill HCP, and actively checking every person entering a facility for fever and symptoms of illness continue to be recommended. As part of source control efforts, HCP should wear a facemask or cloth face covering at all times while they are in the healthcare facility. Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature* and document absence of shortness of breath, new or change in cough, sore throat, and muscle aches. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. *Fever is either measured temperature >100oF or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. Respiratory symptoms consistent with COVID-19 are cough, shortness of breath, and sore throat. Medical evaluation may be recommended for lower temperatures (<100.0oF) or other symptoms (e.g., nausea, vomiting, diarrhea, abdominal pain, headache, runny nose, fatigue) based on assessment by occupational health or public health authorities. Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices. Hand Hygiene Supplies: Put alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas. Extended use of respirators, facemasks, and eye protection, which refers to the practice of wearing the same respirator or facemask and eye protection for the care of more than one resident (e.g., for an entire shift). Extreme care must be taken to avoid touching the respirator, facemask or eye protection. If this must occur, HCP should perform hand hygiene immediately before and after contact to prevent contaminating themselves or others. Prioritizing gowns for activities where splashes and sprays are anticipated (including aerosol generating procedures) and high-contact resident care activities that provide opportunities for transfer of pathogens to hands and clothing of HCP. Make necessary PPE available in areas where resident care is provided. Consider designating staff responsible for stewarding those supplies and monitoring and providing just-in-time feedback promoting appropriate use by staff. Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles). Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE, prior to exiting the room, or before providing care for another resident in the same room. Consider implementing a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing. Environmental Cleaning and Disinfection: Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them. All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. The health department should be notified about residents or HCP with suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or 3 residents or HCP with new-onset respiratory symptoms within 72 hours of each other. In addition to the actions described above, these are things facilities should do when there are COVID-19 cases in their facility or sustained transmission in the community. Resident Monitoring and Restrictions: Encourage residents to remain in their room. If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes. If they leave their room they should wear a cloth face covering or facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others) DOH guidance for facilities: On April 1, 2020, in response to the COVID-19 pandemic, the Florida Department of Health issued a document entitled, Assessment of Long-Term Care Facility Guidance. In a facility without any COVID-19 cases and without any patients under investigation (PUI) for COVID-19, residents and staff should practice social distancing including separating by more than 6 feet, avoiding communal dining, and avoiding groups larger than 10 people. All non-residents, staff included, should be screened prior to entry and wear a facemask whenever inside a building where residents are present. Staff who fail screening or develop symptoms of possible COVID-19 infection during their shift, should leave the facility and isolate themselves while arranging further follow up care. On 4/22/2020 at approximately 9:03AM, an observation was made of a resident sitting in a wheelchair outside the facility without a mask. Also observed was a staff member sitting on a bench next to the resident, the staff member was wearing a surgical type face mask however it was noted to be pulled down below her nose. On 4/22/2020 at approximately 9:06 AM, an interview was conducted with the facility's receptionist who stated the resident was waiting for county transportation to pick him up for [MEDICAL TREATMENT]. She verified he was a resident of the facility and was not currently wearing a mask. On 4/22/2020 at approximately 9:15 AM, an interview was conducted with the Administrator and the Director of Nursing (DON). At this time, they were notified that neither the surveyor nor the accompanying Department of Health representative had been screened prior to entering the building or before being escorted to the conference room. At this time the Administrator obtained a thermometer and the screening forms and began the screening process. The administrator stated that the Medical Director of the Facility had previously tested positive for COVID-19. He received his positive result on 4/13/2020. The last date he visited the facility was 4/3/2020. The medical director also works at the local hospital. One staff member Certified Nurse's Assistant (C.N.A) A had received a positive test result for COVID-19 on 4/16/2020. Another staff member C.N.A B tested for COVID-19 on 4/21/2020, the results were pending. The DON reported that currently none of the residents have tested positive. Resident #1 was tested this morning (4/22/20) due to a fever. They have had two residents under investigation. Resident #2 had direct contact with the medical director at the hospital. Resident #3 was in the hospital at the time but had no direct contact with the medical director at the hospital. Both residents have been on isolation in their rooms but have not yet been tested . So far, the residents have been asymptomatic. The Person's Under Investigation (PUIs) where located on three different halls within the facility, resident #1 on the 200 hall, resident #2 on the 100 hall and resident #3 on the 300 hall. The Administrator stated that there was not dedicated staff caring for these residents. Staff who were caring for these residents were also caring for other residents on the hall. On 4/22/2020 at approximately 9:35 AM, tour of the facility was initiated. There were multiple residents out in each of the three hallways, none of the residents in the facility had face masks on. On the 100 hall six residents were seated near the nurse's station closer than six feet away from each other. Two were seated in armchairs. The rest of the residents were in wheelchairs. During the tour we asked about plans and processes for an isolation/observation area for residents under investigation or positive for COVID-19. The DON responded by showing a tentative area where they might set up in but offered no specific plans. On 4/22/2020 at approximately 11:25 AM, the Administrator stated, I did not know that the residents were required to wear face masks.

Based on observation, staff interview and clinical record review, the facility failed to keep the oxygen concentrator filters clean for 1 of 1 resident's (#32 ) chosen for respiratory care and 2 of 2 random observations for residents receiving oxygen therapy (#59 and #11). The findings include: Resident #32 was observed to have oxygen being administered at 2 liters per minute. The oxygen concentrator was observed to have a dirty filter on Monday 6/3/19 at 10:42 AM and again on 6/4/19 at 9:24 AM. (Photographic evidence obtained). A review of the resident treatment administration record (TAR) was reviewed for (MONTH) and (MONTH) 2019. The TAR had an order dated 4/7/19 to change oxygen tubing and clean filter every Sunday 11PM-7.AM. The review revealed that nursing staff initialed that the oxygen concentrator filter was cleaned every Sunday on 5/5/19; 5/12/19, 5/19/19; 5/26/19 and 6/2/19. An interview was conducted with Registered Nurse (RN) Unit Manager Employee G on 6/4/19 at 4:12 PM. Resident #32's oxygen humidifier was viewed with her. She was asked what type of care was required for the oxygen humidifier. She said the tubing was changed every week. She was then shown the oxygen humidifier and said that looks dirty, and then said, Oh my when she pulled out some to check. She was asked when it should be cleaned and she was not sure. We then went to Employee G's office and viewed the order for cleaning the filter every week. During an observation on 06/04/19 at 3:32 PM, an oxygen concentrator in room [ROOM NUMBER] near bed B in use for resident #59 was observed to have a dirty filter (photographic evidence obtained). On 6/4/19 at 1:14 PM resident #11's oxygen concentrator filter was observed to be dusty (photographic evidence obtained).

Based on staff and resident interviews, observations, and record review, the facility failed to implement communication care plans for 1 of 32 residents whose care plans were reviewed (#101). The findings include: On 6/03/19 at 11:24 AM, the surveyor was unable to communicate with Resident #101. The surveyor was told by Nurse A that she only speaks Spanish. A review of Resident #101's care plan for communication revealed an intervention of, Staff provide Spanish communication board to assist with communication. On 6/05/19 at 11:00 AM the surveyor entered Resident #101's room to look for a communication board and did not see one. On 6/05/19 at 11:01 AM, an interview was conducted with Nurse A. The surveyor told Nurse A that he was having difficulty communicating with Resident #101. She stated that Resident #101 speaks Spanish. Nurse A was then asked if there were a communication board used to better communicate with the resident. She stated that she has seen them in the building, but was not sure if Resident #101 had one. She was then asked to accompany the surveyor down to the room to look. At that time she was unable to locate a communication board. The surveyor then requested the policy for communication boards from the Director of Nursing. On 6/05/19 at 11:08 AM, Nurse A entered the conference room and stated that she found the communication board crumpled up in the corner of a drawer. The survey asked if they had to look that hard for it and it was in that condition, were staff actually using it? She agreed at that time the staff should know where it is located and it should be available and easily in reach for the resident to use.

Based on observation, record review, and interview, the facility failed to provide indwelling urinary catheter care in a manner that is preventative of urinary tract infections for 1 of 1 (resident #39) residents sampled for catheter care. The findings include: According to the resident's medical record review, resident # 39 was admitted [DATE] with the pertinent [DIAGNOSES REDACTED]. Resident #39 had a chronic indwelling urinary catheter in place with urinary incontinence and a stage 2 pressure ulcer of the sacral region with a urinary tract infection noted on 3/18/2019 that was treated with antibiotics. On 6/3/2019 at approximately 11:00 AM resident #39 was observed sitting in a wheel chair self-propelling throughout resident's room with approximately 3 inches of his indwelling urinary catheter tubing visibly dragging across the floor. On 6/3/19 at approximately 2:11 PM resident #39 was observed sitting on the side of his bed with his feet planted on the floor at the bedside table with approximately 3 inches of his indwelling urinary catheter tubing visibly touching the floor. On 6/5/2019 at approximately 9:13 AM resident #39 was observed sitting on the side of his bed with his feet planted on floor at the bedside table eating breakfast with approximately 2 inches of his indwelling urinary catheter tubing visibly touching the floor (photographic evidence obtained). At approximately 9:15 AM Licensed Practical Nurse, LPN, [NAME] confirmed that the tubing was touching the floor and that it should not be. On 6/5/2019 at approximately 2:44, review of the facility's Guidelines for preventing urinary tract infections, (Catheter-associated) includes keeping the bag off of the floor as a measure for the prevention of urinary tract infections.

Based on observation, staff interview, and record review, the facility failed to ensure a significant change assessment was completed for a resident after admission to Hospice, a decline in all areas of activities of daily living, changes in behaviors, and changes in bladder continence, for 1 of 1 residents sampled for Hospice, resident #61. The findings included: Resident #61' s medical record was reviewed and revealed a 14-day Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/16/2018. Under section E for Behaviors, the resident was coded as having no physical, verbal, or other behavioral symptoms. Further, the resident was coded as having no rejection of care during the look-back period. Under section G for Functional Status, resident #61 was coded as requiring only supervision for bed mobility, transfers, walking in room, walking in corridor, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Under section H, bowel and bladder, the resident was coded as being always continent of urine. Under section J, Health Conditions, the resident was coded as not having a life expectancy of less than 6 months. Further review of the record was completed regarding the resident's admission to Hospice. Resident #61 ' s medical record revealed an admission to Hospice on 3/22/2018. A care plan for Hospice was developed and observed within the electronic record. Review of the record revealed resident #61 to have several documented behaviors. In April, the facility was monitoring the resident for refusals of care. The resident was coded as refusing care up to 3 times per shift. On 4/16/2018, the nurse noted the resident was agitated and trying to strike and kick staff when they attempted to assist with showering. On 4/19/2018, the resident had an incontinent episode. Per the nurse's note, the resident refused several times to receive incontinent care and to change clothing. Additionally on 4/19/2018, the nurse noted the resident often declines care and becomes aggressive with staff. On 4/26/2018, nurse's notes revealed the nurse witnessed a certified nurse aide (CNA) attempt to change resident #61. The resident was noted as becoming agitated and refused to accept assistance to change clothing. The resident punched this nurse in the jaw and started kicking with his feet. On 5/2/2018, nurse's notes reveal a CNA reported the resident attempted to hit her. On 5/3/2018, a CNA attempted to assist with incontinent care and the resident refused to allow the care. Continued review of the resident #61's record documented the resident to have a decline in activities of daily living (ADLs). The resident had a functional assessment completed every shift by nursing. The electronic medical record only allowed a search for this assessment for the last 30-day time period. This record could only be reviewed for the dates of 4/17-5/16/2018. During this time period, for bed mobility, the resident was coded as total assistance once, extensive assistance 15 times, and limited assistance 5 times. For dressing, the resident was coded as total assistance 8 times, extensive assistance 14 times, and limited assistance once. For eating, the resident was coded as total assistance once and limited assistance once. For personal hygiene, the resident was coded as total assistance 22 times and extensive assistance 5 times. For toilet use, the resident was coded as total assistance 18 times and extensive assistance 7 times. The resident was observed being assisted by two staff members on 5/14/2018 at approximately 11:30 AM. He required assistance with standing, ambulating to the bathroom, and received total assistance for personal hygiene and dressing. The resident was unable to perform any personal care. Multiple nurse notes for resident #61 revealed the resident was incontinent of bladder and required frequent incontinent care assistance by staff. Further, the resident was observed to have an incontinent episode requiring staff assistance on 5/14/2018 at approximately 11:30 AM. An Incontinence Evaluation Form was completed on 2/27/2018 and revealed the resident had been incontinent of bladder for over a year and was unaware of his incontinence. The facility was monitoring daily incontinent episodes. During a look-back period of 4/17-5/16, the resident was incontinent 2-9 times per day. An interview was conducted with the Resident Care Specialist Manager on 5/16/2018 at approximately 1 PM. She confirmed when a resident was put on Hospice, a significant change assessment should be conducted. She stated she was aware resident #61 was on Hospice. She confirmed the decline in behaviors, incontinence, and functional status and stated the resident should have had a significant change assessment completed after the changes.

Based on observations, interviews and record review, the facility failed to provide care and services at highest practicable wellbeing for 1 of 3 residents sampled for Unitary Tract Infections (#19). The findings included: On 5/15/2018 a record review was conducted for resident #19 which revealed the resident had a positive urine culture for [DIAGNOSES REDACTED] Pneumoniae dated 3/17/2018. The culture identified that the organism was resistant to the antibiotic Ertapenem. Further review of the residents chart revealed an order dated 3/19/18 for [MEDICATION NAME] Solution (Ertapenem) 1 gm one time a day for UTI for 7 days. Review of the resident Medication Administration Record [REDACTED]. On 5/16/2018, at approximately 12:30 PM an interview was conducted with staff member A, an LPN, which revealed that resident #19 had a history of [REDACTED]. When the surveyor and the nurse reviewed the culture and sensitivity report dated 3/17/18 she stated that the bacteria [DIAGNOSES REDACTED] Pneumoniae was identified as being resistant to Ertapenem as evidenced by a R next to the medication on the sensitivity list. She stated that [MEDICATION NAME] and Ertapenem were the same medication and that [MEDICATION NAME] was not an appropriate antibiotic for this resident. On 5/16/2018, at approximately 1:00 PM an interview was conducted with the infection control nurse in which she stated that culture and sensitivity reports were faxed to the unit directly and staff checked the fax machine multiple times throughout the day. She stated that when a culture report was received she or the residents' nurse would review the report and notify the physician who will then order an antibiotic to treat the identified organism. She also stated that the physician who ordered the culture preferred to wait for the culture result before ordering an antibiotic to ensure effective treatment. She stated in the case of resident #19 [MEDICATION NAME] should not have been ordered as it was listed as resistant on the report and that should have been conveyed to the physician at the time. She stated We should have caught that. On 5/17/2018 a review of the facility ' s Antibiotic Stewardship Program revealed that appropriate indications for use of antibiotics include Pathogen susceptibility base on culture and sensitivity to antimicrobial as well as the following guidelines When a culture and sensitivity (C&S) is ordered, it will be completed and: a. Results will be treated as high priority; b. Lab results will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued; and c. Changes to antibiotics orders based on C&S will be reviewed by the facility infection preventions or pharmacist.

Based on record review, staff interview, hospital staff interview and policy review, the facility failed to readmit a resident after hospitalization for 1 of 3 sampled residents (resident #2). The findings include: Review of resident #2's record revealed the resident was transferred from the facility via law enforcement through the Baker Act process on 10/17/17 for behaviors of ambulating in the hall without clothing and striking a staff member. Resident #2 was admitted to a behavioral hospital for treatment on 10/17/17. The resident's payer source was Medicaid. Review of a Preadmission Screening and Resident Review level II determination summary report located in the nursing home record dated 10/31/17 revealed nursing facility placement was considered to be appropriate, once the patient had been psychiatrically cleared, due to the patient's need for medical care and medication management. Review of resident #2's hospital record revealed a psychiatric physician progress notes [REDACTED]. Further review showed hospital staff attempted to contact the nursing home regarding discharge planning on 11/27/17, 11/28/17 and 11/29/17 and left messages. There was also another psychiatric physician progress notes [REDACTED]. As a result of the nursing home refusing to take the resident back, the resident was subsequently transferred and admitted to a state psychiatric treatment facility. An interview was conducted with the nursing home Director of Nursing (DON) on 1/4/18 at approximately 12:58 PM. She stated she spoke to someone at the hospital and they informed her the resident needed to go to a psychiatric facility. She did not recall who she spoke with and did not document the conversation. She was unable to produce any documentation stating the resident was not appropriate for nursing home placement. A telephone interview with the former nursing home admissions coordinator (no longer employed at facility) was conducted on 1/4/18 at approximately 1:17 PM. She stated the hospital called and stated he was ready to come back to the nursing home, and someone at the nursing home told her he was not appropriate for nursing home placement (she did not recall who). She stated the hospital offered to find placement for resident #2, but confirmed she did not receive any document indicating the resident was not appropriate for nursing home placement. A telephone interview was conducted with the hospital Director of Nursing (DON) on 1/4/18 at approximately 11:41 AM. She stated the nursing home refused to readmit the resident and she was not aware of any reason he could not have returned to the nursing home. The facility policy for bed hold was reviewed. The policy stated if the Medicaid resident released their bed-space, the resident was classifed as being on medical leave without a bed-hold, but the resident had readmission rights to the next available bed in a semi-private room, even if the resident had an outstanding Medicaid balance.

Based on record review and staff interview, the facility failed to notify the physician of repeated medication refusals for 1 of 3 sampled residents (#2) reviewed for transfer and hospitalization . The findings include: Review of the October 2017 Medication Administration Record [REDACTED]. The October 2017 MAR indicated [REDACTED]. The record revealed the physician was not notified of the refusals. The resident was then transferred from the facility via law enforcement through a Baker Act on 10/17/17 for behaviors of ambulating in the hall without clothing and striking a staff member. An interview was conducted with the Director of Nursing (DON) on 1/4/17 at approximately 2:13 PM. The DON reviewed the record and confirmed the physician was not notified of the resident's refusal of medications, and stated she would expect the staff to notify the physician.

Based on record review and staff interview, the facility failed to provide the appropriate transfer/discharge notice to the resident and responsible party for 3 of 3 sampled residents (residents #1, #2 and #3) reviewed for transfer and hospitalization . The findings include: Review of resident #1's record revealed the resident was transferred from the nursing home to the hospital for emergent care on [DATE]. The resident had not returned to the facility as of [DATE]. The record contained no evidence the Ombudsman was notified of the transfer/discharge. Review also revealed no written notice of transfer/discharge to the resident and/or resident representative to include the reason for transfer/discharge, effective date of transfer/discharge, location of transfer/discharge, statement of the resident's appeal rights and information on how to obtain an appeal form, with the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. Review of resident #2's record revealed he was transferred from the nursing home via law enforcement through the Baker Act process on [DATE]. The resident had not returned to the facility as of [DATE]. The record contained no evidence the Ombudsman was notified of the transfer/discharge. Review also revealed no written notice of transfer/discharge to the resident and/or resident representative to include the reason for transfer/discharge, effective date of transfer/discharge, location of transfer/discharge, statement of the resident's appeal rights and information on how to obtain an appeal form, with the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. Review of resident #3's record revealed the resident was transferred from the nursing home to the hospital for emergent care on [DATE]. The resident expired at the hospital on [DATE]. Review also revealed no written notice of transfer to the resident and/or resident representative to include the reason for transfer, effective date of transfer, location of transfer, statement of the resident's appeal rights and information on how to obtain an appeal form, with the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. An interview was conducted with the Director of Nursing (DON) on [DATE] at approximately 12:08 PM. The DON stated the facility had not notified the Ombudsman of the transfers or discharges for resident #1, #2, and #3. Further interview was conducted with the DON by phone on [DATE] at approximately 10:47 AM. The DON stated she was not able to find evidence the facility provided the appropriate transfer or discharge notice to the resident and/or resident representative, including the required Ombudsman and appeal information, at the time of, or after the transfer/discharge for each of the sampled residents.

Based on observation and interview, the facility failed to ensure expired medications were removed from medication storage areas for 3 of 4 medication carts inspected. Findings include: Medication storage review was initiated at approximately at 3:00PM on 4/19/17. The facility had a total of three medication storage rooms and four medication carts that were inspected. Observation of Hall 3 medication cart #1 on 04/19/2017 at 3:00 PM reveled a package of medication Albuterol Sulfate dated as expired in March of 2017. An interview was conducted at the time of the observation with LPN A, who verified that the medication was expired. Observation of Hall 3 medication cart #2 on 04/19/2017 at 3:38 PM revealed a package of Ipratropim Bromide/albuterol Sulfate and Levalbuterol HCL that both expired on 4/17/17. An interview was conducted with LPN B at the time of observation, and she agreed the medications had expired. Observation of Hall 2 medication cart #3 was made on 04/19/2017 at 3:52 PM, and revealed a package of Ipratropium Bromide/Albuterol Sulfate that had expired on 3/15/17; and a second package of the same medication that had expired on 2/25/17; and a package of Albuterol Sulfate that had expired on 3/29/17. An interview was conducted on 04/19/2017 at 4:01 PM with Unit Manger D in which he stated that any expired medications should be taken off the cart.

Based on interview and record review, the facility failed to report allegations of abuse as per the facility policy for 1 of 3 residents sampled for abuse, #169. Findings include: An interview was conducted on 04/18/2017 at 3:46 PM with resident #169 in which she reported an incident that occurred in the main hallway accross from physical therapy while she was going outside to smoke. She explained that staff member E came up behind her and hit her in the spinal column with a closed fist. She stated no one else was around her and she was going out to smoke. The incident occurred around 1:00 in the afternoon a week and few days ago. She stated she reported the incident to staff F as he was going down the hallway. An interview was conducted on 04/19/2017 at 12:05 PM with the social service director/abuse coordinator in which she stated that facility had no knowledge of this allegation. An interview was conducted on 4/20/2017 at approximately 10:15 AM with social director/abuse coordinator in which she stated that interviews had been conducted with staff and found incident had been reported to staff member Fby the resident, and that staff F had not reported the incident to anyone else. She indicated that the facility had a policy and training to report any allegation of abuse immediately. A review of the employee handbook was conducted and showed that any allegations of abuse must be reported immediately to the staff member's supervisors or department head and a written report of the situation must be submitted to the abuse coordinator within two hours of the event. The facility stated that the handbook abuse policy was reviewed with all employees on hire and annually through staff inservice.

Based on observation, record review and staff interviews the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 1 sampled resident's receiving [MEDICAL TREATMENT]. The facility failed to ensure medications related to [MEDICAL TREATMENT] were administered as ordered by the physician for resident #37. The findings include: Review of resident #37's record revealed a physician order [REDACTED]. [MEDICATION NAME] is a [MEDICATION NAME] binding medication used frequently for [MEDICAL TREATMENT] patients to lower the amount of phosphorus in the blood. The medication should be taken with meals. Review of the April 2017 Medication Administration Record [REDACTED]. An interview was conducted with employee G (Licensed Practical Nurse) on 4/19/17 at approximately 2:46 PM. Employee G stated resident #37 eats breakfast between 8:00AM and 8:30 AM. She confirmed that the resident's morning dose of [MEDICATION NAME] had been administered at 6:00 AM. She was not able to describe the action of [MEDICATION NAME].

Based on record review, policy review, and staff interview, the facility failed to properly assess and report documented behaviors to the attending physician in an effort to identify triggers and decrease behaviors for 1 of 1 sampled resident reviewed for behavioral and emotional status, #53. The findings include: Review of resident #53's record revealed a quarterly minimum data set (MDS) assessment dated [DATE]. The MDS revealed the resident demonstrated physical behavioral symptoms directed toward others 1 to 3 days of the seven day look back period. Review of the nurses' notes revealed behaviors of: 2/28/17 refusing medications when offered with thickened liquids, 3/16/17 staff responded to call light and resident was attempting to drink roommate's water, 3/22/17 resident taking her roommate's water cup and drinking it, and 4/6/17 the resident grabbed the coffee pot off the food cart, nurse took the coffee pot from the resident and the resident tried to scratch the nurse. The facility documentation did not contain an assessment of the documented behaviors to include triggers, stressors or any other identified factors that could affect the resident's behavior nor documentation of staff notifying the physician of the resident refusal of thickened liquids and subsequent behavior. An interview was conducted with employee G (Licensed Practical Nurse) on 4/19/17 at approximately 2:20 PM. Employee G confirmed there was no documentation of staff notifying the physician of the resident refusing thickened liquids and subsequent behaviors. An interview was conducted with the Director of Nursing (DON) on 4/20/17 at approximately 9:20 AM. The DON confirmed the facility has no formal process to evaluate resident behavior. Facility policy for Refusal of Therapeutic Diet was reviewed and stated for continued refusal of therapeutic diet, the interdisciplinary team addresses the problem and consults with the physician as to a less restrictive diet plan acceptable to the resident while meeting the resident's medical needs.

Based on interview, record review, and observation, the facility failed to obtain dental services for 1 of 1 resident reviewed for dental services. (#169) Findings inlcude: On 04/17/2017 at 12:04 PM, resdient #169 was observed with missing teeth. during iterview with the resident at that time, she reported that she had not had dentures since she was admitted , as she had not brought her dentures with her to the facility. She stated that she would like to have dentures again and was told by the facility staff that she was on a list to see a dentist. A record review revealed a social service note dated 5/24/16 that stated resident wears a full set of dentures, but she was unsure if they were brought to the facility with her. An interview was conducted with the social services assistant (SSA) on 04/18/2017 at 3:02 PM. The SSA stated that resident #169 was not on the list to see the dentist, but stated she would set it up that day. An interview was conducted with the social services director (SSD) on 04/19/2017 at 4:35 PM. She stated that upon admission resdients were interviewed, and assessed for dental issues. She stated that if the resident was missing dentures, they would be refered to Senior Dental for an assessment; however, this had not been done for resident #169.

Based on staff interview and clinical record review, the facility failed to provide services that meet professional standards of quality for 1 of 3 sampled residents (#5) receiving insulin. The facility failed to provide routine blood or urine glucose (sugar) monitoring nor did the facility document rationale as to why this would be inappropriate for resident #5. The findings are: A review of the hospital admission history and physical date 8/12/16 for Resident #5 revealed that she was admitted to the hospital with [REDACTED]. The Mayo clinic web site defines Diabetic hyperosmolar syndrome: http:www.mayoclinic.org/diseases-conditions/diabetic-hyperosmolar-syndrome/basics. This syndrome is a serious condition caused by extremely high blood sugar levels. The condition most commonly occurs in people with type 2 diabetes. It is most often triggered by illness or infection. As a result of diabetic-hyperosmolar syndrome the body tries to rid itself of excess blood sugar by passing it into urine. Left untreated it can lead to life threatening dehydration. Prevention: monitor blood sugar level daily which will alert to dangerous highs. A review of physician orders for resident #5 from her admission in January 2016 until she was transferred to the hospital in August 2016 was conducted. Upon admission, resident #5 had an order for [REDACTED]. There were no physician orders for routine bedside blood glucose checks from January 2016 through August of 2016. A review of nurse's notes failed to identify any blood sugars completed from June 1, 2016 until August 11, 2016 when she had to be hospitalized . On 8/11/16 at 11:31am a nurse documented, called into residents room at 10:15am, resident noted to have change in level of consciousness, not easily responding to verbal stimuli, opens eyes only briefly. Called unit manager (name) and unit manager in to assess resident. The nurse documented that bedside blood glucose monitoring was completed, and the result was too high on the machine to read. The nurse contacted Resident #5's medical doctor (MD) physician P, who was also the medical director. A review of nurse's notes and physician orders revealed the physician P instructed the nurses to give 10 units of fast acting insulin and retake in 30 minutes. After 30 minutes resident #5's blood sugar was still too high to read on the machine. She was transported to the hospital ER ( emergency room ). Per the manufacturer guidelines, the bedside blood glucose machine will read up to a blood sugar of 600. On 8/11/16 at 11:42am, the hospital obtained a CMP (comprehensive metabolic panel) lab test which documented a blood sugar (glucose) of 757 HC (High Critical) mg/dl. (milligrams/deciliter) (Normal 70-105). An interview was conducted with the Registered Nurse (RN) hall 1 manager on 9/13/16 at 1:05 pm. She reviewed the incident occurring with Resident #5 on 8/11/16. The resident was found not acting correctly. They attempted to check blood glucose however the reading was high and continued to read high after the administration of 10 units of a short acting insulin. She was asked if residents taking insulin should have blood glucose monitoring and she stated, I feel it would be a very good nursing practice when giving any type of insulin to monitor blood sugars. An interview was conducted with the RN unit manager side 2 on 9/13/16 at 1:25 pm. She was asked how she would monitor for [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar). She stated, I would want to see blood sugars taken at least twice daily up to four times a day to monitor. She then stated Resident #5 returned to the facility on [DATE] without orders for blood sugars. She said she called the doctor and got an okay to do four times a day accu-checks (blood sugars). An interview was conducted with the Resident Care Specialist (care plans) on 9/13/16 at 1:30 pm. She said a nurse would use her judgement to assess [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. She was asked what a nurse would expect to see if a resident was taking insulin. She stated, I feel she might want to know what the blood sugar reading is when giving insulin. She then stated, As a nurse I would contact the physician to find out why there are no blood sugars ordered for a resident taking insulin. 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 Professional and Practical Nursing. The Act states: (3)(a) Practice of professional nursing means 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 be limited to: The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing.

Based on nursing staff interview, pharmacy consultant interview, physician interview, quality assurance director interviews and clinical record review, the facility failed to provide care and services to meet the needs for 1 of 3 sampled residents (#5) receiving insulin. In August 2016, Resident #5 was transferred to the hospital for a critically high blood sugar and change in level of consciousness. The findings are: Resident #5 was admitted to the facility on [DATE] with some of her [DIAGNOSES REDACTED]. She was under the care of the medical director of the facility (physician P). A review of physician orders [REDACTED].#5 was taking [MEDICATION NAME] 10 units (insulin) subcutaneously nightly beginning on admission. There were no orders for the bedside monitoring of blood sugars. A review of physician progress notes [REDACTED]. The doctor noted blood sugars of 347 in his progress notes on two occasions on 4/9/16 and on 8/1/16. On 4/9/16 the doctor wrote, Blood Sugar: 347, non-fasting and on his 8/1/16 note the doctor wrote Blood Sugar: 347, fasting. There was no change in resident #5's orders for insulin dosage nor was there an order for [REDACTED].>A review of nurse's notes failed to identify any blood sugars completed from June 1, 2016 until August 11, 2016 when she had to be hospitalized . On 8/11/16 at 11:31am a nurse documented, called into residents room at 10:15am, resident noted to have change in level of consciousness, not easily responding to verbal stimuli, opens eyes only briefly. Called unit manager (name) and unit manager in to assess resident. The nurse documented that bedside blood glucose monitoring was completed, and the result was too high on the machine to read. The nurse contacted Resident #5's medical doctor (MD) physician P, who was also the medical director. A review of nurse's notes and physician orders [REDACTED]. After 30 minutes resident #5's blood sugar was still too high to read on the machine. She was transported to the hospital ER ( emergency room ). On 8/11/16 at 11:42am, the hospital obtained a CMP (comprehensive metabolic panel) lab test which documented a blood sugar (glucose) of 757 HC (High Critical) mg/dl. (milligrams/deciliter) (Normal 70-105). The hospital history and physical for Resident #5 was completed on 8/12/16 by the same physician who was treating her at the nursing home, physician P. A review of the History and Physical was conducted. Physician P documented, Her blood glucose (sugar) was checked and it was too high for the machine. Her blood glucose is checked at night. (There were no nightly orders for blood glucose monitoring in the nursing home medical record). The clinical and lab evaluation on the History and Physical shows severe dehydration, severe [MEDICAL CONDITION] (high blood sugar), hyperosmolar state with [MEDICAL CONDITION] (high sodium), [MEDICAL CONDITION], severe [MEDICAL CONDITION], and [MEDICAL CONDITION] (decreased platelet count). Resident #5 was admitted to the hospital in critical condition. Diagnosis: [REDACTED]. Mayo clinic web site defines Diabetic hyperosmolar syndrome: http:www.mayoclinic.org/diseases-conditions/diabetic-hyperosmolar-syndrome/basics. This syndrome is a serious condition caused by extremely high blood sugar levels. The condition most commonly occurs in people with type 2 diabetes. It is most often triggered by illness or infection. As a result of diabetic-hyperosmolar syndrome the body tries to rid itself of excess blood sugar by passing it into urine. Left untreated it can lead to life threatening dehydration. Prevention: monitor blood sugar level daily which will alert to dangerous highs. A review of lab tests revealed on 8/5/16 a hemoglobin A1C was checked and found to be 6.1% (normal 4.0-6.0). Hemoglobin A1C shows average of blood sugar levels over a 2-3 month period. The following statement was printed on the lab slip: American Diabetes Association recently (Diabetes Care, 27:S15-S35) added the following recommendation: more stringent goals (ie a normal hemoglobin A1C, less than 6%). Also on the lab slip were notes that it was faxed to the physician with the medication lists and that the resident was receiving [MEDICATION NAME] 10 units at bedtime. The previous hemoglobin A1C was obtained on 5/5/16, and showed a value of 5.0. An interview with her MD, physician P, was conducted on 9/13/16 at 3:07 pm. He felt the best way to manage Resident #5 was through the use of hemoglobin A1C which were performed twice during her nearly 7 month stay. (hemoglobin A1C's are an average of blood sugars over the past 2-3 months). He could not explain why interventions were not taken for his reported blood sugars of 347 non-fasting on 4/9/16 and 347 fasting on 8/1/16 on his monthly progress notes. The [MEDICATION NAME] remained at 10 units each night from January until August 11, 2016. He was asked about his admitting progress note for the hospital on [DATE] indicating that blood glucose is checked at night. He did not respond to the question. He stated, I use the A1C and if it is stable the resident does not need finger sticks. He stated that if a resident develops an infection it will obviously destabilize the patient and blood sugars will rise rapidly. The pharmacy consultant saw this resident monthly from her admission in January 2016 to present. She failed to recommend that blood sugars be performed at bedside. She stated on 9/13/16 at 11:40 am, Yes, I feel residents on insulin should have blood glucose monitoring on a daily basis. She confirmed she made no recommendations for blood glucose monitoring for Resident #5. An interview was conducted with the Registered Nurse (RN) hall 1 manager on 9/13/16 at 1:05 pm. She reviewed the incident occurring with Resident #5 on 8/11/16. The resident was found not acting correctly. They attempted to check blood glucose however the reading was high and continued to read high after the administration of 10 units of a short acting insulin. (per the manufacturer guidelines, the machine will read up to a blood sugar of 600). She was asked if residents taking insulin should have blood glucose monitoring and she stated, I feel it would be a very good nursing practice when giving any type of insulin to monitor blood sugars. An interview was conducted with the RN unit manager side 2 on 9/13/16 at 1:25 pm. She was asked how she would monitor for [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar). She stated, I would want to see blood sugars taken at least twice daily up to four times a day to monitor. She then stated Resident #5 returned to the facility on [DATE] without orders for blood sugars. She said she called the doctor and got an okay to do four times a day accu-checks (blood sugars). An interview was conducted with the Resident Care Specialist (care plans) on 9/13/16 at 1:30 pm. She said a nurse would use her judgement to assess [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. She was asked what a nurse would expect to see if a resident was taking insulin. She stated, I feel she might want to know what the blood sugar reading is when giving insulin. She then stated, As a nurse I would contact the physician to find out why there are no blood sugars ordered for a resident taking insulin. On 9/13/2016 at 3:33 pm, an interview was conducted with the facility administrator regarding the quality assessment and assurance (QA and A) program. When asked if the QA and A program had identified quality concerns related to blood glucose monitoring, he stated, We have not addressed blood sugars specifically. He also stated that, After Resident #5 was sent out to the hospital regarding her elevated blood glucose level I'm sure we would have discussed why she went out to the hospital in our QA and A meeting. At the end of the interview the administrator added, The doctor makes the orders and nurses are supposed to just follow doctor's orders.

Based on staff interview, physician interview and clinical record review, the facility failed ensure that the medical director was responsible for the coordination of medical care for 1 of 3 sampled residents (#5) receiving insulin. The medical director failed to order routine blood or urine glucose (sugar) monitoring or document rationale as to why this would be inappropriate for resident #5. The findings are: A review of physician orders for resident #5 from her admission on January 27, 2016 until she was transferred to the hospital on August 11, 2016 was conducted. Resident #5 was under the care of the medical director, physician P. Upon admission, resident #5 had an order for [REDACTED]. There were no physician orders for routine bedside blood or urine glucose checks from January 2016 through August of 2016. There was no documented rationale indicating blood or urine glucose monitoring was not indicated for Resident #5. A review of physician progress notes [REDACTED]. Physician P noted blood sugars of 347 in his progress notes on two occasions on 4/9/16 and on 8/1/16. On 4/9/16 the doctor wrote, Blood Sugar: 347, non-fasting and on his 8/1/16 note the doctor wrote Blood Sugar: 347, fasting. There was no change in resident #5' orders for insulin dosage nor was there an order for [REDACTED].>A review of nurse's notes failed to identify any blood sugars completed from June 1, 2016 until August 11, 2016 when she had to be hospitalized . On 8/11/16 at 11:31am a nurse documented, called into residents room at 10:15am, resident noted to have change in level of consciousness, not easily responding to verbal stimuli, opens eyes only briefly. Called unit manager (name) and unit manager in to assess resident. The nurse documented that bedside blood glucose monitoring was completed, and the result was too high on the machine to read. The nurse contacted Resident #5's medical doctor (MD) physician P, who was also the medical director. A review of nurse's notes and physician orders revealed the physician P instructed the nurses to give 10 units of fast acting insulin and retake in 30 minutes. After 30 minutes resident #5's blood sugar was still too high to read on the machine. (per the manufacturer guidelines, the bedside blood glucose machine will read up to a blood sugar of 600). She was transported to the hospital ER ( emergency room ). On 8/11/16 at 11:42am, the hospital obtained a CMP (comprehensive metabolic panel) lab test which documented a blood sugar (glucose) of 757 HC (High Critical) mg/dl. (milligrams/deciliter) (Normal 70-105). The hospital history and physical for Resident #5 was completed on 8/12/16 by the same physician who was treating her at the nursing home, physician P. A review of the History and Physical was conducted. Physician P documented, Her blood glucose (sugar) was checked and it was too high for the machine. Her blood glucose is checked at night. (There were no nightly orders for blood glucose monitoring in the nursing home medical record). The clinical and lab evaluation on the History and Physical shows severe dehydration, severe [MEDICAL CONDITION] (high blood sugar), hyperosmolar state with [MEDICAL CONDITION] (high sodium), [MEDICAL CONDITION], severe [MEDICAL CONDITION], and [MEDICAL CONDITION] (decreased platelet count). Resident #5 was admitted to the hospital in critical condition. Diagnosis: [REDACTED]. Mayo clinic web site defines Diabetic hyperosmolar syndrome: http:www.mayoclinic.org/diseases-conditions/diabetic-hyperosmolar-syndrome/basics. This syndrome is a serious condition caused by extremely high blood sugar levels. The condition most commonly occurs in people with type 2 diabetes. It is most often triggered by illness or infection. As a result of diabetic-hyperosmolar syndrome the body tries to rid itself of excess blood sugar by passing it into urine. Left untreated it can lead to life threatening dehydration. Prevention: monitor blood sugar level daily which will alert to dangerous highs. An interview was conducted with the RN unit manager side 2 on 9/13/16 at 1:25 pm. She stated Resident #5 returned to the facility on [DATE] without orders for blood sugars. She said she called the doctor and got an okay to do four times a day accu-checks (blood sugars). An interview with the medical director, physician P, was conducted on 9/13/16 at 3:07 pm. He felt the best way to manage Resident #5 was through the use of hemoglobin A1C which were performed twice during her nearly 7 month stay. (hemoglobin A1C's are an average of blood sugars over the past 2-3 months). He could not explain why interventions were not taken for his reported blood sugars of 347 non-fasting on 4/9/16 and 347 fasting on 8/1/16 on his monthly progress notes. The [MEDICATION NAME] remained at 10 units each night from January until August 11, 2016. He was asked about his admitting progress note for the hospital on [DATE] indicating that blood glucose is checked at night. He did not respond to the question. He stated, I use the A1C and if it is stable the resident does not need finger sticks. He stated that if a resident develops an infection it will obviously destabilize the patient and blood sugars will rise rapidly.