Every finding on record at Chipola Health and Rehabilitation Center

Based on observations, interviews and medical record review, the facility failed to provide reasonable accommodation for resident needs by ensuring that the call bell was accessible for 5 out 12 residents observed in the 300 hallways. (Residents #7, #301, #8, #3, #23) The findings include: The following issues were noted with call lights: • An observation was made on 05/27/25 at approximately 12:58 PM for Resident #7. He was resting in bed, but his call bell was on the floor. • An observation was made on 05/27/25 at approximately 11:10 AM, 1:37 PM and 2:53 PM for Resident #301. The call bell for Resident #301 was attached to the lower right-side rail, making the call bell unreachable by the resident. • An observation was made on 05/27/25 at approximately 10:55 AM for Resident #8. She was resting in bed and her call bell was observed on the floor behind the headboard out of reach. • Upon observation of Resident #3 on 5/27/25 at 11:00 AM, the call light was observed laying on the floor under the bed where Resident #3 could not reach. • On 5/27/25 at 11:30 AM, Resident #23's call light was observed hanging between the side rail and mattress out of reach of the resident. Resident #23 is blind and when asked she could not locate her call light to call for assistance. Interviews were conducted on 05/27/25 with Staff C and D, both Certified Nursing Assistants (CNA). They confirmed these call bells were out of reach for the residents and should have been placed within easy reach of the residents.

Based on observations, interviews and record review, the facility failed to follow accepted infection prevention and control standards including hand hygiene, proper use of Personal Protective Equipment (PPE) and storage of oxygen tubing, to prevent the spread of infections by staff involved in direct resident care in 4 out 7 residents observed. (Resident #11, #7, #45, and #24) The findings include: Resident #11 An observation was made on 05/27/25 at approximately 10:54AM with Resident #11. There was an oxygen concentrator on the left side of her bed with oxygen tubing connected to it and the prong end of the tubing on the floor. At approximately 12:01PM, the oxygen tubing was still on the floor. At approximately 12:39PM, the oxygen tubing was stored in a plastic bag dated 05/26/25 located above the head of the bed. (Photographic evidence obtained) An interview was conducted with Nurse A at approximately 11:03 AM. She observed the resident and the oxygen tubing on the floor and explained that the resident removes her oxygen often. A second interview was conducted with Nurse A at approximately 12:43PM. She explained that she turned off the oxygen concentrator and secured the oxygen tubing in the storage bag provided. She denied changing the oxygen tubing at that time. When made aware that the oxygen tubing was observed on the floor, she responded that she believed it was placed on the side rail. Upon realizing that the tubing had made contact with the floor, she disregarded and replaced the oxygen tubing. Nurse A confirmed understanding the risk of contamination and potential infection transmission and the importance of proper handling of respiratory equipment. Resident #7 An observation was conducted on 05/27/25 at approximately 1:07PM with Resident #7, who was on Enhanced Barrier Precautions (EBP). During an observation with Staff C and Staff D, both Certified Nursing Assistants (CNA), entered the resident's room to provide incontinence care. Both staff members donned gloves upon entering; however, hand hygiene was not performed prior to resident contact. At approximately 1:19 PM, Staff D exited the room to retrieve additional supplies and re-entered the resident's room and resumed care without performing hand hygiene before contact with the resident. Hand washing was observed by Staff C and Staff D after completion of resident's care. Additionally, both staff member did not don the required Personal Protective Equipment (PPE) as required by the EBP despite the sign posted at the resident's door indicating the need for PPE and care plan for EBP. An interview was conducted on 05/27/25 at approximately 1:26 PM with Staff C and Staff D following the observation of care provided to Resident #7. Both staff members acknowledged that they did not perform hand hygiene prior to providing resident care. They stated that they are aware it is the facility policy and standard of care to wash hands before resident contact care. They verbalized understanding of the risk of Health Care Associated Infections (HAI) and the importance of hand hygiene in infection prevention among the vulnerable residents. Resident #45 On 05/28/25 at approximately 1:15 PM, an observation was made with Resident #45 for her scheduled enteral feeding. Nurse B was observed attempting to don personal protective equipment (PPE) prior to entering the resident's room. She secured the gown over her head; however, after multiple attempts to tie the gown at the waist, her arms remained exposed, indicating improper donning of PPE by failure to fully cover the required body areas for Enhanced Barrier Precautions (EBP). An interview was conducted on 05/28/25 at approximately 1:45PM with Staff B following the observation of care provided to Resident #45. She acknowledged her confusion regarding the correct procedure for donning PPE. She realized that she did not properly secure the gown sleeves, resulting in incomplete coverage of the arms. She recognized that failure to don the gown correctly compromised the effectiveness of the barrier protection and the importance of standard infection control practices. Resident #24 On 05/29/25 at approximately 09:51 AM, an observation was made with Resident #24 for his dressing change to the right heel. The procedure was performed with Nurse A with the assistance of CNA C, who supported the resident's foot. Nurse A initially performed proper hand hygiene using hand sanitizer and gowning with appropriate PPE. After removing the soiled dressing, she performed hand hygiene and applied a new pair of gloves. However, at that time, she exited the room wearing her gloves to retrieve a missing calcium alginate dressing. She touched the doorknob and upon returning, resumed the dressing change without changing her gloves or performing hand hygiene. At the completion of the wound care, both staff members performed hand hygiene. On 05/29/25 at approximately 10:04AM following the dressing change, an interview was conducted with Staff A. She admitted not following proper hand hygiene but believed it was acceptable because she only touched the corner of the dressing. She did not recognize this as a breach in infection control protocol.

Based on interviews and medical record reviews, the facility failed to maintain a complete and accurately documented clinical record as evidenced by inaccurate and missing documentation on the Medication Administration Record (MAR) for 1 out of 6 residents. (Resident #24) The findings include: Resident #24's medical record was reviewed on 05/28/25. An order for Aminocaproic Acid oral 0.25GM/ML, give 30ml twice per day for bleeding, was received with a start date on 05/23/25. The Medication Administration Record (MAR) shows that on May 24th, 25th, 26th, 27th and 28th, 2025 at 09:00AM, Nurse F and Nurse A indicated that the medication Aminocaproic Acid was not available. Similarly, the MAR stated this medication was not available at 5:00PM on May 23rd, 24th and 25th, 2025. However, on May 26th and May 27th at 5:00 PM, Nurse H and Nurse G documented the medication as given, despite the morning staff having recorded it as unavailable. Additionally, the MAR for Resident #24 for medication Linzess oral capsule 145 MCG, give one capsule by mouth in the morning with an administration scheduled at 06:30AM, is missing the signature by staff for 05/11/2025. The MAR for Novolin R injection Solution 100unit/ML subcutaneous injection per sliding scale requires a blood glucose check for Resident #24. The documentation is missing a blood sugar result, documentation if the insulin was given, and staff signature on 05/11/25 at 06:30 AM. An interview was conducted on 05/28/25 at approximately 2:14PM with Nurse A, a Licensed Practical Nurse. She confirmed that the medication Aminocaproic Acid was currently not available and that the facility was awaiting delivery from the pharmacy. She verified that the medication was not located in the medication room, not available in the automated medication dispenser system, and not stored anywhere within the facility. She also explained that a code 9 on the MAR indicates that the medication is not available. She confirmed being the nurse on duty for 05/26/25, 05/27/25 and 05/28/25 and that the medication has not been delivered by the pharmacy. An interview was conducted with the Director of Nursing (DON) on 05/28/25 at approximately 2:36 PM. She explained the process for pharmacy delivery. When an order is received, the pharmacy receives it electronically. The contracted pharmacy is scheduled to deliver twice a day, once in the morning and once in the afternoon. She proceeded to explain that if the medication is not available, she usually gets an email that explains the delay in obtaining the medication. She was not made aware that the medication Aminocaproic Acid for Resident #24 had not been delivered. When asked why the MAR for Resident #24 for medication Aminocaproic Acid Ask was signed by Nurse G and Nurse H on 05/26/25 and 05/27/25 while the medication was unavailable, she was unable to explain how the medication could have been given, as it had not yet been delivered to the facility by the pharmacy. An interview was conducted on 05/28/25 at approximately 4:49 PM with Nurse G about the medication being signed off when it was not available on 05/26/25. She explained that it was a mistake and should have been documented as not available. A second interview was conducted with the DON on 05/29/25 at approximately 09:44 AM. She clarified that it is her expectation for the ordered medication to be delivered by pharmacy within 24 hours. She further indicated that it is her expectation for the staff to notify her if a medication is delay in delivery. She also explained that it is the expectation of the facility to have accurate documentation on the medication administration as the medications are given and any missing signatures are not acceptable. She indicated that staff receive education on PCC upon hire.

Based on observations, interviews, and policy review, the facility failed to facilitate consideration of precautions and safe administration of medication for 2 out of 6 residents as evidenced by 2 expired insulin pens present in the medication cart. The findings include: On [DATE] at approximately 08:55AM, an observation was made during medication administration and overview of the medication cart. An expired insulin pen for Basaglar 100unit/ML KWIKPEN was opened on [DATE] with a discard date of [DATE] (after 28 days) for Resident #7 and an expired insulin Novolin R 100unit/ML Flexpen opened on [DATE] with a discard date of [DATE] (after 28 days) for Resident #24 was found on the top drawer of the medication cart. (Photographic evidence obtained) On [DATE] at approximately 09:00AM, an interview was conducted with Nurse A. She confirmed the expiration dates on the Insulin Basaglar and Novolin R and explained that she has not checked her cart for a while. She proceeded by removing the expired insulins from her cart. On [DATE] at approximately 11:30AM, a record review of the Medication Administration Record (MAR) for Resident #24 was conducted. On [DATE], Novolin R 1 unit was administered at 6:30 AM, Novolin R 7 units was given at 11:30 AM, Novolin R 5 units was given at 4:30 PM, and Novolin R 5 units wasgiven at 9:00 PM per the sliding scale order. Additionally, Basaglar 100unit/ML, 6 units subcutaneously was given to Resident #7 at 9:00 PM. (Photographic evidence obtained) A policy titled Disposal/Destruction of Expired or Discontinued Medication last revised on [DATE] was reviewed. Section 4 of the policy states: Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

Based upon observations and record reviews, the facility failed to ensure adequate documentation of narcotic sheets on 2 out of 3 medication carts. The findings include: On 5/28/25 at 08:00 AM, while observing medication administration and reviewing medications, an observation was made of the narcotic signage sheet for each shift to confirm accurate count of controlled drugs. It was observed that the narcotic control sheet was not signed on 4/22/25, 4/24/25, 5/2/25, 5/13/25, and 5/15/25 on the medication cart for the 100 unit. On the 300 unit, the narcotic count sheet was lacking signatures for 4/8/25, 4/12/25, 12/27/24. 12/28/24, and 1/3/25. On 5/28/25 at 08:20 AM, an interview with Nurse B was conducted. She stated, Yes there should always be a signature of the nurse coming onto shift and going off shift stating that the narcotic count is correct on each shift. She further stated that the purpose of the count is to ensure that no drug diversion has occurred and that each resident has the correct number of medications. The facility policy for controlled substances states, In addition to the medication sheet and the schedule II narcotic sheet; the number of controlled substances on hand must be counted and verified at the end of each shift. The narcotic sign in sheet must be completed at the end of each shift every day. The outgoing nurse or her designee will count all controlled substances being stored. Both staff members signs that the count and verification have been completed.

Based on observations, interviews, records and policy review, the facility failed to maintain acceptable parameters of nutritional status and electrolyte balance for 1 out of 2 enteral feeding residents by not following physician orders for enteral fluid hydration. (Resident #45) The findings include: On 05/28/25 at approximately 1:15 PM an observation was made with Nurse B with Resident #45 for her scheduled enteral feeding. After checking the placement of the percutaneous endoscopic gastrostomy tube (PEG tube) (a tube to provide nutrition directly into the stomach), Nurse B proceeded with 120cc of water via a syringe to the PEG tube, then administrated 1 carton of Jevity 1.5 per order and completed with another 120cc of water. An interview was conducted after the enteral feeding with Nurse B on 05/28/25 at approximately 1:45 PM. She explained that Resident #45 has an order for water flush of 240cc every 6 hours, so she combines the hydration order with the feeding schedule. Nurse B was asked to clarify the resident's enteral feeding and hydration orders. She stated that Resident #45 receives 240cc of water every 6 hours for hydration and acknowledged that she has been combining this hydration order with the enteral feeding order. The nurse demonstrated awareness of the order to flush with 60cc of water before and after each feeding order 5 times a day. However, she admitted to not following the hydration order as written and recognized that by not administering the full prescribed volume, the resident was missing 120cc of water per feeding. She verbalizes understanding that the resident is Nothing by Mouth (NPO), and therefore entirely dependent on enteral intake to meet hydration needs. Nurse B also acknowledged that hydration requirements are calculated by the Registered Dietitian (RD) and following these orders are important for maintaining the resident's hydration and overall health status. A medical record for Resident #45 was reviewed on 05/28/25 at approximately 2:30PM. On 04/29/25 orders were written as follows: Jevity1.5, 1 carton via peg tube, 5 times a day; Flush enteral tube with 240cc of water every 6 hours; Every shift flush the enteral tube with 60 cc of water before and after medications/feeding.

Based on interviews, records reviews, and review of the faciity's policy and porcedure, the facility failed to conduct an accurate assessment by not assigning the proper code to the Minimum Data Set (MDS) that corresponds to the appropriate aspect of the resident care in 2 out of 6 residents. (Resident #24 and #7) The findings include: Resident #24 On 05/28/2025 at approximately 09:10 AM, a record review was performed for Resident #24 that was admitted with a past medical history including cerebrovascular disease, Diabetes-type 2 with neuropathy, Peripheral Vascular Disease, Hypertension, Alzheimer's disease, and Gastrointestinal hemorrhage. The 4/25/25 MDS section for skin documented that the resident did not have a diabetic foot ulcer. However, the 02/06/25 MDS documented that the resident did have a diabetic foot ulcer. A review of the physician's progress note dated 05/14/25 and signed by the wound care doctor documented that the resident still had a diabetic wound of the right lateral heel. On 05/28/25 at approximately 4:52PM, an interview was conducted with Nurse E, a Registered Nurse (RN) and MDS Coordinator. She reviewed the MDS dated [DATE] and confirmed miscoding the diabetic foot ulcer as it does not reflect the resident's current condition. She acknowledged the quarterly assessment completed on 02/06/25 is the proper coding according to the resident's assessment. Resident #7 On 05/28/25 at approximately 5:00 PM, a record review was performed for Resident #7, who was admitted with a diagnosis of nontraumatic intracerebral hemorrhage. Resident #7 has a medical history of Diabetes Mellitus type 2, protein calorie malnutrition, seizures, hypertension, aphasia and requires total care, and dependence for all Activities of Daily Living. The annual MDS skin assessment dated [DATE] acknowledges that a pressure ulcer/injury was present at stage 3. However, the section about pressure ulcer/injury care was documented as a No. A record review verified that the resident is receiving pressure ulcer care as of 02/19/25. On 05/28/25 at approximately 5:30 PM, an interview was conducted with Nurse E. She reviewed the annual MDS skin assessment that noted the pressure ulcer/injury being present but the pressure ulcer/injury care documented as No. She acknowledged miscoding this section and stated that the answer should have been yes since the resident is receiving pressure ulcer care. A policy titled MDS (effective 11/30/2014 and last revised 09/25/2017) was reviewed. It states, Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy.

Based on observations and interviews, the facility failed to provide an environment that is clean and in good condition in 3 of 50 occupied rooms. (Rooms 106B, 107A, 108A/B) The findings include: A tour of the 100 hall was conducted with the Environmental Services Director (EVS Director) on 5/29/25 at 12:20 PM. The following issues were observed: Resident room [ROOM NUMBER]B's privacy curtain had a reddish-brown smear with a quarter sized clump of what appeared to be reddish black crusted matter. Resident room [ROOM NUMBER]'s privacy curtains had multiple brownish red droplet stains. Resident 108A's privacy curtains had numerous grey stains with flecks of brown substance and a grey stain along the bottom portion of the curtain. Resident 108B's privacy curtain had numerous grey and reddish orange stains with dried flecks of a brown substance. (Photographic evidence obtained) An interview was conducted with the EVS director who stated that he will usually change out the curtains when soiled but was having issues getting the curtain width needed for resident privacy.

Based on observation, interview, and review of facility policy, the facility failed to adequately clean fixed equipment (oven, fryer, and other surfaces) and ensure these surfaces were free from buildup and contamination via splashes, dust, and grease. This has the potential to affect 52 of the 56 residents who were consuming food prepared in the facility's kitchen. The findings include: On 4/15/24 at approximately 10:30 AM, during the initial kitchen tour, observations were made of a heavy thick build of multiple layers of various texture and color substances, splashes, and build up adhered to the front and sides of the stove, fryer, oven, and other fixed equipment surfaces. There was a dark color buildup, a layer of yellow splattered sticky substances, and layers of a dusty white substance on the front sides and inside doors of the oven and stove. The same layers were observed on the fryer, and surfaces of other fixed equipment in the kitchen. The Director of Dining Services (CDM) explained that the buildup was oven cleaner that had not yet been wiped off. He showed the surveyors a used stove that the facility had purchased but not yet installed. The manager explained that staff had been focusing on cleaning the used stove to get it ready for installation soon. (photographic evidence obtained) On 4/17/24 at approximately 12:50 PM, a second tour of the kitchen was conducted with Dining Services Technician B. Some of the white substances had been removed from surfaces but multiple thick layers of buildup were still on fixed surfaces of the fryer, oven, and stove. The surveyor inquired about surface cleaning procedures for fixed equipment such as stove and fryer. Dining Services Technician B explained that they were getting new equipment and they have not had time to really clean the surfaces of the stove and oven that was currently in use for quite a while. (photographic evidence obtained) A review of the employee cleaning list for 4/15/24, 4/16/24 and 4 /17/24 was conducted. Line #6 on the check off sheet listed that the cook is responsible for cleaning oven top, racks inside the oven door, oven racks, back of inside of the door and outside surfaces. These tasks were initialed as having been completed on 4/15/24 and 4/16/24. A review of the job description for Dining Services Technician was conducted. The job description directed Dining Services Technicians to maintain a clean, hazard free work area and ensure that the department is maintained in a clean and safe manner by assuring that necessary equipment and supplies are maintained. A review of the job description for director of dining services was conducted. The job description directed the Director of Dining Services to monitor dietary personnel to ensure required tasks are being performed in a manner prescribed by policy and procedure and ensure that the dietary department is maintained in a safe sanitary manner in accordance with established safety and infection control guidelines. On 4/17/24 at approximately 1:10 PM, a second interview was conducted with the CDM. The surveyor voiced concerns with the cleanliness of the surface of oven, stove, and fryer. The CDM explained that he had been focusing on getting the new equipment ready to be installed and that the surfaces of the oven, stove and fryer should have been cleaner.

Based on observation, record review, and staff interviews, the facility failed to provide appropriate treatment to prevent further decrease in range of motion for 1 of 1 residents reviewed for limited range of motion. (Resident #49) The findings include: An observation of Resident #49 was conducted on 3/14/23 at 3:43 PM. The resident was in bed and had a splint device in place on the right upper extremity. Review of the quarterly minimum data set, with an assessment reference date of 2/9/23, revealed the resident had functional limitation in range of motion to upper and lower extremities on both sides. The Occupational Therapy discharge summary, dated 10/21/22, revealed the resident had a diagnosis of hemiplegia and hemiparesis affecting the right dominant side and the resident was referred to restorative nursing program/functional maintenance program for contracture prevention in right upper extremities in order to preserve current level of function. Review of the resident's electronic medical record revealed a current plan of care dated 1/20/23, stating the resident was receiving restorative nursing program and now requires a functional maintenance program for passive range of motion to bilateral upper extremities, communication and a restorative nursing program for splinting top right elbow. The interventions included passive range of motion (PROM) to bilateral upper extremities exercising all joints and planes. Review of the task menu documentation for the last 30 days since 2/15/23 revealed the range of motion had only been completed 3 times in the 30 days. An interview was conducted with the Restorative Licensed Practical Nurse on 3/15/23 at 10:51 AM. She stated the resident was on floor maintenance for PROM of bilateral upper extremities and the assigned certified nursing assistant would complete the task daily. She then reviewed the record and confirmed the PROM had only been documented as completed 3 times in the last 30 days. An interview was conducted with Employee A (a certified nursing assistant) on 3/15/23 at 11:10 AM. Employee A stated she cared for Resident #49 most days. She could not explain why the PROM was only completed 3 days out of the last 30 days.

Based on observations and staff interviews the facility failed to treat 1 of 1 sampled residents with respect and dignity while assisting with feeding the resident (resident #19). The findings include: Employee A, certified nursing assistance (CNA), was observed on 2/24/2020 at approximately 11:40 AM, passing lunch trays on the 200 hall. CNA A, was observed taking the lunch tray into resident #19 room, then sat down beside the resident. CNA A, stated to the surveyor, while in hearing distance to the resident, This resident is a feeder, so I have to sit here to feed her. An interview was conducted with Employee A, on 2/24/2020 at approximately 11:53 AM. CNA A, confirmed that she called the resident a feeder in front of the resident, and confirmed she is not supposed to do that. An interview was conducted with Employee B, a CNA, on 2/25/2020 at approximately 12:46 PM, who stated, We get trays for the feeders first, while we wait for the hall trays to be delivered. An interview was conducted with the Director of Nurses (DON) on 2/25/2020 at approximately 3:05 PM, who confirmed the staff should not refer to the residents as feeders. The facility policy for Dignity (Dec (YEAR)) was reviewed. The policy states, residents are to be treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation, record review, staff interview and policy review the facility failed to provide appropriate care and services in an effort to prevent and treat urinary tract infections for 1 of 1 sampled residents with a urinary catheter and a urinary tract infection. (resident #36) The findings include: Review of resident #36's record revealed the resident was diagnosed with [REDACTED]. The quarterly minimum data set with an assessment reference date of 1/10/20 revealed the resident could eat/ drink with set up only and had a brief interview of mental status (BIMS) with a score of 3 indicating severe cognitive impairment. Review of the current care plan for risk of developing urinary tract infection revealed an intervention to encourage resident to drink fluids. An observation of catheter care was conducted for resident #36 on 2/25/20 at 1:19 PM. Employee A, certified nursing assistant (CNA) was observed to provide catheter care to resident #36. The resident's urine was observed to be dark in color and cloudy. No water pitcher or other fluids were observed in the room of resident #36. Employee A stated she did not know why he did not have a water pitcher, and she would get him one. Further observations of resident #36 were conducted on 2/25/20 at 4:02 PM, 2/26/20 at 9:00 AM, 11:06 AM, and 2:03 PM. No water pitcher or other fluids were in his room. The resident nodded yes when asked if he was thirsty on 2/26/20 at 2:03 PM. An interview was conducted with employee A on 2/26/20 at 2:04 PM. Employee A stated when she was passing out water pitchers this morning she got called away and forgot to come back and pass the rest of the pitchers; he does not drink much anyway. An interview was conducted with the Director of Nursing (DON) on 2/26/20 at 3:15 PM. The DON stated if the CNA gets pulled away she should still go back and ensure the resident has fluids at bedside. She confirmed resident #36 is not contraindicated for fluids at bedside. She stated the facility practice is to pass ice and water for the water pitchers on 7-3 shift and 3-11 shift; the pitchers are picked up on 11-7 shift to wash and the fluids are provided in a cup on 11-7 shift. The facility policy for Encouraging Fluids (October 2019) was reviewed. The policy stated residents will be encouraged to consume fluids on a routine basis (as clinically appropriate). Water pitchers and/or cups at bedside, as indicated.

Based on observation, record review, staff interview, and policy review the facility failed to ensure staff follow appropriate infection control precautions for 1 of 1 sampled residents on contact isolation. (resident #160) The findings include: An observation of employee C (registered nurse) was conducted on 2/25/20 at 4:13 PM. Employee C was observed to enter resident #160's room to with his medications and insulin in her hand. Personal protective equipment to include gown and gloves was available on the resident's door. Employee C did not put on gloves or a gown before entering the room and was in the room about 30 seconds, then exited the room and returned to the medication cart. An interview was conducted with employee C on 2/25/20 at 4:15 PM. She stated she was not thinking and should have applied personal protective equipment prior to entering resident 160's room; she confirmed the resident was on contact isolation precautions. She stated she gave the resident medications and an insulin injection. Employee C confirmed she did not wash or sanitize her hands prior to leaving resident #160's room. Review of resident #160's record revealed he was on contact isolation precautions for [MEDICAL CONDITION] (MRSA) in a wound. Review of the facility policy for Categories of Isolation Precautions (November 2019) revealed in addition to standard precautions, contact precautions must be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. Remove gloves before leaving the room and wash hands or alcohol based use hand rub. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident's room. In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the resident is incontinent, has diarrhea, an [MEDICAL CONDITION], a [MEDICAL CONDITION], or wound drainage not contained by a dressing. Remove the gown before leaving the resident's environment. After gown removal, ensure that clothing does not touch potentially contaminated environmental surfaces.

Based on observation, interview, record review and policy review, the facility failed to follow the care plan for nutrition for 1 of 3 (#20) residents sampled for nutrition. The facility failed to implement the urinary catheter care plan by filing to provide a method of anchoring the indwelling urinary catheter for 1 of 1 (109) sampled for urinary catheter. The findings were: Resident #109 Resident #109 was admitted to the facility with an indwelling urinary catheter. The facility attempted to discontinue the catheter twice but both times had to re-insert due to [MEDICAL CONDITION]. The last time it was re-inserted was 3/5/19. On 3/6/19 a urinalysis was performed which showed 3+ blood in the urine, with white blood cell clumps. A review of #109's care plan revealed a care plan for the indwelling catheter initiated on 3/4/19. The interventions included securing the catheter tubing to the resident's thigh to reduce the risk of trauma. Catheter care was observed on 3/7/19 at 8:52 am. The catheter tubing was not observed to be anchored to the thigh. An interview was conducted with Employee B certified nursing assistant (CNA). She said that normally the tubing for the catheter is anchored to the thigh. There is some blood observed at the insertion site. The CNA sent for the nurse. Employee C licensed practical nurse (LPN) came in and checked the catheter and said he is supposed to have an anchor on the catheter. The CNA completed catheter care appropriately. The nurse returned and placed an anchor for the catheter tubing on #109's thigh. A follow-up interview was conducted with employee C (LPN) around 9:10 am on 3/7/19. She said that the anchor is supposed to be in place for the catheter. It helps to prevent pulling and irritation at the site. She was requested to provide the policy for catheter care which she printed. The policy and procedure entitled Catheter Care, Urinary Nursing Services Procedures, dated 7/9/15 Catheter care was reviewed. On page 1 of 36, Purpose: the purpose of this procedure is to prevent infection of the resident's urinary tract. Key Procedural Points: #11 check to see that the catheter remains secured with a leg strap, if applicable to reduce friction and movement at the insertion site. 12. Report unsecured catheters to the Staff/charge nurse. Be observant of skin irritation. Resident #20 A review of the resident #20's care plan for nutrition revealed the intervention,Provide adequate supervision/assistance as indicated with meals/supplements and snacks. On 3/4/19 at 12:45pm an observation was made of Resident #20. She was observed not being assisted with lunch. The tray was left in room on the bed side table. On 3/5/19 at 12:34pm an observation was made of Resident #20. Staff had set up her tray on the bedside table. No assistance was being provided. On 3/6/19, from 12:35pm to 1:04pm, a continuous observation was made of Resident #20. At 12:35pm her tray was brought to her. Resident #20 stated she was not hungry today. The Certified Nursing Assistant (CNA) explained what was on the tray, set the tray up on the bedside table and then washed her hands and left. Resident#20 made no attempts to eat anything on the plate. At 1:04pm Nurse A entered the room, asked Resident #20 if she was finished, and returned the tray to the rack uneaten. On 3/6/19 at 1:10pm an interview was conducted with the Director of Nursing (DON). She was asked to show the surveyor the kardex (list of care needs for a resident) as a CNA would see it in the computer system. The only intervention listed for food was to the keep the head of the bed elevated. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed in section G that for eating resident #20 required supervision with oversight, encouragement, and cueing. Set up assist only. A review of Resident #20's weights was conducted which revealed: 11/1/2018 - 141 12/1/2018 - 136 01/1/2019 - 122 02/1/2019 - 123 03/1/2019 - 123 On 1/7/2019 a nutritional assessment documented the weight loss and noted the resident's oral intake had decreased starting occurring on week of 12/15/18 and did not improve. Her current intake was between 8 and 19%. The Registered Dietitian recommended a tube feeding regimen to address the weight loss. This was impletmented with susequent weight stabilization. On 3/7/19 at 3:24pm an interview was conducted with the Director of Nursing. At that time she stated that her staff should have attempted to assist the resident to eat or at least give her the opportunity to refuse the meal.

Based on clinical record review and staff interview, the facility did not ensure pharmacy consultant recommendations were acted upon for 1 of 5 residents (#12) reviewed for unnecessary medications. Findings include: Review of current medication orders and Medication Administration Record [REDACTED]. Review of the pharmacist drug regimen review for 9/15/16, showed the pharmacist recommended a gradual dose reduction from the current dose (ordered on [DATE]) to 50 mg while monitoring the resident condition. There was a note on the pharmacy consultation report from the physician (MD) that stated stop it with the MD signature and the date 9/23/16. There was an additional order from the MD's nurse practitioner (ARNP) dated 9/27/16 that stated Don't stop Effexor!! Ignore (MD name)! with no justification of reason to continue the medication at the dose. (Copy obtained.) The facility Director of Nursing (DON) was interviewed at approximately 10:00 AM on 3/15/17 regarding the orders. She stated the ARNP order was after the MD ordered a stop to the medication. When asked if it was standard procedure for the MD's ARNP to supersede the MD order, she stated someone from the facility called the MD, and she would look for documentation. At 10:35 AM, the DON stated there is no documented justification for not attempting the dose reduction, as recommended by the pharmacist. Another pharmacy review dated February 10, 2017 for the resident indicated the resident had a recent fall and medications including the Effexor at the dose of 75 MG should be evaluated. As of 3/15/17, there was no MD response to the recommendation. The DON was asked about this during the 3/15/17 interview, and stated facility staff have not received an MD response yet. She stated their procedure was to go to the MD office to obtain the response, and if they do not receive one, they contact the medical director. When asked if the medical director had been contacted regarding the February recommendation that was over a month old, she stated they would notify the medical director during Quality Assurance activities, which had not yet occurred for the month of March 2017. The facility DON was requested to provide the facility policy regarding drug regimen reviews. The policy entitled Drug Regimen Reviews (dated November 2001) was reviewed. There was no indication on the policy how promptly the facility or MD should respond to the recommendations for any irregularities noted. (Copy obtained.) The DON verified in an interview at 10:45 AM on 3/15/17 there was nothing to indicate a timeframe for facility response.

Based on observation and interview, the facility failed to promote care for residents in a manner that enhances each resident's dignity related to incontinence for 1 random sampled resident, #30. The findings: On 4/3/14 at approximately 9:30am Resident #30 was observed to be sitting in her wheelchair facing the nurse's station for about 30-35 minutes before any staff interaction. Resident #30 was wearing gray pants and a gray shirt. the surveyor observed resident #30's gray pants to have a large dark gray spot between the resident's legs. The resident's pants appeared wet. There were staff at the nursing station and walking up and down the hall in close proximity to the resident. The smell of urine was present when the surveyor stood close to resident #30. On 4/3/14 at approximately 10:05am, Staff A approached Resident # 30 and asked if she wanted to attend the activity. Resident #30 mumbled some words to Staff A. Staff A appeared to be looking down at the resident legs and said something to another staff in reference to the resident. Staff A left the resident sitting in the same spot near the nurse's station. Staff A did not take the Resident #30 to the activity or assist Resident to her room. On 4/3/14 at approximately 10:11am, a staff came around with a nourishment cart giving out snacks and drinks to resident on the unit. The staff gave resident some juice from the cart and resident drank the juice. On 4/3/14 at approximately 10:20am, an interview was conducted with Staff A. Staff A revealed during the interview that she was not allowed to provide personal care to residents because she was not a Certified Nursing Assistant (CNA). Staff A revealed that Activity staff only notify the assigned aide of personal care that needs to be rendered and take the resident to their rooms when personal care is required. Staff confirmed that she had noticed that Resident # 30 had an incontinent episode, but she did not take her to her room. Staff A revealed that she had informed the assigned CNA. She was unable to give a name or description of the CNA that she informed of the resident. While walking back down the hall to interview the assigned CNA, Staff A was observed to be talking with a Staff C. On 4/3/14 at approximately 10:28am, an interview was conducted with Staff B CNA. Staff B CNA is the assigned CNA for Resident # 30. Staff B CNA revealed she had not been informed by Staff A about Resident # 30 needing personal care. Staff was not even sure of resident location at the time because she had just finished assisting another resident with a shower. On 4/3/14 at approximately 10:30am Staff C CNA was observed taking resident #30 her room.

Based on observation during stage I of the survey the facility failed to ensure water temperatures in the residents rooms was safe. The findings are: Interview with the maintenance director on 4/1/14 at 11:25 AM to identify where the hot water heater was located. He indicated there was only one heater it was located outside at the end of 300 hall. The water temperature felt hot to touch in rooms 311, 310, 308 and 204. Actual water temperatures were checked with the maintenance director that read 117.9 degrees in room 310, 118 degrees in room 204, 120 degrees in room 311 and 309. Maintenance indicated the residents complained in resident council meeting that the water was too cold. After several months of their complaints he bumped it (temperature gage) up a bit. I guess I raised it too high. Review of the resident council minutes from 10/13 to present had no mention of cold water from the residents. He indicated he continued monitoring temps following the increase. Review of the water temperature log for the past month indicated no water temperatures were over 111 degree. The log revealed there was no temperatures were monitored from 3/18 to 3/24/14. He indicated he took the readings in the morning before baths started.

Based on resident and staff interviews, record reviews, and policy review, the facility failed to immediately report allegations of abuse to the central abuse hotline as mandated by Florida Statute (415.1034) and failed to file Federal immediate and 5 day reports regarding the allegations and investigations for 1 of 2 sampled residents (#76). The findings include: On January 22, 2013 at approximately 2:33pm an interview was conducted with Resident #76. When asked if the resident had ever been treated roughly by staff, the resident stated, "There was a CNA (certified nursing assistant A) who was angry about something one day. Resident #76 stated that he wanted to clean up in order to go to therapy and his CNA (A) did not want to do it. She had an angry attitude and she manhandled him in the bed and did not do a good job cleaning him. He stated he immediately reported this to the staff and CNA A was terminated. On January 23, 2013 at approximately 9:52am a follow up interview was conducted with Resident #76. He stated he was manhandled by CNA A who is a girl whose family he has known all his life. He stated he doesn't know what she was so outraged about that day. She was definitely manhandling him and "shoving him around on the bed." She refused to help the Physical Therapy staff who were helping him at the time. He also stated he filled out grievance paperwork when he made a complaint about CNA A who manhandled him. He stated they took his statement, a staff person wrote it out for him, and told him they would not tolerate any staff who had an attitude like CNA A had and she was immediately fired. He stated the facility handled this situation really well and he was very pleased with the outcome. Record review of a written statement from Resident #76 dated 12/23/12 revealed the resident's statement to be, "What happened is CNA A had come to finish cleaning me up. She grabbed the covers and snatched them back. Then she said can you roll over cause I can't be pulling on you. When she went to roll me over she put her fist into my back and pushed me over. She was fussing about everything she had to do. She got through cleaning me up. Therapy asked her to assist them with getting me up and she stated aren't you PT? She then stated I will help you when I am finished with what I am doing but she never came back. Resident states I didn't feel threatened, abused or in any harm." Witness by LPN; Writer: LPN for Resident On January 23, 2013, at approximately 2:48pm an interview was conducted with the Risk Manager who stated this incident occurred on a weekend and when she arrived to work on the following Monday morning she stated the Physical Therapist (PT) asked CNA A to assist the resident to the bathroom before therapy, but the CNA A was tied up with another resident. When the CNA (A) was done and went to help the resident she and the PT had words. She stated they took statements from the involved staff and the resident. The resident was adamant that he did not want them to go any further and he was happy with the action the facility took with the employee. The Risk Manager stated that CNA A was brought in and interviewed and displayed a bad attitude with them during this time. This concerned the staff that she would exhibit this type of attitude toward the residents and she was immediately dismissed. When asked if this was reported to the Abuse Registry, she stated this was not reported to the Abuse Registry because the resident was adamant he did not want to go further and they called it into corporate who advised this was not a reportable incident to the Abuse Registry. On January 24, 2013 at approximately 8:56am an interview was conducted with the Risk Manager who stated she is new to the facility and has been there for only 84 days. The letter summarizing her investigation of this incident was mistakenly dated 12/18/12. She stated the incident occurred over the weekend on 12/23/12 and she interviewed this resident and wrote this statement on 12/24/12 at 8:45am. She also stated she does the Risk Management Training for the staff and goes over the policy and procedure for Abuse, discusses the various types of abuse/neglect. She stated she tells staff if this is not how you would treat your own parent then its probably not appropriate and needs to be investigated. She stated that CNA A's attitude was so inappropriate that this is why she was terminated. She felt that if CNA A was this inappropriate with her boss, then she would be inappropriate with the residents and other staff. She states the management team discussed this and they brought it to the Corporate Nurse Consultant. She stated they never had any other complaints about CNA A treating residents this way, but it was definitely her bad attitude and not abuse or mistreatment which is why they did not report this to the Central Abuse Registry. She stated that when she interviewed the resident during her investigation he stated to her that he felt it was more of a communication issue. When asked if she had read this resident's statement about CNA A putting her fist in his back before she interviewed him she stated she had not. When asked why they would not have reported this incident to the Abuse Hotline according to their policy, she acknowledged that she should have reported the incident to the Abuse Registry and let them decide whether or not to investigate. She then stated from this point on, if she receives another allegation of "manhandling" of a resident she will immediately report it to the Abuse Hotline. She stated a grievance report resulted from this incident and the Social Services Director has the grievance reports. On January 23, 2013 at approximately 9:52am an interview was conducted with the Director of Nursing (DON) who stated this incident happened on a weekend and she became involved in the incident when the nurse called her and told her Resident #76 had complained about CNA A. She stated she told the nurse to talk to the resident to determine if he felt that CNA A was rude or abusive. The nurse took the resident's statement and advised the DON the resident stated he did not feel abused but felt she was rude. She stated there was a handwritten statement on file indicating what the resident stated. She removed CNA A from caring for the resident then contacted the corporate nurse and advised her of what she had learned. The DON stated she did not feel that it was abuse because the resident stated specifically that it was not. The resident is alert and oriented and is able to voice his needs. She stated CNA A was terminated because she was not providing care for the resident as she was supposed to while being rude toward the resident during the care provided. On January 24, 2013 at approximately 2:30pm an interview was conducted with the Administrator who stated they did not believe this was an allegation of abuse. They believe this was a complaint about poor customer service and rudeness. This is why they did not treat this complaint as an abuse allegation. She stated the resident expressed to them that he did not feel this was abuse and was very satisfied with the way the facility handled the situation. A follow up interview was conducted with the Administrator on January 25, 2013 at approximately 9:15am who stated they did report this incident to the Abuse Registry on 1/24/13 (the report was not accepted) and they did file the immediate report with the State Survey and Certification Agency. Record review of a written statement dated 12/27/12 signed by RN B, reads in part...."CNA (A)was never witnessed by myself as being rude/aggressive/abusive towards residents while under my supervision. However, CNA (A) did become aggressive and confrontational multiple times with myself in the occurrence when I would question why she was not on the hall monitoring the call lights as she would have been. ...... My professional opinion is reflected by my choice in agreeing to CNA (A) being moved off of my hall due to her inability to assist 2 different residents due to resident complaints against CNA (A)." Record review of letter dated 12/28/12 to CNA A, from Administrator that advised CNA A of her termination of employment effective 12/28/12. Record review of the grievance report dated 12/23/12 filed by LPN C on behalf of Resident #76. The nature of the grievance was: Therapy staff stated to this nurse CNA A refused to help them and was rude. I asked therapy staff to write a written statement of the events that occurred. They stated ok. When I went to retrieve the written statements the therapy staff had gone home. Review of the Grievance Investigation Report dated 12/24 - 12/27 for Resident #76 stated the date of incident was 12/23/12. Resident was not injured. Description of incident was CNA A was rude to the resident while providing care stated he felt she did not want to care for him. Stated CNA A later came to his room and apologized to him he does not want her to care for him any longer. The description as provided by the employee reads: The employee stated she was stopped by 2 therapists in the hallway to get a resident off the bedpan. Stated she did then had to go and help another resident get up before she could help the therapists get that resident up. Recommendations/corrective action taken: CNA A was suspended pending the completion of the investigation- was off 12/24, 12/25 and 12/26. CNA A was terminated for poor customer services. Signed by Administrator on 12/26/12. Review of the facility policy dated July 2011 entitled, "Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property" revealed the training of staff on what constitutes abuse and how to report abuse is offered during their orientation and annually thereafter. This is to include 2. How to report their knowledge of allegations without fear of reprisal. Anyone who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion. FL ONLY - Central Abuse Hotline 1-800-96ABUSE. Prevention of abuse will be accomplished by the timely reporting of the "suspected" abuse and a thorough investigation of these instances. Review of all records revealed there were no other reports filed with state survey agency or the Abuse Hotline.

Based on observation and interview the facility failed to ensure that food preparation surfaces were sanitized prior to use, the microwave oven was free from built-up soil, and that food and clean and sanitized dishes and surfaces in the main kitchen were protected from unrestricted air flow from resident rooms and bathrooms. This had the potential to effect 50 of 54 residents who were taking food orally and residing at the facility. Findings Include: During the comprehensive kitchen inspection--done on 10/26/11 at 2:00p.m.--an interview with the Food Service Director (FSD) and the facility Registered Dietitian (RD) revealed that the facility had not been sanitizing after cleaning, and before using, the food preparation tables and surfaces in the main kitchen. Observation of the microwave/browning combination oven ceiling, also during this inspection, revealed a moderate amount of dried food particle build-up adhering to the browning element attached to the ceiling of this unit. This unit was available to heat resident ' s food at the time of this observation. Various observations done throughout the four days of the survey revealed that the doors leading to the main kitchen from the ALF dining room, and resident rooms beyond, were routinely kept propped fully open. The main kitchen serves both the residents in the ALF and the Nursing Facility. This ALF dining room does not have doors and it emits directly onto the hallway off of which resident rooms and bathrooms issue.

Based on interview and record review, the facility failed to document grievances and failed to respond timely to 1 of 3 grievances reviewed (#15). The findings: On 10/24/11 at approximately 3:00 PM a family interview was conducted with resident #15's wife. The resident's wife stated that her husband's electric shaver had been missing for about 2 weeks. She stated she reported the missing shaver to the nurse and he replied, " Well I don't know where it is. " On 10/25/11 the facility grievance log was reviewed from January 2011 until October 2011. The log did not contain any documentation in reference to resident #15's missing item. According to the Resident Grievance Program - Policy Interpretation and Implementation, Residents and families are invited to bring grievances to the attention of the Facility through one of the following means: Complete a Grievance Report or File a written grievance or file a verbal grievance. All grievances, written or verbal, should be given to one of following individuals: Social Services Director, Director of Nursing or Administrator. In case of a verbal grievance the person receiving the grievance will document the grievance on the Grievance Report. On 10/26/11 at approximately 10:40 AM an interview was conducted with the Social Services Director. The Social Services Director (SSD) stated she talked with resident #15's wife. She reports the wife stated the electric razor was missing several months ago. The SSD stated several months ago meant about 2-3 months. The SSD stated the wife reported the missing razor to a nurse and the wife reported she brought another electric razor to the facility for her husband. The SSD stated the nurse did not report the missing electric razor. On 10/26/11 at approximately 2:25 PM an interview was conducted with the Certified Nursing Assistant (CNA). The CNA stated resident #15 had an electric razor and his wife kept it in the drawer.