Every finding on record at Cypress Village

Based on interviews, medical record review, and facility policy review, the facility failed to provide a discharge summary for one (Resident #1) of three residents reviewed for discharge, out of a sample of 7 residents. At discharge, Resident #1 was given another person's discharge paperwork potentially hindering him from receiving continuous and coordinated, person-centered care. The findings include: A review of the medical record for Resident #1 revealed an admitted [DATE], and the resident was discharged home on 7/8/23. The resident's diagnoses included hemiplegia (affecting left side), CVA, a fib, seizures, GERD, and major depressive disorder. An admission Minimum Data Set (MDS) assessment, dated 6/22/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. Resident #1 required extensive assistance with activities of daily living (ADLs). A review of Resident #1's nursing summary of stay stated, Resident is discharging home with spouse on 7/8/23. Discharge instructions to be given. A copy of the discharge summary provided by the Administrator did not reveal the resident or resident's representative signature. On 8/22/23 at 4:15 pm, a phone interview was conducted with the wife of Resident #1. She stated that when her husband was discharged from the facility on 7/8/23, he was given someone else's paperwork. She explained they didn't realize it wasn't his discharge summary until two days later when he was at his primary care physician for his follow up appointment. She explained that she called the facility to tell them about the error and the facility asked her to shred the paperwork. During the call she also requested the facility send her the correct paperwork. However, she still has not received her husband's discharge paperwork, and that has delayed his outpatient therapy. On 8/23/23 at 2:40 pm, an interview was conducted with the Administrator. When she was asked what residents receive in regard to discharge paperwork. She replied, They get a list of their medications and a summary of their stay with their home health information, durable medical equipment, where they are going, and upcoming appointments. When asked if the resident or their representative sign the discharge paperwork, she replied, Yes, they are supposed to sign it. When asked if there were there two copies of the discharge paperwork, she replied, Typically, we should keep a signed copy, sometimes the nurses will end up giving them both copies. When asked if a resident doesn't receive a copy of their discharge paperwork at discharge, can they get a copy after discharge, she replied, Yes, and if their physician calls, we can also fax them a copy. When asked if any residents had ever received the the wrong discharge paperwork, she replied, Yes, that did happen once recently. I spoke with her and asked her to please shred the paperwork or bring it to me, she choose to shred it. I believe we emailed her the correct paperwork. I'll have to check. On 8/23/23 at 3:45 pm, a follow up interview was conducted with the Administrator. She stated, I can't find the email. I remember it was (Resident #1), her husband discharged on [DATE], and she called us on 7/10/23, because they were at his doctor for a follow up and that's when she realized she had someone else's paperwork. She said she needed his paperwork for the doctor. We spoke with her and apologized, and I asked her to shred the paperwork she had or to bring it back here, she said she would shred it. She never called back after that, so I assume there was no further problems. I can't remember if I faxed the paperwork or emailed it, but I can't find it now, so I'm not sure if I sent it, but she didn't call back asking for it. When asked if the discharge paperwork is reviewed with the patient and family by the nurse prior to discharge, she replied, Very briefly but yes. They mainly go over their medications. When asked if the patient or family signed the discharge paperwork, she stated, I don't know. When she was asked if there was a signed copy of the discharge paperwork for Resident #1. She stated, I'll have to check. No, I can't find any signed discharge paperwork. When asked if Resident #1 has ever received her discharge paperwork, she replied, I can neither confirm nor deny if they ever received it. A review of the facility's policy titled, Transfer or Discharge, Resident-Initiated (revised October 2022) read: Policy Interpretation and Implementation: 2. Discharge refers to the movement of a resident form a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. Information Conveyed to Receiving Provider: 1. If the resident is being transferred and return is expected, the following information is conveyed to the receiving provider: a. Contact information of the practitioner who is responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All special instructions and/or instructions for ingoing care as appropriate; e. The resident's comprehensive care plan goals; f. All other information necessary to meet the resident's needs which includes but may not be limited to: (1) Resident status, including baseline and current mental status, behavioral and functional status; (2) Reason for transfer, recent vital signs; (3) Diagnosis and allergies; (4) Medications (including when last received); (5) Most recent relevant labs, other diagnostic tests, recent immunizations 2. The above information is conveyed as close as possible to the actual time of transfer. 3. Information may be conveyed using a universal transfer form or an electronic health record summary, as long as the method contains the required elements, the resident's privacy is protected, and the receiving facility has the capacity to receive and use the information. 4. For residents being discharged (return not expected) all of the information above is conveyed to the receiving provider, along with a copy of all the required information found at 483.21(c)(2) Discharge Summary (F661) as applicable. 5. Communication of this required information will occur as close as possible to the time of discharge. (Copy obtained)

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety and sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure food preparation equipment was clean and maintained. Food safety and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A follow-up tour of the kitchen was conducted on 5/24/23 at 10:52 a.m. The bottom of the oven and door was covered with food grime. The can opener pixel was greasy and filled with food debris. The inside door area and left side of the convection oven next to the fryer was covered with food grime and grease buildup. The right and left side of the fryer sitting next to the convection oven was covered with grease build up. The right and left side of the tilt skillet was covered with grease build up, and two oven trays were filled with food debris. (Photographic evidence obtained) Another tour of the kitchen was conducted on 5/25/23 at 10:04 a.m. The observations of the kitchen equipment noted above at 10:52 a.m. were made again. (Photographic evidence obtained) An interview was conducted on 5/25/23 at 10:28 a.m. with Kitchen Coordinator/Cook D. When asked who was responsible for cleaning kitchen equipment such as stoves, ovens and oven trays, she replied, The cooks are responsible for cleaning kitchen equipment weekly. An interview was conducted on 5/25/23 at 10:44 a.m. with Cook E, who reported she had worked for the facility for two years. When asked who was responsible for cleaning kitchen equipment such as stoves, ovens, and oven trays, she replied, Cooks clean as we go. Ovens are not cleaned often enough. Most deep cleaning is completed by the night shift. The outside of the oven is sprayed down at night, and the inside of the oven is cleaned every three weeks or as needed. An interview was conducted on 5/25/23 at 11:24 a.m. with Certified Dietary Manager (CDM) F, who confirmed that the Dining Supervisor was responsible for ensuring kitchen equipment was cleaned daily. The kitchen Cleaning Schedule dated from 4/30/23 to 6/1/2023 did not identify cleaning of the stove or oven. (Copy obtained) A review of the facility's policy and procedure titled Cleaning Schedules (Undated), revealed: The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 5/31/23) Chapter 4. Equipment, Utensils, and Linens. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 4-20. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observations, staff interviews, record review, and a review of the facility's policy and procedure for Enteral Tube Feeding via Continuous Pump, the facility failed to maintain acceptable parameters of nutritional status, by failing to 1) Obtain resident weights with the frequency prescribed by the physician, and 2) Provide enteral feeding formula as ordered to address the resident's nutritional needs for one (Resident #346) of one resident reviewed for enteral nutrition, from a total of 22 sampled residents. The findings include: On 05/22/23 at 12:36 PM, Resident #346 was observed sitting in a wheelchair receiving enteral nutrition via tube feeding (feeding tube used to supply liquid nutrition) by pump. Resident #346 was non-verbal. He mumbled in response to attempts to engage him in conversation and was unable to be interviewed. The enteral formula bag documented a handwritten date and time when the feeding was started: 5/22/23 at 9:00 AM. The name of the formula on the label read, Nutren 1.5. (Photographic evidence obtained) Pump settings observed were as follows: Feeding rate 250 ml/hr. (milliliters per hour), flush 150 ml every 1 hr. On 05/23/23 at 10:20 AM, Resident #346 was observed resting in bed with his eyes closed. The feeding tube was not connected. The enteral formula bag was hanging on the pole. The label read, Nutren 1.5. On 05/24/23 at 12:17 PM, Resident #346 was observed sitting in his wheelchair. He responded to greetings with unintelligible mumbling. The feeding pump was running and delivering nutrition to Resident #346. The label on the nutrition bag read, Nutren 1.5. On the back of the bag was a handwritten date and time of 05/24/23 at 7:00 AM. (Photographic evidence obtained) Pump settings observed were as follows: Feeding rate 250 ml/hr., flush 150 ml every 1 hr. (Photographic evidence obtained) On 05/25/23 at 11:56 AM, Resident #346 was observed sitting in his wheelchair receiving enteral nutrition. The label on the nutrition bag read, Nutren 1.5. A review of Resident #346's medical record found he was originally admitted to the facility on [DATE], with his most recent readmission on 05/07/23. His diagnoses included unspecified sequelae of cerebral infarction (stroke), type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, severe protein-calorie malnutrition, acute posthemorrhagic anemia, muscle weakness (generalized), aphasia following cerebral infarction, dysphagia following cerebral infarction, hypovolemic shock, iron deficiency anemia, gastro-esophageal reflux disease without esophagitis, encounter for attention to gastrostomy, and duodenal ulcer unspecified as acute or chronic, without hemorrhage or perforation. A review of the Medicare 5-Day Minimum Data Set (MDS) assessment, dated 05/13/23, revealed that Resident #346 had a brief interview for mental status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. The resident was documented as totally dependent on staff for eating with use of a feeding tube. A review of the resident's active physician's orders revealed an order dated 05/07/23, which read: Weight on admission, repeat x 3 days. The Order Summary read as follows: Weight on admission, repeat x 3 days, every day shift for 3 weeks. Weight on admission, repeat weekly x 3 weeks. A physician's order dated 05/08/23, read: Four times a day, give 1 carton Nutren 2.0 via bolus over 1 hour (250 ml/hr.). This order was discontinued on 05/24/23. A new order, dated 05/24/23, read: Four times a day give 1 carton Nutren 1.5 (250 ml) via bolus to be infused over 1 hour five times daily. A review of one of Resident #346's care plans, initiated on 04/14/23 and revised on 05/23/23, revealed that he required tube feeding for nutrition related to his diagnosis of dysphagia (difficulty swallowing). Review of another care plan, initiated on 05/08/23, revealed that he was at nutritional risk related to his nothing by mouth (NPO) status due to dysphagia with tube feeding (TF) to meet estimated nutritional needs with a diagnosis of protein-calorie malnutrition. Interventions included diet/TF as ordered, monitor weights as ordered. (Copy obtained) A review of Resident #346's weights from 05/07/23 to 05/15/23, revealed a weight loss of more than 4% for that period of time (8 days): On 05/07/23, the resident's recorded weight was 140.0 lbs. (pounds) On 05/12/23, the resident's recorded weight was 134.5 lbs. On 05/15/23, the resident's recorded weight was 134.2 lbs. These three weights were the only recorded weights for this resident between the dates of 05/07/23 and 05/24/23. (Copy obtained) A review of the resident's electronic medication administration record (eMAR) for the month of May 2023 (05/08 to 05/24), revealed that twelve different nurses signed off as having administered Nutren 2 via bolus over 1 hour (250 ml/hr.) four times a day during that time. (eMAR copy obtained) A Nutritional Risk Review, dated 05/08/23, revealed: [Resident #346] is at nutritional risk related to NPO due to dysphagia with TF to meet estimated nutritional needs. Diagnosis: protein-calorie malnutrition. Goal: Meet estimated nutritional needs with adequate oral food/beverage intake. Recommend: 1. Discontinue Nutren 1.5. 2. Give Nutren 2.0 via bolus 4 cartons/day to provide 2000 kcals (kilocalories), 84 g (grams) protein, 692 ml (milliliters) water. 3. Flush PEG (feeding tube) with 150 ml water before and after each bolus administration (300 ml each administration x 4 administrations = 1200 ml). 4. Clarify Juven order to be mixed with 8 oz. (ounces) water at each administration BID (twice daily). 5. Speech Therapy (ST) consult. Monitor: TF tolerance, wound healing, weight trends, labs as indicated. Registered Dietitian (RD) to follow. A review of a Skin/Wound Note, dated 05/19/23, revealed: Patient seen by Wound Care MD (physician) and Nursing Practitioner. Right heel unstageable pressure wound measures L (length): 1.5 cm (centimeters) x W (width) 0.5 cm x D (depth): unstageable full thickness skin or tissue loss - depth unknown (UTD - unable to determine). Right hip unstageable pressure measures L: 3.5 cm x W: 2.5 cm x D: UTD. Continue treatment plan. Offloading implemented. A review of a Nursing Progress Note, dated 05/20/23, revealed: Patient is admitted after cerebrovascular accident (CVA - stroke) affecting right side. Patient receives G-tube feedings. Medications are crushed and given via G-tube (feeding tube). Patient is alert and oriented to person. A review of a Physician's Progress Note, dated 05/24/23, revealed: Per staff, patient has been receiving incorrect feeding. Patient was originally to be on Nutren 2.0. No injuries to report, will monitor. (Copy of progress notes obtained) A Nutritional/Dietary note, dated 05/24/23, revealed: RD notified of inability to receive Nutren 2.0. Nutren 1.5 available and will be substituted. Current BW (05/15) 134.2 lbs. Note trend down (<5%) since admission weight os 140 lbs. Receiving treatment for US to R heel and R hip. Increased nutrient needs to promote wound healing. BMI WNL (Body Mass Index Within Normal Limits). Estimated nutrition needs (61 kg (kilograms): 1830-2135 kcals (30-35 kcals/kg), 91-122 g protein (1.5-2 g/kg - grams per kilogram), 1830 ml fluid (30 ml/kg). Recommendations: 1. DC (discontinue) Nutren 2.0 2. Give Nutren 1.5 (250 ml) via bolus to be infused over 1 hour five times/day. This will provide 1875 kcals, 85 g protein, 955 ml water. 3. Give 175 ml water flush every 4 hours. 4. Give 30 ml Prosource Plus once/day via feeding tube. This will provide an additional 15 g protein and 100 kcals. total nutrition provided (TF + Prosource Plus + flushes) will be: 1975 kcals, 100 g protein, 955 ml water (TF) + 1050 ml (flush) = 2005 ml water. 5. Obtain weight every Monday, Wednesday, and Friday. On 05/24/23 at 12:17 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. She was asked what type of enteral nutrition and calorie density Resident #346 was receiving. LPN A stated she had nothing to do with calorie density; the Registered Dietitian calculated that. She was asked to compare the formula that was hanging and running with the one ordered by the resident's physician. She opened the computer and stated, It is Nutren 2. Are those the calories? It is just the name of the formula. The kcals (kilocalories) per milliliter was explained to LPN A. She was then asked where she obtained the enteral nutrition if she needed it. She stated, From the nutrition room. They brought two (bags) last night. She was asked to point out the enteral nutrition designated for Resident #346. She stated there was none in the nutrition room. I work 7 to 7 shift and administer the tube feeding for [Resident #346] three times. On 05/24/23 at 12:42 PM, an interview was conducted with LPN B/Unit Manager. She was asked how she knew what type of formula should be administered to a resident receiving enteral nutrition. She stated, I verify the order, and if questionable, I talk to the RD. When asked where she obtained the enteral nutrition if needed, LPN B replied, Normally we keep it in central supply. She was asked to look at the formula that was hanging and that Resident #346 was receiving. She went into the resident's room and confirmed that the name of the nutritional formula was Nutren 1.5. She was asked to verify the doctor's order for Resident #346's tube feeding and she confirmed it was Nutren 2. She stated she was not aware of the situation and had to verify that with the dietitian. If we don't have 2.0, we use 1.5. LPN B was asked what the process was for weighing residents on her unit. She stated there should be one weight obtained on admission and then one weight weekly for three weeks. She was asked to look at the order for obtaining Resident #346's weights. She confirmed that thus far, for the resident's 17-day stay, he had three weights recorded in his chart. On 05/24/23 at 1:11 PM, an interview was conducted with the Central Supply Coordinator (CSC). He was asked to describe the process for sending enteral nutrition to the nursing units, and if the formula for a resident was changed, how that was addressed. The CSC stated the RD and/or Admission Coordinator sent him an email and text about formula needs, and/or if there was a change in the formula. He then sent the formula to the nursing units. The CSC said there were supplier issues with Nutren 1.5. He was asked to provide a copy of the email communication regarding the enteral nutrition for Resident #346. (Copies obtained) On 05/24/23 at 1:33 PM, an interview was conducted with the Registered Dietitian (RD). She stated Resident #346 was switched from Nutren 1.5 to Nutren 2 due to the supplier's issues, not due to an increase in caloric needs. She was not aware of how long Resident #346 was on the Nutren 1.5. She stated she needed to reassess Resident #346's nutritional needs, and they would need to re-up the current Nutren 1.5, increasing the frequency of feedings to compensate for the caloric difference. On 05/24/23 at 1:57 PM, an interview was conducted with the DON. She stated Resident #346 originally came to the facility with the Nutren 1.5 order, and they switched him to Nutren 2 due to supplier issues with the Nutren 1.5. From the 8th of May he was receiving Nutren 2. The DON was asked where the facility obtained the cartons of Nutren 1.5 if there was a shortage, and how long was Resident #346 receiving the Nutren 1.5. She stated, I don't know. We have to do some investigation. Officially we switched him to 1.5 today. On 05/24/23 at 4:18 PM, an interview was conducted with Agency LPN C. She was asked how she knew what type of enteral nutrition formula she had to use for a resident receiving tube feedings. We go by orders. If no formula is available, we call the doctor or RD for something compatible. A review of email documentation from 05/08/23 between the RD and CSC revealed that the CSC wrote, We have everything except the Nutren 1.5. We have the cartons of Nutren 2. The RD wrote, Ok, thank you! I will convert the orders for [Resident #346] to reflect 2.0. (Copies obtained) A review of the facility's policy and procedure titled Enteral Tube Feeding via Continuous Pump (revised in November 2018) revealed, 2. Check the enteral nutrition label against the order before administration. Check the following information: b. Type of formula. Documentation: the person performing this procedure should record the following information in the resident's medical record: 3. Amount and type of enteral feeding. According to the National Library of Medicine website at ncbi.nlm.nih.gov/pmc/articles/PMC5930532 (accessed on 05/27/23 at 2:40 PM), Nutritional status plays a central role in the process of wound healing. Malnutrition accompanies a poor outcome and brings about higher morbidity and mortality. Malnutrition should be recognized rapidly and treated accordingly in all patients suffering from pressure ulcers. Malnutrition impedes pressure ulcer healing. While the optimal nutrient intake to promote wound healing is unknown, increased needs for energy, protein, zinc and Vitamins A, C, and E have been documented. .

Based on interviews and record reviews, the facility failed to 1) Ensure it provided abuse/neglect training to Agency staff who cared for one (Resident #1) of six residents reviewed, and 2) Ensure that all Agency staff who cared for 93 of 93 residents in the facility, had documented abuse, neglect and exploitation training. The findings include: 1. A review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) On 5/19/2022 at 12:19 PM the Director of Nursing (DON) was asked for Abuse and Neglect training for a list of employees including Agency Registered Nurse (RN) A, Agency LPN F, and Agency Certified Nursing Assistants (CNAs) B, C, D, E and G. On 5/19/2022 at 1:55 PM, the Administrator provided Chapter 59 A-27 Health Care Services Pools and stated, This is our Agency Staff training plan. She further stated the Agency that provided the staff also provided the abuse, neglect and exploitation training to that staff. We do not provide any abuse and neglect training to Agency staff, the state licensed nurses and the nurse aids who are certified. Their state licensing required abuse and neglect training. After a complaint survey in January 2022, we provided in-service training for abuse and neglect to Agency staff present on the day we had in-service training. The Administrator confirmed that there was no current Performance Improvement Project (PIP) or quality improvement activity related to Agency staff education. (Copy of Chapter 59 A-27 Health Care Services Pools obtained) On 5/19/2022 at 2:48 PM, an interview was conducted with the Administrator, DON and Assistant Director of Nursing (ADON) about Agency CNA E, who had an allegation of abuse/rough treatment lodged against her by a resident in May of 2021. They confirmed the facility had no documented evidence of abuse and neglect training having been provided to Agency CNA E prior to the event documented in May of 2021. 2. An interview was conducted with Agency CNA H on 05/19/2022 at 3:45 PM. She stated she received no orientation or in-service training from this facility prior to working shifts and providing direct resident care at the facility. She stated she just reported to the unit and began work. A telephone interview was conducted on 05/19/2022 with Staffing Agency Representatives #1 and #2 at 4:08 PM. During the interview, Agency Representative #2 confirmed that the Staffing Agency provided no education or clinical training to Agency staff. The Agency verified that Agency staff licensure was valid and background checks were completed. Agency Representatives #1 and #2 confirmed that their Agency staff did not have to provide anything but proof of licensure to the Agency as a requirement for hire, however, the Agency did screen new employees using a 20-question quiz that was randomized. They stated Health Care Services Pool requirements were different than Long-Term Care facility requirements. (Copy of quiz obtained) A review of the facility's copy of the aforementioned 20-question Agency quiz, revealed it was provided to the Administrator by Agency Representative #1 on 5/13/2022 at 10:52 AM. The facility's employee schedule listed each unit and shift on Thursday, 05/19/2022. The census was 93 and the facility had 21 Agency clinical staff scheduled over all shifts. The schedule was provided with the Agency staff highlighted by the facility's DON. (Copy obtained) A review of the facility's Education Plan, provided on 5/19/2022 at 5:24 PM, revealed that [NAME]-PAC-0-UAN titled Understanding Abuse and Neglect, was provided only to facility staff, not to Agency staff. This was confirmed by the DON and Administrator at the time this document was provided for review. The DON stated, We are using Agency staff to fill in last-minute needs. She stated the facility did not have time to provide and document facility orientation for Agency staff. They are already supposed to be ready to work. The Agency staff get their competencies and skills check-offs with their Agency. A review of partial documents provided by the Administrator on 05/20/2022 at 2:49 PM, revealed on page 47 of the Health Center and Nursing Operations and Procedures and Quality Assurance Manual for Agency Staff: Line 1. Prior to utilizing Certified Nursing Assistants (CNA): The nursing agency will be required to fax a copy of its current certification. b. The nursing agency is responsible to ensure the CNA is in good standing with the appropriate State Regulatory Agency, has met required in-services, has received annual PPD, and is in good health. Line 2. Prior to utilizing RNs or LPNs: b. Credentialing and documentation of nurse agencies used by the Community will be maintained current on file and located in the DON's office. No documented evidence of abuse/neglect training was provided for the following Agency Employees: RN A, LPN F, or CNAs B,C, D, E or G. .

Based on interview and record review, the facility failed to ensure it maintained complete medical records for two (Residents #1 and #6) of six residents reviewed for physician-ordered care. Failure to provide physician-ordered care could result in deterioration of a resident's healthcare status, health condition and overall quality of care. The findings include: 1. A review of Resident #1's medical record revealed an admission on 8/31/2021 and subsequent discharge on 9/30/2021. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Pain scale every shift: No documented verification of pain assessment on 9/13/201; Enteral Feed Order every shift 1.5 @ 48 milliliters an hour X 24 hours on 9/13/2021; 9/22/2021 6:31 AM sodium chloride solution 0.9%; and 50 milliliter per hour on night shift dated 9/26/2021. A review of the September 2021 Treatment Administration Record (TAR) for Resident #1 revealed no documentation verifying care was provided on the following dates: For Enteral Drainage System-empty bag every shift, record output, maintain level below bed: 9/21 (night) and 9/23/2021 (night). For Enteral Feed Order Every hour for J tube flush 30 milliliters each hour: 9/13/2021. For Ileosotomy Care every shift and PRN every shift: 9/21 (night) and 9/23/2021 (night). For JP drain #2 (BIG) empty suction bulb every shift, record output every day and night shift: 9/21/2021 (night). For Keep skin clean and dry. Use lotion on dry skin. Do not apply to are of skin breakdown, wound or between toes every day and night shift: 9/21 (night) and 9/23/2021 (night) shift. For Skin prep left and right heels elevated heels off bed with pillow or protective boots/splints: 9/21 (night) and 9/23/2021 (night). For Total Output CC's by shift from Ileosotomy every shift every day and night shift for Ileosotomy: 9/21 (night) and 9/23/2021 (night). 2. A review of the facility's Center for Medicare Services Form 802 (Matrix) was conducted, and Resident #6 was identified under section 8 as receiving Tube Feeding: Enteral (E). A review of Resident #6's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Aspirin 81 milligrams (mg) on 5/07/2022 at 8:00 AM. [MEDICATION(S)] 40 mg on 5/06/2022 at 9:00 PM. Glucerna 1.5 at 75 ml/hour (milliliters per hour) on 5/02 and 5/13/2022 at 6:00 PM. [MEDICATION(S)] Solution 100 mg/ml (milligrams per milliliter) give 10 ml via G-tube (feeding tube) two times a day related to seizures on 5/6/2022 at 9:00 PM. [MEDICATION(S)] (insulin) sliding scale on 5/02 (4:30 PM), 5/06 (9:00 PM) and 5/07/2022 (6:30 AM). Enteral Feed Order: Every 4 hours flush feeding tube with 150 ml water on 5/02 (6:00 PM), 5/06 (10:00 PM), 5/07 (2:00 AM) and 5/13/2022 at 6:00 PM. A review of Resident #6's Care Plan revealed the following focus areas: Requires Tube Feeding (intervention indicated provide local care to G-tube site as ordered and monitor for signs and symptoms of infection), [CONDITION(S)], and Activities of Daily Living/Self-Care Performance Deficit. An interview was conducted with the Director of Nursing (DON) on 5/19/2022 at 4:21 PM. She confirmed that if there was a documentation omission on a resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Administrator on 5/19/2022 at 4:21 PM. She confirmed that there was no Process Improvement Project (PIP) in Quality Committee at that time which addressed omitted documentation in resident medical records. .

Based on observation, interviews, medical record review and facility policy review, the facility failed to ensure that it provided an accurately documented medical record for one (Resident #3) of three sampled residents whose medical records were reviewed for accuracy. The findings include: During a medication observation on 1/20/22 at 9:19 AM, Employee A, Registered Nurse (RN) was observed removing one tablet of [MEDICATION(S)] Sodium 100 milligrams (mg) from the bottle to give to Resident #3. Employee A, RN confirmed, she transcribed the medication from the bottle as [MEDICATION(S)] Sodium 100 mg. She then removed one tablet from the bottle and put it into a medication cup. On 1/20/22 at 9:20 AM, Employee A, RN was observed handing Resident #3 the medication cup with 1 tablet of [MEDICATION(S)] Sodium 100 mg inside it. Resident #3 removed the tablet from the cup and swallowed the medication. A record review for Resident #3 revealed an admitted [DATE]. A review of the care plan revealed a focus area: medication administration with interventions that included: administer medication as ordered. A review of the Resident #3's quarterly minimum data set (MDS) assessment, dated 1/13/22 revealed a brief interview for mental status (BIMS) score of 11, indicating moderate cognitive impairment. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) An interview was conducted with Employee A, RN on 1/20/22 at 12:13 PM concerning the medication given to Resident #3's at 9:20 AM. The RN confirmed that Resident #3 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She then retrieved the over-the-counter bottle of [MEDICATION(S)] Sodium 100 mg and confirmed that she had administered the 100 mg [MEDICATION(S)] instead of the ordered Peri-[MEDICATION(S)]. A review of the administration audit report for the medication observed in the medication cup on 1/20/21 at 9:20 AM was conducted and documented that Resident #3 was administered a Peri-[MEDICATION(S)] Tablet 8.6-50 milligrams (Sennosides-[MEDICATION(S)] sodium) on 1/20/2022 at 9:24 AM by Employee A, RN. This was inaccurately documented. (Copy obtained) On 1/20/22 at 12:30 PM, the Director of Nursing (DON) stated she was made aware of Resident #3 receiving the wrong medication and she spoke with the ARPN, who changed the order to [MEDICATION(S)] Sodium. She mentioned that she would initiate in-service training with the nurses to include verification of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's Long Term Care Pharmacy Services and Procedure Manual effective 12/01/2007 indicated at section 4. Line 4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Time Schedule. (Copy obtained)

Based on kitchen food service observations, staff interviews, and facility document review, the facility failed to ensure that all essential equipment in the kitchen was maintained in safe operating condition. The dish machine was not sanitizing the dishes properly. The facility failed to ensure that the dietary staff were trained and knowledgeable about the proper procedures for the safe operation of the dish machine. Failing to sanitize the dishes could lead to negative health outcomes for the residents who receive meals from the kitchen. The findings include: On 09/07/2021 at 11:10 AM, Dietary Employee A was observed operating the dish machine. The wash cycle temperature was 150 degrees Fahrenheit (F) to 153 degrees F, and the rinse temperature was 159 degrees F. The Registered Dietician (RD) and Certified Dietary Manager (CDM) explained that the dish machine was a hybrid machine. It could run as a high-temperature machine or a low-temperature machine. Currently, they were operating it as a low-temperature machine with a chemical sanitizer, chlorine bleach. A digital thermometer was run through the machine and read 157 degrees F. The CDM tested the water using a chlorine bleach test strip. The test strip remained white, indicating no bleach in the water. She confirmed it was 0 parts per million (ppm). She looked up at the dispensing unit on the wall and stated the tubing for the bleach sanitizer was not attached to the dispensing unit. She stated she was unaware that the tubing had become detached from the dispensing unit. She was not sure how long it had been detached. On 09/08/2021 at 8:55 AM during an interview with Dietary Employee A, he stated he had worked in this facility for [AGE] years. There was a language barrier and several questions had to be reworded so that he understood the questions. He stated he had had training on how to run the dish machine. When asked what type of sanitizer was used and what type of machine the facility used, he hesitated and then when asked if the machine was a high-temperature machine or low-temperature machine, he stated it was a low-temperature machine which used chlorine bleach. He stated he knew how to use the test strips. He stated he thought the chemical tubing was unhooked from the dispensing unit three or more months ago when the representative from the contracted dish machine maintenance company was in the kitchen working on the machine. On 09/09/2021 at 11:15 AM a second tour of kitchen was conducted. The dish machine was tested by Employee C, Dietary Director (DD). The first time he used the test strip it remained white, indicating no chlorine bleach in the water. He then reached up to the dispensing pump on the wall and pushed the button twice to prime the pump. He stated the machine worked fine and sometimes needed to be primed as he just demonstrated. He then tested the water again and the test strip was a dark purple, indicating the water was toxic. He stated he would run the machine a couple of times to dilute the sanitizer. He ran it two more times and the test strip showed 100 ppm. The dish machine operator, Dietary Employee A, was then asked to test the machine. He was not able to demonstrate an understanding of exactly what to do with the test strips. He was cued by the Director about how to do it. He then put the test strip on the coffee cup and the test strip turned a light shade of green indicating 100 ppm. Dietary Employee A did not hold the test strip up to the canister indicator chart to verify the amount of sanitizer on the test strip. The Director instructed him to hold the test strip up to the canister and then to record it on the clip board. Dietary Employee A then documented the amount of chlorine on the test strip in the wrong column on the log. He wrote 100 in the column for the temperature reading of the water. The CDM observed that the readings were documented inaccurately on the log, and she immediately changed them and initialed the log. On 09/10/2021 the dish room employees were observed from 12:40 PM until 1:10 PM. The CDM was asked to test the dish machine sanitizer. The first test strip registered 0 ppm. She then took a test strip from another vial of test strips, and it registered 0 ppm. The DD then pushed the primer button on the pump attached to the wall above the dish machine. A new rack of pans was sent through the machine. The DD used another test strip to test the sanitizer level. It registered between 50-75 ppm. The DD was asked who else had been trained in the dietary department on the operation of the dispensing pump on the wall. He stated no one else had been trained. When asked who would know when to push the pump to prime it if the sanitizer level got low, he stated he was always at the facility and he was the one to prime it. He had not conducted any type of training for the dietary staff on how to run the primer pump. He had no policy and procedure for the operation of the dispensing unit on the wall. On 09/10/2021 at 2:53 PM during an interview with the DD, RD, and Nursing Consultant, they provided the logs for the dish machine and a new log for the staff to use to record the testing of the sanitizer level of the dish machine. The DD stated they were going to start having the dish machine workers test the sanitizer level at least two times during each meal service. The DD stated the service provider for the dish machine was at the facility right now. They were not sure why the sanitizer did not come into the machine consistently. A review of the dietary in-service, dated 07/29/2021, revealed that Dietary Employee A had received training entitled Temperature Log/Procedures, that included completion of the temperature logs, reading thermometers, recording temperatures, and reporting any variance in temperature of 1-2 degrees to a supervisor for review. No documentation was provided verifying that Dietary Employee A had received training on how to test the machine for the sanitizer level. .

Based on observation and interview, the facility failed to post the nurse staffing data specified in paragraph (g)(1) of this section [ (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.] on a daily basis at the beginning of each shift for 3 of 4 days observed. The findings include: On 9/07/2021 at 3:23 p.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 8/18/2021. On 9/08/2021 at 2:21p.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 9/7/2021. On 9/09/2021 at 11:58 a.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 9/8/2021. During an interview and observation of the posted nurse staffing data on 9/09/2021 at 12:13 p.m. with Employee L, Staffing Coordinator, she stated each day she posted the staffing for the day before, so that she didn't have to make corrections on the form if someone didn't show up. The documentation was reviewed with her, pointing out the area that specifically stated daily staffing. She stated she had not noticed that information prior to this, and she had been doing staffing for about a month now. She stated she received limited training in the position. She was referred to the Administrator and/or Director of Nursing for additional education. .

Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to provide care and services in accordance with professional standards of practice, by failing to assess one (Resident #130) of 28 sampled residents, when blood was observed oozing from the resident's urethra surrounding the urinary catheter tubing. The facility also failed to notify the physician regarding possible trauma to the resident's urethra, and the medical record lacked documentation of Resident #130's observed change in condition. This exposed the resident to a delay in treatment and potential clinical complications. The findings include: On 09/07/21 at 2:11 PM, Resident #130 was observed seated in his wheelchair in his room. He appeared to be watching television and leaning to his right side. A urinary catheter bag and tubing were observed hanging on his chair. On 09/08/21at 9:56 AM, Resident #130 was observed with a urinary catheter bag hanging on his chair. On 09/09/21 at 9:15 AM, wound care was observed for Resident #130, which was being performed by Registered Nurse (RN)/Wound Care (WC) Nurse E, Certified Nursing Assistant (CNA) F, and the Assistant Director of Nursing (ADON). Appropriate hand hygiene and use of Personal Protective Equipment (PPE) was performed throughout the entire procedure. Resident #130 was repositioned, and his brief was removed revealing a large amount of stool in the brief. Staff performed peri care prior to continuing with wound care. Once peri care was completed, wound care was performed according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The WC RN cleansed the area and stated she would notify the assigned nurse of the finding. A review of the resident's Comprehensive Minimum Data Set (MDS) assessment, dated 08/31/21, revealed the resident was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was assessed as having an indwelling urinary catheter. (Copy obtained) A review of the care plan, dated 8/20/21, revealed a focus area of: Unstageable Sacral Wound. Revised on 09/01/21. Resident has a Foley (indwelling urinary) catheter. Interventions included: Catheter care per policy, Monitor/record/report to physician signs or symptoms of urinary tract infection, pain, burning, blood tinged urine, deepening of urine color, cloudiness, no output, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Secure catheter to reduce friction. Check tubing for kinks. (Copy obtained) A review of the nursing notes and clinical record from the resident's admission through 09/10/21 at 8:55 AM, did not reveal documentation by the Wound Care nurse verifying that she had notified the assigned nurse or the resident's physician of the blood coming from the resident's urethra. (Photographic evidence obtained) On 09/10/21 at 9:00 AM during an interview with the Wound Care nurse, she stated she did not notify the resident's physician; she verbally notified a nurse. She stated she was not sure which nurse it was that she notified. She confirmed that she did not document it. On 09/10/21 at 9:10 AM during an interview with RN Unit Manager (UM) H, she reviewed Resident #130's electronic medical record and confirmed that she could not see any nursing progress notes or assessments related to the observation of blood oozing from Resident #130's urethra during the wound care treatment performed on 09/09/21. She stated she was not aware that the WC nurse had observed the blood. On 09/10/21 at 4:09 PM, during an interview with the ADON, she stated she was not aware that there were no notes/documentation by RN I, who was assigned to Resident #130 on 09/09/21 during the day shift. There was no documentation in the record indicating RN I had called the resident's physician to notify him of bleeding from the urethra, which had been observed by the Wound Care nurse. After the ADON was made aware of the lack of documentation in the record, she interviewed the WC nurse about what transpired. The WC nurse stated the blood was seen by those in the resident's room after she had left the room to take the soiled dressing and waste out. (This statement is in opposition to what transpired during observation of wound care.) The WC nurse further stated she instructed the floor nurse to notify the physician, and she then continued with her wound care rounds. She did not follow up with the floor nurse to ensure the physician was notified. The ADON stated the floor nurse assigned to the resident went home sick yesterday, and did not give report to the next nurse or document any notes. On 09/10/21 at 5:01 PM during an interview with the ADON, she stated the UM did go and assess the resident's catheter this morning after being made aware of the resident's change of condition by this surveyor. She stated the assigned nurse should have conducted an assessment, notified the physician, obtained any new orders, and then monitored for bleeding, assess vital signs, and made sure the resident was safe. She should have ensured staff were taking care not to put stress on or pull on the catheter tubing. A review of the facility's policy and procedure entitled Change in a Resident's Condition or Status, Version 2.3, revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changed in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; e. need to alter the resident's medical treatment; i. specific instruction to notify the physician of changes I the resident's condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. (Copy obtained)

Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to meet professional standards of quality by failing to assess one (Resident #130) of 28 sampled residents, when blood was observed oozing from the resident's urethra surrounding the urinary catheter tubing. The facility also failed to notify the physician regarding possible trauma to the resident's urethra, and the medical record lacked documentation of Resident #130's observed change in condition. This exposed the resident to a delay in treatment and potential clinical complications. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The Florida Nurse Practice Act, Chapter 464.003, (3)(a) in part defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. 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. 2. 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. Additionally, the Act defines the practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or 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. The findings include: On 09/07/21 at 2:11 PM, Resident #130 was observed seated in his wheelchair in his room. He appeared to be watching television and leaning to his right side. A urinary catheter bag and tubing were observed hanging on his chair. On 09/08/21at 9:56 AM, Resident #130 was observed with a urinary catheter bag hanging on his chair. On 09/09/21 at 9:15 AM, wound care was observed for Resident #130, which was being performed by Registered Nurse (RN)/Wound Care (WC) Nurse E, Certified Nursing Assistant (CNA) F, and the Assistant Director of Nursing (ADON). Appropriate hand hygiene and use of Personal Protective Equipment (PPE) was performed throughout the entire procedure. Resident #130 was repositioned, and his brief was removed revealing a large amount of stool in the brief. Staff performed peri care prior to continuing with wound care. Once peri care was completed, wound care was performed according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The WC RN cleansed the area and stated she would notify the assigned nurse of the finding. A review of the resident's Comprehensive Minimum Data Set (MDS) assessment, dated 08/31/21, revealed the resident was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was assessed as having an indwelling urinary catheter. (Copy obtained) A review of the care plan, dated 8/20/21, revealed a focus area of: Unstageable Sacral Wound. Revised on 09/01/21. Resident has a Foley (indwelling urinary) catheter. Interventions included: Catheter care per policy, Monitor/record/report to physician signs or symptoms of urinary tract infection, pain, burning, blood tinged urine, deepening of urine color, cloudiness, no output, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Secure catheter to reduce friction. Check tubing for kinks. (Copy obtained) A review of the nursing notes and clinical record from the resident's admission through 09/10/21 at 8:55 AM, did not reveal documentation by the Wound Care nurse verifying that she had notified the assigned nurse or the resident's physician of the blood coming from the resident's urethra. (Photographic evidence obtained) On 09/10/21 at 9:00 AM during an interview with the Wound Care nurse, she stated she did not notify the resident's physician; she verbally notified a nurse. She stated she was not sure which nurse it was that she notified. She confirmed that she did not document it. On 09/10/21 at 9:10 AM during an interview with RN Unit Manager (UM) H, she reviewed Resident #130's electronic medical record and confirmed that she could not see any nursing progress notes or assessments related to the observation of blood oozing from Resident #130's urethra during the wound care treatment performed on 09/09/21. She stated she was not aware that the WC nurse had observed the blood. On 09/10/21 at 4:09 PM, during an interview with the ADON, she stated she was not aware that there were no notes/documentation by RN I, who was assigned to Resident #130 on 09/09/21 during the day shift. There was no documentation in the record indicating RN I had called the resident's physician to notify him of bleeding from the urethra, which had been observed by the Wound Care nurse. After the ADON was made aware of the lack of documentation in the record, she interviewed the WC nurse about what transpired. The WC nurse stated the blood was seen by those in the resident's room after she had left the room to take the soiled dressing and waste out. (This statement is in opposition to what transpired during observation of wound care.) The WC nurse further stated she instructed the floor nurse to notify the physician, and she then continued with her wound care rounds. She did not follow up with the floor nurse to ensure the physician was notified. The ADON stated the floor nurse assigned to the resident went home sick yesterday, and did not give report to the next nurse or document any notes. On 09/10/21 at 5:01 PM during an interview with the ADON, she stated the UM did go and assess the resident's catheter this morning after being made aware of the resident's change of condition by this surveyor. She stated the assigned nurse should have conducted an assessment, notified the physician, obtained any new orders, and then monitored for bleeding, assess vital signs, and made sure the resident was safe. She should have ensured staff were taking care not to put stress on or pull on the catheter tubing. A review of the facility's policy and procedure entitled Change in a Resident's Condition or Status, Version 2.3, revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changed in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; e. need to alter the resident's medical treatment; i. specific instruction to notify the physician of changes I the resident's condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. (Copy obtained)

Based on interview and record reviews, the facility failed to provide a discharge summary for two (Residents #1 and #3) of three residents sampled, which included a recapitulation of each resident's stay, inclusive of diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, and a final summary of the residents' status at the time of the discharge that was available for release to authorized persons and agencies, with the consent of the resident or resident's representative. The facility also failed to include in the discharge summary, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter), as well as a post-discharge plan of care that was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which would assist each resident to adjust to his or her new living environment. The findings include: Record reviews for Residents #1 and #3 revealed that the facility failed to issue an appropriate discharge summary to the residents and receiving facilities upon their discharge. A review of the discharge information which the facility stated went out with the resident did not include all of the information required. After several requests during the course of the survey, the facility was not able to provide discharge summaries for Residents #1 or #3. During an interview with the Administrator and the Director of Nursing (DON) on 6/16/2021 at 2:56 p.m., they confirmed that there were no completed discharge summaries available for review for Residents #1 or #3. There was no documented evidence of signed discharge summaries having been provided to Residents #1 or #3, their representatives or the receiving facilities upon their discharge.

Based on interview and record review the facility failed to provide an appropriate discharge for two of three residents sampled ( Resident #1 and #3). The findings include: Record review for Residents #1 and #3 revealed that the facility failed to issue an appropriate discharge summary to the resident and receiving facility. Review of the discharge information which the facility stated went out with the resident did not include all of the information required. Record review for Resident #1 and #3 revealed that the facility failed to develop and implement a care plan which included the resident's discharge then provide the information to the resident and/or the receiving facility. Further review of the records for Resident #1 and #3 revealed blank Nursing Home Transfers and Discharge Notices. During an interview on 6/16/2021 at 1:35 with the Administrator, she stated that she could not explain why these forms were not completed prior to the residents being discharged . During an interview on 6/18/2021 at 3:28pm with the Administrator, she confirmed that discharge is not included in the residents Care Plan. She stated that the care plan summaries are completed by the Social Services Director and that the information is not included in the comprehensive care plan. After multiple requests during the survey, the facility was not able to provide discharge summaries for Residents #1 and #3. During an interview on 6/16/2021 at 2:56pm with the Administrator and the Director of Nursing they confirmed that there were no completed discharge summaries available or provided to Resident #1 and #3. They also confirmed that discharge was not included in either of the residents Care Plan and therefore was not issued to the resident and/or the receiving facility.

Based on observation and interview, the facility failed to ensure accurate reconciliation and disposition of all controlled drugs on one unit for one resident from a sample of 29 residents. (Resident #20) The findings include: An observation of the Rehab 3 Unit medication cart was conducted on 10/4/19 at 10:11 AM with Employee G, Registered Nurse and Employee F, Registered Nurse. The narcotic count sheet for Resident # 20 listed 6 tablets of [MEDICATION NAME] 0.5mg remaining, but the physical count verified by Employee G was 4. During an interview conducted at the time of the observation, Employee F reported that she forgot to sign out the [MEDICATION NAME] this morning. She documented that 2 [MEDICATION NAME] were given to make the count equal to the remainder of 4. Resident #20's order to give [MEDICATION NAME] 0.5mg 1 tab by mouth three times a day was verified with Employee G and Employee F. Employee F stated, Oh, I forgot. I wasted one as it dropped on the floor. Employee F crossed out the documented 2 tablets and wrote 1 [MEDICATION NAME] given. Employee G asked Employee F with whom did she waste the [MEDICATION NAME]. Employee F stated that she wasted it alone, but did not get a second signature to verify. Employee G and Employee F confirmed that the protocol and standard is for two registered nurses to double sign and verify if any narcotic is to be wasted. An interview was conducted on 10/4/19 at 10:33 AM with the Director of Nursing (DON). The DON reported that she believes this incident occurred as Employee F came to her requesting to go home.

Based on record review, observation, and interviews, the facility failed to provide care and services for one (1) of one (1) residents observed for Intravenous Therapy (IV) (Resident #70), from a sample of 29 residents. The findings include: Record review for Resident #70 revealed that she was re-admitted to the facility on [DATE]. The record indicated that she had antibiotic IV therapy ordered on [DATE], for a sacral wound infection. She had a midline catheter inserted to her left upper extremity on 10/1/19. On 10/2/19 at 9:57 AM observation of Resident #70 revealed that she had a midline in place to her left upper extremity. The dressing that was in place, had not been dated and/or labeled to indicate when it was placed on her. On 10/3/19 at 3:55 PM an interview was conducted with Resident #70 regarding her IV care. She stated that her site was hurting. She also stated that it was the same dressing from when the catheter was inserted, and that no one had changed it yet. She had told the nurse that it was hurting, but nothing had been done yet. On 10/4/19 at 10:14 AM an interview was conducted with Director of Nursing (DON). She was asked about the IV policy and procedure that stated the dressing would be changed within 24 hours, and confirmed that it did indeed direct them to change the dressing after 24 hours. Review of the medical record with the DON confirmed that the IV was inserted on 10/1/19. Review of the policy and procedure revealed the following: The Nurses' Infusion Manual For Long Term Care Facilities Page 5 of 6 40. Apply stabilization dressing/securement device over insertion site, catheter and hub. 40.1 New Sterile dressing must be applied 24 hours post-insertion without gauze. 40.2 Sterile gauze will only be reapplied if site continues to ooze blood.

Based on record reviews, interviews, and observations, the facility failed to ensure that they maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to [MEDICAL CONDITION] screenings for two (2) of three (3) residents reviewed for [MEDICAL CONDITION] screenings and wound care for one of three residents reviewed for pressure ulcers, from a facility sample of 29 residents. (Residents #21, #142 & #61) The findings include: 1. Record review of Resident #21's (MONTH) 2019 Medication Administration Record [REDACTED]. On 10/4/19 at 2:25 PM an interview was completed with the Director of Nursing (DON) who confirmed that the nurses had indeed documented negative results for a TB test that had not been administered. 2. Record review of Resident #142's (MONTH) 2019 MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. On 10/4/19 at 12:21 PM an interview was conducted with the DON regarding the missed [MEDICAL CONDITION] screenings. She reviewed the electronic medical records and confirmed that they had missed administering the test, per policy. She was asked the procedure for TB screenings and she confirmed that they do a two-step upon admission, and one step annually if the residents are still here. She stated that the nurses will need further education regarding TB test administration. A review was completed of the facility's policy and procedure for [MEDICAL CONDITION] screenings which revealed the following: Policy Name: [MEDICAL CONDITION] Testing of Residents - CS-50-13 Policy Overview: It is the policy of Brookdale that all residents will be tested for active [MEDICAL CONDITION] (TB) upon admission, readmission and annually thereafter. Policy Detail: [NAME] Screening Residents: - Initial testing will be a two-step procedure, with the first dose given as soon as possible, and the second booster dose given 7-14 days after the first, if the first test is negative. If the booster dose is also negative yearly testing will then be by the single-step method. B. Skin Test: 1. A charge nurse will administer, interpret and document Mantoux (TB) skin test. 3. On 10/3/19 at 10:51 AM, wound care observation for Resident #61 was conducted with Employee E, Registered Nurse (RN). The Unit Manager (UM) and Staff Development Coordinator (SDC) joined her to assist with the dressing change. The UM summoned a CNA (Certified Nursing Assistant) to assist with turning the resident, so Employee D, CNA, came to provide assistance. Employee [NAME] opened the treatment cart to remove her supplies. She locked the cart, went into the room and explained to the resident that she was about to change her dressing. The resident agreed. Employee [NAME] returned to the cart, unlocked it, donned gloves and removed 2 bleach wipes. She entered the room and wiped off the resident's bedside table. She then removed her gloves and washed her hands before she returned to the cart. She unlocked the cart and removed 3 pieces of foil and placed them stacked on each other on top of the cart. She removed three pink tubes of normal saline and placed them on the foil. She obtained her tube of Santyl ointment and went down the hall to obtain a medicine cup from the medication cart. She then opened the Santyl and placed some in the cup. She placed the tube of Santyl back in the bag and returned it to the cart. She then removed an algisite dressing and placed it on top of the cart. She removed her scissors from the tab on her pants, where they were hanging at the top of her pocket. She placed the scissors on top of the treatment cart with no barrier. She opened the algisite dressing and picked up her scissors and cut out a small quarter size piece and then placed it on the foil. She laid her scissors back on top of her cart. During this time, Employee [NAME] did not have any gloves on, and she was touching the mouse pad on the computer to look at her order. She then removed a stack of 2x2 gauze and placed them on the foil. She removed the Allerlyn Life Dressing and placed it on the foil. She continued to touch the computer mouse to look at the order. She lifted her scissors and placed them back in her pocket tab. She locked the cart and knocked to enter the room. She then washed her hands and donned gloves. Resident #61 had already been positioned on her right side by CNA, and the UM was present in the room. Employee [NAME] removed the old dressing dated 10/2/19 and placed it in the trash can next to the bed. She then washed her hands and donned new gloves. The resident was noted to have a very large area of redness with a quarter size yellow area in the center. She then opened the normal saline (N/S) bullet and wet 4-5 2x2 gauze and cleansed the wound. She wiped across the wound, got new 2x2, wet them with N/S and wiped down the wound. She wet 2x2 gauze for the third time and wiped the top area of the wound. She then dried the wound with gauze. She removed her gloves and washed her hands. She then applied gloves and put Santyl on her finger and placed it on the wound, on the red skin around the yellow area. She did not apply any Santyl to the yellow area. She removed her gloves and donned new gloves. She opened the dressing (Allevyn Life), removed a sharpie from her pocket, and dated the dressing. She then placed the sharpie back in her pocket. She picked up the Algisite dressing that she had previously cut with the soiled scissors. The surveyor asked her to please step into the hallway with the piece of dressing. Upon entering the hallway Employee was asked if she had broken infection control anywhere, and she stated, Yes, when I took my sharpie out of my pocket. That was confirmed, but it was explained to her that she was stopped due to her almost applying a soiled dressing from using her soiled scissors from her pocket. She confirmed that she did. She then cleansed her scissors with a bleach wipe, and allowed for them to dry. She cut a new piece of the dressing and returned to the room. Upon entering the room the UM and CNA had allowed the resident to lie back on the soiled brief. The nurse washed her hands and donned new gloves. She pulled the the brief loose from the wound, due to Santyl sticking to the brief. She then placed the new piece of dressing on the wound and covered it with the other dressing. She disposed of the soiled items into the rash can and washed her hands. The UM then washed her hands. An interview was then immediately conducted with the UM and RN regarding what infection control concerns were broken, and they both confirmed that the resident had laid back over on her brief. The UM stated that she had not realized that she did that. Employee [NAME] confirmed that she had to pull the brief loose due to the Santyl.

Based on record reviews and interviews, the facility failed to ensure that two (2) of six (6) residents reviewed from a sample of 29 residents were free from unnecessary drugs due to lack of verification of the necessity at the time of administration. (Residents #26 and #21) The findings include: 1. Record review for Resident #26 revealed that she had an order for [REDACTED]. On 10/4/19 at 11:41 AM, the Director of Nursing (DON) was interviewed regarding the documentation for Resident #26 and confirmed that the [MEDICATION NAME] was given prior to a pulse being documented. She then stated that it would depend on the physician ordering it, if a pulse is taken. She was asked if it was an expectation to obtain a pulse prior to administering [MEDICATION NAME] and she stated, Yes it is, but sometimes they do not document the pulse right away. She reviewed the EMAR on 7/6/19 for an example which documented the medication was administered at 9:00 AM; however, no pulse was documented until 5:00 PM on that date. She confirmed that there were multiple days in July, (MONTH) and (MONTH) 2019 that the medication was administered prior to obtaining a pulse, and on several days it was administered when the pulse was below 60 bpm (beats per minute). A review of Davis's Drug Guide revealed the following for [MEDICATION NAME]: Monitor apical pulse for 1 full min before administering. Withhold dose and notify health care professional if pulse rate is <60 bpm in an adult, <70 bpm in a child, or <90 bpm in an infant. Also notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. 2. A record review was completed for Resident #21. His physician orders [REDACTED]. [MEDICATION NAME] Tablet give 40 mg (milligrams) by mouth one time a day related to essential hypertension, hold if blood pressure is >130 (systolic) or >90 (diastolic). A review was completed of his Medication Administration Record [REDACTED]. On 10/4/19 at 1:50 PM an interview was conducted with Employee B, Registered Nurse (RN) regarding parameters for his blood pressure medication ([MEDICATION NAME]) and she confirmed the blood pressure should be obtained prior to administering the medication. She reviewed the blood pressure recorded on 10/4/19 and confirmed that they should have held his medication. She stated that she will have to fix the order to trigger a blood pressure so the nurse will have to take a blood pressure prior to administering the medication.

Based on record review and interviews, the facility failed to complete a Level I and Level II Preadmission Screening and Resident Review (PASRR) to identify Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID) for one of 29 residents sampled, Resident #69. The findings include: Record review for Resident #69 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses of [MEDICAL CONDITION] disorder, anxiety disorder, and major [MEDICAL CONDITION]. The referring hospital's Internal Medicine Progress note dated 9/2/19 by the physician reported the resident had an underlying [MEDICAL CONDITION] disorder, paranoia, and was extremely anxious. The resident was diagnosed with [REDACTED]. Resident #69's admission Minimum Data Set (MDS) assessment completed on 9/18/19 had the resident coded for anxiety, depression, and [MEDICAL CONDITION] ([MEDICAL CONDITION] disease). The resident was care planned for use of [MEDICAL CONDITION] medication for [MEDICAL CONDITION] disorder, anxiety disorder and major [MEDICAL CONDITION]. Resident #69's Level I Preadmission Screening and Resident Review (PASRR), Section I: PASRR Screen Decision-Making, was not filled out to reflect the diagnoses of anxiety disorder, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. No Level II PASRR completed. No provisional admission or hospital discharge exemption was given for Resident #69. The box in Section IV was checked for No [DIAGNOSES REDACTED]. Level II PASRR evaluation not required. It was signed by an MSW (Master of Social Work) on 9/5/19. An interview was conducted on 10/03/19 at 12:38 PM with Resident #69. The resident reported that she had been seeing a psychiatrist for over [AGE] years. She reported that her psychiatrist passed last year and she has tried to manage without a psychiatrist since that time. The resident reported that she thought she was doing okay until her last hospital admission. She reported that she had this terrible bleeding episode where blood was coming from everywhere; her ears, mouth, and she pointed to her vaginal area. She reported that she just starting screaming and that she almost didn't survive while she was in the hospital. She reported that she was taken to the hospital and from there she ended up this facility. An interview was conducted on 10/3/19 at 3:55 PM with Employee H, Social Worker (SW). Employee H reported that she and Employee I, Social Services Director (SSD), look at the Preadmission Screening and Resident Review (PASRR) form. The PASRRs are obtained from the hospital and they review each one for completeness. The SW reported that the initial check is done by MDS team since they do a chart review. The SW reported that a resident would have a Level II PASRR if they had [MEDICAL CONDITION] or a manic type diagnosis. An interview conducted on 10/03/19 at 4:06 PM with Employee J, Registered Nurse (RN) and Employee K, Licensed Practical Nurse (LPN). Employee J and K reported that the only thing they do with the PASRR is make sure that it is in the chart. They reported that they do chart reviews basically to code the resident's MDS. Employee J reported that social services is responsible for coding the [DIAGNOSES REDACTED]. An interview conducted on 10/03/19 at 4:09 PM with Employee I, Social Services Director (SSD). Employee I reported that if a resident had a diagnosis listed on the Level I PASRR it would be checked off upon admission. She indicated that the [DIAGNOSES REDACTED]. Employee I reported that the clinical team ensures that the Level I PASRR is accurate, but it's primarily the MDS team and social services. She said that if the Level I PASRR is incomplete or inaccurate they follow-up with case management as to why it wasn't done properly. The sending facility of the resident would make the corrections. Additional review of the PASRR record for Resident #69 on 10/4/19 at 4:55 PM, revealed the record remained unchanged.

Based on record review and interview, the facility failed to immediately inform the resident's representative of a significant change in the resident's physical status for one of three residents reviewed (Resident #198) from a sample of 29 residents. The findings include: Record review for Resident #198 revealed he was admitted into the facility on [DATE] and discharged on [DATE]. His admitting [DIAGNOSES REDACTED]. The record also revealed an order on 6/24/2019 for weekly skin checks every Friday. A review of skin sheets provided by the facility from 6/22/2019, resident's date of admission, through 7/20/2019, his date of discharge, revealed that during this time there were only 2 skin checks completed. The skin checks completed on 6/28/2019 and 7/12/2019 both failed to document/identify the wound on the residents heel and/or its progression. The admission skin assessment dated [DATE] did not reflect a wound on the resident's heel. Review of the progress notes for Resident #198 revealed a note created on 7/17/2019 for an incident that occurred on 7/09/2019. Based on the entry, the resident's daughter/POA came into facility with a personal podiatrist to look at the resident's wounds. According to the progress note, the personal podiatrist de-brided the wound bed and applied gauze dressing, and the resident's daughter/POA brought orders for new wound care for resident. The progress note further stated that the facility ordered collagen powder for healing of the wound. Review of all the progress notes for Resident #198 from his admission through his discharge date failed to confirm documentation that his durable Power of Attorney (POA) was notified of his change in condition. Review of the facility's policy on Change of Condition for Skilled Nursing Communities CS-20-1 Effective 11/2007 last revised 09/2019 identified a resident change of condition may include but is not limited to: skin/wound/ulcer. Per the policy's overview: the charge nurse will follow through in documenting notification to family/legal representative once a resident has had a change in condition. During the course of the four day survey (10/1/2019 through 10/4/2019) the facility could not provide documentation confirming that the POA for Resident #198 was notified of his change in condition. During an interview on 10/04/2019 at 11:41 am with the Director of Nursing (DON) she confirmed that the facility could not provide documentation of when Resident #198 acquired the wound on his heel. She confirmed that staff should be documenting all changes in condition. She also stated that facility staff are struggling with timely documentation. The DON could not confirm when/if the resident's daughter/POA was notified of the change in condition prior to her bringing her personal podiatrist into the facility on [DATE]. During a second interview with the DON on 10/04/19 at 3:54 pm, she provided a copy of a Care Plan for Resident #198, dated 07/03/2019, which documented that various wounds were present upon admission and were discussed with the resident's daughter/PO[NAME] The DON was still unable to provide documentation of when the wound occurred on the resident's heel or when the facility notified his daughter/POA of the change in condition.

Based on observations and staff interviews, the facility failed to maintain kitchen equipment (stove burners, freezer, hood) in safe operating condition. The findings include: During kitchen observations on three of four survey days (6/11/18 through 6/13/18), stove burners were heavily impacted with food debris, and freezer #3 had ice condensation all around the door. The kitchen hood was heavily soiled, some slats were hanging off, and other areas appeared burnt and were heavily soiled. The light shades were covered with food debris. On 6/11/2018 at 11:15 AM, the following observations were made during a tour of the kitchen: 1. Freezer #3 was observed with a soiled floor and ice condensation all around the door. During an interview with the executive chef who was present during the tour at 11:20 AM, he stated that repairs were scheduled. 2. There was a build up of food debris on the stove burners, which was a fire hazard. 3. The hood was discolored and heavily soiled. Some slats were hanging off. An interview with the chef and the dining services director at the time of the observation revealed that the hood had been cleaned in (MONTH) (YEAR), and was scheduled for cleaning again in (MONTH) (YEAR). Photographic evidence was obtained for all of the above-mentioned concerns. On 6/12/18 at 2:08 PM, the kitchen was toured again. 1. The hood remained discolored. 2. The air vents were occluded with dust and rust colored debris. Photographic evidence was obtained for all of the above-mentioned concerns. During an interview with the chef on 6/13/18 at 3:00 PM, it was again stated that the hood was cleaned in (MONTH) (YEAR) and was scheduled again for (MONTH) (YEAR).

Based on observations, record review and staff interviews, the facility failed to store, prepare, distribute and serve food as per professional standards for food service safety. The findinds include: On 6/11/2018 at 11:15 AM, the following observations were made during a tour of the kitchen: 1. The produce cooler floor was soiled and impacted with dirt inside it's doorway. 2. Freezer #3 was observed with a soiled floor and ice condensation all around the door. During an interview with the executive chef who was present during the tour at 11:20 AM, he stated that repairs were scheduled. 3. The prep cooler racks were covered with food and debris. The debris had flaked all over the wrapped dishes below the racks. 4. Grease traps on the stove top, the top grill and the flat grill which were lined with foil, were impacted with dried spillage. One trap was overflowing with grease/oil. The oil was observed dripping into a bucket and onto the floor below. 5. There was a build up of food debris on the stove burners, which was a fire hazard. 6. In the food service area, there were dusty and soiled trays holding foam containers. 7. The hood was discolored and heavily soiled. Some slats were hanging off. An interview with the chef and the dining services director at the time of the observation revealed that the hood had been cleaned in (MONTH) (YEAR), and was scheduled for cleaning again in (MONTH) (YEAR). 8.The kitchen doors had peeling paint. 9.The kitchen floor and the dry storage room floors were unkempt. The manager stated at the time of the observation, that the floors would be cleaned at the end of the day. The cleaning schedule was requested. A review of the cleaning schedule did not coincide with the kitchen as it was observed. 10. At 11:57 AM on 6/11/18, the 3 compartment sink unit was being improperly used. The washing section was filled with leftover scrambled eggs soaking in the sink, and egg residue was floating in the sanitizing bucket. 11. The ceiling tiles in the kitchen hood, the dishwashing area, and the cooking areas of the kitchen were impacted with spillage, dust and grease. The standing fan was covered with dust which was blowing over the cleaned dishes, contaminating them. Clean plates and bowls were stacked on top of soiled and dusty carts and trolleys. 12. The loading dock was soiled, resulting in the tracking of dirt into the building. During an interview with the chef at 12:09 PM on 6/11/2018, it was stated that the housekeeping staff was responsible for keeping that area clean. Photographic evidence was obtained for all of the above-mentioned concerns. On 6/12/18 at 2:08 PM, the kitchen was toured again. 1. The kitchen ceiling tiles remained soiled. The hood remained discolored. 2. The air vents were occluded with dust and rust colored debris. 3. All of the pans stacked beside the wall in the dish area were wet-nested. Photographic evidence was obtained for all of the above-mentioned concerns.