Every finding on record at Debary Health and Rehabilitation Center

Based on observations, interviews, record reviews, and review of facility's bowel management process, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (Resident #1, #2, and Resident #4) of three residents reviewed for management of constipation, by failing to implement medical director's directive/order to administer stool softeners/laxatives. The findings include:1.Review of Resident #1's medical record revealed an admission date of 9/7/23, and a discharge date of 2/2/26. Her diagnoses included unspecified Sequelae of Cerebral Infarction, Cerebral Palsy, generalized anxiety disorder, and constipation, unspecified. Review of Resident #1's quarterly minimum data set assessment dated [DATE], noted the resident had a brief interview for mental status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. The resident was noted as always being incontinent of bowel and bladder.Review of the task for bowel movements for Resident #1 revealed she did not have a recorded bowel movement on 1/24/26, 1/25/26, and 1/26/26 and again on 1/31/26, 2/01/26, and 2/02/26. There was no documented evidence that medications were given for relief to the resident on either occasion. Review of the progress note dated 2/2/26 at 18:30 revealed, family/poa visiting reached out to this nurse, POA stated i need to speak to supervisor asap supervisor immediately notified at this time and spoke to poa/ family. Patient is alert with confusion, just staring at staff when ask, refused dinner, vital signs taken 118/66 pulse 69 resp 19 temp 97.6, poa insist to supervisor to call 911 to send to hospital, supervisor called 911, provider notified to send patient to hospital for altered mental status.Further record review revealed the medical provider ordered a Kidney, Ureter, and Bladder x ray study (KUB) on 2/2/26 with the results reported to be Non-obstructive bowel gas pattern. Abundant fecal burden within the colon. No obvious pneumatosis or free intraperitoneal gas. No acute osseous abnormality.2. On 2/5/26 at 11:15 AM, an interview was conducted with Resident #2. When asked about his care he stated it was ok. When asked if he had ever become constipated, he stated yes and they don't help. Review of Resident #2's medical record revealed an admission date of 5/16/18, with a re-entry date of 1/16/26, with a primary diagnosis of Parkinson's disease with dyskinesia with fluctuations.Review of Resident #2's most recent brief interview for mental status (BIMS) score revealed a 12 out of 15 score, indicating moderate cognitive impairment. Review of the task for bowel movements for Resident #2 revealed he did not have a recorded bowel movement for 1/31/26, 2/1/26, 2/2/26, and 2/3/26. There was no documented evidence that medications were given to the resident per bowel management process.On 2/5/26 at 12:10 PM, an interview was conducted with Employee C, Licensed Practical Nurse (LPN) regarding residents who are constipated. When asked what he would do if a resident were constipated or has a change in bowel habits and what kind of assessment is completed before administering stool softeners or laxatives? He stated there is a red binder at the nurse's station that contains the steps to follow for constipation that he would use. He further stated that he would listen for bowel sounds and document them in the nurse's notes. On 2/5/26 at 12:30 PM, an interview was conducted with Employee B, Certified Nursing Assistant (CNA). When asked if he lets a nurse know if a resident has a change in bowel movements, he stated that he would let the nurse know. He explained that they had a standard of three days, and it shows up on the resident's electronic chart as well. If he has a resident that has changes that are out of the normal, he will notify the nurse of the changes. 3. On 2/5/26 at 12:45 PM, a review of the electronic chart for Resident #4 was completed for bowel management. The resident was unable to interview.Review of the task for bowel movements for Resident #4 revealed she did not have a recorded bowel movement on 1/23/26, 1/24/26, 1/25/26, 1/29/26, 1/30/26, and 1/31/2026. There was no documented evidence in the medication administration record or progress notes that as needed or when necessary (PRN), medication was given for relief of constipation.On 2/5/26 at 12:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked how she is notified if a resident was having a problem with constipation, she stated that there is an Icon on upper right corner of electronic chart and would show on the electronic Medication Record (eMAR) as well. The nurse can open it to see what the alert is for. When asked about assessing a resident that has constipation, she stated that they would complete a change in condition form and complete each section in the form. When asked about the protocol she stated she was not aware of one, but residents had standing orders for laxatives and suppositories to use if a resident becomes constipated or goes three days without a bowel movement. During the interview, the Regional Nurse Consultant came into the room. She stated she would check with corporate for a policy or protocol for bowels/constipation. She returned with a bowel management process. She then stated they used this and did not have a policy. Per the protocol, if a resident does not have a bowel movement within 3 days, then they have medications that are to be given. If the resident presents in distress, pain or the interventions are non-effective the provider is to be notified immediately.Review of the facility's Bowel Management process revealed the following: Resident identified as not having a Bowel Movement (BM) in 3 days per the PCC Dashboard will receive the following interventions:*Per our Medical Director, residents without a BM for 3 days receive the designated dose of Milk of Magnesia (30mL every 24 hrs. PRN) and if this intervention has no effect, then a Bisacodyl Supp. 10mg., 1 PR Supp. Every 24 hours PRN to be administered.*If, the resident presents in distress, pain or the interventions are non-effective the provider is to be notified immediately. (Copy obtained)

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide one dependent resident (#8) from a total sample of 35 residents, with services to carry out activities of daily living necessary to maintain appropriate grooming and personal hygiene. Resident #8 was not provided adequate fingernail care. The findings include: On 01/16/24 at 11:56 AM, Resident #8's hands were observed and his fingernails on both hands had jagged edges and brown matter underneath the fingernails. He was asked if staff provided his nailcare and he answered yes. (Photographic evidence obtained) On 01/17/24 at 9:06 AM, Resident #8 was observed in bed. His fingernails remained the same as observed on 01/16/24 at 11:56 AM, with jagged edges and some evidence of deterioration of the nailbeds on the 2nd and 3rd digits of the right hand. Resident #8 stated, I had fungus a long time ago. On 01/19/24 at 10:34 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. The nurse was asked who was responsible for providing the residents' nail care. LPN C stated, Activities staff and sometimes the aides. LPN C further stated Activities staff were in the dining room providing nail care at that time. When asked who was responsible for diabetic nail care, LPN C replied, the podiatrist. When asked if the podiatrist cared for the fingernails and toenails for diabetic residents, LPN C said, I know the podiatrist does the diabetic toenails, but let me confirm who is responsible for the fingernails. She left to find the answer and returned a few minutes later stating, I apologize for giving you the wrong information. I am responsible, as the nurse, for caring for the diabetic fingernails. LPN C was accompanied to Resident #8's room. The nurse asked Resident #8 to allow her to look at his fingernails to determine if he needed nail care. She then stated, Yes, the resident needs nail care and I will try to file them before I cut them. When asked if there was a specific time set aside for resident nail care, LPN C replied that there was not. On 01/19/24 at 10:37 AM, an interview was conducted with Certified Nursing Assistant (CNA) D, who stated he had been employed at the facility for [AGE] years. When asked who was responsible for nail care, CNA D stated the CNAs provided resident nail care. When he was asked whether a specific time was set aside for nail care, he replied, At least once a week for clipping. As far as washing and cleaning the nails, that's done daily. CNA D was accompanied to Resident #8's bedside. Resident #8 asked, Are you going to do my nails now? CNA D looked at the resident's fingernails and stated, Yes, he could use some nail washing and filing. A review of a Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 12/12/23, revealed that Resident #8 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 possible points, indicating severe cognitive impairment. A review of section GG for self-care revealed he was dependent on staff for bed mobility, transfers, toilet hygiene, and personal hygiene. A review of sections E for behaviors revealed that there were no indications of refusal of care behaviors. A medical record review for Resident #8 revealed diagnoses including diabetes mellitus, type 2 and dementia. A review of Resident #8's most current person-centered care plan revealed: FOCUS: Activities of Daily Living (ADL) Deficits related to functional mobility deficits, weakness, cerebral vascular accident (CVA). Goals: Resident will be clean, dressed, and well-groomed with no contractures through next review. Interventions: Set up and supervise simple grooming tasks, Set- up for ADL tasks daily, allow time to do as much on own as able. A review of December 2023 and January 2024 nursing progress notes revealed no documentation of Resident #8's refusal of nail care or preference to wear his fingernails long. A facility policy review for Activities of Daily Living (ADLs) (Revised January 2012) revealed the following: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, nail care and oral care). 4. A resident's ability to perform ADLs will be measured using clinical tools, including Minimum Data Set (MDS).

Based on observation, interviews, and record review, the facility failed to ensure that one (Resident #96) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and resident choices, based on the resident's and resident representative's desire to have bilateral compression stockings placed on lower extremities daily as ordered. The findings include: On 1/16/24 at 12:18 PM, Resident #96 was observed seated in his wheelchair. He was dressed in a long-sleeved shirt, long dark pants, and dark-colored crew socks. When greeted, he smiled and said hello. He was accompanied by his niece, who reported that she visited every day. When asked how the care at the facility had been, she stated He's ordered to wear compression stockings daily, but they never place them on him. I even purchased multiple pairs. The resident's niece pulled up Resident #96's pant legs to expose his lower extremities showing that he was not wearing bilateral compression stockings. Resident #96 was observed on 1/19/24 at 9:05 AM. He was seated in his wheelchair dressed in a long-sleeved shirt, dark-colored pants and dark crewcut socks. A blanket covered his face. When greeted, he smiled and shook his head up and down. When asked to see his socks, he pulled up both pant legs revealing that no compression stockings were in place. Resident #96 was observed again on 1/19/24 at 12:15 PM, in the main dining room, eating lunch with his niece. When asked if his compression socks were on, his niece stated No and pulled up the resident's pant legs showing his dark-colored crew socks. No compression socks were in place. A review of Resident # 96's medical record revealed he was admitted on [DATE] from an acute-care hospital. His diagnoses included traumatic subdural hemorrhage, traumatic brain dysfunction, sequela, type 2 diabetes, hypertension, and anxiety. A review of the 5-day, Admission Minimum Data Set (MDS) assessment, dated 11/10/23, revealed the resident had adequate hearing and vision; was understood, was able to understand others and had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 possible points, indicating severe cognitive impairment. He required partial moderate assistance from staff with lower body dressing, and partial moderate assistance from staff for putting on and taking off footwear. A review of the active physician's orders revealed an order dated 12/7/23: Encourage use of compression stocking to bilateral lower extremities. On AM and remove at HS every day for apply and at bedtime for remove. A review of the electronic treatment administration record (eTAR) found that Resident # 96's placement of compression stockings to bilateral lower extremities on in AM and remove at bedtime, had been signed off as Administered on 1/16/2024 and 1/19/2024, despite the observations and interview with the resident's family member verifying that they had not been placed. (Copies obtained) During an interview with Certified Nursing Assistant (CNA) F on 01/19/24 at 10:24 AM, who reported being assigned to a floating position around the facility to assist with residents, she stated she was not too familiar with Resident #96 but could locate treatments a resident required to include compression stockings through the Kardex system located in the electronic medical record. She confirmed that the CNAs were responsible for placing compression stockings if there was a physician's order. She further stated if a resident refused, the nurse was notified and the refusal was documented. On 1/19/24 at 12:02 PM, an interview was conducted with CNA G, who reported he had been assigned to Resident #96, but not this week. He was aware that Resident #96 had orders for compression stockings and stated he would place them on in the morning and the assigned CNA at night should be removing them. When asked if there would be a reason the compression stockings weren't placed, he stated, No, not unless the staff taking care of him wasn't aware of the order. On 1/19/24 at 12:05 PM, an interview was conducted with Registered Nurse (RN) E, who confirmed that there would be no reason why compression stockings weren't placed on Resident #96 unless there was an updated order from the physician placing the current one on hold, for which there would be a new physician's order and documentation in a progress note.

Based on observations, medical record review, interviews, and review of the policy and procedure for Following Physicians' Orders (revised 1/2024), the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #111) of two residents selected for pressure ulcer review, from a total sample of 35 residents. Resident #111 suffered deterioration of a sacral pressure wound which was facility-acquired. The findings include: An interview was conducted with Resident #111 and her son on 1/16/24 at 11:53 a.m. in her room. The resident was speaking with her son and was observed on a low air loss mattress with pillows on the bed and booties on both her feet. She reported having wounds on her sacrum and lower legs. The son reported the wound care nurse was great, but when she was off on weekends, no one completed the wound care. Both reported that the wound care physician was overseeing and caring for the wounds. On 1/17/24 at 9:00 a.m., Resident #111 was observed lying in bed and stated the wound care physician came by and reported the wound on her sacrum was not improving. He stated he was going to change the treatment. The wound care physician provided the treatment to the resident's sacrum today. A review of Resident #111's record revealed an admitted [DATE]. Diagnoses included: paraplegia, cord compression, diabetes mellitus stage III, sacral pressure ulcer, peripheral vascular disease, osteoporosis, and vascular wounds of the lower extremities. A review of the current physician order, dated 1/18/24, revealed a treatment order for the sacrum which instructed clinical staff to cleanse the sacrum with normal saline or wound cleanser, pack with calcium alginate ropes, apply a sheet of calcium alginate, and cover with a silicone foam dressing every day and as needed. A review of the January 2024 Treatment Administration Record (TAR), revealed treatments to the sacrum were not signed off as having been provided on 1/3 morning and evening, 1/6 morning, 1/12 morning and evening, or 1/16 evening. The December 2023 TAR was reviewed and revealed that on multiple days the sacral treaments, which were scheduled twice a day, were not signed off as having been provided on the following days: 12/8, 12/9, 12/10, 12/16, 12/23, 12/24, 12/28 and 12/29/23. An interview was conducted with the Director of Nursing (DON) at 2:30 p.m. on 1/18/24. She reviewed the TARs for December and January and confirmed that there were multiple blanks where staff did not sign off as having completed the wound care. She reported staff should be signing off on the TAR when wound care is completed. The DON reported that on 1/3/24, she completed the morning dressing change to the sacrum and forgot to sign that TAR. An interview was conducted with Registered Nurse (RN) E/Wound Care Nurse on 1/18/24 at 3:10 p.m. She reported completing wound care on the long-term care side of the facility from Monday through Friday each week. The nurses assigned to the residents completed the wound care on the weekends and when she was not there. On the rehabilitation unit, the desk nurse completed the wound treatments, and if she was absent, the unit manager completed the wound care/dressing changes. Wound care was documented on the TAR and signed off after completion. Residents who had pressure ulcers, and those followed by wound care, had weekly UDAs (User Designed Assessments). Site, wound type, measurements, date identified, reviews, tunneling or undermining, drainage, pain, tissue types, wound color etc were documented in the UDA. The RN reviewed the December and January 2024 TARs. She stated Resident #111's wound was identified on 12/4/23. It was facility-acquired and treatments began on 12/5/23. After reviewing the TARs, the RN confirmed that the treatments for wound care were not signed out on 12/8, 12/9, 12/10, 12/16, 12/23, 12/24, 12/28, or 12/29/23. The January 2024 TAR was reviewed and she confirmed that the 1/3 evening, and the 1/6, 1/12, and 1/16 wound care treatments to the sacrum were not signed out by the nursing staff as having been done. A wound care consult was conducted on 12/6/23 and Resident #111 was evaluated for an initial wound assessment of the sacral wound. The Stage III sacral pressure wound measured 3.5 x 5.5 x 0.1 cm (centimeters). No tunneling was noted. There was a moderate amount of drainage with no odor. The wound was noted with 90% granulation and 10% slough (dead tissue). An order was written to cleanse the wound with wound cleanser, pat dry, apply honey gel silicone border foam dressing and avoid direct pressure to the wound site. A wound consultation note, dated 1/10/24, noted an X-Ray to the sacrum and coccyx with no osseous (bone) abnormalities. There was a plan for a bone scan to rule out osteomyelitis and an infectious disease consultation for evaluation of possible pyoderma gangrenosum (condition that causes large, painful sores (ulcers) to develop on your skin, most often on your legs). The sacral wound continues to demonstrate deterioration. Debridement to sacrum performed today. Sacral Stage III pressure ulcer not healed with measurements 10 x 8 x 5.2 with undermining noted at 1:00 and ends at 3:00. There is a moderate amount of drainage noted with a strong odor. The wound has 40% granulation, 60% slough and is deteriorating. A new treatment order was written. A 1/17/24 UDA wound evaluation note was reviewed and revealed a Stage III to sacrum with measurements 10 x 8 x 5.2 with undermining, moderate drainage, and the treatment order was changed. On 1/18/24, the physician order notes to cleanse sacrum with normal saline or wound cleanser, pack with calcium alginate ropes, apply sheet of calcium alginate and cover with silicone foam dressing every day and as needed. An interview was conducted with Advanced Registered Nurse Practitioner (ARNP) H on 1/19/24 at 9:30 a.m. He reported being notified the wound was deteriorating on the sacrum. A bone scan, X-Ray and labs were ordered along with making an appointment with the Infectious Disease Physician. The ARNP reported the wound was being treated by the wound care physician and he was following. There was a question of pyoderma gangresom, possible osteomylelitis and noncompliance of the resident with turning and positioning. The ARNP stated if wound care treatment/dressings were not being completed, the wound could be compromised. He was not aware that wound care was not being completed. On 1/19/24 at 9:45 a.m., Resident #111's sacral wound was observed with RN I. The wound was the size of a fist and a half with slough and red and black color around the wound. The RN stated signing off on the TAR was expected when completing wound care. The RN noted the wound had deteriorated and the wound care physician was seeing the resident. A review of the facility's policy and procedure for Following Physicians' Orders (revised 1/2024) revealed that physicians' orders should be followed as prescribed and if not followed, the reason should be recorded on the resident's medical record during that shift. The physician should be notified along with responsible party if indicated.

Based on observations, staff and resident interviews, medical record review, and a review of facility policy, the facility failed to ensure that two (Resident #56 and #94) of 35 residents in the total sample, were provided an environment as free of accident hazards as was possible. The findings include: On 01/16/24 at 11:44 AM, razors were observed at the sink in Resident #56's room. On 01/17/24 at 9:12 AM, four razors were observed rubberbanded together in a cup on the sink in Resident #56's room. (Photographic Evidence Obtained) On 01/19/24 at 8:57 AM, three razors were observed in an open cabinet at the sink in Resident #94's room. (Photographic Evidence Obtained) Resident #94 was asked if the razors belonged to him and he stated, yes. He was asked if the razors were usually stored in the cabinet at the sink and he replied, Yes. On 01/19/24 at 9:12 AM, an interview was conducted with Registered Nurse (RN) J. She was asked how sharps were managed at this facility and she replied, We dispose of sharps in the sharps container after use. She was asked to describe some examples of sharps. She stated, needles, razors, lancets. On 01/19/24 at 9:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) K. She was asked to provide some examples of a sharps item. She replied, needles and razors. She was asked if razors were kept out in the open in the residents' rooms. She stated, No, we are not supposed to keep razors in the room. Sometimes the family bring things and we may not be aware, but if I find it, I take it out of the room and store it for the resident, but it's not supposed to be left out in the room. On 01/19/24 at 9:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) C, who was acoompanied to Resident #56's room. She was asked what was in the cup that was located at the sink and why were the items located there. LPN C replied, Those are razors and I don't know why they're here, I'd have to ask the CNA. She was asked how razors were usually stored and disposed of. She replied, Razors should not be kept in the resident's room, and they should be disposed of into the sharps after use. She was asked if she was familiar with the medications that Resident #56 received and she replied, Yes, I think he gets an anticoagulant but let me be sure. She used her computer to look up Resident #54's medication list, then she replied, Yes, he takes Eliquis. She was asked to describe some pertinent side effects or adverse reactions to Eliquis. LPN C stated, Bleeding is a side effect or adverse reaction for taking Eliquis. She was asked if the accepted practice of the facility was to leave razors out in the open in the resident's room and she said, No, we usually get the razors from supply and then dispose of them after use, but I will immediately remove those razors. When she was asked whether the resident could shave himself, LPN C stated, No, his CNA shaves him. A review of the facility's policy and procedure for Sharps Disposal (Revised January 2012), revealed the following: The facility shall discard contaminated sharps into designated containers. Policy Interpretation and Implementation. 1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. 7. Whoever observes incorrect disposal or handling of contaminated sharps should report the information to the Infection Preventionist (or designee).

Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5 percent. Three errors were identified out of 26 opportunities for error, resulting in a medication error rate of 11%, involving two (Residents #50 and #99) of four residents observed during medication administration, from a total of 35 residents in the sample. The findings include: On 1/17/24 at 8:00 a.m., Nurse A was observed preparing medications for Resident #50. She pulled each medication according to the electronic Medication Administration Record (eMAR) and signed off each as she prepared the medications. She administered the medications, which were being given by mouth, to the resident. Upon returning to the medication cart, Nurse A was asked if she had completed this medication pass for Resident #50. She stated yes. She was asked if she had signed off all the medications on the eMAR for this resident. She stated yes. She was asked if she was going to prepare medications for the next resident at this time. She stated yes. She was asked to open the eMAR for Resident #50 and review it. After her review, Lubricant Eye Drop Solution 0.4-0.3% was observed to have been signed off as having been administered. The nurse was asked if she had administered this eye drop to the resident. She stated, Oh, no I didn't. On 1/18/24 at 8:20 a.m., Nurse B was observed preparing medications for Resident #99. Nurse B prepared and poured one Folic Acid tablet 1 mg (milligram) into a medication cup. After completing the medication preparation and pouring for all medications, she locked the eMAR screen and the medication cart. She was asked if the medications she had poured were what she was going to bring into the room to administer to Resident #99. She stated yes. She was asked to review the order for Folic Acid prior to entering the resident's room. Upon reviewing the order in the eMAR, she stated, Oh, Folic Acid 1 mg tablets, give 5 tablets. I need to add 4 more tablets to make the 5 tablets. Nurse B was then observed administering the medications to Resident #99. She administered 2 sprays of Flonase Nasal Spray 50 micrograms (mcg) per spray into each nostril. After Nurse B administered one spray in each nostril, she stated, I'm going to wait a minute or two to do the second spray. She administered a second spray into each nostril. While reviewing Resident #99's medications in the eMAR to sign them off after administration, Nurse B stated, Oh, it was only one spray for each nostril. A review of the facility's policy titled Medication Administration (revised 1/2024) revealed: Standard: Medications are ordered and administered safely and as prescribed. Procedure: 3. Medications are administered in accordance with presciber orders; 9. The individual adminstering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Specifically, the facility failed to ensure that the dietary staff were trained and knowledgeable about proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents, due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. This failure potentially impacted every resident consuming food from the facility's kitchen. The findings include: A tour of the kitchen with the Certified Dietary Manager (CDM) on 02/07/22 at 2:13 PM revealed: -On the refrigerator across from the tray line, the door handles were soiled and sticky with food debris, and the inner door of the refrigerator had dried debris afixed to the surface of the door. -Inside the refrigerator was an opened 46-ounce container of nectar consistency water dated with a use by date of 11/08/21, without an opened date. There was another 46-ounce container of thickened orange juice dated 02/03/22. There was an unlabeled container of a reddish/orange liquid dated 02/04, with the year not indicated. (Photographic evidence obtained) -In the food pantry, 24 single-serve bowls of cereal were observed to be unlabeled and undated, with two large brown boxes stacked on top of them. -Multiple containers of 46-ounce lemon-flavored nectar-thickened water were observed on the shelves with use by dates of 11/08/21. (Photographic evidence obtained) -The 3-compartment sink across from the food line was observed with the first wash compartment containing mixing bowls and utensils soiled with food products, the second rinse compartment #2 had a colander of cooked bowtie pasta in it, and the third sanitized compartment was observed plugged up and ¾ filled with cloudy water. -The large floor storage bins for flour and rice were not sealed. (Photographic evidence obtained) -The walk-in refrigerator was observed with a multi-serving bag of ketchup opened in the cardboard box. The silver ketchup dispensing bag was soiled with residual ketchup and the cap was encrusted with dried ketchup. A large tray of undated food was on the refrigerator shelf not completely wrapped to prevent contamination. Unidentified contents were observed with illegible writing. A red, sticky substance was found on the shelves and floor. (Photographic evidence obtained) -In the walk-in freezer, there was a 17-pound box of opened frozen pie dough sheets with a plastic storage bag that was open to air and undated. Frozen sweet potatoes were poorly wrapped in plastic wrap with a use by date of 02/02 and were exposed to the air. A kitchen observation on 02/09/2022 from 2:30-3:50PM revealed: -A dietary aid was observed working on the dish line with shoulder-length hair. Her hairnet only partially covered her head. -The refrigerator exterior doors had been cleaned, but the interior door remained soiled with dry debris. -Cook G was observed making macaroni salad, not wearing gloves. His mask was positioned on his chin and he adjusted his eyeglasses numerous times. He walked to the refrigerator, returned with salad dressing, then proceeded to break down cardboard. He then returned to continue making the macaroni salad without wearing gloves or washing his hands. -Three containers of peanut butter were found on the can rack with a use by date of 01/22/22, and an additional container was observed in the food prep area with the same use by date. An interview was conducted with Cook G regarding the facility's policy/practice regarding foods use by dates, and he stated they discarded these items before the use by date. He added that it was something everyone in the kitchen kept an eye on; this was not one person's responsibility. -A kitchen blue light was observed with debris inside the fixture and on the bulb. Clean soup containers/warmers were located directly four feet from the light. -There were large 18x12 cooking sheets improperly stored with the edges of the cooking sheets resting on the floor. Ceiling vents over the tray line were soiled with dust and debris hanging from them. (Photographic evidence obtained) -There were two detached hoses from juice concentrate dispensers observed lying on shelves unbagged. The cranberry juice multi-serving dispenser was resting on the counter with the dispenser nozzle in direct contact with the countertop. -At 3:03PM, the walk-in refrigerator was checked and a tray of brownies and a tray of yellow sheet cake, both dated 02/07/2022, were observed partially exposed, loosely covered with white paper. (Photographic evidence obtained) Loosely wrapped cheese was observed on the shelf with a use by date of 12/03/21 and a received date of 12/29, no year indicated. Dinner service was observed on 02/09/2022 from 4:10 PM to 5:15 PM. On the service line, Cook G was observed taking food temperatures correctly, but failing to record them in the meal temperature log. He stated he usually filled them in later. A review of the meal temperature log showed that the temperatures were not recorded for lunch or dinner on 02/09/2022. The Regional Dietary Director was interviewed on 02/10/2022 at 9:00 AM. Information regarding the cleaning of the kitchen vents by an outside vendor was provided. The last date of service was 10/18/2021 with documentation that the hood should be cleaned every 90 days. Documentation was provided stating that the ice machines were cleaned monthly and filters were changed every 6 months as per manufacturer recommendation, with a last changed date of on 10/21/21. A kitchen tour was conducted on 02/10/2022 from 11:50 AM to 12:45 PM with the Regional CDM during the lunch service. The facility CDM was observed in the kitchen on three of the four survey days, wearing a dark-colored beanie on her head with braided hair exposed in the back about 3 inches below the rim of the hat. The regional CDM stated the dietary staff should have their hair completely contained in a hair net, and that they were permitted to wear hats, but the hair must be contained. In the walk-in freezer there were numerous torn bags of opened and undated bags of pizza dough and potato wedges. These food items were stored in cardboard boxes with unclosed lids, not properly resealed/or wrapped up. The Regional CDM stated the items that had been opened should have been dated and properly resealed, but they should not be exposed to the air. Cook G was observed touching his glasses with and without gloves, touching papers in the kitchen and grabbing utensils for meal service numerous times during this kitchen visit. In the walk-in refrigerator, a full-sheet cake approximately 12x18 and a same-sized tray of brownies were observed with white paper lying on top of them dated 02/08/22. An interview was conducted with the Regional CDM and Registered Dietitian (RD) on 02/10/2022 at 1:38 PM. The RD stated she mainly communicated with the Regional CDM, and he would notify her if there was something he needed her to follow up with. She stated her main communication was with facility management. She said when she came to the facility, the CDM would let her know if she needed her to follow up on a resident need, or if a nurse wanted to talk to her. That was the kind of things she worked on. She said she reviewed new admissions and addressed changes in weights and anything that was brought up by the Interdisciplinary Team (IDT). She provided support for the dietary department, but she did not do education for the dietary department. Corporate did that. When she walked through the kitchen, it was the same as the Regional CDM, or corporate staff. They had a checklist, but it was done by the dietary department. She only reviewed the checklist, but she did not complete it. It was something she submitted to the corporate office. An interview was conducted with the Regional CDM on 02/10/2022 at 1:45 PM. He stated he had been here for a little over two weeks, and that this was a new building for him. Going forward he said he would be a part of education, working with the CDM training the management team and deciding what mandatory in-services would be done, what was expected to be done on a monthly basis and would conduct monthly audits in addition to ongoing education and audits. At 1:52 PM, the findings were reviewed with the Regional CDM, who stated he understood and acknowledged the concerns.

Based on interviews and record reviews, the facility failed to thoroughly investigate an allegation of sexual abuse by failing to promptly identify one (Resident #35) of nine hospice residents as a potential victim of an alleged perpetrator's actions. The findings include: A review of Resident #35's medical record revealed an admitted [DATE]. Her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) assessment, dated 11/30/2021, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of a total 15 points possible, indicating moderately impaired cognition. Resident #35 required extensive to total assistance from staff with activities of daily living (ADLs) and was receiving hospice care. A psychiatric evaluation, dated 12/30/2021, indicated Resident #35 was alert and oriented to person, place and time. Her thought processes were documented as organized and she was noted with fluent speech. A review of facility documentation indicated that Resident #35 was not interviewed on 12/15/2021, the date of the alleged incident, regarding whether she had been abused/mistreated by the alleged perpetrator during any of his four visits with her on 11/30/2021, 12/1/2021, 12/2/2021, or 12/6/2021. However, documentation did reveal that Resident #35 was interviewed on 12/20/2021 regarding whether she had any concerns related to her care or concerns related to abuse. Resident #35 denied any concerns on 12/20/2021. Further review of Resident #35's medical record revealed documentation of hospice visits by the alleged perpetrator on 11/30/2021, 12/1/2021, 12/2/2021, and 12/6/2021. During the 11/30/2021 visit, the documentation indicated that lotion was applied to the resident's skin. The hospice CNA task forms noted the application of lotion to a resident's skin as part of residents' personal care. There was no documentation to support that lotion was applied during the remaining three visits. There was no documentation to support that this CNA provided care to Resident #35 at any other time during the resident's stay. (Copies obtained) On 2/9/2022 at 10:15 a.m., an interview was conducted with Resident #35's daughter-in-law. She explained that there had been an allegation of sexual assault in December 2021 against a hospice Certified Nursing Assistant (CNA) who had provided care to her mother-in-law. She further explained that Resident #35 mentioned the alleged perpetrator had attempted to apply lotion to her skin and Resident #35 felt uncomfortable about it. On 2/10/2022 at approximately 12:30 p.m., the Social Services Director (SSD) provided a typed statement dated 2/9/2022 at 6:50 p.m. The statement was regarding an interview conducted by the SSD with Resident #35's son. The interview indicated Resident #35 was lethargic and was unable to answer questions. The resident's son mentioned his mother told him that the male hospice aide wanted to rub lotion on her during one of his visits. She did not think it was okay for him to do this, so she declined the offer. (Copy obtained) On 2/9/2022 at 11:15 a.m., an interview was attempted with Resident #35. She was lying in her bed with her son at the bedside. Her eyes were open and she was able to smile but was unable to answer any questions. On 2/9/2022 at 5:50 p.m., an interview was conducted with the Social Services Director (SSD), Administrator in Training (AIT), and Director of Nursing (DON). The SSD explained that all residents receiving hospice care by the alleged perpetrator were interviewed on 12/15/2021. A list of the residents interviewed by the facility and their responses was reviewed. The list did not contain Resident #35's name. During the interview, the SSD was asked whether Resident #35 had been interviewed. The SSD explained that neither Resident #35 nor her Resident Representative had been interviewed as part of the facility's investigation on 12/15/2021. When asked why Resident #35 had not been interviewed, the SSD explained that Resident #35 had enrolled in hospice care a couple of weeks before the CNA (hospice CNA) was arrested, and added that when the facility developed the list of potential victims, Resident#35 was overlooked. The facility's abuse prevention policy titled Abuse Prevention Program (no effective date, no facility review date) was reviewed. The policy statement read, As part of the resident abuse prevention, the facility's administration will identify and assess all possible incidents of abuse; investigate and report any allegations of abuse within timeframes as required by federal and state requirements; The policy outlined the role of the person conducting the abuse investigation to include interviewing other residents to who the accused employee provides care or services. (Copy obtained)

Based on observations, interviews, and record reviews, the facility failed to effectively manage a resident's pain, by failing to identify and respond to non-verbal indicators of pain for one resident (Resident #7) reviewed for pain management from a total sample of 35 residents. The findings include: A review of Resident #7's medical record, revealed an admitted [DATE]. Her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 also had a contracture of her left arm. A quarterly Minimum Data Set (MDS) assessment, dated 2/1/2022, revealed a Brief Interview for Mental Status (BIMS) score of 02 from a total 15 possible points, indicating severely impaired cognition. Resident #7 required extensive to total assistance with activities of daily living (ADLs) and received hospice services for end-of-life care. On 2/7/2022 at 12:13 p.m., Resident #7 was observed sitting in a reclining geri-chair in her room. The chair was reclined. She was grimacing, her brow was furrowed, and she was repeatedly whimpering. Resident #7 was not able to answer any questions. On 2/8/2022 at 2:05 a.m., an off-hours visit was made to the facility. Resident #7 was observed lying in her bed. Her eyes were open, her brow was furrowed, she was frowning, and she was repetitively whimpering. Resident #7 was not able to answer any questions. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 8/17/2021, was identified for hospice services. (Copies obtained) On 2/8/2022 at 2:15 a.m., an interview was conducted with Licensed Practical Nurse (LPN) A. She confirmed that she was assigned to Resident #7. She was notified that the resident was lying awake in bed and was displaying non-verbal indicators of pain. The nurse stated, Oh, she makes those noises all the time. The nurse was asked whether she had conducted a pain assessment on the resident during the current shift. The nurse stated she had not. The nurse was then asked how she assessed the resident for pain. The nurse stated, She doesn't complain of pain and then explained that the resident was non-verbal. When asked whether the nurse had received any recent education regarding effective management of a resident's pain, she stated, I think so, but I can't say for sure. When asked whether the resident had any medications available for pain, LPN A stated she wasn't sure. LPN A was then asked to review Resident #7's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN A was asked to evaluate Resident #7 for pain, as she appeared very uncomfortable. As of 2/8/2022 at 2:30 a.m., LPN A had still not evaluated Resident #7 for pain. A review of the medication administration records (MARs) for February 2022, revealed one administration of acetaminophen on 2/8/2022 at 4:55 a.m. (Copy obtained) A review of the MARs for January 2022, revealed no documented administration of the acetaminophen for the entire month. (Copy obtained) A review of an Addendum Plan of Care Review by the hospice provider, dated 1/13/2022, revealed no entries for the pain levels section and included a handwritten statement which read, Tylenol effective. (Copy obtained) A review of the resident's comprehensive care plans revealed a focus area for Alteration in Comfort related to Cognitive Impairment and Muscle Spasms (may not be able to express pain). Interventions included the administration of pain medication as ordered, assistance to reposition for comfort, observation for any verbal or non-verbal indicators of pain or discomfort, and to notify the physician/hospice if current pain medications were not effective. (Copy obtained) Resident #7's Pain Level Summaries for February 2022 were reviewed. Of the 25 pain assessments documented in February 2022 for this non-verbal resident, 17 were documented as verbal pain assessments. (Copies obtained) On 2/10/2022 at 11:58 a.m., Resident #7 was observed lying in bed. The head of the bed was elevated. A positioning wedge had been placed next to her right leg. The resident was frowning and was attempting to extend her right leg repeatedly. When asked whether she was in pain, she continued to frown and look around the room. She was not able to answer any questions. On 2/10/2022 at 2:24 p.m., Resident #7 was observed lying in bed. The head of the bed was elevated. The positioning wedge had been removed from the resident's right side. The resident was frowning and repeatedly whimpering. Resident #7 was again unable to answer any questions, but did eventually state, Ow while looking at her right leg. On 2/10/2022 at 3:20 p.m., an interview was conducted with Certified Nursing Assistant (CNA) B. She confirmed that she was assigned to Resident #7 and that she was familiar with the resident's care. She was asked whether Resident #7 ever complained of pain. CNA B stated, No. She doesn't say much. Not that I'm aware of. CNA B was then asked whether she was familiar with non-verbal indicators of pain. She responded, I guess if they have like a scrunched up face or something like that. CNA B was asked whether she had received any recent training in identifying indicators of pain in non-verbal residents. She stated she did not believe she had. On 2/10/2022 at 3:25 p.m., an interview was conducted with Registered Nurse (RN) C. The nurse confirmed that she was assigned to Resident #7 and that she was familiar with the resident. She was asked whether the resident ever complained of or showed signs of pain. She stated, She doesn't talk. She kind of does that sound thing, which we think could be pain but who knows. Other than that, I'm not sure. RN C was asked to review Resident #7's medical record for pain medications. She explained that Resident #7 had acetaminophen available every four hours as needed. She added that there was no documented administration of acetaminophen on the previous shift. RN C was asked whether she had assessed Resident #7 for pain during the current shift. She stated she had just come on duty, but she had not received any concerns about Resident #7 in report from the off-going nurse or CNA. RN C was notified that Resident #7 appeared to be uncomfortable and was asked to assess Resident #7 for pain. She stated, Well, I can't start her medications until 4:00 p.m. RN C was reminded that Resident #7's acetaminophen could be administered every four hours as needed. She stated, Oh that's right. It's as needed. I'll go down and see her. The nurse left the medication cart and went into Resident #7's room. She returned to the medication cart approximately two minutes later and stated, Yea, she's probably in pain. I'll go ahead and get her the Tylenol. The facility's policy for pain management, titled Pain Assessment and Management (Version 1.3 (H5MAPR0208), Revised March 2015) was reviewed. The purpose of the policy read, The purpose of this procedure is to help the staff identify pain in the resident, to develop interventions that are consistent with the resident's goals and needs, and that address the underlying causes of pain. The policy continued, Pain management is a multidisciplinary process that includes the following: Assessing the potential for pain; effectively recognizing the presence of pain; developing and implementing approaches to pain management . The policy directed staff to observe possible behavioral signs of pain which included, verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, etc; guarding, rubbing, or favoring a particular part of the body; insomnia; (Copy obtained) .

Based on record reviews and staff interviews, the facility failed to provide cardiopulmonary resuscitation (CPR) to a resident with a CPR order when she was discovered to be unresponsive and without vital signs. This involved one (Resident #1) of three residents reviewed for quality of care. Resident #1 was discovered unresponsive and without respirations by two certified nursing assistants (CNAs). The resident's assigned nurse was immediately notified. She went to the resident's bedside and found her without a pulse or respirations but did not initiate CPR. Resident #1was a full code. Approximately one hour after discovery, the nurse notified the Director of Nursing (DON) via telephone, stating that the resident was gone. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 12:20 p.m. on [DATE]. On [DATE] at 5:00 a.m., the Immediate Jeopardy (IJ) began. On [DATE] at 11:30 a.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed at the time of survey exit on [DATE] at 3:55 PM. The facility remained out of compliance, and the scope and severity were reduced to a D. The findings include: A review of Resident #1's clinical record revealed an admission date of [DATE] at 7:30 p.m. She was admitted for rehabilitation following hospitalization for gastroenteritis and [MEDICAL CONDITION]. She was a [AGE] year-old female with [DIAGNOSES REDACTED]. The clinical record indicated that she was a full code. There was no documentation of a DNR (Do Not Resuscitate) in the clinical record. A review of the resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated [DATE], revealed Resident #1 required nursing facility services and her rehabilitation potential was fair. A review of Resident #1's Minimum Data Set (MDS) assessment (undated) revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. A review of the facility's Abuse and Neglect Immediate Report, dated [DATE], and submitted to the state agency, revealed the facility's Social Services Director (SSD) reported an incident involving Resident #1 that occurred on [DATE] at 5:00 a.m., as per the report, that was identified as neglect. The SSD documented that she notified the resident's representative, law enforcement, and the Florida State Abuse Registry on [DATE]. The report revealed Resident #1 was found unresponsive on [DATE] at 5:00 a.m. by the two certified nursing assistants (CNAs) who reported it to the nurse on duty (Employee A). The resident was noted as last seen at 3:30 a.m. when the CNA provided care with no issues noted at that time. Employee A went into the resident's room and found the resident without a pulse or respirations and cool to the touch. The nurse indicated that Cardiopulmonary Resuscitation (CPR) was not initiated at that time, and she notified the Director of Nursing (DON) at 6:00 a.m. on [DATE] that the resident was gone, and a Code Blue was called at that time. The resident expired. A review of the facility's CPR Policy, dated ,[DATE], revealed, It is the policy of the center to initiate CPR if the resident is without pulse or respirations and is a full code. The code procedures included calling for assistance (do not leave resident alone), taking vital signs, verifying the code status, and contacting the Emergency Medical Service (EMS - 911). The staff member should begin CPR after determining the resident is without pulse or respirations and is a full code. CPR is not stopped unless EMS arrives and takes over. Paperwork is provided to EMS upon arrival. Medical Director and family are notified. The DON is also notified. A review of the facility's undated statement given by Employee B, Certified Nursing Assistant (CNA), revealed that Employee C (CNA), approached Employee B at 5:00 a.m. on [DATE] and stated Resident #1 had passed. Employee B wrote that she responded to the resident's room and found Resident #1 not breathing. Employee B stated, I went and got my nurse (Employee A) who was in the hall giving morning medication. She came in, rubbed Resident #1's chest and called her name. At this time our nurse said okay and to go ahead and get her ready, meaning to change her and clean her and make ready for anyone who will be coming into the room. As Employee C and I did this, our nurse left the room and proceeded to finish passing medication. A review of the facility's undated written statement given by Employee C, CNA, revealed that on [DATE] (no time noted), Employee C found Resident #1 lying in her bed and noticed the resident was deceased . Per her witness statement, she told Employee B, CNA, that she thought that the resident had passed. Employee C wrote that Employee B went and told the nurse (Employee A) that the resident was deceased . When (Employee A) entered the room, she confirmed the resident had passed, and told me and (Employee B) to do postmortem care and then exited the room. On [DATE] at 10:55 a.m., an interview was conducted with Employee D, Registered Nurse (RN), who stated, I just arrived to work the day shift on [DATE] and I heard Code Blue overhead in room [ROOM NUMBER]B at about 6:00 a.m. I grabbed the crash cart and went to the room. (Resident #1) was unresponsive. Employee D said she assessed the resident as having no pulse or respirations. She initiated CPR. She further stated, Employee A was behind me standing by the door. I don't know why she did not initiate CPR. A review of CPR certification cards revealed that both Employee D, Registered Nurse (RN), and Employee A, Licensed Practical Nurse (LPN), had current CPR certification. On [DATE] at 12:20 p.m., an interview was conducted with the Director of Nursing. She stated she received a call in her office on [DATE] at 6:00 a.m. from Employee A, LPN, concerning Resident #1. (Employee A) said she did not want to call me at 5:00 a.m. because she felt I was on my way in, and she told me (Resident #1) was gone. (Resident #1) was found unresponsive when (Employee A) went in the room at 5:00 a.m. on [DATE]. I asked (Employee A) what the code status was, and she was not aware. This should have been the first thing she checked. The DON stated she immediately checked the medical record and found the resident was a full code (She was to have CPR in the event of the absence of heartbeat and/or respirations.). The DON stated, I told (Employee A) she (Resident #1) is a full code and you need to call a Code Blue and start CPR immediately. She didn't answer me. I immediately called the Code Blue overhead and went to the room to assist. When I got to the room, they were doing CPR at approximately 6:10 a.m. 911, fire rescue, and law enforcement were called. The lieutenant from the fire department pronounced the resident expired. The DON verified that her investigation revealed that Employee A did not know the code status and failed to initiate CPR appropriately. Employee A failed to follow the facility's code response policy to initiate basic emergency care, such as CPR. During an interview on [DATE] at 12:45 p.m., the Administrator stated an investigation of the incident involving Resident #1 was initiated immediately after the incident occurred. (Resident #1) was a full code and (Employee A) did not start CPR at the time the resident was found unresponsive. (Employee A) was able to verbalize the CPR policy and procedure after the incident, but she did not have a response when I asked why she did not call a Code Blue. I asked her, Do you realize that you could lose your license? During a telephone interview on [DATE] at 8:00 a.m., Employee B, CNA stated, (Resident #1) was calling out that evening and said help me please, but when I asked her what is wrong, she wouldn't look at me and just turned her head and ignored me. We were on our last round of changing residents that morning making sure they were clean. It was just before 5:00 a.m. I saw (Resident #1) in the room and the resident was not responding. I told the nurse (Employee A) to come to the room. The nurse came in, rubbed (Resident #1) chest and said it was okay to go clean her. She didn't check the resident's vitals. She told us to do a.m. care. The nurse left the room and did medication for the other residents. The resident had defecated. We cleaned her up. When asked if she told anyone else, she said, No, we were exhausted. When asked if she knew the code status of (Resident#1), she stated, I did not know her code status. You would have to go to the nursing station to find the code status. I heard the Code Blue announced over the intercom just after 6:00 a.m. and I was already at the end of the hallway. The nurses responded. It didn't hit us until later. I said oh my god. I had a breakdown. I had a big talk with the DON about it. A telephone interview was conducted with Resident #1's physician on [DATE] at 11:10 a.m. The physician was also the facility's Medical Director, and stated he received a call from the facility about Resident #1 on [DATE] at 7:00 a.m. He was told that the resident was found unresponsive. He stated, The patient does not have a DNR and the nurse did not call 911. She was a full code. The nurse called me one to two hours later. It was at 7:00 a.m. in the morning the nurse called and informed me the patient expired. The Medical Director said he learned the nurse did not initiate CPR immediately after finding Resident #1 unresponsive. During a telephone interview, on [DATE] at 11:45 a.m., Employee C, CNA, stated she had seen Resident #1 at 5:00 a.m. and the resident looked deceased . I told her (Employee B, CNA) Resident #1 looked like she died . (Employee B) got the nurse (Employee A), and the nurse came in and did a sternal rub, then told us to perform postmortem care. When asked if she knew the code status of Resident#1, she replied, I was exhausted and wasn't thinking about it. Later on, an hour later, I heard them call the code over the intercom. They did CPR later on. During an interview on [DATE] at 1:05 p.m., the Administrator stated, (Employee A) was terminated. She failed to provide CPR for (Resident #1), and I just reported her license to the Board of Nursing. A five-day follow-up report to the State Agency was completed by the Social Services Director (SSD) on [DATE]. The facility conducted its own investigation and substantiated a finding of neglect. It was determined that Resident #1 was a full code, and the facility nurse (Employee A) failed to initiate CPR when the resident was found unresponsive at 5:00 a.m. on [DATE]. Employee A, LPN, was suspended on [DATE] and was terminated on [DATE]. Her license was reported to the Board of Nursing on [DATE]. Throughout the survey, the facility provided their immediate actions to remove IJ, and these immediate actions were verified as having been completed by the survey team as follows: On [DATE] at approximately 6:00 a.m., the DON immediately called a Code Blue for Resident #1, went to the resident's room, and observed nurses performing CPR. On [DATE] at approximately 6:05 a.m. to 6:10 a.m., Emergency Medical Services (EMS) was called by staff via 911. EMS, the county fire department, and the county sheriff's office responded at approximately 6:15 a.m. to 6:20 a.m. Resident #1 was pronounced deceased at the facility by a county fire department officer. On [DATE] at approximately 7:15 a.m. to 7:30 a.m., the Social Services Director called Resident #1's husband to notify him of her death. On [DATE] at approximately 7:30 a.m., an investigation and interviews with staff were initiated by the DON. On [DATE] at 11:45 a.m., Employee A, LPN, was suspended by the Administrator and DON pending investigation. On [DATE], an immediate Federal Report for neglect of Resident #1 was submitted to the State Agency by the Social Services Director. Resident #1's physician was notified of the resident's death by Employee A, LPN, according to the nurses' notes, but the time was not documented. The resident's physician was the facility's Medical Director. The DON notified the medical director of the resident's death, the circumstances related to the deceased resident, and that an investigation was in process at 9:30 a.m. on [DATE]. On [DATE] at 9:00 a.m., Quality Assurance Performance Improvement (QAPI) team members met to discuss the event and formulate a plan of correction. On [DATE] at 9:15 a.m., a Performance Improvement Plan (PIP) was formulated by the DON. On [DATE] at 9:30 a.m., the DON called the Medical Director for an ad hoc QAPI meeting and the PIP and plan of correction were reviewed over the phone at 9:30 a.m. The Medical Director approved the PIP and plan of correction. In-service training on abuse, neglect, misappropriation, initiation of CPR and Code Blue was initiated by the Staff Developer, Registered Nurse (RN), on [DATE] and was completed on [DATE], revealing that 35 nurses, 55 CNAs, 10 PCAs (Patient Care Assistants) and eight therapists participated and were in-serviced by the Staff Developer during that time. The training included information on the location of the residents' yellow/goldenrod DNR forms in the medical records, the fact that the nurse must validate the resident's code status in the medical record before initiating CPR for residents who are a full code, the code procedure and how to run a code. On [DATE], an audit of nurses' CPR cards was completed by the Staff Developer and all nurses' cards were active. On [DATE], an audit was completed by the Wound Care/Restorative Nurse and the Long-Term Care Assistant Director of Nursing for all residents regarding code status orders and presence of a yellow/goldenrod Do Not Resuscitate (DNR) order in the medical record. All residents had code status in place. Audits will be completed by the DON/designee on the presence of code status orders and presence of yellow/goldenrod Do Not Resuscitate orders in the medical record four days a week for six weeks, then weekly for four weeks and quarterly for two quarters. Results of the audits will be reported to the QAPI committee quarterly for two quarters with recommendations implemented as indicated. Code status will be reviewed at the morning clinical meeting to ensure that if there are any changes, the team will be made aware by the DON/designee. Advanced directive choices will also be reviewed for all new admissions during the morning meeting. On [DATE] at 4:45 p.m., the Medical Director signed the ad hoc QAPI meeting signature sheet when he came to the facility. On [DATE], Code Blue drills were conducted on all three shifts by the Staff Developer. Participants were competent with CPR and the Code Blue protocol. The DON/designee will conduct a weekly Code Blue drill every shift for four weeks and monthly thereafter.

Based on observations, resident and staff interviews, and record reviews, the facility failed to provide appropriate treatment and services to maintain activities of daily living for one (Resident #38) of two residents reviewed for activities of daily living, from a total sample of 38 residents. The findings include: A review of clinical records found Resident #38 was admitted to the facility on [DATE] with a primary medical [DIAGNOSES REDACTED]. On 02/18/20 at 12:29 PM an interview was conducted with the resident. He explained that he would like to use his walker to ambulate independently around the facility and that he was recently discharged from therapy services without meeting that goal. The resident explained that he was placed on a restorative nursing program and that he was to be assisted by staff to walk to the dining room with his walker. He further explained that the restorative staff fail to arrive to his room on time which results in him having to use his wheelchair to propel to the dining room. On 02/20/20 at 10:31 AM an interview was conducted with the therapy director. She explained that the resident was discharged from physical therapy services in (MONTH) 2020 at that a functional maintenance plan was recommended at that time. The plan included the resident being assisted to walk to the dining room and back with his walker. This was to occur for each meal. On 02/20/20 at 11:12 AM an interview was conducted with the resident's assigned nurse aide regarding the functional maintenance plan. The nurse aide explained that the resident eats his meals in the dining room and that he uses his wheelchair to get to the dining room and back. She stated the resident uses his walker sometimes when he is on a restorative program or with physical therapy. She was unsure of whether the resident was receiving restorative nursing services at that time. On 02/20/20 at 11:18 AM an interview was conducted with the restorative nurse. She explained that the resident was recently referred to therapy with the hopes that the resident would be released with independent ambulation. She explained the resident was not able to reach that goal and that he was referred back to the nursing department for a functional maintenance plan. She explained that the assigned nurse aide would be responsible for carrying out the intervention of assisting the resident to walk to the dining room. On 02/20/20 at 11:23 AM Resident #38 was observed in the dining room sitting in his wheelchair. He stated he was not assisted to walk to the dining room and had propelled himself there in his wheelchair. On 02/20/20 at 11:27 AM a follow up interview was conducted with the resident's assigned nurse aide. She was asked to explain how she would obtain basic care and ADL information for each resident. She stated We use the kardex. There is one on paper and there is one in the kiosk. The nurse aide accessed the kardex for Resident #38 and pointed to an intervention which read Ambulate resident with extensive assist and FWW (front-wheeled walker) from and to room for every meal. The CNA acknowledged that she was previously unaware of this intervention and that she had not been routinely assisting the resident to the dining room using his walker. A copy of the functional maintenance plan was provided on 02/20/20. It was signed by the physical therapy assistant on 1/20/20 and the restorative nurse on 1/21/20. The functional maintenance plan goal read, Overall goal of restorative program: Patient to improve gait mobility from room to dine. The activities to be completed read Pt requires CGA (contact guard assist)/SBA (stand-by assist) while ambulating to dining room with FWW (front-wheeled walker) for approximately 150' or as tolerated.

Based on observation, record review and interview, the facility failed to provide activities of daily living (ADL) care necessary to maintain grooming and personal hygiene for one of two residents, Resident #82, reviewed for ADL care in a sample of 38 residents. The findings include: On 2/17/2020 at 1:42 PM, Resident # 82 was observed in his room. All of the fingernails on both of his hands were at least 1 centimeter (CM) in length with a dark brown substance underneath each nail. Record review for Resident #82 found he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed Resident #82 had a brief interview mental status (BIMS) score of 6 out of 15. Resident #82 was assessed as needing extensive assist, one person physical assist for personal hygiene and the facility did not document any behaviors or rejection of care on the assessment. Record review of Resident # 82's care plans revealed he was care planned for needing extensive assistance with ADLs/personal care. On 2/19/2020 at 9:10 AM, the fingernails on both of his hands were observed. The fingernails on each hand were observed to be at least one centimeter in length each with a brown caked substance underneath each nail. Resident #82 was interviewed at the time of the observation and asked if he would like his nails cut. He stated, Yes. He stated his certified nursing assistant (CNA) (Employee E) usually cuts his nails, but has been out sick. He was asked if he would allow someone else to cut his nails and he stated, Yes. During an interview on 2/19/2020 at 09:15 AM, with Resident # 82's nurse (Employee B ), she was asked for the schedule for nail care. She stated nail care is done every day or as needed. She stated if a resident is diabetic the CNAs would not cut their nails and that Resident #82 was not diabetic. She was asked to observed Resident #82's nails. She observed them and then asked Resident #82 if it would it be ok if they cut and cleaned his nails. The resident agreed. In a second interview on 2/19/2020 at 10:33 AM, with Employee B she stated Employee [NAME] is Resident #82's regular Hospice CNA and he has been out for three 3 weeks.

Based on observation and staff interview, the facility failed to ensure medications that require refrigeration were stored at the proper temperatures for 1 of 3 medication rooms and failed to ensure safety and security of medications stored in the medication room of 1 of 3 medication rooms (north wing). The findings include: 1. During an interview with the Licensed Practical Nurse (Employee C) on the north wing on 2/19/20 at 1:45pm, a staff person was observed removing a key from the desk drawer and proceeded to open the medication room door. The employee removed a packaged item, closed the door and put the key back in the drawer. Employee C was asked if the key in the desk drawer opened the medication room, and she said it shouldn't. She was asked to try the key in the lock. The key was found to open the medication room door. Employee C stated she was not aware that key was there. An interview was conducted with the Assistant Director of Nursing (ADON) on 2/19/20 at 2:05pm. She was asked if the nurses had a key to the medication room on their key rings, she said, Yes. She was asked why there was a key to the medication room unsecured in the drawer in the nurse's station. She was unaware of the medication key being left at the nursing station; however, would immediately take care of the issue and remove the key from the drawer. 2. An observation of the North wing medication room was conducted with the Assistant Director of Nursing on 2/20/20 at 10:05 am. Observation of the medication refrigerator found the temperature was 28 degrees and was verified by ADON. There were 2 insulin pens and a vial of unopened Humalog insulin on the shelf. Observation of the insulin pens and vial of Humalog found they were cold but not frozen. The standard for storage of these medications is between 36 and 46 degrees F. The temperature log indicated on the night shift the temperature was 36 degrees. The ADON adjusted the thermostat to increase temperature and check in 30 minutes to ensure proper temper.

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for 4 residents in a sample of 38 residents. (Residents #108, #19, #41 and #52) The findings include: On 2/17/2020 at 11:20 AM, two unlabeled urinals were observed in the bathroom between rooms [ROOM NUMBERS]. One urinal was located on the towel rack to the right of the toilet and the second on the grab bar behind the toilet. The urinals were unlabeled. On 2/18/2020 at 10:11 AM both urinals were still in bathroom. During an interview with Resident #41 on 2/18/2020 at 10:12 AM, he stated he did not use the urinals but he did use the bathroom. During an interview on 2/18/2020 at 10:13 AM with Resident #52, he stated he uses the urinals and the bathroom. He had one urinal on the side of his bed that was not labeled. He stated the urinals in the bathroom were his. During an interview with Resident #19 on 2/18/2020 at 10:14 AM he stated he used the bathroom. During an observation on 2/20/2020 at 11:53 AM, three unlabeled urinals were observed in the bathroom between rooms [ROOM NUMBERS]. One was hooked to the towel bar to the right of the toilet. A second was on the grab bar behind the toilet and a third on top of the toilet tank. An observation was then made in room [ROOM NUMBER] next to bed [NAME] There were two trash cans to the right of the bed. Each trash can had two urinals attached. Two of the four urinals were unlabeled. A fifth urinal was observed on the windowsill in room [ROOM NUMBER] near bed B. The urinal was unlabeled. In an interview with Resident #108 in room [ROOM NUMBER] bed A on 2/20/2020 at 11:54 AM, he stated the urinals in the bathroom were not his. He had his own urinals and that he did not think they needed to be labeled. He stated the staff empty them for him. He stated he uses the bathroom. During an interview on 2/20/2020 at 11:58 AM, with the nurse for rooms [ROOM NUMBERS] (Employee B) she was asked to look in the bathroom. She stated the urinals should be bagged and labeled and that she would get the certified nursing assistant from across the hall to do it. Photographic evidence obtained.

Based on observation, interview and record review; the facility failed to ensure that it had accurately documented medication adminstration for pain intervention for 1 resident (Resident #1) of 2 residents sampled for pain medicaiton interventions. The findings include: An observation of the medication card for Resident #1 was made with Employee A, Licensed Practical Nurse (LPN), on 04/29/2019 at 1:38 PM. Employee A confirmed that Resident #1's medication controlled utilization record with the label dated 04/05/2019 was the current pain medication documented on the cart in use. This label was for [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg (milligrams), take 1 tablet orally at bedtime for pain (Non-Acute Pain). Documentation began on 04/23/19 at 8:36 AM, with one dose documented as given and the amount remaining was recorded as 29 tablets. Subsequent documentation was recorded as follows: 04/24/2019 at 8:19 AM - one dose given, 28 remaining. Employee A, LPN confirmed that this was not at bedtime. 04/26/2019 at 21:00 ONE dose given, 27 remaining. 04/27/2019 at 8:28 AM - one dose given, 26 remaining. Employee A, LPN confirmed that this was not at bedtime. 04/27/2019 at 21:00 ONE dose given, 25 remaining. 04/28/2019 at 8:24 AM - one dose given, 24 remaining. Employee A, LPN confirmed that this was not at bedtime. 04/28/2019 at 21:00 ONE dose given, 23 remaining. (Photographic evidence obtained) An interview was conducted with Employee B, Registered Nurse (RN), on 04/29/2019 at 3:08 PM. The documentation concern related to Resident #1's [MEDICATION NAME]-[MEDICATION NAME] was explained to her, and she confirmed that this was an inaccurately documented medical record entry. The medication should be documented on the appropriate card using the example for an as needed (PRN) medication, and the scheduled medication for Resident #1. Employee B confirmed the documentation should be on the correct medication log. An interview was conducted with the Director of Nursing on 04/29/2019 at 3:25 PM, and she confirmed that if the nursing staff did not document on the correct log for the medication provided to Resident #1, the log would be inaccurate. A review of the delivery receipt, dated 04/05/2019 at 22:50 (10:50 PM), for Resident #1, revealed that a package of 30 [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg was delivered for room [ROOM NUMBER]-A, and a package of 24 [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg was also delivered on 04/05/2019. (Photographic evidence obtained) A review of the dated controlled utilization record for Resident #1 with the label dated 04/05/2019 was conducted. This label documented the medication [MEDICATION NAME]-[MEDICATION NAME] 7.5-325, take 1 tablet orally every 4 hours as needed for pain (non-acute pain). Documentation began on 04/07/19 at 9:00 PM, next on 04/08/2019 at 8:56 AM, and continued chronologically through 04/22/2019 at 9:00 PM with (0) tablets documented under remaining. Twenty-four tablets were used of 24 tablets documented received. The date of disposition was 04/23/2019. (Photographic evidence obtained) A review of the dated controlled utilization record for Resident #1 with the label dated 04/05/2019 was conducted. This label documented the medication [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg, take 1 tablet orally at bedtime for pain (Non-Acute Pain). Documentation began on 04/23/19 at 8:36 AM, 1 dose documented as given and amount remaining was 29 tablets. Subsequent documentation was recorded as follows: 04/24/2019 at 8:19 AM - 1 dose given, 28 remaining. 04/26/2019 at 21:00 ONE dose given, 27 remaining. 04/27/2019 at 8:28 AM - 1 dose given, 26 remaining. 04/27/2019 at 21:00 ONE dose given, 25 remaining. 04/28/2019 at 8:24 AM - 1 dose given, 24 remaining. 04/28/2019 at 21:00 ONE dose given, 23 remaining. (Photographic evidence obtained)

Based on observation and interview, the facility failed to ensure safe food storage and food handling practices to prevent the outbreak of foodborne illness affecting the 115 residents that reside in the facility. The findings include: 1. During an observation in the facility kitchen on 10/15/2018 at 7:20 AM, the cook (Employee L) was observed standing behind the steam table. He was wearing gloves. There was a stack of pancakes to his left. He was using his gloved hand to pick up pancakes and place them on the plates to be served to residents. He, at one point, turned around and lifted a lid off of the plates that were on the plate warmer. He removed the plate and put the lid back on. He went back to using his hands to put pancakes on the plates. He removed a pan from the steam table and placed it behind him. He was observed touching several items while he made room for the pan. He then turned around and opened a warmer oven. He removed a pan of pancakes and placed them on the tray line. He closed the doors and then went back to using the same gloved hands to place the pancakes on plates. He at no time changed his gloves or wash his hands. 2. During the second visit to the facility kitchen on 10/16/2018 at 11:26 AM, the cook (Employee Q) and Dietary Supervisor (Employee N) were observed checking the calibration of the digital thermometer. The cook (Employee Q) and the dietary supervisor (Employee N) were asked to take the temperature of the cottage cheese from one of the fruit plates removed from the same reach-in cooler. The temperature was 55 degrees. The outside temperature of the reach-in refrigerator was 54 degrees. During this same observation in the kitchen on 10/16/2018 at 11:45 AM, a cart was observed with small plastic cups, with plastic lids dated 10/15/2018. The cups were filled with several colored beverages. The cups were on a tray that did not have any ice. Employee M was interviewed at the time, and she stated the off-white item was thickened milk. She was asked to take the temperature with the facility digital thermometer. She did and it was 54 degrees. The Kitchen Manager was in the kitchen and was made aware. He instructed the staff to throw the cups of milk out and pour them as needed. 3. During the second visit to the kitchen on 10/16/2018 at 11:45 AM, dietary staff were observed getting ready to start serving food off of the steam table. Employee O was observed on the serving line scratching her forearm. At 11: 47 AM, Employee O placed her hand into her right pocket while waiting for the serving line to start. The service began and from 11:50 AM until 12:05 AM Employee O was observed holding the inside of the plate covers against her clothing before placing the lid over the resident's plate of food. This occurred 18 times. Employee O was also observed touching plates, packaged silverware, and napkins on the trays. At 12:00 PM Employee O was observed coughing into her uniform. At 12:05 PM Employee O was observed wiping both hands on her uniform for 15 seconds. Employee O continued to work on the serving line without any hand hygiene. A second dietary staff member (Employee M) was also not wearing gloves. She was observed putting items on the resident food trays. She was observed moving carts and going back to handling the items placed on the resident food trays. Employee M did not wear gloves or perform any hand hygiene. On 10/18/2018 at 12:16 PM, the cook (Employee L) was observed working behind the steam table. He was wearing gloves. He was observed arranging his eyeglasses, and picking up a dish towel and wiping his hands. He then picked up grilled cheese with his gloved hands and placed them on a plate for a resident. After this observation Employee O was heard telling Employee L to wash his hands. He did and returned to the steam table. He continued to touch items including the white towel he was observed wiping the counters and his hands with previously. He then pick up two more grilled cheese sandwiches with the same glove hands and placed them on plates to be served to residents. This observation was confirmed by the Kitchen Manager, as he was standing by the tray line and was observing.

Based on observation, record review and staff interview, the facility failed to implement physician's orders and a care plan for impaired skin to bilateral heels for one (Resident # 324) of 39 sampled residents. The findings include: On 10/17/2018 at 8:30 AM, a staff member approached Employee E, Licensed Practical Nurse (LPN), and told her that Resident #324 was really in pain and needed something for it. Employee E entered the resident's room. Resident #324 stated that her feet really hurt. She described a pain level of a 9 out of a possible 10 points with 10 being the worst possible pain. She stated she could not sleep all night due to the pain. Employee E removed the blanket from the resident's lower body and exposed her feet and legs. The resident's feet were not floated off the bed nor did she have any booties in place. The nurse removed the resident's yellow non-skid socks and assessed both heels. Each heel had a discoloration. The left heel had a large black area. The right heel had a small dark area. The resident stated her boots were not on all night, and her heels should not be touching the bed. A record review revealed Resident #324 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] revealed a wound to the left heel, a closed purple blister. A 10/8/2018 Initial Wound Evaluation & Management Summary by VOHRA Wound Physicians revealed Resident #324 had an unstageable deep tissue injury of the left posterior heel of at least 5 days duration and a stage 1 pressure wound of the right posterior heel. Recommendations were to float heels in bed to off-load the wound and EZ boot to be worn in bed and chair to off-load the wound. On 10/8/2018, the Restorative Nurse developed a plan of care for the resident's altered skin integrity. There was a left posterior heel unstageable deep tissue injury, and there was another care plan for stage 1 to right posterior heel. The intervention was for EZ boot to be worn in bed and when out of bed. The (MONTH) (YEAR) Certified Nursing Assistant (CNA) Task List revealed EZ boot each shift and heels floated each shift. On 10/17/18 at 2:25 PM, Resident # 324 was observed again lying on her right side. She had a pillow between her legs but her right heel was touching the bed and her left foot was lying on her right foot. No EZ boot was seen. Employee A, CNA, was interviewed on 10/17/2018 at 2:25 PM in the resident's room. She stated that she did have her booties on while she was sitting up in the recliner. She confirmed she did not have them on now. She stated the resident was using a bedpan and then she turned her on her side but did not put the EZ boots on her. She did not float her heels either. She confirmed that the boots should be put on at all times. Employee G, LPN, was interviewed on 10/18/18 at 8:25 AM. She confirmed the resident had skin issues on her heels and her heels should be floated to prevent further breakdown. She also should have boots on them as well.

Based on record review and staff interview, the facility failed to revise a care plan after a significant weight loss and implement weekly weights for one (Resident #60) of 39 sampled residents. The findings include: A record review for Resident # 60 revealed she had a significant weight loss during (MONTH) (YEAR). On 8/2/2018 the resident's weight was recorded at 228 pounds (lbs.) and on 8/27/2018, she was 205 lbs. This was a 10% weight loss. There were seven other weights recorded in (MONTH) (YEAR) ranging from 227 lbs. to 277 lbs. for this resident (which were crossed out and identified as incorrect documentation). On 8/17/2018, a Registered Dietician's (RD) note revealed weight tracking was reviewed related to a weight error. Weight requested today: 205 lbs. Resident has a history of high BMI (body mass index), dependent on staff for meals and activities of daily living, remains in bed most days. Resident continues to be fed by staff, no added salt diet, pureed diet, 76-100% meal intake. Unplanned weight changes. Another RD note was recorded on 8/31/2018. Resident identified with unplanned weight loss. Diet/interventions remain adequate and appropriate for need. Suggested weight maintenance goals 195-205 lbs. Recommend large portions at breakfast. Another RD note was recorded on 9/7/2018. Weight on 9/6/2018 was 203 lbs. Resident identified previously with weight loss. Remains in bed most days, has limited mobility and decreased energy expenditures. Diet/interventions remain adequate and appropriate for need. Remains within prior suggested weight management range. No changes warranted at this time. The resident's care plan indicated that she was at risk for weight changes related to impaired cognition, dementia, and depression. This care plan was last revised on 2/28/2018. One of the goals was that she will experience no significant weight fluctuations through next review. Target date of 8/28/2018. Interventions included weight per facility protocol and notify physician as indicated. There was an Interdisciplinary Care Plan Team (IDT) Conference for Resident # 60 that was held on 8/29/2018 with the Assistant Director of Nursing (ADON) in attendance. In the summary, it revealed a weight discrepancy, will monitor, good appetite, weekly weights ordered (8/27/2018). A record review revealed a physician's orders [REDACTED]. There were only two weights recorded in (MONTH) (YEAR), 203 lbs. on 9/6 and 207 lbs. on 9/24/2018. So far in (MONTH) (YEAR) (As of 10/18/18, there was only one weight that was documented on 10/3/2018 (209 lbs.) The Director of Dietary Services was interviewed on 10/18/2018 at 9:04 AM. He stated he was new to this region and facility. He stated he was responsible for the care plans at this facility, but he was used to getting more input/communication from the RD. He confirmed he did not update the resident's care plan to reflect that she had a significant weight loss, and did not add any new interventions such as weekly weights and large portions for breakfast. Employee H, one of the care plan coordinators, on 10/18/18 at 12:06 PM, stated she did not see any documentation to discontinue the weekly weights and confirmed they did not have documentation of having done them. She also stated she updated the care plan now to include individualized interventions of large portions for breakfast and a protein supplement as ordered. The RD was interviewed on 10/18/2018 at 12:17 PM. She stated she did not do the nutrition care plans. The Dietary Director was to develop them from her notes. She stated she was unsure why the resident lost weight. At first they did not know if the weights were accurate. The restorative CNAs were doing them and then they went back to the floor CNAs doing them. There may have been some discrepancy about weighing her with a mechanical lift. She was not aware that weekly weights were not being performed. An interview was conducted with the assistant director of nursing (ADON) on 10/18/2018 at 12:25 PM. She confirmed she wrote the IDT note on 8/29/2018. She did write for weekly weights but she stated she did not know if physician orders [REDACTED]. She could not say why the weekly weights were not done. She also could not find evidence that the physician was made aware of the significant weight loss. There were visit notes from the physician on 9/12/2018, 9/9/2018 and 8/11/2018 and he did not address any weight loss. A Narrative Nurse Note dated 9/10/2018 written by the ADON revealed the resident had experienced an 11% weight loss within the last 30 days. The daughter was notified along with the doctor. THE ADON stated that she probably called the physician's office and spoke with the nurse. She confirmed she did not document what the nurse's name was or follow up with the doctor to see if he wanted to give any new orders.

Based on observations, record reviews, interviews and policies and procedures reviewed, the facility failed to provide care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one resident (#63) on isolation precautions, of two residents observed during wound dressing changes. The LPN failed to follow hand hygiene procedures during a pressure wound dressing change. The findings include: On 10/15/18 at 11:36 AM, an interview was conducted with the spouse of Resident #63. She stated Resident #63 had received multiple wounds on his bottom, and he had a heel wound that began in the hospital while he was in the Intensive Care Unit (ICU). On 10/04/18, Resident #63 was placed on contact isolation for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in the (R) right heel wound. On 10/16/18 at 3:10 PM, Resident #63's room was observed with Personal Protective Equipment (PPE) hanging in a rack on the door. On 10/18/18 at 10:49 AM, an observation was made of a wound dressing change for the resident. Employee DD, Certified Nursing Assistant (CNA), and Employee V, Licensed Practical Nurse (LPN), were observed conducting multiple wound dressing changes for the resident. The right heel wound dressing change began at 10:55 AM. Employee V, LPN, removed the soiled dressing and exposed the necrotic (dead tissue) right heel. The wound was observed with scant bloody drainage. Employee V, LPN, returned to a small table and prepared the dressing for the wound. He did not remove his gloves or wash his hands. As Employee V prepared the dressing, the resident's right heel wound came to rest on the pillow, leaving a red blood stain. Employee DD, CNA, did not provide any leg support or prevent the resident's heel from contacting the pillow after the wound was cleansed. When Employee V, LPN, returned to dress the heel wound, he raised the resident's leg and applied the wound dressing without cleansing the wound again. He was still wearing the same gloves. Employee V's gloved hands were observed contacting the heel wound and the red stained pillow case. Once the wound was dressed, Employee V removed Resident #63's left sock, he removed the pillows that were supporting the resident's legs, and then replaced the left sock with a new one. Employee V did not change gloves at this time and continued to wear the gloves that he used to dress the necrotic wound, touching environmental surfaces and pushing his glasses up repeatedly throughout the cleaning up of the patient environment. The resident was on contact isolation with a draining wound and blood present on the pillow case, linens, and the resident's leg. The nurse used the same gloved hands for which he provided wound care, picked up the residents' wife's hand bag and another bag, and moved them to the side of the bed. Once Employee V, LPN, finished preparing for the next wound dressing change, he stripped off his gloves and washed his hands at the sink. Employee V and Employee DD repositioned Resident #63 for a sacral wound dressing change. During the sacral wound dressing change, Employee V, LPN, reached under his yellow gown to remove a pair of scissors and a marker to mark the date on the wound dressing. Employee V was observed reaching back into the yellow gown as he put the scissors and the marker back into his shirt pocket. No sanitizing of the scissors or the marker occurred at any time during the wound dressing change. An interview was conducted with Employee V on 10/18/18 at 11:19 AM. He confirmed the wound dressing change observations noted above. He confirmed that the wound should not have contacted the pillow case but did, leaving blood on the pillow case. He confirmed he cleaned the environment, removed the pillow cases, and touched the spouse's purse and handbag with the contaminated gloves. He also confirmed that he pulled and replaced the scissors and the marker from/to his shirt pocket underneath the PPE, and should not have done this. A review of the laboratory report for Resident #63 documented a collection date of 10/02/18 at 4:53 AM, and a reported date of 10/05/18 at 8:56 AM. The site was the right heel with 3+ gram positive Cocci and 1 + white blood cells seen. This isolate is [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). A review of Resident #63's care plans revealed that under the Alteration in Skin Integrity care plan was documented, Contact isolation -[MEDICAL CONDITION] in wound. A review of the facility's policy for Isolation Precautions revealed that the policy was to be used in addition to Standard Precautions. Under section 1. Transmission-based isolation precautions have been established in order to ensure that appropriate isolation techniques are implemented in this Center when necessary. Documented under 4. .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. 4. b. 3, After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident's room. C. Gown 3, After gown removal, ensure that clothing does not touch potentially contaminated environmental surfaces. e. Resident-Care Equipment 1, When possible, dedicate the use of noncritical patient-care equipment.

Based on observation, interview and record review, the facility failed to provide oxygen for a resident with [MEDICAL CONDITIONS] as ordered by the physician for one (Resident #39) of one residents reviewed for respiratory care in a sample of 39 residents. The findings include: On 10/15/2018 at 10:47 AM, Resident #39 was observed lying in bed, flat on her back. She was using oxygen (O2) from an oxygen concentrator. She did not show any signs of having difficulty breathing. The O2 level on the concentrator was set at 1 liter. On 10/16/18 at 9:17 AM, Resident #39 was observed again in her room. She was using oxygen out of a concentrator. The oxygen was set at 1-1.5 liters. (Photographic evidence obtained) Resident #39's certified nursing assistant (CNA) (Employee T) was called into the room and asked to read the level of the O2. She confirmed the setting was at one liter. She further stated she did not touch the setting on the machine. Resident #39 was asked who adjusted the machine and she stated a man came in. She was asked if she changed the setting and she stated, No. During an interview with Resident # 39's nurse, (Employee C) on 10/16/2018 at 9:20 AM, she was asked to check the orders for the oxygen. She looked the computer and stated it should be at 2 liters per minute. She was informed it was not at 2 liters. She then asked if the CNA (Employee T) had fixed it. She was informed Employee T did not. The nurse (Employee C) went into Resident #39's room to look at the oxygen concentrator. She was overheard asking the resident if she messed with it and the resident stated no. Resident #39's nurse came out of the room and confirmed the oxygen concentrator was set at 1 liter. A record review for Resident # 39 found she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #39 was admitted to Hospice on 9/26/2018. A review of the physician's orders [REDACTED]. Prior to that, Resident #39 had an order for [REDACTED]. Resident #39 was visited again in her room on 10/17/2018 at 8:40 AM. She was sitting on the side of her bed. Resident #39 was observed and she was no longer using oxygen. The oxygen concentrator was no longer in the resident's room. Resident #39 was asked what happened to her oxygen and she stated, They took it away. She was asked why and she did not know. During an interview with Resident #39's CNA (Employee T) in Resident #39's room on 10/17/2018 at 8:40 AM, she was asked if she was aware of what happened to the oxygen. She stated she did not know. During an interview with Resident #39's nurse on 10/17/2018 at 9:50 AM, she stated she removed the concentrator yesterday afternoon because Resident #39 was only on as needed oxygen. During an interview with Resident #39's Hospice nurse (Employee R) on 10/17/2018 at 9:47 AM, she stated Resident #39's O2 order should have been ordered as needed. She stated, she had been checking Resident #39's oxygen saturations, and they had been good. She stated, They came to me yesterday and asked about the oxygen so they wrote a clarification. She stated she did not recall when the first order to change to as needed occurred. During further interview on 10/17/2018 at 10:33 AM, with Resident #32's nurse (Employee C), she stated she just took Resident #39's O2 saturation and it was at 94%. She stated the last shift had measured it at 97%, and it was taken at 6:00 AM. The orders read to check every shift, and if below 90 to apply the O2. The nurse further stated she was not the one that changed the order to as needed. She confirmed the Resident did not need to be on continuous oxygen.