Every finding on record at Eden Springs Nursing and Rehab Center

Based on observation and interview, the facility failed to provide adequate supplies of clean laundry in all resident care areas throughout the entire facility. The findings include: On 2/28/24 at approximately 1:20 PM, Resident #3 was observed in the hallway in a reclined geriatric chair. He had a pillow under his legs. The pillow did not have a pillow case on it. On 2/28/24 at approximately 1:20 PM, an interview was conducted with Resident #6. Her bed was stripped with no sheets on it and the call light was on. Resident #6 explained that she has been waiting for staff to change her bed so she can lay down. She complained that there has been a shortage of sheets and other linens. The resident said she has to lay on the bed without sheets sometimes. She stated that staff often run out of sheets and it is not until evening time when she gets her bed made. She said she likes a sheet under her blanket and often staff are unable to put a flat sheet under the blanket due to the shortage of linen supplies. She also explained that sometimes staff runs out of under pads to place on the bed. The resident's husband is present during the interview. He agreed that there has been a problem with the linen supplies. On 2/28/2024 at approximately 10:50 AM, an interview was conducted with Nurse A, a Licensed Practical Nurse (LPN). She said they have been running out of linens recently. She explained that staff found it difficult to complete showers and other activities of daily living due to inadequate linen supplies. Nurse A indicated this has been a problem in the past and has been a problem again over the last week or so. Nurse A presented each of the facility's linen storage areas. Storage cabinet #1 had a stack of approximately 25 washcloths and no fitted bedsheets, no flat bedsheets, no pillow cases, no bed pads, no towels, and no bed spreads. Storage cabinets #2 and #3 had no linen of any kind. The main linen storage area contained approximately 20 pillow cases, 10 towels, 10 flat and fitted sheets and 10 gowns in a box that was sitting on the floor. In the laundry room, there was a table on which staff had folded a few items. There were approximately 2 blankets, 2 fitted sheets, 5 washcloths, 6 flat sheets, and 15 towels on the table. There was also a cart with a few bed pads, sheets, and towels on it. Nurse A was asked if this was all of the linen storage available for the facility with a census of more than 100 residents. Nurse A explained that there might be more in central supply. She explained that someone would need to contact the Director of Housekeeping and Laundry to gain access to those areas. (Photographic evidence of each linen storage area was obtained) On 2/28/24 at approximately 11:37 AM, an interview was conducted with the Director of Housekeeping and Laundry. The surveyor showed him the pictures of the linen storage areas that were taken at approximately 11:00 AM. He was asked if there are specific stock levels for the different types of linen to keep adequate supplies available within the facility. He explained that they were working on restocking the linen storage now. The Director of Housekeeping and Laundry explained that they do not keep a specific stock number of linens on hand inside of the facility. He explained that supervisors hand out bags of linen to direct care. He also said that supervisors have keys to get any additional linens out of central supply. On 2/28/24 at approximately 12:15 PM, an interview was conducted with the Maintenance Supervisor. He was asked to accompany the surveyor to central supply to look at the linen storage out there. All of the linen storage was in central supply in unopened boxes. There was observed 1 case of pillows in a box, 2 cases of flat sheets in boxes, 2 cases of under pads in boxes, 1 case of blankets in a box, and 1 case of wash cloths in a box. He was asked if there are specific stock levels for the different types of linen to keep adequate supplies available within the facility. The Maintenance Supervisor said he was unaware of specific stock levels for linen and this would be up to the Housekeeping and Laundry Supervisor. On 2/28/24 at approximately 12:55 PM, an interview was conducted with the Director of Nursing (DON). She was shown the pictures of the empty linen storage closets and the laundry room linen storage. The DON explained that a bag system was in place. Linen supplies were bagged before shifts based on the number of baths and showers to be completed each shift along with extra bags for extra supply if needed. The DON explained that the maintenance and housekeeping director has access to central supply. The maintenance director lives 5 minutes any and if storage runs short any time day or night he will come refill if needed.

Based on observations and interviews with staff and residents, the facility failed to provide a safe clean homelike environment in 17 of 40 sampled resident rooms or shower rooms in the facility. (Resident rooms 142, 141,140, 139, 138, 137, 136, 135, 134, 128, 127,116, 111, 108, as well as shower rooms [ROOM NUMBER]) The findings include: On 1/18/24 at approximately 10:15 AM, a facility tour was initiated. The following issues were noted: A live roach was observed crawling on the floor in room [ROOM NUMBER]A. The room had an area where a cabinet was removed. The floor was unfinished in this area. Two wheelchair foot rests were on the bare floor. The floor under the cabinet had a buildup of soil, a coin, a piece of candy, and a piece of food laying on the bare floor next to the wheelchair foot rests. (Photographic evidence obtained) In room [ROOM NUMBER], there was a geriatric chair with a thick build of rust and soil on it. The tires had a hair like substance wrapped around them. The room had an area where a cabinet was removed with an unfinished floor underneath. The area under the unfinished cabinet had a roach, a buildup of soil, an old spoon, and a used medication cup. (Photographic evidence obtained). In room [ROOM NUMBER]A, there was an unfinished cabinet with a soil build up over the bare unfinished floor. room [ROOM NUMBER]B had an exposed window air conditioning unit that was covered with a thick layer of a dusty buildup. The floors next to the air conditioning unit were soiled. (Photographic evidence obtained) room [ROOM NUMBER]B had an unfinished cabinet and dirty floors under the cabinet. (Photographic evidence obtained) room [ROOM NUMBER] had a hole in the wall and cracked peeling paint with rust and dirt build up on the bathroom door jams. (Photographic evidence obtained) room [ROOM NUMBER] had an unfinished cabinet and dirty floors under the cabinet. (Photographic evidence obtained) room [ROOM NUMBER] had water damage near the air conditioning unit. (Photographic evidence obtained) room [ROOM NUMBER] had an unfinished base board under the cabinet with a thick buildup of soil. (Photographic evidence obtained) room [ROOM NUMBER] had paint peeling above the head of the bed. (Photographic evidence obtained) room [ROOM NUMBER] had an unfinished cabinet sitting on a bare soiled floor underneath. There was a missing base board in the room as well. (Photographic evidence obtained) room [ROOM NUMBER] had peeling paint on the wall. (Photographic evidence obtained) On 1/18/24 at approximately 11:45 AM, a tour of the shower rooms was conducted with the Director of Nursing (DON). Shower room [ROOM NUMBER] had excess build up of a thick white substance in the first shower where the floor meets the wall. The shower gurney in the room had white hairs scattered over it. The DON was as ked to explain the process for cleaning the gurney. She held up a bottle of quaternary cleaner and explained that the gurney is supposed to be wiped down after and before each use. Shower room [ROOM NUMBER] had excess black build up on grout and build up of a thick white substance on the tiles and under the hand rails. Shower room [ROOM NUMBER] had a large hole in the tile on the wall. (Photographic evidence obtained). On 1/19/24 at approximately 12:00 PM, an interview was conducted with the maintenance supervisor. He was shown pictures of the shower rooms. He explained that he was not aware of the hole in the shower tile and that the wall in shower room [ROOM NUMBER] had already been patched. He was shown the environmental concerns in the rooms. The Maintenance Supervisor explained that they have been renovating many of the rooms on one side of the building and these areas would be corrected. On 1/19/24 at approximately 1:00 PM, an interview was conducted with the Housekeeping Manager. He was shown pictures of the areas outlined above. He was asked if the areas should look like that. The Housekeeping manager explained that all areas of concern would be corrected.

Based on observations and interviews with staff and residents, the facility failed to maintain an effective pest control program. The findings include: Observations: On 1/18/24 at approximately 10:15 AM, a live roach was observed crawling on the floor in room [ROOM NUMBER]A. (Photographic evidence obtained) On 1/18/24 at approximately 11:20 AM in room [ROOM NUMBER], there was a roach on the floor under an unfinished cabinet. (Photographic evidence obtained) Interviews: Based upon the observations made by surveyors, staff and residents were asked about the effectiveness of the pest control program at the facility. On 1/18/24 at approximately 10:15 AM, Certified Nursing Assistant (CNA) E said she sees roaches crawling around the facility frequently. On 1/18/24 at approximately 10:20 AM, CNA H was asked if she sees pests around the facility. She explained that she mostly sees roaches. She explained that it has been a consistent problem at the facility. On 1/18/24 at approximately 10:30 AM an interview was conducted with Resident #10. She said there are roaches in her room. She worries they will get into her food. On 1/19/24 at approximately 11:00 AM, an interview was conducted with Resident #15. When asked if she ever sees bugs, she responded by explaining that she sees roaches every day. She said, I had one on my hand the other day. They are everywhere. On 1/19/24 at approximately 11:30 AM, Resident #17 explained that she saw live roaches 2 days ago and killed them. On 1/19/24 at approximately 11:40 AM, Resident #18 was asked about pests. She explained that she has seen roaches in her room often. On 1/19/24 at approximately 12:00 PM, Resident #19 mentioned during an interview that she sees roaches in her room all the time. On 1/18/24 at approximately 3:00 PM, an interview was conducted with the Maintenance Supervisor. The surveyor notified him that there had been complaints about roaches. He was asked to provide pest control treatment invoices. He explained that the facility had discontinued using an outside pest control contractor to treat pests about a year ago. When asked to specify the type of pests he is treating and to explain how he is tracking the effectiveness of the treatments he is applying, he explained that he is doing treatments once a week and as needed. He explained that most of what they are treating is small roaches. The facility has a log book that was signed off when treatments are completed. He stated one half of the building gets treated once a week and then the other half the other week. Treatments are also applied as needed.

Based on observation, interview, record review, and policy review, the facility failed to provide assistance with nail care for 4 of 10 resident sampled for Activities of Daily Living (ADL) care. (Resident #10, #12, #14, and #16) The findings include: On 1/18/24 at 10:30 AM, during an interview with Resident #10, it was observed that the residents nails were long. The surveyor asked resident if she would like her nails trimmed. She indicated that she recently had pneumonia, which has made herbeen weak and would like assistance with getting her nails done. On 1/19/24, a review of the care plan for Resident #10 was conducted. The care plan noted that the resident has an ADL self-care performance deficit r/t Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Pain, and Shortness of Breath. The resident had been diagnosed with pneumonia on 1/16/24. The care plan directs staff to provide assistance as needed with ADLs. On 1/19/24 at approximately 11:00 AM, it was noted that Resident #12 had long soiled nails. Certified Nursing Assistant (CNA) E was in the room at the time of the observation. She was asked who is responsible for assisting residents with nail care. CNA E explained that nursing assistants are responsible and that she would get his nails cleaned. On 1/19/24, a review of the care plan for Resident #12 was conducted. The care plan noted that Resident #12 has an ADL self-care performance deficit r/t impaired balance limited mobility, pain, and weakness. His care plan directed care staff to check nail length and trim and clean on bath day and as necessary and to report any changes to the nurse. On 1/19/24, during an interview with Resident #14, his nails were noted to be long. He was asked if he would like assistance trimming his nails. The resident indicated that he would love some assistance with nail care. On 1/19/24, a review of the care plan for Resident #14 was conducted. The care plan noted that Resident #14 has an ADL self-care performance deficit related to weakness and depression and bilateral below the knee amputation. The care plan directed staff to check nail length and trim and clean on bath day and as necessary. On 1/19/24 at approximately 12:30 PM, an observation was made of Resident #16. His nails appeared long and untrimmed. A review of the care plan for Resident #16 was conducted. The care plan noted that Resident #16 has an ADL self-care performance deficit related to Dementia with behavior and physical needs due to amputation of the right leg. His care plan directed staff to check nail length and trim and clean on bath day and as necessary. On 1/19/24 at approximately 1:00 PM, an interview was conducted with the Director of Nursing concerning the issues with nail care. She was asked to provide a copy of the facility's nail care policy. She provided a policy that included a CNA monthly check off sheet that mentioned, ensure residents nails are trimmed and clean report to nurse any diabetic residents who needs nail care.

Based on record review, interviews, and policy review, the facility failed to ensure an accurate disposition of controlled drugs to enable an accurate reconciliation for 2 of 3 residents sampled. (Resident #1 and Resident #2) The findings include: A review of Resident #1's medical record was conducted. Records revealed the controlled medication Pregabantin 25 mg was pulled out from the resident's card at 9:00 PM on 8/26/23 and 9/2/23. A physician order dated 8/16/23 ordered Pregabalin capsule 25 mg one time a day for nerve pain. The Medication Administration Record (MAR) for August and September revealed Pregabalin 25 mg was documented as given at 9:00 AM daily. The controlled medication sheet was reviewed and compared with the inventory; this review confirmed that an extra dose of medications were pulled out on 8/26/23 and 9/2/23 at 9:00 PM. Further review revealed there was no documentation of medications being wasted. A review of Resident #2's medical record was conducted. Review of physician's orders revealed Lorazepan 1 mg, a controlled medication, ordered twice a day for anxiety starting on 7/31/23, which was discontinued on 8/24/23, and a new order for Lorazepan 0.5 mg two times a day for anxiety on 8/25/23. The MAR review for August and September revealed Lorazepan 1 MG was given twice a day throughout the two months. The controlled medication sheet was reviewed and compared with the inventory and confirmed that Lorazepam 1 mg had been pulled out and there was no documentation of the 0.5 mg pills being wasted. On 9/5/23 at 11:39 AM, an interview was conducted with Staff A, a Licensed Practical Nurse (LPN). Staff A, LPN, reviewed Resident #1's pregabalin inventory sheet. She stated Staff C, another LPN, should not have pulled out the pills at 9:00 PM because there was not a physician's orders to give that medication at night. Staff A, LPN, confirmed that a day shift nurse pulled out and documented the medications at the right time on those mornings as scheduled. Staff A further stated Staff C, LPN, should have documented waste of those medications but there was no documentation. Staff A, LPN, then reviewed Resident #2's Lorazepam inventory sheet and the physician's order and stated she has been giving 1 mg instead of the 0.5 mg because she had missed the order that was placed on 8/25/23. She stated she gave the 1 mg order this morning. She acknowledged she should have given the 0.5 mg order. On 9/5/23 at 12:32 PM, an interview was conducted with Staff B, a Registered Nurse (RN) and unit manager. She stated it was concerning that a nurse pulled up a controlled medication two times for Resident #1 at a time that it was not scheduled. Staff B, RN, confirmed the medication was pulled out in the mornings as scheduled. Staff B further stated that the medication should have been thrown away, but there was no documentation to verify it. Staff B, RN, then reviewed Resident #2's lorazepam order, MAR and medication's inventory and stated the staff did not notice that Lorazepam was changed from 1 mg to 0.5 mg on 8/25/23 and Resident #2 had been receiving the full pill, 1 mg, instead of half a pill 0.5 mg as it was ordered. Staff B stated she will correct it immediately. A review of facility policy Controlled substances (dated January 2023) was conducted. The policy stated when a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to policy and the disposal documented on the accountability records on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules.

Based on observations, record review, interviews and facility policy review, the facility failed to ensure that CPAP (Continuous Positive Airway Pressure- a device that delivers continuous pressured air through a tubing into a mask that is wore while asleep) masks were properly stored to prevent cross-contamination for 2 of 3 residents sampled (Resident #1 and resident #4). The findings include: On 9/5/23 at 11:30 AM, Resident #1's CPAP mask was observed hanging from the window's blind. On 9/5/23 at 1:31 PM, Resident #4's CPAP mask is on the floor. A review of Resident #1's clinical records revealed a diagnosis of obstructive sleep apnea and a physician's order to use a CPAP device at night. A review of Resident #4's clinical records revealed a diagnosis of dependence on supplemental oxygen. A review of the physician's orders stated, CPAP at night at bedtime for sleep apnea and clean CPAP mask and tubing with warm soapy water and let air dry during day to prepare for use during night on Sundays. On 9/5/23 at 2:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the CPAP masks should be inside proper bags when not in use. The DON observed Resident #1 and Resident #4's masks and confirmed masks were not stored inside proper bags per facility's protocol. A facility protocol was provided by the DON. The DON stated that the facility does not have a specific policy stating masks must be placed inside bags when not in use but all nursing staff are responsible to ensure it is done. A check off list form dated 6/6/23 stated, ensure respiratory tubing/masks are labeled. Keep these items in labeled plastic drawstring bag when not in use.

Based on record review, staff interview, and policy review the facility failed to develop a comprehensive care plan regarding anticoagulant use for 1 of 2 sampled residents reviewed who received anticoagulant medications. (Resident #28) The findings include: Review of resident #28's medical record revealed the resident had been receiving Pradaxa (an anticoagulant medication) 75 Milligrams (mg) by mouth twice daily since 1/3/23. The 5 day minimum data set with an assessment reference date of 1/10/23 indicated the resident received an anticoagulant medication 7 out of 7 days. The record revealed no care plan regarding the use of the anticoagulant medication. An interview was conducted with employee A, Minimum Data Set Registered Nurse, on 2/15/23 at approximately 11:30 AM. She stated the resident should have a care plan for risk of bleeding due to anticoagulant use and confirmed she did not have a care plan regarding the use of the anticoagulant and risk for bleeding. Review of the facility policy Care Plans (effective 2020) revealed a comprehensive care plan will be developed for each resident using the results of the comprehensive assessment. A comprehensive interdisplinary plan of care, based on the comprehensive assessment of the needs of the individual resident, will be developed and implemented within 7 days after the completion of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetables to meet all residents' needs identified in the comprehensive assessment.

Based on record review, family interview, staff interview, and policy review, the facility failed to maintain accurate medical records for 1 of 1 resident's sampled for advanced directives. (Resident #90) The findings include: Review of resident #90's medical record revealed a printed physician order dated 2/1/23 through 2/28/23 and signed by the physician on 2/1/23 indicating the resident was full code status (would require cardiopulmonary resuscitation in the event of cardiac arrest). Review of the legal tab in the resident record revealed a state of Florida Do Not Resuscitate (DNR) Order signed by a physician on 6/20/22. A telephone interview was conducted with the resident's son on 2/14/23 at 2:01 PM. He stated it was his intent that resident #90 was not to be resuscitated in the event of cardiac arrest. An interview was conducted with the Director of Nursing (DON) on 2/14/23 at 2:36 PM. She confirmed the resident had a signed DNR and the printed orders stated full code status. She stated the current MD order should have matched the DNR. Further interview was conducted with the DON on 2/14/23 at 3:34 PM. The DON stated the full code order should have been caught by nursing when they review the orders each month. She stated when the resident was admitted the DNR was not signed so the pharmacy orders defaulted to full code. Review of the facility policy Medical Records (effective 2015) revealed the facility shall maintain accurate medical records to document all physician orders, diagnostic reports, consultants' reports and care/services provided to the resident.

Based on observation, staff interview, and policy review the facility failed to ensure staff effectively disinfect shared blood glucose meters and storage containers during 2 of 2 random observations of blood glucose sampling for resident #55 and #67. The findings include: An observation of blood glucose sampling for resident #55 was conducted with employee B, Licensed Practical Nurse (LPN), on 2/14/23 at 4:23 PM. Employee B obtained the blood glucose meter, a pink basket, alcohol pad, and sampling strips from the medication cart and placed all supplies in the pink basket. She then placed the basket with the supplies on the over bed table in the resident's room with no barrier on the table. Employee B then obtained blood from the resident and placed the sample on the blood glucose meter. She read the result and disposed of the sampling strip, then placed the blood glucose meter on top of the over bed table with no barrier on the table. Employee B then placed the blood glucose meter in the pink basket and then took the basket to the medication cart. She placed the pink basket with the blood glucose meter on top of the medication cart with no barrier. Employee B then cleansed the blood glucose meter with a bleach wipe, allowed it to air dry, and then placed it back in the pink basket. She did not clean the pink basket. She then placed the blood glucose meter in the basket back in the medication cart. An observation of blood glucose sampling for resident #67 was conducted with employee B (licensed practical nurse) 2/14/23 at 4:40 PM. Employee B obtained the same pink basket from the medication cart and placed the blood glucose machine in the basket. She took the basket to the resident's room and placed it on the over bed table with no barrier on the table. Employee B then obtained blood from the resident, placed the sample on the blood glucose meter, and then read the result. She then placed the basket with the blood sampling meter on top of the medication cart with no barrier. Employee B then cleansed the blood glucose meter with a bleach wipe, allowed it to air dry, and then placed it back in the pink basket. She did not clean the pink basket. She then placed the blood glucose meter in the basket back in the medication cart. An interview was conducted with employee B, LPN, on 2/16/23 at approximately 4:47 PM. She stated she had received training regarding cleansing the blood glucose meter with bleach wipes when she was hired. She stated she only cleans the blood glucose machine and confirmed she should have cleaned the basket as well. Review of the undated facility policy Steps for Blood Glucose Monitoring revealed collect supplies and place glucose meter on barrier, collect other supplies to include test strip, lancet, alcohol pads, and place in a plastic cup. Do not take test strip bottle into room. Place barrier on top of med cart for dirty glucose meter when it comes out of room, take glucose meter and supplies into resident room, set cup with supplies down and set glucose meter on a barrier. Perform blood glucose check. Appropriately discard all supplies (including any unused supplies), place lancet and test strip back into plastic cup to discard into sharps container upon exiting room. Use barrier to take glucose meter out of room and place it on clean barrier on cart. Discard lancet and test strip by dumping them from plastic cup directly into sharps container. Discard cup into trash can. Put on gloves to disinfect glucose meter. Ensure glucose meter is saturated on all sides with disinfectant. Place glucose meter on clean barrier and allow to dry per manufacturer's instructions.

Based on observations and staff interviews, the facility failed to provide adequate maintenance services to maintain a clean environment for 1 of 4 zones observed in the facility (Zone 4). Affected areas included black bio-growth substances observed in 3 resident rooms (rooms 106, 107 and 109) and water stained ceiling tiles observed in room 109. The findings include: On 9/12/22 a tour of the facility was conducted beginning at approximately 9:55 AM. Upon entry into room 106, an interview was conducted with the resident who expressed concerns with black mold she saw in her bathroom. Upon inspection, it was found that the top of the inside door jamb had numerous spots of black bio-growth substance. Further inspections of this corner of the building revealed similar growths in rooms 107 and 109. On 9/12/22 at approximately 10:10 AM, an interview was conducted with the resident in room 109 during which he stated that the room had flooded a couple earlier after the area experienced heavy rainfall. The resident indicated that the primary leak was in one corner of the room. When this area was observed, the ceiling tiles were observed to have water stains. (Photographic evidenced obtained) On 9/13/22 at approximately 11:00 AM, an interview was conducted with the Executive Director and Maintenance Director during which they stated they were trying to complete repair and bring resident rooms back into code as they were finding issues. However, they were unaware of the problems that existed in rooms 106, 107 and 109.

Based on observations, staff interviews and quality assurance performance improvement plan review, the facility failed to implement their own action plan to address concerns related to preventative maintenance by failing to maintain a clean/safe environment for 1 of 1 plans of correction reviewed. Cross Reference F584 The findings include: During a tour of the facility on 9/12/22 beginning at approximately 9:55 AM, 3 resident rooms were discovered to have black bio-growth substances growing (rooms 106, 107 and 109) and one room (109) was found to have water logged ceiling tiles. Cross reference F584. A review was conducted of a plan of correction dated 9/23/21 which stated, All Housekeepers, Laundry staff, Floor Techs and Maintenance Staff had received training on replacing soiled ceiling tiles as needed and Housekeeping Director, Administrator and/or Designee will conduct daily audits for overall cleanliness of the facility environment and that ceiling tiles are not stained and/or wet to ensure regulatory compliance. On 9/15/22 at approximately 10:00 AM, an interview was conducted with the Administrator, during which he stated, To be honest, we have gotten lax on keeping up on this.

Based on staff interviews and record review, the facility failed to designate a qualified staff member to serve as the director of food and nutrition services. The findings include: A tour of the kitchen was conducted on 5/16/22 at 12:10 PM with the kitchen manager. The kitchen manager was asked if she had any certification or training to serve as the kitchen manager. She stated she was enrolled in a course but had not yet completed the course. Review of the kitchen manager's employee file revealed no certifications for food or dietary management or degree to qualify the individual as the kitchen manager. An interview was conducted with the facility's Registered Dietician on 5/16/22 at 12:39 PM. He stated he works at the facility 3 days per week and is not full-time. He functions only as a consultant for the kitchen and does not directly supervise the kitchen operations. An interview was conducted with the Administrator on 5/17/22 at 9:52 AM. He confirmed the kitchen manager has no certification and stated they would have to employ the dietician full-time. He stated the dietician has been part-time since February of 2022. Review of the facility's undated job description for Director of Food Services revealed the qualifications of the position include meeting the Federal and State of Florida requirements for the position: a. Registered Dietician b. Certified Dietary Manager/Certified Food Protection Professional c. other requirements as per federal or state guidelines.

Based on family and staff interviews, record review, and facility fall protocol review, the facility failed to promptly notify the resident representative of an accident involving the resident for 1 of 3 sampled residents reviewed for falls. (Resident #1) The findings include: A telephone interview was conducted with Resident #1's son on 5/13/22 at 8:45 AM. He stated the staff used the sit-to-stand lift one day in late April to transfer his mother to bed and dropped her. He was not notified until days later. He stated his mother was supposed to be transferred with the total lift. Review of Resident #1's paper medical record revealed a nurse's note dated 4/6/22 at 3:04 PM, indicating the resident requested the nurse notify her son of a new appointment. The nurse notified the son of the appointment and the son requested he be notified of everything that involved his mother. The nurse asked the resident for permission to notify her son of all changes, appointments, and care. The resident agreed for her son to be notified. The son is noted as health and financial power of attorney. A nurse's note dated 4/27/22 at 8:45 PM stated the resident was observed on the floor beside her bed. Two staff used the sit-to-stand lift to transfer the resident. Resident #1 slid out of the lift sling and staff lowered her to the floor. Resident #1 was lifted from the floor to the bed using a Hoyer lift (full body lift) and 4 staff. The nurse's note did not indicate the resident's son was notified of the accident. An interview was conducted with the Director of Nursing (DON) on 5/16/22 at 4:31 PM. She stated Resident #1's son should have been notified of the fall on 4/27/22 and confirmed that staff did not notify him. She stated the nurse on duty reported she did not consider it a fall since the staff lowered the resident to the floor. Review of the facility's undated Fall Protocol revealed a fall is defined as any unintentional change in body plane or position. Should your resident fall please ensure the Practitioner, Administrator, and family or responsible party are notified.

Based on observation, staff and resident interviews, and policy review, the facility failed to follow the prepared menu during 1 of 2 meals observed. (lunch 5/16/22) The findings include: On 5/16/22 at 12:08 PM, the posted menu was observed on the wall outside the Oasis Dining Room. The menu indicated Monday's (today's) lunch would consist of BBQ pork, American fried potatoes, turnip greens, cornbread and cookies. The approved, prepared menu was reviewed and indicated Monday, 5/16/22, the menu would consist of BBQ pork, American fried potatoes, turnip greens, cornbread and cookies. On 5/16/22 at 12:10 PM, a tour of the kitchen was conducted with the kitchen manager. The residents were being served country fried steak with gravy, scallop potatoes, and spinach. The kitchen manager observed the meal and confirmed it was not the same as the one indicated on the approved menu. She stated if she as to substitute a menu item, she will update it on the posted menu. The kitchen manager stated the pork did not come in and she did not change the posted menu. She stated the residents were not notified of the change in menu items and she had not recorded the change. On 5/16/22 at 1:30 PM, an interview was conducted with Resident #4 on 5/16/22. He stated you do not know what the kitchen will serve each day, you just have to guess. On 5/16/22 at 1:33 PM, an interview was conducted with Resident #6 on 5/16/22. He stated the facility does not let the residents know what will be served for meals until the meal is delivered. He stated the facility used to post a menu near the nurse's station, but they took it down a few months ago. On 5/17/22 at 9:23 AM, an interview was conducted with Resident #5. She stated the facility has not been serving food that is listed on the posted menu. Review of the facility's Menus policy revised October 2008 revealed menus shall meet the nutritional needs of residents, be prepared in advance, and be followed. Deviations from menus that have already been posted will be noted (including the reason for the substitution and/or deviation) in the kitchen and/or in the record book used solely for recording such changes. Copies of menus will be posted in at least 2 resident areas, in positions and in print large enough for residents to read them.

Based on observation, staff interview and policy review, the facility failed to maintain infection prevention measures intended to help prevent transmission of disease and infections for 1 of 6 residents on isolation precautions. (Resident #135) The findings include: On 11/17/2021 at 9:51 AM, an observation was made of Staff A, Licensed Practical Nurse (LPN) entering a room under contact isolation precautions. LPN A was observed to enter the room without donning personal protective equipment (PPE). Upon entering the room, LPN A repositioned the bedside table and delivered medications to Resident #35. LPN A was observed to perform hand hygiene with alcohol based hand rub prior to exiting the room. On 11/17/2021 at 9:54 AM, an interview was conducted with LPN A. The surveyor asked LPN A if she was aware that this was a contact isolation room and she replied, Yes. The surveyor asked if there was any reason she did not utilize PPE. She replied, I was not even thinking about it. I was trying to get my meds in a time range. On 11/17/2021 at approximately 10:05 AM, a review of medical records for Resident #35 was conducted and revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record revealed a positive laboratory test result dated 11/12/2021 for Clostridioides difficile/C.diff (a bacteria that can cause a serious inflammation of the colon and can be life threatening in severe cases). A review was conducted of the facility's Transmission-Based & Isolation Precautions policy last revised in February 2020. Review of the section on Contact Precautions revealed contact isolation was Intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Further review revealed Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. The policy explained that Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. VRE, C-difficile, noroviruses and other intestinal tract pathogens). Contact isolation and hand hygiene with soap and water was recommended for Clostridioides difficile infection, according to the policy. A review of the Centers for Disease Control and Prevention's webpage on FAQs for Clinicians about C.diff last reviewed on 7/20/2021 and accessed on 12/3/2021 at https://www.cdc.gov/cdiff/clinicians/faq.html#prevent revealed steps to prevent the spread include, Wear gloves and a gown when treating patients with C. diff, even during short visits. Gloves are important because hand sanitizer doesn ' t kill C. diff and handwashing might not be sufficient alone to eliminate all C. diff spores.

Based on observations and staff interviews, the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment for 4 of 4 zones observed throughout the facility. Affected areas included the floors on all 4 zones, Station 2 ceiling tiles, Station 2 air vents, and Station 2 biohazard room. The findings include: A tour of the facility was conducted on 9/22/2021 at approximately 11:42 AM with the Agency's Fire & Life Safety surveyor. Several areas of moisture and biological growth were observed. The ceiling tile outside Room 146 was stained with dark colored biological growth and full penetration of the tile per the Fire & Life Safety surveyor. The Station 2 biohazard room was observed to have damaged sheet rock and cove base with dark colored biological growth. The air conditioning vent near Room 140 was observed with moisture and areas of dark colored biological growth and 2 stained ceiling tiles with biological growth were observed near the vent. Three stained ceiling tiles were observed in Room 140's bathroom. The air conditioning vent in front of the conference room was observed with accumulated moisture on the outside of the vent. (Photographic evidence obtained) An interview was conducted with the Maintenance Director on 9/23/2021 at approximately 9:40 AM. The Maintenance Director stated he has worked in the facility for about 3 years. He stated that the air conditioning vents drip condensation and the facility has a company that is going to come in and replace the duct work throughout the whole building. He confirmed this has been an ongoing issue for years. He observed the stained ceiling tile photos obtained on 9/22/2021 and stated the dark substance on the tiles was water mold. He stated the biohazard room on Station 2 had a water leak and they had to bust the wall to repair it. He confirmed it had water damage. The Maintenance Director stated they have not retested the facility for mold since he has worked in the facility. On 9/20/2021 at approximately 1:00 PM, an observation was made of the floors and baseboards throughout the facility. The floors down the length of the hallways and door entranceways contained a thick, grainy buildup of debris. A buildup of a thick, dark brown residue in doorways, corners, and areas where the baseboards join the floors was also noted in each corridor of the facility. (Photographic evidence obtained) On 9/22/2021 at approximately 12:20 PM an interview was conducted with the Director of Laundry and Housekeeping. He was asked to explain the process for cleaning floors and base boards. The Director of Housekeeping and Laundry explained that build up often occurs while utilizing buffers to strip the floors especially at the junction where the floors meet the base boards, behind doors, and under floor mats. He explained that these areas are cleaned by housekeeping staff once or twice a month using Brillo pads to scrape off the build-up. He went on to explain that at times these areas need attention more than twice a month. The Director of Housekeeping and Laundry was asked to provide a copy of any policies pertaining to floor maintenance and cleaning. He explained that the process for cleaning wax build up is not part of any policy. On 9/23/2021 at approximately 10:30 AM, a follow-up interview was conducted with the Director of Housekeeping and Laundry. He provided copies of the Routine Daily Cleaning Policy (dated February 2020), Housekeeping Logs, Floor Tech Logs, and Monthly Cleaning Schedules. He further explained that facility management plans to replace the baseboards with a type of baseboard that is easier to clean and plans are in place for the walls to be painted before applying the new baseboards. He said that they have already started a paint test area, but decided to order a different paint. He also mentioned that he has also investigated prices to purchase a square dry stripper. He explained that this piece of equipment works almost like a [NAME] and would eliminate the formation of wax build up caused by buffers. He was asked if he had copies of receipts or emails pertaining to ordering new baseboards or [NAME]. The Director of Housekeeping and Laundry replied that pricing was completed by phone and that there were no documents to be provided. A review of the Routine Cleaning - Daily policy and procedure last revised February 2020 was conducted. The policy stated that routine cleaning of environmental surfaces shall be performed according to a predetermined schedule and shall be sufficient to keep surfaces clean and dust free. The policy further stated that hallways are included in the areas to be cleaned. According to the policy, the frequency of cleaning and disinfection of the facility environment may vary according to the type of surface, number of individuals in the area, amount of activity in the area, risk to residents, and amount of soiling. Further review revealed that thorough cleaning is done per the Gang Tacking Review (GTR) schedule. The policy and procedure also stated that the Housekeeping Director is responsible to ensure that routine cleaning is maintained. A review of the Gang Tacking Review (GTR) schedule form for September 2021 was conducted. The GTR form stated that the corridors on side 1 will be addressed on 9/15/2021 and that corridors on side 2 will be addressed on 9/28/2021. A review of the AM/Morning Floor Tech - Completion Sheet and PM/Afternoon Floor Tech - Completion Sheet revealed the following tasks: sweep/mop halls and buff halls.

Based on record review, staff interview and policy review, the facility failed to develop a comprehensive plan of care for 1 of 4 sampled residents with falls. (Resident #26) The findings include: Review of Resident #26's medical record revealed the resident had a fall on 5/19/2021 which resulted in a fracture of the right hip. Further review revealed the resident also had falls with no injury documented on 6/15/2021, 9/15/2021, and 9/19/2021. Review of the Admission Minimum Data Set (MDS) Assessment with an assessment reference date of 6/12/2021 revealed the resident had a fall with a fracture in the last 6 months, one fall with minor injury, and one fall with major injury since re-entry or prior assessment. The record revealed no current comprehensive care plan for fall risk. An interview was conducted with Employee A (MDS Registered Nurse) on 9/22/2021 at 5:08 PM. Employee A stated the facility did not continue the previous plan of care from the previous admission prior to the hospitalization for the hip fracture. She stated they would normally pull the previous care plans, revise and update them if needed, and place them in the new chart when a resident is readmitted . Review of the Care Plans, Comprehensive Person-Centered policy and procedure last revised in December 2016 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review revealed that the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy also stated the comprehensive, person-centered care plan is developed within 7 days of the completion of the required comprehensive assessment. According to the policy, the interdisciplinary team must review and update the care plan when the resident has been readmitted to the facility from a hospital stay, when there has been a significant change in the resident's condition, when the desired outcome is not met, and at least quarterly, in conjunction with the required quarterly minimum data set assessment.

Based on observation, interview and record review, the facility failed to provide a safe, clean and homelike environment for 4 of 4 zones observed during the tour. The findings include: On 6/17/2021 from 10:13 AM to 11:54 AM, a tour of the facility was conducted. The following observations were made: Zone 1 (Activity Room and non-resident occupied rooms) - The bilateral hall siderails contained a visible layer of light gray microparticles. The floor down the length of the hallway contained scattered dark brown smears and stains of dried liquids. The floor down the length of the hall contained approximately 2-3 inches of brown/gray discoloration along the baseboards. The doorway from the hallway to the Activity Room contained cobwebs from the base of the floor to approximately 1.5 feet up the wall, food debris, and an accumulation of light and dark gray microparticles and residue. Zone 2 (Nursing Unit 2 and rooms 142-161) - The seating area at Nursing Unit 2 contained bead board with a layer of light gray microparticles spanning from the base of the floor to approximately 6 inches up the wall. Tiles contained dark gray discoloration and loose gray particulate, hair, and food debris. The medication cart parked at Nursing Unit 2 had a golf ball sized mass of lint and human hair wrapped around the [NAME] wheels. Across the hall from the medication cart was a mass of human hair on the floor approximately 2 inches wide by 4 inches long. The housekeeping cart on the hall contained a broom head with a golf ball sized mass of human hair stuck to the bristles. Zone 3 (All Stars Room and rooms 126-141) - The bilateral hall siderails contained a visible layer of light gray microparticles. The floor down the length of the hallway contained scattered dark brown smears and stains of dried liquids. The floor down the length of the hall contained approximately 2-3 inches of brown/gray discoloration along the baseboards. Surveyor's shoes stuck to the floor while touring the hall. The ceiling air vent and surrounding ceiling tiles were noted to have an accumulation of fine gray particles. Food wrappers were observed in the corners on each side of the exit doors located between rooms 130 and 131. The grooves on the textured door mat were filled with a brown powdery substance. A pony tail, leaves, and a pile of a gray/brown powdery substance were also noted on the floor. Upon entrance to the All Stars Room, the doorway was noted with an approximately 2 inches wide by 7 inches long accumulation of hair, debris, and light gray particles and dark gray residue. The All Stars Room ceiling fan blades were covered with a layer of fine powdery gray particles. A desk in the front corner of the All Stars Room had 4 loose cords on the floor which spanned from the wall to various electronics approximately 2.5 to 3 feet away, such as the phone and the computer. These unsecured cords posed a trip hazard to unsupervised residents such as Resident #7 who was seated alone at a table. Dead insects including, but not limited to, June bugs and cockroaches were observed on the All Stars Room floor. Drip marks from a brown liquid now dried on the wall were visible behind a resident's assistive walking device leaned up against an All Stars Room wall. A back corner of the All Stars Room contained cobwebs from the base of the floor to approximately 1.5 feet up the wall. All corners of the room contained a visible accumulation of debris, hair, dirt, and cobwebs. Food items such as a blueberry and a circular piece of cereal were observed on the All Stars Room floor with other debris. Brown splatter marks were dried to the wall next to an All Stars Room table. Spaghetti noodles and red meat sauce on the floor of Room 127B was visible from the hallway. The top layer of the fall mat located at the bedside was observed to be separating from the base of the mat at all four corners. These rolled up edges posed a trip hazard. Dried white liquid stains were observed on the floor in front of the fall mat. The perimeter of the All Stars Room floor was discolored dark gray and the grout between ceramic floor tiles had an accumulation of loose gray microparticles and debris. Zone 4 (Janitor Closet and rooms 101-125) - The bilateral hall siderails contained a visible layer of light gray microparticles. The floor down the length of the hallway contained scattered dark brown smears and stains of dried liquids. The floor down the length of the hall contained approximately 2-3 inches of brown/gray discoloration along the baseboards. The floor outside the Janitor Closet contained a heavy concentration of brown shoe impressions and wheel marks. The shoe impressions and wheel marks went in all directions and their paths could be tracked the length of the hall in either direction. A mass of human hair approximately 1 inch wide by 2.5 inches long was observed from the hallway on the floor of Room 118. Room 118 was occupied by one resident. (Photographic evidence obtained) On 6/17/2021 at 11:10 AM, an interview was conducted with Employee A, Floor Tech/Housekeeping. Employee A informed the surveyor that he was primarily a floor tech but is helping out with housekeeping due to being short staffed today. He stated that the floors are done everyday. The surveyor asked when was the last time that he personally cleaned the floors and he replied, last night. He added that the floors are done on the morning and night shift and are stripped and waxed at the end of every month. The surveyor pointed out the discolored flooring lining the hallways and the doorways and he said, that's just wax build up. On 6/17/2021 at approximately 11:45 AM, an interview was conducted with the Kitchen Manager. The surveyor asked what was served for dinner last night and he replied, spaghetti. On 6/17/2021 at 12:07 PM, an interview was conducted with the Director of Housekeeping. The surveyor inquired about current housekeeping staffing levels and he replied that there are 3 housekeepers when there are no call-ins. He continued that today a housekeeper had called in, so he would be grabbing a housekeeping cart to fill in. The surveyor inquired about housekeeping assignments and he explained that Rooms 101-161 are split into thirds and that each housekeeper also has assigned common areas based on their room assignment. The Director of Housekeeping stated that, floor techs are responsible for stripping and waxing and what looks like feces/dirt on the floors is actually tar. The surveyor asked what hours housekeeping staff are in the building and he replied that they work from 8:00 AM to 4:30 PM. The surveyor showed the Director of Housekeeping photographs of the observations outlined above and asked, Does that look homelike to you? He shook his head and replied, No. The surveyor then asked if the current condition met his level of expectation and he replied, Definitely not. The surveyor asked if he conducts any type of quality assurance measures like audits and he stated, only for GTRs (rooms selected for terminal cleaning). The surveyor asked if spaghetti from the previous night's dinner should still be on a bedroom floor at 11:45 AM the next day and he replied that his staff aren't in the facility at dinner time. The surveyor asked if he thought that would be something that other staff working in the facility at the time would be expected to address he stated, I would think so. A review of the Housekeeping Schedule revealed that housekeeping staff are allotted 45 minutes to clean their assigned common area and 5.75 hours to clean their assigned rooms. Review of the Morning Floor Tech schedule revealed that floor techs are allotted 1.75 hours to sweep/mop halls, 2 hours to buff halls, 30 minutes to clean the All Star Room, and 30 minutes to clean the Activity Room. Review of the Afternoon Floor Tech schedule revealed that floor techs are allotted 30 minutes to clean the Family Room, 30 minutes to clean the Dining Room after the 2nd seating (lunch), 30 minutes to spot mop halls, 30 minutes to sweep and mop the Conference Room, 45 minutes to wipe down all hand rails and door handles on all entry/exits, 30 minutes to clean the Dining Room after the 2nd seating (dinner), and 30 minutes to dust and sweep all halls. A review of the Routine Cleaning - Daily policy and procedure implemented in 2005 and revised in February 2020 revealed that It is the policy of this Facility to identify the functional areas in the Facility that require cleaning and to use routine cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks. Review of the procedure revealed that Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule and shall be sufficient enough to keep surfaces clean and dust free. Further review revealed that specific areas include hallways, dayrooms and dining rooms, lobby, offices and exterior, showers, utility rooms and bathrooms, and resident rooms. The procedure also stated that the frequency of cleaning and disinfection of the facility environment may vary according to the type of surface to be cleaned, the number of individuals in the area, amount of activity in the area, risk to residents, and amount of soiling. According to the policy, the Housekeeping Director is responsible to ensure that routine cleaning is maintained.

Based on observations and interview the facility failed to ensure resident [MEDICAL CONDITION] (Continuous Positive Airway Pressure) mask was maintained in a sanitary manner for 1 of 2 residents reviewed for Respiratory care (Resident #36.) The findings include: On 02/17/2020 at 12:40 PM, an interview and room observations were made for Resident #36. Resident #36 had a [MEDICAL CONDITION] machine at her bedside, the mask was not stored in a sanitary manner when not in use. Resident #36 stated they (the facility) has not stored it mask in a plastic bag. On 02/18/2020 at approximately 1:55 PM, the Director of Nursing (DON) presented a policy entitled 'Oxygen Administration Protocol. The policy does not address how often tubing is changed for oxygen or [MEDICAL CONDITION] machines or how respiratory masks are to be stored when not in use. The DON states they don't have a policy on this but the transportation person who works weekends is responsible for changing the tubing. She did state that she expected [MEDICAL CONDITION] masks to be stored in a plastic bag when not in use. The bag should contain a date of when the tubing was changed on it. On 02/20/2020 at approximately 10:35 AM, an interview was conducted with the Assistant Director of Nursing, who was passing Resident #36's room, she confimred the Resident's [MEDICAL CONDITION] mask was not stored in a santiary manner and should be in a plastic bag when not in use.

Based on observation, record review, and interview the facility failed to provide, in accordance with the resident's care plan, activities to meet the interests of and support the well-being of 2 of 2 resident's sampled for activities (Resident # 25 and #76). The findings include: Resident #25 On 02/17/20 at approximately 01:21 PM during interview with the resident # 25's representative, the representative expressed concern that the resident was not being engaged in or encouraged to participate in activities at the facility. On 02/19/20 at approximately 09:33 AM during record review of resident #25's medical record it showed that the resident had the pertinent [DIAGNOSES REDACTED]. Review of Activity Evaluation dated 11/22/2019 found in the medical record noted that the resident preferred to stay in her room and enjoyed watching television and people watching and noted that the resident was to receive 1 on 1 room visits by staff 2 to 3 times a week. Review of the resident's most recent care plan, dated 2/13/2020, identified that the resident was at risk for limited socialization and some of the interventions listed were to attend at least 2 activities or to have room visits. On 02/19/20 at approximately 10:22 AM during interview with staff A, Registered Nurse, and Unit Manager, she expressed that the resident did not like to leave her room, but that she enjoyed having visitors in her room. On 02/19/20 at approximately 11:01 AM during interview with staff C, Licensed Practical Nurse and activities director, she expressed that resident #25 was to have room visits about 3 times a week because she was resistant to getting out of the room and expressed that her goals in activities were to prevent self-isolation. On 2/19/20 at approximately 1:00 PM during review of completed activity documentation with staff D, Certified Nursing Assistant and activities assistant, she expressed that she was the person who performed room visits. Review of the previous 19 days showed that the resident had only 1 room visit. Staff D expressed that she had no other evidence that the resident was engaged in other activities or room visits and stated, we do our best to get to everybody. Resident #76 On 02/17/2020 at approximately 10:55 AM, Resident #76 was observed seated beside her bed, in her wheelchair - not in view of the doorway. The resident was interviewed regarding activities. Resident #76 stated she'd like to participate in activities but has no idea when they are. She stated no one comes around to invite her to activities. A review of Resident #76's care plan, effective 10/16/2018, for short and long-term memory impairment with impaired decision-making skills, indicates, provide simple, structured activities that help resident's orientation, self-directed activities and social involvement; Encourage participation in small group activities that promote choices, self-expression and/or responsible. Additional observation were made of Resident #76 during the 4 day survey. They were as follows: Observed on 02/18/2020, in the resident's room, was an activity calendar. The activity calendar was a 2-sided paper document with the first 2 weeks activities on one side and the other 2 weeks activities on the other. The current weeks activity was not visible unless the paper was lifted to the reverse side. The resident remained in her room, in her wheelchair beside her bed. Her room-mates television was on, but there was no sound. At 2:20 PM, resident was observed in bed. On 02/19/2020 at 09:00 AM, resident observed in her wheelchair, positioned beside her bed, not in view of her door. At 09:36 AM resident remained in her room as previously described. At 10:21 AM resident remained in her room as previously described. A check of the activity calendar indicates At 12:01 PM- Resident #76 was observed in the dining room. At 12:48 PM Resident #76 was observed back in her room. At 2:20 PM, Resident #76 was observed in bed. On 02/20/2020 at 09:30 AM, Resident #76 was observed seated beside her bed in her wheelchair. She was dozing, but easily aroused. The resident was asked if anyone asked her to attend activities - she stated no one had. When asked if she would like to attend activities this morning she stated, I'd like that. On 02/20/2020 at 09:35 AM, observed Staff Member D, in the Activity Room. There were a few residents in the room, but no activities were underway. When asked what the activity was, Staff Member D went over to the activity calendar, behind her desk. The calendar had not been turned over to display the current weeks activities. She was asked about Resident #76's inclusion in activities - she stated she thought the resident had been to Activities once this week, despite no observations or facility documentation supporting this. Staff Member D stated she does the best she can to inform residents of upcoming activities.

Based on observations, record reviews, staff interviews and policy review, the facility failed to ensure residents with pressure ulcers received wound care that was in accordance with current standards of infection control practice, failed to develop a plan of care related to the resident's wound, failed to provide wound care in accordance with physician orders, and failed to provide appropriate assessment and notification of changes in wound status for 2 of 3 sampled residents with pressure ulcers (#42 and #52). The findings include: Resident #52 Observation of wound care was conducted for resident #52 on 1/31/18 at 1:40 PM with employee I (registered nurse). The nurse washed her hands and placed a paper towel over the top of the treatment cart. A brown colored, dry substance was observed in an area on the top of the treatment cart, and the nurse did not clean the top of the treatment cart prior to placing the paper towel. The nurse then setup wound care supplies on the paper towel, including a pair of unbagged scissors she removed from a drawer of the treatment cart. The nurse then took the supplies to the resident's room and placed them on the over bed table that was covered with a towel. During the wound care, the nurse used the scissors obtained from the treatment cart to cut the silver alginate dressing she applied to the wound. She did not clean the scissors prior to cutting the alginate. After the wound care was complete, the nurse disposed of her supplies. The nurse did not clean the over bed table utilized during the wound care. An interview was conducted with employee I on 1/31/18 at 1:55 PM. She stated no one had ever told her to clean the treatment cart prior to placing a barrier, and confirmed the treatment cart was visibly soiled when she prepared supplies earlier. She also affirmed that she had removed the scissors from the treatment cart and did not clean the scissors prior to cutting the alginate dressing that was applied directly to the wound of resident #52. Review of the medical record for resident #52 revealed an order for [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 2/1/18 at 11:00 AM. She confirmed she was not able to locate wound measurements for resident #52 the week of 12/31/17 through 1/6/18. The facility policy for clean dressing change was reviewed. The policy stated the dressing change procedure included: perform hand hygiene, assemble equipment and supplies needed for dressing change, identify resident and explain the procedure, evaluate resident's pain and the need for pain medication, put on gloves, adjust bedside stand/table to waist level, clean bedside table with germicidal disposable cloth, establish a clean field, place the resident's trash can within easy reach, remove gloves, perform hand hygiene, set-up supplies on barrier, position the resident for comfort, perform hand hygiene, put on clean gloves, remove dressing and place in the resident's trash can, remove gloves and perform hand hygiene, put on clean gloves, cleanse wound with gauze and prescribed cleaning solution using single outward [MEDICAL CONDITION], use separate gauze for each cleansing wipe, use a dry gauze to pat the wound dry, remove gloves and perform hand hygiene, put on gloves, remove gloves and perform hand hygiene, reposition the resident and ensure the call light is in place, discard all disposable items into the appropriate receptacle, clean the bedside table with germicidal disposable cloth, remove trash from resident's room, wash and dry hands thoroughly. The facility policy provided does not include the step to apply a clean dressing. Resident #42 A family interview was conducted for resident #42 on 1/29/2018 at 10:43 AM. The family member stated the resident had a wound to her left heel that she developed in the facility. She stated she was concerned the wound was not getting better and indicated the staff were not performing dressing changes as ordered. She revealed she recently took the resident to a doctor's appointment and noted the resident's left heel dressing was dated from the previous week even though the dressing was ordered to be changed daily. Resident #42's left heel dressing was observed on 1/29/2018 at 2:00 PM and found to have a date of 1/26/2018 on the dressing and had a significant foul odor. The resident's January treatment administration record (TAR) was immediately reviewed and revealed a physician's orders [REDACTED]. The TAR had documented dressing changes only for 10 of the 29 days of the month, including 1/1, 1/2, 1/6, 1/7, 1/8, 1/13, 1/18, 1/19, 1/20, and 1/26. On 1/30/2018 at approximately 9:30 AM, the same TAR revealed each date from January 1-29 had been filled in with initials documenting that wound care was performed. An interview was conducted with the facility Administrator on 1/30/2018 at 9:53 AM. He stated staff should be documenting care immediately. He further stated staff should not be documenting any care before it is actually done. The Director of Nursing (DON) was interviewed on 1/30/2018 at 10:36 AM. She stated she reviewed TARs weekly, and if she found any holes in the documentation, she called the staff that worked that day to come to the facility and complete documentation indicating they had performed the care. She stated she was not aware there was any time frame for documenting when care was done. An interview was conducted with licensed practical nurse (LPN) L on 1/30/2018 at 11:30 AM. She confirmed she changed the dressing to resident #42's left heel. When asked what date was on the dressing when she changed it, she replied, the 26th. She stated the expectation for documenting treatments was to document it immediately. She further confirmed it was common for the DON to call and ask staff to come in and sign the blank spaces on the TARs. She stated, For a while the wound was improving, but has since stopped and remained unchanged. She confirmed the odor to the wound, but stated she did not believe the wound was infected. An interview was conducted with Nurse M on 1/30/2018 at 3:32 PM, who had been assigned to the resident on 1/27/18 and 1/28/18. Nurse M was interviewed in the presence of the DON and Administrator. She stated the resident's left heel was to be cleaned daily. She confirmed she signed the TAR indicating treatments had been performed when she worked on each date. When shown a photograph of the resident's dressing dated 1/26, she stated the resident refused to allow her to change the dressing. Nurse M stated when a resident refuses a dressing change, it should be indicated on the TAR by initialing the date and then circling the initials. She further revealed a progress note should be written to describe the refusal. She confirmed the TAR did not accurately portray that treatments were refused. Resident #42's medical record was reviewed and revealed a stage 3 pressure ulcer to the resident's left heel acquired in the facility on 9/11/2017. Physician orders [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] noted an unhealed pressure ulcer. A care plan meeting was held on 10/24/2017 and also noted skin issues to the resident's left heel. All care plans for the resident were reviewed, but no care plan was observed related to the resident's wound. An interview was conducted with the MDS Coordinator on 1/30/2018 at 1:28 PM. She reviewed resident #42's medical record and confirmed there was no comprehensive care plan for the pressure ulcer. She stated she should have created one with interventions to help heal the wound. Resident #42's wound care was observed on 1/31/2018 at 8:45 AM performed by nurse I, a wound care certified nurse. While gathering supplies at the treatment cart, the nurse was not observed to wash her hands prior to obtaining supplies, nor was she observed to place a barrier on top of the treatment cart. She began obtaining all supplies from the cart, including normal saline, a soufflé cup, a cup, skin prep, an ABD pad, as well as gauze wrap, and placed atop the uncleaned, unprotected cart. She gathered all supplies in her hands and then walked to the laundry room. She obtained a folded towel from the laundry room then entered resident #42's room. She immediately placed the towel on top of the resident's tray table, without first cleaning the table. She then placed all items she was carrying on top of her clean barrier, contaminating it. She asked a staff member walking by the room to bring a ruler and cotton tipped applicator. The staff member was observed to enter the room and hand the ruler and applicator to nurse I, who then placed the ruler on the barrier. Nurse I applied gloves and removed the dressing. She immediately disposed of the dressing and began cleaning the wound without washing her hands, or changing gloves. After cleaning the wound, nurse I was observed to take the ruler, brought in by staff who were not observed to clean hands prior to obtaining, and placed it on the resident's heel. When she moved the ruler, visible blood was noted. The nurse then went to wash her hands, and resident #52 was observed to put his heel, with exposed wound, on the facility's wood floor. When the nurse returned, she picked up the resident's foot from the bare floor and began to press the collagen to the wound. After nurse I completed the wound care, an interview was conducted at 9:10 AM. Nurse I confirmed she should have had a barrier on the treatment cart, and should have obtained the ruler herself to assure it was clean. She also confirmed that there should have been a barrier under the resident's foot during the wound care and should have washed her hands and applied new gloves after removing the old dressing. During the wound care observation, nurse I measured the wound and described the measurements as 3.5 centimeters (cm) in length by 5 cm in width with less than 0.1 cm in depth. She stated the wound had 25% granulation tissue with 75% of the wound as slough. Resident #42's weekly wound assessments were reviewed and revealed a change from the last weekly assessment completed by nurse I on 1/26/2018 which measured 2.5 cm by 3.5 cm with 100% eschar present, and documentation that the wound had deteriorated. The weekly wound assessment conducted 1/18/2018 by nurse I revealed the wound measured 2 cm by 2.5 cm x 0.1 cm. She noted it had 75% granulation tissue with only 25% slough with no eschar present. The nurses' notes for the time period of 1/18/2018 to 1/31/2018 did not reveal any documentation of notification to the physician or resident's responsible party for the deterioration in resident #42's wound. The resident's medical record was reviewed on 2/1/2018 at 8:45 AM and did not reveal any documentation of notification of the physician or responsible party of the deterioration in the resident's wound. An interview was conducted with nurse I on 2/1/2018 at 9:30 AM. She stated she had notified the nurse practitioner yesterday of the wound's condition. She confirmed she had not documented she had spoken with the nurse practitioner. The resident's medical record was reviewed again on 2/1/2018 at 10:30 AM and revealed a nurse's note written 2/1/2018 at 10:00 AM documenting notification to the physician and responsible party of the deterioration of the resident's wound. A new order was given by the nurse practitioner for a change to the wound treatment. An interview was conducted with nurse J, a wound nurse, on 1/30/2018 at 3:28 PM. She stated she would notify the physician immediately for new wounds, any changes to existing wounds, and for any signs of infection. An interview was conducted with the Director of Nursing on 2/1/2018 at approximately 11:00 AM. She stated staff should be notifying the physician and responsible party immediately for any changes in residents' wounds.

Based on staff interviews and resident medical record reviews, the facility failed to implement the plan of care for 6 of 9 residents with pacemakers. (Resident #1, #10, #12, #13, #14 and #15). Resident care plans indicated that pacemaker checks would be done in accordance with physician orders, however record review failed to locate physician orders for pacemaker checks. As a result of this process failure, Resident #1 was transferred to the emergency room and required an emergent generator replacement on 6/15/14. This systemic failure led to a finding on Immediate Jeopardy on August 13, 2014. The administrative staff immediately developed a policy and procedure related to pacemakers and pacemaker checks and began to implement it. However, the new policy was not fully implemented by survey exit, so this led to a determination of Ongoing Immediate Jeopardy. The findings include: A clinical record review for Resident #1 was conducted with the assistance of the Unit Manager for Station Two from the time of her admission in March 2011 through the emergent transfer to the hospital, which occurred on 06/15/2014. The admission paperwork noted that Resident #1 had a permanent pacemaker that was implanted in 2007. The Unit Manager was unable to locate any information regarding when the pacemaker had last been checked, if the resident had been seen by a Cardiologist, or any physician orders to indicate or suggest the need to monitor, consult or arrange for monitoring of the resident's pacemaker. No care plan regarding pacemaker checks was located. The nursing notes were reviewed. Resident #1's Nursing notes indicated on 06/15/2014 at 6:31pm, the resident's roommate summoned staff for help. Resident #1 was found lying face down in front of a wheelchair. She was initially unresponsive, eventually responded to stimuli and was transported via ambulance to a local hospital Emergency Department. A review of the cardiologist's physician progress notes [REDACTED].*, dated 16 June 2014 at 7:54 was conducted. Under the section entitled 'History of Present Illness' the report stated, "She developed a syncopal episode (passed out) and experiencing an acute mental status change. Subsequently, she was brought to (the hospital) for further evaluation. She has a significant history of sick sinus syndrome post dual chamber pacemaker implantation 11/27/2007, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. She has lost follow-up appointment since 6/17/2010 with unclear reasons. Interrogation of her device in emergency room revealed no capture of pacemaker leads. After she developed a syncopal episode, she hit her head on the floor. Subsequently, I was called by ER doctor immediately regarding the patient's current condition and no capture of lead and made consideration of an Emergency generator change out." Per the operative report, the emergency generator change out was performed on 6/15/14 at 10:48pm. The cardiologist noted that it was functioning adequately post procedure. Resident #1 was discharged from the hospital and readmitted to the facility on [DATE]. A further clinical record review was conducted from the re-admission date of [DATE] through present for Resident #1. Resident care plan, dated 06/24/2014 identified a new pacemaker generator implanted on 06/15/2014. Interventions include "4. Pacemaker checks as per MD prn. 5. Cardiologist - pacemaker check every 6 months." The resident's medical record failed to reveal evidence of physician orders related to the monitoring of the resident's pacemaker. With the assistance of the DON, Resident #10's medical record was reviewed regarding the resident's pacemaker. Resident #10's care plan, dated 05/22/2014, identified resident's pacemaker and indicated "4. Pacemaker checks as per MD prn." Resident #10's medical record failed to include recommendations or orders for pacemaker checks per the physician. The resident was identified to have a pacemaker implanted in 09/2011. Medical record from resident's previous admission, revealed resident's last pacemaker check was conducted in November 2013 per note from hospital. Director of Nursing (DON) indicated this information would (now) be included in the resident's plan of care and will stay in the chart. There was no pacemaker monitoring scheduled or identified for the resident. Additional information was obtained at surveyor request, which later revealed that Resident #10 was due for device monitoring in May 2014, according to evaluation recommendations. Appointment was made by the facility for follow-up pacemaker check on 09/10/2014. After facility notification of the IJ, the resident's device monitoring appointment was changed to 08/14/2014 at 11:00am. With the assistance of the DON, Resident #12's medical record was reviewed regarding the resident's pacemaker. Resident #12's most recent facility admitted , was 04/03/2014. Care plan, dated 05/28/2014, indicated pacemaker checks as ordered. However, there were no physician orders for pacemaker checks. The DON indicated they (UM - Station One) were calling the physician now regarding the resident's pacemaker - to see when it was checked and when due again. Information faxed to the facility on [DATE] at 1:09pm from the Device Clinic, indicated the last device check on 03/11/2014. A follow-up pacemaker check appointment was subsequently scheduled for 08/15/2014 at 09:00am. With assistance of the DON, Resident #13's medical record was reviewed regarding the resident's pacemaker. The DON indicated this resident was here for Short Term Rehab. The resident's care plan, dated 06/26/2014 indicated "4. pacemaker check as per MD PRN" There were no MD orders noted for pacemaker monitoring. There was no evidence in the record of when the resident's pacemaker was last checked or when the resident was due for recheck. Information located in the record, merely identified the resident as having a pacemaker from information obtained from the resident's hospital history and physical. On 08/12/2014 with the assistance of the Unit Manager for Station Two, a review of Resident #14's medical record was conducted related to Pacemakers. The Resident's care plan, dated 05/06/2013 to identify risk for decreased cardiac output related to [DIAGNOSES REDACTED]. Last updated on 05/26/2014 indicated "Interventions" - "10. pacemaker checks done in-house every 6 months as scheduled." The Unit Manager was able to locate a nursing note that indicated the resident's pacemaker was checked on 05/14/2014 and all was good. The Unit Manager did not know and was not able to identify when the resident was due for recheck, stating the Pacemaker Clinic would call him when it was time for the resident to be re-checked. The resident's medical record also failed to reveal evidence of physician orders related to the monitoring of the resident's pacemaker. A record review specific to Pacemakers was conducted for Resident #15. The care Plan, dated 08/09/2012 identifies resident status [REDACTED]. Pacemaker checks at vascular ___ - as ordered - every 6 months." Review of record, fail to reveal any physician orders related to the resident's pacemaker. On 08/12/2014 at approximately 12:00pm, an interview was conducted with the MDS Coordinator for Unit Two. The Coordinator indicated when a patient gets admitted she reviews the history and develops a [DIAGNOSES REDACTED]. Each Station has their own MDS Coordinator. The MDS Coordinator is responsible for updating the resident's care plan.

Based on staff interviews and clinical record reviews, the facility failed to provide services to maintain the highest practicable well-being of 8 of 9 residents with pacemakers (1, 5, 10, 12, 13, 14, 15, and 16). The facility failed to have processes in place regarding pacemaker checks. As a result of this process failure, Resident #1 was transferred to the emergency room and required an emergent generator replacement. The facility failed to immediately develop a policy and procedure regarding pacemaker checks following notification of pacemaker failure on June 17, 2014. This systemic failure led to a finding on Immediate Jeopardy on August 13, 2014. The facility's administrator and Director of Nursing were notified of the finding of Immediate Jeopardy on 8/13/14 at about 4:00pm. The administrative staff immediately developed a policy and procedure related to pacemakers and pacemaker checks and began to implement it. However, the new policy was not fully implemented by survey exit, so this led to a determination of Ongoing Immediate Jeopardy. The findings include: A detailed review of Resident #1's medical record was conducted with the assistance of the Unit Manager for Station Two from the time of her admission in March 2011 through the emergent transfer to the hospital, which occurred on 06/15/2014. The admission paperwork noted that Resident #1 had a permanent pacemaker that was implanted in 2007. The Unit Manager was unable to locate any information regarding when the pacemaker had last been checked, if the resident had been seen by a Cardiologist, or any physician orders [REDACTED]. The nursing notes were reviewed. Resident #1's Nursing notes indicated on 06/15/2014 at 6:31pm, the resident's roommate summoned staff for help. Resident #1 was found lying face down in front of a wheelchair. She was initially unresponsive, eventually responded to stimuli and was transported via ambulance to a local hospital Emergency Department. A review of the cardiologist's physician progress notes [REDACTED].*, dated 16 June 2014 at 7:54 was conducted. Under the section entitled 'History of Present Illness' the report stated, "She developed a syncopal episode (passed out) and experiencing an acute mental status change. Subsequently, she was brought to (the hospital) for further evaluation. She has a significant history of sick sinus syndrome post dual chamber pacemaker implantation 11/27/2007, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. She has lost follow-up appointment since 6/17/2010 with unclear reasons. Interrogation of her device in emergency room revealed no capture of pacemaker leads. After she developed a syncopal episode, she hit her head on the floor. Subsequently, I was called by ER doctor immediately regarding the patient's current condition and no capture of lead and made consideration of an Emergency generator change out." Per the operative report, the emergency generator change out was performed on 6/15/14 at 10:48pm. The cardiologist noted that it was functioning adequately post procedure. Resident #1 was discharged from the hospital and readmitted to the facility on [DATE]. Interviews about facility's process for pacemaker checks were conducted with the Unit Managers, Director of Nursing and the Minimum Data Set Assessment (MDS) coordinator. On 08/12/2014 at approximately 10:35am an interview was conducted with the Unit Manager for Station One. She stated she would have to look for the other information or call resident's cardiologist to get other additional pacemaker information. She stated when a resident first comes in, she would try to put it down (on paper), if have a pacemaker - that was how she identified residents with pacemakers. She would try to find out when placed, last time checked. She would personally fill out appointment paperwork. She indicated if a nurse admits a patient with a pacemaker, she would just hope she came into work the next day to find out. There was a section in the Nursing Admission Assessment to include presence of pacemaker and when last checked. That would be how she would find out. She was not sure if the facility has a policy related to Pacemaker monitoring. On 08/12/2014 at approximately 9:10am an interview was conducted with the Unit Manager for Station Two. He stated that generally when he identifies a resident that has a pacemaker, he would make sure they have a cardiologist and are doing routine follow-ups. He stated he had spoken with the DON (Director of Nursing) yesterday regarding Resident #1 and the DON indicated the family had been taking the resident to some of her cardiology appointments (prior to event 06/15/2104). The facility was not aware of these appointments, nor was any documentation produced verifying this. He confirmed that the facility was not aware if the pacemaker was being monitored. There was no evidence in Resident #1's record to indicate the family was taking Resident #1 for cardiology appointments. On 08/12/2014 at 12:20pm an interview was conducted with the DON. She indicated that residents with pacemakers were identified by highlighting on the history & physical. A care plan is then done. They will notify the attending physician that resident has a pacemaker and he will indicate whether to go by the manufacturers recommendations or he will write for cardiac consult. (Resident Records reviewed failed to demonstrate this process). The DON was not sure if they had a policy related to pacemakers, she would have to check. During the interview, the DON indicated that the daughter for Resident #1 was taking care of her appointments. She would pick up the resident and not say anything to anyone about it. The DON stated that she would tell the UM to call to get the Consultation reports. (The facility was unable to locate any cardiology consult reports). On 08/13/2014 at 09:45am phone calls were made to each number listed for Resident #1's daughter. The calls went to voicemail. A message was left for the daughter, but no return call was received by the end of the survey. The DON indicated she had tried to call the daughter as well but had not heard from her. On 08/12/2014 at approximately 12:00pm an interview was conducted with the MDS Coordinator for Unit One. She indicated when a resident gets admitted she reviews the history and develops a [DIAGNOSES REDACTED]. The MDS Coordinator said she identifies resident with Pacemakers, by looking at each Resident's [DIAGNOSES REDACTED]. A staff assisted record review was conducted for each resident identified by the facility as having a pacemaker. There was no clear or consistent process found for identifying residents with pacemakers, pacemaker specifications and the type of monitoring recommended or ordered. Physician orders [REDACTED].#1, 5, 10, 12, 13, 14, 15, and 16. No current physician orders [REDACTED]. With the assistance of the DON, on 08/12/2014 at approximately 12:20pm, Resident #10's medical record was reviewed regarding the resident's pacemaker. Resident #10 was identified past due for Pacemaker screening. Resident #10 was due for a pacemaker check 3 months ago in May 2014. Information obtained from previous admission record determined the resident's last pacemaker check was conducted in November 2013 per note from hospital. There was no evidence of device monitoring follow-up scheduled or the need for monitoring identified for this resident. With the assistance of the DON, Resident #12's medical record was reviewed regarding the resident's pacemaker. The DON indicated they (UM - Station One) were calling the physician now regarding the resident's pacemaker - to see when it was checked and when due again. With assistance of the DON, Resident #13's medical record was reviewed regarding the resident's pacemaker. There was no evidence in the record of when the resident's last pacemaker check was performed or when the resident was due for recheck. The facility's policy and procedure on pacemakers, pacemaker checks and /or Cardiology consults was requested. The facility was unable to produce a policy on their process related to pacemakers. Additional interview with the DON on 08/12/2014 at approximately 3:30pm, indicated she was writing a policy and tweaking it now and developing a procedure on how to set up the rechecking of the pacemaker for residents. She stated that a QA (Quality Assurance) probably should have been done following Resident #1's admission to the hospital on [DATE]. During additional discussion of the facility's Quality Assurance process on 08/13/2014, at approximately 2:15pm, the DON indicated that on 06/17/2014 there was a meeting in which the Unit Manager for Station Two (UM) took minutes. She stated the UM noted pacemakers - who had them and when they were last checked. The pacemaker issue was placed 'on hold' - they had a list of residents and there was no one in trouble. The facility did not present the minutes of this meeting. On 08/12/2014 at approximately 4:15pm an interview was conducted with the Administrator. He indicated he was made aware of the pacemaker failure for Resident #1. It had been his understanding that the facility had done all necessary monitoring of Resident #1's pacemaker before the incident happened.

Based on interviews with the Administrator and Director of Nursing, review of job descriptions and clinical record reviews, the facility failed to provide effective administration services to maintain the highest practicable well-being for 8 of 9 residents with pacemakers. The administrative staff failed to have processes in place regarding pacemaker checks. The administrative staff failed to immediately develop a policy and procedure regarding pacemaker checks following notification that sampled resident #1 had an emergency transfer secondary to pacemaker generator failure. (1, 5, 10, 12, 13, 14, 15, and 16) This failure of the Administrative staff led to a finding of Immediate Jeopardy on 8/13/14. The facility's administrator and Director of Nursing were notified of the finding of Immediate Jeopardy on 8/13/14 at about 4:00pm. The administrative staff immediately developed a policy and procedure related to pacemakers and pacemaker checks and began to implement it. However, the new policy was not fully implemented by survey exit, so this led to a determination of Ongoing Immediate Jeopardy. Please see evidence at F309. The findings: A clinical record review was conducted for Resident #1. Resident #1 was admitted to the facility in March 2011. The admission paperwork noted that Resident #1 had a permanent pacemaker that was implanted in 2007. Resident #1 was transferred to the hospital secondary to a syncopal episode (passed out) the evening of June 15, 2014. From March 2011 until the transfer date of June 15, 2014, there was no evidence in the clinical record that any pacemaker checks had been scheduled or conducted. The physician progress notes [REDACTED]. Under the section entitled 'History of Present Illness' the report stated, "She developed a syncopal episode and experiencing an acute mental status change. Subsequently, she was brought to (the hospital) for further evaluation. She has a significant history of sick sinus syndrome post dual chamber pacemaker implantation 11/27/2007, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. She has lost follow-up appointment since 6/17/2010 with unclear reasons. Interrogation of her device in emergency room revealed no capture of pacemaker leads. After she developed a syncopal episode, she hit her head on the floor. Subsequently, I was called by ER doctor immediately regarding the patient's current condition and no capture of lead and may consideration of an Emergency generator change out." Per the operative report, the emergency generator change out was preformed on 6/15/14 at 10:48pm. The cardiologist noted that it was functioning adequately post procedure. A follow-up cardiology office visit dated 7/3/14 was reviewed. Under 'Reason for Visit' the cardiologist wrote, "The patient is here for follow-up. Device generator replacement and wound check. Under the section for 'Plan' the cardiologist wrote, "Sick sinus syndrome - she had a [MEDICAL CONDITION] due to non-capture of a pacemaker lead. status [REDACTED]." An interview was conducted with the Director of Nursing (DON) on 8/12/14 at approximately 12:20pm. The DON was asked about the current process for residents with pacemakers. The DON stated that when a new resident who has a pacemaker is admitted , the pacemaker is highlighted on the History and Physical and a care plan is done. Then the facility will notify the Medical Director who will either say to follow manufacturer's recommendations for pacemaker checks, or he will write for cardiac a consult. The cardiologist's typically will have residents return every 6 months. A clinical record review for physician orders was conducted for residents #1, 5, 10, 12, 13, 14, 15, and 16. Prior to the initiation of the survey on 8/11/14, there were no physician orders seen regarding pacemaker checks for residents #1, 5, 10, 12, 13, 14, 15, and 16. On 8/12/14 at approximately 3:30pm, another interview was conducted with the Director of Nursing (DON). The DON stated that she is currently in the process of writing a policy and tweaking it now and developing a procedure on how to set up the rechecking of the pacemakers for residents. She stated that a QA (Quality Assurance) probably should have been done following Resident #1's admission to the hospital on [DATE]. An follow-up interview was conducted with the DON on 8/13/14, at approximately 2:15pm. The DON stated that she was aware of the pacemaker issue for Resident #1 on 6/17/14. The DON stated that on 6/17/14 there was a meeting in which the Unit Manager for Station Two (UM) took minutes. She stated the UM noted pacemakers - who had them and when they were last checked. The pacemaker issue was placed 'on hold' - they had a list of residents and there was no one in trouble. The facility did not present the minutes of this meeting for review. An interview was conducted with the administrator on 8/12/14 at approximately 4:15pm. The administrator confirmed that he was aware of the pacemaker incident for resident #1. He stated that had been advised of the pacemaker issue with Resident #1 after it occurred and had been told all prior checks had been done. The administrator was informed that this information could not be located. He stated that he would look into it. Interview with the Administrator on 08/12/0214 at 4:15pm, who serves on the facility's QA Committee, stated he had been advised of the pacemaker issue with Resident #1 after it occurred and had been told all prior checks had been done. A follow-up interview was conducted with the administrator on 8/13/14 at approximately 2:00pm. The administrator stated that he discussed the pacemaker issue with the DON about the time that Resident #1 returned from the hospital. He thought that the DON was taking care of this. The Job Description for the Director of Nursing (DON), dated August 26, 1998, was provided for review. The 'Summary of the Job' stated: "The Director of Nursing is responsible for planning, organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal, state and local standards and established nursing policies and procedures." The 'Essential Functions of the Job' section stated: 2. Plans, organizes, implements, evaluates and supervises the day to day nursing functions in accordance with current rules, regulations and guidelines that govern the facility." 3. Develops methods for coordinating nursing services with other residents services to ensure the continuity of the residents total plan of care. 14. Monitors and evaluates problem areas in the department and conducts meetings as necessary to improve quality of service. 27. Participates in developing and establishing CQI (Continuous Quality Improvements), nursing programs, safety programs and company policies and procedures that will enhance resident care and safety and participates in executing those policies. A very poor copy of the Job Description for the Administrator, dated August 26, 1998, was provided for review. The left-hand side of the job description had been cut off, leaving missing words and partial sentences. What could be read of the 'Summary of the Job' stated: "Administrator is responsible for developing, managing and supervising the overall ___ of the facility in accordance with current Federal, state and local standards and ___ nursing policies and procedures. " The ''Essential Functions of the Job' section included these statements: "Monitors and evaluates problem areas in all department and conducts meetings as necessary to improve quality of service." Ensures that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional ____, as defined by the comprehensive assessment and care plan. " "___, develops and ensures implementation of plans of action to correct ____ and provides copies as required."

Based on staff interview, interview with the Medical Director, review of the Medical Director Agreement and clinical record reviews, the facility failed to ensure that the Medical Director coordinated the medical care in the facility for 8 of 9 residents with pacemakers. The facility failed to have processes in place regarding pacemaker checks. The facility in conjunction with the medical director failed to immediately develop a policy and procedure regarding pacemaker checks following notification that sampled resident #1 had an emergency transfer secondary to pacemaker generator failure. (1, 5, 10, 12, 13, 14, 15, and 16) This systemic failure led to a finding on Immediate Jeopardy on August 13, 2014. The facility's administrator and Director of Nursing were notified of the finding of Immediate Jeopardy on 8/13/14 at about 4:00pm. The administrative staff immediately developed a policy and procedure related to pacemakers and pacemaker checks and began to implement it. However, the new policy was not fully implemented by survey exit, so this led to a determination of Ongoing Immediate Jeopardy. Please see evidence at F309. The findings: A clinical record review was conducted for Resident #1. Resident #1 was admitted to the facility in March 2011. The admission paperwork noted that Resident #1 had a permanent pacemaker that was implanted in 2007. Resident #1 was transferred to the hospital secondary to a syncopal episode (passed out) the evening of June 15, 2014. From March 2011 until the transfer date of June 15, 2014, there was no evidence in the clinical record that any pacemaker checks had been scheduled or conducted. The physician progress notes [REDACTED]. Under the section entitled 'History of Present Illness' the report stated, "She developed a syncopal episode and experiencing an acute mental status change. Subsequently, she was brought to (the hospital) for further evaluation. She has a significant history of sick sinus syndrome post dual chamber pacemaker implantation 11/27/2007, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. She has lost follow-up appointment since 6/17/2010 with unclear reasons. Interrogation of her device in emergency room revealed no capture of pacemaker leads. After she developed a syncopal episode, she hit her head on the floor. Subsequently, I was called by ER doctor immediately regarding the patient's current condition and no capture of lead and made consideration of an Emergency generator change out." Per the operative report, the emergency generator change out was preformed on 6/15/14 at 10:48pm. The cardiologist noted that it was functioning adequately post procedure. A follow-up cardiology office visit dated 7/3/14 was reviewed. Under 'Reason for Visit' the cardiologist wrote, "The patient is here for follow-up. Device generator replacement and wound check. Under the section for 'Plan' the cardiologist wrote, "Sick sinus syndrome - she had a [MEDICAL CONDITION] due to non-capture of a pacemaker lead. status [REDACTED]." An interview was conducted with the Director of Nursing (DON) on 8/12/14 at approximately 12:20pm. The DON was asked about the current process for residents with pacemakers. The DON stated that when a new resident who has a pacemaker is admitted , the pacemaker is highlighted on the History and Physical and a care plan is done. Then the facility will notify the Medical Director who will either say to follow manufacturer's recommendations for pacemaker checks, or he will write for cardiac a consult. The cardiologist's typically will have residents return every 6 months. A clinical record review for physician orders was conducted for residents #1, 5, 10, 12, 13, 14, 15, and 16. Prior to the initiation of the survey on 8/11/14, there were no physician orders seen regarding pacemaker checks for residents #1, 5, 10, 12, 13, 14, 15, and 16. On 8/12/14 at approximately 3:30pm, an interview was conducted with the Director of Nursing (DON). The DON stated that she is currently in the process of writing a policy and tweaking it now and developing a procedure on how to set up the rechecking of the pacemakers for residents. She stated that a QA (Quality Assurance) probably should have been done following Resident #1's admission to the hospital on [DATE]. A follow-up interview was conducted with the DON on 08/13/2014, at approximately 2:15pm. The DON stated that she was aware of the pacemaker issue for Resident #1 on 6/17/14. The DON stated that on 06/17/2014 there was a meeting in which the Unit Manager for Station Two (UM) took minutes. She stated the UM noted pacemakers - who had them and when they were last checked. The pacemaker issue was placed 'on hold' - they had a list of residents and there was no one in trouble. The facility did not present the minutes of this meeting for review. An interview was conducted with the Medical Director on 8/13/14 at approximately 1:45pm. The Medical Director was asked about physician orders for pacemaker checks. The Medical Director stated that he had always left pacemaker monitoring up to the cardiologist or the doctor who put the pacemaker in. It is something that I haven't been actively involved in. If you have a pacemaker, then you always have a Cardiologist and checks are usually done in the Cardiologist's office. Typically the facility takes the resident to the Cardiologist. Sometimes I write the order for a Cardiology consult, and sometimes the families just take them - I don't write an order for [REDACTED]. The medical director was specifically asked about Resident #1. The Medical Director confirmed that he was the designated facility physician for Resident #1. The Medical Director stated, "I don't know how it happened". We are going to look into it at QA (quality assurance) tomorrow. It is such a routine thing that pacemakers get checked. I am not a Cardiologist - I don't know how often the various types of pacemakers need checked. That is why I refer them to the Cardiologist for this. Two of my residents get pacemaker checks every 6 months, but the pacemaker technician told me that in reality they only need done every 12 to 18 months according to how old the pacemaker is. The 'Medical Director Agreement' was requested and reviewed. The Agreement was signed and dated on 2/28/14. The document stated that the Medical Director's Services included: 12a. Provide medical direction and coordination of the Facility medical care. 12e. Facilitate the identification and correction of problem areas.

Based on staff interviews and resident record reviews, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop and implement a plan of action to ensure resident's with pacemakers received appropriate device monitoring. The Quality Assurance committee failed to immediately develop an action plan to address pacemaker checks following notification on 6/17/14 that sampled resident #1 had an emergency transfer secondary to pacemaker generator failure. This affected 8 of 9 total residents with pacemakers. (Residents #1, 5, 10, 12, 13, 14, 15, and 16). This failure of the Quality Assessment and Assurance (QAA) committee led to a finding of Immediate Jeopardy (IJ) on August 13, 2014. The facility's administrator and Director of Nursing were notified of the finding of Immediate Jeopardy on 8/13/14 at about 4:00pm. The administrative staff immediately developed a policy and procedure related to pacemakers and pacemaker checks and began to implement it. A QAA meeting was scheduled for the next day, 8/14/14. The new policy was not fully implemented by survey exit on 8/13/14. This led to a determination of Ongoing Immediate Jeopardy. Please see evidence at F309. The findings include: A clinical record review was conducted for Resident #1. Resident #1 was admitted to the facility in March 2011. The admission paperwork noted that Resident #1 had a permanent pacemaker that was implanted in 2007. Resident #1 was transferred to the hospital secondary to a syncopal episode (passed out) the evening of June 15, 2014. From March 2011 until the transfer date of June 15, 2014, there was no evidence in the clinical record that any pacemaker checks or cardiology consults had been scheduled or conducted. The physician progress notes [REDACTED]. Under the section entitled 'History of Present Illness' the report stated, "She developed a syncopal episode and experiencing an acute mental status change. Subsequently, she was brought to (the hospital) for further evaluation. She has a significant history of sick sinus syndrome post dual chamber pacemaker implantation 11/27/2007, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. She has lost follow-up appointment since 6/17/2010 with unclear reasons. Interrogation of her device in emergency room revealed no capture of pacemaker leads. After she developed a syncopal episode, she hit her head on the floor. Subsequently, I was called by ER doctor immediately regarding the patient's current condition and no capture of lead and may consideration of an Emergency generator change out." Per the operative report, the emergency generator change out was performed on 6/15/14 at 10:48pm. The cardiologist noted that it was functioning adequately post procedure. Resident #1 was discharged from the hospital and readmitted to the facility on [DATE]. Each of the Unit Managers (Station One and Station Two) were interviewed, along with the DON regarding the process for identifying residents with pacemakers and device monitoring. Each Unit Manager and DON identified a different process (see below). On 08/12/2014 at approximately 9:10am an interview was conducted with the Unit Manager for Station Two. He stated that generally when he identifies a resident that has a pacemaker, he would make sure the resident had a cardiologist and that routine follow-ups were being done. On 08/12/2014 at approximately 10:35am an interview was conducted with the Unit Manager for Station One. She stated when a resident first comes in, she would try to put it down (on paper), if have a pacemaker - that's how she identifies residents with pacemakers. She would try to find out when placed, last time checked. She would personally fill out appointment paperwork. She indicated if a nurse admits a patient with a pacemaker, she would just hope she came into work the next day to find out. There is a section in the Nursing Admission Assessment to include presence of pacemaker and when last checked. That would be how she would find out. She is not sure if the facility has a policy related to Pacemaker monitoring On 08/12/2014 at approximately 12:20pm an interview was conducted with the DON. She indicated that residents with pacemakers are identified by highlighting on the history & physical. A care plan is then done. They will notify the attending physician that resident has a pacemaker and he will indicate whether to go by the manufacturers recommendations or he will write for cardiac consult. (Resident Record reviewed failed to demonstrate this process). The DON was not sure if they had a policy related to pacemakers, she would have to check. On 08/12/2014 a list of residents with pacemakers was requested. There were six residents on Station Two and three residents on Station One. The facility was asked to identify what type, when implanted, last device monitoring performed and when next monitoring of pacemakers was due. The facility did not have a process in place, to readily identify this information. The information was obtained by previous admission record, current medical record, contacting of the resident's cardiologist (if identified) or other source. There was no defined process in place to readily identify this information, or a policy established to ensure that residents with pacemakers received the care and services in order to maintain there highest practicable well-being. On 8/12/14 at approximately 3:30pm, an interview was conducted with the Director of Nursing (DON). The DON stated that she is currently in the process of writing a policy and tweaking it now and developing a procedure on how to set up the rechecking of the pacemakers for residents. The DON had confirmed that no QA (Quality Assurance) had been conducted for the pacemaker issue but probably should have. An interview with the DON on 08/13/2014 at approximately 2:15pm indicated that on 06/17/2014, prior to Resident #1's readmission to the facility, there was a meeting held in which the Unit Manager for Station Two took minutes. She indicated that the pacemaker issue was discussed - who had them and when they were checked. She stated the pacemaker issue was placed 'on hold" - as they had a list of residents and there was no one in trouble. The facility did not present minutes of this meeting for review. An interview was conducted with the Administrator, who serves on the facility's QA Committee, on 08/12/0214 at approximately 4:15pm. The administrator stated he had been advised of the pacemaker issue with Resident #1 after it occurred and had been told all prior checks had been done. The Medical Director, who also serves on the QA Committee, was interviewed by telephone on 08/13/2014 at approximately 1:45pm. The Medical Director was asked about physician orders [REDACTED]. It is something that I haven't been actively involved in. If you have a pacemaker, then you always have a Cardiologist and checks are usually done in the Cardiologist's office. Typically the facility takes the resident to the Cardiologist. Sometimes I write the order for a Cardiology consult, and sometimes the families just take them - I don't write an order for [REDACTED]. The medical director was specifically asked about Resident #1. The Medical Director confirmed that he was the designated facility physician for Resident #1. The Medical Director stated, "I don't know how it happened". We are going to look into it at QA (quality assurance) tomorrow. It is such a routine thing that pacemakers get checked. I am not a Cardiologist - I don't know how often the various types of pacemakers need checked. That is why I refer them to the Cardiologist for this. Two of my residents get pacemaker checks every 6 months, but the pacemaker technician told me that in reality they only need done every 12 to 18 months according to how old the pacemaker is.