Every finding on record at Fleet Landing

Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that the resident environment remained free of accident hazards for one (Resident #32) of two residents reviewed for accident hazards, from a total survey sample of 21 residents.The findings include:On 07/21/20 25 at 11:41am, a tube of Voltaren Arthritis Pain (diclofenac sodium) topical gel 1% was observed in the bathroom on a side table, next to the toilet of Resident #32. (Photographic evidence obtained) An interview was attempted with Resident #32 at that time; however, he was unable to answer any questions related to the Voltaren tube observed. On 07/21/2025 at 8:26 am, a tube of Voltaren Arthritis Pain (diclofenac sodium) topical gel 1% was observed in the bathroom on a side table, next to the toilet of Resident #32. (Photographic evidence obtained)On 07/22/2025 at 2:22 pm, Resident #32 was observed in his bathroom by himself. He stated he had just finished and was observed walking out of his bathroom by himself to his bed. A tube of Voltaren Arthritis Pain (diclofenac sodium) topical gel 1% was observed in the bathroom on a side table. (Photographic evidence obtained)A review of Resident #32's medical record revealed diagnoses including unspecified dementia and unspecified glaucoma. A review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/2025, revealed that Resident #32 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 possible points, indicating severely impaired cognitive function. A review of Resident #32's active physician's orders revealed no order for Voltaren Arthritis Pain (diclofenac sodium) topical gel 1%. The tube observed in his bathroom had an expiration date of August 2023.A review of the resident-centered care plan revealed:Focus: (12/31/24) (Resident #32) has impaired cognitive function/dementia or impaired thought processes.Goal: (Resident #32) will be able to communicate basic needs on a daily basis through the review date. Interventions: The resident needs assistance with all decision making. Focus (1/9/25) (Resident #32) has impaired visual function related to Glaucoma.Goal: (Resident #32) will maintain optimal quality of life within limitations imposed by visual function through the review date.Interventions: Tell the resident where you are placing their items; be consistent. The resident is able to see objects in the room. On 07/22/2025 at 2:30 pm during an interview with Certified Nursing Assistant (CNA) A, she was asked if she was caring for Resident #32. She replied that she was. She was asked if he was expected to be in the bathroom by himself. She stated, No, he should have staff with him. She was asked about the tube of Volteran gel in his bathroom which was observed during this interview. She stated, Oh, I think their niece brought that in when they moved here. She was asked who applied the gel to the resident. She stated, I don't know, I've never used it. On 07/22/2025 at 2:40 pm during an interview with Licensed Practical Nurse (LPN) B, she was asked if she was caring for Resident #32. She replied that she was. She was asked if she knew whose tube of Volteran gel was in Resident #32's bathroom, which was observed in the bathroom during this interview. She stated, I'm not sure. I don't think either he or his wife have an order for that. They have a niece. She may have brought it in. She was asked if it should be in the bathroom unattended. She stated, No, it should be labeled and kept locked in the treatment cart. She picked the tube up and stated, It's old. The expiration date is August 2023. I didn't even see it there, and I filled up their briefs in their bathroom this morning. On 07/22/2025 at 3:10 pm during an interview with the Director of Nursing (DON), she was asked what the expectation was for medications being stored in residents' rooms/bathrooms. She stated, They are not allowed to have medication in rooms unless they have an order for self-medication. She was asked if Resident #32 had orders for self-administration of medication. She said no. She was asked if she was aware that there was a tube of Volteran gel in Resident #32's bathroom. She stated it should not have been there. We are going to issue a memo about families bringing in things like that and even cough drops. We have been checking rooms recently for these things. A review of a facility's policy and procedure titled Medication Storage (Effective 03/01/2023, Revised 05/01/2025) revealed: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturers' recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms.)

Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that two (Residents #31 and #32) of two residents reviewed for activities of daily living (ADLs), from a total survey sample of 21 residents, received necessary services to maintain good grooming and hygiene, specifically fingernail care, when they were unable to complete ADLs independently. The findings include: 1.On 07/21/2025 at 11:40 am, Resident #31 was observed lying in bed. Her fingernails on both hands were elongated with brown debris under each of the nails. The resident was asked if she preferred her nails long. She stated, No, I like them trimmed. (Photographic evidence obtained) On 07/22/2025 at 8:30 am, Resident #31 was observed lying in bed with her eyes closed. She opened her eyes when she was greeted. Her fingernails were elongated with brown debris underneath.A review of Resident #31's Minimum Data Set (MDS) assessment, dated 04/14/2025, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. The resident was documented as dependent for self-care of personal hygiene. Further review of the MDS revealed that Resident #31 had no behaviors documented, including refusal of care.A review of Resident #31's person-centered care plan revealed:Focus: (12/31/24, revised 4/17/25) (Resident #31) has ADL self-care deficit performance related to dementia and other medical co-morbidities.Goal: (Resident #31) will maintain current level of function in ADLs through the review date. Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Personal Hygiene: The resident requires supervision with personal hygiene. Resident #31 was not care-planned for behaviors or refusal of care. 2. On 07/21/2025 at 11:38 am, Resident #32 was observed sitting up at the side of his bed. His fingernails on both hands were untrimmed. His right ring fingernail and his left middle, ring, and pinky fingernails were jagged. All of his fingernails had brown debris under them. (Photographic evidence obtained) On 07/22/2025 at 8:28 am, Resident #32 was observed lying in bed with his eyes closed. He opened his eyes when he was greeted and sat up on the edge of the bed to eat his breakfast. Fingernails on both hands were untrimmed. His right ring fingernail and his left middle, ring, and pinky fingernails were jagged. All of his fingernails had brown debris under them.A review of Resident #32's MDS assessment, dated 04/07/2025, revealed a BIMS score of 2 out of 15 possible points, indicating severely impaired cognition. The resident was documented as requiring partial to moderate assistance for self-care and supervision or touching assistance for personal hygiene. No behaviors were documented, including refusal of care. A review of the resident's person-centered care plan revealed:Focus: (12/31/24) (Resident #32) has ADL self-care deficit performance related to dementia and other medical co-morbidities.Goal: (Resident #32) will maintain current level of function in ADLs through the review date. Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Personal Hygiene: The resident requires supervision with personal hygiene. Resident #32 was not care-planned for behaviors or refusal of care. On 07/22/2025 at 2:30 pm, during an interview with Certified Nursing Assistant A, she was asked if she was caring for Residents #31 and #32. She replied, Yes. When she was asked who was responsible for cleaning and trimming the residents' fingernails, she replied that it was an Activities event. They do nails on Saturdays; they file and buff them. She was asked who trimmed the residents' fingernails. She replied, We, the CNAs are not allowed to do that. The nurses trim the nails. She was asked how she cleaned residents' fingernails. She stated, I don't like to use the orange sticks; I'll use a washcloth to try to clean under the nails. She was asked to observe Residents #31 and #32's fingernails. She observed both residents' fingernails and confirmed they both had debris under their nails. She stated some of Resident #32's fingernails were jagged and unkempt and Resident #31's fingernails were elongated with debris under the nails. Resident #31was under hospice care. I think they try to clean her nails but sometimes she refuses. On 07/22/2025 at 2:40 pm during an interview with Licensed Practical Nurse (LPN) B, she was asked if she was caring for Residents #31 and #32. She stated she was. She was asked who was responsible for cleaning and trimming residents' fingernails. She stated, Well, mostly the nurses do fingernails when nails are observed to be long. The CNAs can't trim the diabetics' fingernails; only nursing can do those. Activities, I think, can file nails; I'm not sure if they can trim them. She was asked if there was a schedule for fingernail care. She stated, No, there's no schedule. She was asked to observe Residents #31 and #32's fingernails. She observed Resident #32's fingernails and confirmed that some of his nails were long and jagged with debris under them. She stated, They shouldn't be jagged because he could scratch his skin. She observed Resident #31's fingernails and confirmed that they were elongated with debris under them. LPN B stated, Sometimes she refuses to have them cut, so we try to file them. She was asked what nursing did if a resident refused to have personal care provided. She stated, We should document the behavior and let the doctor know. She was asked where she had documented this resident's refusal of fingernail care. She stated she had not documented it. She was asked which doctor she had notified. She stated she had not notified the doctor. On 07/22/2025 at 3:00 pm, during a second interview with LPN B, she stated, I found out that Activities staff can only file nails, they can't trim them. We don't have specific orders for fingernail care; we just check them as part of our regular care and assessment. Anyone, nurses and CNAs can file the nails, and they should be cleaned on shower days and also as needed, but trimming the fingernails is only nursing. She was asked how often Residents #31 and #32 were scheduled for showers. She replied, Twice a week. On 07/22/2025 at 3:10 pm during an interview with the Director of Nursing (DON), she was asked what the expectation was for residents' fingernail care, including cleaning under fingernails and trimming them. She stated this was a part of their daily hygiene. It's very important for staff to communicate with the residents for their needs. The bath expectation is three times a week, but they do refuse sometimes. Refusals should be documented. Nails should be cleaned and trimmed at that time, on shower days. She was asked who was permitted to trim and clean the residents' fingernails. She stated, The CNAs and the nurses, except CNAs cannot trim diabetics' fingernails. She was asked if a resident refused this care, was it documented. She stated it should be documented in their POC (plan of care) system, and they should be care planned for it. A review of the facility's policy and procedure titled Activities of Daily Living (ADLs) (Effective 3/1/23, Revised 5/21/25) revealed:Policy:The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following ADLs:1. Bathing, dressing, grooming, and oral care.Policy Explanation and Compliance Guidelines:3. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, record review, and facility policy and procedure review, the facility failed to ensure that services provided met professional standards of quality for one (Resident #30) of two residents observed during administration of medication. Medication orders were not verified prior to twice attempted administration of medicated eye drops in the resident's wrong eye. The findings include: On 8/1/23 at 9:33 a.m., Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #30. A review of the resident's medication orders revealed the following: Pilocarpine (medication used for treatment of glaucoma and ocular hypertension) 1% eye drops: Administer one drop to right eye twice a day. LPN A was observed positioning the Pilocarpine eye drop bottle over Resident #30's left eye in order to administer the medication. The resident said, Not that eye. LPN A again attempted to position the eye drop bottle over the resident's left eye. The resident raised his left arm to block the eye drop bottle stating, Wrong eye, it's my right eye. LPN A then stopped and stated, Oh, you're right. LPN A then proceeded to administer the eye drop in the resident's right eye. A review of facility policies and procedures revealed: Medication Administration (revised 4/28/23) Policy Explanation and Compliance Guidelines: 11. Compare medication source with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time. Administration of Eye Drops (revised 4/28/23) Policy Explanation and Compliance Guidelines: 1. Verify orders and labeling prior to administration: c. Confirm which eye requires treatments.

Based on observation, record review, staff interview, and facility policy and procedure review, the facility failed to ensure residents' personal privacy during medical treatment for one (Resident #1) of two residents observed during medication administration. Resident #1 was not provided privacy during medication administration via her gastrostomy tube (feeding tube). The findings include: On 8/2/23 at 1:00 p.m., Licensed Practical Nurse B was observed preparing medications for Resident #1. A review of the resident's medication orders revealed that all her medications were administered through her gastrostomy tube (feeding tube). LPN B was observed administering two medications through the gastrostomy tube to Resident #1. LPN B did not provide privacy to the resident during the medication administration process. LPN B did not pull the privacy curtain or close the door to the room. The resident was visible from the hallway during this medication administration. LPN B then prepared an additional medication that was due but did not provide privacy to the resident during the medication administration process. LPN B did not pull the privacy curtain or close the door to the room. LPN B was asked how she provided privacy to residents during medication administration. She stated, By pulling the curtain. She was asked why she did not provide privacy for Resident #1 during her medication administration. She replied, I don't know, I guess I just thought because you were watching I didn't have to. A review of facility policies and procedures revealed: Medication Administration (revised 4/28/23) Policy Explanation and Compliance Guidelines: 7. Provide privacy Medication Administration via Enteral Tube (revised 4/28/23) 8. Procedure: d. Provide privacy by pulling the privacy curtain or closing the door to a private room.

Based on observation, staff interview, clinical record review, employee record review and facility policy and procedure review the facility failed to ensure infection prevention and control procedures for the [MEDICAL CONDITION] 2019 (COVID-19) pandemic were operationalized by staff to reduce the spread of infection from residents who were residing in identified transmission based precaution rooms (#201 and #202) to a resident who was not residing in a transmission based precaution room (#203). The possible transmission of infectious organisms could present a health risk to the 56 residents of the facility. The findings include: Employee A, Certified Nursing Assistant (CNA) was observed on 07/07/ at 12:05 p.m. with Personal Protective Equipment (PPE) gown, surgical mask and face shield on when passing lunch trays. She took a lunch tray into room [ROOM NUMBER] at 12:08 p.m. The door had a bright pink sign indicating that the room was an isolation/quarantine room. She entered the room and shut the door. She could be heard speaking with the resident. She exited the room at 12:12 p.m. She had the same PPE gown, face mask and shield on. She had no gloves on. She then took a lunch tray off the cart and went into room [ROOM NUMBER] at 12:13 p.m. The door had a bright pink sign indicating that the room was an isolation/quarantine room. She entered the room and shut the door. She could be heard speaking with the resident. She exited the room at 12:16 p.m. She had the same PPE gown, face mask and shield on. She had no gloves on. She then took a lunch tray off the cart and went into room [ROOM NUMBER] at 12:18 p.m. There was no sign on the door indicating it was an isolation/quarantine room. She left the door of the room open and was observed to set the lunch tray on the tray table. She was overheard speaking to the resident. The resident reached up and grabbed the sleeve of the PPE gown and tugged on it. He then let go of it. She moved the tray table in front of him and set up his tray and left the room. She went to the sink in the resident's room and washed her hands for five seconds; dried her hands with a paper towel, discarded the paper towel and then exited the room at 12:24 p.m. She had the same PPE gown, face mask and shield on. She came back to the tray cart to get the next meal tray. During an interview with Employee A at 12:28 p.m., when asked about the rooms with the bright pink signs on them she explained that they are quarantine rooms for newly admitted residents. She confirmed that rooms [ROOM NUMBERS] were isolation rooms for COVID-19 precautions. The residents in those two rooms had been recently admitted from the hospital and they had to be quarantined for 14 days. She stated that she was trained to wear her PPE when entering a quarantine room. She was to wear a gown, mask and face shield. She did not have to wear gloves if she washed her hands thoroughly prior to leaving the room. She did not have to wear gloves to pass meal trays. She did not have to doff the PPE after leaving the room if she were going into another quarantine room. She stated she was expected to doff the PPE when leaving a quarantine room if she were going to another room that was not an isolation/quarantine room. She confirmed that room [ROOM NUMBER] was not an isolation/quarantine room. She stated she was expected to change the PPE if she was going into another room that was an isolation room for another reason other than COVID-19. She stated she did not know where she would throw away the PPE gown after leaving the last quarantine room because there was no red garbage can (biohazardous) in the room and there was no place to hang up the gown in room [ROOM NUMBER]. She stated that she would need to change her PPE if she was assisting residents who were in isolation if she were going from room to room. When asked if she considered her PPE contaminated after leaving an isolation/quarantine room, she stated, I should. I don't know. I was told we could wear them from room to room. Clinical record review for residents in rooms 201 (admitted [DATE]) and 202 (admitted [DATE]) revealed a physician's order that read: Isolation Protocol post hospitalization x14 days. Staff to wear PPE. Every day and night shifts (Photographic evidence obtained). During an interview with the Administrator on 07/07/2020 at 12:51 p.m., she was informed of the observations of Employee A delivering the lunch trays. She agreed the CNA should have doffed her PPE after leaving room [ROOM NUMBER] and prior to entering room [ROOM NUMBER] due to the resident in 203 not being in quarantine. She explained that the staff have been instructed to wear the same PPE from one quarantined room to the next. They hired a consultant to provide more training to the staff regarding infection control. The consultant did train them to wear PPE for the quarantine rooms as if the residents were positive for COVID-19. She stated they have been operating under Crisis Capacity mode and have been trying to use the PPE gowns for a whole shift for quarantined rooms. She stated she would speak to the CNA and the consultant again. During an interview with Employee A on 07/07/2020 at 3:23 p.m. she stated that she is to take off the PPE and throw it away and then wash her hands when leaving an isolation/quarantine room. She later stated that they could re-use the gown during the shift. When asked if she was to leave the gown in the room, she stated yes. She stated she washed her hands in rooms [ROOM NUMBERS]. I always wash my hands. I've been washing my hands for a long time doing this job. I know to wash my hands. She was informed of the observation in room [ROOM NUMBER] when she washed her hands for only 5 seconds. She did not dispute the observation. She stated she is supposed to remove her gloves and wash her hands for 20 seconds prior to leaving a resident's room. During an interview with the Administrator on 07/07/2020 at 4:37 p.m., she stated the facility hired a consultant to advise them on COVID-19. She submitted a written summary of her recommendations to the administrator on 06/25/2020. Review of the report revealed it stated, Gowns worn in 14-day isolation rooms cannot be worn in other rooms. Staff are wearing same gown in and out of all rooms, including 14-day isolation rooms. Develop policy and procedure to dedicate gown to each resident and staff member and prioritize gown use for high contact care activities. (Copy obtained). The administrator confirmed that the staff should use the same transmission based precautions for the quarantined residents as they would any resident in isolation for any reason. They should consider the resident to be infected with COVID-19 and the PPE they wear in the room to be contaminated. Review of the training file for Employee A revealed she received infection control training on 05/19/2020 and 05/21/2020. The training curriculum stated, Strategies to get the best possible use of difficult to obtain PPE. Do Not Wear Gown into multiple resident rooms from a resident that is on Contact Precautions. Handwashing. Practice effective hand hygiene, lather for 20 seconds. Employee A received Infection Control Precautions training on 03/29/2020 and Personal Protective Equipment (PPE) training on 03/26/2020 (Copy obtained). Review of the facility policy and procedure for infection control revealed it read: It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. Definitions: Isolation refers to the practices employed to reduce the spread of an infectious agent and/or minimize the transmission of infection. Standard precautions (formerly Universal Precautions) refers to infection prevention practices that apply to all residents, regardless of suspected or confirmed [DIAGNOSES REDACTED]. Transmission-based precautions (a.k.a. Isolation Precautions) refers to the actions (precautions) implemented, in addition to standard precautions, that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Airborne precautions refers to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air. Contact precautions are measures that are 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. Droplet precautions refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. 1. Facility staff will apply Standard Precautions to all residents under the assumption that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. 3. The facility will use standard approaches, as defined by the Centers for Disease Control and Prevention (CDC), for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Review of the table entitled Recommendations for PPE revealed for Standard precautions gloves, gown, mask, eye protection, and or face shield are to be used. For Contact precautions gloves and gowns are to be worn. For Droplet precautions gloves, gown and mask are to be worn and for Airborne precautions gloves, gown and respirator are to be worn (Copy obtained). Review of the facility COVID-19 Policy and Procedure revealed it read: Staff members have been in-serviced on the following: 1. General Standard Precautions, including respiratory hygiene/cough etiquette. 5. Hand hygiene including a return demonstration. 6. Proper PPE use. 7. Transmission Base Precautions. Physician Appointments: 1. Only medically necessary appointments are recommended at this time ([MEDICAL TREATMENT], life sustaining, etc.). Upon return from the appointment the resident will be placed in isolation/quarantine for 14 days. 2. Staff members rendering care will utilize face shields and surgical masks when entering the room. Admission of new residents: 3. All new admissions will be quarantined to their rooms for 14 days. 4. Staff members rendering care will utilize gowns, face shields and surgical masks when entering the room (Copy obtained). Reference: In healthcare facilities, education and training on Standard and Transmission-Based Precautions are typically provided at the time of orientation and should be repeated as necessary to maintain competency; updated education and training are necessary when policies and procedures are revised or when there is a special circumstance, such as an outbreak that requires modification of current practice or adoption of new recommendations. Education and training materials and methods appropriate to the health care workers (HCWs) level of responsibility, individual learning habits, and language needs, can improve the learning experience. Adherence to recommended infection control practices decreases transmission of infectious agents in healthcare settings. Education and training of healthcare personnel are a prerequisite for ensuring that policies and procedures for Standard and Transmission-Based Precautions are understood and practiced. Understanding the scientific rationale for the precautions will allow HCWs to apply procedures correctly, as well as safely modify precautions based on changing requirements, resources, or healthcare settings. Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings and is an essential element of Standard Precautions. Hand hygiene is always the final step after removing and disposing of PPE. Isolation gowns should be removed before leaving the patient care area to prevent possible contamination of the environment outside the patient's room. Isolation gowns should be removed in a manner that prevents contamination of clothing or skin (Figure). The outer, contaminated, side of the gown is turned inward and rolled into a bundle, and then discarded into a designated container for waste or linen to contain contamination. Removal of a face shield, goggles and mask can be performed safely after gloves have been removed, and hand hygiene performed. The ties, earpieces and/or headband used to secure the equipment to the head are considered clean and therefore safe to touch with bare hands. The front of a mask, goggles and face shield are considered contaminated (Figure). Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Last update: October 2017. Pages 45, 47, 48, 51, and 53 of 203, https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html Reference: Interim Infection and Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic. 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions. HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. Employers should select appropriate PPE and provide it to HCP in accordance with OSHA PPE standards (29 CFR 1910 Subpart I). HCP must receive training on and demonstrate an understanding of: when to use PPE what PPE is necessary how to properly don, use, and doff PPE in a manner to prevent self-contamination how to properly dispose of or disinfect and maintain PPE the limitations of PPE. Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

Based on observations, record reviews and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on 31 opportunities with four errors for Resident #26. This resulted in an error rate of 12.9%. The findings include: On 11/19/19 at 10:30 am, observation of medication administration was conducted with Employee A, Licensed Practical Nurse (LPN), and Resident #26. Employee A had performed blood glucose testing at 10:10 am. The result was a blood glucose level of 446. Employee A reviewed the sliding scale insulin order to determine how much insulin needed to be given. She determined 6 units of Humalog insulin were needed. Also, the order stated for blood glucose levels greater than 430, the physician was to be notified. Employee A prepared 2 syringes with insulin. She drew up 5 units of [MEDICATION NAME]in one syringe and 6 units of Humalog in the other. She entered the resident's room and administered the 2 syringes of insulin to Resident #26. A review of the physician's orders [REDACTED]. The orders also included instructions to administer 2 units of Humalog before each meal and this was due at 11:30 am. There was no dose given at 11:30 am. Blood glucose monitoring was ordered every four hours and the next one due was at 2:00 pm. At 2:30 pm, an interview was conducted with Employee [NAME] She was asked what the resident's blood glucose level was at 2:00 pm. She said she had not done it yet, as she was assisting the wound physician. She verified that she did not give the morning dose of [MEDICATION NAME] at 7:30 am as ordered. She gave it after she performed the 10:00 am blood glucose test, along with the sliding scale insulin. She also confirmed she did not give the 11:30 am dose of [MEDICATION NAME] due before lunch, since she had given the other dose late. On 11/19/19 at 4:30 pm, Employee A was observed preparing 2 syringes of insulin. One syringe contained 3 units of [MEDICATION NAME] scheduled for 5:00 pm, and the other contained 2 units of Humalog, based on sliding scale, and 3 units due before the meal. Employee A was asked what time she performed the blood glucose testing and she said at 4:15 pm. When asked what time the blood glucose testing was scheduled, she said 2:00 pm. When asked why the insulin administration and blood glucose tests were not done timely, she said, Time got away from me. A review of the MEDICATION ORDERS FOR [REDACTED] [MEDICATION NAME] 5 units at 7:30 am and 3 units at 5pm. Humalog 2 units before meals. Accuchecks every 4 hours with sliding scale Humalog insulin Humalog per sliding scale: If 180-229 = 1 unit 230-279 = 2 units 280-329 3 units 330-379= 4 units 380-429 =5 units If greater than 430 give 6 units and call MD. A review of the facility's policy, Administering Medications, included: Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example before or after meals).

Based on observation, record review and staff interview, the facility failed to ensure insulin and blood glucose monitoring were administered/performed in accordance with professional standards of quality for 1 (Resident #26) of 1 resident observed during administration of insulin, from a total of 13 residents in the sample. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner ' practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: On 11/19/19 at 10:30 am, observation of medication administration was conducted with Employee A, Licensed Practical Nurse (LPN), and Resident #26. Employee A had performed blood glucose testing at 10:10 am. The result was a blood glucose level of 446. Employee A reviewed the sliding scale insulin order to determine how much insulin needed to be given. She determined 6 units of Humalog insulin were needed. Also, the order stated for blood glucose levels greater than 430, the physician was to be notified. Employee A prepared 2 syringes with insulin. She drew up 5 units of [MEDICATION NAME]in one syringe and 6 units of Humalog in the other. She entered the resident's room and administered the 2 syringes of insulin to Resident #26. A review of the physician's orders [REDACTED]. The orders also included instructions to administer 2 units of Humalog before each meal and this was due at 11:30 am. There was no dose given at 11:30 am. Blood glucose monitoring was ordered every four hours and the next one due was at 2:00 pm. At 2:30 pm, an interview was conducted with Employee [NAME] She was asked what the resident's blood glucose level was at 2:00 pm. She said she had not done it yet, as she was assisting the wound physician. She verified that she did not give the morning dose of [MEDICATION NAME] at 7:30 am as ordered. She gave it after she performed the 10:00 am blood glucose test, along with the sliding scale insulin. She also confirmed she did not give the 11:30 am dose of [MEDICATION NAME] due before lunch, since she had given the other dose late. On 11/19/19 at 4:30 pm, Employee A was observed preparing 2 syringes of insulin. One syringe contained 3 units of [MEDICATION NAME] scheduled for 5:00 pm, and the other contained 2 units of Humalog, based on sliding scale, and 3 units due before the meal. Employee A was asked what time she performed the blood glucose testing and she said at 4:15 pm. When asked what time the blood glucose testing was scheduled, she said 2:00 pm. When asked why the insulin administration and blood glucose tests were not done timely, she said, Time got away from me. A review of the MEDICATION ORDERS FOR [REDACTED] [MEDICATION NAME] 5 units at 7:30 am and 3 units at 5pm. Humalog 2 units before meals. Accuchecks every 4 hours with sliding scale Humalog insulin Humalog per sliding scale: If 180-229 = 1 unit 230-279 = 2 units 280-329 3 units 330-379= 4 units 380-429 =5 units If greater than 430 give 6 units and call MD. A review of the facility's policy, Administering Medications, included: Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example before or after meals).

Based on record review and staff interview, the facility failed to maintain accurate medication orders and medication administration records for 1 (Resident #46) of 5 residents reviewed from a total of 13 sampled residents. The findings include: A record review for Resident #46 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #46's (MONTH) 2019 physician's orders [REDACTED]. [MEDICATION NAME] Tablet 0.5 milligrams (MG), 1 tablet in the AM for anxiety at 9:00 AM with a start date of 8/6/2019 and a second order for [MEDICATION NAME] Tablet 0.5 MG, 1 tablet in the AM for anxiety at 7:30 AM with a start date of 11/10/2019. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Further review of the (MONTH) 2019 physician's orders [REDACTED]. During an interview with the Director of Nursing (DON) on 11/20/19 at 9:24 AM, she was asked for the physician's orders [REDACTED]. She looked in the computer, confirmed both of the orders and stated she would need to speak to the physician. The DON was also asked to provide the physician's orders [REDACTED]. During an interview with the DON on 11/20/2019 at 10:18 AM, she stated Resident #46 was receiving the [MEDICATION NAME] once in the morning. She stated on 11/9/2019 the physician went in the facility computer system and put in a new order so it could be delivered and did not discontinue the previous order. The DON also stated the as needed [MEDICATION NAME] was listed twice on the MAR for the same reason as the [MEDICATION NAME]. She stated the physician added his new orders on 9/16/2019 and did not discontinue the old order. The DON provided the controlled substance sheet for the [MEDICATION NAME] order that was filled on 11/9/2019. A review of the controlled drug record revealed Resident #46 received [MEDICATION NAME] at 9:00 AM on 11/11/2019, 11/12/2019, 11/13/2019, 11/14/2019, 11/15/2019, 11/18/2019, 11/19/2019 and on 11/16/2019 and 11/20/2019 at 8:00 AM. The controlled substance sheet had no record of the [MEDICATION NAME] being given on 11/17/2019. A count of the medication with the DON found 9 tablets missing from the package validating the [MEDICATION NAME] was not given on 11/17/2019. A review of the Medication Administration Record [REDACTED].

Based on record reviews and staff interviews, the facility failed to address advanced directives and determine residents' code status for 16 (Resident's #8, 13, 14, 16, 17, 18, 21, 22, 23, 26, 28, 42, 46, 48, 54, and 55) of a total sample of 55 residents. The findings include: Record reviews were conducted for Resident's #8, 13, 14, 16, 17, 18, 21, 22, 23, 26, 28, 42, 46, 48, 54, and 55, and revealed that none of these residents had an order indicating either a DNR (do not resuscitate) status or a full codeCPR (cardiopulmonary resuscitation) status. On [DATE] at 3:04 PM, an interview was conducted with Employee B, Registered Nurse/Minimum Data Set (RN/MDS) Nurse, regarding the facility's protocol for advanced directive care plans and orders. She stated that it was the social services director's responsibility to complete advance directive care plans. She stated that she was not sure who was responsible for the orders. On [DATE] at 3:06 PM, an interview was conducted with Employee C, Social Services Director (SSD), and she stated that she did not complete a care plan related to advance directives. She stated that she did not realize that she needed to do that. When she was asked who was responsible for putting the orders in, she stated, I do, when I get the DNR (Do Not Resuscitate) order. She then chose Resident #104 as an example, and stated that she received a DNR for him late last Friday ([DATE]). Upon pulling up his electronic medical record, it was discovered that he still had an order in the system for Cardiopulmonary Resuscitation (CPR). She stated that she did not know where that order came from, or why it was in there. She was asked whether anyone was responsible for completing audits of the residents' charts for their advance directives, and she replied, No one in particular, but we will sometimes randomly audit them. On [DATE] at 3:27 PM, an interview was conducted with the Director of Nursing (DON) regarding the facility's protocol for entering Advance Directive/DNR/Full Code orders. She stated that upon admission, the staff would ask the new resident whether they had a code status, and if they did, they would then request a copy of the paperwork for the chart. She stated that this process usually began prior to admission, because the social services employee would request the information prior to their admission. After admission but within 24 hours, the unit manager and the DON would review the new chart and ensure that the physician's orders [REDACTED]. We ensure that the order for DNR or CPR is put into the system. Then social services is responsible for entering a care plan for each resident, in regards to their preference. The DON was then asked why the code status was different for Resident #104 in the electronic medical record versus the paper record, and she stated it was due to the social worker's failure to notify the nursing staff that she had obtained a DNR for him. The DON was asked about the list of residents that did not have any orders in the system either way, and she reviewed the system to verify the orders. She looked at Residents #8 and #13, and confirmed that they did not have an order describing their code status. She was provided with the list of names, and stated that she would review the chart for each resident listed. A review of the facility's policy and procedure for Advance Directives revealed the following: Policies and Procedures Manual Facility Address Advance Directives Policy and Procedure Policy Number: Orientation/Annual In-service Department (s): All Author: Senior Director of Health Care Services Date: (MONTH) 15, (YEAR), revised (MONTH) 8, (YEAR) Approved By: Senior Director of Health Care Services Policy: All resident's who are admitted to the center will be provided with information on the execution of Advanced Directives. Procedures: 1. Upon admission all Residents will be provided with written information on the execution of Advance Directives. 2. Should a Resident not have written Advanced Directives and express their desire to implement them, the Social Service Coordinator or ALF (Assisted Living Facility) Manager will provide assistance with the execution of the documents. 5. Annually, an audit of all Resident Medical Records will be conducted to verify the presence of Advanced Directives. Second Policy Provided By DON: N14.12 Advanced Directives Page 1 of 2 Facility will ensure that a resident's choice concerning the development of advanced directives relative to his/her refusal of medical or surgical treatment are followed in accordance with our facility's advance directive policies and procedures and current state law. Procedure: 1. Prior to, or upon admission, a representative of the social service department will provide resident's right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare advance directives. 2. Prior to, or upon admission, a representative of the social service department will ask the resident and/or his/her family members about the existence of any advance directives prepared by the resident. Page 2 of 2 6. Changes to or revocation of an advanced directive must be submitted in writing to the Social Services Coordinator. The care plan team will be notified and social services will make necessary changes in the resident's MDS Assessment. 7. The Charge Nurse will notify the attending physician of a resident's advanced directive. The attending physician will be responsible for issuing appropriate orders that coincide with the resident's advance directive. 12. Our facility will assist residents and legal representatives in executing advance directives.

Based on observations and interviews, the facility failed to label and store residents' medications in accordance with currently accepted professional standards, in one (1) of two (2) medication carts reviewed, and in one (1) of two (2) medication rooms reviewed. The facility also failed to dispose of an expired inhaler for one resident (Resident #25). The findings include: On [DATE] at 1:47 PM, a review of Medication Cart #1 (300 hall) was conducted with Employee A, Licensed Practical Nurse (LPN), and revealed the following: 1. Expired [MEDICATION NAME] Diskus for Resident #25 (one on cart expired ,[DATE], and three inhalers in the resident's medication bin in the medication room, all expired ,[DATE]). 2. Undated opened [MEDICATION NAME] for Resident #40 3. Undated opened [MEDICATION NAME] for Resident #16 On [DATE] at 1:51 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN), regarding the concerns related to her medication cart. She confirmed all of the concerns. She stated that she was unsure how long the nasal sprays could be open before they needed to be discarded. She also confirmed that the expired [MEDICATION NAME] was administered to Resident #25 for today's dose. On [DATE] at 1:58 PM, an observation was made of the medication room on the West Wing with Employee A, LPN, and the refrigerator temperature was 32 degrees Fahrenheit (F). Employee A looked at the thermometer and verified the temperature was 32 degrees F. She was asked what the temperature should be, and she replied, I don't know. She then reviewed the temperature log on the counter and stated that it should be ,[DATE] degrees F. She stated, I guess it's just extra cold today. A review of the facility's policy and procedure for Storage of Medications revealed the following: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. A review was conducted of the facility's Medication Refrigerator Temperature Log, and revealed that the range for the refrigerator temperature should have been between ,[DATE] degrees. A review of the Medication Storage policy provided by the Director of Nursing (DON) revealed the following: Medication Storage Date Reviewed/Revised: [DATE] Reviewed/Revised By: DON Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 4. Refrigerated Products: b. Temperatures are maintained within ,[DATE] degrees F. 6. Unused medications: [REDACTED] The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. A review was conducted of the facility's policy and procedure for Labeling of Medications and Biologicals and revealed the following: Date Reviewed/Revised: ,[DATE] Reviewed/Revised By: DON 3 pages Page 1 of 3 Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations. Page 2 of 3 9. Labels for medications designed for multiple administrations (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed. a. The date medication was initially opened or accessed.

Based on observations, record reviews and interviews, the facility failed to ensure that a resident requiring respiratory care, was provided with such care, consistent with professional standards of practice for one (Resident #29) of one residents sampled for a review of oxygen therapy, out of a total sample of 55 residents. The findings include: A record review was conducted for Resident #29, which revealed an [AGE] year-old female admitted to the facility on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. Observations were made of Resident #29 on 7/31/18 at 9:37 AM, on 8/1/18 at 11:32 AM, and on 8/2/18 at 9:36 AM. Upon each observation, she was observed receiving three (3) liters of oxygen via nasal cannula. A record review was conducted of her electronic medical record, and it revealed that the only order she had in place was for oxygen tubing to be changed weekly. A review was conducted of the hard chart medical record (paper chart), and it revealed the following orders: 1.) Check Sp02 (oxygen saturation) every day at bedtime. Start Date 1/1/14, scheduled for 9 PM. 2). Oxygen at 2 L (liters) via nasal cannula, continuous to maintain Spo2 > 92%. On 8/2/18 at 9:37 AM, an interview was conducted with Employee E, Certified Nursing Assistant (CNA), the resident's assigned CNA for the day, regarding the amount of O2 (oxygen) the resident was supposed to be receiving. She stated, I don't know. You would have to ask the nurse. On 8/2/18 at 9:40 AM, an interview was conducted with the hospice aide that entered the room to provide the resident care, and she was not aware of how much O2 the resident was currently ordered. On 8/2/18 at 10:26 AM, an interview was conducted with Employee D, Licensed Practical Nurse (LPN), regarding how much 02 Resident # 29 was currently ordered. She reviewed the orders in the computer, and verified that there was no order for the resident's oxygen. She stated, I'm not sure, it might just be PRN (as needed). I will have to look and get back to you. She was then asked about an oxygen care plan, and confirmed that there was no oxygen care plan in the system. She was asked who was responsible for developing and updating resident care plans, and she stated, I think the unit manager is, but I am not sure. I'll have to find out and get back to you on that and her current oxygen order. On 8/2/18 at 10:39 AM, an interview was conducted with Employee B, Registered Nurse/Minimum Data Set (RN/MDS) Nurse, regarding the oxygen care plan for Resident # 29. She confirmed that there was no care plan in place for oxygen specifically. She stated that under the resident's cardiovascular care plan there was an intervention to administer 02 via nasal cannula as ordered. She then verified that it did not have a dose amount such as two (2) or three (3) liters. She was asked whether she saw an order for [REDACTED]. They would need an order. She was asked whether they went by the computer for the orders or the hard chart, and she stated that they had entered everything from the hard chart into the computer, so they would go by the computer.

Based on observations, record reviews and interviews, the facility failed to develop and implement a care plan for oxygen therapy for one (Resident #29) of one resident reviewed for oxygen therapy and for one (Resident #36) of one resident reviewed for diabetic care and services, out of a total sample of 55 residents.The facility also failed to develop a comprehensive care plan which addressed the administration and monitoring of [MEDICAL CONDITION] medication to ensure that one (Resident #20) of five residents reviewed for unnecessary medication had appropriate care plan interventions, from a total sample of 55 residents. The findings include: 1. A record review was conducted for Resident #29, which revealed an [AGE] year-old female admitted to the facility on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. Observations were made of Resident #29 on 7/31/18 at 9:37 AM, on 8/1/18 at 11:32 AM, and on 8/2/18 at 9:36 AM. Upon each observation, she was observed receiving three (3) liters of oxygen via nasal cannula. A record review was conducted of her electronic medical record, and it revealed that the only order she had in place was for oxygen tubing to be changed weekly. A review was conducted of the hard chart medical record (paper chart), and it revealed the following orders: 1.) Check Sp02 (oxygen saturation) every day at bedtime. Start Date 1/1/14, scheduled for 9 PM. 2). Oxygen at 2 L (liters) via nasal cannula, continuous to maintain Spo2 > 92%. On 8/2/18 at 9:37 AM, an interview was conducted with Employee E, Certified Nursing Assistant (CNA), the resident's assigned CNA for the day, regarding the amount of O2 (oxygen) the resident was supposed to be receiving. She stated, I don't know. You would have to ask the nurse. On 8/2/18 at 9:40 AM, an interview was conducted with the hospice aide that entered the room to provide the resident care, and she was not aware of how much O2 the resident was currently ordered. On 8/2/18 at 10:26 AM, an interview was conducted with Employee D, Licensed Practical Nurse (LPN), regarding how much 02 Resident # 29 was currently ordered. She reviewed the orders in the computer, and verified that there was no order for the resident's oxygen. She stated, I'm not sure, it might just be PRN (as needed). I will have to look and get back to you. She was then asked about an oxygen care plan, and confirmed that there was no oxygen care plan in the system. She was asked who was responsible for developing and updating resident care plans, and she stated, I think the unit manager is, but I am not sure. I'll have to find out and get back to you on that and her current oxygen order. On 8/2/18 at 10:39 AM, an interview was conducted with Employee B, Registered Nurse/Minimum Data Set (RN/MDS) Nurse, regarding the oxygen care plan for Resident # 29. She confirmed that there was no care plan in place for oxygen specifically. She stated that under the resident's cardiovascular care plan there was an intervention to administer 02 via nasal cannula as ordered. She then verified that it did not have a dose amount such as two (2) or three (3) liters. She was asked whether she saw an order for [REDACTED]. They would need an order. She was asked whether they went by the computer for the orders or the hard chart, and she stated that they had entered everything from the hard chart into the computer, so they would go by the computer. 2. A record review was conducted for Resident #36, and it revealed an [AGE] year-old male admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Further review of the record revealed that he was receiving multiple medications ([MEDICATION NAME], and Humalog insulin) to control the diabetes, however there was no care plan in place for his diabetes. On 8/2/18 at 10:39 AM, an interview was conducted with Employee B, Registered Nurse/Minimum Data Set (RN/MDS) Nurse, regarding the resident's care plan for diabetes. She reviewed the electronic medical record and stated, I personally do not see a care plan for his diabetes. I'll have to ask about it, and see. She was asked whether he should have one, and she replied yes. No care plan addressing Resident #36's diabetes was produced by the facility during the time of the survey. 3. A review of Resident #20's medical record revealed that on 3/29/18, Resident #20 was ordered the antipsychotic medication [MEDICATION NAME] 25 mg (milligram) tablets, one tablet by mouth daily at bedtime, and [MEDICATION NAME] 100 mg tablets, one tablet by mouth at bedtime. A review of the resident's care plans revealed that Resident #20 had no specific care plan for psychiatric illness and use of [MEDICAL CONDITION] medication. The current care plan did not address that an antipsychotic medication was started on 3/29/18. It did not include measurable goals in behavioral terms for which the antipsychotic was prescribed. It did not address side effects specific to antipsychotic medication, nor did it address behavioral interventions, how and when dose reductions would be attempted, or that Resident #20 was being seen by a psychiatric advanced registered nurse practitioner. An interview was conducted with Employee D, LPN, on 8/2/18 at 9:30 AM to review the antipsychotic medications Resident #20 was receiving. Employee A reviewed Resident #20's medication list, and stated that he was receiving [MEDICATION NAME] 25 mg tablet, one tablet by mouth daily at bedtime and [MEDICATION NAME] 100 mg tablet, one tablet by mouth at bedtime as ordered by the physician. An interview was conducted with Employee H, MDS Coordinator, on 8/2/18 at 9:55 AM to review Resident #20's care plan related to antipsychotic medications. She stated that any resident on a [MEDICAL CONDITION] medication should have it listed on their care plan. She then acknowledged that Resident #20 had no specific care plan for [MEDICAL CONDITION] medication to include the antipsychotic medication, [MEDICATION NAME] prior to today, (MONTH) 2, (YEAR). She stated, I updated his care plan today and added the [MEDICAL CONDITION] medication to his care plan.

Based on record review and staff interview, the facility failed to provide care and treatment in accordance with professional standards of practice for one (Resident #23) of one resident reviewed for ear care, out of a total sample of 55 residents. The findings include: A record review was conducted for Resident #23 and revealed a [AGE] year-old male, admitted to the facility on (MONTH) 29, (YEAR). A physician's orders [REDACTED]. Sweet oil (Olive Oil), Instill three (3) drops in the right ear at bedtime related to seasonal allergic rhinitis. Continue until seen by ear doctor, start date 5/24/18, no stop date. A review of his medication administration records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed that the nurses were signing off that the medication/treatment had been administered. On 8/2/18 at 2:15 PM, an interview was conducted with the director of nursing (DON) regarding the resident having seen the physician, and she provided a copy (out of a calendar book) of his last appointment. She was asked whether she had any documentation related to his doctor's visit, and she stated, No, I tried to call, but her office is closed this week. She was asked if he would get progress notes when he returned from the appointment and she stated yes. She then confirmed that, according to the physician's orders [REDACTED].

Based on resident interview, staff interview and record review the facility failed to actively seek a resolution to a complaint filed by one (#86) out of 3 sampled residents who reported personal property missing out of 30 total sampled residents. The findings include: During an interview with Resident #86 on 02/24/2015 at 10:15 am she stated that she had some missing clothing. She stated that when the facility moved her for a renovation project she found some of her clothes were missing. She stated it happened sometime shortly after the Holidays. She stated she reported it to staff, but no one has come back to tell her whether or not they looked for them or found any of them. She stated she would like to know. A review of the Grievance Log from November, 2014 through January, 2015 revealed no grievances filed for any residents regarding missing personal property/clothing. For the months of October, September, August, June, May, April, March and February of 2014 and January of 2015 there were no grievances or complaints logged. Review of the Resident Council Meeting Minutes forms from January, 2014 through February, 2015 revealed no complaints were voiced regarding missing clothing. An interview with the Manager of Environmental Services on 02/26/14 at approximately 10:00 AM revealed she does not keep a log of reports of missing items. She stated the CNAs are supposed to look in the lost and found room (she pointed at the door of a small room with racks of clothing in it) and see if they can find it. She stated that if they don't find the items that they are to inform the Administrator. She stated she was unaware of any resident complaining about missing clothing. An interview with the Administrator on 2/26/2014 at 10:30 am revealed the staff member who takes the report of missing personal property should write it down on a complaint/grievance form and give it to the Social Services Director (SSD) so she can investigate. She stated that if after the investigation they can't find the items they usually reimburse them and she has to authorize the reimbursement. She stated she is not aware of anyone complaining of missing clothes. She stated that during the moves for the renovation project, they moved the resident's personal belongings first and got their rooms set up and then moved the resident. She stated that the SSD would have documented any complaints in their charts. Review of the SSD's progress notes and monthly summaries for the last six months for Resident #86 revealed no documentation of any complaint of missing clothing. Interview with Employee G on 02/26/2015 at 11:20 am revealed she has worked with Resident #86 in the past, but she is not assigned to her today. When asked if the resident ever told her she had missing clothing items she stated, "Oh yeah, we looked all over the place for her things one day." When asked if the resident was the one that told her they were missing she stated "No. I'm not sure, but I think it was the lady that does Home Health with her, (Employee H)." Interview with Employee G and Employee D on 2/26/2015 at approximately 11:22 am revealed they both stated that they had looked quite extensively for Resident #86's clothing one day. They couldn't remember exactly when it happened but they couldn't find her clothes. Both stated they did not report it to anyone else or fill out a grievance form. Interview with Employee H on 2/26/2015 at 11:50am revealed she was not ever told about Resident #86's missing clothing. She stated that when clothes are reported missing she goes immediately and looks for them. She stated that she does not usually tell anyone about them missing unless she can't find them then she goes to the laundry department and tells them. She stated there is no form for them to fill out. .

Based on observations and staff interview, the facility failed to ensure that the emergency call lights in 4 bathrooms on the East wing of the facility were functional at all times. The findings include: During the initial observations in rooms 59, 61 and 68 on 2/23/2015 between approximately 10:00 am and 12:00 pm, surveyors observed that the call light pull cords to the emergency call systems in the bathrooms were tied around the toilet bars. On 2/26/2015 between 10:30 AM-10:50 AM, the Director of Environmental Services toured of the facility with the surveyor to check all the bathroom emergency call lights. Observations during the tour revealed the call lights in rooms 59, 61, 63 and 68 were tied to the toilet bars; therefore, rendering them non-functional. Interview with the director of environmental services on 2/26/2015 at 10:30 AM revealed that staff should not have been tying the cords around the commode bars. She discussed the issue with the East wing morning nurse on duty and discovered the problem was specific to the East wing only.

Based on observations and staff interview the facility failed to ensure food was served under sanitary conditions during the lunch meal service in the main dining room and the East Wing of the facility. The findings Include: 1. Observation on 12/03/12 at 12:05 pm of the lunch meal service in the main dining room revealed Employees #130, #113, and an agency Certified Nursing Assistant not sanitizing or washing their hands between tasks or residents. Employee #130 was observed pouring juice/water into glasses from a cart she was pushing from table to table. She was observed putting her hands on the backs and shoulders of residents and then going to the drink cart and pouring drinks for several residents without sanitizing her hands. An agency Certified Nursing Assistant was observed picking up a chair in the main dining room and moving it from one table across the room to another table. She then sat down and began to feed a resident without washing her hands. Employee #113 was observed using a sanitizer cloth to wipe the counter next to the dirty dishes in the main dining room. He then put the cloth down and walked over to the cart with the soup dispenser and soup cups and spoons. Without washing or sanitizing his hands he proceeded to spoon soup into a soup cup and placed it on a saucer with a spoon and took it and set it down in front of a resident. 2. A second dining observation on 12/05/12 at 12:10 pm revealed a private home health aide was assisting a randomly sampled resident in the main dining room. She was observed to place her un-gloved left hand on the resident's sandwich while she cut it with a knife. Interview with the Director of Nursing on 12/05/12 at 12:30 pm revealed that the home health aide assisting the resident during the dining observation on 12/05/12 was not employed by the facility; however, she was given hand hygiene training. She later produced a Hand Hygiene Proper Hand Washing Technique form signed by the aide; a policy on hand washing used for training; and a Spot Handwashing Observation form dated 10/05/12 signed by the aide and the Director of Nursing acknowledging the aide had been trained on hand hygiene. 3. A tour of the kitchen was conducted on 12/03/12 at 9:48 am. Two gallons of milk had been opened and were stored in the walk-in cooler with no date mark. The Certified Dietary Manager (CDM) acknowledged that the milk did not have a date mark and proceeded to mark the date on the lid. A bulk container of bread crumbs stored in the dry storage area had a plastic drinking cup inside it. 4. Bags of salt pellets for the water softener were observed outdoors stored on a pallet wrapped with plastic, near a side door behind the fence of the property. It was not stored in a shed or closet. The CDM stated during the initial tour that the water softener salt is stored as it is on a pallet wrapped in plastic, outdoors. 5. During the initial tour of the kitchen on 12/03/12 at 9:30 am the dishwasher was not reaching the required temperatures to properly sanitize the dishes. The dish machine was a hot water sanitizer machine. The washer temperature gauge read 120?F and final rinse temperature gauge read 150?F. Temperature log read 120?F for the wash temperature for 12/03/12 and the rinse temperature read 180?F. The CDM stated that he was made aware of the dishwasher machine problem when he came in to work on 12/03/12; however this writer observed the staff at 9:30 am using the dish machine to clean all the dishes from breakfast service. The contracted dish machine repair person was onsite during the initial tour of the kitchen. She stated the machine should reach 150?F during the wash cycle and 180?F during the rinse cycle. The CDM was instructed not to use the dish machine until it could be repaired. 6. During the initial tour of the kitchen on 12/03/12 at 9:45 am, the sanitizer sink for warewashing was full and the Dietary Manager tested the water with the appropriate test strip. The water tested 0 parts per million of sanitizer. 7. A second observation of the kitchen on 12/03/12 at 2:30 pm revealed that the dish machine wash temperature did not get above 142?F and the rinse temperature got above 180?F after trays were run through the machine a couple of times. The CDM stated he will call to have the repair person come to service the machine again. The CDM was instructed not to use the machine to wash dishes until it was repaired. 8. A lunch observation in the Special Care (East) Unit Dining Room on 12/05/12 at 11:50 a.m. revealed Home Health Aide (HHA) #129, removed a cup that an unsampled resident had touched from the table and placed it back on the serving tray on the top of the food cart. The HHA (#129) was touching her face and she began to obtain another tray from the food cart without washing or sanitizing her hands. The HHA was asked to perform hand hygiene. HHA #129 obtained ice from a container on top of the food cart, scooping it up with the cup and was observed pouring coke over the ice and serving it to an unsampled resident. HHA #129 returned to the container of ice and pulled a carton of milk from beneath the ice. The surveyor stopped CNA #41 who was also serving in the dining area and asked her to remove the cup of coke that the HHA had given to the unsampled resident. CNA #41 revealed the staff was not supposed to utilize ice from the container storing the cold beverages for resident drinks. The staff was to utilize ice from the ice machine located on the unit. .

Based on medical record review and staff interview the facility failed to accurately assess one of 36 sampled residents (#28) regarding their prognosis. The findings include: Review of Minimum Data Set (MDS) data dated 10/04/12 revealed Resident #28's weight was 129 lbs. The resident was coded as being a hospice patient. Section J (J1400 Prognosis) asks "does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?" The question was answered as no. Review of the physician's orders [REDACTED]. The form stated that based on the patient's [DIAGNOSES REDACTED]. The attending physician checked the box indicating that he desired to retain complete management of patient care. Signed by the physician for Community Hospice of Northeast Florida and the physician for the facility. Interview with MDS coordinator on 12/06/12 at 10:00 am revealed that the facility does not code a resident as having a terminal prognosis automatically if they are certified for Hospice Care. She stated that some residents receive hospice care for a long time, sometimes years prior to their death. She stated that just because they are receiving hospice care doesn't mean they are terminally ill. Interview with Employee #11 at 10:43 am on 12/06/12 revealed that she acknowledged that the resident had been coded wrong on the 10/04/12 MDS to reflect that the resident had a terminal [DIAGNOSES REDACTED]. .

Based on resident record review, staff interview, and observations the facility failed to provide an environment free of accident hazards for 1 (Resident #46) of 36 sampled residents. The findings include: A medical record review for Resident #46 revealed she was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of the History and Physical dated 09/20/12 revealed the resident was evaluated because she was significantly over-medicated for anxiety. One week later the resident was significantly more confused and was sent to see the physician in the office. The resident was slated for special care at the East Wing at the facility (Memory Care). Active problems included senile dementia, hypertension, mild recurrent major depression, [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], allergic rhinitis, glaucoma, degenerative disc disease, panic disorder, anemia, [DIAGNOSES REDACTED], osteo arthritis and insomnia. A review of the fall risk assessment completed on 09/20/12 and 10/12/12 revealed Resident #46's fall risk score was 11 (total score above 10 represents high risk for falls). A review of the Resident Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/02/12 revealed the resident's Brief Interview for Mental Status (BIMS) score was 05 (severely impaired). The resident was coded as having a fall 2-6 months prior to admission and a fracture related to a fall in the last 6 months prior to admission. The resident was coded as having a fall since admission one with no injury and one with injury (except major)-skin tears abrasions, etc. A review of the Physician order [REDACTED]. A review of the resident care plans revealed the resident had a fall care plan on file dated 09/20/12. The resident was noted to be at risk for injury from falls related to a decline in medical and Activity of Daily Living (ADL) status. The goal was the fall risk would be minimized through facility intervention through the next review date. The approaches included complete a fall risk assessment per facility protocol, observe the resident's routine in personal environment, monitor and assist with all transfers, therapy to evaluate and treat as ordered, redirect the resident from unsafe situations, observe for decrease and loss of functional status, observe for impaired safety awareness, encourage the use of hand rails and grips in bathroom, remind the resident to use her walker when ambulating. The care plan was updated on 09/27/12 after a fall to the floor with no apparent injury. The plan was to continue the current plan of care. On 10/02/12 Resident #46 had an unwitnessed fall and sustained a scratch. The plan was to continue the plan of care. On 10/04/12 the care plan was reviewed and the plan was to continue the plan of care. On 10/12/12 the resident fell to ground and sustained a skin tear. On 10/31/12 the resident was found on floor, with a laceration to left hand, the plan was to continue plan of care. On 11/27/12 the resident was eased on floor after standing up with unsteady gait; no injury was noted. On 11/20/12 the resident was observed sitting on the trash can in her bathroom and was noted to have a small scratch noted on her forearm/wrist. There was no documentation of the fall precaution of the gray mat and bed alarm. An interview and observation was completed for Resident #46 on 12/05/12 at 12:27 pm the resident was noted to have expressive aphasia, and was alert with confusion. The gray mat was not located on the floor at the bedside. There was a gray mat rolled up behind the curtain in the resident room. An interview and observation of Resident #46 with Nurse #50 on 12/05/12 at 1:05 pm confirmed the gray fall mat was not in place. The nurse revealed the fall mat rolled up behind the curtain was for the resident's roommate who was down in the dayroom. The nurse looked for the resident's fall mat and revealed it was present the the day before and the resident had been sent out to the hospital for evaluation. Nurse # 50 could not locate Resident #46's fall mat in the room. Per the nurse she would have another fall mat sent down. During an interview with the Minimum Data Set Coordinator (MDS), Employee #4, on 12/05/12 at 1:40 pm, she confirmed there was no documentation of the fall mat and bed alarm as interventions on the fall care plan for Resident #46. .

Based on clinical record review and staff interview, the facility failed to develop comprehensive care plans for 1 of 36 sampled residents assessed for dental pain and receiving a mechanical diet (Resident #113). The findings include: A review of Resident #113's clinical record and Minimum Data Set (MDS) revealed that the resident was coded for dental, mouth or facial pain, discomfort or difficulty with chewing. A review of the resident record revealed that no care plan for a dental pain or chewing difficulty was observed. According to Nutrition Risk Assessments and dietary notes completed on 9/15/2012 and 9/25/2012, the resident was receiving a mechanical soft diet. A review of the resident record revealed that no care plan for a therapeutic diet was observed. An interview with the MDS coordinator was conducted on 12/5/2012 at 1:45 PM. The coordinator confirmed that the resident should have been care planned for dental pain. An interview with the Certified Dietary Manger (CDM) was conducted on 12/5/12 at 2:38 PM. The CDM confirmed that a care plan for the mechanical diet was not in the care planning packet and was unsure why it was not included. The CDM stated that there was a care plan made. The CDM stated that he attends the care plan meetings and brings the care plans with him. An interview with the MDS coordinator was conducted on 12/5/2012 at 3:03 PM. The MDS coordinator confirmed that the CDM did not sign the care plan attendance sheet from Resident #113's last care plan meeting on 10/3/2012. The coordinator stated that when staff attended the meeting, they sign the attendance sheet. .

Based on resident record review and staff interview, the facility failed to revise plans of care for 2 of 36 residents (Resident #46 and #79). The findings include: 1. A medical record review for Resident #46 revealed she was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of the History and Physical dated 09/20/12 revealed the resident was evaluated because she was significantly over-medicated for anxiety. One week later the resident was significantly more confused and was sent to see the physician in the office. According to the Assisted Living Nurse, the patient had been increasingly confused and did not recall the previous meeting. The resident was slated for special care at the East Wing at the facility (Memory Care). Active problems included senile dementia, hypertension, mild recurrent [MEDICAL CONDITIONS], allergic rhinitis, [MEDICAL CONDITIONS] disc disease, panic disorder, [MEDICAL CONDITION], [DIAGNOSES REDACTED], osteo arthritis and [MEDICAL CONDITION]. A review of the fall risk assessment completed on 09/20/12 and 10/12/12 revealed Resident #46's fall risk score was 11 (total score above 10 represents high risk for falls). A review of the Resident Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/02/12 revealed the resident's Brief Interview for Mental Status (BIMS) score was 05 (severely impaired). The resident was coded as having a fall 2-6 months prior to admission and a fracture related to a fall in the last 6 months prior to admission. The resident was coded as having a fall since admission one with no injury and one with injury (except major)-skin tears abrasions, etc. A review of the Physician order [REDACTED]. A review of the resident care plans revealed the resident had a fall care plan on file dated 09/20/12. The resident was noted to be at risk for injury from falls related to a decline in medical and Activity of Daily Living (ADL) status. The goal was the fall risk would be minimized through facility intervention through the next review date. The approaches included complete a fall risk assessment per facility protocol, observe the resident's routine in personal environment, monitor and assist with all transfers, therapy to evaluate and treat as ordered, redirect the resident from unsafe situations, observe for decrease and loss of functional status, observe for impaired safety awareness, encourage the use of hand rails and grips in bathroom, remind the resident to use her walker when ambulating. The care plan was updated on 09/27/12 after a fall to the floor with no apparent injury. The plan was to continue the current plan of care. On 10/02/12 Resident #46 had an unwitnessed fall and sustained a scratch. The plan was to continue the plan of care. On 10/04/12 the care plan was reviewed and the plan was to continue the plan of care. On 10/12/12 the resident fell to ground and sustained a skin tear. On 10/31/12 the resident was found on floor, with a laceration to left hand, the plan was to continue plan of care. On 11/27/12 the resident was eased on floor after standing up with unsteady gait, no injury was noted. On 11/20/12 the resident was observed sitting on the trash can in her bathroom and was noted to have a small scratch noted on her forearm/wrist. There was no documentation of the fall precaution of the gray mat and bed alarm. During an interview with the Minimum Data Set Coordinator (MDS,) Employee #4, on 12/05/12 at 1:40 pm she confirmed there was no documentation of the fall mat and bed alarm as interventions on the fall care plan for Resident #46 2. A medical record review revealed Resident #79 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of the Social Services (SS) Notes for Resident #79 revealed discharge planning was ongoing. On 11/01/12 the resident expressed desire to return to the Assisted Living Facility (ALF). On 10/05/12 the resident scored a 6 on Brief Interview of Mental Status (BIMS -severely impaired). On 10/10/12 a telephone conference was held with the resident's daughter and the writer discussed the resident's poor safety awareness and processing. Discussed transitioning into long term care (LTC). On 10/11/12 an email was received from the resident's family who decided transitioning the resident back to ALF was not possible and the desire for permanent placement in the facility. On 10/26/12 the resident BIMS score was 11. The resident was alert and oriented and agreed skilled nursing services were what she needed at the time. The resident did not wish to be asked about returning to the community. A review of Resident #79's care plans revealed there was a care plan on file for discharge planning dated 09/28/12. The problem was the resident required a discharge plan for safe return to the community. The goal was the discharge plan would be completed prior to the planned discharge date . The approaches included: encourage the resident and family to participate in discharge planning. SS to arrange for home health or outpatient therapy. Therapy to coordinate with SS to determine equipment needed for safe discharge. Home evaluation prior to discharge. Meet with resident/family to discuss concerns arrangements for discharge. Discuss needs with the attending physician, nursing and surgery. Explain and teach follow-up care techniques with the resident and family. An interview with the Social Services Director on 12/05/12 at 2:09 pm she revealed the resident is no longer a candidate for discharge to the community because she is not safe for discharge. She revealed the care plan should have been discontinued. 3. A review of the Physician order [REDACTED]. A review of Resident #79's care plans revealed there was a nutrition care plan on file dated 09/28/12. The problem was the resident had a potential for altered nutrition related to a therapeutic diet order. The goal was the resident risk of altered nutrition would be minimized through the next review date. Approaches included provision of a no added salt (NAS) with finger foods diet as ordered. Provide select menu as requested by resident and as available for ordered diet. Encourage acceptance of ordered diet. Offer choices within parameter of specific diet and disease process; observe for weight loss, refusal of meals offered, loss of appetite, weakness, lethargy, etc. Encourage adequate intake of fluids, supplements as ordered and appetite stimulants as ordered. An interview with the Certified Dietary Manager (CDM) on 12/05/12 at 2:03 pm revealed Resident #79 current diet was regular consistency with no NAS. Per the CDM the finger foods should have come off the care plan. He revealed the resident was on a regular diet. .