Every finding on record at Floridean Health & Rehabilitation Center

Based on observations, interviews and record review facility failed to follow a nutritional care plan for one (Resident #95) out of one sample resident, as evidenced by it was observed that Resident #95 was provided with a ham and cheese sandwich before leaving for dialysis. This meal was not consistent with the prescribed pureed diet, posing potential risks to Resident #95's health and wellbeing. There were 20 residents receiving pureed diets at the time of survey. The findings included: On 9/26/25 at 4:22 AM Resident #95 was observed in bed with no apparent distress.Observation on 9/26/25 at 4:25 AM at the first-floor nursing station revealed a transparent bag labeled with Resident #95's name and room number that contained a ham and cheese sandwich and applesauce (photo evidence).Interview on 9/26/25 at 4:33 AM Staff B, Registered Nurse (RN) was asked about Resident # 95 's snack of ham and cheese sandwich and applesauce provided for the resident to take to dialysis; Staff B replied: This resident has been assessed, is waiting for pick up and always goes with a snack of sandwich and applesauce. On 09/26/25 at 4:58 AM, transportation arrived to pick up Resident#95.On 9/26/25 at 5:11 AM, the Assistant Director of Nursing (ADON) and Staff B, RN, were asked if it is okay for Resident #95 to leave with a sandwich despite the ordered pureed diet. The ADON replied: It is okay for the resident [Resident #95] to eat a ham and cheese sandwich because it can be mechanical soft.On 9/26/25 at 5:15 AM Resident #95 had already left the facility with the ham and cheese sandwich and applesauce that was provided.Interview on 9/26/25 at 6:30 AM, the Director of Nursing (DON) was asked if it is okay for Resident #95 who has an ordered pureed diet to be provided with a sandwich to take to dialysis; the DON replied: I will get back to you on that. On 9/26/25 at 6:45 AM, the Dietician was notified about identified diet concern and stated, A sandwich is not considered pureed.[Resident #95] used to be on a regular diet, and I will check with the Speech therapist to see if it is ok to send a sandwich.On 9/26/25 at 6:56 AM, the DON presented a transparent bag with Resident #95's name that contained a ham and cheese sandwich and applesauce and stated: We got the snack from the Dialysis center and replaced it with applesauce.Observation on 9/26/25 at 10:40 AM, Staff C, Speech therapist (ST), conducted a trial feeding of a ham sandwich with Resident #95. After some difficulty in following directions the therapist placed a small piece of bread into Resident #95's mouth and the resident began chewing. The therapist encouraged Resident #95 to swallow . After failing attempts to swallow, the Speech Therapist concluded that it was not safe for Resident #95 to eat sandwiches due to impaired cognition or physical tiredness from dialysis.Record review of a demographic sheet revealed Resident #95 was admitted on [DATE] with diagnosis that included: End Stage Renal Disease.Record review revealed the 5-day Medicare Minimum Data set (MDS) reference dated 9/11/25 revealed Resident #95 had a Brief Interview of Mental Status score of 8, indicating moderate cognitive impairment, required partial/moderate assistance for eating, received a mechanically altered and therapeutic diet, and held food in mouth/cheeks or had residual food in mouth after meals.Record review of a Care Plan initiated on 10/07/23 and revised on 09/08/25 revealed Resident #95 was at risk for altered nutrition and hydration status, had a goal to show no signs or symptoms of dehydration and the interventions included: Provide and serve diet as ordered. Pureed texture, Nectar Thick consistency, and provide snacks and supplements as ordered.Record review of Resident #95's September 2025 physician's order sheet revealed a diet order for Pureed texture and nectar thick consistency.Record review of a Nutrition/Dietary Note dated 9/10/25 revealed Pureed/Nectar diet.An interview with The Registered Dietician on 9/25/25 at 12:09 PM revealed Resident #95 was on a pureed nectar diet with low sodium and low sugar. Record review of Speech therapy addendum dated 9/15/25 indicated to continue with swallow precautions and compensatory strategies at mealtimes. Record review of a policy titled, Care Plans, Comprehensive Person-Centered revised December 2021, reviewed January 2025 revealed policy statement: 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.

Based on observations, interviews and record review facility failed to provide an environment free from potential accident hazards on one (2nd floor storage room) out of nine storage rooms in the facility as evidenced by an unmarked, unlocked storage room with a door that locks from the inside. There were 90 residents residing in the facility at the time of survey.The findings included:Observation of the facility's Second Floor on 9/23/25 at 3:25 PM, an unmarked door; the Surveyor opened the door, which revealed a small room with enteral feeding supplies stacked on shelves. The door could be locked from the inside and there was no call light observed. (photo evidence).On 9/23/25 at 3:30 PM, the Nursing Home Administrator was notified about the identified concern, acknowledged the door was unlocked and locked the door from the inside.Interview on 9/23/25 at 3:40 PM Staff A, Central Supply was asked about the unmarked, unlocked room Staff A stated: This is the storage room, and it is kept locked. Only Maintenance staff, Administration, the Assistant Director of Nursing and myself have a key. When nursing staff needs anything from this room, they tell me, and I retrieve it for them.During an interview on 9/23/2025 at 3:48 PM, the Maintenance Director stated: I am responsible for posting signs on doors in the facility. I am not sure why there is no sign posted.On 9/24/25 at 12:45 PM, the Second Floor Infection Preventionist was interviewed about the identified concern and stated, I am the supervisor; the storage door is kept locked for the safety of our residents because we have residents with Dementia who can wander into the room.Interview on 9/25/25 at 1:36 PM, regarding the identified concerns, the Risk Manager stated: I am part of the Quality Assurance team, and I discuss any issues concerning resident safety. If there is an identified issue with safety, I come up with a plan to prevent it from happening again. The storage door is normally kept locked and labeled. Normally the maintenance staff checks the doors twice a day and the supervisor checks on the weekends. The possibility does exist for a resident to wander into an open storage room and get locked in.Record review revealed the Second-Floor storage room was 28 square feet in dimension.Record review of Policy entitled, Storage Doors effective date: 04/01/2024 review date: 01/03/2025 revealed Policy Statement: All storage room doors containing medical supplies, cleaning agents, maintenance tools, resident records, personal belongings, or hazardous materials must remain closed and locked when not in immediate use. Only authorized personnel shall have access. Procedure: 1. Access Control: All storage areas must be equipped with locks. 2. Door Security: Storage doors must be closed and locked after use. 3. Daily Monitoring: Unit supervisors and department heads must perform daily checks to ensure all storage doors are locked.

Based on observations, interviews and record review facility failed to properly store and label medications on one (2nd floor east) out of two medication carts sampled as evidenced by an observation of an eye drop bottle with an open date of 8/9/25. There were 90 residents residing in the facility at the time of survey.The findings included:On 9/26/25 at 5:36 AM, a medication storage check was completed with Staff D, Licensed Practical Nurse (LPN) on the 2nd floor east medication cart revealed a Brimonidine eye drop with an open date written on bag of 8/9/25, the dispensed date from pharmacy was 8/8/25.Interview on 9/26/25 at 6:06 AM, Staff D, LPN stated: The eye drops last 28 days after opening. I check every day to make sure there are no expired medications. When I open an eye drop bottle, I write the open date. I did not open this eye drop bottle.On 9/23/25 at 7:01 AM, the Director of Nursing (DON) was notified about the identified concern.Record review of a policy titled, Storage of Medications Revised April 2019, Reviewed January 2025 revealed Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Class III

Based on observations, interviews, and record reviews revealed that the facility did not maintain accurate records for one (Resident #99) out of two sampled residents. As evidenced by a review of the September 2025 Medication Administration Record (MAR) showed that staff signed off on all medications as administered, even though no medications were available for Resident #99. There were 90 residents residing in the facility at the time of the survey. The findings included: Observation on 9/23/25 at 12:17 PM while on the second floor, Resident #99 observed standing in the hallway with oxygen in progress via nasal cannula. Resident #99 stated to Staff E, Registered Nurse (RN) I have not received my medication, and it is becoming difficult to breathe.” Staff E, RN replied, “The medication has not arrived from the pharmacy yet.” Resident #99 then went back into room. Surveyor asked Staff E, RN which medications were missing and if an assessment would be completed and Staff E, RN replied, “Resident #99 vitals were within a normal range, and the medications were ordered last night.” Interview on 9/23/25 at 12:25 PM, Resident #99 stated: “I can breathe but had been waiting on the medication, and I will have difficulty breathing if I don't get it. I was admitted last night.” Record review of the September Medication Administration Record (MAR) for Resident #99 revealed all medications were signed administered at 9:00 AM for the date 9/23/25. On 9/23/25 at 4:40 PM, the Director of Nursing entered the conference room and revealed all medications for Resident #99 had arrived and the physician was notified and stated it was okay to give meds upon arrival. Further revealed Staff E, RN signed the MAR due to being nervous. On 9/23/25 at 4:51 PM Staff E, RN (translated by another surveyor) was interviewed about identified concern and stated, “I sign the MAR after I give the medication. There is not a time I would sign before. If the medication is not here, I mark no and write in the progress notes and call the doctor and pharmacy. I did not give [Resident #99] any medication this morning because it was not here. I signed The MAR as administered in error.” Record review of Resident #99's demographic sheet revealed an admission date of 9/22/25 with Diagnosis that included: Acute and chronic respiratory failure with hypercapnia. Record review revealed the admission Minimum Data set (MDS) reference dated 9/22/25 was in progress. Record review of a Care Plan initiated and revised on 09/23/2025 revealed Resident #99 was at risk for altered respiratory status/difficulty breathing related to: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Acute on Chronic Respiratory Failure, Alkalosis, Hypo-osmolality and Hyponatremia, Hypoxemia, had a goal to maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date and interventions that included: Administer medication/inhalers/nebulizers as ordered and monitor Oxygen saturations as ordered and as needed, and teach resident/family/caregivers appropriate breathing, coughing, and splinting techniques. Record review of Resident #99's September 2025 physician's order sheet revealed orders included: Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 microgram per actuation (MCG/ACT) two puffs every 12 hours related to Acute and chronic respiratory failure with hypercapnia, Ipratropium Bromide Nasal Solution 0.03 % two sprays in both nostrils one time a day for Bronchodilator, Aclidinium Bromide Inhalation Aerosol Powder Breath Activated 400 MCG/ACT one inhalation two times a day for Bronchodilator related to COPD with Acute Exacerbation, and Fluticasone Propionate Nasal Suspension 50 MCG/ACT two sprays in both nostrils one time a day for Congestion, Azelastine hydrochloric acid (HCl) Nasal Solution 137 MCG per spray directions: 1 spray in both nostrils every six hours for congestion, Prednisone oral tablet 20 milligrams (MG) tablet by mouth one time a day for COPD exacerbation, and Montelukast Sodium Oral Tablet 10 MG tablet by mouth in the evening for Bronchodilator related to COPD. Record review of a pharmacy packing slip revealed medications for Resident #99 were delivered to facility and signed received by Supervisor on 9/23/25 at 2:43 PM. Record review of a policy titled, Charting Errors and/or Omissions/Accuracy of Medical Records revised January 2025 revealed Policy Statement: Accurate medical records shall be maintained by this facility.

Based on observations, record review and interview the facility failed to ensure pharmacy procedures were followed as per facility policy for two out of four carts in use. The findings included: On initial entrance to the facility on [DATE] at 06:07 AM; the 1st floor's [NAME] Medication cart assigned to Registered Nurse (Staff A) was observed unlocked in the hallway, Staff A was observed in a resident's room taking care of the resident. Staff A came out of the resident's room, greeted the surveyor and proceeded to lock the unlocked medication cart. During an observational tour on 05/20/24 at 08:12 AM the 1st floor [NAME] Medication Cart assigned to Licensed Practical Nurse (Staff C) was observed with Two (2) round white pills in a medication dosage cup sitting on top of the cart, at the time of the observation, Staff C was in room a resident's room administering medications to a resident. Interview on 05/20/24 at 08:13 AM Licensed Practical Nurse (Staff C) reported that the pills fell on the floor and she needs to discard them, she is not allowed to leave pills on the cart unattended and will put the pills in the drug buster, she checked the medication cart and no drug buster was available on cart at the time and she will have to go get the drug buster from the medication storage room. Interview on 05/21/24 at 03:36 PM Director of Nursing (DON) stated: I will of course do an in-service with all the nurses to educate them on correct medication storage . Review of the facility policy and procedures titled Storage of Medications revision date April 2024 states: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Review of the undated facility policy and procedures titled Medication storage states: medications will be stored in a manner that maintains the integrity of the product and that ensures the safety of the residents and is in accordance with Florida Department of Health Guidelines.

Based on observation, record review and interview the facility failed to implement a comprehensive care plan for an upper extremity device as ordered by the physician for one (Resident #36) out of 19 residents sampled. There were 75 residents residing in the facility at the time of this survey. The findings Included: During observation on 02/13/2023 at 09:08 AM Resident #36 was observed on the hallway in a wheelchair, coughing and stated he is ok. Review of Resident #36's medical records revealed the resident was readmitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing. Muscle Weakness (Generalized). Review of the Physician's Orders Sheet for February 2023 revealed Resident #36 had orders that included but not limited to: 1/12/2023-Device: Right upper extremity, non-weight bearing (NWB) wear sling at all times-every shift. On 02/13/2023 at 12:29 PM, Resident #36 was observed in his room having lunch, no sling was noted on right side. 02/14/2023 11:00 AM Resident# 36 was observed in the facility's therapy room, sitting in wheelchair, no sling noted to upper right side. On 02/15/2023 at 08:53 AM Resident #36 was observed in his room sitting in bedside chair finishing his breakfast. The surveyor asked Resident # 36 where his right shoulder sling was, the resident stated they took it, I guess I don't need it. Record review of Resident # 36's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for cognitive pattern documented Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating the resident is moderately impaired cognitively. Section E for Behaviors documented the resident exhibited no behaviors and had no potential indicators of psychosis. Section G for Functional status documented extensive assistance required for Activities of Daily Living (ADLs). Section J for Health Conditions documented resident received no scheduled or as needed pain medications in the last 5 days, had a fall prior to admission to the facility and experienced no shortness of breath in the last 5 days. Section O for Special Treatments documented resident received 191 minutes of Occupational Therapy and 162 minutes of Physical Therapy in the last 7 days. Review of Resident #36's Care Plans Reference Date 1/11/2023 revealed: The resident requires use of device: Sling right upper extremity NWB. Interventions Include: Monitor sight for device application daily and take off to clean extremity, monitor for pain, moaning, removal of device and report to nurse, notify Medical Doctor (MD) of any adverse sign and symptoms related to device usage, notify to MD resident device use preference, and educate resident on consequences of not following assistive device use. Review of February 2023 Treatment Administration Record (TAR), revealed from 2/1/2023 to 2/14/2023 -every shift (7 AM-30PM, 30PM-11 PM, 11 PM-7 AM) nurses signed off that the resident is always wearing right upper extremity NWB sling. Review of progress notes dated 2/15/2023, timestamped 09:50 AM written by the Assistant Director of Nursing (ADON) documented: Nurse on shift reported that patient not wearing the sling device. When patient interviewed, he reported that he was told by our psychiatrist that he doesn't need anymore . called resident's MD and confirmed about comment from the patient. Physician will submit his progress notes. Phone order obtain to discontinue device. Physical therapy and restorative nurse informed. During an interview on 02/15/2023 at 08:59 AM Registered Nurse (Staff A) when asked about the resident's right shoulder sling, Staff A stated that she will have to ask the Certified Nursing Assistant (CNA) assigned to the resident about the sling. Staff A stated; this resident used the sling before, but I need to know what is going on with the resident's sling now. The surveyor told Staff A to check the TAR which revealed that the nurses have been signing off on the right sling being used every shift. Staff A confirmed that nurses on all shifts have been signing off on resident having the right shoulder sling on. The surveyor and Staff A went to Resident #36's room, Staff A questioned Resident #36 about the upper extremity sling. The resident stated; the sling is in my drawer, and I do not need it, therapy told me I do not need it. Staff A located the right extremity sling in resident's bedside drawer. Staff A stated she will speak to therapy, her supervisor and the resident's doctor and get back with the surveyor afterwards. During an interview on 02/15/2023 at 01:07 PM, the Director of Nursing stated (DON) reported that the resident has an order from the MD to discontinue the upper extremity device. The surveyor requested a copy of the physician note, progress note, care plan, Treatment Administration Record (TAR) for February 2022, face sheet, current and discontinued orders, facility policy and procedure on positioning devices. On 02/15/2023 at 03:16 PM, the Administrator (NHA) brought documentation for the resident's discontinued order related to the right upper extremity sling dated 2/15/2023 at 10:48 AM and a consultation note dated 1/23/2023 from the MD that documented-Findings/Diagnosis: Right proximal humerus fracture, right shoulder pendulum exercise and passive range of motion 0-90 degrees. Patient may feed self if able. Otherwise non weight bearing (NWB) to right upper extremity., 2/15/2023 progress note, February 2023 TAR, care plans, and orders. During an interview on 2/16/2023 at 9:49 AM the Director of Nursing (DON) stated he will be educating the nurses on documentation, which they have done in the past and will continue to do. He stated, we have a nursing dashboard on the units for nurses to use as a quick guide to know which residents have devices, oxygen, peg tube, wounds etc. and the dashboard is updated every Monday. On 02/16/2023 at 03:54 PM the DON brought surveyor a Physiatrist follow up note, the date of service noted was 02/09/2023, follow up care-documented continue with NWB of right upper extremity pending ortho follow up for weight bearing status changes. May remove sling according to orthopedics' recommendations. Review of the facility's policy and procedures titled, Contractures Prevention revision date 8/22/2017 states: Each resident must be evaluated for need of contracture prevention procedure on admission, readmission and as needed. Positioning: Some residents may have braces or splints to prevent or help release contractures-be sure to follow the physicians order regarding the schedule of when to put these on and when to remove them.

Based on record review and interviews, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area, as evidenced by repeated deficient practice during consecutive annual surveys. Cross reference F 656 develop/implement Comprehensive Care Plan. There were 75 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during an annual survey with exit dated 10/15/2021, deficient practice was cited related to F 656-Develop Implement Comprehensive Care Plan related to due to the facility's failure to implement the activities care plan for one (Resident #62) out of 20 sampled residents. During this survey with exit date of 02/16/2023 the facility was cited F 656-Develop Implement Comprehensive Care Plan related to the facility's failure to implement a comprehensive care plan for an upper extremity device as ordered by the physician for one (Resident #36) out of 19 residents sampled. Review of the facility's plan of correction for the last annual survey with an exit dated 10/15/2021 related to F 656- Develop/Implement Comprehensive Care Plan indicated as part of the correction measures revealed: The Activity director and/or designee will conduct an audit of residents' activity care plan to ensure that they are followed and documented, random weekly x 4 weeks, then random monthly, thereafter. Findings will be discussed at the monthly QAA meeting to maintain compliance. During an interview with the Administrator, Director of Nursing (DON), and Admissions Director on 02/16/2023 at 2:37 PM it was revealed that the issues identified and discussed in the in previous meetings were missing items and grievances procedure, dietary issues, pandemic management, staffing issues, and Cyber breach. The administrator stated that they do Quality Assurance meetings daily and that they have not done a general meeting for February. They did not identify any concern with the tag F 656 as they run audits every day. The administrator stated that when it comes to assessments, one thing is for late assessment even though they were completed and submitted on time, they show as not submitted. We have tickets open with IT departments as we have had issues with connectivity, Minimum Data Set (MDS) coordinator and her assistant are on point with everything. The Director of Nursing stated that when it comes to Physician Orders, they hold clinical meetings every morning, and that they do 24-hour orders check. They do audits and he noted; I have never noticed that there is a pattern for not following physician orders. For the subject of this survey in particular, the doctor educated the patient, and he did not put a physician order in the record therefore the nurses kept using the splint, and the resident wanted to keep using the splint. The DON explained that audits are done for everything through a CRO (Conversion Rate Optimization audit also known as a conversion audit). The DON stated, we get audits every morning and especially for the new admission we check anything the nurses documented and whatever it needs to be looked at, we get a full report daily then I personally go one by one and try fixing it, this is consistent, and we also do 24-hour review after new admission. We are on top of everything, and we are going to be auditing physician orders specially for orthopedic patients for adaptive devices. Record review of the facility's Policy and Procedure documented : Subject Quality Assessment & Assurance Committee. POLICY: The QAA Committee shall consist of a minimum of the Director of Nursing, a physician designated by the facility and three (3) other members of the facility staff. Procedure: The Committee shall: 1. Review the following items to identify current and ongoing issues for committee action: a. Quality Indicator Report b. Accident/Incident Tracking Log c. Adverse Incident Tracking Log d. Regulatory Agency Reports e. Grievance Log f. Customer satisfaction results g. Consultant Reports h. Staff Meeting minutes. i. Resident Council Meeting minutes 2. The committee shall implement a CQI or quality review to investigate trends, patterns, positive or negative outcomes related to the topic. 3. The committee will determine an action plan needed to address any concerns. 4. The committee will implement and revise appropriate corrective actions.

Based on observations, interview, and record review, the facility 1.) Failed to store food under sanitary conditions in a manner that ensures they are free from potential contamination in the walk-in freezer, dry storage room and emergency water storage shed, 2.) Failed to ensure dishes and utensils were cleaned under sanitary conditions by failure to maintain the manufacturer recommended minimum wash and rinse temperature while operating a single tank low temperature dish machine, and 3.) Failed to ensure proper rotation of dietary supplements resulting in several expired supplements found in the medication storage room on units one and two. This has the potential to affect sixty eight (68) residents who eat orally out of seventy three (73) residents residing in the facility at the time of the survey. The findings included: 1.) Observation during the initial kitchen tour on [DATE] at 9:07 AM revealed a small walk-in freezer with a heavy accumulation of ice on the plastic curtains and the base of the unit. There were large chunks of ice hanging from the plastic curtains at the entrance to the freezer. Once the door was opened, the ice was observed falling off the curtain onto boxes of food stored in the freezer. There was a large amount of ice on the floor at the entrance to the freezer. Observation revealed the gasket on the freezer door was damaged preventing the door from sealing properly. Observation revealed a sheet of ice on top of a box of meat stored in the freezer. There was an opened box of french fries on the bottom of the freezer and there were ice chunks inside the box. Interview with the Kitchen Supervisor on [DATE] at 9:10 AM revealed they were in the process of replacing the freezer door and the gasket. Observation [DATE] at 2:08 PM revealed the large chunks of ice on the plastic curtains and the base of the freezer had been removed but there was still ice sheeting on top of a box containing Salisbury steak. There was a plastic bag of breaded okra on top of the opened box of French fries. There were ice chunks/crystals inside the box. Observation in the dry storage room on [DATE] at 9:20 AM revealed the integrity of the walls and ceiling in the dry storage room were damaged. There were holes in the base of the walls on the left and right side of the entrance door inside the storage area. There were racks of food stored in front of this area. The ceiling tiles were damaged above shelving units used for dry food storage. Items stored directly below the damaged ceiling tiles included corn starch, boxes of couscous and grits, cake mixes, pasta and rice. Observation on [DATE] at 1:10 PM revealed a shed outside of the building used for the storage of emergency water. The Director of Maintenance stated he stores 900 to 1000 gallons of water in this area. Observation revealed cases containing ,d+[DATE] gallon bottles. The cases were stacked on top of each other approximately six cases high in some areas of the shed. Several of the boxes were crushed, the water was leaking and the cardboard boxes were wet. Several cases were stacked too high and falling over. The floor of the shed was wooden and the wood floor was damaged and the dirt ground was visible through the broken wooden slats. Interview with the Environmental Services Director on [DATE] at 3:16 PM revealed the freezer doors were installed probably eight years ago. The Environmental Services Director reported that the facility have been working on trying to get a gasket for the door, but the company went out of business and if the facility cannot get the gasket the door they will have to be replaced. The freezer goes into the defrost cycle every six hours. The kitchen staff is responsible for clearing the ice. The condensation occurs during the defrost cycle which last for 30 minutes. The door does not seal properly. The gasket is damaged and the freezer is also located outside in the heat. It would not help to adjust the defrost cycles. The Environmental Services Director stated that the Kitchen Supervisor reported that the gasket was damaged about a month ago and the vendor was contacted. The Environmental Services Director stated that in reference to the emergency water storage, I will be replacing the gallon bottles with the 5 gallon bottles. The boxes were stacked too high crushing the plastic bottles which is why they were leaking. This water is due to be replaced because it expires in November. I will have to order racks for the 5 gallon bottles. If I order a rack I will be able to get rid of the damaged wood pallets. Interview with the consultant Registered Dietitian (RD) on [DATE] at 11:22 AM revealed she spoke to the administrator about the concern with the ice in the freezer and provided a quote to replace the freezer door. The RD stated that the gasket cannot be replaced because it is no longer available and the facility may need to replace the entire freezer at some point but, for now the quote is to replace the door. Review of the documentation provided revealed a proposed project agreement for replacement of a cooler and freezer door with inside casing. The project proposal was dated [DATE] and authorized by the Nursing Home Administrator (NHA) on [DATE]. The RD stated she did not know why the proposal was dated in August and the door replacement was still pending. In the meantime the facility had developed a plan to in-service the staff and monitor the freezer three times daily to make sure the area is clear of ice. Review of the facility policy titled, Food Storage Sanitation: (undated) revealed: -To prevent contamination of food supplies, do not store any foods under moist or dripping pipes. Stored canned and dry food items off the floor (6) on clean shelves to protect them from splash and contamination. Review of the facility's policy titled, Food Storage: Dry Goods (undated) revealed the dining service director or designee will regularly inspect the dry storage area to ensure it is well lit, ventilated and not subject to sewage or wastewater back flow or contamination, leakage, vermin or rodents. 2.) Observation on [DATE] at 2:15 PM revealed staff operating a low temperature dish machine equipped with a chlorine sanitizer, detergent and drying agent. Observation revealed the wash and rinse cycle temperatures initially at 80 degrees F (Fahrenheit). After four cycles, the gauge registered 100 degrees F. After three additional cycles the gauge registered 110 degrees F. The posted manufacturers instructions did not include a minimum wash or rinse temperature. Observation of the dish machine log for [DATE] revealed the wash and rinse temperatures and the sanitizer level were not recorded prior to operating the dish machine for the lunch meal on [DATE]. The staff was observed checking the sanitizer level using a chlorine test strip which registered ,d+[DATE] PPM (Parts Per Million). There was no food residue on the dishes. Interview with the Kitchen Supervisor on [DATE] at 2:25 PM revealed, this is a new dish machine which the facility was leasing from a company. The Kitchen Supervisor stated, I have trained my staff to check and record the temperatures on the log before operating the machine after each meal. The wash temperature should be 120 degrees. Review of the dish machine log with the Kitchen Supervisor revealed the staff had not documented the wash/rinse temperature or the sanitizer level on [DATE] prior to washing the lunch dishes. On [DATE] at 3:49 PM, the Kitchen Supervisor asked the surveyor to recheck the dish machine stating the temperature was now correct. Observation revealed the machine running for eight consecutive cycles and the wash/rinse temperatures never exceeded 118 degrees F. Observation on [DATE] 08:39 AM revealed staff operating the dish machine to wash breakfast dishes. Five cycles were observed. The wash temperature reached 110 degrees F and the rinse temperature reached 118 degrees F. The sanitizer level registered 150 PPM. Observation revealed the facility was using disposable foam containers for the main entree but, they continued to operate the dish machine below manufacturer recommended minimum wash and rinse temperatures to process the trays, coffee cups and cereal bowls. Interview with the Nursing Home Administrator (NHA) on [DATE] at 10:00 AM revealed the facility was looking into possibly adding a booster heater to the dish machine to ensure proper temperature were reached. The NHA stated that the facility was using disposables for now and were not using the dish machine. When the NHA was informed that the staff was observed this morning operating the dish machine for trays, coffee cups and cereal bowls she stated this was because the facility did not have disposable cups or bowls and the disposable trays are too flexible. Observation [DATE] at 2:35 PM revealed a dietary aide using the low temperature dish machine to wash an insulated coffee dispenser. The wash temperature was 100 degrees F and the rinse temperature was 110 degrees F. Interview with the Environmental Services Director on [DATE] at 3:16 PM revealed, the facility has three water heaters. Two of the heaters are dedicated for the resident rooms. One water heater is dedicated for the kitchen and laundry. Not long ago, about three weeks ago, the facility leased a new dish machine. Now that we are having a problem with the temperature, I called the vendor representative. He told me how to prime the machine to reach the 120 degrees F. I have to turn off the machine, open the dish machine, draining the water. Then I go to the control board and refill the machine. I have to do this between 5 to 7 times to reach the minimum 120 degrees F. This is a temporary solution. They also started to use disposables. I have the hot water heater set at 125 degrees F. I have a plumber coming in to work on the mixing valve. There may be particles stuck at the mixing valve which affects the temperature. He will check the valve and possibly raise the temperature of the water heater. We have also ordered a booster heater. If we solve the problem with the plumber then we may not need the booster heater. We have already submitted the work order in for the plumber. Interview with the RD on [DATE] at 2:04 PM revealed, the dish machine vendor representative will be coming to the facility on Monday to check the machine and order the booster heater. The Administrator had already contacted the company and received a quote for the booster heater. They are coming Monday to make sure of the size, availability and other specs. Review of the manufacturer ES-2000-V Dish Machine Specifications revealed: Temperatures Wash degrees F - minimum 120, Wash degrees F - recommended 140, Rinse degrees F - minimum 120, Rinse degrees F Recommended 140 degrees F. Water requirements: inlet temperature minimum 120 degrees F, recommended 140 degrees F. Review of the facility's policy titled, Machine Washing (undated) revealed: Staff must be aware of food safety best practices for ware washing. 3. Make sure machine is functioning properly. Check the gauges and compare readings as per machine specs. Low temperature, or chemical sanitizing machines will show typically 120 degrees F for both. 7. In the event that the mechanical dish washing machine malfunctions, single service articles will be used whenever practical. Any non-disposable articles that are used will be hand washed using the Manual Washing and Sanitizing method. 3) On [DATE] at 9:19 AM, During an observational tour of unit one's medication storage room, seven boxes of Nepro Therapeutic Nutrition were found with an expired date of ,d+[DATE]. In addition, on [DATE] at 9:39 AM, during an observational tour of unit two medication storage room, two boxes of Nepro Therapeutic Nutrition and ten boxes of Nova-source Renal were found expired with dates ranging from May to [DATE]. Interview on [DATE] at 01:28 PM with the Director of Nursing (DON) stated that the expired supplements are not usually the ones given to the residents or used in the facility and Staff G, Central supply clerk oversees the rotating and checking of the supplement stock. Interview with Staff A, charge Nurse on [DATE] at 04:54 PM about the expired supplements. Staff A stated the expired supplements are no longer used in the facility and Staff G brings the supplements up to the floor and someone at the nurses' station puts it away in the medication storage room. Review of the facility's undated policy for Food Storage Sanitation states: food will be rotated, and old stock will be used first.

Based on observation, interview and record review, the facility failed to ensure essential equipment was maintained in safe operating condition as evidenced by 1.) Excess condensation resulting in ice build up in the walk-in freezer and 2.) Failure to maintain the minimum wash and rinse temperature of 120 degrees Fahrenheit (F) while operating a single tank, low temperature dish machine. This has the potential to affect sixty eight (68) residents who eat orally out of seventy three (73) residents residing in the facility at the time of the survey. The findings included: 1.) Observation during the initial kitchen tour on 10/12/21 at 9:07 AM revealed a small walk-in freezer with a heavy accumulation of ice on the plastic curtains and the base of the unit. There were large chunks of ice hanging from the plastic curtains at the entrance to the freezer. Once the door was opened, the ice was observed falling off the curtain onto boxes of food stored in the freezer. There was a large amount of ice on the floor at the entrance to the freezer. Observation revealed the gasket on the freezer door was damaged preventing the door from sealing properly. Observation revealed a sheet of ice on top of a box of meat stored in the freezer. There was an opened box of french fries on the bottom of the freezer and there were ice chunks inside the box. Interview with the Kitchen Supervisor on 10/12/21 at 9:10 AM revealed they were in the process of replacing the freezer door and the gasket. Observation 10/13/21 at 2:08 PM revealed the large chunks of ice on the plastic curtains and the base of the freezer had been removed but there was still ice sheeting on top of a box containing Salisbury steak. There was a plastic bag of breaded okra on top of the opened box of french fries. There were ice chunks/crystals inside the box. Interview with the Environmental Services Director on 10/14/21 at 3:16 PM revealed the freezer doors were installed probably eight years ago. We have been working on trying to get a gasket for the door, but the company went out of business. If we cannot get the gasket the door will have to be replaced. The freezer goes in to the defrost cycle every six hours. The kitchen staff is responsible for clearing the ice. The condensation occurs during the defrost cycle which last for 30 minutes. The door does not seal properly. The gasket is damaged and the freezer is also located outside in the heat. It would not help to adjust the defrost cycles. The Kitchen Supervisor informed me that the gasket was damaged about a month ago so I contacted the vendor. Interview with the consultant Registered Dietitian (RD) on 10/15/21 at 11:22 AM revealed, she spoke to the administrator about the concern with the ice in the freezer and quote provided to replace the freezer door. The RD reported, the gasket cannot be replaced because it is no longer available. We may need to replace the entire freezer at some point but, for now the quote is to replace the door. Review of the documentation provided revealed a proposed project agreement for replacement of a cooler and freezer door with inside casing. The project proposal was dated 8/2/21 and authorized by the NHA on 8/5/21. The RD stated she did not know why the proposal was dated in August and the door replacement was still pending. 2.) Observation on 10/13/21 at 2:15 PM revealed staff operating a low temperature dish machine equipped with a chlorine sanitizer, detergent and drying agent. Observation revealed the wash and rinse cycle temperatures initially at 80 degrees F (Fahrenheit). After four cycles, the gauge registered 100 degrees F. After three additional cycles the gauge registered 110 degrees F. The posted manufacturers instructions did not include a minimum wash or rinse temperature. Observation of the dish machine log for October 2021 revealed the wash and rinse temperatures and the sanitizer level were not recorded prior to operating the dish machine for the lunch meal 10/13/21. The staff was observed checking the sanitizer level using a chlorine test strip which registered 100-200 PPM (Parts Per Million). There was no food residue on the dishes. Interview with the Kitchen Supervisor on 10/13/21 at 2:25 PM revealed; this is a new dish machine which we are leasing from the company. I have trained my staff to check and record the temperatures on the log before operating the machine after each meal. The wash temperature should be 120 degrees. Review of the dish machine log with the Kitchen Supervisor revealed the staff had not documented the wash/rinse temperature or the sanitizer level on 10/13/21 prior to washing the lunch dishes. On 10/13/21 at 3:49 PM, the Kitchen Supervisor asked the surveyor to recheck the dish machine stating the temperature was now correct. Observation revealed the machine running for eight consecutive cycles and the wash/rinse temperatures never exceeded 118 degrees F. Observation on 10/14/21 08:39 AM revealed staff operating the dish machine to wash breakfast dishes. Five cycles were observed. The wash temperature reached 110 degrees F and the rinse temperature reached 118 degrees F. The sanitizer level registered 150 PPM. Observation revealed the facility was using disposable containers for the main entree but, they continued to operate the dish machine below manufacturer recommended minimum wash and rinse temperatures to process the trays, coffee cups and cereal bowls. Interview with the Nursing Home Administrator (NHA) on 10/14/21 at 10:00 AM revealed, the facility was looking into possibly adding a booster heater to the dish machine to ensure proper temperatures were reached. For now we are using disposables. We are not using the dish machine. When informed the staff was observed this morning operating the dish machine for trays, coffee cups and cereal bowls, the NHA stated: This is because I did not have disposable cups or bowls and the disposable trays are too flexible. Observation 10/15/21 at 2:35 PM revealed a dietary aide using the low temperature dish machine to wash an insulated coffee dispenser. The wash temperature was 100 degrees F and the rinse temperature was 110 degrees F. Interview with the Environmental Services Director on 10/14/21 at 3:16 PM revealed: I have three water heaters. Two of the heaters are dedicated for the resident rooms. One water heater is dedicated for the kitchen and laundry. Not long ago, about three weeks ago, we leased a new dish machine. Now that we are having a problem with the temperature, I called the vendor representative. He told me how to prime the machine to reach the 120 degrees F. I have to turn off the machine, open the dish machine, draining the water. Then I go to the control board and refill the machine. I have to do this between 5 to 7 times to reach the minimum 120 degrees F. This is a temporary solution. They also started to use disposables. I have the hot water set at the water heater at 125 degrees F. I have a plumber coming in to work on the mixing valve. There may be particles stuck at the mixing valve which affects the temperature. He will check the valve and possibly raise the temperature at the water heater. We have also ordered a booster heater. If we solve the problem with the plumber then we may not need the booster heater. We have already submitted the work order in for the plumber. Interview with the RD on 10/15/21 at 2:04 PM revealed, the dish machine vendor representative will be coming to the facility on Monday to check the machine and order the booster heater. The Administrator has already contacted the company and has received a quote for the booster heater. They are coming Monday to make sure of the size, availability and other specs. Review of the manufacturer ES-2000-V Dish Machine Specifications revealed: Temperatures Wash F - minimum 120, Wash F - recommended 140, Rinse F - minimum 120, Rinse F Recommended 140. Water requirements: inlet temperature Minimum 120 F, recommended 140 F. Review of the facility's policy titled, Machine Washing (undated) revealed: Staff must be aware of food safety best practices for ware washing. 3. Make sure machine is functioning properly. Check the gauges and compare readings as per machine specs. Low temperature, or chemical sanitizing machines will show typically 120 degrees F for both. 7. In the event that the mechanical dish washing machine malfunctions, single service articles will be used whenever practical. Any non-disposable articles that are used will be hand washed using the manual washing and sanitizing method.

Based on observation, record review and interview, the facility failed to ensure 1 out of 20 sampled residents (Resident # 46) was free from restraints. Resident #46 was observed in bed and had two wedge devices on the right and left side of her bed that was observed to be a restraint. There were 73 residents admitted to the facility during the survey. The findings included: The Centers for Medicare and Medicaid Services defines a Physical Restraint as: any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: o Is attached or adjacent to the resident's body; o Cannot be removed easily by the resident; and o Restricts the resident's freedom of movement or normal access to his/her body. During an observation of Resident # 46 on 10/12/2021 at 10:14 AM, the resident was observed in a wheelchair, the resident said a few words, but the words weren't clear. Staff C, a Certified Nursing Assistant (CNA) had completed the resident's morning care. The resident did not respond when her name was called. During an observation of Resident # 46 on 10/12/2021 at 1:00 PM, the resident was sitting in a wheelchair in the 2nd floor activity room, she was observed to be talking to herself and dancing to music by moving her shoulders and feet while sitting in the wheelchair. During observation of Resident # 46 on 10/15/2021 at 8:55 AM, the resident was observed to be in a low bed and asleep. The resident was in the middle of the bed and there were two wedges observed one on the right and one on the left side of the resident. Staff C, CNA was in the room providing care to Resident #46's roommate. Staff C was asked to allow the surveyor to see the wedges on Resident # 46's bed. Staff C reported, she did not have Resident # 46 today. The observation revealed an approximately 3 feet long wedge on the right side of the bed and an approximately 2 feet long wedge on the left side of the bed. In addition, the resident had the two upper side rails up on the bed. Staff C reported, the wedges were there to prevent the resident from getting out of bed because she had fallen in the past. The resident did not wake up during this observation. The wedge devices were observed to be underneath the residents bed sheet, located on the left and right side of the resident, the wedges were observed to be devices that could not be easily removed by the resident and restricted the resident from getting out of the bed. Observation on 10/15/21 at 12:10 PM, the resident was observed in bed asleep and in a hospital gown. The two siderails were up, but the wedges were not observed. Observation on 10/15/21 at 12:55 PM, revealed Resident #46 was in bed and being fed her lunch by Staff C. The resident was observed to be drowsy. The wedges were not observed on Resident #46's bed and were not observed in the residents room. Staff C was asked, where the wedges were, and she didn't know. Staff C was asked to allow the surveyor to open the residents closet to determine the location of the wedges. Upon opening the closet door, the wedges were observed inside the closet. A photo of the wedges was obtained. During this observation, Staff A, Licensed Practical Nurse (LPN) and Unit Manager entered the resident's room. Staff A reported, the small wedge was supposed to be used for the resident's heels and the large wedge shouldn't have been used. Staff A reported, we have to have orders to use the large wedge. On 10/15/21 at 1:00 PM, Staff A was asked to check the resident's physician orders. Staff A showed the surveyor, the resident has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A reported, the small wedge could be used instead of a pillow for positioning. During the review of Resident #46's medical record it was determined, the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/2021, the resident's weight was listed as 98 lbs (pounds). The residents Brief Interview for Mental Status (BIMS) score was listed as 06 out of 15 meaning the resident had severe cognitive impairment. Review of the residents Quarterly Minimum Data Set (MDS) dated [DATE], Section P for restraints did not include the use of restraints. Review of the residents care plan for Risk for Falls related to Cognitive Deficits, Confusion, Gait/balance, Incontinence, Psychoactive drug use and Legally Blind reviewed and updated on 09/13/2021. The goal was to minimize falls through the next review period. The interventions in the care plan included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bed in low position. Fall precautions as indicated Keeping the beds closer to the floor reduces the risk of falls and serious injury. In some healthcare settings, placing the mattress on the floor significantly reduces fall risk. Provide a safe environment, free obstacles. The resident needs activities that minimize the potential for falls while providing diversion and distraction. During the review of the facility's Physical Restraint Policy and Procedure with a revision date of 11/6/2020, the following was documented in the policy: Residents have the right to considerate and respectful care at all times and under all circumstances with recognition of their personal dignity and safety in the least restrictive manner. As needed, the interdisciplinary team will evaluate the resident for the potential need for physical restraint . This policy and procedure does not apply to protective/adaptive/mechanical services. These devices are used for postural support, to assist the resident to obtain/maintain normative body functioning, or to compensate for a specific physical deficit. For example, bed rail used to enable movement. Although the facility's policy and procedure does not identify protective, adaptive and mechanical devices as physical restraints, the policy fails to recognize these devices can meet the definition of a physical restraint as demonstrated by the use of the wedges used on Resident # 46 on 10/15/2021.

Based on record review and interview, the facility failed to 1.) Ensure the Nursing Home Transfer and Discharge Notices were provided to the resident and/or representative and the Office of the Long Term Care Ombudsman for one (Resident #25) related to three hospitalization s, and 2.) Failed to ensure the Nursing Home Transfer Discharge Notice was sent to the Office of the Long-Term-Care Ombudsman's for one (Resident #82) following discharge from the facility. There were 20 sampled residents and there were seventy three (73) residents residing in the facility at the time of the survey. The findings included: 1.) Record review of Resident #25 clinical record revealed she was admitted to the facility on [DATE]. Resident #25 was transferred to the hospital on 06/21/2021, 08/16/2021 and 09/22/2021. There were no Nursing Home Notice of Transfer and Discharge forms on file in the Electronic Health Record (EHR) or the paper record for the dates of these transfers. On 10/15/2021 at approximately 11:00 AM the Director of Social Services (DSS) revealed during an interview that the facility does not provide Notices of Transfer and Discharge to the residents who are sent out to the hospital because they are sent out by the physician so they are not facility initiated. The DSS stated: We used to send the notices to the Ombudsman when a resident was transferred to the hospital. I have a binder with the notices from 2019 and I have some for 2020 but we stopped sending them this year. The DSS explained this to be a problem and the facility will start sending them again beginning September 2021. The DSS acknowledged that the notices were not provided to Resident #25, her representative nor the Ombudsman for the three hospital transfers on 06/21/2021, 8/16/2021 and 9/22/2021. Interview with the Nursing Home Administrator (NHA) on 10/15/2021 at 3:20 PM revealed the facility used to issue the Notices of Transfer and Discharge but during the pandemic the facility stopped completing them. The NHA stated that this was determined to be a company wide problem. The NHA reported, Our corporate office identified this deficient practice. We identified this in August 2021 and the DSS was supposed to start providing the notices again in September 2021. We recently identified that we misinterpreted the intent of the notice and we were not providing the notices when a resident was transferred to the hospital. We felt they were not considered facility initiated, since the residents were transferred by the physician. The notices were not provided to the resident, representatives and the Ombudsman's office. We recently reviewed this procedure again and now we will be revising the process to send the notices out for all transfers. The DSS will be sending the notices to the Ombudsman on a weekly basis. The facility does not have a policy that specifically addresses the procedure related to these notices. 2) Review of the Face Sheet for Resident #82 documented, the resident was admitted to the facility on [DATE] and discharged on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Discharge assessment dated [DATE] documented Resident # 82 had a Brief Interview for Mental Status (BIMS) Summary Score of 10 out of 15 indicating moderate cognitive impairment and the resident would be discharged back to the community. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was written on 8/11/21 and Home Health services were ordered. Review of the Social Service Progress Note for Resident #82 dated 7/19/21 documented that upon rehabilitation completion the discharge plan is home with daughter and spouse. Review of the Nurses' Progress Note for Resident #82 dated 8/13/21 documented, discharged home today via wheelchair. Review of the Notice to Ombudsman documented there were no notices sent to the Ombudsman concerning discharge to the community. On 10/15/21 at 12:08 PM, the Social Services Director stated, She was here for short term and here for therapy. She completed her therapy. She was care planned to be discharged back home with family. We stopped sending notices to the Ombudsman in 2020 and we started back in August, September of this year. No, we started, this year in September. I do not have a notice to the Ombudsman for this resident. There should have been a notice sent to the Ombudsman for this resident.

Based on observation, record review and interview, the facility failed to accurately assess one out of 20 sampled residents (Resident #62) Minimum Data Set (MDS) in Section C - Cognitive Patterns in the section for [CONDITION(S)]. There were 73 residents admitted to the facility during the survey. The findings included: On 10/12/21 at 10:14 AM, Resident #62 was observed in bed awake, scratching her head, the resident reported, these ants are eating me up. Resident #62 was asked, how was breakfast and she said, I needed more meat. The resident was looking up toward the ceiling during the observation. There were no ants observed on the resident. The Television (TV) was off and there was no music playing in the room. On 10/12/21 at 12:39 PM, resident #62 was observed in bed asleep. On 10/12/21 at 12:51 PM, resident #62 was observed sitting up in bed feeding herself lunch. Her eyes are closed while eating. Resident #62 was asked whether she was falling asleep while eating, she said, no, and continued to eat. Her eyes were closed and she was observed to pick up her tea to drink. The TV was off and there was no music playing in the room. On 10/13/21 at 09:05AM, resident #62 was observed in bed awake, the resident reported, she's the same and she's being eaten up by ants. Resident #62 was talking to herself, and using profanity intermittently. The resident was talking as if she was speaking to people that were in the room with her, but nobody was in the room. She was looking up toward the ceiling. The resident had 2 siderails up. The TV was off and there was no music playing in the room. On 10/14/21 at 11:09 AM, resident #62 was in bed awake and lying on her back. The resident was asked whether she likes TV and music and the resident reported, she likes TV and music. The resident was observed talking to herself and she used profanity intermittently. The resident was talking as if she was speaking to people that were in the room with her, but nobody was in the room. The privacy curtains were partially closed next to door and between the resident beds. The TV was off and there was no music playing in the room. During record review it noted, the resident was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents Brief Interview for Mental Status score was 06, meaning the residents cognitive status was severely impaired. During the review of Resident #62's MDS, Section C, Section C1310 for [CONDITION(S)], for the annual MDS dated [DATE] and the last Quarterly dated 09/19/2021, facility staff documented, For Inattention - Did the resident have difficulty focusing attention, for example, being easily distracted, or keeping track of what was said? - The facility staff documented the behavior was not present. For Disorganized Thinking - Was the residents thinking disorganized or incoherant (rambling or incoherrant conversation, unclear or illogiacl flow of ideas or unpredicatible, switching from subject to subject? The facility staff documented the behavior was not present. Although, facility staff documented that the behaviors were not present, facility staff completed care plans for Resident #62 that included, The resident has impaired thought processed related to impaired decision making. The goal was for the resident to maintain her current level of cognitive function through the review date. The care plan was reviewed on 03/19/2021, 06/19/2021, 07/01/2021 and 09/19/2021. The interventions included: Cue, reorient and supervise. Engage resident in simple, structured activities that avoid overly demanding task. Keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. On 10/15/2021 at 2:00pm, the Social Services Director was interviewed about resident #62's Section C, C1310 for [CONDITION(S)]. Staff H, acknowledged the MDS coding was not accurate and should've been coded for the behaviors being present. Staff H provided copies of the residents MDS and care plans.

Based on observation, record review and interview, the facility failed to implement the activities care plan for one out of 20 sampled residents (Resident # 62). There were 73 residents admitted to the facility during the survey. The findings included: On 10/12/21 at 10:14 AM, Resident # 62 was observed in bed awake, scratching her head, the resident reported, these ants are eating me up. Resident # 62 was asked, how was breakfast and she said, I needed more meat. The resident was looking up toward the ceiling during the observation. There were no ants observed on the resident. The Television (TV) was off and there was no music playing in the room. On 10/12/21 at 12:39 PM, Resident # 62 was observed in bed asleep. On 10/12/21 at 12:51 PM, Resident # 62 was observed sitting up in bed feeding herself lunch. Her eyes were closed while eating. Resident # 62 was asked whether she was falling asleep while eating, she said, no, and continued to eat. Her eyes were closed and she was observed to pick up her tea to drink. The TV was off and there was no music playing in the room. On 10/13/21 at 09:05 AM, Resident # 62 was observed in bed awake, the resident reported, she's the same and she's being eaten up by ants. Resident # 62 was talking to herself, and using profanity intermittently. The resident was talking as if she was speaking to people that were in the room with her, but nobody was in the room. She was looking up toward the ceiling. The resident had 2 siderails up. The TV was off and there was no music playing in the room. On 10/14/21 at 11:09 AM, Resident # 62 was in bed awake and lying on her back. The resident was asked whether she likes TV and music and the resident reported, she likes TV and music. The resident was observed talking to herself and she used profanity intermittently. The resident was talking as if she was speaking to people that were in the room with her, but nobody was in the room. The privacy curtains were partially closed next to door and between the residents beds. The TV was off and there was no music playing in the room. During record review it noted, the resident was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents Brief Interview for Mental Status score was 06 out of 15, meaning the residents cognitive status was severely impaired. During record review it was noted, the residents care plans included: Resident is at risk for alteration in Psychosocial well being related to fear of COVID 19, restriction on visitation and social isolation due to COVID 19. On 03/19/2021- The Care plan was reviewed quarterly by the Interdisciplinary Team (IDT). On 06/19/2021- The Residents care plan was reviewed quarterly. On 07/01/2021- The Care plan was reviewed & updated by the IDT. On 09/19/2021- The Care plan was reviewed by the IDT quarterly. The goal for the care plan was: Resident will not experience any adverse effects through next review. The interventions included: Assure resident and family that facility is taking all necessary precautions to keep them safe. The responsible facility departments included - Social Work, Registered Nurse and Licensed Practical Nurse (SW,RN,LPN). Encourage and provide alternate methods of communication with visitors and family. (SW, RN, LPN) Encourage participation in group activities and social events within the facility. The responsible facility department included - Activities Department Assistant and Director (ACTA, ACTD). Observe for psychosocial and mental status changes. Document and report as indicated. (SW, RN, LPN) Provide emotional support and allow resident to express feelings, fears, and concerns. (SW, RN, LPN) Provide in room activities of choice as indicated. (ACTA, ACTD) Update resident and family as needed. (SW, RN, LPN) Resident #62's Care Plans also included - The resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations and depression, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/19/2021- The Care plan was reviewed quarterly by the Interdisciplinary Team (IDT). On 06/19/2021- The Residents care plan was reviewed quarterly. On 07/01/2021- The Care plan was reviewed & updated by the IDT. On 09/19/2021- The Care plan was reviewed by the IDT quarterly. The care plan was initiated on 12/23/2020 and revised on 9/23/2021. The goal was for the resident to attend/participate in community life activities of choice as desired 3 - 4 times per week by the next review date. The interventions included: Establish and record the residents prior level of activity involvement and interest by talking with the resident, caregivers and residents representative on admission and as necessary. (ACTA) Introduce the resident to residents with similar background, interest, and encourage/facilitate interaction. (ACTA) Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self expression and responsibility. (ACTA) The resident needs bedside/in-room visits and activities if unable to attend out of room events. (ACTA) During an interview on 10/15/21 at 12:00 PM, Staff G, the Activities Director was asked about the activities she provides for Resident # 62, since the resident had been observed throughout the survey in her room, with the door closed, the TV was off and there was no music in the room. Staff G reported, the resident was very difficult and she takes her cart to her room and the resident usually refuses, for example, she would ask the resident would she like a hand massage and the resident would refuse. Staff G reported, the resident has a foul mouth and she's usually in her room. Staff G was asked to show the surveyor her notes on the activities she has provided for Resident # 62. Staff G reported, the resident usually had the TV on. On 10/15/21 at 12:10 PM, Staff G and the surveyor went to Resident # 62's room. The TV was off. Resident # 62 was awake, Staff G told the resident who she was and asked the resident whether she wanted the TV on and the resident said, yes. Staff G, turned the residents TV on. On 10/15/21 at 12:30 PM, Staff G provided the residents activity care plan and reported, she didn't think she had any notes for Resident # 62. Resident # 62's medical record progress notes were checked by Staff G in the presence of the surveyor and no activity progress notes were found. Staff G was unable to demonstrate the activities care plans had been implemented for Resident #62.

Based on observation, record review and interview, the facility failed to provide an ongoing activities program for one out of 20 sampled residents. (Resident #62) There were 73 residents admitted to the facility during the survey. The finding included: On 10/12/21 at 10:14 AM, Resident #62 was observed in bed awake, scratching her head, the resident reported, these ants are eating me up. Resident #62 was asked, how was breakfast and she stated, I needed more meat. The resident was looking up toward the ceiling during the observation. There were no ants observed on the resident. The Television (TV) was off and there was no music playing in the room. On 10/12/21 at 12:39 PM, Resident #62 was observed in bed asleep. On 10/12/21 at 12:51 PM, Resident #62 was observed sitting up in bed feeding herself lunch. Her eyes were closed while eating. Resident #62 was asked whether she was falling asleep while eating, the resident stated, no and continued to eat. Resident # 62's eyes were closed, she was observed picking up her tea to drink. The TV was off and there was no music playing in the room. On 10/13/21 at 9:05 AM, Resident # 62 was observed in bed awake, the resident reported, she is the same and she is being eaten up by ants. Resident # 62 was talking to herself, and using profanity intermittently. The resident was talking as if she was speaking to people that were in the room with her, but nobody was in the room. She was looking up toward the ceiling. The resident had 2 siderails up. The TV was off and there was no music playing in the room. On 10/14/21 at 11:09 AM, Resident #62 was in bed awake and lying on her back. The resident was asked whether she likes TV and music and the resident reported, she likes TV and music. The resident was observed talking to herself and she used profanity intermittently. The resident was talking as if she was speaking to people that were in the room with her, but nobody was in the room. The privacy curtains were partially closed next to the door and between the residents beds. The TV was off and there was no music playing in the room. During record review it was noted, the resident was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents Brief Interview for Mental Status score was 06, meaning the residents cognitive status was severely impaired. During record review it was noted, the residents care plans included: The resident is at risk for alteration in Psychosocial well being related to fear of COVID 19, restriction on visitation and social isolation due to COVID 19. On 03/19/2021- The Care plan was reviewed quarterly by the Interdisciplinary Team (IDT). On 06/19/2021- The Residents care plan was reviewed quarterly. On 07/01/2021- The Care plan was reviewed & updated by the IDT. On 09/19/2021- The Care plan reviewed by the IDT quarterly. The goal for the care plan was: Resident will not experience any adverse effects through next review. The interventions included: Assure resident and family that facility is taking all necessary precautions to keep them safe. The responsible facility departments included - Social Work, Registered Nurse and Licensed Practical Nurse (SW, RN, LPN). Encourage and provide alternate methods of communication with visitors and family. (SW, RN, LPN) Encourage participation in group activities and social events within the facility. The responsible facility department included - Activities Department Assistant and Director (ACTA, ACTD). Observe for psychosocial and mental status changes. Document and report as indicated. (SW, RN, LPN) Provide emotional support and allow resident to express feelings, fears, and concerns. (SW, RN, LPN) Provide in room activities of choice as indicated. (ACTA, ACTD) Update resident and family as needed. (SW, RN, LPN) Resident #62's Care Plans also included - The resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations and depression, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/19/2021- The Care plan was reviewed quarterly by the Interdisciplinary Team (IDT). On 06/19/2021- The Residents care plan was reviewed quarterly. On 07/01/2021- The Care plan was reviewed & updated by the IDT. On 09/19/2021- The Care plan reviewed by the IDT quarterly. The care plan was initiated on 12/23/2020 and revised on 9/23/2021. The goal was for the resident to attend/participate in community life activities of choice as desired 3 - 4 times per week by the next review date. The interventions included: Establish and record the residents prior level of activity involvement and interest by talking with the resident, caregivers and residents representative on admission and as necessary. (ACTA) Introduce the resident to residents with similar background, interest, and encourage/facilitate interaction. (ACTA) Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self expression and responsibility. (ACTA) The resident needs bedside/in-room visits and activities if unable to attend out of room events. (ACTA) During an interview on 10/15/21 at 12:00 PM, Staff G, the Activities Director was asked about the activities she provides for Resident #62, since the resident had been observed throughout the survey in her room, with the door closed, the TV was off and there was no music in the room. Staff G reported, the resident was very difficult and she takes her cart to her room and the resident usually refuses, for example, she would ask the resident would she like a hand massage and the resident would refuse. Staff G reported, the resident has a foul mouth and she's usually in her room. Staff G was asked to show the surveyor her notes on the activities she has provided for Resident #62. Staff G reported, the resident usually had the TV on. On 10/15/21 at 12:10 PM, Staff G and the surveyor went to Resident #62's room. The TV was off. Resident # 62 was awake, Staff G told the resident who she was and asked the resident whether she wanted the TV on and the resident said, yes. Staff G, turned the residents TV on. On 10/15/21 at 12:30 PM, Staff G provided the residents activity care plan and reported, she didn't think she had any notes for Resident # 62. Resident #62's medical record progress notes were checked by Staff G in the presence of the surveyor and no activity progress notes were found. Staff G was unable to demonstrate an ongoing activities program was provided for Resident # 62.

Based on observation, record review and interviews, the facility failed to provide adequate supervision to prevent accidents for one (Resident #71) out of one residents sampled for smoking safety. This deficient practice enabled Resident #71 to keep his cigarettes and lighter in his bedside table. There were 71 residents residing in the facility at the time of the survey. The findings included: Review of the facility's policy titled, Smoking effective date November 2014 indicated: Policy Statement: The Company facilities are an established non-smoking facility, unless allowed by state and local regulations. Residents are notified on admission that the facility is a non-smoking facility or allowed to smoke only in designated areas and that they must adhere to the Smoking Policy. Procedure: 5) The ability of a resident to have in their possession smoking materials (cigarettes, cigars, lighters, matches, etc.) will be identified in the residents care plan. Smoking materials will be retained and stored by the nursing staff for residents identified by their care plans as not being responsible to possess materials without supervision; 7) A resident will be allowed to smoke without supervision if they are deemed appropriate by the care plan. Observation of Resident #71 on 10/13/21 at 9:32 AM revealed, the resident sitting in a chair on the patio smoking, alone. The resident had his own lighter and cigarettes. Review of the Face Sheet for Resident #71 documented, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to malignant neoplasm bronchus or lung, malignant neoplasm of prostate, [CONDITION(S)] and heart failure. Review of the Brief Interview for Mental Status (BIMS) dated 3/24/21 documented Resident #71 had a BIMS Summary Score of 13 out of 15 indicating no cognitive impairment and the resident was able to make needs known. The resident required limited assistance with one person physical assist for Activities of Daily Living ( ADL) and was coded as no tobacco use. Review of the Smoking assessment dated [DATE] and 9/17/21 documented Resident #71 smokes safely; Resident is able to light cigarette safely with a lighter and resident is a safe smoker. Review of Resident's #71 Smoking care plan dated 6/17/21 documented the resident is an active smoker exhibits; Goal: Resident will not suffer injury from smoking through the review date; Interventions: Instruct resident about the facility policy on smoking: locations, times, safety concerns; Resident able to smoke in the designated area without supervision; Resident is able to light own cigarette, keep lighter at bedside. On 10/14/21 at 10:58 AM, Staff D Registered Nurse (RN) stated, Resident smokes. I think he doesn't keep his cigarettes and lighter. The resident gets them from the Activity Director. On 10/14/21 at 11:01 AM, the Director of Nursing (DON) stated, He has lung cancer. When he was admitted here he was not smoking and was going through [CONDITION(S)]. Once he finished [CONDITION(S)], he started smoking again. He is alert and oriented times three. Per our policy he is allowed to keep lighter and cigarettes. The roommate is ambulatory and is alert and oriented times three. Subsequent interview on 10/14/21 at 2:32 PM stated, We all met with him today MDS (Minimum Data Set), Certified Nursing Assistant (CNA), Supervisor, Nurse and myself we explained the importance of keeping the cigarettes and the lighter at all times and give it to him when he desires. He was not happy and said he didn't want to be controlled. He agreed to comply, we have the lighter now. He said he was going to talk to his daughter and son to be removed from here. The Activities Director kept the cigarettes in her office but he kept the lighter before now. On 10/14/21 at 11:09 AM, the Activities Director stated, Smoking hours are between 10:00 am to 12:00 PM, 2:00 PM to 4:00 PM for smoking. If they are alert and oriented times three, they are allowed to keep the lighter. They come to the activities for the cigarettes during the day and to the nurse at night if they want to smoke. He keeps his lighter in his pocket or in his socks. When he goes out to an appointment he takes the cigarettes and lighter with him in a box. He is considered a safe smoker. On 10/14/21 at 11:21 AM, Staff E Licensed Practical Nurse (LPN) stated, I conducted both smoking assessments for the resident on 6/17/21 and 9/17/21. He is a safe smoker. He is a long term smoker. He keeps the lighter in his room. I never saw the cigarettes in the room. On 10/14/21 at 11:57 AM, Staff F RN, Minimum Data Set (MDS) Coordinator stated, I did the care plan for him to be a safe smoker on 7/01/21. The resident is able to light his own cigarette and keep his lighter at bedside. I revised his smoking care plan today and removed keep lighter at bedside from interventions. On 10/15/21 at 7:43 AM via Spanish translator Resident #71 revealed that he smokes by himself outside on the patio. He would keep his own cigarettes and lighter in his bedside stand. The staff took his cigarettes and lighter yesterday and now he has to ask the staff for cigarettes and a lighter when he wants to smoke.

Based on observation, interview, and record review, the facility failed to provide accurate respiratory therapy of 2 liters oxygen for one resident (Resident #484), as evidenced by the resident was observed receiving 4.5 liters per minute (LPM) of oxygen instead of the ordered 2 liters of oxygen. There were 13 residents receiving oxygen care out of the 73 residents, who were residing in the facility at the time of this survey. The findings included: Observation of Resident #484 on 10/12/21 at 10:01 AM revealed the resident was seated in her recliner. The oxygen level was observed at 4.5 LPM. The resident stated that she was not feeling well. Observation of Resident # 484 on 10/12/2021 at 11:41 AM. The resident was seated in her recliner, sleeping. The oxygen level was observed at 4.5 LPM. (Photographic Evidence). Observation of Resident # 484 on 10/13/2021 at 09:19 AM. The resident was seated in her recliner. The resident stated that she was not feeling well. The resident was asked if she told the nurse that she was not feeling well and the resident stated: yes, she is going to give me some medications. The oxygen level was observed at 5 LPM. (Photographic Evidence) Observation of Resident # 484 on 10/14/2021 at 9:18 AM. Resident was observed in her recliner. The resident smiled when asked how she was feeling. The oxygen level was observed at 4.5 LPM. (Photographic Evidence). On 10/14/2021 at 9:18 AM, during an interview Resident # 484 stated that she was very anxious, because she wanted to go home where she feels more comfortable. On 10/14/2021 at 12:01 PM Resident #484 was observed eating lunch and the oxygen level was observed at 4.5 LPM. Record review of the Admission record revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physicians' orders revealed an order dated 10/07/2021 for oxygen at 2 LPM via nasal cannula continuously. Record review of the Care Plan initiated 10/08/2021 with next review on 01/6/2022 revealed, the resident has oxygen therapy related to [CONDITION(S)]: Goal: The resident will have no signs or symptoms of poor oxygen absorption through the review date. Interventions: Encourage or assist with ambulation as indicated. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for signs and symptoms of respiratory distress and report to MD (Medical Doctor) as needed. Oxygen Settings: O2 (oxygen) via Nasal Cannula as ordered. Monitor for SpO2 (oxygen saturation). Suction as needed. Interview with Staff B (Registered Nurse) (RN) on 10/14/2021 at 3:54 PM, revealed she works the 7:00 am to 7:00 PM shift. Staff B stated that at the start of the shift she made rounds with the nurse (night shift). Staff B reported that Resident # 484 order is for oxygen at 2 LPM continuously and was being well tolerated. A side by side observation was conducted with Staff B and the surveyor of the oxygen concentrator level for Resident # 484 and the level was noted at 4.5 LPM. Staff B stated that she does not know how that happened and added that someone could have pushed the concentrator and the level changed. and she proceed to change the level to 2 LPM. Record review of Policies and Procedure for oxygen therapy effective date: 11/30/2014 revised on 08/28/2017 revealed Policy: Oxygen Therapy is the administration of FiO2( Fraction of inspirited oxygen) greater than 21% by means of various administration devices. Equipment, Procedure : physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . PRN orders must include specific guidelines as to when the residents is to use oxygen. Review physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on records review, observations and interviews, the facility failed to safeguard resident's rights to be free from physical restraints for two residents (Resident # 1 and Resident #2) investigated for the use of physical restraints, out of six total sampled residents during a complaint investigation survey. The facility failed to ensure assessment or justification for the use of the physical restraints that kept residents from getting out of bed. This facility practice has the potential to have an adverse effect for Resident #1 and Resident #2. There were 78 residents residing in the facility at the time of the survey. The Findings Included: Review of the facility's policies and procedures revealed a policy for Physical Restraints dated 11/30/2014 and revised on 8/22/2017; Residents have the right to considerate and respectful care at all times and under all circumstances, with recognition of their personal dignity and safety in the least restrictive manner. As needed, the interdisciplinary team will evaluate the resident for the potential need for physical restraint. The restraint must be the least restrictive means available. If the resident is identified by the interdisciplinary team and/or a discipline as requiring further intervention due to safety concerns, alternative methods will be attempted before restraint application will be considered. Monitoring and release of restraints will be done according to any state specific regulation . The procedures included but not limited: A restraint evaluation will be performed by nursing to assess physical, mental and other contributing factors which indicate the need for restraint/enabler. The nurse will obtain the Physicians order for the restraint. This order will include the medical reason for the restraint. Restraint use is documented in the resident care plan and in the nurse's notes . Review of the Admissions Record for Resident # 1 revealed, The resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 6 out of 15 indicating cognitive impairment. Further review of the MDS indicated no behavior nor behavioral symptoms. His active [DIAGNOSES REDACTED]. Review of the Admissions Record for Resident # 2 revealed, The resident was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Review of quarterly MDS dated [DATE] revealed the resident's BIMS score was 6 out of 15 indicating cognitive impairment. Further review of the MDS indicated no behavior nor behavioral symptoms. No physical restraints used. Observation of Resident #1's and Resident #2's room on 7/14/20 at 10:00 AM revealed, Resident #1 was asleep in his bed. Resident #1's bed was completely surrounded by furniture devices. To the right side of the resident, adjacent to his bed was a wheelchair that was a closed folded-up wheelchair and a green colored arm side chair, adjacent to the resident's left side of the bed was a night table that was turned with the front against the cabinet and another folded closed wheelchair. (see photo). Resident #2 was not in the room and was in the activity room. On 7/14/2020 at 10:34 AM, Staff A, Certified Nursing Assistant (CNA) reported he worked in the facility for about a year. He received trainings that included caring for residents with dementia. He cared for some residents that showed behaviors such as screaming and agitation. Resident #1 and Resident #2 showed such behaviors at times. During the interview, Staff A agreed to observe Resident #1 and Resident #2's room. On 7/14/2020 at 10:37 AM, during observation and Interview on with Staff A, Resident #1 was in bed surrounded by the above-mentioned furniture items that included, a chair and a wheelchair to his right, and a desk and a wheelchair to his left. Staff A stated that it was common practice to place furniture around Resident#1 because at times, he attempted to get out of bed. Resident #2 also had behaviors that included attempts to get out of bed and worse Staff A reported he usually found both residents like that (with furniture placed around their bed) in the mornings, when he started his shift. He added that this had to be done because it was for the residents' safety. Interview and record review with Staff B, a Licensed Practical Nurse (LPN), on 7/14/2020 at 1:55 PM revealed, she was familiar with Residents #1 and Resident #2. The residents' plan of care included half side rails, for mobility. The LPN explained there was no clinical indication, assessment, nor plan of care to justify the use of physical restraints on the residents. She explained that with the help of Staff A, she helped Resident #2 out of bed that morning. In the process, they accidentally blocked Resident #1's bed. She only noticed all the furniture that surrounded Resident #1 later that morning, when she administered his medications. When I saw that, I told the CNA that when he sees that he needs to remove them because that is a form of restraint . I explained that to the CNA, he told me he did not know. The aid offered no explanation or justification for furniture noted to the left side of the resident. On 7/14/20 at 4:10 PM during an interview and record review with both the Facility's Director Of Nursing (DON) and the Assistant Director Of Nursing (ADON) revealed, Resident #2 had a fall without injury in on 3/15/20 and Resident #1 last fall occurred on 5/7/20, also without injuries. The residents plan of care did not include the use of physical restraints. Upon discussion of the above-mentioned observations, both the DON and ADON agreed it was not appropriate practice to place furniture around the residents' bed; it was a form of physical restraint. None of the residents required the use of physical restraints.

Based on observation, record review and staff interview the facility failed to have appropriate Personal Protective Equipment (PPE) for sorting soiled linen. The laundry failed to have a functional physical barrier between the soiled and clean linen area in order to prevent cross contamination. The findings include: Observation of the laundry area on 06/07/2018 at 1:00 PM revealed the soiled linen area noted two bins with soiled linen. The soiled linen area was separated from the clean linen area by a plastic drape. The plastic drape was observed with a zipper on each side and open underneath. Observation of the Personal Protective Equipment located next to the eyewash station revealed a rubber apron. An interview conducted with the Environmental Services Director on 06/07/2018 at 1:15 PM revealed the laundry facility was utilizing a plastic drape to separate the soiled and clean linen. The Personal Protective Equipment utilized to sort the soiled linen consisted of a rubber apron and rubber gloves. An interview conducted with the Infection Control Nurse on 06/07/2018 at 1:30 PM confirmed there was not a functional separation between the clean and soiled laundry area. The laundry did not have the appropriate Personal Protective Equipment in order to prevent cross contamination. An interview conducted with the Administrator on 06/07/2018 at 1:45 PM confirmed there was not a functional separation between the clean and soiled laundry area. The laundry did not have appropriate Personal Protective Equipment in order to prevent cross contamination. Review of the Policies and Procedures dated 11/30/2014 noted: To enforce the practice that all soiled linen/laundry is considered contaminated. Staff will be required to use precautions listed in this procedure as well as the capital EPC plan. For handling all linen by placing same in bags at the place of care/treatment. Staff must also ensure that linen/laundry is handled, stored and processed, to control the spread of infection. Procedure: 2. Personal Protective Equipment (PPE) should always be worn when handling soiled linen. 12. Personal Protective Equipment (PPE) should always be worn when handling soiled linen.

Based on interviews and records review, the facility failed to provide a bed hold policy at the time hospital transfer or within 24 hours of transfer for two residents (Resident #75, and Resident #179) or their representative, out of five residents reviewed for hospitalization . This facility practice failure has the potential to affect 89 residents in the facility at the time of the survey. The findings included: 1. Records review of the resident's face sheet revealed Resident #75 was admitted from an Acute Care hospital on [DATE]; his [DIAGNOSES REDACTED]. His payer source was Medicare. A review of the facility's census report dated 05/15/2017 verified he is no longer at the facility. Records review of SBAR (Situation, Background, Assessment, and Recommendation) and Resident #75's patient transfer forms, revealed the resident transferred to the hospital on [DATE] per physician's (MD) order. The resident's [DIAGNOSES REDACTED]. Record review of Resident #75's clinical records revealed no documentation on file to indicate Resident #75 or his family received a copy of a bed hold policy at the time of hospital transfer or within 24 hours of hospital transfer. 2. Records review of the resident's face sheet revealed Resident #179 was admitted from Acute Care hospital on [DATE], with [DIAGNOSES REDACTED]. His primary payer source was a private insurance company. A review of the Nurses Notes dated 05/16/2017 revealed Resident #179 transferred to the hospital after a fall. His [DIAGNOSES REDACTED]. Record review of Resident #179's clinical records revealed no documentation on file to indicate Resident #179 or his family received a copy of a bed hold policy at the time of hospital transfer or within 24 hours of hospital transfer. 3. Interview with the Director of Admissions and with Staff H, Business Developer, on 05/18/2017 at 5:30 PM revealed bed hold policies were not offered to Medicare residents. Record review of the Admission Packet at this time, revealed a bed hold policy was not included in the Admission Packet. Interview with Staff J, Registered Nurse and Unit Supervisor, on 5/18/2017 at approximately 5:45 PM, confirmed bed hold policies were not issued to residents at the time of transfer. Staff J/RN demonstrated Resident #75's transfer documentation list did not include the bed hold policy and explained the bed hold policies were only offered to Medicaid recipients and/or their families. 4. Record review of the facility's policies and procedures revealed one bed hold policy titled; Bed Hold Reservation Policy for Medicaid which noted, The Facility shall reserve a bed in the nursing facility for up to eight days for Medicaid (ICP (Institutional Care Program)) patients that are discharged to the hospital or on therapeutic leave during their per diem days.

Based on interview and record review, the facility failed to ensure an environment was free from verbal abuse by not implementing their policy and procedures on abuse, not taking actions to protect the resident from reoccurrence and not investigating or reporting an allegation of verbal abuse for one (Resident #145) out of 13 residents interviewed during stage 1 of the survey. This facility practice failure has the potential to affect 89 residents present in the facility at the time of this survey. The findings included: Record review of the medical Face Sheet revealed Resident #145 was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of the Comprehensive Minimum Data Set (MDS) for Resident #145 dated 03/21/2017 revealed the resident had a score of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was able to verbalize her needs and was not cognitively impaired. A review of the nurse's notes dated 05/12/2017 revealed Resident #145 was alert and oriented times three. Interview with Resident #145 on 05/16/2017 at 11:21 AM revealed she was verbally mistreated and threatened by her Certified Nurse Assistant (CNA). The resident reported not long ago she asked her CNA to help her transfer from the bed to the chair, the CNA responded in a loud and annoyed manner Are you crazy! It's four in the morning! The resident explained she did not know it was that early but could see it was dark. She stayed in bed and managed to fall asleep. A couple of hours later; Resident #145 opened her eyes to see the same CNA's face really close to hers. In a threatening tone, the CNA verbalized, Do you remember what you did to me last night?! Now you are going to have to stay in bed all day! The resident described how scared and upset she felt, the CNA was often rude, and she often cared for her at night. During the interview, Resident #145 explained later that afternoon she reported the incident to her favorite nurse (Staff R/RN). Resident #145 asked if it was ok for the staff to punish residents. Staff R/RN's response was staff was not allow to punish residents, but asked her to understand if she was transferred to the wheelchair the CNA would have had to stay with her and watched her. Interview with Staff R/RN on 5/16/2017 at 3:54 PM revealed he was familiar with Resident #145's care. Staff R/RN reported he is very close to the resident. Staff R/RN explained on Friday 05/12/2017, the resident reported to him someone had verbally threatened her. Staff R/RN explained after some inquiry the resident mentioned she might have been dreaming and did not investigate further. He added there was an issue with medications found at the residents bedside table that influenced his decision. During an interview on 5/16/2017 at 5:33 PM, Staff R/RN reported according to the resident, someone told her if she did not behave well, she would be punished, but he did not report the abuse allegation to the abuse coordinator because it was possible Resident #145 was confused from her medications. Staff R/RN explained he investigated by asking the CNAs about the incident and again asking the resident if she was sure. Because of his investigation, Staff R/RN concluded the resident might have been confused; therefore, he did not report the incident to the Abuse Prevention Coordinator. Staff R/RN agreed if the incident did happen, it was possible the resident was not safe from the alleged perpetrator. Observation and interview with Resident #145 and Staff R/RN on 05/16/2017 at 6:21 PM revealed, Resident #145 asked Staff R/RN if staff was allowed to punish residents. The resident added she might have mentioned she was dreaming, because; how can anybody be so cruel! Resident #145 added she reported the incident only to Staff R/RN and she did not want to get anybody in trouble. After the interview,Staff R/RN expressed an understanding of the abuse prevention policy and stated he would immediately start the process by reporting the incident to the Abuse Prevention Coordinator. During an interview on 5/17/2017 at 6:33 AM, Staff S/CNA confirmed she worked with the resident on the night of 05/11/2017 (the night of the incident); she took care of the resident earlier that morning. The CNA denied having any negative interactions with Resident #145. Interview with Resident #145 on 5/17/2017 at approximately 7:00 AM revealed Staff S/CNA cared for her that morning, during the 11 PM-7 AM shift. The resident reported Staff S/CNA acted differently and was much nicer that night. She added the Staff S/CNA must have learned her lesson because she was very kind and delicate in her approach. Interview with the Social Services Director (SSD) on 518/2017 at 10:51 AM, revealed she learned about the abuse allegation on 5/16/2017. She reported she immediately followed the abuse prevention policy; which included protection, reporting and investigating the allegation. The SSD explained Resident #145 described the perpetrator as someone other than Staff S/CNA. From her investigation, the SSD concluded the alleged perpetrator was on leave. The SSD reported to be on the safe side, she would look into re-assigning and/or suspending Staff S/CNA. Record review of the Facility's Policies and Procedures Subject: Resident Abuse Document Name: N-1265 Effective Date: 11/30/2104 Revision date: 09/01/2016. revealed the Policy: Employee Obligation All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse to a resident, is obligated to report such information immediately to their supervisor. If the immediate supervisor is not available, the employee is to notify the designated Nursing Supervisor on duty at the time of the event. The supervisor is obligated to immediately report to the Executive Director who is the designated abuse coordinator. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 1 out of 3 residents (Resident #187) sampled for pressure ulcers related to the resident's refusal of care and the development of an avoidable pressure ulcer. This practice led to actual harm with the development of an avoidable unstageable pressure ulcer on Resident #187's face. Reference to F281 and F314. Findings Included: During an observation on 02/25/2015 at 9:21 AM, Resident #187 was seen sitting up in bed. He was wearing a bilateral positive airway pressure(Bi-Pap)-breathing mask. Adhesive bandages were on the bridge of the resident's nose under the breathing mask. During an observation on 02/25/2015 at 2:49 PM, the wound care physician's assistant (PA) accompanied the facility's wound care licensed practical nurse (Wound Care LPN) as she performed wound care for Resident #187. The LPN removed the breathing mask from the resident's face. The resident had four adhesive bandages on the bridge of his nose. The nurse removed the bandages and exposed a square shaped wound. White colored cartilage was observed on the bridge of the nose, as was red and pink colored skin tissue. The LPN proceeded to cleanse the area. After wound care was completed the nurse reapplied three adhesive bandages to the bridge of the resident's nose. The nurse attempted to apply a foam bandage on top of the three adhesive bandages, but the resident refused. In an interview on 02/25/2015 at 2:50 PM the Wound Care LPN reported that the resident refused to have the foam pad placed atop the bandages because if she did, this would cause air to leak from the mask. She was not aware of any alternative appliances or equipment that could be used instead of the bandages and foam pad. In an interview on 02/25/2015 at 2:56 PM with the Wound Care PA revealed, that the wound on the bridge of the resident's nose was an unstageable pressure ulcer caused from the pressure that the breathing mask placed on the resident's nose. The PA explained to the resident the risks of not using the foam pad. The resident declined the foam pad and requested that only bandages be placed on the bridge of his nose and stating that, when the foam pad was in place, oxygen escaped from the mask and made it difficult for him to breathe. The PA did not offer alternative treatment or appliances to the resident. He reported, he would have the resident sign a refusal of treatment form indicating that the resident was instructed on what the risks for not wearing the foam pad were. In an interview on 02/26/2015 at 1:21 PM, the Wound Care LPN revealed that Resident #187 developed the pressure ulcer on his nose while in the facility. She also reported, the resident had been refusing the application of the foam pad over the adhesive bandages because it "bothers him." In an interview on 02/27/2015 at 1:30 PM, the facility's Minimum Data Set (MDS)/Care Plan Coordinator confirmed that Resident #187 did not have, but should have had, care plans for refusal of care and the development of a nasal pressure ulcer prior to the date of the wound care observation on 02/25/2015. A review of Resident #187's medical record showed that the resident was admitted to the facility 12/04/2014. Medical [DIAGNOSES REDACTED]. A review of Resident #187's medical record revealed a care plan dated 12/19/14 for resident at risk for skin breakdown due to impaired mobility, fragile skin, and needs assist with turning, repositioning and hygienic needs. There was a note added to this care plan on 01/02/15, "bridge of nose (open wound) - treatment as ordered and until resolved." There were no interventions that addressed the issues for a non-sacral area. There was also no care plan in the medical record indicating that the resident had been refusing care prior to the date of the wound care observation on 02/26/2015. A review of a facility document titled, Healthcare Wound Care Best Practice Guidelines dated October 2009 revealed, upon the development of a new pressure ulcer, the care plan must be updated and revised.

Based on observation, interview, and record review, the facility failed to ensure that qualified personnel perform assessments of wounds. The facility permitted the licensed practical nurses, not certified in wound assessment, to perform assessments of wounds and also had no daily oversight from a registered nurse in accordance with the State of Florida Nurse Practice Act. This practice resulted in actual harm with the development of an avoidable unstageable pressure ulcer on the face for 1 out 3 residents (Resident #187) sampled for pressure ulcer care. Reference to F279 and F314. A review of the State of Florida Nurse Practice Act (Florida Statute 464.003) documents, the "Practice of Practical Nursing" is defined as, "the performance of selected acts including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance, of health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist." ....A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. " Practice of professional nursing " means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (c) The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection. Findings Included: A review of Resident #187's medical record showed that the resident was admitted to the facility 12/04/2014. Medical [DIAGNOSES REDACTED]. A review of Resident #187's Nursing Admission Screening completed by a Registered Nurse (RN) on 12/04/2014 revealed, the resident had no pressure ulcers upon admission to the facility. A review of Resident #187's Initial Profile and Interim Care Plan for Skin revealed, on 01/08/15, the wound care Licensed Practical Nurse (LPN) documented that the resident had a "discoloration" to the nose bridge. Further review of the medical record revealed the following skin/wound care note revealed that on 02/18/2015, the wound care LPN documented that the wound on the resident's nose continued to deteriorate secondary to the use of the bilateral positive airway pressure (Bi-Pap)-breathing mask. A wound care consultation was ordered and the resident was seen by the Physician Assistant (PA). A recommendation was made to use 2x2 gauze under the mask to relieve pressure. The gauze was placed under the mask to relieve pressure, but the gauze prevented a close seal and the resident was unable to breathe. The gauze was removed and the resident verbalized understanding that the use of the mask may prevent or delay wound care healing. A review of Resident #187's Admission Minimum Data Set (MDS) with the Assessment Reference Date of 12/26/2014 revealed, in Section M, Skin Conditions revealed, upon assessment, the resident had no pressure ulcers and was identified as being at risk for the development of pressure ulcers. A review of the Centers for Medicare and Medicaid (CMS) Form 672, Resident Census and Condition, revealed that at the start of the survey on 02/23/2015 there were eight residents in the facility with pressure ulcers. During an observation on 02/25/2015 at 9:21 AM, Resident #187 was seen sitting up in bed. He was wearing a bilateral positive airway pressure-breathing mask (Bi-Pap). Adhesive bandages were on the bridge of the resident's nose under the breathing mask. During an observation on 02/25/2015 at 2:49 PM, the wound care physician's assistant (PA) accompanied the facility's wound care licensed practical nurse (LPN) as she performed wound care for Resident #187. The LPN removed the breathing mask from the resident's face. The resident had four adhesive bandages on the bridge of his nose. The nurse removed the bandages and exposed a square shaped wound. White colored cartilage was observed on the bridge of the nose with red and pink colored skin tissue. The LPN proceeded to cleanse the area. After the wound was cleansed and ointment applied, the nurse applied three adhesive bandages to the bridge of the resident's nose. The nurse attempted to apply a foam bandage on top of the three adhesive bandages however, the resident refused. In an interview on 02/25/2015 at 2:56 PM, the Wound Care PA revealed, the wound on the bridge of the resident's nose was an unstageable pressure ulcer, caused from the pressure that the breathing mask placed on the resident's nose. He reported that he would have the resident sign a refusal of treatment form indicating that the resident was instructed on what the risks for not wearing the foam pad. In an interview on 02/26/2015 at 1:21 PM, the wound care LPN revealed that Resident #187 developed the pressure ulcer to his nose while in the facility. The wound care LPN reported that she had no specialty certification to perform wound care. She said that the facility's Minimum Data Set (MDS)/Care Plan Coordinator Registered Nurse (RN) reviewed her assessments and signed off on the assessments, indicating that he had reviewed the assessments and agreed with the LPN's findings. In an interview on 02/27/2015 at 4:15 PM, the facility's Minimum Data Set (MDS)/Care Plan Coordinator RN reported, he does not review the assessments completed by the Wound Care LPN. In an interview on 2/27/2015 at 5:34 PM, the facility's Director of Nursing (DON) reported that the facility's Wound Care Team consisted only of the Wound Care LPN who worked Sunday through Thursday, on the days that the Wound Care LPN were off, another facility LPN covered the wound care duties. Wound care duties included, the initial wound care assessments, measurements, and wound staging. There was no RN or physician who directly oversaw the work of the LPNs that perform wound care. The wound care physician only visits the facility weekly. Residents with wounds are seen daily by the "Wound Care" LPNs. There was no RN on the wound care team. The DON declined to answer the questions related to whether this was an acceptable practice in regard to using LPNs that are not certified in wound care assessment, in addition, to them not having appropriate oversight.

Based on interview and record review, the facility failed to follow care plans for: 1) one out three sampled residents for hospitalization (resident #103). The blood pressure documentation was not recorded consistently for resident #103, 2) two out five sampled residents for Unnecessary Medications (resident #188). The physician was not notified of a change in the conditions for both resident #103 for low blood pressure and resident #188 for behavioral episodes related to anxiety; 3) Activities of Daily Living (ADL) care for 1 out of 30 residents (Resident #23) sampled for ADL care. The resident was not capable to shave himself, but was left with the shaving supplies in his possession, which resulted in actual harm with multiple bleeding cuts on the resident's face. Reference to F312 and F323. The Findings included: 1) Record review of the medical chart for resident #103 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the Physician order [REDACTED].#103 was prescribed 20 milligrams (mg) of Linsinopril and 25 mg of [MEDICATION NAME]; both medications were for hypertension. The resident was also prescribed 20 mg of "[MEDICATION NAME] for ST-elevation [MEDICAL CONDITION] Infarction". Record review of the Medication Administration Record [REDACTED]. The Chart Code list at the bottom left corner of the MAR indicated [REDACTED]. Record review of the Blood Pressure Summary for resident #103 revealed that the resident's blood pressure readings were documented daily, except for 02/01/2015, 02/02/2015, and 02/05/2015. Record review of the Progress Notes for resident #103 dated 02/05/2015 revealed only low a blood pressure reading of 99/61 mm Hg; there was no notation that indicated that the medication was held or that the physician was notified. On the same day at 10:55 am it was noted that the doctor was made aware of positive lab results, and orders were followed pertaining to antibiotic treatment and starting contact isolation precautions; still the physician was not made aware of the resident's low blood pressure. Record review of the Interdisciplinary Progress Notes for resident #103 dated 02/07/2015 revealed that the resident was noted with shortness of breath (SOB), and oxygen was maintained at 2 liters a minute. The resident's vital signs were taken, and it was noted that the resident's blood pressure was 90/54 with a low oxygen saturation at 88%. The doctor was called and orders were given to increase the resident's oxygen to 3 liters a minute and to continue to monitor the resident. The resident continued with low oxygen saturation, and the doctor ordered to send the resident to the hospital. There was notation to indicate that the doctor was informed of the resident's low blood pressure from two days prior. Record review of the Care Plan for resident #103 dated 01/25/2015 revealed that the resident was at risk for alterations in blood pressure due to hypertension. Some of the interventions included, but were not limited to, checking and recording the resident's blood pressure and monitoring the resident's vital signs and reporting any persistent abnormal results to the doctor. In an interview with the Director of Nursing (DON) on 02/27/2015 at 4:58 pm, she confirmed that the nursing staff should have notified the physician of the resident #103's low blood pressure on 02/05/2015. 2) Record review of the medical facesheet for resident #188 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 02/24/2015 at 12:31 pm revealed resident #188 in the relaxation activity room with staff present. The resident was seated in her wheelchair and the staff member was seated on her right side. The resident was dressed and groomed appropriately and the resident was not in any pain or distress. The resident was alert, but appeared to be confused; the resident was talking to herself. Record review of the physician's orders [REDACTED].#188 revealed that on 01/04/2015 the resident was ordered 0.5 milligrams (mg) of [MEDICATION NAME], an anti-anxiety medication, to be given every 12 hours as needed for anxiety. Record review of the Medication Administration Records (MAR) for the months of January 2015 and February 2015 revealed that on January 2015 MAR indicated [REDACTED]. On the February 2015 MAR indicated [REDACTED]. Review of Nurses Notes for the months of January 2015 and February 2014 revealed that resident #188 had numerous episodes involving behaviors of agitation and anxiousness, and yelling and screaming. Further review of the Nurses Notes indicated that the resident was given [MEDICATION NAME] as needed for anxiety, and was assessed for effectiveness of the medication. There was no notation in the Nurses Notes that revealed that the psychiatrist was notified that the resident was receiving [MEDICATION NAME] more almost routinely due to the resident's behavioral episodes. Record review of the [MEDICAL CONDITION] Drug Use Care Plan for resident #188 dated 10/14/2014, Revised on 1/14/2015 revealed that the interventions included, but not limited to, working with the doctor for possible changes and discontinuation of [MEDICAL CONDITION] drug. In an interview with the Registered Nurse #2 (RN #2) on 02/25/2015 at 1:23 pm revealed that resident #188 compliant with taking her medications, but she needs a lot of redirection. She said that the resident is agitated daily, and she is constantly trying to get out of her chair. She said that the resident takes 0.5mg of [MEDICATION NAME] for her anxiety, but it is used when she gets really agitated like screaming or being aggressive. Staff #2 confirmed that when the resident is agitated and the [MEDICATION NAME] medication is given frequently, the physician should be notified. In an interview with the Psychiatrist on 02/25/2015 at 2:40 pm, via telephone, revealed that he confirmed that nursing staff are supposed to notify him of any changes in the resident #188's behaviors, or if the resident's medication needs to be adjusted related to the resident receiving the as needed medication routinely. He said that they are supposed to work together to help the resident. 3) In an observation on 02/24/2015 at 9:31 AM, Resident #23 was observed in Physical Therapy. He was noted with seven separate cuts on the face containing dried blood. The resident reported that the Certified Nursing Assistant #9 (CNA #9) cut him while shaving about 2 hours ago. In an interview on 02/24/2015 at 10:00AM, the resident added that CNA #9 cut him because she was shaving him too fast. In an interview on 02/24/2015 at 10:05AM, with Staff CNA #9, reported that she went to Resident #23's room at around 7:00 AM that morning, after the bathroom call light was activated. Upon entering the bathroom, the resident was attempting to perform morning care by himself. The resident had begun to shave himself and shaving supplies were near the sink. She noticed that the resident had a cut and was bleeding in one area. She cleaned the area and assisted him with the remainder of his morning care. After care was performed the physical therapist assistant (PTA) came into the room to take the resident to therapy. At this time, the CNA reported that she notified the PTA that the resident had cut himself while shaving. The CNA was asked whom should changes in a resident's condition be reported to, and she replied that she should have notified the nurse caring for the resident not the PTA. In an interview on 02/24/2015 at 11:01 AM Licensed Practical Nurse #1 (LPN #1) reported that she had seen Resident #23 that morning at around 9:00 AM when she administered his morning medications. She said she did not observe any cuts to the resident's face, at that time. During the interview the nurse was observed looking at the resident's face. She went into the bathroom and moistened a napkin with water; she proceeded to wipe the resident's face. The resident requested that the nurse not wipe his face too hard because the cuts hurt him. The nurse reported that she would clean the resident's face later with Normal Saline and apply Triple Antibiotic Ointment. In an observation on 02/25/2015 at 9:08 AM, Resident #23 was observed seated in a wheelchair in the doorway of his room. There were two reddened areas on his face. He denied pain at this time. Interview on 02/25/2015 at 1:08 PM, Resident #23 reported that he used to shave himself in the facility, until recently. The staff took his razors away and he was not supposed to be allowed to shave himself. He denied pain or discomfort. The resident reported that 02/24/2015 was the first time that staff shaved him. A review of the Admission Minimum Data Set (MDS) with the Assessment Reference Date of 01/12/2015 showed in Section G Functional Status that for personal hygiene the resident required extensive assistance to self-perform these activities and he required one person physical support to perform these activities. A review of Care Plans revealed a care plan indicating that the resident needs moderate to maximum assistance with Activities of Daily Living (ADL) related to weakness and difficulty with ADLs. Interventions included setting up articles to perform personal hygiene and encourage/assist to participate in personal care daily. A review of the Nursing Progress Notes revealed that Staff LPN #1 documented on 02/24/2015 at 1:47 PM that at 9:00 AM ADL care provided with one CNA assistance. The resident was shaved on this date and there was no bleeding at that time. At 11:52 AM, Staff LPN #1 documented that at 11:00 AM, the resident returned with small bloody scabs on the chin. The physician was made aware and new orders were received for a wound care consult.

Based on observation, interview, and record review the facility failed to ensure that staff provided assistance for the performance of Activities of Daily Living (ADL) for 1 out of 30 residents (resident #23) sampled during Stage 2. The resident was not capable to shave himself, but was left with the shaving supplies in his possession, which resulted in the actual harm of multiple bleeding cuts on the resident's face. Reference to F282 and F323. The findings included: In an observation 02/24/2015 at 9:31AM Resident #23 was observed in Physical Therapy. He was noted with 7 separate cuts on the face containing dried blood. The resident reported that the Certified Nursing Assistant #9 (CNA #9) cut him while shaving about 2 hours ago. In an interview on 02/24/2015 at 10:00AM the resident reported that the nurse cut him because she was shaving him too fast. In an interview on 02/24/2015 at 10:05AM with CNA #9 reported that she reported to Resident #23's room at around 7:00 AM after the bathroom call light was activated. Upon entering the bathroom, the resident was attempting to perform morning care. The resident had begun to shave himself and shaving supplies were observed near the sink. She noticed that the resident had a cut and was bleeding in one area. She cleaned the area and assisted him with the remainder of his morning care. After care was performed the physical therapist assistant (PTA) came into the room to take the resident to therapy. At this time the CNA reports that she notified the PTA that the resident had cut himself while shaving. The CNA was asked who changes in a resident's condition be reported to the nurse and she confirmed that she should have notified the nurse not the PTA. In an interview on 02/24/2015 at 10:56 AM with the PTA revealed that she came to retrieve the resident for therapy at around 8:00 AM that morning. She observed multiple cuts on Resident #23's face. She asked Staff CNA #9 what had occurred and the CNA reported that she had cut the resident while shaving him. In an interview on 02/24/2015 at 11:01 AM Licensed Practical Nurse #1 (LPN #1) reported that she saw Resident #23 this morning at around 9:00 AM when she administered his morning medications. She did not observe any cuts to the resident's face at that time. At this time, the nurse was observed looking at the resident's face. She went into the bathroom and moistened a napkin with water; she proceeded to wipe the resident's face. The resident stated to the nurse to not wipe his face too hard because the cuts on his face hurt. The nurse reported that she would clean the resident's face later with Normal Saline and apply Triple Antibiotic Ointment. In an observation on 02/25/2015 at 9:08 AM, Resident #23 was observed seated in a wheelchair in the doorway of his room. There were 2 reddened areas on the resident's face. He denied pain at this time. In an observation on 02/25/2015 at 1:08 PM, Resident #23 reported that he used to shave himself in the facility until recently. The staff took his razors away and he was not supposed to be allowed to shave himself. He denied pain or discomfort. The resident reported that 02/24/2015 was the first time that staff shaved him. A review of Resident #23's Medical Record showed that the resident was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS), for resident #23, with the Assessment Reference Date of 01/12/2015 showed, in Section G Functional Status, that for personal hygiene the resident required extensive assistance to self-perform these activities and he required one person physical support to perform these activities. A review of Care Plans for resident #23 revealed a care plan indicating that the resident needed moderate to maximum assistance with Activities of Daily Living (ADL) related to weakness and difficulty with ADLs. Interventions included setting up articles to perform personal hygiene and encourage/assist to participate in personal care daily. A review of the Nursing Progress Notes revealed that Staff Licensed Practical Nurse (LPN #1) documented on 02/24/2015 at 1:47 PM that at 9:00 AM ADL care provided with one-CNA assistance. The resident was shaved on this date and there was no bleeding at that time. At 11:52 AM, Staff LPN #1 documented that at 11:00 AM, the resident returned with small bloody scabs on the chin. The physician was made aware and new orders were received for a wound care consult.

Based on observation, interview, and record review the facility failed to ensure that 1 out of 3 residents (Resident #187) received the care and services to prevent the development of an avoidable unstageable pressure ulcer. The actual harm of resident #187 developing an avoidable pressure ulcer happened because th facility permitted the licensed practical nurses, with no specialization in wound assessment, to perform assessments of wounds and also had no daily oversight from a registered nurse or physician, in accordance with the State of Florida Nurse Practice Act. No facility staff offered alternative appliances/treatments to the resident prior to survey. Reference to F279 and F281. Findings Included: During an observation on 2/25/2015 at 9:21 AM, Resident #187 was seen sitting up in bed. He was wearing a bilateral positive airway pressure(Bi-Pap)-breathing mask. Adhesive bandages were on the bridge of the resident's nose under the breathing mask. During an observation on 02/25/2015 at 2:49 PM, the wound care physician's assistant (PA) accompanied the facility's wound care licensed practical nurse (LPN) as she performed wound care for Resident #187. The LPN removed the breathing mask from the resident's face. The resident had four adhesive bandages on the bridge of his nose. The nurse removed the bandages and exposed a square shaped wound. White colored cartilage was observed on the bridge of the nose, as was red and pink colored skin tissue. The LPN proceeded to cleanse the area. After the wound was cleansed and ointment applied, the nurse applied three adhesive bandages to the bridge of the resident's nose. The nurse attempted to apply a foam bandage atop the three adhesive bandages however, the resident refused. In an interview on 02/25/2015 at 2:50 PM the wound care LPN reported that the resident refused to have the foam pad placed atop the bandages because if she did, this would cause air to leak from the mask. She was not aware of any alternative appliances or equipment that could be used instead, in place of the bandages and foam pad. In an interview on 02/25/2015 at 2:56 PM, the Wound Care PA revealed that the wound to the bridge of the resident's nose was an unstageable pressure ulcer caused from the pressure that the breathing mask placed on the resident's nose. The resident declined the foam pad and requested that only bandages be placed on the bridge of his nose; stating that, when the foam pad was in place, oxygen escaped from the mask and made it difficult for him to breathe. The PA explained to the resident the risks of not using the foam pad. The PA did not offer any alternative treatment or appliances to the resident. He reported that he would have the resident sign a refusal of treatment form indicating that the resident was instructed on what the risks for not wearing the foam pad were. In an interview on 02/26/2015 at 1:21 PM, the wound care LPN revealed that Resident #187 developed the pressure ulcer to his nose while in the facility. She also reported that the resident had been refusing the application of the foam pad over the adhesive bandages because it "bothers him." The wound care LPN reported that she had no specialty certification to perform wound care. She reported that the facility's Minimum Data Set (MDS)/Care Plan Coordinator Registered Nurse (RN) reviewed her assessments. The MDS/Care Plan Coordinator signed off on the assessments indicating that he has reviewed the assessments and agreed with the LPN's findings. In an interview on 02/27/2015 at 4:15 PM, the facility's Minimum Data Set (MDS)/Care Plan Coordinator RN reported that he does review the assessments that are completed by the Wound Care LPN. In an interview on 2/27/2015 at 5:34 PM, the facility's Director of Nursing (DON) reported that the facility's Wound Care Team consisted only of the Wound Care LPN who worked Sunday through Thursday; on the days that the Wound Care LPN was off, another facility LPN covered the wound care duties. Wound duties include initial wound care assessments, measurements, and wound staging. There was no Registered Nurse or physician who directly oversaw the work of the Wound Care LPNs. The wound care physician visited the facility weekly; residents with wounds are seen daily by the Wound Care LPNs. There was no RN on the wound care team. The DON declined to answer the questions related to whether this was an acceptable practice; using LPNs that are not certified in wound care assessment, in addition to them not having appropriate oversight. She reported that she was unaware of any pressure relieving devices or appliance that could be used for residents with a bilateral positive airway pressure-breathing mask. She confirmed that there was no respiratory therapist in the facility for the adjustment of the proper fitting of Resident #187's bilateral positive airway pressure-breathing mask. A review of Resident #187's medical record showed that the resident was admitted to the facility 12/04/2014. Medical [DIAGNOSES REDACTED]. Further review of the medical record revealed the following skin/wound care note revealed that on 02/18/2015 the wound care LPN documented that the wound on the resident's nose continued to deteriorate secondary to the use of the bilateral positive airway pressure-breathing mask. A wound care consultation was ordered and the resident was seen by the PA. A recommendation was made to use a 2x2 gauze under the mask to relieve pressure. The gauze was placed under the mask to relieve pressure but the mask prevented a close seal and the resident was unable to breathe. The gauze was removed and the resident verbalized understanding that the use of the mask may prevent or delay wound care healing. There is no documentation that alternative appliances/treatments were offered to the resident. A review of Resident #187's Nursing Admission Screening completed by a Registered Nurse (RN) on 12/04/2014 revealed that the resident had no pressure ulcers upon admission to the facility. A review of Resident #187's Initial Profile and Interim Care Plan for Skin revealed that on 01/08/15, the wound care LPN documented that the resident had "discoloration" to the nose bridge . A review of Care Plan Meeting Notes indicated that a Care Plan Meeting was held on 02/20/15. The Director of Social Services noted that during this meeting, the resident's status was discussed with his son. The resident had a wound on the bridge of the nose that had not healed despite change of dressing and treatment done. The wound was revealed to be caused by the bilateral positive airway pressure-breathing mask. There was no documentation that the Social Worker discussed alternative treatments or appliances to prevent further skin breakdown. A review of Resident #187's Admission Minimum Data Set (MDS) with the Assessment Reference Date of 12/26/2014 revealed in Section M Skin Conditions revealed that upon assessment, the resident had no pressure ulcers and was identified as being at risk for the development of pressure ulcers.

Based on observation, interview, and record review the facility to ensure that adequate supervision was provided to prevent injuries while shaving for 1 out of 30 residents (Resident #23) sampled in Stage 2. The resident was not capable to shave himself, but was left with the shaving supplies in his possession, which resulted in the actual harm of multiple bleeding cuts on the resident's face. Reference F282 and F312. Findings Included: In an observation on 02/24/2015 at 9:31AM, Resident #23 was observed in Physical Therapy. He was noted with seven separate cuts on the face containing dried blood. The resident reported that the Certified Nursing Assistant #9 (CNA #9) cut him while shaving about 2 hours ago. In an interview on 02/24/2015 at 10:00AM, the resident reported that the nurse cut him because she was shaving him too fast. In an interview on 02/24/2015 at 10:05AM with CNA#9 stated that she reported to Resident #23's room at around 7:00 AM after the bathroom call light was activated. Upon entering the bathroom, the resident was attempting to perform morning care. The resident had begun to shave himself and shaving supplies were near the sink. She noticed that the resident had a cut and was bleeding in one area. She cleaned the area and assisted him with the remainder of his morning care. After care was performed the physical therapist assistant (PTA) came into the room to take the resident to therapy. At this time, the CNA reported that she notified the PTA that the resident had cut himself while shaving. The CNA confirmed that changes in the resident's status should be reported to the nurse, not the PTA. In an interview on 02/24/2015 at 10:56 AM, the PTA revealed that she came to retrieve the resident for therapy at around 8:00 AM that morning. She observed multiple cuts on Resident #23's face. She asked CNA #9 what occurred and the CNA reported that she had cut the resident while shaving him. In an interview on 02/24/2015 at 11:01 AM, LPN #1 reported that she saw Resident #23 this morning at around 9:00 AM when she administered his morning medications. She did not observe any cuts to the resident's face at that time. At this time, the nurse was observed looking at the resident's face. She went into the bathroom and moistened a napkin with water; she proceeded to wipe the resident's face. The resident told the nurse not to wipe his face too hard because the cuts hurt him. The nurse reported that she would clean the resident's face later with Normal Saline and apply Triple Antibiotic Ointment. In an observation on 02/25/2015 at 9:08 AM, Resident #23 was observed seated in a wheelchair in the doorway of his room. There were two reddened areas on the resident's face. He denied pain at that time. In an observation on 02/25/2015 at 1:08 PM, Resident #23 reported that he used to shave himself in the facility until recently. The staff took his razors away and he was not allowed to shave himself. He denied pain or discomfort. The resident reported that 02/24/2015 was the first time that staff shaved him. A review of Resident # 23's Medical Record showed that the resident was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS), for resident #23, with the Assessment Reference Date of 01/12/2015 showed in Section G Functional Status that for personal hygiene the resident required extensive assistance to self-perform these activities and he required one-person physical support to perform these activities. A review of Care Plans for resident #23 revealed a care plan indicating that the resident needs moderate to maximum assistance with Activities of Daily Living (ADL) related to weakness and difficulty with ADLs. Interventions included setting up articles to perform personal hygiene and encourage/assist to participate in personal care daily. A review of the Nursing Progress Notes revealed that LPN #1 documented on 02/24/2015 at 1:47 PM that at 9:00 AM ADLs care provided with one CNA assistance. The resident was shaved on this date and there was no bleeding at that time. At 11:52 AM, LPN #1 documented that at 11:00 AM, the resident returned with small bloody scabs on the chin. The physician was made aware and new orders were received for a wound care consult. In an interview on 02/27/2015 at 5:34 PM, the facility's Director of Nursing (DON) reported that the nurses were not following facility procedures when they left medication unattended. She reported that no medications should be left on medication carts and that nurses should not "turn their backs" to medications. She further reported that nurses should remain with residents during medication administration. Medications should never be left a resident's bedside for self-administration. The DON would not comment as to whether Resident #23 should have received more supervision while shaving. A review of an undated facility document titled Medication Administration General Guidelines showed that during routine administration of medications, the medication cart is locked when unattended. No medications are kept on top of the cart; Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications.