Every finding on record at Healthpark Care Center

Based on observation, record review, policy review, resident and staff interview the facility failed to have documentation of physician's orders for follow up care of surgical incision for 1(Resident #246) of 5 residents reviewed with wounds. The findings included: Facility policy #205, revised 12/20, titled, Wound and pressure Injury Assessment, Treatment and Prevention, defined surgical wound as a physical disruption of the skin caused by a cutting instrument. Policy stated, . Comprehensive assessments must be completed by the registered nurse and documented in the clinical record . Call physician for wound care/dressing change orders if none available on admission . Surgical wound . Dressing as per surgeon orders . Document daily on progress and healing . Alert MD [Physician] to any changes . On 11/1/21 at 10:53 a.m., Resident #246 was observed in wheelchair with left leg elevated. Surgical wound with visible staples to left knee observed. Resident #246 said he was concerned he had the staples for 16 days. The Resident said he knew they should come out in 10 days to 2 weeks. The Resident said, They haven't told me anything about when they will come out. I don't want to get an infection or something. On 11/2/21 at 12:10 p.m., Resident #246 was observed in bed, staples continued to left knee surgical site, resident remained unaware of when they would be removed. On 11/2/21 review of the clinical record revealed on 10/13/21 Resident #246 had a left knee arthroplasty (Surgical reconstruction or replacement of joint). The record had no physician orders for management of surgical incision, including the removal of the staples. On 11/2/21 at 3:50 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said the care of the staples are based on the individual physician's orders. Upon review of the clinical record, LPN Staff A said she was unable to find any information or physician orders addressing the resident's staples to left knee surgical site. On 11/2/21 at 4:00 p.m., Charge Nurse RN Staff B, reviewed Resident #246 electronic medical record and confirmed she was unable to find documentation of physician's orders for follow up care of the surgical incision and staples for Resident #246's left knee. On 11/2/21 at 4:30 p.m., in an interview, the Director of Nursing (DON) said the surgical staples can be removed at the facility or at the follow-up appointment. The DON confirmed the facility should have communicated with the surgeon to find out when he wanted the staples removed. The DON said, We missed it and I will add surgical wound site management to the performance improvement plan (PIP) I currently have for wounds. I recognize it is a problem that none of the staff confirmed what the treatment plan was for this resident.

Based on record review, review of the facility's policies and procedures, and staff interview the facility failed to maintain a system to ensure accurate reconciliation of controlled substances prior to destruction. The findings included: Review of the facility's policy and procedure for narcotic medication administration approved on [DATE] revealed If controlled medication is discontinued and needs to be disposed, Medication Destruction will be completed in Omniview and destroyed in the presence of the Director of Nursing or licensed nurse designee and Pharmacy Consultant. Review of the pharmacy policy and procedure for disposal/destruction of expired or discontinued medications with an effective date of [DATE] revealed In Florida, Schedule II, III, IV and V controlled substances that have been dispensed and not used by the patient shall not be returned to the Pharmacy and shall be securely stored by the nursing home until destroyed. A document must be completed showing the name and quantity of the drug, strength and dosage form, patient's name, prescription number and name of the nursing home. This documentation, at the time of destruction, shall be witnessed and signed by the Consultant Pharmacist, Director of Nursing, and the nursing home Administrator or his/her designee excluding the above. On [DATE] at 11:50 a.m., the Director of Nursing (DON) said when a controlled substance was discontinued, two nurses verified the quantity of the medication to be destroyed and signed on the narcotic count sheet. The Unit Manager placed the controlled medications and the count sheet in a locked cabinet in the medication room on the unit. She said, once a month she collected all the discontinued controlled substances and the count sheets from the cabinet, created a log and prepared them for destruction. She said the log was created on the day the consultant pharmacist came for the destruction. The DON said no one kept track of the discontinued controlled substances once placed in the cabinet. She said the nurses and the unit managers have access to the cabinet. On [DATE] at 2:45 p.m., observation of the medication room with the Assistant Director of Nursing (ADON) revealed a locked cabinet with a large gap of approximately 7 inches between the cabinet and the door. The cabinet contained multiple blister cards of controlled substances. She acknowledged that anyone could easily pull medications from the cabinet through the gap. The ADON said they did not keep a log with a list of the medications in the cabinet. She said the unit manager also had a key to the medication room and the controlled substance cabinet. She verified that all the nurses have access to the medication room. On [DATE] at 4:00 p.m., during an interview with the Unit Manager she said she kept a key for the controlled substances cabinet. She said when she leaves the facility, she placed the key in the Social Worker's office in order for the night shift supervisor to have access to the controlled substances. She said a few people, including the DON and the supervisors had the master key that opens all the doors.

Based on observation, review of facility policy and procedure, resident and staff interview the facility failed to have a system to maintain continuous positive airway pressure ([MEDICAL CONDITION]) machines in a sanitary manner for 4 (Residents #35, #50, #94 and #300) of 5 residents who use a [MEDICAL CONDITION] machine (helps you breathe more easily when you sleep). The findings included: The facility policy, [MEDICAL CONDITION] Cleaning Instructions specified Wash mask daily with a mild soap, wipe with a clean dry cloth. Air dry .empty chamber water daily and replace with distilled water. On 2/5/20 at 10:00 a.m., in an interview, the Unit Manager, Licensed Practical Nurse (LPN) Staff A, said the night shift nurse was responsible to clean the [MEDICAL CONDITION] machines and add water if needed. Staff A said she did not know how the machines were being cleaned. On 2/5/20 at 2:15 p.m., in an interview the Registered Nurse (RN) Staff Educator said, we were told by the Respiratory Therapist to have the nurse clean the [MEDICAL CONDITION] masks daily. She said, the nurse was responsible to change the water and clean the reservoir daily and then the masks were stored in a plastic bag. On 2/4/20 at 10:46 a.m., during an observation of Resident #35's [MEDICAL CONDITION] machine, the machine was turned on and working, but the resident was not in the room. The [MEDICAL CONDITION] mask was lying on top of the nightstand and was not covered. The mask was dirty with flakes of white grime. On 2/03/20 at 10:43 a.m., in an interview Resident #50 said he used a [MEDICAL CONDITION] machine at night. Resident #50 said he brought his own machine with him when he was admitted to the facility in (MONTH) 2019. Resident #50 said the staff gave him a bottle of water for the machine. Resident #50 said staff had never cleaned his mask or tubing for him. On 2/4/20 at 10:50 a.m., during an observation of the [MEDICAL CONDITION] machine for Resident #50, the [MEDICAL CONDITION] mask was lying in the cluttered, top drawer of the nightstand and was not covered. There were flakes of black dust on the mask and tubing. On 2/4/20 at 11:00 a.m., an observation was made of Resident #94's [MEDICAL CONDITION] machine. The [MEDICAL CONDITION] mask was lying on top of the machine and was not covered. The water reservoir had water condensation from use. On 2/4/20 at 11:16 a.m., during an observation, Resident # 300's [MEDICAL CONDITION] mask, was on top of the nightstand, the mask was uncovered on top of the machine and the resident's [NAME]et was lying on top of the mask. On 2/05/20 at 1:58 p.m., in an interview Staff A said there was no documentation of who was responsible to clean the [MEDICAL CONDITION] machines. On 2/05/20 at 2:05 p.m., in an interview the RN Staff Educator confirmed there was no documentation staff had been cleaning the [MEDICAL CONDITION] machines. Photographic evidence obtained

Based on record review, review of the facility's policy and procedure, and staff interview the facility failed to have documentation of reasonable efforts to locate and involve appropriate individuals to assist in decision making for 1 (Resident #8) of 1 resident reviewed for advance directives. The findings included: Review of the facility's policy and procedure for advance directives approved on 9/2019 revealed If a physician has determined a patient lacks capacity to make informed health care decisions, Social Services shall make reasonable efforts to locate the appropriate individual(s) listed below in the following order of priority, if no individual in a prior class is reasonably available, willing, or competent to act: a) The judicially appointed guardian of the patient . b) The resident's spouse c) An adult child of the resident d) A parent of the resident e) The adult sibling of the resident f) An adult relative of the resident who exhibited special care and concern for the patient and has maintained regular contact with the patient . g) A close friend of the resident who exhibited special care and concern for the patient and has maintained regular contact with the patient and who is familiar with the resident's activities, health, and religious or moral beliefs. Review of the clinical record revealed Resident #8 was admitted to the facility on [DATE]. Review of the social service assessment dated [DATE] revealed (Resident #8) had a young woman at his bedside that he said was his daughter & (and) she only speaks Spanish. The Social Worker also documented Resident #8 was married and Pt (patient) has children & (and) a cousin who live in the US. His cousin (name) said that he has a wife in Haiti. On 5/24/18 the Social Worker documented Spoke to (name) in regards to discharge planning. She said that she spoke with her husband (name) & (and) pt. (patient) cannot discharge home w/them (with them) .Pt's (patient's) children live in other people's homes and there is no other family that can take pt (patient). On 5/30/18 the Social Worker documented Cousin (name) and his wife (name) were supposed to be present for the meeting (care plan meeting) but got into a car accident on the way to the meeting. On 9/19/18 the Social Worker documented Family has been offered assistance in helping patient apply for Medicaid for LTC (Long Term Care). On 7/4/19 the attending physician signed a physician's determination of patient's capacity form concluding Resident #8 lacked the capacity to communicate a willful and knowing health care decision for himself or herself or to provide informed consent. On 8/7/19 the facility sent a letter to a Licensed Clinical Social Worker that read Mr. (name) is currently a patient at Health Park Care and Rehabilitation Center. It has been determined that he does not have capacity to make his own medical decisions, and there is no family who will accept responsibility for him .I am requesting that you accept responsibility for this patient as his Health Care Proxy. On 8/29/19 the Licensed Clinical Social Worker who was contacted accepted the health care proxy designation. The clinical record lacked documentation of reasonable efforts to contact the resident's spouse, adult children or interested family members to be responsible for making health care decisions on behalf of Resident #8. On 2/3/20 at 4:53 p.m., the facility Social Worker said she could not locate documentation of efforts made to contact family members to act as a health care proxy for Resident #8. She said the resident's adult children recently visited but the facility did not realize they did not have a phone number for the children. She said she will try to contact the wife, and interested family members. The facility Social Worker verified during the interview the facility failed to reach out to the resident's family members in accordance with the facility's policy and procedure.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure 7 (Resident's #76, #73, #77, #70, #234, #235 and #236) of 8 residents reviewed for accident hazards were assessed for the need for a bed rail, alternative interventions were attempted, and informed consent obtained prior to the use of bed rails. The facility also failed to have ongoing routine maintenance of the bed rails in accordance with manufacturer's recommendations. Failure to ensure bed rails were appropriate and safe put residents at potential risk. The findings included: On 1/16/19, the facility identified 55 of the 90 residents in house had bed rails in use. 1. On 1/14/19 at 10:22 a.m., Resident #76 was observed sitting in his room with quarter bed rails raised on the both sides of the bed. At 1:04 p.m., Resident #76 was observed sitting in his room. Bed rails were observed in the raised position on both sides of the resident's bed. The resident said the rails were already on the bed when he arrived and didn't remember anyone talking about the benefits or risk of having them, or signing a consent for them. Review of Resident #76 clinical record revealed he was admitted [DATE]. There was no evidence of an assessment for the safe use of the rails, other interventions attempted, or informed consent obtained prior to their use. 2. On 1/14/19 at 10:45 a.m., Resident #73 was observed lying in bed with half bed rails raised on both sides of the bed. On 1/14/19 at 1:27 p.m., Resident #73 was observed lying in bed with half rails raised on both sides of the bed. The resident did not recall anyone talking to her about the bed rails. Review of Resident #73 clinical record revealed there was no evidence of an assessment for the safe use of the rails, other interventions attempted, or informed consent obtained prior to their use. 3. On 1/14/19 at 10:30 a.m., Resident #77 was observed lying in bed with left half rail raised up. On 1/14/19 at 11:11 a.m. Resident #77 was observed lying in bed with left rail raised up. Resident said the side rails where there when she was admitted , and she did not recall anyone talking to her about the bed rails. Review of Resident #77 clinical record revealed there was no evidence of an assessment for the safe use of the rails, other interventions attempted, or informed consent obtained prior to their use. 4. On 1/14/19 at 10:29 a.m., Resident #70 was observed lying in bed with both side rails raised on both sides. On 1/14/19 at 1:25 p.m., Resident #70 was observed lying in bed with both side rails raised on both sides. Review of Resident #70 clinical record revealed there was no evidence of an assessment for the safe use of the rails, other interventions attempted, or informed consent obtained prior to their use. On 1/15/19 at 3:10 p.m., Licensed Practicial Nurse (LPN) Staff C confirmed that there was no assessment or informed consent for the use of bed rails. 5. On 1/16/19 at 10:23 a.m., the Director of Plant Operation said there was a preventative maintenance program for the beds done yearly, and they had 2 types of bedrails in use. He was not aware of the manufacturer's recommendations in regards to the bedrails. Review of owner's manual for the facility's model 9000 bed revealed multiple safety warnings in regards to the bedrails and described possible entrapment hazards. The manual included a section for an inspection of the bedrails to be done every 3 months. On 1/17/19 at 9:00 a.m., the Director of Plant Operations confirmed the last inspection of the bed rails was done on 6/2/18 and not every 3 months as per the manufacturer's instructions. 6. On 1/14/19 at 10:42 a.m., Resident #234 was observed in bed with half rails up bilaterally. Resident #234 said no one spoke to her about the risk and benefits of the bed rails prior to installation and she did not give consent for use of the bed rails. Review of the clinical record failed to reveal documentation of an assessment for risk of entrapment or an informed consent. 7. On 1/14/19 at 11:03 a.m., Resident #235 was observed in bed with half rails up bilaterally. Resident #235 said no one spoke to her about the risk and benefits of bed rails. She said she did not sign a consent authorizing the use of the bed rails. Review of the clinical record failed to reveal documentation Resident #235 was assessed for risk of entrapment prior to the installation of the bed rails. There was no documentation of an informed consent for the use of the rails. 8. On 1/14/19 at 11:48 a.m., Resident #236 was observed in bed with half rails up bilaterally. He said no one spoke to him about the risks or benefits of the bed rails. He said he did not remember signing a consent prior to the installation of the bed rails. The clinical record lacked documentation of an assessment for the safe use of the rails, other interventions attempted, or informed consent obtained prior to the use of the bed rails. 9. On 1/16/19 at 9:10 a.m., the Unit Manager for the Dolphin cove unit said the facility just recently changed the beds. The new beds came with grab bars and they were not moveable. He confirmed Resident #235 had bilateral half rails up. He said he was not aware of any policy or consent requirement for the bed rails. 10. On 1/16/19 at 9:15 a.m., the Director of Nursing said they did not obtain consent prior to applying the bed rails. She said the facility was diligently working on creating a policy for the use of bed rails.

Based on record review and staff interview, the facility failed to ensure residents did not receive as needed [MEDICAL CONDITION] medications for greater that 14 days without physician documentation for 1 (Resident #76) of 5 residents reviewed for unnecessary medications. Resident #76's as needed order for [MEDICATION NAME] exceeded 14 days without a rationale. The findings included: Review of the facility policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised on (MONTH) 28, (YEAR), revealed as needed (PRN) orders for [MEDICAL CONDITION] drugs should be limited to 14 days. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. A review of the Medication Administration Record [REDACTED]. On 1/17/19 at 11:29 a.m., the Director of Nursing confirmed the PRN [MEDICAL CONDITION] medication use exceeded the 14 days for Resident #76 without a specified duration or documentation of a rationale to support the continued use of the prn [MEDICAL CONDITION] medication.

Based on record review and staff interview, the facility's consultant Pharmacist failed to report irregularities to the facility's Director of Nursing (DON) for the regulated use of as needed (PRN) [MEDICAL CONDITION] medications for 1 (Resident #76) of 5 residents reviewed for unnecessary medications. The regulation required [MEDICAL CONDITION] medications ordered as PRN to be limited to 14 days. This oversight had the potential for the resident to experience adverse side effects from over use of this medication. The findings included: The facility's pharmacy policy and procedure titled Drug Regimen Review dated 9/18 indicated: B - The consultant Pharmacist shall review the medication regimen of each resident at least monthly and as needed. C - Findings and recommendations shall be reported to the Administrator, Director of Nursing (DON), the responsible physician and the Medical Director, when appropriate. F - The consultant Pharmacist shall document potential or actual medication therapy problems and communicate them to the responsible physician and the Director of Nursing within 3 days. H - Each resident's drug regiment shall be reviewed to ensure it is free from unnecessary medications. A medication shall be considered unnecessary when it is used for excessive duration. Record review on 1/16/19 revealed Resident #76 was receiving [MEDICATION NAME] (a medication for depression) PRN since 11/20/18 (over a month). The prescribing physician did not document in the resident's record a rationale for prolonged use. The record did not contain any duration of use. The resident received this medication 14 times from 12/1/18 through 1/1/19. The pharmacy made no recommendations to the facility. Review of the monthly pharmacy reports for (MONTH) (YEAR) revealed no recommendations were made to discontinue or to continue with documented rationale for [MEDICATION NAME] after 14 days. On 1/17/19 at 11:29 a.m., the DON confirmed there was no pharmacy recommendation related to [MEDICATION NAME] being ordered for more than 14 days. She confirmed the record did not have a rationale for prolonged use and the order did not have a duration for use.

Based on observation, staff interview and record review the facility failed to ensure hygienic practices were followed. Evidence by staff not using sanitary measures while taking the temperature of food items during tray line observation. The findings included During tray line observation on 1/10/18 at 11:15 a.m., Cook Staff A was taking the temperature of hot food items located on the steam table. She proceeded to place the thermometer probe in the food items, retrieve the probe, and wipe the probe with a paper cloth, which had been soaked in a sanitizing solution. Approximated time the probe was in contact with the sanitary wipe was 10 seconds. Staff A continued to use the same sanitary wipe to clean the probe after each reading of the different food items. On 1/11/18 at 10:55 a.m., the Certified Dietary Manager (CDM) said in reference to Staff A using the same wipe numerous times to clean off the thermometer probe that the wipes were very big. They can be used several times, as long as staff did not continually use the same soiled area of the wipe to clean the probe. The CDM proceeded to demonstrate the bucket/container the wipes were stored in. Instructions on the container read you could use sanitary solution of choice in the bucket. The label on the container also had a section to manually mark the solution being used to include name of product, and chemical contents. Observed the label was blank. The CDM confirmed the label was blank, and exhibited the chemical product the facility used, which was a Quaternary Ammonia Solution (intended to be used as a sanitizer safe for food contact). Further review of the label on the chemical solution, instructed there should be a one-minute contact time/wait time after chemical was used. This was brought to the attention of the CDM, who then validated the contact time was short of what the manufacturer recommended. Facility approved policy titled Food Handling Chapter 7, Tab 00, Policy # 025, dated 3/2017 was reviewed on 1/10/18. The policy failed to include the method of how a thermometer probe was sanitized. ***Photos on file***

Based on resident interview, staff interview, and record review, the facility failed to provide activities to meet the needs and interest of 1 (Resident #52) of 1 sampled residents for activities. This had the potential for residents who were not engaged in activities experience a decline in physical, mental and psychosocial well-being. The findings included: On 1/8/18 at 11:27 a.m., Resident #52 said he did not like the activities the facility promoted. He said he liked to play chess. He would like to do that. He said staff never talked to him about trying to organizing a chess group. He says most of the time he just stayed in his room. Resident #52's record contained an activity assessment completed 8/12/17. This assessment did not document the resident's interest in card/other games. On 12/4/17, a care conference was completed with the resident. It noted the resident said he enjoyed playing chess. His chess set would be brought to him. The activity department would find someone to play chess with the resident. It noted the resident liked old movies and the activity department would arrange this activity also. Resident #52's activity care plan was initiated on 8/23/17. Following the care plan meeting dated 12/4/17, the facility had not updated the resident's care plan. The care plan stated under Goal resident would express satisfaction with daily routine and leisure activities. Resident would attend 1-2 scheduled events of choice due to impaired mobility. Under Approach it said: Involve resident with those who have shared interests assist to and from scheduled events of choice. The Goal showed the resident would be satisfied with daily and leisure activities which had not been accomplished. There was no documentation Resident #52 was attending 1-2 scheduled activities of choice. The care plan did not specify if the goal was a weekly attendance. On 1/10/18 at 2:00 p.m., the Activity Director said Resident #52 did express a desire to play chess. They could not find anyone for him to play chess with. They did not track resident's attendance in activities. She said that she did try to do 1 on 1 with Resident #52. This was not being documented. The care plan did not address how often 1 on 1 visits should be attempted. On 1/10/18 at 2:10 p.m., the Social Services Worker on the Long Term Care Wing said that at the time of the care plan meeting the need for a private pay caregiver was discussed. This private pay caregiver could play chess with the resident and escort the resident outside.

Based on record review and interview, the facility failed to ensure 2 (Residents #25 and #382) of 5 residents reviewed for unnecessary medication received medications as ordered and non-pharmacological interventions were attempted prior to the administration of an as needed psychoactive medication. This has the potential for residents to suffer negative side effects from unnecessary medications. The findings included: 1. Record review for Resident #25 found her electronic Medication Administration Record [REDACTED]. The record documented the order for the Humalog had perimeters to be held if the blood sugar was under 180. The information key on the eMAR noted when the initial of the person providing the medication was in parenthesizes it meant the medication was not administered. It also noted when there was an asterisk * this meant there was a comment in Reason/Comment section. From 11/5/16 through 12/5/16 there were 16 incidents where the blood sugar measurement was noted to be less than 180 and the initials of the medication administrator was not in parenthesizes. This indicated the medication was given with the blood sugar below 180. The eMAR documented 8 incidents where the blood sugar was below 180 and there was an asterisk (*) by the initial of the provider. The comment in the comment sections said Late Administration: Charted late. This indicated the medication was administered even with the blood sugar below 180. On 12/6/16 at 3:30 p.m., the Quality Coordinator said the eMAR for Resident #25 documented the Humalog was given when the blood sugar was below the ordered perimeters of 180. On 12/7/16 at 9:33 a.m., the Director of Nursing said she could not say if the Humalog was given but the documentation did show that it was given even when the blood sugar was 180. 2. Resident #382's clinical record contained physician's orders [REDACTED]. The resident's medication record was reviewed on 12/7/16 and indicated the resident was given [MEDICATION NAME] on 11/30/16, 12/2/16 and 12/6/16 for anxiety. The resident was also given [MEDICATION NAME] on 12/1/16, 12/3/16, 12/5/16, and 12/6/16 for anxiety. There were no interventions noted as being attempted prior to the administration of a psychoactive medication in the resident's record. On 12/7/16 at 1:38 p.m., the Assistant Director of Nursing (ADON) said the [MEDICATION NAME] had been given for anxiety instead of the [MEDICATION NAME]. The ADON confirmed the reason for the [MEDICATION NAME] being given was documented by the licensed nurse as for anxiety, and not for [MEDICAL CONDITION] as ordered. The ADON also acknowledged there was no documentation of any non-pharmacological interventions being attempted prior to the use of either medication.

Based on record review and interview the facility failed to ensure the consulting pharmacist identified medications irregularity for 1(Resident #25) of 5 residents reviewed for unnecessary medication. This has the potential for residents to suffer negative side effects from unnecessary medications. The findings included: Record review of the consulting pharmacy review date 11/16/16 does not identify any irregularities regarding Residents #25's administration of Humalog. The documentation on the eMAR showed that on 11/5/16, 11/6/16, 11/7/16, 11/8/16, 11/10/16, and 11/13/16 the Humalog was given when the blood sugar measurement was less than 180. Record review for Resident #25 found her electronic Medication Administration Record [REDACTED]. The record documented the order for the Humalog had perimeters to be held if the blood sugar was under 180. The information key on the eMAR noted when the initial of the person providing the medication was in parenthesizes it meant the medication was not administered. It also noted when there was an asterisk * this meant there was a comment in Reason/Comment section. From 11/5/16 through 12/5/16 there were 16 incidents where the blood sugar measurement was noted to be less than 180 and the initials of the medication administrator was not in parenthesizes. This indicated the medication was given with the blood sugar below 180. The eMAR documented 8 incidents where the blood sugar was below 180 and there was an asterisk (*) by the initial of the provider. The comment in the comment sections said Late Administration: Charted late. This indicated the medication was administered even with the blood sugar below 180. On 12/6/16 at 3:30 p.m., the Quality Coordinator said the eMAR for Resident #25 documented the Humalog was given when the blood sugar was below the ordered perimeters of 180. On 12/7/16 at 9:33 a.m., the Director of Nursing said she could not say if the Humalog was given but the documentation did show that it was given even when the blood sugar was 180.

Based on record review, observation and interview, the facility failed to ensure clean facility linen was not contaminated during the folding process. The finding included: On 12/7/16 at 10:15 a.m., the housekeeping aide was observed folding a resident gown. The gown touched the floor and the aide's uniform during the procedure. In addition, 3 sheets were observed intermittently touching the aide's uniform while being folded. Neither the supervisor of environmental services or the infection control nurse intervened to correct or instruct the aide to avoid clean linen from contact with the floor and/or her uniform. The supervisor of environmental services acknowledged the housekeeping aide did not follow the proper procedure and was trained to avoid touching the floor and her uniform during the folding of clean linen. The supervisor said she would retrain the aide in the proper procedure and confirmed the aide's uniform could not be considered clean. When asked for the written policy and procedure used in the retraining, the supervisor provided a document entitled Standard Precautions, All Patients dated 8/13 (August 2013). Review of this document revealed no reference to avoiding contact with the floor and employee's uniform during the folding of clean linen. In addition, the supervisor made no reference to retraining of other employee's responsible for this procedure to prevent the reoccurrence of this type of contamination.

Based on observation, record reviews and interviews, the facility failed to provide pharmacy services in accordance with physician orders, pharmacy recommendations, and resident preferences to minimize side effects for 3 (Residents #1, #2, and #4) of 4 residents reviewed for medications. The findings included: The facility's policy for Medication Administration directed to administer the right medication at the right time. When appropriate, evaluate and document the patient's response to the medication given. Under Assessment and Monitoring; As part of the monitoring process, staff are expected to include the patient's report of his/her experience of the medication's effects. 1. Resident #1's clinical record indicated the resident was admitted to the facility on [DATE] with physician orders [REDACTED]. On 3/17/16 the Advanced Registered Nurse Practitioner (ARNP) for Resident #1, noted she was in to see the resident for nausea. Nurses notes on 3/19/16 indicated the resident constantly complains of nausea and vomiting. On 3/20/16 at 8:31 a.m., the nurse noted the resident complains of nausea and vomiting on going with no relief from anti-nausea medications. A widely used internet source of drug information www.rxlist.com <http://www.rxlist.com> , showed the common side effects of metoprolol tartrate may include nausea, vomiting, dry mouth, gas, heartburn, . On 5/19/16 at 11:00 a.m., Resident #1's family member said she had asked Staff A why the time of the metoprolol had been changed to 6:00 a.m. and taking it on an empty stomach was what was making her mother sick. She said Staff A attributed the change to the physician and said it was in case the resident had an elevated heart rate during therapy. She said the nurses continued to give the medication to her mother at 6:00 a.m. and was unsure if they contacted the resident's physician about the concern with the metoprolol being given before breakfast. On 5/19/16 at 3:00 p.m., Licensed Practical Nurse Staff A said she recalled talking to Resident #1's daughter about the nausea and she was concerned about the times to administer of the metoprolol being changed. She said the resident's daughter mentioned she thought giving the metoprolol so early was causing nausea so added some toast and the daughter was agreeable to this. Staff A said the facility's Medical Director, not the resident's primary physician, had requested all medications of this type be changed from 9:00 a.m. to 6:00 a.m. On 5/19/16 at 3:25 p.m., the ARNP for Resident #1 said she was not sure why the time of the metoprolol was changed to 6:00 a.m. and was not made aware of any request by the resident or family member to change it back to 9:00 a.m. The ARNP said every patient was different so can not say what was going to make someone nauseous and would have suggested giving this medication with food if that was the case. The resident was first documented as having vomiting on the morning of 3/15/16 when the resident received the metoprolol at 6:00 a.m. The resident continued to have issues with vomiting. The time of the medication was not changed even upon the request of the resident's daughter and Power of Attorney. The ARNP was not notified of the request or aware of the order to change the administration time by the facility's Medical Director. 2. On 5/19/16 at 10:14 a.m., Registered Nurse (RN) Staff B was observed administering the medication Flonase nasal spray to Resident #2. The pharmacy directions on bottle were to gently blow nose prior to spraying the medication into each nostril. Staff B was observed administering the nasal spray without instructing the resident to first gently blow her nose. At 10:50 a.m., Staff B confirmed she did not follow the pharmacy instructions on the bottle. 3. On 5/19/16 at 11:20 a.m., RN Staff B was observed preparing to administer medications to Resident #4. The resident was to receive Vitamin B 12 extended release (ER) at 9:00 a.m. Staff B was unable to locate this medication and only had the regular Vitamin B 12 in the medication cart. Staff B said she would have to check on this and could not administer the medication. The resident was also to receive the medication Zoloft daily with breakfast. Staff B was observed administering this medication to the resident at 11:30 a.m. On 5/19/16 at 11:45 a.m., RN charge nurse Staff C said she checked the medication stock room and did not have Vitamin B 12 ER tablets. Staff C said this medication was not a stocked medication and would have to come from the pharmacy. Resident #4's medication record for May was reviewed and the resident was noted to have received Vitamin B 12ER on [DATE], 5/17/16, and 5/18/16 although the medication was not available. The resident's medication record also noted the medication Zoloft was scheduled for 8:00 a.m. and on 5/16/16 was given at 10:05 a.m.; and on 5/18/16 at 10:19 a.m. Staff C said the resident would have breakfast between 7:30 a.m. and 8:00 a.m. and confirmed the medication had been documented as not being administered in accordance with physician orders [REDACTED].

Based on observation, interview and record review the facility failed to follow a physician's order for 1 (Resident #120) of 5 residents reviewed for unnecessary medications. This deficient practice could result in a potential for deterioration of the residents physical and mental well-being. Findings include: 1. Resident #120 is a [AGE] year old female who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Resident #120's Medication Administration Record [REDACTED]. The medication times are 8:00 a.m., 12:00 p.m., and 5:00 p.m. According to the Federal Drug Administration, "Calcium Acetate is a [MEDICATION NAME] binder indicated to reduce serum phosphorus in patients with end stage [MEDICAL CONDITIONS]." In the same article the FDA instructs to inform patients to take the medication with meals. The reason to take Calcium Acetate with meals is it binds with phosphorus being ingested in the meal and prevents it from being absorbed in the blood. In an interview with Resident #120 at 8:30 a.m., on 10/22/14 she said she is given a bagged lunch when she goes to [MEDICAL TREATMENT] three days weekly. She does not take any medications with her to [MEDICAL TREATMENT]. In an Interview with Staff B, LPN at 12:00 p.m., on 10/22/14 stated she is not aware of what Resident #120 takes with her when she goes to [MEDICAL TREATMENT]. Interview with Staff C, LPN at 12:05 p.m., on 10/22/14 stated she is not aware if Resident #120 takes binders with her to [MEDICAL TREATMENT]. She said she would contact the [MEDICAL TREATMENT] center to find out. In an interview with the Director of Nursing (DON) on 10/22/14 at 2:30 p.m., she said she was contacting the [MEDICAL TREATMENT] unit to see if medications were coming with the resident to the [MEDICAL TREATMENT] center. She verified there was no documentation the resident was receiving [MEDICATION NAME] binders when she was going to the center on the MAR indicated [REDACTED]. Interview with the DON and Staff A, Unit Manager at 9:15 a.m., on 10/23/14 both verified the resident was not receiving Phoslo (Calcium Acetate) as ordered by the physician when going to [MEDICAL TREATMENT]. The DON said a staff member had contacted the [MEDICAL TREATMENT] center when the resident was admitted to the facility and was told they would not administer the medication at [MEDICAL TREATMENT]. The unit manager said she had contacted the [MEDICAL TREATMENT] unit on 10/22/14 after surveyor intervention and they had told her they would administer the medication.

Based on record review, interviews and observation, the facility failed to ensure residents receive medications as ordered by the physician resulting in a significant medication error for 1 (Resident #88) of 5 resident's medication regimen reviewed. This failure included a medication for management of the resident's mental health and constitutes a significant error with the potential for adverse effects, when suspended abruptly. The findings include: Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] since 6/1/14. [MEDICATION NAME] is an antidepressant used in treatment of [REDACTED]. Lexi-Comp's Drug Reference handbook. Document review of www.medscape.com/viewarticle/ 7 <http://www.medscape.com/viewarticle/ 7> on 10/23/14 cautions Providers and users of [MEDICATION NAME] ([MEDICATION NAME] XR) regarding potential discontinuation withdrawal syndrome and/or symptoms regarding abruptly stopping this medication. In an interview and observation of Resident #88 on 10/22/14 at 11:40 a.m., the resident stated, "I feel neglected as they treat the other resident (roommate) very nicely." The resident said the aides will come into the room in the morning, say hello to her roommate and offer her tea but will not pull back the curtain, acknowledge her or offer her coffee. The resident told of her experience of falling in the bathroom on 10/16/14. In relating the experience the resident became emotional and weepy. The resident was describing feelings of depression and paranoia. The fall occurred during the time the resident's mood altering medications were not administered. During the interview the resident was in a wheelchair with her left arm on a supporting rest attached to the wheelchair. The resident tearfully expressed she is frustrated because she is not able to do things due to not having the use of her left hand. A review of the Medication Administration Record [REDACTED]. 75 mg one cap oral once a day. The [MEDICATION NAME] ER was not administered from 10/14/14 to 10/19/14 due to "Drug Item unavailable." Information System Nurse documented received 1st dose 10/19/14. In an interview on 10/22/14 at 10:00 a.m., the Director of Nursing (DON), Unit Manager and Information Systems (IS) Nurse reviewed Resident #88's MAR from 10/1/14 through 10/21/14 and verified the evidence of late administration of medications including [MEDICATION NAME] ER. The findings confirmed Resident #88 did not receive medications as ordered by physician and the facility did not ensure medications were administered as ordered. During an interview on 10/23/14 at 10:40 a.m., the Administrator stated, "The current pharmaceuticals provider no longer has a local satellite storehouse. The medications come from Tampa now and the vendor has not been reliable about delivering the medications on a timely basis." The administrator said the facility collects data on unavailable medications and they know there are residents whose medication arrives late. The administrator said they need to come up with a process for ensuring the residents get their medications.

Based on document review, observations and interviews, the facility failed to revise an individualized comprehensive care plan for activities of daily living (ADLs) in regards to toileting for 1 (Resident #88) of 3 residents reviewed for accidents. Failure to revise the care plan for toileting has the potential for Resident #88 to be at risk for future falls in the bathroom. The findings include: In an interview on 10/22/14 at 11:05 a.m., Resident #88 stated, "I fell in the bathroom last week. I had to use the bathroom so a nurse aide (CNA) helped me onto the toilet. I am tall and the bathrooms are small so I had a hard time maneuvering around. While sitting on the toilet, I reached over to pick up the toilet paper and slid off. I wasn't dizzy or anything. I let myself down to the floor. I slid off the toilet in the bathroom probably due to the ointment I had on my side and back end (buttocks). It was slippery. I was on the floor when CNA came back in." Resident #88 was observed on 10/22/14 at 11:40 a.m., to be up in a wheelchair with their left arm cradled on a rest that is attached to the wheelchair. The left arm is not able to be used by the resident. Observation of the bathroom in the resident's room on 10/22/14 at 12:30 p.m., finds the toilet paper dispenser is on the left side of the toilet. Review of the fall log, occupational therapy discharge summary, care plans, incident report and medical records for Resident #88 were reviewed with the following findings: Fall Report Log dated 10/22/14, provided by the Director of Nursing (DON), noted Resident #88 fell off the toilet on 10/16/14 at 11:24 p.m., in resident bathroom; status - closed. The Occupation Therapist Progress & Discharge Summary report dated 8/13/14 assessed Resident #88 as a fall risk and precautions were required due to left side weakness; "Decreased perception in L (left) visual field. May not see obstacles or hazards on that side. Fall risk L [MEDICAL CONDITION] (left sided weakness)." The care plan for activities of daily living (ADLs) dated 4/10/14 and reviewed on 10/22/14 9:55 a.m., for Resident #88 did not include approaches for toileting. The care plan was not revised to include the 10/16/14 bathroom fall, a reassessment with specific accommodations or approaches to prevent future falls nor did the care plan individualize the personal needs of the resident in supporting ADLs in the bathroom. The care plan dated 4/0/14 for falling related to impaired mobility, reviewed on 10/22/14 for Resident #88, indicated the following approaches were to be started by CNA (certified nursing assistant) and Nursing: Landing strips (fall mats on the floor by the bed) as ordered; encourage nonskid footwear; keep bed in lowest position; keep resident's personal belongings within reach; keep room and walkway clear; provide assist with transfers and bed mobility as needed; monitor for weakness and fatigue; remind resident to use call light prn (when needed) and wait for assist. The care plan for falling dated 4/10/14 did not include information, revisions or documentation of the 10/16/14 fall which had occurred in the bathroom. The care plan did not include information for precautions recommended by Occupational Therapy on 8/13/14 due to left sided weakness nor did the plan included approaches individualized for patient safety and prevention of future falls. In a staff interview on 10/22/14 at 1:50 p.m., the MDS (Minimum Data Set) Coordinator and the Risk Manager/Assistant Director of Nursing (RM/ADON) stated an incident report for Resident #88's 10/16/14 fall in the bathroom was generated and completed by the Risk Manager Assistant. The fall report included the nurse's statement of the event; however there was no resident interview nor analysis of the cause of the fall undertaken. The incident report investigation did not include an interview with Resident #88 which would have provided information regarding the resident's ointments applied to her buttocks contributing to her slip off the toilet while reaching for the toilet paper. The incident report did not include an environmental review of Resident #88's bathroom showing that the toilet paper holder is on the left side where the resident's left sided weakness prevented her from using her left hand. In the interview on 10/22/14 at 1:50 p.m., the RM/ADON and MDS Coordinator acknowledged the care plan was not updated or revised as of 10/22/14 to individualize the personal needs of the resident regarding the fall on 10/16/14 or preventing future falls in the bathroom. The RM/ADON acknowledged the resident has not been interviewed as of 10/22/14 regarding the fall in the bathroom. Normal protocol is that the risk management assistant interviews the resident, the incident report is then reviewed by the risk manager. Record review of resident's care plan on 10/23/14 noted a late entry stating, "At risk for falling related to impaired mobility, Fall 10/16/14, plan of care reviewed." However, no additional interventions or accommodations were made for individualizing the care for Resident #88 to prevent future falls.

Based on document review, observations and interviews, the facility failed to ensure adequate supervision and ensure assistance devices were in place to prevent accidents for 1 (Resident #88) of 3 residents reviewed for accidents. The failure to make accommodations for a resident with left side weakness due to a stroke resulted in a fall in the bathroom. The findings include: In an interview on 10/22/14 at 11:05 a.m., Resident #88 stated, "I fell in the bathroom last week. I had to use the bathroom so a Certified nurse aide (CNA) helped me onto the toilet. I am tall and the bathrooms are small so I had a hard time maneuvering around. While sitting on the toilet, I reached over to pick up the toilet paper and slid off. I wasn't dizzy or anything, I let myself down to the floor. I slid off the toilet in the bathroom probably due to the ointment I had on my side and back end (buttocks). It was slippery. I was on the floor when CNA came back in." Resident #88 was observed on 10/22/14 at 11:40 a.m., to be up in a wheelchair with their left arm cradled on a rest that is attached to the wheelchair. The left arm is not able to be used by the resident. Observation of the bathroom in the resident's room on 10/22/14 at 12:30 p.m., finds the toilet paper dispenser is on the left side of the toilet. Review of the occupational therapy discharge summary, care plans, incident report and medical records for Resident #88 were reviewed with the following findings: The Occupation Therapist Progress & Discharge Summary report dated 8/13/14 assessed Resident #88 a fall risk and precautions were required due to left side weakness; "Decreased perception in L (left) visual field. May not see obstacles or hazards on that side. Fall risk L hemiparesis (left sided weakness)." The care plan dated 4/10/14 and reviewed on 10/22/14 at 9:55 a.m., for Resident #88 did not include approaches for toileting, the individualized personal needs of the resident in supporting ADLs in the bathroom or the precautions recommended by Occupational Therapy on 8/13/14 due to left sided weakness. In a staff interview on 10/22/14 at 1:50 p.m., the MDS (Minimum Data Set) Coordinator and the Risk Manager/Assistant Director of Nursing (RM/ADON) stated an incident report for Resident #88's 10/16/14 fall in the bathroom was generated and completed by the Risk Manager Assistant. The fall report included the nurse's statement of the event; however there was no resident interview nor analysis of the cause of the fall undertaken. The incident report investigation did not include an interview with Resident #88 which would have provided information regarding the resident's ointments applied to her buttocks contributing to her slip off the toilet while reaching for the toilet paper. The incident report did not include an environmental review of Resident #88's bathroom showing that the toilet paper holder is on the left side where the resident's left sided weakness prevented her from using her left hand.

Based on record review and interviews, the facility failed to provide routine drugs by failing to ensure reliable pharmaceutical services were in place to acquire and receive medications as ordered by the physician for 1 (Resident #88) of 5 resident's medication regimen reviewed. The findings include: Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. In an interview on 10/22/14 at 10:00 a.m., the Director of Nursing (DON), Unit Manager and Information Systems (IS) Nurse reviewed Resident #88's MAR from 10/1/14 through 10/21/14 and reported finding evidence of late administration of medications. The DON requested the IS Nurse create an administration compliance report from 10/1/14 through 10/23/14. The administration compliance report findings for Resident #88 are as follows: 1.) Acid Reducer ordered 10/4/14 not administered: Drug/item unavailable IS Nurse documented resident received on 10/5/14 2.) Bio-freeze 4% ordered 10/14/14 not administered: Drug/item unavailable IS Nurse documented resident received on 10/16/2014, substitution 3.) Cymbalta ordered 10/15/14 60 mg one cap oral once a day not administered: Drug Item unavailable IS Nurse documented resident received 1st dose on 10/19/14 4.) Effexor XR capsule extended release 24 hr. 75 mg one cap oral once a day Not administered: Drug Item unavailable IS Nurse documented received 1st dose 10/19/14 5.) Morphine Sulfate ER, Schedule II tablet, one tab oral at bedtime 10/15/14 not administered Drug/Item unavailable The findings confirmed Resident #88 did not receive medications as ordered by physician and the facility did not ensure medications were administered as ordered as documented by the Administration Compliance Report. In an interview on 10/23/14 at 12:45 p.m., the Unit Manager, Staff F, reported the medication omissions were not reported to her. The unit manager said the LPNs and RNs did not follow the facility process. The unit manager said when the managers are made aware that medication has not arrived from the pharmacy they stay in touch with the pharmacy until the medication arrives. In a review of the Medication Administration Compliance Report for the period 10/01/14 through 10/23/14 on 10/23/14 at 10:30 a.m., the DON confirmed medications were omitted. She also acknowledged the nurses did not act appropriately to insure the resident received her medications as ordered. During an interview with the Administrator, on 10/23/14 at 10:40 a.m., the summary of findings of Medication Administration Compliance Report 10/01/14 through 10/23/14 for Resident #88 was reviewed. The Administrator stated, "The current pharmaceuticals provider no longer has a local satellite storehouse. The medications come from Tampa now and the vendor has not been reliable about delivering the medications on a timely basis." The administrator said the facility collects data on unavailable medications and they know there are residents whose medication arrives late.

Based on observation and staff interview, the facility failed to provide cleaning and maintenance services to maintain a sanitary environment in regards to mechanical stand assist lifts and air conditioner vents. The findings include: 1. During an observations on 9/23/13 at 3:07 p.m., the air conditioner vents in Rooms 230 and 232 were observed to be dusty and covered with black residue. During an observation on 9/24/13 at 10: 50 a.m., the mechanical stand assist lift (Sara lift), used to transfer the resident in Room 130 A, was in the 130's hall shower room, and found to have a foot platform filthy with grime, debris and dirty residue. The lift yoke has dirty residue and the edges were the foot platform attaches to the lift arm is dirty with a buildup of grimy debris. The hand grips are dirty and the left elbow rest pad is broken. The mechanical shower lift chair in the shower room is dirty with stains and residue. The Sara lift in the 110's hall has a dirty foot platform with built up debris and grime. The yoke cover is dirty with stains and residue. During an observation on 9/24/13 at 1:45 p.m., a nurse aide was transporting the dirty Sara lift from the shower room into room 130 to assist resident in bed 130A into bed for incontinence change. The nurse aide did not clean or sanitize the lift before use. When finished the nurse aide returned the lift from room 130 to the shower room at 1:52 p.m., without cleaning or sanitizing it. During an observation on 9/24/13 at 2:02 p.m., a stand assist lift used for weighing was taken into room 141 to weigh the resident in bed 141A. The lift is filthy with grime and debris on the foot platform. The lift was brought out of room 141 at 2:09 p.m., and left at the nurse station without cleaning or sanitizing. Observation of the Sara lifts in the shower room on the 210's hall was found dirty with debris, liquid residue and grime on the hand grips, the foot platform and the lift yoke. The padded yoke cover is dirty. During an observation on 9/25/13 at 1:48 p.m., in the shower room on 130's Hall, the Sara lift and the standing weight lift continue to be dirty with debris and grime. During an observation on 9/26/13 at 8:49 a.m., the Sara lifts on the Dolphin wing continued to be still filthy with debris and residue on the foot platform and lift arm yoke. 2. A review of the facility policy for Cleaning of Patient Care Equipment documented: "Reusable durable patient care equipment must be in good repair and will be cleaned in the following manner to prevent the potential spread of infection and cross-contamination. A. All equipment used for patient care shall be kept clean and in proper working condition. 1. Patient care equipment not having had contact with non-intact skin, mucous membranes, blood or body fluids, secretions or excretions or not visibly soiled will be wiped clean with an approved germicidal wipe. 2. Patient care equipment when visibly soiled needing cleaning but not disinfection will be cleaned using the same disinfectant to remove the visible soiling, followed by wiping again with a fresh disinfectant wipe. 3. Patient care equipment having had contact with non-intact skin, mucous membranes, blood, body fluids, secretions or excretions will be first wiped clean with a germicidal wipe, followed by wiping with a fresh germicidal wipe maintaining the surface wet for the length of time per manufacturer ' s instructions for cleaning blood and body fluid contamination. D. All medical equipment used for patient care must be cleaned and disinfected using a System approved disinfectant or wipes before use on another patient. 1. Durable medical equipment brought into the patient room for a brief single application, which is promptly removed, will be minimally cleaned / disinfected on those parts having direct contact with contaminated hands or the patient. " 3. During an interview and environmental tour of the facility on 9/26/13 at 10:00 a.m., the Administrator, the Maintenance Director and the Housekeeping Supervisor confirmed the mechanical lifts are dirty with grime and debris. The Maintenance Director confirmed the air conditioner vents in Rooms 230 and 232 have a build up of grime and a black substance. The air conditioner vents in Room 139 have a buildup black residue. The Sara lifts throughout the building are not clean and sanitary.

Based upon observation, record review and interview the facility failed to coordinate care with the [MEDICAL TREATMENT] center for 1 (Resident #155) of 1 [MEDICAL TREATMENT] residents reviewed and failed to coordinate in-house monitoring of weights for 5 (Residents #29, #272, #303, #306, and #63) of 5 residents reviewed for nutrition. This places 6 (Residents #155, #29, #272, #303, #306, and #63) of 6 reviewed residents of 22 sampled residents at risk for preventable illness and injury related to lack of communication and coordination of care. The findings include: Review of the current policy and procedure entitled Resident Weights documents the following: Purpose: Resident weights are monitored to identify residents at risk for weight change. Policy: Residents are weighed after admission and weekly times 2 weeks. If residents' weight is stable, resident is weighed monthly. Daily weights are monitored as ordered by physician. Procedure: 1. Admission Weights a. Will be done the day after admission by the Restorative Certified Nursing Assistant (CNA) 2. Daily Weights a. 11-7 shift CNAs obtain daily weights and report to the nurse for documentation on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] i. All weight changes of 3 lbs. or greater will be reported to the physician for further intervention B. Any resident on a daily weight will not be weighed again weekly or monthly 3. Weekly Weights a. Restorative Aide obtains weekly weights and records on weight worksheet i. Worksheets are given to appropriate leadership staff. b. The nurse transcribing an order for [REDACTED]. c. All weight changes of 5 lbs. or greater will be automatically re-weighed and reported to the nurse. d. Any resident on weekly weights will not be weighed monthly 4. Monthly Weights a. Monthly weights are obtained by Restorative CNA/assigned staff b. All weight changes of 5 lbs. or greater will be automatically re-weighed and reported to the nurse During an interview on 9/26/13 in the late afternoon, the Director of Nursing (DON) stated the facility does not have an in-house scale. The facility uses either a stand-up (Encore) type lift or a Hoyer type lift (Tempo) for all in-house weights. Those residents on monthly and weekly weights are all weighed using the Hoyer type lift. Residents being alert, oriented, and ambulatory are weighed on the lift. During an observation on 9/26/13 in the afternoon, of a resident being weighed on both the stand up and Hoyer type lift revealed there is a 1.3 pound difference between the two lift type weights. Review of the facility Census and Condition, dated 9/23/13, documents the facility has 17 residents with unplanned significant weight loss or gain. Review of the Quality Indicator Survey (QIS) Stage 1 Census Sample Residents revealed there are 2 residents with a significant weight loss, 3 residents are underweight with no supplement, and 3 residents have had a weight loss since admission. Review of September weights for the Census Sample Residents reveals the following: 1. Resident #306 was admitted on [DATE], with a weight documented at 195 pounds. The documented weight for the resident on 9/14/13 is 185 pounds. There is no re-weigh documented as per facility policy to validate the 185 pounds. The next weight for the resident was on 9/26/13, with the residents weight documented at 181 pounds; a decline of an additional 4 pounds. During an interview on 9/26/13, in the late afternoon, the DON said a reweigh should have been done by the restorative aide when the second weight was obtained at 10 pounds less. She said on 9/14/13, when the 10 pound difference was documented, a dietary consult was completed and interventions were put into place. When asked what the resident's current weight was the DON did not know. She said the resident's physician was in-house and was questioning the accuracy of the admission weight. The staff obtained an updated weight on 9/26/13, after surveyor intervention. When the DON was asked who in the facility is responsible for monitoring the effectiveness of the nutritional interventions to include the frequency of obtaining weights, she said she did not know. 2. Resident #63 was admitted to the facility on [DATE], after a hospital stay for a fractured right hip. Review of the 30 day Minimum Data Set (MDS) assessment, dated 7/21/13, documents the resident has a height of 62 inches and weighs 89 pounds. The documented weights for Resident #63 are as follows: ? 6/21/13 -89 pounds (admission) ? 7/1/13-89 pounds (10 days later) Nursing note dated 7/4/13, documents while attempting to get patient (pt.) to eat her breakfast this a.m., Resident #63 stated "I have never been much of an eater. I usually get a cup of coffee and piece of toast at 11:00 a.m., when I am home." Resident #63 refused breakfast. There is no documentation indicating the nursing staff passed this information to dietary. It was not until 7/26/13 that peanut butter and jelly on toast every day at 10:00 a.m., was added to the residents nutritional care plan. ? 7/8/13 - 89 pounds A review of the physician's order [REDACTED]. ? 7/29/13 - 83 pounds There is no documentation the resident was reweigh or the nurse was notified for a 6 pound weight loss. ? 8/1/13 - 81 pounds A review of the Dietary note dated 8/5/13 documenting - Weight (Wt.) on 8/1/13 at 81 pounds (#). Significant weight loss noted. Receiving great shake with lunch, Ensure three times a day (TID) discontinued (d/c) on 8/1/13. Will contact Medical Doctor (M.D.) There is no documentation a significant weight change notification was completed for the physician. The next documented weight for Resident #63 is on 8/19/13 at 83 pounds. ? 8/19/13 - 83 pounds There are no additional dietary notes or weights until 9/1/1 after the Resident lost an additional 10 pounds. ? 9/1/13 - 73 pounds ? 9/4/13 - 73 pounds ? 9/9/13 - 71 pounds ? 9/10/13 - 71 pounds ? 9/14/13 - 71 pounds ? 9/16/13 - 71 pounds ? 9/24/13 - 78 pounds During an interview on 9/26/13 at 10:30 a.m., the unit manager on Dolphin said normally if a resident is losing weight they will be placed on weekly weights. During an interview on 9/26/13 at 1:16 p.m., the backup Registered Dietician (RD) said there is a significant weight loss from 8/19/13 until 9/1/13. She notified the Medical Doctor (MD) on 8/5/13 when she noted the significant weight loss but there are no additional dietary notes after 8/5/12. The RD said she does not know why the resident's weight was not monitored between 8/19/13 and 9/1/13. The DON present at this time said maybe because the resident gained 2 pounds they did not continue with weekly weights. 3. During an interview on 09/24/2013 at 1:19 p.m., Resident #29 stated she was admitted to the facility last month and since that time she has lost weight. She stated neither the physician nor the dietitian has spoken to her about her weight loss. On 9/24/13, a review of Resident #29's medical records revealed she was admitted on [DATE] from the hospital with an diagnosis/history including to status [REDACTED]. Resident #29's admitting weight was noted as 134 pounds (lbs). The next weight was dated 8/26/13 as 137 lbs., a 3 pound weight gain. On 9/01/13 the facility recorded a weight of 140 lbs., which is a 6 pound weight gain (4.5%) since her admission. On 9/14/13 the facility recorded a weight of 113 lbs. a 27 pound (19.2%) weight loss since 9/01/13. A review of the Dietary Admission Assessment progress note, dated 8/20/13, noted Resident #29 stated her usual body weight is 140 lbs. then 118 lbs. in the same conversation and that Resident #29 appears to be a poor historian. The progress notes then documented the admission weight is "134 lbs. a 134% of ideal body weight." There are no other dietary progress notes in the medical records after the Dietary Admission assessment dated [DATE]. Review revealed no nursing and/or physician progress notes [REDACTED]. a 19.2% weight loss in 13 days. During an interview on 09/24/2013 at 2:00 p.m., Resident #29's primary care physician, after he reviewed Resident #29's medical records including his progress notes, stated the resident is noted to have had 27 lbs. (19.2%) weight loss from 9/01/13 to 9/14/13, which is a significant weight loss and should have been address by the facility. He stated he was not informed of Resident #29's significant weight lost and that he should have been updated on 9/14/13. During an interview on 09/24/2013 at 2:30 p.m., the Unit Manager stated she and the Dietitian monitor all residents' weights on a daily basis. The process is when they note any kind of weight gain or loss which is not expected they will have the staff do a reweigh to check the accuracy of the weight. After the weight gain or loss is verified as accurate they would address the weight gain or loss with the primary care physician, do a dietary assessment, and obtain any physician orders [REDACTED]. The Unit Manager confirmed Resident #29 had a 27 lbs. (19.2%) weight loss from 9/1/13 to 9/14/13. She stated she reviews all resident's weight on a daily basis to check for any weight loss or gain and if there are any significant weight loss or gain she address them with the primary care physician and the Dietitian. After she reviewed her residents weight list she stated the only weight she had for Resident #29 is the 113 lbs. weight so she did not know the resident had a 27 lbs. weight loss in a 13 day period. The resident did not get reweighed as required and the physician was not notified of a significant weight loss. After surveyor interview, the Unit Manager stated she will get a reweigh completed immediately for Resident #29. Upon getting the reweigh the Unit Manager stated Resident #29's current weight on 9/24/13 is 119.4 lbs. The reweigh obtained on 9/24/13 confirms the significant weight loss for Resident #29. During an interview on 09/24/2013 at 2:55 p.m.,the Registered Dietitian (RD) stated she is covering for the facility's full time RD, but after she reviewed Resident #29's medical records and progress notes confirmed Resident #29 had a 27 lbs. (19.2%) weight loss from 9/01/13 to 9/14/13. She stated the last dietary progress note is dated 8/20/13 and there are no progress notes which address Resident #29's significant weight loss on 9/14/13 of 27 lbs.. Any significant weight loss which is not expected should have triggered a reweigh to assure the accuracy of the weight and the physician should have been notified and steps taken to address the weight loss. She stated she is unable to explain why these steps were not completed as required on 9/14/13 but a 27 lbs. weight loss should have been a red flag. During an interview on 09/26/13 at 12:00 p.m., the Director of Nursing (DON) stated as part of the facility's Policy and Procedure dated 6/06/13 and revised 1/12 for Residents' Weight indicated any weekly or monthly weight change of 5 lbs. or greater will be automatically reweighed and reported to the nurse. She was unaware of Resident #29's 27 lbs. significant weight loss dated identified on 9/14/13. She stated the dietary department and the nursing department are responsible to monitor all resident's weights and follow the facility's policy and procedure at all times. She stated she was unaware until after survey intervention of Resident #29's significant weight loss of 27 lbs. She stated due to the facility staff not adhering to the facility's policy for Resident Weight Resident #29's 27 lbs. weight loss noted on 9/14/13 was not identified, a reweigh was not completed and the primary care physician was not notified of a significant weight loss. The potential of a continued and/or prolong significant weight loss due to the lack of coordination of care between the Nursing Department and the Dietary Department was not identified on 9/14/13 when the nursing department recorded Resident #29's weight as 113 lbs. a 27 lbs. (19.2%) which is an significant weight loss. Due to the facility not identifying a significant weight loss approaches/interventions required to resolve the weight loss were not started until after surveyor intervention on 9/24/13. The reweigh obtained on 9/24/13 of 119.4 lbs. confirms the significant weight loss for Resident #29. 4. Resident # 155 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident receives Hemo-[MEDICAL TREATMENT] treatment at a [MEDICAL TREATMENT] center 3 times a week. The facility has a notebook for written communication between the facility and the [MEDICAL TREATMENT] center, which is sent with the resident every time she is transported from the facility to the [MEDICAL TREATMENT] center. This Communication Book contains pertinent information about the resident, and informs the [MEDICAL TREATMENT] center of any new issues or changes in the resident condition, when not attended [MEDICAL TREATMENT]. The communication book is utilized to send documented information back to the facility when the resident's Hemo-[MEDICAL TREATMENT] treatment is completed. Review of the [MEDICAL TREATMENT] Communication book documenting that on several occasions the [MEDICAL TREATMENT] center had requested the facility to send the resident monthly medication list. This is an essential part of all [MEDICAL TREATMENT] patient monthly regimes, in order for the [MEDICAL TREATMENT] center to be aware of changes in medication, to include new medications, or dose changes of a medication. As a medication change may affect the Hemo-[MEDICAL TREATMENT] treatment. Review of the Communication book noting that over a 5 month period the medication list for Resident #155 was not given to the [MEDICAL TREATMENT] center. The list of medication sent from the [MEDICAL TREATMENT] center to the facility was not reviewed and sent back to the [MEDICAL TREATMENT] center as well. [MEDICAL TREATMENT] center document: *9/23/13 in bold letters, and Highlighted in Yellow to provide medication list. Have requested this list 10 times. *9/25/13 "Please complete medication review per instruction." [MEDICAL TREATMENT] center is requesting the unit manager to call the [MEDICAL TREATMENT] center. *6/18/13 "Enclose medication list and return to [MEDICAL TREATMENT]." *6/14/13 "Please return corrected monthly med list" Faxed on 6/10/2013 see front of chart. *6/10/13 "Please correct, sign and return monthly med list also fax a copy." During an interview on 09/26/13 at 10:15 a.m., the Nurse Manager (NM) of Dolphin Cove was asked who is responsible for ensuring the medication list is sent to [MEDICAL TREATMENT]. The NM replied the nurse in charge of the resident's care. The NM went on to say she did send a medication list to the [MEDICAL TREATMENT] center in April of this year. The NM was then asked about the going request in the communication book for the medication list. The NM than said she guess the nurse in charge of Resident #155 is not sending the medication list, but should be sending it. 5. Resident #272 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #272 has an underlying [DIAGNOSES REDACTED]. Resident #272 was ordered by the physician on 07/26/2013 to receive a renal diet. Review of the nutritional assessment reveals the following: "Resident on a no added soft diet (NSA). Missing teeth per observation, no difficulty with chewing or swallowing even though the resident had missing teeth. Usual Body weight (UBW) 140 lbs. (pounds) Current weight 143 lbs. Appetite fair; consuming approximately 50% of meals. Resident reports that he consumes most meals. Resident prefers to eat in his room. Resident refused to be weighed upon admission. Will attempt to get another weight. Resident is 72 inches tall usual weight 190 lb. IBW (Ideal Body Weight). The section with the question recent weight changes revealed no answer." Assessment of weights included the following: Resident recorded weight on 8/1/2012 was 162 pounds (lbs.) Resident recorded weight on 08/05/2013 was 160 lbs. Resident recorded weight on 8/12/2013 was 172 lbs. Resident recorded weight on 9/01/2013 was 200 lbs. Residents recorded weight on 9/09/2013 was 171 lbs. The resident had increased weight, as well as decreasing weight of 16.28% in a period of less than a month. There was no documentation on the fluctuation of the significant weight gain/weight loss. There were no weights recorded on the resident after 09/09/13, until surveyor interview, when a weight was obtained on 09/26/12. The recorded weight at this time was 153.6 lb., an unintended weight loss of 10.2% in a 2 week period. The comprehensive care plan for Resident #272 for Nutritional Risk, dated 06/13/13, documented: At nutritional risk due to Diagnosis; the care plan fails to include the Diagnosis. The care plan lists the resident weight at 170 lb, to include the usual body weight of 170 lb. Demonstrating no weight difference. The goal for the Nutrition Risk indicates the resident will maintain weight within 1-2% through 10/25/13. Approaches/Intervention included to TV room for all meals. Resident #272 prefers to eat in his room. The interventions do not include Resident #272's significant and drastic weight fluctuations in the short period of time. The interventions document that on 8/09/13, a 3 day calorie count will be done on the resident. There was no documentation that a calorie count on the resident occurred. During an observation on 09/26/13 at 3:00 p.m., the resident was lying in bed. Resident #272 was observed to be very frail. Resident #272's legs were exposed and observed to be skin on bone. Resident #272's face was drawn, and his eyes were sunken. 6. Resident #303 was reviewed due to listing as an unattended weight loss. Resident #303 was admitted to the facility on [DATE], initial weight obtained on 09/17/2012 was 143 pounds (lbs.) Resident was again weighed on 09/20/2013 and weight was 139 lb. indicating a 3% loss in a 3 day period. No other weights were recorded on the resident. The weight policy indicated a new resident being weighed weekly for a months period. On 9/26/2013 the resident was weighed. The recorded weight for Resident #303 on this date was 132 lbs., a 7.6% decrease in weight since admission. Review of the nutritional assessment for Resident #303 indicates that the resident is not very happy with the facility's food as he means the resident only eats food from "high end restaurants." Review of the comprehensive care plan, dated 9/20/2013, documented in the potential Problems section: "At nutritional risk due to diagnosis, but does not document the [DIAGNOSES REDACTED]. 143 lb. and usual body weight of 140 lb. Care plan fails to include the date the weight was recorded. In the section for goals "will maintain weight within 1-2% through 12/15/2013." The care plan does not documented the desired the goal weight. The approaches and interventions are not individualized and failed to accommodate the resident is a very selective eater. During an interview on 09/25/2013 at 9:15 a.m., the Registered Dietitian (RD) was asked about the resident's unintended weight loss. The RD said that she was only a part-time Dietitian at the facility, working one day a week, and was not that familiar with the residents.