Every finding on record at Inn at Sarasota Bay Club

Based on observation, interview and record review, the facility failed to ensure 3 (Residents #21, #25, and #180) of 5 residents reviewed received care in accordance with professional standards of practice. The findings included: 1. Review of the clinical record for Resident #21 revealed an admitted [DATE]. The physician's orders dated 7/27/24 included to weigh Resident #21 weekly on Tuesdays starting on 8/1/24 for a diagnosis of malnutrition. The physician's orders dated 7/27/24 also included to obtain the resident's vital signs (Temperature, pulse, respiration, blood pressure) and weight monthly. The clinical record lacked documentation the facility clarified the physician's orders related to the frequency of monitoring the resident's weight. On 8/14/24, review of the weight summary showed Resident #21's weight was obtained on 8/2/24. No other weight was documented after 8/2/24. The clinical record lacked documentation of the reason for the missing weekly weights. On 8/14/24 at 5:09 p.m., in an interview the DON verified the last weight for Resident #21 was obtained on 8/2/24. She said she personally entered the order for the weekly weight and staff should have obtained the weekly weight as ordered. On 8/15/24 at 8:35 a.m., in an interview the Administrator said the order for weekly weights on Tuesdays at 6:00 a.m., was on the Medication Administration Record (MAR) for August 2024. She said the night shift nurse should have obtained the weight or document in a progress note the reason why the physician's order for the weekly weight was not followed. 2. Review of the clinical record for Resident #25 revealed a physician's order dated 8/7/24 to apply a Lidoderm Patch 5% (local anesthetic) to the resident's right shoulder topically for pain. The patch was to be on for 12 hours and off for 12 hours. Review of the MARs for August 2024 revealed the patch was scheduled to be applied each day at 9:00 a.m., and removed each day at 9:00 p.m. The MAR showed the Licensed Nurse placed her initials on 8/12/24 at 9:00 p.m., indicating the Lidoderm patch was removed. On 8/13/24 at 8:17 a.m., LPN Staff C was observed preparing to administer medications to Resident #25, including a Lidoderm patch 5%. Observation of the resident's right shoulder revealed a Lidoderm patch dated 8/12/24. LPN Staff C said the Lidoderm patch applied on 8/12/24 at 9:00 a.m., was not removed on 8/12/24 at 9:00 p.m., as ordered. On 8/13/24 at 8:28 a.m., LPN Staff C documented in a progress note the previous Lidocaine (Lidoderm) patch not removed at hours of sleep. On 8/14/24 5:17 p.m., in an interview the Director of Nursing (DON) said staff should not sign off something they did not do. The nurse was not following the physician's order. On 8/15/24 at 8:50 a.m., the Administrator said the nurse did not follow the physician's orders for the Lidoderm Patch. 25618 3. On 8/12/24 review of Resident #180's medical record revealed she was admitted to the facility on [DATE] with a diagnosis of failure to thrive and on hospice services. Review of the Baseline Care Plan did not identify services which Hospice was to provide for Resident #180 in order to coordinate care between the facility and Hospice. On 8/13/24 at 1:19 p.m., in an interview with Resident #180's Hospice Aid K said today was her first time working with Resident #180. She said when she reviewed Resident #180's medical record she was unable to find Resident #180's Hospice Care Plan which would let her know what care she needed to provide for Resident #180. She said when she was unable to find Resident #180's Hospice Plan of Care she called the main office, they told her she should ask Resident #180's nurse what they needed her to do for Resident #180 today. She said she used each Hospice resident's Hospice Plan of Care to determine what care she needed to provide to the resident, so there is not a duplication of care between the Hospice aid and the facility staff. On 8/13/24 at 1:46 p.m., in an interview with Staff F, Resident #180's nurse said Resident #180 was admitted to the facility on [DATE] under Hospice services. She said Hospice provided a Hospice Plan of Care for each resident which they keep in the resident's medical record. She said the Hospice Plan of Care was used to coordinate the care between Hospice staff and facility staff to ensure there was no duplication of care and the Hospice resident received the best care possible. She confirmed after reviewing Resident #180's medical record, Resident #180's Hospice Care Plan was not in her medical record as required. On 8/13/24 at 1:59 p.m., in an interview with the Minimum Data Set (MDS) Coordinator, she confirmed Resident #180 was admitted to the facility on [DATE] under Hospice care. She said she did not do a full comprehensive plan of care until day 21 after a resident was admitted to the facility, and Resident #180's comprehensive care has not been completed as of today. She confirmed Resident 180's Baseline Care Plan did not identify services that Hospice would provide in order to coordinate care between the facility and Hospice. She said Hospice was required to put their plan of care in each Hospice resident's medical record when a resident has been admitted to Hospice services to ensure coordination of care between Hospice and the facility staff. The MDS Coordinator reviewed Resident's 180's medical record and confirmed it did not contain the required Hospice Plan of Care and/or Hospice staff visit weekly documentation of the care they provided Resident #180 since her admission to the facility 7/24/24. On 8/15/24 at 11:00 a.m., in an interview with the Director of Nursing (DON), she said Hospice did not provide the facility with Resident #180's Hospice Plan of Care which reflected the resident and family goals with interventions addressing the patient's needs, services to be provided by Hospice, and problems identified by the Hospice Interdisciplinary Group as noted in the Hospice contract.

Based on record review and resident and staff interview, the facility failed to ensure the facilities binding arbitration agreement explicitly informed the residents of their rights to have it explained to them in a manner that was understood, that the agreement could be rescinded within 30 calendar days of signing, that the agreement did not have to be signed or that it was not a condition of admission or continued care in the facility, and that the resident would be allowed to communicate with federal, state or local ombudsman for 3 (Resident #10, #12 and #330) of 13 resident reviewed who had signed the facility binding arbitration agreement. The findings included: On review of Facilities binding arbitration agreement, it did not indicate the following: Explained in a from and manner that the resident understood. That the agreement may be rescinded within 30 calendar days of signing. That the agreement was not required to be signed or that it was a condition of admission or continued care in the facility. The resident or their representative could still communicate with federal, state or local officials such as federal and state surveyors, health department or long-term care ombudsman. During an interview on 8/14/24 at 9:07 a.m., the administrator stated that all resident are presented with the binding arbitration agreement on admission. She said she believed that all 30 resident in the facility had signed the agreement. She said that resident are given an admission packet and a separate packet of contracts and are asked to sign all the items in the packet and the arbitration agreement is in that packet. Administrator said she was unaware if the admission person pointed out the arbitration agreement or discussed it to be sure the resident or representation understood what it was or if they were aware that they do not have to sign it as a condition for being admitted . During an interview on 8/14/24 at 10:34 a.m., the Community Liaison Staff stated that he had not ever explained to a resident or their representative about the Binding Arbitration agreement. He said he usually has a stack of things from the admission paperwork and contracts that need to be signed on admission or before admission and he lays it on the resident bedside table before they arrive at the facility. He said that he highlights all the lines that have to be signed. He said, I admit that I have not gone over the form with them or told them it is voluntary and they did not have to sign or that it was not contingent on admission or receiving care here. He acknowledged the language in the form or agreement did not indicate that the signing of the form was voluntary or that it would not keep them for admission or care if they did not sign it. He acknowledged that that the agreement did not indicate that they could rescind it within 30 days after signing the arbitration agreement if they wanted to. During a second interview on 8/14/24 at 10:49 a.m., the Administrator acknowledged that the binding Arbitration Agreement did not inform resident or their represented that they could rescind the agreement within 30 days if they wanted to do so. She verified the agreement did not indicate that the whole agreement was voluntary and was not contingent of admission or continuing care in the facility, and did not indicate if resident could contact state or local agency or ombudsman. or that the resident could have a neutral arbitrator that they agreed on or that they could choose the venue for the meeting if having one. During an interview on 8/14/24 at 2:01 p.m., Resident #10 stated she did remember the paperwork left for her to sign on admission but could not say that she even knew what a binding Arbitration agreement statement was. She said no one came in to explain anything or go over the binding arbitration agreement. she said she just thought it was things for admission. On review of Resident #10 medical record and Minimum Data Set (MDS) Assessment the resident has a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact and was her own responsible party. During an interview on 8/14/24 at 2:15 p.m., Resident #330 stated that she did remember the stack of papers to sign laying on her bedside table when she came in and she remembered the lines to be signed were highlighted in yellow. She just figured it was stuff for admission and did not even know what this was. She said no one came in and went over the paperwork with her. She said when she got there she had just been in the hospital for over two weeks and really could not read all those contracts and comprehend everything. Resident said she thinks someone should go over admission paperwork upon admission. On review of Resident #330 medical record and Minimum Data Set (MDS) Assessment the resident has a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact and is her own responsible party. During an interview on 8/15/24 at 9:50 a.m., Resident #12 said that he remembers the stack of contracts in his room that he was supposed to sign. he said that he signed them but he did not remember seeing the Binding Arbitration agreement. He said that each of the contracts had an (X) mark or highlighted line to sign. The resident said he signed the line and figured it was just admission stuff. He said that on admission he was tired and there was no staff to go over the items with him, so he just signed them. On review of Resident #12 medical record and Minimum Data Set (MDS) Assessment the resident has a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact and is her own responsible party.

Based on record review and resident and staff interview, the facility failed to ensure the facility's binding arbitration agreement signed by 3 (Residents #10, #12 and #330) of 13 resident reviewed explicitly informed residents of their rights to select a neutral arbitrator and participate in the select of venue for dispute resolution that both parties agreed upon. The findings included: Review of the clinical record for Residents #10, #12, and #330 revealed the residents signed the facility's binding agreement upon admission. On review of Facilities binding arbitration agreement, it did not indicate the following: 1. That the resident has a right to be included in selecting a neutral arbitrator agreed upon by both parties 2. That the resident has the right to be included in selecting a venue that is convenient to both parties. During an interview on 8/14/24 at 10:34 a.m., Community Liaison (admission person) stated that he has not ever explained to a resident or their representative about the Binding Arbitration agreement. He said he usually has a stack of things from the admission paperwork and contracts that need to be signed on admission or before admission and he lays it on the resident bedside table before they arrive at the facility. He said that he high lights all the lines that have to be sign. During a second interview on 8/14/24 at 10:49 a.m., Administrator verified that the binding Arbitration Agreement did not inform resident or their represented that the resident could have a neutral arbitrator that they agreed on or that they could choose the venue for the meeting if having one.

Based on observation, clinical record review, review of facility policy, resident and staff interviews, the facility failed to maintain a sanitary environment for 1 (Resident # 22) of 20 residents' rooms observed by failure to ensure the resident's room was free from foul odor. The findings included: The facility's policy and procedure for Housekeeping Expectations revealed to clean all resident bathrooms daily; Clean resident occupied rooms, a minimum of once weekly and as directed or deemed necessary; Clean vacated rooms as directed to prepare for admission ready. A complete room cleaning is performed, please speak with Admissions for any special cleaning requirements. The policy and procedure for the (Brand name) Urine Collection Systems (non-invasive urine collection system for women with urinary incontinence) with and effective date of 10/01/2018 stated, The facility does not provide any [Brand name] Collection systems, parts or supplies. Should a resident be clinically appropriate for the use of this type of urine collection system, the resident understands that they accept the responsibility of the cost and maintenance of the collection system machine, parts and supplies. Residents using a urine collection system such as a [Brand name], agree to hold The Inn harmless for any negative outcomes as a result of the use of this type of system and they are exercising their choice to use the system against the recommendation of The Inn. Information and understanding is provided to the resident prior to use of the urine collection system. Review of Resident #22's clinical record revealed an admitted [DATE]. Diagnoses included Osteoporosis. The Admission Minimum Data Set (MDS) Assessment (Federally mandated evaluation of resident's health needs and functional capabilities) with a target date of 3/6/24 noted Resident #22's cognition was intact with a Brief Interview for Mental Status Score of 14. The Assessment noted the resident was frequently incontinent of urine (inability to control urine from the bladder). On 8/12/24 at 10:00 a.m., Resident #22 was observed in her room. The room had a strong foul odor of urine. On 8/12/24 at 1:05 p.m., in an interview Resident #22 said she has been a resident at the facility for over a year. She said she was incontinent and used a (brand name) urine suction system at night (draws urine away from the body into a sealed collection canister). A urine suction machine was observed on the floor next to the resident's bed with urine in the collection canister. Resident #22's room remained with a strong foul odor of urine. On 8/13/24 at 11:00 a.m., Resident #22 was observed sitting in a lounge chair at her bedside. An empty urine collection canister was stored on the floor next to the resident's bed. The room remained with a strong foul odor of urine. On 8/13/24 at 3:10 p.m., in a joint interview Licensed Practical Nurse (LPN) Staff C and Registered Nurse (RN) Staff L said they were aware of the foul smell of urine in Resident #22's room. They said the facility tried multiple interventions such as daily baths, testing for urinary tract infection, cleaning the room, and washing with vinegar but nothing improved the foul smell of urine. Staff C and Staff L said Resident #22 was admitted with the urine collection system in February 2024 and the room had the foul urine smell ever since. They said the Administrator and the Director of Nursing (DON) were aware of the issue. On 8/14/24 at 10:57 a.m., in a telephone interview Resident #22's daughter said she visited her mother from out of State this past weekend. When asked about the strong foul smell of urine in the resident's room, she stated, I can smell it at times; her room has had the odor since admission in February. She stated, Mom does not know how to use her [brand name urine collection system] or if it is right. The daughter added, I do not think they know how to use it. The staff used to open her windows when the weather was cooler to air out the room. She said her mother has had the urine collection system since her admission to the facility. Review of the clinical record for Resident #22, including physician's orders, progress notes, care plans failed to show documentation of interventions to address the urine odor in the resident's room. The clinical record lacked documentation the facility provided information to Resident #22 about the use of the urine collection system and verified the resident's understanding prior to use of the system. On 8/14/24 at 2:15 p.m., in an interview Certified Nursing Assistant (CNA) Staff M said she noticed the urine smell in Resident #22's room since her admission in February. She said in the morning, she removes and discards the urine collection sponge before washing the resident's peri area. She cleans the urine collection canister with soap and hot water, rinses it with hot water, and wipes it with sanitary wipes. She also wipes the tubing with alcohol and allows the canister to air dry in a basin in the resident's shower. Staff M said the urine smell is so strong, she has to hold her breath. She has to send the resident's bedding and reusable pad to be laundered at least three times a week and sometimes daily. She reported it to the nurse. On 8/14/24 at 3:30 p.m., in an interview the DON said she was aware of the urine odor in Resident #22's room. She said the facility started to pay for the supplies for the urine collection system to replace them more frequently. The DON verified Resident #22's room had the foul smell of urine since her admission. She said the urine collection system was causing the odor but it was the resident's choice to use the machine. The DON said the interdisciplinary team had several discussion about the continuing issue with the smell of the resident's room. The DON was asked but was not able to provide documentation of interventions attempted to address the ongoing foul smell of urine in Resident #22's room.

Based on observation, interview and record review, the facility failed to develop a person-centered comprehensive care plan to meet the needs of 1 (Resident #11) of 3 residents reviewed for care plans. The findings included: Review of the clinical record for Resident #11 revealed an admitted [DATE]. The nursing progress note dated 3/5/24 at 4:43 p.m., noted Resident #11 had a cardiac pacemaker (implanted device to help control the heart's rhythm and rate). The physician's order summary documented the presence of a cardiac pacemaker. The Admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #11's cardiac diagnoses included abnormal heart rhythm. The MDS did not document the presence of the cardiac pacemaker in the active diagnoses, or cardiopulmonary procedures. The assessment noted Resident #11's cognition was intact with a Brief Interview for Mental Status score of 15. The comprehensive care plan initiated on 3/21/24 did not address the presence of the cardiac pacemaker with goals, interventions, precautions, and follow up as appropriate. On 8/14/24 at 4:06 p.m., in an interview the MDS coordinator verified the lack of care plan for the pacemaker. She said she was responsible to ensure care plans were in place. She said she should have developed a care plan with goals and interventions for the pacemaker but she missed it. On 8/14/24 at 5:25 p.m., in an interview the Director of Nursing (DON) said the normal process is to have a care plan for the pacemaker with interventions.

Based on observation, interview and record review, the facility failed to ensure the error rate was less than 5%. 25 opportunities were observed, two medication errors were identified resulting in a medication error rate of 8%. The findings included: 1. On 8/13/24 at 8:00 a.m., observed Registered Nurse (RN) Staff H administer 1 tablet of Vitamin B12 - 500 micrograms (mcg) to Resident #21. On 8/14/24 at 8:50 a.m., review of the physician's order summary for Resident #21 revealed a current order to give 2 tablets of Vitamin B12 - 500 mcg one time a day for B12 deficiency. On 8/14/24 at 9:01 a.m., review of the Medication Administration Record (MAR) for August 2024 revealed Staff H signed off she administered 2 tablets of Vitamin B12 500 mcg. on 8/13/24. On 8/14/24 at 11:33 a.m., during an interview with Staff H she said she thought Resident #21's order for B12 was for 1 tablet, so she gave her one tablet during the observation on 8/13/24. Staff H looked at the order on her computer screen and said, you're correct, the order is for two tablets; my error. Review of the physician's order summary and MAR for Resident #3 revealed an order with a start date of 8/1/24 for Cholecalciferol (Vitamin D) 400 units, 2 tablets one time a day for bone health. 2. On 8/13/24 at 8:57 a.m., Licensed Practical Nurse (LPN) Staff F was observed preparing several medications to administer to Resident #3, including Vitamin D. LPN Staff F placed two tablets of Vitamin D (400 units/each) from a stock bottle into the medication cup. LPN Staff F also placed one tablet of Vitamin D (400) units from a bubble pack into the medication cup. LPN Staff F walked into Resident #3's room to administer the medications to the resident, including 1200 units of Vitamin D instead of 800 units as per the physician's order. LPN Staff F was asked to stop the medication administration and verify the dosage of the Vitamin D she was about to administer to the resident. On 8/13/24 at approximately 9:15 a.m., LPN Staff F verified the physician's order was to administer Vitamin D (400 units) 2 tablets orally one time a day. LPN Staff F verified she placed Vitamin D (400 units) 3 tablets into the cup.

Based on observation and staff interview, the facility failed to ensure proper cleaning and sanitizing of equipment in the kitchen. The findings included: On 5/1/2023 at 9:15 a.m., during a tour of the kitchen conducted with the Certified Dietary Manager (CDM), the following observations were made: Ceiling vents with dust build-up. Photographic evidence obtained. Ice machine with dust build up on vent. Photographic evidence obtained. Stove area and flat cooktop were covered in grease and grime build up. Photographic evidence obtained. There was a container of melted butter sitting on flat cook top that was also covered in grease and grime. Photographic evidence obtained. At the time of the observation, the CDM said the melted butter gets changed before each meal. Oven and exhaust fan over oven, both had build-up of grease and grime. Photographic evidence obtained. At the time of the observation, the CDM said the staff take turns cleaning and would provide cleaning schedule. He said they had been shorthanded recently. On 5/4/2023 at 1:20 p.m., the Administrator reviewed the photographic evidence of the kitchen and said she would not eat a grilled cheese sandwich from the kitchen.

Based on observation, staff and resident interviews, and record review, the facility failed to attempt alternatives prior to the use of bed rails for 4 (Resident #4, #12, #142, and #192) of 6 residents reviewed for bed rails. The findings included: 1. On 5/1/2023 at 10:25 a.m., observation revealed Resident #4 asleep in the bed with bilateral upper bed rails in the up position. On 5/4/2023 at 11:30 a.m., observation revealed Resident #4 sitting up in bedside chair. Both bed rails were in the up position. Record review for Resident #4 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #4. 2. On 5/4/2023 at 11:40 a.m., observation revealed Resident #12 in her bed sleeping with bilateral upper bed rails in the up position. Record review for Resident #4 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #4. 3. On 5/1/2023 at 11:00 a.m., observation revealed bilateral bed rails in the up position on the bed of Resident #192. On 5/1/2023 at 11:10 a.m., in an interview, Resident #192, said he hates the side rails. He said he has had the side rails on his bed since admission and has not been given any reasons why he has the side rails or signed any consents and never had a choice. He also said he bent over to get something that had fallen underneath his bed and his head got caught under the side rail. Record review for Resident #192 revealed no evidence alternatives were attempted prior to use of bed rails on the bed of Resident #192. 41212 4. On 5/1/23 at 12:33 p.m., Resident #142 was observed in bed with bilateral upper rails in the up position. On 5/2/23 at 9:38 a.m., Resident #142 was observed his recliner, his bed was made with bilateral upper rails in the up position. On 5/3/23 at 3:05 p.m., Resident #142 was observed in bed sleeping with bilateral bed rails in the up position. rails in the up position. Record review of Resident #142 revealed no signed consent for use of the bed rails. On 5/4/23 at 12:20 p.m., the Director of Nursing confirmed there was no evidence the facility obtained informed consent for the use of bed rails for Resident #142 or attempted alternatives prior to the use of bed rails on the beds of Residents #4, 12 and 192.

Based on observation, staff and resident interviews and record reviews, the facility failed to ensure all drugs and biological were labeled or stored in a locked compartment for 2 (Resident #4 and #191) of 2 residents reviewed. The findings included: The facility policy Medication Storage in the Facility: ID3 Bedside Medication Storage with an effective date of March 2022 states bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. The manner of storage prevents access by other residents. 1. On 5/1/2023 at 10:25 a.m., observation revealed Resident #4 asleep in the bed. There was an uneaten breakfast tray sitting on the dresser with unlabeled pills in a medicine cup on the breakfast tray. *Photographic evidence obtained. On 5/1/2023 at 11:30 a.m., Licensed Practical Nurse (LPN) Staff B said Resident #4 was asleep during medication pass so she left her morning pills in the pill container in the resident's room so they would be there when she woke up because Resident #4 does things on her own time. 2. On 5/1/2023 at 10:00 a.m., observation revealed two bottles of eye drops on the bedside table of Resident #191. *Photographic evidence obtained. On 5/1/23 at approximately 10:02 a.m., Resident #191 said the eye drops were for his glaucoma. He said he was told by his doctor to bring them to the facility. He said he usually administers the drops himself, but sometimes the nurses do it. He said the drops stay in his room at all times. On 5/2/2023 at 12:10 p.m., the Director of Nursing said there are no residents in the facility at this time who self-administer medications. She said the process would be for the resident to have an assessment completed, obtain a physician order, then the medication would go into a locked container. She also said medications are not to be left in a resident's room. The nurse should stay with the resident until the medications have been taken.

Based on record review, and staff interview, the facility failed to obtain a Do Not Resuscitate Order (DNRO) in accordance with the advanced directives of 1 (Residents #31) of 1 resident reviewed for advance directives. The failure to have accurate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: The facility's policy for Advance Directives- revised procedure for processing an advance directive, dated [DATE]; noted Social Services Director (SSD) documents in the medical record a note that the advance directive document was received and details of the documents. SSD updates the log for DNR orders and delivers a copy of the advance directive to the charge nurse of on the unit where the resident resides. The charge nurse documents receipt of the advance directive by putting the order into the record and changing the Code status if appropriate. Director of Nursing/Assistant Director of Nursing follows up with the check of nursing orders in the medical record. Resident #31's clinical record revealed an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record also contained a DNRO form signed by the resident and physician on [DATE]. On [DATE] at 1:06 p.m., in an interview Registered Nurse (RN) Staff M confirmed Resident #31 had a current physicians order for CPR but his record also contained a signed DNRO form. RN Staff M said she would first look under the advance directive section of the chart for the DNRO form before starting CPR but acknowledged would want everything to match to avoid any confusion and would contact the resident's physician to get the code status order changed after she spoke to the resident to verify his wishes. In an interview on [DATE] at 12:48 p.m., the Social Services Director (SSD) said the admission paperwork for Resident #31 did not have any advance directives. She did visit with the resident on [DATE] and discussed his advance directive in regards to CPR but did not document the conversation about his wishes in the clinical record. The resident did express his desire to be a DNR, so she had the resident sign the DNRO form and sent it to the physician. She acknowledged when he first arrived would have been full code status but after the DNRO form was signed, the order should have been changed.

Based on observation and staff interview, the facility failed to store resident medications in a manner to prevent loss and efficacy of the medications for 3 of 3 medication carts. The findings included: The facility's Medication Storage In The Facility policy, ID1: Storage Of Medications, dated March 2019 stated, all medications dispensed by the pharmacy are stored in the container with the pharmacy label. Orally administered medications are kept separate from externally used medications and treatments such as ointments and creams. 1. On 10/5/21 at 9:14 a.m., observation of the Coral Unit medication cart revealed an open unlabeled plastic medication cup with 3 different medications inside the top drawer. Licensed Practical Nurse (LPN) Staff K was present during the observation and said she was the only nurse administering medications from the cart and did not put the pills there or know to which resident they belonged. LPN Staff K immediately removed the pills and disposed of them without attempting to identify the medications or if they were intended for a resident who did not receive them. There were other loose pills not in their original packaging and pill debris inside the second drawer of the cart. LPN Staff K confirmed this finding at the time of the observation. 2. On 10/5/21 at 10:01 a.m., observation of the Sand Dollar Unit medication cart revealed an open unlabeled jar of Vaseline being stored in the top drawer along with the medications. LPN Staff L was present during the observation and said the Vaseline had been for a treatment to Resident #29. LPN Staff L said the treatment had been discontinued and removed the jar from potential use. There were loose pills and pill debris inside the second drawer of the cart and to the right of the narcotic lock box. LPN Staff L confirmed this finding at the time of the observation. 3. On 10/5/21 at 10:23 a.m., observation of the Triton Unit medication cart revealed loose pills and pill debris in the second medication drawer. A white capsule and gel caplet were among the debris next to the narcotic lock box. Registered Nurse (RN) Staff M was present during the observation and confirmed this finding. **Photographic Evidence Obtained**

Based on observation, staff interview, and policy review the facility failed to properly disinfect therapy equipment between residents to prevent the spread of potential infection. This has the potential for cross contamination to other residents and staff. The findings included: On review of facility's Therapy Gym-Infection control Policy dated Dec/2019, the facility will follow an infection control procedure to prevent the spread of infection through the use of equipment in the therapy gym. Procedure: Each resident will be properly educated on proper hand hygiene and encouraged to wash hands and/or use hand sanitizer before leaving their room and /or before using equipment in the therapy gym. Therapy staff will properly sanitize equipment by using sanitation wipes appropriately on equipment between each resident use and again at the end of each day. On 12/9/19 at 11:16 a.m., residents were observed working out in therapy gym on the parallel bars and stationary bike. There was no sanitization of these pieces of equipment prior to resident starting the exercise. No sanitizer cloths were seen in the gym for wiping down equipment after each resident. After one resident move from one machine to another no cleaning was done of the machine just used or of the next piece of equipment used. On 12/10/19 at 11:22 a.m., residents were observed working out on various pieces of equipment in the therapy gym. No sanitizer cloth wipes were use prior to another resident coming into the gym to use the equipment. No equipment was seen being wipe off after use. On 12/10/19 at 3:08 p.m., in an interview the Therapy Manager said that the equipment was wiped down once a day at the end of the day. He said that during flu season they did the same. He said if a resident was obviously coughing and appears to be sick they would wipe down the machine. On 12/11/19 at 10:21 a.m., in interview the Assistant Director of Nursing/Infection Control Nurse (ADON), said that each piece of equipment was supposed to be wiped down between residents after each use and it should not be only at the end of the therapy day. She referred to the facility policy above and stated that this was not a new policy.

Based on record review and staff interview the facility failed to ensure a physician's order correctly matched the advance directive and failed to ensure the correct Durable Power of Attorney (DPOA) or Health Care Surrogate signed the Do Not Resuscitate (DNR) form for 2 (Residents #132 and #23) of 2 residents reviewed for Advance Directives. In addition, Resident #23 signed a consent for treatment after being declared incapable of making healthcare decisions. This has the potential for confusion if the situation arises that a decision be made relating to advance directives. The findings included: 1. On 12/11/19, record review of Resident #132 revealed a DNR form signed by the resident. Further review revealed a physician's order for Resident #132 to be a Full Code. There was no documented evidence the DNR was ever rescinded by Resident #132 or her representative. On 12/11/19 at approximately 2:30 p.m., the resident representative for Resident #132 confirmed the correct Advance Directive is DNR. On 12/11/19 at 1:50 p.m., in an interview the facility Director of Nursing (DON) confirmed the record for Resident #132 contained a valid DNR form and a physician's order for Full Code. She said the Full Code order was because the facility did not have the DNR form at the time of admission. She confirmed the physician's order should have been changed to DNR when they received the form. 2. On 12/11/19, record review of Resident #23 revealed a DPOA form appointing one of her daughters as the DPOA for healthcare when the resident cannot make health care decisions. Resident #23 was determined to lack the mental capacity to make health care decisions on 11/19/19. A DNR form was enacted on 11/23/19 and signed by a different daughter. In addition, the facility Consent for Treatment was signed by the Resident on 12/7/19, 18 days after being declared not competent to make health care decisions. On 12/11/19 at 1:53 p.m., in an interview the facility DON confirmed the DNR for Resident #23 was signed by a different daughter than the one listed on the DPOA forms and confirmed Resident #23 signed the Consent for Treatment form after being declared incapacitated.

Based on observation, owner's manual review, staff and resident interview, the facility failed to conduct regular inspections to assess the compatibility of the bed frame, mattress, and bed rails to identify any entrapment zones for 3 (Residents #230, #233, and #276) of 5 residents reviewed for accident hazards. The facility failed to ensure a mattress was not placed on Resident #276's bed before being inspected for safety concerns. The findings included: The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment for industry and Food and Drug Administration (FDA) staff, issued on (MONTH) 2006, identified the area between the bed rails and mattress and between the head or foot board and mattress as a risk for head entrapment. Recommendations included caution should be taken when using these products to ensure a tight fit of the mattress to the bed system. (source: https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM 9.pdf) The manufacturer published owner's manual for the (brand name) model 3500 bed (one type present in the facility) noted, Warnings 1. Failure to comply with all directions and warnings may result in injury or death. The warnings included The mattress must be properly sized to meet entrapment zone dimensional guidelines published by the FDA. and Possible entrapment hazard may occur if you do not use an appropriate mattress. The facility identified of the 41 occupied facility beds, 41 beds were equipped with bed side rails. 1. On 11/13/18 at 10:57 a.m., Resident #233 was observed lying in bed with quarter bed rails raised on both sides of the bed. 2. On 11/13/18 at 11:03 a.m., Resident #230 was observed lying in bed with a quarter bed rail raised on the right side of the bed. 3. On 11/14/18 at 12:13 p.m., Resident #276 was observed to have an alternating air pressure mattress on his bed with quarter bed rails in the raised position on both sides of the bed. There was a 3 inch to 4 inch gap observed between the edge of the mattress and the bed side rail. The mattress was also noted to have gaps of approximately 2 inches to 3 inches between the mattress and both the headboard/footboard. On 11/14/18 at 12:13 p.m., Resident #276 said the mattress was not the original mattress and a new one had been placed on his bed for comfort. 4. On 11/15/18 at 1:30 p.m., the Director of Plant Operations said there was no preventative maintenance program for the bed rails and beds to identify any potential entrapment zones. He observed Resident #276's bed and measured the mattress as 35 inches wide and the distance between the bed rails as 39 inches, creating a possible 4 inch gap. He also confirmed there was a 3 inch gap between the headboard and mattress; and a 2 inch gap between the footboard and mattress. He said this was one of the newer beds and the facility's air mattress did not fit the new bed frames. At 1:35 p.m., Resident #230's bed was was observed along with the Director of Plant Operations. A 3 inch to 4 inch gap was observed between the headboard and mattress. He said this bed was an older model but had several in use by residents. ***photos on file***

Based on record review, and staff, resident, and family interviews, the facility failed to provide the resident and/or representative with a written summary of the baseline care plan including a summary of current medications and physician orders [REDACTED].#230, #233, and #276) of 3 recently admitted residents reviewed for baseline care plans. The plan should include health and safety concerns to prevent decline or injury. Failure of this has the potential to cause confusion as to the expected care to be provided and could affect resident safety. The findings included: The facility's policy for Baseline Care Plans (undated) indicated the baseline care plan was to include instructions needed to provide effective and person-centered care of the resident. The baseline care plan must be developed within 48 hours of a resident's admission and include physician orders. 1. On 11/13/18 at 12:19 p.m., Resident #230 said she did not recall receiving a written summary of the baseline care plan to include physician orders [REDACTED]. Review of Resident #230's clinical record revealed an Admission and Baseline Care Plan, signed by the resident. There was no date as to when the plan was developed or who reviewed the information with the resident. The Baseline Care Plan did not include admission orders [REDACTED] 2. On 11/13/18 at 1:02 p.m., Resident #233 was approached for interview and noted to be confused in her responses. The resident's family member was present and said the resident had dementia with short-term memory loss, and he was her representative. The family member said he did not receive a copy of the baseline care plan or summary of physician orders [REDACTED]. Review of Resident #233's clinical record revealed an Admission and Baseline Care Plan, signed by the resident. There was no date as to when the plan was developed or who reviewed the information with the resident. The Baseline Care Plan did not include admission orders [REDACTED] 3. On 11/14/18 at 12:13 p.m., and 11/15/18 at 3:45 p.m., Resident #276 said he did not receive a written summary of the Baseline Care Plan with physician orders [REDACTED]. Review of Resident #276's clinical record revealed an Admission and Baseline Care Plan, signed by the resident. There was no date as to when the plan was developed or who reviewed the information with the resident. The Baseline Care Plan did not include admission orders [REDACTED] 4. On 11/15/18 at 9:29 a.m., Licensed Practical Nurse Staff A said the baseline care plans were completed on admission and reviewed by the admitting nurse who obtained the resident's signature. A written copy was not provided to the resident and no other information including admission orders [REDACTED].

Based on record review, resident and staff interview, the facility failed to ensure the resident's participation in the development of the care plan for 1(Resident #16) of 4 residents reviewed for development of care plans. This has the potential for the failure of coordination of care and risk the resident not understanding his care. The findings included: Record review for Resident #16 found he was admitted on [DATE]. The record showed an Interdisciplinary care plan was developed on 10/4/18. The record had a care conference signature sheet dated 10/4/18. The only signature on the sheet under staff attending column was that of Licensed Practical Nurse (LPN) Staff A. It was checked the resident attended. The form did not have the resident's signature. Review of the facility's policy and procedure for Care Plan Meetings (undated) revealed it did not have a policy number or an effective date. It did say that the purpose of the policy and procedure was to ensure the resident and their representatives were given the opportunity to participate in the development of their comprehensive care plan with the interdisciplinary team. On 11/13/18 at 4:16 p.m., Resident #16 said staff did not speak with him concerning his care. He said he had not been invited nor had he participated in the development of any care plan. He said he did not understand what his plan of care was. On 11/14/18 at 1:29 p.m., LPN Staff A said she was working as the Multiple Data System Coordinator. She acknowledged Resident #16 was not invited to a care plan meeting. This was because no care plan meeting was conducted for Resident #16. The resident did not participate in the development of the care plan dated 10/4/18.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure 3 (Resident's #230, #233, and #276) of 5 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 failed to have ongoing routine maintenance of the bed rails in accordance with manufacturer's recommendations. Failure to ensure bed rails are appropriate and safe puts residents at potential risk. The findings included: The facility's Policy and Procedure on Bed Side Rail Use (undated) indicated an evaluation/assessment is conducted by nursing on admission for resident appropriate use of quarter bed rails at the head of the resident bed. A consent for side bed rails to be obtained, signed by the resident or responsible party. The resident will be advised of the risks of bed side rails including the possible dangers associated with their use. 1. On 11/13/18 at 11:03 a.m., Resident #230 was observed lying in bed with a quarter bed rail raised on the right side of the bed. At 11:39 a.m., Resident #230 was observed sitting in her 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 she arrived and remembered them asking if she wanted them. She was not offered any alternative to the bed rails, just if she wanted them or not. She did sign something in regards to the rails and did use them sometimes. Review of Resident #230's clinical record revealed she was admitted [DATE]. A physician's orders [REDACTED]. A consent for the side rails was signed on 11/9/18 and an Evaluation for Side Rail Use was completed on 11/10/18. 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 11/13/18 at 10:57 a.m., Resident #233 was observed lying in bed with quarter bed rails raised on both sides of the bed. On 11/13/18 at 3:00 p.m., Resident #233 said she guessed the bed rails would be used to keep someone from falling out of bed but did not use them. The resident did not recall anyone talking to her about the bed rails. Review of Resident #230's clinical record revealed a physician's orders [REDACTED]. An Evaluation for Side Rail Use was completed on 10/31/18. There was no evidence of an assessment for the safe use of the rails, or other interventions attempted, prior to their use. On 11/14/18 at 11:53 a.m., Licensed Practical Nurse (LPN) Staff B said the bed rails were already on the bed when someone was admitted . LPN Staff B said when she was doing the initial paperwork, the resident was asked if they wanted to keep the rails, and she had them sign a consent. LPN Staff B said the bed rails help with mobility and were not confining so really there was no risk. LPN Staff B acknowledged she did not offer any alternatives to the bed rails prior to their use. 3. On 11/14/18 at 12:13 p.m., Resident #276 was observed sitting in his room. Quarter bed rails were observed in the raised position on both sides of the resident's bed. On 11/14/18 at 12:13 p.m., Resident #276 said the rails were already on the bed and he did not request them. He said no one talked to him about the rails, he just figured it was a hospital bed. The resident said sometimes he used them and did not recall signing any consent for them, but there was a lot of paperwork when he was first admitted . Review of Resident #276's clinical record revealed he was admitted [DATE] and a physician's orders [REDACTED]. The Evaluation for Side Rail Use was completed 11/3/18. There was no evidence of an assessment for the safe use of the rails, or other interventions attempted prior to their use. On 11/15/18 at 2:20 p.m., the Director of Nursing (DON) acknowledged the assessment for the bed rails was being done after the physician order [REDACTED]. On review, there was no documentation as to what alternatives were offered or attempted before installing the bed rails. The DON confirmed bed rails were already installed on the bed when a resident was admitted . On 11/15/18 at 1:30 p.m., the Director of Plant Operations said there was no preventative maintenance program for the bed rails and they had several different types of rails in use. He was not aware of the manufacturer's recommendations in regards to the rails and would have to do some research to obtain that information. Review of owner's manual for (brand name) model 3500 bed (one type used in the facility) revealed multiple warnings and described possible entrapment hazards. The manual included a section on periodic inspection.

Based on record review and staff interview the Pharmacist failed to report irregularities to the attending physician and the facility's Director of Nursing (DON) for the regulated use of as needed (PRN) [MEDICAL CONDITION] medications for 1 (Resident #11) of 5 residents reviewed for unnecessary medications. The regulation requires [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 Consultant Pharmacist dated 11/17 indicated: #1 - Each resident's drug regime must be reviewed at least once a month by a licensed pharmacist, #4 - PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days and cannot be continued without physician rationale and documentation, and # 5 - . If the physician wishes to continue an antipsychotic medication on a PRN basis then the attending physician or prescribing physician must first evaluate the resident and determine if a new order is warranted. Record review on 11/14/18 revealed Resident #11 was receiving [MEDICATION NAME] (a medication for anxiety) PRN since 9/3/17 (over a year). 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 8 times from 9/3/18 through 11/14/18. The pharmacy made no recommendations to the facility. Review of the monthly pharmacy reports for June, July, August, September, October, and (MONTH) (YEAR) revealed no recommendations were made to discontinue or to continue with documented rationale [MEDICATION NAME] after 14 days. On 11/15/18 at 5:00 p.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 rational for prolonged use and the order did not have a duration for use.

Based on record review and staff interview, the facility failed to ensure residents did not receive as needed (PRN) [MEDICAL CONDITION] medications for greater than 14 days without physician documentation of the rationale for 1 (Resident #11) of 5 residents reviewed for unnecessary medications. The findings included: The facility's Medication Monitoring Policy titled Psychoactive Drug Monitoring dated 11/17 indicated: #1 - Residents receive a psychoactive medication only if supporting documentation is provided in the medical record. Supporting documentation is kept on the Behavior Monitoring Form #2 - The continued need for the psychoactive medication it is reassessed regularly by the prescriber and the care planning team. If continuation is deemed necessary, this is indicated in the medical record . #3 - Non-pharmacological interventions and their effects are documented as a part of the medical record. Resident #11's clinical record revealed a physician's orders [REDACTED]. There was no specific duration for this PRN [MEDICAL CONDITION] medication. There was no documentation as to the rationale for the extended use past14 days. The Medication Administration Record [REDACTED]. These records indicated the [MEDICATION NAME] was administered a total of 8 times, 2 of which were administered on the same day. The physician's orders [REDACTED]. There was no documentation of non-pharmacological interventions attempted prior to administration of the [MEDICAL CONDITION] medication. On 11/15/18 at 4:41 p.m., the Director of Nursing (DON) confirmed the PRN [MEDICAL CONDITION] medication use exceeded 14 days for Resident #11. The DON acknowledged the lack of documentation as to the reason the medication was being given or what non-pharmacologic interventions were tried prior to administering the medication.

Based on observation, staff interview, Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement precautionary measures for 1 (Resident #230) of 1 resident sampled for isolation precautions. The facility failed to place Resident #230 on droplet precautions upon admission with under treatment for [REDACTED]. The findings included: CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) was reviewed: I.C.1.b. [MEDICAL CONDITION] (MDROs). In general MDROs are defined as microorganisms - predominantly bacteria - that are resistant to one or more classes of antimicrobial agents . Patient-to-patient transmission in healthcare settings . has been a major factor accounting for the increase in MDRO incidence and prevalence, . Preventing the emergence and transmission of these pathogens requires a comprehensive approach that includes administrative involvement and measures . application of infection control precautions during patient care, environmental measures . III.A.1.a. Respiratory hygiene/cough etiquette . Healthcare personnel are advised to observe Droplet Precautions (i.e., wear a mask) and hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection . III.B.2. Droplet Precautions. Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions . V.B.2.b. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis after considering infection risks to other patients in the room and available alternatives. (Source: https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html) On 11/15/18, review of the facility's policy and procedure Infection Prevention and Control Program (undated) included: All residents are assessed upon admission for any infections. Any infections are reported to the Director of Nursing . Any possible isolation needs are met at the time of determination of infection type . Any possible chance that other residents in the vicinity or staff could be subject to the spread of this infection is taken into consideration in determining the type and length of precaution used. On 11/14/18 at 2:20 p.m., observed Resident #230 sharing a room with Resident #231. There was no sign on the door or personal protective equipment indicating Resident #230 was on isolation precautions. On 11/15/18 record review included Resident #230's nursing admission progress note dated 11/9/18, describing Resident #230 was transferred from a local hospital with pneumonia and pleural effusion (fluid in the lung cavity). She was receiving intravenous [MEDICATION NAME] and Cefepine (antibiotics) for pneumonia and has a history [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus, a MDRO) pneumonia X2 before this admission. Resident #230 has periods of coughing producing clear sputum. The record showed no current results of sputum cultures to determine status of the disease. A review of Resident #230's physician progress notes [REDACTED]. A review of Resident #230's previous hospital history and physical dated 11/1/18 showed she had a previous history significant [MEDICAL CONDITION] pneumonia on two separate occasions. Resident #230 had a [MEDICATION NAME] in (MONTH) (YEAR) and 9/18/18, which [MEDICAL CONDITION]. The physician impression and plan included,[MEDICAL CONDITION] pneumonia and previous history [MEDICAL CONDITION] pneumonia persisting since (MONTH) that has failed two separate courses of [MEDICATION NAME]. On 11/14/18 at 2:45 p.m., the Director of Nursing (DON) and Infection Control Nurse said Resident #230 was admitted on [DATE] with pneumonia and effusion. The DON said Resident #230 was admitted while on intravenous (IV) antibiotic for pneumonia. She said if a resident is admitted on an antibiotic, nursing is to report it to her. She said nursing did not report Resident #230 [MEDICAL CONDITION] respiratory pneumonia. She stated, If I knew that, she would have been immediately placed into a private room, not have a roommate. She would have been placed on droplet precautions. She said the admission nurse documented the history [MEDICAL CONDITION] and still put her in room with (Resident #231), who was admitted with multiple medical conditions. She stated, The admission nurse should not have placed the two residents in the same room. Especially because of (Resident #230)'[MEDICAL CONDITION] and with (Resident #231) who is extremely compromised. On 11/15/18 5:09 p.m., Advanced Registered Nurse Practitioner Staff G stated, The resident (#230) with [MEDICAL CONDITION] pneumonia should have been admitted on droplet isolation and placed in a private room. The resident (#231) they put her with [MEDICAL CONDITION], gangrene of her toes, had an open wound on her leg, and had just come out of the ICU (intensive care unit). They never should have been put in the same room.