Every finding on record at Isle Healthcare & Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to maintain a safe environment for two (Resident #20 and #44) of six residents reviewed for smoking safety. Specifically, cigarette lighters were found in the residents' rooms, in violation of the facility's smoking policy, which prohibits residents from possessing smoking materials in their personal living spaces, placing residents at risk for fire and smoke related injuries. The findings include: 1. A review of Resident #20's medical record revealed an admitted [DATE] and diagnoses including atherosclerotic heart disease, chronic congestive heart failure, use of a cardiac pacemaker, major depressive disorder, cognitive/communication deficit, and anxiety disorder. Resident #20's smoking evaluation, dated 01/13/25, revealed that Resident #20 was permitted to smoke unsupervised in designated smoking areas. Resident must request smoking material from staff. (Photographic evidence obtained) Resident #20 was care planned on 05/06/25 with a focus area for Smoker/Tobacco User. The goal was to smoke safely at designated areas through the next review. Interventions included: Instruct resident about smoking/tobacco use risks and hazards and about smoking/tobacco use cessation aids that are available. Instruct resident about the facility's policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility's smoking policy. The resident can smoke unsupervised, and the resident's smoking supplies are stored in nurses' cart or nurses' station. (Photographic evidence obtained) A smoking observation and interview was conducted on 05/21/25 at 9:30 AM with Residents #20 and #44 while in the facility's designated smoking area. Resident #20 stated she was permitted to keep her smoking materials in her room. Resident #44 stated she kept her lighter and cigarettes in her red bag on her wheelchair in her room. An interview was conducted on 05/21/25 at 10:46 AM with Certified Nursing Assistant (CNA) C who stated residents were assessed for safe smoking during admission. Residents were then permitted to smoke independently. Smoking material was locked in the medication carts and residents were not permitted to keep cigarettes or lighters in their rooms. On 05/21/25 at 10:51 AM, a gray cigarette lighter was observed in Resident #20's room in a flower colored pouch. (Photographic evidence obtained) On 05/21/25 at 11:02 AM, Unit Manager A was accompanied to Resident #20's room. Two cigarette lighters and two packs of cigarettes were retrieved from Resident #20's room. 2. A record review conducted for Resident #44 revealed an admitted [DATE] and diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, cerebral palsy, Parkinsonism, cognitive/communication deficit, dementia - unspecified severity with other behavioral disturbance, major depressive disorder, and anxiety disorder. A smoking evaluation for Resident #44, dated 01/13/25, revealed that the resident was permitted to smoke unsupervised in designated smoking areas. Resident must request smoking material from staff. (Photographic evidence obtained) Resident #44 was care planned on 05/20/25 with a focus area for Smoker/Tobacco User. The goal was to smoke safely at the designated area thru next review. Interventions included: Instruct resident about smoking/tobacco use risks and hazards and about smoking/tobacco use cessation aids that are available. Instruct resident about the facility's policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility's smoking policy. The resident can smoke unsupervised and the resident's smoking supplies are stored in nurses' cart or nurses' station. (Photographic evidence obtained) On 05/21/25 at 11:11 AM, Licensed Practical Nurse (LPN) B was accompanied to Resident #44's room. LPN B retrieved a lighter and a pack of cigarettes in a red pouch from Residents #44's room. (Photographic evidence obtained) An interview was conducted on 05/21/25 at 11:49 AM with LPN B who stated she asked Resident #44 if she had her cigarettes and lighter in her room, and Resident #44 responded yes, in the red bag on her wheelchair. LPN B confirmed that smoking material was to be kept in the medication room and residents were not permitted to keep smoking material in their rooms. A review of the facility's policy titled Standards and Guidelines: Smoking Policy (dated 08/22), revealed that the resident may smoke independently; however, lighters/ignition materials must be returned to the nursing station or designated area and not remain on their person. (Photographic evidence obtained)

Based on a review of resident records, the facility's standards and guidelines, facility reports, hospital records, and interviews with staff, the facility failed to act in accordance with a resident's advance directives in accordance with her Do Not Resuscitate (DNR) status (the desire have cardiopulmonary resuscitation (CPR) withheld in the event of cardiac or respiratory arrest) after finding her unresponsive. This affected one (Resident #2) of four residents reviewed for advance directives. The facility's failure to review and honor Resident #2's DNR status prolonged her dying process, deprived her of a natural death, and likely resulted in severe pain and organ damage. Additionally, Resident #2 could not express her reaction to this event. Applying the reasonable person concept, Resident #2 would likely experience serious psychosocial harm by being resuscitated against her wishes. Resident #2 died at the hospital after removal of life support. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified at 3:35 p.m. on [DATE]. On February 20, 2025 at 6:17 a.m., Immediate Jeopardy began. On [DATE] at 4:50 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was ongoing as of the survey exit on [DATE]. The findings include: A closed electronic medical record (EMR) review revealed that Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses including alcohol dependency with withdrawal delirium (a potentially life-threatening condition after someone suddenly stops drinking alcohol, and resulting in confusion or hallucinations), and unspecified encephalopathy (a disorder of the brain that can cause confusion, disorientation and memory loss). A Discharge/Return Not Anticipated minimum data set (MDS) assessment, dated [DATE], revealed that Resident #2 had modified independence with daily decision making. She was dependent on staff for activities of daily living. Additional diagnoses included urinary tract infection, malnutrition, psychotic disorder, melena (black tarry stools as a result of bleeding in the upper gastrointestinal tract) and fatty liver. She had no condition or chronic disease that might result in a life expectancy of less than six months. Discharge planning was not occurring. Resident #2 was care planned on [DATE] for Advance Directives (AD)/Do not Resuscitate. Goal: If Resident #2's heart stopped or if she stopped breathing, CPR would not be initiated in honor of her DNR wishes, ongoing, through the next review date. Interventions included: Advise resident/representative to provide copies of any updated AD. Allow resident to discuss feelings about their AD. Advance Directives can be revoked or changed if the resident or representative changes their mind about the medical care they want delivered. Discuss AD with resident and/or appointed health care representative. For DNR status: Verify presence of physician's order for DNR. Notify physician of resident's wishes regarding life-prolonging procedures. Resident is DNR . (Photographic evidence obtained) Resident #2 had a physician's order dated [DATE] for Advance Directive: DNR. She had a corresponding yellow DNR form (DH 1896) that was signed by her friend/health care surrogate/proxy and the physician on [DATE]. The form was scanned into the electronic medical record on the day of execution, [DATE]. (Photographic evidence obtained) A physician's progress note dated [DATE] revealed that Resident #2 had chronic diastolic heart failure (the heart's left ventricle becomes stiff, resulting in reduced blood flow), hypertension, weakness, hepatic steatosis (fatty liver), polysubstance abuse, anxiety/depression and a thoracic vertebral fracture (cracking or breaking of bone). The practitioner noted that Unfortunately, this patient continues to decline. Family has requested a hospice consult. (Photographic evidence obtained) A nursing progress note authored by Registered Nurse (RN) A and dated [DATE] at 7:00 a.m., revealed that during medication administration, Resident #2 was found unresponsive around 6:15 a.m. She had been checked 20 to 30 minutes prior and was breathing and responsive. Once the resident was found unresponsive by RN A, a Code Blue (a universal term that signifies a medical emergency, specifically a cardiopulmonary arrest (cardiac or respiratory arrest), requiring immediate and comprehensive medical intervention) was called on the overhead speaker system. Emergency Medical Services (EMS) was called by RN A. The resident's chart was reviewed by RN A and a Full Code status was noted. The cart (crash cart - a rolling cart with drawers used for transporting life support equipment to the site of an emergency) was outside the resident's door when her status was checked, and CPR was initiated by staff members. Paperwork was gathered by RN A and then handed off to EMS by Licensed Practical Nurse (LPN) B. EMS arrived within a few minutes, then took over Resident #2's care. She was transferred via EMS to the hospital. (Photographic evidence obtained) RN A authored a follow-up nursing progress note on [DATE] at 7:15 a.m. It indicated that the hospital called RN A about Resident #2's code status and made her aware that the resident's status was DNR. It was then double-checked by RN A who discovered that Resident #2 did, in fact, have a DNR status. The Unit Manager was notified. A final nursing progress note, dated [DATE] at 4:04 p.m., revealed that Resident #2's friend came to pick up her personal belongings and notified the staff that Resident #2 had passed away with the chaplain and herself present. (Photographic evidence obtained) A review of facility documentation revealed that on [DATE], the Director of Nursing Services (DNS) authored a report, which noted that on admission, Resident #2 was a Full Code status. On [DATE], Resident #2 was deemed incapacitated, and a friend became her Health Care Surrogate (HCS). The HCS signed the DNR, and an order was received from the doctor to change her code status to DNR on [DATE]. On [DATE] at approximately 5:45 a.m., RN A went into Resident #2's room and noted that she was responsive and breathing. Then at 6:15 a.m., she reentered the room for medication administration and found the resident unresponsive. RN A notified staff, Code Blue was paged overhead, and EMS was called. The resident's code status was checked by RN A, and she indicated to the other nurses that Resident #2 was a Full Code. The nurses then began CPR and RN A went to print paperwork for EMS. EMS arrived within a few minutes, and they took over the care. At 7:15 a.m., the hospital called and spoke to RN A to inform her that Resident #2 was a DNR. RN A double-checked the medical record and realized that the resident was indeed, a DNR. She immediately notified the Unit Manager (UM), who notified the DNS. The DNS arrived at the facility and notified the Executive Director at 7:50 a.m. At 8:15 a.m., the UM notified the Doctor and the HCS of the events. Later that afternoon, the HCS came to the facility to pick up the resident's belongings and informed staff that Resident #2 had passed away in their church Chaplain's presence. After a complete and thorough investigation, the facility did find a deviation of practice by RN A. An interview was conducted with Certified Nursing Assistant (CNA) E on [DATE] at 1:10 p.m. She stated she had worked in the facility since [DATE] and recently received training in Code Blue responses. She stated if she found a resident unresponsive, she would let the nurse know and call Code Blue three times overhead with the location or room number. CNAs were not permitted to do CPR but could check the code status with a nurse. Code status for all residents could be found in the electronic medical records (EMR) or in the DNR book, which was behind each nurses' station. CNA E pulled up an unsampled resident's electronic Point of Care where the CNAs documented daily on each shift. The resident's code status was prominently displayed on the EMR's dashboard. CNA E explained that you must know the resident's code status before performing CPR. Even if the electronic records and internet were down, You go get the book. Licensed Practical Nurse (LPN) F stated in an interview on [DATE] at 1:20 p.m. that Advance Directives were obtained for each resident on admission. If a resident had a DNR, they requested the yellow DNR form. Additional yellow copies were made for the east and west wing DNR books, and one copy went to medical records to be scanned into the EMR. As soon as the order was entered, the code status would populate on the EMR dashboard for all to see. An interview was conducted with the DNS on [DATE] at 4:05 p.m. He explained that on the day of the event, RN A went into Resident #2's room and found her responsive. She returned to the room for medications 20 to 30 minutes later, and the resident was unresponsive. RN A called a code blue, looked in the chart and said she thought she read Full Code. The order for the code status was highlighted in a gray bar at the top of the EMR dashboard. RN A didn't explain how, just that she swore she saw Full Code. LPNs B and C went into the resident's room and initiated CPR. RN A called 911 and got the paperwork ready for the EMTs, who arrived quickly, took over and transported the resident to the hospital. RN A received a phone call from the hospital around 7:15 a.m. informing her that You realize this resident was a DNR. RN A reviewed the computer and verified that, indeed, was the order. She was pretty upset. At the time, one nurse was permitted to verify the code status. The HCS came and picked up Resident #2's belongings and advised staff that the resident had passed away the same day in the hospital. A review of the facility's standard and guideline titled Advance Directives (Implemented [DATE], Reviewed/Revised [DATE]), revealed: Standard: It will be the standard of this facility that the resident has the right to request, refuse, and/or discontinue treatment . and to formulate an advance directive and participate in advance care planning. Advance Directives/Advance Care Planning designations will be respected in accordance with state law and facility policy. Definitions: . Advance Directive means, according to 42 C.F.R. $489, 100, a written instruction, such as a healthcare surrogate, living will, Do Not Resuscitate and/or durable power of attorney for healthcare and/or financial decisions. Recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Some States also recognize documented oral instruction . 1. Prior to or upon admission of a resident to the facility, the Admission Department, Social Services, or designee will provide written information in a manner easily understood by the resident or resident representative about the right to refuse medical or surgical treatment and formulate an advanced directive . Staff will assist residents or resident representatives if they wish to formulate advance directives. . 5. Facility staff will provide assistance, if needed, if the resident/responsible party wishes to execute one or more directives. Facility staff will document in the medical record these discussions and any advance directives that the resident executes . . 13. Facility staff will identify, clarify, and periodically review, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. . 14. Facility staff will identify situations where health care decision-making is needed, such as a significant decline or improvement in the resident's condition. 15. Facility staff will document and communicate the resident's choices to the interdisciplinary team and to staff responsible for the resident's care . . 18. In the event that the resident does not have previously developed advance directives or declines to create and participate in development of advance directives/advance care planning, the resident will be considered a full code until validation of the resident/representative wishes otherwise. 19. The Director of Nursing Services, Social Services, members of the nursing staff, or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 20. The Nurse or Nurse Supervisor should inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. (Photographic evidence obtained) A review of the facility Standards and Guidelines (S and G) for Code Blue and CPR (Implemented [DATE], reviewed/revised [DATE] and [DATE]) revealed: Standard: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of cardiopulmonary resuscitation (CPR) . in accordance with related physician's orders, such as DNRs, and the resident's advance directives. In the event that a resident experiences cardiac arrest (cessation of pulse and/or respirations), CPR will be provided in the absence of a valid physician's order for Do Not Resuscitate (DNR), a State of Florida DNR Order Form (DH 1896), or documented verbal wishes indicating otherwise, which are pending physician order . Definitions: . Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased . . Do Not Resuscitate (DNR) Order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record should show evidence of documented discussions leading to a DNR order. Guideline: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. Remain with the resident. 2. Call out for help. 3. Licensed Nurse will assume command of the scene and will direct other personnel in the effort. 4. Direct a staff member to announce the emergency per facility protocol (i.e. Code Blue & Room Number three times) and direct staff to bring Emergency Equipment Cart and AED Machine (automated external defibrillator, a portable device used to treat sudden cardiac arrest) to the scene. 5. A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the EHR (electronic health record), eMAR (electronic medication administration record) or point of care kiosk . 6. (*ln the event the EHR is unavailable, code status may by validated using a secondary check of the code binder via presence of physician order and/or a signed State of Florida Do Not Resuscitate Order (DH form 1896), and/or documented verbal wishes of resident/resident representative indicating code status preference. A telephone order of DNR status is validated and/or if obvious clinical signs of irreversible death as defined by the AHA (American Heart Association) are present, do not initiate CPR. If CPR/Code Status is undefined (absence of DNR, Advance Directive, documented verbal wishes of resident /representative or physician order), CPR will be initiated and will continue until the arrival of EMS or until discovery of a valid DNR (Do Not Resuscitate). (Photographic evidence obtained) A review of hospital records for Resident #2's admission on [DATE], revealed that on [DATE], Resident #2 was transported to the emergency department (ED) by EMS. She had already been intubated (a tube placed into the mouth or nose then down into the trachea/windpipe to keep the airway open) by the emergency medical technicians (EMTs) and received CPR. She had also been defibrillated (the delivery of an electrical current to stop the heart from beating irregularly and start a normal rhythm). Resident #2 was unresponsive, on a mechanical ventilator (a device that assists or replaces breathing for a person who is unable to breathe adequately on their own) and Norepinephrine (a drug that increases the heart rate, blood pressure and breathing rate), and intravenous fluids were administered as well as the antibiotic, Cefepime. Resident #2's heart rate was noted with regular rhythm with tachycardia (a rapid heart rate that is not proportionate to movement or activity), and there was decreased air movement. The principal problems included dyspnea (shortness of breath), acute, severe, uncontrolled, and worsening secondary to cardiac arrest. Her prognosis was grim. The record indicated that Resident #2 had a return of spontaneous circulation after CPR was administered, then went back into V-tach (a problem with the heart's electrical impulses that results in the lower chambers of the heart beating rapidly). She was defibrillated (the delivery of an electrical current to stop the heart from beating irregularly and start a normal rhythm) once and received two doses of Epinephrine (Adrenalin, a medication that acts as part of the body's fight-or-flight response to stress). While in the ED, the HCS was called and reported to the hospital staff that Resident #2 was a DNR; the forms were at the nursing home and signed two days ago. The hospital staff called the nursing home and they condirmed that they had the forms. The plan was to get Resident #2 into the intensive care unit and begin comfort measures (alleviating suffering in patients nearing the end of life). She was extubated (the breathing tube was removed) at 2:22 p.m. and passed away at 2:40 p.m. (Photographic evidence obtained)

Based on resident and staff interviews, record review, and a review of facility policies and procedures, the facility failed to ensure that individual financial records were available through quarterly statements and upon request for 56 of 56 residents with personal funds accounts in the facility. Quarterly statements were not provided to the residents since at least May 2024. The findings include: During an interview with Resident #1 on 3/14/25 at 12:13 p.m., she stated she did not know what her personal funds account balance was, and she was unaware that the facility was to provide her with statements of her account. A review of Resident #1's medical record revealed an admitted [DATE]. A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 12/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. She was documented with adequate vision and hearing, clear speech, she was understood, and she understood others. On 3/14/25 at 12:24 p.m., the Business Office Manager (BOM) was asked for a list of residents with personal funds accounts. At 1:35 p.m. a list was received and reviewed, revealing that as of 3/14/25, there were 56 residents in the facility who had personal funds accounts. Six of 56 resident accounts had balances exceeding $2000.00, which is the Social Security Income (SSI) resource limit for Medicaid eligibility in Florida On 3/14/25 at 1:35 p.m., an interview was conducted with the BOM. She stated she had been the BOM at the facility since May 2024 and the Assistant BOM from 2023 through May 2024. She further stated she was responsible for maintaining the residents' accounts. The statements were to be provided to the residents quarterly but had not been provided since she had become the BOM in May 2024. The facility utilized a third-party billing company who assisted with the statements. The BOM stated resident accounts were monitored by the facility's Regional BOM and the third-party billing company. When asked, the BOM stated she was unsure of how residents were notified of times they could access their funds. She stated none of the residents with more than $2000.00 in their accounts had been notified of their balances. (If residents exceed their SSI resource limit, they may lose their eligibilityfor Medicaid or SSI.) She and the Regional BOM were working together to reconcile resident accounts so that all balances matched and residents with accounts received notices. She did not provide a timeframe for when the process started or a possible resolution date. On 3/14/25 at 4:29 p.m., an interview was conducted with the Regional BOM. She confirmed that residents had not been receiving their quarterly account statements and stated, They haven't gotten them, but they will. It's a part of what we've been working on. Residents will begin to receive letters when they get close to $2000.00 in their accounts. The facility's policy: Resident Trust Fund Notification Authorization and Beneficiary Designation (Undated) was reviewed and revealed: The resident may see records of his/her account through quarterly statements and upon request. (Photographic evidence obtained)

Based on resident and staff interviews and record review, the facility failed to notify each resident that received Medicaid benefits when the amount in the resident's account reached $200.00 less than the Social Security Income (SSI) resource limit for one person; and that if the amount in the account, in addition to the value of the resident's other nonexempt resources, reached the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected six of 56 residents with personal funds accounts in the facility. The findings include: During an interview with Resident #1 on 3/14/25 at 12:13 p.m., she stated she did not know what her personal funds account balance was, and she was unaware that the facility was to provide her with statements of her account. On 3/14/25 at 12:24 p.m., the Business Office Manager (BOM) was asked for a list of residents with personal funds accounts. At 1:35 p.m. a list was received and reviewed, revealing that as of 3/14/25, there were 56 residents in the facility who had personal funds accounts. Six of 56 resident accounts had balances exceeding $2000.00, which is the Social Security Income (SSI) resource limit for Medicaid eligibility in Florida On 3/14/25 at 1:35 p.m., an interview was conducted with the BOM. She stated she had been the BOM at the facility since May 2024 and the Assistant BOM from 2023 through May 2024. She further stated she was responsible for maintaining the residents' accounts, and none of the residents with more than $2000.00 in their accounts had been notified of their balances. She and the Regional BOM were working together to reconcile resident accounts so that all balances matched and residents with accounts received notices. She did not provide a timeframe for when the process started or a possible resolution date. On 3/14/25 at 4:29 p.m., an interview was conducted with the Regional BOM. She stated, Residents will begin to receive letters when they get close to $2000.00 in their accounts.

Based on observations, interviews, and record review, the facility failed to maintain appropriate infection control practices during medication administration for two (Residents #51 and #15) of five residents observed during medication administration from a total of 27 residents in the sample. Failure to adhere to infection control and prevention protocol increases the risk of transmitting communicable diseases and infection. The findings include: During a medication administration observation on 6/27/23 at 4:32 p.m., Licensed Practical Nurse (LPN) A was observed outside of room [ROOM NUMBER]. She reviewed the Medication Administration Record (MAR) for Resident #51. She performed hand hygiene with hand sanitizer. She then obtained a lancet and an alcohol wipe. She proceeded to the resident's room and obtained a glucometer and glucose monitoring test strips that were stored in the drawer inside the resident's room. She removed the glucometer and a container of test strips from the zip lock bag. She removed one test trip from the container and inserted it in the glucometer. She then placed the glucometer on the resident's bed. LPN A did not don gloves but proceeded to clean the resident's left middle finger with an alcohol wipe. She obtained a blood sample, holding the lancet with her bare hand. After obtaining the sample, she used the soiled alcohol wipe that was used for cleaning the resident's finger prior to the procedure, to clean the resident's finger after the procedure. LPN A then went to the medication cart, removed a sani-wipe (disinfectant wipe) from the bottom drawer and cleaned the glucometer. She placed it on the resident's bedside table, which had not been cleaned, and left it to air dry. She washed her hands in the resident's bathroom, reviewed the MAR for the insulin sliding scale, and obtained the insulin pen for Resident #51. She did not don gloves. She injected four units of Novolog insulin in Resident #51's left lower abdomen. She performed hand hygiene with hand sanitizer. She did not don gloves. She obtained artificial tears for Resident #51 and instilled one drop on each eye. She documented both medications as given, then performed hand hygiene. During another observation on 6/27/23 at 4:32 p.m., LPN A was observed preparing medication for Resident #15. She crushed the medication and mixed it with apple sauce. Upon entering the resident's room, she donned gloves then called another staff member to help her adjust the resident in the bed. After adjusting the resident in bed, she used the same gloved hand to administer the medication in the resident's mouth. In an interview on 6/27/30 at 4:58 p.m., LPN A was asked to evaluate herself. She said, I think I did good and followed all the steps I was taught in school. She was asked to explain the process for using the Accucheck device (blood glucose monitor). She explained the process the same way she had performed the task. When asked if she was supposed to use a barrier or don gloves during the process, she hesitated, then said, but I performed hand hygiene. LPN A could not correctly state the proper way to use the Accucheck device, and could not identify that she should have donned gloves for the task. She was asked if she was familiar with the facility's policy and procedure for this task, and she stated she was not sure, then added that she would consult the Director of Nursing (DON). On 6/28/23 at 11:30 a.m., the DON was asked to describe the facility's process for medication administration competencies. He stated the competencies were conducted upon hire and annually. He was informed of the observation made during medication administration. He confirmed that there was a breach in infection control standards and added that education and competencies had already been initiated and they would be provided to all nurses. When he was asked about the glucose monitoring/Accucheck policy and procedure, he stated the facility did not have a specific procedure for glucose monitoring. The facility utilized the medication administration and infection control policies. A review of the facility's policy and procedure titled Medication Administration (Revised on 1/01/2021), revealed guidelines that must be followed during medication administration. The guidelines included, but were not limited to the following: Follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.). The facility's Infection Prevention and Control Program policy (revised 01/01/2021) read, The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infection. Guidelines indicated that standards and transmission based precautions were to be followed to prevent the spread of infections (selection and use of PPE). Hand hygiene guidelines were to be followed by staff involved in direct resident contact. According to the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html. (Accessed on 07/05/2023): Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings include but is not limited to: Wearing gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids; Changing gloves between patient contacts. Changing gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other persons (CDC, 2011).

Based on observations, interviews, medical record review, and policy and procedure review, the facility failed to assist with making podiatry appointments and ensuring appropriate foot care was provided for one (Resident #36) of 27 sampled residents. Failure to provide appropriate foot care can result in ingrown toenails, fungal infections, skin infections, and can potentially impact the resident's dignity and sense of self-worth. The findings include: During an interview with Resident #36 on 06/26/2023 at 1:20 PM, his toenails were observed to be untrimmed with dark matter growing under the nail on both large toes. He stated, They used to cut them, but it hasn't been done in a while. He stated he would like to have them cut. He explained that he had suffered a stroke and could not walk anymore. He had muscle wasting in his legs, and his feet were turned inward toward one another. During an interview with Resident #36 on 06/27/2023 at 5:20 PM, his toenails were not trimmed as was observed on 06/26/2023 at 1:20 PM. He again stated they needed to be trimmed. During an interview with Resident #36 on 06/28/2023 at 2:20 PM his toenails were not trimmed was was observed on 06/26/2023 and 06/27/2023 at 1:20 PM and 5:20 PM respectively. He again stated they need to be trimmed. During an interview with Resident #36 on 06/29/2023 at 12:33 PM he stated he still needed his toenails trimmed. He cut his own fingernails and could still do that. I can't reach my toenails or else I could probably do it myself. During an interview with Resident #36 on 06/29/2023 at 3:08 PM, he was asked how long it had been since his toenails were trimmed. He stated he could not remember exactly when he last had them trimmed. A man used to come and cut my toenails, but then he started using a sanding machine to file them down and my legs would shake all over. It was painful. He again stated he needed to have his toenails trimmed but did not know why the man stopped coming. (Photographic evidence obtained) A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 04/29/2023, revealed the resident was assessed as having diagnoses including type II diabetes mellitus, hemiplegia or hemiparesis, rash and other nonspecific skin eruption, localized edema, muscle weakness, and cerebrovascular disease. He was usually understood by others, usually understood others, had clear speech, adequate hearing and vision. His Brief Interview for Mental Status (BIMS) score was 15 out of a possible 15 points, indicating no cognitive impairment. The resident did not walk during the assessment period and required extensive assistance of one staff member for personal hygiene. (Copy obtained) A review of the resident's care plan, dated 11/30/2021, revealed a focus area for Assistance with Activities of Daily Living (ADL)/Self-Care Performance Deficit related to cerebrovascular accident (CVA - stroke) with right-sided hemiplegia (Severe or complete loss of strength or paralysis on one side of the body). Resident currently requires assistance with activities of daily living. (Copy obtained) A review of the resident's physician's orders revealed an active order for ophthalmology, podiatry, and dental services as needed with a start date of 10/21/2020. (Photographic evidence obtained) A review of the contracted podiatry provider evaluation note, dated 04/03/2023, revealed that the resident was seen on 04/03/2023. The note read: Without debridement and treatment of mycotic nails, further complication and marked limitation of ambulation/or a secondary infection is likely to occur. Patient to be seen: 2 months. (Copy obtained) During an interview with the Director of Nursing (DON) on 06/29/2023 at 11:00 AM, he stated he was unaware that Resident #36 needed to be on the list for the contracted podiatry provider to have his toenails trimmed. He explained that the staff member who was responsible for scheduling appointments for the contracted podiatry provider was recently terminated from employment. The DON assumed that role in the interim until the facility could get someone hired to fill that position permanently. He stated he would look to see when the resident was last seen. During a second interview with the DON on 06/29/2023 at 2:33 PM, he provided the documentation from the contracted podiatry provider and stated the last time Resident #36 was seen by the provider was on 04/03/2023. He confirmed that Resident #36 was a diabetic and foot care was important. He confirmed that the facility nursing staff did not trim the toenails of the diabetic residents. That was why they contracted with the podiatry provider. He confirmed that Resident #36 needed to have his toenails trimmed and he should have been seen by June 3, 2023, which was two months after his last appointment. A review of the facility's policy and procedure for Foot Care (dated 01/15/2021), revealed: Standard: It will be the standard of this facility to ensure that residents receive proper treatment and care to maintain mobility and good foot health. 2. Provide foot care and treatments as needed/ordered by the physician. 3. Staff will monitor the resident for changes in foot condition and notify the nurse and/or physician as is appropriate. 5. If necessary, staff will assist the resident in making appointments with a qualified person, such as the podiatrist, and arrange for transportation to and from such appointments. (Copy obtained)

Based on observations and interviews, the facility failed to store and serve food in accordance with professional standards for food service safety. This failure could lead to the spread of foodborne illness, and potentially impacted every resident who consumed food from the facility's kitchen. The findings include: On 10/11/21 at 1:30 p.m., an observation of the dry storage closet was made. A scoop was discovered inside a plastic container of sugar. A flour container had plastic wrap over it, but it was not securely covered. A plastic bin labeled bread crumbs was open as well. In the area of the dry storage closet where loaves of bread and bread products were kept, bags were observed without dates on them, not securely closed, and a bag of muffins that was wide open, was also observed. Observations were made of two air vents in the kitchen that had matter hanging from them appearing to be rust and dust debris. At the time of the observations, the traveling Dietary Manager stated a work order had been placed to clean and replace the vents. (Photographic evidence obtained) On 10/11/21 at 1:45 p.m., a resident wearing socks but no shoes walked into the kitchen. He was observed standing next to a rack of plastic dome covers in a location were he would have had to have passed the beverage preparation area, refrigerator, sink, and other kitchen equipment in order to get to. On 10/13/21 at 11:30 a.m., the Culinary Director was interviewed about non-kitchen staff and residents walking into the kitchen. He stated there was a line of tape at the door jamb that residents were not supposed to cross. The Culinary Director pointed out the tape line that non-kitchen staff and residents were not supposed to cross. The tape was faded. The doorway he pointed out was centrally located inside of the kitchen, and from this doorway, the entire trayline service area and stove could be observed. Nursing staff and residents without hairnets were able to walk through the beverage preparation area that included the coffee maker, an ice machine, and the refrigerator. There was no supply of hairnets at this door. On 10/14/21 at 2:00 p.m., an interview was conducted with the Maintenance Director. He reported that no work orders had been received from the kitchen for cleaning the vents, but there was an order to replace the vents. (Photographic evidence obtained) On 10/13/21 at 10:58 a.m., observations were made of dietary staff prepping for the trayline lunch service. At this time, Dietary Staff Member Y was wearing gloves. She was observed touching the top of the garbage can to open it further before disposing of an item. She proceeded to continue with lunch service without changing her gloves. She was observed washing a trayline item serving spoon in the sink and picking up a hand full of plates and set them down on the trayline counter with the same gloves. She was observed holding dishes while putting food on the plate again with same gloves. She did not replace her gloves or wash her hands during these events. Cook Z was also observed in the kitchen at this time. He was seen discarding his gloves and replacing them with new gloves, but he did not wash his hands between glove changes. An Interview was conducted with the Culinary Director on 10/13/21 at 11:30 a.m. He stated the kitchen staff were expected to wash their hands between glove changes. .

Based on record review, observations and interviews, the facility failed to ensure that one (Resident #141) of one resident reviewed for Peripherally Inserted Central Catheter (PICC) dressing changes, from a total of 34 residents in the sample, received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure an order was written for PICC dressing changes upon the resident's admission, and failed to change the dressing per its own policy. The findings include: A review of Resident #141's medical record revealed she was admitted to the facility from an acute-care hospital on 09/22/21 with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was receiving an antibiotic that required a PICC. No physician's order for a PICC dressing change was located in the resident's record. On 10/11/21 at 11:30 AM, Resident #141 was observed in bed. She had a PICC line located in her left upper arm. The dressing was dated 09/22/21 at 9:05 AM. On 10/11/21 at 11:35 AM, an interview was conducted with Licensed Practical Nurse (LPN) A. She confirmed that the PICC dressing should be changed every seven days; should have been changed on 09/29/21, and that a physician's order should have been written for the PICC dressing change upon Resident #141's admission. On 10/12/21 at 10:00 AM, Resident #141's PICC dressing was observed. The dressing was dated 10/12/21. On 10/12/21 at 10:05 AM, an interview was conducted with LPN A. She stated she requested the PICC dressing change order from the physician and then changed the PICC dressing. A review of the facility's policy and procedure titled, Standards and Guidelines: PICC IV Line with an implementation date of 01/15/21 and a reviewed date of 01/15/21, revealed PICC dressing changes will be performed 24 hours post-insertion, upon admission and least weekly. On 10/14/21 at 10:20 AM, an interview was conducted with the Director of Nursing (DON). He confirmed that the PICC dressing should have been changed within seven days as per facility policy.

Based on record review and interviews, the facility failed to ensure that residents who required [CONDITION(S)] received such services and associated care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #49) of one resident receiving [CONDITION(S)] services, from a total of 34 residents in the sample. Specifically, the facility failed to ensure ongoing communication was monitored and maintained with the [CONDITION(S)] center, and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: The facility's policy on Charting and Documentation, implemented on 1/1/2021 without revision, stated in pertinent part: It is the standard of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. A review of Resident #49's medical record, revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/6/2021 minimum data set (MDS) assessment documented a brief interview for mental status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. She was documented to not reject care. A resident care plan, initiated on 9/13/2021, documented that the resident needed [CONDITION(S)] due to renal failure. Interventions included: -administer/monitor effectiveness of medications as ordered; -check access site for signs and symptoms of infection, pain, or bleeding daily and PRN (as needed); check and change dressing daily at access site. Document. To left chest cath site; and, -communicate and collaborate with [CONDITION(S)] center regarding weights, medication, diet, and lab results. Resident record review revealed a 10/12/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident record review revealed a 9/6/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If signs or symptoms were present, notify the physician. A review of the September 2021 treatment administration record (TAR), revealed the catheter site was not monitored on 12 of 75 potential observations. A review of the October 2021 TAR, revealed the catheter site was not monitored on 9 of 40 potential observations. Resident record review of [CONDITION(S)] Communication Forms revealed: -9/24/2021: Facility did not document follow-up blood pressure, respiration. and oxygen saturation directly upon return to the facility. -9/29/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. -10/1/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. -10/8/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. The catheter site was not monitored. -10/11/2021: Facility did not document follow-up blood pressure, weight, pulse, and respiration directly upon return to the facility. -10/13/2021: Facility did not document follow-up blood pressure, temperature, pulse, and respiration directly upon return to the facility. Resident #49 was interviewed on 10/12/2021 at 11:27 a.m. She stated she went to [CONDITION(S)] three times a week. She took a communication book with her each time. The last time she went to [CONDITION(S)], the staff there did not send a weight back to the facility. She said she was supposed to remind them. Upon return to the facility, her catheter was not regularly checked by the nurse but was kept covered. An interview was conducted with Registered Nurse (RN) J at 10:50 a.m. on 10/14/2021. She stated she would fill out the top portion of the resident's [CONDITION(S)] Communication Form, and the resident would then take the notebook (with the form) with her to the [CONDITION(S)] center. When the resident returned, the nurse would see that the [CONDITION(S)] center had completed their section of the form. The nurse would then assess the resident and document their status upon return. An interview was conducted with Medical Records (MR), at 11:08 a.m. on 10/14/2021. The Medical Records Clerk stated that until about two months ago, the [CONDITION(S)] communication forms would be filled out by the nurse before the resident left for [CONDITION(S)]. When the resident returned, the [CONDITION(S)] center staff would have filled out their portion of the form. If that portion had not been filled out, the nurse would call the [CONDITION(S)] center for missing information, and fill out the return portion of the form. She stated she used to receive the [CONDITION(S)] Communication Forms, made sure they were completely filled out, and then put them in the resident's record. She said the nurses were now responsible for ensuring the communication forms were completed and put in the system. An interview was conducted with Licensed Practical Nurse (LPN) G at 11:27 a.m. on 10/14/2021. She stated the facility staff filled out their portion of the [CONDITION(S)] Communication Form before the resident left for [CONDITION(S)]. She further stated the [CONDITION(S)] staff would fill out their portion of the form while the resident was away. When the resident returned, they would chart the resident's vitals and put the information directly into the vitals section of the resident's electronic record. She stated the nurse would also make a progress note if they noticed a concern with the resident. She did not contact the [CONDITION(S)] center when the communication forms come back with the resident and were incomplete. She also would not directly chart on the communication form after the resident returned to the facility, but would put that information directly into the resident's record. She had not been made aware that she needed to follow-up with [CONDITION(S)] if the information was missing. She said she did not check the resident's catheter upon return from [CONDITION(S)], but would ask the resident if they had any concerns. Resident #49 was interviewed on 10/14/2021 at 11:35 a.m. She stated the [CONDITION(S)] staff seldom completed their portion of the communication forms. When she returned to the facility, she was tired. She'd give the facility staff her notebook upon return, but the facility staff seldom checked her vital signs upon her return from [CONDITION(S)]. An interview was conducted with the Director of Nursing (DON), at 12:00 p.m. on 10/14/2021. He stated he expected the facility nurse to complete the [CONDITION(S)] Communication Forms. The [CONDITION(S)] center did not always complete the information that they were supposed to. If the resident returned to the facility and the nurse noted that the communication information was not complete, the nurse would contact the [CONDITION(S)] center and have the information sent over, which could sometimes take a few days. The nurse would also chart vital signs in the resident's record directly. Sometimes there were communication failures due to the fact that the nurse on duty could change from the time the resident left for [CONDITION(S)] and returned to the facility. He stated he would ensure there was better communication between staff shifts.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (Resident #390) of six residents whose medications were reviewed, from a total of 34 residents in the sample. Specifically, the facility failed to ensure antibiotics were administered for a new resident admitted with [CONDITION(S)]. The findings include: The facility policy on Antibiotic Orders, implemented on 1/15/2021 without revision, stated in pertinent part: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antimicrobial Stewardship Program. If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all of the above drug and dosing elements. The facility's consultant pharmacist will review: a. antibiotic orders; b. changes in duration, including unplanned discontinuation of antibiotic orders. A review of Resident #390's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was documented on the Nursing Admission Assessment as alert and oriented to person, place, time, and situation. The resident's baseline care plan, initiated 10/2/2021, documented that the resident had an infection and needed an antibiotic to treat it. Interventions included the administration of the antibiotic as ordered by the physician. The Nursing Admission Assessment, dated 10/1/2021, documented that the resident was admitted with an active infection requiring antibiotic therapy. Resident record review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident record review revealed a second physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident record review of the medication administration record (MAR) for October 2021, revealed that the resident was not administered [MEDICATION(S)] Capsule 300 mg on 10/1/2021 at 9:00 p.m., 10/2/2021 at 9:00 a.m., 10/3/2021 at 9:00 p.m., or 10/6/2021 at 9:00 p.m. There was no indication why the resident did not receive the medication on 10/1/2021, 10/3/2021, or 10/6/2021. The nurse documented on the MAR for 10/2/2021 at 9:00 a.m., to see the nurses' notes. Resident record review revealed a progress note on 10/2/2021 at 8:40 a.m. indicating that [MEDICATION(S)] Capsule 300 mg medication not available. Resident record review revealed a physician's progress note on 10/4/2021 that documented for the resident to continue [MEDICATION(S)] as ordered for the urinary tract infection. The progress note did not indicate that they were aware the resident had missed three doses prior to this visit. An additional physician's visit progess note on 10/11/2021 again documented to continue antibiotics, but did not identify that the resident had missed numerous doses. An interview was conducted with Registered Nurse (RN) I at 8:30 a.m. on 10/14/2021. She stated when a resident was admitted , the nurses would use an audit form to ensure they had gone through all important information upon admission. The medication reconciliation form was provided upon admission. She said upon admission, the nurse would contact the pharmacy and put the medical information into the admitting resident's chart. The RN said the facility usually received the resident's medications the same night. Antibiotics and pain medications were medications that she would expect to see administered as soon as possible. An interview was conducted with Licensed Practical Nurse (LPN) G at 8:48 a.m. on 10/14/2021. She stated she contacted the physician and the pharmacy once a resident was admitted to the facility and she was able to review the medication reconciliation form. She would then document everything in the resident's record. She did not have many concerns with medications taking too long to arrive, but if the medication had not arrived timely, she would document in the resident's chart that she had contacted the pharmacy again. She would communicate with the physician to see whether the he/she wanted to modify the order. The physician would often extend the antibiotics so that the resident continued to get the dosage that was needed even if the days were extended. She stated this information would be documented in the chart. Upon review of Resident #390's record, LPN G stated she did not know why the resident did not receive all of her antibiotics. If the medication was not administered, there should be documentation in the resident's chart. An interview was conducted with the Director of Nursing (DON), at 9:20 a.m. on 10/14/2021. He stated the admitting nurse would use the facility's audit sheet to make sure a new resident's medications and assessments were in place upon admission. The IDT (interdisciplinary team) would look to see that everything was put in place in the resident records, Monday through Friday. The admitting nurse would electronically send over the medication list to the pharmacy. If a new resident was admitted prior to 4:30 p.m., and the medications were put in the electronic system, they would usually get the medications back from the pharmacy by 11:00 - 11:30 p.m. If the resident came later, the medications would usually arrive by 3:00 - 6:00 a.m. If the medications did not arrive, there would usually be a note in the resident record that indicated the physician or pharmacy was notified. The DON stated antibiotics would be crucial. There should not be missing documentation related to medication administration. There should be a note indicating why the medication was not given. Usually the physician would extend the dosing to the quantity needed, so the resident would get the correct number of doses. He stated they would contact the physician to see whether they would extend Resident #390's antibiotics or not. He stated the failure to document administration of antibiotics should have been identified. .

Based on medical record reviews and staff interviews, the facility failed to ensure that the care plans were reviewed and revised quarterly by an interdisciplinary team for two (Resident #3 & #4) of five residents sampled for multiple medical conditions. Failing to revise care plans places residents at risk of not receiving appropriate care. The findings include: 1. A review of Resident #3's clinical record revealed an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's care plan revealed he had multiple medical conditions that needed support with a next care plan review date of 3/18/21. (Photographic evidence obtained) 2. A review of Resident #4's clinical record revealed an admitted [DATE] followed by a readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's care plan revealed he had multiple medical conditions that needed support with a next care plan review date of 1/20/21. (Photographic evidence obtained) 3. An interview was conducted with the Minimum Data Set (MDS) nurse on 4/22/21 at 1:35 PM. She reviewed Resident #3 and Resident #4's care plans and confirmed they were overdue for review and should have been updated. The MDS nurse stated the care plans had not been updated as required because the MDS nurses have been working the floor and on the medication carts.

Based on observation, record review, and interview, the facility failed to ensure 1 of 28 sampled residents was supplied equipment necessary to ensure privacy during personal care services. (Resident #32) The findings include: Record review for Resident #32 revealed she was care planned for having a terminal condition, and was at risk for loss of dignity during the dying process. An intervention listed was to preserve dignity as much as possible by protecting privacy . The care plan also included a risk for falls with an intervention to place the bed in the lowest position, and for a deficit in self-care ability in performing activities of daily living due to dementia. Upon observation of Resident #32 on 10/29/2019 at 10:01 AM, she was in bed resting quietly. Her bed was in a lowered position. A pink privacy curtain was situated between her side of the room, closer to the window, and her roommate's, which was closer to the door. The curtain was pulled to divide the two sections of the room. When pulled, Resident #32 was still visible under the curtain, because of the short length of the fabric, and the low position of the resident's bed. Photographic evidence was obtained. The Housekeeping Director was interviewed at 10:00 AM on 10/31/2019. She was asked about the privacy curtains and explained that the facility was in the process of replacing the shorter (pink colored) curtains with newer, longer, white curtains. When the facility changed owners, the new company toured their building and requested the shorter curtains be replaced. She explained that this was not done, however, because a former Executive Director decided not to follow through on the mandate. She further explained that when she gets her budget she orders a few at a time in hopes of slowly changing all the curtains to the longer ones. She was asked to provide documentation of the facility's efforts to slowly replace the curtains. On 10/31/2019 at 10:34 AM the Housekeeping Director confirmed she could not find any current documentation. An invoice was produced for (MONTH) (YEAR) of quotes for new curtains. She stated the new Executive Director requested a quote after this, and this documentation was requested. She was asked when the last replacement occurred, and she estimated it had been about 6 months. During the interview, a second observation was made of Resident #32's room. Upon entering, the resident was again seen lying in bed, with the bed in a low position. The privacy curtain was pulled, and the Housekeeping Director confirmed its short length and the lack of privacy afforded to Resident #32. The 400 Hallway was observed following this observation, and she confirmed none of the curtains had been replaced yet. The short term rehab units were then toured, and she pointed out the longer, white curtains that reached a length that provided privacy when pulled. The Executive Director was asked on 10/31/2019 at 2:20 PM for any evidence showing current efforts to replace the curtains, but she confirmed that the only documentation available was the quote from (YEAR).

Based on record review and interview, the facility failed to ensure that each resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two of 38 residents sampled. (Residents #49 and #69) The findings include: 1. Record review revealed that Resident #49 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. Additional record review for Resident #49 revealed that there were no revisions or reviews of the comprehensive care plans performed after 3/28/2019. 2. Record Review revealed that Resident #69 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. Additional record review for Resident #69 revealed that there were no revisions or reviews of the comprehensive care plan after 3/26/2019. 3. An interview was conducted on 10/31/2019 at 11:23 am with Employee B, Registered Nurse (RN), who was the Minimum Data Set (MDS) Coordinator. She stated that she is responsible for completing assessments, evaluations, reviewing hospital evaluations and the comprehensive care plans for the residents in the facility. She stated that comprehensive care plans are reviewed each morning in the interdisciplinary team meeting, upon admission, quarterly and in the event of any changes in conditions. When the quarterly assessment is due she gathers information, reviews the comprehensive care plan, identifies any changes and updates the comprehensive care plan accordingly. Employee B confirmed that the comprehensive care plans for Resident #49 and Resident #69 had not been reviewed and/or revised since (MONTH) of 2019. She confirmed that Resident #49 and Resident #69 should have had a quarterly in (MONTH) and (MONTH) 2019.

Based on observations, interviews, and record review, the facility failed to maintain optimal refrigerator temperatures to maintain safety and potency for the storage of medication in one refrigerator (East wing), out of 2 medication refrigerators reviewed. Refrigerator settings should be mid-range, at 41 degrees Fahrenheit (F) to allow the largest safety margin or level of fluctuation within the acceptable range. Refrigerated medications should be stored at temperatures between 35 F and 46 F (Source - How To Store Refrigerated Medications In A Pharmacy https://www.pbahealth.com/how-to-store-refrigerated-products-in-your-pharmacy) The findings include: During an observation of the East Wing Medication storage refrigerator on 10/29/2019 at 1:00 PM, the Unit Manager was asked to read the thermometer inside the refrigerator. She stated the temperature reading was 50 degrees F. The surveyor observed the thermometer and confirmed the correctness of her reading. The refrigerator contained unopened insulin, eye drops, and PPD injections to administer to facility residents. A record review was conducted of the East Wing's refrigerator temperature log for the month of (MONTH) 2019. It revealed refrigerator temperatures ranging from 48 to 50 degrees F, outside of the safety storage range, on 14 dates. The Unit Manager was interviewed on 10/29/2019 at 1:00 PM, and asked what should be done if the temperatures were outside the required ranges. She stated that maintenance should be informed and medication should not be stored in the refrigerator until it was fixed. The Unit Manager confirmed the refrigerator had not been checked by maintenance, and she only became aware of the temperature problem at the time of the survey. The Director of Nursing informed the surveyor on 10/30/2019 at 9:15 AM that the East Wing's refrigerator had been removed from the unit and that medication stored there had been destroyed.

Based on record review, observations, staff interviews, and facility policy review, the facility failed to maintain appropriate infection control measures by not performing adequate hand hygiene during a dressing change for one resident (Resident #55), potentially putting the resident at increased risk of wound contamination and cross infection, from a sample of 38 residents. The findings include: Record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on long term steroid therapy. The admission skin records on 5/29/2019 documented that the resident had blanchable redness to the coccyx. Resident #55 had a Stage IV pressure ulcer, with wound care records indicating its inception on 9/17/19. An observation was made of a dressing change to the resident's coccyx wound on 10/31/2019 at 10:54 AM performed by Staff B, Unit Manager, and an unidentified Certified Nursing Assistant (CNA). Staff B and the CNA repositioned the resident on the bed, and no hand washing was done after repositioning by Staff B or CN[NAME] Staff B then put on her gloves, removed the soiled dressing from Resident #55 and then removed her gloves. Next, Staff B proceeded to put on a fresh pair of gloves without washing her hands or sanitizing. She began cleaning the wound with a Dakin-soaked gauze that was lying on the clean bedside table. Following cleaning of the wound with the Dakin-soaked gauze, without removing gloves or sanitizing, Staff B took another clean gauze, placed on that gauze a crushed [MEDICATION NAME] tablet, and then placed it into the wound bed. Following application of [MEDICATION NAME] powder into the wound bed and still using the soiled gloves that had cleaned the wound originally, she took a Xeroform dressing and proceeded to put the Xeroform dressing into the wound bed, probing with her dirty gloved fingers. At this point, she removed her gloves, and without hand washing or sanitizing, donned a new pair of gloves, took the fresh outer border gauze dressing, wrote the date on it, and applied to Resident #55's wound. On 10/31/19 at 3:02 PM the Director of Nursing was asked at what point in a dressing change should hand washing or sanitizing be done. He stated, Hand washing or sanitizing should be done before dressing change, after removal of dirty dressing, after placing on fresh dressing, and following disposal of soiled things. Review of the facility policy titled Standards and Guidelines Wound Care, revised 11/1/2016, stated that staff are to maintain proper technique during wound care. Review of the facility policy titled Hand Washing/Hand Hygiene, revised 3/2018, showed that staff should use an alcohol based hand rub or soap and water before handling clean or soiled dressing, gauze pads, and after handling used dressings or removing of gloves.

Based on record review and interview the facility failed to ensure that 3 of 4 residents sampled, Residents #1, #2 and #4, received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents' choices. The findings include: An interview on 10/1/18 at 4:01pm with the DON who stated: The computer lists the residents' preference on whether bed bath or shower and the time. They can also state their preference at the time if they are able to speak. They can change it and we will respect their wishes. Residents should not be refused their shower. The bathing preference is in the computer. An interview on 10/1/18 at 4:13pm with the DON where he was asked to provide documentation of bathing times and preference for sampled residents. An interview on 10/1/18 at 5:20pm with the DON where he was asked for documentation of bathing preferences and times for sampled residents was needed for July, (MONTH) and (MONTH) (YEAR) to which he responded: I'll see what I can do. An interview on 10/1/18 at 6:17 pm with the Administrator and DON at which neither could produce documentation of bathing preferences and times for sampled residents for July, (MONTH) and (MONTH) (YEAR). Review of documentation provided by the facility on 10/1/18 revealed that three of four residents sampled required the use of a Hoyer lift. Review of documentation provided by the Administrator and DON revealed that the three residents requiring the use of a Hoyer consistently received bed baths and were not bathed as scheduled based on the facility bathing schedule nor as documented in their individual care plan. Review of East Wing assignment sheet revealed that Resident #1 was scheduled for showers on Monday, Wednesday, and Friday on the 3pm-11pm shift; Resident #2 was scheduled for showers on Monday, Wednesday, and Friday on the 3pm-11pm shift; Resident #3 was scheduled for showers on Monday, Wednesday, and Friday on the 7am-3pm shift and Resident #4 was scheduled for showers on Monday, Wednesday, and Friday on the 7am-3pm shift Review of the Task List Report listed: Resident #1 bathing schedule as Monday, Wednesday, and Friday on the 7am-3pm shift, three times a week and as needed; Resident #2 bathing schedule as Monday, Wednesday, and Friday per family request on the 3pm-11pm shift; Resident #3 bathing schedule as Monday, Wednesday, and Friday on the 7am-3pm shift three times a week and as needed and Resident #4 bathing schedule as Monday, Wednesday, and Friday on the 7am-3pm shift three times a week and as needed Review of CNA bath/skin reports revealed that Resident #1 received a bed bath on 2/14/17, 5/14/18, 7/9/18, 8/24/18 and 8/31/18. An interview on 10/1/18 at 6:03pm with the DON in which he was asked why there were only five bath/skin reports produced for Resident #1 to which he replied: Her's is different. Her baths are PRN (as needed). That's what the family requested. It'll be in her Care Plan. Review of most recent Comprehensive Care Plan for Resident #1 revealed that she transferred with the use of a Hoyer lift X 2 and that it was initiated on 10/1/18, the date of the survey, that she received bed baths on Monday, Wednesday and Friday on the 7am-3pm shift. Review of Follow Up Question Report documentation provided by the DON on 10/1/18 revealed that Resident #1 was bathed three times from 7/1/18 thru 7/31/18 and once from 9/1/18 thru 10/1/18. No documentation was provided for 8/1/18 thru 8/31/18, three of the three received were bed baths. An interview on 10/1/18 at 1:09pm with the daughter and Power of Attorney of Resident #1 in which she stated: I have asked that they give her a shower at least once a week and to shampoo her hair because it gets so matted in the back. Review of most recent Comprehensive Care Plan for Resident #2 revealed that she transferred with the use of a Hoyer lift X 2 and that it was initiated on 10/1/18, the date of the survey, that she received showers on Monday, Wednesday and Friday on the 3pm-11pm shift. Review of CNA bath/skin reports revealed that Resident #2 received a bed bath on 5/11/18, 8/3/18, 8/13/18, 8/24/18 and 9/5/18. The documentation also revealed that Resident #2 received a shower on 7/20/18, 8/7/18 and 9/7/18. Review of Follow Up Question Report documentation provided by the DON on 10/1/18 revealed that Resident #2 was bathed 22 times from 7/1/18 thru 9/30/18, 13 of the 22 received were bed baths. Review of most recent Comprehensive Care Plan for Resident #3 revealed that she transfers with limited to extensive assistance. She preferred a shower, however some days chose to have a bed bath. Review of Follow Up Question Report documentation provided by the DON on 10/1/18 revealed that Resident #3 was bathed 35 times from 7/1/18 thru 9/30/18, 35 of the 35 received were showers. Review of most recent Comprehensive Care Plan for Resident #4 revealed that she transfers with extensive to total assistance and that it was initiated on 10/1/18, the date of the survey, that she received bed baths on Monday, Wednesday and Friday on the 7am-3pm shift. Review of Follow Up Question Report documentation provided by the DON on 10/1/18 revealed that Resident #4 was bathed 35 times from 7/1/18 thru 9/30/18, 32 of the 35 received were bed baths.

Based on interviews and record review, the facility failed to ensure 1 of 3 sampled residents had complete and accurate medical records, as evidenced by documentation for Resident #1's clinical diagnoses. The findings include: Record review revealed that Resident #1 was admitted from the hospital to the facility for short term rehab on 06/02/2016. Hospital records that summarized Resident #1's clincial information included a list of medications the physican ordered to be discontinued, continued, and newly started. This form was titled as Discharge Note with Med Rec and electronically signed by the hospital's physician. This form included 3 pages on medications covering all 3 categories. The last medication, listed on page 3, listed Humalog 100mg, 0 units every 6 hours, with instructions to start taking the medictaion. The form was dated 05/31/2016. Further review of hospital records indicated that on the day he was admitted (05/09/2016), he was listed as being dependant on insulin due to his [DIAGNOSES REDACTED]. The face sheet for the facility, which lists demographic information and a list of [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. The assessment completed by the nursing staff at admission on 06/02/2016 indicated that he was a diabetic. On 06/03/2016, the nursing note had a negative response for the question about whther he was diabetic, indicating he did not have diabetes. The MDS assessment completed for Resident #1 did not code him as being diabetic on the 5 day assessment. The response was no for that question, meaning the resident did not have a [DIAGNOSES REDACTED]. The Director of Nursing (DON) was asked at 1:41 PM on 09/07/2016 about Resident #1's intake to the facility. She pulled out the list of medications from the hospital (the above mentioned form) and said staff would use this form to get physician orders. She pulled out the admission orders [REDACTED]. She was asked for clarification and acknowleged the insulin was not on the admission orders [REDACTED] At 2:25 PM on 09/07/2016, in an interview with the nurse who conducted Resident #1's intake when he arrived at the facility, she indicated she used the list of medications from the hospital to call the physician and get orders for care and treatment. She held up the form cited above. She said she usually checks off each medication that she has read to the physician and a second nurse checks off the list for accuracy, but this list did not have those checks. She and the DON reviewed all the hospital records and could not find any other hospital records with medication lists that were checked off during this interview. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There were no progress notes or assessments completed on 06/04/2016 for Resident #1 to give an indication as to why the insulin was ordered. There was no note from the clinical team that indicated the phsycian was called for the order, why the order was written, or if there were any changes in condition that led to the physician being contacted. On 9/7/16 at 3:20 PM, the DON indicated that the facility did not expect a daily note from their nurses, and they consider documenting in the MAR indicated [REDACTED].

Based on interviews and record review, the facility failed to ensure 1 of 3 sampled residents had complete admission orders [REDACTED]. The findings include: Record review revealed that Resident #1 was admitted from the hospital to the facility for short term rehab on 06/02/2016. Hospital records that summarized Resident #1's clincial information included a list of medications the physican ordered to be discontinued, continued, and newly started. This form was titled as Discharge Note with Med Rec and electronically signed by the hospital's physician. This form included 3 pages on medications covering all 3 categories. The last medication, listed on page 3, listed Humalog 100mg, 0 units every 6 hour, with instructions to start taking the medication. The form was dated 05/31/2016. Further review of hospital records indicated that on the day he was admitted (05/09/2016), he was listed as being dependant on insulin due to his [DIAGNOSES REDACTED]. Resident #1's daughter was interviewed at 10:20 AM on 09/07/2016. She expressed dissatisfaction that her father did not get his insulin right away when he was in the facility, because he had a history of [REDACTED]. She cited an instance when she spoke to staff and they were unaware he was diabetic, and she reported the staff did not know he was insulin dependant until she told them. The Director of Nursing (DON) was asked at 1:41 PM on 09/07/2016 about Resident #1's intake to the facility. She pulled out the list of medications from the hospital (the above mentioned form) and said staff would use this form to get physician orders. She pulled out the admission orders [REDACTED]. She was asked for clarification and acknowleged the insulin was not on the admission orders [REDACTED] At 2:25 PM on 09/07/2016, in an interview with the nurse who conducted Resident #1's intake when he arrived at the facility, she indicated she used the list of medications from the hospital to call the physician and get orders for care and treatment. She held up the form cited above. She said she usually checks off each medication that she has read to the physician and a second nurse checks off the list for accuracy, but this list did not have those checks. She and the DON reviewed all the hospital records and could not find any other hospital records with medication lists that were checked off during this interview. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED].

Based on observations, interviews, and record review, the facility failed to administer medications as ordered for 5 residents (Residents #5, #38, #45, # 260, and #261) of 35 residents sampled. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, and evaluation of care; health teaching and counseling of the ill, injured and infirm; and the promotion of wellness, maintenance of heath, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. Additionally, the Act states that the practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. The findings include: During a medication administration observation with a Licensed Practical Nurse on 4/6/2016 at 9:42 a.m., Resident #38 received a potassium CL 10 milliequivalents (meq) by mouth without food. The manufacturer's specification is that Potassium CL (printed on Resident #38's medication card) should be taken with food. Meal time for the resident was 8 am. During a medication administration observation with a Registered Nurse on 4/6/2016 at 9:48 a.m., Resident #45 received a [MEDICATION NAME] 850mg tablet by mouth without food. The manufacturer's specification (printed on Resident #45's medication card) is that [MEDICATION NAME] should be taken with food. Meal time (breakfast) for the resident was 8 am. An interview with the Director of Clinical Services on 4/7/2016 at 11:42 a.m., revealed that the medications [MEDICATION NAME] and Potassium CL with the manufacturer's recommendation to give with food, should not have been given without food. She stated that it's the facility's policy to follow the manufacturer's recommendations. During a medication administration observation with a Registered Nurse on 4/6/2016 at 9:00 a.m., Resident #260 stated, I did not get my [MEDICATION NAME] last night. The nurse said they did not have it. I have it at home. I can get it. My levels are high. I need my [MEDICATION NAME]. Can you find out, because I have it at home if you don't have it. Employee Y responded, We should have it. I'll check. In an interview with Employee Y on 4/6/2016 at 9:10 a.m., he stated he did not know about the missed [MEDICATION NAME] dose for Resident #260. He would check on it with the Nurse Manager. On 4/6/2016 at 9:25 a.m., Employee K confirmed the error and stated he just notified the doctor for Resident #260 about the missed [MEDICATION NAME] dose and the physician ordered a stat PT/INR (A blood test that measures how long it takes blood to clot. The higher the INR the greater the risk for bleeding.). Resident #260's PT/INR level was 27.4 (PT) and 2.4 (INR) flagged as High on 4/6/16, according to the lab reports. [MEDICATION NAME] ([MEDICATION NAME]) is an anticoagulant (blood thinner). [MEDICATION NAME] is used to treat or prevent blood clots in veins or arteries, which can reduce the risk of stroke, [MEDICAL CONDITION], or other serious conditions. Upon documentation review of the Medication Administration Record [REDACTED]. Review of progress notes for Resident #260, dated 4/5/16 19:55 hours, Employee G specifically wrote, Medication was not given; Awaiting Pharmacy to deliver the medication. A review of the medical record for Resident #261 revealed Employee G wrote on 4/5/2016 at 19:51 Progress Notes that described [MEDICATION NAME] Sodium 2.5 MG Med not given, awaiting Pharmacy arrival. The MAR for Resident #261, dated 4/5/16, also revealed [MEDICATION NAME] was not given on this day. An incident note was created by Employee O, dated 4/6/16 at 2:51 a.m., note described Resident #261 Moderate nose bleed. Ice pack applied and was effective. Order received to hold Aspirin and [MEDICATION NAME] today and in am. In an interview with Resident #261 on 4/6/2016 at 10:00 a.m., when asked about his [MEDICATION NAME], he stated, I have been taking that for [AGE] years. I didn't get it yesterday. They did not tell me why. An interview with Employee B was conducted on 04/06/2016 at 11:16 AM. She stated she was aware of the error and it was unacceptable to document that a medication was not given because it was unavailable. She stated it was the same nurse that failed to give two residents their [MEDICATION NAME]. She further stated she did an in-service on 3/24/16 to all staff concerning this. A review of the in-service education form, dated 3/24/16, revealed, It is unacceptable to document that a med was not given because it was unavailable. Failing to provide medication is failing to provide care. If a medication is not available, it can be drop shipped by the pharmacy. If the medication cannot be provided by the pharmacy, the MD needs to be called to get an alternative available medication order. If the pharmacy refuses to send the med in a timely manner, the Director of Nursing needs to be notified immediately to assist in getting the medication delivered. Resident #5 was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].*hold if SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) is less than 60; Metroprolol 25 mg twice a day related [MEDICAL CONDITION]*hold if SBP is less than 100 or DBP is less than 60; Losartan potassium 50 mg 1 by mouth daily related [MEDICAL CONDITION] if SBP is less than 100 or DBP is less than 60; and Dilitazem CD capsule extended release 240 mg 1 capsule daily related [MEDICAL CONDITION]*hold if SBP is less than 100 or DBP is less than 60. A review of the MARs (Medication Administration Record) for February, March and April of 2016 found that in February 2016, all four blood pressure medications were given each day of the month. However, on 2/3/16, 2/4/16, 2/5/16, 2/9/16, 2/10/16, 2/12/16, 2/13/16, 2/14/16, 2/18/16, 2/19/16, 2/22/16, 2/23/16, 2/26/16, and 2/28/16, the resident's blood pressure fell below the ordered parameters for DBP. For March, there were orders for the same blood pressure medications. One or more of the medications were given at least one time a day on 3/3/16, 3/7/16, 3/10/16, 3/11/16, 3/16/16, 3/17/16, 3/25/16, 3/27/16, and 3/30/16. Photographic evidence obtained. In an interview with the DON (Director of Nursing) at 2:30 pm on 4/7/16, she reviewed the printed copies of the MAR (Medication Administration Record) for February and March of 2016. She confirmed that there were multiple dates when the blood pressure was recorded and was below the parameter for DBP (diastolic blood pressure). She also confirmed that the medication was documented as given for the dates above which was not correct.

Based on record reviews and interviews, the facility failed to make prompt efforts to resolve grievances for 14 residents (Resident #156, #145, #212, #121, #93, #80, #193, #217, #124, #169, #263, #264, #83, and #179) out of 17 residents reviewed. The facility also failed to follow their policy regarding the grievance procedure. The findings include: At 9:45 am on 4/6/2016, a request was made to Employee L, Social Worker, to review the Grievance logs from January 2015 through April 2016. At 11:00 am on 4/6/2016, the Administrator came to the conference room and asked the surveyor if she received the grievance log for the dates requested, and surveyor replied, No. At 11:45 am on 4/6/2016, Employee L was again asked for the grievance logs from January 2015 through April 2016. Employee L stated that she only had the previous six months of grievance logs in her office. Employee L stated that all the other grievance logs were in a storage unit and she had to dig through the storage unit to find the other grievance logs. Employee L stated that she would make a copy of the six months of grievance logs she had, and then look for the other logs. Employee L went to the printer to copy the grievance logs. While at the printer, Employee L was observed writing in the nature of concerns and resolutions in several blank areas of the log, prior to making a copy. Surveyor left the printer and went back into the conference room. At 12:15 pm on 4/6/2016, the surveyor observed several grievance/complaint forms with no resolutions and no facility follow-up. Observations also revealed an incomplete grievance tracking form. Review of Resident #156's grievance/complaint form, dated 1/19/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding missing items. Review of Resident #145's grievance/complaint form, dated 2/3/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding missing items. Review of Resident #212's grievance/complaint form, dated 2/4/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding missing items. Review of Resident #121's grievance/complaint form, dated 2/19/2016, showed no documentation of facility follow up and no resolution. The resident complained of medication not being given when asked. The back of the form said the resident stated that the 7-3 nurse told her to need to stop being a baby. Review of Resident #93's grievance/complaint form, dated 10/19/2015, showed no documentation of the resolution. There was a sheet attached but it did not show the resolution. The grievance was regarding a missing hearing aid. Review of Resident #80's grievance/complaint form, dated 1/6/2016, showed no documentation of resolution. The back of the form was blank. There were no additional sheets attached. The grievance was regarding missing items. Review of Resident #193's grievance/complaint form, dated 1/23/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank. There were no additional sheets attached. The grievance was regarding missing items. Review of Resident #217's grievance/complaint form, dated 3/28/2016, only showed the word 'housekeeping' under the facility follow-up section. The resolution section was blank. The back of the form was blank. There were no additional sheets attached. The grievance was regarding missing items. Review of Resident #124's grievance/complaint form, dated 1/22/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding a missing hearing aid. Review of Resident #169's grievance/complaint form, dated 1/24/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding missing items. Review of Resident #263's grievance/complaint form, dated 3/26/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding family not being notified of resident being transferred to the hospital. Review of Resident #264's grievance/complaint form, dated 3/25/2016, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding the resident turning on his call light and waiting over one hour before the light was answered. Review of Resident #83's grievance/complaint form, dated 9/8/2015, showed no documentation of facility follow up and no resolution. Both sections were blank. The back of the form was blank and there were no additional sheets attached. The grievance was regarding the resident unable to change the station on T.V. without affecting the roommate's channel. Review of Resident #179's grievance/complaint form, dated 12/30/2015, found the record was incomplete. The section Documentation of Facility Follow Up was incomplete, the section Resolution of Grievance/Complaint was blank. There was no writing on the back side of form. No additional pages were attached. The grievance was made by a family member for Resident #179 for missing personal property. Interview was conducted with Employee L, Social Worker, at 12:40 pm on 4/6/2016. She stated that the facility policy was to document the facility follow-up and resolution for the resident on the grievance/complaint form. Staff L stated that once she receives a grievance/complaint form, she would forward the form to the appropriate department and document the grievance concern on the grievance log. Once the department follows-up on the grievance, they would document the facility follow-up on the grievance/complaint form and give it back to her. Once she received the grievance/complaint form back from the appropriate department, she would write the resolution on the grievance/complaint form. She stated that she would then notify the complainant and document on the form the means by which she notified the complainant. She stated that each department had 5 days to resolve the grievance and return the grievance/complaint form to her. She stated that she did not know why there was no facility follow up nor resolutions documented on the grievance/ complaint forms. She stated that she would have to get back with surveyor regarding the grievances. She was unable to tell the surveyor whether or not the grievances with no facility follow-up nor resolutions were resolved. Employee L stated that she takes full responsibility for the incomplete grievance/complaint forms. Review of the facility's resident/patient/family grievance policy revealed that the grievance complaint form would be completed when an issue or concern was voiced to a staff member. The completed form will be forwarded to the Social Service Director in order to be recorded and categorized on a grievance log. The Social Service Director must ensure that the Medical Director reviews the grievance log for any concerns monthly at the Quality Assurance meeting. The Social Service Director will send a copy of the grievance/complaint report to the appropriate department for resolution within 1 business day. The appropriate department manager/designee is responsible to complete the investigation of the issue/concern in writing and return the completed form to the Social Services Director within 5 business days. The Social Service Director/designee must provide oral/written documentation of the resolution/disposition to the person voicing the issue/concern within 10 days. The Social Worker was responsible for maintaining the grievance log and reporting the number of grievances monthly to Quality Assurance committee. (Evidence photos obtained.)