Every finding on record at Life Care Center of Estero

Based on observation, review of facility's policies and procedures and staff interviews, the facility failed to ensure the proper storage of refrigerated food in accordance with professional standards for food service safety.This has the potential to affect all 150 residents who consume an oral diet at the facility.The findings included: On 1/26/26 at 9:26 a.m., observation of the food in the walk-in refrigerator revealed:An undated bag of cantaloupe.A box of slices of bacon stored in an opened card box without appropriate covering or containment. The slices of bacon were exposed to air and were not stored in a sealed container. In an interview during the observation, the Director of Food Service verified that the bacon was not stored in a sealed container and verified the bag of cantaloupe was undated. Photographic evidence obtained.Review of the facility's policy for Food Safety with an effective date of 11/28/17, and a review date of 5/1/25 revealed Policy: Food is stored and maintained in a clean, safe and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. Procedure: Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label or product when applicable.

Based on observations, review of facility's policy and procedure, review of records, residents and staff interviews, the facility failed to maintain an effective pest control program for the kitchen and 7 (Residents #2, #3, #4, #7, #8, #9 and #10) of 7 sampled residents who said they observed pest in their rooms or throughout the facility. The findings included: Review of the facility's Pest Control policy reviewed and revised 6/4/24 revealed, The facility will maintain an effective pest control program that provides frequent treatment of the environment for pests so that the facility is free of pests and rodents . An effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice and rats). On 7/9/24 at 8:27 a.m., in an interview Resident #2 said she had a roach in her room a few weeks ago. The nurse sprayed some bug spray all over her floor. They found two big roaches dead on their back after that. On 7/9/24 at 8:40 a.m., in an interview Residents #3 and #4 said they saw bugs every day in their rooms. Resident #3 said he sees bugs along the base of the cabinet and kept a can of insect killer in his room. On 7/9/24 at 8:43 a.m., in an interview Certified Nurse Assistant (CNA) Staff E said she sees flies all the time. She sees them by the kitchen and sometimes in residents' rooms by the sink. On 7/9/24 at 8:47 a.m., in an interview Licensed Practical Nurse (LPN) Staff G said she saw flies and roaches on a weekly basis. On 7/9/24 at 8:50 a.m., during a tour of the kitchen with the Director of Food Service, several small black flying insects were observed hovering around the sink areas. A white large bucket was observed under the back sink. When the bucket was moved, several small black flying insects were seen hovering in the area. The bucket was coated with an oil substance with black specks. On 7/9/24 at 9:40 a.m., in an interview Housekeeping Assistant Staff D, said she saw roaches a lot. Staff D said she catches the live ones with her mop sometimes when she is cleaning rooms. On 7/9/24 at 10:30 a.m., during a group interview Residents #7 (Resident Council President), #2, #8, #9, and #10 said they see bugs every day. They said the kitchen doors are left open 75% of the time. The doors are connected to the dining room and they see roaches daily. On 7/9/24 at 11:05 a.m., in an interview the Maintenance Director said if staff write a work order, he will go spray for bugs. If it is excessive, he will call the bug company to come. The drains in the kitchen are to be cleaned daily and then they pour a product to remove organic debris down the drains. There are 6 drains in the kitchen. The bug company comes twice a month or as needed. On 7/9/24 at 11:45 a.m., in an interview the technician from the pest control company said he comes twice a month to treat the facility. He reviews the logbook at each nurse station and treats the areas. Sometimes staff pulls him aside and tells him other areas to treat. He said he treats the kitchen drains during each visit. He sold the Director of Food Service a product to clean the drains when organic matter is present. He said the flies are attracted to decay, dirty dishes, and other organic matter. They need to keep the drains clean to prevent the flies to nest. On 7/9/24 at 1:22 p.m., in an interview the Director of Food Service said the pest control technician told her to use the [brand name] cleaning product daily in the mop water and then pour the mop water down the drains. The staff mops three times a day with multiple pails of water. They make sure to pour mop water down each drain. On 7/9/24 at 3:45 p.m., in an interview the Director of Food Service Manager said they started roughly nine months to a year ago to treat the drains with the cleaning formula. The pest control technician trained the dietary staff were trained on how to use the [brand name] biologically enhanced cleaning formula. She said staff signed the education form but did not have documentation of the education. Review of the commercial services agreement dated 5/26/23 with the pest control company revealed under service instructions, Fly control program: Current activity: Fruit flies/house flies. Includes twice per month fly treatment of all drains in the kitchen area.

Based on record review, resident representative and staff interviews, the facility failed to have documentation of an appropriate facility initiated discharge for 1 (Resident #1) of 3 sampled residents not permitted to return to the facility after a hospital stay. The findings included: On 7/9/24, review of the facility initiated discharges revealed on 5/25/24 Resident #1 was transferred to an acute care hospital and had not returned to the facility. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included dementia and cognitive communication deficit. On 5/25/24 at 1:29 p.m., a nursing progress note documented Resident #1 was found unconscious and transferred to a local emergency room for evaluation and treatment. Review of the hospital physician's progress note dated 5/25/24 revealed Resident #1 presented from the skilled nursing facility with an episode of syncope. The resident was unable to provide history. The physician documented the information was obtained from staff and medical records. Diagnoses listed included dementia. Resident #1 was admitted to the hospital with diagnoses including severe dehydration. The hospital discharge summary dated 5/27/24 noted Resident #1 will benefit from going back to snf [skilled nursing facility]. The discharge disposition was , SNF. Review of the hospital care management progress note dated 5/27/24 at 12:19 p.m., revealed Resident #1 was unable to provide permission to contact the family and state preferences and post-acute plan of care due to Dementia. The Case Manager placed a call to Resident #1's daughter and discussed discharge order for return to Life Care Center of Estero. The daughter agreed but requested to speak with the attending physician to discuss her concerns for a safe discharge and to request cardiology to see the resident before leaving the hospital. The discharge plan was to return to Life Care Center of Estero. The patient's goals included, dementia, daughter's goals return to SNF with possible transition to LTC [Long Term Care]. Return to SNF referral sent . On 5/28/24 at 10:52 a.m., the hospital Case Manager documented receiving a call from the facility informing the case manager Resident #1, Was no longer accepted back at facility. The Case Manager documented receiving a call from the resident's daughter and her spouse, they expressed confusion over facility change in decision. The Case Manager offered to have paperwork faxed to other facilities to assist with placement. The daughter reported they were looking at Assisted Living Facilities. On 7/9/24 at 2:07 p.m., in an interview the facility's Admission and Business/Development Director said the facility communicates electronically with the hospital through an online referral system once a resident is ready to be discharged . The Director of Business Development provided the communication notes from the online referral system which she said were for Resident #1. On 5/27/24 at 3:33 p.m., the hospital documented asking if the facility had a bed today. The communication note documented the resident had a discharge order. On 5/27/24 at 4:01 p.m., and on 5/28/24 at 10:32 a.m., the facility documented on the online referral system, Yes willing to accept patient. On 5/28/24 at 10:40 a.m., the facility documented on the online referral system, No, unable to accept patient. Under Reason the facility documented, Care Needs Exceed Current capacity. On 7/9/24 upon request of the facility provided a Nursing Home Transfer and Discharge Notice dated 5/25/24 noting Resident #1 was transferred to a local hospital as his needs could not be met at the facility. The Nursing Home to Hospital Transfer Form dated 5/25/24 noted the reason for transfer was loss of consciousness (syncope). The facility did not provide documentation that a Nursing Home Transfer and Discharge Notice was provided to Resident #1 or his representative on 5/28/24 when the facility did not permit Resident #1 to return to the facility upon discharge from the hospital. On 7/9/24 at 4:15 p.m., in an interview the Admission and Business/Development Director said there was no additional documentation justifying the decision not to accept Resident #1 back after his hospital stay. On 7/9/24 at 4:47 p.m., in a telephone interview Resident #1's daughter said the hospital called and informed her that the facility would not accept her father back. She said no one at the facility called her to explain the decision not to take her father back. On 7/10/24, after the survey, the facility Administrator emailed a Witness Interview/Statement Form dated 7/10/24 for an incident date of 5/27/24 in which Unit Manager Registered Nurse Staff I documented, On 5/27/24 the unit received a call from [Resident #1's daughter] stating she was blaming us for her father's hospital visit as he was dehydrated. She said if we couldn't be with him at all times to ensure his hydration which we couldn't, then she wanted for him to go elsewhere. RN Staff B documented he notified the admission department. The clinical record lacked documentation of an appropriate basis for the facility initiated discharge for Resident #1, including what care needs exceeded the facility's current capacity, or the facility's attempt to meet the resident's needs.

Based on record review, review of facility initiated discharges, resident representative and staff interviews the facility failed to allow 1 (Resident #1) of 3 sampled residents to return and resume residence at the facility after a transfer to the hospital. The findings included: Review of the clinical record showed Resident #1 was admitted the facility on 4/19/2024. Diagnoses included dementia, and cognitive communication deficit. The 5-Day Minimum Data Set (MDS) assessment with a target date of 5/10/2024 noted Resident #1 cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 7. Resident #1 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe, and footwear. He needed partial/moderate assistance (helper does less than half the effort) for dressing. Resident #1's mobility needed partial/moderate assistance. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS noted the resident required setup or clean-up assistance with eating. The care plan initiated on 4/26/24 noted Resident #1 has potential for fluid deficit related fair intake. The resident had a history of diuretic use (helps the body get rid of extra fluid) and history of fluid restriction. The interventions as of 4/26/24 included to honor fluid preferences; Staff to offer fluids in-between meals, and water at bedside. Review of the nursing progress notes revealed on 5/25/2024 at 1:29 p.m., Resident #1 was found unconscious and was transferred to a local hospital, and subsequently admitted . The facility completed an MDS on 5/25/24 for a, Discharge-return anticipated. Review of the hospital emergency room physician progress note dated 5/25/24 noted Resident #1 came from Life Care Center of Estero. Resident #1 was severely dehydrated. The resident was admitted for further evaluation and treatment. Review of the hospital care management progress note dated 5/27/24 at 12:19 p.m., revealed Resident #1 was unable to provide permission to contact the family and state preferences and post-acute plan of care due to Dementia. The Case Manager placed a call to Resident #1's daughter and discussed discharge order for return to Life Care Center of Estero. The daughter agreed but requested to speak with the attending physician to discuss her concerns for a safe discharge and to request cardiology to see the resident before leaving the hospital. The discharge plan was to return to Life Care Center of Estero. On 5/28/24 at 10:52 a.m., the Case Manager documented receiving a call from the facility informing the case manager Resident #1, Was no longer accepted back at facility. The Case Manager documented receiving a call from the resident's daughter and her spouse, they expressed confusion over facility change in decision. The Case Manager offered to have paperwork faxed to other facilities to assist with placement. The daughter reported they were looking at Assisted Living Facilities. On 7/9/24 at 4:47 p.m., in a telephone interview Resident #1's daughter said the hospital called and informed her that the facility would not accept her father back. She said no one at the facility called her to explain the decision not to take her father back. She said her father remained at the hospital until 5/30/24 while she looked for a different facility. With the help of the hospital Case Manager, her father was placed in an Assisted Living Memory Care Facility where she is now paying $6000.00 per month for his care. She lives out of state, had to drive a full day to move him to the Assisted Living Facility, buy furniture, a television set, and other items required by the Assisted Living Facility. Resident #1's daughter said she called, left messages for the skilled nursing facility Administrator but no one returned her calls. On 7/9/24 at 2:07 p.m., in an interview the Admission and Business/Development Director said the facility communicates electronically with the hospital through an online referral system. once a resident is ready to be discharged . The Director of Business Development provided the communication notes from the online referral system which she said were for Resident #1. On 5/27/24 at 4:01 p.m., and on 5/28/24 at 10:32 a.m., the facility documented on the online referral system, Yes willing to accept patient. On 5/28/24 at 10:40 a.m., the facility documented on the online referral system, No, unable to accept patient. Under Reason the facility documented, Care Needs Exceed Current capacity. On 7/9/2024 at 3:36 p.m., in a telephone interview Registered Nurse (RN) Staff F said Resident #1's daughter called and spoke with her about her father's return to the facility. The daughter wanted to make sure he was drinking water. She informed the daughter she could not discuss her father's care at that time as he was not an active resident. On 7/9/24 at 4:15 p.m., in an interview the Admission and Business/Development Director said there was no additional documentation justifying the decision not to accept Resident #1 back after his hospital stay. On 7/10/24 the facility Administrator emailed a Witness Interview/Statement Form dated 7/10/24 for an incident date of 5/27/24 in which Unit Manager RN Staff I documented, On 5/27/24 the unit received a call from [Resident #1's daughter] stating she was blaming us for her father's hospital visit as he was dehydrated. She said if we couldn't be with him at all times to ensure his hydration which we couldn't, then she wanted for him to go elsewhere. RN Staff B documented he notified the admission department.

Based on observations, interviews, and record review, the facility failed to ensure infection control practices were followed for 2 (Residents #107 and #336) of 2 residents reviewed with urinary catheters. The findings included: Review of the facility's Indwelling Urinary Catheter Management Policy reviewed on 8/24/23 indicated the facility will ensure residents admitted with a urinary catheter or determined to need a urinary catheter for a medical indication, will have the following areas addressed: Ongoing care (will) adhere to professional standards of practice and infection prevention and control procedures . Do not rest the bag on the floor. 1. Review of Resident #107's clinical record revealed an admitted [DATE], with diagnoses including urine retention. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed use of an indwelling catheter (Catheter inserted in the bladder to drain urine). Review of the care plans revealed Resident #107 had a history of and is at risk for Urinary Tract Infections (UTIs) due to indwelling catheter: readmitted on [DATE] with sepsis/UTI; on 4/17/23 on antibiotic for 10 days; on 6/17/23 on antibiotic for 7 days; on 9/19/23 on antibiotic for 10 days for UTI. On 10/16/23 at 11:26 a.m., observed Resident #107 in her room, sitting in the wheelchair, eyes closed. The resident's urinary catheter drainage bag was hanging from the wheelchair and resting on the floor. On 10/16/23 at 2:56 p.m., Resident #107's urinary catheter drainage bag was hanging from the wheelchair and resting on the floor. On 10/18/23 at 9:09 a.m., Certified Nursing Assistant (CNA) Staff Q said the urinary catheter drainage bag should never touch the floor. Staff Q said bacteria on the floor can travel up the tubing and give the resident a urinary tract infection (UTI). On 10/18/23 at 3:55 p.m., observed catheter care for Resident #107 with CNA staff P. The Staff Developer, the person responsible for ensuring all CNAs meet criteria for skill competency, was present to hold the resident's legs. Staff P wiped the catheter tubing from an area farther away from the resident back up towards the resident's urinary meatus four times. Staff P then applied a clean incontinent brief for the resident. She did not remove her gloves or wash her hands after catheter care, before, or after applying the clean incontinent brief. Staff P fixed the resident's blanket and handled the call bell. Staff P picked up the wash basin, went to the bathroom to discard the dirty water. Staff P stored the wash basin directly on the floor under the sink. Staff P exited the bathroom, removed gloves and gown. Staff P did not sanitize or wash her hands after removing the gloves. Staff P went back to the resident's bathroom, picked up the resident's body wash, squirted the body wash into her hand, and washed her hands. On 10/18/23 at 4:20 p.m., the Staff Developer acknowledged the infection control breaches by Staff P during the observation which included, wiping the catheter tubing back up to the resident's meatus, not removing gloves and using hand sanitizer before applying the brief, placing the wash basin on the floor, and using the resident's body wash with dirty hands. On 10/19/23 at 8:45 a.m., during a telephone interview, staff P said the facility did not provide catheter care training. Review of Staff P's skills competency for indwelling urinary catheter care conducted by the Staff Developer on 8/16/23 revealed Staff P verbalized catheter care management but had no competency demonstrating urinary catheter care. There was no other documented catheter care training or competency from 8/16/23 through 10/19/23. On 10/19/23 at 9:27 a.m., the Staff Developer verified the lack of return demonstration to ensure competency in catheter care for Staff P. 41155 2. The facility policy Indwelling Urinary Catheter (Foley) Management (revised 6/37/23) documented Based on comprehensive assessment of a resident the facility must ensure that residents receive treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices. Maintain unobstructed urine flow. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. On 10/16/23 at 3:17 p.m., a male staff member was observed assisting Resident #336 to her room in in a wheelchair. The bottom of the urinary catheter drainage bag was dragging on the floor. Registered Nurse (RN) Unit Manager Staff I observed the drainage bag dragging on the floor and called out to the other staff member, the bag is on the floor. The staff escorting the resident stopped, looked at the catheter drainage bag for a second and continued to push the resident in the wheelchair. On 10/16/23 at 3:46 p.m., Resident #336 was observed sitting in her wheelchair in her room. The catheter drainage bag and tubing were observed touching the floor. Photographic evidence obtained. On 10/17/23 at 8:47 a.m., Resident #336 was out of bed sitting in her wheelchair. The catheter drainage bag was on the floor. Resident #336 said she did not know why she had the catheter, they put it in when I was in the hospital. I really don't know why. Photographic evidence obtained. On 10/17/23 at 9:00 a.m., RN Staff J was observed in the hallway of the unit at the medication cart. RN Staff J was notified Resident #336's catheter drainage bag was on the floor. Staff J said ok and did not go to the room to address the concern. On 10/18/23 at 9:38 a.m., Resident #336 was observed in her room, sitting in her wheelchair. The catheter drainage bag was on the floor. RN Staff I was notified and said, I know. I told therapy when I saw it dragging the other day that it has to be off the floor. All the staff know that. I went over it with them. RN Staff I entered the resident's room with the certified nursing assistant and said, the bag needs to be off the floor, we will take care of it.

Based on observation, interview, and record review the facility failed to follow the menu prepared in advance for residents on oral diets. The facility policy titled Menus, Substitutions, and Alternatives, revised on 4/25/23 stated, Menus are planned in advance and followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Residents with known dislikes of food and beverage items, who express a refusal of the food served or requires a different meal choice are offered a substitute of similar nutritive value . The residents are informed of the alternates at each meal per facility guidelines. The findings included: Observation of the posted menu for 10/17/23 revealed the lunch meal consisted of barbecue chicken, potato salad, and seasoned green beans. On 10/17/23 at 11:45 a.m., observation of tray line revealed the lunch meal consisted of Barbeque Pork, Coleslaw, Baked Beans, Pureed Beans, Pureed Mashed Potatoes and Pured bread. The Kitchen Manager said the mashed potatoes were the fortified food item for the lunch meal. He verified all residents received fortified mashed potatoes, even those without an order for fortified food. The dietary manager said, this is a problem, and we will begin education. On 10/17/23 at 11:52 a.m., the cook said, So many people get fortified mashed potatoes, that's why I didn't make the regular. On 10/17/23 at 12:20 p.m., the tray line ran out of Barbeque pork. The staff verified there was no additional pork in the kitchen or freezer. The 13 remaining residents on the 100 hall were served the alternate of a cold chicken salad sandwich with potato chips. On 10/18/23 at 8:46 a.m., Resident #64's responsible party said there had been no menus for a long time. There are people in the dining room that do not eat anything, no one asks them if they want an alternate or substitution. On 10/18/23 at 1:01 p.m., observation of the lunch meal in the dining room revealed nine residents were not given fruit cups as was specified on their meal ticket and the menu. Facility dietary aide Staff ZZ said he didn't bring the fruit cups out to them. They were not offered any substitution. On 10/18/23 at 3:01 p.m., The Kitchen Director stated there had been delivery issues. She said, We give the resident as much information as possible regarding substitutions. Today they already have the menu for tomorrow. Sometimes the residents are notified of changes, sometimes not. We do our best. The dietary manager verified the Everyday Available Menu is provided to residents on admission but is not posted in the facility. On 10/19/23 at 9:00 a.m., Resident #63 said, I've never seen the everyday menu, that would be very nice to have choices. On 10/19/23 at 9:02 a.m., Resident #103 said she had never seen the everyday available menu before. On 10/19/23 at 9:05 a.m., Resident #114 said she had never seen any everyday available menu.

Based on observation, review of the policies and procedures, resident and staff interview, the facility failed to obtain food preferences and provide meals according to resident's choice for 4 residents, (#42, #51, #64, #111) of 4 residents who complained about not having food choices. The findings included: The facility policy titled Nutritional Assessment, revised 4/25/23 stated a representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences are obtained, and a nutritional assessment to determine nutritional needs on admission. The facility policy titled, menus, substitutions, and Alternatives revised on 4/25/23 included Residents preferences are followed to the extent possible in order to promote food acceptance. On 10/17/23 at 10:03 a.m., Resident #111 said, The food has no taste and texture. We never get what we ask for ever. The chicken is always dry, and you only get a small portion. On 10/17/23 during the Resident Council Meeting, Resident #51 said, we complain and nothing is done. I ask for a salad at night, and I never get it. You never get what you ask for. On 10/17/23 at 12:00 p.m., Resident #42 said, There are problems with the food, we do not get what we have ordered. On 10/17/23 at 1:41p.m., The Registered Dietitian said Today, we ran out of the barbeque pork. The chicken salad was the alternate and they had enough to make the alternate sandwiches. So far, we have not have any complaints from people that got the chicken sandwich versus the pulled pork. 10/18/23 8:46 a.m., Resident #64's responsible party said during a telephone interview that there were no menus for a long time. Resident #64 would taste the food and not like it. No one asks them if they want an alternate or substitution. No one has met with us regarding preferences. No one has ever offered something else. She would have preferred the pulled pork, but they ran out. I don't understand how they could have run out of food. They frequently run out of desert. On 10/18/23 12:15 p.m., The Kitchen Manager said, Preference meetings have not occurred in all situations. The Kitchen Manager stated she would meet with the residents to obtain their preferences.

Based on interview and record review, the facility failed to review and revise the comprehensive care plan for 2 (#99 and #107) of 29 residents reviewed for Advance Directives. Advance Directives includes code status, whether the resident wants Cardiopulmonary Resuscitation (CPR) or does not, Do Not Resuscitate (DNR). The findings included: The facility's policy and procedure titled, Comprehensive Care Plans and Revisions with a reviewed date of [DATE] noted the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery. The facility's policy and procedure titled, Advance Directives and Advance Care Planning with a reviewed date of [DATE] noted the DNR order is incorporated into the resident's care plan and is periodically reviewed, at least quarterly. 1. Clinical record review for Resident #99 revealed an admitted [DATE]. The clinical record included a physician's determination of incapacity statement dated [DATE] which noted Resident #99 no longer had the capacity to make knowing health care decisions for herself or provide consent after sufficient explanation without coercion or undue influence. The clinical record included a yellow State of Florida Do Not Resuscitate order form signed and dated by the physician on [DATE] directing the withholding or withdrawing of cardiopulmonary resuscitation from the resident in the event of cardiac or respiratory arrest. The physician's order summary report noted a Do Not Resuscitate Order dated [DATE]. Review of the Social Services assessment dated [DATE] revealed Resident #99 was a DNR. The care plan initiated on [DATE] with a revised goal of [DATE] was not updated to reflect the resident's Do Not Resuscitate status. The care plan noted the resident chose to receive CPR (Cardiopulmonary resuscitation) if her heart should stop or if she should stop breathing and remain a full code. On [DATE] at 9:45 a.m., during an interview Resident #99's daughter said she has the power of attorney and confirmed Resident #99 was a DNR. 2. Review of the clinical record for Resident #107 revealed an admitted to the facility of [DATE]. The clinical record included a physician's determination of incapacity statement dated [DATE] which noted Resident #107 no longer had the capacity to make knowing health care decisions for herself or provide consent after sufficient explanation without coercion or undue influence. Review of the Social Services assessment dated [DATE] revealed Resident #107 was a full code. Review of the physician's orders revealed an order for DNR on [DATE]. Review of the medical record revealed a State of Florida DNR order dated [DATE]. Review of the care plans last revised on [DATE] noted due to Resident #107's cognitive deficit, education was provided to her spouse, and he requested for the resident to remain full code. On [DATE] at 4:16 p.m., Resident #107's spouse said the resident was a DNR. On [DATE] at 10:28 a.m., the Social Services Director (SSD) said she was responsible to revise the care plan whenever there is a code status change. She said the care plan should reflect the wishes of the resident and/or responsible person and should match the physician's orders and the State of Florida DNR form. The SSD provided documentation of an audit completed on [DATE] which noted Resident #99 and #107's code status as DNR. The SSD verified the care plan for Residents #99 and #107 were not updated to reflect the change in code status.

Based on observation, record review, staff interviews and review of facility policy, the facility failed to ensure 2 (Residents #1, and #21) of 4 sampled residents with bedrails were assessed for alternative interventions prior to the use of bed rails and failed to accurately assess the continued need for the bed rails. The findings included: The facility policy, Bed Rails-Safe and Effective Use of Bed Rails, documented the facility must attempt to use appropriate alternatives prior to installing a side or bed rail . Residents will be assessed upon admission, readmission or upon initiation utilizing the Evaluation for Use of Bed Rails Assessment . If bed rails are determined to be appropriate for use with a resident a reassessment of bed rail(s) will be assessed at a minimum quarterly and potentially with a change of condition utilizing the Evaluation for Use of Bed Rails form . The facility will document alternatives to the use of bed rails and how these alternatives did not meet the resident's assessed needs prior to the utilization of bed rails . 1. Review of the clinical record revealed Resident #21 had an admitted [DATE] with diagnoses including dementia, muscle weakness, cognitive communication deficit and lack of coordination. Review of the plan of care initiated 12/29/21 (revised 9/20/23) identified Resident #21 uses 1/4 bed rails to aid in mobility. The goal for the resident was bed rails will safely assist resident in repositioning and transfers. The plan of care interventions specified, Encourage resident to use bed rails to aid in repositioning and/or transfers. Provide continued patient teaching/reminders on safe use of bed rails as needed. Complete the Evaluation for use of Bed Rails, upon admission, readmission, quarterly, and change of condition. Review of the Quarterly Evaluation for Use of Bed rails dated 9/13/23, documented alternatives that were attempted since last review- practice with moving in bed. Are bed rails still appropriate for resident- coded yes. The form documented Resident #21 had weakness, pain, and fear of falling out of bed. The form specified Bed rails will assist the resident in turning side to side, moving up and down in bed, pulling self from lying to sitting, improving balance, supporting self, entering/exiting the bed more safely, and transferring more safely. On 10/17/23 at 9:40 a.m., Resident #21 was observed in bed with 1/4 bed rails in the raised position on both sides of the bed. There was a long-padded device on both sides of the inner rails. The Resident was lying on a scoop mattress (a mattress with inflatable raised sides). On 10/17/23 at 3:30 p.m., in an interview the Risk Manager said the pads placed in front of the bed rails were for resident safety. If a resident was moving their extremities, they would not get hurt. On 10/18/23 at 12:09 p.m., Certified Nursing Assistant (CNA) Staff M said Resident #21 had no use of the left arm because she could not move it. Staff M said Resident #21 required total care and was not able to turn herself in bed. Staff M said the resident was not able to grab the bed rail on cue. We turn her, she can't do it. She does not walk. On 10/18/23 at 11:40 a.m., the Director of Nursing (DON) said the process for bed rails was at admission the nurse puts the bed rails down and the bed is in low position. The nurse completing the admission asks if the resident wants the bed rails to assist them with turning and positioning. Some residents have a fear of falling. If the resident wants the bed rails, then the rails are raised. If the resident does not want the rails, then maintenance comes and removes them, or the staff just leave them down. The evaluations for the bed rails are done quarterly, on admission and if a significant change had occurred. On 10/19/23 at 9:09 a.m., in an interview CNA Staff O said Resident #21 used to move around but not now, she is total care. I got her up today, she does not use the bed rail to turn, she can't. Staff O said Resident #21 rarely speaks and she does not understand. Staff O said she had to do everything for the resident. If you told her to turn or grab the bed rail, she can't. On 10/19/23 at 9:33 a.m., Registered Nurse Unit Manager Staff I, said the nurse doing an admission was responsible to do the admission bed rail evaluation but he did not know who was responsible to complete the quarterly and annual bed rail evaluation. Staff I said Resident #21 was able to move in bed and uses the bed rail to move around in bed. On 10/19/23 at 10:11 a.m., the DON said the assigned nurse does the admission, the quarterly and annual bed rail evaluations. The nurse is to assess the resident and evaluate for use of bed rails. The DON said she was unaware Resident #21 had both a scoop mattress and bed rails. On 10/19/23 at 12:10 p.m., the DON confirmed Resident #21 was not able to use the bed rails for mobility and said they were removed from the bed. 22651 2. Review of the clinical record for Resident #1 revealed and admitted [DATE] with diagnoses including Alzheimer's disease, dementia, and muscle weakness. On 10/16/23 at 10:00 a.m., and on 10/18/23 at 11:00 a.m., Resident #1 was observed in bed with 1/2 bedrails up elevated on both sides of the bed. Resident #1 was not able to answer questions. The clinical record lacked documentation of appropriate alternatives attempted prior to installation of the bedrails. There was no documentation the risks and benefits of the bed rails were reviewed with the resident or representative, and informed consent obtained prior to installation of the bed rails. On 10/18/23 at approximately 11:05 a.m., the Unit Manager said Resident #1 received hospice services. Hospice provided the bed, and the mattress. She said she would look for documentation of appropriate alternatives used prior to installation of the bed rails, and the informed consent with documentation the risks and benefits were reviewed with the resident and/or representative. As of 10/19/23 the facility failed to provide documentation of appropriate alternatives used prior to the installation of the bed rails, the risks and benefits of the bed rails were reviewed with the resident or representative, and informed consent obtained prior to installation of the bed rails.

Based on observation, facility policy review, staff and resident interviews, the facility failed to ensure medications were labeled, secured and inaccessible to unauthorized staff and residents for 1 (Resident #38) of 1 resident reviewed. The findings included: Review of facility policy 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles revised 10/28/19 revealed, .Bedside Medication Storage: Facility should not administer/provide bedside medication or biologicals without a Physician/Prescribed order and approval by the Interdisciplinary Care Team and Facility administration. Facility should store bedside medications or biologicals in a locked compartment within the resident's room . On 12/6/21 at 11:00 a.m., observation revealed two white, unidentified medications in a medication cup on the overbed table of Resident #38. At the time of the observation, in an interview, Resident #38 said he thought the medications were Tylenol. He said the nurse left them for him to take as needed for the [MEDICATION(S)] in his hip. He said he could not recall how long the pills had been there and did not know the name of the nurse who left them. *Photographic evidence obtained* On 12/6/2021 at 2:30 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A who was assigned to Resident #38, said she had not given any Tylenol to Resident #38. She said the resident usually turns down taking Tylenol because it hurts his liver. LPN Staff A said she did not see the medication at his bedside and did not know how they got there. On 12/9/2021 at 10:30 a.m., in an interview, the Director of Nursing said unless there was an assessment for self-medicating there should never be any medications left at a resident's bedside. She added they have no residents in facility who self-medicate at this time.

Based on record review and staff interview the facility failed to notify the state's Long-Term Care Ombudsman Council (LTC[NAME]) of facility-initiated transfers and discharges since (MONTH) 2019. The Ombudsman was not notified of 7 (Resident #24, #380, #382, #383, #385, #76, #123) of 7 sampled facility-initiated transfer/discharges. The findings included: Review of the facility's discharge log from 2/13/19 through 2/13/20 which included 114 transfers to acute care hospitals. A sampling of facility-initiated discharges from (MONTH) 2019 through (MONTH) 2020 found: July 2019, Resident #24 was transferred on 7/3/19 to an acute care hospital. August 2019, Resident #380 was transferred on 8/2/19 to an acute care hospital. September 2019, Resident #382 was transferred on 9/9/19 to an acute care hospital. October 2019, Resident #383 was transferred on 10/13/19 to an acute care hospital. November 2019, Resident #385 was transferred on 11/19/19 to an acute care hospital. December 2019, Resident #76 was transferred on 12/19/19 to an acute care hospital. January 2020, Resident #123 was transferred on 1/2/20 to an acute care hospital. There was no documentation at the time of the survey the facility notified the LTC[NAME] of the facility-initiated discharges. On 2/13/20 at 1:32 p.m., the Administrator said the list of discharges to the hospital was not going to match what the facility sent to the ombudsman's office because not all transfer to the hospital were sent to the ombudsman's office. He said if someone was in a coma, they would consider it a facility-initiated discharge. On 2/13/20 at 1:57 p.m., the Medical Record Clerk said the facility used to send a monthly list of discharges to the hospital to the office of the ombudsman, but they had stopped since 5/19.

Based on observation, record review, and staff interview the facility failed to store and maintain resident equipment in a sanitary manner on 1 (Estero Bay) of 3 units. The findings included: The oxygen administration/safety/storage/maintenance policy reviewed on 4/15/19 specified to Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. Clean exterior of oxygen concentrators weekly with bactericidal surface cleaner. 1. On 2/11/20 at 11:00 a.m., the following observations were made: room [ROOM NUMBER]a the nebulizer's mouthpiece was resting uncovered on the resident's bedside table. room [ROOM NUMBER] b the nebulizer's mouthpiece was resting uncovered on the resident's chair. The compressor (mattress pump) in room [ROOM NUMBER]b had a thick layer of dust. The oxygen concentrator in room [ROOM NUMBER]b had a thick layer of dust. The mattress pump in room [ROOM NUMBER]a had a thick layer of dust. On 2/12/20 at 9:30 a.m., the mattress pump in room [ROOM NUMBER]b was dusty. 2. On 2/12/20 at 9:35 a.m., the same observations were made with the Assistant Director of Nursing (ADON). She verified the concentrators and the mattress pumps were dusty. She said the housekeeper was supposed to make rounds and dust them every week. 3. On 2/12/20 at 9:59 a.m., during an interview the Housekeeping Supervisor said the oxygen concentrators should be cleaned every week when the housekeeping staff changes the tubing. She said Housekeeper Staff K was responsible for the cleaning and dusting of residents' equipment this week. The Housekeeping Supervisor said the facility did not maintain an equipment cleaning log. 4. On 2/13/20 at 8:36 a.m., during an interview with Housekeeper Staff K, he said he usually cleaned the oxygen concentrators every week. He admitted this week he did not clean them all. He also said the mattress pumps were not on a weekly cleaning schedule, but he sometimes cleans them. ***Photographic evidence obtained***

Based on record review and staff interview the facility failed to obtain Do Not Resuscitate Orders (DNRO) in accordance with the advance directives for 1 (Resident #101) of 2 residents reviewed for DNROs. The findings included: The facility's policy for Advance Directives with an effective date of [DATE] included An advance directive is a written document prepared by the resident as to how he/she wants medical decisions to be made should he/she lose the ability to make decisions for him or herself . The resident or resident's representative must sign an informed consent as required by state specific requirement indicating that the resident consents to a 'DNR' (Do not resuscitate) or 'no CPR' (cardiopulmonary resuscitation) or 'no resuscitation' in the event of [MEDICAL CONDITION] or respiratory arrest. Review of the clinical record revealed on [DATE] Resident #101 signed a form indicating she appointed (Daughter A) to be her health care surrogate in the event that she was determined to be temporarily or permanently incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures in accordance with Florida Statute 765, Healthcare Advance Directives. The form designated (Daughter B) as a successor in the event that (Daughter A) shall die, become legally disabled, resigned or refused to act. The clinical record included a physician statement dated [DATE] indicating Resident #101 was no longer able to provide informed consent for medical treatment. Further review of the clinical record revealed on [DATE] (Daughter B) signed a do not resuscitate form directing that cardiopulmonary resuscitation be withheld or withdrawn in the event of Resident #101's cardiac or respiratory arrest. The daughter indicated on the form she was Resident #101's surrogate. The clinical record lacked documentation Daughter A who was the designated health care surrogate had died , was legally disabled, resigned or refused to act. On [DATE] at 12:20 p.m., during an interview the Social Worker verified the lack of documentation. She said Daughter B had been making all healthcare decisions for Resident #101 because she lived locally. On [DATE] at 12:50 p.m., during an interview with Daughter B she said her mother used to live where Daughter A resided, but since she moved to this area, she took over making decisions for her mother. She said she didn't have any paperwork indicating her sister was not available or refused to act.

Based on observation resident and staff interview the facility failed to implement necessary restorative care to prevent the decline in range of motion or mobility for 1 (Resident #28) of 3 residents reviewed for limited range of motion. The findings included: Review of the facility's policy and procedure for restorative nursing with an effective date of 5/16/19 revealed The facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome . Accurate and thorough assessment of the patient is fundamental in determining the patient's need for restorative services .Restorative Nursing Functions can be within one of the following categories: Range of Motion (Active and Passive) Review of the clinical record for Resident #28 revealed [DIAGNOSES REDACTED]. Review of the functional goal care plan (not dated) revealed Resident #28 had limited physical mobility related to [MEDICAL CONDITION] (stroke). The goal was for the resident to remain free of complications related to immobility. The interventions included nursing rehabilitation and restorative program for active range of motion, transfer exercise-bed to wheelchair, sit to stand at grab bar in bathroom and bilateral lower extremity exercise. On 2/11/20 at 8:59 a.m., Resident #28 was observed in bed, alert and able to answer questions appropriately. He was not able to move his left arm or leg. He said he thought they would send someone to exercise his arm and leg but they don't. Resident #28 added They're not doing anything with my left arm. On 2/12/20 at 2:09 p.m., during an interview with the Restorative Nurse, she said that Resident #28 received restorative treatment (program that focuses on achieving and maintaining optimal physical functioning) only to his lower extremities. On 2/12/20 at 2:35 p.m., during an interview the Restorative Certified Nursing Assistant said Resident #28 participated in a restorative program three times a week for his lower extremities. She said there was no restorative program for his affected left arm, but he did exercise his right arm (non-affected arm) sometimes. On 2/12/20 at approximately 2:40 p.m., during a second interview Resident #28 said no one did any range of motion for his left arm, shoulder, or hand. The resident said the pain in his left arm was not getting any better. He said if he even tried to move his left arm the pain makes him shoot through the ceiling. He said he would like to receive therapy for his left arm to get it going again. On 2/12/20 at 3:12 p.m., during an interview the Director of Rehabilitation said Resident #28 had received occupational therapy for the left upper extremity from 5/19/19 to 9/6/19. They worked on his shoulder. On 9/6/19 they discharged him with a restorative nursing program for his upper extremities. Review of the restorative nursing communication tool dated 9/4/19 revealed the resident was discharged to the nursing restorative program with the following exercises: Bed to wheelchair, sit to stand at grab bar in B-room (bathroom) Bed mobility; roll left to right and return to lying on the bed Lying to sitting on the side of the bed Transfer moving from chair, toilet, or wheelchair The restorative program did not include any range of motion to the resident's left shoulder, elbow, wrist, or hand. On 2/12/20 at 4:12 p.m., during an interview the Occupational Therapist (OT) said Resident #28's left arm was totally flaccid (limp). The resident was experiencing left shoulder pain and they provided treatment to stabilize the joint and decrease the pain. The OT said Resident #28 would benefit from a passive range of motion program to the left arm to prevent pain, atrophy (wasting away), and adhesion (scar tissue formation). The OT said the restorative nursing program Resident #28 was discharged to was not adequate to prevent pain, atrophy, and adhesion to the left upper extremity. She said the program should have included range of motion of the left upper extremity. She said she would evaluate the resident as soon as 2/13/20 to determine the level of functioning for the resident for the left upper extremity. Review of the OT evaluation dated 2/13/20 revealed documentation in the clinical impression Resident presents with left [MEDICAL CONDITION] ([DIAGNOSES REDACTED] on one side of the body) with request for RNP (restorative nursing program) in order to maintain soft tissue length-tension relationship and joint alignment for pain prevention and decreased risk for contracture. On 2/13/20 at 2:05 p.m., the OT said based on her evaluation Resident #28 needed therapy for four weeks for his left upper extremity. She said the goal was to perform range of motion for four weeks and then discharge him again to a restorative nursing program.

Based on observation, review of policies and procedures, review of maintenance logs and staff interview the facility failed to store and process linen in a sanitary manner. The facility failed to maintain an effective water management program and failed to identify and monitor areas where waterborne pathogens can grow. The findings included: 1. The facility's procedure for separating clean from dirty in the laundry (Chapter 7) indicated clean linen must always be kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door provides the most secure methods for reducing the risk of accidental contamination. In the laundry, dirty linen should be moved from the dirtiest to the cleanest areas as it was being processed. Dirty linen should be clearly separated from areas where clean linen was handled. Observation on 5/31/19 at 10:20 a.m., of the laundry room with the Laundry Supervisor and the infection prevention nurse revealed 2 large uncovered bins of soiled linen stored within approximately 5 to 6 feet of the washing machines. All 3 washing machines were in use at the time of the observation. The Laundry Supervisor verified the uncovered bins contained soiled linen and were stored where the clean linen was handled as it came out of the washers. She said there wasn't enough room in the soiled part of the laundry room to store the bins of dirty linen. The infection prevention nurse was present during the observation. She confirmed the uncovered soiled linen should not be stored with the clean linen. On 5/31/19 at 10:25 a.m., Laundry Aide Staff A said she has been working at the facility for approximately 9 years. She said the soiled linen bins were always uncovered and stored in close proximity of the washing machines. Observation on 5/31/19 at 10:30 a.m., of the folding area of the laundry room revealed a multi tier wired rack used to store clean, folded laundry. The bottom shelf contained stacks of clean, folded hospital gowns. Parts of the gowns protruded through the wires of the bottom shelf and rested on the floor. The observation was confirmed by the infection prevention nurse and the laundry room supervisor who instructed the laundry aide to store the folded gowns at a different location to prevent them from touching the floor. 2. The legionella water management plan indicated the purpose of the plan was to protect the health and safety of residents, visitors, and associates from Legionnaires' disease with prevention and early recognition, by formulating this water management plan to help identify and control hazardous conditions that support the growth and spread of bacterial organisms, such as legionella. The logbook documentation listed the following steps for testing and monitoring of the water system: You need to test and monitor your water system and supply for legionella against the water management plan you put together. It is recommended that weekly you are doing necessary visual inspections of areas such as decorative fountains or ice machines for any 'biofilm' (slime), scale or sediment that could encourage the growth of legionella. If any unclean areas are found, follow your equipment owner's manual and 'water management plan' and document, clean and retest and monitor until conditions improve and are then maintained. This may mean increasing your monitoring to daily until conditions return. All of these inspections, tests and measurements need to be documented and recorded. Conduct biocide (chlorine level) test on a monthly basis. Observation of the foyer of the facility on 5/31/19 at 8:00 a.m., revealed a large 3 tier decorative water fountain. The fountain had multiple areas of black and green biogrowth. On 5/31/19 at 10:40 a.m., the Maintenance Director said the building's water source was from the county and the disinfectant used was chlorine bleach. He said the facility's water management program included random testing of the water for bleach level content. The Maintenance Director said he did not have a risk assessment identifying potential areas of concern in the building that support the growth and spread of waterborne bacterial organisms, such as legionella. He said on a monthly basis he randomly picked a few areas such as different faucets, the decorative water fountain, bathrooms or resident's rooms and measure the bleach level in the water. The Maintenance Director provided documentation which he said was from the water management office of the county, indicating a minimum level of chlorine bleach of 0.57 PPM (part per million) was required to prevent the growth of legionella. Review of the logbook documentation revealed the last chlorine level check for the decorative water fountain was done on 2/26/19. On 5/31/19 at 10:50 a.m., the Housekeeping Supervisor and the Maintenance Director both verified the large amount of green and black biogrowth in the decorative water fountain. The Housekeeping Supervisor said the fountain was cleaned on a weekly basis but she did not maintain a log of the cleaning. On 5/31/19 at 11:15 a.m., observed the Maintenance Director's assistant measure the content of the chlorine bleach. The bleach level was 0.04 PPM. The Maintenance Director said the level of chlorine bleach in the water fountain was not adequate to prevent the growth of legionella and other water borne pathogens.

Based on observation, staff interview and record review, the facility failed to ensure food was prepared and served in a sanitary manner to prevent the spread of harmful microorganisms. This deficient practice had the potential of causing food borne illness to those residents' receiving an oral diet. The findings included: During a tour of the kitchen on 2/19/18 at 10:08 a.m., Director of Food and Nutrition Services Staff H observed several metal pans stacked up in each other on the bakers rack while still wet. Staff H removed the top pan and observed water in between pans. At 10:10 a.m., observed a small table with a special orders warmer on top of it. The table had white residence from tape. Staff H said she was unable to remove it and acknowledged the potential for food to come into contact with it. During a tour on 2/19/18 at 10:23 a.m., observed Cook Staff I chop chicken using a green cutting board. She placed salad bowls on top of green cutting board and made 6 salads using the chicken. At 10:28 a.m., she sliced strawberries on the green cutting board with the same knife used to chop the chicken. Staff I did not clean the cutting board between using it for the chicken and strawberries. On 2/21/18 at 11:21 a.m., Registered Dietician (RD) observed Cook Supervisor Staff J during lunch time tray line. Staff J did not wash her hands at the start of tray line. She did not have a temperature log to document the food item temperatures. Staff J was observed washing her hands from 1 to 10 seconds, each time she turned the faucet handle off and then dried her hands. Observed Staff J touch surfaces, remove scoopers from food, without washing her hands. The RD had to intervene and replace the food scoopers 5 times. The RD was observed with his hands in his pockets. The RD then picked up the scooper from the puree bread without washing his hands. The scooper remained in the puree bread and Staff J continued to use it. On 2/21/18 at 2:00 p.m., Cook Supervisor Staff J said she realized she should have washed her hands better and should have washed them when she touched multiple items during the tray line. On 2/21/18 a review of the facility's hand washing policy and procedure dated 4/1/15 documented the purpose was to decrease the risk of transmission of infection by appropriate hand hygiene. The policy documented hand washing/hand hygiene was generally considered the most important single procedure for preventing infections. Antiseptics control or kill microorganisms containing skin and other superficial tissues and sometimes composed of the same chemicals that are used for disinfection of innate objects. Although antiseptics and other hand washing agents do not sterilize the skin, they can reduce microcobial contamination depending on the type and amount of contamination, the agent used, the presence of residual activity and the hand washing technique followed. The procedure to appropriate hand washing: When hands are visibly dirty, contaminated, or soiled, wash with non-anti-microbial or anti-microbial soap and water. (1) turn on water to a comfortably warm temperature (2) moisten hands with soap and water and make a heavy lather (3) wash well under running water for a minimum of 20 seconds, using a rotary motion and friction (4) rinse hands well under running water (5) dry thoroughly with a disposable towel (6) use a towel to turn off the faucet then discard.

Based on record review, family interview, staff interview and observation, the facility failed to ensure 1 (Resident #449) of 1 resident surveyed for hearing aids of 29 residents surveyed received proper treatment and assistive device to maintain hearing abilities. Failure to maintain adequate hearing has the potential to inhibit the residents ability to communicate effectively. On 2/20/18, Resident #449's daughters said staff where not putting his hearing aide in his ear in the morning or taking the battery out at night. They said the battery in the hearing aid was having to be changed every two days. They said they had come in and found the resident without the hearing aid and they had also come in and found the hearing aid not functioning in the resident's ear because the battery was dead. The daughter said they had left a note for the staff at the facility but it had been ignored. On 2/22/18, Resident #449 was observed without his hearing aid at 8:00 a.m., and 10:00 a.m. On 2/22/18 at 1:40 p.m., Resident #449's daughter said she had placed the resident's hearing aid in his ear at 11:30 a.m., that morning. The resident's daughter said the resident went to physical therapy without his hearing aid in place. On 2/22/18 at 1:49 p.m., Certified Nursing Assistant (CNA) Staff B said she did not regularly have Resident #449 as an assignment. Staff B Said Resident #449 did not have a hearing aid. Staff B said she would be told verbally by the staff if the resident was to have a hearing aid. After reviewing the Care Directive for Resident #449 Staff B said the information that Resident #449 had a hearing aid was not on the care directive for CNA's to know to apply the hearing aid. On 2/22/18 at 1:52 p.m., Licensed Practical Nurse Staff C said some residents have hearing aids placed on the Medication Administration Record [REDACTED]. He said he did not admit Resident #449 so he could not say why the resident did not have the hearing aid listed on the MAR.

Based on record reviews, observations, staff interviews, and family interviews the facility failed to develop and implement a comprehensive care plan consistent with the resident's assessment. The facility failed to ensure each resident was furnished the care the individual required to attain or maintain his/her highest practicable well-being for 3 (Resident #55, #12 and Resident #449) of the 29 residents sampled. The findings included: 1. Review of Resident #55's record revealed a comprehensive assessment, dated 1/5/18 noting the resident had fractures. The therapy note dated 1/15/18 stated, Other non-displaced fracture of upper end of right humerus. Increase in [MEDICAL CONDITION] at digits 1-5 without bandaging over the weekend with maintained reduction at dorsal hand. Recommended a light compression glove, size medium with full fingers to right hand in order to assist with fluid reduction and for maintained reduction with resident agreeable and reporting comfort with donning of glove. Review of orders dated 1/15/18, Right hand compression glove to be on in a.m. and off in p.m. Check skin integrity under compression glove every shift and notify Medical Doctor (MD) if abnormal findings. Review of the February 2018 Treatment Administration Record (TAR) revealed the orders were discontinued on 2/8/18. Review of the care plan with an onset date of 12/29/17 revealed the care plan failed to provide documentation noting the resident's right arm restriction due to the cast and swollen hand. The facility failed to develop and implement a care plan to apply the compression glove and assess the skin under the compression glove. On 2/21/18 at 9:34 a.m., Certified Nursing Assistant Staff N said the resident did wear the compression glove and it is usually put on by the Certified Nursing Assistant (CNA) or the therapist. On 2/21/18 at 9:39 a.m., Licensed Practical Nurse (LPN) Staff C said he was unable to find the order to stop applying the glove. On 2/21/18 at 9:44 a.m., LPN Staff C said he notified the physician and received an order to continue with the compression gloves. On 2/23/28 at 10:30 a.m., the resident was observed in the beauty shop not wearing the compression gloves. The resident's hand continued to be swollen. 2. On 2/20/18, Resident #449's daughters said staff where not putting his hearing aide in his ear in the morning or taking the battery out at night. They said the battery in the hearing aid was having to be changed every two days. They said they had come in and found the resident without the hearing aid and they had also come in and found the hearing aid not functioning in the resident's ear because the battery was dead. The daughter said they had left a note for the staff at the facility but it had been ignored. Review of Resident #449's care plan read, 2/8/2018 Resident has impaired communication D/T (due to) poor cognition and hearing . Goals .Residents needs will be anticipated and met by staff through the next review date .Approaches .Apply/check placement/observe placement of hearing aid daily .roles CNA, Licensed Nurse. On 2/22/18, Resident #449 was observed without his hearing aid at 8:00 a.m. and 10:00 a.m. On 2/22/18 at 1:40 p.m., Resident #449's daughter said she had placed the resident's hearing aid in his ear at 11:30 a.m. that morning. The resident's daughter said the resident went to physical therapy without his hearing aid in place. On 2/22/18 at 1:49 p.m., CNA Staff B said she did not regularly have Resident #449 as an assignment. Staff B said Resident #449 did not have a hearing aid. Staff B said she would be told verbally by the staff if the resident was to have a hearing aid. After reviewing the Care Directive for Resident #449, Staff B said the information that Resident #449 had a hearing aid was not on the care directive for CNA's to know to apply the hearing aid. On 2/22/18 at 1:52 p.m., LPN Staff C said some residents have hearing aids placed on the Medication Administration Record [REDACTED]. He said he did not admit Resident #449 so he could not say why the resident did not have the hearing aid listed on the MAR. On 2/22/18, Unit Coordinator Staff D said she was going to place the hearing aid on Resident #449's MAR indicated [REDACTED]. 3. On 2/20/18 at 9:49 a.m., Resident #12 was observed in the bed. Resident #12 was bald on the top of his head. The hair around his ears and the back of his head was observed to be greasy and unwashed. When the resident was asked if he had a choice on when he got a shower or bath Resident #12 said he did not have a choice. Resident #12 said he would like to have a shower. Resident #12 said he could not remember when he had last had a shower. On 2/22/18 at 9:00 a.m., Resident #12 said he had still not had a shower. Review of Resident #12's care plan showed he was care planned for activities of daily living deficit and required extensive assistance with activities of daily living. The goal of the care plan was for Resident #12 to be kept clean and dry. One of the approaches listed on the care plan was Shower Twice Weekly. Review of the CNA documentation on the Monthly Flow Report showed Resident #12 had one shower on 1/6/18. There were no further documentation of any showers by CNA's in the month of January 2018. The documentation showed Resident #12 did not receive a single shower in the month of February 2018. On 2/22/18 at 10:20 a.m., the Director of Nursing (DON) said it was the practice of the facility to allow residents to have a least two showers weekly.

Based on resident interview, staff interview, record review and observation, the facility failed to honor personal choice for 2 (Residents #449 and #12) of 29 residents reviewed regarding frequency of showers. The findings included: A review on 2/21/18 of the Resident Rights policy dated 11/9/16 documented (25) The resident has a right to choose activities, schedules, healthcare and providers of healthcare consistent with their interests, assessments and plan of care. 1. On 2/21/18 at 3:57 p.m., Resident #449 said he had not had a shower since he was admitted on [DATE]. He said he would like one. A review on 2/21/18 of the unit's shower schedule revealed it was last updated 2/5/18, and documented Resident #449 was in room [ROOM NUMBER] A and should receive a shower on Wednesdays and Saturdays. A review on 2/21/18 of physician orders [REDACTED]. On 2/21/18 at 5:14 p.m., the Director of Rehabilitation said she thought Resident #449 was unsafe for transfer to the shower chair because of his poor trunk control. She said she was unable to provide any documentation showing the therapy department was working with him for shower services or to improve his trunk control. On 2/21/18 at 5:45 p.m., Unit Coordinator, Registered Nurse (RN) Staff D said Resident #449 had not had a shower since his admission. She stated, he is a very large man and I don't know if he can sit up in a shower chair. She said if he had poor trunk control it would require several aids to give him a shower. She said she did not see him not getting a shower as an issue because he got bed baths. She said she did not know there was a physician order [REDACTED]. She said she was not aware the resident wanted a shower. She said Resident #449 did not get a shower today (2/21/18) his designated shower day, because the aide did not know how to give him a shower. She said she did not have any documentation the staff attempted to shower him and was unable to transfer him. She said the physician was not informed the staff were unable to follow his orders for showers. On 2/22/18 at 1:40 p.m., Resident #449's daughter said her father had not had a shower since his admission. She said yesterday at 6:00 p.m., RN Staff D came in and asked him if he wanted a shower now and he said no. She said he said no because of the hour, he was already tired and they were visiting. She said she was able to transfer him when he was home to give him a shower and she did not understand why he has not had one. She said she knew he was scheduled to get a shower every Wednesday and Saturday. She said last Saturday she asked the staff about him getting a shower and no one ever got back to her. She said he did not get one that day either. On 2/22/18 at 2:27 p.m., Resident #449's physician stated, There is no reason he (Resident #449) can not have a shower. I ordered a shower twice weekly. They might need to use a lift for him or an extra person, but he can have a shower. He stated the resident's paralysis does not affect him getting a shower. 2. Resident #12 was admitted to the facility on [DATE]. He has a history of muscle weakness and dyspnea (difficulty breathing). On 2/20/18 at 9:49 a.m., Resident #12 was observed in the bed in a hospital gown. Resident #12 was bald on the top of his head. The hair around his ears and the back of his head was observed to be greasy and unwashed. Resident #12 said he did not have a choice of when he got a shower or bath . Resident #12 said he would like to have a shower. He said could not remember when he had last had a shower. On 2/22/18 at 9:00 a.m., Resident #12 was observed lying in the bed in a hospital gown, he said had still not had a shower. Review of Treatment Administration Record (TAR) for January and February of 2018 showed nurses documented Resident #12 received a shower twice weekly. Review of the CNA documentation on the Monthly Flow Report showed Resident #12 had one shower on 1/6/18. There was no further documentation of any showers for Resident #12 in the month of January 2018. The documentation showed Resident #12 did not receive a shower in the month of February 2018. On 2/22/18 at 10:06 a.m., Licensed Practical Nurse Staff C verified he had documented on 1/17/18, 1/20/18, 1/27/18, 2/3/18, and 2/17/18 Resident #12 had received a shower. He said the aide told him verbally. After reviewing the Monthly Flow Sheet Staff C verified the aides had not documented Resident #12 was given a shower on these dates. Staff C said he was not able to verify if the aides reported to him they had given Resident #12 a shower. He said they could have reported they were giving the resident a bed bath. On 2/22/18 at 10:20 a.m., the Director of Nursing (DON) said it was the practice of the facility to allow residents to have a least two showers weekly. After reviewing the documentation, the DON said they would have to look at the system for documentation of showers. On 2/22/18 at 10:25 a.m., Unit Coordinator Staff D said she did not know if the resident had a shower yesterday. The DON was observed telling the unit coordinator to ensure Resident #12 received a shower.

Based on staff interview and observation, the facility failed to ensure one (Resident #85) of two residents surveyed for dignity out of 29 residents surveyed. were treated with respect and dignity. The findings included: On 2/21/18 at 8:20 a.m., Licensed Practical Nurse (LPN) Staff A was heard yelling at Resident #85 She said You have to get up out of that bed. You've been up all night and you are not going to sleep all day. The tone of voice the nurse used was gruff. Staff A acknowledged she was speaking loudly to Resident #85. She said the the reason for her tone of voice and yelling was due to the resident being hard of hearing. She said she was was trying to encourage the resident to get up and eat his breakfast. On 2/21/18 at 9:01 a.m., LPN Staff A said she was a loud talker and came across a little brash. Staff A said other staff tried to wake Resident #85 up and he wouldn't get up. Staff A said, maybe it did come across a little loud. I do talk to loud sometimes. I have been gruff for [AGE] years. I apologize and I will make it up to (Resident #85) because he is a nice guy. On 2/21/18 at 9:08 a.m., LPN Staff A was observed passing medications to Resident #85. She spoke to the resident in a normal tone while telling him the medications he was receiving. The resident understood without Staff A raising her voice at him.

Based on observation, record review, and interviews, the facility failed to ensure 1 (Resident #179) of 3 sampled residents reviewed for falls was adequately supervised and monitored when he fell from his wheelchair onto his stomach in the courtyard, sustaining skin tears to his left arm, left leg and right eyebrow. The findings include: According to a nursing progress note on 1/17/15 at 2:45 p.m., Resident #179 had an unwitnessed fall out of the wheelchair in the courtyard. He was found lying on his stomach. A physical assessment was completed. Redness was noted on the resident's stomach. Skin tears were sustained to the left arm, left leg and right eye brow. Resident #179 denied head injury or pain. The resident's skin tears were addressed according to facility protocol. Neurochecks and vital signs were obtained and found to be within normal limits for Resident #179. The resident was placed on 15 minute checks. Review of the medical record on 1/27/15, showed his [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) is a primary screening and assessment tool of health status comprehensive assessments for Residents in long term care facilities certified to participate in Medicare and Medicaid. Resident #179 had a Significant change MDS assessment on 12/18/14, Section C, Cognitive Patterns with a BIMS score of 4. The Brief Interview for Mental Status (BIMS) determines the individual's attention, orientation and ability to register new information. The total possible BIMS score ranges from 0 to 15. 13-15: cognitively intact, 08-12: moderately impaired, 00-07: severe impairment. During an Interview on 1/28/15 at 2:24 p.m., the Unit Manager said she was not sure the resident was unsupervised when he fell in the courtyard on 1/17/15. Sometimes activities take them out. Resident #179 generally does not go out in the court yard. The Unit Manager said the courtyard is monitored by the Activity department. "Their windows face the courtyard and they can see the residents when they are out there." During an interview on 1/28/15 at 3:15 p.m., the Activity Director said, when residents are involved in activities and are out in the courtyard, they monitor them every 15 minutes, "I set the timer for 15 minutes." If a resident goes out into the courtyard, the nurse will sometimes let them know who is going out so they can keep an eye on them. The Activity Director said she was not aware Resident #179 had a fall on 1/17/15 and was not notified the resident was out in the courtyard. The Activity Director also said they can only see the courtyard closest to the door. They cannot see the whole courtyard. No one is in the activity department when providing activities in other areas of the building. During an interview on 1/28/15 at 3:45 p.m., Staff J, CNA said he was providing care to another resident in Room 136. While providing care, he heard someone yelling "Help me, Help me" from the courtyard. Staff J said he went to the window and saw Resident #179 lying on the ground in the courtyard and called for staff to assist the resident. Staff J said he did not observe the resident in the facility and did not know how long the resident was in the courtyard. During an interview on 1/30/15 at 8:45 a.m., Staff L said, Resident #179 received his prescribed dose of Xanax 0.25 mg. by mouth and his prescribed snack at 2:00 p.m. Staff L said the resident was still sitting at the table adjacent to the door to the courtyard at 2:30 p.m., and was unsure when the resident went into the courtyard. During an interview on 1/28/15 at 4:30 p.m., Resident #179 said he remembers falling out of the wheel chair in the courtyard, but could not recall the cause of the fall. The resident said he was only on the ground for a short while, but could not verbalize an accurate length of time. The resident was unable to offer additional information. During an interview on 1/29/15 at 4:45 p.m., Staff K stated on 1/17/15, she was to have "assignment 2." Staff K said Resident #179 is not on assignment 2. Staff K stated she went to the nurses station to start her shift on 1/17/15 at 2:00 p.m., and the resident assignment for the 2:00 p.m. to 10:00 p.m. shift had not been completed or posted on the white board. Staff K stated she looked in the assignment book and went to check her assigned residents. Staff K said she was not aware Resident #179 had been added to her assignment, until she was notified after the resident fell . Staff K said "I never provided him care because I was sick and leaving to go home." Staff K said she did not know how the resident entered the into the courtyard. According to Resident #179's care plan, revised on 12/30/14, the resident is at risk for falls with injuries. According to the medical record, the resident has a history of multiple falls, related to CVA with left sided hemiparesis, cognitive impairment, poor safety awareness, anxiety, degenerative joint disease and impulsive behaviors. Resident #179 is on the falling star/ falling leaf program. According to the falling star program, management plan, facility staff are educated to recognize residents participating in the Falling Stars/ Falling Leaf Program (as identified by a star/leaf) may be limited in safety awareness, have a greater potential to fall, and require more diligent supervision. During a phone interview with the daughter of Resident #179 on 1/30/15 around 8:30 a.m., she said the facility notified her regarding her fathers fall in the courtyard. She asked the facility why he was in the courtyard unsupervised but she said knowing her father he could have followed another resident or family out the door. The resident's daughter said she feels her father can get out the door to the courtyard independently. She said the facility is good about keeping an eye on him. She said even when she takes him out the nurse will come and find him. She said when he attempts to get up by himself there is usually someone around to prevent him from falling. During an interview on 1/28/14 at 4:45 p.m., the Director of Nursing (DON) said the facility has a Safety Management Program with an Inclement Weather Restrictions Policy. The Policy states, "Each facility should provide for periodic monitoring of residents in courtyards, secured patios, or porches to provide hydration in warmer weather and residents with moderate to severe cognitive impairment should be attended by staff or visitor when outside." The DON said the facility does not have a system to monitor residents when there are no weather restrictions. The facility uses the "Risk of Elopement/Wandering Review" to assess the Resident's competency to access the courtyard without supervision. 'Only residents that are an elopement risk must be supervised in the courtyard.'" Resident #179 is not an elopement risk and is not restricted from entering the courtyard unsupervised. According to the "Risk of Elopement/Wandering Review, dated 12/18/14, Resident #179 is cognitively impaired with poor decision-making skills and a pertinent [DIAGNOSES REDACTED]. This systems failure created a situation resulting in harm for Resident # 179 on 1/17/15.

Based on observation, interview and record review, the facility failed to provide intervention(s) based on this assessment for one (Resident #1) out of a sample of 8 residents; and provide safe and timely mechanical lift transfers for 8 (Resident #1, #2, #3, #4, #5, #6, #7 and #8) out of a sample of 8 residents. The findings include: 1. A review of the medical record for Resident #1 contained a "Non-Pressure Skin Condition Record", dated 11/23/12 and completed on the 11-7 shift, noting "bruise, R (right) axilla, 2.5 cm x 2.3 cm, color purple, MD (physician) notified, 'Is the resident experiencing pain? Yes.' " A "Witness Interview Form", dated 11/23/12, documented the following statement by Staff B: "Had resident on 7-3 shift. Res (resident) requested to go to the bathroom around 11 a.m. I used the Sabina Lift d/t (due to) no pad on Hoyer Lift. No bruising noted, but when I came in for 11-7 (shift on 11/22/12 - 11/23/12) when giving care I noticed 2 sm (small) bruises on RT (right) breast area & (and) axilla area. No c/o (complaint) of pain. No problems with transfer. Res (resident) could bear weight." An "Investigation: Bruise of unknown sources, Bruise to right axilla and right side of breast area near the armpit (Resident #1), and Date: 11/23/12." This document, completed by the Risk Manager, notes "Resident is extensive to total assist with transfers, bed mobility, and care. Resident requires a lift for transfers. According to therapy resident can bear some weight. Upon interviewing staff it was found that on 11/22/12 during the 7-3 shift CNA (Certified Nursing Assistant) transferred the resident to the bathroom using a Sabina Lift. Same CNA that noted the bruising that evening when giving care. It is felt that the bruising is consistent with the Sabina lift use. The bruising is not suspicious in nature. And Coumadin can be a continuing factor for severity of bruising." Upon interview on 11/29/12 at 12:00 p.m., Staff B stated "I transferred the resident, using a Sabina Lift, on the day shift (11/22/12) at about 12:15 p.m., around lunch time. She said she had to go to the bathroom. I usually use the Hoyer lift but there was no sling, with a hole in it, so she could use the toilet." When asked to explain how she used the Sabina lift, Staff B stated "I placed a pillow on the lift, where the resident stands because she did not have shoes on. I used a sling with padding under the arms." When asked if there were any knots in the sling straps, Staff B stated "Maybe, there usually are knots in the slings." Staff B stated she transferred the resident out of bed and pushed the lift into the bathroom. When asked if she did this alone, Staff B stated "Yes." Staff B clarified that the resident was in the window bed and that she had to push the resident, standing on the lift, past the other bed in the room to get to the bathroom. Staff B also stated that the resident was very heavy and that is why Staff B usually used the Hoyer lift. Upon review of the medical record revealed that the resident had a recorded weight of over 250 lbs., with a height of 60 inches, a [DIAGNOSES REDACTED]. The nursing notes, dated 11/19/12 at 4:06 a.m., state "pt. (patient) alert and confused, on abt (antibiotic therapy) for UTI, speech slurred, pt. total care and Hoyer lift needs two CNAs (Certified Nursing Assistants)." During an interview with the In-service Coordinator, on 11/28/12 at 2:00 p.m., revealed that there is no facility procedure for the use of the Hoyer or Sabina lifts. The facility did have Manufacturer's directions, for the use of a Sabina lift, which gave no directive to use a pillow under a resident's feet when Resident #1 is standing on the lift. The In-service Coordinator continued to state that she teaches staff how to use Sabina lifts, and this instruction does not include placing anything under a resident's feet when standing on the lift. An Interim Care Plan, dated 11/5/12, noted "At risk for physical injury from falls" with interventions that include "Assist of 2 for transfers, Assist of 2 for toileting." A Comprehensive Care Plan dated 8/7/12, with an update of 11/6/12 states "Hoyer or Sabina for transfer". 2. Upon interview on 11/28/12 at 10:00 a.m., Resident #2 stated that she transfers using a Hoyer Lift. She continued to state "it is not very convenient and they have to but me back to bed to use the bedpan when I have to go to the bathroom." When asked if she ever used the Sabina Lift for transfer, Resident #2 stated "Yes, but I developed an abscess under my arm when I used it. It was very painful. They had to treat me outside the facility to get rid of it. They did the best they could and I cannot use that type of lift (Sabrina)." When asked if the staff uses a Hoyer lifting sling with a whole (cut out) so she can use the toilet, the resident said "No, I do not know if they have anything like that." On 11/28/12 at 1:00 p.m., Resident #2's room door was open and she responded to a knock on the door stating "come in". Her wheel chair was in the middle of the room and her bathroom door was open. She said "come in, it ' s okay with me." The resident was sitting on the toilet and a Sabina Lift was in front of her. Resident #2 stated "I never use this lift, but I needed to go right away and could not wait for them to find the Hoyer lift." Knots were observed in the straps of the sling being used. Upon interview at this time, the Director of Nursing stated that the staff stated that Resident #2 requested to use the Sabina Lift and they complied with her request. "We will contact the physician to see if we can get an order (for the Sabina Lift)." A review of the physician orders, this date, documented an order, dated 10/27/12, noting "Hoyer Lift to be used for transfers." Review of the medical record documented a Physician Note, dated 10/10/12, noting "(Resident #2) has developed a rather large abscess which started in her left axilla and has now spread to the left upper outer quadrant of her breast. It has drained some but the [DIAGNOSES REDACTED] continues to spread. " Physician Notes dated 10/16/12 stated "(Resident #2) still complaining of thoracic/breast pain secondary to a cyst. I originally had her on Keflex with some mild improvement. She went out to Dermatology who opted not to I&D (incision and drainage) but changed her antibiotic." 3. On 11/28/12 at 1:30 p.m., Resident #3 was observed sitting in a wheelchair in her room. Staff C was observed walking down the hall, past the nurse's station, and entered Resident #3's room. Staff C was holding a black vinyl pad, with straps, in her hand and a white folded blanket under her arm at her axilla. Staff C placed a sling, with knots in the straps, under the resident arms and placed the black vinyl pad on the standing platform of the lift. Resident #3 was then raised to a standing position. She appeared to be standing on her toes (heels not resting on the platform) with minimal weight bearing. Her toes were at the outer edge of the lift and were sliding. She was also observed to have facial grimacing, at this time, until she was lowered unto her bed. At the completion of the transfer, Staff C was asked why the black vinyl pad was used on the platform. Staff C stated "You can use a pad or a blanket to position her feet better (on the platform)." When asked why one strap, from the sling was hanging loose on the resident's chest, Staff #C replied she noticed that and said the other part of the strap seems to be missing. She continued to stated "It is supposed to snap into this one." When asked if the sling was broken, the Staff C said "Yes." Staff C removed the Sabina lift sling, it was observed that the knots in the sling straps were under the resident arms and the resident stopped grimacing. A review of the medical record for Resident #3 documented a current physician orders, with an original order date of 8/21/12, that noted "Use Sabina lift until sling for Hoyer lift arrives." Upon interview on 11/29/12, the Director of Nursing (DON) had no explanation why Resident #3 was waiting over 2 months for a Hoyer lift sling and acknowledged that the physician's orders [REDACTED]. The DON had no explanation why the Sabina Lift sling had knots in the straps; but concurred that it did and also concurred that the sling (which had been brought to her office by the surveyor) was missing a (safety) strap and should not be used. 4. Resident #4 has physician orders, signed on 11/8/12, noting "Hoyer lift for all transfers." Observation of the resident on 11/29/12 at 8:00 a.m., revealed the resident sitting in a wheelchair in his room. There was no Hoyer lifting sling beneath the resident. When asked, Staff A stated "The Hoyer lift pad was removed because it was soiled. Staff A continued to state that Resident #4 "got a shower this morning and that is when the lifting sling was removed." When asked how the resident was transferred into the chair, Staff A stated "we used a Sabina Lift." At 8:45 a.m., on this date, Staff A was interviewed regarding the transfer of Resident #4. When asked when a sling would be placed under the resident so he could be transferred using the Hoyer Lift, Staff A said she would have to find one because "there are none on the unit." Staff A went to the laundry, accompanied by the surveyor, and was told there had been no slings, of any type, in 2 days. Staff A went to the rehabilitation unit and did not find any slings. The charge nurse on the unit stated "We do not have any lift (mechanical) transfers here. Staff A went to the remaining facility unit and found one Hoyer Lift sling and stated "I don't know if I can use this, it looks too small." Staff A asked the Occupational Therapist (who said he would help her apply the sling) if the sling was okay and the therapist stated "It should work." At 9:00 a.m., the Administrator advised the surveyor that there were no slings, of any type, available on the nursing units. Within a few minutes he advised that "new Hoyer Lift slings have been removed from our supply room." Upon interview at 9:30 a.m., this date, the Director of Nursing stated "the staff only brought the resident to a standing position using the (Sabina) lift. The staff can use their discretion in that type of situation because the sling was soiled". The Director of Nursing acknowledged that the physician order [REDACTED]." The "Care Directive" form (used by the CNA giving care) notes "Hoyer Lift, total assist of 2." 5. Resident #5 was observed being transferred on 11/29/12 at 7:30 a.m., using a Sabina Lift. Two Certified Nursing Assistants (CNA) were doing the transfer. An Occupational Therapist was in the room. During the transfer, the therapist intervened to adjust the sock on the residents left foot (so his bare foot did not touch the metal standing platform) and intervened a second time to apply the brakes on the lift as the CNAs were attempting to raise the resident to a standing position. When asked how many assists the resident needs for the transfer, the therapist replied "I am here to support the staff." Physician orders [REDACTED]." A "Care Directive" dated 11/27/12, used by the Certified Nursing Assistants (CNA)caring for the resident, noted "Sabina Lift, assist of one (1). A Comprehensive Care Plan dated 11/10/12 does not address the use of a Sabina Lift. During an interview with an Occupational Therapist (OT) and a Physical Therapist (PT), on 11/28/12 at 1:30 p.m., in the therapy supervisors office, reporting that PT and OT are not involved in the mechanical lift training of Certified Nursing Assistants (CNA). The Physical Therapist stated "They should know that through their CNA training." It was also clarified, at that time, which the nursing department was responsible for orientation and competency evaluation of the CNAs related to the use of mechanical lifts. 6. Resident #6 was observed being transferred by 2 Certified Nursing Assistants (CNA), using a Hoyer Lift, at 9:15 a.m., on 11/29/12. The resident was being transferred from the bed to a wheelchair". An Occupational Therapist (OT) was in the room. During the procedure, the OT was observed to intervene, two times, by adjusting the sling position under the resident. The OT was observed to move the lift closer to the bed. Physician orders [REDACTED]. A Comprehensive Care Plan, dated 11/4/12, documented "Hoyer lift for all transfers." A "Care Directive" dated 11/27/12 documents "Mechanical Lift Hoyer as needed" and the number of assists needed was crossed out on this form. Upon interview after the transfer of the transfer, the CNA assigned to the resident stated "We always use a Hoyer Lift, we cannot transfer him without one." 7. Resident #8 has physician orders, dated 11/13/12, documenting "Hoyer Lift for transfers." A Comprehensive Care Plan, dated 11/9/12, notes "Non Wt. (weight) bearing R (right) leg. R knee brace at all times. Hoyer Lift for transfers." A "Care Directive", dated 11/27/12, documents "Hoyer Mechanical Lift;" and the number of assists needed was crossed out on this form. Resident #8 was observed being transferred by 2 Certified Nursing Assistants (CNA) and a therapist, using a Hoyer Lift, on 11/29/12 at 10:00 a.m. The resident was wearing a knee brace on his right leg. After the transfer, Resident #8 stated "They used another lift (to transfer) me yesterday. I had to stand up and I am not supposed to stand on this leg (pointing to right leg). I had a very difficult time and I lost my balance and it hurt my leg. When asked if the therapist is usually in the room during the transfer, the resident stated "No, but I am glad she was." 8. On 11/29/12 at 9:45 a.m., the responsible party for Resident #7 was interviewed. During the interview she stated "It takes a very long time for them (the staff) to find a Hoyer Lift to transfer him (the resident). Sometimes they find a lift and then cannot find a sling; it takes at least 30 minutes this time of day. It also takes a long time after lunch and in the evening. A lot of times, like today, he has to go to the toilet and is made to wait. That is a problem and sometimes he has an accident and gets very upset." Upon interview at 11:00 a.m., on 11/29/12, the Administrator advised that the facility had 4 Hoyer Lifts and 6 Sabina Lifts. He advised that the facility had 31 Hoyer slings, 6 Hoyer slings with holes, and 30 Sabina slings. The In-service Coordinator advised on this date, that there were 23 residents requiring Hoyer Lift transfers and 23 residents requiring Sabina Lift transfers in the facility. Surveyor observation, regarding Hoyer Lift transfers this date, revealed that the procedure takes approximately 10 minutes. It is thus feasible that a resident could potentially wait 30 minutes, during peak transfer times, to be transferred via a Hoyer Lift.

Based on observation, record review and interview the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable psychosocial well-being of each resident. The facility administrator failed to ensure the fire alarm system was installed or tested in accordance with NFPA 72 (2002 Edition) "The Standard for the Installation of Fire Alarm Systems," and maintained in reliable operating condition. This could delay or deny the required early warning of fire in the building. This placed all residents' lives at risk during a fire or smoke event in the facility, due to the fire alarm system failure to work. This was identified as Immediate Jeopardy beginning on 8/12/11 and ending on 9/20/11. The findings include: Cross refer to K052. The facility failed to ensure the fire alarm system was installed or tested in accordance with NFPA 72 (2002 Edition) "The Standard for the Installation of Fire Alarm Systems," and maintained in reliable operating condition. In the initial record review process on September 20, 2011 at 9:15 a.m., the facility could not produce documents confirming the required Annual testing of the fire alarm system which was due in August, 2011. It was then confirmed by the Administrator and the Director of Maintenance that the facility had installed a new fire alarm system. Further record review indicated a new Silent Knight 5230 had been permitted by Cintas Fire Protection through Lee County on May 24, 2011 (Permit Number FIR2011- ), and, based on the Administrator's statement, was to be an "emergency replacement" for the existing FCI 7200 system. The Cintas installation would have required the facility to maintain a "fire watch" for approximately 28 days during the installation period and the panel installation could not be "paralleled" with the existing system. On July 25, 2011, Lee County records indicate a "Change of Contractor" notification was completed from Cintas Fire Protection to Electraserve, Inc. and the Administrator confirmed that the facility changed contractors, since the new company could do a "parallel" installation which would mean maintaining the old system in functional condition while installing a new system prior to full connection. The new company, Electraserve, Inc., utilized the Cintas fire permit and plans while installing a new Notifier 640 E system. The available fire system record log documents indicate the old system was still in place on July 6, 2011 and the installation took place after that date. However, the fire alarm company did not complete the "Fire System Record Log" to verify an installation date. During an interview on September 23, 2011 at 10:40 a.m., a technician at Electraserve, Inc. stated the work began on the facility's fire system on August 12, 2011. At 3:15 p.m. on September 20, 2011, the Inspector notified the Estero Fire Department of the situation based upon the unreliability of the installed fire alarm panel and required the facility to institute a "fire watch" for an indefinite period of time to protect the safety of the 125 current residents and approximately 70 staff on property. The facility Administrator and the Director of Maintenance concurred and immediately began the fire watch. At 3:40 p.m., the Estero Fire Division Chief of Prevention arrived on the property and, as the local AHJ, mandated the "fire watch" to be conducted at half-hour intervals indefinitely. The contractor stated the system was fully functional, all devices had been installed and tested and they had not fully completed the project since the "plans" were still under "review" by Lee County. The contractor also stated no submission had been made to the State Office of Plans and Construction, since they were unaware of that requirement for health care facilities; to his knowledge they never installed any nursing home/health care facilities. On September 21, 2011 at 8:15 a.m., in the presence of the Estero Fire Division Chief, The Chief Estero Fire Inspector, the Electraserve representatives, the facility Administrator and staff, and two State FPS Inspectors, the system was tested for functionality and failed to annunciate the installed strobe and horn devices. The Estero Division Chief halted further testing until all the plans, permits and blueprints were current and acceptable by all authorities having jurisdiction and further mandated the continual "fire watch" with thirty minute rounds and hourly visual inspections of the wood truss roof assemblies in all five (5) smoke compartments. State officials were notified of the situation and it was determined that Immediate Jeopardy existed. The facility Administrator was in agreement with the decision. On September 20, 2011 the facility instituted a continual fire watch. The survey team determined at this point, based on the facility implementing a continual fire watch, that Immediate Jeopardy was removed and the deficient practice remains at a Scope and Severity of F.