Every finding on record at Life Care Center of Jacksonville

Based on food service observations, staff interviews, facility documentation and a review of the facility's policies and procedures, the facility failed to follow proper temperature documentation requirements for food safety to prevent bacterial growth and the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to consistently monitor, verify, and document accurate operating temperatures and sanitizer concentrations for the mechanical dish machine and 3-compartment sink. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:A tour of the kitchen was conducted on 06/22/2026 at 10:25 AM. During the tour, Dietary Aide (DA) L demonstrated the high-temperature dish machine, stating the wash cycle operated between 167-170 F and the final sanitizing rinse reached 180 . A review of the High Temperature Dish Machine Logs revealed identical wash (167 degrees) and rinse (180 degrees) temperatures across all recorded cycles consistently from 02/2026 through 06/2026. Test 1 of the dish machine revealed a wash temperature of 130 and a final rinse temperature of 140 . Test 2 revealed a wash temperature of 142 and a final rinse temperature of 170 . Test 3 revealed a wash temperature of 144 and a final rinse temperature of 178 . Test 4 revealed a wash temperature of 146 and a final rinse temperature of 178 . A final test run of the high-temperature dish machine revealed a wash temperature of 148 and a final rinse temperature of 180 . The High Temperature Dish Machine Log instructions noted that the surface temperature test should be completed using a test strip and with the result (pass/fail) being logged daily. There was no documentation completed of the surface temperature using a test strip and nothing was documented on the log. During the same tour, [NAME] M demonstrated the ware washing process and use of sanitation. During the demonstration, she stated the sanitizer concentration should be maintained between 300-400 parts per million (ppm): however, observations of the posted service guide above the sink revealed the required concentration was 200-400 ppm. A review of the Pot and Pan Sink Sanitizer Concentration Log revealed identical sanitizer concentrations consistently from 01/2026 through 06/2026. (Photographic evidence obtained)An interview was conducted on 06/25/2026 at 11:18 AM with Dietary Aide (DA) I. He was asked to explain the exact steps taken to measure and record dish machine temperatures. DA I stated the following setup and testing procedures: He fills the tank, dips a test strip to ensure the sanitizer concentration is between 200-400, and checks the machine's temperature. He stated the required temperatures were 80 for the wash and 50 for the rinse, and all results were recorded on the log sheet. If the levels were too high or too low, the process was repeated. When he was asked if he was aware that intentionally logging temperatures or concentrations without taking the measurement was considered falsification of official records, he replied, yes. When he was asked if it was possible for the machine to produce the same temperatures daily, he replied, No, that is not possible.An interview was conducted on 06/25/2026 at 11:34 AM with [NAME] J. She was asked explain the exact steps taken to measure and record dish machine temperatures. [NAME] J stated she was responsible for the use of the 3-compartment sink with the following setup and testing procedures: Filling the wash sink with hot water and detergent, filling the rinse sink with warm water, and filling the sanitation sink with cold water. The sanitizer was tested by dipping a test strip into the solution for 10-15 seconds and comparing the color change to the chart. If the levels were too high or too low, the water was drained and the process was repeated. [NAME] J explained that the sanitizer system was automated and there was no need for manual mixing. The dispenser tube connected directly from the sanitizer concentrate bottle to the sink, automatically pulling the chemical ratio. As long as the tube remained properly connected, enough sanitizer was continuously dispensed. When asked if she was aware that intentionally logging temperatures or concentrations without taking the measurement was considered falsification of records, she replied, yes.An interview was conducted on 06/25/2026 at 11:52 AM with the Certified Dietary Manager (CDM) who stated the high-temperature dish machine wash cycle operated at 150 F or above and the final sanitizing rinse reached 180 or above. The CDM was not sure about the surface temperature test for the dish machine. She confirmed that the acceptable sanitizer concentration range for the 3-compartment sink was 200-400 ppm. The target concentration was 300 ppm, and the valve would be adjusted if levels exceeded 400 ppm. Since the exact same chemical concentration was noted on the log every single day, the CDM was asked to explain how the sanitizer was mixed to ensure it was always perfectly accurate. She replied, it cannot. When asked if she was aware that intentionally logging temperatures or concentrations without taking the measurement was considered falsification of records, she replied, yes.A review of the facility's policy and procedure titled, Ware Washing - Dish Machine/Manual Process (last revision: 4/26/2023), revealed:Policy: The Director of Food and Nutrition Services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state and local requirements. Mechanical Ware Washing. High Temp Dish Machine. 1. Dish machine will be used in accordance with the manufacturer specification.3. A surface temperature test using a surface temperature indicator strip should be completed and logged daily on the High Temperature Dish Machine Log. 4. An irreversible surface temperature indicator strip will be readily accessible for measuring surface temperatures per facility guidelines.Manual Ware Washing. Use of Three-Compartment Sink.3. Sinks are filled as wash with detergent for washing, rinse with clean water to remove all soap residue and sanitize with appropriate sanitizer using guidelines noted by manufacturers.

Based on record reviews, observations and interviews, the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible for four (Residents #98, #38, #109 and #125) of four residents reviewed for accidents, from a total survey sample of 31 residents. The facility failed to properly store scissors, hair shears, and knives used by Residents #98, # 38, 109 and #125. This placed the residents reviewed for accidents and any other residents who could access their rooms, at risk for accidents with injury. The findings include:1.On 6/22/2026 at 11:39 AM, Resident #98 was observed in bed with his eyes closed. He did not respond when greeted. Hair shears were observed on his bedside table. The shears were visible and accessible to anyone who entered the resident's room. (Photographic evidence obtained)On 6/23/2026 at 11:17 AM upon entering Resident #98's room, hair shears were again observed on the resident's bedside table. The shears were visible and accessible to anyone who entered the resident's room. (Photographic evidence obtained)On 6/24/2026 at 12:33 PM, upon entering Resident #98's room, hair shears were observed on his bedside table. The shears were visible and accessible to anyone who entered the resident's room. (Photographic evidence obtained)A review of Resident #98's Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 5/23/2026, revealed a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating the resident's cognition was intact. Resident #98 had no impairment to his upper extremities, used a walker and had no physical restraints or alarms.Licensed Practical Nurse (LPN) E was interviewed on 6/24/2026 at 3:10 PM. She stated independent residents could have spray deodorant and electronic shavers at their bedsides. Residents who were permitted to use electronic shavers should have a care plan for them. Residents were not permitted to have razors or any other sharps at their bedside. For residents who required assistance with shaving, facility staff were to store disposable razors in a locked supply closet, and the razors were discarded after use. She stated if she noticed a resident had a prohibited item at bedside, she would remove the prohibited item, call the resident's family member, document the occurrence in the resident's electronic medical record and notify her supervisor.On 6/24/2026 at 3:15 PM, Licensed Practical Nurse (LPN) E was accompanied to Resident #98's room. She observed the hair shears on the resident's bedside table. She confirmed that the shears should not be on the resident's table and accessible to anyone who entered the resident's room.On 6/24/2026 at 3:17 PM, Resident #98 was interviewed. He stated LPN H gave him hair shears so that he could easily open candy and food condiment packets.2. On 6/22/2026 at 11:41 AM, upon entering Resident #38's room, scissors were observed on her bedside table. The scissors were visible and available to anyone who entered her room. (Photographic evidence obtained)3. On 6/22/2026 at 1:52 PM, upon entering Residents #109's room, scissors were observed on his bedside table. The scissors were visible and accessible to anyone who entered the resident's room. (Photographic evidence obtained)4. On 6/25/2026 at 10:39 AM, upon entering Resident #125's room, a steak knife was observed on her bedside table. The knife was visible and accessible to anyone who entered the resident's room. (Photographic evidence obtained)On 6/25/2026 at 1:14 PM the Director of Nursing was interviewed. She was asked if the facility had a policy describing which personal items a resident was permitted to have at bedside. She replied, Yes, the facility has a policy for this, and residents are prohibited from keeping electrical cords, aerosol cans, and space heaters at the bedside. She stated independent residents could have electric razors, nail clippers, regular razors, creams and lotions at their bedsides, but these items should be put in a bag or stored in the bathroom and should not be accessible to anyone who entered the resident's room.

Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #25) of 42 sampled residents, who was unable to carry out activities of daily living (ADLs), received the necessary services to maintain good grooming and personal hygiene. The findings include: A review of Resident #25's medical record revealed he had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points, indicating moderate cognitive impairment. There were no documented behaviors, bathing was noted as very important to him, and he required extensive assistance with his ADLs, including personal hygiene (combing hair, brushing teeth, shaving, and washing/drying face and hands). On [DATE] at 10:13 AM, Resident #25 was observed with a contracture of the right hand and appeared to be immobile on his right side. Upon further observation it was noted that his fingernails were long with a dark brown substance beneath them. (Photographic evidence obtained) He was unshaven. When asked if he preferred his fingernails long, he stated he would like them trimmed and would also like a shave. A review of the care plan dated [DATE] revealed that Resident #25 was a vulnerable resident who was at risk for abuse based on his need for assistance with transfers, toileting, transport, dressing, and other ADLs. The plan included ADL goals, which stated the resident should be clean, dry, and well groomed with assistance from staff, including assistance from staff for personal hygiene and oral care. Review of a Personal Hygiene task completion form, revealed that on a 30-day look-back period from [DATE] through [DATE], the resident was totally dependent requiring full staff performance for personal hygiene. Documentation indicated this was not performed on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 8:52 AM, Resident #25 was observed with very long fingernails with dark brown debris beneath them. A full beard remained as well. Resident #25 reiterated that he had informed the facility that he would like to have his nails trimmed and cleaned, along with a clean shave. On [DATE] at 10:28 AM, Resident #25 was again observed with dark brown debris beneath his fingernails. He remained unshaven. An interview was conducted with Certified Nursing Assistant (CNA) A on [DATE] at 10:32 AM, who stated she had been working at the facility for six years as an Agency CNA, and more recently (over the last three weeks) she had been working here more often. She stated orientation training was conducted at the facility which included resident hygiene, documentation of tasks, appointments, CPR (cardiopulmonary resuscitation), falls, and personal hygiene. When asked about resident showers, she said showers were generally conducted on the 7A-3P and 3P-11P shifts, and shower sheets had to be signed and filled out to show the task had been completed. When asked to talk through the process of cleaning the residents, she said she would first wake the resident, help if needed to brush their teeth and get them ready to eat breakfast. She would wait for approximately 30 minutes after the meal so they could digest their food, and then she would shower the resident which usually occurred between 9:00 AM and 9:30 AM. During the showering process, she said she would look for skin redness, signs of injury, skin tears or anything abnormal, and she would notify the nurse of such things. She added that she would make sure the residents were clean shaven, toe nails and fingernails were trimmed and clean, and ensure the residents' eyes were clean. If the nails did need trimming, she would let the nurse know, because CNAs could not trim or cut the nails, only clean them. An interview was conducted with Licensed Practical Nurse (LPN) B, Unit Manager, on [DATE] at10:43 AM, who stated personal hygiene training was provided, and she expected the CNAs to attempt to shower the residents as cleanliness was important. She continued, stating she expected residents not to have soiled hair, and for the CNAs to do their best to keep the residents clean paying close attention to perineal care, washing and cleaning fingernails, have podiatry trim toenails, and make a full-body observation from head to toe. She stated if toenails need trimming, this need was placed in the Podiatry book. When asked who trimmed residents' fingernails, she stated fingernails were done by the Activities Department staff. They had what was called a manicure day every Tuesday and on an as needed basis. When she was asked how it was known whether or not a resident needed fingernail or toenail care, she said she would know based on a visual assessment, if the resident verbalized it themselves, or through notification by the CNA. Activities Director C was interviewed on [DATE] at 11:08 AM in reference to residents' fingernail and toenail care. she stated she had been employed by the facility for [AGE] years. She had a CNA license and would help with tasks such as fingernail care. She stated the facility had what they called Fancy Fingers activities on Thursdays, and this consisted of manicures, fingernail cleaning, nail trimming and filing, and if the resident wished, the nails would be polished. When asked about toenail care, she said her team would place information inside the Podiatrist book and the Podiatrist came to the facility on Fridays to take of the residents' feet. On [DATE] at 11:24 AM, an interview with the Director of Nursing (DON) revealed that if residents needed assistance with ADLs, it would be listed on the Kardex (brief paper-based summary of a resident's needs). If a resident needed or wanted a bath/shower, there were shower sheets that would indicate who needed showers on certain days. When asked about her expectations of staff for the provision of ADL care and personal hygiene, she said she expected showers to be given in a timely manner and CNAs to do a minimum of two-hour rounds, change residents in a timely manner, assist with brushing teeth, washing faces, combing hair, and skin observation. She further stated along with the skin observation, there should be no new bruising or skin tears/lacerations, and if something like that was observed, the CNA should report it to the nurse or herself (DON). When asked about CNA roles and capabilities when providing personal hygiene as it relates to fingernails, she stated, CNAs can clean, file, and paint fingernails but no cutting or trimming. Nurses are allowed to cut/trim fingernails, and toenail care is left for the podiatrist. She further stated her nurses should be observing as well That's their job and they should be doing weekly checks. When asked if this was just for women, she replied, Nno, men get their nails cleaned and filed, and they get shaved. A review of the facility's Assisted Daily Living Policy stated for Fingernail Care: Ensure fingernails are clean and trimmed to avoid injury and infection; Explain importance of fingernail care to the resident; assemble all necessary equipment, which may include fingernail clipper, nail file, orange sticks, wash basin, towel, and any other necessary equipment; report any abnormalities to the nurse.

Based on observations, a records review, a review of the facility's policies and procedures for Cardiopulmonary Resuscitation (CPR) and Advance Directives and Advance Care Planning, and interviews with staff, the facility failed to ensure clinical staff appropriately provided basic life support, including cardiopulmonary resuscitation (CPR) to a resident (#1) requiring such emergency care, out of five residents reviewed for Code Status/Advance Directives, by failing to 1) Verify the resident's code status when the resident was found unresponsive, 2) Provide CPR as per the resident's documented wishes and her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:30 AM, Registered Nurse (RN) A was notified that Resident#1 had a change in condition. The resident was warm to the touch and unresponsive. RN A assessed the resident, but did not check her code status. RN A did not initiate CPR as per the resident's wishes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A later discovered that the resident was a full code status (desired to be resuscitated if found in cardiac/respiratory arrest) and informed the Assitant Director of Nursing (ADON). The incident was not reported to the Director of Nursing (DON) or the Administrator. The facility failed to initiate Cardiopulmonary Resuscitation (CPR) to a resident who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:40 a.m. on [DATE]. On [DATE] at 1:30 a.m., the Immediate Jeopardy (IJ) began. On [DATE] at 5:55 p.m., the Administrator was notified of the IJ determination. Immediate jeopardy was removed upon survey exit on [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D. On [DATE], the facility's census was 88. Any residents whose Advance Directives indicated a Full Code Status were at risk. There were 58 residents who had a Full Code status at that time. The findings include: A review of Resident #1's Electronic Medical Record (EMR), revealed that she was [AGE] years old. She was admitted to the facility on [DATE], and was readmitted on [DATE], with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1's Initial Social Services Assessment, dated [DATE], revealed that her code status had been discussed with her and her preference was to be a full code. Resident #1 had an electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Death in Facility Tracking Minimum Data Set (MDS) assessment, dated [DATE], revealed that Resident #1 had been admitted from an acute-care hospital on [DATE]. She was discharged on [DATE]. Her discharge status was deceased . Resident #1's quarterly MDS assessment, with an assessment reference date of [DATE], assessed her with a brief interview for mental status (BIMS) score of 10 out of a possible 15 points, indicating moderate cognitive impairment for daily decision making. She required extensive assistance with activities of daily living. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Active discharge planning was occurring for her to return to the community. Resident #1 actively participated in the assessment. Resident #1 was care planned on [DATE] for having no Advance Directives on file. The care plan noted CPR-Full Code, and that it was a readmission care plan that had been reviewed and re-initiated. The goal was for Resident #1's Advance Directives to be honored. Interventions/Tasks included a code status review on a quarterly basis and as needed (prn), and that the resident had decided to remain a full code. (Photographic evidence obtained) A nursing progress note authored by Registered Nurse (RN) A on [DATE] at 1:30 a.m., revealed she was called into Resident #1's room by a Certified Nursing Assistant (CNA) B, who found Resident #1 unresponsive. RN A was unable to palpate a peripheral or carotid pulse, and noted there was no rise and fall of the resident's chest. The resident's skin felt warm. Time of death pronounced at 1:30 a.m. The physician's on-call health care provider was notified. (Photographic evidence obtained) A review of the Physician's Progress Notes found Resident #1 had last been seen by her primary care physician on [DATE] for a follow-up visit. The primary assessment was displaced intertrochanteric fracture of the right femur, initial encounter for closed fracture. The physician noted Resident #1 had no active disease (NAD) and no complaints at the time of the visit. Resident #1 was assessed as alert and oriented to person, place, time and situation. An addendum to the progress note, electronically signed by the Advance Practice Registered Nurse (APRN), indicated nursing had called to report the patient expired on [[DATE]]. Further review of the record found no indication Resident #1 was having a decline in her health or a significant change in her condition leading up to her death. A review of facility records found there were seventeen (17) residents assigned to Employee A on the night of [DATE]. Eleven (11) of the seventeen (17) had a full code status. In an interview with CNA C on [DATE] at 10:25 a.m., she was asked where to find the code status for her residents. She stated the status was located in the electronic record and was visible as soon as you logged into the resident's electronic record. In an interview on [DATE] at 10:30 a.m., Licensed Practical Nurse (LPN) D stated that a resident's code status was in the chart (she demonstrated by showing a DNRO (Do Not Resuscitate Order) from a resident's paper chart) and in the EMR. LPN D stated she would start CPR on a resident, no matter how cold or stiff the resident was, until paramedics arrived. A telephone interview was conducted with RN A on [DATE] at 11:40 a.m. She confirmed she was the nurse who found Resident #1 unresponsive, without a pulse, and still warm to the touch. She pronounced the resident deceased at the scene. Employee A explained that there was nothing, so she withheld CPR. RN A confirmed that she did not look for Resident #1's code status prior to making that decision. Later, while completing paperwork, she discovered Resident #1 had a full code status. The RN was asked if Resident #1 had been declining, or if there were any factors leading up to her death to indicate it was anticipated. She said, No, absolutely nothing. She explained that the CNAs had been joking with Resident #1 that day. RN A did not know what happened, speculating that maybe Resident #1 had a stroke. When asked why she did not look for Resident #1's code status, she said she didn't look because there was nothing. RN A was asked where Resident #1's code status would have been located. She replied, in the chart. RN A was asked why, when the resident was still warm, did she not check the code status of Resident #1 and initiate CPR per Resident #1's wishes. RN A replied by explaining that the resident's legs were still warm, but her torso was cold, so she thought she did the right thing. RN A stated she reported her discovery of the full code status to the ADON. The ADON was interviewed on [DATE] at 12:15 p.m. She confirmed that she was called by RN A the night of the event. She thought the call came in at approximately 2:00 a.m. RN A found Resident #1 unresponsive and without a pulse. She thought Resident #1 might have been cold. The ADON instructed RN A to report that to the doctor and document her findings. Later on, she could not recall if it was the same morning or the next day that RN A told her she had discovered Resident #1 was a full code. The ADON asked RN A if she reported that to the physician, and RN A said yes, she had. The ADON was asked what her expectation of the clinical staff was when any resident was found unresponsive and without a pulse. She stated the code status of the resident should be checked first. Do Not Resuscitate Order (DNRO) forms were kept in the medication book. Code status was also reflected on the resident's electronic record dashboard and in the electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what happened after the event, the ADON said she spoke with RN A about checking the charts. She did not recall whether she told the Administrator or the DON about the occurrence. An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:30 p.m. When asked about his awareness of the incident, he stated the ADON had never reported the event to him or anyone else until just now. The facility had no awareness that Resident #1 was not provided CPR per her wishes on [DATE]. His expectation for any resident found unresponsive was for the nurse to call Code Blue and check the code status of the resident in the chart. The DON stated he could think of three conditions for which CPR could be withheld when a resident was a full code, including decapitation and rigor mortis. He could not recall the other. He confirmed Resident #1 did not appear to meet any of the criterion for withholding CPR. The DON had no explanation for why RN A failed to check Resident #1's code status, adding that she was a seasoned nurse. The DON stated they would need to start retraining the nurses. An interview was conducted with the Social Services Director (SSD) on [DATE] at 1:57 p.m. She explained that Advance Directives were discussed with residents on admission as part of the initial Social Services Assessment. Resident #1 chose to be a full code. The SSD presented a copy of the Social Services assessment dated [DATE], which reflected Resident #1's full code status. The SSD added that Resident #1 was also care planned for this, and provided a copy of the care plan dated [DATE]. This also reflected Resident #1's wishes to be a full code. (Photocopies obtained) A telephone interview was conducted with CNA B on [DATE] at 2:26 p.m. She confirmed that she found Resident #1 unresponsive and reported her findings to RN A. CNA B explained that she made rounds to check on her assigned residents every two hours. During her 1:30 a.m. rounds, she went into Resident #1's room and found her lying across the bed horizontally with her legs hanging over the side. When CNA B went to assist her back into the bed, she discovered the resident was unresponsive. Resident #1 was still warm and her color was good. RN A came in the room and touched Resident #1. She checked for a pulse, but found none. Nothing else occurred after that, and CNA B started post-mortem care. CNA B explained that most of the time she was assigned to hospice patients, so checking a resident's code status wasn't really ever an issue; however, she did check Resident #1's code status later, as this resident was not ill. RN A recalled that at 11:00 p.m., Resident #1 was still awake and stable. RN A had given her some medication a couple of hours before that. Nothing was out of the ordinary. CNA B concluded by stating she would assume the nurse would check the resident's code status, as she had never had to do that in her working career as a CNA. A review of the facility's Clinical Services Manual procedures for Cardiopulmonary Resuscitation (CPR) Guidelines (revised [DATE] and last reviewed [DATE]) found the following: Purpose: To ensure that each facility is able to and does provide emergency basic life support immediately, when needed, including CPR to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Federal Regulations (F 678) §483.24(a)(3): Personnel provide basic life support, including CPR, to a resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . . The AHA (American Heart Association) urges all potential rescuers to initiate CPR unless: -A valid Do Not Resuscitate (DNR) order is in place; -Obvious clinical signs of irreversible death (e.g. rigor mortis (stiffening of the joints and muscles, which occurs a few hours after death), dependent lividity (reddish/blue discoloration of the skin resulting from gravitational pooling of blood in the blood vessels evident in the lower lying parts of the body in the position of death), decapitation (the head is apart from the body), transection (cut across), or decomposition (the state or process of rotting and decaying of flesh). -Initiating CPR could cause injury or peril to the rescuer. If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death ( e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's Advance Directives and any related physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Policy: 1. Staff must maintain current CPR certification . 2. Facility must address the provision of basic life support and CPR including: i. Directing staff to intiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death and: ii. Who had requested CPR in their Advance Directives, or . . iv. Who do not have a valid DNR order . . 6. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photocopy obtained) A review of the facility's Clinical Services Manual procedures for Advance Directives and Advance Care Planning (last revised [DATE] and last reviewed [DATE]) revealed the following: Purpose: The ability of a person to control decisions about medical care and daily routines has been identified as one of the key elements of quality of care at the end of life. The process of advance care planning is ongoing and affords the resident, family and others . an opportunity to reassess the resident's goals and wishes as the resident's medical condition changes. Policy: Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive. Procedure: 1. All residents or responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care . and the formation of Advance Directives upon admission. 2. A written description of the facility's policies regarding Advanced Directives and applicable state law is provided to the resident/representative . 3. The Admissions Director or designee interviews the resident/family upon admission . . c. If the resident has Advance Directives, the social worker will request a copy of the directive so that it may become a part of the medical record. Documentation of such directives are placed in the Social Services progress notes. The resident's attending physician is made aware of such, and the appropriate orders are incorporated into the resident's care plan . . 16. Do Not Resuscitate (DNR) - Regardless of whether a resident is in a persistent vegetative state or has a terminal condition . all residents receive full resuscitative measures unless a DNR is written in the resident's medical record and is identified in the resident's Advance Directives . (Photocopy obtained) On [DATE] at 2:44 p.m., the facility provided their immediate actions to remove the Immediate Jeopardy. These immediate actions were verified by the surveyor on-site as having been completed as follows: The ADON and RN A were suspended pending investigation on [DATE]. A 100% audit of all active residents' code status was completed on [DATE] by the Director of Medical Records and Director of Social Services. The audit revealed that all residents had a current code status with a corresponding physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], an additional newly admitted resident was reviewed, and code status was also indicated on the resident's record with a correlating physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], in-service trainings on the Advanced Directives and Advance Care Planning, Cardiopulmonary Resuscitation, and Pronouncement of Death policy commenced. No licensed nurse was permitted to work until training was received. As of [DATE], all 34 licensed nurses had been trained. The 17 nurses who received training via telephone would be met by a trainer upon return to the facility to demonstrate and verbalize CPR and code status competencies. An audit of all licensed nurse CPR certification was conducted by the Human Resource Clerk/Designee on [DATE]. As of [DATE], 32 of 34 nurses' certification had been verified and were on file. On [DATE], a Code Status Verification upon Admission/Readmission audit was conducted by the Social Services Director for new admissions, with one newly admitted resident reviewed. All newly admitted /readmitted residents' code status' will be verified on admission by the nursing department and verified by the Social Services Director/Designee on admission. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The DON filed a report with the Abuse Hotline on [DATE] at 8:10 p.m. The State Agency arrived to investigate on [DATE]. This was noted in the resident's chart on [DATE] at 10:15 a.m. An electronic immediate federal report was filed with the State Agency by the Administrator (report # 3) on [DATE]. Mock Code Blue/Emergency drills were conducted on [DATE] at 6:42 p.m. and 6:50 p.m., and on [DATE] at 10:52 a.m. A total of 35 employees participated in the drills. Medical emergency worksheets were completed with the drills and were reviewed and verified. Prior to the survey exit on [DATE] at 2:57 p.m., another mock medical emergency drill was called over the loudspeaker. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted with the Medical Director, DON, and Administrator on [DATE], and a Performance Improvement Plan reflective of the Immediate Jeopardy removal plan was developed and implemented. A copy was voluntarily provided to the surveyor and reviewed. In an interview with the Staff Developer on [DATE] at 3:11 p.m., training on the facility policy related to Advance Directives was provided to all employees on day one of new employee orientation. In an interview with Personal Care Attendant (PCA) J, on [DATE] at 3:27 p.m, she stated she had access to the residents' electronic records and knew their code status was on the page where she did her charting. In an interview with LPN E on [DATE] at 12:10 p.m., she stated if she found a resident unresponsive, she would check the code status in the chart on the face sheet and call a Code Blue. If the resident was a full code, she would get the crash cart. In an interview on [DATE] at 12:13 p.m., LPN F stated she had training in Advance Directives in the past. Should she find any resident unresponsive, she would check for a pulse and quickly assess them. If the resident required CPR, someone must always stay in the room. She would run and check the chart and the code status of the resident. If there was no DNR anywhere, she would start CPR. Even if the resident was gone, she said they still had to start CPR until the AED (automated external defibrillator) was obtained and/or emergency medical services (EMS) arrived. You don't stop. In an interview with RN G on [DATE] at 12:19 p.m., she stated, You need to check everything, especially the DNRO, before you perform CPR on a resident. LPN H was interviewed on [DATE] at 1:07 p.m. She stated if she found a resident unresponsive, she would check the chart for the code status. If the resident had a DNRO, she would withhold CPR. She stated she would look for the goldenrod copy of the DNRO to verify the resident's status. She has had to do it so many times. The DNRs are in the narcotics (narc) books and in the paper chart, and all Advance Directives are in the electronic record on the top banner and in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN I stated on [DATE] at 1:10 p.m., that documentation of the residents' code status was in the narcotic book and in the resident's profile on the electronic record dashboard next to the resident's picture. The DNROs were in the narcotic books. If she was notified that a resident was unresponsive, she would check their vitals and the code status before starting any compressions.

Based on observations, record reviews and interviews, the facility failed to ensure a medication error rate of less than 5% for two (Residents #66 and #18) of three residents sampled for medication administration review. There were 27 opportunities for error with six medication errors identified, for a medication error rate of 22.22%. The findings include: 1. A review of Resident #66's medical record revealed current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/17/21 at 8:20 AM, an observation of medication administration was made with Employee A, Registered Nurse (RN), for Resident #66. Employee A failed to administer the Potassium 20 meq, Lactobacillus, [MEDICATION(S)] 10 mg (milligrams) and [MEDICATION(S)] 500 mg per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/17/21 at 9:00 AM, an interview was conducted with Employee A. She confirmed that she missed four of Resident #66's medications during the morning medication pass. She stated she failed to scroll to the next page of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 2. A medical record review for Resident #18 revealed that an apical pulse (a pulse site on the left side of the chest over the pointed end of the heart) check was required prior to administration of [MEDICATION(S)]. The parameters instructed nursing to hold medication for a pulse of less than 60. The record review also revealed that rinsing the resident's mouth with water after administration of [MEDICATION(S)] diskus was required. On 3/17/21 at 8:40 AM, an observation of medication administration was made with Employee A, RN, for Resident #18. Employee A failed to take an apical pulse prior to administering [MEDICATION(S)] 125 mcg (micrograms), and she failed to have Resident #18 rinse her mouth with water after administering [MEDICATION(S)] diskus aerosol powder. On 3/17/21 at 9:00 AM, an interview was conducted with Employee A. She confirmed that she failed to check the apical pulse prior to administering Resident #18's [MEDICATION(S)], and she failed to ensure the resident rinsed her mouth with water after she received her [MEDICATION(S)] diskus. On 3/17/21 at 9:15 AM, an interview was conducted with Employee I, Regional Nurse. She confirmed that the nurse missed four of Resident #66's medications during the medication pass at 8:20 a.m. Employee I confirmed that an apical pulse should have been taken prior to administering [MEDICATION(S)], and she confirmed that after administering [MEDICATION(S)] diskus, the resident should have rinsed their mouth with water. .

Based on observation, interviews and record review, the facility failed to appropriately store medication in one (1) (Bermuda Cart #1) of two (2) medication carts observed, from a total of four (4) medication carts in the facility. The findings include: On 03/17/21 at 9:05 AM, an observation of the medication cart was made during medication pass with Employee A, Registered Nurse (RN). An unopened insulin pen for Resident #29 was observed, and Employee A confirmed that it should have been in the refrigerator. (Photographic evidence obtained) A review of the facility's policy and procedure titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, with an effective date of 12/07/07 and a revised date of 04/15/19, revealed on page 2 number 11, that the facility should ensure medications and biologicals were stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Refrigerated (36 - 46 degrees F (Fahrenheit) NOT IN USE - Insulin [MEDICATION(S)] 100 unit/ml (milliliter) Pen. Outdated, contaminated or deteriorated medication and those in containers that are cracked, soiled or without secure closures, are immediately removed from stock, locked in the medication room in a segregated area, and disposed of according to procedure for medication destruction and re-ordered from the pharmacy if a current order exists. On 03/17/21 at 9:15 AM, an interview was conducted with Employee I, Regional Nurse. She confirmed that the unopened insulin pen should have been stored in the refrigerator until it was opened.

Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% for 4 of 8 sampled residents (Residents #14, #15, #32 and #199) for medication administration. There were 6 medication errors with 27 opportunities, for a medication error rate of 22.22%. The findings include: 1) On 3/12/19 at 11:08 AM, observation of medication pass was conducted with Employee V, Licensed Practical Nurse (LPN), with Resident #14. Employee V, LPN administered [MEDICATION NAME] (insulin) 8 units to Resident #14. She obtained his [MEDICATION NAME] flex pen, dialed up 8 units, and administered it to him in his left abdomen. She failed to prime the needle with two (2) units prior to administering the 8 units, causing him to get the incorrect dose. On 3/12/19 at 8:11 PM, a medication observation was observed with Employee F, Licensed Practical Nurse (LPN), with Resident #15. She obtained his blood sugar, and it was 213, requiring him to need 4 units of Humulog (insulin). She obtained his Humulog flex pen, dialed up 4 units, and administered it to him in his left arm. She failed to prime the needle with two (2) units prior to administering the 4 units, causing him to get the incorrect dose. On 3/12/19 at 8:31 PM, an interview was obtained with Employee F, Licensed Practical Nurse (LPN), and she was asked about priming the needle on the insulin pen, and confirmed that she failed to do that. She was asked how long did she leave the needle in the residents arm and she stated, about 2-3 seconds. The Surveyor then asked her if she realized that she had to leave it in for at least 10 seconds, or until she see's the dial go to 0, and she stated, Oh. She then stated, Thank you for teaching me some things. On 3/12/19 at 8:40 PM, a medication observation was observed with Employee G, Registered Nurse (RN), with Resident #14. She obtained his blood sugar, and it was 326, requiring him to need 8 units of [MEDICATION NAME] (insulin). She obtained his [MEDICATION NAME] flex pen, dialed up 8 units, and administered it to him. She failed to prime the needle with two (2) units prior to administering the 8 units, causing him to get the incorrect dose. On 3/12/19 at 8:45 PM, interview was conducted with Employee G, RN, and she confirmed that she did not realize that she needed to prime the needle, prior to administering the insulin. 2) On 3/12/2019 8:19 PM, Employee B, a Registered Nurse was observed to administer insulin to Resident #32. Employee B went into the resident's room and first obtained the resident's blood sugar level via a fingerstick. The level was 265. Employee B stated that the resident gets sliding scale insulin for a blood sugar over 200. She stated she was going to give the [MEDICATION NAME]which was scheduled. Employee B took the cap off of the [MEDICATION NAME], cleaned the tip of the flex pen with alcohol pad and then put on a new needle. Employee B dialed the [MEDICATION NAME] to 30 units and injected it into the resident's left lower quadrant. Employee B did not prime the insulin [MEDICATION NAME] before giving the injection. On 3/12/2019 at 8:30 PM, Employee B went out to the hallway and entered 265 into the Electronic Medication Record (EMR) under the [MEDICATION NAME] sliding scale and it displayed in red - 4 units of insulin to be given for a blood sugar level between 251-300. Employee B returned to the resident's room with the [MEDICATION NAME]. Employee B removed the cap off the [MEDICATION NAME], cleaned the tip of the pen with an alcohol pad and put on a new needle. Employee B dialed the [MEDICATION NAME] to 4 units and injected it the resident's left lower quadrant. She held the [MEDICATION NAME] to the resident's skin for about 4 seconds. Employee B did not prime the [MEDICATION NAME] before injecting the 4 units of insulin. Record review for Resident #32 revealed a 3/3/2019 physician order [REDACTED].= 4. On 3/12/2019 at 8:42 AM, Employee B was asked if the [MEDICATION NAME] and [MEDICATION NAME] Flex Pens should have been primed with insulin prior to giving the actual physician ordered dose? She stated no, she did not need to prime the needle first. That is always how she had done it. On 3/12/2019 at 845 PM, Employee C was observed to administer insulin to Resident # 199. Employee C first went into the resident's room and obtained the resident's blood sugar level via a fingerstick. The level was 181. Employee C stated the resident gets sliding scale insulin for any level over 140. Employee C went into the hallway and entered the blood sugar level of 181 into the EMAR. It displayed in red to give 4 units of Humalog for a blood sugar level between 180-219. Employee C returned to the resident's room with two insulins, Humalog [MEDICATION NAME] and [MEDICATION NAME]. Employee C removed the cap off the Humalog [MEDICATION NAME], cleaned the tip with an alcohol pad and put on a new needle. She dialed the Humalog [MEDICATION NAME] to 4 units and injected it into the resident's left upper arm. Employee C did not prime the Humalog [MEDICATION NAME] before injecting the insulin into the resident. Employee C then removed the cap from the [MEDICATION NAME], cleaned the tip of the pen with an alcohol pad, and put on a new needle. Employee C dialed the [MEDICATION NAME] to 4 units and injected it into the resident's left upper forearm. She held the [MEDICATION NAME] to the resident's skin for about 3 seconds. Employee C did not prime the [MEDICATION NAME] needle before injecting the insulin into the resident. Record review for Resident #199 revealed a physician order [REDACTED]. There was also another physician order [REDACTED]. Employee C was interviewed on 3/12/2019 at 8:50 AM. She stated she did not prime the insulin [MEDICATION NAME] before giving the injections. She stated she should have done that. She also stated that she was not taught to hold the insulin [MEDICATION NAME] to the skin for a certain length of time to ensure all insulin was administered. The Director of Nursing on 3/13/2019 at 9:49 AM produced Medication Subcutaneous Insulin (05/16) . On Page 4 there are instructions to always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly and removing air bubbles. Select the dose of units by turning the dosage selector. For [MEDICATION NAME], and Humalog pens, use 2 units to prime. For other pens, follow manufacturer's direction. Then set the physician order [REDACTED]. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise upwards toward the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. Insert the needle into the skin at a 90 degree angle. Deliver the dose by pressing the injection button in all the way. The number in the dose window will return to 0 as you inject. Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. For [MEDICATION NAME], and Humalog pens count to 6.

Based on observation, record review, and staff interview, the facility failed to develop a plan of care for [MEDICAL CONDITION] for Resident # 65, 1 of 48 residents. The findings include: On 3/11/2019 at 10:54 AM, Resident # 65 was observed in her room lying in bed. Her bilateral lower legs were slightly swollen and bluish. She had her right lower leg partially wrapped in gauze (treatment). The resident was not observed to be wearing any compression stockings. She stated that she sustained a skin tear to her right leg when transferring and her son grabbed her leg. She stated she had to keep her legs elevated at all times to help with the swelling. Record review revealed a 1/25/2019 physician order [REDACTED]. There was another order on 3/1/2019 for [MEDICATION NAME] tablet 500 mg every 12 hours for the right lower extremity [MEDICAL CONDITION] for 7 days. End date 3/8/2019. A physician visit note dated 1/30/2019 revealed: [MEDICAL CONDITION] 1/25/2019- begin Keflex 500 mg twice a day for seven days which was improving. On 3/13/2019 at 11:39 AM, the Unit Manager, Employee E stated that she did not see a specific plan of care for the [MEDICAL CONDITION] of the right lower extremity. One of the Care Plan Coordinators (Employee I) on 3/13/2019 at 11:53 AM also confirmed that he could not find a care plan for [MEDICAL CONDITION]. Employee J another Care Plan Coordinator was interviewed on 3/13/2019 at 12:28 PM. She stated they did develop a care plan for antibiotic use for (Keflex) on 1/24/2019 and revised on 3/4/2019 . The Resident was on Keflex 500 mg by mouth every 12 hours related to [MEDICAL CONDITION]. She confirmed the goal and interventions were only directed at the use of antibiotics and not the [MEDICAL CONDITION].

Based on observation, record review, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice for Residents #23, # 65, and #247, 3 of 48 residents. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner 'practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirm and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: 1. Record review for Resident #23 revealed the IV (Intravenous) Company inserted a Peripherally Inserted Central Catheter (PICC) line on 2/28/2019 for IV antibiotic infusion for a wound abscess. Per the (MONTH) and (MONTH) 2019 Medication Administration Record, [REDACTED]. There was a 3/6/2019 physician order [REDACTED]. The clinical record did not have any orders/treatments for care of the PICC line (i.e. dressing changes, flushes, monitoring for any concerns like infection). The Unit Manager, Employee E was interviewed on 3/11/2019 at 2:50 PM. She confirmed the Treatment Record(s) did not have any physician orders [REDACTED]. She stated that the PICC line should be flushed each shift and night shift was not doing it. On 3/11/2019 at 2:57 PM, Employee L, a Registered Nurse was interviewed. She stated she worked 12 hour shifts (7A-7P) and flushed the PICC line with 10 ml of normal saline before and after the IV [MEDICATION NAME] infusion. She has not been flushing the PICC line at any other time. She was not documenting the flushes because it was not on the treatment record. On 3/11/2019 at 3:02 PM, the resident's PICC line was observed with Employee [MI] The PICC line was on the resident's right upper arm. The dressing was not dated when it was done. Employee L also confirmed there were no orders for the frequency of dressing changes, flushing the PICC line or monitoring for concerns. She was unsure of the facility policy but stated that the dressing changes might have to be changed every 2-3 days. The resident's clinical record did not have the [MEDICATION NAME] peak and trough lab done before the fourth dose. The RN Supervisor, Employee H on 3/12/2019 at 9:30 AM confirmed this was not done. She stated the 4th dose would have been on 3/10/2019. Therapeutic IV [MEDICATION NAME] monitoring per physician order [REDACTED]. The Facility's 4.2 Short Peripheral Catheter Flushing Policy dated 1/14/2004 last revised 5/1/2005 revealed as follows: Specific flush orders must be documented. Flushing is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. The Facility's 5.2 Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change dated 1/15/2004 revised 1/1/2016 revealed as follows: Central Venous access devices include Peripherally Inserted Central Catheters. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Sterile dressing change using transparent dressing is performed at least weekly. Assessment of the vascular access site is performed upon admission and during dressing changes, before and after administration of intermittent infusions, at least once every shift when not in use, and routinely for signs and symptoms of infusion related complications at a frequency based on patient condition, age, type of medication and flow rate. 2. On 3/11/2019 at 10:54 AM, Resident # 65 was observed in her room lying in bed. Her lower bilateral legs were slightly swollen and bluish. The resident was not observed to be wearing any compression stockings. She stated that her legs were weak and she had to keep them elevated at all times to help with the swelling. She also stated that she would like a recliner chair in her room because she was tired of lying in bed all day and night. On 3/11/2019 at 1104 AM, the Unit Manager Employee E was told by the surveyor that Resident #65 would like a recliner chair so she could sit up and still elevate her feet. She stated she would look into it. On 3/12/2019 at 240 PM, Resident #65 was in the Rehabilitation room with a Certified Occupational Therapy Assistant (COTA), Employee P. The Resident's legs were exposed (she had on shorts) and there was a dressing on her right lower leg. The Resident was not wearing any compression hose (stockings). Employee P stated that part of his job can be to take on and off compression hose if it was ordered by the physician. He looked at the resident's initial evaluation and stated it did not mention any compression stockings. Employee H, a Supervisor was interviewed on 3/12/2019 at 245 PM. She stated there was a 2/4/2019 physician order [REDACTED]. The Director of Nursing on 3/12/2019 at 301 PM stated that the Certified Nursing Assistants (CNA) should be applying the TED hose and removing them and it should be on their task list. She stated that physician order [REDACTED]. On 3/12/2019 at 3:05 PM, Employee A, a CNA stated she was taking care of Resident #65 today. She was not aware that the Resident was to be wearing TED hose. On 3/13/2019 at 11:02 AM, Resident #65 was interviewed. She stated she has her own stockings she brought in from home ([MEDICATION NAME] Fit). She stated she can not put them on herself. She stated she doubts she can get it on her right leg due to her skin tear and dressing. She has not seen any TED hose brought in by the facility staff. She also stated that no one brought her a recliner chair for her to elevate her legs. She stated not to worry about it now because she was going home on Saturday. On 3/13/2019 at 11:10 AM Employee L, another CNA was asked where the TED hose was for Resident #65? Employee L looked through the Resident's room. She replied she did not see any, only the resident's [MEDICATION NAME] Fit. On 3/13/2019 at 11:11 AM, the Unit Manager, Employee E stated she would call the physician and ask him what he wanted to do about the TED hose order. She stated the physician's orders [REDACTED]. On 3/13/2019 at 11:12 AM, Employee K, the CNA assigned to Resident #65 stated she did not offer to assist Resident #65 with putting on her TED hose this morning. On 3/13/2019 at 2 PM, Employee K, a CNA was interviewed. She stated she knew this resident. The resident did not like to wear the TED hose. She had her own hose. Her daughter comes in and puts them on. Employee K stated she does not assist the resident with putting them on. It was not on their task list to do so. She just reports to the nurse that the Resident did not wear them. An interview was conducted with the Resident's nurse (Employee L) on 3/13/2019 at 2:03 PM. She stated that she has not been documenting that the resident was refusing to wear TED hose and she did not notify the doctor either. Record review revealed a 2/13/2019 physician visit note. The resident had a [DIAGNOSES REDACTED]. The resident was prescribed diuretics and TED hose. 3.) A record review was conducted for Resident #247 and revealed a [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 3/11/19 at 10:58 AM an observation was conducted of Resident #247 and it revealed that she had a midline intravenous line (IV) in her left upper arm. Further observation revealed a dressing intact, with a date of 3/1/19. On 3/13/19 at 1:53 PM. Interview was conducted with Employee T, Licensed Practical Nurse (LPN), regarding if the resident was discharged with her IV, she stated, Oh no, they took that out over the weekend. She was then notified that that could not be correct, because I observed it in her arm on Monday 3/11/19. She then stated, Oh, I'm not sure then, I will call her and see if she went home with it. She then returned a few minutes later and stated that the weekend supervisor had removed it on Monday afternoon. On 3/13/19 at 1:57 PM. Interview was conducted with the weekend supervisor sitting at the nurses station in regards to discontinuing the IV, and she stated that she remembered doing it on Monday. She then was asked for the orders to provide care/dressing changes/to discontinue it, care plan, and documentation for discontinuing the IV, and she reviewed the electronic medical record and was unable to find any documentation. On 3/13/19 at 3:25 PM. Interview was conducted with the Director of Nursing (DON) in regards to the orders and care plans for Resident # 247 regarding her IV. She reviewed the care plan that she brought in and verified that there was no care plan for her. She then reviewed her physician orders [REDACTED].g.; flushes, dressing changes, discontinuing the IV. She also verified that there was no documentation in relations to discontinuing the IV e.g.; length removed, tip intact, etc. She was then asked how often are they supposed to change the dressing on a residents IV, and she confirmed that they should be changed weekly.

Based on record review, facility policy review, and staff and resident interview, the facility failed to ensure residents receive care and services to improve or maintain urinary function for 2 of 3 sampled residents, Residents # 36, and #38. The facility Resident Census and Condition as of 3/12/2019 revealed 58 residents who are occasionally or frequently incontinent of urine with no urinary toileting program. The findings include: 1. Resident #36 was admitted on [DATE]. She had a 8/8/2018 Admission Assessment revealed the resident was totally incontinent of urine and there was no current toileting program. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed toilet use extensive assistance of two person physical assist, frequently incontinent of urine, and no attempts of toileting program. She had a urinary tract infection in the past 30 days. There was no Evaluation for Bowel and Bladder Training in the clinical record on admission. A comprehensive care plan was initiated on 12/13/2018. Periods of Incontinence places her at risk for another urinary tract infection and/or skin breakdown. The goal was for her not to have a urinary tract infection and or skin breakdown associated with incontinence through next review. The last revision date was 1/31/2019 with target date of 5/28/2019. Interventions include: staff assist with toileting and/or incontinent care, apply protective barrier at time of incontinent care, give reminders to use call light to call for assistance with toileting, promote good fluid intake unless contraindicated, note for any signs and symptoms of urinary tract infection, and staff to observe for changes in bowel and bladder elimination and notify physician as needed . There was no mention of a specific bladder program/plan. The Resident's current Minimum Data Set (MDS) Assessment was a quarterly dated 1/27/2019. It revealed the resident was frequently incontinent of urine. For the question Has a trial of a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility. It was answered No. The Assessment also revealed the resident needed limited assistance with toileting. There was 1/29/2019 Evaluation for Bowel and Bladder Training revealing the resident was independent with mobility, always continent of urine, and was a good candidate for individual training. It revealed proceeding to a Urinary Incontinence tool. ( This evaluation was signed by an LPN with no co-signing of an RN). One of the MDS nurses, Employee M was interviewed on 3/14/2019 at 12:24 PM: She stated that she did the 1/27/2019 quarterly MDS Assessment for this resident. She did code the resident as frequently incontinent of urine , not on a toileting plan/program, and needed limited assistance with toileting. She does not know why the other nurse documented that the resident was continent of urine and independent with mobility. She was not aware of any toileting program/plan that the facility provides for the resident and that was why she has to code No on the Assessment. Employee M stated she has here since (MONTH) 2019. She stated that since she is a Licensed Practical Nurse (LPN) , she gets one of the other Registered Nurses to co-sign the MDS Assessment. Another MDS Nurse (a Registered Nurse) Employee I was interviewed on 3/14/2019 at 1250 PM. He stated they used to have a toileting programs last year but when they switched software programs, it seems to have disappeared. The Director of Nursing (DON) on 3/14/2019 at 1:40 PM stated that they do quarterly evaluations on residents. She stated one should have been done in (MONTH) (YEAR) but they changed software programs in (MONTH) (YEAR) and it must have been left out for this resident. The resident's current 30 day look back Bowel and Bladder Elimination Record ( 2/13/2019-3/3/3019 revealed documentation of urinary status was only been doing 2-3 times a day. The resident had 36 episodes of continence and 50 incontinent episodes of urine recorded during this time frame. There was a physician order [REDACTED].# 36 for [MEDICATION NAME] 500 mg (antibiotic) for a urinary tract infection. On 3/14/2019 at 1:10 PM, Resident # 36 (Brief Interview for Mental Status: score 12 out of 15) was interviewed. She stated she did not have a urinary tract infection and never did. She stated that she takes herself to the bathroom using the wheelchair. Employee N, the resident's Certified Nursing Assistant was interviewed on 3/14/2019 at 1:12 PM. She stated the resident does toilet herself, she does not need help. She wears brief. She is lazy and just does not want to get up and urinates in her brief. The Resident's nurse (Employee O was interviewed on 3/14/2019 1:15 PM. She stated the resident does have a long history of urinary tract infections. The resident and her husband was living in squalor and they had to come because they can no longer live alone. They did not have the best hygiene either. Resident #36 was on long term antibiotics. The Unit Manager ( Employee E) was interviewed on 3/14/2019 at 120 PM. She was asked about the facility's Bowel and Bladder Retraining Program. She was not aware of one. On 3/14/2019 at 138 PM, the Director of Nursing (DON) stated based on this resident's Admission Assessment, an bladder evaluation should have been completed. She confirmed there was not one done. 2. Resident #38 was admitted to the facility on [DATE]. There was an Admission assessment dated [DATE] which revealed the resident was not continent of urine (functional incontinence) . Current Toileting Program was left blank. The Resident's admission MDS assessment dated [DATE] revealed she was frequently incontinent of urine with no toileting program attempted and she needed extensive help with toileting. There was no Bowel and Bladder Assessment/Evaluation seen for this resident. There was a 1/27/2019 quarterly MDS Assessment revealing the resident was still frequently incontinent of urine with no toileting program attempted and she needed one person physical assist with toileting. A comprehensive care plan was initiated on 12/10/2018 revealing the resident's incontinence places her at risk for urinary tract infection and skin breakdown. The goal was for the resident not to have a urinary tract infection or skin breakdown through next review. It was last revised on 1/29/2019 with a target date of 5/1/2019. Interventions included to give reminders to use the call light, monitor for signs and symptoms of urinary tract infection and notify physician of any changes, staff to assist with toileting and or incontinent care, and the resident does not wish to wear briefs while in bed. The Residents current 14 day look back Bowel and Bladder Elimination Record (3/1/2019-3/14/2019) revealed documentation of urinary status was only been done 2-3 times a day. They recorded 2 continent episodes and 33 incontinent episodes recorded during this time frame. The Regional Nurse (Employee Q) on 3/14/2019 at 345 PM confirmed there was no quarterly Bowel and Bladder Assessment for this resident on admission or quarterly. She also stated that they did go to a new charting system last year and this might have led to the missing documentation. The Facility's Guidelines to Assessment (Revised 11/28/2016) revealed: The Charge Nurse will complete an initial Urinary Incontinence Assessment only if the patient is incontinent. The assessment will be completed no later than 7 days after admission in order to obtain a good understanding of the patient's bowel and bladder pattern. The Charge Nurse will complete the Assessment for Bowel and Bladder Training if the patient is incontinent to determine if the patient is a candidate for individual training or timed/scheduled toileting. The interdisciplinary team will identify in the care-plan specific interventions that minimize potential adverse effects of urinary incontinence . The patient will be placed in a bladder program appropriate for the patient.

Based on record reviews and interviews, the facility failed to provide pain medications as ordered for one (1) (Resident #251) of three (3) residents reviewed for pain, out of a total sample of 48 residents. The findings include: A record review was conducted for Resident #251 and revealed an [AGE] year-old female, admitted with the following diagnoses, including, but not limited to: gastrointestinal hemorrhage, difficulty ambulating, spinal stenosis, weakness, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION], and hypertension. On 3/12/19 at 9:23 AM, an interview was conducted with Resident #251, and she stated, I am in so much pain in my thighs and hips. They will give me Tylenol, but it does not take the pain away, just dulls it a little. I have been laying here in pain for over a week, and they just are not doing anything about it. A further record review was conducted for her, and it revealed a physician's orders [REDACTED]. The order was received from the physician on (MONTH) 6, 2019. On 3/13/19 at 1:22 PM an observation of the medication cart was conducted with Employee G, Registered Nurse (RN), and it revealed that Resident #251 did not have any [MEDICATION NAME] on the medication cart. It had also revealed that her [MEDICATION NAME] (laxative) that was also ordered on [DATE], was not available on the cart. She was asked about the medications, and she stated, We do not have them, the orders must have just been sitting in the que. She then stated that she would have to call pharmacy and let them know that they needed the medications. On 3/13/19 at 3:27 PM, interview was conducted with the Director of Nursing (DON), in regards to the orders for Resident # 251, her [MEDICATION NAME] and [MEDICATION NAME]. She reviewed the Medication Administration Record [REDACTED]. She then verified that the [MEDICATION NAME] was blank for the documentation, and she had no explanation for the X's on the [MEDICATION NAME]. She confirmed that the medications had not been administered as ordered, according to the documentation. On 3/14/19 at 11:51 AM, interview was conducted with Resident # 251 regarding her pain, and she stated it is about a five right now, (on a scale of 1-10) and rubbed her bi-lateral hips. She was asked if the [MEDICATION NAME] they started this morning was helping her pain, and she stated, Not yet, but I hope it does by this afternoon. I am in just so much pain all the time, it's terrible.

Based on record reviews and interviews, the facility failed to provide medications to one (#251) resident reviewed for availability of medications, out of a facility sample of 48 residents. The findings include: A record review was conducted for Resident #251 and revealed an [AGE] year-old female, admitted with the following diagnoses, including, but not limited to: gastrointestinal hemorrhage, difficulty ambulating, spinal stenosis, weakness, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION], and hypertension. A further record review was conducted for her, and it revealed a physician's orders [REDACTED]. The order was received from the physician on (MONTH) 6, 2019. She also had an order for [REDACTED]. On 3/13/19 at 1:22 PM, an observation of the medication cart was conducted with Employee G, Registered Nurse (RN), and it revealed that Resident #251 did not have any [MEDICATION NAME] on the medication cart. It had also revealed that her [MEDICATION NAME] (laxative) that was also ordered on [DATE], was not available on the cart. She was asked about the medications, and she stated, We do not have them, the orders must have just been sitting in the que. She then stated that she would have to call pharmacy and let them know that they needed the medications.

Based on observations and interviews, the facility failed to appropriately store medications in two (2) of three (3) medications carts observed, out of a total of six (6) medication carts in the facility. The findings include: On [DATE] at 8:45 PM an observation of the medication cart was observed during medication pass with Employee G, Registered Nurse (RN), and she confirmed that the insulin pen for Resident #14 was on the cart, unopened, and should have been in the refrigerator. On [DATE] at 9:17 PM Observation of the medication cart was observed with Employee C, Licensed Practical Nurse (LPN), and it revealed an expired insulin pen, an unopened insulin pen (which should have been in the refrigerator), and an insulin pen with multiple dates; [DATE], [DATE], and expiration date of [DATE]. Photographic evidence was obtained. An interview was conducted with Employee C, and she confirmed that she did not know which date to go by. She also confirmed that the expired insulin should have been disposed of, and the unopened pen should be stored in the refrigerator. A review of the facilities policy and procedure was reviewed and revealed the following: Pages ,[DATE] through ,[DATE] Revised [DATE] Page ,[DATE] Clinical Services Policies & Procedures, Nursing Volume 1 Policies for Medication Administration, Chapter 12 Medication Storage & Security in the Facility Policy - Medications and biological's are stored safely , securely, and properly following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to have access. Page ,[DATE] 18. Insulin Pens and Cartridges: Defer to the individual manufacturer recommendations outlined in the table below. Pens/Cartridges Refrigerated (36 - 46 degrees F) NOT IN USE - [MEDICATION NAME] Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, locked in the medication room in a segregated area, and dispose of according to procedure for medication destruction and re-ordered from the pharmacy if a current order exists.

Based on observation, record review and staff interview, the facility failed to accurately document medical records for 1 of 48 sampled residents, Resident # 23. The findings include: On 03/12/19 at 1050 AM an observation of wound care was done by Employee D, a Licensed Practical Nurse for Resident #23. Resident # 23 was observed to have three wounds, one of the left buttocks, one on the resident's left side, and one of the left breast. Employee D cleansed the buttock with Dankin's solution, applied [MEDICATION NAME] and covered with a [MEDICATION NAME] dressing. On 3/12/2019 at 11:15 AM, Employee D cleaned the other two wounds with normal saline, wiped with [MEDICATION NAME]-iodine swabs and placed a non adherent dressing over them. The resident's Electronic Treatment Record (TAR) was reviewed on 3/11/2019 at 305 PM. There was not a treatment order for the left buttocks to be cleansed with Dankins solution, [MEDICATION NAME] and [MEDICATION NAME]. On 03/12/19 at 315 PM, Employee D was asked why the treatment she performed on the resident's buttock was not on the (MONTH) 2019 TAR. She replied there was a 3/6/2019 physician treatment order but she did not know why it was not showing up on the TAR. Employee D stated she did not have evidence that she has been doing the daily dressing changes to the resident's buttock. The (MONTH) 2019 TAR for Resident #23 revealed a 2/28/2019 physician order [REDACTED]. It was discontinued on 3/6/2019. There was no documentation that this was done on (MONTH) 1, 2nd, 5th or 6th. Also, there was no documentation that there was any treatment done for this wound from (MONTH) 7th-11th, 2019. On 3/12/2019 at 325 PM, the Director of Nursing confirmed the lack of documentation of these wound treatments on (MONTH) 1, 2nd, 5th, 6th, 7th, 8th, 9th, 10th, and 11th, 2019. On 3/13/2109, the Regional Nurse (Employee Q) stated that they figured out why the treatment order was not showing up on the TAR. The original nurse who input the order into the computer did not do it correctly. When putting the order in she should have used the drop down box and directed the order to go to the TAR.

Based on observation, record review, and staff interview, the facility failed to maintain infection control standards to prevent the spread of infection by not properly washing hands, not properly disinfecting glucometers, and not wearing personal protective equipment (PPE) for residents in isolation for Residents #55, #54, #64 and #14, 4 out of 48 sampled residents. The findings include: 1. On 3/12/2019 at 8:11 AM, Employee B, a Registered Nurse was observed to perform a bladder scan on Resident #55. Resident #55 was lying in bed with her urinary brief opened. Employee B stated she just performed a catherization on her and obtained no urine. After the procedure, Employee B took her gloves off and retrieved a clear baggie out of the trash can and went back to the resident's bed and placed it on the floor. She gathered the soiled supplies she used for the procedure (catherization and bladder scan) and placed them in the trash bag that was on the floor. She then went out into the hallway to the medication cart, opened it and removed some Sani Cloths and came back to the resident's room. She did not perform any hand hygiene after removing the gloves, leaving the room, and returning to the room. She then cleaned the bladder scan machine with the Sani Cloths. On 3/12/2019 at 8:15 AM, Employee B stated she must have forgotten to use hand sanitizer or wash her hands when leaving the room to retrieve the Sani Cloths. She stated she should have. Record review for Resident #55 revealed she was previously on contact isolation (discontinued on 2/25/2019) for Extended Spectrum Beta-Lactamse (ESBL), a bacteria that is harder to treat with antibiotics. The Staff Development Coordinator (also the Infection Control Nurse) was interviewed on 3/14/2019 at 904 AM. She confirmed that trash bags should not be placed on the floor. She also stated that after direct resident contact after a procedure and removing gloves, hand hygiene should be performed before leaving a room. She also stated that if a resident was on isolation, PPE should be worn and it would be a break in infection controls procedures if staff did not. The facility's Infection Control Plan last revised 3/20/2017 revealed: Methods to reduce the risks associated with procedures, medical equipment and medical devices may include the following: Appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipment and the appropriate use of personal protective equipment. 2. On 3/11/2019 at 12:12PM, Employee R was observed standing in the room of Resident # 54. She was not wearing any personal protective equipment (PPE). This resident was under isolation precautions for ESBL in her urine. On 3/11/19 at 1:00PM, Employee S was observed coming out of an isolation room with a meal tray belonging to Resident #64 without wearing PPEs. This resident also was on isolation for ESBL in her urine. Interview with Employee S at 1:00PM at the door, she stated that she did not touch anything in the room. She said she was aware that Resident #64 was in isolation and she was to wear the PPE. The Staff Development Coordinator (also the Infection Control Nurse) was interviewed on 3/14/2019 at 9:04 AM. She confirmed that trash bags should not be placed on the floor. She also stated that after direct resident contact after a procedure and removing gloves, hand hygiene should be performed before leaving a room. She also stated that if a resident was on isolation, PPE should be worn and it would be a break in infection controls procedures if staff did not. The facility's Infection Control Plan last revised 3/20/2017 revealed: Methods to reduce the risks associated with procedures, medical equipment and medical devices may include the following: Appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipment and the appropriate use of personal protective equipment. 3) An observation was conducted on 3/12/19 at 8:44 PM of Employee G, Registered nurse (RN), cleaning the glucometer, after obtaining Resident #14's blood sugar, and it revealed the following: Employee G, RN obtained all supplies and carried them into Resident #14's room, she then obtained a paper towel from the bathroom, and placed it on his bedside table for a barrier. She then placed the supplies on the paper towel, including the plastic bag with the insulin pen for the resident, however, the entire bag did not fit on the paper towel and the bag was noted to be on the residents bedside table. Photographic evidence was obtained. She then proceeded to obtain his blood sugar. After obtaining the blood sugar, she opened a bleach wipe and cleansed the glucometer and then placed it back down on the same paper towel barrier, she failed to provide a clean barrier. After cleaning the glucometer, she carried the glucometer, and the plastic bag containing his insulin pen back out to her medication cart, and placed them in the top drawer. The facility policy and procedure was reviewed and revealed the following: Chapter 18: Laboratory and Diagnostic Services Clinical Services Volume 1 Cleaning and Disinfection of the Glucometer Revised 6/28/18 Page 1 of 2 Equipment and Supplies - Super Sani-Cloth or Sani-Cloth Plus wipe (individual wipe)or an equivalent product that kills [MEDICAL CONDITION] and blood-borne pathogens Note: The product must contain specific language addressing these two criteria. - A disposal cup if using a tub or a quick-pull canister of Super Sani-Cloth or Sani-Cloth Plus to place the wipe in before taking into the resident's room - Gloves - Damp paper towel for cleaning (if visible blood or body fluids are seen on the machine) - Two barriers (e.g., paper towels) Policy - The following procedure is to be completed in the resident's room after a glucometer check before leaving the room. Note: The canister or tub of wipes is not to be taken into the resident's room. Place one wipe in the disposable cup to transport it into the resident's room. Procedure: Follow the steps below after you have taken the glucometer reading per the policy/procedure. 1. Dispose of the glucose strip in the biohazard container (sharps container) in the resident's room. 2. Place a barrier (e.g., a paper towel) on the table surface. 3. Place the glucometer on the barrier. 4. Remove your gloves, wash or sanitize your hands, and put on fresh gloves. 5. Place a second barrier on the table surface, away from and not touching the first barrier. Page 2 of 2 6. Use the damp paper towel to remove any visible blood or body fluids. Dispose of the paper towel appropriately. 7. Pick up the glucometer from the first barrier and disinfect it with a Super Sani-Cloth wipe or an equivalent product that kills [MEDICAL CONDITION] and blood-borne pathogens. Follow the manufacture's guidelines for wet time when applying disinfectant. Pay close attention to the strip holder area and be sure to not over-saturate the area. 8. Place the glucometer down on the second barrier. Allow enough time to dry per manufacture's instructions. 9. Dispose of the first barrier. 10. Remove your gloves and wash or sanitize your hands. 11. After the glucometer is dry, throw away the second barrier and put the glucometer away. 12. Follow hand hygiene protocol. * (MONTH) sanitize glucometer outside of resident's room.

Based on observations and staff interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. This impacted every resident who received meals prepared in the facility's kitchen. The findings include: On 1/8/2018 at 10:20 a.m. during the kitchen tour, this surveyor observed in the walk-in refrigerator, outdated leftover foods as follows: 1 carton of sliced, uncooked potatoes with an expiration date of December 2017, containers of garlic butter, chicken salad , prunes, pears, cocktail sauce, mandarin oranges, egg salad and cherry tomatoes all marked with the last date to use as 12/27, 12/28 and 12/29/2017 respectively. Two gallons of whole milk was observed with an expiration date of 1/7/2018. During an interview with the kitchen manager on 1/8/18 at 10:30 a.m., he stated that he had been on vacation for the past 12 days, and his assistant was not experienced yet to take care of these things. On 1/8/18 at 10:35 a.m., during further tour of the kitchen, this surveyor observed in the reach-in refrigerator, glasses of individually poured juices, thickened drinks of water and various flavors of fruit juices and tomato juices which had been poured since 12/28/2017. The manager stated that the drinks should have been thrown away after 72 hours. The walk-in freezer was observed with recently delivered food that was observed on the floor. The chef stated that two weekend aides called off, and so the remaining staff could not put things away before the end of their shift. On 1/9/2018 at 11:32 a.m., an observation of the meal service line revealed that the banana pudding was measured at 56 degrees Fahrenheit (F) instead of 41 degrees F or cooler. The carousel where clean dishes were stored was observed dirty with dust and food debris on 1/10/18 at 11:00 a.m. The manager was unable to explain the condition of the carousel, but stated that the kitchen had a lot of cleaning to do. On 1/10/18 at 10:20 a.m., Resident #20 brought a dirty spoon to the Resident Council meeting . The resident stated that she was served breakfast with the dirty spoon. Despite her request for a clean spoon, the dining room staff were indifferent to her request, and none of them took the time to get her a clean spoon. This surveyor observed the dishes carousel with debris and food debris. At 10:25 a.m. on 1/10/18, the stove hood and the kitchen walls were observed with dust. The manager stated that he would request for the walls to be cleaned by the maintenance department staff.

Based on observation, record review, and resident and family interview, the facility failed to maintain palatable food temperatures for Residents #231, #2 #56, #48, and #60 , 5 out of 13 sampled residents. The findings include: 1. On 01/08/18 at 12:10 p.m., an interview was conducted with Resident #231. She stated that the food was usually cold. At 12:30 p.m., she observed the tray cart sitting in the hallway outside of her room. She indicated that she did not understand why the trays were just sitting there and no one was distributing them. During the lunch meal service on the Caymen Unit on 01/08/2018 from 12:20 p.m. until 12:57 p.m., the two certified nursing assistants (CNAs) assigned to the unit passed the meal trays on the wing with room numbers 310 through 313. After the trays were passed, one of the CNAs left the unit. The other CNA pushed the cart to the other end of the unit to pass the rest of the trays to rooms 301 to 309. The resident in room [ROOM NUMBER] requested a bowl of soup. The CNA left the unit, went to the kitchen to get a bowl of soup, and returned eleven minutes later. The meal trays remained on the tray cart. No other staff member distributed the trays. The nurse's station on the unit was observed at 12:30 p.m. The unit manager and the floor nurse were seated at the desk. Resident #2 was interviewed on 1/8/2018 at 1:41 p.m. She stated that the food was horrible. The dinner meal was always cold. They will not heat it up. You can ask for a substitute, but it will take an hour to an hour and a half to get something else. On 01/09/18 at 10:20 a.m., an interview was conducted with Resident #56. She stated, The meals are always cold here. The trays sit too long. She did not know why the dietary staff did not pass their own trays. You never get a hot meal here. She stated she liked her food to be hot when it is supposed to be hot. Resident #48 was interviewed on 01/09/18 10:48 a.m. She stated the food was good, but was sometimes cold. On 01/10/2017 at 1:00 p.m., an interview was conducted with the unit manager and the administrator. They were informed of the observations made on 01/08/2017. It was stated that one of the CNAs assigned to this unit was split with the Bermuda Unit due to a shortage of staffing. They were not sure why only one CNA was passing trays on Monday. The administrator stated that residents had complained about their food being cold. The son of Resident #60 was interviewed on 1/10/2018 at 3:21 p.m. He stated that his mother told him that dinner last night was cold. He came to visit his mother every night. She had been in her room for the past week or so, because she was not allowed to go to the dining room (on isolation for infection). The food had been cold every single night. He requested that she go back to the dining room hoping that the food was warmer.

Based on resident interview, staff interview and bathing documentation, facility staff did not accommodate residents' choices related to showering for two of two residents reviewed regarding choices (Residents #43 and #2). The findings include: 1. On 01/08/2018 at 01:50 PM Resident #43 was interviewed. She stated she had been in the facility since September 2017. She stated staff scheduled her for Tuesday, Thursday & Saturday showers/baths. She stated she completed paperwork twice to change her bathing schedule to Monday, Wednesday, Friday, so as not to interfere with her [MEDICAL TREATMENT] days. She stated staff on the other unit where she resided (Cayman) told her they lost the paperwork. She stated she had been in this room/unit for about two weeks. She stated it had been about four weeks since she received any bath/shower. She stated someone told her she would get a bath today (01/08/2018). The resident was again interviewed at 9:05 AM on 01/09/2018. She denied having received a bed bath or shower yesterday. On 01/09/2018 at 9:30 AM, Employee A, Certified Nursing Assistant (CNA), was interviewed about the bathing schedule for Resident #43. She looked at the facility computerized system for showers, which stated the last shower for Resident #43 was more than 10 days ago. Employee A reviewed the shower schedule with the surveyor . Resident #43 was not on the shower sheet. Her room number indicated skin checks were completed on Mondays and Fridays by hospice, and showers were provided on Saturdays. (Photographic evidence obtained) An interview was then conducted with Employee B, Licensed Practical Nurse (LPN). She verified the resident who had been in that bed had passed away, and this was the schedule for the previous resident, not Resident #43, who was not on hospice. An interview was then immediately conducted with Employee C, Registered Nurse (RN). She stated that Resident #43 moved to bed 113A on 01/03/2018. She looked in the shower sheets, which indicated no showers for resident #43 in the month of January 2018, except January 2 was marked as refused. On 01/09/18 at 05:20 PM the resident was interviewed. She was asked if she had received any bed baths & she stated that she had been wiped down by staff this date but had not received any other bed baths recently . She was asked if she had refused any showers/bed baths, and she said she had declined a few times recently when they offered after her [MEDICAL TREATMENT] appointment & she was feeling too sick from the [MEDICAL TREATMENT]. Staff had not offered her an alternative schedule. An interview was conducted with the Director of Nursing (DON) at 9:57 AM on 1/11/17, and she stated that the CNAs were to encourage a resident who refused a shower on their designated day to take one. They were to report refusals to the nurse. If the resident continued to refuse, staff were to contact the responsible party regarding the resident not wanting to take a shower. Managers were able to pull the reports from the computerized system to see if residents had not showered. The DON stated that staff were able to rearrange shower dates/the shower list in to meet resident preference. 2. On 1/08/18 at 1:34 PM, an interview was conducted with Resident #2 (a resident with bilateral amputations) regarding his care. Resident #2 stated, I tried waiting for my shower a couple times, but they don't show up to give you one, or they come to give you one when they want to. They will wait until after 10:00 PM, and I am already in bed by then, so now it is easier to just shower myself. Resident #2 confirmed that he was not offered an alternate schedule even after informing staff that 10:00 PM was too late. A record review was completed for Resident #2 regarding his functional abilities when bathing. The most recent available Minimum Data Set (MDS) assessment, dated 10/15/17, revealed that Resident #2 required supervision with one person physical assist during his shower/bath. The previous MDS assessment, dated 7/27/17, revealed that Resident #2 required limited assistance with one person physical assist during his shower/bath. A review of Resident #2's shower sheets revealed the following: 10/16/17 - Gave himself a shower 10/25/17 - Completed shower with no assistance 10/27/17 - Showered self complete 10/30/17 - Showered himself 11/01/17 - Self-showered 11/03/17 - Self-showered 11/06/17 - Showered self after supper 11/14/17 - Gave himself a shower 11/27/17 - Showers himself with little or no help 12/01/17 - Showered self 12/06/17 - Showered self 12/11/17 - Showered self 12/18/17 - Showered self No shower sheets were available for review for the following dates : 11/8/17; 11/10/17; 11/17/17; 11/20/17; 11/24/17; 12/4/17; 12/8/17; 12/13/17; 12/15/17; 12/18/17; 12/20/17; 12/22/17; 12/25/17; 12/27/17; 12/29/17; 1/3/17; 1/5/18; or 1/8/18. These were days that the resident was scheduled for his shower/bath. On 1/11/18 at 11:45 AM, an interview was conducted with Employee L, Licensed Practical Nurse (LPN), regarding the shower schedule for Resident # 2. Employee L verified that this resident's showers were scheduled for Mondays, Wednesdays, and Fridays on the 3-11 PM shift. Employee L was asked whether Resident # 2 showered himself, or if staff assisted him with his showers. Employee L stated that he would shower himself, but he was supposed to be supervised by staff. Employee L confirmed that Resident #2 was coded on his Minimum Data Set (MDS) assessment as requiring assistance of one person for supervision during his showers, and that he should not be in the shower unsupervised.

Based on record reviews and staff interviews, the facility failed to notify the residents, the residents' representatives, and the office of the Long-Term Care Ombudsman of the residents' transfers and the reasons for the transfers in writing for two of two residents (#65 and #82) reviewed for hospitalization . The findings include: 1. Based on a review of the clinical record, Resident #65 was transferred to the hospital on [DATE] due to vomiting, and was readmitted to the facility on [DATE]. No evidence was found in the resident's record to confirm that the resident/representative/ombudsman were provided written notice of the hospital transfer. An interview was conducted with Employee D, Registered Nurse (RN), at approximately 2:45 PM on 1/10/18. She stated that when a resident was transferred to the hospital, the nursing department sent transfer paperwork, but nothing regarding discharge rights. At 3:00 PM on 1/10/18, an interview was conducted with the business office manager. She verified that the business office did not provide discharge paperwork related to transfer rights when a resident was transferred to the hospital. 2. Review of the chart for Resident #82 revealed that the resident had an admission date of [DATE] and a discharge date of [DATE]. The resident was transferred to an acute care hospital on [DATE] due to a change in mental status and hypoxemia (low oxygen levels in the blood). Further review of the record revealed no evidence to confirm that notice to the resident, representative, or ombudsman regarding transfer/discharge rights was provided. An interview was conducted with the business office manager at 3:20 PM on 01/11/18. She verified that the facility did not provide discharge paperwork related to transfer rights when a resident was transferred to the hospital.

Based on record review and staff interview, the facility failed to provide a notice of the facility's bed-hold policy for two of two residents (#65 & #82) reviewed for hospitalization . The findings include: 1. Based on a review of Resident #65's clinical record, the resident was transferred to the hospital on [DATE] due to vomiting, and was readmitted to the facility on [DATE]. No evidence was found to confirm that a notice to the resident/representative related to the bed hold policy was provided by the facility. An interview was conducted with Employee D, Registered Nurse (RN), at approximately 2:45 PM on 1/10/18. She stated that when a resident was transferred to the hospital, nursing sent transfer paperwork with them, but nothing regarding the facility's bed-hold policy. She stated that bed-hold information was handled by the business office staff. At 3:00 PM on 1/10/18, an interview was conducted with the business office manager. She verified that the business office did not provide discharge paperwork related to the bed-hold policy when a resident was transferred to the hospital. She stated that residents received a written copy of the bed-hold policy upon admission to the facility, but not at the time of hospital transfer. 2. A review of the clinical record for Resident #82, revealed that the resident had an admission date of [DATE] and a discharge date of [DATE]. The resident was transferred to an acute care hospital on [DATE] due to a change in mental status and hypoxemia (low oxygen levels in the blood). Further review of the record revealed no evidence that a notice to the resident or representative regarding the facility's bed hold policy was provided. An interview was conducted with the business office manager at 3:20 PM on 01/11/18. She verified that the facility did not provide discharge paperwork related to their bed-hold policy when a resident was transferred to a hospital.