Every finding on record at Life Care Center of Palm Bay

Based on interview, and record review, the facility failed to ensure 2 of 3 residents reviewed for Care Planning were offered participation in plans or revisions to their care, out of a total sample of 54 residents, (#39, #86). Findings: 1. Review of the medical record revealed resident #39, an [AGE] year old male was admitted to the facility from an acute care hospital on 4/02/23. The resident's diagnoses included, abnormalities of gait and mobility, insomnia, major depressive disorder, anxiety disorder, osteoarthritis, Chronic Obstructive Pulmonary Disease (COPD), presence of cardiac pacemaker, acute kidney failure, atrial fibrillation (abnormal heart rhythm), artificial opening of urinary tract, and type 2 diabetes mellitus. The Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 12/31/24 revealed during the look-back periods, resident #39 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was cognitively intact. The assessment showed there were no delusions or behaviors, the resident did not walk, required a wheelchair for mobility, staff supervision and assistance to complete activities of daily living (ADLs), he had frequent, very severe/horrible pain, received high-risk insulin, anti-coagulant (blood thinner), hypoglycemic (sugar lowering), and anticonvulsant (seizure) medications, and no active discharge plan to the community occurred. On 1/06/25 at 3:38 PM, resident #39 was observed sitting in a wheelchair in the facility's activity room. The resident explained he was not aware of his plan of care meetings, nor had he been invited to attend. He said he had problems with his meals, shoulder pain, and he hadn't received therapy that could help with his strength and movement in a long time. The resident stated, I need updates; I have a lot going on. Review of resident #39's Comprehensive Care Plan included focuses, interventions, and goals for Activities, Advanced Directives, ADL assistance and therapy services, ADL self-care performance deficit, insomnia, discharge planning, hearing deficit, risk for oral/dental health problems, diabetes mellitus, risk for falls, anticoagulant therapy, compression fracture, medication self-administration, potential nutritional problems, knee pain, risk for skin integrity breaks, suprapubic catheter care, bladder obstruction, impaired visual function, and COPD. The Order Summary Report included active physician's orders for Biofreeze Gel for pain, Melatonin 3 milligrams (MG) at bedtime for insomnia, Eliquis (blood thinner) 5 MG twice daily for blood clots, Gabapentin 100 MG three times daily for neuropathy, Brinzolamide 1% Suspension eye drops twice daily for glaucoma, Metoprolol 12.5 MG twice daily for blood pressure, Lantus Insulin 12 units at bedtime, Novolog insulin 5 units before meals, and Novolog Insulin as needed per sliding scale before meals for diabetes mellitus. The most recent Care Plan Conference Record dated 10/22/24 noted the resident's family representative was unable to be reached by phone. The form did not indicate the resident or his family were invited. On 1/09/25 at 9:06 AM, the Director of Rehabilitation checked resident #39's medical record and said the last time he received any Physical Therapy (PT) was in January 2024, one year prior. She said a screening for a resumption of services was available to the resident, if requested. She could not recall, and did not locate a recent screen for determination of services in the resident's medical record. On 1/09/24 at 9:24 AM, the Licensed Practical Nurse (LPN) MDS Coordinator explained long term care resident care plan meetings were scheduled every quarter and a business card with the date and time were provided to the resident. She acknowledged she could not locate any documented record of resident #39's most recent invitation. She stated, it's important for the resident [to attend the meetings] so they know if they've made progress, and if they have therapy, to discuss discharge planning and what to expect next if discharge is not pending. 2. Review of the medical record revealed resident #86, a [AGE] year old female was admitted to the facility from an acute care hospital on 12/28/23. The resident's diagnoses included, left hip fracture, muscle weakness, abnormalities of gait (walking pattern) and mobility, dementia, dysphagia (difficulty swallowing), heart failure, malnutrition, insomnia, arthritis, and history of falling. The most recent MDS Quarterly Assessment with an ARD of 12/19/24 noted resident #86 scored 7 out of 15 on the BIMS that indicated she was cognitively impaired. The assessment showed there were no delusions or behaviors, the resident did not walk, she required a wheelchair for mobility, and staff assistance to complete ADLs and mobility functions. The assessment indicated she had frequent, very severe/horrible pain, shortness of breath with exertion and when lying flat, received high-risk diuretic (fluid removing), opioid (narcotic pain) and anticonvulsant (seizure) medications, and that no active discharge plan to the community occurred. The Order Summary Report included active physician's orders for ace wraps to both legs for edema, Amlodipine 10 MG once daily for blood pressure, Diclofenac 1% gel to the left knee for pain, Dicyclomine 10 MG four times daily for irritable bowel syndrome, Enalapril 10 MG once daily for blood pressure, Gabapentin 400 MG three times daily for neuropathy, Lasix 40 MG once daily for edema, Levothyroxine 150 Micrograms (MCG) once daily for thyroid hormone, Percocet 5-325 MG twice daily and every 8 hours as needed for pain, Primidone 100 MG at bedtime for tremors, and Spironolactone 12.5 MG once daily for edema. Resident #86's Comprehensive Care Plan included focuses, interventions, and goals for Activities, Advanced Directives, Medication allergies, Activities of Daily Living (ADL) assistance and therapy services, ADL self-care performance deficit, insomnia, a return home discharge plan, impaired cognition, congestive heart failure, hearing deficit, potential for dehydration, edentulous (no natural teeth), hypothyroidism, risk for falls/history of falls, incontinence, irritable bowel syndrome with diarrhea, anemia, Rheumatoid Arthritis, left hip fracture, tremors, pain, risk for impaired skin integrity, potential nutritional problems, and impaired visual function for dry eyes. On 1/07/25 at 9:38 AM, resident #86 was observed sitting in a chair in her room. The resident said she was not aware there were care plan meetings or participated in plans and reviews of her care. Review of the most recent Care Plan Conference Record dated 12/31/24 did not note staff attempted to reach the resident's family and read, IDT meeting, Care Plan: Diet, Diagnosis, weight, code status discussed. No family present. On 1/09/25 at 9:16 AM, the Registered Nurse (RN) MDS Coordinator said family representatives were notified of care plan meetings by phone and the Care Plan Conference Records were marked by a check box when invitations were provided. The RN explained, it's [the meeting] important so they can speak on behalf of themselves; if they need to express something that's important to them; it's about them, they are the one who is here getting care; it's important for them to participate. On 1/09/24 at 2:45 PM, the DON explained the MDS staff reported to her and resident care plans were reviewed every morning with the Interdisciplinary Team. She said it was important for residents to have the opportunity to participate in their plan of care so they could voice their concerns and staff could look into any problems. Review of the facility's standards and guidelines titled, Comprehensive Care Plans and Revisions dated 9/11/24 read, .the facility will ensure . each resident and resident representative, if applicable is involved in developing the care plan and making decisions about his or her care. Review of the facility's Admission Packet included the residents' [NAME] Of Rights that read, . the resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical conditions, the right to participate in the development and implementation of his or her person-centered plan of care. the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care .

Based on interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to not scheduling physician ordered specialist consultation, for 1 of 1 residents reviewed for , of a total sample of 54 residents, (#14). Findings: Resident #14 was initially admitted to the facility on [DATE] from an acute care hospital with diagnoses that included obstructive sleep apnea, atherosclerotic heart disease of native coronary artery, and presence of cardiac pacemaker. Review of resident #14's Annual Minimum Data Set assessment dated [DATE], revealed that she had a Brief Interview for Mental Status score of 14 out of 15 which indicated intact cognition. She had no upper or lower limb impairment and required minimal to no assistance with Activities of Daily Living. On 01/07/25 at 11:22 AM Resident #14 stated that she had been in the facility for over a year but had not seen the cardiologist to check the batteries of her pacemaker. She said that prior to being admitted to the facility she was seeing the cardiologist every six months and would like to see one. She reported that her son was involved and helped manage her care. According to the American Heart Association, pacemakers were indicated for people with abnormal heart rhythms, also known as arrythmias. Pacemakers should be checked every six months to a year to assess the battery and find out how the wires were working, (retrieved from www.heart.org/en/health-topics/arrhythmia/prevention on 1/10/25 at 3:00 PM). Review of resident #14's active physician orders revealed that on 10/15/24 there was a prescriber written order for a cardiology consult to check the pacemaker. There was no documentation in the medical record to show that the facility had scheduled the appointment or that the resident had scheduled it on her own. Review of resident #14's medical record revealed a care plan for pacemaker care initiated on 11/27/23 with interventions that included cardiology consult as ordered, pacemaker checks as ordered, and documentation in the medical record of heart rate, rhythm, and battery check. Both interventions were initiated on 10/16/24 but there was no documentation in the medical record indicating that a battery check had been done per the plan of care. Review of the Care Plan Conference Record for resident #14 dated 12/03/24, revealed the resident's son attended the meeting and asked about scheduling a cardiologist appointment. On 1/09/25 at 10:14 AM, the Unit Manager (UM) of the Bayside unit confirmed she was responsible for scheduling appointments. She said that every morning she would print out the orders for all residents on the unit to verify if any consults had been ordered. She confirmed that resident #14 was ordered a cardiology consult on 10/16/24 but she was unable to find any documentation that showed the consult had been scheduled. She said that she had been hired on 10/31/24 and was unsure why the order had not been followed. She said that she must have missed it when she printed out the orders every morning. The Director of Nursing was also present during the interview with Bayside unit UM and stated that her expectation was for physician orders to be followed by staff or have documentation to reflect why an order was not followed and the physician notified. Review of the facility's Policies and Procedures on Physician Orders revised 2/26/24, revealed that the facility was obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.

Based on interview, and record review, the facility failed to review, revise, and ensure interventions were implemented for a person-centered care plan for falls to address supervision for 1 of 3 residents reviewed for accidents of a total sample of 39 residents, (#1). Findings: Resident #1, a [AGE] year-old female, was admitted to the facility initially on 1/04/21, with her most recent readmission on 4/12/23. Her diagnoses included, Multiple sclerosis, contracture of the left and right knees, history of falls, major depressive disorder, and cognitive communication deficit. On 4/12/23 the diagnosis of stable burst fracture of the first cervical vertebra was added. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/30/23, revealed the resident's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS) score of 09/15. Resident #1 required extensive assistance of two persons for bed mobility, dressing, toilet use and personal hygiene, and was totally dependent on staff for transfers. Her balance during transitions and walking, for surface-to-surface transfer was not steady and the resident was only able to stabilize with staff assistance. She had impairment in functional limitation in range of motion to both sides of her lower extremities. On 4/17/23 at 11:20 AM, resident #1's daughter stated her mother was a fall risk. She recalled her mother had 12 to 15 falls since she was admitted to the facility and added the facility knows she is at risk for falls. The daughter explained on 4/10/23, her mother fell from her wheelchair in the day room and broke her neck. She said her mother had reached for a cup that had dropped to the ground and when she reached to pick it up, she fell out of her wheelchair. She noted her mother was transferred to the hospital after the fall and was then sent to a higher level care of care for trauma. She conveyed surgery was not done but her mother had to wear a neck brace/collar for nine weeks. She stated she did not know what to do to keep her mother safe. On 4/19/23 at 4:39 PM, the resident's care plans at risk for falls related initiated 1/05/21, revised 12/17/21, and Actual fall initiated 1/28/23, revised 4/11/23, were reviewed with the Director of Nursing (DON). The care plans revealed the resident had falls on 2/12/21, 3/05/21, 5/21/21, 5/29/21, 7/13/21, 8/30/21, 9/2/21, 10/03/21, 9/12/22, 1/28/23, and 2/01/23. On 4/10/23 the resident fell from her wheelchair, sustained a neck fracture, and was transferred for a higher level of care. Care plan interventions included, ensure items in reach, raised edge mattress, medication review, bed in lowest position, call bell in reach, and therapy screens. There was no indication that supervision was addressed on the care plans. Care plan interventions did not address supervision, and when asked about supervision to mitigate the risk for falls, the DON said they could not provide one to one supervision all the time. However, there was no intervention for one-on-one supervision, or any additional monitoring to ensure resident #1's safety. On 4/19/23 at 11:38 AM, the Harborside Registered Nurse/Unit Manager (RN/ UM) stated care plans were updated with input from the leadership team. She explained that when a resident fell , the team discussed the fall and interventions were put in place. The resident's care plans for falls were reviewed with the RN/UM. She said she could not say what the level of supervision was implemented for the resident prior to her fall on 4/10/23. On 4/19/23 at 11:45 AM, the RN MDS Coordinator, stated that to develop a care plan, a review of the resident's clinical records would be conducted, which would include diagnoses, medications, documentation by nurses, and Certified Nursing Assistants, along with input from the resident, family/responsible party. He stated care plans were discussed during the risk meeting and morning meeting, and interventions would be a collaborative decision by the Interdisciplinary Team. The MDS Coordinator confirmed the resident had multiple falls since her admission to the facility, and that her cognition was moderately impaired. The resident's care plans for risk for fall, and actual falls were reviewed with the MDS Coordinator. He stated the care plans did not address level of supervision needed or frequent rounding for resident #1. The Facility's policy and procedure Person Centered Care Planning dated 8/16/22 read, The facility will develop a person-centered care plan that addresses the goals .needs . of the resident The care plan will reflect interventions that are person-centered, measurable, and include time frames to achieve the desired outcomes.

Based on interview, and record review, the facility failed to provide adequate supervision and monitoring for a vulnerable, physically, and cognitively impaired resident to prevent fall with major injury for 1 of 3 residents reviewed for accidents, of a total sample of 39 residents, (#1). This failure contributed to an unwitnessed fall resulting in a fracture of the cervical vertebra. Findings: Resident #1, a [AGE] year-old female, was admitted to the facility initially on 1/04/21, with her most recent readmission on 4/12/23. Her diagnoses included, multiple sclerosis, contracture of the left and right knees, history of falls, major depressive disorder, and cognitive communication deficit. On 4/12/23 the diagnosis of stable burst fracture of the first cervical vertebra was added. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/30/23, revealed the resident's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS) score of 09/15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, dressing, toilet use and personal hygiene, and was totally dependent on staff for transfers. Her balance during transitions and walking, for surface-to-surface transfer was not steady and the resident was only able to stabilize with staff assistance. She had impairment in functional limitation in range of motion to both sides of her lower extremities. A nursing progress note documented by Licensed Practical Nurse (LPN) G dated 4/10/23 read, At approximately 7:20 PM this nurse heard the other nurse yelling help. Someone is on the floor Resident (#1) was lying on the floor in front of w/c (wheelchair) face-down and actively bleeding from forehead .Pressure applied to area and 911 called .Transported to (name of hospital) via ambulance. Review of the resident's Fall Risk Evaluation dated 2/14/2023 revealed a score of 18 and fall risk score on 4/13/23 was 24. The form did not have a key/legend to explain the score, category was 10 or above The hospital's history and physical dated 4/10/23 revealed her chief complaint was neck pain. The document read, per report, patient was reaching to grab something when she fell forward out of her wheelchair . Had complaints of severe neck pain .CT (Computerized Tomography) scan of her cervical spine demonstrated a C1(cervical) burst fracture. Trauma transfer was requested for higher level care .Forehead laceration and multiple areas of skin tears .CT head Impression: Frontal scalp laceration. CT c-spine: acute burst-type fracture. [NAME] fracture involving C1 vertebral body. The hospital Progress Note -Trauma dated 4/11/23 listed the resident's problems as active forehead laceration, Jefferson's fracture (C1 burst fracture with subluxation of the right lateral mass), right shoulder pain, friction burns/skin tears, and acute pain secondary to trauma. A Jefferson's fracture is another name for a bone fracture of the front and back arches of the C1 vertebra. (Retrieved on 4/28/23 from healthline.com) A C1 through C2 vertebrae injury is considered to be the most severe of all spinal cord injuries as it can lead to full paralysis. (Retrieved on 4/28/23 from www.spinalcord.com). The Neurosurgery consult dated 4/11/23 read, This accident has caused Jefferson's fracture and further maligned the upper cervical canal; there is more canal stenosis at C1\2 than prior. Because of her medical issues I prefer to treat her cervical fracture with a collar. She needs to wear it for 90 days at all times except to eat and shower. If she tends to fall out of a wheelchair then she should be bed bound for safety. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/12/23 revealed resident #1's diagnosis included, Trauma .fall from wheelchair. Resident #1's Admission/Readmission Collection Tool dated 4/12/23 revealed the resident had cognitive impairment, was confused, oriented to place, and had poor trunk control. Documentation read, Resident has a fracture of the C1 has orders to keep her neck brace on at all times. On 4/17/23 at 11:20 AM, resident #1 was lying in bed on her back. She had a neck collar/brace on with dried blood to her right forehead, and in her hair. A dressing was noted to her left upper arm, dated 4/17/23. The resident's daughter was at the resident's bedside and verbalized the resident was a fall risk. The daughter said that on 4/10/23 her mother was in the dayroom by herself and her cup fell on the floor. She explained her mother reached for her cup and fell from her wheelchair. She said her mother was transferred to the hospital and a broken neck was identified. She said she was then transferred to a trauma hospital for higher level of care. The daughter indicated surgery was not done, and her mother had to wear neck brace/collar for nine weeks. She noted her mother had twelve to fifteen falls in the facility since her admission. She said the facility knows she was a fall risk, but she was alone in the dayroom. She stated she did not know what to do to keep her mother safe. On 4/18/23 at 9:54 AM resident #1 recalled she was by herself when she fell in the dayroom. She remembered it felt like she was on the floor forever before she was assisted but could not recall the details of the incident. On 4/18/23 at 3:10 PM, Certified Nursing Assistant (CNA) F confirmed she was assigned to resident #1 on the 3 PM to 11 PM shift on 4/10/23, the day of the incident. CNA F said the resident required total care and a mechanical lift for transfers. She recalled on 4/10/23, she transported resident #1 by wheelchair from the main dining room to the day room on the Harborside Unit. She said the resident always sat at a table in the day room and read. She remembered the resident wanted some water, and she provided it for her, and left the day room. She explained that she was in the shower room when a coworker called and told her that resident #1 was on the floor. CNA F said that when she went to the dayroom, the resident was on the floor face down, and blood was coming from her forehead. She noted the resident told her she tried to pick her cup off the floor and fell . The CNA indicated the nurse was in the day room when she arrived and 911 was called and transported the resident to the hospital. CNA F said the resident was placed in the dayroom, because she had a tendency of trying to get out of her wheelchair. She recalled three other residents were in the day room at the time she transferred the resident there. The CNA said no staff was in the dayroom when the resident fell , and said the last time she saw the resident was at 6:20 PM. She was aware the resident sustained a fractured neck, and said she now required three persons to provide care. She explained staff should check on residents every fifteen minutes if residents were assessed as being at risk for falls but she could not confirm if resident #1 was checked every fifteen minutes. On 4/18/23 at 3:23 PM, the Harborside Registered Nurse/Unit Manager (RN/UM) stated she was not at the facility when resident #1 fell and sustained a neck fracture. She said she was made aware of the incident when she came to work the following day and an investigation was initiated by the Assistant Director of Nursing (ADON) and herself. She explained they called the staff who worked on the 3 PM to 11 PM shift on 4/10/23 and obtained statements. She indicated the resident sat in her wheelchair after dinner in the Harborside day room when she dropped her cup, bent down to pick it up, and fell . She reported the resident sustained C-spine fracture. She identified their investigation showed two other residents were in the day room, but no staff were present. The RN/UM explained resident resident #1 was at risk for falls. She said that if residents were in the dayroom, they should always be supervised by a staff member. She conveyed staff on the 3 PM to 11 PM staff were scheduled to rotate in the dayroom at 30-minute increments to supervise residents. She could not provide a staff rotation schedule for 4/10/23 when the resident fell . On 4/19/23 at 9:05 AM, the Director of Nursing (DON) stated resident #1 had diagnosis of multiple sclerosis, had history of falls, and required maximum assistance from staff for her activities of daily living. She explained LPN G reported she gave pain medication to resident #1 at 7:00 PM on 4/10/23. At 7:20 PM, LPN G heard someone calling for help, as someone was on the floor. She indicated LPN H's statement revealed that around 7:30 PM she the resident said, oh Lord and observed resident #1 on the floor face down with blood coming from her face. The DON verbalized that all CNAs on the 3 PM to 11 PM shift on 4/10/23 were interviewed. She noted interviews revealed the resident had dinner and left the main dining room at 5:45 PM, by self- propelling herself to the Harborside day room where two other residents were. This contradicted CNA F's statement that she brought the resident in her wheelchair to the main dining room to the day room. The DON said CNAs were rotated in the day room in thirty minute increments. She explained on 4/10/23, CNA F, the resident's assigned CNA was giving a shower to another resident, one CNA was on break, and she was not sure of where the other two CNAs were at the time the resident fell . She indicated the two nurses, LPN G and LPN H were in the hallway giving medications. On 4/19/23 at 9:25 AM, the ADON recalled that on 4/11/23, she reviewed the fall incident and spoke to LPN H who saw the resident on the floor. LPN H told her she was at the nurses' station, and saw the resident in the day room, however, she did not see the fall. She noted LPN H only heard when the resident said, oh my God. The ADON said LPN H informed that when she went to the resident, she saw a cup on the floor. When she asked the resident what happened, the resident said she dropped her cup and was reaching for it. The ADON said the fall happened at the entrance of the Harborside day room. She recalled that Staff Development reached out to LPN G, the resident's primary nurse, who came back in and documented a statement. She verbalized the DON then took over the investigation. On 4/19/23 at 9:30 AM, the DON stated she was not at the facility when the incident occurred, and when she returned, she asked the UM to reach out to all the staff. She recalled the fall was discussed by the Interdisciplinary Team (IDT) on 4/11/23. She said the team did not think the fall was an adverse incident since the resident was able to make her needs known, could self-propel in her wheelchair, was in a reclining high back wheelchair, was positioned appropriately, and did not lack capacity. She said an incident report was not submitted to the Agency for Health Care Administration as this was not an injury of unknown origin, the facility knew what happened. She acknowledged the resident sustained a major injury as a result of the fall and was transferred to a higher level of care. On 4/19/23 at 4:39 PM, the resident's falls and care plan for falls were reviewed with the DON. The resident had falls on 2/12/21 at 4:30 PM, 3/05/21 at 6:56 PM, 5/21/21 at 11 AM, 5/29/21 at 3:30 PM, 7/13/21 at 8:40 PM, 8/30/21 at 11:40 AM, 9/2/21 at 1:41 PM when the resident fell from her wheelchair in the bathroom, on 10/03/21 the resident slid from her wheelchair, on 9/12/22 at 4:21 AM. On 1/28/23 at 1:08 PM, the resident was observed on the floor on her knees, complained of pain in both knees, and was sent to the hospital. On 2/01/23 at 5:15 AM, the resident was found lying on the floor mat with her head at the foot of her bed, and her feet towards the head of the bed. The resident said she was looking for her sister and slid off the bed. She stated she hit her right hip and knees, was medicated with Tylenol, and x rays of the hip, pelvic, femur, and knees were ordered by the ARNP. On 4/10/23 the resident fell from her wheelchair, sustained a neck fracture, and was transferred for a higher level of care. Care plan interventions included to ensure items within reach, a raised edge mattress, medication review, bed in lowest position, antibiotic therapy for urinary tract infection, call bell in reach, therapy to screen, and naps after lunch as tolerated. There was no indication on the care plans to address supervision of the resident despite being at risk for falls and twelve actual falls including the fall on 4/10/23 with major injury. When asked to speak about the level of supervision the resident required, the DON said they could not have one-on- one supervision all the time. There was however no intervention on the care plan for one to one supervision or any type of supervision to monitor the resident to mitigate risk for falls. On 4/19/23 at 10:48 AM, the Director of Rehab stated resident #1 had limited range of motion to her knees, and therapy worked with her heavily on wheelchair positioning. Resident #1's Occupational Therapy (OT) Evaluation & Plan of Treatment revealed the resident's start of care was on 4/13/23. The reason for the referral was Pt (patient) had a fall out of the w/c (wheelchair) resulting in a C1 Burst-Jefferson's fracture, now in a Miami J C collar on at all times except for eating and bathing. The document revealed that equipment prior to the resident's start of care included a standard wheelchair, and documentation indicated the resident had impaired safety awareness. The Physical Therapy (PT) Evaluation & Plan of Treatment with start of care on 4/13/23, indicated the resident was referred to PT following a fall out of her wheelchair with cervical fracture. The document read, This fall caused a [NAME] fracture and further malalignment of upper cervical canal. The evaluation indicates that equipment prior to onset/hospitalization included bilateral floor mats, hospital bed, and a standard wheelchair with pressure relieving cushion. On 4/19/23 11:09 AM, CNA E stated that resident #1 was able to make her needs know, but sometimes the evening shift reported periods of confusion. CNA E stated that if residents were at risk for fall, CNAs were told to place the residents in the day room, so nurses, and CNAs could monitor the residents. She said that up until resident #1's incident, no staff provided supervision in the day room. CNA E verbalized that during the day shift, activity staff were usually in the day room doing various activities, but not during the 3 PM to 11 PM shift. On 4/19/23 at 12:49 PM, the ARNP stated she assumed care for resident #1 on 3/01/23. She said the resident was assessed by psychiatry and was deemed to be lacking ability to make her own decision, prior to her fall on 4/10/23. The ARNP said the resident had an overall decline since March 2023, On 4/19/23 at 1:25 PM, in a telephone interview, LPN H recalled that on 4/10/23, resident#1 was trying to come out of the Harborside day room by self-propelling her wheelchair. LPN H said she was at the nurses' station cleaning her medication cart when she heard the resident say, oh my God. The LPN said she turned, and the resident was on the floor face down, gushing blood from her forehead. The resident told her she was trying to get her cup and complained of pain to her head. She noted the resident's assigned nurse, LPN G was in the long hallway giving medications and no staff member was in the day room. She said resident #1 was the only person in the dayroom at that time. On 4/19/23 at 1:42 PM, in a telephone interview, LPN G stated she worked on the 3 PM to 11 PM shift on 4/10/23 and confirmed that resident#1 was included in her assignment. LPN G verbalized that she knew the resident for quite some time and had seen the resident decline. She indicated sometimes the resident was confused and delusional. She recalled the last time she saw the resident on 4/10/23 was at 6:45 PM when she administered the resident's pain medication, Hydrocodone. She remembered the resident was in her wheelchair, watching television. The LPN recalled she left the resident in the dayroom close to the television, along with other residents who were watching television. LPN G stated she moved her medication cart down to the long hallway and was there when she heard LPN H yelling. When she went to the dayroom, the resident was on the floor face down at the doorway that opened to the nurses' station with her wheelchair behind her. She recalled the resident complained her head was hurting, and she was bleeding a lot from her forehead. She reported pressure was applied to the bleeding site and 911 was called. LPN G explained that staff were not necessarily rotated. to supervise residents in the day room for safety. She acknowledged there was no scheduled rotation for staff to supervise residents in the day room. The resident's care plan was reviewed with LPN G. She stated she had not reviewed the resident's care plan recently and reported that staff just knew to make visual observations of residents at risk for falls. She did not explain the level of supervision required for resident #1 with 12 previous falls. On 4/19/23 at 3:42 PM, the Director of Rehab stated the resident did not propel her wheelchair with her feet, but with her hands. She verbalized that Therapy had set her up in a raised wheelchair, and explained this meant the wheelchair had the ability to go higher or lower based on the resident's height. The Director of Rehab said Maintenance and PT had the resident's chair raised one inch higher, so that straight leg rest could be placed, and the resident's feet would fit on the leg rest without dragging. Review of the resident's clinical records revealed the wheelchair was never adjusted. The Director stated the straight leg rest were placed to prevent dragging of the resident's feet, and at the time of the fall the resident was in a standard wheelchair, not in a high back wheelchair. On 4/20/23 at 12:59 PM, in an interview with the Administrator and DON, the Administrator said the facility did not lack supervising the resident, since LPN H was within 16.3 feet of the resident. The DON stated she reviewed the regulatory guideline regarding adequate supervision, and feels that the facility was in compliance. When asked how much supervision resident #1 required to keep her safe, the Administrator said the resident needed no more supervision than anybody else. The DON said supervision would depend on the time of the day. When asked if the facility interviewed the resident regarding the incident, the DON stated the facility did not obtain a statement /interview from the resident. The resident's Fall Risk Evaluation dated 2/14/23, and 4/13/23 were reviewed with the DON, and an explanation of the score could not be provided. At 4:22 PM, the DON stated the Fall Risk Evaluation in the resident's electronic clinical records did not have a legend/key. She said that in discussion with the Regional nurses she was informed that on the Evaluation form if the score was 10 and above, fall prevention intervention measures should be implemented. Review of the facility's policy and procedure Fall Management revised on 4/07/22, and reviewed on 9/29/22, revealed residents would be assessed for any fall risks, and appropriate interventions to minimize the risk of injury related to the falls would be identified. The document read, Implement interventions, including adequate supervision .consistent with a resident's needs .care plan and current professional standards of practice in order to eliminate the risk if possible, and if not, reduce the risk of an accident .Adequate supervision is determined by assessing the appropriate level and number of staff required .and the frequency of supervision needed. Review of the Facility Assessment Template reviewed on 10/11/22 revealed the care and services offered to residents by the facility included Mobility and fall/fall with injury prevention

Based on interview, and record review, the facility failed to ensure a copy of the Baseline Care Plan was provided to 7 of 7 sampled residents or their representatives out of a total sample of 39 residents, (#58, #81, #436, #437, #439, #545 and #547). Findings: 1. Review of the medical record revealed resident #545 was admitted to the facility on [DATE] with diagnoses of left artificial hip joint, history of falls, gait and mobility abnormalities, neoplasm of bladder, bladder-neck obstruction, benign prostatic hyperplasia with lower urinary tract symptoms. Review of the baseline care plan summary assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated he was cognitively intact. On 04/17/23 at 1:30 PM, resident #545 stated he did not receive a written copy of his Baseline Care Plan. Review of resident #547's medical record noted she was admitted to the facility on [DATE] with diagnoses of right artificial shoulder joint, muscle weakness, abnormalities of gait and mobility, and atrial defibrillation. Review of the staff assessment for mental status conducted on 04/07/23 revealed the resident was alert and oriented, was capable of making her own decisions and was able to make her needs known. On 4/17/23 at 10:00 AM, the resident stated she had participated in therapy and planned on returning to her home. She added she would be discharged from the facility within the next few days and was frustrated as she had not been provided a copy of her care plan. 32962 2. Review of resident #436's medical record revealed she was admitted to the facility on [DATE] with diagnoses of syncope and collapse, fracture of the right femur with surgical repair, and depression. Review of resident #436's Baseline Care Plan documented it was completed on 04/05/23 by Registered Nurse (RN) A. On 04/17/23 at 1:45 PM, resident #436 stated, I have never had a meeting to discuss my care plan and I have not received a copy of my care plan. Review of resident 81's medical record revealed she was admitted to the facility on [DATE] with diagnoses of right femur fracture, fracture of the second metacarpal bone of right hand, Alzheimer's Disease, depression, and chronic kidney disease. Review of resident #81's Baseline Care Plan documented it was completed on 03/19/23 by RN A. On 04/17/23 at 2:15 PM, resident #81 said she had not had a care plan meeting and had not received a copy of her care plan. Review of resident #439's medical record revealed he was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. Review of resident #439's Baseline Care Plan documented it was completed on 03/30/23 by RN A. On 04/17/23 at 2:30 PM, resident #439 explained he never had a care plan meeting and had not received a copy of his care plan. Review of resident #437's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Transient Cerebral Ischemic Attack (TIA), dementia, neuropathy, and diabetes mellitus. Review of resident #437's Baseline Care Plan documented it was completed on 03/24/23 by RN A. On 04/17/23 at 3:50 PM, resident #437 said she never had a care plan meeting and never received a copy of her care plan. Review of resident #58's medical record revealed she was admitted to the facility on [DATE] with diagnoses of left knee effusion and pain, depression, anemia, and diabetes mellitus. Review of resident #58's Baseline Care Plan revealed it was completed on 03/28/23 by RN B. On 04/18/23 at 10:50 AM, resident #58 stated she never had a care plan meeting and she never received a copy of her care plan. On 04/19/23 at 2:15 PM, RN A said she had been the Bayside Unit Manager and had completed the Baseline Care Plans for the newly admitted residents on the unit. I took it upon myself to ensure the Baseline Care Plans were completed on time. RN A explained the Baseline Care Plan was started as part of the resident's admission assessment. She said the Baseline Care Plan was in a checklist form and noted I never gave a copy of the Baseline Care Plans to the residents or their responsible party. On 04/19/23 at 3:55 PM, the Director of Nursing (DON) stated, The Baseline Care Plans were completed by the nurse and a copy was given to the residents. She was informed residents #58, #81, #436, #437, #439, #545 and #547 had not received copies of their care plans. She did not explain why copies of the Baseline Care Plans were not provided to the residents. Review of the Facility's Baseline Care Plan Policy, dated 08/17/2022, read, Policy: A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care . Federal Regulations: . 483.21 (a) (3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: i. The initial goals of the resident. ii. A summary of the resident's medications and dietary instructions. iii. Any service and treatments to be administered by the facility and personnel acting on behalf of the facility. iv. Any updated information based on the details of the comprehensive care plan, as necessary . Procedure . 5. Provide the resident and/or representative with copies of the baseline care plan and physician orders .

Based on observation, record review, and interview, the facility failed to follow the menu for food items and serving sizes to ensure all resident received foods based on their individual prescribed diets and nutritional requirements. Finding Review of the facility's lunch menu for 4/20/23 showed beef burgundy, buttered noodles, stir fry vegetables, garlic toast, frosted banana cake and beverage of choice. The lunch alternatives included ham salad sandwich, chips, marinated vegetable salad, and dinner roll. On 4/20/23 at approximately 11:58 AM, the dietary staff were at the lunch tray line. The therapeutic menu next to the steam table noted residents on mechanical soft diet texture and pureed diet texture, would receive a #16 scoop (2 ounces) of pureed bread. There was no pureed bread on the steam table. The cook who was plating the meals stated it was an oversight. Further observations of the steam table revealed a #12 (2.6 ounces) scoop was used to plate the pureed beef burgundy, pureed stir fry vegetables, and the mechanical beef burgundy. The therapeutic menu noted that a #10 (3.2 ounces) scoop was to be used for the pureed beef, pureed stir fry vegetables and the mechanical beef burgundy. This indicated residents who were either on a mechanical soft texture diet or puree texture diet received less food than what the menus had indicated. On 4/20/23 at 12:30 PM, the facility's Certified Dietary Manager (CDM) stated the facility had four residents on finger food diet. The therapeutic menu indicated these residents would receive bow tie pasta, pita bread and a cupcake. The facility's Consultant Registered Dietitian, (RD) and CDM were not able to explain the protein source for the finger food diet. The cook stated he did not make any bow tie pasta and they did not have any pita bread. He explained he sent buttered noodles and some broccoli that he picked out from the stir fry vegetables for the residents who were on finger food diet. There was no indication the cook was aware of what food items were to be served to residents on finger food diet. The CDM said the regular cook was sick today and the replacement cook was not very experienced. The RD and CDM did not explain why they did not provide any oversight for today's lunch meal, that was being prepared by a less experienced staff member. On 4/20/23 at 2 PM, the RD said she looked up the recipe for the finger foods. She explained the beef burgundy was to be placed into a pita for the residents on finger foods to be eaten like a sandwich.

Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for splint application after discharge from Occupational Therapy (OT) for 1 of 5 residents reviewed for limited Range of Motion (ROM), (#76), and failed to ensure resting hand splint was applied as per physician's order for 1 of 5 residents reviewed for limited ROM, of a total sample of 39 residents, (#84). Findings: 1. Resident #76 was an [AGE] year-old male, admitted to the facility on 4/ 12/18. His diagnoses included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting his left non-dominant side, generalized muscle weakness, pain, and diabetes type II. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 1/06/23 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 12/15. The assessment showed he had impairment in functional limitation in ROM on one side of his upper and lower extremities. Review of the Occupational Therapy (OT) Discharge Summary with dates of service from 1/31/23-2/13/23 revealed a discharge recommendation for the resident to wear a left resting hand orthosis for 4 hours per day, then use the left-hand palm guard as tolerated. On 4/17/23 at 11:37 AM, and 4/18/23 at 9:46 AM, resident #76 was sitting up in bed, watching television. The resident stated he had weakness to his left side. His left hand and fingers were contracted, and he was not wearing a splint. Resident #76 stated he did not have a splint for his left hand/fingers. On 4/18/23 at 4:12 PM, Registered Nurse (RN) C, stated resident #76 had a contracted left hand. Observation of the resident's contracture with RN C confirmed a splint was not in place. A review of the resident's physician's orders with RN C noted there was no order for splint application to the resident's left hand. On 4/19/23 at 10:19 AM, the Director of Rehab stated resident #76 had a left resting hand splint as tolerated. She stated OT did an evaluation on 1/31/23, and the resident was on OT case load through 2/14/23, working on wheelchair positioning, left hand ROM, and to encourage him to use a left resting hand splint. The Director of Rehab stated when the resident was discharged from OT, nursing staff were trained on how to apply the hand splint. She explained that a master splinting list was on each unit, created and updated by the Director of Therapy. She noted resident #76 was placed on the list on 2/14/23 after staff education was completed. The Director of Rehab verbalized that splinting was recommended for the resident due to worsening of his left-hand ROM and contractures, and the splint helped to prevent worsening of contracture. The Director of Rehab identified the therapist failed to enter the physician's order for splint application in the medical record and said, however, the other steps were in place, such as education and the master splinting list. She reported the splint was in a box in the resident's room and the Unit Manager, Nurses, and Certified Nursing Assistants (CNA) were aware. On 4/20/23 at 9:21 AM, the Harborside Registered Nurse/Unit Manager (RN/UM) stated the master splinting list was implemented by therapy, posted in the charting room, and Nurses, and CNAs were aware. The RN/UM said she was not sure if anyone reached out to the physician for an order for splint application for the resident. She explained the physician order for splinting was missed by both therapy and nursing staff. 2. Resident #84 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left side. Review of the resident's physician's orders revealed an order dated 2/15/22 for Splint/Brace: Comfy resting hand splint, Apply to Left hand to be worn at all times, off for care, as tolerated. The resident's quarterly MDS assessment with ARD of 3/17/23 revealed the resident's cognition was intact with a BIMS score of 15/15. The assessment revealed the resident had impairment in functional Limitation in ROM on one side of his upper and lower extremities. The resident's care plan for activities of daily living self-care performance deficit related to limited mobility, and left hemiplegia initiated on 10/15/19 and revised 7/23/20 revealed an intervention for splint/brace comfy resting hand splint, apply to left hand to be worn at all times. On 4/17/23 at 11: 51 AM, resident #84 was sitting in his wheelchair to the right of his bed. His left hand was contracted, and he was not wearing a splint. On 4/18/23 at 9:48 AM, resident #84 was in his wheelchair watching television. He did not have a splint to his left hand. The resident stated he should have a splint to his left hand daily when the nurses remembered. He recalled the last time his left-hand splint was placed was three days ago. He noted he never refused to wear the splint. On 4/18/23 at 4:15 PM, RN C stated resident #84's left hand was contracted. He reviewed the resident's physician's orders, and confirmed a physician order was in place for the resident to always have splint to his left hand. Observation of the resident's contracture was conducted with the RN. He confirmed the resident was not wearing a splint. The resident reiterated the splint had not been applied for three days. On 4/18/23 at 4:27 PM, the Harborside RN/UM stated resident #84 had physician's order for a comfy hand splint to be on at all times. The RN/UM could not confirm if the splint was applied as ordered. She stated that review of the Treatment Administration Record (TAR) showed the task was signed off by nurses as being done every shift. On 4/19/23 at 10:32 AM, the Director of Rehab stated the resident was on Occupational Therapy (OT) caseload from 2/09/22 through 2/22/2022. He was provided with a resting hand splint, and the order was still in effect. She explained the splint was to prevent worsening of his contracture. On 4/19/23 at 11:04 AM, CNA E stated therapy trained staff to don/doff splints, and said she should have placed the resident's left-hand splint on but did not. On 4/19/23 at 11:27 AM, Licensed Practical Nurse (LPN) D stated CNAs usually applied the resident's splint, and she signed on the TAR for skin integrity, not for splint application. She said CNAs would let nurses know if the resident refused splint application, but there was no report of the resident's refusal to wear the splint. The facility did not have a policy regarding splint application. The DON stated they followed the Lippincott Procedures-Splint application. The document read, Obtain a physician's order as needed prior to application .Verify the practitioner's order.

Based on observation, interview, and record review, the facility failed to provide individualized activities to meet the interest and needs for 1 of 2 residents reviewed for activities of a total sample of 46 residents, (#80). Findings: Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 8 which indicated moderate cognitive impairment. Section F of the assessment Preferences for Customary Routine and Activities indicated it was very important for her to listen to music and to do her favorite activities. It was not very important to her to do things with groups of people or go outside to get fresh air when the weather was good. Resident #80 required extensive assistance from 2 staff for bed mobility and transfers and did not walk during the lookback period. She had unsteady balance, was only able to stabilize with assistance from staff and used a wheelchair for mobility. Review of resident #80's activity care plan initiated on 7/07/2020 revealed she had little to no involvement due to physical limitations. The goal was for the resident to express satisfaction with the type of activities and level of activity involvement. Interventions included explaining the importance of social interactions and encourage her to participate. The care plan directed staff to escort resident #80 to activity functions and provide room visits if she declined to attend small group activities. On 5/24/21 at 10:36 AM, resident #80 was lying in bed in a private room, staring through the window. The room was silent and there was no television or radio noted. She was alert, responded to her name only, but was not able to respond to simple questions or participate in conversation. There was a sign at the door indicating resident #80 was on contact isolation precautions. On 5/25/21 at 11:51 AM, resident #80 remained in bed seated in an upright position, again staring through the window. The room was still silent. On 5/26/21 at 10:58 AM, resident #80 was sitting up in bed with her eyes closed. On 5/26/21 at approximately 5:15 PM resident #80 remained alone in her room without any activities. On 5/26/21 at 5:37 PM, the Activities Director recalled resident #80 previously resided on the facility's Memory Care Unit. The Activities Director explained the resident was currently in a private room on the other unit as she had an infection. Review of the Record of One-To-One Activities form with the Activities Director revealed documentation that noted resident #80 watched television in her new room on the Harbor Side Unit on 5/23/21 and 5/25/21. The Activities Director was informed resident #80 did not have a television in her room. On 5/26/21 at 5:39 PM, the Activities Director entered resident #80's room and acknowledged there was no television or radio in the room. She explained the resident was placed in her new room on 5/21/21, and her television was not moved at that time. She said whenever a resident relocated to a different room, staff needed to ensure all items the resident enjoyed as activities were in the new room and accessible to the resident. The Activities Director said resident #80 enjoyed watching television and listening to music. On 5/27/21 at 1:14 PM, a telephone interview was conducted with resident #80's nephew. He was informed his aunt was placed in a private room without a television for 6 days. He said, I am taken aback that my aunt would just be in a room without television or radio all by herself. She enjoys listening to music. On 5/27/21 at 2:09 PM, the Activities Director stated activities were important to enhance the resident's quality of life. She explained documentation by activity staff dated 5/23/21 and 5/25/21 that reflected television watching activity was incorrect. On 5/27/31 at 3:23 PM, Certified Nursing Assistant (CNA) A stated she regularly cared for resident #80 and remembered she always wanted to be in her bed watching television. CNA A said, She did not want to do anything else. On 5/27/21 at 3:25 PM, CNA B stated the resident loved to watch television in her room. CNA B, recalled, when she came out of her room, she would sit in the Day Room and watch television. The facility policy and procedure Activity Evaluation, reviewed 5/18/2020 read, The facility must provide, based on comprehensive assessment and care plan and the preferences of each patient, an ongoing program to support patients in their choice of activities . The document indicated the facility would provide person-centered care related to identifying each resident's preferred activities.

Based on record review and interview, the facility failed to provide care and services to appropriately assess, monitor and treat [MEDICAL CONDITION] to prevent the development and worsening of non-pressure skin breakdown for 1 of 4 sampled residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her hospital transfer form dated 11/08/19 revealed she had no pressure ulcers, [MEDICAL CONDITION] or wounds on discharge from the hospital. The Admission/Readmission Collection Tool dated 11/09/19 revealed the admitting nurse was able to feel the pulses in resident #1's feet and noted she had no [MEDICAL CONDITION] or swelling. The skin evaluation section revealed her skin was intact with only an area of discoloration to the right inner elbow. Review of the Minimum Data Set admission assessment, dated 11/13/19, revealed resident #1 had no pressure ulcers, other ulcers, wounds or skin problems. The assessment indicated resident #1 had not received diuretic medication since admission. A diuretic or water pill is a drug that increases urine production to promote the removal of fluid from the body. (www.drugs.com) Resident #1's admission physician orders [REDACTED]. The physician assessed resident #1 on 11/09/19, and a history and physical note indicated he reviewed her medication list, continued the [MEDICATION NAME] as ordered and noted her extremities showed no [MEDICAL CONDITION]. In a Skilled Note dated 11/11/19 at 12:54 PM, licensed practical nurse (LPN) A wrote resident #1 had . 2-3+ [MEDICAL CONDITION] to both feet; her feet up to lower calf feels cool to touch. LPN A applied compression stockings to resident #1's legs. When pressure is applied to a swollen area, it may leave an indentation in the skin. The classifications 1+ (the least severe) through 4+ (the most severe) indicate the depth of the indentation and duration of time the skin takes to rebound. (www.medicalnewstoday.com) Later that day at 10:54 PM, the advanced registered nurse practitioner (ARNP) assessed resident #1 and documented there was no [MEDICAL CONDITION] to her extremities. On 11/12/19, resident #1 was assessed by a consulting physician who noted she had 2+ [MEDICAL CONDITION] and compression stockings for [MEDICAL CONDITION] control. A Skilled Note dated 11/13/19 at 1:40 PM revealed resident #1 informed LPN A her compression stockings felt too tight and painful . The note indicated resident #1 had 2+ [MEDICAL CONDITION] to her lower extremities. LPN A's documentation showed she removed the compression stockings and wrapped resident #1's legs with elastic bandages instead. On 11/15/19 at 3:28 PM, LPN A's nursing note revealed resident #1's legs remained swollen and the elastic bandages were in place. A Skin/Wound Note written by Registered Nurse (RN) B on 11/15/19 at 10:45 PM revealed resident #1 had an intact fluid-filled blister to the the base of the 3rd toe on her right foot and skin prep was to be applied every shift. On 11/18/19 at 1:54 PM, a nursing progress note indicated resident #1 continued to have 2 - 3+ [MEDICAL CONDITION] to both legs and elastic bandages were in place. Review of the Medication Administration Record [REDACTED]. A nurse's note written by LPN A later that afternoon at 3:34 PM read, This morning I gave her a dose of ([MEDICATION NAME]) for 3+ [MEDICAL CONDITION] . Later that evening at 9:52 PM, RN B noted resident #1's blister popped and she applied antibiotic ointment and a dressing to the area. The medical record revealed on 11/20/19, resident #1 received another dose of [MEDICATION NAME] 20 mg and the attending physician ordered daily administration of the drug for an additional 3 days for continued [MEDICAL CONDITION]. A nursing note dated 11/21/19 read, She has 3+ [MEDICAL CONDITION] and a physician's orders [REDACTED]. On 11/23/19, nursing documentation indicated resident #1 had [MEDICAL CONDITION] to both legs and reported she had not urinated much during the day shift. On 11/24/19, LPN A noted resident #1 still had 3+[MEDICAL CONDITION] to her legs and on 11/25/19 her condition remained the same. On 11/26/19 and 11/27/19, progress notes indicated resident #1 again wore compression stockings rather than elastic bandages for 2+ [MEDICAL CONDITION]. On 11/28/19, LPN A noted resident #1 had 2-3+ [MEDICAL CONDITION] and She has multiple open blisters to her feet; her dressings were changed as indicated and (elastic bandages) were applied. Resident is not to have (compression stockings) as they are creating a problem. Review of resident #1's Order Summary Report and treatment administration record (TAR) revealed an order dated 11/11/19 for compression stockings to be applied in the morning and removed at bedtime. The order was discontinued on 11/13/19. A new physician's orders [REDACTED]. There was an order dated 11/15/19 for skin prep, a liquid protective film dressing to be applied to the fluid-filed blister on resident #1's right foot. On 11/29/19, a nursing note written by LPN A read, Resident was seen by nurse practitioner; she has ordered wound consult for her related to multiple open areas to her feet and weeping [MEDICAL CONDITION]. This morning I cleansed both feet and applied skin prep peri-wounds; I then wrapped with (gauze) and applied (elastic dressing). Weeping [MEDICAL CONDITION] occurs when excess fluid in swollen extremities leaks through the skin.(www.woundsource.com) There were no physician's treatment orders for cleansing the areas of concern, application of an antibiotic ointment and dressing as completed by RN A, or any physician orders [REDACTED].#1's feet identified by LPN [NAME] an order for [REDACTED]. However, review of progress notes for Monday 12/02/19 revealed nursing documentation of resident #1's swelling in her legs, but no reference to a visit by the wound specialist as ordered. The wound care specialist's Weekly Report dated 12/02/19 did not include resident #1's name, and there were no new physician's orders [REDACTED]. The physical therapy discharge summary dated 12/04/19 revealed resident #1's progress was limited by significant [MEDICAL CONDITION] in her legs that inhibited strength and range of motion. A nursing discharge summary dated 12/04/19 revealed resident #1 was discharged home with weeping [MEDICAL CONDITION], blisters and open areas to both legs. In a telephone interview on 1/17/20 at 12:40 PM, resident #1's daughter recalled her mother suddenly developed swelling in both legs while she was in the facility. The daughter said, Her legs were so swollen and they started wrapping them. One day my sister took her out and unwrapped them to see what they looked like. It was so bad! The daughter explained she was very concerned about her mother's feet because she was diabetic. She asked the facility to arrange a consult with a wound doctor. Resident #1's daughter stated her mother's condition worsened and the swelling in her legs caused blisters on both feet by the time she was discharged home. She stated despite multiple requests, her mother was never seen by a wound doctor. She stated her mother was scheduled to see a vascular surgeon due to non-healing wounds on her feet. Resident #1's daughter explained prior to admission to the facility her mother lived independently, and if she had her foot or toes amputated because of the wounds, it would change her life forever. On 1/19/20 at 1:20 PM, the Bayside unit manager (UM) recalled resident #1 had significant [MEDICAL CONDITION] in both legs that caused blisters. She validated although nursing documentation indicated resident #1's [MEDICAL CONDITION] was noted on 11/11/19, the ordered medication was not given until 11/19/19. She explained resident #1 had kidney disease and nurses might not have wanted to give a diuretic because of potential adverse effects. She acknowledged nurses should have called the physician for clarification of the order or to request another medication since the [MEDICAL CONDITION] required treatment. The Bayside UM stated nurses should notify the attending physician of any new skin breakdown or changes in condition and obtain immediate treatment orders. She validated a wound physician consult was ordered and said, It appears to have been missed by the wound doctor. The Bayside UM confirmed resident #1 was diabetic and said, With her being diabetic and having blisters or wounds on her feet, it could really go wrong. The Bayside UM confirmed nurses were expected to complete a head to toe skin check on every resident at least once weekly. However, review of the medical record revealed only 1 Weekly Skin Integrity Data Collection form dated 11/17/19, which showed resident #1's skin was intact, with no new findings. On 1/19/20 at 2:32 PM, LPN A recalled resident #1 had [MEDICAL CONDITION] in both legs that worsened until she developed blisters. LPN A said, I'm not sure if I called the doctor for that. She reviewed the medical record and confirmed she did not document notification of the physician related to the change in condition. She acknowledged she did not give [MEDICATION NAME] 20 mg as ordered when she first noted the [MEDICAL CONDITION] in resident #1's legs. LPN A recalled the blister on resident #1's foot was initially small, but kept getting bigger until she could no longer tolerate the compression stockings. She said, I think I got an order for [REDACTED]. LPN A again reviewed the medical record but could not find any documentation regarding orders for gauze to cover the blister. In a telephone interview on 1/19/20 at 3:21 PM, RN B recalled resident #1 had [MEDICAL CONDITION] in both legs and developed blisters on her feet. She said, The fluid has to come out. She explained the blister was initially treated with a liquid skin barrier and gauze wrap. RN B confirmed the blister popped and she treated the area with antibiotic ointment and a gauze dressing. She acknowledged an order was required for antibiotic ointment and a new wound treatment. RN B was informed no such order was noted in resident #1's medical record. She explained, Quite often we write telephone orders for treatments without calling the doctor. They will say don't call me for a treatment order. You know what you use there. RN B stated she would usually write treatment orders and the physician would review and sign them when they came to the facility. In interviews on 1/19/20 at 3:12 PM and 4:23 PM, the director of nursing (DON) acknowledged nurses did not notify the physician regarding resident #1's [MEDICAL CONDITION] nor administer the medication that was ordered and available. The DON could not explain why the wound consult ordered by the ARNP was not implemented in a timely manner. She said, It should have been done. I don't know why she wasn't seen. The DON validated resident #1's [DIAGNOSES REDACTED]. The DON stated all residents should be weighed on admission and then every week for a minimum of 4 weeks. She explained residents with [MEDICAL CONDITION] could have orders to be weighed more often. However, review of the medical record with the DON revealed resident #1's initial weight was not obtained until 11/11/19, 3 days after admission, followed by weights on 11/12/19 and 11/14/19. She confirmed there were no other weights obtained during resident #1's 4-week stay in the facility, despite her worsening [MEDICAL CONDITION]. The DON validated weekly skin checks were not completed as ordered and said, If the skin checks were done we would have noticed the decline. She stated residents' charts were reviewed in daily clinical meetings on admission and if there was documentation of any changes in condition or new orders. The DON acknowledged staff members did not identify the concerns related to resident #1's [MEDICAL CONDITION] and blisters during the chart review process. Review of the care plans for [MEDICAL CONDITION] and diuretic use revealed interventions to give medications as ordered and obtain weights per facility protocol. A care plan for risk for break in skin integrity directed nurses do treatments and weekly skin checks as ordered. Resident #1 had a care plan for the blister on her right foot initiated on 11/18/19. The goal was she would maintain or develop intact skin. The interventions directed nurses to assess the skin, report failure to heal to to the physician and follow facility treatment protocols. Review of the policy and procedure (P&P) for Skin Integrity & Pressure Ulcer/Injury Prevention and Management effective 10/03/19, revealed weekly skin assessments would be performed by a nurse and any skin breakdown requires attention and a change in the plan of care to appropriately treat the patient. The P&P for Changes in Resident's Condition or Status reviewed on 4/15/19 indicated the physician would be notified of significant changes, clinical complications and the need to significantly alter treatments. The P&P for Physician order [REDACTED]. may not be administered to the resident without a written order from the attending physician.

Based on observation, interview, and record review, the facility failed to provide activities of daily living care (ADL) care related to personal hygiene based on preference for 1 of 2 residents, (#74). Findings: Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the minimum data set ((MDS) dated [DATE] noted the resident was rarely and never understood. The resident required extensive assistance with personal hygiene, and had moderately impaired cognition. On 10/28/19 at 4:00 PM, resident #74 was seated in her wheelchair in the television room. She had several strands of gray hair approximately ¾ to 1 inch long on both sides of her chin. Resident stated she wished she had scissors so she could cut them off. Observation on 10/29/19, 10/30/19 and 10/31/19 revealed her facial hair remained unchanged. On 10/31/19 at 10:01 AM, certified nursing assistant (CNA) F stated he was assigned to resident #74. He stated the resident required total care for ADLs and removal of facial hair was part of her daily personal hygiene. He stated he should anticipate the residents needs for personal hygiene and provide per resident preference. On 10/31/19 at 10:25 AM, the license practical nurse (LPN) [NAME] explained that the CNA was responsible for ADL care. She stated that facial hair was included in daily ADL care. Review of the facility policy Activities of Daily Living, date 12/11/18, read, . The resident will receive assistance as needed to complete activities of daily living (ADLs)

Based on interview and record review the facility failed to address pharmacy recommendations in a timely manner for 1 of 5 residents reviewed for unnecessary medications, (#42). Findings: Resident #42 was an [AGE] year-old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medications for resident #42 included [MEDICATION NAME] 500 milligrams (mg) one tablet two times per day. Review of pharmacy monthly medication review (MMR) recommendation dated 8/24/19 read, resident #42 has received a [MEDICATION NAME]-containing product and had an estimated creatinine clearance of 14 milliliters per minute (mL/min) on 8/08/19. Recommendation: Please discontinue [MEDICATION NAME]. Glucose monitoring should continue following any change in antidiabetic medications and guide future therapy. The rationale for recommendation noted that [MEDICATION NAME] had a BOXED WARNING for increased risk of lactic acidosis with renal impairment. [MEDICATION NAME] is CONTRAINDICATED when creatinine clearance or glomerular filtration rate is less than 30 mL/min. [MEDICATION NAME]-associated lactic acidosis has resulted in death, hypothermia, [MEDICAL CONDITION], and resistant [MEDICAL CONDITION]. The onset of [MEDICATION NAME]-associated lactic acidosis is often subtle, accompanied only by non-specific symptoms such as anxiety, nausea and vomiting, malaise, myalgia, respiratory distress, weakness, somnolence and abdominal pain. Review of physician's progress notes that were available dated 10/02/19 and 10/24/19 revealed no indication that this pharmacy recommendation was addressed. Review of nursing progress notes dated from 8/21/19 through 10/30/19 revealed no indication that this pharmacy recommendation was addressed. Another pharmacy recommendation dated 10/23/19 read, REPEATED RECOMMENDATION from 8/24/19: Please respond promptly to assure facility compliance with Federal regulations. Resident #42 has receives a [MEDICATION NAME]-containing product and had an estimated creatinine clearance of 14 milliliters per minute (mL/min) on 8/08/19. Recommendation: Please discontinue [MEDICATION NAME]. Glucose monitoring should continue following any change in antidiabetic medications and guide future therapy. The rationale for the recommendation was the same as on 8/24/19. On 10/31/19 at 1:32 PM, licensed practical nurse (LPN) A said, we get faxes on a regular basis, for pharmacy recommendations. Floor nurses check the recommendations and the unit manager gives the information to the doctors to see if they want to act on the recommendations. We call resident's #42's physician and tell him when pharmacy recommendations come in and then fax them to him. Other physicians come in weekly. We don't have a unit manager on this unit. It's been a couple of months now since we had a unit manager. She would coordinate the pharmacy recommendations and keep the Director of Nursing (DON) in the loop. I didn't see the pharmacy recommendation for resident #42. It's a lot to deal with. Once we address each pharmacy recommendation, we fax them back to pharmacy, and file it in the resident's chart. On 10/31/19 at 1:52 PM, the DON stated, we have a consultant pharmacist that comes to the facility each month. She reviews charts and emails her recommendations to me. I print them and pass them out to the physicians. The physicians have boxes on the unit and we put the recommendations in which are used for the whole building. The physicians will sign them and put them back in their boxes. I check the boxes about three times per week for the completed recommendations and follow through with them. Sometimes the nurses will follow through with them and come back to me to file them in the pharmacy binder. The DON could not explain why the pharmacy MMR dated 8/24/19 and 10/23/19 had not been addressed until 10/30/19. Review of facility policy, 9.1 Medication Regimen Review, 11/28/16, read, . Procedure . 7. Facility should encourage Physician/Prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR .8. Facility should alert the Medical Director when MMRs are not addressed by the attending physician in a timely manner

Based on observation, interview and record review, the facility failed to ensure that a recommendation for gradual dose reduction (GDR) of a [MEDICAL CONDITION] medication had physician justification for not implementing the reduction for 1 of 5 residents reviewed for unnecessary medications, (#24). Findings: Resident #24 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. On 10/29/19 at 3:00 PM, resident #24 was in the activity room participating in a coloring activity. On 10/30/19 at 10:01 AM, he was observed in the Harborside day room. He had no signs of pain or discomfort. He was alert, calm, smiling and showed no signs of behaviors. He was actively engaged in the activity and participated by answering questions about the news presented by the activities aide. On 10/30/19 at 12:45 PM, resident#24 was observed eating lunch independently in the main dining room. Review of the (MONTH) 2019 physician orders [REDACTED].#24 was receiving multiple [MEDICAL CONDITION] medications including [MEDICATION NAME] 250 milligrams (mg) twice daily, [MEDICATION NAME] 0.25 mg 1 tablet at night, [MEDICATION NAME] 20 mg once daily and [MEDICATION NAME] 25 mg at night. A pharmacy consultant recommendation dated 6/20/19 requested a GDR for [MEDICATION NAME] 25 mg since the resident had received the dosage since 3/30/19. The physician's response revealed a check mark declining the recommendation noting it was clinically contraindicated. The physician signed the report on 6/24/19 but failed to justify the reason for not completing a GDR. The pharmacist again recommended a gradual dose reduction of the [MEDICATION NAME] 25 milligrams on 10/19/19. On 10/31/19 at 10:28 AM, resident #24's primary physician confirmed that he did not document the rationale for declining the dose reduction.

Based on observation, interview and record review the facility failed to ensure proper storage and replacement of the refrigerated emergency drug kit (EDK) in 1 of 2 medication rooms, (Bayside Unit). Findings: On 10/31/19 at 9:47 AM, an observation of the Bayside medication storage room was conducted with the Bayside Unit Manager. A small plastic standard EDK was observed in the refrigerator. The EDK did not have a plastic red or green seal to secure the contents of the kit. A list of the items contained in the EDK was attached to the outside of the box which included: [MEDICATION NAME] R insulin (used to treat high blood sugar levels)10 milliliter (ml), [MEDICATION NAME] N insulin 10 ml, [MEDICATION NAME] 70/30 insulin ml, [MEDICATION NAME] 10 ml, [MEDICATION NAME] (used to treat anxiety) 2 milligrams (mg)/ml and 3 [MEDICATION NAME] suppositories (used to treat nausea and vomiting) 25 mg. The EDK contained only the [MEDICATION NAME] R insulin, [MEDICATION NAME] N insulin, [MEDICATION NAME], and 3 [MEDICATION NAME] suppositories. The [MEDICATION NAME] 70/30 insulin and the [MEDICATION NAME] had been removed from the kit. There were 2 pharmacy copy slips inside the kit. One slip documented on 09/15/19 at 4:25 PM the 70/30 insulin was removed by (nurses name) for (resident's name and room number) and the broken seal identification (ID) number and replacement seal ID#. The second pharmacy copy slip dated 09/17/19 (2 days later) documented resident name and that [MEDICATION NAME] was removed. On 10/31/19 at 9:59 AM, the Bayside Unit Manage stated that the process for use of the EDK was that the nurse filled out the pharmacy copy slip, removed the medication and then notified the pharmacy to replace the kit. The Unit Manager confirmed that the EDK was missing the replacement ID seal and the [MEDICATION NAME] 70/30 insulin and the [MEDICATION NAME] since 09/17/19. On 09/17/19 the nurse should have called the pharmacy to replace the EDK. The EDK was missing the required medications for emergency resident use for 44 days. On 10/31/19 at 10:56 AM, the Director of Nursing (DON) stated that the Unit Manager was responsible for monitoring the medication storage to assure there are no issues. Review of the facility Storage and Expiration Dating of Medications, Biological's, Syringes and Needles Policy, revision date 04/05/19, read, . Procedure . 2. Facility should ensure that medications and biological's are stored in an orderly manner in cabinets, drawers, carts, refrigerators . 19. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station to assist Facility in complying with its obligations pursuant to Applicable Law relating to proper storage, labeling, security and accountability of medications and biologicals.

Based on record review and interview, the facility failed to accurately assess the resident's status for 2 of 3 sampled residents of a total of 56 sampled residents, (#72, #110). 1. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] identified resident #72 was receiving Hospice services (Section O). Review of Section J for other health conditions did not identify that the resident had a condition or chronic disease which may result in a life expectancy of less than six months. Review of the clinical record revealed the initial Hospice assessment by the physician in (MONTH) 2019 identified that the resident had end stage [MEDICAL CONDITION]. On 10/31/19 at 10:50 AM, MDS coordinator C confirmed Section J was coded incorrectly by the previous MDS coordinator. 2. Review of resident #110's medical record revealed she was discharged to an assisted living facility (ALF) on 8/12/19. The discharge MDS assessment documented she was discharged to the hospital. On 10/31/19 at 3:45 PM, the MDS coordinator C stated the discharged MDS was coded in error. The MDS assessment noted the resident was discharged to an acute care hospital, but she was discharged to an ALF.

Based on record review and interview, the facility failed to accurately assess the level of assistance needed during transfers for 10 of 18 residents who required a full body mechanical lift to transfer between surfaces (#1, 2, 3, 4, 5, 6, 7, 8, 9 & 10). Findings: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual (October (YEAR)) Section G: Functional Status revealed section G0110 assessed the level of assistance residents needed for activities of daily living (ADLs) including transfers. Coding Tips and Special Populations provided guidance for assessments that involved different types of lifts. The document revealed residents who transferred with standing lifts should be assessed as needing extensive assistance since they participate in the transfer by bearing some weight. Residents who transferred with a full-body mechanical lift should be assessed as totally dependent on staff since they did not participate in the transfer. The facility's policy and procedure for Mechanical Lift Use (undated) read, Two (2) persons are required to perform this procedure. The facility provided a list of 18 residents who required a full body mechanical lift for transfers. However, 10 of the 18 residents were not assessed as totally dependent on staff for transfers, as directed by RAI guidelines. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 11/09/18 revealed resident #1 had impaired range of motion of both legs. The assessment indicated she transferred between surfaces with extensive assistance of 2 people. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment with ARD of 1/11/19 revealed resident #2 had impaired range of motion of both arms and legs. The assessment indicated she transferred between surfaces with extensive assistance of 2 people. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment with ARD of 12/12/18 revealed resident #3 had impaired range of motion of both legs and required extensive assistance of 2 people for transfers. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment with ARD of 11/12/18 revealed resident #4 had impaired range of motion of both legs and required extensive assistance of 2 people for transfers. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment with ARD of 11/15/18 revealed resident #5 had impaired range of motion of all extremities. The assessment indicated she transferred with extensive assistance of 2 people. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#6 had impaired range of motion of both legs. The assessment indicated she transferred with extensive assistance of 2 people. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS annual assessment with ARD of 1/08/19 revealed resident #7 had impaired range of motion of both lower extremities. The assessment indicated she required extensive assistance of 2 people for transfers. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Significant change in status assessment with ARD of 12/06/18 revealed resident #8 had impaired range of motion of both lower extremities and one upper extremity. The assessment indicated she required extensive assistance of 2 people for transfers. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 60-day Medicare Part A scheduled assessment with ARD of 12/30/18 revealed resident #9 had impaired range of motion of all extremities. He was assessed as requiring extensive assistance of 2 people for transfers. Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS annual assessment with ARD of 12/11/18 revealed resident #10 had impaired range of motion of both legs. The assessment indicated she required extensive assistance of 2 people for transfers. On 1/28/19 at 3:25 PM, the Regional Clinical Reimbursement Specialist (RCRS) validated all residents who used a full body mechanical lift for transfers should be assessed as totally dependent for transfers. She confirmed the MDS assessments for residents #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 were inaccurate because they indicated the residents required extensive rather than total assistance. The RCRS explained although the facility did not have a policy regarding assessment accuracy, they followed CMS RAI guidelines. On 1/28/19 at 3:34 PM, MDS Coordinator A, who assessed residents #1, 2, 3, 4, 5, 7, 8, 9 and 10 and verified the accuracy of their assessments, validated the assessments related to transfer status were inaccurate. She explained she completed the assessments after evaluating residents, and reviewing certified nursing assistants' documentation and nurses' notes. MDS Coordinator A said, I am familiar with them and I know they are (full body) lifts for transfers. MDS Coordinator B, who assessed resident #6 and verified the accuracy of that assessment, acknowledged a full body mechanical lift required documentation of total dependence for transfers, therefore her MDS assessment was inaccurate.

Based on observation, interview and record review the facility failed to ensure proper personal protective equipment (PPE) was provided to staff and family to prevent exposure of clothing during resident care, and visits in 1 of 2 isolation rooms (#108) on 1 of 3 nursing units (Harborside) and failed to store clean mechanical lift pads, clean cloth oxygen cylinder holders, clean floor mop and duster heads, and dryer vacuum (vac) in a clean and sanitary manner to prevent cross-contamination in the laundry room. Findings: 1. On 07/25/18 at 3:01 PM an observation in room [ROOM NUMBER] (isolation) was to be conducted with the Maintenance Director. Due to the isolation status of resident #277 the Maintenance Director and this surveyor were required to wear personal protective equipment (PPE) prior to entering the room. While putting on the isolation gown it was found that the gown only covered the front of my clothing to my sides. The gown did not cover the entire back of my clothing. The Maintenance Director was also observed with the isolation gown covering only the front of his clothing and the entire back of his clothing was uncovered. The Regional Nurse Consultant stated, The gown just needs to cover the front of your clothes. Upon opening room [ROOM NUMBER] door an observation revealed a therapy staff member wearing an isolation gown with the back of her clothing exposed and a family member (son) wearing an isolation gown with the back of his clothing exposed. On 07/26/18 08:45 AM a therapy staff member was observed in room [ROOM NUMBER] with gown and gloves on providing services to resident #277. The entire back of her clothing was exposed and she was observed turning around with her back exposed to the resident bed. On 07/26/18 at 8:49 AM Licensed Practical Nurse (LPN) B stated that resident #277 was on isolation for Multidrug Resistant Organisms (MDRO) in a hip wound. (MDRO is bacteria that have become resistant to more than one class of antimicrobial agents (antibiotics). LPN B stated that she wears a gown so that she does not get germs on her clothing and she does not spread germs to any of her other residents. Using the gowns with no back coverage, my clothes can touch any area in the room that could be contaminated. I don't want to take her germs home to my family. On 07/26/18 at 9:49 AM Certified Nursing Assistant (CNA) C stated that goal for residents on isolation is to protect ourselves, residents and the entire facility. I wear a gown to protect my clothes. The gowns that we have do not go all the way around to cover my back so we could touch something. Everything in a isolation room is considered contaminated. Review of the Infection Control Policy, last revised 3/3/2017 read, facility provides an active and comprehensive Infection Control Program through surveillance, prevention, and control of infections acquired or brought into the facility between residents, visitors, associates, and/or from the community or other heath care facilities Review of the Infection Prevention and Control Assessment, policy dated 10/2/17 read, Regulatory Requirements, 483.80 Infection Control. The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the Transmission-based Precautions and Isolation Procedures, last revised 11/28/2016 read, Purpose, Minimize risk of spread of infections between facility patient and/or associates Control spread of infection by intercepting its method of transmission from person to person Contact Precautions, Contact precautions are used for diseases transmitted by contact with the patient or the patient's environment by direct or in direct contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients, bathe patients, or perform other patient-care activities that requires physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patients environment Isolation Equipment, Central to the success of these procedures is the selection of the proper equipment and the adequate training of those who use it. Materials required for isolation typically include barrier clothing Review of the Personal Protective Equipment (PPE) policy for residents and Visitors, dated 8/10/2017 read, Purpose, To decrease the risk of transmission of infection by providing personal protective equipment (PPE) to visitors. Policy, The shared living environment of a LTC (long term care) facility can allow the spread of easily [MEDICAL CONDITION] and bacteria leading to respiratory, gastrointestinal, or other infections. Personal protective equipment (PPE) is utilized as needed for the protection of residents, staff and visitors Review of the Center for Disease and Prevention, Sequence For Putting On Personal Protective Equipment (PPE), (www.cdc.gov) read, The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE. 1. GOWN fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in back of neck and waist Use safe work practices to protect yourself and limit spread of contamination 2. On 07/24/18 at 2:40 PM an observation conducted in the laundry room revealed 7 clean mechanical lift pads used for residents and 2 clean cloth oxygen cylinder holders being stored on a clothing rack directly across from the 3 washing machines where soiled linen was emptied into the washers for washing. Two clean floor duster heads and 5 clean mop heads were observed hanging over the edge of a laundry cart which was placed next to the third washing machine. The Director of Environmental Services stated that the mop heads were clean and air drying and will be used by housekeeping staff to mop the floors in the facility. A wet/dry vacuum with hose and brush attachment was observed sitting on the floor directly across from the washing machines. The Director of Environmental Services stated, The vacuum was used to clean the lint out of the dryer vents. The Director of Environmental Services and Laundry Aide A confirmed that the clean mechanical lift pads, clean cloth oxygen holders, clean mop heads and dryer vacuum were exposed to the soiled linens, and potentially contaminated. Nothing clean should be stored in the washer room. On 07/24/18 at 3:00 PM the Administrator confirmed the above findings. Review of the Departmental Policies, A Guide to Infection Control, Laundry Services, last revised 5/21/2004 read, Purpose, To assure a clean supply of linens Separating Clean from Dirty in the Laundry, In the laundry, . dirty linen should be clearly separated from areas where clean linen is handled

Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) care with regards to nail & hair hygiene for 2 dependent residents of a total of 52 sampled residents, (#14, #107). Findings: 1. Resident #14's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] noted that the resident required extensive assistance of one staff person to complete her ADL. On 7/24/18 at 12:55 PM the resident was in bed and her family was at the bedside. The resident had offloading boots to both feet/ankles. The resident's toenails were exposed and noted to be long measuring between 1/2-3/4 inches. The family confirmed that the toenails needed to be trimmed and could not recall the last time the resident was seen by a podiatrist. On 7/26/18 at 1:05 PM the Harborside Unit Manager stated that the Social Worker sets up the podiatry visits to the facility. There is a list of residents that are to be seen when the podiatrist comes to the facility. On 7/26/18 at 1:27 PM, the Assistant Social Worker (ASW) stated that the podiatrist visits the facility every other month and as needed. She stated that the next podiatry visit was scheduled for August. The ASW explained that the nurses inform Social Services Staff which residents need to be added to the podiatry list. On 7/26/18 at 1:33 PM the resident's licensed practical nurse, (LPN) B, stated that since the resident was diabetic, her toenails were trimmed by the podiatrist. She could not provide any documentation as to when the resident's toenails were last last trimmed. A review of the podiatry list for the month of (MONTH) with LPN #B revealed the resident's name was not on the list. LPN B confirmed that the resident's toenails were long and needed to be cut/trimmed. On Tuesday, 7/24/18 at 1:22 PM resident #107's hair was noted to be oily and disheveled. Resident #107 was confused, and dependent on staff for ADL care. Review of the quarterly MDS dated [DATE] noted that the resident required extensive assistance of 1 staff for personal hygiene. Two days later, on 7/26/18 at 12:45 PM the resident was observed in bed alert but confused. Her hair was oily and unkempt. She stated that staff did not wash her hair when she was showered. When asked if she would like to get her hair washed, the resident responded, very much so. Review of the resident's ADL Care Plan dated 10/2717 noted, staff to ensure neat, clean and appropriate appearance daily. On 7/26/18 at 1:40 PM the resident was observed with LPN B present. LPN B stated the resident was showered 2 times a week on Mondays and Thursdays. She confirmed that the resident's hair looked oily and could not explain why the resident's hair was not washed. The resident stated that her hair felt like,that stuff you cook with, meaning cooking oil. The resident indicated to LPN B that she wanted her hair washed.

Based on interview and record review the facility failed to ensure the physician justified the continued use of a [MEDICAL CONDITION] medication, ([MEDICATION NAME]) on an as needed (PRN) basis for 1 of 5 sampled residents, (#75). Findings: Review of the medical record revealed that resident #75 had an active order since 5/31/18 for [MEDICATION NAME] Gel 0.5 milligrams (mg) three times daily (TID) PRN for anxiety with no stop date. Review of the Controlled Medication Utilization Record and Medication Administration Record [REDACTED]. He received seven doses of [MEDICATION NAME] PRN for anxiety between 7/6-7/21/18. An interview with the unit manager on 7/25/18 at 11:00 AM revealed that the [MEDICATION NAME] gel was a current order and the last time the resident received the medication was on 7/21/18. A review of the physician order [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from 1 of 4 medication carts reviewed for medication storage. Findings: On 7/25/18 at 11:00 AM the Garden Terrace medication cart was observed to have a syringe of [MEDICATION NAME] gel for resident #75 that expired on 7/4/18. The syringe of [MEDICATION NAME] gel was received from the pharmacy on 6/4/18. The Unit Manager stated he checked the carts regularly and confirmed that the [MEDICATION NAME] Gel did expire on 7/4/18. He stated that the [MEDICATION NAME] gel was a current order and the resident could have received the medication. The DON on 7/25/18 at 11:15 AM stated that the expired [MEDICATION NAME] gel should have been removed from the cart. Review of the policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles revision date 10/31/16, read, Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications .

Based on interview and record review the facility failed to ensure 3 of 5 residents reviewed for immunizations were educated and offered the pneumococcal vaccine, (#5, #16, #66). Findings: Review of resident #5's medical record revealed the last completed, Informed Consent For Pneumococcal Vaccine, form was in 2013 which read, I hereby DO NOT GIVE the facility permission to administer a pneumococcal vaccination. There was no other documentation indicating the resident was educated or offered the pneumococcal vaccine after 2013. Review of resident #16's medical record revealed the last completed, Informed Consent For Pneumococcal Vaccine, form was in (YEAR) which read, I hereby DO NOT GIVE the facility permission to administer a pneumococcal vaccination. There was no other documentation indicating the resident was educated or offered the pneumococcal vaccine after (YEAR). Review of resident #66's medical record revealed the last completed, Informed Consent For Pneumococcal Vaccine, form was in (YEAR) which read, I hereby DO NOT GIVE the facility permission to administer a pneumococcal vaccination. There was no other documentation indicating the resident was educated or offered the pneumococcal vaccine after (YEAR). On 07/24/18 at 1:40 PM, the Assistant Director of Nursing/Infection Control Practitioner(ADON/ICP) stated the unit managers were responsible for obtaining the consents for the pneumococcal vaccine annually. The consents are then sent to me for record keeping. She stated that the, pneumococcal vaccine is offered on admission and then yearly. The tracking of the vaccines was done by the previous Director of Nursing. On 07/24/18 at 3:12 PM the Director of Nursing (DON) stated that she had been at the facility for less than one month and could not find the tracking of the pneumococcal vaccine consent forms for the residents. When asked who was responsible for overseeing the resident vaccines, the DON stated, I am sorry to put her under the bus, it is the ADON/ICP. On 07/24/18 at 3:15 PM the ADON/ICP stated, I was never told that I was responsible for the facility immunization tracking, no one ever told me that. On 07/26/18 at 1:01 PM, the ADON/ICP stated that newly admitted residents are given the vaccine consent forms to sign by the Admissions Director. On 07/26/18 at 2:04 PM the Admissions Director stated that as part of the admission process, she asks the resident if they have had the vaccines and/or would like to have the vaccines. The resident or responsible party will then sign or decline the vaccine forms. The consent forms then go with admission paperwork to the nursing unit. I am not a nurse but I am a Certified Nursing Assistant (CNA). I have not had any formal education or training regarding the influenza or pneumococcal vaccinations. Review of the Influenza Vaccine, Pneumococcal Vaccine, and Flu Outbreak Management, policy dated 3/3/17 read, To facilitate the delivery of appropriate vaccinations in a timely manner, To increase the levels of vaccination coverage, and To decrease the morbidity and mortality rate of influenza and pneumococcal diseases .Pneumococcal Vaccine . Education is provided to the resident and/or representative regarding benefits and side effects or risks and a consent form is signed. 3. On admission to the facility, the pneumococcal vaccine is offered if the resident has not received it or if his/her prior vaccination status is unknown. Residents [AGE] years of age or older who have not received the vaccine within 5 years (and were less that [AGE] years of age at the time of vaccination) should receive another dose of the vaccine.