Every finding on record at Life Care Center of Pensacola

Based on observations, interviews, and record reviews, the facility failed to implement Enhanced Barrier Precautions (EBP) as an infection control intervention designed to reduce transmission of organisms that employs targeted gown and glove use during high contact resident care activities for 1 of 1 residents observed for transmission based precautions. (Resident #131)The findings include: Observations performed on 09/07/25 at approximately 12:58 PM and 4:25 PM and 9/08/25 at 8:19 AM discovered that there was no EBP signage posted and no Personnel Protective Equipment (PPE) access outside of the room for Resident #131. (Photographic Evidence Obtained). On 09/07/25 at approximately 12:58 PM, an interview was conducted with Resident #131. She explained that she has been newly admitted to the facility status post colostomy and requires wound care to her surgical scar. On 09/08/25 at approximately 8:19 AM, an additional interview was conducted with Resident #131. She explained that the staff do not wear additional gowns or protective equipment during wound care. On 09/09/25 at approximately 11:25 AM, an interview was conducted with the Director of Nursing (DON) and the Infection Preventionist. They explained that Resident #131 was admitted with a small dehiscence to her surgical scar on 09/02/25. They further indicated that EBP was initiated in her care plan on 09/05/25, however they forgot to place the signage that includes instructions for use of specific PPE to be used and make PPE readily available near the entrance of the room for Resident #131. They acknowledged that between 09/05/25 and 09/08/25, EBP were not followed during high-contact resident care activities, providing opportunities for transfer of organisms.The physician's orders initiated on 09/03/25 for Resident #131 include cleanse area of dehiscence to proximal end of midline abdominal with wash, loosely pack wound with calcium alginate, cover with small foam dressing.The Care Plan initiated on 09/05/25 for Resident #131 has a focus for break in skin integrity with open area to proximal end of surgical wound, including a goal to minimize risk for symptoms of infection with an intervention that includes Enhanced Barrier Precautions. The weekly Wound Care progress note dated 09/09/25 reveals proximal end of midline abdominal surgical scar dehiscence present on admission. The Treatment Administration Record (TAR) for September 2005 reveals wound care to the proximal end of midline abdominal surgical scar dehiscence was provided on 09/03/25, 09/06/25 and 09/08/25.A facility policy titled Enhanced Barrier Precautions (EBP) (reviewed 07/03/25 and revised 08/19/25) states, EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Policy for use of EBP as an additional Multidrug-Resistant Organism (MDRO) mitigation strategy for residents that meet the following criteria, during high contact resident care activities. EBP are indicated for residents with the following wounds even if the resident is not known to be infected or colonized with a MDRO Wounds generally include chronic wounds that include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, wound care, skin opening requiring a dressing. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. The facility may choose to post signage on the door or wall outside of the resident room indicating the resident is on EBP. The facility should ensure PPE and alcohol-based hand rub are readily accessible to associates.A review of the Center for Disease Control and Prevention website at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html#cdc_generic_section_2-enhanced-barrier-precautions-in-nursing-homes-video-posters-pocket-guide, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MRDO), dated 04/02/2024 was reviewed. It reveals that: when implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff awareness of the facility's expectations about hand hygiene and gown/gloves use, initial and refresher training, and access to appropriate supplies. To accomplish this, post clear signage on the door or wall outside of the resident room indicating the type of Precautions and indications for high contact resident care activities the use of gown and gloves; make PPE available immediately outside of the resident's door.

Based on observation, interview, and policy review, the facility failed to ensure measures to prevent the spread of infection were followed for 1 of 3 residents observed on contact isolation precautions. (Resident #1) The findings include: During an initial facility tour between 10:37 am and 11:40am on 10/01/2024, an observation was made of Staff G, a Housekeeper, through the open door of room [ROOM NUMBER] mopping the floor. Housekeeping Staff G was wearing gloves while mopping, but no other personal protective equipment (PPE) was observed. A sign outside the door of room [ROOM NUMBER] indicated contact isolation precautions were in place and indicated that all staff were to wear a gown and gloves upon entering room and another sign on the door indicated staff are to wash hands with soap and water after completing care in this room. A plastic bin containing gowns was observed outside the door. The door for room [ROOM NUMBER], which was adjacent to room [ROOM NUMBER], also had a contact isolation precautions sign and handwashing with soap and water sign present. Additional observations revealed similar signage for contact precautions a little way down the hall for room [ROOM NUMBER]. Upon exiting the room, Staff G was interviewed and asked about the contact isolation sign, which was visible and pointed out during the interview. Staff G stated as long as the door of the room is open, he does not need to wear a gown. He repeated this statement when asked for clarification. During the interview, it was noted housekeeping staff G spoke with an accent and may not be a native English speaker. The signs on the doors were observed to be printed only in English. In an interview with the Infection Preventionist on 10/01/2024 at 10:47 am, she indicated that the resident in room [ROOM NUMBER] was diagnosed with Clostridioides Difficile (C. diff) in August and the residents in rooms [ROOM NUMBERS] were diagnosed in the past week and received confirmative positive results on 09/30/2024 and 10/01/2024 and placed on contact isolation precautions. During an interview on 10/02/2023 at 10:47AM with the Director of Environmental Services and the Infection Preventionist, they discussed the training of housekeeping staff and acknowledged that Staff G is not a native English speaker but does speak English. Both acknowledged that signs are provided in English and they try to provide training that is color-coded for transmission-based precautions because there are staff who are native speakers of languages other than English and may have difficulty reading English. A review of the facility policy for transmission-based precautions included a policy titled Transmission-based Precautions and Isolation Procedures from chapter 4: Standard Precautions, transmission-based precautions: A guide to infection prevention and control. Issued 01/30/2019; reviewed 06/03/2024; revised 09/24/2024. Under the heading categories of transmission-based precautions paragraph 2. Contact Precautions included the language: contact precautions .require the use of appropriate PPE, including a gown and gloves before or upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. Refer to the Contact Precautions Policy for additional information. The Contact Precautions policy issued 02/15/2021, revised 08/22/2022; reviewed 06/03/2024 contained a paragraph with the heading environmental measures which specified environmental service workers should don gown and gloves before room entry to clean and disinfect the patient's room. For patients with organisms that are resistant to traditional cleaning methods (e.g. C. difficile, norovirus), bleach may be used as an adjunct to cleaning or as a final wipe down of the frequently touched surfaces.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure staff follow appropriate isolation precautions during the provision of resident care for 1 of 3 sampled residents on transmission-based precautions. (Resident #13) The findings include: An observation of resident #13 was conducted on 3/27/23 at 3:29 PM. The resident was sitting in her wheelchair in her room and employee A, Certified Nursing Assistant (CNA) was observed taking the resident's blood pressure using a rolling vital sign machine. Employee A, CNA was not wearing a gown or gloves while taking resident #13's blood pressure. Contact precautions signage was observed on resident #13's door stating everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit, do not wear the same gown and gloves for the care of more than one person, use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. (Photographic evidence obtained.) When Employee A finished taking resident #13's blood pressure, she exited the resident's room and then entered resident #53's room. She donned a pair of gloves and then began taking resident #53's blood pressure with the same rolling vital sign machine. Employee A did not wash her hands before leaving resident #53's room and did not disinfect the rolling vital sign equipment between uses on resident #13 and #53. Review of resident #13's electronic record revealed a current physician order dated 3/23/23 for contact isolation every shift for C-diff (clostridium difficile). An interview was conducted with the Director of Nurses (DON) on 3/3/23 at 9:07 AM. She stated staff should sanitize the vital sign machine between each resident regardless of if they are on isolation or not. Staff are to sanitize their hands upon entering a C-diff isolation room and if they are providing care they should also wear appropriate personal protective equipment (PPE) to include gown and gloves. Review of the facility policy for Clostridium Difficile (revised 6/7/22) revealed C. difficile is a spore-forming gram-positive anaerobic bacillus that was first isolated from stools of neonates in 1935 and identified as the most commonly identified causative agent of antibiotic associated diarrhea and pseudomembranous colitis in 1977. This pathogen is a major cause of healthcare associated diarrhea and has been responsible for many large outbreaks in healthcare settings that were extremely difficult to control. Alcohol-based hand rubs do not kill spore-forming organisms therefore hand washing must be done with soap and water. Mitigation of Spread: Place patient on Standard plus contact precautions if they have symptoms consistent with C-diff. Clean and disinfect equipment after use and before use by another resident. Review of the policy for Transmission-based Precautions and Isolation Procedures (reviewed 6/6/22) revealed the facility will implement and utilize transmission based precautions to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. Contact Precautions are intended to prevent transmission of infections that are spread by direct or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed.

Based on observations, policy review and interviews, the facility failed to properly store medications for 1 of 5 residents sampled for unnecessary medications (#47). The findings include: On 10/25/21 at 11:13 AM, an observation was made of resident #47. A bottle of medication was observed on the over the bed table. The medication was [MEDICATION(S)], brigandine [MEDICATION(S)]/[MEDICATION(S)] ophthalmic solution 0.2%-0.5%. [MEDICATION(S)] is an eye drop medication used to treat [CONDITION(S)]. There was no staff in the residents room at the time (photographic evidence obtained). A review of the facility's policy LTC Facility's Pharmacy Services and Procedure Manual, revised October 2016, page 1 item 3.3 stated Facility should ensure that all medications and biological, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 10/28/21 at approximately 1:58 PM, an interview was conducted with Director of Nursing who stated her expectation is for the nurses to administer the medications and not leave the medications at the bedside and not leave any medications or empty med cups in the room. On 10/28/21 at approximately 2:23 PM, an interview was conducted with staff A, a Registered Nurse, caring for resident #47 on 10/25/21 during the day shift (7 AM-3 PM) who stated she signed into the computer, administered the medication and left it at the bedside as this was her first day on orientation. Staff A stated she went back found the medication and locked it back in the cart.

Based on record review and interview, the facility failed to report all allegations of abuse or neglect to the State Agency for 1 of 1 residents sampled for federal reporting requirements. (Resident #1) The findings include: A review of Resident #1's clinical record was conducted. Review of progress notes revealed a note made by the Executive Department on 7/8/2021 related to facility initiated contact with the resident's family regarding care concerns and APS (Adult Protective Services) complaints. On 8/12/2021 at approximately 10:00 AM, an entrance conference was conducted with the Administrator and the Director of Nursing/Risk Manager. The surveyor requested any mandatory federal reports filed since 1/25/2021. The Administrator was unable to provide any report related to Resident #1, however, she informed the surveyor that APS had been in the facility earlier to investigate a complaint regarding Resident #1. On 8/12/2021 at 1:00 PM, a telephone interview was conducted with the APS investigator who investigated the abuse and neglect allegations involving Resident #1. The surveyor asked what date APS was onsite conducting their investigation. The APS investigator replied that it was on 7/1/2021. A review of the facility's Protection of Rights: Reducing the Threat of Abuse and Neglect policy and procedure revised 8/10/2021 revealed that item #8 in the section titled Reporting and Response stated, The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Failure to do so will mean that the facility is not in compliance with the federal regulations. A review of the Nursing Homes Federal Reporting System, which allows for real-time electronic submission, tracking, and confirmation of all reports submitted on behalf of the facility by authorized users, revealed that no reports had been filed involving Resident #1. On 8/25/2021 at approximately 2:02 PM, a telephone interview was conducted with the Administrator. The surveyor asked if the facility filed a report for allegations of abuse/neglect involving Resident #1 when the APS investigator arrived at the facility to investigate the allegations on 7/1/2021. The Administrator stated they had not filed a report and that the APS investigator did not state the reason for the investigation. They (APS) mentioned that it had to do with the loss of hearing aids and a fall. At that time, the Administrator stated she surmised that concern was related to Resident #1 who was one of their residents who had lost a hearing aid and had a fall for which she was sent to the hospital at the request of the family. They received more concrete information that it was about Resident #1 when APS called back a few days later and stated they did not substantiate the allegations.

Based on observation, staff interviews, and policy review the facility failed to ensure medications were discarded after the expiration date for 1 of 3 medication storage rooms observed and 1 of 3 medication carts observed (Seville hall medication cart and 2nd floor Seville medication room). The findings include: On 10/08/2020 at approximately 5:44 PM, observation of the medication storage room on the 2nd floor and the automated medication dispensing cabinet contained within with staff C, Licensed Practical Nurse (LPN) and Unit Manager, was conducted. Random review of medications stored in the cabinet showed 10 blister packs of [MEDICATION NAME] tablets 50 mg (milligrams) with an expiration of 9/30/2020, 4 individually wrapped [MEDICATION NAME] 0.083% inhalation solution pouches with an expiration of September 2020, 4 1 ml (mililiters) vials of vitamin K with an expiration of 9/1/2020, and 4 multi-dose vials of 80mg/2ml [MEDICATION NAME] with an expiration of 9/1/2020. Interview conducted at that time with staff C, confirmed all expirations and stated that the last check for expired medications was performed on the system in August 2020. On 10/08/2020 at approximately 6:13 PM, during observation of medication cart on Seville hall for resident room's 214-227 with staff C, LPN, a blister pack card of pantoprazole 40 mg with an expiration of 9/30/2020 was identified. Staff C confirmed the expiration date and stated that checks for expired and discontinued medication should be identified during weekly checks of the medication carts. On 10/09/2020 at approximately 9:49 AM, during policy and procedure review titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles revised 10/28/2019 stated Facility should ensure that medications and biologicals that have an expired date on the label . are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

Based on observation, record review, and staff and resident interview, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain grooming and personal hygiene for 1 of 2 sampled residents for ADL care (resident #16). The findings include: On 10/06/2020 at approximately 11:15 AM, during observation and interview with resident #16, the female resident was observed with facial hair across the span of her chin approximately an 1/8 of an inch to 1/4 an of inch in length. The resident stated it was not her personal preference to have facial hair and that she was unable to shave herself due to limited mobility in her right hand. The resident stated that staff help with trimming/shaving the facial hair once a week but she would really like it done every other day so it would not show. On 10/07/2020 at approximately 12:55 PM, and again at 3:30 PM, observation of resident #16 showed the resident with facial hair across the span of her chin approximately an 1/8 of an inch to 1/4 of an inch in length. On 10/07/2020 at approximately 2:30 PM, during record review of the resident's medical record and care plan dated 7/17/2020 identified that the resident was unable to independently complete ADL with a goal listed for the resident to remain clean, and well groomed. The interventions listed identified assistance with bathing/showering three times a week. The resident's quarterly comprehensive assessment dated [DATE] identified that the resident maintained personal hygiene through extensive assistance with one person's assistance. Bathing Kardex reviewed showed that care provided on 10/5/2020, 9/30/2020, 9/28/2020 and 9/24/2020. The personal hygiene Kardex was reviewed and showed that care being provided on 10/7/2020, 10/6/2020, 10/5/2020, 10/4/2020, 10/3/2020, 10/1/2020, 9/30/2020 twice a day. On 10/07/2020 at approximately 3:38 PM, during interview with staff A, Certified Nursing Assistant (CNA), identified that ensuring the resident looked presentable and performing personal hygiene, including shaving facial hair, were a part of CNA duties. The CNA identified that shaving facial hair for residents would be performed on bath days and during morning care, and that the resident's preference would be honored by giving them options and asking what they would like. The CNA expressed that unless it's a female's preference their facial hair should be trimmed. The CNA expressed that resident #16 refused care at times and that refusals of care would be documented in the tasks Kardex in the medical record and reported to the nurse. On 10/07/2020 at approximately 4:44 PM, during interview with staff B, CNA, who was responsible for resident #16's care that day, identified that the CNAs were responsible for personal hygiene care which included facial hair shaving. The CNA identified that immediately prior to the interview being conducted she provided the resident with personal care and shaved her facial hair and reported that the resident was happy that it was done. On 10/07/2020 at approximately 4:59 PM, during interview with resident #16, the resident was asked if she ever refused being shaved and the resident stated, why would I do that? The resident expressed that staff do not offer the care often enough. On 10/08/2020 at approximately 11:24 AM, during interview with staff C, Licensed Practical Nurse (LPN) and Unit Manager, familiar with resident #16, expressed that the expectation for the documentation of the refusal of care by a resident would be for the staff to attempt the care again and if the resident continued to refuse they should notify the nurse on duty and the nurse should document that refusal under progress notes. The LPN expressed that CNA staff should offer trimming of facial hair daily and as often as they see it. The LPN expressed that resident #16 was able to make her needs known. Resident #16's medical record was reviewed with staff C at that time and there was no indication that the resident refused facial hair shaving in the nursing progress notes or in the resident's most recent care plan. On 10/08/2020 at approximately 2:41 PM, during record review of policy and procedure titled Activities of Daily Living (ADLs) with an effective date of 12/11/2018 stated, The resident will receive assistance as needed to complete ADL's. Any change in the ability to perform ADL's will be documented and reported to the licensed nurse.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that included measurable objectives and timeframes to meet the medical needs for someone with identified limited range of motion for 1 of 2 residents sampled for limited range of motion (resident #56). The findings include: On 10/05/2020 at approximately 7:07 PM, during observation and interview, resident #56 stated that he had a contracture on his right hand. The resident raised his hand and showed his third, fourth, and fifth digit curled towards his palm. The resident stated he could not fully open that hand. On 10/06/2020 at approximately 10:05 AM, during record review of resident #56's medical records showed that the resident had an admission date of [DATE] with the pertinent [DIAGNOSES REDACTED]. The resident's brief interview for mental status (BIMS) score was 15, cognitively intact. It was noted on the Minimum Data Set (MDS), comprehensive assessment, dated 8/28/2020, that the resident had an upper extremity impairment on one side. Review of Occupational Therapy (OT) treatment encounter notes dated 6/1/2020 identified that the resident had a PIP (proximal interphalangeal, the second joint in the finger) and DIP (distal interphalangeal, the third joint in the finger) flexor contracture at digits 3-5 on the right hand. OT treatment encounter dated 6/08/2020 stated 3-5 digit on right hand fixed in flexion contracture. On 10/08/2020 at approximately 10:17 AM, during interview and observation with staff F, Certified Nurse Assistance (CNA), the CNA performed range of motion (ROM) exercises on the resident and demonstrated that the resident had limited ROM on right hand, specifically on the 3-4-5 digits. Record review of the resident's Care Plan dated 8/28/2020 did not identify any mobility impairment or contracture to the resident's right hand. On 10/08/2020 at approximately 11:45 AM, during interview with staff H and staff I, both MDS coordinators, who were responsible for the development of resident care plans, stated that a contracture or decrease in mobility should be included in the care plan. During record review of the resident's most current care plan dated 8/28/2020, staff H and staff I, confirmed that the care plan did not identify a contracture or mobility concerns to the resident's right hand. On 10/09/2020 at approximately 10:28 AM, during interview with the Director of Therapy Services, and Staff J, Registered and Licensed Occupational Therapist (OTR/L), they expressed that resident #56 received an OT assessment and evaluation that day,10/09/2020, and stated we have been working on our communication with MDS to ensure things do not fall through the cracks and stated that normally information that was to be included in the resident's care plan was communicated to the MDS coordinators through functional nursing notes. They further explained that the area was sensitive to the resident, he often refused care in that area and staff were to monitor that area for changes. They further expressed that information had not been communicated through the functional nursing notes. Record review of facility's Resident assessment instrument and care plan issued 6/8/2020 stated observing and interviewing the patient, family, and staff from all disciplines are required to develop an individualized person-centered care plan that provides a path toward the resident achieving or maintaining their highest practicable level of well-being

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 3 (#2 & #3) residents which resulted in [MEDICAL CONDITION] for resident #2. The findings include: Resident #2 A review was conducted of Resident #2's Nurses' Notes which revealed the following: On 12/13/2019 at 12:30pm, the note read, MD (medical doctor) notified nurse that there was a medication discrepancy with the resident's medications. New orders obtained. Resident's son here at the facility and was informed of the discrepancy. Resident is sleeping but does not arouse (wake up) when name is called for a few seconds. At 1:00 IV (intravenous line) started in the right forearm as ordered. On 12/13/2019 at 6:17pm, the note read, Notified by Unit manager that medication discrepancy related to wrong patient's medication reconciliation upon admission had occurred when orders entered by this nurse on 12/12/2019. MD notified staff that med list was for a different patient than Resident #2 which was admitted on the evening of 12/12/2019. Orders written by MD and carried out by day shift staff. Director of Nursing was also notified when order entry error and medication discrepancy discovered. Staff notified next of kin, son immediately as well. IV hydration begun per orders and patient vital signs closely monitored for remainder of day and evening shifts. A review of Resident #2's blood pressure documentation revealed the resident had a documented blood pressure on 12/13/19 at 10:30 AM as 140/70 however a follow up blood pressure on 12/13/19 at 12:30 PM was noted to be 88/48. A review of physician's orders [REDACTED]. Review of MD orders: 12/12/2019 - [MEDICATION NAME] 5 milligrams (mg) by mouth every day for high blood pressure 12/12/2019 - [MEDICATION NAME] 50mg by mouth twice per day for high blood pressure 12/12/2019 - [MEDICATION NAME] 0.1mg by mouth twice per day for high blood pressure 12/12/2019 - [MEDICATION NAME] 50mg by mouth three times per day for high blood pressure 12/13/2019 - Start peripheral intravenous line (IV) 12/13/2019 - 12:30pm - D5 ½NS (An IV fluid with sugar and salt water in it) infuse 75 milliliters(ml) per hour intravenously every hour for low blood pressure and lethargy until 12/14/2019 13:00, check IV. (Discontinued on 12/13/2019 at 3:48pm) 12/13/2019 at 1:00pm - Check and record blood pressure every hour for lethargy until 12/14/2019 at 0100. 12/13/2019 at 2:50pm - D5 ½NS infuse 50 ml per hour intravenously every shift for lethargy, check IV every hour, may discontinue when resident is alert and taking fluids. On 1/14/2020 at 9:43am, an interview was conducted with the Director of Nursing. At that time she stated the staff input medications based on the 3008 (a form that comes from the hospital when they are transferred to a long-term care facility) for admission as batch orders (all the orders are entered at once together). She stated that, in this particular case, the nurse that put the orders in did not realize that the medication reconciliation (a form that tells the facility what medications the resident should be taking) was for a different hospital patient and put those orders in for Resident #2. There were blood pressure medications given because of this that caused Resident #2's blood pressure to lower significantly and the facility had to intervene to stabilize her while the medications wore off. On 1/14/2020 at11:17am, a follow up interview was conducted with the Director of Nursing and Administrator. At that time, they stated that they recognized that there was an issue with medication errors starting in November when they had their December Quality Assurance and Performance Improvement meeting. They stated when they looked back on November there were 4 medication errors. They further stated when they started looking back on December there were more, and they realized that there was a trend that needed to be corrected. The Director of Nursing stated that she was putting together a performance improvement plan to present to the Quality Assurance and Program Improvement Committee to have it approved at their next meeting. When asked directly she again stated that it was not complete or implemented at the time fo the interview. On 1/20/2020 at 11:45am an interview was conducted with Resident #2's physician. At that time, he stated that the issue that occurred in this case was that the hospitalist at the hospital sent over the wrong medication list and the facility staff failed to realize this and put the orders in for Resident #2. He stated that he discovered the error himself when he saw what medications that resident was receiving and realized that it did not make sense based on the resident's medical history. He stated that the resident's blood pressure did have to be managed until the medications wore off, but no [MEDICATION NAME] effects came from the error. Resident #3 A review of Resident #3's nurses' notes was conducted which revealed the following: On 1/7/2020 at 4:51pm the note read, Medication discrepancy was discovered regarding resident's [MEDICATION NAME] (a medication given to prevent blood clots) order. The physician was notified, and new orders obtained. Resident's husband notified and stated that he would be in tomorrow and thanked for the call. A review of resident #3's, Patient Discharge Instructions, from the hospital which revelaed the following order: [MEDICATION NAME] (also called [MEDICATION NAME]) 40 milligrams subcutaneous once a day. The note to the side stated, Stop [MEDICATION NAME] when patient restarts Eliquis 2 weeks after surgery. A review of the physician progress notes [REDACTED]. Medication list: [MEDICATION NAME] Sodium (another name for [MEDICATION NAME]) solution . inject 40 milligrams subcutaneously one time a day for anticoagulation (prevention of blood clots) until 1/1/2020 at 11:59pm, stop [MEDICATION NAME] when patient restarts Eliquis 2 weeks after surgery. A review was conducted of the Medication Administration Record [REDACTED]. The first dose of Eliquis was documented on 1/7/2020 at 5pm, 6 days after [MEDICATION NAME] was stopped. On 1/14/2020 at 9:43am an interview was conducted with the Director of Nursing. At that time, she acknowledged the medication error with [MEDICATION NAME] and Eliquis and she stated that they got a new ordered on [DATE] for the Eliquis and [MEDICATION NAME]. She stressed that the resident suffered no ill effects from the discrepancy. She reviewed an internal incident report from the facility that she summarized as saying that [MEDICATION NAME] was stopped on 1/1/2020 in error and that the resident, family and Physician were notified. On 1/20/2020 at 11:45am an interview was conducted with Resident #3's physician. At that time, he stated that he was aware that the facility was having recent issues with medication errors. He stated that when the facility discovers an error, they contact him to let him know about the errors and give them the appropriate follow up orders. When asked about Resident #3 he stated that he came in to do his follow up 2 weeks after the resident's procedure. He stated that he told the staff that he was going to discontinue the [MEDICATION NAME] and start Eliquis. At that time, he stated that the staff made him aware that [MEDICATION NAME] was already discontinued.

Based on interview and policy review, the facility failed to establish an infection control program that includes the tracking and reporting of Facility Acquired Infections to include Urinary Tract Infections [MEDICAL CONDITION] for 2 of 2 residents sampled (48 & 102). The findings included: On 03/21/19 at approximately 11:47 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who also oversees the infection control program. She presented a white binder in which she stated she used to track infections within the facility. She stated that she tracks Facility Acquired Infections only and when a resident is admitted with an infection or is on an antibiotic the antibiotic is included on the daily log. She stated, however, it is not counted in the monthly review which is reported during quality meetings. At this time two residents were randomly selected to review. The first was resident #102 who was noted to be listed as having a Community Acquired Infection (CAI) which was not included in the monthly report for January. Review of the resident record found the resident was admitted to the facility on [DATE] and ordered Keflex for Ecoli in his urine on 1/30/2019. When asked why this infection was not considered a Facility Acquired Infection the ADON stated That was my mistake and stated that she had thought he was not admitted to the facility until 1/30/19. Further review of the antibiotic tracking form revealed that resident #48 was listed as having a CAI and was receiving [MEDICATION NAME] for [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) in her urine ordered on [DATE]. Further review of the record found that the resident was admitted to the facility on [DATE] with no history of VRE. Additional documentation reviewed for resident #48 revealed a urine culture performed by the hospital 2 days before the resident was admitted to the facility (1/2/19) which identified [MEDICAL CONDITION][MEDICATION NAME] and not VRE. When asked about this infection the ADON reported that the resident had a history of [REDACTED]. Review of the Antibiotic Stewardship Policy dated 3-2017 found that Process measures for tracking antibiotic stewardship track how and why antibiotics are prescribed. Process measures include review of SBARs and other clinical documentation during clinical meetings and ongoing review of the completeness of prescribing documentation to include does, route, duration and indications of use. The policy goes on to say Measures of antibiotic use include tracking the proportion of resident receiving antibiotics during a given time period, the rate of new antibiotics starts initiated in a nursing homes and antibiotics days of therapy. Antibiotic outcome measures track adverse outcomes from antibiotics including adverse drug events and the prevalence of [MEDICAL CONDITION] and multidrug resistant organism in the facility. Item 6 of this policy states Reporting - Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff through QAPI (Quality Assurance Performance Improvement) meetings, staff education and provider specific feedback.

Based on staff interview, electronic and paper records the facility failed to follow professional standards by failing to have a physician order [REDACTED]. The findings were: Resident #73 is a long term care resident who has been in the facility since 11/25/15. She has a [DIAGNOSES REDACTED]. She was observed to have oxygen being administered per nasal cannula on 3/18/19 at 2:15 pm. Her humidifier was not dated, or the oxygen tubing. She continued to be observed to have oxygen per nasal cannula on 3/19 and 3/20/19. Her electronic and paper chart was reviewed. an order for [REDACTED].>An interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) employee A on 3/20/19 at 3:39 pm. We went into resident #73's room. She was asked if she could find a date on the tubing or humidifier. She searched the tubing and humidifier and could not find a date. She then said the oxygen tubing should be dated as well as the humidifier and there should be an order for [REDACTED]. We then went to the nursing station and she was asked to show me the order for oxygen. She searched the hard chart and then the electronic record but could not find an order. She was then requested to provide the policy and procedure for oxygen use. The policy for oxygen was reviewed: Chapter 11 Respiratory Therapy Clinical Services Manual Oxygen Administration /Safety/Storage/Maintenance Effective Date 12//3/18 1 of 4 pages: Infection Control: 1. change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out. 2. Humidifier/Aerosol bottles should be dated and replaced every 7 days regardless of water level. Page 2 of 4: #4 clean exterior of concentrators weekly with bactericidal surface cleaner ---*external filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed. Dry with a towel and re-insert . Discard and replace when damaged.

Based on staff interview, electronic and paper records the facility failed to follow professional standards by failing to have a physician order [REDACTED]. The findings were: Resident #73 is a long term care resident who has been in the facility since 11/25/15. She has a [DIAGNOSES REDACTED]. She was observed to have oxygen being administered per nasal cannula on 3/18/19 at 2:15 pm. Her humidifier was not dated, or the oxygen tubing. She continued to be observed to have oxygen per nasal cannula on 3/19 and 3/20/19. Her electronic and paper chart was reviewed. an order for [REDACTED].>An interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) employee A on 3/20/19 at 3:39 pm. We went into resident #73's room. She was asked if she could find a date on the tubing or humidifier. She searched the tubing and humidifier and could not find a date. She then said the oxygen tubing should be dated as well as the humidifier and there should be an order for [REDACTED]. We then went to the nursing station and she was asked to show me the order for oxygen. She searched the hard chart and then the electronic record but could not find an order. She was then requested to provide the policy and procedure for oxygen use. The policy for oxygen was reviewed: Chapter 11 Respiratory Therapy Clinical Services Manual Oxygen Administration /Safety/Storage/Maintenance Effective Date 12//3/18 1 of 4 pages: Infection Control: 1. change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out. 2. Humidifier/Aerosol bottles should be dated and replaced every 7 days regardless of water level. Page 2 of 4: #4 clean exterior of concentrators weekly with bactericidal surface cleaner ---*external filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed. Dry with a towel and re-insert . Discard and replace when damaged. Professional Standard of Care is defined in Chapter 766.102 as, the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines Professional and Practical Nursing. The Act states: (3)(a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing.

Based on staff interview, electronic and paper chart review, the facility failed to follow the care plan for 1 of 2 (#73) reviewed for oxygen therapy by not having an order for [REDACTED].>The findings were: Resident #73 is a long term care resident who has been in the facility since 11/25/15. She has a [DIAGNOSES REDACTED]. She was observed to have oxygen being administered per nasal cannula on 3/18/19 at 2:15 pm. Her humidifier was not dated, or the oxygen tubing. She continued to be observed to have oxygen per nasal cannula on 3/19 and 3/20/19. Her electronic and paper chart was reviewed. an order for [REDACTED].> The care plans were reviewed. A care plan for resident #73 revealed she is at risk for alterations in respiratory status secondary to having a [DIAGNOSES REDACTED]. The interventions included oxygen as ordered and change oxygen tubing as ordered . An interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN) employee A on 3/20/19 at 3:39 pm. We went into resident #73's room. She was asked if she could find a date on the tubing or humidifier. She searched the tubing and humidifier and could not find a date. She then said the oxygen tubing should be dated as well as the humidifier and there should be an order for [REDACTED]. We then went to the nursing station and she was asked to show me the order for oxygen. She searched the hard chart and then the electronic record but could not find an order.

Based on review of physician orders, physician S.O.A.P. (Subjective, Objective, Assessment, and Plan) notes, facility policies, laboratory results, pharmacy recommendations and interviews with Nurse A and Nurse H, the facility failed to obtain laboratory services in a timely manner to meet the needs of 2 of 24 residents (#56 and #17). The findings were: Resident #17 A review of physician's orders [REDACTED]. Repeat TSH ([MEDICAL CONDITION] stimulating hormone, which is a laboratory result used to monitor effectiveness of [MEDICATION NAME]) in 6 weeks. There were no newer orders for TSH monitoring in the chart. A review of laboratory results revealed a laboratory report on 12/20/2017 for a TSH. There were no other TSH results in the chart. A review of pharmacy recommendations revealed a recommendation given on 2/15/2018 that stated, Missing lab values TSH in 6 weeks from 12/21/2017. Written on the recommendation was, Already completed and in chart on 12/20/2017. On 2/27/2018 at 1:23pm an interview was conducted with Nurse A. She looked through the chart to find the lab or another order and was unable to locate one. She then called the physician and received a verbal order to complete a TSH lab in the morning for resident #17. Resident #56 A review of resident #56 ' s medical record revealed a physician's orders [REDACTED]. Further review of the medical record for resident #56 revealed a physician's Subjective, Objective, Assessment, and Plan (SOAP) note, dated (MONTH) 24, (YEAR), which stated: UA was ordered 1/19 but never delivered to the lab. UA was delayed. An interview was conducted on (MONTH) 1, (YEAR) at approximately 7:52 am with Nurse H. This staff member stated that a UA C&S would need to be completed as soon as it was ordered. Staff H confirmed there was no evidence in the nursing notes or the laboratory system of a UA C&S being completed as ordered between (MONTH) 19 - 21, (YEAR) for resident #56. An interview was conducted on (MONTH) 1, (YEAR) at approximately 8:11 am with Nurse A. This staff stated that once a UA C&S is ordered, it is expected for it to be done within 24 hours unless a resident refuses or the staff member is unable to obtain the specimen. A review of the policy entitled Diagnostic Services: Revised 11/19/2016, revealed the following: All orders for diagnostic services will be promptly carried out as instructed by the order.

Based on review of narcotics sheets, medication administration records (MARs), physician orders, nurses' notes, pharmacy recommendations, pain flowsheets, behavioral monitoring sheets, laboratory results and interviews with Nurse A, Nurse G and the unit manager, the facility failed to ensure the drug regimen was free from unnecessary drugs for 3 of 5 residents, by failing to conduct adequate monitoring related to the administration of [MEDICAL CONDITION] medication, and use of a hypnotic medication for resident #17, by failing to administer and monitor effectiveness of pain medication for resident #96 per the resident's plan of care and physician orders, and by failing to monitor indications for use and potential adverse effects of an antipsychotic medication for resident #87. The findings were: Resident #17 A review of the plan of care for resident #17 revealed the intervention, Monitor labs as ordered. A review of physician's orders [REDACTED]. Repeat TSH ([MEDICAL CONDITION] stimulating hormone, which is a laboratory result used to monitor effectiveness of [MEDICATION NAME]) in 6 weeks. There were no newer orders for TSH monitoring in the chart. A review of laboratory results for resident #17 revealed a laboratory report on 12/20/2017 for a TSH. There were no other TSH results in the chart. A review of pharmacy recommendations for resident #17 revealed a recommendation given on 2/15/2018 that stated, Missing lab values TSH in 6 weeks from 12/21/2017. Written on the recommendation was, Already completed and in chart on 12/20/2017. On 2/27/2018 at 1:23pm an interview was conducted with Nurse A. She looked through the chart to find the lab or another order and was unable to locate one. She then called the physician and received a verbal order to complete a TSH lab in the morning for resident #17. Further review of the physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. The back side of the Medication Administration Record [REDACTED]. A review of the current behavior monitoring sheets revealed a significant amount of holes in the documentation on the form for resident #17, including the dates of 2/14/2018 and 1/6/2018. A review of nurses' notes failed to reveal documentation regarding the 2/14/2018 and 1/6/2018 dose of [MEDICATION NAME] or its effectiveness. On 2/28/18 at 1:52pm an interview was conducted with Nurse G in which she agreed there was no documentation related to the effectiveness of the [MEDICATION NAME] given to resident #17 on 2/14/2018 and 1/6/2018 . Resident #96 A review of physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. The administration blocks for the medication on the resident's MAR indicated [REDACTED]. A review of the narcotics sheet (a form used to track the whereabouts of controlled medications) revealed that [MEDICATION NAME] was signed out on 2/21/2018 at 6am and on 1/9/2018 at 6am. There was no indication on the narcotic sheet that the medication was wasted (thrown away for any reason). A review of the nurses' notes revealed no documentation regarding the administration of the [MEDICATION NAME] or its effectiveness for pain relief for the above dates and times. A review of the pain flow record revealed no documentation regarding the above doses of pain medication. On 2/28/18 at 1:52pm an interview was conducted with Nurse G in which she agreed that there was no documentation that the 6am doses of [MEDICATION NAME] for 1/9/2018 and 2/21/2018 were administered to resident #96, nor was there any documentation regarding the administration of the [MEDICATION NAME] or its effectiveness for pain relief for the above dates and times. Resident #87 A review of the physician orders [REDACTED]. [MEDICATION NAME] (an anxiety medication) 0.5 mg (milligrams) by mouth each night for anxiety disorder. Started 1/9/18. [MEDICATION NAME] (an antipsychotic medication) 25mg by mouth each night for agitation. Started 1/10/18. A review of the behavioral monitoring flow sheet was conducted for resident #87. The flow sheet had spaces for the nurse on each of the three shifts (7-3, 3-11, 11-7) to document the number of behaviors, interventions, outcomes and side effects related to each [MEDICAL CONDITION] medication the resident received. The Medication Administration Record [REDACTED]. There was also no documentation of monitoring for night shift on the dates of 2/6/18, 2/11/18, 2/14/18, 2/19/18, 2/24/18 and 2/28/18. The flow sheet for the medication [MEDICATION NAME] had no documentation of monitoring for the day shift on 2/1/18 and 2/11/18. There was no documentation of monitoring for the night shift on 2/5/18, 2/11/18, 2/14/18, 2/19/18, 2/23/18 and 2/24/18. A review of the nurses notes on the days of the missing documentation did not make mention of the absence or presence of resident behaviors or adverse effects monitoring of the [MEDICAL CONDITION] medications. On 3/1/18, and interview was conducted with the Unit Manager at approximately 10:30 AM. The Unit Manager confirmed the lack of monitoring documentation for the listed dates and stated the nurses were supposed to document on the flow sheets each shift.

Based on review of physician orders, the treatment administration record and an interview with Nurse A, the facility failed to provide treatment to prevent new pressure ulcers from developing for 1 of 2 (#61) residents sampled for pressure ulcers. The findings were: A review of physician orders [REDACTED]. Skin prep (a liquid rubbed on skin to make it tougher) left heel, cover with foam dressing, and change 3 times per week for prevention. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the order was transcribed as: Skin prep left heel cover with foam dressing change three times a week and as needed. Then as needed (abbreviated as PRN) was written in the time code spot. There were no initials indicating that the order was completed for the entire month of (MONTH) (YEAR). On 2/28/18 at 9:22am an interview was conducted with Nurse A. She was asked about the lack of documentation on the (MONTH) TAR for resident #61 and was unable to find proper documentation that the order was carried out as written.

Based on review of physician orders, narcotics sheets, pharmacy recommendations, medication administration records, pain flowsheets, treatment administration records, resident care plans, nurses' notes and interviews with Nurse A and Nurse G, the facility failed to implement the comprehensive plan of care for 3 of 24 residents by failing to provide treatments as ordered for resident #61, failing to monitor medication levels through laboratory testing for resident #17, and by failing to complete pain assessments for resident #96. The findings were: Resident #61 A review of physician orders [REDACTED]. Skin prep (a liquid rubbed on skin to make it tougher) left heel, cover with foam dressing, and change 3 times per week for prevention. A review of the plan of care related to skin integrity for resident #61 revealed the intervention of, provide skin care and treatments as ordered. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the order was transcribed as: Skin prep left heel cover with foam dressing, change three times a week and as needed. Then as needed (abbreviated as PRN) was written in the time code spot. There were no initials indicating that the order was completed for the entire month of (MONTH) (YEAR). On 2/28/18 at 9:22am an interview was conducted with Nurse A. She was asked about the lack of documentation on the (MONTH) TAR for resident #61 and was unable to find proper documentation that the order was carried out as written. Resident #17 A review of the plan of care for resident #17 revealed the intervention, Monitor labs as ordered. A review of physician's orders [REDACTED]. Repeat TSH ([MEDICAL CONDITION] stimulating hormone, which is a laboratory result used to monitor effectiveness of [MEDICATION NAME]) in 6 weeks. There were no newer orders for TSH monitoring in the chart. A review of laboratory results revealed a laboratory report on 12/20/2017 for a TSH. There were no other TSH results in the chart. A review of pharmacy recommendations revealed a recommendation given on 2/15/2018 that stated, Missing lab values TSH in 6 weeks from 12/21/2017. Written on the recommendation was, Already completed and in chart on 12/20/2017. On 2/27/2018 at 1:23pm an interview was conducted with Nurse A. She looked through the chart to find the lab or another order and was unable to locate one. She then called the physician and received a verbal order to complete a TSH lab in the morning for resident #17. Resident #96 A review of the plan of care for resident #96 revealed the intervention, Assess for tolerance and effectiveness of pain medication. A review of physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. The administration blocks for the medication on the resident's MAR indicated [REDACTED]. A review of the narcotics sheet (a form used to track the whereabouts of controlled medications) revealed that [MEDICATION NAME] was signed out on 2/21/2018 at 6am and on 1/9/2018 at 6am. There was no indication on the narcotic sheet that the medication was wasted (thrown away for any reason). A review of the nurses' notes revealed no documentation regarding the administration of the [MEDICATION NAME] or its effectiveness for pain relief for the above dates and times. A review of the pain flow record revealed no documentation regarding the above doses of pain medication. On 2/28/18 at 1:52pm an interview was conducted with Nurse G in which she agreed that there was no documentation that the 6am doses of [MEDICATION NAME] for 1/9/2018 and 2/21/2018 were administered to resident #96, nor was there any documentation regarding the administration of the [MEDICATION NAME] or its effectiveness for pain relief for the above dates and times.

Based on interview and record review, the facility failed to ensure medications were available to meet the needs of 1 of 3 residents sampled for medication administration observation (Resident #312). Findings: On 2/28/18, commencing at approximately 8:45am, medication administration observation for resident #312 was conducted with the Licensed Nurse, Employee C. The resident's scheduled 9:00am medications included two respiratory inhalant medications for a [DIAGNOSES REDACTED]. The inhalation device needed to administer one of the two resident's respiratory medications ([MEDICATION NAME]) was not on the cart. Upon entering the resident's room, the nurse had one of the two resident's scheduled respiratory medications ([MEDICATION NAME] Diskus) to administer. Resident #312 stated, I have not had my inhalants for several days. Review of the Medication Administration Record [REDACTED]. There was documentation that the pharmacy was called at 9am on 2/27/18 to send a new one. The medication was still not available for the 9:00am administration on 2/28/18. Further review of the MAR indicated [REDACTED]. Interview with the Unit Manager, Employee E, on 2/28/18 at approximately 9:20am revealed she was aware the medications were not available yesterday, and had notified the pharmacy. She stated she would speak with the Director of Nursing (DON) and get the [MEDICATION NAME] ordered immediately. The [MEDICATION NAME] arrived at the facility on 2/28/18 at approximately 11:30am; and the scheduled 9am dose was administered at that time. Review with the DON on 3/1/18 at 8:30am revealed scheduled pharmacy deliveries were daily between 6-8pm and 2-4am. She further stated medications could be obtained from a local pharmacy if needed prior to scheduled delivery times. She further stated that if the medications were not available for administration, the physician should be called and an order obtained to administer the medication when available. Review of the resident's medical record failed to document physician notification of the medications not being available on 2/27/18.

Based on observations and interviews the facility failed to ensure resident care equipment was stored in a sanitary manner for 3 of 40 resident bathrooms per facility protocol. The findings are: On 10/27/2015 at 10:27:55 AM an observation of the bathroom for the two residents who resident in 240A and 240B revealed an unmarked/unlabeled/uncovered pink plastic bed pan placed on the wall between the wall and the back hand rail located behind the toilet. Observation again on 10/27/2015 at approximately 2:40:36 PM revealed the same observation. Observation on 10/28/15 at approximately 1:48PM revealed the bed pan continues to be located at the same place and observation also revealed a white plastic urinal placed on the resident's table. The urinal is not labeled with a resident's name. Interview and observation with the resident's certified nurses' assistant (C.N.A.) sampled staff B on 10/28/2015 at 1:53:52 PM confirmed the unmarked/unlabeled urinal sitting on the table. She stated it was not labeled with the resident's name but stated it belonged to sampled resident #373. She placed the urinal in the trash and stated she would get another one and label it. Continued observation with this staff of the bathroom revealed she confirmed the presence of the pink plastic bed pan and confirmed it was not labeled and should have been labeled with a resident's name as well as placed in a plastic bag; she removed the bed pan and placed it in the trash. She stated neither resident uses a bedpan at this time. 10/28/2015 1:58:49 PM interview with sampled staff A, the Unit Manager for Garden unit revealed all resident care items such as emesis basins, bed pans and wash basins should be labeled with the resident's name and placed in plastic bags and stored in the bottom drawer of the resident's bedside cabinet. Interview with the regional nurse on 10/28/15 at approximately 4:41PM revealed it is facility expectations that items such as washbasins, emesis basins and bed pans are to be labeled and stored in plastic bags and placed in the resident's cabinet. The bed pan should also be appropriately labeled and stored but is not to be stored in the bathroom. Review of the Continence Care policy revealed the staff are to store the bedpan and do not leave it in the bathroom or on the floor. On 10/26/2015 at approximately 4:00pm, a bedpan was observed to be stored above the toilet in the bathroom shared by two residents in room 103. The bedpan was observed not to be contained in a bag and observed not to be labeled with a resident name. In interview with the Certfied Nursing Assistant assigned to this resident room, at the time of the observation, she stated that neither of the residents use a bedpan and discarded the equipment. On 10/30/15 commencing at approximately 9:15am, a tour was conducted of additional 20 resident rooms, excluding the 29 resident rooms previously observed. On 10/30/15 at approximately 9:20am, a disposable bedpan was observed in the bathroom of room 104, currently occupied by two residents. The pan was observed to be bagged in a clear plastic bag and hung on the grab bar adjacent to the toilet. There was no labeling to indicate for which resident the pan was used for. This observation was made in the presence of the Certified Nursing Assistant assigned to this room, Employee A, who stated she was not sure who the bedpan was used for. She further stated the pan should have been placed in a plastic bag, labeled with the resident's name and stored in the resident's bedside cabinet. On 10/30/15 at approximately 9:45am, the bathroom shared by two residents in room 242 was observed. Observed an unlabeled, unbagged bedpan on top of an elevated toilet seat in the corner of the bathroom. On top of the counter, observed a hairbrush and denture adhesive stored in a styrofoam cup without any labeling. There was an additional unlabeled hairbrush, two bottles of perineal wash and two tubes of protective ointments. Interview with resident A at the time of the observation revealed he has been using the hairbrush located in the corner of the cabinet top. He stated the other items were there when I came in yesterday. The resident in bed B was determined not to be interviewable. Interview with Employee B, at the time of the observation, revealed personal items are to be labeled and stored in the resident's individual cabinets. On 10/30/15 at approximately 9:50am, the Unit Manager, Employee C, was summoned to observe the items in the bathroom. She stated she had made rounds earlier and the items were not present. She further stated personal items are to be stored in ziplock bags and stored in the resident's bedside table. She stated bedpans should be labeled, bagged and stored in the resident's bottom drawer of their tables. On 10/30/15 at approximately 9:55am, an interview was conducted with the Certified Nursing Assistant, Employee D, assigned to this room. She stated she was not aware the items were in the bathroom, stated she had not been in the bathroom yet today, and stated neither of the residents use a bedpan. She was able to verbalize the proper process for storing personal care items.

Based on record reviews, review of the facility policy and procedure and staff interviews the facility staff failed to implement the facility Pneumococcal vaccine policy by failing to administered the resident's requested Pneumococcal vaccination for 1 of 5 sampled residents reviewed for the infection control pathway (#255). The findings are: Review of the facility's Influenza Vaccine, Pneumococcal Vaccine and Flu Outbreak Management dated 11/18/14 revealed 1. On admission to the facility, both PCV13 and PPSV23 should be routinely administered in series to all adults [AGE] years or older. 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. Record review for sampled resident #255 revealed she is a seventy-nine year old female who was admitted to the facility on [DATE]. Continued review revealed on 09/10/15 the resident's representative gave the facility permission to administer the influenza vaccine and a Pneumococcal vaccine. Review of the physician orders revealed an order dated 10/2/15 for influenza vaccine and the Pneumococcal vaccine. Continued review revealed on 10/7/15 the physician wrote a clarification order for the resident to receive the Pneumococcal Vaccine 23. Record review of the October medication administration record (MAR) revealed the resident received the influenza vaccine on 10/05/15. Record review of the resident's October 2015 MAR and interview was done with the Garden Unit Manager, Tamera Miller, LPN, sampled staff A on 10/27/15 at approximately 9:55AM. This record review failed to reveal documentation of the Pneumococcal vaccination being administered. Continued review of the resident's 10/15 MAR with sampled staff A revealed the date of 10/19/15 was blocked off for the nurses on the 11-7 shift to administer the Pneumococcal vaccine 23. There was no documentation the vaccination was administered. Continued interview with sampled staff A revealed after through record review the resident has not received the Pneumococcal vaccine 23. At approximately 10:04AM sampled staff A informed the surveyor the resident would get the Pneumococcal vaccine 23 today.