Every finding on record at Life Care Center of Punta Gorda

Based on record review, review of facility policy and procedures, resident and staff interviews, the facility failed to ensure staff followed policies and procedures and established plan of care to ensure prompt evaluation and safe transfer after a fall for 1 (Resident #31) of 4 residents reviewed for falls. The findings included: The facility policy Incident and Reportable Event Management reviewed 9/14/23 documented, The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable incidents . Avoidable accident means that an accident occurred because the facility failed to . Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, 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 . Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force . Incident/Injury. The Licensed nurse should evaluate the resident and render first aide if needed. The nurse evaluation should be completed prior to moving a resident who has fallen to determine presence of injury . Review of the clinical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included a left above the knee amputation and left hemiplegia and left hemiparesis (weakness or inability to move the arm and leg on one side of the body). The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 5/7/24 documented Resident #31's cognitive skills for daily decision making were intact with a Brief Interview for Mental Status score of 14. The MDS noted the resident was dependent for chair/bed-to chair transfer (Helper does all of the effort. Resident does none of the effort to complete the activity). The CNA Kardex specified for transferring, The resident is dependent and requires [Brand name] mechanical lift with 2 staff assistance for transfers. Review of the nursing progress notes showed on 7/6/24 Resident #31 complained of new onset of left arm pain. The Advanced Practice Registered Nurse was notified and ordered an X-ray of the left arm. The X-ray result showed an acute left humeral fracture. Review of the facility's investigation revealed the X-ray obtained on 7/6/24 showed Suspect incomplete fracture in proximal shaft of the left humerus with rather severe osteoporosis [weak, brittle bones] The investigation noted Certified Nursing Assistant (CNA) Staff N said on 7/5/24 when she went to assist Resident #31 into bed, the resident was leaning to the side and bent over forward. She said while repositioning the resident in the chair, he began to slide forward out of the chair so she lowered him to the floor. CNA Staff N stated the resident's left arm did not hit the chair or the floor and he was seated upright in front of the wheelchair. Resident #31 did not complain of any pain at the time. She said she got CNA Staff J and they lifted the resident from the floor onto the bed. Staff N said she put her arms under the resident's lower extremities and Staff J put his arm around the resident's upper body and they lifted him into the bed. CNA Staff J reported that Staff N asked him to help transfer Resident #31 into bed. When he entered the room the resident was sitting on the floor in front of his wheelchair. He put one arm under the resident's right arm and the other arm around the resident's left arm as the resident told him that his left arm was paralyzed from a stroke. Staff N put her arms around the resident's lower extremities and they lifted him into bed. Staff J reported the resident did not complain of any pain or discomfort to his left arm before, during, or after the transfer. The investigation noted on 7/6/24 Resident #31 complained of pain to his left arm and told the nurse he thought something happened to his arm when he was transferred into bed on 7/5/24 without the full body mechanical lift. On 7/8/24 the primary provider assessed and diagnosed Resident #31 with a fragility fracture of the left humerus related to severe osteoporosis and ordered to continue current pain medication regime as resident reported effectiveness. On 7/9/24 Resident #31 was assessed by an orthopedic doctor. An X-ray of the resident's left arm showed a fracture in the area of the humeral neck. The X-ray noted diffuse demineralization (losing bone minerals which can cause the bones to become brittle). The facility's investigation noted the resident was inconsistent in reports of events. Staff assigned to resident reported that resident was lowered to the floor while they were repositioning him in his wheelchair. Staff reported that resident was seated on the floor in front of the wheelchair. They performed a two person transfer from the floor to the bed. On 7/22/24 at 12:05 p.m., in an interview Resident #31 said he uses a mechanical lift for transfers. He said, I remember what happened when they dropped me. It was a female and a male CNA. I was in my wheelchair and they were lifting me, the girl had my foot and he had me around the waist under my arms and just as we got close to the bed they dropped me and down I went to the floor. I don't know why they didn't use the lift with me. My left arm hurts, they said it is broken. On 7/22/24 at 12:18 p.m., in an interview Restorative CNA Staff M, said Resident # 31 required a mechanical lift for all transfers with a special sling since his left leg is amputated. On 7/23/24 at 12:00 p.m., in a second interview Resident #31 said, I fractured my arm because the staff did not use a lift with me. I was in my wheelchair. They tried to transfer me to bed without the lift and they dropped me. The guy had me under the arms around my chest, I guess he didn't know I can't use my left arm at all, it does not work. They dropped me and then they picked me up and tossed me into the bed. The girl had my right leg, and down I went on the floor. They did not use the mechanical lift; I don't know why. I did not have pain right then and there because I don't always have feeling in the left arm. But the next day it really hurt. On 7/24/24 at 8:39 a.m., in an interview CNA Staff L said she was not working on 7/5/24 when the incident with Resident #31 occurred. She said a day or so after the incident Resident #31 was yelling loudly that his arm hurts so she reported it to the nurse. On 7/24/24 at 9:41 a.m., in an interview the Director of Nursing (DON) said she was notified Resident #31 complained of pain to left arm. He told the nurse he believes something happened when he was put into bed the other night. The resident said it had happened the other night when the CNA's transferred him. He went to the orthopedic physician, and they did another x-ray that showed a fracture of the left humeral neck. When she spoke with Resident #31, he confirmed he was on the floor and they lifted him into bed. I asked and he kept saying they dropped me, they dropped me. He said he was in the wheelchair and was leaning to the right. He confirmed he was lowered to the floor and picked back up. The DON said they did not know when the fracture happened, and the provider documented a pathological fracture (fracture caused by weakness of the bone structure). She said the policy specifies to notify the nurse when a resident falls or is lowered to the floor. Staff N did not notify the nurse when she lowered the resident to the floor. The resident said the pain started later in the night and he did not tell anyone until morning. He said he felt the injury was from the transfer. CNA Staff J said he had his arm over the resident's left arm, in a bear hug to get him into bed. She concluded it could have happened during the transfer. Resident #31 directly said the pain occurred after the fall and the likelihood was the fracture did happen during the transfer. The DON said, They did not call the nurse and they did not use the lift but I can't say how the fracture happened. I can't say exactly, there are different factors. I can't connect the two occurrences, the lowering to the floor and bear hug to lift him in the bed as the cause of the fracture. On 7/24/24 at 11:12 a.m., a phone call was placed to CNA Staff J. He did not answer and did not return the call. On 7/24/24 at 11:14 a.m., in a telephone interview CNA Staff N said on the night of 7/5/24, Resident #31 was in the wheelchair. She was trying to get the sling behind him which was hard to do. He could not grip the chair and started to slide out of the wheelchair. She could not stop him so she lowered him to the floor, next to the bed. She got CNA Staff J to come and help her. She grabbed the resident's buttocks and the right leg. CNA Staff J grabbed the top of the resident. Staff J had his arms wrapped around the resident like a hug. She verified they manually lifted and transferred the resident from the floor to the bed and did not use the mechanical lift as specified in the care plan and the Kardex. She also verified she did not notify the nurse of the resident's fall since he did not complain of pain at that time. On 7/24/24 at 11:47 a.m., in a telephone interview Registered Nurse (RN) Weekend Supervisor Staff M said, first thing in the morning about 8:00 or 8:30 a.m., on 7/6/24 the nurse became aware the resident had pain. She went to speak with him. Resident #31 complained of pain to the left shoulder rated seven out of 10. Resident #31 told her he thought it happened the night before when they transferred him. He said the CNAs lifted him without the mechanical lift. He did not tell anyone about the incident but told the CNA and the nurse his arm was hurting. He got a pain pill. Staff M said when the X-ray revealed a fracture she notified the Director of Nursing. She spoke with CNA Staff J who said Resident #31 was sitting on the floor, slumped and leaning forward when he went in to help CNA Staff N. They lifted the resident off the floor and put him to bed. He did not know if the resident had fallen. On 7/24/24 at 5:38 p.m., in an interview the DON said if a resident is on the floor, the process is to notify the nurse who will assess for any injury, potential fracture, get a gait belt to transfer. She said it is not always feasible to use the lift to get a resident off the floor. It depends on the situation, such as the position of the resident, weight bearing status. If therapy is present they would assist with the transfer and determine if the lift is needed. She said the main error was that CNA Staff N did not notify the nurse immediately. The nurse should have assessed the resident.

Based on observation, record review and staff interview the facility failed to follow the manufacturer's instruction for cleaning and disinfecting of the Blood Glucose Monitoring System (glucometer) for 2 (Residents #57 and #556) of 3 residents reviewed with physicians' orders for blood glucose monitoring. Inadequate disinfection may result in indirect contact transmission (the transfer of an infectious agent through a contaminated inanimate object) of blood borne pathogens. The findings included: Review of the Journal of Diabetes Science and Technology (March 2009): Finger-stick devices, blood glucose testing meters, or even a health care worker's hands may all become vehicles for indirect transmission of viruses if they become contaminated with blood. Since HBV (Hepatitis B virus) is highly infectious and environmentally stable, even invisible amounts of blood are sufficient to spread infection. Review of the Center for Disease Control website at https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html noted, Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place . Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person. Dedicated meters should be stored in a manner that prevents cross-contamination and inadvertent use for the wrong patient. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared . On 7/23/24 at 11:40 a.m., Licensed Practical Nurse (LPN) Staff Q was observed doing a fingerstick and using a glucometer to measure Resident #57's blood glucose level. Staff Q retrieved the glucometer from a sealed plastic bag from the medication cart. She wiped the front of the glucometer three times with an alcohol prep pad. She used a second alcohol prep pad and wiped the back of the glucometer three times. Staff Q placed the glucometer on a clean tissue on the medication cart and said she had to wait two minutes for the glucometer to dry. After measuring the resident's blood glucose, Staff Q wiped the glucometer with an alcohol prep pad, allowed it to dry. She placed the meter in a sealed plastic bag and stored it in the cart. On 7/23/24 at 11:46 a.m., in an interview Staff Q said the glucometers can be used for multiple residents but currently only used for Resident #57. She said the facility's policy was to wipe the glucometer down with an alcohol prep pad before and after using on a resident. She said she wipes the glucometer three times on the front and three times on the back and allows it dry for two minutes before placing it back into the medication cart in a sealed plastic bag. 2. On 7/23/24 at 12:00 p.m., LPN Staff P was observed doing a fingerstick and measuring Resident #556's blood glucose with a glucometer. Staff P removed the glucometer stored in a sealed plastic bag from the medication and gathered the supplies needed. Staff P performed a fingerstick and used the glucometer to measure the resident's blood glucose level. Upon completion of the task, Staff P wiped the glucometer with an alcohol prep pad, placed it on a clean tissue on the cart and allowed it to dry. She then placed the glucometer back into the sealed plastic bag and stored it in the cart. In an interview Staff P said the policy was to wipe the front and the back of the glucometer with an alcohol wipe and let the meter dry for two minutes. Staff P said currently only Resident #556 used the glucometer. On 7/23/24 at 1:08 p.m., in an interview Unit Manager LPN Staff K said she thought alcohol wipes or a (brand name) disinfecting wipes could be used to disinfect the glucometers but she would have to find out for sure. She said the facility's policy was to wipe the glucometer three times with an alcohol wipe, using one wipe for the front and one wipe for the back. On 7/23/24 at 5:22 p.m., the Director of Nursing (DON) provided a copy of the facility's policy for Cleaning and Disinfection of the Glucometer. Review of the facility's policy for Cleaning and Disinfection of the Glucometer revised on 9/28/2022 and reviewed on 9/20/2023 noted the policy was, To prevent the spread of infections, specifically blood borne pathogens through the use of point of care blood glucose monitoring, by cleaning and disinfecting glucometers after each resident use. The procedure specified the brand name of glucometers used by the facility and cleaning procedures. The instructions specified the meter should be cleaned and disinfected after use on each patient. The instructions listed four disinfectant brands with an EPA (Environmental Protection Agency) number and specified, wipes with EPA registration numbers not listed should not be used to clean and disinfect the brand name glucometer used by the facility. Alcohol prep wipes were not listed on the list of approved disinfectants to clean and disinfect the glucometer used by the facility. The DON confirmed only the approved wipes with the EPA number should be used to ensure the disinfection of the glucometers.

Based on record review, and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional. This had the potential to affect all current residents residing in the facility. The findings included: On 7/24/24 at 12:24 p.m., the Activity Director said the prior Activity Director's last day of employment was 5/30/24. She said she has been the facility's interim Activity Director since 6/1/24. She said she was responsible for completing the activity assessment for each resident, create and post the activity calendar for the facility and arrange when outside entertainment would come to the facility. She said she did not have a degree, and/or a certificate as an activities professional, did not have two years of experience in a social or recreational program within the last 5 years, and was not a qualified Occupational Therapist or Occupational Therapist Assistant. She said in mid-May 2024 she started but had not completed a course to receive a national certificate to become an activity professional. Review of the Activity Director job description stated under the education, experience, and licensure/certifications section the Activity Director, Must be a qualified activities professional who is licensed or registered, if applicable, by the State in which practicing, and eligible for certification as an activities professional by a recognized accrediting body and or after 10/1/1990 or has 2 years of experiences in a social or recreational program within the last 5 years, one which was full-time in a therapeutic activities program, or is a qualified occupational therapist or occupational therapist assistant or has completed a training course approved by the State. The Therapeutic Activities Program policy issued on 1/06/2020 and revised on 4/01/22, stated per federal regulation the facility's activities program would be directed by a qualified activities director. The director was responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This included the completion and/or directing/delegating the completion of the activity's component of the comprehensive assessment. On 7/24/24 at 12:57 p.m., in an interview the Executive Director (ED) confirmed after reviewing the current Activity Director's employee file, their Activity Director did not have the required certification showing she had completed a training course to become a activity professional, was not a qualified occupational therapist, and/or had two years of experience in a social or recreational program with in the last 5 years prior to becoming the facility's Activity Director on 6/1/24 as required per federal regulation as noted in the Therapeutic Activities Program policy.

Based on record review, and staff interview, the facility failed to assess, evaluate, and plan care to provide individualized approaches to restore as much normal bladder function as possible for 1 (Resident #114) of 3 residents reviewed for incontinence. The findings included: Review of the facility policy for Urinary Incontinence Management, Reviewed 8/23/2023 noted, Each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible . The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain . An incontinent resident typically feels frustrated, embarrassed, and hopeless. Fortunately, bladder retraining - a program that aims to establish a regular voiding pattern - can usually correct this problem. Follow these guidelines: Assess elimination patterns . Establish a voiding schedule . Record results . Clinical record review revealed Resident #114 was admitted to the facility on [DATE]. Diagnoses included fracture of the right knee and legal blindness. The Nursing Admission Collection Tool dated 5/24/24 noted Resident #114 was able to make herself understood, was oriented to person, place, time and situation. Resident #114 was continent of urine. The baseline care plan dated 5/24/24 did not include urinary incontinence as a concern requiring interventions. The Admission Minimum Data Set (MDS) assessment with a target date of 5/30/24 noted Resident #114's cognition was intact with a Brief Interview for Mental Status Score of 15. The assessment noted the resident was occasionally incontinent of urine. The assessment did not document an assessment, or interventions attempted since the urinary incontinence was noted to maintain or restore urinary continence status. The care plan initiated on 5/24/24 noted Resident #114 has bowel and bladder incontinence at times related to impaired mobility and decreased functional range of motion of the right lower extremity. The goal was to decrease the frequency of incontinence through the next review date. The interventions included to administer preventative creams as ordered (5/28/24), clean peri-area with each incontinence episode (5/24/24), observe for and document signs and symptoms of urinary tract infections (5/24/24), Provide unobstructed path to the bathroom (5/24/24), weekly skin checks and as needed (5/28/24). The Kardex (Provides instructions for care) noted the resident required limited assistance of one person for bladder and bowel. The care plan and Kardex did not include individualized interventions to maintain or restore urinary continence. Review of the Skilled nursing documentation for 6/25/24, 6/28/24, 7/1/24, 7/2/24, 7/5/24, 7/10/24, 7/11/24, 7/12/24 and 7/14/24 revealed abnormal genitourinary findings. The intervention was, Incontinent care provided as needed. Review of the CNA documentation for 30 days from 6/25/24 through 7/24/24 revealed Resident #114 had 28 episodes of incontinence during the day, evening, and nighttime. On 7/22/24 at 2:37 p.m., in an interview Resident #114 said she is continent and can tell when she needs to urinate. She said she needs assistance to use the bedpan to urinate. Resident #114 said she takes a water pill and wets herself when staff do not answer the call light and get to her in time. Resident #114 said today she waited 20 minutes after she activated the call light for assistance to use the bedpan. The CNA told her she was passing meal trays and would only be a minute. Resident #114 said she's been having more and more episodes of incontinence the longer she's been at the facility. She stated, When I put the call light on, I really need to go, and I told them that. Sometimes I feel as though I am being ignored. I do not need to wear an incontinence product all the time when I'm at home. She said the facility provided her incontinence brief to wear but she does not like to urinate in them. On 7/23/24 at 4:03 p.m., in an interview Certified Nursing Assistant (CNA) Staff A said Resident #114 is continent and puts her light on when she needs to use the bedpan. She said the resident prefers the bedpan. Staff A said the resident uses an incontinent brief but does not need it since she is continent. On 7/24/24 at 2:10 p.m., in an interview CNA Staff B said she finds bowel and bladder instructions for each resident on the Kardex. She said the Kardex should tell whether the resident is continent or incontinent. She said Resident #114 takes a water pill and if they don't get to her in time, she will urinate in the incontinent brief. She said she checks the resident every two hours. She said no one, including the nurse, instructed her to check on Resident #114 more frequently than every two hours. On 7/24/24 at 2:17 p.m., in an interview CNA Staff C said Resident #114 is continent and will tell staff when she needs to go. She said she was not told to put her on a schedule or offer toileting more often than every two hours. On 7/24/24 at 2:27 p.m., in an interview MDS Coordinator Registered Nurse (RN) Staff D said she completed the MDS section, and care plan addressing the continence status for Resident #114. She verified the care plan did not list interventions to restore Resident #114's urinary continence. She said the nursing staff should be checking on the resident every two hours but they should do that with all residents. She said in order to decrease Resident #114's episodes of incontinence, she would have to be placed on a scheduled voiding program. RN Staff D verified no voiding program was implemented for Resident #114. On 7/24/24 at 2:56 p.m., in an interview Unit Care Coordinator, Licensed Practical Nurse (LPN) Staff F said the Admission Skilled Nursing Assessment noted Resident #114 was continent of urine, and now the resident was having incontinent episodes. She said she did not know how the new incontinence would have triggered but the nurses should monitor for things like this. On 7/25/24 at 10:20 a.m., in an interview the Director of Nursing (DON) verified Resident #114 had been at the facility for two months. She said the MDS coordinators should be looking at the data they have available for Resident #114. She said Resident #114 should have been evaluated to determine if she was a candidate for a toileting program but the evaluation was not completed until today. Review of the Occupational Therapy progress note dated 7/24/24 noted Resident #114 participated in mock commode transfers with focus on improving hand placement, body mechanics, and balance to further improve independence with task. Despite education the resident prefers to use the bedpan due to self-limiting behaviors. The therapist documented Resident #114 actively participated in the therapy session. Encouragement and education were provided to overcome barriers.

Based on observation, record review, review of the facility's policy and procedure, resident and staff interview, the facility failed to provide care and services in accordance with professional standards by failure to follow the physician's order for 1 resident (#114) of 1 resident reviewed with lower extremities swelling. The findings included: Review of the facility policy for Physician Orders Revised 2/26/24 noted the facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. The receiving nurse or therapist immediately enters telephone or verbal orders into the clinical software. Review of the clinical record for Resident #114 revealed an admitted [DATE]. The Admission Minimum Data Set (MDS) Assessment with a target date of 5/30/24 noted Resident #114's cognition was intact with a Brief Interview for Mental Status Score of 15. Review of the physician's order revealed on 6/13/24 to apply knee high [NAME] hose (compression stockings) to bilateral lower extremities in the morning and remove at bedtime for edema (swelling). On 7/22/24 at 2:53 p.m., Resident #114 was observed in her room sitting on the side of the bed. The resident was not wearing the [NAME] hoses on her lower legs. In an interview Resident #114 said the [NAME] Hoses are uncomfortable and she refuses to wear them. The resident said they are applying Ace bandages (elastic bandages) instead of the [NAME] hoses but they were not applied today. Resident #114 said, The aid told me they were too busy. On 7/23/24 at 12:39 p.m., Resident #114 was observed in her room sitting on the side of the bed. The resident was not wearing the [NAME] hose to her legs as per the physician's orders. In an interview Resident #114 said the nurse told her she would apply ace bandages to her lower legs after lunch. Two Ace bandages were observed on the nightstand. On 7/23/24 at 5:18 p.m., Resident #114 was observed in bed in her room. Her right lower leg was wrapped with an Ace bandage. Resident #114 said the Ace bandage to her left lower leg came off. On 7/24/24 at 9:51 a.m., Resident #114 was observed in bed with an Ace bandage to her right leg. In an interview Resident #114 said the Ace bandage was applied to her right leg the prior day and left in place all night. The clinical record did not reveal a physician's order authorizing the use of an Ace bandage instead of the [NAME] hose to the resident's lower extremities. On 7/24/24 at 10:00 a.m., Review of the Treatment Administration Record (TAR) for July 2024 revealed documentation [NAME] hose were applied to the resident's lower legs on 7/22/24, and 7/23/24 at 8:00 a.m. and removed at 10:00 p.m. On 7/24/24 at 12:29 p.m., in an interview Licensed Practical Nurse (LPN) Staff G verified the documentation on the TAR was not accurate for 7/22/24 and 7/23/24 since the [NAME] hose were not applied to the resident's legs at 8:00 a.m. She said she wraps Resident #114's legs with Ace bandages instead of the [NAME] hose as the resident complained the [NAME] hose hurt her legs. Staff G verified on 7/23/24 she did not apply the Ace bandages to the resident's lower legs in the morning as ordered but at 1:51 p.m., for no reason in particular. She said when she went to apply the bandages to the resident's legs this morning around 10:30 a.m., the resident's right leg was still wrapped with an Ace bandage. It appeared as though it was not removed all night. On 7/24/24 at 1:08 p.m., in an interview Unit Care Coordinator LPN Staff F said it was not acceptable to apply Ace bandages instead of the physician ordered [NAME] hose to the resident's lower legs. On 7/25/24 at 10:12 a.m., in an interview the Director of Nursing (DON) said LPN Staff G did not follow the facility's process. She said the nurses should only place their initials on the TAR after the treatment is completed. When LPN Staff G obtained a new order to use Ace bandages instead of [NAME] hose, she should have written a progress note and changed the order.

Based on observation, staff interview, clinical record review and facility policy and procedure review, the facility failed to safely secure medications by leaving them unattended at bedside for 1 (Resident #266) of 1 resident observed. The findings included: Review of facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles revised 10/28/2019 which stated, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 8/30/21 at 11:16 a.m., Resident #266 was observed in her room and lying in bed. Observed in her room at this time were two boxes of medication, respiratory inhalers, on the resident's bedside table. Medications at bedside were Wixela 250/50(generic form of Advair), a respiratory inhalation medication used to treat asthma, opened on 8/24/21. Dose one puff inhaled orally two times a day. The second medication at the bedside was Incruse 62.5 micrograms (mcg), a respiratory inhalation medication used to treat [CONDITION(S)] ([CONDITION(S)]), opened on 8/26/21. Dose one inhalation one time a day for [CONDITION(S)]. Resident interviewed said she did not know where they came from and was not on any inhalers and not aware of what medications she was taking. On 8/30/21 at 11:19 a.m., interviewed Unit manager Licensed Practical Nurse (LPN) Staff B. She confirmed Resident #266 did not have an order or assessment for self-administering medications. Unit Manager LPN Staff B confirmed there was no reason for medication to be there at the bedside and confirmed resident was confused. Unit Manager LPN Staff B went into resident's room and confirmed two boxes of medication inhalers were on the bedside table next to the resident's bed. Unit Manager LPN Staff B removed the medications. On 8/30/21 at 11:24 a.m., interviewed LPN Staff A who said she gave resident #266 her medications that morning around 8:30 a.m. LPN Staff A confirmed she documented on Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN Staff A said the resident was very confused. Clinical record review for Resident #266 included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/2/21 at 9:37 a.m., interviewed Director of Nursing (DON) about medications left at bedside for Resident #266 observed on 8/30/21. The DON said, I know all about the incident. The LPN came and told me that day. I agree it is a safety issue for the resident and should not have occurred. We have started education for the staff. The DON confirmed the resident did not have a self-medication order or assessment.

Based on observation and interview the facility failed to safeguard residents' well-being by failing to follow current infection control standards related to COVID-19 recommendations set forth by Centers for Disease Control and Prevention (CDC). Refer to https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html The findings included: On 6/9/20 at 11:00 a.m., during a tour of the facility with the Director of Nursing (DON), Licensed Practical Nurse Staff A was observed seated at a table in the hallway outside room [ROOM NUMBER]. The table Staff A was seated at had multiple Styrofoam cups with lids and straws on it. Several people were observed to be moving freely about the hallway near Staff A. Staff A had her mask pushed down to her chin with her mouth and nose exposed. On 6/9/20 at 11:03 a.m., Certified Nurse Assistant Staff B was observed using a computer mounted to the wall in the 129-137 hallway. Several people were observed to be moving freely in the hallway and nurses' station near the computer. Staff B had her mask pushed down to her chin with her nose exposed. On 6/29/20 at 11:05 a.m., in an interview the DON agreed Staff A and Staff B had their masks down on their chins and was not proper Infection Control standards related to CDC recommendations. On 6/29/20 at 12:30 p.m., in an interview the Administrator agreed it was not proper infection control standard related to COVID 19.

Based on observation, record review, and interview the facility failed to prevent a fall with injuries for 1 (Residents #6 ) of 2 residents reviewed for falls. Resident #6 sustained an acute fracture of her clavicle bone (collarbone) and a hematoma with laceration on the left side of her forehead. Resident #6 was a dependent resident who rolled off the bed in the presence of staff. Safety precautions had been removed at time of fall. The findings included: Policy review for Event management & Emergency Procedures: Fall Management (Effective Date 12/13/18) reviewed 4/15/19. The policy states; The facility must ensure that the resident's environment remains as free of accident hazards as possible and each resident receives adequate supervision to prevent accidents. Supervision refers to an intervention and means of mitigating the risk of an accident. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff. Hazards refer to elements of the resident environment that have the potential to cause injury or illness. Hazards over which the facility has control are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness. Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Record review revealed on 10/1/19 at approximately 3:07 p.m., Resident #6 rolled out of bed and fell to the floor sustaining an acute [MEDICAL CONDITION] clavicle (collarbone), and a hematoma with laceration on the left side of her forehead. At the time of the fall Certified Nursing Assistant (CNA) Staff L had placed Resident #6 on her bed and positioned her on her side. After turning away from the dependent resident to reach for his supplies, he heard something and turned to find Resident #6 laying on the floor. Resident #6's feet/ankles had gotten caught between the wheelchair arm and the bed while her upper body was twisted with her head landing hitting bed wheel area and left shoulder hitting the floor. Record review of progress notes written on 10/2/19 by Assistant Director of Nursing (ADON) documented CNA Staff L, did not see the fall because he was facing the other way. She wrote when CNA turned around, Resident #6's feet/ankles had gotten caught between the wheelchair arm and the bed, while her upper body was twisted with her head landing hitting bed wheel area and left shoulder hitting the floor. On 10/31/19 at 10:08 a.m., observed reenactment of fall incident done by ADON to demonstrate how Resident #6 fell . CNA Staff L had transferred the resident to her bed. He did not have his supplies in reach, so he had to take his eyes and his hands off the resident. This was when the resident rolled off the bed. CNA Staff L left the resident unsupervised at the side of the bed. There was not a second CNA with the resident during the procedure. Record review of Resident #6's quarterly assessment minimum data set (MDS) dated (MONTH) 22, 2019 records the resident was severely cognitively impaired and total dependent for her daily care including bed mobility and toileting. Resident #6 was coded as needing two staff to assist with bed mobility. The resident had the following Diagnosis: [REDACTED]. On 10/31/19 2:15 p.m., in interview with CNA Staff D, she said when doing incontinence care for a dependent resident she made sure she gets all of her supplies ready and had them on the bedside table right beside her or on the foot of the bed so she did not have to leave the resident or turn away. She said that you were never to take your eyes off the resident and really you should hold on to them if they were on their side. Staff D said she would not turn the resident away from her if there was not another staff member helping. On 10/31/19 2:37 p.m., in an interview LPN Staff [NAME] said she would never turn the resident away from her on a bed if no one was assisting on the other side. She also said you can never tell what residents would do, so it was best to never take your eyes off them when you have them on their side on a bed. She said it was like having a baby on a changing table, they might fall. On 10/31/19 at 9:58 a.m., in an interview ADON said she investigated Resident #6's 10/1/19 fall. She did not find that CNA Staff L could have prevented the fall. On 10/31/19 at 10:30 a.m., in interview with Director of Nursing (DON), she stated I do not feel that the incident was adverse or neglect. I do not feel that the CNA could have done anything different to prevent the fall. On 10/31/19 at 11:55 a.m., in interview RN Facility Educator Staff H said after review of the reenactment of the Resident #6 fall incident I was not included in the investigation. Staff H said she did not do staff re-education for any staff after the resident fell out of the bed. Staff H said she did not feel CNA Staff L could have done anything different to prevent the fall from the bed. Record review of Suspension Pending Investigation Form dated 10/2/19 at approximately 3:10 p,m., interview with CNA Staff L has documentation the residents bed was not in low position and the safety mats were removed from the side of the residents bed at the time of the fall.

Based on observation, resident and staff interview the facility failed to consistently provide necessary restorative care to minimize the worsening of contracture and range of motion for 1 (Resident #62) of 3 residents reviewed for limited range of motion. Failure to consistently follow the plan of treatment and provide restorative therapy to the resident increased the risk for worsening of contracture and decrease range of motion. The findings included: A review of the clinical record for Resident #62 revealed a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Nursing Rehabilitation/Restorative Care form indicated Resident #62 had decreased range of motion on bilateral lower extremities and upper extremities and required complete active and passive range of motion on all joints and the application of a right hand splint to prevent further contracture (shortening and hardening of muscles, tendons or other tissue, leading to deformity and rigidity of joint). On 10/28/19 at 10:05 a.m., Resident #62 was observed in bed. Resident was alert, oriented and able to answer questions appropriately. Resident #62's right hand was contracted. The prescribed splinting device was not observed on the right hand. During interview, Resident #62 said he was not currently receiving any therapy or treatment for [REDACTED]. Several observations throughout the day and afternoon on 10/28/19 through 10/31/19 revealed Resident #62 in bed. He was not wearing the splinting device on his right hand. On 10/31/19 at 10:00 a.m., Resident #62 said no one had came to do any exercise with him or apply the splint to his right hand all week. The Restorative Nursing documentation for 10/28/19 through 10/30/19 indicated Resident #62 completed the restorative program each day as ordered, and the splint was applied to the right hand as ordered. On 10/31/19 at 10:10 a.m., during an interview the Restorative Certified Nursing Assistant (CNA) Staff G said the Restorative Nursing Documentation was inaccurate. She said she had not provided any restorative treatment and had not applied the splint to the resident's hand since sometimes last week. Staff G said Resident #62 liked to get up late. She said she gets distracted and did not return to provide the treatment and apply the splint as ordered. The Restorative Nurse was present during the interview. She said she was not aware Resident #62 had not received the treatment as ordered. On 10/31/19 at 11:30 a.m., Director of Rehabilitation said Resident #62 did not like to move at all and there was always a potential for decline if the restorative treatment was not completed as ordered.

Based on observation, staff interview, and record review the facility failed to administer medications in accordance with physician orders [REDACTED].# 101 and #130) of 6 residents observed for medication administration. Four licensed nurses with 25 opportunities were observed. Two medication errors were observed resulting in an 8% error rate. The findings included: The facility policy #6.0 General Dose Preparation and Medication Administration (revised 5/1/10: 1/1/13), #3.7 specified Facility staff should verify that the medication name and dose are correct. On 10/28/19 at 9:53 a.m., Licensed Practical Nurse (LPN) Staff B was observed administering four different medications to Resident #130, including one tablet of Senna Plus (a medication to treat constipation). Staff B verified she administered one tablet of Senna Plus to Resident #130. Upon reconciliation with the physician order, it revealed an order to administer three tablets of Senna Plus twice a day for constipation. On 10/28/19 at 10:01 a.m., LPN Staff A was observed administering eight different medications to Resident #101, including a chewable tablet of aspirin 81 milligram. Staff A verified she administered one chewable 81 milligram tablet of aspirin to Resident #101. Upon reconciliation with the physician order, it revealed an order to administer 81 milligrams of Aspirin [MEDICATION NAME] Coated (the [MEDICATION NAME] coating helps to prevent stomach ulcers and bleeding).

Based on observation, review of policies and procedures, and staff interview the facility failed to follow infection prevention technique during medication administration for 1 (Resident #101) of 6 residents observed. The facility failed to store resident's personal care items in a sanitary manner om one of two floors of the facility. The findings included: room [ROOM NUMBER] was a double occupancy room. On 10/28/19 at 2:40 p.m., a bedpan was stored on the handrail behind the toilet. The bedpan was not labeled making it impossible to determine whom it belonged to. room [ROOM NUMBER] is a double occupancy room. On 10/28/19 at 1:00 p.m., an unlabeled bedpan was observed stored on the bedrail and an unlabeled wash basin was stored on the floor in the bathroom next to the garbage can with a pair of used gloves in the basin. On 10/28/19 at 11:10 a.m., two bedpans were observed stored on the floor next to the toilet in room [ROOM NUMBER]. On 10/31/19 at 9:21 a.m., observations and pictures were shared with the Director of Nursing (DON) and the Regional Nurse Consultant. DON said the expectation was that bedpans and basins were bagged and placed in the drawer. She said the managers make rounds every day. She said the Certified Nursing Assistants have been educated on how to store the bedpans and wash basins. ** Photographic evidence on file** The facility policy #6.0 General Dose Preparation and Medication Administration (revised 5/1/10; 1/1/13), specified in sections 3.4 facility staff should not touch the medication when opening a bottle or unit dose package and 3.5 if a medication which is not in a protective container is dropped, Facility staff should discard it according to facility policy. On 10/28/19 at 10:01 a.m., Licensed Practical Nurse (LPN), Staff A was observed administering medications for Resident #101. Staff A opened a bottle of aspirin 81 milligrams and poured several pills into the bottle's cap. She held the pills with her fingers and poured 1 tablet into a medication cup. Staff A returned the rest of the pills back into the bottle that was used for all residents receiving aspirin. Staff A poured two [MEDICATION NAME] 250 mg Capsules (live bacteria that are good for the digestive system) into the medication cup. Staff A inserted her fingers into the medication cup and removed one of the [MEDICATION NAME] capsules. In the process, she touched all the pills previously poured into the cup. Staff A took the unit dose package of Potassium Chloride 10 milliequivalent capsules (a potassium supplement) and removed three capsules. Two of the capsules fell on the top of the medication cart. Staff A picked them up and placed them into the medication cup. Staff A administered the medications to Resident #101. On 10/28/19 at 10:20 a.m., Staff A confirmed she had dropped and touched several of Resident #101's medications during the medication administration. Staff A verified she should have discarded the medications.

Based on observation, record review, and interview, the facility failed to label, date, and monitor refrigerated food in 5 of 5 nourishment room refrigerators observed. This places residents at risk for serious complications from foodborne illness. The findings included: Review of the facility's policy titled Nourishment Storage Areas, last revised 1/1/2007, indicated food is covered, labeled, and dated appropriately. Food is rotated and/or discarded according to the facility guidelines. On 7/24/18 at 4:52 a.m., the memory care nourishment room refrigerator contained a plastic container with cookies in it and a jar with a spread in it. Neither container had a dated label on it. On 7/24/18 at 4:56 a.m., the Harbor Isle nourishment room refrigerator contained a bag of grapes and a bag of sausages/hotdogs. Neither had a dated label on them. On 7/24/18 at 4:57 a.m., the Captains Cove nourishment room refrigerator contained a half of a sandwich on a Styrofoam plate. The sandwich was exposed to air with no plastic covering over it. There was no dated label. On 7/24/18 at 5:06 a.m., the nourishment room refrigerator near room [ROOM NUMBER] contained a plastic container with a pasta mixture in it. There was no dated label on this. On 7/24/18 at 5:07 a.m., the Sunset Terrace nourishment room refrigerator contained a plastic bag with cut up strawberries. There was no dated label on this. During an interview on 7/24/18 at 4:59 a.m., Licensed Practical Nurse (LPN) Staff B said all food is to be labeled with the resident's room number, name, and date. LPN Staff B said usually all shifts are to check the refrigerators and night shift is supposed to double check as well. During an interview on 7/24/18 at 6:03 a.m., Certified Nurse Aide Staff C said food should have resident's name, date, and room number on it. During an interview on 7/24/18 at 5:35 a.m., the Executive Director (ED) admitted there was a problem with labeling food in nourishment room refrigerators.

Based on observation, record review, and interview, the facility failed to protect the privacy of the residents' personal information on 1 (Harbor middle cart) of 5 medications carts observed. The findings included: On 7/24/18 at 4:46 a.m., an observation of the Harbor unit middle cart revealed an empty blister pack of medication lying face up on the top of the medication cart. There was no staff observed anywhere in the hallway. The blister pack clearly displayed the resident's name, the medication name and dosage, and the resident's diagnosis. During an interview on 7/24/18 at 5:56 a.m., the Licensed Practical Nurse (LPN) Staff A assigned to Harbor unit middle cart said they are supposed to cut off the label from the blister pack and put it in the shredder. LPN Staff A said no personal information about a resident should be exposed. She offered no explanation of why she had left the resident information exposed on the cart. During an interview on 7/24/18 at 6:45 a.m., the Executive Director said residents' personal information should not be exposed for the public to see. **picture**

Based on observation, record review, and staff interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies regarding safe food handling in the kitchen. Failure to implement appropriate practices of safe food handling continued the opportunity for the spread of food borne illness. The findings included: A review of the plan of correction developed under the quality assurance program found the dietary staff was in-serviced on the correct process for distribution of food including safe handling. The quality assurance (QA) plan required the Food Service Director/designee to complete random weekly audits of tray line to ensure preparation and distribution of food was done in accordance with correct food handling. The results of the audits to be discussed at the monthly QA Performance Improvement meeting for a period of three months or until substantial compliance was achieved. Sign in sheets for dietary in-service show all dietary staff attended in-service training which included: Do not use thumbs on dinner plates; Cook - Do not retrieve cold plates, etc., from refrigerators; Wash hands before tray line; All dishes and bowls should be handled from the bottom; Lips on bowls and plates should not be touched by hand. The monitoring sheets list two safe food handling issues observed: Thumbs will not touch dinner plate rim and Cook will not retrieve cold plates/refrigerator. The monitor sheet had check marks on these two indicators for each date observed. There were no documented observations of deficient practice during the monitoring event. On 1/18/18 during tray line service beginning 11:25 a.m., observed the cook's assistant dietary aide Staff H, serving food at the steam table, she left the service line to retrieve cold plates and returned to the line without washing hands. The cook's assistant was also observed touching the food surfaces of dishes with bare hands. The cook's assistant put on gloves without first washing her hands and handled food. Staff H was observed rubbing her nose and her forehead with bare hands and continue working with food without washing her hands. The quality assurance monitoring did not adequately assess compliance with safe food handling. No non-compliance was documented and no re-training implemented as part of the QA process. On 1/18/18 at 1:15 p.m., interview with the facility Administrator and the Certified Dietary Manager (CDM), the Administrator acknowledged she had not verified the QA monitoring. The Administrator said the CDM completed the monitoring sheet on the dates indicated and the dietician observed tray line operation once per month. The Administrator acknowledged the quality assurance process had not effectively verified implementation of the plan of correction.

Based on observation, record review, and staff interview, the facility failed to distribute food in a safe manner or consistency safe for all residents during 1 of 1 trayline observations. These breaches in safe food handling practice had the potential to lead to foodborne illness. The findings included: 1. On 11/15/17 during the noon meal the food was placed on the trayline between 10:30 a.m. and 11:25 a.m. Trayline service began at 11:19 a.m. The pureed oriental vegetables were brought to the tray line at a temperature of 129 degrees Fahrenheit (F), but returned to the warming oven to heat. Once heated it was returned to the trayline. The pureed oriental vegetables were observed to have the consistency of a thin soup. When served it would run freely over any unused portion of the plate. The pureed bread was observed to be runny also. At the trayline, the Nutrition Assistant was observed adding instant bread mix to the pureed bread and stirring it in. The pureed bread then obtained the consistency of lumpy oatmeal. The Nutrition Assistant then added thickening to the pureed oriental vegetables, while on the trayline, and stirred it in. The vegetables were not observed to thicken appreciably. When served they continued to run into any unused portion of the plate. The cook Staff E was observed reading the trayline ticket for a resident, take the paletted plate (warming palette to keep food warm) from the Nutrition Assistant by gripping the side of the plate and resting her bare thumb on the plate lip area, then plate the items of preference selected by each resident. The touching of each ticket and each plate continued throughout the entire trayline. Staff E was observed to break from tray line to open the refrigerator to get a salad, or prepared sandwich. Staff E continued the trayline each time without washing her hands. The cook Staff E was observed to obtain bowls for various food items which were to be served separately. She took several bowls from the rack and placed them on the steam table with the mouth of the bowl resting on the steam table surface. The cook also took the lids used for the bowls and palmed the food side of the lid. She was observed stacking the lids, food side down on the steam table surface. These lids were served throughout the trayline or return to the stack of plastic lids after the service was completed. Dietary aides Staff F and Staff G were observed picking the plate cover up by gripping the side and the inside of the cover then covering the plates. This continued throughout the trayline. At 12:19 p.m., the dietary aide Staff G was observed to add the broccoli from a pan on the stove to the small amount of broccoli remaining in the pan on the steam table and stirred the vegetables. The cook was observed to put on the oven mitts and change out the meatballs, and rice. Without washing her hands she returned to plating food. She was observed to take the warmed plate by the side and place her thumb on the plate lip and touch the eating area. This continued for all the dining room service. Observation of the trayline found no temperatures were being taken by midpoint to ensure the holding temperatures of the food items. Temperatures were only taken before the trayline began and as food items were replaced. At the end of the trayline at 12:38 p.m., by surveyor request, the temperatures of the remaining food items were taken. The mechanical meat was 124 degrees F. The pureed bread was 130 degrees F. The pureed oriental vegetables were 122 degrees F. The steam table did not maintain these food items at or above the steam table safe holding temperature of 135 degrees F. 2. On 11/15/17 at 12:24 p.m., observation of the noon meal on the second floor main dining room revealed residents being served a puree diet had food that was not formed and/or not completely blended. The plates also had excessive amounts of standing brownish liquid on them. Resident #180, #85, #113, #81, and #64's meal tickets indicated the residents required puree diets with thickened liquids. Resident #113 was being assisted by Certified Nursing Assistant Staff B. The resident had standing pools of liquid on her plate. At 12:30 p.m., Staff B said the kitchen had given the resident's a ton of sauce and was too liquidly, especially for residents on thickened liquids. Resident #57 was observed to have a desert in a form of chopped pineapple and was not blended. The resident's pureed bread had chunks of unblended food and was not a mashed potato consistency. The resident's meal ticket indicated the resident was to have a puree meal. On 11/16/17 at 9:25 a.m., the Food Service Director (FSD), the Executive Director and the Speech Therapist said the consistency of the pureed bread and oriental vegetables was discussed. The Speech Therapist agreed the consistency would not meet the needs of persons on honey thicken and possibly not for nectar thicken either. The FSD said the cook had always handled the food tickets during the trayline. He said the tickets were printed the day before and placed in a slotted box separated for breakfast, lunch and diner and taken to the line to be used. He had not considered the tickets could not be sanitary.

Based on observation, record review, and staff interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies regarding safe food handling in the kitchen. Failure to implement appropriate practices of safe food handling continued the opportunity for the spread of food borne illness. The findings included: A review of the plan of correction developed under the quality assurance program found the dietary staff was in-serviced on the correct process for distribution of food including safe handling. The quality assurance (QA) plan required the Food Service Director/designee to complete random weekly audits of tray line to ensure preparation and distribution of food was done in accordance with correct food handling. The results of the audits to be discussed at the monthly QA Performance Improvement meeting for a period of three months or until substantial compliance was achieved. Sign in sheets for dietary in-service show all dietary staff attended in-service training which included: Do not use thumbs on dinner plates; Cook - Do not retrieve cold plates, etc., from refrigerators; Wash hands before tray line; All dishes and bowls should be handled from the bottom; Lips on bowls and plates should not be touched by hand. The monitoring sheets list two safe food handling issues observed: Thumbs will not touch dinner plate rim and Cook will not retrieve cold plates/refrigerator. The monitor sheet had check marks on these two indicators for each date observed. There were no documented observations of deficient practice during the monitoring event. On 1/18/18 during tray line service beginning 11:25 a.m., observed the cook's assistant dietary aide Staff H, serving food at the steam table, she left the service line to retrieve cold plates and returned to the line without washing hands. The cook's assistant was also observed touching the food surfaces of dishes with bare hands. The cook's assistant put on gloves without first washing her hands and handled food. Staff H was observed rubbing her nose and her forehead with bare hands and continue working with food without washing her hands. The quality assurance monitoring did not adequately assess compliance with safe food handling. No non-compliance was documented and no re-training implemented as part of the QA process. On 1/18/18 at 1:15 p.m., interview with the facility Administrator and the Certified Dietary Manager (CDM), the Administrator acknowledged she had not verified the QA monitoring. The Administrator said the CDM completed the monitoring sheet on the dates indicated and the dietician observed tray line operation once per month. The Administrator acknowledged the quality assurance process had not effectively verified implementation of the plan of correction.

Based on observation, record review, and staff interview, the facility failed to prepare and serve food in accordance with identified resident needs for a therapeutic diet for 6 (Residents #180, #85, #64, #113, #81, and #57) of 10 residents observed receiving a puree meal. The findings included: The facility's policy for Puree Diet; Chapter 1: Types of Diets, Food and Nutrition Services; indicated the diet was to provide foods with a semi-liquid to semi-solid consistency (i.e., applesauce to mashed potatoes). The policy for Thickened Liquids indicated for Nectar: easily pourable and comparable to thicker cream soups and for Honey: slightly thicker, less pourable, and drizzles from a cup or bowl. On 11/15/17 at 12:24 p.m., observation of the noon meal in the second floor main dining room revealed the following: 1. Residents being served a puree diet had food that was not formed and/or not completely blended. The plates also had excessive amounts of standing brownish liquid on them. 2. Resident #180, #85, and #64's meal tickets indicated the residents required puree diets with thickened liquids. Record review revealed Resident #180 required a puree diet and nectar thickened liquids for dysphagia (difficulty swallowing); Resident #85 required a puree diet and honey thickened liquids for dysphagia; and Resident #64 required a puree diet and nectar thickened liquids for dysphagia. 3. Resident #113 was being assisted to eat a pureed meal by Certified Nursing Assistant (CNA) Staff B. The resident had standing pools of liquid on her plate. At 12:30 p.m., Staff B said the kitchen had given the resident's a ton of sauce and was too liquidly, especially for residents on thickened liquids. Resident #113's record revealed the resident required a puree diet and honey thickened liquids for dysphagia. 4. Resident #81 was being assisted to eat a puree meal by CNA Staff C. The resident's plate had pools of brown liquid which the CNA identified as the sauce for the pureed meat. At 12:35 p.m., Licensed Practical Nurse Staff A who was seated nearby said when the meal has too much liquid on the plate and the resident was on thickened liquids, she poured the excess off the plate. Resident #81's record revealed the resident required a puree diet and honey thickened liquids for dysphagia. 5. Resident #57 was observed to have a desert in a form of chopped pineapple and was not blended. The resident's pureed bread had chunks of unblended food and was not a mashed potato consistency. Resident #57's record revealed the resident required a puree diet due to dysphagia. 6. On 11/16/17 at 9:25 a.m., the Food Service Director (FSD), the Executive Director and the Speech Therapist said the consistency of the pureed bread and oriental vegetables (brown liquid on the pureed plates) was reviewed. The Speech Therapist agreed the consistency would not be in a form to meet the need of residents on honey thickened liquids and also possibly for nectar thickened as well. The FSD confirmed the desert served to Resident #57 was not puree and should have been blended. **Photos on file**

Based on observation and interview the facility failed to provide sufficient staffing for 6 residents, (Resident #144, #119, #178, #307, #164, and #124 ) of 24 sampled residents plus one random resident (Resident #120) interviewed regarding waiting long periods of time for activities of daily living care and incontinence care. Findings include: 1. On 9/21/15 at 9:25 a.m., Resident #144 was observed in the bed in a hospital gown. During an interview with the resident she said she had no choice on when she got up in the morning. Resident #144 said she had to wait in the morning for a long time before she received assistance in getting out of bed. On 9/22/15 at 9:14 a.m., Resident #144 was observed in the bed with her breakfast tray in front of her and in a hospital gown. At that time resident #144 said, See, I told you I have to wait a long time. She was asked how long she had been waiting. She said, I wanted to get up an hour ago. At this time the resident was instructed to put her call light on and ask staff for assistance. The light was observed to come on and go off within a few minutes. On 9/22/15 at 9:30 a.m., Resident #144 was observed still unattended and said staff had answered her call light and told her they would be back. On 9/22/15 at 9:51 a.m., the resident was observed still in her bed unattended and the resident was observed crying at this time and saying, This happens all the time. On 9/22/15 at 10:40 a.m., the resident was still in the bed unattended. Staff was observed coming down the hall at this time to assist the resident. On 9/22/15 at 11:05 a.m., Resident #144 was observed dressed appropriately and being pushed by staff in her wheel chair to the 2nd floor nursing station. The Assistant Director of Nursing (ADON) verified Resident #144 had put her light on at 9:14 a.m., and requested staff to get her out of bed. The resident was observed to be visibly upset. On 9/22/15 at 11:15 a.m., Staff G, Certified Nursing Assistant (CNA) said her assignment had been changed and she was not aware Resident #144 was assigned to her until 9:00 a.m. She was feeding a resident until 9:30 a.m. Staff G said during meal times there are only two CNA's on the floor. Both of the CNA's on the floor are assisting residents in being feed. Staff G said she had not seen Resident #144's call light come on. Staff G said the nurses assist residents in the dining room but never help in answering call lights on the floor. Staff G said last Saturday she heard Resident #144 was banging her hand on the bedside table and was upset because the CNA assigned to her had not gotten her out of bed. Staff G verified she had not checked on Resident #144 after finding out her assignment had been changed. Staff G had gone on break at 10:30 a.m. 2. On 9/22/15 at 1:16 p.m., room [ROOM NUMBER]'s call light was observed to come on and at 1:17 p.m., the call light was answered. On 9/22/15 at 1:19 p.m., the call light in room [ROOM NUMBER] was observed to come on. The call light was answered at 1:22 p.m. On 9/22/15 at 1:24 p.m., the call light in room [ROOM NUMBER] was observed to come on again and was answered in seconds after coming on. On 9/22/15 at 1:29 p.m., Resident #119 was observed in a wheel chair next to her bed. She was asked about her call light coming on several times. Resident #119 said she has been calling for assistance from staff since 1:00 p.m., because she wanted to be changed. She said staff are coming in and turning her light off and telling her they will get her aide. On 9/22/15 at 1:40 p.m., staff was observed assisting Resident #119. On 9/23/15 at 9:40 a.m., an interview was conducted with Staff H, CNA. Staff H verified she had been assigned to Resident #119 on 9/22/15. Staff H said on 9/22/15 she had gone to the 2nd floor dining room to assist residents in eating lunch at 1:00 p.m. She said she finished feeding residents at 1:30 p.m., and a staff member told her Resident #119 needed assistance. She said Resident #119 is a two person assist and uses a standing lift to transfer. She said during meal times, there are only two CNA's on the floor to assist residents due to the amount of staff needed to assist residents in dining room. Staff H said after lunch everybody wants assistance at the same time. She said there needs to be more staff on the floor. 3. On 9/22/15 at 9:15 a.m., Resident #178 was observed in a wheelchair sitting next to his bed. The resident said he had told staff he needed to go to the bathroom and he had been waiting a long time. Staff L, Licensed Practical Nurse, was observed next to the medication cart outside of Resident #178's door. He said he was trying to get a staff member to assist him at this time. Several staff members were observed in the dining room at this time assisting residents with breakfast. On 9/22/15 at 9:30 a.m., Resident #178 was observed receiving assistance from staff to go to the bathroom. On 9/22/15 at 10:05 a.m., Resident #178 said he was unable to go to the bathroom because he had waited too long and lost the urge to go. On 9/22/15 at 1:25 p.m., Resident #178 was observed saying he needed to go to the bathroom. The resident said staff are bringing residents into the dining room and they would not assist him until they were through in the dining room. On 9/23/15 at 11:15 a.m., during an interview with Staff G, CNA she said Resident #178's family members have complained numerous times about the resident having to wait a long time. On 9/23/15 at 1:47 p.m., Resident #178's daughter-in-law said she had not made a formal complaint but she had told staff during Resident #178's care plan meeting about the resident waiting for long periods. She said the resident suffers from constipation and hemorrhoids and it is important for him not to wait. She said she observed Resident #178 wait for 45 minutes to be taken to the bathroom last Saturday. She said the problem occurs when all hands are on deck for feeding times. She said there are sometimes less staff on the weekends. Review of progress notes for Resident #178's last two care plan meetings shows the resident's daughter-in-law was involved in the meeting on 8/26/15. There was no documentation noted of the daughter-in-law telling staff of the resident waiting for long periods to go to the bathroom. On 9/24/15 at 9:00 a.m., Staff J, Minimum Data Set (MDS) Coordinator verified Resident #178's daughter-in-law had told staff the resident was waiting long periods of time to go to the bathroom during the care plan meeting on 8/26/15. She said she would look for documentation. On 9/24/15 at 9:15 a.m., Staff J said she had not been able to find documentation. She said she had failed to document this because this was a frequent complaint of the family. On 9/24/15 at 10:00 a.m., the Social Services Director (SSD) said she did not remember the resident's daughter-in-law complaining during the 8/26/15 care plan meeting. She said the resident's wife had complained in the past and she thought staff had been on top of this by obtaining assistance for the resident when he asked. The SSD verified there was an issue with residents having to wait during meal times for staff to finish before they receive assistance. 4. On 9/22/15 at 12:53 p.m., Resident #307 said she sometimes had to wait a long time for staff to assist her. She said this occurs more frequently on the weekends. Resident #307 said last Sunday staff forgot about her. It got so late, a nurse came in and asked her what was she doing still up. She said a male CNA had answered her call light and told her he had 10 residents, he did not have time to put her to bed. On 9/22/15 at 11:15 a.m., Staff G said there are not enough staff to assist resident's on the weekend. Staff G said the nursing staff had reported this to the weekend supervisor. On 9/22/15 at 2:00 p.m., the Weekend Nursing Supervisor said staff had asked for assistance in feeding residents two weekends ago. She said this happens occasionally. She said she would provide additional staff to the 2nd floor dining room when staff ask. She verified there are times when there were two CNA's on the floor and they both were feeding residents. She said there are three nurses on the floor that can answer call lights. She said nurses would rotate in and out of the dining room to provide care to the residents on the floor. On 9/23/15 at 4:00 p.m., during an interview with Staff K, CNA, he verified he was the staff who had was careing for Resident #307 on Sunday night. He verified he had 10 residents. He denied he had told the resident he had 10 residents and could not assist her. He said there were three CNA's on the floor at the start of the shift. He said the weekend supervisor had taken two staff off the floor. He did not know where the staff had gone. He said he answered Resident #307's light and told her that her aide was busy and she would be right with her. He said the reason the resident was not put to bed is because it was so hectic. You kind of have to choose your battles. 5. On 9/22/15 at 9:25 a.m., Resident #164 said she thinks staff are overstressed. She thinks there are times when residents need immediate attention and there is not enough staff. 6. On 9/21/15 at 11:05 a.m., Resident #120 said she did not feel there was enough staff. She said she had to wait a long time for staff all the time. 7. On 9/22/15 at 10:22 a.m., Resident #124 said there was not enough staff to assist residents on the weekends.

Based on record review and interview the facility failed to ensure 2 (Resident #154 & #195) of 5 residents reviewed for unnecessary medications had appropriate indication for the use of as needed medications. This has the potential for residents to be adversely effected by [MEDICAL CONDITION] medications without appropriate indication for use or without attempting to use non-pharmacological intervention to address behaviors. The findings included: Record review for Resident # 154 found on her annual Minimum Data Set ((MDS) dated [DATE] she had a Brief Interview for Mental Status (BIMS) score of 4. (A score of 0 - 7 means a resident is severely impaired). Resident #154 would not be aware of when a medication was required and understand the purpose for taking the medication. Record review for Resident #154 found a physician's orders [REDACTED]. The Controlled Drug Use Record for this mediation documented Resident #154 received this medication 9 times from 9/1/15 through 9/20/15. The medication was given once each day on 9/1/15, 9/2/15, 9/4/15, 9/8/15, 9/10/15, 9/13/15, 9/14/15, 9/18/15 and 9/20/15. On 9/21/15 Resident #154's September, 2015 PRN Administration Record for [MEDICATION NAME] 0.25 mg documented the medication was given on 9/1/15, 9/2/15, 9/4/15, 9/8/15, 9/9/15, 9/14/15, and 9/18/15. The PRN Administration Record does not document this medication was given on 9/10/15, 9/13/15 or 9/20/15. Resident #154's record also included a Behavior/Intervention Monthly Flow Record for September 2015. This record noted it was for the psychoactive drug [MEDICATION NAME] ([MEDICATION NAME]). The [DIAGNOSES REDACTED]. The behavior that was being monitored was agitation. Record review on 9/21/15 the flow sheet documented the resident had episodes of agitation on 9/1/15, 9/10/15, 9/13/15, 9/14/15 and 9/18/15. The Progress Note Review for Resident #154 from 9/1/15 through 9/23/15 had no documentation of any episodes of anxiety/agitation. On 9/23/15 at 9:35 a.m., the Director of Nursing said that it appeared Resident #154 received [MEDICATION NAME] 0.25 on 9/2/15, 9/4/15, 9/8/15 and 9/20/15. There was no documentation that any non-pharmacological interventions were attempted to address Resident #154's behavior prior to the administration of the [MEDICATION NAME] 0.25 mg. On 9/23/15 at 9:40 a.m., the Assistant Director of Nursing (ADON) said the progress note did not document why [MEDICATION NAME] 0.25 mg was given to Resident #154 on 9/20/15. 2. Review of Resident #195's Medication Administration Record [REDACTED]. Review of Resident #195's Controlled Drug Use Record documented she was administered [MEDICATION NAME] 0.5mg 1 tablet by mouth PRN every 6 hours for agitation on the following days: 6/1/15, 6/2/15, 6/4/15, 6/6/15, 6/9/15, 6/10/15, 6/12/15, 6/15/15, 6/18/15, 7/2/15, 7/11/15, 7/12/15, 7/14/15, 7/30/15, 8/1/15 and 8/31/15. Review of Resident #195's Behavior Monitoring Flow Sheet documented her as not having displayed any increased agitation/anxiety on: 6/9/15, 6/10/15, 6/18/15, 7/11/15, 7/14/15, and 7/30/15. On 9/24/15 at 9:30 a.m., the ADON explained after checking the resident's paper chart and electronic chart, no documentation was found of behavior's warrenting administration of [MEDICATION NAME] 0.5 mg., on 6/9/15, 6/10/15, 6/18/15, 7/11/15, 7/14/15, 7/30/15 or 8/1/15. She said the nurses should have documented the resident's behaviors on the flow sheet. Review of the Care Plan identified mood and behaviors with a goal of demonstrating an improved mood. No documentation to administer [MEDICATION NAME] as needed was found. Resident #195 was administered [MEDICATION NAME] 0.5 mg for increased agitation/anxiety and the nursing staff failed to document behavior's to warrant the PRN medication. The ADON confirmed there was no evidence of increased agitation or anxiety on 6/9/15, 6/10/15, 6/18/15, 7/11/15, 7/14/15, 7/30/15 or 8/1/15. She confirmed the nurses failed to document on the Medication Administration Record [REDACTED].

Based on record review and interview the facility failed to complete a comprehensive care plan for residents who use [MEDICAL CONDITION] medications as needed (PRN) to manage behaviors for 1 (Resident #154) of 5 residents reviewed for unnecessary medications. This has the potential for residents who display episodes of behavior to be adversely affected by the use of [MEDICAL CONDITION] medications without appropriate indication for use. A Care Plan for management of behaviors should outline specific non-pharmacological intervention to be used prior to the administration of medications. Findings included: Record review for Resident # 154 found a annual Minimum Data Set ((MDS) dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 4. (A score of 0 - 7 means a resident is severely impaired). Resident #154 would have limited ability to be aware of when a medication is required and to understand the purpose for taking the medication. Record review for Resident #154 found a physician's orders [REDACTED]. The Controlled Drug Use Record for this mediation has documentation Resident #154 received this medication 9 times from 9/1/15 through 9/20/15. The medication was given once each day on 9/1/15, 9/2/15, 9/4/15, 9/8/15, 9/10/15, 9/13/15, 9/14/15, 9/18/15 and 9/20/15. On 9/21/15 Resident #154's September 2015 PRN Administration Record for [MEDICATION NAME] 0.25 mg documented the medication was given on 9/1/15, 9/2/15, 9/4/15, 9/8/15, 9/10/15, 9/13/15, 9/14/15, and 9/18/15. Resident #154's record also included a Behavior/Intervention Monthly Flow Record for September, 2015. This record noted it was for the psychoactive drug [MEDICATION NAME] ([MEDICATION NAME]). The [DIAGNOSES REDACTED]. The behavior that was being monitored was agitation. On 9/21/15 this flow sheet documented the resident had episodes of agitation on 9/1/15, 9/10/15, 9/13/15, 9/14/15 and 9/18/15. It noted on each of these days the resident was redirected, given 1 on 1 attention and then medicated. These interventions are general interventions listed on the standardized form used by the facility. Record review for Resident #154 found no Care Plan specifically addressing the behavior of anxiety/agitation. The record has a Care Plan for Moods which said the resident was at risk for behaviors. It did not identify the behavior of anxiety/agitation. It did not address interventions to manage the resident's anxiety/aggression including the administration of [MEDICATION NAME] medications. It did not include any non-pharmacological intervention to be used prior to the administration of medications. On 9/23/15 at 9:35 a.m., the Director of Nursing (DON) said that it appeared Resident #154 received [MEDICATION NAME] 0.25 mg on 9/2/15, 9/4/15, 9/8/15 and 9/20/15. There was no documentation that any non-pharmacological interventions were attempted to address Resident #154's behavior prior to the administration of the [MEDICATION NAME] 0.25 mg. The DON said it is the facility's practice to attempt 2 non-pharmacological interventions prior to the administration of PRN medication. She said that the intervention listed on the behavioral tracking form which included redirect and 1 on 1 attention are generalized interventions. They did not reflect specific intervention identified by the Inter Disciplinary Team as effective interventions to manage Resident #154's behavior of anxiety/agitation. The DON said there was no care plan initiated specifically addressing Resident #154's behavior of anxiety/agitation. Review of the Care Plan for Resident #195 identified mood and behaviors with a goal of demonstrating an improved mood. The Care Plan did not address increased agitation and anxiety were added 9/22/15 to the etiologies and the following interventions were added: offer fluids and/or snacks as needed; provide redirection as needed; provide 1:1 as needed and medicate with prn medication as ordered.