Every finding on record at Manor at Blue Water Bay, The

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the interdisciplinary team (IDT) assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 16 sampled residents to self-administer medications. (Resident #30) The findings include: An observation of Resident #30 was conducted on 4/20/2026 at 12:51 PM. A medication cup containing several pills was observed to be sitting on her overbed table in her room. (Photographic evidence obtained.) During the observation, Resident #30 stated she thought she was asleep when the nurse brought the medications in her room. A review of Resident #30's electronic medical record revealed a self-administration of medication observation form dated 2/7/26, indicating the resident did not wish to self-administer medications, it was not appropriate for resident to self-administer any medications, and the resident had a history of dementia. The record revealed no care plan or current physician order for self-administration of medications. An interview was conducted with Employee A (Licensed Practical Nurse) on 4/20/26 at 12:59 PM. Employee A stated she gave the cup of medications to Resident #30 and did not observe her take the medications. Review of the undated facility clinical guidelines for Self-Administration of Medication revealed, .if a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a Self-Administration of Medication Evaluation. The nurse will interview the resident to determine their ability to identify, prepare, and administer medications. The nurse will obtain a physician's order for each resident conducting self-administration of medications. The nurse to educate the resident regarding reaction and side effects of the medication. Nurses will evaluate compliance of self-administration and record self-administered medications as indicated.

Based on observations, interviews and facility policy review, the facility failed to ensure staff adhered to the appropriate hand hygiene and infection control procedures to prevent cross contamination of wounds for 1 of 1 resident observed for wound care (Resident #5). The findings include: On 10/19/22 at approximately 12:15 PM, Staff A, Registered Nurse (RN), was observed performing wound care to Resident #5. The RN was observed performing hand hygiene, applying gloves, creating a barrier, and setting up wound care supplies. The RN proceeded to assist the resident into the side lying position with the assistance of Staff B, Licensed Practical Nurse (LPN). The RN did not change gloves or perform hand hygiene and proceeded to remove the soiled dressing. The RN proceeded to cleanse the wound without changing gloves and performing hand hygiene. The RN proceeded to apply the clean dressing then applied Silvadene Cream (a medication used for burns and excoriated skin) to the skin surrounding the dressing without changing gloves or performing hand hygiene. After completing care, the RN removed the gloves and performed hand hygiene. On 10/19/22 at approximately 12:31 PM, an interview was conducted with Staff A, RN. When questioned if she performed hand hygiene and changed gloves in between removing the soiled dressing and cleaning the wound; cleaning the wound and applying the clean dressing; or prior to applying cream to the surrounding tissue, Staff A replied, No I did not. On 10/19/22 at approximately 12:47 PM, an interview was conducted with the Administrator who stated that it was his expectation that the nurse follow the policy and procedures for wound care. On 10/19/22 at approximately 1:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that it was of course her expectation that the nurse follow the policy and procedures for wound care. Review of the policy and procedure Titled Wound Care last revised October 2010 was conducted which revealed under subsection Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Further review of the section Steps in the Procedure revealed the following: 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . A review of the Centers for Disease Control and Prevention's (CDC's) webpage on Hand Hygiene in Healthcare Settings was conducted. According to the CDC's Hand Hygiene Guidance located at https://www.cdc.gov/handhygiene/providers/guideline.html and last reviewed on 1/30/20, healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Before moving from work on a soiled body site to a clean body site on the same patient.

Based on observations, staff interview, resident record review, and review of manufacturer instructions, the facility failed to implement the plan of care for 1 of 4 residents (#50) sampled for falls and failed to develop a care plan for 1 of 2 residents sampled for range of motion (#35). The findings include: Resident #50: A view of Resident #50's orders revealed an order, dated 6/12/2019, which stated, Call light alert pad to bed due to decreased safety awareness. Review of Resident #50's care plan, initiated 9/25/2018, revealed that under the section of the care plan related to falls risk there was an intervention for, Call light alert pad to bed. On 7/23/19 at 2:51 PM an observation was made of Resident #50. The fall alarm was attached to the bed. The bed alarm did not appear to be operational. There were no lights blinking on the machine. On 7/23/19 at 3:13 PM an observation was made of Resident #50 along with another surveyor. At that time, no lights were observed to be blinking on the machine. Certified Nursing Assistant F (CNA F) and CNA G were asked to enter the room and explain the machine. CNA F stated that they checked to make sure the unit was working every two hours with rounds. They were asked to reposition the resident to see if it was working. CNA F was asked to trigger the alarm from the pressure pad and was unable to do so. CNA F agreed that there were no lights blinking on the machine to indicate that it was operational. When the CNA pulled the mat from under the resident the surveyor noticed that there were instructions printed on it. The instructions stated that there would be a blinking light to indicate that the machine was operational. This was pointed out to both of the CNAs in the room. The next day, on 7/24/19 at 9:33 AM, an observation was made of Resident #50. At that time the alarm still had no lights blinking to indicate that it was working. On 7/25/19 at 4:46 AM an interview and observation was conducted with CNA H. At that time she confirmed that the bed alarm was not blinking and said this indicated that the machine needed a new battery. On 7/25/19 at 2:12 PM an observation was made of Resident #50. The machine was then blinking to indicate that it was operational. On 7/25/19 at 3:45 PM the Director of Nursing provided the manufacturer instructions for the alarm machine. The instructions stated that there would be a blinking light to indicate that the unit was operational. Resident #35 On 7/22/19 at approximately 2:30 PM, resident #35 was observed to be up in her wheelchair and her right ankle was noted to be twisted inward, no braced or other positioning device was noted. On 7/25/19 at approximately 4:00 PM a follow up observation was made of the resident in the presence of staff member N, a Physical Therapist, in which the resident was noted up in her wheelchair with a brace to her left lower extremity and the right lower extremity was resting on the foot rest of the wheelchair twisted inward. At this time staff member N stated the brace was on the wrong foot. On 7/23/19 a record review was conducted for resident #35 which revealed a physician order [REDACTED]. Review of the resident's plan of care dated 6/21/19 did not identify the presence of a boot or alignment concerns with her lower extremities. A review of the Medication Administration Record [REDACTED]. On 7/25/19 at approximately 2:07 PM an interview was conducted with staff member M, an LPN (licensed practical nurse) during which she stated that whoever gets the resident up is the one who applies the boot but that it is not documented within the electronic medical record. On 7/25/19 at approximately 2:10 PM an interview was conducted with the nursing supervisor during which she stated the boot for resident #35 was not on the MAR indicated [REDACTED].

Based on observations, staff interviews and record review, the facility failed ensure a therapy boot was consistently utilized to ensure proper alignment for 1 of 2 residents sampled for Limited Range of Motion, resident #35. Findings include: On 7/22/19 at approximately 2:30 PM, resident #35 was observed to be up in her wheelchair. Her right ankle was noted to be twisted inward, no brace or other positioning device was noted. On 7/25/19 at approximately 4:00 PM, a follow up observation was made of resident #35 in the presence of staff member N, a Physical Therapist. Resident #35 was noted up in her wheelchair with a brace to her left lower extremity and the right lower extremity was resting on the foot rest of the wheelchair twisted inward. At this time staff member N stated the brace was on the wrong foot. A review of the resident record revealed a physical therapy (PT) evaluation dated 2/18/19 in which the resident was referred to PT due to new onset of decrease in strength, functional mobility, transfers, and reduced ability to safety ambulate as well as risk for falls. The resident was discharged from therapy on 4/17/19 with order for multipodus boot on right when OOB (out of bed) to promote proper alignment and decrease foot inversion and plantar flexion. Further record review for resident #35 revealed a corresponding physician order [REDACTED]. Review of the resident's plan of care dated 6/21/19 did not identify the presence of a boot or alignment concerns with her lower extremities. A review of the resident's Medication Administration Record [REDACTED]. On 7/25/19 at approximately 2:07 PM an interview was conducted with staff member M, a licensed practical nurse, during which she stated that whoever gets the resident up is the one who applies the boot but the boot is not documented within the electronic medical record. On 7/25/19 at approximately 2:10 PM an interview was conducted with the nursing supervisor during which she stated the boot for resident #35 was not on the MAR indicated [REDACTED]. On 07/26/19 at 9:23 AM, an interview was conducted with staff member N, a physical therapist, who stated that he reassessed Resident #35 yesterday (7/25/19). He stated that the ROM and strength in her ankle was no worse than it was based on her previous assessment, and that he would be putting her on therapy services to establish a good program to improve her flexibility.

Based on observation, staff interview, family interview, clinical record review and policy review, the facility failed to ensure residents were free of significant medication errors by failing to ensure medications were administered to the correct resident for 1 of 6 residents reviewed for unnecessary medications (#30). Findings include: On 7/23/19 at approximately 9:15 AM, an observation was made of resident #30 in which he was laying in his bed sleeping with his spouse sitting at his bedside. The spouse had been interviewed on 7/22/19 and reported her husband enjoyed walking around the facility and required the use of a wander guard for his safety. At the time of this observation an interview was conducted with the spouse of resident #30 during which she stated that on the night of 7/22/19 the nurse had medicated her husband with medication intended for his roommate. She stated that the facility called her and the physician after it occurred. She stated the medications had made her husband very sleepy but he did not have to go to the hospital. She explained the nurse told her that when he came to the room with medications in a cup for the resident in B bed he found her husband (housed in A bed) on his knees by his bed. The nurse reported he had gotten stressed and after he got her husband back in bed he gave the medications to him instead of B bed as he intended. On 7/23/19 a record review was conducted for resident #30 which revealed a progress note dated 7/23/19 at 12:31 AM which stated Medication error resident received 2000 (8:00 PM) medications intended for room (room number noted) B. Review of the Medication Administration Record [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the [NAME] report provided by the Risk Manager on 7/23/19 revealed that staff member O, a nurse, reported a medication error had occurred on 7/22/19 at 9:00 PM. The report indicated that the physician was notified at 9:10 PM with orders to monitor resident for 72 hours and hold all [MEDICATION NAME] until further notice. Review of the times provided for observation of resident #33 revealed that vital signs were obtained about 5 hours prior to the incident on 7/22/19 at 3:58 PM and not again until about 5 hours after the incident on 7/23/19 at 4:08 AM. Further review of the record revealed a Progress note dated 7/23/19 prepared by the Physician's Assistant (PA) which stated the resident was sedated, had stable vitals and was alert. The PA documented she provided education to the wife. On 7/23/19 at approximately 9:30 AM, an interview was conducted with staff member B, a Licensed Practical Nurse (LPN), who stated that the night nurse, staff member O had reported the medication error to the family and the physician immediately and that he was told not to come to work until after they had completed the investigation. She further stated the Physician's Assistant (PA) reported that the medications the resident received in error would dissipate and that the staff should monitor the resident so they put him on 72 hour neuro checks. She reported the PA did not feel they needed to send the resident out of the facility to be evaluated at the emergency room . At this time a review of the physician orders found initiate 72 hour for medications error assessment dated [DATE] at 12:53 AM. On 07/25/19 at 12:06 PM, an interview was conducted with the Director of Nursing (DON) who reported that the nurse involved in the incident had been suspended pending investigation. She reported the nurse pulled medications from the medication cart for bed B and after entering the residents room found the resident from bed A on the floor. At this time he placed the medications on the tray table and assisted the resident back to bed and left the room to call the physician and the residents spouse. The CNA entered the room found the medications on the tray table and brought them to the nurse who returned to the room and gave them to the resident in bed A as opposed to the intended resident in bed B. She then stated she had concluded the incident was isolated and did not require further investigation. On 07/25/19 at approximately 12:15 PM, an interview was conducted with the physician during which he stated he was notified of the medication error the night it occurred however did not feel based on the medications that were given that they needed to do more than monitor the resident and not to give the ordered [MEDICATION NAME]. On 07/25/19 at approximately 12:17 PM, an interview was conducted with the Physician's Assistant during which she stated that she had been notified the following morning of the incident. She stated she reviewed the medications that were given and that resident #30 had received two medications that were not prescribed to him which included [MEDICATION NAME] 10, a narcotic and lorazpam 1 mg a sedative used to treat anxiety, by the time she saw him he was awake and his normal self. She reported his wife was present during the exam and was aware of the error. Review of the facility policy Administering Medications states that under item #6. the individual administering medications must verify the resident's identify before giving the resident his/her medications. Item #7 The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication and item #23 Medication ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services.

Based on observation, interview, and policy review, the facility failed to store drugs in a locked compartment on one of six medication carts. The findings included: On 7/25/19 at approximately 6:49 AM, an observation was made of three blister packs for medications left on top of a medication cart unattended in the 300 hallway. Staff A, a licensed practical nurse (LPN), was observed coming out of room [ROOM NUMBER] and interviewed at approximately 6:50AM. Staff A confirmed that the medications should have been locked in the cart and that they were left unattended. Further observation revealed that two of the blister packs were empty, and one contained several pills of the medication Ropinirole 0.25mg tablets (photo evidence obtained). The medication was labeled for a resident who resided in the 400 hall. Staff A stated, I know that should have been locked up, that was an honest mistake. No residents were observed in the hallway at the time of the observation. A review of the facility's Administering Medications Policy with a most recent revision date of (MONTH) 2012 indicated on page 2, paragraph #16 no medications are kept on top of the cart.

Based on record review and interview, the facility failed to ensure that the medical record for 1 of 6 sampled residents (#10) was maintained in accordance with accepted standards of practice by failing to ensure the resident's physician order [REDACTED]. The findings include: Record review for sampled resident #10 revealed a physician order [REDACTED]. Review of the (MONTH) (YEAR) medication administration record (MAR) for resident #10 revealed there was documentation to stop this medication on 8/30/2018. Review of the physician's orders [REDACTED]. On 09/13/18 at approximately 09:00 AM an interview was conducted with the facility director of nurses (DON), who explained the process for preparing the monthly routine physician orders [REDACTED]. She revealed the pharmacy prepared the monthly physician order [REDACTED]. Once received, the facility had assigned nurses who reviewed them for accuracy and to reconcile with any new physician orders. These nurses would then make any changes necessary and ensure needed corrections were communicated back to the pharmacy. On 09/13/18 at approximately 09:04 AM an interview was conducted with the two nurses (sampled staff A and B) responsible for monthly reconciliation of the physician order [REDACTED]. Staff A revealed that about 3-5 days before the end of each month they received the next month's physician order [REDACTED]. She confirmed that they reviewed each resident's POS and MAR to ensure accuracy, and stated if a medication needed to be discontinued, they would mark it discontinued on the POS and MAR and return a copy to the pharmacy to make them aware of the changes. Sampled staff A stated she reviewed the (MONTH) POS and MAR for sampled resident #10. When shown [MEDICATION NAME] order, she revealed the order on the (MONTH) POS and MAR for the [MEDICATION NAME] should have been discontinued on 08/30/18 and should not have been on the (MONTH) paperwork for the resident. She stated she must have missed that order in her review, but stated the pharmacy should have also removed it because the date on the physician order, written 7/30/18, was to discontinue the medication within 30 days, which would have been 08/30/18. On 09/13/18 at approximately 09:46 AM, a telephone interview was conducted with the facility's consultant pharmacist. She explained that normally the pharmacy places a discontinue date on the orders so that nursing and pharmacy both know when the medication should be discontinued and no longer on the next months physician orders [REDACTED].#10.

Based on observation, record review and interview, the facility failed to implement care planned fall interventions (personal alarm) for 1 of 16 sampled residents (#312). The findings are: Record review for sampled resident #312 revealed he was admitted to the nursing home on 5/23/2017 after hip surgery due to a fall in which he suffered a [MEDICAL CONDITION]. Resident #312 had a physician's orders [REDACTED]. A tab alarm features a pull string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed, the pull string magnet is pulled away from the alarm causing the alarm to sound, and alerting the staff. Review of the fall care plan for resident #312 revealed an intervention for the use of a personal bed alarm and personal chair alarm. Observation on 6/22/17 at approximately 8:30AM revealed sampled resident #312 fully dressed and lying on his bed. The personal tab alarm was hanging on the back of the resident's wheelchair and there was no observation of a personal alarm in use while the resident was in the bed. At the time of this observation, unit supervisor staff C, confirmed there was no TABS/personal alarm attached to the resident while he was in the bed. Interview on 6/22/17 at 8:53AM with sampled staff D, the resident's nurse, revealed that the resident required assistance for transferring and walking and suffered a fall on 6/5/17 at which time they implemented the intervention of the use of a TABS/personal alarm while in the wheelchair or in the bed. Observation of the resident on 6/22/17 at approximately 8:58AM with sampled staff D continued to reveal the resident in his bed with no personal alarm in use. She confirmed the staff should have attached the personal alarm to the resident while he was in his bed. Continued review of the resident's record revealed a physician's orders [REDACTED]. On 06/22/2017 at approximately 1:09 PM an observation revealed the resident self propelling in his wheelchair down the hallway without staff assistance. There was no TABS/personal alarm attached to the resident at the time of this observation. On 06/22/2017 at 1:11 PM a subsequent observation was conducted of resident #312 with sampled staff D. The resident was observed in his room and still sitting in his wheelchair. The resident's personal alarm was attached to his bed and not attached to him while he was in his wheelchair. Interview with sampled staff D at that time confirmed this observation. Staff D stated the personal alarm should have been placed on the resident, and she stated she would put in in place and reeducate her staff as to the personal alarm use for resident #312.

Based on observation, staff interview and record review, it was determined the facility failed to ensure 1 of 3 sampled residents (#312) reviewed for accidents received ordered assistive devices to help prevent accidents. The findings are: Record review for sampled resident #312 revealed he was admitted to the nursing home on 5/23/2017 after hip surgery due to a fall in which he suffered a hip fracture. Resident #312 had a physician's orders [REDACTED]. A tab alarm features a pull string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed, the pull string magnet is pulled away from the alarm causing the alarm to sound, and alerting the staff. Review of the fall care plan for resident #312 revealed an intervention for the use of a personal bed alarm and personal chair alarm. Observation on 6/22/17 at approximately 8:30AM revealed sampled resident #312 fully dressed and lying on his bed. The personal tab alarm was hanging on the back of the resident's wheelchair and there was no observation of a personal alarm in use while the resident was in the bed. At the time of this observation, unit supervisor staff C, confirmed there was no TABS/personal alarm attached to the resident while he was in the bed. Interview on 6/22/17 at 8:53AM with sampled staff D, the resident's nurse, revealed that the resident required assistance for transferring and walking and suffered a fall on 6/5/17 at which time they implemented the intervention of the use of a TABS/personal alarm while in the wheelchair or in the bed. Observation of the resident on 6/22/17 at approximately 8:58AM with sampled staff D continued to reveal the resident in his bed with no personal alarm in use. She confirmed the staff should have attached the personal alarm to the resident while he was in his bed. Continued review of the resident's record revealed a physician's orders [REDACTED]. On 06/22/2017 at approximately 1:09 PM an observation revealed the resident self propelling in his wheelchair down the hallway without staff assistance. There was no TABS/personal alarm attached to the resident at the time of this observation. On 06/22/2017 at 1:11 PM a subsequent observation was conducted of resident #312 with sampled staff D. The resident was observed in his room and still sitting in his wheelchair. The resident's personal alarm was attached to his bed and not attached to him while he was in his wheelchair. Interview with sampled staff D at that time confirmed this observation. Staff D stated the personal alarm should have been placed on the resident, and she stated she would put in in place and reeducate her staff as to the personal alarm use for resident #312.

Based on observations, staff interviews and review of facility policy and procedure, the facility failed to store food under sanitary conditions in the kitchen and failed to serve food under sanitary conditions in one of three dining rooms (main dining room). This had the potential to affect 98 of 102 residents who eat orally. The findings are: Initial inspection of the kitchen was done on 5/16/16 beginning at approximately 10:00AM. Inspection at approximately 10:15AM was done of the walk-in refrigerator with the dietary manager and staff B, the dietary cook. The dietary manager removed two tall food carts from the walk-in refrigerator. Observation of the one cart revealed a tray of marinating raw meat which was sitting directly over a tray of biscuits. The biscuits were covered with a large piece of parchment paper. At this time the dietary manager acknowledged the observation and stated the raw unwrapped meat should not be stored over the biscuits, she removed the biscuits and placed them on a higher shelf. Observation of the tray of biscuits revealed no concerns with meat juices on the tray at this time. Interview with sampled staff B at this time revealed she knew that the raw meat should not be stored over other foods due to the possibility of the raw meat dripping on the other food. Review of the facility's 'Food Safety' policy and procedure revealed the statement, store raw foods on pans on lowest shelves to prevent them from dripping or splashing on other foods. Observation of the residents' lunch meal was done in the main dining room on 05/16/2016 beginning at approximately at 12:02 PM. The main dining room had a buffet area for the residents to be served from. Observation revealed sampled staff C, dietary staff working at the tray line/buffet getting the food ready to serve. Observation revealed he was wearing gloves, he stepped away from the tray line/buffet, he opened the door leading to the kitchen with his left gloved hand, he entered the kitchen, he returned to the main dining room tray line/buffet at approximately 12:04PM with a container of food. He began preparing to check the food temperatures on the tray line/buffet. Observation revealed he cleaned the food thermometer probe with a probe pad and checked the tray of turkey. Interview with dietary staff C at this time revealed the meat was at a temperature of 140 degrees, he stated he would have to reheat the meat. Holding the tray of turkey with his right gloved hand he opened the kitchen door with his left gloved hand, handling the door knob and the door surface itself with the gloved hand. He entered the kitchen and placed the meat in the steam oven, handling the steam oven door with his gloved hand, he returned to the kitchen door, where the surveyor was standing, as he was walking toward the surveyor and the dining room he was observed to pulled up his pants and handled his shirt with both of his gloved hands. He entered back into the dining room returning to the tray line/buffet. Staff C then picked up the thermometer to test the food temperatures again, he wiped the food thermometer probe with a probe pad and he then handled the thermometer probe with his gloved right hand and went to test the mashed potatoes after touching the thermometer probe with the dirty gloved hand which had just touched the kitchen door and his clothes. He was stopped by the surveyor before he placed the dirty thermometer probe into the mashed potatoes. He confirmed he had not changed his gloves between touching the kitchen door and his clothes with his gloves. He went to the kitchen washed his hands and returned to the tray line and regloved. The surveyor continued to watch the staff prepare the food on the tray line. At approximately 12:15PM the staff C was observed to continue to prep the food on the tray line, he again was observed with gloved hands to enter the kitchen via the same door touching the door with his gloved hands, he was observed reentering the dining room with gloves remaining on, observed touching the door with his gloved hands as he entered the main dining room and handling his apron to wipe his forehead, as he was perspiring heavily, again using his gloved hands. At approximately 12:20PM he has been observed to have not changed his gloves and has not left the dining room. At this time he is observed placing pieces of unwrapped/uncovered corn bread onto individual plates, he is observed to handle the bare corn bread with the same gloves he had on to open the kitchen door earlier and handling his apron and wipe his forehead. The surveyor asked the staff if he had changed his gloves at anytime between handling the kitchen door, his clothing and the corn bread and he confirmed he had not. He removed the plated corn bread from the serving line. He regloved and preceded with the tray line. On 05/16/2016 at 12:36 PM this male staff C was observed with a full beard, he had had it completely covered with two beard covers, but at this time the one covering the lower portion of his beard was lying on his chest under his neck; it is no longer covering the beard. Observation continued of this staff as his beard cover remained off. He continued to serve the residents' lunch trays and work the buffet/tray line. At approximately 12:57PM the surveyor asked the staff to cover his beard and he said okay. This staff left the dining area reentered the kitchen at 05/16/2016 12:59 PM he returned to the dining room and his beard remained uncovered. At 1:01 PM, he began removing the food trays from the serving line and returning the food to the kitchen. The lower portion of his full beard remained uncovered with the cover around his neck. Interview on 5/18/16 at approximately 9:45AM with the dietary manager, sampled staff A, revealed kitchen staff are to wash their hands and change their gloves before moving from one task to another and use thongs to handle food, including bread and should keep hair and beard covered at all times. She stated the dietary staff have been re-inserviced on 5/17/16 as a result of the concerns noted on 5/16/16 during the survey. Review of the facility's policies and procedures for 'Personal Hygiene' and 'Glove Use' revealed dietary staff are to wear hair restraints including beard restraints while preparing and serving food. Gloves should be changed often. change gloves before moving from one task to another. Change gloves if they become punctured, torn or contaminated.

Based on observations, interviews and record reviews the facility staff failed to provide services in accordance with each resident's written plan of care for 2 of 17 sampled residents by failing to provides heel protectors (resident #40) and failing to provide assistance with meals (resident #24). The findings are: 1. Observations on 1/14/14 at approximately 11:07AM revealed sampled resident #40 in the activity room with other residents and she was in a reclining wheelchair with her feet dangling; she is wearing non skid gray socks only. An interview was attempted with the resident and was unsuccessful. A telephone interview was conducted with her son on 1/14/14, at approximately 11:30AM and he stated she had developed a [DIAGNOSES REDACTED] and her condition has declined severely and she no longer is able to communicate appropriately. Observations on 1/14/14 at 3:05PM revealed her sitting in a reclining wheelchair in her room her feet are supported by the chair foot rest and are placed on a pillow, no heel protectors, gray socks observed only. Observation at 4:14PM revealed no heel protectors but with gray socks and pillows under feet while sitting in wheelchair. Observations on 1/15/14 8:14AM revealed her sitting in her wheelchair next to her bed and she has gray socks on her feet which are resting on pillow on the foot rests. Interview with sampled staff E and sampled staff F, certified nurses' assistants (C.N.A.'s) for the resident on 1/15/14 at 8:58AM revealed in reference to preventing skin concerns including pressure ulcers, they assist her to reposition often, they provide support while in the chair and provide pillows between knees and legs while in bed, float the heals while in bed, she wears socks, will use the waffle boots while she is in bed at times. When asked if the resident is to wear any kind of heel protectors, any other times, sampled staff E stated no, waffle boots at times. At approximately 9:05AM sampled staff E returned to surveyor and stated she was nervous previously and miss-spoke and stated that the resident is to wear heel protectors, waffle heel protectors at all times except for when in the shower. Observation on 1/15/14 at 9:13AM, with sampled staff E and F, revealed the resident in her room in her wheelchair beside her bed, gray socks are observed on her feet placed on a pillow. They confirmed the resident does not have any type of heel protectors on her feet. Interviews with sampled staff E and sampled staff F, at this time confirmed the resident has not had her any type of heel protectors on this morning as the night shift did not put them on when they got her up this morning and she is suppose to wear them at all times except for getting a shower. The staff indicated the orange heel protectors/waffle boots which were observed lying on the resident's bed were the boots to use. Observation of incontinence care was observed and the staff applied the orange colored waffle boots to the resident's feet when finished. Interview with sampled staff G, the resident's nurse, on 1/15/14 at approximately 10:15AM revealed that the resident should wear the heel protectors at all times except for showers. She stated they off load her heels while in bed. She stated she missed that the resident did not have the heel protectors on yesterday or this morning. Record review of the resident's care plan for skin integrity related to unstageable pressure wound of the left heel revealed the intervention for the staff to use heel protectors to bilateral heels at all times, remove for showers. Record review of the physician orders [REDACTED]. 2. On 1/13/14 at approximately 2:00pm observation of sampled resident #24 revealed her lying flat in bed, cloth napkin across her chest, she is calling out asking someone to help feed her. Her tray is sitting beside her bed and is still covered she is unable to reach her tray. Observation revealed several staff has walked by the resident's room, no one responds. Observation at 2:11PM revealed the resident's eyes closed, no one has assisted her to eat, trays remain at bedside. 2:16PM resident uses the call light, sampled staff A, a Certified Nurses ' Assistant (C.N.A.), responded to the resident. When asked she stated she did not know how long the tray had been here that the resident normally eats in the assisted dining room, but did not today. The C.N.A. looked at the tray and stated the food is cold, she ordered a new tray. Interview with sampled staff B, the resident's assigned C.N.A. today, at approximately 2:27PM revealed that the resident usually goes to assisted dining, but she refused today, she stated when the resident refuses to go to the assisted dining room then they deliver a tray to her room and no one let her know the resident's tray had arrived and she does not know who delivered the tray. Interview with sampled staff C, Unit 1's registered nurse, unit manager at 2:28PM revealed that the resident must have assistance to eat. 2:34PM observation revealed sampled staff A is assisting the resident to eat a sandwich and soup. Interview with sampled staff A at approximately 2:45PM revealed the resident ate about 25%. Interview with sampled staff C, Unit 1 registered nurse, unit manager at approximately 2:45PM revealed the resident needs assistance to eat and the staff who delivered her tray should ensure that the floor staff knows that the resident has her tray so they may assist her to eat. 2:48PM interview with sampled staff D, a C.N.A., revealed that she worked in assisted dining room today and the resident was not in there, so she delivered her tray to her room at approximately 1:20PM, when asked if she told staff she had delivered the resident's tray she stated no, but she motioned to sampled staff B that the tray was in her room and thought she understood. Review of the sampled resident ' s latest quarterly Minimum Data Set (MDS) of 12/7/13 revealed that the resident requires extensive assist of one staff to eat. The resident is pleasantly confused and not interviewable. The resident, who requires extensive assistance from staff to eat, had her food from approximately 1:20PM till 2:16PM without anyone assisting her to eat. Record review of the resident's most recent nutritional care plan included the interventions the staff are to assist the resident with meals encourage meals to maximize nutritional status as much as possible.

Based on observations, interviews and record review the facility staff failed to provide appropriate assistance with meals for 1 of 1 sampled resident's (#24), who requires extensive assistance with eating. The findings are: On 1/13/14 at approximately 2:00pm observation of sampled resident #24 revealed her lying flat in bed, cloth napkin across her chest, she is calling out asking someone to help feed her. Her tray is sitting beside her bed and is still covered she is unable to reach her tray. Observation revealed several staff has walked by the resident's room, no one responds. Observation at 2:11PM revealed the resident's eyes closed, no one has assisted her to eat, trays remain at bedside. 2:16PM resident uses the call light, sampled staff A, a Certified Nurses Assistant (C.N.A.), responded to the resident. When asked she stated she did not know how long the tray had been here that the resident normally eats in the assisted dining room, but did not today. The C.N.A. looked at the tray and stated the food is cold, she ordered a new tray. Interview with sampled staff B, the resident's assigned C.N.A. today, at approximately 2:27PM revealed that the resident usually goes to assisted dining, but she refused today, she stated when the resident refuses to go to the assisted dining room then they deliver a tray to her room and no one let her know the resident's tray had arrived and she does not know who delivered the tray. Interview with sampled staff C, Unit 1's registered nurse, unit manager at 2:28PM revealed that the resident must have assistance to eat. 2:34PM observation revealed sampled staff A is assisting the resident to eat a sandwich and soup. Interview with sampled staff A at approximately 2:45PM revealed the resident ate about 25%. Interview with sampled staff C, Unit 1 registered nurse, unit manager at approximately 2:45PM revealed the resident needs assistance to eat and the staff who delivered her tray should ensure that the floor staff knows that the resident has her tray so they may assist her to eat. 2:48PM interview with sampled staff D, a C.N.A., revealed that she worked in assisted dining room today and the resident was not in there, so she delivered her tray to her room at approximately 1:20PM, when asked if she told staff she had delivered the resident's tray she stated no, but she motioned to sampled staff B that the tray was in her room and thought she understood. Review of the sampled resident's latest quarterly Minimum Data Set (MDS) of 12/7/13 revealed that the resident requires extensive assist of one staff to eat. The resident is pleasantly confused and not interviewable. The resident, who requires extensive assistance from staff to eat, had her food from approximately 1:20PM till 2:16PM without anyone assisting her to eat.

Based on interview, record review and policy review, the facility failed to ensure clinical record documentation was accurately documented as evidenced by the failure to document the administration of controlled medications for 4 of 9 residents sampled for monitoring and securing of medications. (Residents #1, #5, #6 and #9). Findings: On 4/30/13 at approximately 11:00am, an interview was conducted with the facility Director of Nursing (DON) and Day Shift Nursing Supervisor (who identified herself to be assistant to the facility's designated abuse prevention coordinator/risk manager). The DON stated facility's administrator is designated as the Abuse Prevention Coordinator/Risk Manager and was out of town, but could be reached by phone. Interview revealed that, on or around 2/24/13, an employee was arrested for possession of controlled drugs belonging to residents residing in the facility which included [MEDICATION NAME] (for anxiety) and [MEDICATION NAME] (for pain). The Day Shift Nursing Supervisor stated the employee who was reordering the residents' medications from the pharmacy; and when delivered to the facility, she would take them into her possession along with the delivery sheet from pharmacy which resulted in there being no evidence the medications had ever been delivered to the facility. The DON stated the facility first became suspicious when other employee reported "odd behavior" of the nurse; and review of controlled inventory sheets revealed the employee was signing-out and documenting administration of controlled medications to residents who normally did not require them. On 4/30/13 at approximately 11:35am, a medication record review was conducted from Medication Cart of Middle Hallway/Side 2 for narcotic administration for Resident #1 in the presence of the licensed nurse (Employee A) and Day Shift Nursing Supervisor. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of April MAR indicated [REDACTED]. Review of pain medication documentation sheet indicated 3 doses were administered. Review of the Controlled Drug Record documented 13 doses had been signed-out for the month of April. Staff present at the time of the observation confirmed there were 8 doses of pain medication signed out on inventory sheet that were not accounted for in medical record documentation. On 4/30/13 at approximately 12:10pm, a medication record review was conducted from Medication Cart of Rehabilitation Unit for narcotic administration for Resident #5 in the presence of the licensed nurse (Employee B) and Day Shift Nursing Supervisor. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of April MAR indicated [REDACTED]. Review of "as needed" documentation sheet for the use of the medication indicated resident received only 1 dose. Review of the Controlled Drug Record documented 5 doses had been signed out for the month of April. Staff present at the time of the observation confirmed there was 1 dose not accounted for in medical record documentation. On 4/30/13 at approximately 12:20pm, a medication record review was conducted from Medication Cart of Middle Hallway/Side 1 for narcotic administration for Resident #6 in the presence of the licensed nurse (Employee C) and Day Shift Nursing Supervisor. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of April MAR indicated [REDACTED]. Review of the Controlled Drug Record documented 16 doses had been signed out for the month of April. Staff present at the time of the observation confirmed there were 2 doses of medication not accounted for in medical record documentation. Resident #9. On 4/30/13 at approximately 12:30pm, a medication record review was conducted from Medication Cart of Front Hall/Side 2 for narcotic administration for Resident #9 in the presence of the licensed nurse (Employee F) and Day Shift Nursing Supervisor. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of April MAR indicated [REDACTED]. Review of the Controlled Drug Record documented 16 doses had been signed out for the month of April. Staff present at the time of the observation confirmed there were 4 doses of medication not accounted for in medical record documentation. Review of facility policy titled "Medication Administration" documents the individual administering the medication must initial the resident's MAR indicated [REDACTED].documents when medications are administered, the individual administering the medication must record in the resident ' s medical record: (a) date and time medication was administered (b) the dosage (c) route of administration (d) injection site if applicable (e) complaints or symptoms for which the drug was administered (f) any results achieved from administering the drug and the time such results were observed, and (g) the signature and title of the person administering the drug. Interview conducted with the facility DON and Day Shift Nursing Supervisor on 4/30/13 at approximately 3:00pm confirmed the facility's medication administration procedure was not followed for Residents #1, #5, #6 and #9.

Based on interview, record review and policy review, the facility failed to ensure the exploitation/misappropriation of resident property and results of facility investigation was reported to the State agency. This was for an unknown number of residents impacted by theft of medications within the facility. Findings: On 4/30/13 at approximately 11:10am, an interview was conducted with the facility Director of Nursing (DON) and Day Shift Nursing Supervisor (who identified herself to be assistant to the facility's designated abuse prevention coordinator/risk manager). The DON stated the facility's administrator is designated Abuse Prevention Coordinator/Risk Manager and was out of town, but could be reached by phone. Interview revealed that, on or around 2/24/13, an employee was arrested for possession of controlled drugs belonging to residents residing in the facility which included [MEDICATION NAME] (for anxiety) and [MEDICATION NAME] (for pain). The Day Shift Supervisor stated she assists the administrator with investigations related to abuse, neglect, exploitation/misappropriation of resident property. She stated she was not aware of any Immediate Report or 5-Day Report being filed with the State Agency (SA) regarding the medications stolen from residents. She stated the facility did inform Law Enforcement, State Board of Nursing and State Board of Pharmacy. The DON stated reporting to the SA was not conducted as the residents were not affected as they always had access to their medications if needed. She stated the employee who was reordering the residents' medications from the pharmacy; and when delivered to the facility, she would take them into her possession along with the delivery sheet from pharmacy which resulted in there being no evidence the medications had ever been delivered to the facility. The DON stated the facility first became suspicious when other employee reported "odd behavior" of the nurse; and review of controlled inventory sheets revealed the employee was signing-out and documenting administration of controlled medications to residents who normally did not require them. The DON further stated there were many residents affected and the administrator is going through records from 6 months back to come up with a list of all residents. The DON stated she did not have access to the list of residents involved at the time of survey as the Administrator had these records in his possession. In interview conducted with the DON on 4/30/13 at 1:15pm, she stated the administrator did not report as exploitation of resident property, as residents were not impacted as a result as the nurse was taking the medications from pharmacy delivery. The DON stated the incident was reported to Pharmacy Board and Board of Nursing immediately after the incident. The DON stated the facility conducted a "sting" operation and had sheriff in attendance at time of discovery with the employee admitting to having taken the medications found to be in her possession on 2/24/13. The DON stated it is believed this diversion of prescription drugs took place over a period of 6 months and the facility is back-tracking to determine the reconciliation in order to reimburse Medicaid. A telephone interview was conducted with the facility ' s administrator on 4/30/13 at approximately 4:00pm. Administrator stated he did not file Immediate and 5 Day Federal Report or an Adverse Incident Report as the residents were not affected by the incident. When asked if he considered filing a report with the State Agency, he replied " the State was notified by notifying the State Board of Pharmacy, the State Board of Nursing, and Law Enforcement." Administrator stated approximately 25 residents were involved and that he continues to work on identifying the residents involved. Request for list of residents affected was requested. Administrator stated he would fax the information to the Agency for Healthcare Review of facility's policy and procedure titled "Abuse Response and Protection Policy" with revision date of 11/08, documents misappropriation of patient property to be " the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of patient's belongings or money without the patient's consent. " Procedure documents that "any and all staff observing or heating about such events will report the event immediately to the ABUSE HOTLINE. Procedure documents " the Abuse Prevention Coordinator and/or designee will also submit The Agency for Health Care Administration AHCA Federal Immediate and 5-Day Report. " Telephone conversation with the Agency's Field Office Manager on 5/9/13 at approximately 10:00am revealed the facility had not yet faxed a list of residents impacted from the medication diversion.

Based on clinical record review, staff interview and interview with the facility psychiatrist the facility failed to ensure residents were free of unnecessary medications, failed to discontinue a medication per the psychiatrists recommendation, for 1 of 10 residents reviewed for unnecessary medications (#165). The findings are: A review of the clinical record reveals resident #165 has an order for [REDACTED]. Resident #165 is followed by the facility psychiatrist and was last seen 9/12/12. At that time the psychiatrist recommended [MEDICATION NAME] 15mg prn be discontinued. The resident has continued to received this medication. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview was conducted with the day shift supervisor on 11/15/12 at approximately 10:00 AM. She was asked what the process was for following the physician's recommendations. She stated, "The physician usually writes orders the day he is in the building and his typed progress notes will come later". She stated, "There is no order written for September to discontinue the medication". When she was asked what the process was for reviewing recommendations for follow up and who was responsible for the follow up she stated, "He has never written the order so that is why she has continued to receive the medication. He is aware that she is still taking the medication because he has a list of what medications she is taking. We contacted him this morning and he wants no changes at this time. She was not seen by him in October". "Medical records files the recommendations in the chart, we have a nurse that goes through medications with him when he comes in each month". She was asked again who was responsible for following up on the recommendations and she stated, "Nursing would be". She was asked for the policy and procedure for following up on physicians recommendations. An interview was conducted with the director of nursing (DON) on 11/15/12 at approximately 1:15 PM. She was asked what the process was for receiving/reviewing recommendations from consulting physicians. She stated, "Within seven days the physician will dictate his notes and once they come in we have a nurse that oversees the process and delegates a nurse to review. The psychiatrist had removed the medication from the medication list for October but there was still no order written to discontinue the medication". The DON stated that "nursing should have contacted the physician for clarification". She stated they had no policy and procedure for following up on the physicians recommendations. A phone interview was conducted with the facility psychiatrist on 11/15/12 at approximately 3:20 PM. When he was asked about his recommendation for resident #165 in September 2012 what were his intentions he stated, "The intention was to discontinue this medication ([MEDICATION NAME]). The resident was receiving [MEDICATION NAME] every night and I continued the [MEDICATION NAME] and discontinued the prn (as needed) medication. I was just told this morning that the medication had not been discontinued".

Based on interview and record review the facility failed to allow the resident to participate in planning care and treatment changes for 1 of 18 ( #188) residents and family sampled for care plan participation. The findings are: Resident #188 was interviewed on 10/26/11 at 10:26 am during Stage I. He stated that he has not been involved in decisions about his daily care. He then stated, "No one says anything to me unless I ask them". A review of the resident chart showed a care plan meeting attendance sheet on 10/5/11 with attendance only by the registered nurse Minimum Data Set Coordinator/Assessment Coordinator ( MDS). An interview was conducted with the MDS coordinator on 10/27/11 at 5:00 pm. She explained that the procedure for care plan meeting is to send the resident and or family an invitation to the care plan meeting 2-3 weeks in advance. On the day of care plan we will review the care plan with them and have them sign this form. The form is labeled The Manor at Bluewater Bay Patient Care Plan Approval. She said that if the resident does not attend the care plan meeting she will discuss the care plan with them at a later date and have them sign the care plan approval form. She was asked if Resident #188 had been invited to a care plan meeting. The MDS Coordinator/ Assessment Coordinator presented a copy of the invitation sent to Resident #188 for a care plan that was scheduled for 10/5/11. She then said that the resident did not attend the care plan meeting. She was then asked to show me a copy of The Manor at Bluewater Bay Patient Care Plan Approval form signed by the resident or his family. She stated,"I discussed the care plan with him in passing. I did not have him sign the form. There is no reason why I did not get him to sign. I really should have. ". The MDS/Assessment Coordinator was asked if she could show any documentation that the care plan was discussed with Resident #188. She was asked if she had any written documentation anywhere that the care plan was reviewed with him. She stated, " No, I have no written documentation that I had reviewed the care plan with him.