Every finding on record at Marianna Health and Rehabilitation

Based upon observations, interviews, and record reviews the facility failed to provide care and services to prevent further decrease in range of motion for 1 of 1 residents reviewed for range of motion issues. (Resident #99) The findings include: On 1/27/25 at approximately 11:00 AM, an observation of Resident #99 revealed contractures of bilateral hands. Resident #99 had hand splints laying on top of the refrigerator at his bedside. At approximately 3:30 pm, the resident was observed lying in bed again with no splints to bilateral hands. Bilateral hand splints are observed to still be on top of the refrigerator at bedside. Resident #99 was resting with his eyes closed. A record review at 3:45 pm on 1/27/25 revealed a physician's order for splints to bilateral hand/wrist to maintain neutral wrist alignment. Wear 3-5 times a week for 3-6 hours a day. On 1/28/25 at approximately 9:00 am, the resident was lying in bed with the head of the bed elevated at approximately 60-70 degrees. An oxygen nasal cannula was observed on the resident with staff at bedside assisting Resident #99 with breakfast due to contractures of bilateral hands. Resident #99 was awake and alert and denied having pain or discomfort at this time. Once again, the bilateral hand splints werelaying on top of the refrigerator at bedside. At 10:00 am, Resident #99 was laying in bed awake and alert. This surveyor asked about his hand contractures. He revealed that he had a stroke and is unable to use them. Resident #99 stated he is not getting therapy services currently. When asked if he wears his hand splints every day, he stated, No they don't put them on me. The resident demonstrated that he is unable to open his hands and extend his fingers when asked. At 1:00 pm, Resident #99 again stated that no one comes in to apply his hand splints or assist with range of motion exercises. Bilateral hand splints were observed on top of the refrigerator at bedside. At 4:00 pm, the bilateral hand splints were still observed on top of the refrigerator at bedside. On 1/29/25 at approximately 8:30 am, 12:30 pm, 2:00 pm, and at 4:00 pm, observations of Resident #99 revealed bilateral hand splints were not applied to Resident #99's hands and wrist. Bilateral hand splints were observed on top of the refrigerator at bedside during each observation throughout the day. Upon review of the medical record on 1/28/25 at 11:00 am, Resident #99 was found to have a physician order for a restorative program for range of motion and hand splints. Resident #99 has a diagnosis of bilateral hand contractures, knee contractures post CVA (stroke), dated 2/11/2023. Upon further record review, Resident #99 was on restorative program services. Documentation shows services were provided in November 2024 on the 4th, 5th, 8th, 11th, 12th, and the 13th for 15 minutes each visit. No documentation was observed for the month of December 2024. January 2025's restorative documentation reveals that the resident received services on the 2nd, 3rd, 6th, 7th, 8th, 9th, 13th, 14th, and the 16th. Resident #99 is care planned (initiated on 6/11/2024) for limited mobility related to contractures of upper and lower extremities with the goal that Resident #99 will remain free of complications related to immobility . On 01/29/25 at 12:40 PM, an interview with the Assistant Director of Nursing (ADON) was performed about the restorative program. She stated that there is a Certified Nusing Assistant (CNA) that does all the splinting and range of motion for residents on restorative care. The ADON stated that they just hired a new person to assist with restorative programs but this person has not started yet. An interview with the Director of Nursing (DON) on 1/29/25 at approximately 1:00 pm revealed that the therapy manager is over the restorative program at this time. The DON stated that, if the Restorative Nursing Aide (RNA) is not in facility, then the nurses and CNAs on the unit are expected to carry out the program. The nurse then documents on the TAR (treatment administration record) and the CNAs document on the plan of care (POC) under task. The DON reviewed Resident #99's range of motion exercises and application of splints to bilateral hands and wrist and acknowledged that no task for restorative was found in the POC. The TAR noted that a nurse signed off indicating that the splints had been applied on 1/28/25 and 1/29/25. She acknowledged that the splints and exercises were not being consistently done.

Based on observations, record review, and interviews, the facility failed to provide proper care and services for 1 out of 2 residents reviewed for hemodialysis services. (Resident #50) The findings include: On 01/27/25 at approximately 12:30 pm, Resident #50 was observed sitting in a wheelchair in his room. Resident #50 revealed that he just returned from dialysis treatment. He denied having any pain or discomfort. He stated he receives dialysis treatments on Mondays, Wednesdays, and Fridays from early in the morning and until around lunch time. Upon further interview with Resident #50, he voiced concerns in regard to a few weeks ago, after my treatment when I got back, my arm was hurting pretty bad. Resident #50 rubbed his right upper arm with his left hand and pulled his shirt sleeve up and to show his dialysis shunt site. He stated he informed the nurse of the pain. He stated the nurses did nothing in regards to the pain. He stated the nurses did not check his shunt site. When asked if he informed the dialysis center upon return, he responded, No I had to go to the hospital a few days later. On 1/27/25 at approximately 3:00 PM, the record review revealed no dialysis orders at all. Upon further review, the facility has no communication record to or from the dialysis center. The progress notes and nurse documentation revealed a progress note dated 12/23/24 stating that a family member requested Resident #50 be sent to hospital due to complaints of pain to his right arm. The nurse assessed Resident #50 and medicated Resident #50 with pain medication. The nurse documented that the bruit and thrill are present (phrases indicating blood flow occurring over a fistula site). On 12/24/24, Resident #50 continued to voice complaints of pain to the right upper arm and once again Resident #50 is medicated for pain. However, no assessment of the arteriovenous (AV) shunt was documented for two shifts. On 12/25/24, Resident #50 continued to voice complaints of pain to the right upper arm and once again Resident #50 was medicated for pain on the first shift with no assessment documented of the dialysis shunt site. On 12/25/24 at 06:30 pm, Resident #50 was observed in bed crying. When the nurse questioned Resident #50, he stated that he wanted to go to the hospital because his right arm is hurting. He stated the area to his dialysis had a pain radiating down his entire arm. He stated, on a scale of 1-10, that his pain is a 10. The resident was medicated with PRN pain medication and he stated that the medication was not effective. Emergency Medical Services were called at this time. Resident #50 was admitted to the hospital on 12/25/24. After his transfer to the hospital, he underwent a surgical procedure to declot his Arteriovenous fistula. On 01/28/25 at 4:52 PM,an interview with the Director of Nursing (DON) was performed. The DON stated that dialysis communication sheets should be scanned into the electronic medical recors and, if they are not there, they can be found in the resident's medical paper chart. The DON stated that all residents receiving dialysis treatment have orders for what day the resident attends dialysis, where they go for dialysis treatments, and to monitor site prior to treatment and post treatment. The DON stated that nurses assess the resident before leaving for their treatment and assess again after the resident returns from treatment. However, the DON was not able to locate any physician orders or documentation of assessment prior to dialysis treatment and post dialysis treatment when Resident #50 returned to the facility. The DON located a communication sheet under the miscellaneous section of the paper chart from November 2024 and one from early December 2024. The DON acknowledged that Resident #50 should have orders to monitor what days he goes to dialysis, where he goes to receive dialysis, monitor for symptoms of infection at the dialysis fistula site, and documentation of bruit and thrill at the dialysis fistula site. A record review of Facility policy, End Stage Renal disease states, Care of a resident with End stage renal disease reveals residents with end stage renal disease will be care for according to currently recognized standards of care. Staff caring for residents with end-stage renal disease shall be trained in the care and special needs of these residents. Education and training of staff include specifically: the nature and clinical management of ESRD including infection prevention and nutritional needs. The type of assessment data that is to be gathered about the resident's condition on a daily pr per shift basis. How to recognize and intervene in medical emergencies such as hemorrhages and septic infections. Upon reviewing education records no education training has been completed related to Residents with End Stage Renal Disease and the care they receive.

Based on observation, record review and interview, the facility failed to provide needed medications as ordered for 2 of 5 residents sampled. (Resident #543 and #69) The findings include: Resident #543 On 1/27/25 at approximately 1:20 PM CST, Resident #543 stated she was in pain and but had not received her pain medication all weekend. She was observed in a fetal position and was having a hard time talking but kept saying, it hurts, it hurts. On 1/27/25 at approximately 4:28 PM CST, Staff J, a Registered Nurse (RN), stated during an interview that the reason that Resident #543 was in so much pain was because the facility had run out of her pain medication. Per the medical record, her order was for HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, Give 1 tablet by mouth as needed every 8 hours for pain. Based on the Medication Administration Record (MAR), Resident #543 did not receive her pain medication on January 24, 25, 26 or 27, 2025, even though the facility logged her pain level each time as a 9 on a 1-10 scale. On 1/27/25 at 5:06 PM, Staff J was asked why the resident was out of medication. Staff J stated, The only reason I can think of is someone forgot to renew the order. When asked if the facility had an emergency medication supply, she stated, We do, we have a Pyxis machine. She stated that Staff H, also an RN, was her nurse all weekend and she had no idea why Staff H did not get a code for the Pyxis since Resident #543 was in pain. On 1/28/25 at 5:05 PM, during an interview with the Director of Nursing (DON), she was asked if it was not acceptable for a medication to run out. She stated that staff had access to after hours doctors for a reason and, if they could not get the order, they know to call her and she will get it done. She also stated, We have emergency meds for a reason. On 01/29/25 at 10:34 AM, the DON in a follow up interview stated that the order states the medication was routine and they should have given the medication every 8 hours whether she was in pain or not. Staff also should have notified someone that they were out of the medication. More importantly, staff should not have run out of the medication. On 1/29/25 at 12:04 PM Staff F, also an RN, and Staff G, a Licensed Practical Nurse (LPN), were interviewed. Staff F stated she was not sure why the medication was not ordered, and that it was the responsibility of Staff H, who worked that weekend. Staff G stated she works with Resident #543 and was not aware that Resident #543 was out of pain medications. On 1/29/25 at 2:09 PM, an interview was held with Staff H, who worked with Resident #543 during the weekend and marked the medication as not available on the first day it ran out. She stated she was waiting for Monday to have the prescription signed. When asked why the emergency doctor was not called, she stated, I did not know this facility had access to after-hours doctors. Resident 543's Care Plan, dated 2/23/25, states for pain management the interventions include, administer pain medications as ordered and anticipate the residents need for pain relief and respond immediately to any complaint of pain. 51224 Resident #69: During an observation of Resident #69 on 01/28/25 at approximately 12:10 PM, Resident #69 was in the hallway sitting in her wheelchair. The residents' eyes appeared droopy, red, and irritated. On 01/28/25 at approximately 2:12 PM, Resident #69 was obsereved still in her wheelchair in the day area with no changes to her eyes. On 01/28/25 at approximately 2:28PM, Resident #69 was observed requesting medication for a headache. On 1/29/25 at approximately 8:45 am, Resident #69 was observed in the hallway sitting in her wheelchair again with noticeably red eyes. On 1/29/25 at approximately 4:02 PM, Resident #69 was observed in her room sitting in a wheelchair and again both eyes appeared red and irritated. On 1/28/25 at approximately 12:10 PM, when asked if her eyes hurt or were itchy, Resident #69 nodded yes. On 1/29/25 at approximately 8:45 am, when asked if her eyes hurt or were itchy, Resident #69 again stated yes. On 1/29/25 at approximately 11:45 AM during an interview with Staff I, a licensed practical nurse (LPN), the LPN verified Resident #69 had an as needed (PRN) eye drop medication (Systane Gel 0.4-0.3%) with an order that read, instill 1 drop in both eyes as needed for RED EYES THREE TIMES A DAY. The LPN verified that the medication was in the drawer and presented a brand new unopened box of Systane gel dated in black marker 01/28/25. The LPN was asked if Resident #69 is assessed for eye redness routinely, and the LPN stated she was. Upon review of Resident #69's physician orders, it was noted in the electronic medical record (EMR) that Systane Gel 0.4-0.3 % Instill 1 drop in both eyes, as needed for RED EYES THREE TIMES A DAY was placed on 06/20/2022. According to the EMR, the last dose of Systane gel was administered on 02/19/2024. (Photographic evidence obtained)

Based on observations, interviews and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 37 residents reviewed. (Resident #105) The findings include: Resident #105 On 1/27/25, during the initial tour, Resident #105 was found to be unavailable for interview. When asked about Resident #105's whereabouts, staff stated that she was currently in the hospital. Upon record review, it was discovered that Resident #105 was transferred to the hospital on 1/24/25 due to abnormal lab readings. Resident #105 was admitted to the hospital for further care and treatment and was diagnosed with respiratory failure secondary to worsening of urinary tract infection. Upon further review of the medical record, Resident #105 was also admitted to the hospital on 4/14/24 - 4/17/24, 5/11/24 - 5/20/24, 5/30/24 - 6/6/24, 7/6/24 - 7/12/24, and 1/8/25 - 1/13/25 with abnormal vital signs of tachycardia and abnormal respirations, and altered mental status. Admitting diagnoses for each hospitalization revealed worsening urinary tract infections and sepsis. On 1/29/25 at 1:40 pm, an interview was conducted with Staff Member C, a Certified Nursing Assistant (CNA). CNA C stated she had worked at the facility for a year now. She stated she works with Resident #105 with her morning activities of daily living. Staff C reported that the resident has been sick the last several weeks and has not wanted to get up to her wheelchair. Staff C stated she informed the nurse that the resident was not feeling well. An interview with Staff Member B, a Licensed Practical Nurse, was performed on 1/29/25 at approximately 2:00 pm, Nurse B revealed that the facility process for a resident with a change in condition is for the nurse is to assess the resident, and notify the physician and the supervisor. If we receive orders from the physician, the nurse will implement the orders. Staff member B stated that they use the Situation, Background, Assessment, Recommendation (SBAR) form to keep track of assessments and recommendations. Staff Member B stated that if a person is sent out to the hospital, a transfer packet is also done, with the bed hold notice, transfer sheet, EMS sheet for need of transport, and it is documented electronically under assessments. An interview with Staff Member D, the Registered Nurse (RN) unit manager, was completed on 1/29/25 at 2:30 pm. She was asked if the SBAR was an expectation of the nurses to complete when there is a change in a resident's status. Staff member D stated it is the expectation to complete a SBAR when a resident has a change in condition and when they are transferred to the hospital. However, some staff nurses will put in a communication note, or a progress note instead of an SBAR assessment. On 1/29/25 at 3:00 pm, an interview with the Director of Nursing (DON) was performed. She confirmed that a SBAR assessment is to be completed by nursing staff when a change in condition is observed. A transfer packet is also to be completed on all residents when there is a change in condition that requires them to be transferred to the hospital for further treatment. The DON was asked if a SBAR assessment was completed on Resident #105 prior to being transferred out to the hospital. The DON stated that the resident has had several hospitalization s, but she was unsure if an SBAR was completed. The DON confirmed that it was her expectation that the nurses complete an SBAR assessment for each resident when a change occurs. The DON was then asked what measures are used to prevent hospitalization of a resident with a urinary tract infection. The DON stated they encourage the resident to drink fluids, call the physician if the resident does not show improvement of symptoms, provide peri-care for residents who are incontinent and dependent on staff, and implement probiotics and medications as prescribed by physician. The DON was asked if these measures were implemented for Resident #105 with each hospitalization . The DON stated Resident #105 refused to get up out of bed and always fussed about not getting the therapy she needed. The DON stated, Her family was always complaining about something. I have a grievance in the book in regard to her therapy, but she refused to participate when the therapist went to work with her. The DON stated there was a SBAR assessment completed for this last hospitalization on [DATE]. The DON was asked if one was competed on the other hospitalization s in April, May, and July of 2024. The DON stated that she did not see one, but the nurses could have put a progress note in about it. The DON revealed a progress note written on 5/30/24, 7/6/24, and on 1/8/24 indicating a change in Resident #105's status. Upon further record review, Resident #105 was admitted to the facility on [DATE] and was diagnosed with a urinary tract infection on 4/17/24. On 6/6/24, Resident #105 was noted to have a new diagnosis of Extended spectrum beta lactamase (ESBL) resistant urinary tract infection. On 1/30/25 at approximately 10:34 AM, an interview was completed with the Infection Control Preventionist (ICP). She stated she tracks and trends when a resident is admitted to the facility with an infection or if they acquire an infection while here at the facility. She reviews the physician orders every morning in clinical meeting, and reviews the progress notes for the last 24 hours to see if a resident has documented symptoms of a possible infection. She states she reviews the facility map for patterns of any infections and showed a facility map colored coded by types of infections. When asked about the response if a pattern in one unit reveals an increase of urinary tract infections (UTI's), she stated she would bring up the concern to the clinical team and monitor for handwashing and performance of proper peri-care. She stated they will do staff training with the staff nurses and CNAs on that unit when a pattern of infections is present. She was asked about any tracking and trending related to Resident #105 to review her infections and hospitalization s. On 1/30/25 at approximately 12:15 PM, the ICP provided a handwritten form of Resident #105 hospitalization s which reveals the resident was diagnosed with a UTI when admitted to the hospital on 4/14/24, 5/11/24, 5/30/24, 7/6/24, and 1/8/25 and had no prior antibiotic therapy. (photographic evidence obtained) A review of the care plan for Resident #105 reveals she is at risk for urinary tract infections with history of ESBL. Care plan goal states that the resident will have no complications of UTIs and will minimize risk for complications for worsening UTIs through next review date. Resident #105 was hospitalized six times with in the last year related to worsening of urinary tract infections.

Based on record reviews, staff interviews, and policy review the facility failed to obtain the results and promptly notify the provider of an abnormal urine culture resulting in a delay in treatment for 1 of 3 sampled residents reviewed for urinary tract infection. (Resident #2) The findings include: A review of Resident #2's paper and electronic medical record revealed the resident was examined by the Advanced Practice Registered Nurse (APRN) on [DATE] at 5:45 PM. The examination note revealed the family was concerned about the resident having increased drowsiness during the day and the facilty nurse reported some episodes of tachycardia. Respirations were elevated and even while resting. She was noted as continuing to decline. The current plan indicated orders for laboratory studies to include urinalysis with culture and sensitivity, comprehensive metabolic panel, platelets, magnesium, complete blood count, thyroid stimulating hormone, and a chest x-ray. Review of nursing notes: The nurse's notes dated [DATE] indicated the labs were obtained that morning. The nurse's notes dated [DATE] indicated the urine culture results revealed contamination and would need to be obtained again. The nurses note dated [DATE] indicated another urinalysis for culture and sensitivity was obtained and sent to the laboratory at the hospital. The record revealed the resident received Bactrim DS antibiotic by mouth daily since her admission on [DATE] for urinary tract infection prevention. The nurse's notes dated [DATE] at 7:00 PM indicated the resident had a temperature of 99.7. The family visiting reported resident had an occasional cough and was not feeling well. The nurse's notes dated [DATE] at 9:00 PM indicated the resident had a non-productive cough, a temperature of 99.4, and the resident was hallucinating about speaking to her mother. The physician was contacted and advised to retest the resident for COVID-19 in the morning. The resident was tested for COVID-19 on the morning of [DATE] and was negative. The nurse's notes dated [DATE] at 1:00 AM indicated the resident continued to have a non-productive cough and a temperature of 99.0 with continued hallucinations of speaking to her mother and father. The nurses note dated [DATE] at 2:00 PM indicated the resident had been extremely fretful and the resident's daughter reported she had been calling out to past family members, awaiting a response from the physician. A physician order dated [DATE] indicated send resident to the hospital. Review of the resident record on [DATE] during the survey revealed no result from the urinalysis culture obtained on [DATE]. The facility contacted the laboratory on [DATE] and obtained the result of the urinalysis culture dated [DATE]. Review of the urinalysis culture report dated [DATE] revealed the urine was positive for Escherichia coli and Proteus mirabilis and both organisms were resistant to Bactrim DS. The electronic culture report indicated it was reviewed by the APRN on [DATE] at 8:26 AM. The record revealed no additional antibiotic or treatment was ordered for the positive urine culture while the resident was in the facility. A review of the resident's hospital records dated [DATE]-[DATE] revealed a discharge summary by the physician dated [DATE]. The discharge summary indicated the resident was admitted to the hospital on [DATE] and expired in the hospital on [DATE]. The admission diagnoses were: altered mental status, COVID with concomitant pneumonia, hypoxia, urinary tract infection, coronary artery disease, and anemia. The discharge summary indicates the cause of death was presumed sepsis of a urinary source coupled with COVID positive pneumonia and a background history of Alzheimer's dementia. She was admitted , placed on Maxipime (an antibiotic) in addition to treatment with remdesivir (a medication for treatment of COVID-19) and some intravenous fluids. She had been placed on oxygen and ultimately required more of that as her stay progressed. Urine cultures returned positive for multiple organisms including Escherichia coli and Proteus. Eventually after some discussion, the family decided to make her simply care and comfort measures. Review of the hospital admission history and physical documented by the physician [DATE] revealed the resident has been deteriorating fairly rapidly over the last 4 to 6 months. According to family, within the last 2 or 3 days, she had substantial changes with altered mental status and not being able to recognize family, which was unusual for her. She had not been eating at all or taking any fluids. Of note, her roommate had tested positive for COVID, but for 3 consecutive days Resident #2 had not. Nonetheless, upon arrival to the emergency room , she was found to be altered with positive COVID and urinary tract infection and she was admitted for management, oxygenation, and intravenous antibiotics. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:09 PM. The DON stated the facility staff called the lab on [DATE] to obtain a copy of the urine culture lab report as stated in the progress notes, but the lab did not send a copy of the urine culture result. She confirmed the facility did not obtain a copy of the urine culture result for Resident #2 until today ([DATE]). The DON stated the floor nurse, or the unit manager, is responsible for ensuring laboratory results and culture results are received back from the laboratory and reported to the provider. An interview was conducted with Employee A (Licensed Practical Nurse unit manager) on [DATE] at 11:03 AM. She stated it was each nurse's responsibility to ensure they receive pending laboratory results. She stated they document the laboratory tests on a checklist log and check them off when received. She provided the laboratory log for [DATE]. The urinalysis with culture and sensitivity for Resident #2 was listed on [DATE] as obtained but the results received area of the log was blank. She stated it was both the floor nurse and unit manager's responsibility to ensure the results were obtained and reported to the physician. A telephone interview was conducted with the APRN on [DATE] at 12:38 PM. She stated she had no recollection of reviewing the urine culture report dated [DATE] for Resident #2. She stated the resident was declining and at the end of life. She felt for some time hospice should be considered. The resident had an abnormal chest computed tomography scan and the family refused a biopsy. She stated the resident was taking a prophylactic antibiotic for prevention of urinary infections and she would not prescribe additional antibiotics without a culture unless the resident was really symptomatic. She felt the resident's decline could be attributed to a possible lung malignancy. Review of the facility policy for Test Results (Version 1.0 H5MAPL0881 revised [DATE]) revealed the policy stating, The resident's Attending Physician will be notified of the results of diagnostic tests. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record.

Based on interview, record review, and policy review, the facility failed to provide a 30-day notice of discharge for 1 of 4 sampled residents. (Resident #1) The findings include: On 3/30/2023 at approximately 12:30 PM, an interview was conducted with the Director of Social Services. She explained that Resident #1 went home on 3/4/23 for a weekend visit with his family. She said: I was told by the Facility Administrator (FA) that the decision was made for him not to return to the facility. He was discharged to home with his daughter. He has two daughters. They take turns taking care of him. One of his daughters works here. We sent a packet to another facility but he was not accepted. On 3/30/23 at approximately 1:30 PM, an interview was conducted with Resident #1's daughter. She explained that her brother-in-law came to the facility to pick him up to go out on pass on 3/4/23. She said she was told that her father was under investigation. She explained that the FA called Monday 3/6/23. The FA explained that he would be discharged . Resident #1 is now living with her and her sister. On 3/30/23 at approximately 2:30 PM, an interview was conducted with the FA. She explained that Resident #1 left with his family to go on pass on 3/4/23. It had been reported by another resident (Resident #2) that Resident #1 groped her breast. Resident #2, who made the allegations, was competent, credible, and capable of expressing herself. The FA explained that the event had been reported and an investigation was conducted. The FA explained that Resident #1 was ambulatory and capable of getting around the facility easily. Resident #1 has a Brief Interview for Mental Status score (BIMS) of 15, which indicates full mental capabilities were observed. She explained that he has become agitated in the past when on enhanced supervision. The FA explained that Regulation 483.15 C8 contains exceptions to the 30-day requirement. The FA said that she had concerns for the safety of other residents in the facility. She called the family to notify them that arrangements for his discharge were being made. The Director of Social Services was notified. The FA provided a typed statement and a copy of the facility's discharge policy. A record review was conducted. The resident was discharged from the facility on Monday 3/6/23 after being sent home on pass with his family. On 3/30/23 a review of the discharge policy was conducted. The policy stated that a 30-day notice of discharge would be issued. Exception to this rule would be when the health and safety of individuals in the facility would be endangered due to the clinical or behavioral status of the Resident.

Based on observation, interview and policy review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. Findings include: An initial tour of the facility's kitchen was conducted on [DATE] at 2:54 PM. Six clear large storage bins were observed on shelves in the kitchen with no labels to identify the contents or use by date. (photo evidence obtained) An interview was conducted with staff E, the Assistant Kitchen Supervisor at 3:06 PM on [DATE]. When asked what the facility's labeling policy was as it relates to food storage containers, she replied I don't know that. Observations of the refrigerators and freezers were made as part of the initial kitchen tour. Observation of the milk refrigerator revealed a large container of plain yogurt with an expiration date of [DATE]. The temperature logs observed to be posted on the outside of the doors were dated (MONTH) 2019. The logs contained blanks indicating missing entries. (photo evidence obtained) An interview was conducted with the Assistant Kitchen Supervisor on [DATE] at approximately 3:29 PM. When asked what the facility's policy was for monitoring food storage temperatures, she stated that the temperatures are supposed to be taken once during the 5:00 AM to 1:00 PM shift and twice during the 11:30 AM to 7:30 PM shift, but no specific person is assigned the task. When asked who's responsible for posting new logs at the beginning of each month, she stated that herself and the Dietary Director were responsible. When asked what the policy is for maintaining temperature logs, she stated we tell our staff to check temperatures everyday. When asked who's responsible for overseeing that it's actually done, she stated either her or the Dietary Director. When asked what they do if they observe that it's not being done, she replied we need to start writing them up because that's the procedure and they're not doing it. When asked how many times she's walked by the temperature logs this month and noticed they weren't being completed, she responded we got behind on a lot of stuff, I apologize for that. An interview was conducted with staff D, the Dietary Director on [DATE] at approximately 3:36 PM. When asked who's responsible for checking the refrigerators and freezers for expired items, she stated that any of the kitchen aids are supposed to complete this task once per day. When asked who is responsible for overseeing that it's actually done, she stated herself or the Assistant Kitchen Supervisor. When asked what her expectations are concerning this task, she responded for there to be no expired items in there. When asked what type of training the kitchen staff receive, she stated they have a meeting or provide in-service training when issues are identified. According to staff D, no in-service has been provided related to expired food items. Review of a Dietary Department policy titled Policy - Temperature Checklistrevealed the purpose was To establish a standard procedure for recording temperature of refrigerator, walk-in cooler, freezer, ice cream box, and dishmachine. Review of the procedure revealed An individual temperature checklist shall be maintained for each refrigerator, walk-in cooler, freezer, ice cream box, and dishmachine. Temperatures are to be recorded daily at 5:15 A.M., 1:00 P.M. and 7:15 P.M. Persons recording temperatures shall put date, temperature, and initials. If there is a problem with the temperature varying from the normal listed below, the person responsible for recording temperatures must report the variance to the Dietary Supervisor. The Dietary Supervisor shall then give a written work order to the Maintenance Department for repair. Temperature of refrigerator must be 40 degrees Fahrenheit; freezer - 0 degrees Fahrenheit or below; and dishmachine - wash cycle 140 degrees F and final rinse 180 degrees F. Further observation of the refrigerator during the initial tour revealed that employee food was being stored in the walk-in refrigerator with the residents' food. A fountain drink from Hardee's was observed sitting on the refrigerator shelf with plastic wrap placed over the top of it. Half of a cooked ham was observed to be wrapped in plastic wrap without a date.(photo evidence obtained) During an interview with the Dietary Director on [DATE] at approximately 3:40 PM, she was asked what the facility's policy was regarding employee food or beverages being stored in resident food storage areas. She replied, it's not supposed to be there. She was asked what meal the ham was from. She stated that she couldn't remember exactly without looking at the menu, but it was from either last night or the night before. When asked what she intended to do with it, she stated re-freeze it. Review of the Dietary Department's policy titled Infection Control, revealed that Leftovers shall be immediately labeled, dated, and refrigerated or frozen. A follow-up tour of the kitchen was conducted on [DATE] at approximately 11:45 AM. Review of the Trayline Temperature Log laying on top of the holding table revealed it only contained the last two days with missing entries on each day. (photo evidence obtained) During an interview with the Dietary Director on [DATE] at approximately 11:45 AM, she was asked to provide additional logs prior to the last two days. She responded that she didn't know where they were, but thought she may have thrown them out. No other temperature logs were provided during the survey. Review of the Dietary Department's policy titled Procedure for Properly Taking and Recording Food Temperatures revealed Step 1 of the Procedure stated No more than twenty (20) minutes prior to tray and cafeteria service all food items must be checked for appropriate temperatures, and the temperatures shall be recorded on a quality assurance sheet. During the follow-up kitchen tour on [DATE] at 12:00 PM, staff C, a cook, was observed without gloved hands to open the oven door, remove foil from a pan of fried chicken, reach her hand in the pan and remove a set of tongues and a scooper. The Dietary Director was standing beside the surveyor watching staff C at the time of the observation. The Dietary Director was immediately interviewed on [DATE] at 12:01 PM. She was asked if serving utensils are typically stored in pans when their is food in them. She stated that the employee must have just put it in there. An interview was conducted with staff C on [DATE] at 10:45 AM regarding the observation of the serving utensils being retrieved from the food with bare hands. She stated that she thought she had gloves on and should've had them on. She stated that having surveyors in the kitchen makes them nervous.

Based on observation, interview, and record review, the facility failed to ensure a catheter bag was kept off the floor for 1 of 1 resident (#3), reviewed for suprapubic catheter use (a device to drain urine from the bladder). This failure placed the resident at risk for infection. The findings included: Observation on 8/12/2019 at approximately 10:39 AM showed Resident #3's suprapubic catheter was attached to a full-size drainage bag. The drainage bag was observed to be laying on the floor without a privacy cover. (Photographic evidence obtained) Per record review, Resident #3 resident's admission assessment on 1/28/2018 showed that the resident had a suprapubic catheter.Resident #3's records revealed that a urinalysis was collected on 7/11/2019. The following out-of-range results were reported: color-dark yellow, occult blood 2+, [MEDICATION NAME]- positive, leukocyte esterase 3+. The resident was treated for [REDACTED]. The resident received Bactrim DS ([MEDICATION NAME] and [MEDICATION NAME], an antibiotic) BID (latin for bis in die which means twice a day) for 5 days. During an interview with Resident #3 on 8/12/2019 at approximately 10:40 AM, the resident reported that this occurrence (the drainage bag being on the floor) does not happen often. Resident #3 stated, It probably fell . During an interview with Staff I on 8/12/2019 at approximately 10:45 AM, staff I confirmed that the catheter drainage bag was on the floor and that the bag did not have a privacy cover. Staff I confirmed that catheter drainage bags should be kept off the floor and have a privacy cover. According to Infection Control and Hospital Epidemiology, Vol. 35, No. 5 (May 2014), pp. 464- 479, published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America, stable URL: https://www.jstor.org/stable/10.1086/ 8 accessed 22 [DATE], . Maintain unobstructed urine flow (quality of evidence: III). a. Keep the collecting bag below the level of the bladder at all times; do not place the bag on the floor (quality of evidence: III). Page 469.

Based on staff education review, review of the facility's policy and procedure and staff interviews, the facility failed to implement their Abuse, Neglect and Exploitation/ Misappropriation of Property/Injury of Unknown Source, prevention policy, by failing to ensure that staff were provided with abuse education at least annually for five of eight staff members reviewed. (Staff Members A, C, D, [NAME] and F) The findings include: On 06/13/2019 a total of eight staff records were reviewed for annual Abuse and Neglect training. Four of the eight staff training record reviewed failed to include Abuse and Neglect training within the last 12 months or last year. The records presented revealed: - Staff Member A - last training documented 01/29/2018 - Staff Member C - last training documented 05/29/2018 - Staff Member D - last training documented 01/29/2018 - Staff Member [NAME] - last training documented 03/24/2009 - Staff Member F - last training documented 08/24/2011 The facility presented an Abuse training inservice, dated 04/22/2019 with a 3 page sign-in attendance sheet. The last entries on the sign in sheet were, Staff Member A, C, [NAME] and F. On 06/13/2019 at approximately 11:30 AM, Staff Member [NAME] was interviewed regarding the last time she had Abuse training. she stated it has been awhile,, she says she does it online for her license. When prompted whether there had been any recent in-services to include Abuse training - she was not aware of any. Staff E, confirmed that the signature on the sign-in sheet for the 4/22/2019 inservice was not hers. On 06/13/2019 at approximately 11:45 AM, an interview was conducted with Staff Member F, she says she has not had any abuse training in a long while, months at least. She doesn't remember any Abuse training with Elder Affairs or Adult Protective Services. She was asked to confirm her signature - she stated she was not sure. She said she did not remember attending the in-service on abuse. Staff Member A was not available for interview. Staff Member A's signature was on the 04/22/2019, Abuse education attendance sheet provided, however, Staff Member A's name and signature was misspelled and when her signature was compared with her Affidavit of Compliance - the signature did not match. (photographic evidence obtained) On 06/13/2019 at approximately 1:00 PM, an interview was conducted with Staff Member I, the In-Service Coordinator. Staff Member I stated that Adult Protective Services came in on 4/22/2019 to conduct the 'Abuse' training inservice. It was pointed out to Staff Member I that Staff Member A, C, [NAME] and F were the last four names on the inservice sign-in sheet, which led to concerns with authenticity. She stated they don't let her record the inservice, so those staff members that can't attend she catches them as she can and verbally repeats the information. She did not have any other forms of education provided to staff regarding Abuse Prevention training. She said, some of the staff may not have attended the inservice on that exact day. She was informed that Staff [NAME] and F were interviewed had no recollection of this inservice held on 04/22, and one confirmed that the signature on the sign in sheet was not hers, the other staff member was not sure. When signatures were compared to the Affidavit of Compliance - they were not the same. Also of note, Staff Member A's name and signature was misspelled. She stated she took full responsibility and indicated she signed their names to imply that she had reviewed Abuse training with them. A review of the facility's policy and procedure entitled - Abuse / Neglect / Exploitation / Misappropriation of Property/Injury of Unknown Source, indicates under the heading of, In-service Education - All staff will be in-serviced at 'least annually' regarding resident's rights and abuse prevention policies and procedure, social media policies and procedure related to mental abuse, to include their responsibility to report, without fear of reprisal, an procedures for reporting suspected abuse, neglect, exploitation, misappropriate of property and injury of unknown source. Supervisor will be in-serviced regarding their monitoring responsibilities to ensure the prevention of abuse and required reported. Targeted in-service education will be provided as needed to staff responsible for residents with aggressive or catastrophic behavior.

Based on observations, staff interviews, review of the manufactures instructions and telephone interview with the manufacturer's technical support staff, the facility failed to ensure nursing staff appropriately cleaned and disinfected the Evercare G2 glucometer between resident use for one of three medication carts inspected. The findings are: On 8/16/18 at approximately 9:43AM, an inspection of the medication cart for the residents located on the 600 West hall was conducted with sampled staff A, a licensed practical nurse and the medication nurse. During the inspection, the surveyor observed an Evercare G2 Glucometer in the top drawer of the medication cart. Sampled staff A, the medication nurse for this medication cart indicated this is the meter used to check her residents ' blood sugar. The surveyor asked sampled staff A to explain the procedure for cleaning and disinfecting the glucometer between resident uses. Interview with sampled staff A at this time revealed she uses the facility provided Medline Medium Alcohol Prep Pads to clean/disinfect the glucometer between resident uses. She stated she does not use the facility provided bleach wipes as the container is too bulky on her medication cart and it is easier to use the alcohol preps wipes. She further stated she does not even have a container of bleach wipes available on the medication cart for use. The manufacturer's care information for cleaning the Evercare G2 meter and the facility's policy on the cleaning of the Evercare G2 Glucometer between uses were requested. On 9/16/18 at approximately 10:02AM, the director of nurses brought the requested information. At this time, an interview with review of the facility's policy concerning the Evercare G2 Glucometer Care dated 4/5/18 was conducted with the director of nurses. Interview with the director of nurses revealed her statement that the staff may clean these glucometers with bleach but also can clean them with anything including just the facility alcohol prep pads. She revealed the statement in the policy; which revealed the staff are to Make sure that glucometers are wiped down with a bleach wipe before and after use; per the manufacturer, you may wipe the meter dry, or allow to air dry. She further stated that per manufacturer's suggestion that alcohol wipes may be used. She provided a copy of the manufacturer's information. A review of page 45 of the manufacturer's booklet on Evercare G2 Caring for the Meter was conducted with the director of nurses and she said see it says, Cleaning wipes with alcohol. She was indicating the statement on this page which stated the following statement the following products are validated for disinfecting the Evercare G2 meter: Medline Micro Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: -10). The information also stated other EPA Registered wipes may be used for disinfecting the Evercare G2 system; however, these wipes have not been validated and could affect the performance of the meter. At approximately 11:10AM, a telephone interview was conducted with the Medline Technical Service line at [PHONE NUMBER]. Interview with a Medline Technical Support staff revealed the use of the Medline alcohol prep pad is not effective or appropriate to use to clean the Evercare G2 meter. She stated she spoke with staff in product division primary care division and he confirmed the use of the Medline Alcohol Prep pad is not approved to clean the meter properly between resident use. She stated the four suggested disinfecting agents listed in the manufacturer's manual contain bleach products and EPA approved chemicals to clean the meter; not alcohol only. An alcohol prep is not sufficient to clean/disinfect the meters. At approximately 1:20PM, another interview was conducted with the director of nurses and she was informed of the telephone conversation with the Medline Technical Support staff stating the use of the Medline Alcohol Prep pad is not sufficient to appropriately disinfect the Evercare G2 glucometer. She stated the staff were inserviced as recently as 4/23-4/25/2018 and are supposed to only use the bleach wipes provided.

Based on observation, staff interviews, and record review, the facility failed to implement the Plan of Care for 1 of 4 residents sampled for nutrition (#92) and 1 of 6 residents sampled for mobility (#85). The findings include: Resident #92: On 8/13/2018 at 1:06PM an observation was made of resident #92 who was being assisted by staff member C, a Certified Nursing Assistant (CNA). During the observation the CNA was noted to be sitting at the side of the resident's bed with a tray table that housed a divided plate with pureed food items. Also noted on the tray was a vanilla magic cup (a nutritional supplement) and a small container of vanilla pudding. The CNA was observed to use a large syringe to pull up a mixture of the pureed food from a plastic cup. She then placed the tip of the syringe into the back of the resident's mouth and pressed the plunger injecting several cc's of the food mixture into the back of the resident's throat. The resident was observed coughing and gagging repeatedly while being fed. The CNA continued to feed the resident despite the coughing. At 1:10pm, the CNA left the resident's room leaving the vanilla magic cup untouched, the cup of pudding untouched, and food left on the divided plate. On 08/14/2018 at 1:08 PM an observation was made of resident #92 who was being assisted by staff member F, a certified nursing assistance (CNA). During the observation the CNA was noted to be using a spoon to feed the resident a pureed diet. CNA F stated that resident #92 only receives fluids with the syringe and a spoon is used for other soft foods. CNA F reported that resident #92 usually eats 100% of her meals to include the magic cup. Resident #92 was not coughing or gagging during the meal observation. On 8/13/18 a record review was conducted for resident #92. Review of the Minimum Data Set (MDS) showed that the resident #92 had a BIMS (Brief Interview for Mental Status) score of 99, which means the resident was unable to complete the interview. The MDS also showed that resident #92 was total care and required max assistance with all activities of daily living (ADL) to including feeding. There was a physician's orders [REDACTED]. Review of the Dietitian progress notes and recommendation revealed resident #92 is on a pureed diet with double portions and honey thick liquids. (MONTH) use syringe for liquids and medications as needed. Provide pureed diet with honey thickened liquids. Review of the Plan of Care found double portions and honey thick liquids goal to maintain weight through review date (10/11/18). Interventions include Monitor weight as indicated and to Monitor/document/report PRN (as needed) any signs or symptoms of dysphagia; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. As well as Provide and serve diet as ordered, provide and serve supplements as ordered. On 8/15/18 at approximately 9:00 AM an interview was conducted with the Speech Therapist/Director of Therapy in which she stated that resident #92 has always been given liquids and medications through a syringe. She stated this is not the standard of practice and goes against everything she was taught in school however she states this is how it has been done with this resident for the last 20 plus years and it seems to work. She states that she cannot support the practice but the physician has written an order for [REDACTED]. On 8/15/18 at approximately 12:37 PM a telephone interview was conducted with the Registered Dietitian (RD) in which she stated that she has requested a clarification for the physician to see if the resident could receive food via the syringe but that was several months ago and he has not updated the orders so the resident is not to receive food via the syringe. She also stated that the patient has a history of fluctuating weights and she monitors this monthly. She state the resident has extreme tremors and this can affect the weight because she is moving so much during the weight process. On 8/15/18 at approximately 9:30 AM an interview was conducted with staff member C, a CNA. During the interview she stated she assists resident #92 with feeding and transfers. She stated that she dilutes the pureed food on the divided plate with water to thin it out so she can give it to the resident through the syringe. She also stated she has worked here [AGE] years and this is the way it has been done. She stated that the resident coughs and gags throughout her meals so she does not report it to the nurse. When asked why another CNA observed feeding the resident used a spoon and did not have issues with coughing and gagging she stated, I am not sure . Resident #85: A record review was conducted on resident (#85). Review of the Minimum Data Set ( MDS) showed that the resident #85 was coded for impaired range of motion in the upper extremities on one side. Additionally, review of the resident plan of care indicated that the resident was to wear right elbow splint/ right hand-wrist splint 6 hours daily to prevent further contractures. Six observations were made on resident (#85) from (MONTH) 14, (YEAR) through (MONTH) 15, (YEAR) were the resident was not wearing any elbow/hand wrist splints as indicated by his orders. Observations were made on (MONTH) 14, (YEAR) at 9:35 AM, 11:00 AM, and 2:30 PM, and on (MONTH) 15, (YEAR) at 10:58 AM, 11:33 AM, and 12:34 PM. On each of these observations, the resident was observed to have his right hand contracted and was observed to not be wearing his elbow/hand wrist splint on his right hand during these observations. Further review of the restorative nursing logs showed that during (MONTH) 14, (YEAR) through (MONTH) 15, (YEAR) there were no documented refusals of splints or any documentation showing the splints were put in place during that time. On (MONTH) 16, (YEAR) at approximately 10:41 AM an interview was conducted with the RN Supervisor (staff G) who explained that Certified Nursing Assistants are typically responsible for making sure that residents have on the appropriate splinting equipment if required. She also stated that CNA should document any refusal of splinting devices on the restorative sheets. She confirmed that in the restorative nursing program book that there were no sheets for CNA to signs that indicated were putting on the splints or if residents were refusing them. She did state that she will add splints to the restorative sheets and retrain staff where to document any refusals.

Based on observation, record review and staff interviews, the facility failed to provide the eating assistance in accordance with physician orders [REDACTED].#92). Findings included: On 8/13/2018 at 1:06PM an observation was made of resident #92 who was being assisted by staff member C, a Certified Nursing Assistant (CNA). During the observation the CNA was noted to be sitting at the side of the resident's bed with a tray table that housed a divided plate with pureed food items. Also noted on the tray was a vanilla magic cup (a nutritional supplement) and a small container of vanilla pudding. The CNA was observed to use a large syringe to pull up a mixture of the pureed food from a plastic cup. She then placed the tip of the syringe into the back of the resident's mouth and pressed the plunger injecting several cc's of the food mixture into the back of the resident's throat. The resident was observed coughing and gagging repeatedly while being fed. The CNA continued to feed the resident despite the coughing. At 1:10pm, the CNA left the resident's room leaving the vanilla magic cup untouched, the cup of pudding untouched, and food left on the divided plate. On 08/14/2018 at 1:08 PM an observation was made of resident #92 who was being assisted by staff member F, a certified nursing assistance (CNA). During the observation the CNA was noted to be using a spoon to feed the resident a pureed diet. CNA F stated that resident #92 only receives fluids with the syringe and a spoon is used for other soft foods. CNA F reported that resident #92 usually eats 100% of her meals to include the magic cup. Resident #92 was not coughing or gagging during the meal observation. On 8/13/18 a record review was conducted for resident #92. Review of the Minimum Data Set (MDS) showed that the resident #92 had a BIMS (Brief Interview for Mental Status) score of 99, which means the resident was unable to complete the interview. The MDS also showed that resident #92 was total care and required max assistance with all activities of daily living (ADL) to including feeding. There was a physician's orders [REDACTED]. Review of the Dietitian progress notes and recommendation revealed resident #92 is on a pureed diet with double portions and honey thick liquids. (MONTH) use syringe for liquids and medications as needed. Provide pureed diet with honey thickened liquids. Review of the Plan of Care found double portions and honey thick liquids goal to maintain weight through review date (10/11/18). Interventions include Monitor weight as indicated and to Monitor/document/report PRN (as needed) any signs or symptoms of dysphagia; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. As well as Provide and serve diet as ordered, provide and serve supplements as ordered. On 8/15/18 at approximately 9:00 AM an interview was conducted with the Speech Therapist/Director of Therapy in which she stated that resident #92 has always been given liquids and medications through a syringe. She stated this is not the standard of practice and goes against everything she was taught in school however she states this is how it has been done with this resident for the last 20 plus years and it seems to work. She states that she cannot support the practice but the physician has written an order for [REDACTED]. On 8/15/18 at approximately 12:37 PM a telephone interview was conducted with the Registered Dietitian (RD) in which she stated that she has requested a clarification for the physician to see if the resident could receive food via the syringe but that was several months ago and he has not updated the orders so the resident is not to receive food via the syringe. She also stated that the patient has a history of fluctuating weights and she monitors this monthly. She state the resident has extreme tremors and this can affect the weight because she is moving so much during the weight process. On 8/15/18 at approximately 9:30 AM an interview was conducted with staff member C, a CNA. During the interview she stated she assists resident #92 with feeding and transfers. She stated that she dilutes the pureed food on the divided plate with water to thin it out so she can give it to the resident through the syringe. She also stated she has worked here [AGE] years and this is the way it has been done. She stated that the resident coughs and gags throughout her meals so she does not report it to the nurse. When asked why another CNA observed feeding the resident used a spoon and did not have issues with coughing and gagging she stated, I am not sure .

Based on observation, record review and staff interviews the facility failed to ensure coordination of care with [MEDICAL TREATMENT] services for 1 of 2 sampled resident's receiving [MEDICAL TREATMENT]. The facility failed to ensure that medications were administered as recommended by the [MEDICAL TREATMENT] physician (#106). Findings include: On 8/13/18 a record review was conducted for resident #106 which revealed she was receiving [MEDICAL TREATMENT] 3 days a week on Monday, Wednesday and Fridays. The record also revealed she was receiving [MEDICATION NAME] 800mg 2 tablets three times daily (8:00AM, Noon and 4:00 PM) and with Snacks at 10:00 AM and 2:00 PM. On 8/14/18 at approximately 7:30 AM, an observation was made of resident #106 obtaining her morning meal in her room while up in a wheelchair. She was noted to eat 100% of her meal without concern. On 8/14/18 at 9:06 AM, 1.5 hours later, an observation was made of nurse B preparing the morning medication for resident #106 outside the resident's room. During the observation the nurse obtained two tablets of Sevelamer [MEDICATION NAME] ([MEDICATION NAME]) 800mg and placed the tablets into a cup with the residents other morning medications. The nurse entered the resident's room and handed the cup to the resident who was still in her wheelchair with her tray table in front of her, minus the morning breakfast tray, and the resident was observed to take her medications. On 8/15/18 at 11:25 AM, an interview was conducted with the Registered Dietitian (RD) at the [MEDICAL TREATMENT] center, where the resident receives [MEDICAL TREATMENT] treatments. The dietitian stated the [MEDICATION NAME] is to be given to meals and stated take a bite, take a binder. She stated she faxes the facility monthly with End of the Month Reports and Nutrition Profile Report that includes a detailed list of medications. She also was able to provide the fax confirmation sheets that supported the time and the date the information was sent to the facility and that the information was faxed to the East Wing Nursing station as well as the facility RD. Mentioned within each report were She is on [MEDICATION NAME] 800mg, 2 tables at meals/ 1 tablet with snacks. Review of the medication list revealed orders for [MEDICATION NAME] 800mg 2 tables three times daily with meals and 1 with snacks twice daily. The [MEDICAL TREATMENT] RD stated that the longer [MEDICATION NAME] is given from the first bite of food the less effective it is and that after 2 hours it is not effective at all. She stated that she has educated the facility staff on the need to do this many times and that it is standard practice with [MEDICATION NAME]. On 8/15/18 at approximately 1:15 PM, a telephone interview was conducted with the facility RD in which she stated that she was aware that [MEDICATION NAME] was to be given with food and had thought the facility orders reflected that. She stated that she should have caught that the orders failed to state 'give with food', but felt that given the times of the medications it would be covered regardless. When told of the observation of the medication being given 1.5 hours after the resident had eaten her breakfast, she stated that she would update the orders to include give with meals when she returned to the facility and would provide education to the nurses. On 8/15/18 at approximately 1:20 PM, an interview was conducted with the East Wing Unit Manager in which she stated that the facility communicates with the [MEDICAL TREATMENT] center every day the resident has [MEDICAL TREATMENT] via a notebook that goes with the resident. She stated that staff write notes with updates within the notebook and she reviews it each time the resident returns. She stated she was not aware the resident was not getting her [MEDICATION NAME] with meals as the medication order is for three times a day at 8, 12 and 4 - with 2 extra doses ordered at 10 & 2 if the resident eats snacks. She stated there really isn't a reason to give the medication at 4 because trays do not come until after 6 and snacks are ordered at 2. She stated that she would educate the nurses to give the medications with food and will update the orders to include give with food. On 8/16/18 an interview was conducted with the Director of Nursing (DON) in which she stated that the facility had scheduled the [MEDICATION NAME] at times when the resident was eating but can see how the 4:00pm dose would be off given that dinner does not arrive on the floor until well after 5:00pm and snacks are passed at 2:00pm. She stated she would educate the nursing staff. Review of the Policy and Procedure for using the [MEDICAL TREATMENT] Communication Record dated 3/2/18 states, If any orders have been sent, the charge nurse must write them on the physician order [REDACTED].

Based on observation, resident interview, staff interview and policy review, the facility failed to appropriately store all medications in locked compartments or locked areas in 1 of 36 resident rooms observed during stage one of the survey. (room [ROOM NUMBER]) The findings include: An observation of room [ROOM NUMBER] was conducted on 6/26/17 at 2:11pm, and revealed 2 partially filled tubes of permethrin 5% cream sitting on the counter near the sink (photographic evidence was obtained). An interview was conducted with resident #189 on 6/26/17 at 2:23pm. Resident #189 stated she did not know where the medication came from or how long it had been on the counter. An interview was conducted with employee A (Registered Nurse Unit Manager) on 6/26/17 at 2:26pm. Employee A observed the permethrin cream on the counter and confirmed it should not have been left in the room. Employee A stated resident #189 had been treated with the cream last week. The facility policy for Storage of Medication (section 4.1) was reviewed. The policy stated the medication supply shall only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.

Based on observation, staff interview and review of Centers for Disease Control (CDC) recommendations, the facility failed to follow staff practices consistent with current infection control principles in order to prevent cross contamination for 1 of 1 residents on contact isolation, #177. The findings are: During the initial facility tour on 05/23/2016, an observation of an isolated resident's room, resident #177, revealed that personal protective equipment (PPE) was located inside the resident's room and was not readily accessible for donning by staff or visitors prior to entering the room. A chair was positioned inside the room sitting adjacent to the doorway. An over-bed table was positioned in front of the chair. A backpack labeled with a certified nursing assistant's (CNA) name and title and a cup of ice water was sitting on the table. Two trash cans and a plastic bin with drawers were placed in the corner of the room on the far side of the chair and table. There were no red biohazard bags or liners in either of the cans. Personal protective equipment was located inside the plastic drawers of the bin which was inaccessible to anyone entering the room. On 05/23/2016 at 10:30 AM, an interview was conducted with Certified Nursing Assistant G (CNA G). CNA G stated that this arrangement of equipment and supplies was not the normal setup for any resident on isolation. She stated that personal protective equipment is usually kept outside of the doorway of the room. She did not know why the bins were inside the room or why there were no bags in the trash and linen bins. On 05/23/2016 at approximately 10:40 AM, an interview was conducted with Registered Nurse H. She acknowledged that the setup of this room was inappropriate for a resident on isolation. Registered Nurse H stated that the personal protective equipment should be located outside of the room by the doorway. A review of guidelines from the Centers for Disease control was conducted. A training program entitled 'Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings' and the '2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings'. The CDC guidance stated, There are four key points to remember about PPE use. First, don it before you have any contact with the patient, generally before entering the room. When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces (54, 72, 73, 88).

Based on observations, record reviews and interviews, the facility failed to follow the plan of care for 1 of 2 (#129) residents reviewed for accidents. The facility failed to ensure a care plan intervention for a Wander Alert device was implemented. The findings are: On 05/24/16 at 2:53 PM, Resident #129 was observed not wearing a wander guard (Wander Alert) device. Nurse I and nurse J visually inspected resident #129 and confirmed the resident was not wearing a wander alert device. On 05/26/16 at 8:50 AM, Resident #129 was observed standing at her bedside. The Wander Alert device was not on the resident's person. It was observed to be on the chest of drawers next to the bed. A review of the resident's care plan initiated on 2/17/16 and revised on 5/12/16 was conducted. The care plans included an intervention that a Wander Alert device was to be worn. An interview was conducted on 5/24/16 at 3:30 PM with the unit manager, staff H who stated the checking of the wander active is done in the computer under treatment administration record (TAR). When asked to demonstrate where the documentation is in the TAR, she checked and the resident did not have a check off on the system for Wander Alert device. When asked what is done when upon check, the wander active is not on the resident, she stated it is replaced by another one. On 05/25/2016 at 9:45 AM, a follow-up interview with the unit manager, staff H was conducted. When asked who was responsible for entering nursing orders into the TAR, she stated whoever did the admission and placed the wander active (Wander Alert) should have put it in the computer. When asked about the omission of the Wander Active device on the TAR (treatment administration record), she stated I don't know how that one got missed. An interview was conducted on 05/25/2016 at 10:21 AM with certified nursing assistant, staff M. When asked, how do you know what the residents needs are as far as their care plan? She stated I do not have access to the care plans. She stated we are given a form that lets the CNAs know what a resident can or cannot do. Review of the form (aide assignment sheet) was conducted at that time. The wander alert section of the form for resident #129 under column titled devices, alarms was not checked off. CNA M stated the resident is exit seeking all day. When she is exit seeking, she is redirected. I only knew she was a wander alarm because I saw it on her leg this morning. An interview was conducted on 05/25/2016 at 10:29 AM with unit staff N. When asked how frequently the form (aide assignment sheet) is updated, she stated I updated this form this morning.

Based on observation, staff interview, resident interview and record review, the facility failed to ensure an accurate assessment and monitoring of a wound for 1 of 1 residents, #196. Findings include: Resident #196 was observed on 5/24/2016 at 2:55 pm to have a blue padded boot to his left foot. The resident stated, I've had a sore for a few months. They put the boot and a dressing on it sometimes. It doesn't hurt. The wound was observed to be approximately 6.5 cm (centimeters) by 6 cm full thickness wound to the left heel. There is a 1 cm by 2 cm margin that was dark red and dry. The remaining area was calloused. There was no dressing. A review of resident #196's clinical record revealed a history of uncontrolled diabetes and [MEDICAL CONDITION] of the extremities. The admission MDS (Minimum Data Set) assessment dated [DATE] showed no wounds. On 4/13/2016 a nurse's note stated, Patient in bed with lower extremities elevated. Left heel soft. Skin prep applied. Blister interior left heel leaking pink tinged fluid. On 4/15/2016, a nurse's note indicated the blister was no longer intact. There was no assessment documentation describing the wound in order to determine whether the wound was improving or getting worse. There was no baseline assessment, nor regular follow-up assessments describing underlying condition contributing to the ulceration, ulcer edges and wound bed, location, shape, size, depth and condition of surrounding tissues. There was no documentation that the physician was notified about wound assessments. There were regular nurses notes stating that wound care was done and noting drainage and the absence of infection signs and symptoms. A review of physician progress notes [REDACTED].#196 was seen by a physician on 5/5/2016 for [MEDICAL CONDITION] of the lower extremities per the note. The physician did not document the resident had a heel wound. An interview was conducted with the DON (Director of Nursing) on 5/25/2016 at 3:08 pm. The DON stated, We didn't stage it or measure it because it wasn't a pressure ulcer. It was a blister. The DON stated that the unit manager should be performing and documenting a weekly wound assessment. The DON confirmed that there was no documentation showing that the physician was notified. An interview was conducted on 5/26/2016 at 10:05 am with registered nurse A (RN A). RN A stated that the doctor had faxed his notes from an office visit which occurred on 5/6/2016. The physician documented that the resident has a stage 2 decubitus to his left heel. The doctor added an addendum on 5/6/2016 that stated Left heel ulcer is healing well, improved redness. No swelling. 4 x 3 cm area. An interview was conducted with the resident's physician on 5/26/2016 at 10:35 am. The doctor confirmed that the resident does have a healing stage 2 ulcer to his left heel that was 4 by 3 cm on that visit and that he had not seen the resident's wound since the visit on 5/6/2016.

Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary condition and failed to store food appropriately during 1 of 3 kitchen observations. The findings include: The initial kitchen tour was conducted on 5/23/2016 at beginning at approximately 10:22 AM in the presence of the Dietary Manager. The hood above the dishwasher was observed to have several quarter or larger size dust accumulations and the inside borders of the hood and a build- up of dirt and debris. Photographic evidence was obtained. Observation of the stand- up freezer revealed 5- 4 ounce ice cream cups with ice on top of them that had previously thawed and froze again. An interview was conducted with the Dietary Manager during the tour and she confirmed the ice creams had previously been on the tray line and should have been discarded. She stated maintenance cleans the dishwasher hood. An interview was conducted with the Maintenance Director on 5/25/2016 at approximately 8:45 AM. He stated the hood above the dishwasher was cleaned semi-annually by maintenance and confirmed it was dirty.

Based on observation, interview and record review, the facility failed to accurately account for and monitor prescribed refrigerated narcotics for 1 of 3 sampled residents (#111) in 1 of 3 locked medication refrigerators that contain controlled medications. The facility had failed to identify a missing vial of Ativan that had been used over a month previously on 4/8/16. The findings are: On 05/26/2016 at approximately 9:18 AM an observation of the refrigerated locked medications on the south wing of the facility was conducted. Upon random selection of the refrigerated narcotics, a count was conducted with the unit manager of south wing, staff B for all three residents on the unit that received refrigerated narcotics. All 3 sampled residents were receiving Ativan which is a schedule four controlled substance that requires refrigeration and is given via intramuscular injection, (IM). A count was conducted on all three randomly selected residents. Resident #111 only had 3 vials of Ativan in the locked refrigerator. On 5/26/16 A record review of resident #111 narcotic medication administration sheet indicated that the resident was to have 4 vials of Ativan via (IM) on hand in the refrigerated narcotic storage. Only 3 unopened vials were observed. On 5/26/16 at approximately 9:34 am, an interview was conducted with the Unit manager on the south wing, staff B, whom stated that she was not aware that the count was incorrect. The count was to be done daily and on each shift and each nurse is to sign that the count is accurate and correct. The unit manger went on to confirm that only 3 vials were present. The unit manager looked on the Electronic Medical Record (EMAR) and confirmed that it was signed out by a night shift nurse, staff C. On 05/26/2016 at approximately 10:00AM an interview was conducted with Staff C, who stated that she was told that she had to come in to sign off on a narcotic that was given on resident #111 on 4/8/16. She stated that a count is done each shift and a sign in and out sheet is on the cart where they have confirmed the count is accurate and when we give medications. She stated, it must have slipped my mind because I know I gave it I just didn't sign it out on 4/8/16. On 05/26/2016 at approximately 10:07 AM an interview was conducted with Staff D, whom stated that the sign in sheet is to indicate that the count is accurate and correct on the medication cart. We don't count them daily. On 5/26/16 at approximately 1: 47PM an interview was conducted with the Director of Nursing (DON) and Pharmacy consultant who both confirmed that the staff did not follow proper protocol they are to sign for and count for all narcotics and that include the refrigerated narcotics as well. A review of ' Controlled Medication Storage ' policy and procedure, dated 12/12, indicated that each shift change or when keys are transferred, a physical inventory of all Scheduled drugs including refrigerated items is conducted by two nurses. All controlled substances should be documented on the controlled substances accountability record or verification of controlled substances count report.

Based on record review, staff interview and facility policy review, the facility failed to ensure that each medical record contained evidence that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of immunizations for 5 of 5 sampled residents (#99, 70, 46, 189, 69). The findings are as follows: A record review was performed of 5 sampled clinical records, #99, 70, 46, 189, 69, for evidence of resident and/or family education of risks versus benefits of the influenza and pneumococcal vaccines. None of the 5 charts contained this information. On 05/26/2016 at 1:30 PM a staff interview was conducted with the Director of Nursing (DON). The DON confirmed that resident charts do not contain evidence of education of the risks versus benefits for the influenza and pneumococcal vaccines. She stated that the education form from the Centers for Disease Control with the risks versus benefits was only given out in the facility Admission Packet.