Every finding on record at Moultrie Creek Nursing and Rehab Center

Based on resident record review, observations, interviews with the resident and staff, and a review of the facility's policy and procedure, the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for one (Resident #17) of two residents reviewed for accident hazards, from a total survey sample of 33 residents. The findings include: An observation was made of Resident #17 on 9/30/2024 at 1:55 PM in his room. He was awake and lying in bed under the covers watching television. During the observation of the resident's room, one shaving razor was observed inside of a plastic container on the bedside table located over the resident's bed. No facility staff were present. (Photographic evidence obtained) On 10/1/2024 at 9:39 AM, Resident #17 was observed again, lying in bed under his covers and watching television. During observations of the surrounding area, one shaving razor (same razor observed the previous day), was still inside of a plastic container on the bedside table next to the resident's bed. No facility staff were present. (Photographic evidence obtained) A return visit and interview on 10/2/2024 at 9:40 AM found that Resident #17 was in his room lying in bed under his covers and watching television. During the observation of the surrounding area of the bed, one shaving razor (same razor observed on previous days) was observed inside of a plastic container on the bedside table next to the resident's bed, and one shaving razor (second shaving razor found) was observed on top of the nightstand behind the resident's oxygen concentrator equipment, next to the bed. (Photographic evidence obtained) When asked if the facility allowed residents to store shaving razors inside their rooms, Resident #17 stated the certified nursing assistants (CNAs) were supposed to remove the razors from the rooms after shaving the residents. No facility staff were present. A review of Resident #17's medical record found that he was admitted to the facility on [DATE] with a previous admission on 6/19/2013. He had diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting his left non-dominant side, anemia, chronic respiratory failure, diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, chronic kidney disease - stage 2, anxiety disorder, cervical disc disorder with myelopathy, and fusion of the spine - cervical region. There was no indication in the record that the resident could safely shave himself. There were no physician's orders permitting Resident #17 to independently engage in personal hygiene tasks such as shaving. A review of the resident's Annual Minimum Data Set (MDS) assessment, dated 9/20/2024, revealed that Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. There were no documented signs of psychosis, behavioral symptoms, or rejection of care. Impairments in both upper and lower extremities, limitations in Activities of Daily Living (ADLs), and a need for substantial to maximal assistance for oral hygiene, toileting, and personal hygiene were also documented. Resident #17's care plan was reviewed on 9/24/2024 (Photographic evidence obtained) and revealed that he was at risk for decreased mobility, skin integrity issues, visual deficits, and communication deficits due to a history of cerebrovascular accident (CVA) with left hemiplegia. The goal was to ensure that he remained free from injury and skin breakdown. Interventions included providing substantial to maximal assistance with bathing, personal hygiene, dressing, nail care, and grooming on a daily basis, and as needed. CNA D was interviewed on 10/03/2024 at 1:45 PM. When asked which supplies were maintained inside of the residents' rooms, CNA D replied, Soap, lotion, and basins are kept in the residents' rooms. When asked where shaving razors or nail clippers were kept, CNA D stated items such as razors and nail clippers were kept in the central supply room. CNA D also stated after the CNAs finished shaving the residents, the razors were removed from the residents' rooms and disposed of inside of a sharps container. An interview was conducted with CNA C on 10/3/2024 at 2:12 PM. She was assigned to Resident #17 on 10/3/2024. When asked which items were allowed to be kept inside of residents' rooms, CNA C stated, Hairbrushes, lotions, basins, blue barrier cream, and items brought by family members such as body wash are allowed to be stored in the rooms. When asked about the process of shaving a resident at bedside, CNA C stated, I bring a razor from the central supply room and assist the resident with the shave. Once finished, I remove the razor from the resident's room and dispose of the razor in the sharps container. CNA C also stated sharps containers were located in the medication administration carts and in the shower rooms. On 10/3/2024, at 2:22 PM, CNA C was accompanied to Resident #17's room and was advised of the observation of the razors. CNA C observed two shaving razors that were left inside of the room: One shaving razor was in a plastic container on the bedside table, and one shaving razor was located behind the oxygen concentrator equipment, next to the bed, on top of the nightstand. CNA C confirmed that the shaving razors should not have been left inside of the resident's room. She acknowledged the oversight and promptly removed both razors from the room for disposal in a sharps container. A review of the facility's policy and procedure titled Procedural Guidelines (effective 1/2023 and updated 9/2023), revealed the following: 18. Tidy environment, remove supplies and store appropriately. A review of the facility's procedural guidelines found no evidence that the facility had established procedures to address sharp objects such as shaving razors and the proper storage and handling of them. (Photographic evidence obtained)

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on three errors from 27 opportunities for error, resulting in an error rate of 11%, and impacting three (Residents #48, #259 and #33) of five residents observed for medication administration, from a total survey sample of 33 residents. Failure to administer medications appropriately as ordered, could result in side effects and/or potential harm to the residents. The findings include: 1. During medication administration observation on 10/2/24 at 8:35 a.m., Licensed Practical Nurse (LPN) A was preparing medication for Resident #48. After reviewing the medication administration record (MAR), she stated she did not have Vitamin D3 1.25 milligrams (mg) equivalent to 5000 international units (IU) that was ordered for the resident. She checked the medication cart and obtained an over the counter (OTC) container of Vitamin D3, stating it was the wrong dosage because it contained Vitamin D3 25 microgram (mcg)(1000IU) tablets (Note: 1000 mcg = 1 mg, therefore 1.25 mg = 1250 mcg or 5 tablets of 25 mcg). On 10/2/24 at 8:47 a.m., LPN A notified Resident #48 that she did not have the Vitamin D3 and she would bring them to him once it was available. She proceeded to the nurses' station and contacted the pharmacy to see when the medication would be delivered. She stated the pharmacy representative explained to her that the medication was an OTC, therefore the facility was responsible for providing it. She then contacted the facility's central supply room and was notified that only Vitamin D3 25 microgram (mcg) tablets were available. LPN A stated she would check with another nurse to see whether she had the medication in her cart. Shortly thereafter, she returned and stated that medication was not available, and she would have to notify the physician to see what he would like to do. A review of Resident #48's active physician's orders revealed an order dated 6/6/24 for Vitamin D3 (Cholecalciferol) 1.25 mg (5000IU) by mouth one time a day (QD) every two weeks on Wednesday as a supplement. 2. During medication administration observation on 10/2/24 at 9:20 a.m., Registered Nurse (RN) B was observed preparing medication for Resident #259. She obtained an Aspirin 81 mg enteric coated (EC) tablet, crushed it, and mixed it with applesauce. She proceeded to the resident's room and administered the medication to the resident. A review of Resident #259's active physician's orders revealed an order dated 9/21/24 for Aspirin EC delayed release 81 mg one time a day for analgesic (pain). In an interview on 10/2/24 at 11:03 a.m., RN B confirmed that the medication was enteric coated and should not have been crushed. 3. During medication administration observation 10/2/24 at 8:23 a.m., Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #33. She obtained the resident's vital signs and reported a blood pressure (BP) of 114/73 millimeters of mercury (mmHg) and a pulse of 114 beats per minute. She reviewed the Medication Administration Record (MAR) and obtained Aspirin 81 milligrams (mg), one tablet of Probiotics, Magnesium 500 mg, Metformin 500 mg, Clopidogrel 75 mg, Lasix 20 mg, Potassium 10 milliequivalent (mEq), and Protonix 40 mg from the medication cart. She stated she would be holding the Nifedipine 60 mg and Atenolol 25 mg because of the low blood pressure reading. She went to the resident 's room, administered the medication and notified the resident that she was holding her blood pressure medication because her blood pressure was low. A review of Resident #33's active physician's orders revealed an order dated 7/16/24 for routine Atenolol 25 mg one time a day for hypertension (high blood pressure) and routine Nifedipine Extended Release (ER) 24 hours 60 mg one time a day for blood pressure. In an interview on 10/2/24 at 8:47 a.m., LPN A was asked if the medication she held included parameters for when it should be held. She replied, No. She was then asked if she had an order to hold the medication and again, she answered, No, I was just using nursing judgement. She added that she normally held the medication when the resident had a systolic blood pressure (SBP) of less than 120 mmHg. During an interview on 10/3/24 at 2:48 p.m., the Director of Nursing (DON) confirmed that medication should not be held unless there is an order to hold it. If there were concerns with a resident's vital signs and the resident had scheduled medication, the expectation was that the nurse should notify the resident's physician. A review of the facility's policy and procedure titled Medication Pass and Med Pass with Medication Cart (Effective 1/2023, Updated 8/14/2024), revealed: Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systemically distribute medications to residents in accordance with state and federal guidelines. Fundamental Information: Physicians' Orders: Medications are administered in accordance with the written orders of the attending physician. If the dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, contact the physician for clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate.

Based on observations, staff interviews, and a review of policies and procedures, the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure staff served food in a sanitary manner during two of two dining observations (lunch meals on 11/14/22 and 11/16/22) affecting Residents #34 and #18. The findings include: An observation of the lunch meal was conducted in the main dining room on 11/14/22 beginning at 11:57 AM. Certified Nursing Assistant (CNA) B was observed placing butter on Resident #34's roll using her bare hands. At 12:12 PM, CNA B used her bare hand to remove bread from a package (touching the bread with her bare hand) for Resident #49. Another lunch meal observation was made on 11/16/22 at 12:02 PM on the 100 hallway. CNA B was observed serving Resident #18 her meal tray. CNA B touched the roll on the lunch tray with her bare hand to place butter on the roll. An interview was conducted with CNA B on 11/16/22 at 12:03 PM. She stated she had recent training regarding safe food handling, and she probably should not have touched the bread with her bare hand. An interview was conducted with the Director of Nursing (DON) on 11/16/22 at 12:08 PM. The DON stated it was not acceptable for staff to handle food with bare hands. A review of the facility's policy for Serving Foods (SHCO30001.13, revised 2/21/17) revealed the purpose was to serve foods at the proper temperatures, attractively, and under sanitary conditions. .

Based on observations, interviews and record reviews, the facility failed to implement an effective infection control program, by failing to 1) Ensure staff followed infection control guidelines for hand hygiene during wound care for one (Resident #26) of two residents sampled for pressure ulcers, 2) Prevent cross contamination during catheter care for one (Resident #17) of one resident sampled for catheter care, 3) Ensure that the infection control committee was fully involved in the infection control program by offering feedback on infection control concerns during monthly meetings, and 4) Investigate an increase in urinary tract infections for one of two months available for review (October 2022). The findings include: 1. On 11/16/22 at 11:28 AM, an observation was made of Licensed Practical Nurse (LPN) A performing wound care for Resident #26. LPN A performed hand hygiene, applied clean gloves, removed the soiled dressing, removed her gloves, washed her hands, applied clean gloves, and then cleaned the wound. LPN A then applied the clean dressing without changing gloves or washing hands. LPN A proceeded to apply barrier cream to the peri-area without changing gloves or washing hands. On 11/16/22 at 11:50 AM, an interview was conducted with LPN A. When asked if LPN A changed her gloves and washed her hands between cleaning the wound and applying the clean dressing, she stated, No, I did not. When asked if LPN A changed her gloves and washed her hands after applying the dressing and applying barrier cream to the peri-area, she replied, No, I did not. LPN A confirmed that this could be an infection control issue. On 11/16/22 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated her expectation of the nurses was that they should wash their hands, apply gloves and remove the soiled dressing, then wash their hands and apply gloves, clean the wound from the inside out, wash their hands, apply gloves, and apply a dressing as per the facility's policy. On 11/16/22, a review was conducted of the facility's policy titled Clean Dressing Change, last revised on 11/28/2017, which revealed under Purpose: To ensure the licensed nurse or therapist completes dressing change in accordance with State and Federal Regulations, and National Guidelines. Under Procedure: 23. Cleanse wound as ordered with single outward strokes and using separate gauze for each cleansing wipe. 24. Use dry gauze or other ordered supply to pat the wound dry, as needed. 25. Discard any used gauze for cleaning/drying in resident's trash, as needed. 26. Remove gloves. 27. Hand hygiene. 28. Don gloves. 29. Apply clean dressing as ordered and ensure dressing is dated. 30. Remove gloves. 31. Hand hygiene. 32. Hand hygiene. etc. 2. On 11/16/22 at 4:00 PM, an observation was made of Certified Nursing Assistant (CNA) D providing catheter care to Resident #17 with the assistance of CNA E. At the start of the observation, Resident #17's brief was loosened and tucked under his left side. CNAs D and E assisted the resident onto his right side. The brief was noted to be slightly soiled with a dark brown substance. CNA D instructed CNA E to get a new brief for the resident. Upon returning to the bed, CNA E proceeded to place the new brief on top of the soiled brief without attempting to remove the old brief. CNA E then informed CNA D to remove the old brief. The old brief was removed, however the new brief was left under the resident. At this time, the resident was rolled onto his back and CNA D left to gather supplies, leaving the resident uncovered with his genitals exposed. CNA D returned to the bedside with a basin of soapy water, two wash cloths and a package of disposable wipes. He then dampened the first washcloth in the basin and began to clean the catheter tubing in a back-and-forth motion from the tip of the penis down the tubing then back up the tubing toward the penis. CNA D discarded the cloth, changed his gloves, dampened the second wash cloth in the basin and washed the resident's genital area starting at the pubic bone, down between his right thigh and the right testicle, across the pubic bone, down between the left thigh and the left testicle, and then down the penis shaft and over the head of this penis. CNA D then wiped down the catheter tubing away from the penis. At no point did CNA D change the cloth or use a different area of the cloth. On 11/16/22 at 4:20 PM, an interview was conducted with CNA D. He stated during catheter care, you wash the head of the penis and the shaft, and then down the tubing starting with the cleanest field possible. He further stated that you start at the top and work your way down the penis. He then verified that the new brief was placed on top of the soiled brief and should have been changed out. On 11/17/22 at 9:00 AM, an interview was conducted with the Director of Nursing (DON), who stated that it was her expectation that during catheter care the staff member would clean down the tubing away from the penis and use a new cloth or another area of the washcloth to clean the genitals. She stated it was never okay to start at the top and work your way down the penis. The DON provided a copy of an in-service dated 9/2/22 titled Peri Care/E-Coli/UTI Prevention. CNA D signed as having attended. Attached to the sign-in sheet was a copy of the Perineal and Catheter Care training offered in the facility's online education program. Under the section titled Catheter Care it stated, Start by cleansing around the urethral meatus, which is the catheter's point of insertion, using a downward motion. Repeat this process to clean the entire perineum as described above. Remember to use a clean part of the washcloth with each stroke. Using a clean washcloth, cleanse the catheter itself starting at the urethral meatus working your way down the catheter about four inches or further if visibly soiled. Under the section titled Cleansing the Genital Area for males it stated, Grasp the penis and clean the tip using a circular motion starting at the urethral opening and working outward. Repeat until the area is clean moving down the shaft of the penis to the scrotum and inner thighs. Remember to use a clean part of the washcloth for each stroke to prevent contamination. A review of the policy SHCRC20007.06, Indwelling Catheter Care, last revised on 3/26/2019, stated on page 2, item #11, Clean by wiping away from the urinary meatus and not towards the urinary meatus. 3. On 11/17/22 at 9:00 AM, an interview was conducted with the DON, during which she stated that the infection preventionist had been out for several weeks due to an injury, and that she had been working in the role until his return a few weeks ago. She stated she had identified an increase in urinary tract infections (UTI) for the Month of October and felt this was due to the Medical Director ordering Urinalysis (UA) on any resident noted to have confusion. She stated she spoke with him a few nights ago about the need to have more than confusion to order a UA. She was asked if she had done any staff education as a result of the increase or if the infection control committee had made other recommendations. She stated the infection control committee met monthly at the beginning of each month and was made up of the department heads and a nurse and a CNA she pulled off the floor. She stated she only reported the infection rates for the previous month, and that she did all the talking and they just listen to me. She stated she had conducted an in-service in September for UTI Prevention and felt that the increase in UTIs for October was skewed, because everyone would test positive for a UTI if they were to have a UA every time they got confused. She stated the issue was systemic and not the fault of staff or care concerns. She stated she had not conducted audits of staff performing catheter or perineal care. She also stated that she was behind in the documentation related to tracking and trending of infections in the facility and that the data was available but was not always mapped out. She handed the surveyor two maps of the facility for what she stated were September and November. The maps identified each resident room and any room with an identified infection was highlighted using a color system on a key in the bottom left-hand corner of the documents. UTIs were highlighted in pink. Neither document had a month written on it to identify what month was being mapped out. When asked how she could tell what month the maps represented, she stated she would compare the map to the Monthly Infection Prevention & Control Summary Report. It was then when she realized the map she reported for September was actually for October, and she then wrote the month on the bottom of the map. She reported that she did not have a map for September but could make one quickly if needed. At this time, the DON provided a copy of the Monthly Infection Prevention & Control Summary Report for October 2022, which stated that the UTI (Urinary Tract Infection) rate for the facility was 14.2% in October, up from 2.1% in September, 2.8% for August and 2% in July. A review of the facility floor map dated for October for Healthcare Acquired Infections (HAI) revealed that of the 9 UTIs identified in October, 7 were on the south hall where the observation of catheter care had been conducted the previous afternoon in which concerns had been identified. When shown the map that identified increased concerns on the south hall, she stated, I did not catch that and I take full responsibility for that. A review of the policy Infection Prevention and Control Program, last revised in October 2018, revealed it read that the Infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Under item 11. Prevention of Infection (3) educating staff and ensuring that they adhere to proper techniques and procedures.

Based on record reviews and interviews, the facility failed to provide treatment in accordance with professional standards of practice for one (Resident #58) of 34 sampled residents, by failing to hold a medication for five days prior to a scheduled procedure, as ordered, requiring the procedure to be rescheduled for a later date. The delay resulted in the resident being transferred to the hospital for care prior to her rescheduled surgery date. The findings include: In an interview on 3/30/2021 at 11:29 AM with Resident #58's the niece (Health Care Proxy), she stated, My aunt was scheduled for a procedure about two weeks ago, but the facility forgot to hold her aspirin prior to the procedure, and this caused the procedure to be put off for another week. My aunt ended up having to go out to the ER (emergency room ) because of the procedure being delayed, because she was vomiting coffee grounds. A review of Resident #58's electronic medical record (EMR), revealed nursing progress notes which stated: Progress note: 3/11/2021: Resident returned to facility from appt. at approx 1700 (5:00 PM). New appt. 3/19/21 10 AM for upper endoscopy. Resident to be there at 8:30. Hold aspirin 5 days prior to appt. NPO (nothing by mouth) after midnight on 3/19/21. Can have clear liquid diet 3 hours prior to appt. Follow up appt. 4/1/21 at 11:45 AM. Progress note: 3/17/2021: Cancel appt. upper GI (gastrointestinal) for 3/19 and change to 3/24, NPO after mn (midnight) and clear liq (liquids) up to 3 hours prior to arrival time at 8:30. Stop clear liq at 5:30 AM, only 1/2 insulin morn (morning) of procedure. Trans slip in and niece notified. See instructions in chart. Progress note: 3/22/2021: New orders per Doctor, send to ER for GI bleed. Resident has had no further vomit at this time. Family notified. A review of the medication orders in the EMR revealed only one order, dated 3/19/2021, to hold the resident's aspirin dose: 3/19/2021: Aspirin 81 mg (milligram) tablet (chewable): one time only: hold aspirin x 5 days for surgery procedure 3/24/2021. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It was signed off as held on March 17, 2021. It was signed off as given on March 18 and 19, 2021. It was signed off as held on March 20, 21, 22 and 23, 2021. The dose was discontinued on March 24, 2021. On 4/1/2021 at 10:21 AM, in an interview with the ADON, she was asked if she had any grievances or medication variances for Resident #58 related to her not having her aspirin 81 mg held for five days in March per the March 11, 2021 progress note mentioned above. She replied, Let me go see what I can find on that. I'm not familiar with Resident #58's occurrence. On 4/1/2021 at 11:10 AM, the ADON returned and stated, Okay, I just looked into this. Resident #58 was supposed to have her aspirin held for five days prior to a GI procedure on March 19th. It wasn't held, so it had to be rescheduled for March 24th, but on March 22nd she had some GI bleed symptoms and she was sent to the ER. The aspirin was on hold at that point for the March 24th procedure. I just called her niece to make sure she was aware that this happened, and she was. When asked whether a medication variance report was generated, she replied, Yes, I'll print you a copy. (Copy obtained) A review of the Medication Variance Report for Resident #58, dated 3/17/2021, read: Nursing description: Omission of order to hold aspirin for GI procedure. Resident description: Resident unable to give description. Immediate action taken: MD and family notified. GI procedure rescheduled for 3/24/2021. Though the facility documented on 3/17/2021 that the aspirin 81 mg had not been ordered or held per the 3/11/2021 progess note/order, and the appointment was rescheduled for 3/24/2021 with an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . The surgery appointment was delayed due to the facility's failure to hold medication as ordered, and the resident had to be sent to the hospital for care prior to her rescheduled surgery date as a result. (Copies obtained of all documentation noted above.)

Based on record review, observations, and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #63) resident in a total sample of 34 residents. The findings include: A review of Resident #63's medical record, revealed and admitted [DATE], with a primary diagnosis of [CONDITION(S)] and [CONDITION(S)] following CVA (cerebrovascular accident - stroke). The secondary diagnoses included visual loss in the right eye, spondylosis and right hand contracture. The resident's cognition was impaired and she required extensive assistance with activities of daily living, including toileting and transfers. During a tour of the facility on 3/31/2021 at 2:58 PM, Resident #63 was overheard from the hallway yelling for help. Upon entering the room, the resident was observed yelling for help while sitting on the toilet in her bathroom. The room's call light was then triggered by the resident's roommate. On 3/31/2021 at 3:05 PM, two employees, identified as certified nursing assistants (CNA), were observed walking down the hallway and entering each room while giving verbal report. Resident #63 continued to yell for help and her call light was on outside of her room. The employees did not acknowledge the call light or the resident's verbal pleas for assistance. On 3/31/2021 at 3:08 PM, Employee G, CNA, was asked to check on the resident, as she had been yelling for assistance for approximately ten minutes. The employee explained that the resident was able to use the call cord in the rest room. She then entered the room. The CNA exited the room and exclaimed, That wasn't the resident I thought it was! That resident is actually blind and she can't pull the call cord. She is blind and has half a skull. She should never be left unattended! On 3/31/2021 at 3:10 PM, Employee H, CNA, entered Resident #63's room. She was the resident's assigned CNA. Upon exiting the room, Employee H stated, I could do it if we had more staff. Then we wouldn't have to run around like chickens with our heads cut off. A review of the resident's comprehensive care plan revealed a focus area for bowel and bladder incontinence. The care plan indicated the resident's incontinence placed her at risk for falls. An intervention on the care plan directed staff to remain with the patient during toileting to ensure safety. (Photographic evidence obtained) On 4/1/2021 at 2:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). She was asked to explain how staff accessed the care information specific to each resident. She explained that the facility's process was for direct-care staff to use the Kardex for each resident, and that the staff were required to sign off on the care they provided each shift. The ADON confirmed that if a resident's care plan directed staff to remain with the patient during toileting, the resident should not be left alone while toileting.

Based on observation, interviews and record review, the facility failed to maintain complete, documented medical records for two (Residents #13 and #40) of 34 sampled residents , by failing to document apical pulses for [MEDICATION(S)] and blood pressures and heart rates for [MEDICATION(S)] and Carvediolol. The findings include: 1. A record review was conducted for Resident #13, which noted an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current Medication Administration Record (MAR) revealed that [MEDICATION(S)] and [MEDICATION(S)] were given daily with no blood pressures or heart rates documented. (Photographic evidence obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 3/31/2021 at 2:11 PM. She was asked to review the current MAR. The ADON reviewed the current MAR and confirmed the [MEDICATION(S)] and [MEDICATION(S)] had parameters which were not documented on the MAR. She confirmed the heart rates and blood pressures were missing. 2. A record review was conducted for Resident #40, which noted an admitted [DATE] and a re-entry date of 11/17/2020, with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current MAR, noted [MEDICATION(S)] 125 mcg (micrograms) daily, dated 8/24/2018, for heart disease, with no apical pulses documented. An interview was conducted with Employee D, Registered Nurse (RN), at 8:40 AM on 3/31/2021, while observing medication administration. The RN reported that when physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the ADON on 3/31/2021 at 2:03 PM. She reviewed the current MAR, and confirmed that apical pulses were not documented for the [MEDICATION(S)]. The ADON confirmed apical pulses should be taken and documented before administering [MEDICATION(S)]. The ADON corrected the MAR and added apical pulse to the [MEDICATION(S)] order. She also reported the resident required monthly vital signs. An interview was conducted with the ADON on 3/31/2021 at 4:30 PM. She reported that the resident had not had apical pulses documented since July 2020. (Photographic evidence obtained) A review of the policy and procedure for Medication Pass Guideline (Revised on 4/25/2017), noted the following under physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Under Procedure 6:If applicable and or prescribed, take vital signs or tests prior to administration of dose (pulse with [MEDICATION(S)], blood pressure with anit-hypertensive) use.

Based on observation, clinical record review, and staff interviews, the facility failed to implement the comprehensive person-centered care plan for 1 (Resident #251) of 2 residents reviewed for intravenous (IV) therapy, of 3 residents in the facility receiving IV medication. The findings included: Resident #251 was observed on 3/25/19 at 10:53 AM in his room. A translucent bandage, approximately 4 x 5 inches in size was observed on the inner aspect of his right upper arm. In the center of the dressing underneath the transparent bandage was a 2 inch piece of white material resembling gauze or [MEDICATION NAME] (a non-stick bandaging material). A small amount of light brown drainage was observed soaking thorough the gauze-like pad. The bandage was dated 3/13/19. Resident #251 stated he had a kidney infection and pneumonia, and received IV antibiotics 3 times daily. Observation of the empty IV bag hanging on the pole next to his bed revealed it was labeled [MEDICATION NAME] Injection, USP 2g (grams)/100 ml (milliliters). An IV pump was installed on the pole. Resident #251 was observed in his bed on 3/25/19 at 2:20 PM. The IV pump was now running at 100 ml/hour. The bandage over the IV insertion site was observed to be in the same condition described above, dated 3/13/19. Resident #251 stated he had asked the nurse to change his bandage but nobody had. With verbal consent from the resident at this time, he pulled up his shirt sleeve, and photograph evidence was obtained. On 3/26/19 at 12:14 PM, Resident #251's IV site was observed with a clean, white and unstained pad underneath. It was dated 3/25/19. Resident #251 confirmed his nurse changed it. Review of the clinical record found Resident #251 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An initial skin assessment dated [DATE] noted Resident #251 had a right upper arm midline (a catheter inserted into into a large vein for IV therapy), and scattered bruises. The assessment did not include documentation of the condition of the midline site dressing. Review of the physician's orders [REDACTED]. The order was dated 3/13/19. Review of Resident #251's care plan related to infection UTI/bacteremia found the goal was the infection will be resolved without complications through next review. Interventions included: Midline: right upper arm/measure arm circumference at site every week with dressing change . Review of the corresponding Treatment Administration Record (TAR) for the catheter site dressing change found it was signed off as completed on 3/13/19 by Registered Nurse/Employee I. It was signed again as completed on 3/20/19 by Licensed Practical Nurse (LPN)/Employee A. The corresponding box for the dressing change performed on 3/25/19 was not signed off as completed, although the new dressing was dated 3/25/19. An interview was conducted with LPN/Employee A, on 3/27/19 at 12:43 PM. He stated he changed Resident #251's midline dressing most recently on 3/25/19. When asked why this was not signed off on the TAR, he stated he may have noted in the nursing progress notes instead of the TAR. When asked to explain how he signed the TAR indicating he changed the dressing on 3/20/19, but on 3/25/19, the dressing was still dated 3/13/19, LPN/Employee A had no explanation. Review of nursing progress notes found no documentation of the midline dressing changes on either 3/20/19 or 3/25/19. .

Based on observations, resident, facility and hospice record reviews and staff interviews, the facility failed to obtain a copy of the hospice comprehensive person-centered care plan in order to ensure treatment and services were coordinated and delivered in accordance with the end of life plan of care for 1 (Resident #60) of 1 resident reviewed for hospice and end of life services. The findings included: Resident #60 was observed on 3/26/19 at 8:52 AM in her bed. An over-bed table was in front of her, with a large uneaten breakfast. When asked how she was, Resident #60 weakly and softly replied Not good. She began to cry. On 3/26/19 at 4:02 PM, Resident #60 was observed in her bed. The Hospice Registered Nurse (RN) was at her bedside providing mouth care. The Hospice RN explained Resident #60 was declining. She had been tearful and there are various psychosocial and family issues the team has been dealing with. A prescription for [MEDICATION NAME] (anti-depressant) was obtained about a week or so ago to help with the tearfulness. Today she was put on [MEDICATION NAME] (a liquid version of the narcotic used to treat moderate to severe pain), since she was not eating. Resident #60's [MEDICATION NAME] (anti-anxiety) was increased, and [MEDICATION NAME] (a narcotic for moderate to severe pain) started today. A Hospice aide came in twice a week, but they were considering increasing the visits. Resident #60 responded well to attention and to company. The Hospice RN believed the Hospice Chaplain came in once a month, and would come more often with a decline, or upon request. There was a Hospice binder in the facility and all of her notes were copied and filed there. An interview was conducted with Resident #60 on 3/27/19 at 9:55 AM. She was in her bed, awake and alert. She started crying. When asked if she was in pain, she said, Yes, my legs. She reached up for a hand to hold, and cried, repeatedly asking to go home. Please help me go home. Certified Nursing Assistant (CNA)/Employee B came in after a couple of minutes and greeted Resident #60. She took the resident's hand, who then instantly quieted with the hand holding. She remained quiet for several minutes, then resumed crying and began begging for help, asking to go home. An interview was conducted with CNA/Employee B on 3/27/19 at 10:00 AM. She explained Resident #60 was declining. All she wanted was to go home and to have company and physical contact with people. When she cried, CNA/Employee B just tried to comfort her and hold her hand. She began to decline soon after admission and has started to become contracted into a fetal position. CNA/Employee B felt Resident #60 was giving up. Resident #60's daughter came for visits but only cried when she did, which did not help. She believed the Hospice staff came in daily or every other day. She had no awareness of any spiritual support or visits in place for this resident. She said since Resident #60's contractures were worsening in her lower extremities, and she no longer liked to get out of bed. Care was difficult due to lower extremity pain. Resident #60 no longer ate or drank much at all and had not urinated on her shift, other than a very scant amount, in 3 days. CNA/Employee B stated resident's care plans were in the care plan book at the nurse's station. CNA/Employee J was interviewed on 3/28/19 at 10:19 AM. She stated Resident #60 no longer liked to get out of bed due to pain. As long as there was a person with her she remained calm. Resident #60 wanted to hold hands, and was tearful and depressed. She started declining over the last month, and since then she just really wanted someone to be with her. Yesterday, Resident #60's daughter came in to feed her, but Resident #60 only took 2 bites. She was not eating much any more. CNA/Employee J concluded by reporting Resident #60's daughter cried the entire time when she came to visit her mother. An interview was conducted on 3/28/19 at 10:25 AM with Licensed Practical Nurse (LPN)/Employee C. She reported Resident #60 was on Hospice, and was in the process of transitioning (entering the final stage of dying). She had stopped eating. The Hospice nurse was in frequently and verbally communicated with LPN/Employee C regarding issues with Resident #60. A record review for Resident #60 revealed an Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/22/19. Resident #60 was assessed with [REDACTED]. It was very important for Resident #60 to have a family member or close friend involved in discussions about her care. She required extensive assist with activities of daily living (ADLs), and supervision with eating. [DIAGNOSES REDACTED]. She was coded as having a terminal illness that resulted in a life expectancy of less than 6 months, and was on Hospice. Resident #60 was care planned on 2/26/18 for for palliative care and Hospice, related to a [DIAGNOSES REDACTED]. The goal was for dignity and autonomy to be maintained at the highest level. Interventions included to adjust ADL provision to compensate for her changing ability, assess coping strategies and respect resident wishes, encourage support, provide a quiet calm environment, and work cooperatively with the Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Review of the care plan conference signature sheet dated 2/18/19 found there was no indication a member of the Hospice team was in attendance. Resident #60's clinical record included a Hospice Physician's Plan of Care dated 2/15/19 (the date of admission to Hospice Services), which detailed her medication treatment. There was a summary of all Hospice staff visits, but the last entry was dated (MONTH) 26, 2019; one month earlier. Further review of the clinical record found no Hospice person-centered plan of care that detailed the scope and frequency of the services the Hospice team would provide, the resident's choices for end of life support, or the treatment objectives and goals to ensure her highest attainable well-being. An interview was conducted with Registered Nurse (RN)/Employee K, on 3/28/19 at 10:50 AM. When asked where Resident #60's Hospice care plan might be, she stated all Hospice records should be in her chart. An interview was conducted with North Wing Unit Manager(NWUM)/Employee D, on 3/28/19 at 11:21 AM. She was asked where Resident #60's Hospice plan of care was located, and how the facility and Hospice staff coordinated the care plan goals. She was not able to state where the Hospice plan of care was or what the Hospice goals were for this resident. She stated the Hospice nurse, facility, and physician communicated verbally regarding issues pertinent to the resident. NWUM/Employee D did not know if the Hospice nurse had the plan of care for this resident, or why the visitation notes did not extend beyond (MONTH) 26, 2019. LPN/Employee C joined the conversation. When asked how she knew what the individual Hospice plan of care goals were, she stated she and the nurse talk face-to-face about what were the resident's needs or conditions. An interview was conducted with the Hospice Social Worker (SW) on 3/28/19 at 11:53 AM. She stated the Hospice patients comprehensive plans of care were generated in the Sun Coast system's electronic charting. She stated her Hospice organization, for some reason, did not put the plan of care on the facility's charts. The Hospice SW said a representative of their organization would attend care plan meetings, if invited. She acknowledged the importance of the coordination of the care plan goals and services between the Hospice and the facility. Review of the Hospice Nursing Facility Service Agreement executed on 3/1/10 and signed by the facility administrator on 3/8/10 included a First Amendment to Nursing Facility Service Agreement effective 3/17/15. It noted a new paragraph 3.6.7 was added to the agreement as follows: 3.6.7 Facility Coordinator. Facility shall appoint a member of facility's interdisciplinary team who has a clinical background . as Facility Coordinator. Facility Coordinator shall be responsible for obtaining: (i) a copy of the most recent Hospice Plan of Care. Section 3. Hospice Responsibilities: (c) Verification of Regulatory Requirements. Hospice shall verify compliance with the requirement of the Agreement and this Addendum . The method of verification by Hospice may include audits and review of one or more of the following: (i) Copy of Hospice Plan of Care. Hospice shall document in the Hospice patient record that the Hospice Plan of Care has been provided to the facility . An interview was conducted with the Administrator on 3/28/19 at 1:48 PM. He reviewed the Amendment, and confirmed per the agreement, the facility was required to obtain a copy of the Hospice plan of care. He acknowledged the challenges in coordinating care plan goals if the facility did not have access to the Hospice care plan.

Based on observation, facility records review and staff interview, the facility failed to ensure the nutritional supplements kept in 1 (North Wing) of 2 nourishment refrigerators in the facility were stored in accordance with professional standards for food service safety. The findings included: During an observation of the North Wing Nourishment refrigerator on [DATE] at 4:00 PM, 17 bottles of Ensure Plus nutritional supplements were found with an expiration date of (MONTH) 1, 2019. An opened container of Bologna cold cuts was not dated was located in the refrigerator. An interview was conducted with the North Wing Unit Manager(NWUM)/Employee D at 4:06 PM on [DATE]. She explained the bottles of Ensure were supplied by the Hospice program and she was not aware they had expired. The package of Bologna belonged to one of the male residents and NWUM/Employee D failed to date the package for when it was opened. Per review of the facility policy, food brought into facility for residents should be kept for 72 hours. The lack of the opened date precludes staff from determining the shelf life of the food.

Based on observation, clinical record review, and staff interviews, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices, and that were complete and accurately documented for 2 of 2 residents reviewed for intravenous (IV) therapy (Residents #251 and #350), out of 3 residents in the facility receiving IV medication, and of a total of 33 sampled residents. The findings included: 1. Resident #251 was observed on 3/25/19 at 10:53 AM in his room. A translucent bandage, approximately 4 x 5 inches in size was observed on the inner aspect of his right upper arm. In the center of the dressing underneath the transparent bandage was a 2 inch piece of white material resembling gauze or [MEDICATION NAME] (a non-stick bandaging material). A small amount of light brown drainage was observed soaking thorough the gauze-like pad. The bandage was dated 3/13/19. Resident #251 stated he had a kidney infection and pneumonia, and received IV antibiotics 3 times daily. Resident #251 was observed in his bed on 3/25/19 at 2:20 PM. The bandage over the IV insertion site was observed to be in the same condition described above, dated 3/13/19. Resident #251 stated he had asked the nurse to change his bandage but nobody had. With verbal consent at this time, photograph evidence was obtained. On 3/26/19 at 12:14 PM, Resident #251's IV site was observed with a clean, white and unstained pad underneath. It was dated 3/25/19. Resident #251 confirmed his nurse changed it. Review of the clinical record found Resident #251 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An initial skin assessment dated [DATE] noted Resident #251 had a right upper arm midline (a catheter inserted into into a large vein for IV therapy), and scattered bruises. Resident #251 had a physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for the catheter site dressing change revealed it was signed off as completed on 3/13/19 by Registered Nurse (RN)/Employee I. It was signed again as completed on 3/20/19 by Licensed Practical Nurse (LPN)/Employee A. The corresponding box for the dressing change performed on 3/25/19 was not signed off as completed, although the new dressing on Resident #251 was observed to be dated 3/25/19. An interview was conducted with LPN/Employee A, on 3/27/19 at 12:43 PM. He stated he changed Resident #251's midline dressing most recently on 3/25/19. When asked why this was not signed off on the TAR, he stated he may have noted in the nursing progress notes instead of the TAR. When asked to explain how he signed the TAR indicating he changed the dressing on 3/20/19, but on 3/25/19, the dressing was still dated 3/13/19, Employee A had no explanation. Review of nursing progress notes found no documentation of the midline dressing changes on either 3/20/19 or 3/25/19. 2. On 03/25/2019, at 10:49 AM. a peripherally inserted central catheter (PICC) line was observed in Resident #350's right upper arm with the medication Ertapenem Sodium infusing at 100 milliliters an hour via a single lumen. Resident #350 reported she was admitted last Friday to the facility from the hospital and she was receiving treatment for [REDACTED]. A medical record review was completed and it was documented Resident #350 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Per Mayo Clinic, a peripherally inserted central catheter (PICC) line is a catheter that is inserted into a peripherally vein in the arm that is guided into a large blood vessel that leads to the heart (https://www.mayoclinic.org/diseases-conditions/cancer/multimedia/picc-line-placement/vid- 657). A Licensed Practical Nurse (LPN) may perform intravenous therapy via central lines with the appropriate education/training of a minimum of 4 hours of central line instruction included in a 30 hours of intravenous therapy education under the direction of a registered professional nurse (www.flrules.org-64B9-12.005 F.A.C.) A review of the physician orders [REDACTED]. Physician orders [REDACTED]. A review of (MONTH) 2019 electronic-Medication Administration Record [REDACTED]. During the night shift on (MONTH) 26, 2019, it was documented the normal saline flush was performed by LPN/Employee G. A personnel file review conducted for LPN/Employee G found she had no intravenous therapy (IV) or central line certification. An interview was conducted with the Staff Development Coordinator (SDC)/Employee H on 03/28/2019, at 09:45 AM and she reported Employee G was a LPN. She confirmed LPN/Employee G was not intravenous therapy (IV) or central line certified. SDC/Employee H reported LPN/Employee G did not flush the PICC line during the night shift on (MONTH) 26, 2019, even though LPN/Employee G signed in the e-MAR she performed the task. SDC/Employee H reported the RN who performed the task of flushing the PICC line for LPN/Employee G was unreachable to confirm the above statement because she was out-of-state with family. A written Event/Interview statement was provided by SDC/Employee H from LPN/Employee G. It stated LPN/Employee G did not flush the PICC line. The written statement documented an RN performed the task of flushing the PICC line, and LPN/Employee G accidentally signed-off on the TAR.

Based on observation, clinical record review, and staff interviews, the facility failed to provide timely dressing charges to ensure infection prevention for 1 (Resident #251) of 2 residents reviewed for intravenous (IV) therapy, of 3 residents in the facility receiving IV medication. The findings included: Resident #251 was observed on 3/25/19 at 10:53 AM in his room. A translucent bandage, approximately 4 x 5 inches in size was observed on the inner aspect of his his right upper arm. In the center of the dressing underneath the transparent bandage was a 2 inch piece of white material resembling gauze or [MEDICATION NAME] (a non-stick bandaging material). A small amount of light brown drainage was observed soaking thorough the gauze-like pad. The bandage was dated 3/13/19; 14 days earlier. Resident #251 stated he had a kidney infection and pneumonia, and received IV antibiotics 3 times daily. Resident #251 was observed in his bed on 3/25/19 at 2:20 PM. The IV pump was running at 100 milliliters (ml)/hour. The bandage over the IV insertion site was observed to be in the same condition described above, dated 3/13/19. Resident #251 stated he had asked the nurse to change his bandage but nobody had. With verbal consent from the resident at that time, he pulled up his shirt sleeve, and a photograph evidence was obtained. On 3/26/19 at 12:14 PM, Resident #251's IV site was observed with a clean, white and unstained pad underneath. It was dated 3/25/19. Resident #251 confirmed his nurse changed it. Review of the clinical record found Resident #251 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An initial skin assessment dated [DATE] noted Resident #251 had a right upper arm midline (a catheter inserted into into a large vein for IV therapy). Review of the physician's orders [REDACTED]. The order was dated 3/13/19, the day after admission. Review of Resident #251's care plan related to infection UTI/bacteremia found the goal was the infection will be resolved without complications through next review. Interventions included: Midline: right upper arm/measure arm circumference at site every week with dressing change . Review of the corresponding Treatment Administration Record (TAR) for the catheter site dressing change found it was signed off as completed on 3/13/19 by Registered Nurse (RN)/Employee I. It was signed again as completed on 3/20/19 by Licensed Practical Nurse (LPN)/Employee A. The corresponding box for the dressing change performed on 3/25/19 was not signed off as completed, although the new dressing was dated 3/25/19. An interview was conducted with LPN/Employee A, on 3/27/19 at 12:43 PM. He stated he changed Resident #251's midline dressing most recently on 3/25/19. When asked to explain how he signed the TAR indicating he changed the dressing on 3/20/19, but on 3/25/19, the dressing was still dated 3/13/19, LPN/Employee A had no explanation. Review of nursing progress notes found no documentation of the midline dressing changes on either 3/20/19 or 3/25/19. Review of the facility pharmacy's policy and procedure provided titled 4.10 Midline Catheter Dressing Change last revised (MONTH) 1, 2012, found the following: Considerations: 1. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Guidance: 1. Sterile dressing change using transparent dressings is performed: 1.1 24 hours post-insertion of upon admission. 1.2 At least weekly. An interview was conducted with the Director of Nursing on 3/28/19 at 4:33 PM. She reviewed photographic documentation of Resident #251's soiled bandage dated 3/13/19, and confirmed it was a transparent dressing over gauze. She acknowledged the policy and procedure instructed it should be treated as a gauze dressing and changed every 2 days. The South Wing Unit Manager (UM) joined the conversation. She reviewed the photographic documentation and confirmed the transparent over gauze dressing. The South Wing Unit Manager acknowledged the guidance in the policy. The The South Wing Unit Manager confirmed the physician's orders [REDACTED].

Based on observations, interviews, and record review, the facility failed to provide the texture consistency specifications for 17 residents with an order for [REDACTED].#19, #37, #41, #48, #51, #59, #83, #85, #99, #102, #132, #145, #182, #199, #238, #239, and #240). The findings include: During the comprehensive kitchen tour on 3/29/2017 at 7:40 a.m., an observation was conducted of the food tray line as one of the 17 pureed breakfast trays were prepared. The pureed breakfast tray consisted of regular oatmeal, pureed eggs, pureed sausage patty, and pureed bread. A closer examination of the oatmeal revealed the oatmeal consisted of lumpy chucks of oats and pieces of oat husk. During a follow up kitchen tour on 3/30/2017 at 7:30 a.m., an observation was conducted of the food tray line for breakfast, which included regular oatmeal. A sample test tray of a pureed breakfast tray included regular oatmeal. A finger test revealed the oatmeal with chunky pieces of oats, husk, and quarter size lumps. Interview with the Dietary Manager (DM) on 3/29/2017 at 7:45 a.m. confirmed the consistency of the oatmeal served. She stated residents on a pureed diet have regular oatmeal with breakfast, and the Speech Therapist gave the okay for residents on a pureed diet. Follow up interview with the DM on 3/30/3017 at 7:30 a.m. revealed the facility uses the Crandall Corporate Dietitians diet manual. Review of the Food Manual, dated 2014, showed on page thirty-six, titled 'Dysphagia pureed diet level 1' stated the pureed diet is a modification of the regular diet. Puree all foods to the consistency of smooth, moist mashed potatoes or pudding like consistency. No course textures or lumpy as allowed. Foods to avoid in food group grains/ starches included oatmeal. Interview with the Registered Dietitian on 3/30/2017 at 9:15 a.m. revealed she was unable to determine the last time she conducted a tray line audit. She stated, If (therapist) stated an item was okay to be served, the kitchen would serve it. Interview with the DM and Speech Therapist on 3/30/2017 at 9:30 a.m. revealed the therapist confirmed the texture consistency of the oatmeal. She stated there has never been a problem with the consistency of the oatmeal for residents on a pureed diet. She stated she adheres to the National Dysphasia Diet Standardization for Optimal Care Manual, and the committee goes back and forth with the discussion of oatmeal. Review of the manual revealed dysphagia pureed diet level one states this diet consists of foods that are pureed, homogenous, and cohesive. Foods should be pudding like. Foods that require bolus formation, controlled manipulation, and chewing are not allowed. Under the food group cereal, avoid oatmeal. Review was conducted of the facility's policy Diet Formulary, reviewed 3/29/2016 and revised 2/21/2017. The purpose stated the facility provides each resident with regular and therapeutic diet, as ordered by the physician. Procedure 4(D) titled Mechanical Altered Diets, Number (ii) pureed is a dysphagia pureed level 1. All foods should be pureed to a pudding like consistency.

Based on resident interviews, observations, staff interviews, and facility policy and procedure review, the facility failed to take measures to maintain proper hydration by ensuring two residents (Residents #163, and #235) were provided water at the bedside, which could potentially lead to discomfort or dehydration. The findings include: 1. During an interview and observation of Resident #163 on 03/27/2017 at 2:12 PM, he stated his water cup was empty. The water cup was dated 03/27/2017. He stated he has to ask the staff for water most of the time because they do not fill up his cup often enough. He was asked to press his call light to alert the staff that he needed water. He could not push the cushion hard enough to make it come on. He pushed it four times, but it would not come on. This surveyor squeezed the cushion twice before it came on. The cushion was very stiff and hard to squeeze. The resident stated that he did not think it worked. During an interview with Resident #163 on 03/28/2017 12:03 PM, he stated he does not get enough to drink. His Styrofoam water cup was observed on his tray table, as he was speaking. It was dated 03/27/2017 and was empty. (Photo obtained.) During an interview with Employee A, LPN Unit Manager, on 03/28/2017 at 2:49 PM, she was asked to observe the resident's room. She entered the room and observed the resident's tray table was two to three feet away from the bed. The resident's Styrofoam water cup was on the table. She asked the resident if he could reach it and he stated that he could not. She pushed the tray table over the bed so he could reach it. She took the water cup, stated that the date was 03/27/2017, and needed to be filled up. She stated that sometimes the Certified Nursing Assistants (CNAs) forget to change the date on the cup. She stated that the cup should have been changed and today's date put on it. She stated that his water cup should be filled on every shift. Review of the medical record for Resident #163 revealed he was admitted on [DATE]. He had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Give one tablet by mouth one time a day for [MEDICAL CONDITION]. Review of the Minimum Data Set (MDS), dated [DATE], Section G, Activities of Daily Living (ADL) Functional Status revealed the resident required extensive assistance with a two + person physical assist for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. He had impairment on one side in both the lower and upper extremities. Copy obtained. Review of the care plan for Resident #163, dated 03/06/2017, revealed a focus area for nutrition. It stated, Observe for s/s of dehydration. Offer fluids during care. Review of the facility's policy and procedures for Dehydration Protocol revealed: Purpose: To ensure that each resident receives a sufficient amount of fluids based on individual needs to prevent dehydration. Each resident will be assessed to identify dehydration risk factors to facilitate early intervention. Risk Factors: If two or more of the following are present, dehydration protocol is to be implemented: Decline in ADL status, Receives a diuretic. Review of the Hydration Evaluation & Approaches policy (SHCRC .05), reviewed 03/29/2016 revealed the Purpose as: To identify risk factors that lead to dehydration and develop an appropriate preventative care plan. To provide the resident with sufficient fluid intake to maintain proper hydration and health. Procedure 7. Observe care and delivery to determine if the interventions identified in the care plan have been implemented. Does staff provide the necessary fluids as described in the plan? 2. An interview was conducted with Resident #235 on 3/28/17 at 11:50 am. When asked if he received enough fluids, he stated, No. If you look around my room, I don't even have a Styrofoam cup today. The staff is supposed to change the cup every night and give you ice water every shift. Sometimes they do and sometimes they don't. I put my call light on last night because I needed water; however, they did not respond. Observation of the resident's room at the time of the interview found no Styrofoam cup for water. An interview was conducted with the Licensed Practical Nurse (Employee F) at 11:55 am. When asked if Resident #235 was on fluid restriction, she stated No. She was asked if there was a reason why he did not have access to drinking water, and she said all residents receive ice water every shift and a new Styrofoam cup every night on the 11-7 shift. When asked if she was aware Resident #235 did not have water at his bedside, she stated No. The LPN went to observe the resident's room and confirmed he did not have any water.

Based on observations, staff interview, and document review, the facility failed to ensure the environment was sanitary for 6 out of 37 Stage I sampled resident rooms. These concerns related to soiled/stained privacy curtains, which could potentially cause the spread of infections and could impede the resident's enjoyment of their environment. The findings include: During the recertification survey from 03/27/2017 through 03/30/2017, observations were made of residents' rooms. Privacy curtains in Rooms 128, 130, 141, 146, 231, and 233 were observed to be soiled and stained on 03/27/2017, 03/28/2017, and 03/29/2017 at various times throughout the day. (Photos obtained). During an interview with Resident #30 and the private sitter in Room 233 on 03/29/2017 at 9:39 AM, she stated that she does not ever remember having her privacy curtains taken down, washed, and rehung or replaced. She stated she has lived in the facility for over a year. The private sitter stated she comes to sit with Resident #30 every weekday for at least 2 hours a day and she has been coming for over a year. She has never seen the privacy curtains taken down, washed, and rehung or replaced. During an interview with the Housekeeping Director on 03/29/2017 at 1:35 PM, she stated she was not aware of the dirty curtains in Rooms 128, 130, 141, 146, 231, and 233. She stated that she has a calendar that they follow for cleaning the privacy curtains and it usually takes them only a couple of days to check and clean all the curtains in all the rooms every month. During a second interview with the Housekeeping Director on 03/29/2017 at 2:10 PM, she produced cleaning schedules for the rooms. Room 128 had been deep cleaned on 02/15/2017. Room 141 had been deep cleaned on 02/01/2017. Room 146 had been deep cleaned on 01/25/2017. Rooms 128, 130, 141, 146, 231, and 233 had been cleaned almost every day in the month of March 2017. However, the curtains in these rooms remained soiled and stained. Review of the job description for Housekeeping revealed the job functions of a housekeeper included: Inspects furnishings for wear and defects and reports to supervisor. Reports observations concerning structural and equipment wear, defects, and malfunctioning to supervisor. During an interview with the Administrator on 03/29/2017 at 3:35 PM, he stated he had ordered new curtains for all the resident rooms a few months ago, and the curtains were changed in the South Wing. There had been a problem with the length and they had to be adjusted. He was not aware of the stained privacy curtains in Rooms 128, 130, 141, 146, 231, and 233. He stated he has the new curtains for the North Wing and they will be hung right away. He stated the facility's Angel Program is a program where the staff are assigned to various residents. The staff person assigned is to inspect the room daily for cleanliness.

Based on record review and interviews, the facility failed to provide a care plan for nutrition with measurable goals for weight loss for 1 of 49 sampled residents (Resident #163). The findings include: Review of the medical record for Resident #163 revealed the resident was admitted on [DATE]. He had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]., and in 2016, the weight was 209 lbs. Review of Resident #163's dietary progress notes, dated 03/10/2016, revealed a note that read, RD consult. MD requested dietary consult for planned weight loss program. Resident refused to allow. Weight team to obtain a monthly weight. Resident has refused in the past with a refusal in January 2016. Diet is Regular/Regular with meal intake 75-100% consistently. Approached resident in the past to see if he would be in agreement with Planned Weight Loss, resident did agree but quickly changed his mind. Resident continues to receive diuretic therapy. Skin remain intact. Will continue to follow per facility protocol. Review of the Dietary Assessment, dated 06/21/2016, revealed the diet order as regular, mechanically soft, chopped vegetables. The resident's weight was 198 lbs. The MDS notes read, planned weight loss. The plan/intervention was written as: -offer foods as requested. -update care plan and follow per facility protocol. The Dietary note, dated 11/08/2016, read: Planned wt. loss program per MD. Remains on diuretic therapy. Remains above IBWR. BMI 29.0 (obese range). Review of the Dietary Assessment, dated 03/06/2017, revealed the current diet order as controlled carbohydrate /mechanical soft texture. It read: On a prescribed weight-loss regimen. The Minimum Data Set (MDS), dated [DATE], Section K revealed the resident was on a physician-prescribed weight loss regimen. His height was 67 inches and weight was 179 pounds (lbs.). He did not have any problems with swallowing and was on a therapeutic diet, mechanically altered diet. He had not had a 5% weight gain in the last month. Section L revealed the resident was assessed as having no natural teeth, broken or loosely fitting or partial denture, no mouth or facial pain, discomfort or difficulty with chewing. Review of the care plan for Resident #163, dated 03/06/2017, revealed a focus area for nutrition. It read: Assist with meals as needed; Diet as ordered: Ccho/Mech Soft Texture, chopped vegetables; Dietary assessment on admission and as needed; Encourage/monitor meal intake; Labs as ordered; Observe for s/s of dehydration; Offer fluids during care; Provide food preferences and substitutions within facility protocol and MD order. The care plan did not have measurable goals and desired outcomes for safe weight loss for Resident #163. During an interview with the Registered Dietitian on 03/30/2017 at 1:00 PM, she stated that the resident wanted to lose weight so that is why she was documenting a prescribed weight loss plan. She did not know how much the doctor wanted the resident to lose or how fast he should safely lose the weight. She did not know when the weight loss regiment should stop and the resident should be put on a weight maintenance plan. She left the interview to get clarification. During an interview with the Director of Nursing and the Regional Nurse Consultant on 03/30/2017 at 2:00 PM, they reviewed the Registered Dietitian's assessments, care plan, and physician's orders [REDACTED].

Based on interview and record review the facility failed to maintain four of seven sampled residents with the highest practicable well being by not holding blood pressure (BP) medication for defined parameters and not administering medications timely per the facility policy (Residents #1, #3, #6 and #7). The findings include: 1. An interview was conducted with Resident #3 at 6:15 am on 9/19/2016. Resident #3 stated that she gets her medications, but the staff mess up on her medications. She stated that staff give her the blood pressure medications when she is not supposed to take it and it makes her dizzy. Review of Resident #3's physician orders [REDACTED]. Review of Resident #3's Medication Administration Record (MAR) showed [MEDICATION NAME] tablet 50 mg; give 1 tablet by mouth two times a day related to Hypertension, hold if systolic is less than 115. On 9/3/16 (1700), 9/9/2016 (1700), 9/10/16 (0900), 9/11/16 (0900, 1700), 9/12/16 (1700), 9/15/16(0900), and 9/16/16 (0900), the medication [MEDICATION NAME] was administered when Resident #3's systolic BP was less than 115. Review of Resident #3's MAR showed [MEDICATION NAME] tablet 2.5mg; give one tablet by mouth one time a day related to Essential Hypertension, hold if systolic is less than 115. On 9/6/2016 (0900), 9/10/2016 (0900), 9/11/2016 (0900), and 9/13/2016 (0900), [MEDICATION NAME] was administered when Resident #3's systolic BP was less than 115. An interview was conducted with the Director of Nursing (DON) at 1:02 pm on 9/19/2016. The DON confirmed that Resident #3's medication [MEDICATION NAME] should have been held on 9/3/16 (1700), 9/9/2016 (1700), 9/10/16 (0900), 9/11/16 (0900, 1700), 9/12/16 (1700), 9/15/16 (0900), and 9/16/16 (0900), and [MEDICATION NAME] should have been held on 9/6/2016 (0900), 9/10/2016 (0900), 9/11/2016 (0900), and 9/13/2016 (0900). The DON stated that if Resident #3's Systolic BP was less the 115 the medication should have been held. 2. Review of Resident #6's physician orders [REDACTED]. Review of Resident #6's MAR showed Latanoprost Solution 0.005% medication administration time as 8:00 pm (20:00). According to the MAR the resident received the medication on 7/2/16 at 22:15, on 8/13/16 at 21:23, on 8/27/16 at 21:39, and on 8/28/16 at 22:53. An interview was conducted with the DON at 11:46 am on 9/19/2016. The DON stated that the nurses have an hour window timeframe to give the medication. She stated that they should give the medications within the hour before the administration time or within the hour after. The DON provided the surveyor with the Administrating Medications Policy. Review of the facility Administering Medications Policy on 9/19/2016 showed that medications must be administered within one hour of their prescribed time unless, otherwise specified. 3. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's MAR for [MEDICATION NAME] revealed omissions in the boxes on 7/13/2016 (2100), 8/5/2016 (2100), 9/7/2016 (2100), 9/13/2016(2100), and 9/16/2016 (2100). Additional Review of Resident #7's MAR showed that [MEDICATION NAME] scheduled administration times were 09:00, 17:00, and 21:00. Medication administration times were documented as follows: The 9:00 medications were administered on 7/8/2016 at 10:40; 7/11/2016 at 11:01; 7/17/2016 at 10:34; 7/18/2016 at 10:45; 7/27/2016 at 10:54; 7/29/2016 at 10:22; 8/14/2016 at 13:52; 8/17/2016 at 10:31; 8/18/2016 at 10:35; 8/26/2016 at 12:33; 9/1/2016 at 10:23; 9/5/2016 at 10:24; 9/9/2016 at 10:34; 9/11/2016 at 10:28; 9/14/2016 at 12:03; and 9/15/2016 at 10:24. The 17:00 medications were administered on 7/18/2016 at 18:29; 8/1/2016 at 18:42; and 8/17/2016 at 21:25. The 21:00 medications were administered on 7/14/2016 at 22:45; 7/15/2016 at 22:24; 8/16/2016 at 23:36; and 9/14/2016 at 23:40. An interview was conducted with the DON at 12:49 pm on 9/19/2016. She stated that no one documented in the boxes on 7/13/2016 (2100), 8/5/2016(2100), 9/7/2016 (2100), 9/13/2016 (2100), and 9/16/2016 (2100). The DON stated that because no one documented it that means it was not administered. The DON and the surveyor reviewed the MAR and the DON confirmed the dates and times listed above as the times Resident #7's medications were administered. The DON again stated that the nurses have an hour window. She stated that they should give the medications within an hour before the administration time or within an hour after. 4. Review of Resident #1's physician orders [REDACTED]. Review of Resident #1's MAR showed [MEDICATION NAME] capsule 3 mg, give 3mg by mouth at bedtime for [MEDICAL CONDITION]. The medication was scheduled to be given at 21:00. On 7/23/2016 the medication was given at 22:30 and on 8/28/2016 the medication was given at 22:52. An interview was conducted with the DON at 1:10 pm on 9/19/2016. She confirmed that Resident #1's [MEDICATION NAME] was not given according to the facility policy. Review of the facility Administering Medications Policy showed that medications must be administered within one hour of their prescribed time, unless otherwise specified. Evidence Photos obtained.

Based on observations and staff interviews, the facility failed to maintain dignity for 1 of 1 residents sampled for dignity (Resident #126), out of a total of 36 sampled residents. The findings include: An observation of Resident #126 on 2/8/16 at 1:30 pm revealed the urinary catheter tubing was exposed and dragging on the floor under the wheelchair. The resident was also observed wearing Ted hose on both legs. The resident's name was written in big black letters down the entire length of the hose. A second observation was made on 2/9/16 at 3:30 pm, and revealed the catheter tubing was exposed and dragging under the wheelchair. A third observation was made on 2/10/16 at 10:30 am, and revealed the catheter tubing was exposed and dragging on the floor. An interview was conducted with Employee B (Certified Nursing Assistant (CNA) on 2/8/16 at 1:50 pm. When asked if the facility used covers for urinary catheter bags and tubing, she stated the facility does not use cover bags. The catheter bag has a flap on the front to prevent the urine from being exposed, but there was no place to secure the tubing from hanging on the floor.

Based on observations, record reviews, and resident and staff interviews, the facility failed to honor a significant dietary choice for 1 of 4 residents reviewed for nutritional status (Resident #31), and 1 of 4 residents reviewed for choices (Resident #31), out of a total of 36 sampled residents. The findings included: An interview was conducted with Resident #31 at 3:04 pm on 02/09/2016. She stated she had lost some weight, and did not always like what was served at mealtimes. The facility could provide alternate meals, but by the time she decided she does not want what was served, she had to find an aide, and someone to go get something else to eat. Resident #31 stated she had not been offered, or had taken, nutritional supplements to her knowledge. She then stated her roommate received a milkshake of some sort every day, and they looked good. She stated she would like to get a daily milkshake too. This request was then reported to the Director of Nursing (DON) upon exiting Resident #31's room, at approximately 3:10 pm on 02/09/2016. The DON stated she would determine what the roommate was receiving and handle the request for milkshakes. An interview with Employee N, Certified Nursing Assistant, at 3:00 pm on 02/09/2016 found Resident #31 ate well if served something she liked. Resident #31 was observed at 8:25 am on 02/10/2016 in her room. She was eating her breakfast from an overbed table. Breakfast consisted of two waffles with syrup, a bowl of oatmeal, a cup of fruit, milk, and coffee. Resident #31 also had two graham crackers and a banana on the table. Resident #31 consumed both of her graham crackers, all of her fruit, and drank her milk. She did not touch her oatmeal or her waffles. She stated she did not like waffles. Resident #31 said she never received a milkshake last night. Observation and interview with Resident #31 in her room at 8:38 am on 02/11/2016 found she still had not received a milkshake, but she hoped she would. Record review found Resident #31 was [AGE] years old. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) 12/16/15, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10. [DIAGNOSES REDACTED]. Section F of the assessment revealed it was somewhat important for the resident to have snacks between meals. Resident #31 was able to feed herself with set-up assistance only. [DIAGNOSES REDACTED]. Resident #31 weighed 93 lbs. and was 63 tall. Resident #31 was care planned on 12/17/15 for activities of daily living (ADLs), and fluctuated between being independent, to requiring limited assistance with setup for eating. Approaches included provide meal trays, open containers, and season food as desired. She was care planned for a history of leaving 25% of food on her plate at mealtimes. Goals included encouraging the resident to consume 75% or more of her meal through next review date. If she consumed less than 75%, report to the nurse. Monitor weights weekly x 4 weeks if weight falls out of usual body weight range, which was noted as 100 lbs -115 lbs. A Nutrition Screening, dated 2/18/15, noted a body mass index (BMI) of 18.5, with fair intake at 76-100% of meals consumed (75% average). Resident #31 was noted with a low BMI, and the Registered Dietician placed an alert. Review of the physician's orders [REDACTED]. A follow-up interview was conducted with the Director of Nursing (DON) at 11:39 am on 02/11/2016. She stated Resident #31 had been interviewed about her request for milkshakes; however, she was unable to confirm Resident #31's roommate received milkshakes each day. Resident #31 could only report she wanted milkshakes like her roommate. The DON stated no milkshake was ever offered or provided to Resident #31. An interview was conducted with the Dietary Manager (DM) at 11:45 am on 02/11/2016. When asked about Resident #31's request for milkshakes, she stated the resident was interviewed, and wanted what her roommate received. Since the roommate received no milkshakes, nothing was offered. When asked if a milkshake of any kind could have been offered to Resident #31 to satisfy her desire, the Dietary Manager stated, Yes, and guessed she could have offered (the resident) a shake. The DM then stated she would send one out on the resident's the lunch tray today to see if she liked it. She had no explanation as why no effort was made to provide Resident #31 a milkshake of some sort over the past 3 days. .

Based on observations and staff interviews, the facility failed to ensure accommodation of needs for call lights being withinin reach and functioning properly at all times for 3 of 41 residents sampled for call lights (Residents #146, #224, and #230). The findings include: An observation of Resident #146 on 2/8/16 at 1:45 pm revealed his call light was on the floor under the bed. He was lying in bed on his right side and was unable to reach the light. On 2/9/16 at 9:20 am, he was observed lying in bed with his eyes closed, his breakfast tray was sitting on the bedside table, and had not been offered to the resident. Also, the call light was not in reach. It was found beside the bed on the floor. During an observation on 2/10/16 at 11:05 am, he was observed sitting up in a wheelchair in his room. He was sitting on the opposite side of where the call light was positioned, and he could not reach the cord. An interview was conducted with the Employee D on 2/10/16 at 11:15 am. When asked if Resident #146 could reach his call light, she stated she would have to check. After observing the resident, she stated it was located on the other side of the bed and he could not reach. 2. An observation of Resident #224 was conducted at 8:29 am on 02/10/2016. He was in his room sitting in his wheelchair to the right side of the bed. His call light was observed on the far side of the bed, approximately 5 feet away from the resident, and out of reach. Observation of Resident #224 at 9:44 am on 02/10/2016 found his call light was still out of reach on the opposite side of the bed. Resident #224 was asked if he could reach the call light. He reached back toward the bed with his left hand, but could only grab his oxygen concentrator tubing. He shook his head No, indicating he could not reach the call bell. At 12:01 pm on 02/10/2016, the resident in bed B (Resident #230), requested assistance from this surveyor. He was instructed to press his call light to alert facility staff, which was observed clipped around the resident's right side bed rail. The activator bulb was lying on the floor underneath the bed. Resident #230 attempted several times to reach the bulb or the cord, but was unable to do so, even with verbal directions as to the location of the cord. The call was placed by this surveyor. Employee K, a Certified Nursing Assistant, entered the room at 9:51 am on 02/10/2016. He confirmed the call light was not in reach for Resident #224. He stated call lights should be within arms length of residents at all times. At 9:25 am on 2/11/2016, Resident #230 was observed with his call bell dangling off of his siderail. The bulb hung approximately 15 inches below the bed. When asked he could reach it, he tried, but could not. Resident #230 asked this surveyor to assist by handing him the call light. When Resident #230 was asked to activate the pneumatic air bulb, he tried repeatedly. No sound was emitted, and no light illuminated above his door. He said, No wonder they take so long to come when I call!. The light was released back to it's original position 15 inches below the resident. The South Wing Unit Manager entered the room at 9:30 am on 02/11/2016. When asked if Resident #230 could reach his call light in its current position, she approached him and asked him to locate it. He could not. She acknowledged the light was out of reach. The Unit Manager then tested the light, which illuminated immediately and emitted a sound. She handed it back to Resident #230 who made numerous, unsuccessful attempts at activating his call light. The Unit Manager stated she would report the malfunction to maintenance.