Every finding on record at Northwest Florida Community Hospital (Snu)

Based on observation, interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety. The findings include:On the initial tour of the kitchen on 6/30/2025 at approximately 11:15 am, an observation was made in the produce refrigerator located in the hospital's kitchen. The General Manager was present for the tour. The following was found on shelves inside: Two pieces of cooked salmon were in a pan covered with plastic wrap with a handwritten label that stated 'Salmon 5/24/25, out 6/2/25'. A pan of cooked rice with a handwritten label dated 6/28/25. Cooked bacon was wrapped in plastic wrap and unlabeled. Sliced peaches in liquid were in a plastic wrap covered pan with a printed label that stated 'Prep 6/12/25 12:56 pm, Enjoy by 6/17/25 12:56 pm'. (Photographic evidence obtained)An interview was conducted with the Kitchen Supervisor on 6/30/25 at approximately 11:20 am about the process of cleaning and removing outdated food items from the refrigerators. When asked if the outdated food should have been removed, she agreed that the food is expired and should have been removed. She stated that they have a cleaning assignment task list that is to be signed off by staff at the end of shift. The logs are then reviewed by a supervisor or manager to ensure task completion. When asked if the logs are kept for review, she stated the logs are not kept once reviewed. An interview was conducted with the General Manager on 6/30/25 at approximately 11:30 am about the expired food found in the fridge. He states that they have recently hired a new utility person who will check the refrigerator to ensure that old food is removed. The process has been a supervisor or manager is to check daily for expired foods for disposal.An undated policy entitled 'Cleaning and Sanitizing' states, IV. Procedures b. cleaning logs/schedules are available for all areas of the kitchen and retail areas. (dish room, tray line, walk-ins, freezers, refrigerators, offices, beverage dispensers, cafeteria, etc.)

Based on record review and interview, the facility failed to have accurate Advance Directive information on the medical chart for 2 of 4 residents sampled (Resident #19 and #23). The findings include: Resident #19: Resident #19 was observed to have a No Code sticker on the front of the medical chart. However, Resident #19's face sheet listed the resident as a full code dated 8/5/2024. On 5/19/23, the resident had signed a form saying he wished to be DNR (Do Not Resuscitate). On 09/23/24 at 04:50 PM, during an interview with Staff B, a registered nurse (RN), she was asked what No Code means. Staff B stated that the resident has chosen not to be resuscitated. When asked how new staff would find out the resident's advance directives, Staff B stated they were always instructed to look at the face sheet in the medical chart. On 09/24/24 at 12:21 PM, an interview with the facilities Minimum Data Set (MDS) coordinator was held. When asked about Resident #19's advance directives, the MDS coordinator stated this resident was a DNR. When shown that the record contained conflicting information, the MDS coordinator stated that was done in error. She explained the pharmacy prints out the face sheets and the facility had forgotten to update the pharmacy, so it was showing inaccurate information. The DON was present and was asked how staff would know the advance directives, the DON stated they go by the sticker. She also stated they would correct the discrepancy right away. 50082 Resident #23: The chart for Resident #23 had a sticker stating NO CODE. A Do Not Resuscitate (DNR) form was not found in the chart of Resident #23. The medication administration record (MAR) code status however indicated, FULL CODE. A review of the advance directives for Resident #23 revealed a document signed on 3/21/24 by the legal representative for Resident #23 which indicated the desire for no resuscitative measures to be taken. On 09/24/24 at approximately 12:25 PM, during an interview with Staff A, the Minimum Data Set coordinator (MDS) stated that Resident 23 was a DNR, NO CODE. She indicated that the FULL CODE printed on the MAR was an error. She stated that the facility had not communicated the correct code status with the pharmacy who is responsible for printing out the MAR.

Based on observations, staff interviews, and record reviews, the facility failed to store and discard medications properly for 3 of 20 patients observed. (Resident #8, #19, and #15) The findings include: Residents #8 and #19: On 09/24/24 at approximately 01:46 PM, an observation of the west hall medication cart revealed expired medications were present for two residents, Resident #8 and Resident #19. For Resident #8, it was observed that Lasix (a medication used to remove assess fluid from the body) 20mg tablets were present, although the tablets had an expiration date on 06/30/2024. A review of the physician's order revealed the medication was ordered on 10/20/2023 and was currently an active order. (photographic evidence obtained) For Resident #19, it was observed that Clonidine 0.1mg tablets for high blood pressure was present, although the packaging stated the tablets had expired on 08/31/2024. A review of the physician's order revealed the medication was ordered on 08/10/2020 and was currently an active order. (photographic evidence obtained) On 09/24/24 at approximately 2:01 PM, during an interview with the director of nursing (DON) and assistant director of nursing (ADON), the DON stated, the night shift nurses check medication expiration dates on the cart daily. I don't know that they check the expirations on the blister packs because they go through them so quickly. The DON also stated, the pharmacist does monthly cart checks for expired medications and completes audit reports. A review of the medication audit report dated 8/13/2024 and 9/17/2024 performed by the Pharmacist revealed, no irregularities, no expired medications for the east medication cart, west medication cart and medication room. A review of the facilities policy labeled Expired Medications revealed, The night shift nurse on duty will monitor the upcoming expiration dates of any medications prescribed to the residents of the skilled nursing unit. The pharmacist provided by Omnicare comes to the facility monthly for routine medication and chart audits. At this time both medication administration carts as well as the medication administration room is assessed for any expired medications by the pharmacist herself. Any expired medications will be removed from the cart/medication room. Routine medications are returned to the prescribing pharmacy (Omnicare). Narcotics are destroyed on site. 45951 Resident #15: During a tour of the facility conducted on 09/23/24 at 12:37 PM, it was observed that Resident #15 had 4 packets of Calmoseptine ointment (this medication is used to prevent skin irritation) and 1 tube of Hydrocortisone cream (this medication is used to treat skin irritation) at their bedside with no staff present. (photographic evidence obtained) During a tour of the facility conducted on 09/24/24 at 10:01 AM, the surveyor observed the Hydrocortisone cream tube was still present along with 2 packets of the Calmoseptine ointment. A review of Resident #15's Quarterly Minimum Data Set, dated dated [DATE], revealed Resident #15 had a Brief Interview of Mental Status score of 5, indicating she had severe cognitive impairment. A review of Resident #15's Medication Administration Record (MAR) revealed there were active physician orders for both medications. However, the Hydrocortisone cream had not been signed off by the staff for the month of September and the Calmoseptine ointment had been signed off only on 09/17/24 and 09/18/24. An interview was conducted with Staff D, a Licensed Practical Nurse, on 09/24/24 at 12:32 PM revealed that she cares for Resident #15 often. Staff D stated she was unaware these medications were present in Resident #15's room. She stated she did not know when the medications were given last but that the Hydrocortisone cream should be kept in the medication cart. She confirmed the Hydrocortisone cream should be given by a nurse. Staff D also confirmed that the nursing staff should be signing off each application of these medications.

Based on resident record review, staff interview, and facility policy review, the facility failed to refer a resident with a diagnosis of Dementia and a serious mental disorder for a PASRR (pre-admission screening and resident review) Level II evaluation for 1 of 2 sampled residents reviewed for PASRR. (Resident #16) The findings include: A review of the PASRR form for Resident #16 (dated 03/17/2021) noted an identified diagnosis of Anxiety Disorder and a primary diagnosis of Dementia. Per the PASRR form, the combination of a Serious Mental Illness (SMI) diagnosis and Dementia or neurocognitive disorder would trigger the requirement for the resident to receive a PASRR Level II evaluation. A review of the admission diagnosis in the medical record (dated 03/15/2021) noted diagnoses of Dementia, Depression, and Anxiety. On 10/21/2021, a diagnosis of Dementia with psychosis was added to Resident #16's list of diagnoses. A review of the Care Plan for Resident #16 revealed the resident was care planned for antipsychotic and antidepressant therapy for a diagnosis of Dementia with psychosis. A review of the medication administration record revealed Resident #16 was receiving the following psychotropic medications: Mirtazapine, Namenda, Sertraline, Oxcarbazepine, Donepezil, and Quetiapine Fumarate, for diagnoses of Dementia with psychosis, Depression, and Anxiety. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed that section A did not acknowledge the submission of a PASRR Level II and Section I included active diagnoses of Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. A review of the complete medical record could not locate a Level II PASRR for Resident #16. On 10/03/2023 at approximately 4:40pm, the Director of Nursing (DON) was asked about the PASRR process, and she explained that all residents should come with a PASRR prior to admission. The DON was advised that a Level II PASRR could not be located for Resident #16. After reviewing Resident #16's PASRR, the DON acknowledged that a Level II PASRR was not done but should have been based on Resident #16's admission diagnoses, further stating the form was filled out incorrectly by a previous DON. A review of the policy titled, Admission of Resident to SNU, stated in item #5, The LPN or RN will complete admission paperwork to include PASRR and establish a medical record for the new resident. A review of the policy titled, Antipsychotic Medication Use, stated in item #5, The interdisciplinary team will complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate.

Based on observations, interviews and record review the facility failed to provide behavior health services to maintain the highest practicable physical, mental and psychosocial well being for 1 of 2 residents reviewed for behavior services. (Resident #8) The findings include: On [DATE] at 1:18 PM, an observation was made of the Resident #8 in her room. The resident appeared depressed and withdrawn. The resident would answer questions with a simple yes or no. The resident would not make open conversation. On [DATE] at 9:35 AM, an observation was made of Resident #8 in the dining area. The resident was sitting in a chair with her eyes closed. The resident responded to verbal stimuli with simple yes or no answers. The resident was asked if she was happy. The resident indicated no. The resident indicated she feels alone. On [DATE], a record review was conducted for Resident #8. The records indicated the resident was on Lexapro 10mg PO once a day when admitted to facility. The admitting diagnoses did not list depression as a diagnosis. A Pharmacy Consult Report dated [DATE] indicated the resident's family requested an increase in antidepressants due to the resident's depression becoming more severe and the resident being more withdrawn. The report indicated the resident has been on Lexapro 10mg qd since [DATE] with no improvement. There is no evidence in the record of the facility contacting the psychiatrist to report the family's concern and request. A review of the psychiatric notes indicated the resident has a history of depression. A neuropsychological evaluation on [DATE] indicated the resident suffered a decline in April of 2021 following the death of her son, becoming socially withdrawn. Additionally, a review of the care plan indicated the resident was not care planned for depression or possible side effects of antidepressant medication being prescribed. A review of the psychiatric note from [DATE] indicated the resident's depression was stable. The neuropsychological evaluation on [DATE] indicates the resident suffered a decline in [DATE] following the death of her son. She also became socially withdrawn. On [DATE] at 1:36 PM, an interview was conducted with the resident's daughter and Power of Attorney (POA) regarding resident's psychiatric care and history. The daughter indicated the resident was abused by a former husband physically and emotionally. Her two sons were also physically abused by the husband. The daughter indicated her mother has a history of seasonal depression due to the abuse from the former husband. She indicated her mother's depression worsened after the death of her oldest brother in 2021. The daughter indicated her mother and the deceased brother had a strange relationship. She indicated her mother was placed on Lexapro by her Primary Care Physician (PCP) while she was living with her daughter in [DATE]. The daughter indicated her mother has never been had visual or auditory hallucinations. She also indicated her mother has never been diagnosed with psychosis or any other psychiatric disorders other than depression. \On [DATE] at 2:13 PM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding the resident's family's request to increase the antidepressant dosage and observations of increased depression and withdrawal. The ADON was asked if the psychiatrist was notified following the family's request and multiple observations of the resident's depression worsening. She indicated no, the psychiatrist was not notified because she knew the psychiatrist would be visiting soon. On [DATE] at 2:35 PM, an interview with the Director of Nursing (DON) was conducted regarding the resident not being care planned for depression. The DON acknowledged the resident does take an antidepressant for depressed mood. She also acknowledged the resident is seen by psychiatry. She indicated the resident should be care planned for depression/mood. She indicated she was not sure why the diagnosis was overlooked. She also indicated the resident should be care planned for possible side effects of the antidepressant.

Based on interviews and record review, the facility failed to maintain medical records by not including psychiatric visit records and psychiatric progress notes within the medical record for 2 of 2 residents reviewed. (Residents #8 and #12) The findings include: Resident #8 On 10/03/23 at 2:20 PM, a binder titled Psych Progress Notes was reviewed. The binder contained psychiatric notes for multiple residents. A note from a psychiatric visit on 1/26/23 was found for Resident #8 and was signed by the psychiatrist. The note indicated the resident was found to be currently stable with her depression. He reported the resident was sleeping well and eating well with no side effects from medication. He describes the resident's feelings of depressed mood as frequent, excessive worry is frequent, hopelessness is frequent. He also describes feelings of paranoia and racing thoughts as frequent. On 10/04/23 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) regarding psychiatric notes not being part of the medical chart. The DON and ADON were asked for further and more recent psychiatric notes and have been unable to provide them. The ADON indicated the psychiatrist comes to visit and then has notes dictated later. The ADON indicated it can be months before the notes are received. The ADON was asked why the psychiatric notes are not kept in the medical record. She indicated they have always been kept in a separate binder in her office. On 10/05/23 at 11:03 AM, a phone interview conference call was conducted with the psychiatrist regarding Resident #8. The physician was made aware of the resident's diagnoses listed from his visits on 5/18/23 and 7/13/23. The diagnoses are schizophrenia, unspecified, unspecified dementia, unspecified severity, with psychotic disturbances, unspecified mood (affective) disorder, major depressive disorder, recurrent severe without (w/o) psychosis. The physician was informed during the call that the resident was on Lexapro when she was admitted to facility with a history of depression. The physician indicated at the beginning of the call that he was familiar with the resident. The physician asked questions throughout the call as to what medications the resident was currently taking and what diagnoses were listed in medical record. The physician indicated perhaps a nurse told him during rounds that the resident was schizophrenic. He indicated he is not sure why he diagnosed the resident with schizophrenia and other psychotic disorders. The physician indicated he thought it was in the medical record. The physician indicated he is not sure why his psychiatric notes do not make their way to the resident's medical record. The physician indicated during the Covid 19 outbreak that he was aware the process was broken getting his psychiatric notes into the medical records. The surveyor asked the physician why his notes state on the last page Note has not been signed. He indicated his notes may not be completed if there is not an electronic signature. He indicated his office is responsible for making sure his notes are given to the facility. On 10/05/23, a review of the facility's Psychiatric Service Agreement, dated August 4, 2011 was conducted. The agreement does not address the psychiatric provider providing records to the facility. 47847 Resident #12 On 10/02/2023 a review of Resident #12's medical record was performed which revealed diagnoses of Parkinson's Disease, Hypertension, Gastro-Esophageal Reflux Disease, Anxiety Disorder, Depressive Disorder, Squamous Cell Carcinoma, and Macular Degeneration (all dated 12/16/22). The record failed to contain the psychiatric progress notes. On 10/03/2023 at approximately 4:00 PM, an interview was conducted with the DON, who was asked to assist in locating the missing psychiatric progress notes from the medical record. The DON explained the notes were not in the record and described difficulties in obtaining these notes from the psychiatrist. A further explanation was provided of the ADON notifying the psychiatrist and his office staff on 10/02/2023 that the facility was undergoing a current survey, and surveyors were requesting resident medical records from psychiatric consult visits. The DON confirmed the psychiatrist's office sent a large number of progress notes via fax today and they are in the process of separating/sorting them and would provide them to the surveyor in the morning. On 10/04/2023, the psychiatric progress notes for Resident #12 were provided and a review was performed of the notes dated 01/26/2023, 05/18/2023, and 07/13/2023. A review of the visit dated 01/26/2023 did not include a diagnosis or a physician signature. A review of the visit dated 05/18/2023 did not contain a physician signature, however it listed diagnoses of Schizophrenia and Dementia with psychotic disturbance. A review of the visit dated 07/13/2023 did not contain a physician signature, but did list diagnoses of Schizophrenia, Dementia with psychotic disturbance, and generalized anxiety disorder. (Photographic evidence obtained) A thorough review of resident #12's complete medical record showed no supporting evidence that the diagnosis of Schizophrenia was identified nor readily available in the medical record prior to this review. On 10/04/2023 at approximately 6:00 PM, an interview was conducted with the DON and ADON, who were asked if Resident #12 had a diagnosis of Schizophrenia, both answered no, they were not aware. They confirmed that Resident #12's medical record did not contain any documentation to support that care staff, including the primary care doctor, was aware of this new diagnosis. On 10/05/2023 at approximately 11:15 AM, a telephone interview was conducted with the psychiatrist, who confirmed familiarity with Resident #12. The psychiatrist was made aware of the surveyor findings, discrepancies within the records, and care staff reports. The psychiatrist was asked to confirm the accuracy of documenting a new Schizophrenia diagnosis for Resident #12, as it is reflected in the progress note dated 05/18/2023 and again on 07/13/2023. The psychiatrist stated that the information likely came from within the medical record. He stated he probably reviewed the list then added it or it came from nursing staff reporting symptoms or behaviors. The psychiatrist was asked to describe his process for comprehensively assessing Resident #12 which led to concluding a new diagnosis of Schizophrenia. He stated that he would have to look at the medical record to ensure this diagnosis is correct, and that his notes may not be inclusive enough. The psychiatrist was then asked how he ensures that care staff have accurate and sufficient information to respond to the changing status and needs of the residents. He replied, obviously that is something we need to work on. On 10/05/2023 at approximately 12:30 PM an interview was conducted with Employee D, a Registered Nurse, who explained she rounds with the psychiatrist and provides compiled information obtained from care staff and resident behavior records. She provided retained information from those rounds and stated that she never reported any behaviors for Resident #12. (Photographic evidence obtained) Employee D confirmed that the medical record did not contain psychiatric progress notes from the psychiatrist's consults prior to now and that she was unaware of Resident #12 having a diagnosis of Schizophrenia. A review of the facility provided Bylaws for the Medical Staff updated on December 2012 states on page 6 of 73 Section 3.5, d. Preparing and completing in timely fashion medical records for all the patients, to whom the member provides care at the hospital. An interview with the DON on 10/05/2023 at approximately 11:25 AM confirmed that there were no other policies or procedures that outlined the process/procedure for maintaining a complete medical record.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 initial kitchen tour conducted. The findings include: On 05/09/2022 at approximately 10:45 AM, an initial tour of the kitchen was conducted in the presence of the facility's Certified Dietary Manager (CDM). An observation of the walk-in cooler revealed the following 4 unlabeled items: 1 unsealed bag of meat, an unlabeled package of aluminum foil (contents unknown) and 2 sealed plastic bags (contents unknown). On 05/09/2022 at 11:10 AM, an interview was conducted with the CDM regarding the facility's food storage policy. The CDM identified the 4 unlabeled packages as precooked ham used for seasoning and confirmed the ham was used in meal preparation earlier that day (05/09/2022). On 05/09/2022 at approximately 1:00 PM, a review of the facility's Policy for Labeling and Dating (undated) All foods will be properly labeled and dated to maintain food safety. Review of the procedure revealed All foods that require time and temperature control (TCS) should be labeled with the following: Common name of the food, date the food was made, and use by date. A review of the U.S. Food & Drug Administration Food Code 2017 was conducted. According to Chapter 3, Limitations of Growth of Organisms of Public Health Concern, Subpart 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking revealed packing shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded.

Based on resident, family, and staff interviews and review of the facility's visitor log and visitation policies and procedures, the facility failed to honor residents' right to receive visitors of their choosing at the time of their choosing for 3 of 3 residents sampled for visitation. (Residents #1, #2, and #3) The findings include: On 7/8/21 at approximately 10:10 AM, an interview was conducted with Staff Member A, a screener (an individual who verifies the absence of signs or symptoms of COVID-19 for all persons entering the building). She was asked to explain the visitation process for the Skilled Nursing Unit (SNU). When we have someone who wants to see someone in the SNU, we tell them that there is no visitation. They must call the Director of Nursing for the SNU and make an appointment. They make appointments and meet in the specialty center in a big room. The surveyor inquired about the last time she received an update on the visitation processes for the SNU to which Staff Member A replied, We have not had an update on the visitation since I started three months ago. On 7/8/21 at approximately 10:15 AM, an interview was conducted with Nurse B, a registered nurse (RN). She was asked to explain the visitation process for the SNU. She explained that visitation is not open on the third floor. At this time, Staff Member C, Registration Clerk, added, They must call to set up appointments for visitation. She was asked if visitors can call from the screening area to schedule an immediate appointment. Staff Member C responded by explaining that they call from home or elsewhere and that appointments for visitation often do not occur on the day the call is made. On 7/8/21 at approximately 2:10 PM, an interview was conducted with Resident #1 who was asked if she has had any difficulties receiving visitors. She explained that she tells visitors to schedule an appointment ahead of time. She was asked if the visitors can visit at a day and time of her choosing. She replied, I do not think so. She explained that Resident #2 was unable to see her family when they came to visit from out of town. She explained that the family was told no visitation was allowed. On 7/8/21 at approximately 2:25 PM, an interview was conducted with a family member of Resident #2. She was asked about attempts to visit Resident #2. The family member reported that she lives a good distance away from the facility and dates she was able to travel to [NAME] were on weekends and holidays. She further stated that visitation at the facility's community center was unavailable on those days. She continued that she has been allowed to sign Resident #2 out of the facility to take her out into the community, however she explained that she thinks the risk of contracting Covid is greater outside of the facility. She explained that previously she was allowed compassionate care visits when Resident #2 was ill, but this is no longer allowed. On 7/8/21 at approximately 2:40 PM, an interview was conducted with a family member of Resident #3. He explained that appointments must be set up for visitation. He went on to say that he wants to be able to visit Resident #3 in her room on the weekends. On 7/8/21 at approximately 2:40 PM, an interview was conducted with Director of Nursing (DON) for the SNU. She was asked to explain the visitation process. She described the process in steps. Individual families are called to set up visitation in the Education Center based upon availability of appointments. Visits are scheduled on Tuesdays, Wednesdays, Thursdays, and Fridays from 9:00 AM to 5:00 PM. The Education Center is in another building in the adjoining parking lot to the hospital. She mentioned that some visitors visit two times a week. She was asked about the process for a visitor that arrives at the hospital unannounced. She explained that the screening area would direct family to call and speak with staff in the SNU. The staff would attempt to make accommodations while the visitor is present. If an appointment is not available, one would be scheduled for the next available appointment. The DON provided a copy of the NFCH SNU Resident Visitation forms for review. Staff Member D, Licensed Practical Nurse (LPN) Social Services Director (SSD) added that they often explain to visitors that they can sign out the resident they wish to visit if they are a family member for a Leave of Absence (LOA) from the facility. She went on to say that quite a few family members have signed residents out for visitation. On 7/8/21 at approximately 3:00 PM, the DON was asked to explain all the dates crossed out on the facility's resident visitation schedule. She explained that visitation is based on the Education Center's availability and the weather outside. If the Education Center was not available, the corresponding date was crossed out on the schedule. The DON also reported that 13 of 27 residents in-house had received two doses of the COVID-19 vaccine and 1 resident had received 1 her first dose of the vaccine on 7/3/21. She explained that there are currently no COVID positive residents in the facility. In fact, no residents had tested positive for COVID since 12/8/20. Currently, the facility was conducting COVID testing monthly in accordance with current guidance. The last staff member that tested positive for COVID-19 was on 1/16/21. The DON also reported that the county positivity rate had been around 3%. She provided a copy of Washington County's COVID case positivity rate as of 7/7/21. The rate was 3.21%. A review of the facility's resident visitation schedules revealed that visitation was not allowed on 57 of 87 days reviewed from 4/13/21 to 7/8/21. Visitation appointments were scheduled on Tuesdays, Wednesdays, Thursday, and Fridays from 9:00 AM to 5:00 PM. Appointments were not scheduled on Saturdays, Sundays, or Mondays. In addition, there were several dates between Tuesday and Friday where visitation had been cancelled. Visitation not available at any time on the following dates: 4/14/21, 4/17/21, 4/18/21, 4/19/21, 4/24/21, 4/25/21, 4/26/21, 5/1/21, 5/2/21, 5/3/21, 5/5/21, 5/7/21, 5/8/21, 5/9/21, 5/10/21 5/14/21, 5/15/21, 5/16/21, 5/17/21, 5/18/21, 5/19/21, 5/22/21, 5/23/21, 5/24/21, 5/28/21, 5/29/21, 6/1/21, 6/3/21, 6/4/21, 6/5/21, 6/6/21, 6/7/21, 6/8/21, 6/9/21, 6/12/21, 6/13/21, 6/14/21, 6/15/21, 6/16/21, 6/17/21, 6/19/21, 6/20/21, 6/21/21, 6/23/21, 6/24/21, 6/25/21, 6/26/21, 6/27/21, 6/28/21, 6/30/21, 7/1/21, 7/2/21, 7/3/21, 7/4/21, 7/5/21, 7/7/21, or 7/8/21. A review of the facility's COVID-19 Visitation policy and procedure dated 3/12/20 revealed, Visitors will temporarily be prohibited from entering the Skilled Nursing Unit. Spouses, domestic partners, children, grandchildren, friends, and other family members are considered visitors that are prohibited from visiting the Skilled Nursing Unit during this time. The policy also stated that: Limited visitor exceptions will apply to the following: a. Family members during end-of-life situations. b. Hospice or palliative care workers in end-of-life situations. c. Representatives of state and federal government seeking entry as part of their official duties A record review was conducted of the Centers for Medicare and Medicaid Services (CMS) memo QSO-20-39-NH (subject: Nursing Home Visitation-COVID-19) revised 4/27/21 revealed, While CMS guidance has focused on protecting nursing home residents from COVID-19, we recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents and their loved ones. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress .The information contained in this memorandum supersedes and replaces previously issued guidance regarding visitation in nursing homes during the COVID-19 [NAME] (public health emergency). The memo also stated that Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. According to the memo, these scenarios include limiting indoor visitation for unvaccinated residents, if the nursing home's COVID-19 county positivity rate is greater than 10% and less than 70% of residents in the facility are fully vaccinated; residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; or residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria to release from quarantine. Further review of the memo revealed Facilities shall not restrict visitation without a reasonable clinical or safety cause, consistent with 42 CFR 483.10(f)(4)(v). A nursing home must facilitate in-person visitation consistent with applicable CMS regulations .Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of 42 CFR 483.10(f)(4). On 7/8/21 at 10:30 AM, an interview was conducted with the DON. She reported that 13 of 27 residents in-house had received two doses of the COVID-19 vaccine and 1 resident had received 1 her first dose of the vaccine on 7/3/21. A review was conducted of the CMS COVID-19 Test Positivity Rates Archive for Washington County Florida. The time reviewed was from 4/13/21 to 7/8/21. Review of the archive revealed that test positivity rate for Washington County was 3.21% on 7/7/21. The record review indicated that the facility's county positivity rate remained below 10% from 4/13/21 through 7/8/21.

Based on staff interviews and review of the facility policy, entitled, Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to self-identify that social distancing of residents and face covering or masks were not implemented. The failures occurred during a COVID-19 pandemic and had the potential to affect 26 of 26 residents that resided on the Skilled Nursing Unit (SNU). The findings include: Cross-reference F880. The facility failed to implement social distancing of six (6) feet or more during dining; and failed to encourage the use of face covering or masks while residents were out of their rooms for six (6) of 14 sampled residents (Residents #s 9, 14, 15, 16, 22, and 175) and four (4) of four (4) unsampled residents (13, 18, 21, and 75). The failures occurred during a COVID-19 pandemic and had the potential to affect 26 of 26 residents that resided on the Skilled Nursing Unit (SNU). During an interview on 04/08/21 at 9:45 a.m., the Chief Executive Officer (CEO)/Administrator of the SNU stated, during the COVID-19 pandemic he participated in the QAPI meetings virtually. He confirmed that he was not aware, nor had he identified to date any concerns with residents not social distancing at least six (6) feet apart, nor residents not wearing face covering or mask. He stated the Director of Nursing (DON) oversaw the QAPI meeting. The CEO/Administrator indicated that he participated in QAPI meeting virtually, to ensure social distancing amongst facility staff during the COVID pandemic. The Administrator acknowledged an awareness of the current COVID pandemic. During an interview on 04/08/21 at 4:09 p.m., the Infection Preventionist (IP) stated she attended the QAPI meeting mainly to gather information. The IP confirmed that she was not aware nor had she identified residents were not wearing facial covering or mask, when out of their rooms, and were not social distancing at least six (6) feet apart. The IP concluded that she thought if residents were sitting less than six (6) feet apart that was acceptable. The IP acknowledged an awareness of the current COVID pandemic. During an interview on 04/08/21 at 5:47 p.m., the DON accompanied by the hospital Chief Nursing Officer (CNO), the DON stated, she was not aware that residents should be social distancing at least six (6) feet apart, wearing facial covering or mask when out of their rooms. The DON/CNO provided no documentation where the facility addressed with staff and residents, the importance of social distancing six (6) feet apart, face covering or mask wear, as recommended by the Centers for Disease Control and Prevention. The DON/CNO acknowledged an awareness of the current COVID-19 pandemic. Review of the undated QAPI policy, provided by the facility, revealed, .All departments and services will be involved in QAPI activities and the organization's efforts to continuously improve services .Our QAPI plan includes the policies and procedures used to: Identify and use data to monitor our performance .Identify and prioritize problems and opportunities for improvement .Develop corrective action or performance improvement activities .The administrator has responsible and is accountable for ensuring for ensuring that QAPI is implemented throughout our organization .

Based on observations, staff interviews, facility record review, and facility policy review, the facility failed to implement social distancing of six (6) feet or more during dining; and failed to encourage the use of face covering or masks while residents were out of their rooms for six (6) of 14 sampled residents (Residents #s 9, 14, 15, 16, 22, and 175) and four (4) of four (4) unsampled residents (13, 18, 21, and 75). The failures occurred during a COVID-19 pandemic and had the potential to affect 26 of 26 residents that resided on the Skilled Nursing Unit (SNU). The findings include: 1. Observation in the dining room of the lunch meal on 04/06/21 at 12:27 p.m., revealed Resident #s 9 and 22 were seated together with only 67 (5.50 feet) between them. Resident #s 13 and 75 were seated together and had 62 (5.16 feet) between them. Resident #s 16 and 15 were seated together with only 65 (5.41 feet) between them Residents #s 18 and 21 were seated with 61 (5.08 feet) between them. There were no barriers observed between the residents, and all the residents were observed not wearing masks prior to the meal and drinks being served. Continued observation revealed Resident #s 175 and 14 were seated six feet apart; however, neither resident was wearing a mask while waiting for drinks and lunch to be served. Measurements were taken by the Plant Operations Director on 04/06/21 at 12:45 p.m., using his measuring tape. During an interview with the Infection Preventionist (IP) on 04/06/21 at 12:37 p.m., the IP stated she had Never read anything stating residents were to wear masks other than during an outbreak. The IP also stated, The state agency guidance said, if you can't socially distance residents, place no more than two (residents) at a table. The Director of Nursing (DON) provided the guidance document that the IP stated was from the state agency; however, it was recommendations from the American Health Care Association and the National Center for Assisted Living (NCAL.) The information was titled, Communal Dining Guidance. Facility record review revealed, the aforementioned residents who were seated together during dinning, were seated with someone who was not fully COVID-19 vaccinated. Review of the facility's undated document titled, Communal Dining Guidance, stated the Centers for Medicare and Medicaid Services (CMS) updated their guidance on 03/10/21 on visitation and dining in nursing homes. The Communal Dining Guidance stated, .Attempt to separate tables as far apart as possible; at least six (6) feet if practicable .Ideally, have residents sit at tables by themselves to ensure social distancing .can be maintained .If necessary, arrange for meal sittings with only two (2) residents per table . 2. Observation on 04/06/21 at 10:49 a.m., Resident #22 was in the hallway outside of his room coughing. The resident was not wearing a mask. Observation on 04/07/21 at 10:46 a.m., Resident #22 was in his wheelchair across from the nursing station coughing with no mask on. Observation on 04/07/21 at 11:45 a.m., Resident #22 was observed up in his wheelchair across from the nurses' station with a hacking cough with no mask on. The staff did not redirect the resident to his room or provide him with a mask. During an interview with the Chief Executive Officer (CEO), who also was the Administrator of the SNU, on 04/08/21 at 10:03 a.m., the CEO stated he was not aware of the lack of social distancing between residents on the SNU during dining, and residents not wearing masks when out of their rooms. He went on to state he had not rounded on the unit much since the COVID-19 pandemic began last year. When asked if he thought residents should be wearing face masks he responded, I would guess so, then asked how they could enforce the wearing of masks with residents' rights. During an interview on 04/08/21 at 3:50 p.m., the IP indicated she handled policy and procedure reviews related to COVID-19. The IP stated she Passed on information from the CDC (Centers for Disease Control and Prevention) and the Florida Department of Health (FDOH) to the DON. When asked if she performed any training or education related to hand hygiene, PPE (personal protective equipment), etc., on the SNU, the IP stated she did not directly provide any education, but the Chief Nursing Officer (CNO) helped provide some education on the unit. The IP stated she, Didn't come up here (on the SNU) from the hospital side because the facility limited access to the SNU from the hospital. She stated her understanding was, As long as we were screening everyone, residents didn't need to wear masks. This is their home. She stated, I didn't know they (residents) were to be wearing masks on the SNU. On 04/08/21 at 4:26 p.m., the DON joined the IP for the ongoing interview. The DON confirmed residents were not asked to wear masks when they were out of their rooms except while the facility was in a COVID-19 outbreak. The DON stated she was not aware residents should have been wearing masks all along when they were out of their rooms. Review of facility records provided by the facility revealed 20 residents and 23 staff had tested positive for COVID-19. There were no positive cases at the time of the compliance review. Review of the facility policy titled, Novel Coronavirus-COVID 19 Precautions last revised 02/08/21 stated, .If the resident develops more severe symptoms and requires a transfer to higher level of care, the receiving facility (and EMS is used) (emergency medical services) should be alerted to the resident's [DIAGNOSES REDACTED]. Further review of the facility's policy revealed, the policy did not indicate a procedure related to the use of a mask by residents when residents were out of their rooms for reasons other than transfers out of the facility for a higher level of care.

Based on resident and staff interview, and clinical record review the facility failed provide privacy of accommodations for 1 of 1 (#7) residents reviewed for privacy. The findings include: An interview was conducted with resident #7 on 9/23/19 about 2:45 PM. She stated that there is a resident who comes in her room and it bothers her even though she knows the other resident means no harm. The MDS (minimum data set) was reviewed and revealed a quarterly review completed on 7/9/19. The BIMS (brief interview for mental status) had a score of 14 which indicates she is cognitively intact. Clinical record review revealed some of the [DIAGNOSES REDACTED]. The care plan revealed an addition on 6/19/19 resident gets agitated/ upset if residents go in her room. The intervention is to re-direct wandering residents if observed going into her room, or are in her room. The nurse's notes did not have a corresponding note regarding what happened on 6/19/19. There are no notes indicating any episodes occurring in the past week with wandering residents or of attempts by the facility to provide a barrier to prevent unwanted visitors in the resident's room. Resident #7 was interviewed again on 9/24/19 about 1:55 PM, about other residents wandering into her room. She further identified the resident and said the last time it happened was about three nights ago. The Director of Skilled Nursing Unit (DNSU) was interviewed on 9/24/19 about 2:10 PM. She indicated that residents did have a right to wander. The concern was expressed to her that Resident #7 also has a right to her privacy and not have unwanted visitors. A follow up interview was conducted with the DNSU and the risk manager on 9/24/19 about 3:07 PM. They said they had talked the resident and to the evening nurse who confirmed another resident was in her room a few nights ago. At this point Resident #7 has agreed to keep her door shut to deter unwanted visitors.

Based on staff interview, and clinical record review, the facility failed to implement the care plan for 1 of 3 (#13) reviewed for accidents. The findings include: On 9/23/19 at 11:22 AM, Employee E, a Certified Nursing Assistant (CNA) was observed coming out of resident #13's room pushing a Hoyer lift. There were no other CNAs observed coming out with her. The resident was observed in her room in the Geri-chair. Employee E, CNA was interviewed on 9/23/19 at approximately 11:23 AM. She was asked if she had received help using the Hoyer lift for #13. She stated, No, no one helped me use the Hoyer. Yes, they are supposed to, she gets up for every meal. A review of Resident # 13's minimum data set (MDS) revealed a quarterly review dated 7/25/19. The MDS indicates the resident is totally dependent on staff for all activities of daily living. The care plan for Resident #13 indicates she is at risk for falls initiated on 10/29/18 and last updated 7/25/19. Some of the interventions put in place include: Geri-chair bound and requires a Hoyer lift for all transfers. Hoyer lift for all transfers with a two person assist. The Director of the Skilled Nursing Unit was interviewed on 9/25/19 at approximately 2:47 PM. She said that employee [NAME] had come to her and told her she had used the lift without a second person.

Based on staff interview, clinical record review, and policy review the facility failed to use Hoyer lift appropriately for 1 of 3 (#13) reviewed for accidents. The findings include: On 9/23/19 at 11:22 AM, Employee E, a CNA (certified nursing assistant) was observed coming out of resident #13's room pushing a Hoyer lift. There were no other CNAs observed coming out with her. The resident was observed in her room in the Geri-chair. Employee E, CNA was interviewed on 9/23/19 at approximately 11:23 AM. She was asked if she had received help using the Hoyer lift for #13. She stated, No, no one helped me use the Hoyer. Yes, they are supposed to, she gets up for every meal. A review of Resident # 13's minimum data set (MDS) revealed a quarterly review dated 7/25/19 indicates the resident is totally dependent on staff for all activities of daily living. The clinical record review indicates the resident has a care plan for risk of falls initiated on 10/29/18 and last updated 7/25/19. Some of the interventions put in place include: Geri-chair bound and requires a Hoyer lift for all transfers. Hoyer lift for all transfers with a two person assist. The Director of the Skilled Nursing Unit was interviewed on 9/25/19 at approximately 2:47 PM. She said that employee [NAME] had come to her and told her she had used the lift without a second person. The policy for the Hydraulic/Hoyer patient lift was reviewed. The Effective Date 11/02 and last review date of 8/19. Purpose: the purpose of this policy is to ensure safe transfer of physically disabled patients requiring greater than 2 persons to assist with transfer. Policy All patients requiring greater than 2 persons to transfer will be transferred using Hoyer or hydraulic patient lift and will receive assistance of two persons for each transfer. Procedure #2 ensure at least 2 persons are present for transfer.

Based on observation, staff interview, and policy review the facility failed to ensure that chicken was thawed appropriately for 1 of 1 kitchen observation and failed to store ice scoops in a manner to prevent cross contamination for 1 of 1 nursing unit observed (Skilled Nursing Unit). The findings include: Thawing Chicken A kitchen tour was conducted on 9/25/19 at approximately 8:23 AM. The dietary manager, Employee C, was in attendance. An observation was made of chicken being thawed in a blue container in the sink. Water was observed flowing over the chicken; however, the container was sitting in standing water. Employee C, attempted to move the chicken container to allow water to drain out of the sink, but it remained. (Photographic evidence obtained) Employee F, the cook, stated the chicken had been in the sink for about 20 minutes. He then said the sink had been getting slower and slower to drain the last few days. Employee D, the registered dietician (RD), advised Employee C to take the temperature of the chicken. The temperature read 79.8 degrees. The kitchen manager said that is in the danger zone and threw the chicken away. A review of the policy for Food Preparation was viewed: Policy 016 the policy statement reads all foods are prepared in accordance with FDA (food and drug administration). The procedure for thawing foods includes several methods for the cook to use. The third method is to completely submerge the item under cold water (at a temperature of 70 degrees Fahrenheit or below) that is running fast enough to agitate and float off loose ice particles. Ice Scoop Observations were conducted of the nurse's station on 9/24/19 at approximately 9:37 AM, and 4:00 PM and again on 9/25/19 8:36 AM, 9:30 AM and 10:52 AM which revealed a yellow ice chest that housed crushed ice sitting on the counter. The chest had a clear lid that allowed full visualization of the ice along with a clear ice scoop that was positioned down in the ice. On 9/25/19 at approximately 8:36 AM, an interview was conducted with the facility's director of the skilled nursing unit, sampled staff A, during which she stated the ice chest was being used by staff to serve the residents' ice with their beverages because the ice machine was currently broken. At this time, she confirmed the chest contained crushed ice with the ice scoop positioned down in the ice. She stated this is not the correct way to store the ice scoop. She further stated the scoop should be stored in a plastic bag and not in the ice. She stated she would have the current ice thrown away and the ice chest and the scoop cleaned and replaced with new ice and that the ice scoop would be placed in an appropriate container, not stored in the ice. On 09/25/19 a review of the facility's policy concerning ice revealed ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention

Based on staff interview, the facility failed to develop and implement corrective action plans to correct identified quality deficiencies for 2 of 2 areas identified by the facility to need quality improvement. The findings were: An interview was conducted on December 13, 2017 at approximately 9:16 am with the Skilled Nursing Unit Director. When asked if there was anything that the Quality Assessment and Assurance Committee had identified as potential areas requiring corrective action, she stated that earlier in the year she had identified high rates of urinary tract infections and repeated falls on the same resident but had not yet put a corrective action plan into place to address these areas of concern.

Based on staff interview, record review and review of facility policy, the facility failed to ensure adequate interventions to prevent accidents were identified and carried out following resident falls for 3 of 3 residents sampled (#20, #26, #5). The findings were: Resident #20 Review of the medical record for resident #20 showed the resident had suffered a total of nine falls since February 2017. Resident #20 was noted as having hit her head on the falls for 11/12/2017, 9/10/2017, 8/16/2017, and 7/26/2017. Review of the medical record for resident #20 showed the following falls and facility initiated interventions: 11/12/2017 - Nurse has spoken with resident and her daughter regarding need for safety alarms to remind resident to sit down and wait on staff. Daughter states she will let me know. Resident has already said no. 10/18/2017 - History of repeat falls. Oriented and able to use call light. Refuses to change rooms and move closer to nurse's station. Refuses safety alarms and daughter is aware and agreeable. Bedside commode in place to decrease noncompliant ambulation at night when resident requests door to be shut. Resident states she can't sleep with door open. Resident educated to call for assistance. 9/10/2017 - There was no listed intervention for this fall. 8/16/2017 - Resident is noncompliant with asking for help and has a history of falls with her and her daughter refusing the use of safety alarms. 7/26/2017 - Educated resident on the importance of calling on the call light for assistance. Resident continues to refuse alarms. 6/5/2017 - Resident has history of noncompliance with walking in room without assistance and not calling for help. Her daughter is aware and supportive of her mother's decision not to have safety alarms. 4/25/2017 (resident fell twice) - Resident had diarrhea and became dizzy and weak. These falls were 30 minutes to 1 hour apart. After second fall she was sent to the emergency room . Cause of falls was due to decreased blood levels and acute care needs. 2/10/2017 - Resident is noncompliant with safety alarms. She is encouraged to participate in her own safety measures as she will. An interview was conducted with the Director of Nursing (DON) on 12/14/2017 at 11:45am. She was unable to provide evidence that other interventions were attempted after the above referenced falls and was also not able to provide evidence that neurological assessments had been completed on the resident following the falls where she was noted as having hit her head. The DON indicated several times that the resident and family refused the use of alarms, but did confirm the facility had not attempted any other interventions that might have been more agreeable to the resident and her family, such as having staff check on the resident more often. Resident #26 A record review was conducted for resident #26 which revealed the following: Resident #26 suffered a fall on 9/14/17 at 6:05AM. Upon review of the facility provided incident report, there was no evidence of an investigation to find the root cause for the fall. The department manager investigative facts section of the incident report stated, resident verbalizes he will call for assistance in the future and physical therapy (PT) notified. Review of the resident's PT notes showed no mention of the resident's fall, and there was no evidence to suggest that PT had been notified of the resident's fall. The risk manager's note stated patient found on floor with no complaints of injury. The patient is difficult to keep oriented and unable to cooperate. Review of the resident's plan of care revealed no monitoring for effectiveness of current interventions or modification of the interventions to address the cause of the fall. Resident #26 suffered two falls on 9/19/17 at 12:30AM and again at 11:15AM. There were no neurological checks for either unwitnessed fall or follow-up documentation in the nurses notes. Review of the incident reports revealed no evidence of investigation to find the root cause for the falls. The department manager investigative facts section of the incident report had only PT written in the section; however, the resident was discharged from therapy services on 9/20/17. The risk manager's note stated, second fall this month. Staff responded promptly to bed alarm to find patient on the floor. Will continue to make efforts to keep patient safe. There was no further documentation of an investigation, and review of the resident's plan of care showed no monitoring for effectiveness of current interventions or modification of the interventions to address the cause of the falls. Resident #26 was noted with a fall on 10/30/17 at 7:45PM. A review of the incident report revealed no evidence of an investigation to find the root cause for the fall. The department manager investigative section on the incident report stated, resident with increased confusion, urinalysis ordered. Previous falls do not show a correlation in time of occurrence. No further documentation concerning the fall was noted. Review of the resident's plan of care showed no monitoring for effectiveness of current interventions or modification of the interventions to address the cause of the fall. The last fall noted in the medical record of resident #26 occurred on 11/24/17 at 4:20PM. A review of the nurses' notes revealed no neurological checks had been completed for this unwitnessed fall. A review of the incident report showed no evidence of an investigation to find the root cause for the fall. The department manager investigative section on the incident report stated, PT notified of fall, will encourage resident to call for assistance. The risk manager's note stated, found lying on floor by bed, trying to get from wheelchair to bed without assistance. Review of the resident's plan of care showed no monitoring for effectiveness of current interventions or modification of the interventions to address this fall. On 12/13/17 at 12:22 PM, an interview was conducted with the Director of Nurses (DON). She stated the incident report was completed by the floor nurse and statements were written by the Certified Nursing Assistants (CNAs), if indicated. She stated the incident report was then placed in a box for the risk manager to pick up and review. She stated the risk manager got the reports the same day, reviewed them, and then returned them back to the DON. The DON stated she then conducted an investigation and documented in her section titled, Department Manager Investigative Facts, and made any recommendations for interventions. She confirmed, when she looked at the incident reports for the five falls for resident #26, she did not do complete investigations. She stated she felt he was more confused due to his dementia, and he had the alarms to his bed and wheelchair and therapy to help him. She stated she did not realize therapy was discontinued for him on 9/20/17 and not restarted again until 10/06/17. She confirmed the alarms were not effective and interventions on the plan of care after each fall did not address the reasons for the resident's falls. Resident #5 A review of the plan of care for resident #5 revealed the resident had falls on 12/31/16, 4/9/17, 4/13/17 and 4/29/17 with an injury that resulted in an emergency room evaluation and monitoring on a medical unit after the 12/31/16 fall. There was no evidence that post fall assessment was completed, no evidence that the falls had been reviewed by the facility to determine root cause, and no evidence that new interventions related to the cause of the falls were put into place to prevent further accidents. On 12/12/17 at approximately 3:06 PM an interview with the DON was conducted. The DON stated there should have been neurological checks for the falls of resident #5, but none were found. Review of the facility's policy on falls indicated the facility would complete and document the following information after each resident fall: check orthostatic vital signs (vital signs checked in a lying and sitting position), assess for range of motion, and monitor the resident's condition each shift for 72 hours.

Based on observation and interview, the facility failed to provide appropriate incontinent care to prevent urinary tract infection for 2 of 5 residents sampled for infection control (#2 and #7). The findings include: On 12/13/2017 at approximately 10:15 AM, CNA E with CNA F were observed providing incontinent care for resident #2. During the care, CNA E was noted to use a fresh wash cloth soaked in warm soapy water to wipe the resident starting at the right hip, under the abdominal fold, down through the perineal area with one long stroke. She then repeated this action after folding the wash cloth, starting with the left hip, under the resident's abdominal fold, down through the perineal area with one long stroke. She completed the care, applied barrier cream to the resident's coccyx, and returned the resident to a sitting position in her bed. On 12/13/2017 at approximately 11:30 AM, an observation of incontinent care for resident #7 was conducted with CNA G providing care for an episode of bowel incontinence. The CNA was noted to wipe the resident appropriately using a front to back motion with the cloth being folded so a different area of the cloth touched the resident's perineal area; however, the washcloth was saturated with loose, wet stool that was visible prior to each subsequent wipe. On 12/13/2017 at approximately 4:28 PM, an interview was conducted with the Director of Nursing (DON) and the infection control designee. The DON stated that the facility had identified a higher rate of urinary tract infections (UTIs) in january 2017, and had provided education to the residents during their Skilled Nursing Unit School, (an educational program for residents) to address proper hygiene techniques in their female population. She stated this education had been provided in January 2017 and that there had not been any additional education or follow-up since that time. She also stated that it was determined by her and the risk manager that the care provided by staff did not play a role in the increased UTI occurrence, as the majority of their population could provide their own care. She confirmed that staff had not been in-serviced or educated on proper hygiene and incontinent care in the last year, as it was not deemed necessary. When asked if she was aware that the list she provided to the surveyors on 12/13/2017 identified 28 of the facility's 34 residents as incontinent and requiring staff assistance with care, she stated, no.

Based on observation and staff interview, the facility to conduct and maintain a facility-wide assessment to determine necessary resources to care for its residents on a daily basis as well as in emergency situations. This has the ability to affect all residents within the facility. The findings were: During entrance conference with administrative staff, the facility was asked to provide their facility-wide assessment for review, but no assessment was located in the paperwork provided by the facility. An interview was conducted on December 13, 2017 at 8:43 AM with the Skilled Nursing Unit Director. During this interview she stated that the facility did not have a facility assessment, but stated she would begin to develop one.

Based on observation, record review, policy review and interview, the facility failed to implement transmission based precautions to prevent the transmission of communicable disease for 1 of 5 residents sampled (#26). Findings included: Review of the medical record for resident #26 revealed a culture result for a wound to resident's right upper chest. The culture was ordered 12/6/17 and verified on 12/12/17 with result of [MEDICAL CONDITION] (MRSA) being present in the wound. An order was written on 12/12/17 at 2:15PM for the antibiotic [MEDICATION NAME] 300mg, twice a day for 7 days for infection in the wound. On 12/13/17 at 9:10 AM an observation of the resident's room showed no indication of transmission based precautions being in place. At 9:12 AM an interview was conducted with resident's Certified Nursing Assistant (CNA), employee F. She stated she was not aware of anything new going on with the resident and was told in report the resident had a good night. On 12/13/17at approximately 9:30AM an interview was conducted with the Director of Nursing (DON). She stated she was aware of the culture results for resident #26. She stated she had assessed the resident's wound the previous day, and noted the area was dry, not draining and was contained by a dressing. She stated she did not start contact isolation precautions due to the wound being covered with the dressing. She also stated normally there would have been staff education when the results of the culture were received to make sure the nurses and CNAs knew the resident was positive [MEDICAL CONDITION], and a copy of the education would have been placed in the activities of daily living (ADL) book for the staff to review. She confirmed she had not had an opportunity to provide the education to the staff and transmission based precautions had not been initiated as of the time of this interview. The DON confirmed the resident was being treated for [REDACTED]. Review of the facility policy on early identification, isolation and transmission prevention of Multidrug Resistant Organisms (MDROs) showed contact precautions were used in addition to standard precautions and were intended to prevent transmission of identified infectious agents, including epidemiologically important microorganisms which are spread by direct or indirect contact with the resident or the resident's environment. Examples of possible situations that required implementation of contact precautions included active infection with an MDRO for the duration of signs and symptoms and length of treatment.

Based on record review and interview, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use involving 2 of 5 residents sampled for infection control (#3 and #29). Findings included: Review of the medical record for resident #3 found that on 10/08/2017 resident #3 was ordered to receive [MEDICATION NAME] twice daily for 3 days for a urinary tract infection [MEDICAL CONDITION], with a follow-up order [MEDICATION NAME] mg for 4 days for UTI on 10/13/2017. Review of the residents record found that the resident [MEDICATION NAME] the 9th, 10th, & 11th and the 14th, 15th, 16th and 17th. In reviewing the medical record and physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the MAR found that the resident received the antibiotic twice daily on the 12th, 13th, 14th and 15th. Further review found that resident #29 was ordered antibiotic Cefil 250mg twice daily for 3 days on 11/9/2017 and that the antibiotic was initiated on 11/10/2017 and administered on the 10th, 11th and 12th. A follow-up order was written on 11/16/2017 for Cezil 250mg twice daily for 4 days. Review of the MAR found the medication was administered on the 17th, 18th, 19th and 20th. On 12/14/2017 at approximately 7:00 AM a telephone interview was conducted with a pharmacist from the facility's primary designated pharmacy. The pharmacist stated that antibiotics needed to be ordered and administered for 7 consecutive days in order for them to be effective in treating infections such as a UTI. He stated that a break in administration of an antibiotic of greater than 24 hours would require the antibiotic to be restarted for an additional 7 days and to do less than 7 days would be ineffective. When told of the scenarios with ordered antibiotics for resident #3 and resident #29, he stated, this is a problem that could result in resistant organisms such as [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE).