Every finding on record at Oasis at the Keys Nursing and Rehab

Based on record review and interviews, the facility failed to provide an appropriate discharge for 1 (Resident #115) out of 4 residents reviewed for admission, transfer and discharge rights.The findings included: a.) Record review of the Discharge Planning Process Policy and Procedures (implemented 11/2020, revised 09/2022) documented: Policy-It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care and the reduction of factors leading to preventable readmission; Procedure-1) The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge; 3) If discharge to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why and 4) In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: a) Discuss with the resident and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b) Off other, more suitable, options of locations that are equipped to meet the needs of the resident and d) At time of discharge, follow policies regarding discharges Against Medical Advice. Review of the clinical record for Resident #115 revealed he was admitted to the facility on [DATE]. His diagnoses included neurogenic bladder, obstructive uropathy, anxiety disorder, depression, paraplegia (paralysis of lower half of the body), pressure ulcer of sacral region, insomnia due to medical condition, myocardial infarction and interstitial cystitis (inflammation of the bladder). (Electronic copy obtained). Review of the progress notes dated 03/12/2025 for Resident #115 revealed it read: ambulance came at 10.55 to pick up the resident to go to [NAME] Main Hospital Psychiatric unit for evaluation after been [NAME] acted. Resident initially refused to go unless we call the police. The police came and explained to him why he must go there and the hospital will decide what's next. Resident is stable and AAOx4 (Awake, Alert, Oriented to Person, Place, Time, Situation) with no distress at this time. Finally, they left the facility at 23:50 (11:50 p.m.). (Electronic copy obtained). Review of the progress notes dated 03/12/2025 at 11:19 revealed it read: follow-up. Chief complaint: Agitation, combative behaviors, anxiety, refusal of medications History of present illness: [AGE] year-old Hispanic male patient in no acute distress. Seen today for continued evaluation and assessment for agitation, anxiety and combative behaviors. It was reported that patient's behaviors have been intimidating to other patients. Noted with increased agitation, combative behaviors, he has been exhibiting verbal and physical aggressions and was allegedly involved in physical altercation with another resident, he has been refusing his medications and had not received wound care yesterday, education provided on safety awareness, understanding verbalized. Currently working with the facility to make arrangement to send him to a Psych hospital for further evaluation and treatment. (Electronic copy obtained). Review of the progress notes dated 3/11/2025 at 14:24 (2:24 p.m.), revealed: Physician Progress Note. [Resident #115] is a [AGE] year-old Hispanic male seen today for a follow-up of symptoms and medication management. The patient reports to be feeling irritable and delusional. The patient is feeling anxious, experiencing anger outburst, mood swings, irritability, frustration, and engaging in risky behaviors. The patient denies any auditory or visual hallucinations. The nurse confirms that the patient often becomes restless, frustrated having a hard time controlling emotional outbursts. The patient will be sent out for psychiatric evaluation today. No signs of suicidal or homicidal ideation. (Electronic copy obtained). Review of the progress notes dated 3/4/2025 at 08:40 (8:40 a.m.), Mood/Behavior revealed it read that the resident was upset and angry with another male resident for wearing a hat with a Confederate flag on it. He found it offensive and told the resident to take it off. He was told by the Social Worker and the Director of Nursing that the other resident had the right to freedom of speech, and he responded that he also has the right to freedom of speech in telling the other resident he was offended by the symbol. He also said that he ended the Power of Attorney (POA) with his sister yesterday and that he doesn't want us to contact his father or his sister because from now on she is no longer his POA. If there are any issues to speak directly with him, that he is an adult. The electronic record was updated on his wishes (Electronic copy obtained). Review of the progress notes from 12/17/2024 through 03/03/2025 revealed Resident #115 had angry outbursts with other residents and staff on multiple occasions. It was documented that he was offended by other residents religious beliefs and symbols of racism. It was reported to the Nurse Practitioner that Resident #115 had a physical altercation on 03/10/2025 documented with another resident in which he fell out of his wheelchair and while on the ground he kicked the other resident. The other resident denied that it happened. He refused wound care and to take his medications on multiple occasions. (Electronic copy obtained). Review of the Nursing Home Transfer and Discharge Notice given 03/12/2025 and effective 04/11/2025 indicated the resident was to be discharge to [NAME] Crisis 1611 NW 12 Ave, Miami, FL 33136. The reason for transfer was checked: The health of other individuals in this facility is endangered. The safety of other individuals in this facility is endangered. the form was signed and dated by the administrator and the nurse Practitioner. The notice was received by: Sent with ambulance/Police. Unable to sign. Local Long Term Care Ombudsman Council 03/11/2025. There was no documentation attached to show that the resident was danger to other individuals at this facility. (Electronic copy obtained). Review of the Nursing Home Transfer and Discharge Notice given 03/12/2025 and effective 03/12/2025 indicated the resident was to be discharge to [NAME] (Main) Hospital, 1611 NW 12th Ave, Miami, FL 33136. The reason for transfer was checked: Your needs cannot be met in this facility. The section Brief explanation to support this action was blank and no documents were attached. The name of the doctor handwritten on the form, but it was not signed by the doctor. The form was signed by a registered nurse and dated 03/12/2025. No date was documented for notification to the Local Long Term Care Ombudsman Council. (Electronic copy obtained). Review of the Nursing Home Transfer and Discharge Notice dated 03/05/2025 and effective 04/04/2025 indicated the resident was to be discharged to [NAME] Memorial [NAME] Medical Center 19500 Old [NAME] Road, Miami FL 33157. The reason for the transfer was checked: Your needs cannot be met in this facility. The health of other individuals in this facility is endangered. The safety of other individuals in this facility is endangered. This form was signed by the administrator, the resident's physician and the resident refused to sign the form and in handwriting it read: wants a lawyer. It did not indicate that the Local Long Term Care Ombudsman had been notified of the discharge. In handwriting at the bottom of the second page, it was signed and witnessed by the facility Social Worker. (Electronic copy obtained). Review of care plan dated 2/26/2025. Care planned for mood/behavior: Resident presents with behaviors as exhibited by: Verbal/ physical aggression towards staff and other residents. Discharge Planning: The resident has no discharge plans at this time and will remain here at [The facility] for long-term care. Goal: Resident will continue to remain comfortable in-home environment through next review date. Interventions: Involve me in my own plan of care, allow me to choose the things I can and continue to make decisions. Know that you do not need to ask him about discharge planning during Minimum Data Set interviews as he plans to stay at the facility long term. There were no updates to the care plan. (Electronic copy obtained). Review of the MDS dated [DATE] revealed. Brief Review of Mental Status Exam score of 14 out of a possible 15, indicating the resident had mild to no cognitive impairment. No hallucinations, no delusions. Behaviors: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). Behaviors not exhibited. Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). Behaviors not exhibited. Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL (Activities of Daily Living) assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family), and determined to be consistent with resident values, preferences, or goals. Behavior not exhibited. On 08/27/2026 at 12:50 PM during a telephone interview with the Social Worker at [NAME] Memorial Hospital in Miami. She stated she did remember Resident #115. He had been given no information when he left the facility, and the hospital received no information about his medical condition. He did tell her that he wanted to return to this facility. She stated, He was adamant about that. He told her that he had received a discharge notice several days prior to being [NAME] Acted (Emergency, involuntary psychiatric examination). He did not want to be discharged , and they wanted to [NAME] Act him. He told her he was not acting out or meeting [NAME] Act criteria in any way when they did initiate the [NAME] Act on 03/12/2025. She did have a phone conversation with the Admissions Coordinator about having the resident return and remembered that the admission Coordinator told her that the facility was not going to accept him back. She was not given a reason and was told to call the facility administrator. She attempted to speak with the administrator by calling him at least three times, leaving messages which he did not return. She stated that Resident #115 did not meet [NAME] Act criteria at the time he was transported to the hospital and they had no grounds to keep him under a [NAME] Act. He was stable psychiatrically. She stated that even though the facility gave him a discharge notice, they should have taken him back and proceeded with a safe discharge plan for him. She stated, A [NAME] Act is not a discharge plan. On 08/27/2026 at 10:07 AM a phone interview was conducted with the admission Director. She stated that she did not know Resident #115 and was only aware of him from the [NAME] Act. She stated she had no conversations with hospital staff regarding him returning to the facility because he did not want to return. On 08/27/2026 at 10:15 AM during an interview with the facility Social Worker, she stated that before Resident #115 was admitted at this facility, the resident attempted to commit suicide. Because of this he then became a paraplegic. His sister would visit once a week when he was at this facility. They talked to his father about visiting him and the father came to the facility a couple of times. The discharge plan was to set him up to live in a group home or an apartment. His sister was going to look for placement for him. He had many behaviors over the course of his admission here. He would get into fights and become verbally and physically aggressive. They gave him 30-day discharge notice before he was [NAME] Acted on 03/05/2025. She could not state how the resident met [NAME] Act criteria on the day he was [NAME] Acted. She stated that the resident told her after he was [NAME] Acted I don't want to return to this place. I never want to see your faces again. She confirmed that she did not document this conversation anywhere in her notes. She was asked to produce the documentation showing evidence that the resident met [NAME] Act criteria at the time of transfer. When asked why the facility did not take him back when the hospital called, she stated that they could not meet his needs. She could not explain why they could not meet his needs anymore after having done so for over a year. She confirmed there was little evidence documented that on the day he was [NAME] Acted he presented a danger to himself or any other resident. She confirmed that she did not document her attempts to discharge the resident to another facility or to the community. She did not provide a discharge summary. She could not provide copies or documentation to show the receiving facility was notified at the time of his transfer of his medical condition, physician's orders, a bed hold, advance directive information, treatments and devices, care plan, diagnoses and allergies, most recent labs or any special instructions. On 09/08/2026 at 11:02 AM during a telephone interview with the facility nurse Practitioner he confirmed that he was very familiar with Resident #115's case. He was Resident #115's provider for medical concerns. The facility contracted with a provider for psychiatric services and Resident #115 was seen weekly by that provider as well. He remembered that Resident #115 was non-compliant with some of his medications, but that was not a new problem. He stated that as a provider, if he sees that a resident has a need for a psychiatric evaluation he will send them out to a facility that they use that specializes in psychiatric care. He stated he was reading the progress notes as the interview was being conducted but he could not remember initiating the [NAME] Act on 03/12/2025 for Resident #115. He thought the police initiated it. He was not sure why Resident #115 did not return from the hospital. He stated that he could think of no reason that the facility would not take Resident #115 back after the [NAME] Act if the hospital had determined he did not meet [NAME] Act criteria. He stated, We will accept them back, we have done that in the past. If the hospital cleared him to come back then we would take him. He was not sure if there was a medical problem. He could not think of any new need the resident had that the facility could not meet. He had no new conditions, and they had been managing his needs and treatment for the entire time he had lived at the facility. He confirmed that he had no records of the altercations that had been reported to him that Resident #115 had been involved in. He could not find any documentation in the progress notes to indicate that Resident #115 had been the aggressor. It was reported to him that he was involved in an altercation with another resident. He was not sure if any other resident was physically harmed. He did not witness the incidents. He could not think of any other resident that had been physically harmed by Resident #115. He confirmed that there would be an incident report for each altercation. He was informed that no incident reports had been provided. Review of the facility policy and procedure entitled Discharge Planning Process implemented 11/03/2020, revised 9/19/2022. Policy: It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the residents discharge goals the preparation of residents to be active partners and effectively transition them to post discharge care and the reduction of factors leading to preventable readmissions. Definitions: Discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs developing and implementing interventions to address them and continuously evaluating them throughout the resident stay to ensure a successful discharge. 7.) the ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan and updating of the discharge plan as needed to reflect the modifications. 10.) the facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider that will meet the resident's needs, goals, and preferences. 11.) The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. 12.) The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer and to assist the resident in adjustment to his or her new environment. (Electronic copy obtained). Review of the facility policy and procedure entitled Transfer and Discharge implemented 11/03/2020, revised 7/17/2023 read: 10.) For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All other information necessary to meet the resident's needs, which includes, but may not be limited to: i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii. Diagnoses and allergies; iii. Medications (including when last received); and iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. e. All special instructions and/or precautions for ongoing care, as appropriate such as i. Treatments and devices (oxygen, implants, IVs, tubes/catheters); ii. Transmission-based precautions such as contact, droplet, or airborne; iii. Special risks such as risk for falls, elopement, bleeding, pressure injury and/or aspiration precautions; f. The resident's comprehensive care plan goals; g. All other information necessary to meet the resident's needs, which includes, but may not be limited to: i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii. Diagnoses and allergies; iii. Medications (including when last received); and iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. v. Additional information, if any, outlined in the transfer agreement with the acute care provider h. Additional information, if any, outlined in the transfer agreement with the acute care provider. (Electronic copy obtained).

Based on clinical record review, staff interview and facility policy and procedure review the facility failed to notify the receiving facility of all applicable information regarding the resident at the time of transfer to the hospital for 2 of 3 residents reviewed for transfer/discharge (#115 and #118), and failed to provide written notification of the transfer/discharge to the resident or representative for 1 of 3 residents reviewed (Resident #118), out of a total of 49 residents in the sample. The findings included: 1. A record review for Resident #118 found he was admitted to the facility on [DATE] and discharged [DATE]. He was [AGE] years old and had diagnoses including metabolic encephalopathy (brain dysfunction caused by chemical imbalance that stems from systemic issues and may cause confusion, behavioral symptoms or physical symptoms), hemiplegia (total paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting his right dominant side, aphasia (inability to speak clearly as a result of brain damage) following cerebral infarction, Diabetes Mellitus type 2, chronic pain and morbid obesity. A Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] noted he had an unplanned discharge to a short-term general hospital on 6/25/26. Resident #118 was assessed with moderately impaired cognition, and he required maximum assist with transfers. He had an indwelling urinary catheter. The assessment reported Resident #118's current reconciled medication list was provided to the subsequent provider both verbally and on paper upon his transfer. A nursing progress note dated 6/25/26 at 6:31 pm noted Resident #118 was vomiting undigested food. At 8:50 pm he presented with watery diarrhea and at 12:40 am was sent to the hospital due to generalized weakness, multiple diarrhea episodes, low blood pressure and lethargy. Further review of the record found there was no documentation that the facility sent the required information to the receiving hospital (contact information for Resident #118's primary care physician, the resident representative's name and contact information, Advance Directives information, special instructions or precautions, comprehensive care plan goals or any other necessary information) to ensure a safe and effective transition of care. An interview was conducted with the Director of Nursing (DON) on 8/27/26 at 5:34 pm. She was asked for evidence of the information sent to the hospital regarding Resident #118 at the time of transfer. The DON stated facility staff usually send a transfer form, a face sheet and a medication list with the resident upon transfer to the hospital. She searched Resident #118's chart abut could not locate a change in condition form, transfer form, or documentation noting what information was sent to the hospital with the resident. The DON said she would go look in Resident #118's record. The DON returned at 5:54 pm and presented blank transfer form, explaining the nurses complete the form and send it out with residents when they are sent to the hospital. The DON said she could not find that form for Resident #118 or evidence of what was sent to the hospital with him. 2. Review of the clinical record for Resident #115 revealed he was admitted to the facility on [DATE]. His diagnoses included neurogenic bladder, obstructive uropathy, anxiety disorder, depression, paraplegia (paralysis of lower half of the body), pressure ulcer of sacral region, insomnia due to medical condition, myocardial infarction and interstitial cystitis (inflammation of the bladder). (Electronic copy obtained). Review of the progress notes dated 03/12/2025 for Resident #115 revealed it read: ambulance came at 10:55 to pick up the resident to go to [NAME] Main Hospital Psychiatric unit for evaluation after been [NAME] acted (Emergency, involuntary psychiatric evaluation). Resident initially refused to go unless we call the police. The police came and explained to him why he must go there and the hospital will decide what's next. Resident is stable and AAOx4 (Awake, Alert, Oriented to Person, Place, Time and Situation) with no distress at this time. Finally, they left the facility at 23:50 (11:50 p.m.). (Electronic copy obtained). Review of the Nursing Home Transfer and Discharge Notice given 03/12/2025 and effective 04/11/2026 indicated the resident was to be discharge to [NAME] Crisis 1611 NW 12 Ave, Miami, FL 33136 Review of the Nursing Home Transfer and Discharge Notice given 03/12/2025 and effective 03/12/2026 indicated the resident was to be discharge to [NAME] (Main) Hospital, 1611 NW 12th Ave, Miami, FL 33136. Review of the Nursing Home Transfer and Discharge Notice dated 03/05/2025 and effective 04/04/2025 indicated the resident was to be discharged to [NAME] Memorial [NAME] Medical Center 19500 Old [NAME] Road, Miami FL 33157. On 08/27/2026 at 12:50 PM during a phone interview with the Social Worker at [NAME] Memorial Hospital in Miami. She stated she did remember Resident #115. He had been given no information when he left the facility, and the hospital received no information about his medical condition. He did tell her that he wanted to return to this facility. She stated, He was adamant about that. He told her that he had received a discharge notice several days prior to being [NAME] Acted. He did not want to be discharged , and they wanted to [NAME] Act him. He told her he was not acting out or meeting [NAME] Act criteria in any way when they did initiate the [NAME] Act on 03/12/2026. She did have a phone conversation with the facility's Admissions Coordinator about having the resident return and remembered that the admission Coordinator told her that the facility was not going to accept him back. She was not given a reason and was told to call the facility administrator. She attempted to speak with the administrator by calling him at least three times, leaving messages which he did not return. She stated that Resident #115 did not meet [NAME] Act criteria at the time he was transported to the hospital and they had no grounds to keep him under a [NAME] Act. He was stable psychiatrically. She stated that even though the facility gave him a discharge notice, they should have taken him back and proceeded with a safe discharge plan for him. On 08/27/2026 at 10:15 AM during an interview with the facility Social Worker, she stated that she did not provide a discharge summary to the receiving facility. She could not provide copies or documentation to show the receiving facility was notified at the time of his transfer of his medical condition, special risks such as for pressure ulcers, falls or elopement, physician's orders, a bed hold, advance directive information, treatments and devices, transmission-based precautions, care plan, diagnoses and allergies, current mental, behavioral, and functional status, reason for transfer, recent vital signs; most recent labs, diagnostic tests or immunizations or any special instructions. On 8/27/2026 at 3:43 PM during an interview with the facility Director of Nursing, she stated that copies of the medications, labs, physician's orders, treatments and special instructions are sent with the resident at the time of the transfer. She did not provide documentation to show that copies were sent with Resident #115 at the time of his transfer on 03/12/2026 to [NAME] Memorial Hospital or at a later date. Review of the facility policy and procedure entitled Transfer and Discharge implemented 11/03/2020, revised 7/17/2023 read: 10.) For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All other information necessary to meet the resident's needs, which includes, but may not be limited to: i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii. Diagnoses and allergies; iii. Medications (including when last received); and iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. e. All special instructions and/or precautions for ongoing care, as appropriate such as: i. Treatments and devices (oxygen, implants, IVs, tubes/catheters); ii. Transmission-based precautions such as contact, droplet, or airborne; iii. Special risks such as risk for falls, elopement, bleeding, pressure injury and/or aspiration precautions; f. The resident's comprehensive care plan goals; g. All other information necessary to meet the resident's needs, which includes, but may not be limited to: i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii. Diagnoses and allergies; iii. Medications (including when last received); and iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. v. Additional information, if any, outlined in the transfer agreement with the acute care provider h. Additional information, if any, outlined in the transfer agreement with the acute care provider (Electronic copy obtained).

Based on observation and interview, the facility failed to ensure medications were secured, locked and inaccessible to unauthorized staff, residents, and visitors, or under direct observation of authorized staff for 1 (Resident #6) of 3 residents interviewed in their room. The findings included: Facility policy titled Medication Administration indicated under Bullet #7: Medications cannot be left at the bedside of residents. Nurses must ensure the residents take medications. On 1/4/24 at 9:31 a.m., during an interview with Resident #6 in her room, a medication cup with a blue pill in it was noted on her dresser. Resident #6 said she didn't know why the medication was there, what the medication was or who had left it there. (photographic evidence obtained) On 1/14/24 at 9:35 a.m., Staff F Registered Nurse (RN) said she hadn't given Resident #6 medications and that it may have been left there by the overnight staff. On 1/14/25 at 9:35 a.m., the Director of Nursing (DON) said it is policy not to leave meds unattended in room and she would begin an investigation and re-education.

Based on observation, interview, and record review, the facility failed to ensure the ice machine was kept clean and sanitary and maintained in safe operating order to prevent contamination of the ice for 1 of 1 ice machine in the facility. The facility also failed to ensure food items in 1 of 2 nourishment refrigerators on the units were dated and labeled so as to prevent the potential for foodborne illness. The findings included: On 04/22/24 at 11:27 a.m., during a tour of the kitchen, the white plastic flap inside the ice machine was noted to be dirty with condensation dripping down through the dirty areas onto the ice. When wiped with a cloth this substance revealed a milky, tan colored, slimy substance. The rear of the ice machine had black spots and when wiped with a cloth revealed a dry, black substance. The filter on the ice machine had spaces to write when it was installed and when to replace but both spaces were blank. The filter label said recommended filter replacement every 12 months. The inspection sticker was dated 9/20/21. * On 4/22/24 at 11:30 a.m., the Food Service Director (FSD) said the ice machine was cleaned every 2 weeks by the staff. He said it wasn't due to be cleaned for 2 more days. He said it was an old machine and he thought the filter had been changed within the last 6 months but would have to look for the paperwork documenting this. He said this was the only ice machine for the whole facility. FSD provided a cleaning schedule checklist. This checklist indicated the ice machine can be completed once a month. Instructions were to initial block under the date completed. 2 columns for month were both filled in with April 24. The only dates initialed for Ice machine were April 29 and April 26, both dates which had not yet occurred. The FSD also provided a Monday through Sunday Dietary Cleaning Schedule. The ice machine was not listed for any day. On 4/23/24 at 11:30 a.m., the Food Service director said the facility had changed hands multiple times and he did not have any paperwork documenting the last time the filter had been changed or when the ice machine had been serviced last. The FSD said this should be done yearly and he had taken the unit out of service for the time being. On 4/25/24 at 9:30 a.m., the FSD said each column of the cleaning schedule checklist should indicate a different month. He said it had been filled out wrong. He agreed at this time there was no way to discern the last time the ice machine was cleaned. Facility policy titled Food Brought by Others with approval date 3/1/23 indicated: 4. Items stored for later consumption are labeled and dated before placing in the pantry located on the unit. A. Label includes resident name and room number. B. Label includes content of food/beverage if not a prepackaged item. C. Label includes date stored. 5. Potentially hazardous food items that remain in the pantry will be discarded after 3 days. On 4/22/24 at 12:00 p.m., the second-floor pantry refrigerator was noted to have a bright orange posting on the front indicating everything must be labeled with name, room number and date. Open food must be discarded after 3 days. On the side of same refrigerator, the facility policy was posted. Upon opening the refrigerator, a grocery bag containing sandwich bags with various food in them was found. The outside of the grocery bag had been marked with initials and a three-digit number. Nothing further was written on the bag or the bags inside. A second grocery bag contained a Styrofoam container with food inside the container. Nothing was written on the outside of the bag or the container. A fast-food chain bag was also in the refrigerator containing food. A residents name was written on the bag but nothing else. The receipt stapled to this bag was dated 4/10/24. * On 4/22/24 at 12:12 p.m., the Administrator said the pantry refrigerators are for residents only for left-over food. He said they should be labeled, dated and kept for 3 days. He said this should be checked daily by dietary. The Administrator observed the 3 bags in the second floor pantry refrigerator and threw the bags away. He said the policy was posted right on refrigerator and staff should be following the policy. * photographic evidence obtained

Based on interview and record review the facility failed to report Payroll Based Journal (PBJ) information on a quarterly basis and ensure staffing information was accurately reported as required by regulation. The findings included: Review of the PBJ report shows the facility had not been reporting quarterly staffing data as required by regulation. On 4/25/24 at 9:39 a.m., the Administrator verified the facility had not reported PBJ data for the last three quarters. There was a change of ownership in March of 2023 and he was not made aware of the company not reporting the PBJ data for two quarters. He said he had attempted to complete the data on the third quarter but was not able to. The Administrator said he now has a software contract that will enable him to report the PBJ data on time.

Based on interview, record review and facility policy the facility failed to ensure quarterly elopement risk assessments were completed appropriately for 1 of 6 residents surveyed for elopement risk (Resident #17). The lack of appropriately assessing the resident had a potential to contribute to the resident eloping from the facility. The findings included: The facility's policy on elopement reads, Cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without the knowledge of the facility staff .Residents shall be reassessed at least quarterly related to elopement risk. Resident #17 was admitted to the facility on [DATE]. Upon admission she was diagnosed with Alzheimer's Disease. On 12/2/21 Resident #17 was diagnosed with General Anxiety Disorder, and Major Depressive Disorder. Review of the facility investigation shows On 2/26/24 at 3:45 p.m. facility staff were informed by the Sheriff's Department Resident #17 was seen off of the premises of the facility. According to the investigation, the resident was immediately returned to the facility without any harm. The investigation showed Resident #17 had not had any exiting behaviors prior to the incident. The Annual Minimum Data Set (MDS) dated [DATE] shows Resident #17 had a Brief Interview for Mental Status (BIMS) which scored a four. A score of 4 shows the resident to be cognitively impaired. Review of Section E of the MDS dated [DATE] shows Resident #17 had been having delirium that was a new behavior at the time of her annual MDS. Section E showed Resident #17 had not had any wandering behaviors. Review of the elopement assessments completed by staff for Resident #17 shows her last elopement assessment completed prior to incident was completed on 7/25/22. The score on the elopement assessment was a 6. The resident would be at risk for elopement if the score was 10 or higher. On 4/24/24 at 9:18 a.m., the MDS Coordinator said she did not complete quarterly assessments for elopement risk. She said she would check the elopement book to see if a resident was an elopement risk when completing the MDS. On 4/24/24 at 9:22 a.m., the Assistant Director of Nursing said The Director of Nursing (DON) was responsible for completing the elopement risk assessments. On 4/24/24 at 9:28 a.m., the Director of Nursing verified prior to 2/26/24, when the incident occurred, Resident #17 had not had an elopement assessment completed since 7/25/22. The DON said she was not completing quarterly assessments on all facility residents. On 4/24/24 at 9:32 a.m., the Administrator said he was not aware Resident #17 had not had a quarterly elopement assessment since 7/25/22. The Administrator verified it was the policy of the facility to assess all residents quarterly for elopement risk.

Based on observation, record review, review of facility's policies and procedures, and staff interview the facility failed to implement timely preventive measures and failed to alter the plan of care to include offloading of the area when a pressure ulcer developed for 1 (Resident #6) of 2 residents reviewed who developed a pressure ulcer at the facility. The lack of timely and appropriate interventions resulted in Resident #6 developing a new unstageable pressure ulcer on her right heel as well as a worsening of her previously resolved pressure ulcer on her right heel. Resident #6 now has 2 unstageable facility acquired pressure ulcers. The findings included: On 4/25/24 at 9:50 a.m., during a wound care observation for Resident #6 performed by RN Staff C the resident was observed in bed laying slightly on her right side. Resident was awake and stated that she was ok with the nurse doing her wound care treatment at the time. Resident feet were uncovered and her left foot was observed to be laying on one pillow with her heal just slightly elevated off the bed. There was a small adhesive dressing that was coming off the left heel at the time of the observation. The nurses stated that the heel treatment had changed since the pressure ulcer was resolved for a week or two. A nurse and CNA staff B, who was assisting, lifted the resident heel up further so that it could be assessed. The nurse removed the dressing and started to assess the area. The area was noted to have a large area of redness that encompassed the entire heel. Then in the dorsal area of the heel an area about the size of a quarter was deeper red, boggy and non-blanchable. The nurse stated that she was going to call the wound care doctor and give him a report on the condition of the left heel and ask for a change in dressing. After this she got a new order she cleaned the area with normal saline apply skin prep, covered the area with a betadine-soaked dressing, covered with ABD pad (absorbant dressing) and wrap with Kerlex. After the nurse completed dressing and had it secured she plumped up the pillow under the resident lower leg so the foot would not be pressing on the bed. Next it was observed that the residents right foot was lying flat on the bed with no elevation of the foot. The nurse was asked if the right foot and heal could be looked at. The nurse stated that the heel was ok. Surveyor asked to observed Right heel. When staff CNA and Nurse picked up the lower leg and foot to reveal the right heel it was deep read encompassing the entire heal and the heel had an elongated fluid filled blister towards the right lateral side of the heel, the size of large peanut or 25 % of the heel area. The facility policy titled, Pressure Ulcer and Skin Breakdown Policy Assessment and Recognition. The nursing staff, Wound Consultant, and practitioner will assess and document an individual's significant risk for developing pressure ulcers (i.e., immobility, recent weight loss, history of pressure ulcers). Current resident will receive weekly skin evaluations. The Wound Consultant, Practitioner, or physician will: *Order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing and/or topical agents. A review of an Admission Record indicated the Resident #6 was admitted to the facility on [DATE] diagnosis that include: Multiple sclerosis, diabetes, dementia, history of stroke, obesity and muscle weakness. The Significant Change Minimum Data Set (MDS) (tool used to assess and plan care) dated 1/17/24 revealed resident #6 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Resident's functional limitation in range of motion of upper extremities are impaired on one side. Resident is able to sit up in the wheelchair but is non-ambulatory. Resident is dependent for toileting, bathing, dressing and personal hygiene. Resident is maximum assist for transfers and bed mobility and frequently incontinent of bowel and bladder. Resident was noted to have pressure ulcer injury and is at risk for developing pressure ulcer injuries. At the time of the assessment resident had 1 stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.) Resident also had 1 unstageable & 2 unstageable Deep tissue injury. Skin and Ulcer injury treatments indicated pressure ulcer care. Review of Resident #6 Care Plans initiated on 4/22/24 revealed Resident #6 was at risk for developing pressure ulcers related to a history of pressure ulcers. Interventions include, Apply pillows under left and right heels as tolerated to preventive measures date initiated 2/8/24, Apply treatment to left heel per primary care providers orders initiated 3/25/24. Strive to keep bed linens clean, dry and wrinkle free, strive to keep skin clean and dry, weekly skin assessment per facility protocol, wound care consult if needed. A Review of Resident #6 electronic medical record revealed only one Braden Scale for predicting Pressure Sore Risk dated 2/5/24. No other Braden Scale assessment was found in the record since 2019. The resident scored a 14 which indicated a moderate risk for developing pressure ulcers. A review of Resident last weekly skin/wound observation form dated 4/23/24 indicated that resident still had skin issues of a stage I pressure ulcer on her left heel with the dimensions of 1cm x 1 cm x 0.2. area was intact but had scant serous (thin, watery, clear drainage). Resident also had an area of Moisture Associated skin damage (MASD) on her sacrum. There was no mention of the condition of right heel. During an interview on 4/25/24 at 10:10 a.m., wound care nurse RN staff C she stated after completion of the above wound care treatment on resident left and right heels, that the left heel that had previously been resolved was now unstageable due to the noted closed blister with bogginess and discoloration. She said she would also stage the resident right heel as unstageable with the bogginess and a closed blister formation. The nurse stated that she did call the wound care ARNP and got new treatment orders for both heels. The nurse also said that the pillow use to elevate resident #6 leg were often not effective enough because her legs are heavy and push down the pillows. When asked RN staff C was unaware if the resident had any heel protectors. During an interview on 4/25/24 at 12:07 p.m. Director of Nursing (DON) stated that she was aware of the resident and that she did have a facility acquired pressure ulcer on her left heel that had recently been resolved on 4/18/24. The DON then reviewed the wound care Nurse documentation and acknowledged that the resident now had a worsening or reoccurrence of her left heel pressure ulcer which was now unstageable and a new unstageable area that on her right heel. DON stated that even though the resident was on hospice service she should not be getting new pressure ulcers. After reviewing the resident record the DON acknowledged that the only intervention was to offload the left heel with pillows which was put in in May of 2023. There was no interventions put in place for right heel or any positioning or preventative treatment for bilateral heels. During an interview on 4/25/24 at 12:14 p.m., facility Nurse Practitioner (NP) stated that even though the resident is on hospice care she should still not be getting new pressure ulcers. NP stated that he does not believe that the blister on the resident right heel could have developed in the 2 days since the last nurses weekly skin check. During an interview on 4/25/24 at 12:36 p.m., wound care Advanced Registered Nurse Practitioner (ARNP) via phone he said that he had been seeing the resident for a while treating her left heel house acquired pressure ulcer. He stated that it had recently been resolved. Wound care ARNP stated that he did get a call from the wound care nurse about the worsening of the left heel and the request for new order for the area she described as unstageable blister area and about the new unstageable area on the resident right heel. He stated that the resident will need to have her heels always offloaded and she will need an air mattress on her bed.

Based on observation, review of facility policy and procedure, review of the Operating Manual for the concentrator, review of the clinical record and staff interview, the facility failed to follow their policy and procedure and physician orders for the use of oxygen for 1(Resident #32) of 1 resident reviewed for oxygen use. The facility failed to have a system in place to ensure the oxygen concentrator filters were in place when the concentrator was in use per the manufacturers recommendations. The findings included: The facility policy Oxygen Equipment Use Policy documented, The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. Clean oxygen concentrator filters weekly. Review of the Operating Manual for the 5-liter oxygen concentrator specified: Never block air openings of the oxygen concentrator or place it where the air openings may be obstructed. Keep the openings free of lint, hair dust, etc. Warning: Do Not operate the concentrator without the filters installed, or if filters are wet. Permanent damage to the concentrator could occur. Review of the clinical record revealed Resident #32 had an admitted [DATE] with diagnoses including chronic kidney disease stage 5, arteriosclerotic heart disease and anxiety disorder. On 4/22/24 at 10:53 a.m., Resident #32 was observed in her bed with oxygen on via a nasal cannula at 4.5 liters per minute (L/M). Photographic evidence obtained. On 4/23/24 at 10:35 a.m., Resident #32 was observed in her bed using oxygen via a nasal cannula. The oxygen concentrator set on at 4 L/M. The resident said she has panic attacks and the oxygen helps with her breathing and calms her. On 4/23/24 at 10:38 a.m., observation of the oxygen concentrator with Registered Nurse (RN) Staff A, the RN confirmed there was no filter in the concentrator and the oxygen was set at 4 L/M. On 4/23/24 at 1:44 p.m., in an interview the Director of Nursing (DON) said the nurse was responsible to turn the oxygen concentrator on and the resident puts the nasal cannula on when she needs it. The DON said, the resident gets anxious, panics, and then needs her oxygen. We put the oxygen on between 2 and 3 liters. The DON said sometimes it is difficult to adjust the flow dial, so you have to turn it up a little, sometime the dial is not accurate. Review of the Physician order dated 12/4/23 specified oxygen at 2 L/M as needed for increased confusion or shortness of breath.

Based on observation and staff interview the facility failed to ensure the safety of residents, staff and guests by failing to ensure propane emergency shut off valve for the laundry room dryers was accessible in the event of an emergency. The findings included: On 4/23/24 at 8:23 a.m., during an initial tour of the laundry room the propane emergency shut off valve for the dryers was blocked by carts, cleaning carts and bins of clothing, making it unreachable in an emergency situation. * On 4/23/24 at 8:43 a.m., in an interview the Maintenance Director said he said he only handles the maintenance concerns and had nothing to do with the blocked access to the propane emergency shut off valve. The Maintenance Director said, The end dryer does not work so it does not matter if there is stuff blocking it, the dryer is broke. This writer asked if the other 2 working dryers run on propane and he said yes. He was asked how anyone would get to the propane shut off valve in case of an emergency and he replied, I see what you mean, I will get the Housekeeping Supervisor. On 4/23/24 at 8:55 a.m., during an interview the Housekeeping Supervisor said she was unaware that the propane shut off valve could not be blocked. * Photographic evidence obtained

Based on observation and interview the facility failed to maintain cooking equipment, storage racks and physical facilities in a sanitary manner. The findings included: On 6/27/22 at 9:24 a.m., during an initial tour of the kitchen the cooking oven, range, hood, prep tables, utility carts, and storage racks were observed dirty with grease, grimy residue, and debris. Photographic evidence obtained The wall in the dish room had large patches of missing tiles and the floor has broken and missing tiles. Photographic evidence obtained The grease trap on the griddle was full of grease and unable to be removed. The drip pan on the range had a large accumulation of grease and debris. A large amount of liquid grease was observed under the foil liner on the drip pan. Photographic evidence obtained The Utility carts were dirty with grime and debris. Photographic evidence obtained The storage rack holding clean baking sheets and cooking pans has collected grease, lint, and other debris. Photographic evidence obtained Shelves below and above preparation tables are dirty with grime and debris. On 6/29/22 at 7:11 a.m., during observation of the breakfast service the utility carts remained dirty with grime and debris. The storage rack for the clean cooking pans was still dirty with lint and grime. There was no improvement to the wall in the dish room. On 6/29/22 at 3:06 p.m., the Dietary Manager acknowledged the kitchen was not as clean as it should be. He confirmed the storage racks were dirty with grime and lint, and the steam table wells had scaling and burnt-on residue. Photographic evidence obtained He said he did not have the staff to keep the kitchen clean.

Based on observation and interview the facility failed to properly contain and dispose of garbage and refuse. The findings included: On 6/27/22 9:10 a.m., the two dumpsters were observed to be full of bags of refuse and cardboard boxes. One of the dumpsters was overflowing. The lids were not closed over the garbage. There were bags of refuse on the ground around the dumpsters and litter around the area. There was a container the size of a dumpster constructed of a steel frame and chain link fencing filled with construction debris and cardboard boxes. Observation of the dumpsters on 6/29/22 at 7:45 a.m. found the garbage was still not properly contained. The dumpsters were overflowing and uncovered. On 6/30/22 at 12:01 p.m., the administrator said he was aware the garbage was not properly contained in the dumpsters. He said he was not sure when the last pick up was made but the pick-up schedule with the waste company was for Mondays, Wednesdays and Fridays.

Based on observation and interview the facility failed to provide a safe and clean environment with regard to furnishings and personal care items for 5 (Room 202, 213, 215, 214 and 216) of 20 occupied resident rooms reviewed on the second floor of the facility. The findings included: On 6/27/22 at 10:05 a.m., during initial tour of the second floor, the base of over bed table in room 213 B was observed dirty with food splatter and corrosion. Photographic evidence obtained The side chair was dirty with grime and stains. Photographic evidence obtained The wall and privacy curtain in room 215 were splattered with multiple brownish stains of tube feeding residue. Photographic evidence obtained The bed frame in room 216 A was dirty with sticky brown residue. Photographic evidence obtained On 6/29/22 at 10:32 a.m., the base of the over bed tables of room 213 A and B were dirty with residue and corrosion. Photographic evidence obtained The wall and privacy curtain in room 215 remained splattered with tube feeding residue for three days of the survey. Photographic evidence obtained The bed in room 216 A remained dirty with sticky brown residue for three days of the survey. On 6/30/22 at 10:32 a.m., the Housekeeping Director said normally the residents' rooms are cleaned daily and deep cleaned monthly, including bed frames, and furniture. Currently there was only one housekeeper staff on each floor, and they were only able to do the essentials. She said the maintenance staff takes down and washes all the privacy curtains monthly, but they have not been able to do that. The housekeepers are expected to report soiled privacy curtains to her, and she would see that it gets done. She said the facility did not have a written reporting system for items that needed to be cleaned. On 6/30/22 at 10:40 a.m., during a tour of the second floor with the Director of Housekeeping the following was observed: The over bed tables in room 213 A and B were dirty with food splatter residue and corrosion. The side chair remained stained. The over bed table in room 214 was dirty with food splatter residue. Tube feeding splatter residue remain on the wall and privacy curtain in room 215. The bed frame in room 216 was dirty with brown sticky residue. The over bed table was dirty with food splatter residue. The Housekeeping Director verified the resident room furnishings were dirty with residue. She acknowledged the walls, bed frames, over bed table bases were not being cleaned. On 6/27/22 at 9:57 a.m., and 6/28/22 at 3:19 p.m., multiple unlabeled, unbagged hygiene products including toothbrushes, toothpaste, body wash, and lotions were stored on the sink of room 202, shared by two residents. Photographic evidence obtained On 6/29/22 at 9:40 a.m., Certified Nursing Assistant (CNA) Staff C verified the personal hygiene items stored on the sink in room 202 were not labeled and bagged. She said, That shouldn't be like that. I know I can try to tidy it up and put them into individual baggies with their names on them. CNA Staff C said she wasn't sure which toothbrush belonged to which resident. On 6/30/22 at 11:46 a.m., the Director of Nursing (DON) personal residents' hygiene items, should be separated, either in baggies or drawer. On 6/30/22 at 3:58 p.m., the DON said the facility did not have a policy for labeling or storing personal hygiene items.

Based on observations, interviews, records review and facility policy review the facility failed to ensure an ongoing activities program for 7 (Residents, # 9, #52, #18, 36, #15, #55 and #61) of 9 residents reviewed for activities. The findings included: Review of the facility policy titled, Resident Activities, revised May 16, 2022, which said Purpose: To ensure residents are offered activities that are compatible with the resident's individual physical and mental capabilities. 1. On 6/27/22 at 9:57 a.m., Resident # 61 was observed wandering in hall repeatedly pacing back and forth the length of the unit. On 6/27/22 at 1:21 p.m., Resident #61 observed again wandering in hall, repeatedly pacing back and forth the length of the unit occasionally attempting to enter rooms not assigned to Resident #61. Redirected by staff when attempting to enter rooms not assigned to Resident #61. On 6/28/22 at 8:22 a.m., Resident # 61 observed doing the same wandering behavior on unit. On 6/28/22 at 3:45 p.m., Resident # 61 observed again walking back and forth in hall. During several observations activities staff did not engage or attempt to engage Resident #61. On 6/29/22 at 11:25 a.m., interviewed Activities Director and Activities Assistant, Staff I, about activities for Resident #61. Activities Director replied, She likes to walk, and her daughter used to bring her dog up for visits. She loves coming downstairs when we have singing and dancing. Resident #61 really likes music, she likes snacks. We do activities like one to one with her. Asked to see documentation of Resident #61 participating in activities. Activities Director said We recently just started doing progress notes but unfortunately, I am not seeing any for Resident #61 There was no evidence of documentation in the Point of Care (POC) for activities. Activities Director said, I did not even know we were supposed to document there. 2. On 6/27/22 at 10:29 a.m., observed Resident # 15 in bed asleep. Room quiet, no music or television observed and currently no roommate in room. On 6/28/22 10:22 a.m., Resident #15 in bed awake in bed with television playing in room. During observations of resident no staff from the activities department entered resident's room. On 6/29/22 record review of Resident #15 revealed no evidence of participation in activities in the POC. On 6/29/22 at 11:48 a.m., in an interview, the Activities Director said You would think it would have been done especially since she has been here since 2018. 3. On 6/27/22 at 9:45 a.m., Resident #55 observed in bed watching TV. Asked how she was doing. Resident #55 replied, I am okay. On 6/28/22 at 11:05 a.m., Resident #55 observed in bed. Asked about going to activities and replied, Sometimes I do stuff but not really too much. There isn't a lot to do. During observations of resident, no staff from the activities department entered resident's room. On 6/29/22 at 12:03 p.m., interviewed Activities Director about activities for Resident #55. Activities Director said, She stays mostly in her room and in bed. Record review for Resident #55 revealed no documentation in POC for activities on 30 days look back. On 6/29/22 at 1:35 p.m., in an interview, the Facility Administrator said the expectation for Activities Director and Activities Assistant is to perform the activities that are needed and document that they are done. 4. On 6/27/22, Resident #18 was observed lying in bed all day in night clothes. On 6/28/22 at 01:05 p.m., during observation throughout the day, Resident #18 was not observed out of bed or involved in any activity participation. On 6/29/22 at 12:00 p.m., in an interview, the Activities Director said she has not been able to have many group activities. She said Resident #18 moved to a new room due to the need for isolation of her roommate and Resident #18 has not been getting out of bed. The Activities Director said she has not been documenting activities participation. There was no record of group activity attendance or one-to-one activity encounters for Resident #18. On 6/29/22 at 2:02 p.m., the Activities Assistant said she has not been working with Resident #18 but was going to try to have a one-to-one activity this day. On 6/30/22 at 1:48 p.m., the Activities Director said Resident #18 has been very tired and sleeping a lot lately. She said the activities staff have been putting notes in 'General Progress Notes'. The Activities Director said the Activities Assistant made a note yesterday about providing coloring materials for Resident #18. A review of the Progress Notes finds the last prior Activities note was documented on 7/23/20. 5. On 6/27/22 during multiple observations from 10:10 a.m. to 3:00 p.m., Resident #9 was observed in her room wearing a hospital gown not involved in an organized activity program. On 6/28/22 during multiple observations from 9:00 a.m. to 4:00 p.m., Resident #9 was observed in her room wearing a hospital gown not involved in an organized activity program. On 6/28/22 review of Resident #9's medical record, an activity plan of care stating Resident #9's was dependent on staff for meeting physical, and social needs related to cognitive deficits, Resident #9 would participate in 1:1 activities of choice weekly, staff would assist Resident to and from all locations of interest and break activities into simple and easy-to-follow steps. Further review of Resident #9's medical record revealed no documentation Resident #9 had attended any activities of her choice in 2022. On 6/29/22 at 1:20 p.m., during an interview with the MDS (Minimum Data Set) Nurse, she said Resident #9 was admitted to the facility on [DATE] and her last quarterly care plan meeting was conducted on 3/14/22. She confirmed Resident #9's activity plan of care stated Resident #9's was dependent on staff for meeting physical, and social needs related to cognitive deficits, Resident #9 would participate in 1:1 activities of choice weekly, staff would assist Resident to and from all locations of interest and break activities into simple and easy-to-follow steps. The MDS Nurse said the Activity Director was responsible to ensure Resident 9's activity plan of care was followed and documented in the medical record. The MDS Nurse said after reviewing Resident #9's medical record she was unable to find documentation of Resident #9 attending activity programs and the Activity Director completed the mandatory quarterly activity assessment progress notes in 2022. On 6/29/22 at 4:09 p.m., interview with the Activity Director said she was an activity assistant and became the Activity Director in September 2021. She attended each resident's care plan meetings and was responsible to complete the MDS section for activity and complete the quarterly activity assessment for each resident. She confirmed Resident #9's activity plan of care stated Resident #9's was dependent on staff for meeting physical, and social needs related to cognitive deficits, Resident #9 would participate in 1:1 activities of choice weekly, staff would assist Resident to and from all locations of interest and break activities into simple and easy-to-follow steps. The Activity Director said after reviewing Resident #9's medical record she did not have any documentation Resident #9 had attended any activity programs in 2022. She further said she was unable to find documentation she had completed Resident #9's quarterly activity assessment as required. 6. On 6/27/22 during multiple observations from 9:00 a.m. to 4:00 p.m., Resident #52 was observed in his room wearing a hospital gown not involved in an organized activity program. On 6/28/22 during multiple observations from 10:00 a.m. to 3:00 p.m., Resident #52 was observed in his room wearing a hospital gown not involved in an organized activity program. On 6/28/22 review of Resident #52's medical record, noted the activity plan of care stated Resident #52 was dependent on staff for meeting physical, and social needs related to cognitive deficits, [CONDITION(S)], and physical limitations and Resident #52 would attend and participate in activities of his choice on a weekly basis. Further review of Resident 52's medical record revealed no activity progress notes for Resident #52 since 2/24/21 and no documentation Resident #52 had attended any activities of choice in 2022. On 6/29/22 at 2:00 PM, in an interview with the MDS Nurse, she said Resident #52 was admitted to the facility on [DATE]. She confirmed Resident #52's activity plan of care stated Resident #52 was dependent on staff for meeting physical, and social needs related to cognitive deficits, [CONDITION(S)], and physical limitations. The plan of care further stated Resident #52 would attend and participate in activities of his choice on a weekly basis. The MDS Nurse said after reviewing Resident #52's medical record she was unable to find documentation of Resident #52 attending activity programs and the Activity Director completed the mandatory quarterly activity assessment progress notes in 2022. On 6/29/22 at 4:33 p.m., during an interview with the Activity Director, she confirmed Resident #52 was admitted to the facility on [DATE]. She confirmed Resident #52's activity plan of care stated Resident #52 was dependent on staff for meeting physical, and social needs related to cognitive deficits, [CONDITION(S)], and physical limitations and Resident #52 would attend and participate in activities of his choice on a weekly basis. The Activity Director said after reviewing Resident #52's medical record she did not have documentation Resident #52 had attended any activity programs in 2022. She further said she was unable to find documentation she had completed Resident #52's quarterly activity assessment as required. 7. On 6/27/22 at 10:05 a.m., Resident #36 was observed lying in bed no TV on, 12:15 p.m. sitting up in eating lunch, and 2:58 p.m., observed lying in bed sleeping. On 6/28/22 at 9:40 a.m., observation revealed Resident #36 sitting up in bed drinking a shake. On 6/28/22 at 11:15 a.m. Resident #36 was observed sitting up in bed sleeping, and on 6/28/22 at 2:59 p.m., Resident #36 was observed lying in bed. There was no evidence of activity participation occurring with Resident #36 at the time of the observations. On 6/29/22 at 9:31 a.m., observation revealed Resident #36 sitting up in bed eating breakfast. On 6/29/22 at 12:00 p.m., Resident #36 was observed lying in bed sleeping, there was no evidence of an activity program being conducted at either time. Review of Resident #36's clinical record revealed no documentation of activity participation for the last 30 days. On 6/29/22 at 3:10 p.m., in an interview, the Activity Director confirmed they had not completed any documentation under activities for Resident #36.

Based on review of the employee file, and staff interview, the facility failed to ensure the activities program was directed by a professional with the required qualifications. This has the potential to affect all current residents at the facility. The findings included: On 6/29/22 at 11:25 a.m., the Activities Director said she was currently working on her Activities Professional Certification. The Activities Director said she has not worked within the last five years in a social or recreational program and had no experience in long term care. She said the past eight years she was watching her grandchildren. On 6/30/22 at 4:48 p.m., review of the Activity Director with the Administrator verified the Activities Director did not have the qualifications to develop and supervise the activity program. the Administrator said, No she does not have the training. We have paid for her training, and she is working on it.

Based on staff interviews and staff record reviews, the facility failed to ensure 3 (Staff B, C, and D) of 3 nursing assistant employee records reviewed had a performance review completed at least once every 12 months/yearly. The facility failure to conduct a 12-month/yearly performance review could lead to the nursing staff not receiving the required in-service education to address areas of weakness identified in their yearly performance review. The findings included: On 6/30/2022, a review of Certified Nursing Assistant (CNA) Staff B's employee file revealed they were hired 8/28/19. There was no documentation Staff B's employee performance review was completed in 2021 with in-service education to address any areas of weakness identified. On 6/30/2022, a review of CNA Staff C's employee file revealed they were hired 9/23/2019. There was no documentation Staff C's employee performance review was completed in 2021 with in-service education to address any areas of weakness identified. On 6/30/2022, a review of CNA Staff D's employee file revealed they were hired 7/30/2020. There was no documentation Staff D's employee performance review was completed in 2021 with in-service education to address any areas of weakness identified. On 6/30/2022 at 12:48 p.m., the Human Resources Director (HRD) said after a review of Staff B, C and D's employee files she was unable to find documentation they had completed their mandatory staff education every 12 months and the facility had completed a yearly performance review with education based on the outcome of their yearly performance review. On 6/30/2022 at 2:04 p.m., the Administrator and Director of Nursing said the facility did not have a written policy related to completing the required staff yearly performance reviews. The Administrator said they followed the Federal regulation stating the facility must complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of their performance review. The Administrator and Director of Nursing said they reviewed Staff B, Staff C and Staff D employee files and were unable to find documentation the facility had completed each employee's yearly performance review in 2021 and the employee had received in-services education based on the outcome of their performance review as required per Federal regulation.

Based on observation, facility policy review, and staff interviews, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The findings included: Review of facility policy titled, Controlled Substance Storage dated August 2019 stated, Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of. On 6/29/22 at 12:44 p.m., interviewed the Director of Nursing (DON) about the process for management of controlled substances after medication is discontinued or resident is discharged . The DON said, After resident discharged or the controlled substance is discontinued, the nurse brings the controlled substance and log paper to me. We both verify the log is accurate and number listed on log matches the number of medications being turned in. The nurse signs the log and I store the controlled substances in the locked file cabinet in my locked office until I can meet with the pharmacist and do the destruction. The DON said she does not sign the controlled substance count when receiving the medication from the floor nurse. She said, I probably should but I have only been signing at the time of destruction. She said she has not been keeping a log of the controlled substances waiting to be destroyed since she started her employment as the DON at the facility in March 2022. She said the procedure was to keep a log but she has not done so. Observation during the interview of the file cabinet where the DON said she stored the controlled substances to be destroyed showed the drawer filled to capacity with controlled substances waiting to be destroyed. The DON said the last destruction of narcotics (controlled substances) at the facility was done on February 3, 2022, before she became the DON. The DON said, I have no idea what controlled substances are in the drawer at this time. The DON said, I can't say what is in the drawer and would not know if something had gone missing. It is my failure is not getting the log done. I need to get this log up to date as soon as possible. It's a priority unfortunately that has been kicked back in the past with so much to do otherwise. On 6/29/22 at 1:10 p.m., interviewed clinical pharmacist. The Pharmacist confirmed the last narcotic destruction was done in February 2022. The Pharmacist said, We try to schedule destruction the DON and I, but it can be as needed. March 2022 and April 2022 were not planned for destruction but May 20, 2022, was rescheduled since the DON said she had not had time to enter all controlled substances which needed destruction into the Polaris system. The Pharmacist said We have a triple check system. The DON and nurse check the dates and the counts when meds are given to the DON. Then the DON scans into Polaris for destruction portal, and finally the pharmacist and DON confirm the list with the actual controlled substances at time of destruction. The pharmacist said there were no controlled substances awaiting destruction scanned into the system. The pharmacist verified he would not know if any controlled substance was missing since they were not counted and entered in the system. He said, I agree it is a concern to have so many controlled substances not logged as waiting for destruction without anyone knowing for sure what is there.

Based on record review and staff and resident interview, the facility failed to provide the resident and the representative, if applicable, with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 4 (Resident #42, #57, #60, and #417) of 5 residents reviewed for baseline care plans. The findings included: 1. On 6/28/22 at 11:16 a.m., Resident #60's wife said she did not recall receiving a copy of a written summary of the baseline care plan or a summary of medications. On 6/30/22 at 9:50 a.m., record review showed Resident #60's admitted was 5/27/22. The clinical record lacked evidence of a written baseline care plan which included initial goals, and a summary of current medications and dietary instructions. 2. On 6/30/22 at 9:51 a.m., Resident #417 record review revealed an admitted [DATE]. The clinical record lacked evidence a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instructions was provided to the resident or resident representative as required. 3. On 6/30/22 at 9:53 a.m., Resident #42 record review revealed an admitted [DATE]. The clinical record lacked evidence a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instructions was provided to the resident or resident representative as required. On 6/30/22 at 9:55 a.m., interview with Staff R (MDS Coordinator) verified a written baseline care plan summary was not completed for Resident #42, #60 or #417. 4. On 6/27/22 at 12:45 p.m. observed Resident #57 in her bed with her right arm in a sling. Resident #57 said she fell at home, broke her arm and she is here to get better so she can go home. She said since arriving at the facility she doesn't remember anyone going over the plan of care or giving her a copy of her baseline care plan. On 6/29/22 review of Resident #57's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed the Nursing Admission Data Collection which contain the Interim Care Plan/Baseline was started on 5/22/22 but was not completed and/or a copy of a completed baseline care was not given to Resident #57 as required. On 6/30/22 at 10:12 a.m., during an interview with the MDS (Minimum Data Set) Nurse, she said Resident #57 was admitted to the facility on [DATE] after a fall at home where she fractured her right humerus. She said the admitting nurse was responsible to start the Nursing Admission Data Collection form and nursing was responsible to complete the baseline care plan within 48 to 72 hours. She said the IDT (Interdisciplinary Team) met daily and reviewed the Nursing Admission Data Collection form including the Baseline care plan to ensure they were completed as required. The MDS Nurse said after reviewing Resident #57's medical record she was unable to find documentation Resident #57 baseline care plan was completed and Resident #57 had received a copy of her baseline care plan as required. On 6/30/22 at 11:00 a.m., during an interview with the Director of Nursing (DON), she said the admitting nurse was responsible to start the Nursing Admission Data Collection form to include the baseline care plan. She said the IDT reviewed each new admission's baseline care plan for completion within 48 to 72 hours of the resident admitted and comprehensive care plans were finalized during the resident's comprehensive care plan meeting with the IDT. After reviewing Resident #57's medical record, the DON confirmed Resident #57's Nursing Admission Data Collection and Baseline care plan were not completed, and Resident #57 did not receive a copy of the baseline care plan as required.

Based on observation, staff and resident interviews and record review the facility failed to develop and implement a comprehensive resident-centered care plan for 1 (Residents #57) of 3 residents reviewed for specialized rehabilitation services. The failure to develop and implement a resident-centered care plan could lead to a decline and/or failure to meet the resident's highest practicable physical, mental, and psychosocial well-being. The findings included: On [DATE] at 12:45 p.m., observed Resident #57 in her bed with her right arm in a sling. Resident #57 said she fell at home, broke her arm and she was here to get better so she can go home. She said since arriving at the facility she doesn't remember anyone going over their plan of care in getting her strong enough so she can go home. On [DATE] review of Resident #57's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed the Nursing Admission Data Collection which contain the Interim Care Plan/Baseline was started on [DATE] but was not completed. Review of Resident #57's comprehensive plan of care revealed she had care plans with goals and interventions for; no CPR (comprehensive pulmonary respiration), risk for injury with hot liquids, nutritional problem or potential nutritional problem, and discharge planning. Resident #57's medical record did not reveal a comprehensive person-centered plan of care for Resident #57's fractured right humerus with measurable objectives and interventions which meets the resident's medical, nursing, and mental and psychosocial needs. On [DATE] at 9:31 a.m., in an interview with the Director of Therapy (DOT), she said Resident #57 was admitted to the facility on [DATE]. Physical and Occupational therapists conducted evaluations on [DATE] and the protocol for a proximal humerus and greater tuberosity fractures the resident was to wear a sling for 4 weeks and was non-weight bearing of the upper extremity for 4 weeks. The DOT said after reviewing Resident #57's medical record she was unable to find physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:12 a.m., during an interview with the MDS (Minimum Data Set) Nurse, she said Resident #57 was admitted to the facility on [DATE] after a fall at home where she fractured her right humerus. She said the admitting nurse was responsible to start the Nursing Admission Data Collection form and nursing was responsible to complete the baseline care plan within 48 to 72 hours. She said the IDT (Interdisciplinary Team) met daily and reviewed the Nursing Admission Data Collection form including the Baseline care plan to ensure they were completed as required. She said Resident #57's comprehensive care plan meeting was held on [DATE] but she was unable to determine who attend the comprehensive care plan meeting. She confirmed Resident #57 only had a comprehensive care plan for no CPR (comprehensive pulmonary respiration), risk for injury with hot liquids, nutritional problem or potential nutritional problem, and discharge planning with interventions. The MDS Nurse said after reviewing Resident #57's medical record, a comprehensive person-centered plan of care was not created or implemented addressing Resident #57's fractured right humerus with measurable objectives and interventions to include the use of the right arm sling. On [DATE] at 11:00 a.m., during an interview with the Director of Nursing (DON), she said the admitting nurse was responsible to start the Nursing Admission Data Collection form to include the baseline care plan. She said the IDT reviewed each new admission's baseline care plan for completion within 48 to 72 hours of the resident admitted and the comprehensive care plans were finalized during the resident's comprehensive care plan meeting with the IDT. The DON confirmed after reviewing Resident #57's medical record, Resident #57's comprehensive care plan meeting was held on [DATE]. The DON said the facility did not complete the Nursing Admission Data Collection form, or initiate a baseline care plan, and did not create and implement a comprehensive person-centered plan of care related to Resident #57's fractured right humerus with measurable objectives and interventions which met the resident's medical, nursing, and mental and psychosocial needs.

Based on observations, record review, and staff interviews, the facility failed to revise, and update the resident's care plan to accurately reflect the resident's condition and needs for 1 (Resident #49) of 3 residents reviewed with pressure ulcers. The findings included: The facility Pressure Injury Prevention and Management Policy provided by the facility (undated) page 3 under the Risk Assessments heading number 4 reads: Findings from the pressure ulcer/injury risk assessment will be incorporated into the resident's plan of care. On 6/28/2022 at 11:15 a.m., Licensed Practical Nurse Staff L was observed, cleaning and changing the dressings to Resident #49's wound to the right heel and right lateral malleolus (bone segment that forms the ankle). No wound was observed to the sacrum. Review of the Advanced Practice Registered Nurse (APRN) wound report dated 5/5/22 showed Resident #49 had a pressure wound to the right heel and the right lateral malleolus which were facility acquired. Review of the clinical record for Resident #49 revealed a care plan for skin integrity revised on 2/28/22 noting the resident had a stage 3 (Full thickness skin loss) pressure ulcer to the sacrum (Bone just below the lumbar vertebrae). The care plan was not updated to reflect the current pressure ulcers to the right heel and the right lateral malleolus. On 6/30/2022 at 2:15 p.m., Registered Nurse (RN) Staff R, MDS (Minimum Data Set) Coordinator verified Resident #49's care plan was not updated to include the wounds to the right heel and right ankle. She said tries to make changes to the care plan as soon as she finds out about them. She said no one notified her to update care plans regarding pressure ulcers. She finds it randomly on the computer.

Based on observation, record review, and staff interview, the facility failed to provide care and services to maintain or improve ability to carry out activities of daily living for 1 (Resident #47) of 3 residents reviewed for functional abilities. The findings included: Review of record for Resident #47 revealed she was admitted to facility on 8/7/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the list provided by the facility showed Resident #47 was included in a Functional Maintenance Program (program designed to maintain performance after discharge from therapy). On 6/27/22 at 10:00 a.m., 6/28/22 at 9:40 a.m., and 11:15 a.m.,6/29/22 at 9:31 a.m., and 6/30/22 at 10:00 a.m., Resident #47 was observed in bed, sleeping. On 6/27/22 at 12:00 p.m., and 2:58 p.m., Resident #47 was observed in bed watching television. Resident #47 was not observed participating in a functional maintenance program during the survey. On 6/29/22 at 1:24 p.m., Certified Nursing Assistance (CNA) Staff S said she has been out on leave since March 25, 2022, and returned to work on June 4, 2022. She said no one has done the functional maintenance program since March 25, 2022. She said since her return to work on 6/4/22, she has been working an assignment on the floor and has not done the Functional Maintenance Program. On 6/30/22 at 10:00 a.m., the Director of Therapy, confirmed Resident #47 was on their Functional Maintenance Program, and had not received the services. She said the CNA in charge of the program had just returned from medical leave and had been pulled to the floor.

Based on observation, record review and interview the facility failed to follow the manufacturer's instruction for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System (blood glucose meter) for 2 (Residents #15 and Resident #64) of 3 residents reviewed who had physicians' orders for blood sugar test (a blood sugar test was a procedure that measures the amount of sugar, or glucose, in your blood). Inadequate disinfection may result in indirect contact transmission (the transfer of an infectious agent through a contaminated inanimate object). Certain pathogens could contaminate and survive on equipment and environmental surfaces for long periods of time. The facility was unable to show documentation of a functioning infection control program. The failure to properly disinfect the blood glucose meters used for multiple residents resulted in a pattern of noncompliance at Immediate Jeopardy (IJ), scope and severity of K starting on 11/18/20. The Administrator was notified of the IJ on 11/18/20 at 4:00 p.m. The immediacy was removed on 11/20/20 at 1:25 p.m., after the facility completed the removal plan which included: Glucometer disinfection policy and assigned individual glucometers to diabetic residents. The facility provided documentation Licensed and Registered Staff were educated and demonstrated competency on procedure for proper disinfection of the glucometers to prevent indirect transmission of highly infectious diseases, including blood borne pathogens. Any new or outstanding licensed or registered staff will be educated and demonstrate competency on proper disinfection of glucometers prior to their scheduled shift. The facility initiated random audits during medication administration to ensure licensed staff are properly disinfecting glucometers. The results of the audits will be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meetings until compliance is maintained. The scope and severity was lowered to an E after credible evidence of measures taken to correct the IJ. The findings included: According to the Journal of Diabetes Science and Technology (March 2009): Finger-stick devices, blood glucose testing meters, or even a health care worker's hands may all become vehicles for indirect transmission of viruses if they become contaminated with blood. Since [MEDICAL CONDITION] Virus (HBV) is highly infectious and environmentally stable, even invisible amounts of blood are sufficient to spread infection. According to the Food and Drug Administration: For blood glucose meters, the primary viruses of concern for bloodborne pathogen transmission between multiple patients are Human Immunodeficiency Virus ,[MEDICAL CONDITION]., HBV, and [MEDICAL CONDITION] Virus (HCV). However, due to its robust nature, HBV is the most [MEDICAL CONDITION] in the observed outbreaks to date. Therefore, Blood Glucose Monitoring System sponsors should demonstrate that their disinfection protocol is effective against human [MEDICAL CONDITION] Virus. Studies have demonstrated [MEDICAL CONDITION] can remain infective on surfaces for different time periods. The disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens . https://www.fda.gov/medical-devices/vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda According to the Centers for Disease Control: Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include: . Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. (Blood glucose meters are devices that measure blood glucose levels.) . .Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html 1. On 11/17/20 11:19 a.m., during an observation Registered Nurse (RN) Staff E was observed taking a blood glucose level on Resident #15 using the blood glucose meter (BG meter). When Staff E completed the task, she wiped the BG meter with an alcohol prep pad, placed it on top of medication cart to dry for a four seconds then placed the BG meter back in top drawer of the med cart. Staff E then used the blood glucose meter on another resident. On 11/17/20 at 11:26 a.m., in an interview Staff E said the BG meters were used for multiple residents. Staff E said she wiped it down with an alcohol prep pad after using on a residents. At at the end of the shift, Staff E would wipe it down with a Clorox wipe. On 11/17/20 at 11:42 a.m., in an interview the Director of Nursing (DON) said the BG meters were supposed to be wiped down with an alcohol pad, Clorox wipe, or some disinfectant was supposed to be used. The DON said they did not have a policy and procedure for the process and said she would have to look at manufacturer's directions for the correct process. On 11/17/20 at 1:50 p.m., in an interview Licensed Practical Nurse (LPN) Staff L said she used one of the wipes on the med cart to wipe down the BG meters for about 15-20 seconds and then sets it down to dry. On 11/18/20 at 12:50 p.m., Staff M (LPN) was observed taking a Blood Glucose level on Resident #64. When Staff M completed the task, she wiped the BG meter sideways and vertically with a Micro Kill wipe for approximately 4-5 seconds and set the machine down to air dry. When Staff M was completely done cleaning the machine, she was asked to read the instructions on the Micro Kill. The Micro Kill label notes it is effective [MEDICAL CONDITION].HBV, and HCV in 2 minutes wet time. Staff M said she did not know if she had ensured a wet time of 2 minutes when cleaning the BG meter. The Manufacturer's instruction manual for the Assure Prism multi Blood Glucose Monitoring System revealed the following: Pages 38-39 of manual indicates the meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. The manufacturer has validated Clorox Germicidal wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Cavi Wipes 1 and PDI Super Sani Cloth Germicidal disposable wipe for disinfecting the Assure Prism Multi meter. Page 42-43 of manufacturer's instruction manual indicate a 2-step process for cleaning and disinfecting. Clean first using 1 wipe to wipe the entire surface of the meter 3 times horizontally and 3 times vertically then disposing of the wipe. No actual drying time is necessary before starting the disinfecting process. Next disinfect using a second wipe and wipe the entire surface of the meter 3 times horizontally and 3 times vertically, disposing the towelette and allowing exteriors to remain wet for the corresponding contact time of the disinfectant. photographic evidence obtained On 11/18/20 at 7:50 a.m., the DON said they did not have a policy and procedure for cleaning the BG meters. She said she would develop a policy using the manufacturer's instructions and educate staff on proper procedure. On 11/18/20 at 4:00 p.m., the Administrator said he would develop a system for monitoring proper cleaning of the BG meters and ensure that all staff are trained in the proper process. On 11/19/20 at 2:30 p.m., the DON who was the identified Infection Control Preventionist said the facility had an infection prevention and control program. She said the policies are all in the computer and need to be updated. She showed binders full of monthly infection numbers for the QAPI (Quality Assurance and Performance Improvement) program meetings, but the rest of the pages for tracking and trending of infections were blank for each month. She was not able to produce any documentation of tracking, trending or any other analysis of infections in the facility to prevent the further spread of infections. df

Based on observation, record review and interview, the administration failed to use its resources effectively and efficiently. The facility failed to self-identify deficient practices which had the likelyhood to produce negative outcomes. The findings included: On 11/20/20 at 1:00 p.m., during the Quality Assurance interview the facility Administrator said he was not aware the facility had an issue with the cleaning and disinfection of the blood glucose meters. The administration staff did not identify the nursing staff was not following the manufacturer's instructions for cleaning and disinfecting the Assure Prism multi-use Blood Glucose Monitoring System (blood glucose meters). The DON said they did not have a policy or procedure for the process and said she would have to look at manufacturer's directions for the correct process. She said she thought you could wipe it with an alcohol wipe. This practice likely put 17 residents who have glucose monitoring at risk of contracting bloodborn pathogen's. On 11/19/20 at 2:29 p.m., in an interview the Director of Nursing (DON), who was the designated Infection Preventionist, said I have not taken any Infection Preventionist training. No one in the facility has taken any additional infection control classes. The facility failed to have a qualified infection control preventionist. The DON who was the identified Infection Control Preventionist could not produce any minutes from the Antibiotic Stewardship meetings. The DON could not produce any documentation of Antibiotic Stewardship activities or meetings. She said they were Zoom calls, but minutes were never taken regarding what was talked about. The facility failed to provide evidence of a functional Antibiotic Stewardship program. The DON who was the identified Infection Control Preventionist was not able to produce any documentation of tracking, trending or any other analysis of infections in the facility. This has the likelyhood of further spread of infections to the other residents in the facility. The administration failed to identify broken equipment and maintain a safe and sanitary environment in the laundry room which could lead to infections since the entire resident population uses the laundry services. The administration failed to identify issues with the resident call bell system and maintain a fully functioning resident call bell system including the auditory function in the facility. This has the likelihood for residents to be injured due to the inability of the staff hear the auditory portion of the call bell system. The administration failed to ensure residents in the facility were provided prescribed diet portions sizes. Eight residents were identified as not receiving enough food which could contribute to unintentional weight loss. The Infection Preventionist required qualifications are to have completed specialized training in infection prevention and control, the facility failed to have a qualified Infection Preventionist. The facility failed to maintain physicians visit notes from one physician, the administrator said he was aware of the problem.

Based on clinical record review, observation and staff interview, the facility failed to provide adequate care and services to prevent the development and worsening of a pressure ulcer for 1 (Resident #25) of 1 resident selected for review of pressure ulcer management. The facility failed to revise interventions to keep the pressure off the resident's heels at night when she continued to remove the pillows used to off load her heels. The facility failed to conduct an in depth nutritional assessment in order to identify needs for additional dietary interventions to assist in healing of the ulcer. The facility failed to maintain infection control practices to prevent potential infection of the pressure ulcer. The facility failed to follow the physician's orders [REDACTED]. The findings include: A review of the clinical record for Resident # 25 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility conducted a pressure ulcer risk evaluation on 6/23/12, 7/7/12 and 7/14/12. Each time the resident scored 11 on the assessment tool, indicating a high risk for development of a pressure ulcer. A pressure ulcer may develop in areas where continued pressure impairs the circulation to the tissue. The physician issued an order on 6/23/12 to off load the resident's heels while in bed. On 7/9/12, the nurse documented she observed a left heel suspected deep tissue injury measuring 3.0 cm by 5.5 cm purple non blanchable soft intact tissue. The physician was notified and ordered to continue to offload the heel and apply skin prep to the left heel. On 8/27/12 the physician ordered to apply a waffle boot to the resident's left heel while in bed. A waffle boot is a pressure relieving device used to relieve pressure on the heel and prevent the development or worsening of a pressure ulcer. A review of the Treatment Administration Record (TAR) for 9/12 revealed each shift, the nurses placed their initials on the TAR, attesting the waffle boot was placed on the left heel while the resident was in bed. On 9/11/12, there was documentation the wound care physician debrided the resident's left heel necrotic tissue and applied Santyl ointment and a dressing. The pressure ulcer was classified as unstageable and measured 2 centimeters by 2.4 centimeters by 1.8 centimeters. An observation on 9/12/12 at 9:30 a.m., revealed Resident #25 in her wheelchair, self-propelling in the hallway. The resident had a shoe on the right foot and a non-skid sock to the left foot. Serosanguinous drainage was observed seeping through the sock as the resident wheeled herself throughout the facility. On 9/12/12 at 10:15 a.m., the CNA was observed putting the resident back to bed. She did not apply the waffle boot. In an interview on 9/12/12 at 10:20 a.m., with the CNA revealed she has been taking care of Resident #25 for approximately 3 months. When asked about the measures put in place to prevent the worsening of the pressure ulcer, the CNA stated she knows the resident has a pressure relieving mattress. She stated she also made sure she placed a pillow under the resident's foot to off load the heel but Resident #25 never keeps it in place, she kicks it all the time. She stated she did not know of any other intervention to prevent the worsening of the pressure ulcer. The CNA stated she gets Resident #25 out of bed every morning and she has never had a waffle boot on. The CNA stated she was not aware Resident #25 required a waffle boot while in bed. She stated in the morning, the resident's heels are never on a pillow because she never keeps the pillow in place. She kicks everything to the floor. The CNA stated she obtains her information through the "Nurse Aide's information sheet" that would list all the precautions necessary to safely care for each resident. The Nurse Aide's information sheet failed to list the waffle boots as an intervention to prevent the worsening of the pressure ulcer. Interview on 9/12/12 at 10:25 a.m., with the wound care nurse revealed the order for the waffle boot was written at the end of the August but somehow it does not trickle down to nursing. She stated it's been a struggle and she does not know how to obtain the supplies needed. An observation on 9/12/12 at 10:45 a.m., of the left heel wound care with the wound care nurse revealed a large stain of Serosanguinous drainage seeping through the dirty sock removed from the resident's left foot. The Observation was confirmed with the wound care nurse. On 9/12/12 at 11:10 a.m., the Director of Nursing asked the Rehab Director if a waffle boot had come in for Resident #25. The Rehab Director stated, "No but it would be good for her to have one." After observation and interview, the Director of Nursing confirmed on 9/12/12 at 12:05 p.m., the waffle boots were never ordered for this resident. An observation of the resident on 9/12/12 at 12:30 p.m., revealed the resident in bed. Her heels were not offloaded and she had pushed the pillows aside. Further review of the clinical record revealed on 7/8/12 the Registered Dietician visited the resident and documented the resident's weight was unavailable but "appears normal weight." The dietician further documented although Resident #25 visually appears to be normal, she was not able to assess accurately without the resident's height or weight. She indicated in her notes the resident was at moderate risk for nutritional impairment due to abnormal lab results such as a low [MEDICATION NAME] level, low total serum protein, low hemoglobin and hematocrit. The Registered Dietician requested the height and weight from the nursing department. A review of the laboratory results dated [DATE] revealed the resident's [MEDICATION NAME] level was low at 2.47 (normal of 3.5 to 5.0 g/dl), the total protein serum was low at 4.6 (normal of 6.4 to 8.9 g/dl). Sufficient protein intake is necessary to assist in wound healing. On 7/9/12, the nurse documented she observed a left heel suspected deep tissue injury measuring 3.0 cm by 5.5 cm purple non blanchable soft intact tissue. The next note from the Registered Dietician was dated 7/12/12 in which she documented:" Ht.- 5'0". Wt. - 123 lbs. 6/23/12? ". The dietician decided no further nutritional concerns other than previously noted for diet to provide enough protein for adequate healing. No further dietary notes were found in the clinical record. The Registered Dietician's assessment was incomplete and did not calculate the total calories, total protein and total fluid needed in order to assist in the healing of the developing pressure ulcer. On 9/14/12, the physician added an order for [REDACTED].

Based upon observation, interview and record review, the facility failed to implement the Functional Maintenance program for 1 (Resident #28) of 1 residents reviewed for passive range of motion which included application of splints and range of motion exercises. This resulted in a decline in range of motion of the resident ' s lower extremities and right wrist. The facility also failed to ensure all direct care staff were competent in performing range of motion exercises. The findings include: During an interview with the Resident #28 on stage 1 of the survey on 9/10/12 at 11:18 a.m., the resident was observed lying in bed in a hospital gown with no splints applied. Splints were observed in the room on the empty bed. During an interview with the resident on 9/11/12 around 11:00 a.m., the resident was observed lying in bed with a hospital gown on. The resident was observed with no splints applied. The resident was observed in bed with a hospital gown on around 4:30 p.m., on 9/11/12. The resident was observed with no splints applied. During an interview with Resident #28 on 9/12/12 at 10:00 a.m., he said the staff came into the room last night to give him a shower and they could not find the sling. He was observed to be lying in bed with a hospital gown on. The resident stated he was discharged from therapy and thought he was supposed to get some exercises however he said the staff has not exercised his extremities in over a week. The resident said the staff place the splints on his legs mostly at night and he sleeps with them. He said the hand splints are on occasionally. Observations of the resident on 9/12/12 around 4:00 p.m., revealed the resident was lying in bed with a hospital gown on with no splints applied. Observations of the resident on 9/13/12 at 8:20 a.m., revealed the resident does not have any splints applied. During an interview on 9/12/12 at 3:46 p.m., the OT (occupational therapist #41) said the resident received therapy beginning 4/23/12 and discharged on [DATE]. The resident goals for OT were to increase ROM (range of motion) of right elbow flexion to 100 degrees- Decrease contractures and increase self-feeding. The resident will be fitted for and tolerate B(bilateral) hand splint wearing schedule to decrease B hand contractures and decrease L (left) hand [MEDICAL CONDITION] to 8.5 inches and will demonstrate improved finger control to the right hand to enable him to type on a small keyboard with moderate assistance. Pt. (resident) will tolerate splint wearing schedule to decrease contractures and pt. will demonstrate good wheel chair positioning and toleration to 5 hours to increase QOL (quality of life). Start of care 4/23/12. Review of the discharge summary for OT- 90 degrees for right flexion- not enough for self-feeding Resident was tolerating 5 hours of sitting on 8/11/12 The OT said she was working with the facility to get the computer set up for the resident to use (still not set up as of 9/15/12). She said the previous therapist told her that the resident would not qualify for a power chair if he was in a facility with custodial care. She said they currently do not have a restorative aid in the facility. The Functional Maintenance Program dated 8/22/12 documents the occupational therapist in-serviced some of the direct staff on range of motion and how and when to apply splints. The splints were to be worn from 8 a.m. to 5 p.m., to right elbow and left hand splint and the right hand splint from 10 p.m. - 8 a.m. During an interview with the resident on 9/13/12 at 12:18 p.m., he said he told the staff to put his left splint on last night and they did. The facility was not able to find the functional maintenance flow record for August documenting the splints being applied and the passive ROM being completed. A review of the Functional Maintenance Flow Sheet Record for September revealed it was blank. During an interview with the director of nursing on 9/13/12 around 9:00 a.m., she said the passive range of motion was supposed to done with his ADL (activity of daily living) care but it was not documented. During an interview with the physical therapist (#42) on 9/13/12 in the late afternoon she said the resident had a decline in the flexion of his left ankle from 35 degrees to 16 degrees and of his left ankle from 35 degrees to 22 degrees since discharge from therapy on 8/15/12. She was not aware there was not a current physician order [REDACTED]. During an interview with the interim director of rehab on 9/14/12 at 10:12 a.m., she said if the resident was getting the range of motion exercises and splints were being applied as ordered the resident should have at least maintained the degree of flexion or at least close to the degree of flexion that was documented upon discharge from therapy on 8/15/12. She said the therapy department has requested to purchase adaptive equipment that could facilitate the resident eating and drinking independently but it was denied. This could not be confirmed. During an interview with the OT (#41) on 9/14/12 at 10:57 a.m., she said the resident has had a decline of about 5 degrees in his right elbow since discharge from therapy. She said at times the resident is verbally abusive during his range of motion exercises because it is painful. She said she thinks it scares the staff. She said when she came in May she was focusing on the splints, call light and computer for the resident instead of adaptive equipment to facilitate independence in activities of daily living. The current physician orders [REDACTED]. There were no current orders for the bilateral leg splints. The original order for the splints dated 7/3/12 documents the resident is to wear bilateral ankle boots x 8 hours during the day and then at night. The physician order [REDACTED]. Resident is to wear right had splint x 8 hours at night after new call light is received. The current treatment administration record (TAR) documents the nurses are signing off the resident is receiving passive range of motion on every shift. During an interview with the resident on 9/13/12 at 12:18 p.m., he said the staff are not exercising his arms and legs every shift and only occasionally. The current TAR documents the nurses are documenting the resident has bilateral hands splints on every shift with the exception of the 11-7 shift on September 2nd,7th, 8th, 9th and 13th and the 3-11 shift on September 8th and 9th. The resident did not have current care plans in place for application of splints, contracture management or range of motion. The nurse aides' information sheet documents the resident is to have hand rolls at all times, remove for ADLs. Bunny boots when in bed, passive range of motion to all extremities and neck during routine care. The special equipment section that includes splints is blank. During an interview with the resident's mother, who is his guardian, on 9/14/12 at 10:35 a.m., she said the facility is not getting her son out of bed and they are not doing his exercises. She said she has complained to the facility without resolve. Employee #24 was hired at the facility on 2/28/12. A review of the personnel file revealed an incomplete competency checklist and it was not signed by either trainer. Range of motion exercises and feeding dependent residents was not checked off. Employee #1 was hired at the facility on 11/4/11. The competency checklist was incomplete. Range of Motion and Feeding dependent residents were blank and checklist was not signed by either trainer. Employee #28 was hired at the facility on 10/20/11. The competency checklist was incomplete and not signed by either trainer. The employee was not signed off on Range of Motion exercises and feeding dependent residents. Employee #32 was hired at the facility on 5/15/12. The competency checklist was incomplete and not signed by a trainer. Only 3 skills are signed off. Range of Motion was one of the items not checked off. Employee #33 was hired on 8/15/11. The competency checklist was incomplete. Range of Motion and feeding dependent residents was not signed off. The checklist was signed off by the charge nurse trainer on the same day the employee was hired, 8/15/11. The employee was given a merit increase on 3/26/12. Employee #16 was hired at the facility on 5/23/12. Review of the personnel file revealed the competency checklist was blank. Employee #17 was hired at the facility on 10/12/11. Range of Motion and Feeding dependent residents were blank and not signed by either trainer. Employee #19 was hired at the facility on 3/19/12. A review of the personnel file revealed she has not completed a competency checklist. Employee #3 was hired at the facility on 3/19/12. A review of the personnel file revealed she has not completed a competency checklist. Employee #20 was hired at the facility on 3/1/12. A review of the personnel file revealed he has not completed a competency checklist. Employee #21 was hired at the facility on 12/9/11. A review of the personnel file revealed she has not completed a competency checklist. Employee #11 was hired at the facility on 3/5/12 and documents the employee was enrolled in the nurse aide registry in Pennsylvania with an expiration date of 7/31/12. She is not a certified nursing assistant in the state of Florida and has not completed a competency checklist. Employee #14 was hired at the facility on 7/8/12. The competency checklist was incomplete and it had not been signed off by either trainer. Range of Motion and feeding dependent residents was blank.