Every finding on record at Parkside Health and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to serve beverages in accordance with professional standards for food service safety, by failing to clean the ice and juice machines in the kitchen. Failure to maintain the cleanliness of the ice and juice machines could result in potential health risks to any resident receiving ice or beverages from the facility's kitchen. The findings include: On 10/21/24 at 11:10 AM during the initial tour of the kitchen, the ice machine was observed with a pink slimy substance resembling pink biological growth along the entire bottom edge of the ice dispenser chute. When wiped with a clean napkin, the substance described above transferred onto the napkin. (Photographic evidence obtained). An observation of the external distribution lines of the kitchen's juice machine at the area where they delivered juice into the machine, were observed with a black slimy substance resembling biological growth on and around the lines. When wiped with a clean napkin, the substance described above transferred onto the napkin. (Photographic evidence obtained). When the findings were shown to Dietary Aide C, she reported that the kitchen staff only cleaned the juice dispenser spouts, not the delivery lines. She wiped some of the black substance off the lines and said it looked like mildew. Adjacent to the juice machine was a yellow 8-outlet power strip. Three pieces of kitchen equipment were plugged into the power strip, which was covered in a red sticky dried-on substance resembling juice splatters. The splatters were on and around the live outlets and the on/off breaker switch. When asked about the substance on the strip, Dietary Aide C acknowledged its presence. Without identifying the substance, she stated she would wipe it down with a wet rag. She was stopped from obtaining a wet rag and was reminded that it was a live outlet. A cleaning schedule for the ice machine was observed hanging on the side of the machine indicating it was last cleaned on 10/01/2024. (Photographic evidence obtained) On 10/21/24 at 11:30 AM, an interview with the Dietary Manager related to the above concerns was conducted. He stated the machines were cleaned monthly. The Dietary Manager observed the areas of concern described above and confirmed the findings. He then stated the ice machine would be cleaned immediately, and he would change the cleaning schedule to bi-weekly. He also stated the juice lines would be cleaned immediately and added to the bi-weekly cleaning schedule.

Based on record review, interview, and a review of the facility's policy, the facility failed to revise the resident's code status in the care plan for one (Resident #68) of a total survey sample of 36 residents. Failure to update the resident's care plan for code status could result in staff confusion and the resident's wishes not being followed. The findings include: A review of Resident #68's medical record revealed an admitted [DATE] and diagnoses including sepsis, partial intestinal obstruction, anemia, dementia-mild with mood disturbance, unspecified sequelae of cerebral infarction, major depressive disorder, schizoaffective disorder-depressive type, generalized anxiety disorder, and chronic kidney disease. A review of the resident's active Care Plan revealed the following Focus Areas, Goals and Interventions: Focus: Resident/Representative/Proxy has requested DNR (Do Not Resuscitate) status indicating (CPR) cardiopulmonary resuscitation measures are not performed (initiated [DATE], revised [DATE]). Goal: Resident or resident representative will communicate any desired changes to code status through next review (initiated: [DATE], revision: [DATE], target date: [DATE]). Interventions: Communicate resident/representative choice to appropriate staff members (initiated [DATE]). Notify physician of changes in code status preference (initiated [DATE]). Review/discuss Advanced Directives with the resident/resident representative as needed (initiated: [DATE], revision: [DATE]). Further review of the record revealed that an Advanced Directives Discussion Document was signed on [DATE] by the resident's health care proxy to establish the resident's wish to have CPR administered in the event of sudden cardiac arrest for any reason. (photographic evidence obtained) A review of the active physician's orders revealed the resident's Full Code status was ordered on [DATE] and signed by the physician on [DATE]. On [DATE] at 11:48 AM, the DNR Binder at the nurse's station was reviewed and revealed that Resident #68's status was Full Code. On [DATE] at 12:49 PM, a performance improvement plan (PIP) for Care Plan Interventions, initiated on [DATE], was reviewed, including periodic audits, which were documented as having been completed by [DATE]. No audits specific to care plan revisions/updates were made available for review. The PIP was reviewed in the monthly QAPI (Quality Assurance and Performance Improvement) meeting for three months after the plan was initiated. There was no indication that further monitoring of care plans was in place. (photographic evidence obtained) On [DATE] at 11:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) A, the minimum data set (MDS) assistant. She explained that the baseline care plan was initiated by the admitting nurse and MDS staff worked on the comprehensive care plan. She explained that the purpose of the care plan was to address all of the problems the resident had and the goals and interventions they needed. She reported that all staff had access to the care plan. Care plan meetings were held at least every quarter and more often if the resident had a significant change in status. The meetings were attended by the Dietary Manager, Activities Director, Social Services, Unit Manager, and Therapy. The family comes if they want to and whoever they request to attend. Sometimes the resident wants to come, oh and me, I usually do the long-term people. She was asked what was discussed during care plan meetings. She stated, We discuss the plan, any skin issues, any concerns the resident has, any dietary issues, any problems, any discharges and what needs to be done prior to discharge. We talk about therapy issues, just a lot of different things. She was asked how often care plans were updated. She stated, Anytime we get any new orders and quarterly when we do their assessment. She explained that sometimes other staff asked the MDS staff to add things to the resident's care plan and they did so. A copy of Resident #68's care plan was requested. A review of the facility's policy titled Standards and Guidelines: Care Plans, Development Baseline and Comprehensive (effective ,d+[DATE], revised ,d+[DATE]) revealed: 13. Assessments of residents are on-going, and care plans are revised as information about the residents and the resident's conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition b. When the desired outcome is not met c. When the resident has been readmitted to the facility from a hospital stay d. At least quarterly, in conjunction with the required quarterly (MDS) minimum data set assessment.

Based on observations, staff and resident interviews, medical record review and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs), specifically nail care, for one dependant resident (#73) in a sample of 30 residents. The findings include: On 12/12/22 at 12:40 PM, Resident #73 was observed lying in bed, awake. His right hand was out of his bed covers and all fingernails were observed to be elongated with brown debris under each nail. The resident was asked if he could show his left hand. He pulled his covers back and picked up his left hand with his right hand to show his left hand. The nails were also elongated with brown debris under each nail. On 12/13/22 at 10:27 AM, Resident #73 was observed lying in bed, awake. Both hands had elongated nails with brown debris under the nails. The resident was asked if he preferred his nails to be trimmed and clean. He stated Yes, they used to trim my nails but no one has trimmed or cleaned them in months. He was asked if he had asked the staff to trim and clean his nails during that time frame. He stated, Yes, I have, many times, but no one has come back to do it. On 12/14/22 at 9:50 AM, Resident #73 was observed lying in bed, awake. Both hands had elongated nails with brown debris under the nails. He was asked when he last had a shower. He stated, This week. Yesterday. He was asked if staff tended to his nails during his shower. He stated No, they used to come by and trim my nails, but no one does that anymore; it's been months now. On 12/14/22 at 2:12 PM, Resident #73 was observed lying in bed, awake. He put his right hand out to show that his nails were trimmed and clean. He was asked if he was happy with the length of the nails. He stated yes. A medical record review revealed that Resident #73 was admitted on [DATE] with diagnoses including CVA (cerebral vascular accident) affecting the left non-dominant side, and contracture of the left hand. In a record review for Resident #73, it was revealed that a doctor's order, dated 11/28/22, read, Restorative nursing: Check and complete skin and nail hygiene as tolerated. Complete nails and skin hygiene to promote skin integrity. A review of the Minimum Data Set (MDS) quarterly assessment, dated 11/18/22, revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. Further review of the MDS quarterly assessment, revealed rejection of care behaviors were not exhibited. The functional status assessment revealed that Resident #73 required extensive assistance and one person physical assistance for personal hygiene, including washing and drying hands. A review of the Care Plan revealed: Focus: 4/1/20 (revised 9/21/20) Needs assistance with ADL care, dependent on staff care, related to CVA with left-sided weakness. Goals: Will be clean, dressed and well groomed through next review date (revised 9/8/22) Will accept care daily through next review. Will be able to to complete at least one simple ADL task through the next review date. Interventions: Extensive assist with all ADLs, encourage participation in some simple upper body tasks. Focus: 11/30/22: Resident has a need for the restorative nursing program for PROM LUE. (Passive Range of Motion, Left Upper Extremity) Goal: Resident will maintain current level of function and mobility through the next review period. Interventions: PROM gentle to LUE from bed/wheelchair level. Check and complete skin and nail hygiene as tolerated. Complete nails and skin hygiene to promote skin integrity. A review of the Certified Nursing Assistants' (CNAs) Plan of Care task documentation for 11/15/22 thru 12/14/22 revealed: Personal Hygiene self performance: How resident maintains personal hygiene (including washing/drying hands): extensive assistance/one person physical assist. Behavior Symptoms: None of the above observed (rejection of care behavior not documented as observed). In an interview with CNA A on 12/14/22 at 1:34 pm, she was asked who assisted residents with nail care. She replied We do, the CNAs do. She was asked if she was caring for Resident #73 today. She replied yes. She was asked if he needed assistance with his nail care. She replied, Yes, he always tells me he wants the podiatrist to do his fingernails, but I told him they only do the toenails. He did let me me cut his fingernails and clean under them today, after four months of me asking him to do them. She was asked about the brown debris under his nails. She stated, He does refuse that too, but he let me clean them today. He only let me trim the nails on both hands but clean under right hand nails. He wouldn't let me clean under the left hand fingers. She was asked if the restorative aides worked with him. She stated, Yes, they work with him for a brace on his left hand. She was asked if they ever trimmed his nails or cleaned under his nails. She stated, Not that I'm aware of. She was asked what she did when Resident #73 refused nail care. She stated, I let the nurse know. She was asked if he ever refused showers. She stated, No, he gets showers twice a week. In an interview with Licensed Practical Nurse (LPN) B on 12/14/22 at 2:32 PM, she was asked if she was caring for Resident #73 today. She stated yes. She was asked if he had every refused fingernail trimming or cleaning. She stated No, not that I'm aware of. She was asked how she was made aware if any resident refused any aspect of their care. She stated, The CNAs will tell us; they tell the nurse. She was asked if the CNAs always let her know if a resident refused any ADL care, such as bathing, mouth care, or nail care. She stated, Yes, they do. She was asked if she charted anywhere when care was refused. She stated, Yes, I'll write a progress note, and the CNAs will mark refused in their documentation. In an interview with Occupational Therapist (OT) C on 12/14/22 at 1:53 PM, she was asked if she had seen Resident #73 for Occupational Therapy (OT). She stated yes. She was asked if she had completed a Restorative Program referral for this resident in November 2022. She stated yes. She was asked if OT provided nail care for the resident. She stated, I'm not sure. The restorative aide would be following the plan of care. She was asked if she had provided any nail care for the resident. She stated, No, we have nail brushes and emery boards to file nails. She was asked if the resident had declined or refused any care or treatments. She stated, Not with me. In an interview with LPN D on 12/14/22 at 2:50 PM, she was asked if she was the manager of the Restorative Nursing Program. She stated yes. She was asked if Resident #73 was current on restorative services. She stated yes. She was asked who created the restorative plan of care. She stated, Physical Therapy or Occupational Therapy create the plan of care during their initial evaluation. She was asked who followed that plan of care. She stated, We have two restorative aides. They are also CNAs. I also help out hands on, like if one of them is out on a transport with a resident. She was asked what was in the restorative plan of care for Resident #73. She stated, Passive range of motion to his left upper extremity is done daily, he wears a splint on his left hand, and restorative applies the splint. Ensure skin is clean and dry where the splint is, and his palm and in-between fingers. Provide nail and skin hygiene. She was asked if the resident was receiving nail care. She stated, They haven't trimmed them in a while, but they have been cleaning under them. She was asked if Resident #73 ever declined nail care. She stated, He has in the past; he has refused the cleaning sometimes. They try to do the best they can so they are charting that they are doing it. She was asked if it was charted anywhere when he refused nail care. She stated, They can put refused on the care. She was asked if anyone had charted any of his care as refused. She stated, No, they have not charted his nail care as refused. She was asked how she was made aware if the resident declined the care. She stated, Normally they tell me, but they have not told me he's refused any care. A review of the facility policy titled Activities of Daily Living, Supporting (revised 3/2018) revealed a policy statement which read: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on record reviews and interviews, the facility failed to permit a long-term care resident (Resident #5) readmission to the facility following a Baker Act transfer. Resident #5 was one of three residents reviewed for transfer/discharge. The findings include: A review of Resident #5's medical record revealed a [AGE] year-old male who was admitted to the facility on [DATE]. He was then discharged and readmitted on [DATE] due to a change in health status. Resident #5 had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was also diagnosed with [CONDITION(S)] and [CONDITION(S)] disorders. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 8/21/21, revealed that Resident #5 required extensive to total assistance from two staff members for bed mobility and transfers. He did not ambulate and required extensive assistance from one person for mobility on and off the nursing unit. He required extensive assistance from one person for dressing/personal hygiene and extensive assistance from two people for toileting/bathing. Limited assistance from one staff member was needed at mealtimes. He used a wheelchair for mobility. His Brief Interview for Mental Status (BIMS) score was documented as 10 out of a possible 15 points, indicating moderately impaired cognition. (Photocopy obtained) A review of a Social Services note dated 6/22/21 at 2:12 p.m., revealed the following: Resident seen by the Advanced Practice Registered Nurse (APRN) on 6/16/21 for psychiatric evaluation. Resident is stable. Gradual Dose Reducation (GDR) is contraindicated at this time. No new psychiatric recommendations. Will continue to monitor. See psychiatric evaluation. A review of the facility discharges from 8/01/21 to 10/13/21, revealed that Resident #5 was discharged from the facility to an acute care hospital on 9/9/21. (Photocopy obtained) A review of the facility census, dated 10/13/21, revealed that Resident #5 was not in the facility. The census indicated 96 residents currently resided in the 122-bed facility. (Photocopy obtained) A review of the facility-initiated Certificate of Professional Initiating Involuntary Examination form used for transferring a resident under the Baker Act, indicated that Resident #5 was transferred to the hospital under the Baker Act on 9/9/21 at 8:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented that Resident #5 was unable to determine for himself whether an examination was necessary, and there was a substantial likelihood that without care or treatment, he would cause serious bodily harm to others. The supporting evidence included that Resident #5 had assaulted a staff member, and that he continued to make threats to staff and others. He was unable to understand the seriousness of his behavior due to poor insight, and he was currently a danger to others that care for him. The form was signed by the facility's psychiatric Advanced Practice Nurse Practitioner (APRN). (Photocopy obtained) A review of the Nursing Home Transfer And Discharge Notice provided to Resident #5 and documented as provided to the family member of Resident #5, revealed that the date the notice was given was 9/9/21. The effective date was documented as 9/9/21. The documented reason for discharge/transfer was that The safety of other individuals in this facility is endangered. The resident assaulted a staff member and continued to make threats to staff members who were fearful of him. The form indicated the resident's family member/responsible party acknowledged the transfer/discharge verbally over the phone. (Photocopy obtained) Further review of the resident's record found no documentation to confirm that the facility ascertained an accurate status of the resident's condition once hospitalized or determined what medications, treatments or services the hospital provided to improve the resident's condition. A review of the hospital Patient Flow Sheet, dated 9/10/21, revealed that the hospital recommended Resident #5 return to the skilled nursing facility. He was documented as requiring maximum assistance of two people for bed mobility and moderate assistance of two people for sit-to-stand transfers. He had poor balance. He was noted as alert and oriented to year, and was able to follow one-step commands with a delay 90 % of the time. Cognition seems to be impaired. States he is incarcerated and being accused of beating up a nurse. The Physical Therapy Assessment (on the same form) indicated Resident #5 was admitted for combative behavior while in the nursing home, accompanied by lethargy (a lack of energy) and [CONDITION(S)] (a deficiency in the amount of oxygen reaching the tissues) 88% on room air). The [CONDITION(S)]'s etiology (cause) was unknown. He was receiving supplemental oxygen to maintain a blood oxygen saturation of greater than 92 %. Also indicated, was that the resident was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient's personal goal was to return home. The patient participated in the development of goals and his plan of care per the documentation. (Photocopy obtained) A hospital Psychiatry Progress Note, dated 9/13/21, documented that Resident #5 was found calm, alert, very pleasant and oriented times three, but at times could be a little bit confused. He was cooperative and told the physician that he was in a good mood today. There was no agitation or aggressive behavior. He denied visual and auditory hallucinations. He had been compliant with medications with no significant side effects. His judgement and insight were adequate. There was no suicidal or homicidal ideation. The primary care team discussed the case, and the plan was to clear Resident #5 and discharge him back to his residential facility to continue psychiatry care as an outpatient. Resident #5 was cleared by hospital psychiatry on 9/13/21 at 11:03 a.m. Psychiatry evaluated the resident and indicated he was at baseline and did not meet the criteria for involuntary psychiatric commitment. (Photocopy obtained) On 10/12/21 at 2:08 p.m., a telephone interview was conducted with the hospital case manager who attempted to return Resident #5 to his home at the facility. She stated Resident #5 was medically cleared on 9/20/21 for discharge, the facility was contacted, and they refused to readmit Resident #5. He was still in the hospital at the time of this interview. On 10/13/21 at 4:07 p.m., a telephone interview was attempted with the APRN who signed the Baker Act form. There was no answer and the voice mailbox indicated it was full. A message could not be left. On 10/13/21 at 1:00 p.m., a telephone interview was attempted with Resident #5's family member/responsible party. The family member stated he was unable to talk at that time, but would return the call later. No call was received. On 10/13/21 at 1:30 p.m., an interview was conducted with the Administrator. He confirmed that if a skilled nursing facility resident was discharged from the hospital to a skilled nursing facility, then the appropriate environment would be the skilled nursing facility. If a bed was available, then the facility was expected to readmit the resident. He confirmed that Resident #5 was not being readmitted because of his behaviors. He stated the facility was currently looking for alternate placement for Resident #5 while he was in the hospital. On 10/13/21 at 2:13 p.m., an interview was conducted with the Admissions Director (AD). She confirmed that the hospital case manager called her during the third week of September, and told her that the hospital cleared Resident #5 to return to his home at the facility. The AD stated she was told by Nursing and the Administrator that the facility was not to accept Resident #5 back. She confirmed that she told the hospital case manager the facility would not allow Resident #5 to return. On 10/13/21 at 1:43 p.m., an interview was conducted with Certified Nursing Assistant (CNA) G. She stated she was familiar with Resident #5 and had worked with him in the past. She described him as rude, but everyone behaves the way he behaves at times. She stated if she asked him to stop the inappropriate behavior, he would stop, and he would do what was asked of him. On 10/13/2021 at 1:48 p.m., an interview was conducted with CNA D, who stated she knew Resident #5 well. He required assistance with everything except eating and ignored the fact that she had other residents to care for. CNA D stated Resident #5 would dominate your time. She stated this behavior did not upset her, as she had been trained how to deal with it. She did not take it personally. When asked whether Resident #5 had ever struck her or threatened to strike her, she replied that he had never struck her or threatened to strike her. She stated if he did strike her, she would not strike him back. You can never hit the resident back. We are taught how to avoid that. She added that Resident #5 was not the only resident who had ever cursed at her. On 10/13/21 at 1:53 p.m., an interview was conducted with RN E, who stated she was familiar with Resident #5. He had been sent to the hospital under the Baker Act. She stated Resident #5 was friendly and mostly compliant. She further explained that he needed assistance with acitvities of daily living, and he knew what he was doing. He was never confused and he was not particularly violent. She stated he was more agreeable with nursing staff than with the CNAs, but she didn't know why that was. He would get aggravated at times and curse or yell, but he had never threatened her. She stated she had no idea whether he was returning to the facility from the hospital. On 10/13/21 at 2:06 p.m., an interview was conducted with the Social Worker. She confirmed that she had made no attempts to locate another facility for Resident #5 since he was sent to the hospital on 9/9/21 under the Baker Act. She stated her last attempt to locate alternate placement for Resident #5 was on 6/25/21 and was unsuccessful. When asked whether this facility had enough open beds to readmit Resident #5 after his current hospitalization , she replied, I'm sure there are beds available. Our census is only 97. This facility has a total of 122 beds. The Social Worker stated she spoke with the hospital case manager a couple of weeks ago. The hospital was trying to discharge Resident #5 back to the facility, but we were not going to take him back. She stated Resident #5 struck a facility CNA who intended to press charges against him, and this was the reason they did not intend to readmit him. On 10/13 21 at 3:11 p.m., an interview was conducted with CNA F. She stated she was working with Resident #5 on the date of the incident, 9/9/21. He was upset because the facility had just revoked his smoking privileges. CNA F and another CNA helped Resident #5 to bed. Once in bed, they proceeded to change him. He was still cussing and angry about not being able to smoke. As the CNAs removed his shirt, he continued yelling and cursing at them, and then struck CNA F in the eye. CNA F yelled, and the nurse and two additional CNAs entered the room. The two additional CNAs helped Resident #5 with the removal of his clothing. CNA F stated she did not feel safe around Resident #5. She further stated she was just taking his clothes off, and When you try to de-escalate him, he just gets worse in behavior.

Based on observations and staff interviews, the facility failed to store dishware, covered or inverted, in a location where it was not exposed to splash, dust and other contamination. This deficient practice potentially affected all residents in the facility who took their meals from the facility's kitchen. The findings include: During a kitchen visit on 04/28/21 at 11:31 AM, the plate dispenser was observed next to the stove and partially under the vent hood. The plates were stored face-up and were not covered in a manner to prevent food, grease splatters, or dust and debris from landing on the face or lip of the plates. A second kitchen visit and interview with Employee C, Dietary Cook was conducted on 04/29/21 at 09:45 AM. The plate dispenser was once again observed full of plates partially under the vent hood with plates face-up not inverted. The Dietary Cook acknowledged the potential for cross-contamination of the eating surface of the plates and confirmed they should be stored face down or covered. During an interview with the Certified Dietary Manager on 4/29/21 at 10:00 AM, he acknowledged the potential for contamination of the eating surfaces of the plates.

Based on observation, interviews, and record reviews, the facility failed to ensure it provided restorative services for one (Resident #40) resident sampled for restorative care provided, from a total sample of 44 residents. This placed Resident #40 at risk for functional decline. The findings include: During an interview with Resident #40 on 4/26/21 at 11:36 AM, he was observed using a wheelchair as a mobility aid. He reported that he was supposed to be on restorative programs for stand-to-sit and for walking, but it was not happening. During another interview with Resident #40 on 4/28/21 at 09:30 AM, he revealed that he spoke with the Physical Therapy Manager/Therapist who told him his services would start on 5/03/21. A record review for Resident #40 revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #40's Significant Change Minimum Data Set assessment, dated 3/6/21, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive response. The assessment was documented that he required extensive assistance of 2 people with bed mobility and transfers, and 1-person extensive assistance to walk in his room and in the corridors. His balance during transitions and walking was not steady, and he used a walker and a wheelchair as mobility aids. The care plan for Resident #40 was reviewed and documented that Resident #40 was a fall risk and non-compliant with waiting for assistance and using his walker for transfers and ambulation. Approaches included refer to physical therapy as needed. A review of Resident #40's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the RNP Occupational Therapy Functional Maintenance Program for Resident #40, dated 4/16/21, revealed the goal: Sit to stand transfers x 5 repetitions at the hall rail or parallel bars with minimal assistance and cues for hand/foot placement, scoot to edge of chair. (Photographic evidence obtained) A review of the CNA Kardex for Resident #40, asking how Resident #40 ambulated in corridors and his room revealed many of the fields over the last 30 days were marked not applicable. The Kardex section titled Nursing Rehab: Transfers: Sit to stand transfers x 5 repetitions at hall rail and cues for hand/foot placement, scoot to edge of chair for staff to fill in was left blank for the past 30 days. The Nursing Rehab: Walking, assist to toilet using 2 WW (wheeled walker) from elevated EOB (edge of bed), 3 x's a week as tolerated section for staff to complete was also blank for the past 30 days. (Photographic evidence was obtained) An interview was conducted with Employee A, Restorative Certified Nursing Assistant, on 4/29/21 at 10:27 AM. She stated that Resident #40 was put on restorative services a week ago and his goals are to walk to the bathroom and move from sitting to standing position for 5 repetitions. During the interview, Employee A revealed that due to short staffing and restorative department having to finish monthly weights, they had not been able to provide Resident #40's restorative services.

Based on observations, resident and staff interviews and resident record review, the facility failed to develop a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical and psychosocial needs for one (Resident #77) of one residents observed with restraining devices in use, out of a total sample of 52 residents. The findings include: An observation of Resident # 77 conducted on 04/23/19 at 10:45 AM found he had a seatbelt fastened around his waist, and a large rubber band tied around his ankles. The band secured both feet onto the footrest of Resident #77's wheelchair. When interviewed at this time, he stated the mechanisms were necessary for his positioning. He was asked if he was able to unbuckle his seatbelt. He replied, What for? I cant jump up and run! Resident #77 was observed on 4/23/19 at 3:22 PM in the dining room. He was resting with his eyes closed. His wheelchair was tilted back, and his lower legs were extended parallel to the ground. The foot strap was across his feet securing them to the footrest, and his seatbelt was fastened around his waist. An interview was conducted on 4/23/19 at 3:32 PM with Employee E, Certified Nursing Assistant (CNA). He explained that as a result of his physical condition, staff had to bend Resident #77's feet and secure them in the footbox with a duraband (an elastic exercise band). It is on all the time while the resident was in his wheelchair. The seatbelt held him upright and in place. There was a trick to positioning Resident #77, and he can tell you how to do it. Resident #77 was observed on 4/24/19 at 11:56 AM. He was in his wheelchair, with the seatbelt and footstrap in place. Employee A, Licensed Practical Nurse (LPN), was interviewed on 4/24/19 at 2:50 PM. She stated Resident #77 requested his seat belt and foot strap be in place when he was up in his chair. His feet dangled off of the footrests if the strap was removed, and he asked for his seatbelt when he was up in his chair at all times. On 4/25/19 at 10:01 AM, Resident #77 was observed in the dining room. He was fully reclined in his wheelchair with his seatbelt on, and the elastic band securing both feet to the footrests. A record review for Resident #77 found he was admitted to the facility on [DATE]. His quarterly minimum data set (MDS) assessment with an assessment reference date of 3/2/19 documented that he required extensive assistance of two staff members with bed mobility, transfers and activities of daily living. He had upper and lower extremity impairments on both sides. Active [DIAGNOSES REDACTED]. He used a wheelchair as a mobility aid. Resident #77 was care planned on 3/10/19 for his medical conditions and his care needs; however, the use of the seatbelt and the foot straps were not noted anywhere in his plan of care. There were no instructions as to why, when, how they were to be utilized and removed, and no instructions for monitoring the integrity of his skin underneath the devices. Initial review of the physician's orders [REDACTED]. On 4/23/19, a physician's orders [REDACTED]. It stated Resident #77 may wear a seatbelt while up in his electric wheelchair, and may use a theraband across his feet for positioning while in the chair. A Physical Examination dated 12/31/18 noted a [DIAGNOSES REDACTED].#77 required total care. There was no mention of the positioning devices observed in use. He was last seen by the advanced registered nurse practitioner (ARNP) on 4/9/19; however, the report made no mention of the apparatuses in use. In an interview with Employee A on 4/25/19 at 3:59 PM, she confirmed the use of Resident #77's seatbelt and footstraps should have been care planned. She stated she had brought this to the attention of the Director of Nursing (this week), and the order was written by the physician for their use. An interview was conducted with the MDS Coordinator on 4/25/19 at 4:29 PM. She confirmed the seatbelt and duraband should have been care planned for Resident #77. She stated at the time of assessment and care planning for this resident, she had no awareness the devices were present on his wheelchair.

Based on observations, interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice for skin tears for two (Residents #1 and #77) of two residents reviewed for skin tears, out of a total sample of 52 residents. The findings include: 1. A record review was conducted for Resident #1 which revealed an [AGE] year-old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 04/22/19 at 1:13 PM, an observation was made of Resident # 1. She had multiple dressings on both of her arms and right shin. There were no dates, times, and/or initials noted on the dressings. On 4/24/19 at 9:51 AM, another observation was made of Resident # 1, and the dressings remained in place to her right shin. They remain unlabeled and undated. Further review of the record revealed that she had no orders for any dressings and/or other treatments to her right shin. Her weekly skin check, dated 4/23/19 at 7:15 PM, revealed the following: healing skin tears on bilateral forearms, steri strips still intact, LLE (left lower extremity) several discolorations. Resident's skin appears to be very thin and dry, continuing P[NAME] (plan of care). There was no mention of skin tears and/or dressings on her right shin. On 4/24/19 at 11:03 AM, an observation and interview was conducted with Employee G, Licensed Practical Nurse (LPN), regarding Resident #1's right shin dressings. LPN G confirmed that the resident had two dressings in place to her right shin from a fall she sustained. She reviewed the electronic medical record and confirmed that there was no order in place for the dressings. She also confirmed that there were no initials and/or date on the dressings to verify who applied them, and how long they had been there. She was asked about the brown adhesive dressing on the resident's left upper arm, and she confirmed that there was no order, date, and/or initials for that dressing either. She stated the resident had an order in for [MEDICATION NAME] (clear dressing) to bilateral (both) arms, however the [MEDICATION NAME] was no longer in place. She now had steri-strips to bilateral arms. 2. An observation of Resident #77 on 4/23/19 at 4:02 PM, found he had a small brown bandaid (approximately 1 inch by 2.5 inches) on his right wrist underneath his coiled rubber wrist keychain. On his left elbow, he had two of the same style bandaids that had been criss crossed over each other. None of the bandages were labeled with the date the bandage was applied. Resident #77 explained his wrist band had rubbed him raw, but had no explanation for the elbow wound. On 4/24/19 at 11:56 AM, Resident #77 was observed again with the bandaid on his wrist and the two crossed bandaids on his elbow. None were dated. Resident #77 was interviewed on 4/24/19 at 2:03 PM. His bandages were still in place with no labels. Resident #77 was asked what happened, and he replied he may have bumped his elbow, but he was not sure. He said he beleived staff changed the bandages every other day. Record review for Resident #77 revealed a quarterly minimum data set (MDS) assessment with an assessment reference date of 3/2/19. [DIAGNOSES REDACTED]. He was assessed with [REDACTED]. (Photocopies were obtained) Employee A, Licensed Practical Nurse (LPN), was interviewed on 4/24/19 at 2:50 PM. She stated Resident #77 sometimes bumped himself in his wheelchair. He had bad spasms related to his [DIAGNOSES REDACTED]. Wound Care performed all bandage changes. Employee A confirmed that all bandages were supposed to be labeled with a date once applied. She was asked to look, and after doing so, confirmed Resident #77's bandages were not labeled. On 4/25/19 at 10:01 AM, Resident #77 was observed in the dining room,. All bandages were now labeled with the date. An interview was conducted with Employee C, Registered Nurse (RN), on 4/25/19 at 11:14 AM. He stated there would be a physician's order for any skin tear. The wound care nurse tended to larger wounds, but floor nurses could dress smaller ones. He described how he would provide wound care, explaining that after checking the treatment order and dressing the wound, he would conclude by dating the bandage(s). The Risk Manager was interviewed on 4/25/19 at 11:30 AM, and stated all dressing changes should have a physician's order. He was not able to explain why Resident #77 had no treatment order for his wrist or elbow wounds.

Based on observation, interview and record review, the facility failed to ensure provision of wound care consistent with professional standards of practice, to promote healing and prevent infection for one resident (#64) observed during wound care out of 10 residents with pressure ulcers, in a total sample of 52 residents. The findings include: Wound care was observed for Resident #64 on 4/24/19 at 11:50 AM. It was performed by Employee D, Licensed Practical Nurse (LPN)/Wound Care Nurse. Employee D gathered supplies from the wound cart outside of Resident #64's room, and placed all of them on one aluminum barrier (biohazard bag, 4 or 5 pairs of gloves, non sterile 4 X 4 dressing sponges, skin prep, Dakins's solution (in small medication cup), two [MEDICATION NAME] of normal saline and two large [MEDICATION NAME] sponge dressings). The Risk Manager (RM) arrived to assist. Employee D, Employee E, Certified Nursing Assistant (CNA) and the Risk Manager entered the resident's room at 12:07 PM. Resident #64 was lying on his back and was turned toward his right side by the Risk Manager. This exposed the wound on the left posterior thigh, which was open to air and had drained a moderate amount of serosanguinous drainage onto the towel and soaked through to the blanket on which Resident #64 was positioned. Employee D proceeded to perform the wound treatment with the visibly soiled towel and blanket in place beneath Resident #64. She retrieved a gauze sponge from the wound, which was beefy red with scant serosanguinous drainage present, and stopped during the treatment to ask for direction about using a Q-tip applicator. She then stated, I am starting over. She removed her gloves, and left the room as the RM continued to position Resident #64 exposing the wound. Employee D obtained additional supplies including a cotton applicator, and started the treatment over, cleansing the wound and then dressing the wound on the left posterior thigh. She did not date the applied dressing. The RM and Employee D switched sides, and the RM positioned Resident #64 on his left side, exposing the right wound, which was observed with scant serosanguinous drainage and was open to air except for some gauze observed protuding approximately two inches from the wound. The RM told Employee D to Fold the blanket over. Employee D folded the blanket over the red stains on the towel and continued with the treatment, and at one point, she raised her right, gloved hand to brush her hair from her eyes, then proceeded to contact the clean supplies and work with the [MEDICATION NAME] with the same glove. As Employee D continued, her fingers that contacted other supplies on the work table, came in contact with the white absorbent pad of the [MEDICATION NAME] that was placed onto the exposed wound, firmly secured and not dated. On 4/24/19 at 12:25 PM Employee E, CNA, was interviewed about the resident's wounds. Employee [NAME] stated he removed the dressings today, because they were soaked with drainage. He took them off to put Resident #64 in the shower. He reported that Resident #64 was placed back into the bed with no wound dressings and only a towel was placed on the bed. The wounds were observed directly contacting the towel and blanket that was already on the bed. The towel was soaking up the red-tinged to brown colored wound drainage. Observation continued of Resident #64 being placed onto the Hoyer pad (a sling used to lift immobile residents) by Employee E, CNA. The towel with red tinged and tan to brown stains was folded over to expose the underside and the Hoyer pad was placed under Resident #64. The Hoyer pad contacted the towels and blankets that were observed soiled throughout the wound dressing change. There was no barrier placed between the soiled sheets and the Hoyer pad to prevent seeping and/or cross contamination from the red tinged, tan/brown fluid stained towel and blanket on the bed of Resident #64. An interview was conducted with the Risk Manager, who was also the infection control nurse, on 4/25/19 at 7:48 AM. He confirmed the wound dressing change would be documented in the treatment administration record (TAR); but, he stated I would date the wound dressing. He confirmed that Resident #64's dressings were not dated by Employee D. Employee D was interviewed on 4/25/19 at 8:05 AM about the wound care observation conducted on 4/24/19, and she confirmed that Resident #64 had just gotten out of the shower. She reported that she would usually remove the dressings herself. She reported that she should have placed down drapes to cover the soiled areas, and Resident #64 should not have been lying in bed with open wounds. She also confirmed that she should have dated the wound dressings. An interview was conducted with Employee C, Registered Nurse (RN), on 4/25/19 at 11:13 AM. Regarding wound care/dressings, he stated the nurse should review the order, get the supplies, perform the treatment, apply the bandage and date the bandage. An interview was conducted with the Administrator on 4/25/19 at 12:49 PM, who stated that the facility was required to date the wound dressings, and there would be an ongoing 100% review of wound care to ensure that orders were being followed and bandages were being dated appropriately. A review of Resident #64's care plan revealed a focus on: Alteration in Skin Integrity related to pressure wounds to the left great toe, right buttock, left ischium and left heel. All treatments have been updated. Due to the length of time the resident is seen as needed to keep free from infection and if condition worsens. New area observed to scrotum on 4/17/19 (Initiated on 03/08/2019). A wound evaluation summary, dated 4/11/19, documented that the wounds present included: stage 4 pressure wound of the left ischium measuring 2.3 X 1.4 X 3 cm with a surface area of 3.22 cm. Moderate serosanguinous exudate. Unstageable deep tissue injury of the left first toe, stage 4 pressure wound of the right buttock measuring 13 X 6 X 4 cm with a surface area of 78.0 cm. Moderate serosanguinous exudate present. Stage 1 pressure wound of the left, medial heel. A review of the physician's orders [REDACTED]. It was started on 4/23/19 at 7:00 AM. Also documented Apply Dakins wet-moist to right buttock wound, cover with dry dressing BID (twice daily) every day and evening shift for wound 4/11/19. Surveyor:(NAME) Sally

Based on observations and interviews, the facility failed to ensure that one (Resident #61) of six residents receiving respiratory treatment/medication, out of a total of 52 sampled residents, was administered respiratory treatments/medication consistent with professional standards of practice. Resident #61's [MEDICATION NAME] was left at bedside for self-administration when the resident had not been assessed for and had no physician's order to self-administer this medication. The findings include: A record review was conducted for Resident #61, which revealed an [AGE] year-old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 4/22/19 at 11:51 AM, an observation of Resident #61 and his room revealed multiple [MEDICATION NAME] of [MEDICATION NAME] inhalation solution at bedside. No nurse was present. (Photographic evidence obtained) On 4/24/19 at 9:31 AM, another observation was made of Resident #61 and his room. The [MEDICATION NAME] of [MEDICATION NAME] inhalation solution remained at bedside. No nurse was present. Further review of the medical record and the resident's care plan and physician's orders revealed no order to self administer the [MEDICATION NAME] breathing treatments, and no care plan indicating the resident had been assessed to self-administer the medication. On 4/25/19 at 9:51 AM, an interview was conducted with Employee I, Registered Nurse (RN), regarding Resident # 61's breathing treatments. She stated, He administers his own nebulizer (breathing) treatments. He has an order for [REDACTED]. On 4/25/19 at 10:39 AM, an interview was conducted with the Director of Nursing (DON) regarding the physician's order or assessment for Resident # 61's self-administration of [MEDICATION NAME] nebulizer (breathing) treatments. She confirmed the resident had no order to self-administer medication, and that no assessment had been completed to ensure he was safe to do so. She stated she was unaware that he was self-administering this medication. She confirmed that because he had orders for scheduled and PRN (as needed) breathing treatments, the nurses would need to know when he was using them. She stated there could be a concern with his heart rate, if he received too much [MEDICATION NAME]. She stated she would have to educate the nurse.

Based on observations and interviews with staff, the facility failed to post the required nurse staffing information on a daily basis in a prominent location that was readily accessible to residents and visitors. The findings include: Observations throughout the four-day recertification survey from (MONTH) 22, 2019 through (MONTH) 25, 2019, found there was no daily nurse staffing information in any prominent location in the facility, including the front lobby or either of the two nurses' stations. On 04/25/19 at 5:23 PM, the staffing hours were located at the end of the first hallway (100 hallway) across from the Social Services office. The 100 hallway was the first residential hallway in the facility. Any visitor who came to see a resident in the 100 hallway would not see the information unless they continued through the entire unit toward the dining room at the center of the facility. The survey team had difficulty locating the required posting. An interview was conducted with the Administrator on 4/25/19 at 5:31 PM. She confirmed the only copy of the daily staffing hours was posted at the end of the 100 hallway. She acknowledged the requirement for the hours to be posted in a location where they were easily viewed by all visitors and residents.

Based on observation, resident and facility record review and staff interviews, the facility failed to maintain complete and accurate medical records for catheter care for one (Resident #75) of two residents reviewed for urinary catheters), for the code status of one (Resident #110) of 52 residents whose records were reviewed, and for skin treatment orders for two (Residents #1 and #77) of two sampled residents observed with skin issues, out of a total of 52 residents in the sample. The findings include: 1. During an interview conducted regarding Resident #75's care on 4/23/19 at 2:53 PM, the resident's representative reported he had a urinary catheter in place and had two recent urinary tract infections. A clinical record review for Resident #75 revealed a significant change minimum data set (MDS) assessment with an assessment reference date of 3/2/19. It noted he required extensive assistance with dressing, personal hygiene, toileting and bathing. He used a wheelchair as a mobility aid and had an indwelling urinary catheter. [DIAGNOSES REDACTED]. Resident #75 was on hospice care. Resident #75 was care planned for his indwelling catheter related to his [DIAGNOSES REDACTED]. A review of the resident's physician's orders revealed he had an order for [REDACTED]. The task did not specify that the care was to be provided on each shift. Over 30 days, care was provided on: 3/26/19- 1x 3/28/19- 1x 3/29/19- 2x 4/5/19- 2x 4/7/19- 2x 4/8/19- 2x 4/9/19- 2x 4/11/19- 2x 4/14/19- 2x 4/16/19- 2x 4/18/19- 2x 4/23/19- 2x 4/24/19- 2x There was no documentation confirming that catheter care was provided at all on 12 days during the review period. (Photographic evidence obtained) An interview was conducted on 4/25/19 at 4:00 PM with Employee A, Licensed Practical Nurse (LPN). She reviewed the record and confirmed the aides were not documenting catheter care three times daily per the physician's order. 2. On 04/23/19 at 10:12 AM, an electronic medical record (EMR) review revealed the code status was documented as full code for Resident #110. A review of the paper medical record revealed a code status of both Full Code and DNR. A Do Not Resuscitate (DNR) order was located in the record and was documented on the appropriate Florida Do Not Resuscitate Order form. It was dated 4/1/19. This document was also scanned into the EMR and was located under the EMR tab labeled Misc. An interview was conducted with Employee G, LPN, on 4/25/19 at 12:12 PM. She was asked to provide the code status for Resident #110. She stated as she went for the paper medical record, I do not go to the computer; that thing is never accurate. She identified the Florida State DNR form for Resident #110 and then brought up the EMR on the computer. She confirmed that Resident #110's EMR documented both a Do Not Resuscitate (DNR) order and Full Code. (Photographic evidence obtained) An interview was conducted with the Administrator, the Nurse Consultant and the Regional Director of Nursing on 4/25/19 at 12:00 PM> They each confirmed that the resident's EMR and paper medical record did not match. Resident #110 was admitted to the facility on [DATE]. The updated Full Code status occurred on 4/1/19, and was signed by Resident #110 and the resident's physician. 3. A record review for Resident #1 revealed an [AGE] year-old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/22/19 at 1:13 PM, an observation of Resident #1 revealed multiple dressings on both of her arms and her right shin. On 4/24/19 at 9:51 AM, another observation of Resident #1, revealed that the dressings remained in place to her right shin. Further review of the record revealed that she had no orders for any dressings and/or other treatments to her right shin. Her weekly skin check was reviewed that was completed on 4/23/19 at 7:15 PM, and it revealed the following: healing skin tears on bilateral forearms steri strips still intact, LLE (left lower extremity) several discolorations resident skin appears to be very thin and dry, continuing P[NAME] (plan of care). There was no mention of her skin tears and/or dressings on her right shin. On 4/24/19 at 11:03 AM, an observation and interview was conducted with Employee G, LPN, regarding Resident #1's right shin dressings. She confirmed the resident had two dressings in place to her right shin from a fall she sustained. She reviewed the electronic medical record and confirmed that there were no orders in place for the dressings. 4. An observation of Resident #77 on 4/23/19 at 4:02 PM found he had a small brown bandaid (approximately 1 inch by 2.5 inches) on his right wrist underneath his coiled rubber wrist keychain. On his left elbow, he had two of the same style bandaids that had been criss crossed over each other. On 4/24/19 at 11:56 AM, Resident #77 was observed again with the bandaid on his wrist and the two crossed bandaids on his elbow. Resident #77 was interviewed on 4/24/19 at 2:03 PM. His bandages were still in place. A record review for Resident #77 revealed a quarterly minimum data set (MDS) assessment with an assessment reference date of 3/2/19. He was assessed with [REDACTED]. (Photocopies were obtained) An interview was conducted with Employee C, Registered Nurse, on 4/25/19 at 11:14 AM. He he state there would be a physicians order for any skin tear. The Risk Manager was interviewed on 4/25/19 at 11:30 AM and stated all dressing changes should have a physician's order. He was not able to explain why R#77 had no treatment order for his wrist or elbow wounds.

Based on observations, interviews, and record reviews the facility failed to maintain infection control practices for two (Residents #267 and #29) of a total sample of fifty-two (52) residents. The facility failed to follow contact precautions for Resident #267, and failed to follow infection control guidelines for handling a soiled urinal for Resident #29. The findings include: 1. A record review was conducted for Resident #267, revealing that he was on contact precautions for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his wound. There was appropriate signage posted, and PPE (personal protective equipment) was available on the door. On 4/24/19 at 9:52 AM, an observation was made of Resident #267's room. The Physician's Assistant (PA) was observed in the room talking to the resident in Bed A. The PA then walked over and began speaking with the resident in Bed B. Upon exiting the room, he utilized the hand sanitizer on the wall. He was immediately interviewed and asked about the isolation status of the room. He confirmed that the resident in Bed B was on isolation precautions [MEDICAL CONDITION] in his wound. He was asked whether he was to don a gown and gloves prior to entering the room, and he confirmed that he should have gowned and gloved up. On 4/25/19 at 11:53 AM, an interview was conducted with the Risk Manager/Infection Control Nurse. He confirmed that anyone who entered an isolation room should use PPE. He stated he would in-service the PA. When asked about the trash can in the room next to Bed A, which was uncovered and overflowing with used PPE, and shown the photographic evidence of the overflowing can, he stated this was not acceptable practice. He further stated he would look into getting an appropriate trash can. He was then asked about staff using alcohol sanitizer gel in an isolation room instead of washing their hands. He stated that staff should be washing their hands with soap and water. 2. An observation and interview was conducted with Resident #29 on 4/25/19 at 10:09 AM. He was in his bed. He had an overbed table to his right that had a bin full of sandwiches, food and food trash inside. On the table sat three wrapped slim jim snacks, one opened can of soda, one unopened soda can, and a lidless cup of ice. Sitting directly beside the food and drink was an uncapped urinal that was approximately halfway full of dark yellow liquid. Employee J, the resident's CNS, entered the room after knocking and spoke with him briefly about lunch. She then donned a pair of rubber gloves, removed his half full urinal from the over bed table, and emptied it in the bathroom. She returned the emptied but unwashed urinal to the same location on the overbed table. As she returned to the bathroom to wash her hands, the urinal tipped over on the table, the open mouth of the vessel coming to rest over one of the slim jims. A pool of dark yellow liquid was observed to pool in the recessed rim, directly above the slim jim snack and next to the soda cans and cup of ice. Resident #29 requested his cup be refilled with ice. Employee J picked up his insulated cup, emptied it in the bathroom sink, departed the room, and returned with the cup which was now full of ice. The CNA set the uncovered ice cup right next to the now-tipped urinal on the table and departed the room. (Photographic evidence obtained) In an interview with the resident at the time of the observation, he acknowledged the proximity of the unclean urinal to his snacks and beverages. An interview was conducted with the Risk Manager/Infection Control Nurse on 4/25/19 at 11:30 AM. He stated the expectation for urinals was that they were emptied and the cap replaced prior to placing them back down. He stated if there was no bedrail to hang the urinal on, it would likely be placed on a table. He was shown the photograph of Resident #29's urinal, and the proximity to his food and drinks on the overbed table. He confirmed the unclean, uncovered urinal's proximity to the food items and cup of ice, and confirmed this was inappropriate infection control practice.

Based on observations and staff interviews, the facility failed to provide dignity for 2 (Residents #4 and #420) of 9 residents reviewed for dignity, out of a total of 40 sampled residents. The findings include: 1. A review of the clinical record revealed that Resident #4 was a [AGE] year-old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 1/29/18 at 2:12 PM, Resident #4 was observed sitting in a wheelchair with white socks on both of his feet. His name was clearly written in black marker on both socks and was easily read. A second observation was conducted on 1/31/18 at 9:34 AM, and Resident #4 was once again observed sitting in a wheelchair in the hallway with white socks on both of his feet. His name was clearly written in black marker on both socks and was easily read. 2. A review fo the clinical record revealed that Resident #420 was an [AGE] year-old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 1/31/18 at 9:51 AM, Resident #420 was observed in the hallway walking with therapy staff. Resident #420 was wearing white socks on both of his feet with Resident #4's name visibly written on them. On 1/31/18 at 9:52 AM, an interview was conducted with Employee G, Certified Occupational Therapy Assistant regarding Resident #420 wearing Resident #4's socks. Employee C stated, I see that, but I'm sorry, those were in the drawer. On 01/31/18 at 11:14 AM, an interview was conducted with the Administrator regarding Resident #420 wearing Resident #4's socks. The Administrator stated that they had already changed Resident #420's clothes, however Resident #4 had donated the socks. That was why Resident #420 was wearing them. The Administrator stated that she would speak to her Housekeeping Manager to make sure that this did not happen again. The Administrator was then asked whether Resident #420 and Resident #4 should be wearing socks with Resident #4's name written on them, and the Administrator replied, No, they shouldn't. On 1/31/18 at 3:47 PM, an interview was conducted with Resident #4 regarding whether he had donated any of his socks to the facility or another resident. Resident #4 stated, No, I did not donate my socks. We just have to share everything with everybody around here.

Based on record reviews, staff and resident interviews, observations, and facility document review, the facility failed to ensure that residents received treament and care in accordance with professional standards of practice by failing to provide physician-ordered medications in a timely manner and as per the physician's orders [REDACTED].#45) of 5 residents sampled for medication review. The facility failed to provide urinary catheter treatment for 1 (Resident #92) of 2 residents with indwelling catheters, and the facility failed to respond in a timely manner to resident call lights. This affected 2 (Resident #107 and an unsampled resident) of a total sample of 40 residents. The findings include: 1. Resident #45 was interviewed on 1/30/18 at 10:53 AM. Resident #45 stated, I have another concern. I have [MEDICAL CONDITION], and they are always late with my medication, and I need my medication on time. A record review was conducted for Resident #45, and it revealed a physician's orders [REDACTED]. The start date was 1/19/18. Prior to that order, Resident #45 had an order for [REDACTED]. A record review was conducted related to the resident's [MEDICATION NAME] and the times it was actually administered. The following was identified: 1/17/18 dose scheduled for 5:00PM, was administered at 7:37PM (1 hour 37 minutes late) 1/20/18 dose scheduled for 5:00PM, was administered at 9:33PM (3 hours 33 minutes late) 1/21/18 dose scheduled for 5:00PM, was administered at 9:19PM (3 hours 19 minutes late) 1/24/18 dose scheduled for 5:00PM, was administered at 7:57PM (1 hour 57 minutes late) 1/25/18 dose scheduled for 5:00PM, was administered at 8:12PM (2 hours 12 minutes late) 1/29/18 dose scheduled for 5:00PM, was administered at 9:45PM (3 hours 45 minutes late) ** Note all the times listed above were actually administered an hour later than calculated; however, facility had an hour window to administer the medication, so the hour window was deducted). Progress notes were reviewed over the time-frame noted above, and there was no documentation of the physician having been notified on any of the dates above-listed dates regarding Resident #45's [MEDICATION NAME] CR Extended Release being administered late. On 02/01/18 at 02:01 PM, an interview was conducted with Employee E, Licensed Practical Nurse (LPN). Employee E was asked to explain the facility's expectation regarding what should happen if [MEDICATION NAME] extended release medication is administered late. Employee E stated that the nurse would need to call and notify the physician, and obtain an order for [REDACTED]. 2. During an interview with Resident #92 on 1/30/2018 at 11:00 AM, he stated that he had a suprapubic catheter. He added that there had been a problem with it leaking over the last year. During an interview with Resident #92's nurse (Employee A) on 1/31/2018 at 10:46 AM, she stated she was aware that Resident #92 had a suprapubic catheter. She stated the nursing staff provided catheter care each shift. They checked it for patency, and they flushed it. A record review for Resident #92 found the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further record review found Resident #92 had a urologist visit in October 2017, and had a [DIAGNOSES REDACTED]. A record review of the current physician's orders [REDACTED]. A record review of the January 2018 Treatment Administration Record (TAR) for Resident #92 found the resident's suprapubic catheter was last irrigated on January 21, 2018. The blocks on the TAR for January 25 and January 29 were blank. Further record review of the February 2018 TAR found the next irrigation of the catheter was due on 2/2/2018. Continued review of the resident's clinical record found no evidence that the catheter had been irrigated since 1/21/2018. There was no documented explanation regarding why is had not been done as ordered. These findings were confirmed during an interview with the Unit Manager (Employee B) on 2/01/2018 at 2:47 PM. She looked at the TAR and the physician's orders [REDACTED]. On 2/1/2018 at 4:15 PM, the Unit Manager brought a copy of the current physician's orders [REDACTED]. At this time, she stated the doctor wrote the order to irrigate the catheter due to the resident having a lot of sediment in his urine. The Unit Manager was asked whether she had any evidence that the irrigation had been done, or whether she knew why it was not done on 1/25 and 1/29/2018. She shook her head and stated 'No'. 3. During the initial tour of the facility on 01/29/2018 at 12:08 PM, Resident #107 was interviewed in her room, and stated that there were concerns with call lights not being answered. During the interview, Resident #24 was identified as the resident who was in the bathroom and had activated the call light. The resident's bathroom was a shared bathroom between two resident rooms. Four residents shared this bathroom, including Resident #24, Resident #43, and Resident #107. On 1/29/2018 at 12:13 PM, Resident #24 was interviewed to establish why she was calling out. Resident #24 stated that the call light was activated (which was observed to be operational at the time the interview was being conducted), about 15 to 20 minutes ago. Resident #24 stated that she went into the bathroom, and activated the call light for assistance with her brief. Resident #24 stated that the staff were in the lunch room serving meals. Interviews were conducted with Residents #107, #24, and #43 at this time. They also stated that the staff were probably in the lunch room serving people, so they could not respond to the call light. Resident #24 stated that she had to wait a long time during lunch time, because the staff went to the dining room to assist with the meal service. She stated that this happened two or three times a week. On 01/29/2018 at 12:17 PM, Employee H, Unit Manager, arrived to the room. The call light was still illuminated. Employee H turned off the call light at 12:18 PM. An interview was conducted with Employee H at that time, and she stated that Resident #24 was in need of one of the girls (a certified nursing assistant (CNA). Employee H stated that she turned off the call light to go and get someone to assist. When she was asked where the CNA was, she stated that she did not know. On 01/29/2018 at 12:24 PM, Employee M (CNA), who was called by Employee H arrived to the resident's room. Employee M attended to Resident #24's needs. At 12:35 PM, Employee H stated that she expected a sounding call light to be responded to within 4 minutes. Employee H also stated that both CNAs were in the dining room at that time, and Ideally, an additional aide would be nice, however more communication among the hall partners was important. An interview was conducted on 02/01/2018 at 10:38 AM with Employee I, LPN, who was caring for Resident #24. Employee I stated, It depends on the days as to how much assistance was needed. (Resident) is incontinent for bowel and bladder and alert and oriented times three. Employee I stated that the expected time to respond to call lights would be as soon as we can get by the room. A review of the facility's call light answering policy and procedure, revealed under purpose, The purpose of this procedure is to respond to the resident's requests and needs. Under section 7.) states, Answer the call light as soon as possible. A medical record review was conducted and documented that Resident #24 was a [AGE] year-old resident who was admitted to the facility on [DATE], with multiple comorbidities including anxiety disorder and [MEDICAL CONDITIONS]. The Minimum Data Set (MDS) assessment dated [DATE], was reviewed and the resident was documented with a Brief Interview for Mental Status (BIMS) score 15, indicating that she was alert and oriented to herself, her location, the time and her circumstances. She was also documented as always incontinent of bowel and bladder. A review of Resident #24's care plan revealed, Needs extensive assistance with most ADLs related to general weakness. (Resident #24) is at risk for falls related to unsteady gait and has history of falls. Resident #24 was also documented in the care plan as incontinent of bowel and bladder, and was not a candidate for retraining. She was also at risk for skin breakdown related to impaired mobility and fungal rashes, with closed shear to buttock. 4. An observation was made on 2/01/2018 at 8:58 AM of a call light activated for a room near the nurses' station. During this time, two CNAs, Employees N and O, were observed at the nurses' station. Both employees failed to respond to the call light. The call light was answered at 9:09 AM by Employee P, Registered Nurse (RN). An interview was conducted with Employee P on 2/01/2018 at 9:13 AM. She confirmed that when a call light was observed activated, it should be answered even if staff were passing by. Employee P assisted the resident while Employees N and O did not respond to call light at all. Employee F, Licensed Practical Nurse (LPN), was also observed between the two rooms near the call light and failed to respond to it. An interview was conducted on 02/01/2018 at 1:06 PM with the Director of Nursing (DON). The DON stated, Call lights should be answered as soon as possible, and I cannot put a time frame on it., and We have a no pass zone for all call lights. The DON also stated that each CNA should have a hall partner. If the hall partner was at lunch or off the unit, there should still be a response to the call light. If someone else sees the call light on, they should respond to this in a timely fashion.

Based on observations and interviews, the facility failed to maintain an Infection Control Program designed to help prevent the spread of infection by failing to ensure facility staff followed procedures implemented to reduce the spread of infection from a resident placed on droplet precautions (Resident #419) to the facility's remaining residents, other staff members and visitors. The facility also failed to follow infection control practices prior to withdrawing insulin from medication vials for 2 of 2 sampled residents (Residents #23 and #12) receiving insulin, and failed to properly clean blood glucose meters during care for 2 (Residents #23 and #12) of 2 sampled residents. The findings include: 1. On 1/30/18 at 11:40 AM, this surveyor observed Employee K, Certified Nursing Assistant (CNA) and an unknown visitor in the room of Resident #419. There was a sign on the door instructing visitors to see the nurse before entering. There was also a sign on the door for contact precautions with instructions to wear a mask, gloves and a gown before entering the room. A metal shelf was noted hanging over the resident's door. It contained gowns, gloves and masks (Personal Protective Equipment-PPE). Neither Employee K nor the visitor were observed wearing PPE. An interview with Employee J, Registered Nurse (RN), revealed that Resident #419 was on droplet precautions. During the interview, Employee J stated that all staff members and visitors were to wear PPE prior to entering the room of Resident #419 and any other isolation rooms. The facility staff received training regarding how to care for residents who were on isolation. She stated that Staff member K would have received this training and that Staff member K would receive additional education on how to properly care for residents who were on isolation. During an interview with Employee K on 01/31/18 at 01:20 PM, the staff member stated that when providing care for a resident on isolation, all employees should stand outside the door, and put on a gown, mask and gloves. The gloves were to be placed over the gown sleeves and make the gown was to be tied so that it was closed. If someone refused to wear PPE, staff would recommend that they wear PPE and then report the situation to the nurse. Employee K confirmed having been educated regarding proper care of residents who were on isolation and the need to use PPE. Employee K stated that the unknown visitor in the room was Resident #419's daughter who refused to wear PPE in spite of continuous education in the facility by various staff members including himself. 2. On 1/30/18 at 4:20 PM, Employee D, Licensed Practical Nurse (LPN), was observed performing blood glucose monitoring for Resident #23. The nurse gathered supplies on a plastic tray. Supplies included an Accu-check machine, lancet, alcohol wipe, and a container of blood glucose testing strips. Employee D took the tray into room [ROOM NUMBER] B and placed it on the seat of Resident #23's rolling walker (which was visibly soiled). Employee D then tested Resident #23's blood sugar. Afterward, she removed the tray, and took it back to the top of her medication cart. She then obtained the Humalog insulin, 8 units ordered for Resident #23. She did not wipe off the top of the insulin vial with alcohol prior to drawing up the insulin. She returned to the room and placed the plastic tray on the seat of Resident #23's rolling walker again. She administered the insulin and gave the resident all of his oral medications. She then returned to the medication cart and placed the tray on top of the cart. She cleaned the glucometer by wiping the machine with a bleach wipe for five seconds, however, she failed to wipe the area where the glucometer blood collection strip went into the machine. The glucometer was placed on top of the cart to dry with no barrier provided between the glucometer and the top of the medication cart. On 1/30/18 at 4:24 PM, and interview was conducted with Employee D regarding the cleaning procedure for the glucometer, and failure to cleanse the insulin vial with alcohol prior to drawing up Resident #23's insulin. Employee D confirmed the breaches in infection control as they related to cleansing the glucometer and the top if the insulin vial. On 1/30/17 at 4:29 PM, this surveyor approached Employee C, Licensed Practical Nurse (LPN), at her medication cart, and asked to observe the nurse conducting blood glucose monitoring for one of her residents. Employee C stated, I can do Resident #12. Employee C picked up the glucometer and cleansed it with a bleach wipe for 4 seconds, then placed it back down on her medication cart with no barrier. Employee C excused herself from the medication cart to see whether Resident #12 was in her room. She returned and stated the resident was in her room. Employee C gathered supplies on a plastic tray including an Accu-check machine, alcohol wipe, blood glucose strips, and a lancet. She entered the resident's room with the tray and placed in on Resident #12's bed side table, then moved it to Resident #12's bed. She obtained the resident's blood glucose level, picked up the tray and brought it back to her medication cart, placing it on top of the cart. She removed the items and then discarded the tray. Resident #12's blood sugar level was 270, so Humalog insulin, 6 units was ordered. Employee C drew up the insulin without cleansing the top of the insulin vial with an alcohol wipe. She placed the syringe of insulin on a second tray with an alcohol wipe, then cleansed the glucometer with a bleach wipe, failing to cleanse the end where the blood glucose strip was inserted. She started to place the Accu-check machine into her cart, however, the machine was still very wet, so she removed a tissue from the box on the side of her medication cart and wiped the glucometer dry. Then she placed the glucometer in her medication cart. On 1/30/17 at 4:39 PM, an interview was conducted with Employee C regarding her practice of not wiping the top of the insulin vial for Resident #12 prior to drawing up her insulin. Employee C stated, I know, I'm sorry. She was asked about the process for cleansing the glucometer, and was asked why she had dried it with a tissue. She stated that some of the bleach wipes are wetter than others, and that is why she had to dry the glucometer. She was asked what length of time she was expected to wipe the glucometer in order to ensure its disinfection and whether and how long it was supposed to air dry. She stated, I'm not sure, I would have to ask somebody. On 01/31/18 at 10:29 AM, and interview was conducted with the Risk Manager regarding the policy and procedure for cleaning the glucometer, and he stated that the facility only had the line on the policy regarding how to obtain a finger stick. The Risk Manager stated that they were looking for a policy that may address something else regarding the cleansing of the machines. On 02/01/18 at 09:02 AM, an interview was conducted with the Administrator regarding a policy and procedure for cleaning the glucometers. The Administrator stated, We do not have an actual policy and procedure for cleaning the machines (glucometers), only the sentence on the other policy I gave you. A review of the container of germicidal bleach wipes provided by the Administrator indicated the following: Contact Time: Allow surfaces to remain wet for 30 seconds to kill all of the bacteria [MEDICAL CONDITION], except a 1 minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] and [MEDICATION NAME] mentagrophytes, and a 3 minute contact time is required to kill [MEDICAL CONDITION] spores. A review of the policy and procedure entitled Obtaining a fingerstick glucose level, Diabetic Care, Nursing Services and Procedures, page 6 of 7, January 2010, revealed under the heading - Steps in the procedure, #19: Clean glucose monitor with approved disinfectant before and after each resident use.

Based on interviews and record review, the facility failed to maintain complete, accurate clinical records for 1 of 24 sampled residents (Resident #18). The findings include: A medical record review was conducted for Resident #18 which revealed an admitted on 1/29/2008, and with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. A physician's orders [REDACTED]. A record review of the Medication Administration Record [REDACTED]. The medication was documented as not given, but blood pressure and pulse were not documented. An interview was conducted with Employee C on 1/6/17 at 8:46 AM. Employee C stated, Blood pressures are taken prior to giving the blood pressure medication ([MEDICATION NAME]) for Resident #18. If the blood pressure is low, it is documented in the nurse's notes, and the Medical Doctor or Nurse Practitioner is notified. An interview was conducted with Employee A, RN, and Employee B, LPN, on 1/6/17 at 11:20 AM. Employees A and B confirmed the documentation for the blood pressures and pulses for Resident #18 were missing on 12/15, 12/17, 12/18, 12/21, 12/22, and 12/23/16.

Based on observations and staff interviews, the facility failed to store and prepare food under sanitary conditions in the kitchen and 2 of 2 nourishment rooms (West & North Nursing Station), during two of two days observed (12/14/2015 and 12/16/2015 and ) related to: 1. Food products were not securely wrapped and correctly labeled with expiration dates, 2. One of one walk in freezer was not maintained clean, 3. One of one ice machine was not maintained clean and sanitary, 4. Employees were not wearing the proper attire and protective garments and 5. Two of three microwaves were not clean and sanitary. The findings include: During the kitchen tour on 12/14/2015 at 7:30 a.m. and on 12/16/2015 a 1:30 p.m. the following was observed: 1. One of one walk in freezer with unlabeled and undated open package of muffins. It was confirmed by the Certified Dietary Manger (CDM) that the muffins were open, and they were immediately removed. 2. One of one walk in freezer with 2-4 inches of ice built up along one of the shelf racks below the freezer fans. The CDM pointed out a broken pipe which caused condensation and ice buildup. 3. Ice machine with gelatinous black biological growth along the inner lining of the base where the ice falls out. 4. Kitchen Aide, Employee A, performed a dishwasher demonstration with improper use of a hairnet, with top of head exposed. In addition, at the nourishment stations - West Unit on 12/16/15 at 2:30 p.m and North Unit at 2:45 p.m. the following was observed: 5. Both unit microwaves had caked on dried food particles along the entire roof and back of appliance. Interview with the Certified Dietary Manager on 12/16/2015 at 1:30 a.m. confirmed kitchen staff are tasked with daily cleaning assignments in conjunction with other duties. He further presented cleaning logs that indicted cleaning schedules. He also confirmed hair restraints are part of the uniform for kitchen staff.

Based on record review and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being related to physician ordered laboratory services for 1 of 5 residents reviewed for unnecessary medication use in a sample of 30 residents. (Resident #80) The findings include: Record review for Resident #80 found he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the December, 2015 physician orders [REDACTED]. Aspirin 325 milligrams (MG), 1 tablet each day for [MEDICAL CONDITION] Atorvastatin Calcium Tab 10 MG give 1 tablet at bed time for [MEDICAL CONDITION]. [MEDICATION NAME] Sprinkles 1000 MG twice a day for mood disorder. [MEDICATION NAME] HCI tablet 25 MG 1 tablet three times a day for high blood pressure. [MEDICATION NAME] 20 MG 1 tab each morning for [MEDICAL CONDITION]. Record review for Resident #80 found physician orders [REDACTED]. Further record review found the last time Resident # 80 received a CMP, CBC and [MEDICATION NAME] Acid level was on 7/17/2015. There was no record of a lipid panel in the last 6 months. The findings were confirmed by interview with the Director of Nursing on 12/16/2015 at 3:07 PM. She stated all of the labs that were ordered were completed in July except the lipid level. During further interview on 12/16/2015 at 3:23 PM she stated she spoke with the physician and will do the lipid level in the morning.

Based on record review and staff interview, the facility failed to ensure the "Notice of Medicare Provider Non-Coverage " was given timely for 2 of 3 sampled residents (Residents #26 and #94) and failed to ensure 2 of 3 sampled residents were given a choice related to the continuation of skilled services. (Resident #94 and #127) The findings include: Record review of the Notice of Medicare Non-Coverage given to Resident #26 found her skilled occupation therapy services ended on 5/12/2014. Further review of the Notice of Medicare Non Coverage found the notice was signed by Resident #26's power of attorney. The form contained a typed date of 5/9/2014 and no written date. During an interview on 10/9/2014 at 4:30 p.m. with the Business Office Manager, she stated she did not know when the form was signed. She further stated the typed date on the form is the date she printed it. Record review for Resident # 94 found his occupational and physical therapy ended on April 22, 2014. Further review of the "Notice of Medicare Non-Coverage found revealed it was signed by Resident #94 on 4/21/2014. Review of the "Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for Resident #94 found a typed date of notice of 4/19/2014 and the typed signature date of 4/22/2014. The notice was signed by the resident. The section "Next: Please choose one option below. Check one box. Date and sign this notice" was found not to have either option checked. (Option 1. Yes I want to receive these items and services and Option 2. No. I will not receive these items or services.) During an interview on 10/9/2014 at 4:30 p.m. with the Business Office Manager, she confirmed she did not give the notices timely. Record review for Resident #127 found his occupational therapy was ending on 9/27/2014. Review of the "Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for Resident #127 found the notice was signed by the resident. The section "Next: Please choose one option below. Check one box. Date and sign this notice" was found not to have either option checked. (Option 1. Yes I want to receive these items and services and Option 2. No. I will not receive these items or services.) During an interview on 10/9/2014 at 4:30 p.m. with the Business Office Manager, she stated the facility informs residents who the facility feels Medicare will no longer pay for therapy. She stated she did not have Resident #94 or #127 mark the box for option 1 or 2 because she was not aware the box needed to be marked unless the resident wanted to appeal. .