Every finding on record at Sandy Ridge Center for Rehabilitation and Healing

Based on observations, interviews, and record reviews, the facility failed to implement and maintain accident prevention interventions for 1 resident (Resident #1) who previously sustained a fall with major injury, resulting in the resident experiencing a second preventable injury. The facility did not follow the resident's updated care plan requiring two person assistance for bed baths only and allowed the resident to be taken to the shower despite this restriction. This failure resulted in the resident sustaining a humerus fracture and placed the resident at continued risk for further avoidable harm. This deficient practice is cross referenced to F0689 due to the facility's failure to provide adequate supervision and accident prevention interventions. The findings include:A record review of Resident #1's chart on 02/25/2026 revealed that she had a right closed hip fracture and displaced hip following a fall from the bed on 09/29/2025. The facility reported the following corrective action after the incident: All bed baths for [Resident #1] are now conducted with two person assistAn interview and observation of Employee B, a Certified Nursing Assistant (CNA), on 02/25/2026 at 11:19 AM revealed that the facility uses a sticker system outside each resident's door to indicate the required level of assistance, with 1P meaning one person assist and 2P meaning two person assist. An observation of the sticker outside Resident #1's room indicated she requires a two person assist.An interview with two of Resident #1's daughters on 02/25/2026 at 11:30 AM revealed that the resident had recently sustained an injury to her left shoulder, and an X ray confirmed a humerus fracture. The resident's daughter stated that Resident #1 was able to describe the event, telling them, I was brought to the shower room, they pulled on my arm, and hurt me. They further explained that an investigator reviewed the incident and closed the case after determining the fracture was pathological and related to the resident's history of osteopenia. Following this event, the daughter reported attending a meeting where it was agreed that Resident #1 would receive bed baths only, with two staff assisting. A sign reading 2 person bed baths only was observed above Resident #1's bed, and the daughter confirmed it had been placed there after the September 2025 fall from the bed. The daughter stated that Resident #1 was complaining of shoulder pain 2 days before the x-ray and Employee D, a Licensed Practical Nurse (LPN), was made aware.A review of the Resident #1's Xray report for 01/05/2026 showed an acute left humeral fracture.An interview with Employee D on 02/25/2026 at 1:20 PM revealed that she notified the Nurse Practitioner in January about Resident #1's increased pain and subsequently received orders for an X ray and additional pain medication. She further stated that after Resident #1's first injury, the facility revised its practice to require two person assistance for bed baths for residents on hospice or those with limited mobility in bed.A review of Resident #1's revised care plan revealed that the following:09/30/2025 (After hip fracture)- The resident is dependent with staff of 2 persons for bathing/showering 3 times per week as tolerated and as necessary.10/02/2025- The resident is dependent with staff of 2 persons for bathing/showering 3 times per week as tolerated and as necessary. Cloth bed pad to be placed under the resident when bathing.10/02/2025- The resident is dependent with staff of 2 persons for bathing 3 times per week as tolerated and as necessary. Cloth bed pad to be placed under the resident when bathing.1/7/2026 (after humerus fracture)- The resident is dependent with staff of 2 persons for bathing/showering 3 times per week as tolerated and as necessary. Cloth bed pad to be placed under the resident when bathing.A review of Resident #1's bath documentation showed inconsistent adherence to the care plan interventions following her fall related hip fracture. In October 2025, records showed 2 bed baths and 5 entries marked not available. In November 2025, documentation reflected 4 bed baths, 2 showers, and 2 refusals. In December 2025, the resident received 6 bed baths and 4 showers. In January 2026, the record showed 4 bed baths, 1 shower, and 1 refusal, including documentation of a shower provided on 01/02/2026-prior to the resident reporting to her daughter that she had been taken to the shower and that her arm had been pulled.During an interview with the MDS Coordinator on 02/25/2026 at 2:18 PM, she stated she was unsure why the care plan had been updated to include baths/showers following the reported shoulder fracture. She also stated there was no clinical reason that would prevent the resident from using the shower, even with a history of a hip fracture and despite the family's expressed preference for bed baths.During an interview with the Administrator and Director of Nursing on 02/25/2026 3:25 PM, they stated that Resident #1's injury investigation was closed based on the Nurse Practitioner's (NP) assessment that the fracture was pathological. They explained that the NP reached this conclusion because no tissue damage or inflammation was observed. While the plan of correction following the October fall mandated a two-person assist for bed baths, the facility could not explain why the care plan was edited to allow showers after the January incident. The Administrator verbalized that the family preferred bed baths.During an interview with the Nurse Practitioner on 02/25/2026 at 3:56 PM, he explained that he determined the fracture to be pathological rather than traumatic based on the resident's history of diffuse osteopenia and the absence of visible swelling or bruising. When asked whether he was aware that the family had requested bed baths only and that this was reflected in the care plan, he stated he was not. He also stated he was unsure whether Resident #1 had been taken to the shower. He was informed that documentation showed the resident received a shower on 01/02/2026, that nursing staff had been notified of the resident's arm pain, and that he was contacted after Resident #1's daughter reported pain and noted swelling. When asked if this injury could have been caused by pulling the resident's arm, he stated yes. When asked if he discussed his findings with the radiologist who concluded Resident #1 had an acute fracture, he said no.

Based on observations, interviews, and record reviews, the facility failed to implement and maintain accident prevention interventions for one resident (Resident #1) with a known history of fall related injury. The facility did not follow the resident's updated care plan requiring two person assistance for bed baths only, and allowed the resident to be taken to the shower despite this restriction. This failure resulted in the resident sustaining a left humerus fracture and placed her at continued risk for avoidable injury.The findings include:A record review of Resident #1's chart on 02/25/2026 revealed that she had a right closed hip fracture and displaced hip following a fall from the bed on 09/29/2025. The facility reported the following corrective actions after the incident: All bed baths for Resident #1 are now conducted with two person assist.An interview and observation of Employee B, Certfied Nursing Assistant, on 02/25/2026 at 11:19 AM revealed that the facility uses a sticker system outside each resident's door to indicate the required level of assistance, with 1P meaning one person assist and 2P meaning two person assist. An observation of the sticker outside Resident #1's room indicated she requires a two person assist.A sign above Resident #1's bed stating 2 person assist, bed bath only was observed on 02/25/2026 at 11:30 AM. Resident #1's daughter, who was present during the observation, reported that this sign had been in place since the resident's first injury in September 2025. The daughters also stated Resident #1 informed them she sustained an injury while being showered in January. Resident #1 alleged staff pulled on her arm and hurt her.A review of Resident #1's radiology report from 01/05/2026 revealed: Acute left humeral neck fracture.During an interview with Employee D, Licensed Practical Nurse (LPN), on 02/25/2026 at 1:20 PM, she stated that bath preferences should be listed on each resident's care plan.A review of Resident #1's care plan and chart showed that it was updated on 10/02/2025, following the September 2025 injury, to require a two person assist for bed baths. The care plan was later revised again on 01/07/2026, after the resident sustained a second injury, to indicate a two person assist for baths/showers. Documentation also showed that the resident had been taken to the shower on 01/02/2026, along with six additional showers documented since September 2025.During an interview on 02/25/2026 at 2:18 PM, the Minimum Data Set (MDS) Coordinator stated she was unsure why the care plan had been modified to include baths/showers after the January fracture. She acknowledged that Resident #1's family preferred two person assist bed baths but maintained that there was no clinical contraindication that would prevent the resident from receiving a shower.An interview with Employee F, CNA, on 02/25/2026 at 3:13 PM revealed that she recalled assisting another CNA in bringing Resident #1 to the shower in January, prior to the resident's left arm injury.An interview with the Director of Nursing and the Administrator on 02/25/2026 at 3:25 PM confirmed they were aware that Resident #1's family preferred bed baths only with two staff assisting. They were unable to explain the subsequent care plan changes that allowed for baths/showers.

Base on staff interview and record reviews, the facility failed to develop care plans for 2 of 5 residents sampled for unnecessary medications, Resident #7 and 41. The findings include: Resident # 41 Electronic Medical record review reveals resident #41 was readmitted to the facility on [DATE] with a previous admission in October 2023. Medical diagnosis and history include Cerebral infarction (stroke), type 2 diabetes and chronic Atrial Fibrillation (AFIB-an irregular heartbeat). Admission orders revealed resident receiving Insulin Glargine and Insulin Lispro (injectable medications used to lower blood glucose levels) for type 2 diabetes. Resident is also receiving Eliquis (a blood thinner used to prevent blood clots). A review of the initial care plan, dated 1/25/2024 for resident #41 did not include a care plan for Diabetes or use of an Anticoagulant. On 04/03/24 at approximately 12:35 PM an interview with the care plan coordinator, registered nurse, who indicated that the resident should have a care plan for anticoagulants, if taking one, and a diabetic care plan if the resident is diabetic. The care plan coordinator confirmed resident #41 care plan did not include being diabetic or use of an anticoagulant. The care plan coordinator further stated, she would add these care plans. On 04/03/2024 at approximately 2:49 PM in an interview was conducted with the director of nursing (DON) and the regional nursing director. The surveyor asked, is a care plan for Diabetes and anticoagulant use expected when a resident is receiving medications for diabetes and an anticoagulant? DON indicated, yes, a care plan is expected for both. The DON confirmed care plans for anticoagulant use and diabetes were not present for resident #41. 47306 Resident #7 On 4/2/24 a record review was conducted for resident #7 who had diagnoses of Diabetes Type II (non-insulin dependent), Anxiety disorder, atrial fibrillation (heart dysrhythmia), depression, altered mental status, and hypertension (high blood pressure). Resident #7 was prescribed the following medications: Eliquis (a medication used to thin blood and prevent blood clots), Prozac (a drug used for depression), Trazadone (a drug used for depression and trouble sleeping), Ozempic (a drug used to lower blood sugar), Glipizide (a drug used to lower blood sugar), Tresiba (a drug used to lower blood sugar), Lasix (a drug used to excrete excess fluid), and Ativan (a drug used for anxiety). A review of resident #7's care plan dated 4/2/24 revealed the resident did not have care plans addressing medication monitoring and side effects. On 4/2/24 at approximately 1:09 PM, an interview was conducted with the Director of Nursing (DON) regarding care plans for resident #7. The DON indicated they have had recent issues with the care plans not being adequate and the facility is working on the problem. The DON indicated the facility has hired a new coordinator for the development of care plans. 35609

Based on observation, resident interview, staff interview, and clinical record review, the facility failed to develop and implement a process regarding turning and repositioning to prevent the development of pressure ulcers for 1 of 3 residents sampled for facility acquired pressure ulcers, resident #49. The findings include: On 4/1/2024 at 2:02 PM an interview was conducted with resident #49. Resident #49 indicated he had a bed sore on his bottom for which he was receiving wound care every day. The resident indicated he was dependent upon staff for mobility, and was unable to turn or reposition himself when he arrived at the facility back in February. The resident indicated he does not recall any staff turning or repositioning him in bed or a chair during the time he was unable to reposition or turn himself. The resident indicated the facility ordered an air mattress for him after he developed a pressure ulcer. On 4/3/2024 at 9:45 AM a wound care observation was made of resident #49 with Registered Nurse A (RN A, Wound Care Nurse). The wound was observed to be an oval size stage 2 (an open wound affecting both the top and bottom layers of the skin) pressure ulcer of the coccyx (tailbone) area with a small amount of granulated tissue in the center of the wound. The wound appeared to be the circumference of a half dollar. On 4/3/2024 at 9:58 AM an interview was conducted with RN A immediately following the wound care observation. RN A was asked if she thought the residents are being turned and repositioned often enough to prevent and heal pressure ulcers. RN A indicated the Certified Nursing Assistants (CNAs) have gotten better about repositioning the residents, but there needs to be a system in place to remind the CNAs to turn and reposition the residents to promote healing of pressure ulcers and prevent pressure ulcers. RN A confirmed the pressure ulcer was facility acquired (developed after admission to the facility) On 4/3/2024 at 1:26 PM a telephone interview was conducted with Advanced Practice Registered Nurse (APRN) C regarding facility acquired pressure wounds and Resident #49. APRN C indicated she was routinely treating and assessing resident #49's wound. APRN C indicated she educates the staff and residents regarding offloading pressure wounds, changing positions, pressure relief and wound care in general. APRN C indicated she was not aware if the facility has a policy for turning and repositioning immobile dependent residents. On 4/3/2024 a medical record review was conducted for resident #49. The record review revealed resident #49 was admitted to the facility on [DATE] with diagnoses to include MRSA (Methicillin-resistant Staphylococcus aureus), Sepsis (blood poisoning), acute respiratory failure, exacerbation of Chronic obstructive pulmonary disease (COPD), malnutrition, Discitis of thoracic region (a rare but serious infection of the discs that cushion the spine's vertebrae), and limited mobility. The resident's admission history, initial comprehensive assessment and Minimum Data Set Assessment section M dated 2/20/24 were reviewed and revealed the resident did not have a coccyx pressure ulcer upon admission to the facility on [DATE]. A review of resident #49's progress notes indicate the coccyx wound was discovered on 2/25/2024, 9 days after admission to the facility on [DATE]. A review of resident #49's physician orders indicated resident #49 had current wound care ordered for the coccyx pressure ulcer. The Baseline Plan of Care dated 2/16/24 indicated resident #49 was at risk for skin breakdown. Interventions marked with a check mark included inspecting the skin daily and food and fluid to promote nutrition. The section stating encourage, remind, assist in position change regularly and frequently was not checked, and nothing was circled to indicate level of assistance needed. The Activities of Daily living indicated that Resident #49 required extensive assistance with bathing, dressing, grooming and toileting. The Braden Scale (pressure ulcer risk assessment) dated 2/16/24 indicated Resident #49 was scored at 16 indicating At Risk for skin breakdown. The form indicated that resident #49 has probably inadequate nutrition, had very limited mobility, was chairfast and had a potential problem with friction and shear.

Based on staff interviews, record review and policy review, the facility failed to ensure resident's are free from unnecessary psychotropic (medications that affect behaviors) medications for 1 of 5 residents sampled for unnecessary medications. (Resident # 28). The findings include: A review was conducted of the Electronic Medical Record for resident #28, which revealed an order for Lorazepam Oral tablet (a medication used to treat anxiety) 1 milligram (MG) tablet twice a day as needed for anxiety dated 3/20/24. Further review of the medication order revealed no stop date for the medication. On 4/3/24 at approximately 1:37 PM, an interview was conducted with the Director of Nursing (DON) who confirmed that the order for Lorazepam for resident #28 had no stop date. The DON indicated that it is her expectation for all 'as needed' psychotropic medications to have a 14 day stop date at which time the physician should review the medication for continuation or discontinue and document the reasoning for the decision. Review of facility policy titled Pharmacy services: Psychoactive meds revealed: In accordance with State and Federal Guidelines, revised regulation S483.45(e) Psychotropic Drugs which states that based on a comprehensive assessment of a resident, the facility must ensure that: -Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. -Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated. -Residents do not receive PRN psychotropic drugs unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. -PRN (as needed) orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then he or she should document the rationale in the resident's medical record and indicate the duration for the PRN order.

Based on observation, staff interview, resident interview and policy review, the facility failed to demonstrate a water management plan had been implemented for the prevention and surveillance of legionella (a water born virus). The facility failed to follow infection control practices for 2 of 55 residents observed during initial tour for nebulizer equipment (machine that provides breathing treatments for respiratory compromised residents), Resident #202 and #252. The findings include: On 4/3/24 at approximately 3:45 PM, an interview was conducted with the Maintenance Director concerning the water management plan. The Maintenance Director indicated that he did not have a book for monitoring for legionella, or any water temperature monitoring completed weekly for this year per facility plan. The Maintenance Director went on to state that he has gotten behind due to being the only maintenance worker for the building. On 4/3/24 at approximately 4:00 PM, an interview was conducted with the Administrator, who indicated that the monitoring for legionella in his experience has always been completed by the Maintenance director and kept with the emergency preparedness plan for testing annually. Stated he was not sure when the last time the facility was tested but would see what he could find. On 4/3/24 at approximately 4:30 PM a follow up interview was conducted with the Administrator, who indicated he was unable to find the last test for legionella for the facility and had attempted to contact his predecessor to see if it was located somewhere he was not aware of and has not received a reply at this time. Review of the facility policy titled: Administrators-Water Management Plan revealed: A water management plan will be implemented to identify and manage conditions that support the growth and spread of legionella. The plan includes a facility risk assessment along with control measures and monitoring. Legionella is found naturally in [NAME] environments, like lakes and streams but generally the low amounts in [NAME] do not lead to disease. Legionella can become a health problem in building water systems. To pose a health risk, legionella first has to grow and has to be aerosolized so that people breathe in small, contaminated water droplets. Procedure: A. A team will be formed to coordinate activities for the water management effort. B. The team will describe the facility water system. C. The team will conduct facility risk assessments. D. Control measures will be implemented and monitored 47306 Resident #202 On 4/1/2024 at 1:20 PM during the initial pool process an observation was made of resident #202's room. A nebulizer mask was observed on the resident's bedside table. On 4/2/2024 at 9:38 AM an observation was made of resident #202's room. A nebulizer mask was observed on the resident's bedside table with tubing connected to the nebulizer machine. On 4/2/2024 at 12:44 PM an interview was conducted with resident #202 who is alert and oriented regarding the nebulizer mask. The resident indicated when his nebulizer treatment is complete, he places the mask on the bedside table. The resident indicated he has not seen the staff place the nebulizer mask in a bag. The resident indicated the nebulizer mask always stays out on his bedside table. On 4/3/2024 at 11:35 AM an interview was conducted with Infection Preventionist regarding the storage of nebulizer masks when not in use. The Infection Preventionist indicated the nebulizer mask should be placed in a plastic bag after each use and stored in the plastic bag until the next use. 50082 Resident #252 On 04/01/24 at 03:04 PM an observation of Resident #252 room was conducted. The nebulizer machine and mask are observed sitting on the nightstand, mask is not inside a plastic bag. On 04/02/24 at 10:01 AM The nebulizer machine and mask are seen sitting on nightstand in the room of resident #252, they are not covered with plastic bag. On 04/02/24 at 02:35 PM an observation of the room of resident #252 was conducted. The nebulizer machine and mask are seen on the nightstand, not in plastic bag. On 04/03/24 at 09:04 AM Resident #252 is observed lying in bed, nebulizer machine and mask are seen on the nightstand, not in plastic bag. (Photographic evidence obtained). On 04/03/24 at approximately 11:01 AM an interview conducted with Staff (G), a Registered nurse (RN), indicated that the nebulizer mask should be covered in a plastic bag when not in use. The RN acknowledged that this nebulizer mask has not been in a plastic bag. On 04/03/2024 at approximately 2:49 PM an interview was conducted with the Director of Nursing (DON) and regional nursing director. The surveyor asked, what is the policy for storage of respiratory equipment such as nebulizer masks while not in use? The DON indicated, this equipment should be stored in a bag while not in use.

Based on staff interviews, record review, policy review, and review of the facility corrective action plan, the facility failed to initiate basic life support including Cardio-Pulmonary Resuscitation (CPR) for 1 of 3 residents sampled for Advanced Directives (#1). The facility failed to commence CPR after finding resident #1 in bed without respirations and heartbeat. The facility failure to initiate CPR led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Director of Nursing (DON) and the Nursing Home Administrator were informed of the Immediate Jeopardy on [DATE] at 2:45 PM. The Immediate Jeopardy began on [DATE] at approximately 5:30 AM and was corrected on [DATE] after verification of compliance achievement. The findings include: A review of the facility investigation dated [DATE] found that Licensed Practical Nurse D (LPN D) failed to honor Resident #1's Advanced Directives. On the early morning of [DATE] at approximately at 5:30 AM, Certified Nursing Assistant A (CNA A) entered the room of Resident #1 to get her up for breakfast and found the resident unable to arouse. CNA A immediately informed the nurse, LPN D, who entered the room and found Resident #1 to be without heartbeat or respirations. LPN D then asked a second nurse, LPN C, to verify her findings. LPN D made three attempts to notify the family of the change in condition and post-mortem care was provided. LPN D did not initiate basic life support to include cardiopulmonary resuscitation (CPR) nor did she contact Emergency Medical Services (EMS), the physician, the administrator, or the Director of Nursing (DON). A review of the medical record for Resident #1 found that Resident #1 was admitted in early 2021 and expired at facility on [DATE]. Resident #1 had diagnoses which included cerebral infarction (stroke), type 2 diabetes mellitus (condition involving the way the body regulates and utilizes sugar and insulin), dementia with severe agitation, major depressive disorder, generalized anxiety, dependence of supplemental oxygen and hypertension (high blood pressure). A review of the Advanced Care Planning Discussion/Review form for Resident #1 dated [DATE] found the Resident Physician Ordered Code Status to be Full Code (basic life support including CPR should be initiated in case of death). On [DATE] at approximately 2:22 PM, an interview was conducted with Registered Nurse B (RN B), who stated she arrived at facility at approximately 7:10 AM on [DATE]. Upon arrival, the person at the front desk (CNA F) made her aware that Resident #1 had died . RN B found LPN D and inquired about Resident #1. LPN D informed her that Resident #1 had died . RN B stated she asked LPN D if she performed CPR, and LPN D replied, no. RN B stated that LPN D denied calling EMS, the DON or the Administrator. RN B stated when she asked LPN D if she was aware that Resident #1 was a full code, LPN D replied, I did not check. RN B stated that upon assessment she found Resident #1 pale, cold, stiff, mouth open, and eyes closed. RN B stated she called 911 per facility protocol for an unresponsive resident with a full cardiovascular code status. On [DATE] at approximately 2:44 PM, an interview was conducted with CNA A who stated she was rounding (going room to room) with CNA E, and they entered Resident #1's room together and found Resident #1 laying on her back holding her doll that her husband had brought her. Her face looked a little greyish and she was unresponsive, cold, and not breathing. CNA A reported that she instructed CNA E to go get the nurse while she (CNA A) remained at bedside. CNA E immediately returned to the room with LPN D who checked for pulses and stated the resident had no pulses and that the resident was dead. CNA A further stated 911 was not called and there were no cardiovascular compressions provided to Resident #1. CNA A stated she and CNA E cleaned Resident #1 to get her ready for her husband. She looked like she was at peace. On [DATE] at approximately 10:51 AM, an interview was conducted with LPN D who stated that she is sad and she feels for the family. She stated that she wanted to apologize and was not aware Resident #1 was a full code. LPN D stated that CNA E came to get her around 5:25 AM to 5:30 AM, and informed her Resident #1 was unresponsive. LPN D stated she checked her pulses and listened with the stethoscope, and she was gone. LPN D stated she had last seen Resident #1 at about 4:13 AM when she checked the resident's oxygen saturation. On [DATE] at approximately 3:03 PM, an interview was conducted with LPN C who stated that she was at the nurse's station getting ready to pass morning medications when CNA A stepped out of Resident #1's room and stated that Resident #1 was gone. LPN C stated that LPN D borrowed her stethoscope, checked the resident and then returned to the nurses' station and asked her to also check Resident #1. LPN C stated she checked Resident #1 and found no heartbeat. Resident #1 was still warm, but her fingers were a little blue. She looked peaceful. During a clarification interview on [DATE] at approximately 11:31 AM, LPN C stated she checked Resident #1 around 5:45 AM. LPN C stated she checked the resident's wrists and neck and found no pulses, then put a stethoscope on her chest, but could not hear respirations or a heartbeat. On [DATE] at approximately 11:00 AM, an interview was conducted with the DON, Risk Manager and Administrator about the incident, facility response and facility policies. The DON stated LPN D indicated that she assumed the resident had a DNR (do not resuscitate) order because she recalled previously seeing a goldenrod paper in her chart. Upon investigation, there were no goldenrod colored papers in the resident's record, but the chart did contain a dark gold colored section divider. These have since been removed. The resident's husband visits daily, and had not reported any condition changes the evening before. Staff had seen Resident #1 around 4:30 AM with no changes in condition. At approximatley 5:30 AM, 2 CNAs tried to arouse her and immediately called out for the nurse because she wasn't responding. The Administrator and DON immediately drove to the facility. The staff reported that the first thing they did was to obtain witness statements and initiate a PIP (performance improvement plan). They suspended both nurses and LPN D will be terminated and reported to the Florida licensure board. Abuse Registry and law enforcement (LE) were both notified and LE came on site. The team reported that after they started looking at every resident's code status to ensure it was correct and a corresponding goldenrod DNR paper was included in the file as indicated. They reported auditing all nurses' training records for CPR status and found that everyone was certified. The team then started conducting Mock Cold Blue drills every shift beginning on [DATE] with plans to continue until 100% staff are all retrained. The team reported that the facility does not allow CNAs to perform CPR, but there is always a nurse nearby who can start immediately. The staff that night included 2 nurses and 4 CNAs. The team reported that LPN D was devastated about what happened. The facility policy is to start CPR until the resident's status is verified. All staff have all been educated to go and grab that CPR/DNR book immediately and we are drilling in on the importance of verifying and double checking the residents code status. The Social Services Director is responsible for updating the code status of each resident, and coordinating the DNRs with the physicians. Review of facility policy Nursing-Emergency Care (CPR), undated, was conducted. The policy instructed: In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's advance directives. The policy further stated: In the absence of a Do-Not-Resuscitate (DNR) order or for those residents who do not have a valid DNR order, CPR must begin. Review of facility's Licensed Practical Nurse (LPN) position description was conducted. The LPN's essential functions included to initiate emergency support measures (i.e. CPR). The facility provided a corrective action plan to the survey team upon entrance on [DATE]. The facility's corrective measures included the following: -A review of the facility's investigation and interview with the Administrator and DON found that the Administrator, DON, and Risk Manager (RM) began investigation immediately on [DATE] at approximately 7:20 AM upon notification of LPN D's failure to honor Resident #1 advanced directive (full code status) and resident death. The investigation began with interviews with staff on duty at the time of the event and review of the residents' medical record. The nurse assigned to the resident was LPN D had been an employee since [DATE]. LPN C, who was called to the room about ,d+[DATE] minutes after the event, was hired [DATE]. The Administrator and DON verified that both LPN D and LPN C completed annual training including education and training on residents' rights related to honoring advanced directives, emergency care (CPR) and verified CPR certification is active and up to date. LPN D was terminated from employment on [DATE]. Appropriate referrals were made to the department of health, abuse hotline, EMS, and police. A QAPI sub-committee consisting of the DON, Administrator, RM and Medical Director discussed the investigation and audit findings on [DATE] and made plans for further steps, such as the initiation of Mock Codes (training drills for emergency response). The investigation findings were again discussed during a full Ad-hoc QAPI team meeting on [DATE]. The survey team verified this via review of the investigation, audit findings, QAPI minutes and interviews with the Administrator, DON and RM. -Upon completion of a root cause analysis, it was identified that the process required to effectively train and communicate the facility's Emergency Care/CPR and Abuse/Neglect/Exploitation policies were in place. The root cause analysis identified one Licensed Practical Nurse (LPN D) failed to validate the code status of her resident leading to CPR not being implemented. LPN D who failed to initiate CPR on the resident was verified to have a current and active license to practice and current CPR certification. This nurse had been educated and trained in the facility's emergency care/CPR policy and chose not to comply. This nurse stated she thought this resident was a DNR and failed to verify code status, so she did not initiate CPR. The survey team verified this via review of the investigation and policies and staff interview. -The DON and Risk Manager initiated re-education on [DATE] at 4:30 PM with licensed nursing staff including LPN D & LPN C (just before suspension) on honoring advanced directives, location of advanced directives, and facility process for ensuring CPR is provided to residents with full code status. All nurses not out of town, 15 of 20 nurses on staff, completed this education by [DATE]. All nurses will be required to complete the training prior to their first shift. The survey team verified this via training record review and interviewing 7 nursing staff representing all 3 shifts. -Mock code-blue drills (CPR response) were initiated [DATE] at 6:00 PM and were every shift. There were 7 Mock Code Drills completed prior to the survey team's entrance which included 13 of 20 nurses on staff (out of town nurses, plus the 2 suspended nurses, LPN C and D had not partipated in a mock code). All nurses will be required to participate in a mock code their first shift back. An after-action evaluation was completed following each mock code drill. The facility has plans to continue mock code drills until quality goals are met. The survey team verified this via training record review, DON interview, QAPI review and interviewing 7 nursing staff representing all 3 shifts. -Audits were conducted immediately on [DATE] by the DON for all residents under the care of LPN D to ensure no identifiable changes in conditions were present. No concerns were identified. The survey team verified this via audit review and DON interview. -An audit was completed immediately on [DATE] by the DON and Administrator to ensure all current residents advanced directives were documented and code status was is in place and current. All 56 residents had current code status verified in place and accurate for both the paper and electronic medical records. The survey team verified this via clinical record review, audit review and interview with the DON and Administrator. -An audit was completed by Human Resources (HR) of all licensed nursing staff to ensure CPR certification was in place and current. 100% of licensed nursing staff had current CPR certification in place. HR also verified current nursing licensure and background screening requirements with 100% compliance. The survey team verified this via personnel record review, and interview with the DON, Administrator and HR Director. -Nurse competencies, which include emergency response and CPR were audited to ensure current. All nurses employed as of [DATE] were current with their skills competencies. The survey team verified this via personnel record review, audit review and interview with the DON. -Performance improvement plan (PIP) including immediate plan of action reviewed and approved during AD HOC QAPI meeting held [DATE] at approximately 2:00 PM with the Interdisciplinary Team and the Medical Director. Attendees included the Administrator, DON, Minimum Data Set Coordinator, Medical Director, Risk Manager, Restorative Nurse, Social Services director, Housekeeping and Maintenance Directors, Admissions Director, Medical Records Coordinator, Nursing Supervisor, Therapy Director, Dietary Supervisor, Business Office Manager and Staffing Coordinator. The survey team verified this review of QAPI plan and minutes and interview with the DON, RM and Administrator. -The morning of [DATE] at about 9:00AM, the Administrator, DON and department heads again reviewed the current PIP, mock code drills, education, and implementation of the new Code Status binder for all residents. The team discussed the after action reports from the mock code drills conducted the day before. The survey team verified this via interview with 7 nursing staff, interview with the DON and administrator and review of the QAPI plan and minutes. -A review of the PIP found a new process to identify residents who are a full code status. Previously, residents who elected DNR [do not resuscitate] status had a goldenrod colored form in the front of their paper charts. The new process was to include a bright pink sheet in the front of the resident paper charts to identify resident's with full code status. Additionally, the facility augmented the current system by including a separate Code Status binder at the (only) nurses' station for quick and easy reference. All staff who were not out of town had educated on this new process by [DATE]. All remaining staff will receive education prior to their next shift. The Social Services Director, Administrator, Nurse Supervisor on duty or designee will be responsible to update the resident chart and Code book as changes are received. The survey team verified this via interview with about 7 nursing staff, interview with the DON and review of the binders. -Facility Crash carts were audited to ensure all necessary items/supplies were present and in date. The survey team verified this via interview with the DON and observation of the crash carts. -A CPR audit tool was developed to monitor resident's code status to ensure residents advanced directives are in place. The audit tool will be incorporated into QAPI, and all new and readmissions will be audited daily to ensure ongoing compliance. The facility processes included reviewing new admits/readmits for changes in code status during morning clinical meetings, and this was done on [DATE] & [DATE]. The survey team verified this via interview with the DON and review af QAPI minutes and audits.

Based on observation, record review, staff interviews, and policy review the facility failed to maintain proper infection control practices for 1 of 1 residents sampled for pressure ulcers (resident #1). The findings include: On 3/8/23 at approximately 11:49 AM, an observation was made of Nurse B, Registered Nurse (RN), providing wound care for resident #1. Nurse B was observed to perform hand hygiene and don two pairs of clean gloves, one pair over then other, after which she proceeded to clean resident #1's sacral wound. Nurse B removed the outer pair of gloves and applied Santyl (a chemical debriding medication) to the wound bed, removed the second pair of gloves and performed hand hygiene. Nurse B then applied clean gloves and applied calcium alginate and covered the wound with a foam boarder dressing, disposed of the soiled items in a red bag, closed the bag, removed gloves and performed hand hygiene. At approximately 12:00 PM, a interview was conducted with Nurse B, RN, who confirmed that she did not remove both sets of soiled gloves, perform hand hygiene, and then apply clean gloves in between cleaning the wound and applying the Santyl ointment. Nurse B went on to confirm that this could be considered an infection control issue. At approximately 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that it was her expectation that the Nurse would follow the policy and procedures for best practice with infection control during wound care. The DON further stated she would expect the nurse to remove soiled gloves perform hand hygiene and apply clean gloves after cleaning the wound and before applying the clean dressing. Review of the policy titled Dressings, Dry/Clean last revised 3/2023 revealed under Purpose The purpose of the procedure is to provide guidelines for the application of dry, clean dressings. Under Steps in the Procedure step 15 states cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). Step 16 Use dry gauze to pat the wound dry. Step 17, remove gloves perform hand hygiene and apply new gloves. Step 18, apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initials to top of dressing.

Based on interview and review of physician orders and medication administration records the facility failed to ensure prescribed [CONDITION(S)] medications were limited to 14 days for 1 of 6 residents (#15) sampled for medication review. The findings include: A review of physician's orders for Resident #15 revealed an order for [MEDICATION(S)] (a medication that treats anxiety) 0.25 milligrams by mouth every six hours as needed. There was no end date for the medication. A review of the medication administration record revealed that Resident #15 received the as needed [MEDICATION(S)] medication on the following dates: 10/2/2021 at 4:45pm 10/5/2021 at 4:35pm 10/7/2021 at 11:53am 10/11/2021 at 4:22pm 10/12/2021 at 4:34pm 10/16/2021 at 4:29pm 10/17/2021 at 4:33pm 10/19/2021 at 4:05pm 10/21/2021 at 4:12pm 10/27/2021 at 4:32pm There were none documented in November. On 11/03/21 at 12:24 PM, an interview was conducted with the Director of Nursing. At that time she was shown the order for [MEDICATION(S)] and stated that it should have been ordered for 14 days. She said that she would be fixing it after the interview was over. She further stated that she would get with the providers that practice in the facility to reaffirm the timeframes for [CONDITION(S)] medications.

Based on observation, interview and review of facility's policy, the facility failed to ensure that medications were stored in a secured area for 1 of 2 random observations during initial tour. The findings include: On 11/01/2021 at approximately 11:14 AM, an observation conducted during initial tour inside the room of resident #208. The observation revealed a blue-colored pill inside a medication cup that was left unattended. Resident #208 was in the physical therapy room and away from their room at the time of the observation. On 11/01/2021 at approximately 11:28 AM, an interview was conducted with Staff A, registered nurse (RN), revealing the medication was left inside resident 208's room after the resident was having difficulties swallowing the medication. Review of facility's policy Policy and Procedure Manual dated February 2014, page 50, read Bedside drugs and biologicals must be store in a secure area within the resident's room [ .] resident drug and biological storage areas are not readily accessible by other residents or visitors to the facility [ .] resident drugs and biologicals of each resident are kept and stored in their originally received containers.

Based on resident and staff interviews and clinical record review, the facility failed to allow 1 of 1 resident (#102), sampled for choices, to get out of bed when she desired. The findings are: On 4/2/19 at 1:35 pm an interview was conducted with Resident #102. She was asked if she could make choices about her daily routine such as getting up out of bed and going to bed when she desired. She said, No, I have no choice, they get me up about 6:30 am. She was then asked if she ever told staff that she was not ready to get up at 6:30am and she said they were pretty persistent that she get up. A follow-up interview was conducted with Resident #102 on 04/04/19 at 8:08 AM, at which time the resident was observed up in her wheelchair in her room finishing breakfast. She said she had been up since about 7:30 am, stating, They are not happy unless they are getting me up. Review of the most recent minimum data set (MDS) assessment for Resident #102, dated 3/25/19, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident #102's registered nurse (RN), Employee F, was interviewed on 4/4/19 at 8:32AM. She was asked the time Resident #102 normally got out of bed and stated the resident was up in her wheelchair when she arrived to work at 7:00 am. The certified nursing assistant (CNA), Employee B, was interviewed on 4/4/19 at 8:40 am and was asked when Resident #102 was normally gotten out of bed in the mornings. Employee B said she usually gets her up out of bed 7 - 7:30 am. She then said, she says she is not ready to get up but she needs to go to therapy early at times so I have to get her up. An interview was conducted with the certified occupational therapy aide (COTA) Employee C on 4/4/19 at 8:43 am. He was asked if Resident #102 ever says she is not ready to get up when he goes in. He said that she does say she is not ready to get up. I just tell her I would like to get her up and dressed for breakfast. I like them sitting up and dressed by breakfast. The Rehabilitation Director was interviewed on 4/4/19 at 8:47 am. She was asked how they ensured resident's made choices about the times they get up. She said the staff talk to them about their normal routines such as the time they normally get up. We will ask them if they are ready for therapy when we go in to see them. She then said nursing usually has them up and ready for breakfast by 7:30 am anyway so it is usually not an issue.

Based on staff interview and record review, the facility failed to have physician documentation prior to initiating an immediate transfer and discharge for 1 of 4 residents reviewed for transfer/discharge (#53). Findings include: On 4/3/2019 a record review was conducted for resident #53 which revealed the resident was admitted to the facility on [DATE] at approximately 2:30 PM and discharged the same day 5 hours later at 7:30 PM. Further review of the record found that after the residents spouse had completed the admission paperwork the resident became combative with staff and refused care. Review of the nursing home to hospital transfer form dated 2/3/2019 found the reason for the resident transfer was Altered Mental Status (AMS). A record review was conducted of the 'Nursing Home Transfer and Discharge Notice' issued on 2/3/2019 to Resident #53. The effective date of discharge was 2/03/2019. The discharge location was the hospital where the resident was admitted from earlier that same day. The reasons for discharge were listed as, Your needs cannot be met in this facility and The safety of other individuals in this facility is endangered. Under the section for 'Brief explanation to support this action', the facility documented, Resident struck staff member with food tray and kicked staff members while attempting to provide medications and care needs. Review of the medical record failed to find physician documentation regarding the reason for the discharge. Review of nursing notes from resident admission at 2:32pm on 2/3/2019 until transfer back to the hospital the same day at about 7:30pm revealed the resident to be agitated and combative. Resident #53 was noted to have had an incontinent episode upon arrival. There is documentation of refusal of incontinent care at least 10 different times during the resident's 5-6 hours at the nursing home. Documentation included refusal of care and both verbally and physically aggressive behaviors including throwing objects at staff, hitting, kicking and using profane language. Additionally, these same behaviors of care refusal and aggression were documented in nursing notes on 2/3/2019 during attempts to check blood sugar and provide medications. Some of the documentation included: 6:00pm: Patient is extremely combative, slapping at nurse, refusing care, will not let us change his brief. Had to have wife assist in order to check blood sugar and administer insulin. Patient slapped dinner off his tray and onto the floor. Patient verbally inappropriate toward staff. At one point his wife tried to intervene, but patient continued his verbal abuse. 7:00pm: Continues to refuse care and is verbally abusive. Care attempted. 7:30pm: Care attempted. Resident refused and began swinging at nurse. Physician, wife and DON (Director of Nursing) notified and ambulance contacted to transfer back to hospital. On 4/04/2019 at approximately 2:31 PM an interview was conducted with the facility Administrator in which she stated that shortly after Resident #53 was admitted he became combative with staff and was refusing care. The physician was notified and they obtained an order to send the resident to the emergency room (ER) for evaluation. On 4/04/2019 at approximately 3:11 PM an interview was conducted with the Administrator, Risk Manager (RM), Admission/Marketing Director as well as the Director of Nursing (DON) during which the Admission/ Marketing Director. The staff reported that Resident #53 wanted no one touching him or doing anything with him. The wife stated that these behaviors were not normal for him. The staff reported that it took Emergency Medical Services (EMS) 40 minutes and extra EMS personnel to get the resident into the ambulance for transport due to his behaviors.

Based on resident and staff interviews and record reviews, the facility failed to implement the plan of care for 1 of 3 residents sampled for activities of daily living (ADL) review (#11). The findings include: An interview with resident #11 was conducted on 4/2/2019 at approximately 12:58 PM. Resident #11 expressed a concern that she had physician orders [REDACTED]. Resident #11 stated that last week she started to receive walking assistance from staff again. Review of resident #11's clinical record was conducted on 4/4/2019. According to resident #11's Care Plan dated 1/8/2019, resident #11 was identified to have a self-care deficit and a potential for falls and fall related injury due to age related weakness and other comorbidities. Care Plan interventions included, but were not limited to, ambulate daily and provide Restorative Nursing Program (RNP) services 5 days a week for exercise and strength to help maintain the highest functional level. A review of resident #11's (MONTH) (YEAR) - (MONTH) 28, 2019 Treatment Administration Records (TAR) revealed blank entries beside the physician's orders [REDACTED].#11 had been on the current case load or receiving RNP services. There was documentation on the TAR beginning (MONTH) 28, 2019 that ambulation assistance in the hallway had resumed. On 4/4/2019 at approximately 9:41 AM, staff E (1 of 2 staff who provides RNP services in the facility) was asked to help locate documentation that the resident was receiving the care planned ambulatory and RNP services. However, staff E returned at approximately 10:28 AM to report that she was unable to produce documentation from restorative or locate any documentation from the nursing staff that showed ambulatory services had been provided to the resident on the unit. In an interview with staff E at 10:29 AM, staff E was asked if staff were expected to document the completion of care planned services and she replied, yes, and again confirmed that she could not provide that documentation. Review of Section G of the quarterly Minimum Data Set (MDS) Assessment (10/16/2018) and annual MDS (1/8/2019) assessment showed no decline in ADL function.

Based on observations of resident rooms the facility failed to have privacy curtains that completely surround the bed and provide full visual privacy for 4 of 18 sampled rooms (rooms 11 A, 17 A, 19 A, and 21 A) The findings are: Observations of rooms #11, #17, and #19 were found not to have privacy curtains that completely surround the bed on 4/3/19 from 09:30 to 09:36. The curtains were about 12-18 inches short of providing full visual privacy. (Photographic evidence obtained for rooms #11, 17, and 19) An interview was conducted with the Employee A Housekeeping Supervisor on 4/5/19 at 08:34 am. She was shown resident room [ROOM NUMBER] bed A's privacy curtain. She stated, no that does not go all the way around the bed. We then went to room [ROOM NUMBER] A and pulled the curtains. Once pulled Employee A stated, Yes, I see that is a short one. We then went to room [ROOM NUMBER] A and found it was too short. We then went to room [ROOM NUMBER] A. The curtain again does not go all the way around the bed. Employee A said we will have to buy new curtains I will make sure of that.

Based on record review and staff interview, the facility failed to implement the written plan of care for 1 of 5 residents sampled for unnecessary medications (#29). The findings were: Review of the plan of care for resident #29 revealed the following intervention: Labs as ordered. Report and review with MD. A review of pharmacy recommendations for resident #29 revealed a recommendation on 2/26/2017 that stated: On [MEDICATION NAME] with no labs. Consider periodic lipid profile while on this medication. The physician's response to the recommendation was for the resident to have a lipid panel conducted every 12 months. A review of laboratory data revealed that the physician ordered lipid panel for resident #29 was last completed in (MONTH) (YEAR), with no other results after that date found on the resident's chart. On 4/18/18 at 9:49am an interview was conducted with Staff Nurse A. When asked if the lab result could have been somewhere else she stated that it would be in the lab section of the chart. She looked in the chart and was unable to locate it, so she called the lab. The lab reported they did not have a record of a lipid profile being conducted for resident #29 since 3/2017.

Based on record review and staff interview, the facility failed to ensure each resident's medication regimen was free of unnecessary medicaitons by failing to perform ordered laboratory testing for monitoring of an antipsychotic medication for 1 of 5 residents sampled for unnecessary medicaitons (#29). The findings were: Review of the plan of care for resident #29 revealed the following intervention: Labs as ordered. Report and review with MD. A review of pharmacy recommendations for resident #29 revealed a recommendation on 2/26/2017 that stated: On [MEDICATION NAME] with no labs. Consider periodic lipid profile while on this medication. The physician's response to the recommendation was for the resident to have a lipid panel conducted every 12 months. A review of laboratory data revealed that the physician ordered lipid panel for resident #29 was last completed in (MONTH) (YEAR), with no other results after that date found on the resident's chart. On 4/18/18 at 9:49am an interview was conducted with Staff Nurse A. When asked if the lab result could have been somewhere else she stated that it would be in the lab section of the chart. She looked in the chart and was unable to locate it, so she called the lab. The lab reported they did not have a record of a lipid profile being conducted for resident #29 since 3/2017.

Based on record review, staff interview, and review of the facility nursing policy, the facility failed to provide an adequate indication for continued use of a [MEDICAL CONDITION] medication ([MEDICATION NAME]) on an as needed (PRN) basis for 1 of 5 residents reviewed for [MEDICAL CONDITION] medication use (resident #39). The findings are: A clinical record review was conducted for resident #39 related to the use of [MEDICAL CONDITION] medications, specifically, the medication [MEDICATION NAME] (an anti-anxiety medication). Current physician orders [REDACTED]. 2/4/18 [MEDICATION NAME] (the generic name for [MEDICATION NAME]) 0.5 mg tab. One tab PO (by mouth) four times a day for anxiety 2/4/18 [MEDICATION NAME] 0.5 mg tab. One tablet PO every two hours as needed for break-through anxiety The consultant pharmacist communication to the resident's physician, dated 2/14/18, stated, the resident receives the psychoactive medication [MEDICATION NAME] 0.5 mg Q (every) 2 hrs (hours) PRN. CMS guidelines seek to decrease the use of these medications on a PRN-as needed basis and requires re-evaluation of these orders after 14 days of therapy. The physician checked the block to indicate the medication improves the quality of this resident's life. The resident is responding to therapy and is experiencing no adverse effects from this therapy. A review of Medication Administration Record [REDACTED]. On 04/17/18 at approximately 1:51 PM an interview was conducted with unit nurse D. The nurse confirmed that there had only been one dose of the PRN [MEDICATION NAME] medication, given on 2/19/18, with no other doses of the PRN medication administered. She stated that the psychiatric physician had recommended that this PRN dose of [MEDICATION NAME] be discontinued, but was overruled by the residents primary physician. On 04/18/18 at approximately 3:30 PM and interview was conducted with the Director of Nursing (DON). The DON confirmed during the interview that the PRN order of [MEDICATION NAME] 0.5 mg did not have an end date or any other parameters and the order was more than 14 days old without a re-evaluation of the order.

Based on observation, staff interview and policy review, the facility failed to have all items within facility refrigerators and freezers labeled and dated for 1 of 1 kitchen freezer and 1 of 1 unit refrigerator. The findings are: An initial tour of the kitchen was conducted on 4/18/18 at 10:10 am. The freezer was entered and a container of unlabeled breads was observed on a shelf in the freezer to the right of the door. The diet tech stated, All the food opened in the freezer should be labeled and dated. It will be disposed of in three days. The nourishment refrigerator on the unit was observed on 4/18/18 at 10:30 am with the diet tech. There was a frozen bottle of yellowish liquid in a water bottle without a date or name. The refrigerator also had a container of rice and gravy without a date or name. The diet tech stated, Only resident food that is labeled and dated should be in the refrigerator. She disposed of both items. A policy was brought in by the Administrator on 4/18/18. A review of the policy revealed the following. Policy: Cleaning and Sanitation of Refrigerators and Freezers on Unit. Policy Number: 04.035. Policy: the facility recognizes the importance of ensuring that all foods are held at a safe temperature in order to ensure the safety of its residents. All refrigerators on the units will be monitored for correct temperatures and cleaned weekly. Only resident food will be stored in the pantry refrigerators. All food will be labeled, dated, and covered. Refrigerators will be checked each day for any food or supplement over 48 hours old and any outdated food will be discarded.

Based on observation, interview, and record review, the facility failed to provide an environment in good repair for 5 of 18 resident rooms observed (Rooms #7,8,10,11,18) and one of 2 halls (north hall). The Findings Include: An observation was made of the bathroom in room # 7 on 5/2/17 at approximately 9:20 AM. The paint was observed to be cracked and peeling on the bathroom wall. An observation was made of room #8 on 5/2/17 at approximately 10:26 AM. Nine (9) separate holes were observed in the walls. Four (4) holes on the external closet wall, and 5 holes on the wall above the headboard of A bed. Holes appeared to be evidence of previously mounted items, which had not been filled since removal of the mounted items. An observation was made of room #10 and showed gashed bathroom door on 05/04/2017 at approximately 9:00 am. An observation was made of room #11 on 05/01/2017 at approximately 1:00 pm, and showed 12 unused wall anchors in the walls and spider web type cracked paint on the wall to the right of the window. An observation was made of room #18 on 05/04/2017 at approximately 9:00am and showed torn baseboard and drywall at the base of the closet. An observation was made of the north hall on 05/03/2017, and revealed base boards peeling off the wall. An interview was conducted with the maintenance director on 05/03/2017, in which he stated that he had no documentation of a preventative maintenance program and repairs items as he is told about them.

Based on interviews and record review, the facility failed to coordinate care and services with Hospice for 1 of 1 residents sampled for Hospice services. (Resident #42) Findings inlcude A chart review was conducted on 5/3/2017 for resident #42 which found that the resident was admitted to hospice services on 4/13/17 with the hospice plan of care stating that hospice would provide assistance with Activities with Daily Living (ADLs) 3 times weekly. The hospice chart also revealed documentation supporting that the hospice aide (HA) was to visit on Mondays, Wednesdays, and Fridays. Further review of the resident ' s chart found that the facility treatment record (TR) provided documentation that the resident was to receive bathing assistance on Tuesday, Thursday and Saturday by the facility, per the facility ' s routine bathing schedule. An interview was conducted with staff nurse A on 5/3/17 at 9:27 AM. She stated that hospice provides assistance with bathing resident #42 on Tuesdays, Thursdays and Saturdays as evidenced by the TR in the resident ' s chart, in which the facility Certified Nursing Assistants (CNAs) write the word hospice in the blocks under the corresponding visit date. Review of the TR found that the word hospice was written under dates that corresponded with bathing on Tuesdays, Thursdays, and Saturdays. An interview with the Hospice aide was conducted on 5/3/17 at 1:29 PM. She stated she visits resident #42 three times weekly on Mondays, Wednesdays and Fridays to bathe the resident. She stated the facility staff provides bathing on the alternate days. An interview was conducted on 05/03/2017 at 1:51 PM with the Administrator who stated that when a resident is admitted to hospice services, the hospice company assumes responsibilities for providing assistance with Activities of Daily Living (ADL) to include bathing the resident and that the facility only provides care if such care is needed on the days that hospice is not in the facility. A follow-up interview was conducted with the Director of Nursing on 05/03/2017 at 2:50 PM. She stated that the facility was documenting that hospice was bathing resident #42 on Tuesday, Thursday and Saturday when they should have been documenting that a bath was offered to resident #42 by the facility staff on those days, in keeping with the facility's bathing schedule for those rooms with hospice providing baths on the alternate days of Monday, Wednesday, and Friday. Review of the Skilled Nursing Facility Services Agreement dated March 7, 2014 and signed by both the facility and the hospice provider revealed that facility room and board services were defined and stated that the facility was required to continue to provide assistance with activities of daily to include bathing.