Every finding on record at Sarasota Memorial Nursing & Rehabilitation Center

Based on observations, review of clinical records, review of policy and procedure, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Resident #18, #26 and #53) of 3 residents reviewed for activities of daily living (ADL's). The findings included: Review of the facility policy Bath/Shower effective 1/24/21 (revised 1/6/25) revealed, Patients will be showered twice weekly on the shift they request. If patients decline a shower, they will be offered one at another time as per their request. Patients may always have additional showers per request. 1. Review of the clinical record for Resident #18 revealed an Annual Minimum Data Set (MDS) assessment with an assessment reference date of 1/21/25. The MDS noted Resident #18's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14. Resident #18 required substantial to maximum assistance with bathing, dressing and toileting, and partial assistance with personal hygiene. On 3/10/25 at 10:49 a.m., in an interview Resident #18 said she was not getting her showers in the morning. She said, They give them to me at night before bed and I want morning showers. I spoke to the Unit Manager last week and she said she would fix it for me but here it is my shower day and there is no shower yet. Review of the Certified Nursing Assistant (CNA) shower schedule revealed Resident #18's showers were scheduled on Tuesdays, Thursdays, and Saturdays, on the 7:00 p.m., to 7:00 a.m., shift. Review of the CNA shower documentation for February 2025, and March 2025 failed to reveal Resident #18 received her scheduled showers on 2/6/25 (Tuesday), 2/11/25 (Tuesday), 2/13/25 (Thursday), 2/15/25 (Saturday), 2/20/25 (Thursday), 2/25/25 (Tuesday), 3/4/25 (Tuesday), 3/6/25 (Thursday), 3/8/24 (Saturday) and 3/11/25 (Tuesday). 2. Review of the clinical record for Resident #26 revealed an admitted [DATE]. Diagnoses included Peripheral Vascular Disease, Osteoarthritis, artificial knee and joint pain. Review of the Quarterly MDS with an assessment reference date of 2/11/25 revealed Resident #26 required substantial to maximal assistance with showers, and partial to moderate assistance with dressing and personal hygiene. Resident #26's cognition was intact with a BIMS score of 15. On 3/10/25 at 11:42 a.m., in an interview Resident #26 said the staff do not always give the showers as scheduled. He said he sometimes does not get his showers. Resident #26's family member was present during the interview and said Resident #26 did not get his scheduled shower on Friday 3/7/25. The resident's family said, He needs to get showers. He wets himself and has a wound on his buttocks. Review of the CNA shower schedule revealed Resident #26's showers were scheduled on the night shift (7:00 p.m., to 7:00 a.m.) on Mondays, Wednesdays and Fridays. Review of the CNA shower documentation for February 2025 and March 2025 failed to reveal Resident #26 received a shower as scheduled on 2/3/25 (Monday), 2/5/25 (Wednesday), 2/7/25 (Friday), 2/10/25 (Monday), 2/12/25 (Wednesday), 2/14/25 (Friday), 2/17/25 (Monday), 2/19/25 (Wednesday), 2/21/25 (Friday), 2/24/25 (Monday), 2/28/25 (Friday), 3/3/25 (Monday), 3/5/25 (Wednesday), 3/7/25 (Friday) and 3/10/25 (Monday). 3. Review of Resident #53's clinical record revealed a Quarterly MDS with an assessment reference date of 12/18/24. The assessment noted Resident #53's cognition was intact with a BIMS of 13. Resident #53 was dependent on staff for personal hygiene and showers. Diagnoses included right hemiplegia (paralysis of right side of the body), and Fibromyalgia (widespread body pain). On 3/11/25 at 11:21 a.m., in a telephone interview, a family member said Resident #53 did not speak English but had all her senses. She said Resident #53 calls her at night to tell her she wet herself because no one answered her call light. She spoke to the Unit Manager who said she would take care of it. She said, It is good for a few days then things will go back the way they were. They do not give her showers. She is to get them on Tuesdays, Thursdays and Saturdays. She needs them because she wets herself. Review of the CNA documentation revealed Resident #53's showers were scheduled on Mondays, Wednesdays, and Fridays on the day shift (7:00 a.m., to 7:00 p.m.). Review of the CNA shower documentation for February 2025 and March 2025 failed to reveal Resident #53 received her scheduled showers on 2/3/25 (Monday), 2/5/25 (Wednesday), 2/7/25 (Friday), 2/10/25 (Monday), 2/12/25 (Wednesday), 2/14/25 (Friday), 2/19 25 (Wednesday), 2/21/25 (Friday), 2/24/25 (Monday), 2/26/25 (Wednesday), 2/28/25 (Friday), 3/3/25 (Monday), and 3/5/25 (Wednesday). There was little to no documentation to show Resident #53 received toileting assistance for each shift in February 2025 and March 2025. On 3/10/25 at 11:43 a.m., in an interview CNA staff I said Resident #53 was total care with her Activities of Daily Living and incontinent at night. On 3/12/25 at 9:26 a.m., in an interview CNA Staff D said each unit has a shower schedule in the CNA assignment book and we follow the shower list. If a resident refuses we can ask them on the next day or the next shift. Each resident receives three showers a week. If the resident is always refusing, I let the nurse know, We document the showers in the computer. On 3/12/25 at 9:30 a.m., in an interview CNA Staff E said there was a shower list in the assignment book at the desk. We document the showers in the electronic record. Sometimes the resident will refuse and say we did not offer the shower; we can't always change the shower day because you get behind. Some residents refuse and then will take a shower the next day, if I can do it I will. Sometimes we forget to put it in the computer but we gave the shower. On 3/12/25 at 9:39 a.m., in an interview, Unit Manager Registered Nurse (RN) Staff C said, The shower assignments are in the CNA assignment book and staff use electronic charting, there is no paper documentation. RN Staff C said she was working on creating a new sheet for the showers. The Unit Manager said sometimes the residents will refuse showers and the staff go back later in the day or the next day to shower the resident. I understand if it wasn't documented what that means. There are times when the staff give them showers at night instead of the day and they have nowhere to document it. I'm working on changing the way we document the showers so if it is given on a different day the aids can chart it. RN Staff C said, Resident #18 did tell me last week that she wanted showers in the morning but I have not changed it yet, I'm working on a new system. She said, Resident #53 is showered and toileted, but she will tell her daughter she did not get care.

Based on observation, review of facility policy and procedure and resident and staff interviews, the facility failed to ensure medications were safely stored at the bedside for 1 (Resident #52) of 8 residents observed during medication administration. The facility failed to ensure medications were secured when unattended and properly labeled in 1 (North Unit Medication Cart B) of 2 medication carts observed. This had the potential for residents and others to have access to medications that could create hazardous health consequences for residents in the facility. The findings included: The facility policy Administration of Medications documented Facility staff should avoid touching the medication with bare hands when opening unit dose package. Only prepare medications for one resident at a time. Ensure that medication carts are always locked when out of sight or unattended. On 3/11/25 at 8:53 a.m., during a medication administration with LPN Staff J, a tube of Voltaren Gel was observed on the bedside table of Resident #52. The resident said she puts the gel on her right knee daily for pain relief. Review of the clinical record revealed there was no physician order for the medication and Resident #52 had not been assessed to see if she was able to self-administer the medication. On 3/12/25 at 8:46 a.m., in an interview Registered Nurse (RN) Unit Manager Staff C said Resident #52 had the Voltaren Gel since her admission on 11/1/24. Staff C said the resident must have bought it at the store because they were not aware she had it. On 3/11/25 at 9:15 a.m., Licensed Practical Nurse (LPN) Staff F was observed at the North Unit medication cart B with three medication cups containing unidentified pills on top of the cart. LPN Staff F grabbed the three medication cups from the cart and placed them into her right hand. LPN Staff F said she was just going to give them to Resident #98 and #350. LPN Staff F confirmed she prepared the medications for both residents and was going to administer them to the residents. On 3/12/25 at 9:26 a.m., North Unit medication cart B was observed unlocked. The medication cart was against the wall with the drawers facing the hallway. There were residents, staff and visitors in the hall passing by the unsecured medication cart. Three medication cups with unidentified pills were observed in the unlocked, top drawer of the medication cart. One cup containing a white liquid was stacked in one of the cup of pills. Approximately three minutes later, RN Staff H came to the unsecured cart. She verified she left the medication cart unlocked and unattended and the unlabeled medication cups in the top drawer. She said she got interrupted by staff and residents. Photographic evidence obtained.

Based on observation, staff and resident interview and record review, the facility failed to ensure an assessment for clinically appropriate self-administration of medications and a care plan was completed for 3 (Residents #301, #303 and #11) of 20 residents reviewed for medications left at the bedside. The findings included: The Self-administration policy provided by facility revised 5/9/22 indicated, Residents have the right to self-administer medications if the interdisciplinary has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation .2-The Nursing Assessment of Self-Medication tool is completed which identifies the resident's ability to read and understand medication labels . 1. Resident #301 was admitted on [DATE] with diagnoses of unspecified glaucoma, hypertension, and major depression. On 12/5/22 at 11:24 a.m., observation revealed a bottle of artificial tears, a bottle of Timolol Maleate 0.5 % ophthalmic solution, and a bottle of Alphagan 0.1% ophthalmic solution stored on Resident #301's nightstand. Resident #301 said she has been self-administering her drops since her admission on 11/29/22. Photographic evidence obtained. The physician's order for Resident #301 included Timolol Maleate 0.5 % eye drops, one drop by ophthalmic (eye) route in left eye two times per day and Alphagan 0.1 % eye drops, one drop by ophthalmic (eye) route in left eye two times per day. On 12/5/22 at 11:35 a.m., a review of the clinical record failed to reveal documentation the interdisciplinary determined it was clinically appropriate and safe for the resident to self-administer the Timolol Maleate, the artificial tears or the Alphagan. On 12/7/22 at 8:10 a.m., review of the Medication Administration Record (MAR) for Resident #301 revealed Registered Nurse (RN) Staff C signed administration of the timolol on 12/3/22 at 8:00 a.m. RN Staff C said Resident #301 told her she had already done it and she signed. She said, I don't necessarily observe her doing so. On 12/7/22 at 9:04 a.m., Licensed Practical Nurse (LPN) Unit Manager Staff I said it was her understanding Resident #301 has been self-administering her eye drops since her admission and the nurses have been signing off the administration of the eye drops on the MAR. Staff I said, we did not have a self-administration tool until 12/5/22. On 12/8/22 at 9:12 a.m., LPN Staff G said Resident #301 mentioned wanting to administer her eye drops and could not remember if she had told the management or followed up. 2. On 12/5/22 at 12:57 p.m., observation revealed a bottle of Nyamyc powder (antifungal) stored on Resident #303's nightstand. Resident #303 said she came with the medication from the hospital and has been using it since admission on a small area on her abdomen. Photographic evidence obtained On 12/5/22 at 1:18 p.m., a review of Resident #303's clinical record revealed an admitted [DATE]. The physician's order did not include the use of Nyamyc powder to the resident's abdomen. On 12/8/22 at 9:58 a.m., Registered Nurse Minimum Data Set Coordinator said Resident #303 did not have a care plan for self -administration of medication or a self-administration assessment. On 12/7/22 at 9:04 a.m., Licensed Practical Nurse (LPN) Unit Manager, Staff I said she was told Resident #303 had an ointment in her possession. She said Resident #303 came with it from the hospital, and she did not know she was using it. On 12/8/22 at 12:01 p.m., the Director of Nursing (DON) said she was aware medications were left at bedside and facility protocols were not followed. 41905 3. Review of Section C of the Minimum Data Set (MDS) for Resident #11 dated 11/1/22 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the Medication Administration Records (MARs) for Resident #11 dated December 2022 revealed a physician's order for antacid, 2 tablets, two times a day with food at 9:00 a.m. and 5:00 p.m. starting 8/2/22. The antacid was signed off each day from 12/1/22 through 12/8/22 at 9:00 a.m., indicating the nurse gave the medication. On 12/06/22 at 11: 00 a.m. and 12:15 p.m., Resident #11 was observed in her room sitting up in a chair, tray table in front of the resident. There were two round tablets in a plastic medication cup on the tray table in front of her. Resident #11 confirmed they were the antacid the nurse gives her at 9:00 a.m. with meals to prevent gas. She said the nurse gives them to her in the cup and she takes them when she wants to. She said if she does not take them, she puts them in her drawer. On 12/08/22 at 9:47 a.m., Unit Manager Staff M said there is no medication self-administration assessment for Resident #11. Staff M said before a resident can self-administer medications on their own at the facility, they must pass an assessment indicating it is a safe thing for the resident to do. The Unit Manager said if the resident passes the assessment, an order is obtained from the physician, and it is documented in the care plan. Staff M said she was not aware staff was allowing Resident #11 to take the antacid on her own. On 12/08/22 at 9:57 a.m., Minimum Data Set (MDS) Registered Nurse (RN) Staff L confirmed there was no assessment, physician's order, or care plan indicating Resident #11 was deemed safe to take her own antacid while at the facility. On 12/8/22 at 10:22 a.m., the Unit Manager said Resident #11 confirmed with her staff was allowing her to self-administer the antacid.

Based on observation, staff and residents' interview, the facility failed to promote the resident's rights to make choices related to dining location for 3 (#44, #6, #11) of 10 residents reviewed for choices. The findings included: 1. On 12/5/22 at 12:51 p.m., during observation of the lunch service, residents were noted to have trays being delivered to their rooms and eating at the bedside table in their rooms. No residents were in the dining room. The same observation was made for the lunch meal of 12/6/22, 12/7/22, and 12/8/22. On 12/5/22 at 12:47 p.m., the Certified Dietary Manager (CDM) said communal dining never resumed since the COVID pandemic. She said residents had been dining in their rooms for the past 2-3 years. She said they had begun discussing going back to using the dining room, but it has not happened. 2. On 12/5/22 at 12:57 p.m., Resident 44 said he didn't know why they ate in their rooms. He said he would prefer to eat in the dining room to be able to talk with people. He said they just redid the dining room, and it was a waste of money to not use it. On 12/7/22 at 9:18 a.m., the Administrator said the residents have not dined in the dining room in at least three years. The Administrator said he was aware pandemic restrictions on communal dining were lifted over a year ago. He said initially the pandemic shut the dining room down and then they did a renovation which the pandemic caused issues with getting supplies. He said the renovation was completed shortly after Hurricane [NAME] which occurred on 9/28/22. He said they had not had servers for the dining room in at least three years and they needed to get the dining room in order with staff, but had no specific date or plans when the dining room would be reopened for dining. 41905 3. On 12/6/22 at 09:32 a.m., Resident #6 said she has been a resident at the facility for several years and always ate her meals in the dining room. She said she is very social and likes talking to people. Resident #6 said dining in her room was terrible, she did not like it. On 12/7/22 at 9:08 a.m., in a telephone interview, Resident #6' Health Care Surrogate said the resident told her she wants to eat in the dining room. She said Resident #6 told her it was disappointing she had to eat Thanksgiving dinner in her room. On 12/07/22 at 12:04 p.m., Resident #6 said she has been telling the staff she wants to dine in the dining room. She said there were other residents who do not like eating in their rooms either. 4. On 12/6/22 at 11:00 a.m., Resident #11 said she misses having her meals in the dining room. She misses the social aspect of dining in the dining room. On 12/6/22 at 2:05 p.m., Certified Nursing Assistant (CNA) Staff N said all residents dine in their rooms and have been doing it since COVID-19 began. She said some residents don't like it, but that's the way it is.

Based on observation, record review and resident and staff interview, the facility failed to ensure proper storage of medications left at the bedside for 2 (Residents #301, and #303) of 20 residents reviewed for medication storage. The facility failed to remove expired medications in 1 ( South Unit Medication Cart A) of 3 medication carts reviewed for proper storage and labeling of medications. The findings included: The facility's Medication Storage and Disposal/Destruction policy revised on 5/23/22 noted medications and biologicals including treatments items are secured in a locked cart which is inaccessible to residents or visitors. Medications with expiration dates will not be kept stored and will be disposed of as per appropriate procedure. Facility should dispose of discontinued medication, outdated medications or medications left in facility after a resident has been discharged in a timely fashion. 1. On 12/5/22 at 11:24 a.m., observation revealed a bottle of artificial tears, a bottle of Timolol Maleate 0.5 % ophthalmic solution, and a bottle of Alphagan 0.1% ophthalmic solution stored on Resident #301's nightstand. Resident #301 said she did not have a locked box to store the bottles of eye drops. Photographic evidence obtained. On 12/7/22 at 11:50 a.m., Certified Nursing Assistant (CNA) Staff B said Resident #301 kept the bottles of eye drops on the table. On 12/8/22 at 9:12 a.m., Licensed Practical Nurse (LPN) Staff G said Resident #301 mentioned wanting to administer her eye drops and could not remember if she had told the management or followed up. 2. On 12/5/22 at 12:57 p.m., observation revealed a bottle of Nyamyc powder (antifungal) stored on Resident #303's nightstand. Resident #303 said she came with the medication from the hospital and has been using it since admission on a small area on her abdomen. Photographic evidence obtained On 12/7/22 at 9:04 a.m., Licensed Practical Nurse (LPN) Unit Manager, Staff I said she was told Resident #303 had an ointment in her possession. She said Resident #303 came with it from the hospital, and she did not know she was using it. 3. On 12/5/22 at 12:02 p.m., observation of South Unit medication cart A with Registered Nurse Staff F revealed one bottle of Nitroglycerin 0.4 milligram (mg) with an expiration date of 11/2022, and two bottles of Nitroglycerin 0.4 mg with an expiration date of 9/11/22. On 12/5/22 at 12:12 p.m., RN Staff F said the expired Nitroglycerin should not be in the cart and should have been sent to pharmacy . On 12/8/22 at 12:01 p.m., the Director of Nursing (DON) said she was aware medications were left at bedside and facility protocols were not followed.

Based on record review, review of facility policy and procedure, resident and staff interview, the facility failed to follow the physician's discharge orders and ensure 1 (Resident #340) of 2 residents received home health services as ordered resulting in rehospitalization . The findings included: The facility policy, Resident Transfer and Discharge (revised 4/21/21) specified, Social Services will collaborate with the resident/ resident representative the Physician and the Interdisciplinary Team (IDT) to assist in planning the discharge care and services for the resident. Review of the clinical record showed Resident #340 was admitted to the facility on [DATE] after a hospitalization for acute [CONDITION(S)] and discharged home on 2/13/21, where he lived independently. The discharge summary created on 2/10/21 and completed on 2/18/21 noted Resident #340 lived alone and was discharged home with Home Health Services. Further review of the clinical record showed Resident #340 was admitted to the hospital on 3/26/21 for hemorrhagic shock and abdominal wound and discharged to the facility on [DATE]. Review of the hospital record revealed a physician's progress note dated 3/26/21 that read . He was discharged from [hospital name] 2 months ago to rehabilitation for 2 weeks, then went home where he lives alone. Sustained a burn to his abdominal wall skin, at the large hernia site 2 weeks ago from hot ball . Started bleeding last night . On my exam, removing the abdominal binder that is soaked with large quantity of red blood, he has a 3 cm [3 centimeters] round necrotic wound with oozing blood . Home medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Past medical history: 1. [CONDITION(S)]/flutter, on anticoagulation with [MEDICATION(S)]. He could not afford the recently prescribed [MEDICATION(S)] when he was discharged from [hospital name] early February 2021, has had difficulty monitoring his [MEDICATION(S)] at home with a nonfunctioning machine. A facility IDT discharge summary completed on 4/24/21 noted Resident #340 was alert, oriented and lived alone. The Discharge Summary included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record showed Resident #340 was admitted to the hospital on 5/2/21 and discharged to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/21 at 10:12 a.m., in an interview Resident #340 said this was his third admission to the facility in 4 months. Resident #340 said he was discharged home and was too weak to care for himself. He said he was bleeding from an abdominal wound and called 911. Resident #340 said he was supposed to receive Home Health services after each discharge but there was no follow through, and he did not receive it. Resident #340 said he lived alone, in a 1-bedroom apartment, on an upper floor, and required continuous oxygen. The resident said he needed the home health services and was not able to care for himself. Resident #340 said he called for emergency transport to the hospital and was admitted to the hospital on 5/2/21. He said the hospital discharged him to the facility because I was too weak and could not do anything. On 5/12/21 at 8:30 a.m., in an interview Resident #340 said he had an abdominal wound when he was discharged home on 4/24/21. He said Home Health never came and he was doing his own wound care even though he was not taught how. On 5/11/21 at 1:30 p.m., in an interview, the Social Service Director (SSD) said Resident #340 was on his 3rd admission to the facility. The SSD said the resident's insurance informs the facility of the resident's last covered day. The SSD said she talked with the resident and set up home health. The SSD said Resident #340 did not want to apply for Medicaid during the last admission for fear of having to get rid of his possessions and lose control of his money to live in an assisted living facility. The SSD said Resident #340 filed and lost an appeal during his last admission and was discharged on [DATE]. The SSD said she faxed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD said the facility did not provide follow up once the resident was discharged to ensure the resident received home health services as ordered. She said she would not be aware of a resident needing community resources or additional health care services. The SSD said the resident's insurance company was responsible to determine if the resident was safe to discharge home. The SSD also confirmed she had no documentation she notified the HHA of Resident #340's discharge orders. On 5/12/21 at 11:30 a.m., in an interview, the Administrator said the facility was aware the HHA did not accept Resident #340's insurance upon discharge on 4/24/21 and did not refer the resident to another HHA that would accept his insurance. The Administrator said, Normally it is the home health agency that will refer the resident to another agency that accepts the insurance of the resident. On 5/12/21 at 1:00 p.m., in an interview, Resident #340 confirmed he never received a home health visit after his discharge on 2/13/21 or 4/24/21. Resident #340 said, They told me I would get help, but I never did get any visit from home health. Resident #340 said the SSD did not tell him the HHA did not accept his insurance. He said he did not receive information regarding community services that would have provided him with assistance after discharge. Resident #340 said, They are planning to discharge me on 5/14/21 and I don't know what I will do. I have no phone and relatives in the area that can help me. I need help, even taking a shower after 3 minutes feels like an eternity. I don't know what I'm going do, I can't take care of myself. On 5/12/21 at 1:08 p.m., in a telephone interview, the home health director for home health agency A said there was no record of Resident #340 being referred to the HHA. The Home Health Director said, Even if we do not accept the patient, we would still put the referral into the electronic record system but there is no record the patient was ever referred. The Home Health Director said if they did not accept a referral's insurance plan, they would contact the facility, but the facility usually knew before they even got a referral, whether the HHA would accept the insurance. The Home Health Director confirmed there was no record Resident #340 was referred to the HHA upon discharge on 2/13/21 and 4/24/21.

Based on observation, record review, review of facility policy and procedure, resident and staff interview, the facility failed to complete an assessment to determine the ability to self-administer medications for 1 (Resident #339) of 1 resident observed with unsecured medication at the bedside. The findings included: The facility policy, Self Administration of Medications-Assessment (revised 4/18/19) documented, For those residents who have expressed a desire to self-administer their own medications. This form takes in to account all aspects of their ability to do so. It provides a working tool from which the interdisciplinary team (IDT) can base its decisions for approval and disapproval of self-administration of medications by the resident .An individual resident may self -administer drugs if the IDT has determined that this is a safe practice. On 5/10/21 at 9:45 a.m., during an interview with Resident #339, a medication cup with six unidentified white tablets were observed at the bedside in a clear plastic medication cup. Resident #339 said the pills were her morning medications provided by the nurse. The resident said, I take them slowly one at a time, so I don't get an upset stomach and it takes me until 1:00 p.m., to take them. The nurse can't stay here all day to watch me. Resident #339 said she did not know what pills were in the medication cup. On 5/12/21 at 8:35 a.m., during an interview with Resident #339, an observation was made of 4 white, loose pills on the bedside table. The resident said the pills were her morning medications but did not know what they were. The resident said, I can't take them all at once, so they leave them, and I take them a little at a time. Review of Resident #339's clinical record revealed no evidence a Self-Administration of Medications Assessment had been completed for Resident #339. On 5/12/21 at 8:39 a.m., in an interview Licensed Practical Nurse (LPN) Staff D confirmed Resident #339's medications were left at the bedside table and verified the resident was not assessed to self-administer the medications. On 5/12/21 at 9:00 a.m., in an interview, North Wing Unit Manager LPN Staff F said Resident #339 had not been assessed to self-administer her medications. LPN Staff F said no residents were currently identified to self-administer medications on the North Unit. The North Wing Unit Manager LPN Staff F confirmed the medications should not have been left with Resident #339 to self-administer.

Based on record review, review of facility policy and procedure, resident and staff interview, the facility failed to provide necessary services and assistance to maintain continence for 1 (Resident #341) of 1 resident sampled. The failure to provide the needed incontinence care caused the resident embarrassment, and has the potential to cause anxiety, skin breakdown and psychological harm to the resident. The findings included: The facility policy, Bowel and Bladder Management Program (revised 4/12/21) specified, .All new admissions are evaluated for continence through the bowel and bladder assessment. A patterning assessment will be completed to assist in assessing the resident's continence.Based on the nursing assessment, facility will develop a plan of care based on residents' needs. On 5/10/21 at 10:10 a.m., in an interview, Resident #341 said it was hard for her to get help in the evening and she waited to be toileted. Resident #341 said she required assistance with toileting and during the night of 5/7/21 she waited over an hour for help and wet herself. The resident said she reported it to the nurse and said the facility staff tried to tell me I did not have my light on that long, but I still have my mind and I know how long I waited. I don't like to mess the bed. On 5/11/21 at 9:14 a.m., in an interview, Resident #341 said she waited over an hour the previous night to use the toilet. Resident #341 said, It is urgent for me, with my bladder I can't hold it. The resident said it was worse on the night shift to get the help she needed, and she reported it to the nurse. Resident #341 said, I can't hold it and I don't want to mess up the bed. On 5/12/21 at 8:42 a.m., in an interview, Resident #341 said the previous night she had a problem with her bladder and bowels. The resident said, It depends on the staff working. I have an urgent need and when I feel the urge, they cannot come fast enough because they are busy with other residents. I need them instantly when I feel the pressure to go but I know they cannot always be there. They had to clean me, and I don't like it. On 5/12/21 at 8:56 a.m., in an interview, the North Wing Unit Manager said there were no residents on the North Wing who were on a bladder program and said the procedure was all residents were toileted upon rising, before and after meals, and before bed, then as needed. The North Wing Unit Manager said she was notified on 5/11/21 of an incident with Resident #341 and her toileting needs that occurred over the weekend and she would discuss it with the resident. On 5/12/21 at 3:22 p.m., in an interview Certified Nursing Assistant (CNA) Staff E said she was working a 12-hour shift and had been an employee for [AGE] years. CNA Staff E said Resident #341 puts the call light on when she needs to use the toilet and I know when she puts the light on, she really needs to go. CNA Staff E said Resident #341 required extensive assistance with ambulating to the toilet. A review of the clinical record for Resident #341 showed a Bowel/Bladder Patterning Assessment for 5/7/21, 5/8/21 and 5/9/21 which documented Resident #341 was continent of bowel and bladder. On 5/12/21 the North Wing Unit Manager completed a Nursing Bladder Assessment Form created on 5/9/21 which noted Resident #341 was continent of bowel and bladder and no further assessment was necessary. On 5/13/21 at 8:50 a.m., in an interview, the North Wing Unit Manager said she went by what the CNAs had documented in their charting, to determine if the resident was continent or not. The North Wing Unit Manager said the process was, We have 7 days to assess a new admissions bowel and bladder pattern and determine if they are continent or incontinent. The North Wing Unit Manager said, I did not go and talk to Resident # 341. I heard she was incontinent a few days ago. Her family member called, and a grievance was filled out. I did not talk with Resident #341 when completing the bladder assessment, I went by the CNA documentation only. On 5/13/12 at 9:05 a.m., in an interview, the Director of Nursing (DON) said she received a grievance on 5/10/21 from a family member of Resident #341 regarding call lights and she placed a request with the Maintenance Director to check the call light to see if it was functioning correctly as no staff reported call lights not answered timely. A review of the Grievance/Complaint Investigation Report dated 5/10/21 for Resident #341 documented, 2 x's [two times] she had urinary urgency during the nighttime and had to wait too long for someone to come. She urinated and was embarrassed to have to be cleaned up. On 5/13/21 at 10:00 a.m., in an interview, the North Wing Unit Manager confirmed there were no interventions initiated once she was made aware of the grievance concerning Resident #341's bowel and bladder needs.

Based on observation, staff interview, and record review, the facility failed to ensure its medication error rate remained below 5%. Four licensed nurses with 31 opportunities were observed. Two medication errors were identified resulting in a 6.45% error rate. The findings included: The facility policy, Administering Medication (reviewed / revised 5/2/2021) specified, Medications shall be administered in a safe and timely manner, and as prescribed. Procedure item #6 said, The licensed nurse administering the medication must check the label to verify the following before administering the medication: (a)Right medication, (b)Right dosage, (c)Right time. (d)Right method of administration. 1. On 5/11/21 at 8:50 a.m., Licensed Practical Nurse (LPN) Staff G was observed administering four medications, including [MEDICATION(S)] 90 mcg/actuation aerosol inhaler (medication used for management of chronic obstructive pulmonary disease) to Resident #4. LPN Staff G shook the [MEDICATION(S)] inhaler and handed the inhaler to Resident #4. Resident #4 took two puffs of medication orally, 5 seconds apart. Review of the pharmacy packaging revealed documentation to Wait 1 minute between puffs. Review of the [MEDICATION(S)] manufacturer's insert revealed in the instructions for use, If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again. On 5/11/21 at 9:00 a.m., in an interview LPN Staff G confirmed the pharmacy packaging for the [MEDICATION(S)] inhaler specified to, Wait 1 minute between puffs. LPN Staff G confirmed she did not wait or instruct Resident #4 to wait 1 minute between puffs per the pharmacy label or manufacturer's specification. 2. On 5/11/21 at 9:05 a.m., LPN Staff H was observed administering 11 medications, including [MEDICATION(S)] HFA 45 mcg-21 mcg/actuation aerosol inhaler to treat [CONDITION(S)] to Resident #9. LPN Staff H shook the [MEDICATION(S)] inhaler and handed the dispenser to Resident #9. Resident #9 inhaled two puffs orally, 7 seconds apart. Review of the pharmacy label revealed to Wait 1 minute between puffs. Review of the manufacturer's specification for use of the [MEDICATION(S)] inhaler revealed to Push the top of the metal canister firmly all the way down while you breathe in deeply and slowly through your mouth . Breathe out slowly as long as you can. Wait about 30 seconds and shake the inhaler well for 5 seconds . Repeat steps 2 through 6. On 5/11/21 at approximately 9:15 a.m., LPN Staff H confirmed the pharmacy packaging for the inhaler specified to, Wait 1 minute between puffs. LPN Staff H confirmed she did not wait or instruct the Resident #9 to wait 1 minute between puffs per specification on the pharmacy label. On 5/13/21 at 10:20 a.m., in an interview, the Director of Nursing (DON) confirmed the nurses were expected to follow the instructions on the medication label. The DON said, It would be a medication error if a nurse did not follow labeled pharmacy instructions. **Photographic Evidence Obtained**

Based on observation, record review, and staff interview, the facility failed to assess for compatibility of the bed frame and mattress to identify areas of possible entrapment for 1 (Resident #239) of 1 resident reviewed for accident hazards. The findings included: The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment for Industry and Food and Drug Administration (FDA) issued on March 2006, identified the area between the head or foot board and the end of the mattress a risk for head entrapment. Entrapment is a situation where an individual can become caught by their head, neck, chest, or other body parts. The FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment document can be found at: https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM 9.pdf On 5/10/21 at 11:32 a.m., Resident #239 was observed lying in bed. Resident #239 was confused and unable to be interviewed. A 6-inch gap was observed between the footboard and frame/mattress with an open area to floor, creating a large area for potential entrapment. On 5/11/21 at 1:55 p.m., in an interview, Licensed Practical Nurse (LPN) Staff K said Resident #239 was confused and could be restless in bed. On 5/11/21 at 2:11 p.m., in an interview, Certified Nursing Assistant (CNA) Staff I said Resident #239 was confused most of the time. When he first came, he tried to get up unassisted, so a bed alarm was placed on him to alert staff if he did try to get up. Resident #239's clinical record revealed a Nursing Admission Data Collection form completed on 4/21/21. The form included a Fall Risk Assessment, which identified the resident as high risk for falls. On 5/12/21 at 8:38 a.m., in an interview, the facility's Project Coordinator said he used the FDA Bed Safety measuring kit to check for entrapment zones in the bed environment. He said all the beds were checked annually and/or if any change or if bed rails were required. Nursing notified him of any issues. Resident #239's bed was measured by the Project Coordinator at the time of the interview and he confirmed a 6-inch gap was present between the bed frame/mattress and footboard. He said it was way too much of a gap and the bed frame needed to be adjusted to fit the mattress. He also confirmed the mattress was slippery on the bed and could easily move on the frame. On 5/13/21 at 8:54 a.m., in a follow up interview, Project Coordinator said he used the FDA guidelines for bed safety to check for entrapment zones, including zone 7 (area between mattress and footboard). The guidelines did not specify the size of the space but if it was too large the risk increased. He would consider 4 and 3/4 inches a potential entrapment zone (the measurement guide for between the mattress and a bed rail if in use). **Photographic Evidence Obtained**

Based on interview and record review the facility failed to honor a legally executed Do No Resuscitate Order (DNR) for 1 (Resident #1) out of 11 residents reviewed for advanced directives. The facility's electronic medical records listed the Resident #1's code status as DNR, and there was a valid DNR order at the time of admission. The facility failed to follow its own policy and procedure. The DNR form was not put in the advance directive book. Staff were unable to find a copy of the resident's DNR, and started Cardiopulmonary Resuscitation (CPR) against the resident's advance directive. The resident received approximately 10 minutes of attempted resuscitation (CPR). The facility's actions to perform CPR against the resident's wishes could have resulted in the resident experiencing severe pain, broken ribs, internal bleeding, aspiration pneumonia, organ damage, permanent brain damage, or coma. If the resident was resuscitated, this could result in undesired intubation (a tube inserted through the mouth to assist with breathing), mechanical ventilation, a prolonged dying process and deprive the resident of a natural death. This action resulted in an Immediate Jeopardy level deficiency. The facility self identified the deficient practice. The facility filed an Adverse Incident Report which detailed the steps the facility took to ensure compliance, and to prevent this type of incident from reoccurring. The facility operationalized the action plan to correct the deficient practice. The deficient practice was corrected [DATE] making it past noncompliance Immediate Jeopardy. The findings included: Facility policy title: Do Not Resuscitate Order Effective [DATE] (reviewed [DATE], [DATE]) and reviewed [DATE] after the death of Resident #1 shows: Policy: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a DO NOT RESUSCITATE ORDER (DNR) in effect. Procedure: 1. Do Not Resuscitate orders must be signed by the residents attending physician and resident on the Goldenrod DNR form, the form is kept on the unit assigned to the resident in a green book on the desk. 2. A Do Not Resuscitate Order is placed in the EMR (Electronic Medical Record). An icon will appear next to the resident name. The icon in blue and is a heart with a x thru it. The form is signed by the physician and the resident (or resident's legal surrogate, as permitted by state law) (note: use only the state approved DNRO forms) Record review showed on [DATE] Resident #1 was admitted to the facility with a State of Florida Do Not Resuscitate (DNR) Order form. The DNR form was signed by the resident on [DATE]. A current physician order [REDACTED]. Resident Record review on [DATE] at 9:05 a.m., showed Staff A Licensed Practical Nurse (LPN) was alerted by a CNA (Certified Nurse's Assistant) Resident #1 was unresponsive. She did a sternal rub and but was not able to arouse the resident. Staff A noted a second nurse checked the patients BS (blood sugar) and confirmed it to be within normal range at 126. Two nurses confirmed there was no apical pulse. Supported measures were initiated. When the staff were unable to find the resident DNR form, Emergency Medical Services (EMS) was called and arrived at the facility at 9:23 a.m. A electrocardiogram (EKG) was done and confirmed the resident was in asystole (no heartbeat). The DNR form was found and given to the EMS staff. EMS then discontinued CPR. EMS staff called the time of death at 9:34 a.m. In an interview on [DATE] at 2:33 p.m., Staff C RN said on the day Resident #1 was admitted , the paperwork included a State of Florida DNR Order form. She left the admission paperwork for Staff E LPN to complete. Staff C RN said on [DATE] when the resident was found unresponsive, she tried to locate the DNR order form she saw in the admission paperwork. The form was not in the advanced directive book. After locating the DNR form, she brought it to EMS, and they stopped CPR. Staff C RN said the form was found in the admission packet and had not been placed into the DNR book per facility procedure. In an interview on [DATE] at 2:34 p.m., the Director of Nursing (DON) said Resident #1 received CPR when she had a signed State of Florida DNR Order form and a current physician's orders [REDACTED]. In an interview on [DATE] at 3:07 p.m., Staff A LPN said when alerted by the CNA that Resident #1 was unresponsive, she went to the resident's room. She did a sternal rub and was not able to arouse the resident. She called for assistance, Staff C RN went to check the advance directive book, and then we called for 911. She said she informed EMS Resident #1 was a DNR and the staff was looking for the form. Staff A LPN said they were coding (performed CPR) for about 10 minutes. In an interview on [DATE] at 4:15 p.m., Staff F Social Worker (SW) said the day after Resident #1's admission she went to the chart and checked on her advance directives. She did look in the resident's electronic record and saw a current DNR order. She verified the active DNR order with Resident #1, and the resident said she wished to continue it. Staff F SW said she looked in the advance directive book and did not see a State of Florida DNR Order form for Resident #1, but did not follow through to find out where the DNR form was. In an interview on [DATE] at 12:34 p.m., the DON said the nurse who admits the resident was responsible to ensure advance directive information was in the record. Staff in the admission office, and social service staff were the additional layers to catch a mistake if it happens. There were other things which should have been put in place, but were not found like the admission check list. The admission check list is the form the nurse had to check a box which documented she has seen the DNR form and were it was put. The DNR can be in the chart and in the Advance directives book (DNR book). It was also in the electronic record and on the EMAR (medication administration record). A QAPI comittee meeting was held on [DATE] and a plan of correction was developed. The corrective action started on [DATE], (date of resident death) and was completed on [DATE]. During interview the Administrator and Director of Nursing said all correction action was completed on [DATE] to include the night shift education. The corrective action included a facility wide audit to review all Advanced Directive orders and to ensure DNR forms were placed in the advanced directive book if applicable. The education included code blue drills on all shifts and for all nurses and CNA's. Re-education to all nursing staff and social service staff on the advanced directives procedures and responsibilities. Individual education was provided to the social worker and admitting nurse involved on importance of following established processes and procedures. Facility policies and procedures were reviewed and revised. The Do Not Resuscitate Order policy with effective date of [DATE] (reviewed [DATE] and [DATE], and [DATE]) was reviewed and further revised on [DATE]. The 48 hour baseline care plan assessment template was revised to include more detailed information on advanced directives. The revision of the baseline assessment is now reviewed by the interdisiplinary team and the social worker checks the book for the presence of the DNR form, and documents this step. The corrective actions were completed to ensure compliance, and prevent this type of incident from reoccurring to any existing or future residents. The corrective action plan was completed. The completed action plan was confirmed.

Based on observation, resident interview, staff interview and policy review, the facility failed to facilitate resident self-determination through support of resident choice for 1 (Resident #92) of 2 residents reviewed for choices. This resulted in Resident #92 not being able to use a bed rail as a mobility enabler. The findings included: On 8/20/19 review of the facility policy titled Bed Rails, revised date 3/25/19 noted SMNRC recognizes the right of the resident's personal freedom in conjunction with well-being and security. Residents who utilize bed rails to assist with bed mobility, or for stabilization during transfers, are utilizing the rails as mobility enablers and to promote independence . If a resident/representative request the use of bed rail(s), the facility will complete a bed rails assessment prior to the installation of bed rails to ensure the resident is an adequate candidate for use of bed rail(s). On 8/19/19, at 11:36 a.m., observation revealed Resident #92 lying in bed with no evidence of bed rails. On 8/19/19, in an interview, Resident #92 said she told Certified Nursing Assistants, (CNA), therapists and nurses that she would like bed rails. She added someone told her the State passed a law saying bed rails have to come off the beds. She said Even my therapist has asked them. I asked the maintenance guy about a month and a half ago and he came back and said he was looking into it. She added no one has gotten back to her about her request. On 8/22/19 at 9:04 a.m., in an interview, Physical Therapy Assistant Staff D said about a month ago Resident #92 asked her about getting bed rails. She said she told the treating therapist and was told we don't get to make those decisions or something like that and after that it was pretty much dropped. On 8/22/19 at 9:20 a.m., in an interview, Maintenance Assistant Staff [NAME] said Yes, about 2 weeks ago she told me she would like bed rails. I told her there is a process we have to go through, and I went and told the Unit Manager or another nurse at the desk that she wanted bed rails. On 8/21/19, record review of Resident #92 revealed no evidence of a bed rails assessment had been completed for Resident #92. There was no evidence the request for bed rails by Resident #92 had been honored. On 8/21/19 at 10:09 a.m., in an interview, the Director of Compliance said We did not do a side rail assessment because she never asked for side rails, this is the first I have heard of it. We will start the process if that is what she would like.

Based on record review and staff interview, the facility failed to ensure documentation of non-pharmacological interventions attempted prior to administration of PRN (whenever necessary) [MEDICAL CONDITION] (medications that affect a person's thinking) medication for 1 (Residents #83) of 5 residents reviewed. This has the potential to lead to administration of unnecessary medication. The findings included: On 8/22/19, record review for Resident #83 revealed prn [MEDICAL CONDITION] medications were administered on 7/28/19, 7/30/19, 7/31/19, 8/11/19 and 8/13/19. There was no documented evidence of non-pharmacological interventions attempted prior to administration of the prn [MEDICAL CONDITION] medication. On 8/22/19 at 11:47 a.m., the North Unit Manager confirmed there was no documented evidence of non-pharmacological interventions attempted prior to administration of PRN [MEDICAL CONDITION] medication to Resident #83 on 7/28/19, 7/30/19, 7/31/19, 8/11/19 and 8/13/19.

Based on observation, staff interview, and record review, the facility failed to ensure their bi-metallic thermometers used to record food temperatures were calibrated to guarantee the temperature of food was accurate. This had the potential of affecting the health and safety of residents consuming an oral diet. The findings included: The United States Department of Agriculture (USDA) Food Safety and Inspection Service identifies the food danger zone: Bacteria grow most rapidly in the range of temperatures between 40 °F and 140 °F, doubling in number in as little as 20 minutes. This range of temperatures is often called the 'Danger Zone'. (from https://www.fsis.usda.gov/shared/PDF/Danger_Zone.pdf) On 6/20/18 at 11:00 a.m., observation of tray line revealed the following: Cook Staff A was observed taking the temperature of the food on the steam table. After many attempts, Cook Staff A recorded the temperature of several food items and could not get a temperature above the danger zone. Cook Staff A removed the food from the steam table, and placed the container of food in the steamer to bring the food up to the appropriate temperature and out of the danger zone. Cook Staff A continued to take the temperature with the same thermometer with the remaining food on the steam table. The remaining food was also recording temperatures in the danger zone. Cook Staff A proceeded to use another thermometer. The replacement thermometer also recorded the food temperature of all food items in the danger zone. Cook Staff A then placed all the remaining food items in the steamer to bring them back up to the appropriate temperature and out of the danger zone. The Food Service Director (FSD) was present during the observation and asked Cook Staff A if she had calibrated the thermometers before initiating the process of taking the temperatures of the food on the steam table. Cook Staff A admitted she had not calibrated the thermometers before taking the temperature of the food. Cook Staff A proceeded to calibrate the two thermometers. She confirmed one thermometer needed to be adjusted to the freezing point. The other was not functioning properly. Review of the contracted Registered Dietitian (RD) policy titled Sanitizing and Calibrating Thermometers (Policy #03.03.010, approved 12/1/11) included: Guideline 2. The thermometer is calibrated before taking food temperatures . On 6/21/18 at 9:01 a.m., met with the FSD, Certified Dietary Manager (CDM), and RD about identified concerns with calibrating thermometers. The FSD, CDM, and RD agreed it was a concern, and felt Cook Staff A should have calibrated the thermometer when not achieving appropriate temperatures.

Based on observations, staff interview, and review of records and infection control policies, the facility failed to follow proper hand hygiene, failed to use appropriate personal protective equipment (PPE, such as a gown and gloves), and failed to disinfect equipment for 3 (Residents #14, #44 and #67) of 3 residents reviewed for infection control. The failure to perform proper hand hygiene is one of the most important steps that can be taken to avoid getting sick and spreading germs to others. The findings included: On 6/18/18 at 10:00 a.m., during a tour of the facility, observed Resident #14's room with an isolation cart outside of the room. Nursing Staff C and D reported Residents #14 and #44 [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus, an antibiotic resistant infection). Observed an isolation cart outside of Resident #67's room; Nursing Staff C and D reported the resident had [MEDICAL CONDITION] (C. diff, a contagious intestinal infection that causes diarrhea). Thus, identified Residents #14, #44, and #67 were on contact precautions. 1. On 6/18/18 at 1:00 p.m., observed there was no designated trash receptacle for PPE in Resident #14's room. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (page 50) by the Healthcare Infection Control Practices Advisory Committee recommended: Designated containers for used disposable or reusable PPE should be placed in a location that is convenient to the site of removal to facilitate disposal and containment of contaminated materials . (from: https://www.cdc.gov/hai/pdfs/Isolation2007.pdf) 2. On 6/18/18 at 3:25 p.m., observed Certified Nursing Assistant (CNA) Staff P enter Resident #14's room, on contact precautions [MEDICAL CONDITION], and used the mobile standing vital signs equipment. CNA Staff P donned gloves and took the vital signs of both residents in the room without changing gloves and washing her hands in between residents. When she was finished taking vital signs, she removed the gloves and exited room without sanitizing her hands or the equipment. She entered the next room with the same equipment. 3. On 6/20/18 at 8:14 a.m., and 9:11 a.m., observed CNA Staff Q bring a bag of trash into the soiled utility room and exit without sanitizing her hands. She entered other resident rooms to retrieve breakfast trays. On 6/20/18 at 1:25 p.m., Infection Control Nurse said if the staff was throwing trash in soiled utility room, they were to wash their hands while in the utility room. She said the hand washing policy was to wash with soap and water for 20 seconds, and then rinse and dry hands. As for equipment used for vital signs, and for enhanced precautions, they kept dedicated equipment in the room. If there was no dedicated equipment in the room, the staff were to wipe down the equipment with bleach wipes located on the isolation cart outside of room. If on regular contact, they could wipe it down with the hydrogen peroxide based product. On 6/21/18 a review of the 2007 Guideline for Isloation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings published by Centers for Disease Control (CDC) included: Hand Hygiene IV.A.1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Perform hand hygiene in the following clinical situations: IV.A.3.c. After contact with a patient ' s intact skin (e.g., when taking a pulse or blood pressure or lifting a patient) IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. IV.A.3.f. After removing gloves. IV.A.4. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., [DIAGNOSES REDACTED]icile) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, [MEDICATION NAME], and other antiseptic agents have poor activity against spores. Patient-care equipment and instruments/devices V.B.5.b. In acute care hospitals and long-term care and other residential settings, use disposable noncritical patient-care equipment (e.g., blood pressure cuffs) or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. (from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf)

Based on observation, record review, staff, family, and resident interview, the facility failed to ensure 15 (Residents #36, #67, #88, #194, #31, #12, #142, #3 #7, #65, #50, #291, #69, #74, and #300) of 30 residents reviewed for accident hazards were assessed for alternative interventions prior to the use of bed rails, had informed the residents and/or their representative of the risks and benefits of bed rails, and/or obtained an informed consent prior to use of the bed rails. The findings included: 1. On 6/18/18 at 10:00 a.m., during a general tour of the facility, observed bilateral side rails in the up position on Resident #36, #67, #88, and #194's beds. On 6/19/18 at 11:28 a.m., observed bilateral side rails in the up position for Resident #36, #67, #88 and #194's bed. On 6/19/18 at 11:28 a.m., during an interview with Resident #67, he said no one talked to him about the risks or benefits of having the bed rails on the bed in the up position. He said he thought they were there so he would not fall out of bed. On 6/19/18 at 11:30 a.m., during an interview with Resident #36's wife, she said she did not know why the bed rails were up and stated, Isn't it just because it's part of the bed? She said no one had talked to her about the risks or benefits of having bed rails up on the bed. On 6/19/18 at 11:51 a.m., during an interview with Resident #194's daughter, she said she thought the bed rails were up for safety purposes but no one explained the risks or benefits to her. On 6/19/18 at 1:52 p.m., a review of Resident #36, #67, #88 and #194's medical record revealed no evidence of a bed rail assessment or of other interventions prior to use. There was no evidence of an informed consent including risks versus benefits discussed with the residents. 2. On 6/19/18 at 10:00 a.m., observed Resident #31 in bed sleeping with bilateral quarter side rails raised. Review of Resident #31's clinical record failed to include alternate interventions before the use of the side rails. Review of the record failed to find an assessment for the use of side rails, or resident/family being advised of the risks and benefits of the use of the side rails. There was no signed consent for using the side rails given by the resident or family. 3. On 6/19/18 at 10:22 a.m., observed bilateral quarter side rails engaged while visiting Resident #12 in her room. Review of Resident #12's clinical record failed to include alternate interventions before the use of the side rails. Review of the record failed to find an assessment for the use of side rails, or resident/family being advised of the risks and benefits of the use of the side rails. There was no signed consent for using the side rails given by the resident or family. 4. On 6/19/18 at 11:25 a.m., observed Resident #142 in her room with bilateral quarter side rails raised. Review of Resident #142 clinical record failed to include alternate interventions before the use of the side rails. Review of the record failed to find an assessment for the use of side rails, or resident/family being advised of the risks and benefits of the use of the side rails. There was no signed consent for using the side rails given by the resident or family. 5. On 6/19/18 at 10:02 a.m., bilateral quarter rails were observed on Resident #3's bed. Resident #3 said the rails were on the bed when she came in the facility. Resident #3 said no staff member had talked to her about the rails. 6. On 6/19/18 at 11:26 a.m., bilateral quarter rails were observed on Resident #7's bed. Resident #7 said he was not told why he had side rails. Resident #7 said he did not know why he had them on his bed. 7. On 6/19/18 at 11:10 a.m., bilateral quarter rails were observed on Resident #65's bed. Resident #65 suffered from dementia and was not interviewable. Review of Resident #65's medical record showed no documentation of, or notification for side rails on the bed. 8. On 6/18/18 at 12:01 p.m., Resident #50 was observed lying in bed with half side rails raised on both sides of the bed. Resident #50 said the rails have been on the bed the whole time he had been here. Resident #50's clinical record was reviewed and there was no evidence of any interventions being attempted prior to the use of the side rails and no informed consent reviewing the risks versus benefits of the side rails. 9. On 6/18/18 at 12:35 p.m., Resident #291's bed was observed to have side rails. The resident said the reason for the side rails was to keep him from falling out and when he was in bed they were both raised. Resident #291 said he did not recall signing any consent for their use. The resident's clinical record was reviewed and there was no evidence of any interventions being attempted prior to the use of the side rails and no informed consent reviewing the risks versus benefits of the side rails. 10. On 6/19/18 at 10:15 a.m., Resident #69's bed was observed to have side rails. Resident #69 said the side rails had been on the bed since admission and no one had talked to him about them. The resident said he did not sign any informed consent for their use. Resident #69's clinical record was reviewed and there was no evidence of any interventions being attempted prior to the use of the side rails and no informed consent signed by the resident. 11. On 6/19/18 at 9:09 a.m., Resident #74's bed was observed to have side rails raised on both sides of the bed. The resident was confused and unable to answer any questions in regards to the side rails. Resident #74's clinical record was reviewed and there was no evidence of interventions attempted prior to the use of side rails or informed consent signed by the resident or responsible family member. 12. On 6/19/18 at 9:15 a.m., Resident #300 was observed lying in bed with a side rail raised on one side of the bed. The resident said the reason for the side rail was to hold the controls and were on the bed when she first came in. The resident said staff pull both rails up at night but no one has talked to her about them and she had not signed any consent for their use. Resident #300's clinical record was reviewed and there was no evidence of any interventions being attempted prior to the use of the side rails and no informed consent signed by the resident. On 6/19/18 at 1:56 p.m., the Director of Nursing (DON) said upon admission, staff evaluate a resident's need for assistance getting out of bed and may indicate side rails could be used and enables them. The DON said all beds were equipped with side rails and confirmed there was no full assessment of the need or safety of side rails and no informed consent for their use.

Based on observation, staff interview, and record review, the facility failed to ensure a medication error rate of less than 5%. The facility had 3 medication errors in 25 opportunities involving 2 (Resident #38 and #44) of 7 residents observed during medication pass. The calculated medication error rate was 12%. The findings included: 1. a. On 6/20/18 at 8:45 a.m., Registered Nurse (RN) Staff B was observed to administer [MEDICATION NAME] coated aspirin 325 milligrams (mg) to Resident #38. Review of the physician's orders [REDACTED]. On 6/20/18 at 9:00 a.m., RN Staff B verified he had administered the wrong dosage of aspirin to Resident #38. b. On 6/20/18 at 8:50 a.m., RN Staff B verified he had completed the medication administration of Resident #38's 9:00 a.m. medications. No topical medications were observed to be applied during Resident #38's medication observation. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] On 6/20/18 at 9:20 a.m., RN Staff B said the aides apply the topical medications and the nurses verify the medications were applied. RN Staff B acknowledged that he had not verified the aide had administered [MEDICATION NAME] powder to Resident #38 during this shift. On 6/20/18 at 9:29 a.m., Certified Nursing Assistant (CNA) Staff K said she did not put any medication on Resident #38. CNA Staff K stated, Medications are for the nurse to apply. On 6/20/18 at 9:35 a.m., Unit Manager, RN Staff L said nurses were responsible to apply all topical medications to residents. The Unit Manager acknowledged Staff B had made 2 medication errors in administering the wrong dosage of aspirin and failing to administer a topical antibiotic. 2. On 6/20/18 at 9:10 a.m., Licensed Practical Nurse (LPN) Staff C was observed administering medications by gastric tube to Resident #44. After administering the last medication (liquid potassium chloride) to Resident #44, LPN Staff C closed the port of the gastric tube without flushing the tube. Review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. On 6/20/18 at 9:45 a.m., LPN Staff C verified she had not flushed the gastric tube after administering the last medication during her medication pass. LPN Staff C said the tube feeding pump was set to administer 225 ml of water to Resident #44 every 4 hours. Observation of the tube feeding pump showed the machine was set to infuse 195 ml of water every four hours. LPN Staff C said the order had changed last night and the evening nurse had not changed the tube feeding pump to infuse the correct amount of water. LPN Staff C verified she had not checked the flush setting on the pump since she had started her shift. Review of Resident #44's MAR indicated [REDACTED].

Based on observation, resident family and staff interviews, and record review, the facility failed to provide activities to accommodate resident needs for 1 (Resident #36) of 2 residents reviewed. The findings included: On 6/18/18 at 12:55 p.m., Resident #36's wife said her husband used to have a chair for him but they did not anymore. She said he had a little bible recorder and it just sat in his drawer. She said he had been flat on his back for over 2 weeks. She thought they have given up on him. On 6/18/18 at 2:00 p.m., a review of Resident #36's Minimum Data Set ((MDS) dated [DATE] documented his favorite activities. Resident #36 considered the following as very important: to have books, and newspapers; listen to music he liked, be around animals and pets, keep up with the news, do favorite activities, go outside for fresh air, and participate in religious services. Doing things with groups of people was somewhat important. On 6/20/18 at 11:00 a.m., review of Resident #36's care plan identified activity as an area of requiring need. The goal of resident participating in activity of choice; preferred to self-direct leisure activity with reading the bible; staff to offer spiritual support with catholic group; enjoyed country music and watching news, and sports on television. The interventions included resident would benefit from one to one and small groups; preferences of being outdoors, television (TV) viewing, music listening; and spiritual activities. On 6/20/18 at 8:30 a.m., 11:00 a.m., 12:30 p.m., and 2:59 p.m., observed Resident #36 lying on his back, staring up at the ceiling. His TV was off and there was no external stimuli in progress. On 6/20/18 at 2:59 p.m., Registered Nurse Staff H said the resident had not gotten out of bed because he was in pain. He said he did not go to activity because he was in pain. On 6/20/18 at 3:13 p.m., the Activity Director said Resident #36 used to get up into a wheel chair but had not since he had been back. She said she thought he had not done any activity because he was in pain. She said he liked to listen to the bible, enjoyed country music, watched westerns and old movies on TV and liked to go out in the fresh air. She asked the resident if he would like to get into a chair and go outside for fresh air and he responded, I would like that. She said she did not know why his TV was off and they did not play the bible recorder or country music for him. She acknowledged if he was in pain, that he might enjoy those activities. On 6/21/18 at 11:59 a.m., Resident #36's wife said she had never come in and found his bible player on. She said she did not know why they did not get him up in a chair or had taken him outside. At 12:30 p.m., she said she had just taken him outside for some air. She said he told her he enjoyed getting out of bed yesterday. On 6/21/18 at 12:30 p.m., Resident #36 smiled and said he enjoyed getting to go outside. He said he had very little pain right now, maybe a 2. Resident #36 said he wanted to continue to get up and go out. On 6/21/18 at 1:00 p.m., the policy and procedure provided by the facility titled Well Being - Activity Program (no policy number, no effective date, no reviewer) was reviewed. The purpose of the policy was to maintain cognitive and physical functioning levels for quality of life for long-term and Short-term residents. The policy showed This Well-Being Activity Program is designed to address the needs of those residents who have physical and cognitive limitations. It will provide residents with a supportive setting through flexible and creative activities. This program is also a reinforcement of the residents (sic) remaining physical and mental capabilities. The policy goes on to say, The Well-Being Activity Program should enable residents to function at the highest capacity possible within their ability level . The activities should be carefully designed and structures (sic) to meet the needs and interests of impaired residents through a series of large, small and individual interactions. 1. The daily schedule of activities needs to be consistent . 3. The activity schedule should follow a pattern where cognitive activities alternated with less stressful activities such as exercise of (sic) music. 4. The pattern and timing of the activity calendar should reflect an awareness of the resident's strengths and capabilities throughout the day. 5. Well being activities should be designed to encourage participation with all functional levels of residents. The procedure identified that the resident may participate at various levels depending on the activity. It may be active, passive or observing in nature.

Based on observation, staff interview, and record review, the facility failed to provide positioning for 2 (Resident #65 and Resident #36) of 3 residents sampled for following the physician's orders [REDACTED].#65) and positioning (Resident #36) having a potential for skin breakdown related to pressure. The findings included: 1. On 6/18/18 at 9:30 a.m., Resident #65 was observed lying on his right side in the bed. Resident #65 was contracted in all his extremities and he was severely demented and unable to make his needs known. Resident #65's body was in a fetal position due to his contractures. Resident #65's heels were on his mattress and were not offloaded to prevent pressure on his heels. On 6/18/18 at 12:03 p.m., Resident #65 was observed in the same position in the bed without his heels being offloaded to prevent pressure on his heels. On 6/19/18 at 10:57 a.m., Resident #65 was observed in the bed lying on his back. Resident #65's heels were not offloaded to prevent pressure on his heels. On 6/20/18 at 4:05 p.m., Resident #65 was observed lying in the bed on his back. Resident #65's heels were not offloaded to prevent pressure on his heels. Review of Resident #65's current physician's orders [REDACTED]. Review of the care plan for Resident #65 under: Pressure Ulcers and Risks for Pressure Ulcers read, Float heels initiated 3/26/14. On 6/21/18 at 9:50 a.m., Certified Nursing Assistant (CNA) Staff D was observed pulling a sheet over Resident #65 and lowering his bed. Staff D verified she had just finished placing Resident #65 in the bed for the afternoon. Staff D said she had just placed the resident in the bed. Observation of Resident #65's heels at that time showed they had not been offloaded. Staff D said there was a third pillow that went under the resident's feet and she did not know where it was right now. Staff D said she would have to go and find it. Staff D verified she had cared for Resident #65 yesterday and had not offloaded the resident's heel while he was in the bed. Staff D stated, He did not have a pillow under his feet yesterday. On 6/21/18 at 9:55 a.m., Licensed Practical Nurse Staff E said nurses were responsible to monitor Resident #65 to ensure his heels were offloaded every shift. Staff E verified she had not checked the resident's heels on 6/20/18 or 6/21/18 to ensure they were offloaded. On 6/21/18 at 10:19 a.m., the South Unit Manager was heard telling staff there were enough pillows now for Resident #65's care. The Unit Manager said Staff D had told her that Resident #65's pillow had been taken to the laundry because it had been soiled. The Unit Manager said she was going to get an order for [REDACTED]. 2. On 6/18/18 at 1:16 p.m., Resident #36's wife said when she was here staff did not reposition her husband. She said he was in the same position in bed, on his back. She said that was how he stayed during the time she came in until the time she left. She said she did not think they reposition him after she was gone either. On 6/19/18 at 9:16 a.m., observed Resident #36 lying on his back and at 2:50 p.m., observed him in the same position. On 6/19/18 at 2:50 p.m., CNA Staff N said she was going to turn Resident #36 on his side earlier but he said he was comfortable. Staff N said he got off loaded when she turned him to be checked if he had a bowel movement. She said the resident was supposed to be turned every 2 hours. On 6/20/18 at 9:00 a.m., observed Resident #36 lying on back in bed with head elevated. At 11:00 a.m., 12:30 p.m., 2:00 p.m., and 3:00 p.m., resident was observed in the same position. On 6/21/18 at 8:30 a.m., observed Resident #36 lying on his back. At 10:41 a.m., resident was observed lying on his back in the same position. On 6/21/18 at 10:41 a.m., Registered Nurse Staff H said the CNAs were telling him they were repositioning Resident #36. Staff H said he did not realize the resident was in the same position. Staff H said he understood the resident may be uncomfortable with totally being turned onto his side; however, the CNA could place a pillow under one hip for a while, then the other. Staff H acknowledged this was not being done. On 6/21/18 at 10:55 a.m., review of Resident #36's admission care plan dated 6/8/18 documented pressure sore/skin care with a goal of current areas of skin impairment will demonstrate healing and included the intervention of assist with turning and repositioning every 2 hours. On 6/21/18 at 11:00 a.m., observed CNA Staff N entering Resident #88's room. As she entered she was heard stating, I need to turn him a little on his side. We have to do this every two hours now.

Based on observation, resident and staff interviews, and record review, the facility failed to coordinate care and services for 1 (Resident #67) of 1 sampled resident receiving [MEDICAL TREATMENT] treatment. This was evidenced by the facility's failure to coordinate care by lack of communication with the [MEDICAL TREATMENT] unit. The facility also failed to communicate missed or refused medication to the doctor, or give ordered medication timely. This had the potential of causing interference with the effectiveness of the [MEDICAL TREATMENT] treatment, including complications from calcium-[MEDICATION NAME] imbalance ([DIAGNOSES REDACTED]). The findings included: On 6/18/18, a review of Resident #67's medical record revealed he was admitted to the facility with [MEDICAL CONDITIONS] and ordered to receive [MEDICAL TREATMENT] treatment 3 times a week. On 6/19/18 at 11:00 a.m., a review of Resident #67's physician orders [REDACTED]. On 6/19/18 at 9:30 a.m., review of Resident #67's comprehensive care plan in reference to renal insufficiencies related to [MEDICAL CONDITION] initiated on 5/16/18 included communication with the [MEDICAL TREATMENT] center and medication as ordered and nursing intervention to monitor thrill (feel of blood flow) and bruit (sound of blood flow) every shift and as needed per ordered. On 6/19/18 at 10:30 a.m., review of the policy and procedure titled [MEDICAL TREATMENT] (effective 11/28/17, revised 6/1/18) documented the procedure of nursing notified interdisciplinary team of [MEDICAL TREATMENT] schedule to ensure coordination of other needed care, treatment and meals. Coordination of care and services/communication to ensure planning, coordination and quality of care. Nursing provides resident with Coordination of care/communication book for [MEDICAL TREATMENT]. The book includes current physician orders, labs and other pertinent information. Additional communication takes place between the facility and [MEDICAL TREATMENT] center interdisciplinary team as indicated to ensure quality of care. On 6/19/18 at 11:30 a.m., review of Resident #67's Medication Administration Record [REDACTED]. Many of the missed doses are marked LOA for leave of absence. However, physician order [REDACTED]. On 6/18/18 at 9:08 a.m., observed Licensed Practical Nurse (LPN) Staff O attempted to administer Resident #67 his [MEDICATION NAME] and Velphoro. Resident #67 informed LPN Staff O he had already eaten his breakfast because he was hungry. He said he could not wait until she decided to bring him his medication. He said he had breakfast an hour ago and he had to take the binders with food. He stated, I already took them from stash. On 6/20/18, a review of Resident #67's medication label indicated pharmaceutical recommendations and label instructions documented medication should be given with meals to benefit the binding of excess phosphorus to the medication as to eliminate the phosphorus via a bowel movement. The risk of not following directions could cause an increase of phosphorus to accumulate in the blood stream, which had the potential of causing [DIAGNOSES REDACTED], a painful condition. The condition causes [MEDICAL CONDITION] and severe pain and usually had a high mortality rate. (source: National Kidney Foundation at https://www.kidney.org/professionals/Sagar-Nigwekar-Seeking-Treatment-[DIAGNOSES REDACTED]). On 6/18/18 at 9:30 a.m., Resident #67 said he had his binders he could take from his own stash. He stated, I have to have them with meals. Sometimes the nurse tries to give it to me anywhere from 30 minutes to an hour after my meal has arrived. I should not have to eat cold food, so I take the binders from my stash. He said he keeps the container in his bag. He opened a large brown, unlabeled pill bottle. He stated, The long white ones are the [MEDICATION NAME] and the dark circle tablets are the Velphoro. On 6/19/18 at 10:16 a.m., Resident #67 said when he returned from [MEDICAL TREATMENT] he had a bandage over his fistula site. He said he removed it after 24 hours. He said the nurse at [MEDICAL TREATMENT] checked the site for a thrill and bruit, but the facility nurses never check for thrill or bruit. On 6/19/18 at 2:00 p.m., LPN Staff C said they used a communication book for [MEDICAL TREATMENT]. She said Resident #67 returned with a dressing on the fistula site and she would visualize it for drainage. She said she did a post-assessment in the computer upon his return from [MEDICAL TREATMENT]. She acknowledged she had placed a check mark in the box for patency. She admitted , I just look at it to see if it is bleeding. I do not know what thrill or bruit is. I need to look that up. On 6/20/18 at 11:52 a.m., the facility Registered Dietician said Resident #67's phosphorous level was 7.2 (normal range 2.5-4.5) and corrected serum calcium was 10.4 (normal range 8.5-10.2). She said he got his binder with all meals. She said he should take his binders at the time he got the meal. She was not aware of any issues of not getting the medication timely with meals. She said he got the medication from the nurse; for him to take his own medication he would need a physician's orders [REDACTED]. She said she did a nutritional review with him monthly. On 6/20/18 at 3:45 p.m., review of the [MEDICAL TREATMENT] communication forms dated 5/4/18 through 6/20/18 failed to include any information notifying the [MEDICAL TREATMENT] center of the resident's medication refusal or missing doses. On 6/21/18 at 10:30 a.m., the [MEDICAL TREATMENT] Center's Registered Dietician said Resident #67 got his binders from the facility. She said the facility did not tell her Resident #67 refused or missed doses of his binders. She said the resident had told her he had trouble getting his binders on time; he had told her they give it to him way after his meals instead of with his meals. She said she thought his phosphorous was still high because he was missing his binders and he had to take them when he ate. On 6/21/18 at 12:19 p.m., Resident #67 said he did not take a lunch with him to [MEDICAL TREATMENT] because they facility did not send his binder with him. He said he had explained to the nurses on many occasions that he must take the binder with his meals even if it was a snack. He said even this morning (6/21/18) he got his breakfast and it was not until 20-30 minutes after he finished his meal that the nurse brought in his binders. He told her it did not do any good to take them at that time if he was not eating. On 6/21/18, a review of the standard for care coordination in an article by Agency for Healthcare Research and Quality (at http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/) revealed the following: Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences were known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient .