Every finding on record at Sarasota Point Rehabilitation Center

Based on observation, record review and staff interviews, the facility failed to ensure 1 (Dietary Staff B) of 1 dietary staff observed operating the dishwasher was trained, and competent to test the sanitizing solution of the low temp dishwasher to ensure dishes were properly sanitized to prevent foodborne illnesses of residents consuming an oral diet. The findings included: The facility's policy and procedure titled, Testing Sanitizer & Temperature in Low Temp Dish Machines revised 8/2023 noted, Test sanitizing solution and temperature before cleaning each meal's dishes . Test the sanitizer with chlorine test strips obtained by the chemical vendor or food distributor. A proper level is 50 ppm (part per million) chlorine in the rinse water. An appropriated temperature is 120 - 160 F (Fahrenheit) . Record water temperature and sanitizer levels on the Dishwashing Temperature/Sanitizer Record. On 10/24/2024 at 9:20 a.m., during a tour of the kitchen with the Certified Dietary Manager (CDM), Food and Nutrition Aide Staff B was observed using the low temp dishwasher. In an interview Staff B said she has been employed at the facility for 2.5 years and had not received any training or instructions on testing the sanitizing solution of the dishwasher. Staff B said she signed the Dishwashing Temperature/Sanitizer log every day she worked but did not know what the log was for. She said, I just sign it because I was told to. She said she filled in the blanks with numbers on the form but did not know what it was for. The CDM was present during the observation and interview She told Staff B her where the chlorine test strips were kept and began to instruct her on how to test the dishwasher sanitizer. The CDM said she did not know if Staff B had been trained to use the dishwasher. She said Staff B only uses it sometimes and she signs the logbook for the person who is doing the testing. On 10/24/24 review of the Dishwashing Temperature/Sanitizer Record for October 2024 showed Staff B signed the log for 64 of the 67 meals documented. No temperature or sanitizer level was documented for the dinner meal on 10/21/24, 10/22/24 and 10/23/24. On 10/24/2024 at 10:30 a.m., documentation of Staff B's training and competency to test the water temperature and sanitizing solution for the dishwasher was requested. The CDM said she began employment at the facility six months ago. She did not know what training the dietary staff had received but she was working on that. On 10/24/2024 at 12:00 p.m., in an interview the Administrator said Staff B had been trained on using the dishwasher upon hire but did not provide the requested documentation Staff B was trained upon hire and competent to use the dishwasher, including measuring the water temperature and the sanitizing solution level to ensure dishes were properly washed and sanitized.

Based on observation, record review, resident and staff interview, the facility failed to update the care plan to accurately reflect safety precautions for 1 (Resident #30) of 2 sampled residents at risk for elopement. The findings included: Review of the clinical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses included non-Alzheimer's dementia. The Elopement risk evaluations completed on 4/26/24, 5/21/24, and 10/14/24 noted Resident #30 scored 2, indicating the resident was at risk for elopement. Review of the care plan initiated on 5/21/24 and revised on 10/14/24 noted Resident #30 was at risk for elopement. The goal was Attempts to prevent resident from eloping from facility will be provided. The interventions included an alerting bracelet (alerts staff when the resident leaves a designated safe area) placed to the right ankle. The care plan specified to check the alerting bracelet function and placement every day. Review of the Order Summary Report revealed a physician's order dated 10/16/24 to, Check placement of Alerting Bracelet walker every shift for monitoring. The care plan was not updated to reflect the alerting bracelet to the resident's walker. On 10/21/24 at 3:30 p.m., on 10/22/24 at 11:00 a.m., and on 10/23/24 at 11:13 a.m., Resident #30 was observed in her bedroom. The resident was not wearing an alert bracelet to the right ankle. An alert bracelet was observed attached to the resident's rolling walker. On 10/22/24 at 11:02 a.m., in an interview Resident #30 said she used to have an alert bracelet to her right ankle but she used a butter knife to cut it off. On 10/23/24 at 4:57 p.m., in an interview Minimum Data Set Registered Nurse (RN) Staff F said the physician's order and the care plan should match. She verified on 10/16/24 the physician's order for the alert bracelet to the rolling walker. Staff F said the care plan should have been revised to reflect the alert bracelet on the rolling walker. On 10/23/24 5:14 p.m., the MDS coordinator said she verified Resident #30's alert bracelet was attached to the rolling walker and not to the resident's right ankle. She said the care plan was incorrect.

Based on observation, record review, resident and staff interviews, the facility failed to provide care and services in accordance with physician's orders to meet the needs of 1 (Resident #30) of 1 resident observed with edema (swelling) of the legs. The findings included: Review of the clinical record for Resident #30 revealed an admission to the facility of 4/25/24. Diagnoses included heart failure. The physician's orders dated 6/10/24 noted to apply [NAME] hose (compression garment to legs to help circulation and lower swelling) in the morning and off in the evening for edema. The care plan initiated on 4/25/24 noted Resident #30 was at risk for altered cardiovascular status related to hypertension and congestive heart failure. The goal was for the resident to have decreased risk of signs and symptoms of cardiac complications. The interventions included to observe for changes in lung sounds, edema or changes in weight. The care plan initiated on 5/6/24 noted Resident #30 is resistive to care and medications related to adjustment to admission, and new environment, and on 6/10/24 refused to wear the [NAME] Hose. Interventions included to allow the resident to make decisions about treatment regime to provide sense of control, give clear explanation of all care activities prior to and as they occur during each contact. On 10/21/24 at 3:30 p.m., 10/22/24 at 10:53 a.m., and 10/23/24 at 11:13 a.m., Resident #30 was observed sitting in her room with her legs in dependent position. Resident #30 was not wearing the [NAME] Hose. Her legs were swollen. Review of the Treatment Administration Record (TAR) for October 2024 showed on 10/21/24, 10/22/24 and 10/23/24 the nurse placed her initials indicating the [NAME] hose were applied in the morning. On 10/22/24 at 10:53 a.m., in an interview Resident #30 said no one offered to apply the [NAME] hose on 10/21/24 or today (10/22/24). On 10/23/24 at 11:13 a.m., in an interview Resident #30 complained her legs were swollen. She said she has not refused to wear the [NAME] hose, but no one offered to apply them recently. Review of the Medication Administration Audit Report revealed the [NAME] hose were scheduled to be applied at 7:00 a.m. Licensed Practical Nurse (LPN) Staff D documented on the TAR the [NAME] hose were applied on 10/23/24 at 11:57 a.m. On 10/23/24 at 12:25 p.m., Resident #30 was observed in her room. She was not wearing the [NAME] Hose. On 10/23/24 at 1:09 p.m., in an interview Certified Nursing Assistant (CNA) Staff C said she was assigned to care for Resident #30. Staff C said she knew Resident #30 needed the [NAME] hose. The resident did not refuse the [NAME] hose but it slipped her mind and she did not offer to apply the [NAME] hose. On 10/23/24 at 1:23 p.m., in an interview LPN Staff D said the CNAs are supposed to apply the [NAME] hose. She said she did not verify Resident #30 had the [NAME] hose on before documenting on the TAR the [NAME] hose were applied as ordered. On 10/23/24 at 1:30 p.m., Resident #30 was observed in her room. She was not wearing the [NAME] hose to her legs as ordered. Unit Manager Registered Nurse Staff E verified Resident #30's legs were swollen and she did not have the [NAME] hose on. She said staff should not be documenting a treatment before confirming it was completed. On 10/24/24 at 10:30 a.m., in an interview the Director of Nursing said staff should not document a treatment was completed before they confirmed that it was done.

Based on observation of medication administration, record review, staff and resident interviews, the facility failed to ensure 2 (Residents #74 and #38) of 3 sampled residents were free from significant medication error related to the administration of transdermal pain patches. The findings included: 1. Review of the clinical record for Resident #74 revealed a physician's order dated 5/25/23 for Lidocaine (topical anesthetic) External Patch 4%, apply to hip topically in the morning for pain and remove per schedule. Review of the Medication Administration Record (MAR) for October 2024 revealed the Lidocaine Patch was scheduled to be applied every day at 6:00 a.m. and removed every day at 6:00 p.m. The MAR for October 2024 had an order dated 5/12/23 to validate the Lidocaine Patch to the right hip was present every shift. The diagnoses for the Lidocaine Patch was fracture of the right femur. On 10/22/24 at 9:10 a.m., Licensed Practical Nurse (LPN) Staff A was observed administering medications to Resident #74. An undated Lidocaine Patch was observed on the resident's right thigh, near his groin. LPN Staff A said the previous shift applied the Lidocaine Patch. She said the patch should have been applied to the resident's right hip, not his thigh and should have been dated. On 10/22/24 at 10:21 a.m., Resident #74 was observed with the Director of Nursing and the Regional Clinical Director. Resident #74 remained with the undated patch to the right thigh. A Lidocaine Patch dated 10/18/24 was observed to the resident's left thigh. Review of the packaging for the Lidocaine patch revealed a warning label that said, Do not use more than one patch on your body at a time . Do not use more than one patch in a 12-hour period. Maximum 2 patches per day. Photographic evidence obtained. 2. On 10/22/24 review of the clinical record for Resident #38 revealed a physician's order dated 9/28/24 to apply a Lidocaine Patch 4% topically to the resident's right shoulder in the morning for pain and remove at bedtime, remove per schedule. Review of the MAR for October 2024 revealed the Lidocaine Patch was scheduled to be applied every day at 6:00 a.m., and removed at 5:59 p.m. The MAR noted the Lidocaine Patch was applied as ordered on 10/22/24 at 6:00 a.m. On 10/22/24 at 10:40 a.m., in an interview Resident #38 said she felt the Lidocaine Patch was just cold and did nothing to help her pain. She said she had not used the Lidocaine Patch in about 10 days. Resident #38 showed a patch to her right shoulder which she said was a Thermacare Patch. She said Physical Therapy applied the Thermacare patch to her right shoulder which worked better. The Director of Nursing and the Regional Clinical Director were present during the interview, and observation. Review of the facility policy and procedure titled Medication Pass and Med Pass with Medication Cart Updated 8/14/24 noted to, Complete documentation on the medication MAR. Record the name, dose, route, and time of medication on the Medication Administration Record. Initial the record after the medication is administered to the resident. Record the reason for not administering the medication. On 10/22/24 at 10:45 a.m., the DON said there was no separate policy for transdermal patches, but the process was patches should be dated on the day they are placed. She said she was not aware of an order for Resident #74 to have a patch on his left thigh and the Lidocaine Patch should not have been left in place for four days. She also agreed Resident #38's MAR documented the patch as given and it was not in place on Resident #38's shoulder. The Regional Clinical Director said transdermal patches should be dated when applied.

Based on observation and interview, the facility failed to ensure a safe, functional, sanitary and comfortable environment for residents, staff and the public in 3 (Halls 100, 300 and 400) of 4 halls observed. The findings included: During a tour of the facility on 6/4/24 multiple environmental issues were observed, including: Common hallways with tiles cracked, missing or stained throughout the building. Photographic evidence obtained The hallway handrail near the activity director room was missing with an exposed nail. Photographic evidence obtained rooms [ROOM NUMBER] were observed with damage to the wall near the window and electrical outlet for the air conditioning unit with wall plaster missing, cracked, peeled paint and dirty surfaces. Photographic evidence obtained Rooms 330, 105, 328 and 408 had cracked tiles in the residents' rooms and bathrooms. photographic evidence obtained room [ROOM NUMBER]'s bathroom had plaster missing off the wall and peeled paint. Photographic evidence obtained room [ROOM NUMBER] had the walls scraped, and plaster missing with a dirty surface. photographic evidence obtained Multiple areas throughout building had warped and/or missing cove base with exposed, cracked plaster and dirty surfaces including the hallway near exit door by room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. Photographic evidence obtained On 6/4/24 at 12:08 p.m., in an interview Resident #5 said they recently they went through and repainted the hallways. She said the hallways looked beautiful but the resident rooms could use some love. She said the cover base in her room had been peeled away for quite some time and they had told her when they fixed the hallways it would be fixed, but it never was done. On 6/4/24 at 10:07 a.m., in an interview the Maintenance Director said he had only been with the facility for two months. He said corporate had just had the building painted and were in the works of having the floors and shower rooms redone. The Maintenance Director said there were only two people in the building working maintenance and they were responsible for all the sheet rock repairs and painting. On 6/4/24 at 12:41 p.m., in an interview the Administrator said they had painted the hallways but maybe should have addressed floors first. She agreed with the surfaces disrupted in the various materials (plaster, cove base, cracked tiles) there was no way to thoroughly clean and it could pose infection control issues.

Based on record review, review of facility's incidents, and policy and procedure, resident and staff interview, the facility failed to protect residents' right to be free from abuse for 1 (Resident #1) of 3 sampled residents reviewed. Resident #1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (mental health condition causing dramatic shifts in mood), and alcohol abuse. On 3/10/23 Resident #1 was agitated and shoving his walker at Certified Nursing Aide (CNA) Staff C. Therapy Staff observed CNA Staff C raise his right hand and made contact with the left side of the resident's face. The findings included: The facility's Abuse, Neglect and prohibition policy with a date effective 10/24/22 noted, Each resident has the right to be free of mistreatment, neglect, and abuse . Physical abuse includes hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder and ETOH (alcohol) abuse. The care plan initiated on 3/10/23 noted Resident #1 had behaviors of cursing at staff, using racial slurs, and spitting at staff. The goal was for the resident to demonstrate effective coping skills. The interventions included anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Evaluate for side effects of medications. Give as many choices as possible about care and activities. Medications as ordered. Psychiatric evaluation as needed. Review of the facility's incidents investigations revealed on 3/10/23 at 10:35 a.m., Occupational Therapist (OT) Staff A and Physical Therapist (PT) Staff B reported they were in Resident #1's room to provide therapy services while Certified Nursing Assistant (CNA) Staff C was assisting the resident to get out of bed. Both therapists reported they observed Resident #1 sitting on the edge of the bed with the walker in front of him. CNA Staff C was standing to the resident's left side and the resident was repeatedly picking up the walker and slamming it back down on the floor. Both therapists reported they observed CNA Staff C raise his right hand and mad contact with the left side of the resident's face. The therapists did not hear any noise with the contact they observed. They then observed CNA Staff C immediately exit the room. Both therapists reported Resident #1 said, Did you see him hit me? That's abuse. On 3/10/23 at 10:40 a.m., the Nursing Home Administrator documented she interviewed CNA Staff C who reported he was in Resident #1's room providing personal care. CNA Staff C stated throughout the morning the resident had been swearing at him and calling him, the N-word. CNA Staff C reported therapy personnel entered the resident's room as he was assisting him up to the edge of the bed. Resident #1 took the walker that was in front of the bed as he sat up and was shoving it at him and hitting him in the groin repeatedly. CNA Staff C stated the resident was yelling to get the fuck out of the way. He reported he was to the resident's left side. CNA Staff C said Resident #1 continued to call him the N-word and hit him with the walker. He reacted and pushed against the left side of the resident's head with his right hand. CNA Staff C described the action as pushing with mild force and stated it was a reflex after being hit with the walker in the groin area. CNA Staff C was immediately removed from the facility with statement obtained and sent home. The investigation noted Registered Nurse (RN) Unit Manager completed a head to toe skin assessment on 3/10/23 with no injury noted. Resident #1 reported a mild headache to the RN Unit Manager on 3/10/23 around 11:00 a.m. On 3/13/23 the Clinical Psychologist documented Resident #1 reported that he was abused by the staff and documented a diagnosis of Acute Stress reaction. On 3/20/23 at 12:46 p.m., OT Staff A stated she and PT Staff B were going to do an evaluation, CNA Staff C was already present in the room when they got there. The CNA was attempting to get Resident #1 out of bed. The resident was agitated, had come to sitting part of the way, and became more frustrated. The CNA was standing next to the bed bedside the walker. The patient became agitated, took the walker and was slamming it down on the floor. The CNA said the walker hit him. That's when he took his right hand and hit the resident with an open hand. OT Staff A said she did not hear any sound but saw the resident kind of move in a backward motion. CNA Staff C walked out of the room. He just said, I am sorry, and walked out in general. On 3/20/23 at 12:46 p.m., PT Staff B said she saw the same thing OT Staff A reported. She said they made sure Resident #1 was toileted and safe then went directly to the Administrator and gave their statements. Resident #1 did not voice any complaint about his head hurting. There were no marks on the resident's face. She said, We did not hear a slap noise as you hear when someone is slapped. It just happened so fast. On 3/20/23 at 3:30 p.m., Resident #1 was observed in his room. The resident asked the surveyor if she's heard about, the guy hitting him. He said, I get very anxious, and I do have issues with mood. I yell when I am angry, and these people need to be put in their place. The resident added, I like things done a certain way, half of these people I don't even want them in my room, period!. Resident #1 said he felt safe after CNA Staff C was sent home.

Based on record review, review of the facility's policies and procedures, observation, staff, and resident interview the facility failed to promptly obtain needed dental services for 1 (Resident #18) of 1 resident reviewed with repeated requests to see a dentist for dental pain. The findings included: The facility policy Dental Services SHC .08 revised 8/29/2017 read, The facility provides each resident with access to dental services. Residents will be referred to a dentist based on assessed need. The facility will obtain services of a qualified dental provider.Basic services will be provided in-house. Facility staff will assess dental status through the interdisciplinary resident assessment process and daily provision of care. The physician, residents and family/responsibility party may request dental services at any time . Social Services designee will be responsible for coordinating dental services in the facility. Review of the clinical record revealed Resident #18 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment with a target date of 12/29/21 noted Resident #18 had no natural teeth or tooth fragments (edentulous). The Quarterly MDS assessment with a target date of 6/29/22 noted the resident scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The care plan initiated on 12/20/21 noted Resident #18 had dental health problems related to being edentulous. The goal was for the resident to be able to eat and drink free of pain through the next review date. The interventions included to monitor for signs and symptoms of oral/dental problems such as pain to gums, toothache, palate, abscess, teeth missing, loose, broken, eroded, decayed. Coordinate arrangements for dental care, transportation as needed/ordered. On 8/29/22 at 2:30 p.m., Resident #18 said for the past eight months she has repeatedly asked to see a dentist since her admission to the facility. The Resident said she had missing teeth and her gums hurt. Observation of the resident's mouth on 8/29/22 at 2:35 p.m., with her permission showed red gums and small pieces of damaged teeth. Resident #18 said she has not seen a dentist since her admission to the facility. On 8/31/22 at 10:38 a.m., Resident #18 said she has pain when chewing and when the food goes into the open pockets in her gums. The staff give her Tylenol, but feels she needs something stronger. Resident #18 said her brother has also called to find out why they have not done anything with her teeth since she has been here for almost a year. Resident #18 said she spoke to the social worker again one week ago about her teeth and seeing a dentist. Review of progress notes revealed on 4/1/22 the dentist documented, Unable to locate patient-attempted twice. On 5/2/2022 the dental hygienist documented Resident #18 stated she has pain all over and would like dental care. Finding/Observation: . Possible fistula (abnormal passage) #7 facial, generalized root tips and severe gingival (gums) redness and swelling. Very large bilateral mandibular [NAME] (bumps in both sides of the lower jaw made of bone tissue covered by gum tissue). She needs to be seen by a dentist and have radiographs to review. On 6/7/22 the dental hygienist documented Resident #18, stated she has pain all over and would like dental care. Finding/Observation: . She pointed to the root tips on the upper anterior and 31 area root tip. She expressed more interest in the area on the lower right (31) causing pain. She asked about pain medication. The floor nurse stated she will administer Tylenol. Informed the floor nurse she needs the dentist to examine and radiographs to determine treatment plan. I stressed the need for the dentist to examine the patient. Informed the resident of severe gingival swelling and redness especially lower right . Possible fistula #7 facial, generalized root tips and severe gingival redness and swelling . On 9/1/22 at 8:57 a.m., the Social Services Director said the dentist and or the dental hygienist are at the facility every month. He confirmed Resident #18 had not seen the dentist since her admission on 12/20/2021 and said, I apologize for that. He said since Resident #18's admission, the only intervention implemented for her dental issues/pain was Tylenol. The Social Services Director said there was no system in place to follow up and ensure residents who need dental services were seen by the dentist. He said Resident #18 asks him to see the dentist almost every day. He has sent multiple emails to the dentist on her behalf. On 9/1/22 at 9:53 a.m., Certified Nursing Assistant (CNA) Staff H said Resident #18 complains of teeth pain at least twice a week and she informs the nurses. On 9/1/22 at 12:04 p.m., the Director of Nursing (DON) said she was aware of Resident #18's requests to see the dentist. She said, She did ask me to see the dentist. The DON said she thought the resident's request for dental care was being addressed. The Administrator who was present during the interview said, I am not the person to ask about a reasonable time frame when asked about suitable time frame to see a dentist. The DON said they will have Resident #18 see the dentist immediately.

Based on record review, review of facility's policies and procedures, staff and resident interviews , the facility failed to immediately report an alleged violation that could constitute neglect within specified time frame to the State Survey and Certification Agency for 1 (Resident #75) of 3 residents reviewed for incidents. The findings included: The Facility policy titled, Incident Reporting for Residents or Visitors revised 1/13/2017 noted, All accidents and unusual occurrences involving a resident or visitor will be documented and reported so as to meet all regulatory (state and federal) . requirements. Unusual Occurrence or Event. Any event not consistent with routine resident care; Any event reportable to federal and state agencies as defined by those agencies; An event or happening involving a resident . with unintended, undesirable, or unexpected results or outcomes. Review of the clinical record revealed Resident #75 was admitted to the facility on [DATE]. The 5-day scheduled Minimum Data Set (MDS) assessment with a target date of 8/24/2022 noted Resident #75 scored 15 on the Brief Interview for Mental Status, indicating intact cognition. Resident #75 required extensive physical assistance of two persons for transfers (How resident moves between surfaces, including to and from bed, wheelchair). The Care Plan initiated on 12/8/21 noted Resident #75 was at risk for falls related to impaired mobility secondary to [CONDITION(S)] (paralysis of the lower body) due to lumbar [CONDITION(S)] (inflammation of bone caused by infection). The care plan was revised on 2/7/22 and documented, Fall with injury noted. On 2/13/22 the care plan noted Hip fractured [sic] noted via radiology report. The facility's investigation for the incident of 2/7/22 included a typewritten statement dated 2/8/22 noting Resident #75 was interviewed related to the pain in his leg. Resident #75 stated during the transfer via the Hoyer lift (Total body electric lift) he was uncomfortable and demanded to be lowered to the floor. When lowered to the floor his right leg was to the right side of the lift and while on the ground he noted to be in pain. The Nurses Progress Note dated 2/8/22 at 10:03 a.m., noted Resident #75 reported pain to the right lower extremity. Resident has been medicated with routine pain medications per orders. The physician was notified, and new orders received to send the resident to the emergency room for evaluation and treatment. The Emergency Department physician's note dated 2/8/22 at 10:41 a.m., noted Resident #75 stated at his nursing facility staff was trying to lift him with a Hoyer lift and his leg got caught resulting in significant amount of pain in his right anterior thigh. concerned because this morning he woke up with excruciating leg pain and increasing swelling. The X-Ray of the pelvis dated 2/8/22 noted, Clinical Indication: Fall. Hip pain. Result: Generalized osteopenia (reduced bone mass). No acute fracture or dislocation is seen. The Nurses Progress Note dated 2/8/22 at 3:09 p.m., noted Resident #75 returned from the hospital with no acute changes. No acute fractures found from the X-ray. The Nurses Progress Note dated 2/13/22 at 3:30 p.m., noted Resident #75 called EMS (Emergency Medical Services) to be transferred to the hospital, due to pain. The Hospitalist History and Physical report with a date of service of 2/13/2022 noted Resident #75 . presented to the Emergency Department with complaints of right thigh pain. Patient was dropped while trying to move into a Hoyer lift, after which he developed right thigh pain. Patient was seen in the Emergency Department about 4 days ago where he had an x-ray and venous doppler were both negative for acute findings he was discharged back to the nursing facility. CT (Computerized Tomography) right hip subcapital right femoral neck fracture. and soft tissue swelling . On 8/29/2022 at 11:25 a.m., Resident #75 said he sustained a broken right femur on February 7, 2022, when he was dropped from the Hoyer lift. The resident said four staff members manually picked up each corner of the Hoyer sling. The sling slipped out of their hands, and he was dropped to the ground. He said he immediately felt pain. Resident #75 said he was sent to the hospital on 2/8/22 but the right hip X-ray came back negative for a fracture. He was discharged back to the facility but continued to have pain and bruising to his right upper leg. He continually complained of pain to everyone, including his doctor on 2/13/22. Resident #75 said he called 911 himself on 2/13/22 because he was in severe pain. The CT scan done at the emergency room showed a right femur (thigh bone) fracture. On 8/30/2022 at 10:45 a.m., the Administrator said the facility did not report the incident to the State Survey Agency. He said Resident #75 was not dropped, he was lowered to the ground. He said there was no documentation of the incident in the Resident's medical record. He said he conducted a full investigation after the incident. The resident told him he was flailing in the Hoyer lift and asked to be lowered to the ground. After landing on the ground, he developed right upper leg pain. He said the resident then agreed to let staff move him from the floor to the bed using the Hoyer lift. He said the resident was complaining of pain the next morning, so he was sent to the hospital for evaluation. He said his first x-ray report was negative. The incident was never reported to anyone by the involved staff. The Administrator said he concluded the incident was not avoidable, so it was not reported.

Based on observation, clinical record review, and staff interviews, the facility failed to ensure its medication error rate remained below 5%. Three errors occurred while observing five licensed nurses on two different shifts with 27 medication administration opportunities. Three medication errors were identified resulting in an 11.11% error rate. The failure to administer medications as per the pharmacy labeling and manufacture guidelines placed the residents at risk for harmful errors, sub-optimal therapy, or pharmacological effects. The findings included: Facility policy SHCRC .01 Medication Pass Guidelines (revised 4/25/2017) specified The nurse is responsible to read and follow precautionary or instructions on prescription labels and Check the Do Not Crush list before crushing medications. 1. On 2/1/21 at 10:15 a.m., the Director of Nursing (DON) was observed administering nine different medications to Resident #486 including [MEDICATION NAME] 90 micrograms inhaler (used to prevent and treat shortness of breath), and Trelegy EL (100-62.5-25) inhaler (used for chronic lung conditions). The DON handed the [MEDICATION NAME] to Resident #486 who inhaled two puffs without pausing between puffs. The DON immediately handed the Trelegy to Resident #486 who inhaled one puff of the medication. Review of the pharmacy label for the [MEDICATION NAME] inhaler revealed instructions to wait 1 minute between puffs. **Photographic evidence obtained** Review of the pharmacy label for the Trelegy inhaler revealed to rinse the mouth after using the Trelegy. Rinsing the mouth and spitting out the water prevents oral thrush, a fungal infection of the mouth. **Photographic evidence obtained** On 2/3/21 at 11:30 a.m., in an interview the DON confirmed she did not instruct Resident #486 to wait one minute between puffs of the [MEDICATION NAME] inhaler and did not instruct the resident to wait one minute between use of the two inhalers. The DON confirmed she did not instruct Resident # 486 to rinse his mouth after using the Trelegy inhaler as directed on the medication label. 2. On 2/3/21 at 9:15 a.m., Licensed Practical Nurse Staff U was observed administering eight medications to Resident #27 including Aspirin [MEDICATION NAME] Coated (coating to prevent stomach ulcers and bleeding and is not to be crushed) 325 milligrams tablet. Staff U placed the [MEDICATION NAME] coated aspirin into a plastic pouch with other pills to be administered and crushed them together. Staff U verified she crushed the [MEDICATION NAME] coated aspirin.

Based on observation, record review and interview the facility failed to maintain evidence of investigation and resolution of expressed grievances for 1 (Resident #60) of 6 residents reviewed for grievances. The findings included: Review of the facility's policy 'Grievances' (revised 10/30/19) read: 2. Grievances may be submitted orally or in writing; they may be submitted anonymously. The resident, or anyone acting on their behalf submitting the grievance, should be encouraged to utilize the Grievance Report. When a grievance is submitted orally, the facility employee accepting the grievance must document it on the Grievance Report. 5. The Grievance Official will document receipt of all grievances on the Grievance QAPI Log. 7. The Grievance Official will review the conclusion with the person investigating the grievance to determine what corrective actions need to be taken. 8. The resident, or anyone acting on their behalf filing the grievance, will be communicated with regarding the conclusion of the investigation and the corrective actions that will be taken. On 2/1/21 at 10:30 a.m., in an interview Resident #60 said she was unhappy due to Certified Nursing Assistant (CNA) Staff K assigned to her care. Resident #60 said she and her Power of Attorney (POA) had asked numerous times that she be removed from CNA Staff K's assignment. She said CNA Staff K was rough with her and had an attitude. She said it was most recently addressed the previous week. On 2/2/21 at 11:37 a.m., in an interview Resident #60 said she was unhappy due to CNA Staff K being assigned to her for the day. On 2/2/21 at 11:50 a.m., observation of assignment board at the nurse's station showed CNA Staff K was assigned to care for Resident #60. On 2/2/21 at 1:04 p.m., during a telephone interview Resident #60's designated power of attorney (POA) expressed concerns over CNA Staff K caring for Resident # 60. She said because of complaints Resident #60 felt uncomfortable with this CNA. The POA said she had taken the concern to the Administrator numerous times, most recently the prior week. The Administrator said CNA Staff K would no longer be assigned to care for Resident #60. On 2/2/21 at 4:09 p.m., during an interview Social Services Director Staff V said he was working part-time in facility and the Administrator had been handling grievances. SSD Staff V said the normal process dealing with complaints and grievances was anyone can write a grievance. When he hears of a grievance in morning meeting, he talks to the resident, identifies the matter, and hands it to appropriate authority to address. Once the investigation is completed, he reviews it and then it would go to the Administrator. On 2/2/21 at 4:50 p.m., during an interview the Administrator said he was not aware of any grievances regarding staff members. He acknowledged he spoke with Resident #60's POA the prior week regarding a concern involving a CNA but did not have a name and felt this was not a grievance. On 2/2/21 at 5:33 p.m., during an interview the Administrator said he had just gone to speak with Resident #60 who confirmed concerns regarding Staff K. He said if he had been told this last week, he did not take notes of conversation, and did not feel it was a grievance. He says he did not write it down, but possibly made staffing aware to remove her from schedule. On 2/3/21 at 9:53 a.m., during an interview CNA Staff K said she has gone to Director of Nursing (DON) numerous times regarding allegations made against her by Resident #60. CNA Staff K said the Unit Managers and the scheduler were also aware of allegations made by Resident #60 against her. CNA Staff K said the DON had told her that Resident #60 was on a lot of psych meds and to take a witness in when dealing with her. On 2/3/21 at 11:05 a.m., during an interview the Clinical Resources Coordinator Staff L said she was responsible for making the schedule and she was not aware any resident in the facility had requested not to have a certain CNA assigned to them. On 2/3/21 at 11:15 a.m., SSD Staff V said he was made aware of a grievance regarding Resident #60 and CNA Staff K last evening, at which time he went to speak with her. On 2/3/21 at 11:27 a.m., during an interview Registered Nurse Unit Manager Staff S said it was very well known Resident #60 had requested CNA Staff K not be assigned to her. On 2/3/21 at 11:44 a.m., during an interview Licensed Practical Nurse Staff M said she was aware Resident #60 on numerous occasions had requested CNA Staff K to not be assigned to her, and this had been discussed many times with the DON over the past months. On 2/3/21 at 1:27 p.m., during an interview the DON said she was made aware of an issue with Resident #60 and CNA Staff K last Thursday or Friday, and it was addressed at that time. The DON said Resident #60 never told her she did not want CNA Staff K to care for her, Resident #60 told the Administrator.

Based on observation and staff interview, the facility failed to secure medications in 2 of 3 (Lido and Siesta halls)) medication carts reviewed. The facility also failed to have a system of record keeping ensuring an accurate inventory and reconciliation of controlled substances stored for destruction. The findings included: 1. On 2/1/21 at 11:00 a.m., observation of the Lido 2 medication cart with Licensed Practical Nurse (LPN) Staff U revealed five whole unidentified pills and four half tablets of unidentified pills in drawer of the medication cart. LPN Staff U confirmed the observation of loose, unidentified pills in the drawers. Photographic evidence obtained. 2. On 2/1/21 at 11:42 a.m., the medication cart on the Siesta hall was observed unlocked and unattended. Several staff and 2 residents were observed passing by the unlocked cart. The cart contained medications used for residents on the Siesta hall. On 2/2/21 at 11:47 a.m., the Director of Nursing confirmed the medication cart was unlocked and unattended. She proceeded to lock the cart. Photographic evidence obtained. 3. On 2/2/21 at 4:00 p.m., LPN Staff R was observed going into Resident #70's room to administer medications. LPN Staff R left a medication card of [MEDICATION NAME] (used to treat muscle spasms) 2 milligrams unlocked, unattended and out of her line of vision on top of the Lido 2 cart. The medication was easily accessible to several residents observed, walking or wheeling themselves past the unsecured medication. 4. On 2/3/21 at 11:30 a.m., the process for reconciliation and disposition of controlled substances was reviewed with the Director of Nursing (DON). The DON said she counted and reconciled each medication with the count sheet with the nurse then locked all controlled substances in a file cabinet in her office. The DON said she was the only one with access to the file cabinet. The pharmacist came in monthly to count and destroy the controlled substances with her. The DON said she did not have a way to reconcile the medications or quantity of controlled substances in the locked cabinet.

Based on observation and staff interview the facility failed to maintain the laundry room and laundry equipment in a safe and sanitary manner. This has the potential for the spread of infection to residents and possible injury to staff. The findings included: On 3/12/20 at 11:40 a.m., during a tour of the laundry area with the facility's Infection Control Preventionist, observation revealed the entrance to the clean side of the laundry area is from a heavy, metal door to the outside air. The door could not be closed and there was a noticeable gap below the bottom edge of the door where daylight was clearly visible. This has the potential to allow insects and other environmental factors to enter and possibly contaminate the clean linen. The air vents and duct work discharging air into the clean side of the laundry area were dirty with black, brown and pink residue. The vent was coated with a black residue with the appearance of bio-growth. The edge of the vent was spotted with rust. The duct work had splotches of brownish and pink residue. The light fixtures had metal corrosion. The chain and conduit to the light fixture had an accumulation of lint and dust. There was a piece of sheet metal hanging from the air vent that was held in place by a corroded screw or bolt and had the potential to fall and injure staff members. The baseboard was pulled away from the wall and a hole is broken through the wallboard on the dirty side of the laundry area, providing possible access for pests and contaminates. Leaking connectors for the tubing from the chemical vats to the washing machines had caused corrosion of the equipment and left a white powdery residue. This corrosive residue subjects' linens and staff to contact with a potentially caustic substance. Chemical leaks have the potential for not providing the correct amount of cleaning and disinfecting product for the wash cycle. On 3/12/20, during the tour of the laundry area beginning at 11:40 a.m., the Infection Control Preventionist confirmed the observations noted in the laundry room. ** photographic evidence on file **

Based on observation, record review, resident and staff interview, the facility failed to ensure appropriate alternatives were attempted prior to use of side rails for 4 (Residents #10, #31, #75, and #297) of 6 residents reviewed for side rail use. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: On 6/19/19, review of the facility's Policy and Procedure on Side Rail Usage, effective 4/24/18 indicated the facility will attempt to use appropriate alternatives prior to the use of side rails. Prior to installation, the facility must obtain informed consent prior to the use of bed rails. 1. On 6/18/19 at 10:03 a.m., ¼ rails were noted in the up position on the bed of Resident #10. On 6/19/19, record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the bed of Resident #10. 2. On 6/18/19 at 10:05 a.m., ¼ rails were noted in the up position on the bed of Resident #31. On 6/19/19, record review revealed Resident #31's consent form on 3/13/18, the representative did not consent for the use of bedrails. Screen done by facility on 1/24/19 at 18:12 p.m., showed no rails at this time. On 6/19/19 at 10:40 a.m., Unit Manager Staff O confirmed Resident's #31 side rails were up. 3. On 6/17/19 at 11:41 a.m., Resident #297 was observed lying in bed with 2 half bed rails raised on both sides of the bed. The resident's feet were in contact with the foot board. The resident said he was just admitted yesterday afternoon. He said the bed rails were so he won't topple out of bed as he was over 6 feet tall, weighed 250 pounds, and didn't fit the bed. The resident said he did not remember anyone talking to him about the rails or being offered any interventions. He did sign a consent for them. Resident #297's clinical record was reviewed, and a consent was signed for the use of bed rails on 6/16/19. There was no evaluation for the bed rails, bed environment, or evidence of other alternatives being offered and/or attempted prior to the use of rails. On 6/17/19 at 1:24 p.m., Licensed Practical Nurse Staff M confirmed no evaluation for the safe use of bed rails had been completed for Resident #297. 4. On 6/17/19 at 3:19 p.m., Resident #75 was observed lying in bed with 2 half bed rails raised on both sides of the bed. The resident said the bed rails were to help her turn. She was not sure if the rails were already on the bed and did not recall anyone discussing the risks with her or signing any consent. Resident #75's clinical record was reviewed and indicated the resident was admitted on [DATE]. A consent for use of side rails was signed on 2/18/19 by the resident's representative. An admission assessment including a Side Rail Screen was completed on 2/19/19 indicating the resident preferred rail(s) up. There was no evidence of other alternatives being offered or attempted prior to the use of bed rails or the resident being made of the risks associated with the use of bed rails. On 6/18/19 at 1:47 p.m., Certified Nursing Assistant (CNA) Staff H said the rails were on the beds and if the resident wanted them up, she would raise them. On 6/18/19 at 3:05 p.m., CNA Staff J said in the evening, she put the side rails up when residents went to bed. Staff J said she did this for all of of the residents and was not aware of any resident who was not supposed to have them. On 6/19/19 at 3:40 p.m., reviewed concern with no evidence of alternative interventions being offered or attempted prior to use of the bed rails with the Director of Nursing (DON). She confirmed the side rail screen and offering this option was still part of admission process. The DON acknowledged this gave no time to assess the resident for alternatives to bed rails if they were being used upon admission to the facility.

Based on observation, menu review, and staff interview, the facility failed to ensure 46 residents who chose the main entrée at lunch out of 88 residents who consumed oral diets received an adequate amount of the entrée for lunch. The failure could potentially cause significant unintentional weight loss. The findings included: On 6/19/19 at 11:13 a.m. through 12:39 p.m., during the lunch tray line observation, 37 of the 70 residents on regular diets, 9 of the 15 residents on mechanical soft diet, and 4 of 4 residents on pureed diets who chose the main entrée as listed on the resident diet information form provided by the facility did not receive an adequate amount of the entrée for lunch. Those residents were served a #8 scoop (4 ounces) instead of 6 ounces of spaghetti sauce as listed on the menu. This was confirmed by the Dietetic Technician, Registered at 12:05 p.m. on 6/19/19.

Based on observation, staff interview and policy review, the facility failed to ensure the food service staff washed or sanitized their hands between tasks while serving food to 88 residents on oral diets as listed on the resident diet information form provided by the facility. This failure could cause contamination to the food served to the residents. Review of Policy SHCO .04, Infection Control, Hand Washing/Hygiene, Chapter Infection Control, revised 2/20/18 revealed, The facility considers hand hygiene the primary means to prevent the spread of infections and provides guidance to perform hand hygiene. This policy is in accordance with national standards from the Centers of Disease Control and Prevention and the World Health Organization. On 6/19/19 at 12:15 p.m., during observation of the lunch tray line, Diet Aide Staff F picked up a meal ticket that had fallen to the floor and put it on a meal tray and continued serving on tray line without handwashing/hygiene. On 6/19/19 at 12:25 p.m., during observation of the lunch tray line, Diet Aide Staff G was standing on tray line with her arms crossed with one hand on the other upper arm and the other under her arm pit. She then leaned on the tray line with the same stance with her clothes touching the tray line. She continued serving on tray line without handwashing/hygiene. On 6/20/19 at 1:16 p.m., during interview, Staff Development Coordinator said the kitchen staff use the same policy as the rest of the facility for handwashing.

Based on record review, family member and staff interview, the facility failed to assess, evaluate, and plan care to provide individualized approaches to restore as much normal elimination function as possible for 1 (Resident #6) of 1 resident with the identified problem of a decline in bladder incontinence. The findings included: The facility's policy SHCRC2007.02, Bladder Elimination Evaluation Form, revised on 8/29/17; indicated the basic evaluation related to urinary incontinence included a history of bladder function. identification of possible causes of urinary incontinence, a urinalysis, and if necessary simple tests of the lower urinary tract function may be required. Type of incontinence such as: urge, stress, overflow or functional. Care plan interventions as appropriate. A quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE], indicated Resident #6 was continent of bladder and required staff supervision with toileting. On 6/7/19, an annual MDS was completed and indicated the resident was now occasionally incontinent of bladder. The Care Area Assessment worksheet for the triggered area of Urinary Incontinence indicated the decision was to proceed to care plan this problem as the resident had episodes of urinary incontinence and did not always voice the need to toilet. Wore an adult brief to protect clothes and dignity and was at risk of a urinary tract infection. Would proceed to care plan for urinary incontinence with nursing interventions. On 6/17/19, Resident #6's care plan and Certified Nursing Assistant (CNA) Kardex was reviewed. No care plan had been developed to address the resident's problem of incontinence, to include a measurable goal and approaches to help the resident maintain his highest level of continence and to prevent decline. There was no toileting plan in place for the resident on the CNA Kardex. CNA task documentation for Resident #6's bladder function was reviewed from 4/1/19 through 6/18/19. The documentation indicated the resident was incontinent on 34 occasions mostly on the day and evening shifts. On 6/17/19 at 11:02 a.m., in an interview with Resident #6's family member, she said the resident had been incontinent and going in his pants more. She did provide a brief for him and was not aware of any toileting program to help with this problem. On 6/18/19 at 1:44 p.m., CNA Staff H said Resident #6 liked to be independent but got off balance when walking. She did assist with toileting and would ask if he had to go to the bathroom. Staff H said the resident did wear a brief as he was sometimes incontinent. On 6/19/19 at 1:54 p.m., CNA Staff K said Resident #6 had occasional incontinence of bladder. He might take himself to the bathroom and not make it, so was incontinent in his brief. Staff K said she had to help him with personal hygiene and he needed help with his brief. An Incontinence Evaluation Form was completed by Registered Nurse (RN) Staff I on 6/3/19, indicating Resident #6 was continent of bladder. The section identifying the type of incontinence, if resident was a candidate for bladder retraining, and care plan initiated were all left blank. On 6/19/19 at 2:00 p.m., RN Staff I confirmed she completed an Incontinence Evaluation Form for Resident #6 on 6/3/19. Staff I said the resident was not incontinent and just needed assistance to go to bathroom. Staff I said the reason she left several of the questions blank was due to resident not being incontinent. On 6/19/19 at 2:11 p.m., MDS Staff L confirmed the MDS for Resident #6 was accurately coded to reflect episodes of occasional incontinence for the 7 day review prior to the 6/7/19 assessment. Staff L confirmed she did not develop a care plan based on any assessment or evaluation of the resident's incontinence to include a specific goal and individualized approaches to improve and maintain the resident's urinary function.

Based on observation, record review and interview, the facility failed to provide oxygen as ordered by the physician for 1 (Resident #297) of 1 sampled resident reviewed for respiratory care. The facility identified a total of 9 residents received oxygen therapy. This failure had the potential to cause complications from excessive oxygenation in residents with respiratory issues. The findings included: The facility's policy SHCRC2005.02A, Oxygen Administration via Concentrator, revised on 4/24/18; was to turn the proper flow rate as ordered by the physician. On 6/17/19 at 3:03 p.m., observed Resident #297 lying in bed, with continuous oxygen therapy by concentrator unit via nasal cannula (tubing that delivers oxygen directly into nasal passages) in use. The concentrator unit was plugged into the wall and set at a flow rate slightly above the 3 liter line. Resident #297 said he used oxygen all the time when he was at home. On 6/17/19 at 3:25 p.m., record review for Resident #297 revealed a [DIAGNOSES REDACTED]. On 6/18/19 at 2:10 p.m., and again on 6/19/19 at 9:46 a.m., observed Resident #297 in bed with a nasal cannula and continuous oxygen therapy by concentrator in use. The flow rate was checked and observed to be flowing at a rate slightly above the 3-liter mark. On 6/19/19 at 9:48 a.m., Registered Nurse Staff I also observed the oxygen flow rate was currently set over 3 liters for Resident #297 and said she would check the order. Staff I confirmed the resident's physician had ordered the oxygen at 2 liters and she would notify the physician the resident had been receiving oxygen at a higher rate than ordered.

Based on observation, record review, family and staff interview, the facility failed to document clinically pertinent rationale for the use of psychoactive medications that may be causing an adverse reaction, sedation for 1 (Resident #10) of 4 residents reviewed for psychoactive medication side effects. The findings included: Review of the facility's Policy and Procedure for [MEDICAL CONDITION] Medication Assessment and Monitoring, revised on (MONTH) 30, 2108, states documentation of progress or lack of progress to the dose reduction, in the progress notes. Review of Resident #10's clinical record revealed physician's orders [REDACTED]. Medication records for Resident #10 showed an order for [REDACTED].#10's son said he had asked facility to decrease her medication due to her increased sedation. On 6/14/19 at 13:21 p.m., nurses note states Son and Daughter in law in facility to visit resident. Met with this writer to discuss her medication and lethargy. Requested to decrease some meds to hopefully boost mom. Orders as of 6/14/19 in medication records: Trazadone order was decrease to 50 mg twice a day; [MEDICATION NAME] 300 mg twice daily remained the same; [MEDICATION NAME] was decreased to 0.25 mg was twice a day; and [MEDICATION NAME] 7.5 mg at bedtime added to medication profile as of 6/14/19. Resident #10 was observed sleeping; on 6/17/19 at 10:35 a.m., 12:35 p.m., and 2:52 p.m., on 6/18/19 at 8:27 a.m. and 10:02 a.m., on 6/19/19 at 8:41 a.m. and 12:00 p.m On 6/19/19, review of nurses notes for Resident #10 showed no documentation of monitoring residents side effects on decreased medication. Medication Administration Record [REDACTED]. No notes related to sedation found documented on medication administration records. On 6/20/19 at 9:20 a.m., the Unit Manager (UM) Staff O confirmed there no documentation in the progress notes after 6/14/19.

Based on observations, and staff interviews, the facility failed to maintain the laundry room in a clean manner. The failure to maintain a clean and sanitary laundry room had the potential to spread infection. The staff failed to maintain 2 of 2 dryer lint traps in a safe manner. The failure to maintain dryer lint traps had the potential to be a fire hazard. The findings included: On 6/19/19 at 2:05 p.m., a tour of the laundry room with Infection Control Nurse and the Laundry Manager. The Infection Control Nurse said she never checks the laundry room. She said it was up to the Laundry Manager to keep on top of everything in the laundry room. The following observations were made: There were two dryers with a large amount of lint on each lint trap and above the trap on top of the electric wires. The rubber gloves used to sort the soiled linen were lying on top the back of the double sink. The double sink was dirty on the bottom and had several black spots on them. The single white sink had several dark yellow stains. The floor in the room with the washing machines was dirty with a black substance stuck to the floor. There were buckets of chemicals sitting directly on the floor. This area had missing tile and a black substance covered the area. There were bottles of water, pocketbooks and miscellaneous items on the table used to fold clean linens. Some of these items were touching the clean linens. On 6/19/19 at 2:06 p.m., the Laundry Manager said the lint traps were cleaned every 2 hours. He reviewed the lint dryer cleaning log and stated, the last time it is signed as being done is 11:00 a.m. On 6/19/19 at 2:08 p.m., after the tour of the laundry room, the Laundry Manager said he thought everything looked okay to him. He didn't see any issues. The Infection Control Nurse pointed out to him the lint traps, personal items touching the clean linen on the folding table, the dirty floors and sinks. On 6/19/19, immediately after the tour, the Director of Nursing (DON) was informed of the findings in the laundry room. On 6/19/19, at appprox. 3:30 p.m., the Administrator was sitting in the DON's office. He said the Infection Control Nurse and the DON had informed him of the findings in the laundry room. He stated, I check the lint traps every morning because I had a fire in a different facility that had started with the lint traps. I don't want that to ever happen again, so I am really surprised of this.

Based on observation, record review, and staff interview the facility failed to prevent the misappropriation of medications for 13 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13) of 100 residents residing in the facility. Six (Residents #1, #3, #7, #8, #9 and #11) of 13 residents identified with tampered medication cards received unknown medications. A facility nurse tampered with packaging of medication cards, substituting various pills in place of the narcotics. Some residents received the substituted drugs. Receiving incorrect or unknown medications has the risk for serious harm by under-medication, over-medication, medication interaction, and/or anaphylactic allergic drug reaction from the substituted drugs. The facility failed to ensure through applicant screening. The Administrator was informed of the immediate jeopardy on 2/26/19 at 9:40 a.m. Based on the verified allegation of compliance, the jeopardy was removed on 2/22/19. Cross reference to F755 and F760. The findings included: Review of facility policy Abuse & Neglect Prohibition (SHCO .03, revised 5/23/2017) defined Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The corresponding procedures do not include misappropriation in screening or training sections. Review of facility policy Background Checks, Chapter: Recruitment & Hiring (SHC HR 0004.05, revised 6/1/2010) included to provide quality services and to ensure a safe working environment. The purpose is To facilitate the employment of qualified personnel who, at a minimum, meet all applicable state requirements for individuals providing services in post-acute care facilities. Personnel records revealed Registered Nurse (RN) Staff A was hired at the facility on 1/18/19. She worked at the facility until 2/11/19. Observations on 2/11/19 included RN Staff A's arrest at the facility for suspicion of medication diversion. In an interview on 2/11/19 at 3:15 p.m., the Human Resources Director (HRD) said prior to hiring RN Staff A, she ran an Agency for Health Care Administration (AHCA) Level 2 background check. The level 2 background check for Staff A came back eligible as of 7/2/18. The HRD said Staff A's multi-state license was active with no discipline or board actions. The HRD said Staff A told her she had not worked in Florida, she had just moved here from Colorado. Review of the Florida Background Screening Clearinghouse revealed RN Staff A had been employed in Florida three times with hire dates of 6/13/18, 7/5/18 and 11/7/18. On 2/11/19 at about 3:20 p.m., the HRD admitted she had not looked at the clearinghouse to check the employment history for Staff A, and had not verified any prior employment in Florida, since Staff A reported she had just recently moved to Florida. Personnel records revealed Registered Nurse (RN) Staff A was hired at the facility on 1/18/19. She worked at the facility until 2/11/19. Medication records showed during her employment she floated to various units. On 2/11/19 at 10:45 a.m., an inspection of the facility's 5 med carts was conducted with the Assistant Director of Nursing (ADON). On 2/11/19 at 11:00 a.m., the ADON said she was not aware of any drug diversion issues at the facility. On 2/11/19 at 11:34 a.m., the surveyor identified a tampered medication card on the Longboat #1 med cart. The narcotic medication card for Resident #3, [MEDICATION NAME]/ [MEDICATION NAME] 7.5-325 milligrams (mg) appeared tampered on the back of the card. There were 24 tablets on the card. No other tampered medication cards were identified at that time. On 2/11/19 at 12:00 p.m., the Sarasota County Sheriff's Detective from the Pharmaceutical Diversion Investigative Unit arrived. He explained to the Administrator, DON, and ADON he had reason to believe one of the nurses was diverting medications. The DON told the Detective the ADON inspected the 5 med carts a second time and found additional cards which were tampered. The ADON gave the tampered medication cards to the detective. The facility staff cooperated with the investigation to narrow down the nursing schedule to identify the only staff who could have had access to all the med carts which contained tampered narcotic cards. Part of the facility plan to further identify the nurse who possibly tampered with the med carts was the have all the nurses on duty sent for drug testing. RN Staff A was identified as the suspect who tampered with the medication cards on 4 of the 5 units in the facility On 2/11/19 at approximately 4:30 p.m., the ADON brought RN Staff A to her office for the Detective to interview her. After the interview, the Detective shared the nurse had 4 pills in her pocket, and had a urine cup with urine in it hidden under her armpit. On 2/11/18 at approximately 6:30 p.m., the Detective escorted RN Staff A in hand cuffs from the facility and said he was taking her to jail. The surveyor had no further opportunity to interview RN Staff A. The Sarasota County Sheriff's Office made a preliminary determination of the drugs which were substituted on the 15 tampered medication cards. The cards were sent to a forensic unit to be tested . The initial identification of drug substitutions for the narcotics were: Resident #1 had [MEDICATION NAME] 10 mg ordered and had received [MEDICATION NAME] (an antidepressant) at least 8 times. Resident #2 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with [MEDICATION NAME] (an anti-diarrheal). Resident #3 had [MEDICATION NAME] 7.5 mg ordered and received [MEDICATION NAME] at least 4 times. Resident #4 had [MEDICATION NAME] 5 mg ordered which was replaced with 3 different medications, [MEDICATION NAME] (a steroid), [MEDICATION NAME] (an anti-anxiety drug), and Fludrocortisone (a steroid). Resident #5 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered which was replaced with [MEDICATION NAME] (a mild pain reliever). Resident #6 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered which was replaced with Atorvastatin (a cholesterol lowering drug). Resident # 7 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered and received [MEDICATION NAME] 500 mg at least 3 times. Resident # 8 had [MEDICATION NAME] 10 mg ordered and received [MEDICATION NAME] at least 3 times. Resident # 9 had [MEDICATION NAME]/ [MEDICATION NAME] ordered and received [MEDICATION NAME] 6 times. Resident #10 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 ordered which was replaced with [MEDICATION NAME]. Resident # 11 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered and received [MEDICATION NAME] at least 1 time. Resident #12 had [MEDICATION NAME] 10 mg ordered which was replaced with an unidentified pill. Resident #12 had [MEDICATION NAME] 10 mg ordered which was replaced with an unidentified pill (a second card). Resident #13 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with [MEDICATION NAME]. Resident #13 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with an unidentified pill (a second card). The Sarasota County Sheriff's criminal investigation of the facility's drug diversion was still progress and the full results were not available at the completion of the Agency for Health Care Administration's complaint investigation. The practice of hiring staff who have full access to residents without a thorough background screening and employment history verification placed the residents at risk for abuse, neglect, exploitation and misappropriation of residents' property, including controlled substances.

Based on observation of medication cards, record review, interview with the facility staff and pharmacy consultant, the facility failed to provide pharmaceutical services to include procedures that assure the accurate administering of all drugs to each resident. The residents effected by this failure include 6 (Residents #1, #3, #7, #8, #9 and #11) who actually received incorrect or unknown drugs of the 13 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13) whose medication cards had been tampered. Those 13 residents had the potential to receive the incorrect or unknown drugs of the 100 residents residing in the facility. A facility nurse tampered with the packaging of the medication cards, substituting various pills in place of the narcotics. The packaging of the 15 medication cards was found tampered. Some residents received the substituted drugs. Receiving incorrect or unknown medications has the risk for serious harm by under-medication, over-medication, medication interaction, and/or anaphylactic allergic drug reaction from the substituted drugs. The facility nurse worked at this facility from 1/18/19 until 2/11/19 when she was arrested. The facility Pharmacy consultant and nurses did not routinely inspect medications for possible tampering. After the facility notified the Pharmacy Consultant of the drug diversion and drug tampering, the Pharmacy Consultant did not promptly assist the facility to identify, evaluate, and resolve these concerns. The Administrator was informed of the immediate jeopardy on 2/26/19 at 9:40 a.m. Based on the verified allegation of compliance, the jeopardy was removed on 2/22/19. Cross reference to F602 and F670 The findings included: On 2/11/19, review of the facility's Medication Pass Guidelines (SHCR: .01, revised 04/25/17), the chapter Medication Administration revealed a procedure to Note the physical appearance and packaging of the medication. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved. On 2/11/19 at 11:34 a.m., the surveyor began an inspection of the medication carts with the Assistant Director of Nursing (ADON). A narcotic medication card which appeared tampered was identified on the Longboat #1 med cart. The card appeared to have been wet in the past and felt sticky in spots. The medication card for Resident #3 was [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 milligrams (mg) prescribed for pain. The ADON took the medication card to the nursing office. The ADON later re-inspected the med carts and found additional tampered narcotic medication cards for a total of 15 tampered medication cards on 4 different units. The Sarasota County Sheriff's Office made a preliminary determination of the drugs which were substituted on the medication cards; the cards were sent to a forensic unit to be tested . The initial identification of drug substitutions for the narcotics were: Resident #1 had [MEDICATION NAME] 10 mg ordered and had received [MEDICATION NAME] (an antidepressant) at least 8 times. Resident #3 had [MEDICATION NAME] 7.5 mg ordered and received [MEDICATION NAME] (an anti-diarrheal) at least 4 times. Resident # 7 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered and received [MEDICATION NAME] 500 mg (a mild pain reliever) at least 3 times. Resident # 8 had [MEDICATION NAME] 10 mg ordered and received [MEDICATION NAME] at least 3 times. Resident # 9 had [MEDICATION NAME]/ [MEDICATION NAME] ordered and received [MEDICATION NAME] 6 times. Resident # 11 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered and received [MEDICATION NAME] at least 1 time. Other residents whose medication cards had been tampered, but may or may not have received incorrect medications were: Resident #2 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with [MEDICATION NAME]. Resident #4 had [MEDICATION NAME] 5 mg ordered which was replaced with 3 different medications, [MEDICATION NAME] (a steroid), [MEDICATION NAME] (an anti-anxiety drug), and Fludrocortisone (a steroid). Resident #5 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered which was replaced with [MEDICATION NAME]. Resident #6 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered which was replaced with Atorvastatin (a cholesterol lowering drug). Resident #10 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 ordered which was replaced with [MEDICATION NAME]. Resident #12 had [MEDICATION NAME] 10 mg ordered which was replaced with an unidentified pill. Resident #12 had [MEDICATION NAME] 10 mg ordered which was replaced with an unidentified pill (card #2). Resident #13 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with [MEDICATION NAME]. Resident #13 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with an unidentified pill (card #2). The Sarasota County Sheriff's criminal investigation of the facility's drug diversion was still progress and the full results were not available at the completion of the Agency for Health Care Administration's complaint investigation. On 2/11/19 the facility held an Ad Hoc Quality Assessment and Performance Improvement Plan (QAPI) meeting named QAPI - Drug Diversion. The Objective & Goal, observe and report narcotic cards for tampering to ensure resident comfort level. Initiative: 1: Immediate corrections to ensure resolution 2: Identification of how the system will be corrected. 3: Education to ensure appropriate system is followed. 4: Plan for future follow up to ensure that interventions are working. On 2/11/19 at 3:35 p.m., the Administrator stated, The QA plan was developed by the DON and ADON. I signed off on the plan, as did the Medical Director. He said there has been no official QA/PI meeting since the drug diversion was identified; a meeting is scheduled for 2/27/19 with all committee members. Review of the facility's Action Steps for a 4 point QA/PI plan included: Audit narcotic cards, which was done by the ADON. Interview residents to evaluate pain level, which was completed by nursing staff. Notify pharmacy of allegation. Notify Medical Director, new prescriptions to replace only the medication cards which were identified as being tampered with, no new orders given. Weekly random audit of narcotic medications to ensure narcotics are tamper free (by DON/designee responsible) and re-inservice nursing staff regarding identification of tampering (by DON/designee responsible). The 4-point plan to identify, and educate staff to prevent further drug diversion initially did not include any request for assistance or any consultation with the pharmacy consultant. On 2/11/18 at approximately 6:30 p.m., the Sarasota County Detective escorted RN Staff A from the facility. Arrest records (accessed 3/1/19 from: sarasotasheriff.org) showed she was charged with multiple counts of obtaining controlled substance by fraud. In a telephone call on 2/21/19 at 10:30 a.m., the Pharmacy Consultant said her last medication review at the facility was 1/30/19. Personnel records revealed Registered Nurse (RN) Staff A was hired at the facility on 1/18/19. She worked at the facility until 2/11/19. The initial allegation of compliance documented, Consultant Pharmacist was notified of the allegation of drug diversion by the Director of Nursing (DON) on 2/11/19. No recommendations were received. The facility Pharmacy Consultant did not collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility after the drug diversion and identified drug tampering occurred. After being notified of the drug diversion on 2/11/19, the Pharmacy Consultant did not promptly assist the facility to identify, evaluate, and resolve the drug diversion concerns in a timely manner, which affected the resident's medical care and quality of life. On 2/21/19 at 10:30 a.m., in a telephone call, the Pharmacy Consultant said she was informed of the narcotic diversion on 2/11/19. She said she did not come to the facility until 2/15/19 (4 days after she was notified). She said she was planning to come to the facility on the last Wednesday of the month (2/27/19) for the monthly QA meeting. She said she was told the sheriff was involved and took all the tampered cards. She acknowledged, I did not inspect the med carts for any other narcotic cards which might have been missed. She stated, The Director of Nursing did call me with descriptions of pills but they must have been colored because they did not match any pills I have seen, I could not identify them by her description. In an interview on 2/21/19 at 2:20 p.m., the Pharmacy Consultant said she changed her visit day because the survey agency was in the building. She said she inspected the medication carts and did not find any additional medication diversion today. The Pharmacy Consultant stated I stepped in when appropriate; I had 10 other buildings. I did what I thought was appropriate at the time; I allowed the nursing staff do their inspections. She said, I talked to the DON today and she asked me to come in and look at the medication carts. The Pharmacy Consultant said she will be inspecting the medication cards once monthly, especially the narcotic box; I will now be reinforcing the education of nurses on how to identify wrong medications. On 2/21/19 at 12:30 p.m., review of the Pharmacy Education Plan dated 2/21/19 revealed the pharmacy consultant is now included in the staff education plan to in-service nursing staff regarding pharmacy topics such as diversion and medication administration.

Based on observation of medication cards and staff interviews, the facility failed to ensure residents were free from significant medication errors for 6 residents who received the unknown drugs (Residents #1, #3, #7, #8, #9 and #11) of 13 residents whose medication cards had been tampered. The other 7 (Residents (#2, #4, #5, #6, #10, #12 and #13) had tampered cards but had not received any medications from them yet. Thus, there were 13 residents who received or could have received unknown drugs out of the 100 residents in the facility. A facility nurse tampered with medication cards, substituting various pills in place of the narcotics. Some residents received the substituted drugs. The facility nurse worked at this facility from 1/18/19 until 2/11/19 when she was arrested. Receiving unknown drugs has the risk for serious harm by under-medication, over-medication, medication interaction, and/or anaphylactic allergic drug reaction from the unknown drugs. The Administrator was informed of the immediate jeopardy on 2/26/19 at 9:40 a.m. Based on the verified allegation of compliance, the jeopardy was removed on 2/22/19. Cross reference to F755. The findings included: Review of the facility's Medication Pass Guidelines (SHCR: .01, revised 04/25/17), the chapter Medication Administration revealed a procedure to Note the physical appearance and packaging of the medication. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved. None of the 15 altered medication cards had not been identified by the nursing or pharmacy staff prior to survey. The facility medication policy did not include how to document and process medication errors. On 2/11/19 beginning at 10:45 a.m., the narcotic medication cards on all 5 of the facility's med carts were inspected with the Assistant Director of Nursing ADON. In an interview on 2/11/19 at 11:15 a.m., the ADON said she did not know of any medication diversion in the facility. On 2/11/19 at 11:34 a.m., one tampered medication card was found by surveyor on medication cart #1 on the Longboat wing. The packaging of the narcotic medication card for Resident #3, [MEDICATION NAME]/ [MEDICATION NAME] 7.5-325 milligrams (mg) was identified as altered. There were 24 tablets remaining of 30 tablets on the card. No other tampered cards had been identified at that time. In an interview on 2/11/19 at 11:45 a.m., Licensed Practical Nurse Staff B, who was working the Longboat medication cart #1, said he never noticed any problems with any of the narcotic cards. The ADON looked through the medication carts a second time. Tampered medication cards in the medication carts put residents at risk for a significant medication error. This time she found additional cards for a total of 15 medication cards which were tampered on 4 different units. The 15 tampered medication cards were given to the Sarasota County Sheriff's Detective who was onsite at the time. Record review revealed, after the tampered medication cards were identified, the nursing staff assessed the effected residents. There were no negative effects noted from the substituted medications. There were no residents complaining of lack of pain control. If the substitutions had not been discovered, it would have continued for some time, continuing the risk. The tampered cards belonged to residents on 4 different units. The Sarasota County Sheriff's criminal investigation of the facility's drug diversion was still progress and the full results were not available at the completion of the Agency for Health Care Administration's complaint investigation. The Sarasota County Sheriff's Office made a preliminary determination of the medications which were substituted on the medication cards; the cards were sent to a forensic unit to be tested . The initial identification of drug substitutions for the narcotics were: Resident #1 had [MEDICATION NAME] 10 mg ordered and had received [MEDICATION NAME] (an antidepressant) at least 8 times. Resident #3 had [MEDICATION NAME] 7.5 mg ordered and received [MEDICATION NAME] (an anti-diarrheal) at least 4 times. Resident # 7 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered and received [MEDICATION NAME] 500 mg (a mild pain reliever) at least 3 times. Resident # 8 had [MEDICATION NAME] 10 mg ordered and received [MEDICATION NAME] at least 3 times. Resident # 9 had [MEDICATION NAME]/ [MEDICATION NAME] ordered and received [MEDICATION NAME] 6 times. Resident # 11 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered and received [MEDICATION NAME] at least 1 time. There was potential for serious harm. Prior to interventions, unknown drugs were being unknowingly administered to unsuspecting residents. In addition to any possible allergic reaction, the potential risks presented by substituted drugs may include (source: RxList, a prescription drug website at https://rxlist.com): [MEDICATION NAME] ([MEDICATION NAME]) - possible life threatening heart rhythms and sudden death, which have been observed in post-marketing reports. It is recommended that [MEDICATION NAME] should not be used in patients with certain congenital rapid heart rhythms, [MEDICAL CONDITION], [DIAGNOSES REDACTED] or [DIAGNOSES REDACTED], recent acute [MEDICAL CONDITION] infarction, or uncompensated heart failure. [MEDICATION NAME] should also not be used in patients who are taking other drugs (including some antiarrhythmics, antimicrobials, antipsychotics, and antidepressants) that prolong the QTc interval (a measurement of part of a heart beat). [MEDICATION NAME] ([MEDICATION NAME]) - should not be used when inhibition of peristalsis is to be avoided due to the possible risk of significant sequelae including ileus, megacolon and toxic megacolon. [MEDICATION NAME] (Tylenol) - severe liver damage may occur if an adult takes more than the maximum daily amount or taken with other drugs containing [MEDICATION NAME]. [MEDICATION NAME] ([MEDICATION NAME]) - have been reports of elevated blood pressure when [MEDICATION NAME] tablets have been added to a regimen including a monoamine oxidase inhibitors (Emsam, Marplan, Nardil, and Parnate). Atorvastatin ([MEDICATION NAME]) - a history of renal impairment merits closer monitoring for skeletal muscle effects. Should be used with caution in patients who have a history of liver disease. Active liver disease is a contraindication to [MEDICATION NAME]. Other residents whose medication cards had been tampered, but may or may not have received incorrect medications were: Resident #2 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with [MEDICATION NAME]. Resident #4 had [MEDICATION NAME] 5 mg ordered which was replaced with 3 different medications, [MEDICATION NAME] (a steroid), [MEDICATION NAME] (an anti-anxiety drug), and Fludrocortisone (a steroid). Resident #5 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered which was replaced with [MEDICATION NAME]. Resident #6 had [MEDICATION NAME]/ [MEDICATION NAME] 10/325 mg ordered which was replaced with Atorvastatin (a cholesterol lowering drug). Resident #10 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 ordered which was replaced with [MEDICATION NAME]. Resident #12 had [MEDICATION NAME] 10 mg ordered which was replaced with an unidentified pill. Resident #12 had [MEDICATION NAME] 10 mg ordered which was replaced with an unidentified pill (2nd card). Resident #13 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with [MEDICATION NAME]. Resident #13 had [MEDICATION NAME]/ [MEDICATION NAME] 5/325 mg ordered which was replaced with an unidentified pill (2nd card). In an affidavit dated (MONTH) 28, 2019, signed by the Medical Director who wrote he was notified by the DON of a concern that one or more of the residents taking narcotic medications, could have medication cards which were tampered with. He and the DON discussed possible implications related to this situation. One concern was for the integrity of the narcotic medications. It was determined that they would give the narcotic medications to the Sarasota County Sheriff's Detective so that they could be removed from the facility, analyzed by law enforcement, and at the facility expense replacement medications would be secured. He said he was asked about possible negative outcomes related to the patients. His only concern was one resident who may have had problems with pain control. There is no mention in his affidavit of any concerns about the residents receiving the wrong medications and any possible side effects from the wrong medications being administered. Review of the facility's Pharmacy Sales Transaction Report for 2/11/19 through 2/16/19 showed documentation of orders for 14 narcotic medications. These medications were replacements for the tampered medications that were identified on 2/11/19. The residents listed on the order were the residents identified as having tampered narcotic mediation cards. No other narcotic medications were replaced. All other residents may have been at risk if any more tampered medication cards were not identified by the nurses. Randomly substituted drugs may interfere with prescribed medications and lessen effectiveness; add dosage to exceed safe medication limits or increase the effect of prescribed medication; interact resulting in adverse side effects; or result in an allergic reaction. Without knowledge of the administered drug, these potential effects would be unexpected and therefore difficult to treat. By substituting unknown drugs in place of prescribed medications, the facility Nurse Staff A showed flagrant disregard for the health and safety the vulnerable residents receiving medication.