Every finding on record at Solaris Healthcare Apopka

Based on interview and record review the facility failed to implement medication regimen review (MRR) recommendations for medication administration parameters of physician's orders for 1 of 5 residents and failed to ensure MRRs were reviewed by the physician for 1 of 5 residents reviewed for unnecessary medications from a total sample of 39 residents. (#8, #43) Findings: 1. Review of the medical record revealed resident #8 transferred from the facility to an acute care hospital on 7/20/2022, readmitted to the facility on [DATE], and transferred to an acute care hospital on 4/05/2023. The resident had diagnoses that included, systolic congestive heart failure, hypotension (low blood pressure), essential hypertension (high blood pressure), sick sinus syndrome, coronary artery disease, atrial fibrillation, and presence of a cardiac pacemaker. Review of the pharmacy Consultation Report for resident #8 dated from 11/01/2022 to 11/30/2022 showed there were recommendations for the medication Midodrine, a medication to treat low blood pressure. The Consultant Pharmacist noted, CLINICALLY URGENT RECOMMENDATION: PROMPT RESPONSE REQUESTED .Please remind staff of the importance of administering/holding medication within the parameters ordered. The report indicated this medication should have been held in accordance with the physician's orders/parameters. The report was signed by the Registered Pharmacist on 11/26/2022, and the Director of Nursing (DON) on 11/28/2022. Review of resident #8's Medication Administration Record, (MAR) for December 2022, January 2023, February 2023, March 2023, and April 2023 showed physicians orders for Midodrine HCI tablet, 5 milligrams (MG), HOLD for SBP (systolic blood pressure) GREATER than 130 or DBP (diastolic blood pressure) GREATER than 70 for blood pressure, started 7/29/2022. The records documented nurses continued to administer the medication to the resident multiple times outside of the physician's parameters. On 4/6/2023 at 3:26 PM, the DON said she received the MRR for resident #8 from November 2022. She reviewed the resident's MARs from December 2022 to April 2023, and acknowledged there were multiple instances Midodrine was administered to the resident by nurses outside physician ordered blood pressure parameters. The DON explained it was particularly important for nurses to follow the medication orders correctly to avoid blood pressure complications. She stated additional monitoring should have been conducted to ensure nurses administered the medication correctly. On 4/06/2023 at 3:52 PM, the Registered Pharmacist Consultant was interviewed by telephone. He stated the pharmacy consultant submitted MRR reports to the DON monthly and as needed. He explained reports were tracked for follow up, and if continued issues were identified, the DON received additional notifications. The pharmacist said Midodrine could cause or lead to complications related to blood circulation when it was administered beyond the parameters ordered by the physician. 2. Review of the medical record revealed resident #43 was admitted to the facility on [DATE] from an acute care hospital. The resident had diagnoses that included thyroid imbalance, abnormal weight loss, hypertension, anemia, kidney disease, insomnia, paranoid schizophrenia, and depression. Review of the pharmacy Consultation Report dated from 12/01/2022 to 12/31/2022 for resident #43, noted a recommendation for Levothyroxine, a medication to treat thyroid imbalances. The report read, Please administer Levothyroxine consistently 30 to 60 minutes before breakfast, or at bedtime 4 hours after the last meal of the day. The pharmacist signed the Consultation Report on 12/24/2022, and the DON signed the report on 12/28/2022. There was a handwritten notation, DONE. Review of resident #43's MARs from January 2023 to March 2023 indicated that the nurses were administering the resident's Levothyroxine, every day at 9:00 AM, after she had eaten breakfast. On 4/06/2023 at 3:08 PM, the DON said all residents MRR recommendations were provided to physicians for review within one day after she received them. She reviewed resident #43's MRR from December 2022 and acknowledged there was no documentation to indicate the physician had reviewed it. The DON reviewed the resident's medical record and said the physician had revised the Levothyroxine order on 3/31/23, 3 months after the Consultant Pharmacist had made the recommendations. The physician changed the administration time of the Levothyroxine from 9:00 AM to 6:00 AM. The DON said the MRR should have been addressed within 30 days. On 4/06/2023 at 3:52 PM, the Registered Pharmacist Consultant said Levothyroxine, is recommended to be administered on an empty stomach, to ensure proper absorption and optimal therapeutic effects. He explained administration of the medication with food could cause or lead to malabsorption and abnormal thyroid hormone levels that could affect multiple areas of organ functioning. The facility's policy and procedure titled, LTC Facility's Pharmacy Services and Procedures Manual . 9.1 Medication Regimen Review, revised 3/03/2020 read, 9. When the Consultant Pharmacist identifies an urgent medication irregularity during MRR that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician to communicate the issue and obtain direction or new orders., and The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident .

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 9 sampled residents, (#3). Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Solution is used to treat [CONDITION(S)] (low red blood cell count) in people with long-term serious kidney disease (chronic kidney failure), .(www.webmd). Review of the Medication Administration Record (MAR) from 5/11/22 to 6/06/22 revealed [MEDICATION(S)] Solution had not been administered to the resident. The dates Epoetin was to be given, 5/24/22 and 5/26/22 were blank and there was no explanation documented in the nurses notes as to why the medication was not administered. Review of the resident's lab results on 5/12/22 revealed HGB level of 8.9 and on 5/24/22 the HGB had dropped to 8.2. The normal reference range for HGB level is 11.4 to 14.7. On 6/6/22 at 3:45 PM and 4:20 PM, the Director of Nursing (DON) reviewed resident #3's MAR and acknowledged Epoetin was not given. The DON said the medication helped to boost blood count in residents with [CONDITION(S)] to prevent need for blood transfusion. The DON noted the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON added, the nurses should have clarified the orders with the physician on 5/24/22 or 5/26/22 and not just left the MAR blank with no explanation as to why medication was not given. On 6/7/22 at 9:57 AM, the Floral Unit Manager (UM) validated LPN A and RN B both entered the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM stated, nurses should know to question a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM reported they were not aware resident #3 did not receive Epoetin as ordered until it was brought to their attention by the surveyor. On 6/7/22 at 10:41 AM, the Regional Nurse and DON said they spoke to RN D who worked 7 AM to 11 PM on 5/26/22 and verified she had not given Epoetin medication as it was not available at the facility. They indicated RN D called the pharmacy and the pharmacist requested the HGB lab result be forwarded to them. They said RN D had left report for the oncoming nurse, RN E to administer the medication. They could not find any documentation to verify RN E had administered the medication. The DON and Regional Nurse acknowledged 2 nurses entered the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/22 at 12:02 PM, RN D explained the first time she noticed Epoetin for resident #3 was not in the fridge was on 5/24/22 and she recalled she sent the most recent HGB result of 8.3 to the pharmacy. RN D said she also worked on 5/26/22 from 7 AM to 11 PM and again looked for the Epoetin and it was not in the fridge. She remembered the medication did not arrive at the facility from pharmacy by 11 PM on 5/26/22 and she gave passed this information to the oncoming nurse, RN E. She acknowledged she had not documented any of her communication with the pharmacy and should have reached out to the UM to assist with getting residents' needed medication. On 6/7/22 at 7 PM, LPN A stated he entered resident #3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He added he was not sure if the physician gave an incorrect order or he entered it incorrectly. LPN A noted if the physician had given him order to hold mediation for HGB less than 10, he should have questioned the order as the medication was used to boost blood counts. On 6/7/22 at 4:15 PM, the facility's Consultant Pharmacist (CP) stated, the original order for the Epoetin was written by the physician and the nurse copied off what the physician had entered to hold if HGB lower than 10. However clinically it is usually the other way around. He said Epoetin was used to treat [CONDITION(S)] for patients with chronic disease, blood loss or kidney disease. It helps the person make more hemoglobin in the blood instead of getting a blood transfusion. The facility's nursing policy for Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .in accordance with state guidelines .

Based on observation, interview, and record review, the facility failed to implement procedures to ensure accurate narcotic reconciliation for 1 of 1 narcotic medication reviewed, and failed to ensure safe administration of medications for 6 of 19 residents of a total sample of 51 residents, (#2, #35, #48, #72, #77 and #108). Findings: On 05/05/21 at 6:34 PM, an inspection of the Arbor Oaks medication cart assigned to Licensed Practical Nurse (LPN) A was conducted with the Arbor Unit Manager (UM). The Arbor UM opened the top left drawer of the medication cart and LPN A quickly returned to the cart and whispered to the Arbor UM who asked if the medication cart inspection could be completed at a later time. Their request was declined and the inspection of the Arbor Oaks medication cart continued with LPN A and the Arbor Oaks UM. When the top left drawer of the Arbor Oaks medication cart was fully opened by the Arbor UM, eight pill cups with pre-poured medications were sitting uncovered in the drawer. Each pill cup was labeled with a handwritten room number. The Arbor UM said, I am very disappointed, shocked and angry. It is not the expectation of any nurse to pre-pour medications. When asked if he usually pre-poured medications, LPN A stated that was not his usual process. LPN A explained his reason for pre-pouring medication was sometimes it makes me go faster. LPN A said, Yes, I'm aware why it is not safe. I don't want to give the wrong medication to the wrong resident. LPN A stated he had never been told not to pre-pour medications. Further inspection of the Arbor Oaks medication cart revealed a [MEDICATION(S)] 60 milligram (mg) narcotic medication card for resident #72 with 2 tablets remaining. Reconciliation with the narcotic inventory sheet for resident #72, revealed there should have been 3 tablets remaining. LPN A acknowledged the discrepancy between the narcotic medication card and the narcotic inventory sheet. He explained he removed the narcotic tablet but did not sign it out on the narcotic inventory sheet. The Arbor UM acknowledged the discrepancy between the [MEDICATION(S)] 60 mg medication card and the narcotic inventory sheet. The UM said that nurses should document the removal of narcotic medication immediately to ensure an accurate medication count. On 5/05/21 at 7:02 PM, the Director of Nursing and the Assistant Director of Nursing noted administration of pre-poured medication would be viewed as a potential medication error. Review of the facility's Medication Pass Observation competency form for LPN A, dated 4/19/21 revealed medications should be prepared just prior to administration. Review of the facility's 6.0 General Dose Preparation and Medication Administration policy, read, . 3.2 Facility staff should only prepare medications for one resident at a time.

Based on observation, interview, and record review, the facility failed to ensure the controlled medication compartment was properly secured on 1 of 6 medication carts, (Arbor Oak medication cart). Findings: On 5/05/21 at 6:34 PM, during an inspection of the Arbor Unit medication cart, the narcotic compartment labeled Oak was not securely locked. Licensed Practical Nurse (LPN) A was easily able to lift the lid of the narcotic compartment with one finger without using his key. On 5/05/21 at 7:02 PM, the Director of Nursing (DON) stated nurses should not rely on the drawer closure to lock and secure the narcotic compartment. The DON stated Licensed Practical Nurse (LPN) A should have pushed down hard enough on the lid of the narcotic compartment to ensure it was locked before he closed the drawer. The DON acknowledged nurses were responsible for ensuring the narcotic compartments in medication carts were locked and secure to prevent unauthorized access. On 5/06/21 at 11:52 AM, the Consultant Pharmacist stated he periodically checked medication carts at the facility which included narcotic checks and reconciliation with the narcotic log. He stated the process was for nurses to open the locked drawer, remove the narcotic medication and ensure the drawer was locked afterwards. When asked about the unlocked narcotic compartment in the Arbor Oaks medication cart, the Consultant Pharmacist said, Yes, it was an unsafe practice. The narcotic drawer is supposed to be double locked. All narcotics should be double locked. Review of the facility's policy 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised on 10/31/16, read, . 3.1 Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device . 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security.

Based on observation, interview and record review, the facility failed to provide wound care treatment in accordance with physician's orders and acceptable standards of practice for two skin tears for 1 of 1 resident reviewed for non-pressure skin conditions of a total sample of 51 residents, (#28). Findings: Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set quarterly assessment dated [DATE] revealed resident #28 required extensive assistance from two staff for bed mobility, toilet use and personal hygiene. Review of the physician's order for resident #28 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A sleeve arm is a protective sleeve used on upper extremities to prevent abrasions, bruises, snags and tears (retrieved on 5/14/21 from www.agingcare.com). A physician's order dated 4/23/21 directed nurses to cleanse skin tears to left forearm with normal saline solution, then cover with a 4x4 bordered gauze dressing and change every other day. On 5/03/21 at 12:45 PM, resident #28 had a wrapped gauze dressing to her left arm initialed and dated 4/30/21, 7-3. The dressing was loosely applied and had slipped down her forearm to expose a skin tear with 2 wound closure strips. There was dark purple bruising above the skin tear close to her left elbow. Resident #28 did not have a sleeve arm for protection as ordered. On 5/03/21 at 12:48 PM, the Arbor Unit Manager (UM) verified the wrapped gauze dressing on resident #28's arm was loose and dated 4/30/21. She acknowledged the dressing change should be done every other day. The Arbor UM unwrapped the dressing which revealed a dried petroleum gauze and a 4x4 gauze pad adhered to a second skin tear. The Arbor UM said there were 2 separate skin tears with 2 wound closure strips on the upper skin tear and 3 wound closure strips on the lower skin tear. On 5/03/21 at 12:53 PM, a review of the Order Summary Report with the Arbor UM noted no physician's order for wound closure strips, petroleum gauze or 4x4 gauze pads for resident #28's dressing. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/05/21 at 12:35 PM, Registered Nurse (RN) C said she applied the dressing dated 4/30/21 to resident #28's left arm. She acknowledged she did not document the dressing change on 4/30/21 and did not call the physician to obtain an as needed (PRN) order. RN C acknowledged resident #28 was not wearing a sleeve arm and stated they should be kept in her drawer. She searched all drawers of both bedside tables and explained there were no sleeve arms in resident #28's room. She explained the reason for a sleeve arm was to prevent further skin tears. RN C was informed resident #28 was also observed without a sleeve arm on 5/03/21 at 12:45 PM, and 5:29 PM and on 5/04/21 at 2:26 PM. Resident #28 had a care plan dated 2/26/21, revised 4/29/21 for risk for skin impairment. The care plan interventions included encourage sleeve arm use for skin protection, to provide treatment per physician's orders, and use caution during transfers and bed mobility to prevent striking her arms. On 5/05/21 at 12:40 PM, the Wound Care Nurse (WCN) stated the expectation was nurses would do dressing changes as ordered. The WCN stated he expected nurses to do wound care when it was due and as ordered to prevent infection and help the wound heal. He said there were no standing orders for wound care and nurses were supposed to call the physician for appropriate orders for a new wound. The WCN said he had called the physician and obtained the order for the border gauze dressing for resident #28. He stated he did not obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The WCN could not explain why a nurse applied another type of dressing without notifying him or calling the physician. On 5/05/21 at 2:00 PM, the Arbor UM stated although the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Skin & Wound Care policy, reviewed 3/2021, read, The facility will promote dignity and enhance the resident's quality of life and quality of care by maintaining or restoring resident's skin integrity. The facility will implement preventative measures that meet the standards of care The Physician Orders policy, reviewed 1/19/18, read, . 3. Physician orders will be transcribed, noted, implemented, and followed in a timely manner.

Based on observation, interview and record review, the facility failed to ensure 1 of 4 nurses cleaned and disinfected the blood glucose meter (used to monitor resident blood sugar levels) according to manufacturer's guidelines to prevent cross-contamination and spread of blood-borne pathogens and infectious bacteria, and failed to ensure the laundry manuals (used daily) were stored in a proper manner to prevent exposure to soiled linens and potential for cross-contamination to clean resident linens. Findings: 1. On 10/17/19 10:44 AM, an observation of the blood glucose meter cleaning and disinfection was conducted with registered nurse (RN) A on the Arbor, Royal Palm unit. RN A stated that she had 2 blood glucose meters on her medication cart and she uses the germicidal bleach wipes to clean the glucose meters before and after resident use. RN A removed 1 germicidal bleach wipe from the container and wiped the front and back surface of the meter with one pass. She then wiped the sides of the meter and then placed the meter on the medication cart to air dry. RN A reviwed the germicidal bleach wipe manufacturer's guidelines for use located on the back of the container and stated You have to have wet contact time for 1-3 minutes, I did not do that. She than stated that the blood glucose meter comes in contact with a resident's blood during testing and blood carries blood-borne pathogens (human immunodeficiency virus, [MEDICAL CONDITION] and C.) You need to kill the bacteria so that other residents don't come in contact with another resident's blood. On 10/17/19 at 11:10 AM, the director of nursing (DON) confirmed that RN A did not clean and disinfect the blood glucose meter correctly. The DON stated that the only way to assure wet contact time is to wrap the meter in the germicidal bleach wipe. At 1:53 PM, the DON stated that the facility did not have a policy for the cleaning and disinfecting of the blood glucose meters. We just follow the manufacturer's guidelines. Review of RN A Glucometer Competency, completed by the assistant DON on 10/03/19, revealed she had passed the glucometer competency and was competent to function with blood glucose testing. On 10/17/19 at 1:53 PM, the DON stated that the competency included education on how to clean and disinfect the blood glucose meter. Review of the Glucometer Competency form #12 reflected that a moist germicidal bleach wipe was required to wipe all external areas of the meter. The form did not include the manufacturer's guidelines on how to clean and disinfect the blood glucose meter. Review of the germicidal bleach wipes manufacturer's guidelines read, Contact Time: allow surface(s) to remain wet for 30 seconds to kill bacteria [MEDICAL CONDITION] on the label expect 1 minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] (yeast-type fungus) and [MEDICATION NAME] menlagrophytes (fungi) and 3 minute contact time is required to kill ,[MEDICAL CONDITION].n difficile spores (bacteria transferred through spores of feces). Review of the facility Infection Prevention and Control Policy and Procedure, dated 9/11/2011, read, It is the policy of the facility to provide a safe, sanitary . environment. This facility will control, and attempt to prevent the development and transmission of infections. The infection prevention and control program will control infections and communicable diseases for all residents 2. On 10/17/19 at 9:21 AM, an observation was conducted in the laundry department with the Laundry Supervisor. There were 2 washers and approximately 6 feet across from the washers was a large bulletin board with multiple papers attached to the board. A metal type basket was attached to the wall and contained 4 binders. A monthly sling inspection log, a resident laundry request binder, a Welcome to (facility name) binder and a pink binder containing the daily dryer vent cleaning sign-off forms. On 10/17/19 at 9:38 AM, the Laundry Manager stated that room with the 2 washing machines is considered a soiled area since the residents' soiled linens are washed in the room. Everything in the room is contaminated including the binders. They should not be in the room with the soiled linens. On 10/17/19 at 9:52 AM, Laundry Aide B stated that the binder for the dryer vent cleaning is used every day and the sling inspection binder is used monthly. I don't know why we have Welcome to the (facility name) binder and the resident laundry request binder. We have not used the laundry requests for over a year. Review of the dryer vent sign-off log revealed the staff are signing off every 2 hours that the dryer vents have been cleaned. As a result of the laundry staff touching the dryer vent binder every 2 hours with unprotected hands, there is a high likelihood of cross-contamination during the processing of clean linens. Review of the facility Laundry Services Policy, dated 01/01/07, read, It is the policy of this facility to provide an adequate amount of hygienically clean and odor free linens to meet the needs of the residents Definition: Hygienically Clean - free of pathogens in sufficient numbers to cause human illness. Procedure 3. The laundry staff will be trained in safe linen handling and infection control guidelines

Based on observation, interview and record review, the facility failed to maintain appropriate freezer temperature and failed to label food in the freezer in 1 of 2 nourishment rooms, (Arbor Unit). Findings: On 8/23/18 at 10:13 AM, the Arbor Unit nourishment room freezer thermometer read 10 degrees Fahrenheit (F) and contained a package of beef patties wrapped in a plastic bag with no name or room number. On 8/23/18 at 10:19 AM, the Assistant Director of Nursing (ADON) read the temperature in the Arbor Unit freezer as 18 degrees F. She stated it was recorded as 10 degrees this morning on the Dining Room/Nutrition Room Temperature Log in the morning. She validated the food found in the freezer should have been labeled with name, date and room number. The ADON said the temperature for the freezer should be 0 degrees F or below. She stated that the nursing staff on the 11 PM to 7 AM and 3 PM to 11 PM were responsible for checking and documenting the refrigerator/freezer temperatures. The ADON stated the nurse should have notified maintenance verbally and written a Service Maintenance request. On 8/23/18 at 12:21 PM, the Director of Nursing said the freezer temperatures were not to be above 0 degrees F. The nurse should have contacted maintenance immediately. Food should be labeled and dated with a name on it. The night nurse was responsible for checking the food in the refrigerator and freezer was labeled appropriately when they checked the temperatures. The temperature log read, Refrigerator temperature should remain between 36-41 degrees F. Freezer temperature should remain below 0 degrees F. Device is cleaned weekly by nursing staff.

Based on interview and record review the facility failed to ensure Advance Directives (AD) were accurately documented for 1 of 1 sampled resident, (#21). Findings: Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet showed the resident's code status as, Full Code and Do Not Resuscitate (DNR). The facility's electronic medical record (EMR) showed both Full Code and DNR were Active (current) orders for resident #21. On 08/20/18 at 01:32 PM the licensed practical nurse, (LPN) E verified that resident #21 was designated as both Full Code and DNR on the resident's face sheet, and in the EMR. On 08/20/18 at 01:37 PM Arbor unit manager (UM) verified that on the face sheet, and in the EMR, resident #21 was designated as both Full code and DNR. The UM said Full code was active from 8/10/16, and should have been changed/discontinued when the DNR was initiated on 7/31/17. On 08/20/18 at 02:06 PM the social services director, (SSD) stated, If a resident initiated/has a DNR, the Do Not Resuscitate order (DNRO) would be scanned into the EMR system, and documented in the progress notes. The SSD said, if there had been a change, the change would be documented and the resident's medical record would be updated to reflect the change(s). The SSD said a progress note was completed on 7/26/17 when she spoke with resident #21, and the resident elected the DNR status. This change was not reflected on the face sheet or the EMR until it was bought to the attention of the UM by the surveyor.

Based on record review and interview, the facility failed to complete a discharge Minimum Data Sets (MDS) assessment for 1 of 1 sampled resident, (#2). Finding: On 8/21/18 at 4:08 PM, the resident assessment MDS licensed practical nurse, (LPN) coordinator stated that resident #2 was discharged on [DATE]. The last MDS completed and submitted was on 4/13/18. She said, I don't see a discharge MDS for 4/25/18. She stated that the process was to review the discharge in the computer system but the discharge assessment had to be submitted by the 14th day post discharge. She confirmed that she missed doing the MDS discharge assessment for resident #2. On 8/23/18 at 12:16 PM, the Director of Nursing said the MDS should be done upon admission, quarterly, and discharge. She stated that the discharge MDS for resident #2 was not done. The policy on Resident Assessments (RAI) and MDS completion dates from the CMS's RAI Version 3.0 Manual Chapter 2: Assessments for the RAI (MONTH) (YEAR) page 2-17 read, Discharge Assessments- return not anticipated MDS completion date is discharge date plus 14 calendar days and MDS transmission date no later than MDS completion date plus 14 calendar days.

Based on record review and interview, the facility failed to complete resident assessments (Minimum Data Sets- MDS) in a timely manner for 1 of 1 sampled resident, (#1). Findings: A review of the clinical record revealed that resident #1 was admitted on [DATE]. The most recent quarterly MDS assessment was completed on 3/26/18. On 8/21/18 at 4:17 PM, this information was verified by the resident assessment coordinator MDS licensed practical nurse (LPN). She stated that she did not know why a quarterly MDS was not completed unless resident #1 was discharged . She then verified that resident #1 did not leave and stated, I just missed her assessment. The MDS LPN coordinator provided the policy from CMS's RAI Version 3.0 Manual, Chapter 2: Assessments for the RAI (MONTH) (YEAR), page 2-17, a quarterly (non-comprehensive assessment assessment reference date (ARD) should be completed no later than the ARD of the previous assessment plus 92 calendar days and the MDS completion date should be ARD plus 14 calendar days, and the transmission date should be no later than the MDS completion date plus 14 calendar days.

Based on observation, interview and record review the facility failed to implement and coordinate the care for 2 of 2 residents with [DIAGNOSES REDACTED].#187, #74). The failure of the facility to implement and coordinate the care had the potential to cause negative outcome to the resident's physical health. Findings: Resident #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS] is a chronic progressive condition that affects the pumping power of the heart muscles. While often referred to simply as heart failure, [MEDICAL CONDITION] specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently. (https://www.healthline.com/health/congestive-heart-failure). The physician's orders [REDACTED].) in 1 day or 5 lbs. in 1 week. Review of physician's orders [REDACTED]. [MEDICATION NAME] is a diuretic that helps to rid the body of excess fluid. Review of resident's care plan for complication of [MEDICAL CONDITION] dated 8/4/18 revealed interventions for nurses to evaluate cardiac and respiratory status, signs of pedal [MEDICAL CONDITION], changes in weight status and for signs of increased [MEDICAL CONDITION] such as shortness of breath, congestion, cough and [MEDICAL CONDITION]. A review of weights revealed that resident #187's weights were not checked daily as ordered on [DATE]. The weights were checked at various times of the day and there was no evidence that the same scale was used or any explanation for extremely erratic readings except for note on 8/18/18 that weight was 140.5 lbs., not 135 lbs. On 8/6/18 the resident's weight increased 14.6 lbs. in 1 day. On 8/8/18 the resident's weight decreased by 19.9 lbs. in 2 days. On 8/10/18 the resident's weight decreased by 20 to 30 lbs. in 1 day. On 8/20/18 the resident's weight increased by 10 lbs. in 1 day. The weight log showed the following readings: 8/4/18 3:59 PM -155.1 lbs. 8/5/18 2:24 PM- 154.3 lbs. 8/6/18 7:08 AM- 168.9 lbs. 8/7/18 -no reading for weight 8/8/18 3:05 PM- 150 lbs. 8/9/18 6:57 AM- 147.6 lbs. 8/10/18 6:15 AM-127 lbs. 8/10/18 7:37 AM- 117 lbs. 8/11/18 6:32 AM- 147 lbs. 8/12/18 5:40 AM-146.5 lbs. 8/13/18 6:23 AM- 148.8 lbs. 8/13/18 4:10 PM- 148.8 lbs. 8/14/18 -no weight reading 8/15/18 5:39 AM- 144.3 lbs. 8/16/18 6:48 AM- 147 lbs. 8/17/18 6:50 AM- 145 lbs. 8/18/18 7:47 AM- 135 lbs. and reweigh at 8:04 AM- 140.5 lbs. 8/19/18 6:31 AM- 138.6 lbs. 8/20/18 5:32 AM- 141.9 lbs. and reweigh at 2:32 PM 149.2 lbs. 8/21/18 7:00 AM-138 lbs. 8/22/18 7:47 AM- 140.6 lbs. Review of the nursing documentation revealed the physician was not notified when the resident had greater than 3 lb. weight gain in 1 day on the following dates: 8/6/18, 8/11/18, 8/16/18 and 8/20/18. The Registered Dietician (RD) documented that she noted weight discrepancies on 8/13/18. The RD also documented on 8/21/18 that weight accuracy of 149 lbs. on 8/20/18 was questionable. On 8/21/18 at 12:26 PM resident #187 was observed sitting up in wheelchair wearing oxygen via nasal cannula. He was not able to be interviewed and only grunted when interview was attempted. On 8/22/18 at 12:30 PM, the Certified Nursing Assistant (CNA) D, stated that she was not the usual person that checked the resident's daily weights but did the weight once last week. The CNA said that it took 2 staff to do the resident's weight on the stand lift type of scale. After checking the weight, she reported the results to the nurse. She said there were no written instructions on the type of scale to be used but the scale used for resident #187 was usually in front of the nurses' station. On 8/22/18 at 1:28 PM the Stand Lift #10 Scale was found on Orchid Lane. At this time, the Floral Unit Manager (UM) indicated that this was the type of scale that was used to check daily weights for resident #187. She said that only 1 staff person was required to check his weights. It was the night nurse's responsibility to enter the weights into the computer system. The UM said that initially the resident was weighed with a mechanical lift and now he was weighed using a stand lift. The UM confirmed that the CNAs were not given any written instructions regarding which number/model scale to use to weigh residents. On 8/22/18 at 1:44 PM the Restorative Registered Nurse (RN) stated that the 11 PM-7 AM staff were responsible to do the daily weights at 6:00 AM for [MEDICAL CONDITION] residents. They did not document the type of scale or number of the scale used to weight residents. The CNAs would know which scale to use according to the resident transfer status in the Nursing Aid Data Sheet (NADS). If a resident could stand and bear weight the CNA would use the stand lift device. The Restorative RN verified that resident #187 did have an order for [REDACTED]. She could not provide any evidence in the medical record as to why the physician was not notified as per physician orders [REDACTED]. weight gain in 1 day on 8/6/18, 8/11/18, 8/16/18 and 8/20/18. The restorative RN verified that she could not provide any documentation to explain the erratic weight variation for resident #187 such as change in scale, scale being repaired, and notification to supervisor. The Restorative RN indicated she was not aware of erratic weight readings for resident #187 until it was brought to her attention by the surveyor. 2. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physicians' orders dated 7/20/18 included check weight daily with the absence of parameters as to when to call the physician regarding weight gain or loss. Review of physician's orders [REDACTED]. Review of the care plan dated 7/10/18 for cardiac complications due to [DIAGNOSES REDACTED].with goals that the resident will not have complications related to cardiac status. Resident #74 also had a care plan for [MEDICAL CONDITION] in both lower extremities dated 7/10/18 with nursing interventions to observe for changes in fluid status and weight as ordered. There were no instructions as to when to notify the physician or parameters regarding weights on the care plan. Review of the weight log from 7/20/18 to 8/22/18 revealed that resident #74 did not have his weights checked daily as ordered by the physician for [MEDICAL CONDITION]. There were no weights documented on 7/21, 7/22, 7/24, 7/31, 8/1, 8/2, 8/4, 8/6, 8/9, 8/13, 8/14, 8/15, 8/16, and 8/21 (total of 14 out of 33 days). There was no documentation to indicate why the weights were not obtained as ordered by the physician. On 8/22/18 at 1:17 PM CNA B stated that she used the stand lift scale to weigh resident #74 daily on the night shift. She said that he was a 1 person assist on the stand lift scale for weights. The UM of Floral Wing was present during the interview and confirmed that he should be weighed daily due to the [DIAGNOSES REDACTED]. On 8/22/18 at 1:52 PM the Restorative RN verified that resident #74 had a physician order [REDACTED]. Review of the weight log for resident #74 between 8/7/18 and 8/10/18 revealed the following: 8/7/18 10:47 AM- 161 lbs. 8/8/17 6:17 AM- 149.5 lbs. 8/8/17 7:00 AM- 159.5 lbs. - reweigh 8/10/18 7:30 AM- 143.5 lbs. - (16 lb. weight loss in 2 days) On 8/22/18 at 5:28 PM a telephone interview was conducted with night staff LPN A. She verified she was familiar with resident #74 and had been his assigned nurse. She said that the resident had orders to be weighed daily for [MEDICAL CONDITION]. She indicated that the weights were not always done on her shift. She said he had a significant weight loss of approximately 14 lbs. between 8/8/18 and 8/10/18 but she did not reweigh him or notify the physician as she should have. On 8/22/18 at 4:37 PM the Director of Plant Services (DPS), verified that the facility had the following lift devices (total of 6) to check the residents' weights. The lifts were not assigned to any particular unit and staff used different scales from the various units as needed. #6- Stature/sling type scale #13-Stature/sling type scale #7- Stature/sling type scale- taken out of service on 7/6/18 #5- Stand up lift scale #10-Stand up lift scale #12-Stand up lift scale The DPS verified that they had a total of 5 lift device type of scales being used at the facility at this time. He checked and calibrated each scale monthly with weights and the equipment company serviced all scales yearly. The most recent service was provided 7/6/18 for all scales by the equipment company. Since doing his monthly checks all lifts were working properly. He stated that the last time staff were trained on using the lift/scales was about 5 years ago when the lift scales were purchased. The training was provided by the company the lift scales were purchased from. He was not involved in the staff training on how to use the scales. On 8/22/18 at 2:44 PM the RD and Certified Dietary Manager (CDM) both indicated that the weight readings for residents #187 and #74 had been erratic and they had been questioning the accuracy. When asked as to why the facility had difficulty with obtaining accurate resident weights, they said there were too many hands in the pot and this had been going on now for approximately 3-4 months. They indicated reporting concerns to the Director of Nursing (DON). The facility had tried different solutions which had not made a difference to the present date. They tried having the CNAs do the weights and then the restorative team do the weights. The weights were to be monitored by the restorative nurse prior to inputting into the computer. An interview was conducted with the Medical Director on 8/22/18 at 6:24 PM regarding erratic weight readings at the facility. He said this issue was discussed at the last Quality Assurance (QA) meeting. The Medical Director stated that a 2-3 lb. weight variance was okay. He would expect this especially if residents were on diuretics. If there was a greater weight variance, then the physician should be contacted. He said some well-defined [MEDICAL CONDITION] facility policies were needed as well as a plan of correction as the concerns of irregular weights had been ongoing and were discussed at the last month's Quality Assurance (QA) meeting. On 8/23/18 at 12:24 PM the DON confirmed that resident #74 had a physician order [REDACTED]. She said the nurse who obtained the order should have clarified the [MEDICAL CONDITION] parameters. She confirmed that the weights should be done daily prior to the breakfast meal. She stated that the number scale/or type of scale used should have been documented. The CNAs should have received directives from the nurse regarding which scale to use. She confirmed there was no place in their electronic system to document the type of scale or number of the scale that were being used to obtain the weights. Contrary to staff interviews, the DON said that all lift type devices required 2 staff. She stated she became aware of weight discrepancies with [MEDICAL CONDITION] residents on 8/14/18. Education was provided to nurses regarding accuracy of documentation of weights. The DON was made aware that on 8/22/18 the Restorative RN was asked to provide needed interviews from the night staff and as of now only 1 LPN interview was provided. The DON verified that the facility did not have a process in place to document which scale was used when obtaining daily weights. Scales were not assigned to each unit and that for [MEDICAL CONDITION] residents it would be critical to use the same scale to ensure accuracy of weights. There were no facility guidelines for heart failure to review.

Based on interview and record review the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN Form CMS- ) for 3 of 3 sampled residents, ( #12, #36, #235), and failed to provide beneficiary discharge notification for 1 of 3 residents, (#235). Findings: On 8/22/18 at 4:25 PM, the Social Service Director stated that she had never heard of the form, SNFABN Form CMS- so she had not provided it to the residents. Residents #12 and #36 did not have SNFABN Forms CMS- when they were discharged from therapy but remained in the facility. The SSD on 8/22/18 at 4:26 PM stated that resident #235 was admitted on [DATE] and left the faciity on [DATE], with a family member on a leave of absence to attend a funeral. She said resident #235 did not return to the facility after the funeral so she did not have time to give him the form of discharge notification. A review of resident's medical record noted a discharge order for 7/17/18 that read, resident #235 to be discharged on [DATE] with all medications, [DIAGNOSES REDACTED]. A progress note on 7/19/18 read that resident #235 was alert and oriented times 3. A clinical discharge note dated 7/19/18 at 10:46 PM read, resident #235 alert and responsive and able to make needs known. Resident discharge home with friend with medications. Education given on medications. Verbally gave instructions on how to do dressing changes to right plantar foot and heel. Resident understood. The Discharge Summary/Recapitulation of Stay V04- for social services note was written for discharge to the community and signed on 8/16/18. There were no other social service notes in the medical record to indicate the resident left facility without medical advice or was absent without leave. The care plan was written for resident #235 to be discharged back to the community. On 8/23/18 at 12:56 PM, the Director of Nursing said she did not remember anything about resident #235's discharge. On 8/23/18 at 2:54 PM, the SSD admitted there was no social services note for resident #235 but there was a discharge order in place for him to leave the facility and that note dated 7/19/18 read discharge home with all medications. The SSD said resident #235 didn't go home, he went to Miami to an aunt's funeral. The SSD told the doctor that he was going to Miami. He was not discharged against medical advice and the facility got a discharge order in place. However, the SSD admitted she did not give resident #235 a Notice of Medicare Non-Coverage (CMS ) or any paperwork. The SSD admitted she did not write anything about resident #235 going to Miami for a funeral.

Based on observation and interview, the facility failed to maintain the dumpster area free of debris. Findings: On 5/08/17 at 9:55 AM, to the left side and adjacent to the dumpster was trash including debris, lids, plastic bags, napkins, about 4 feet long and 1 foot wide at the widest spot. On 5/08/17 at 9:55 AM, the Consultant Dietitian and the Certified Dietary Manager (CDM) both validated that trash being was present. The CDM said the debris on the ground next to the dumpster was left behind from when the dumpster was emptied that morning. On 5/08/17 at 11:54 AM, the Administrator stated the debris was left next to the dumpster because the dumpster had a hole in the bottom of it.

Based on observation, interview and record review, the facility failed to remove expired narcotic medications from medication cart for 1 of 1 resident in 1 of 5 narcotic medication carts, and failed to properly label stored medications for 2 of 2 residents in 1 of 5 treatment carts on 2 of 2 nursing units (floral and arbor) reviewed for medication storage out of a sample of 25 (#193, #300 & #72). Findings: 1. On 5/10/17 at 9:22 AM, an observation of the narcotic drawer (top right) medication cart floral fern hallway was conducted with Staff C LPN (licensed practical nurse) on floral unit. Which revealed a clear bag with labels and 28 syringes each with a label showing expiration date of 4/08/17 which was validated with Staff C LPN Resident #193. Review of the physician order showed medication order date of 3/16/17 (CP-ABH 1/25/2-lorazepam, diphenhydramine, and haloperidol transdermal gel apply X1 topically every 6 hours as needed for anxiety. Staff C LPN stated the medication carts are cleaned by everyone (all nurses each shift) and not assigned on a specific shift). When asked what is the facility's process for expired medication within the medication carts? She stated expired medications should not be in the cart. On 5/10/17 at 9:40 AM, an interview was conducted with FUM LPN (floral unit manager licensed practical nurse), When asked for what was facility policy when expired medications are located within medication carts? She stated expired medications should be pulled, taken out of the cart and returned to pharmacy. If the medication is a narcotic it is to be given to the DON (director of nursing), so it can be destroyed when pharmacy returns. When asked how often she checks the medication carts she said, I checked the medication carts last Monday. When asked if she looks at the labels she stated, I look at the date on the label not on the syringes. Review of the Medication Administration Record [REDACTED]. Review of the facility policy 6.0 general dose preparation and medication administration with effective date 12/01/07 and revision date of 1/01/13, showed on page 1 of 3 section 3.3 Facility staff should not administer a medication if the medication or prescription label is missing or illegible. Page 2 of 3 section 4.1.1 showed Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct date, route, rate, time for the correct resident and section 4.1.3 showed check the expiration date on the medication. 2. On 5/10/17 11:21:30 AM, observation of the treatment cart on floral azalea hallway with Staff E LPN for medication storage. Located in the top drawer of the cart were clear plastic bags. One bag contained X1 tube of santyl ointment for Resident #300 with no label. There was a clear plastic bag containing a tube of santyl ointment for Resident #72 with the last name written in black ink only. The tube of santyl ointment did not have labels that listed resident's full name's, dose, frequency, route, or instructions. When asked are medications labeled before use? What is the facility policy regarding medication labels and storage of medications in treatment carts? FUM LPN stated, I believe it (Santyl) is a stock medication. When asked are you sure because there are several Residents with santyl tubes of medications and they all have labels. She stated let me get the wound nurse for you. An interview was conducted with wound nurse LPN on 5/10/17 at 11:22 AM, when asked, is santyl a facility stock medication? He said, No, it should have a label I will get one from the pharmacy. In an interview with the ADON (assistant director of nursing) on 5/10/17 at 5:53 M, regarding the labeling of medications and facility policy/practices regarding expired medications on medication cart, She said, medications and treatments should have a pharmacy label. If it does not have a label we are to call the pharmacy for a label. When asked if staff is aware of this process? She said, Yes. When asked regarding the facility process of expired medications? She said, should be locked up in the medication cart on the narcotic side, counted and when the DON (director of nursing) rounds picked up for destruction of the medication. Review of the facility policy 5.3 storage, expiration dating of medications, biologicals, syringes, needles with an effective date of 12/07 and a revision date of 10/31/16, revealed on page 2 of 3 section 4 Facility should ensure that medications and biologicals, (1) have an expired date on the label .are stored separate from other medications until destroyed, returned to the pharmacy or supplier.

Based on observation, interview, record review, and policy/procedure review, the facility failed to ensure policies and procedures were followed for investigation of alleged abuse for 1 of 3 residents allegations reviewed for abuse protocols (#20), and failed to protect residents by allowing alleged employee to continue working (Certified Nursing Assistant B). Findings: Resident #20 was admitted to the facility on [DATE] and re-admitted on [DATE]. A review of the resident's most recent Minimum Data Set (MDS) assessment, dated 3/23/17, indicated her Brief Interview for Mental Status (BIMS) score of 14/15, which meant she was cognitively intact. The MDS assessment dated [DATE] revealed that she had a BIMS score of 14/15 and on assessment dated [DATE], her score was 15/15. On 5/9/17 at 9:42 AM, resident #20 was observed in her room sitting up in wheelchair. The Resdient was asked Has staff, a resident or anyone else here abused you - this includes verbal, physical or sexual abuse? She said, They slung me by the right leg into the bed after using the bathroom. She was not sure of the name of the staff person involved and said her daughter reported this to staff. On 5/9/17 at 10:07 AM, the Director of Nursing (DON) and Administrator who is also the Abuse Coordinator were notified of Resident #20's allegation of abuse made on 5/9/17 at 9:42 AM. The DON said that she thought this might have been regarding a grievance that was filled about a month ago, and the facility was not aware of any allegations of abuse regarding this resident. On 5/9/17 at 10:20 AM, the DON and Abuse Coordinator brought in a grievance repot that was filed on 2/13/17 regarding resident #20. The grievance/complaint read, Resident reports that Certified Nursing Assistant (CNA) B hurt her right knee when she put her to bed about 1 ½ weeks ago. She stated he lifted her leg by the knee into the bed and it started hurting. When asked why the CNA involved in the abuse allegation on 2/13/17 was not suspended pending an investigation, the DON said, We made the decision that it wasn't anything. On 5/10/17 at 6:52 PM, a telephone interview was conducted with Resident #20's daughter. When asked about the concern she brought to the facility's attention on 2/13/17, she said she reported to the Unit Manager that the lady tending to her mother threw her in bed. When asked if she thought her mom was abused, she said, I reported that they hurt my mom and she was thrown into bed. Last week the daughter attended the care plan meeting at the facility. She told the Assistant Director of Nursing (ADON) and other staff that, she did not want CNA B to continue being her mother's caregiver. The staff told her that they were short staffed and CNA B would continue to be her mother's caregiver at times. On 5/11/16 at approximately 11:30 AM, Licensed Practical Nurse (LPN) MDS Coordinator A confirmed she filled out the grievance form on 2/13/17 at 7:30 AM involving Resident #20. The resident reported to her that , CNA B hurt her right knee. LPN A stated it wasn't anything like abuse, was not willful or intentional and she made the determination that it was not abuse after she talked with the CNA, Unit Manager and nurse caring for the resident on that day. On 5/11/17 at approximately 12:00 PM, the DON revealed that on 2/13/17 at the morning meeting, although an investigation was not conducted regarding Resident #20 reporting that the CNA hurt her, the CNA involved was not suspended at that time and abuse investigation was not initiated. On 5/10/17 at 3:11 PM, Arbor Wing Unit Manager (UM) confirmed that on 2/13/17, resident #20's daughter reported to her that CNA B hurt her right knee when putting her into bed about 1 ½ weeks ago. The UM said the resident reported to her, when she came out of the bathroom, the CNA tried to pick of her right leg. She told the CNA to stop because her leg started to hurt. On 5/10/17 at 11:24 AM, the Social Services Director verified that she is also the Grievance Officer for the facility. She said that if reading a grievance read, Someone hurt me, that would indicate the need to initiate an abuse investigation. On 5/11/17 at 9:41 AM, an interview was conducted with the Abuse Coordinator. He said he became aware of grievance filed regarding Resident #20 on 2/13/17. He also confirmed the facility's abuse policy is to protect the resident and suspend the staff immediately who is involved the alleged abuse. However, CNA was not suspended at that time. On 5/11/17 at 1:42 PM, the administrator was asked to provide a job description for the Abuse Coordinator and said the facility does not have one. The facility's policies and procedures regarding resident abuse, last revised on 2/24/17, read Protect: In order to prevent potential harm while the investigation is in progress, any employee accused will be relieved from duty until the timely investigation is complete 6. Report and Investigate: d. Allegations of abuse, potential neglect/exploitation will be thoroughly investigated. The investigation will be initiated as soon as alleged abuse, potential neglect/exploitation has been identified.

Based on record review and interview, the facility admissions agreement page 85 of 96 waived the facility responsibility for loss or damaged resident personal property. Findings: On 5/10/17 at 4:05 PM, the Admissions Assistant Coordinator provided the policy in the Admission Agreement that referred to theft or loss of personal property on page 85 of 96 that stated the facility is not responsible for damaged and/or lost items. On 5/11/17 at 12:36 PM, the Social Service Director said if there was a lost item it would be logged on the lost item form and placed on the missing items log. All items were replaced if placed on the inventory sheet / personal property form. All personal items need to be logged. Residents are informed of this policy upon admission. If a resident or family brings in a new item, they need to make staff aware so it is added to inventory list. If families bring in valuable items, the facility will provide a lock box or offer the use of a safe. On 5/11/17 at 4:19 PM, the Administrator provided the policy on loss or theft and validated the policy says the facility is not responsible for loss or theft for residents personal items. The Administrator said he was not aware the facility must be responsible for loss or theft of resident personal items in the facility and the facility can not waive their responsibility to replace items.

Based on observation, interview and record review, the facility failed to provide personal hygiene care for 1 of 1 dependent residents (#2). Findings: Resident #2 was admitted to the facility on [DATE] with history including [MEDICAL CONDITION], contractures of all extremities, and [MEDICAL CONDITION]. A review of the quarterly Minimum Data Set, dated dated [DATE], revealed that the resident required extensive assistance of one person for personal hygiene. An observation at 11:15 AM on 6/22/16 showed the resident resting in bed. The resident was able to voice yes/no and was able to gesture and point. He had severely contracted hands and fingers. His fingernails were long and had dark brown/black debris under the nails. The fingernails were digging into the skin of the adjacent fingers and into the his palms. Licensed practical nurse A was present at the time of the observation and confirmed the findings. When the resident was asked if he wanted his fingernails long, he stated No. When he was asked if he wanted his fingernails cut, he stated Yes. On 6/22/16 at 12:30 PM, certified nursing assistant (CNA) B she stated that the resident's regular CNA was off today. She said that she only cared for the resident twice per month and could not explain why his fingernails had not been cleaned or trimmed.

Based on observation and interview, the facility failed to ensure that a call light was within reach for a dependent resident capable of using the call bell for 1 of 2 sampled residents (#2). Findings: Resident #2 had a history of [REDACTED]. An observation of the resident on 6/22/16 at 11:15 AM showed the call light wrapped around the control panel on the wall out of the resident's reach, approximately 3.5 feet away. Licensed practical nurse A, present at the time, stated that the resident had returned from the hospital yesterday and the staff probably forgot to put it back in place. She removed the call bell from the wall panel and pinned it on the bed within the resident's reach. The resident was asked if he ever used the call bell and he stated Yes. When he was asked how he used the call light, he was able to press the call light.

Based on observation, interview and record review, the facility failed to ensure safe handling and processing of linens to prevent cross contamination in one soiled utility room (Orchid Lane), and in the laundry department. Findings: 1. In an observation conducted on Orchid Lane on 2/08/16 at 10:06 AM, laundry staff J was in the soiled utility room moving white soiled laundry bags from one gray laundry bin into another gray laundry bin. She was wearing only disposable gloves for protection from contact with the soiled linens. Soiled linen fell out of the white laundry bags and laundry staff J scooped up the soiled linen and stuffed them back into the white laundry bags. The soiled linen came in contact with laundry staff J's personal clothing. On 2/11/16 at 10:50 AM, laundry staff J stated that she was in the soiled room on Orchid Lane and was moving the soiled laundry from one soiled laundry bin to another soiled laundry bin so it could be transferred to the laundry department. She said, I did not wear a protective gown when picking up the soiled linen on the unit and my clothes were exposed to the soiled laundry. 2. On 2/11/16 at 10:42 AM, two laundry staff separated soiled laundry from the gray laundry bins into three soiled yellow bins. The door separating the soiled linen room and the washer room was open and one of the soiled yellow bins was located in the doorway connecting the two rooms. On 2/11/16 at 10:44 AM, the environmental services supervisor stated, The door from the soiled room and washer room should be closed at all times. On 2/11/16 at 10:44 AM, two laundry staff filled two washing machines with soiled linen. Two clean wire rolling carts, used to move clean linens to the dryers, were sitting next to the washing machines while laundry staff filled the washing machines with the soiled linen. The environmental services supervisor stated that the two clean rolling carts should not have been in the washer area when the soiled linen was being put into the washing machines because of contamination to the clean linen carts. 3. On 2/11/16 at 10:44 AM, three personal staff jackets were on a wire shelving cart, which contained laundry chemicals, located directly across from the washers. The jackets hung on the cart while soiled linen was placed in the washing machines. The environmental services supervisor stated that the laundry staff jackets should not be hanging on the cart, and she removed the jackets from the wire rack. On 2/11/16 at 11:05 AM, laundry staff J, K and L were in the clean folding room. Laundry staff J and K folded towels on the folding table. Two plastic bottles of water were on the folding table. One bottle of water was full and the second bottle of water was 1/4 empty. The clean folded towels on the folding table were touching the 1/4 empty plastic bottle of water. On 2/11/16 at 11:10 AM, the environmental services supervisor stated that staff do not eat or drink in the laundry department. Further interview with laundry staff L revealed that she does drink in the clean folding room. On 2/11/16 at 12:58 PM, the plant services director confirmed that the door between the soiled linen room and washer room should be shut, the clean wire carts for the clean washed linen should not have been in the washer room when the soiled linen was being put into the washer, staff jackets are not to be in the same area with soiled linens, and eating and drinking is not permitted in the laundry area. Review of the Sunbelt Health & Rehab Center - Apopka, Inc. Policy and Procedure, dated 02/12/16, read, It is the policy of this facility to provide an adequate amount of hygienically clean and odor free linens to meet the needs of the residents Definition: Hygienically Clean - free of pathogens in sufficient numbers to cause human illness. Procedure: 1. The laundry department will maintain an adequate supply of hygienically clean linens to provide resident care. 2. The laundry department will maintain separation of clean and soiled linens. 3. The laundry staff will be trained in safe linen handling and infection control guidelines Laundry Services, Administration Guidelines, dated 04/10/13, read, General Guidelines:1. All potential contaminated linen from bedside to laundry, will be handled utilizing Standard Precautions to prevent cross-contamination Laundry Services Staff: 1. Laundry staff will be provided with .personal protective equipment, such as gloves and protective gowns and eyewear, for use in handling soiled linens Standard precautions should be utilized when handling soiled laundry. 2. The laundry area should be arrange so there is a distinct separation between clean and soiled linen to prevent cross contamination 3. Laundry service will be provided to assure that a clean supply of linen is on hand at all times

Based on interview and record review, the facility failed to provide social services to attain highest practicable well being for 1 of 38 residents (#300). Findings: Resident #300 was admitted to the facility from the hospital on [DATE] with a history including mental retardation, bipolar disorder, psychosis and aphasia. The level 1 Pre Admission Screening Resident Review (PASRR) was reviewed with the social services director on 2/10/16 at 10:38 AM. The question was asked if the individual had a disorder that affected his functional limitations in major life activities. This was answered no. The social services director stated that this should have been marked yes. Another question asked if the individual had serious difficulty communicating effectively with other persons. This was answered no. The social services director stated that this should have been answered yes because the resident was not able to communicate and was aphasic. After reviewing the form, she stated that question C was also answered incorrectly. She stated that she had not looked at the PASRR level 1 closely and had not realized the errors. A review of the form 3008 was also reviewed with the social services director. On 2/10/16 at 10:38 AM, she stated that this form also had errors. She stated that when the resident was first admitted , she had not reviewed the level 1 PASRR screen or the 3008. She said that both forms were filed in the resident's chart. She said that this also affected the resident's discharge planning as a level PASRR was not done up until now. She stated that the 3008 form was sent to elder affairs on 1/19/16 and it was sent back to her on 2/08/16 indicating that it was incomplete. She sent the 3008 to the hospital to complete on 2/10/16, almost 2 months after the resident's admission to the facility. When she was asked what the resident's status was now, she said she was waiting for a level II screen to be done. She said that the resident had resided in a group home for the past [AGE] years but they were not going to accept him back after discharge from the facility. When asked why, she said that maybe it was because he was no longer walking but was not certain. When she was asked if there were other residents at the group home in wheelchairs, she said she did not know. A phone call was made to the group home administrator on 2/11/16 at 2:37 PM. The administrator stated that they could not accept the resident back to the group home as he could not weight bear or pivot and would require transfers with a mechanical lift. The director of rehabilitation services was in the room at the time of the phone call and said the resident was able to weight bear, was able to pivot and only required minimal assist with transfers. A conference call was held with the group home in the social service director's office. The rehabilitation director and the director of nursing were also in the room during the conference call. The group home director stated that she would come to the facility tomorrow morning to reassess the resident. An interview was held with the social service director on 2/11/16 at 4:45 PM. When she was asked if she had any ongoing dialogue with the group home in regards to the resident's discharge, she stated no. She said that she was working on alternative discharge placement for the resident because she did not question why the group home was not accepting him back. When she asked why she would not question the group home's refusal to take the resident back considering that it was his home for more than [AGE] years, she did not have an answer.