Every finding on record at Solaris Healthcare Daytona

Based on observation, interviews and record reviews, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. This could have a potentially negative outcome on its current census of 67 residents. At the time of the survey, none of the dietary staff had current dietary training. The findings include: A tour of the kitchen was conducted on 6/29/2025 at 11:23 a.m. [NAME] C was observed and Dietary Aide D was also present. On 6/29/2025 at 11:35 a.m. Dietary Aide D was observed in the sanitation area of the kitchen. She was asked if the dishwasher was a high-temperature or low-temperature machine. She stated she was not sure. She was asked how she would determine whether or not the dishes were clean and sanitized. She again stated she was not sure and added that she eyeballs it. Observed the dishwasher temperature log hanging on the wall. The temperature had not been recorded for five shifts. The Certified Dietary Manager (CDM) arrived on 6/29/2025 at 11:57 a.m. He was made aware of the incomplete temperature log. He confirmed that it should have been completed. During an interview on 6/29/2025 at 12:15 p.m. with the CDM, he was asked to provide any dietary education provided to the staff within the last six months. A follow-up tour of the kitchen was conducted on 6/30/2025 at 9:18 a.m. Observed that the dishwasher temperature log had not been completed for any shift on 6/29/2025. (Photographic Evidence Obtained) During an interview conducted on 7/01/2025 at 11:45 a.m. with the CDM, he stated he was unable to locate any of the recent training for the dietary staff. On 7/02/2025 at 11:05 a.m., the Human Resources Manager provided training rosters for all of the dietary staff. Observed multiple training topics were marked Not Attempted. She was asked what this meant. She stated it meant the training was assigned but the employer had not completed the training. (Photographic Evidence Obtained) During an interview conducted on 7/02/2025 at 11:40 a.m. with the CDM, he stated the dietary staff were required to complete annual training. He confirmed that none of the dietary staff had completed any of their required training. He stated this was not discovered until June 2025. He stated they started doing the basic facility required training and that all of the dietary-related training remained undone. A review of the facility's policy titled Storage of Foods Brought to Residents by Family/Visitors (revised 1/18/2018), revealed: Policy Statement: Staff must be aware of, and approve, food(s) brought to a resident by family/visitors to ensure safe and sanitary storage, handling and consumption of foods. Policy Interpretation and Implementation: * Family members / responsible parties should inform nursing staff of their desire to bring foods into the facility, The Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. * If necessary, the nursing staff or Dietitian will discuss with the Physician whether a diet can be liberalized. * The Dietitian will counsel residents or families about requests that conflict with residents' dietary restrictions and whenever diets cannot be liberalized. *The Dietitian or a nurse will document any such discussions in the residents' medical records. * Non-perishable foods retained in the residents' rooms must be stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in a manner which minimizes risk of cross contamination in the designated resident refrigerators. These foods will be labeled with the resident's name, and dated. * The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/ expiration date, whichever comes first. * The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (or example, mold growth, foul odor, past due package expiration dates). 9. Home-prepared and home-preserved foods are permitted if brought by family or visitors for individual residents. Such foods may not be shared or distributed to other residents. 10. Facility staff only will assist with reheating food to ensure safe food handling practices. 11. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. Reviewed the facility's policy: Food Receiving and Storage revised 1/30/2024 Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times, 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 3. Foods that are prepared off site will only be accepted from institutions that are subject to federal, state or local inspection. The Food Service Manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 4. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 5. Food in designated dry storage areas shall be kept off the floor (at least 6 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated. 8. Refrigerated foods must be stored at 41°F or below. 9. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. 10. Freezer temperature maintained to keep frozen food solid. Frozen food wrapping must stay intact until thawing. 11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented on an approved log. 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers with a date and below fruits, vegetables and other ready-to-eat foods. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: *Perishable food items will be covered/labeled and dated under refrigeration at 41°F or below. *Frozen food items will be covered/labeled and dated at a temperature maintained to keep frozen *All foods belonging to residents must be labeled with the resident's name, room number and food solid. *Refrigerators and freezers must have working thermometers and be monitored for temperature. date. *Other opened containers (food/beverage) must be dated and sealed or covered during storage and held no longer than 72hrs *Partially eaten food may not be kept in the refrigerator. *Medications, blood or blood products may not be stored in the same refrigerator with food 14. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils. 15. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage. .

Based on observations, record reviews and interviews, the facility failed to store food kept in the nourishment room refrigerator in accordance with professional standards for food service safety. Food stored in the nourishment room refrigerator was observed to be unlabeled and undated, which could result in residents receiving other residents' food items, or food items that were potentially unsafe due to extended storage in the refrigerator. The findings include: A tour of the facility's nourishment room was conducted on 6/30/2025 at 10:18 a.m. Signage attached to the door of the refrigerator revealed Resident Food Only. Any resident food stored here must be labeled with: Resident name and date. Any food items stored here that are open/already prepared must be thrown away if > 3 days old. Food items may be kept until expiration date only if prepackaged and sealed/unopened. No staff food. Several undated and unlabeled items were observed in the refrigerator and freezer. (Photographic Evidence Obtained) A follow-up tour of the nourishment room was conducted on 7/1/2025 at 2:32 p.m. Undated and unlabeled items remained in the refrigerator and freezer. Additional items had been added since 6/30/2025 at 10:18 a.m. which were not dated or labeled. (Photographic Evidence Obtained) On 7/2/2025 at 11:28 a.m., undated and unlabeled items remained in the refrigerator and freezer of the nourishment room. (Photographic Evidence Obtained) An interview was conducted on 7/2/2025 at 11:36 a.m. with Licensed Practical Nurse (LPN)/Unit Manager E. She stated all staff were responsible for the upkeep of the nourishment room. She stated it was usually checked in the morning by herself, the Assistant Director of Nursing (ADON), or a Dietary Staff member. She stated all items had to be labeled with the residents' names and room numbers. She also stated that open items had to be discarded within three days. A review of the facility's policy titled Storage of Foods Brought to Residents by Family/Visitors (revised 1/18/2018), revealed: Policy Statement: Staff must be aware of, and approve, food(s) brought to a resident by family/visitors to ensure safe and sanitary storage, handling and consumption of foods. Policy Interpretation and Implementation: - Family members/responsible parties should inform nursing staff of their desire to bring foods into the facility, The Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. - If necessary, the nursing staff or Dietitian will discuss with the Physician whether a diet can be liberalized. - The Dietitian will counsel residents or families about requests that conflict with residents' dietary restrictions and whenever diets cannot be liberalized. - The Dietitian or a nurse will document any such discussions in the residents' medical records. - Non-perishable foods retained in the residents' rooms must be stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in a manner which minimizes risk of cross contamination in the designated resident refrigerators. These foods will be labeled with the resident's name, and dated. - The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/ expiration date, whichever comes first. - The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (or example, mold growth, foul odor, past due package expiration dates). 9. Home-prepared and home-preserved foods are permitted if brought by family or visitors for individual residents. Such foods may not be shared or distributed to other residents. 10. Facility staff only will assist with reheating food to ensure safe food handling practices. 11. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. A reviewed the facility's policy titled Food Receiving and Storage (revised 1/30/2024), revealed: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times, 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 3. Foods that are prepared off site will only be accepted from institutions that are subject to federal, state or local inspection. The Food Service Manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 4. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 5. Food in designated dry storage areas shall be kept off the floor (at least 6 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated. 8. Refrigerated foods must be stored at 41°F or below. 9. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. 10. Freezer temperature maintained to keep frozen food solid. Frozen food wrapping must stay intact until thawing. 11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented on an approved log. 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers with a date and below fruits, vegetables and other ready-to-eat foods. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: *Perishable food items will be covered/labeled and dated under refrigeration at 41°F or below. *Frozen food items will be covered/labeled and dated at a temperature maintained to keep frozen *All foods belonging to residents must be labeled with the resident's name, room number and food solid. *Refrigerators and freezers must have working thermometers and be monitored for temperature. date. *Other opened containers (food/beverage) must be dated and sealed or covered during storage and held no longer than 72hrs *Partially eaten food may not be kept in the refrigerator. *Medications, blood or blood products may not be stored in the same refrigerator with food 14. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils. 15. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage. .

Based on observations, medical record review, and interviews, the facility failed to ensure that one (Resident #25) of ten residents receiving oxygen, from a total sample of 27 residents, received oxygen at the correct settings as ordered by the physician. The findings include: An observation was made of Resident #25 on 8/22/23 at 9:00 a.m. in her room. She was lying in bed with oxygen infusing at 3 liters per minute via an oxygen concentrator. (Photographic evidence obtained) On 8/22/23 at 3:01 p.m., Resident # 25 was observed sitting in a wheelchair at bedside with oxygen flowing at a rate of 3 liters per minute via nasal cannula via the oxygen concentrator. Resident #25 did not know what the flow rate setting should have been. (Photographic evidence obtained) An observation was made of Resident #25 on 8/23/23 at 12:25 p.m. receiving a.m. care. Oxygen was observed infusing at 3 Liters per minute via nasal cannula. (Photographic evidence obtained) An observation was made of Resident #25 on 8/23/23 at 1:26 p.m. sitting up in a wheelchair at bedside. She had just finished her lunch. Oxygen was infusing at 3 Liters per minute via nasal cannula. (Photographic evidence obtained) A review of Resident #25's electronic medical record revealed that she was admitted on [DATE] with diagnoses including congestive heart failure, atrial fibrillation and neoplasm of the uterus. A physician's order dated 7/27/23, noted oxygen continuous at 2 liters per minute via nasal cannula in the medical record. A review of the Medication Administration Record (MAR) for August 2023, revealed that the physician's order dated 7/27/23 for oxygen continuous at 2 Liters per minute via nasal cannula, was signed off daily as having been administered per the order. The care plan, updated on 7/28/23, noted the resident was at risk for complications related to respiratory disease, shortness of breath, and congestive heart failure. The intervention was to administer oxygen as ordered by the resident's physician. An interview was conducted with Registered Nurse (RN) A at 1:28 p.m. on 8/23/23. The RN was asked how many Liters of oxygen Resident #25 was receiving, and she stated she needed to review the resident's physician's orders. She reviewed the orders and reported that oxygen should be infusing at 2 Liters per minute. RN A was accompanied to Resident #25's room to check the resident's oxygen flow rate. RN A confirmed that the resident's oxygen was set at 3 Liters per minute and she changed the setting to 2 Liters per minute. An interview was conducted with the Director of Nursing (DON) on 8/23/23 at 1:45 p.m. The DON reported continuous oxygen settings should be checked every shift by the assigned nurse. A review of the facility's policy for Oxygen (revised on 1/25/23) revealed the following: Steps in setting up the oxygen: Number 2: Turn on oxygen. Start flow at ordered rate. Under step #4: Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observations and interviews, the facility failed to appropriately store medications in accordance with currently accepted professional principles and guidelines. Medications were stored improperly on three (140 hall, 120 hall and 160 hall) of four medication carts reviewed, from a total of four carts in the facility. Medication was also left with a random resident to consume after the nurse exited the resident's room, and medications were observed at bedside in a second random resident's room (room [ROOM NUMBER]B). The findings include: On 11/12/19 at 10:57 a.m., an observation was made of the medication cart on the 140 hallway and loose pills were noted in the cart. A second cart was observed at 11:01 a.m. on the 120 hallway, and loose pills were also noted in that cart. An interview was conducted with Employee G, Licensed Practical Nurse (LPN), at the time of the observation. When asked who was responsible for cleaning the carts and ensuring there were no loose medications inside, she stated that 11:00 p.m. to 7:00 a.m. nursing staff was responsible. She confirmed that the loose pills in the medication cart could not be identified. On 11/14/19 at 9:22 a.m., medications were observed on the sharps container on the 140 hall medication cart. The pills were lying on the sharps container and were in reach of anyone who passed by. During an interview with Employee B, LPN, at the time of the observation, she stated, I dropped the pills, so I put them in there. When her attention was brought to the pills on the sharps container, she stated, I'm sorry. I thought I dumped those. When asked who the medications were for, she replied that they were for the resident in room [ROOM NUMBER]. A review was conducted of Resident #144's 9:00 a.m. scheduled medications, which revealed the following: [MEDICATION NAME] 10 mg (milligrams) (blood pressure medication) Aspirin 81 mg (pain med/blood thinner) [MEDICATION NAME] 0.1 mg (blood pressure medication) [MEDICATION NAME] 75 mg (anti-platelet medication) [MEDICATION NAME] 25 mg (blood pressure medication) [MEDICATION NAME]/hydrochlorothiazid (blood pressure medication) On 11/14/19 at 9:32 a.m., a cup of water with [MEDICATION NAME] (laxative) inside and a spoon were observed on the 160 hall medication cart. After approximately five minutes, when the nurse hadn't returned to the cart, the staff at the nursing station was asked which nurse was assigned to that medication cart. The Unit Manager located Employee I, the LPN assigned to the cart, in a resident's room. Upon returning to the cart, Employee I picked up the cup of liquid and confirmed it contained [MEDICATION NAME]. She stated, I forgot to give it to her. She picked up the cup, entered the resident's room and handed it to the resident. As the nurse was exiting the room, she was asked whether the resident took the medication. She stated, She is drinking it now. On 11/15/19 at 10:36 a.m., a review of the 160 hall medication cart was made with Employee K, LPN. Medicated ointments (anti-fungal cream (multiple tubes), Zinc Oxide, and Biofreeze) were observed in the outside pocket of the cart. The nurse confirmed that the medication should be locked up and not stored there. She was then asked about the medications observed at bedside in room [ROOM NUMBER]B. She stated that the resident had a locked box and her medications should be locked up. The medications had been noted to be at the resident's bedside since 11/12/19, during the initial tour. A review of the facility's policy and procedure revealed the following: Manual Title: LTC Facility's Pharmacy Services and Procedures Manual Policy #/Title: 5.3 Storage and Expiration Dating Medications, Biological's, Syringes and Needles. Application: LTC Facilities Receiving Pharmacy Products and Services from Pharmacy Effective Date: 12/01/07 Revision Date: 05/10/10, 01/01/03, 10/31/16, 04/05/19, 07/23/19, and 10/28/19. Pages: 1 of 3 Applicability: This policy 5.3 sets for the procedure relating to the storage and expiration dates of medications, biological's, syringes and needles. Procedure: 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. 3.3 Facility should ensure that all medications and biologicals, including treatment items, are stored securely in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observations, review of facility and resident records and staff interviews, the facility failed to properly clean and disinfect glucometers sufficiently between residents' use as part of their infection prevention efforts. The facility also failed to ensure appropriate disposal of biohazardous waste and sharps, and failed to properly use personal protective equipment (gloves) during blood glucose testing for three (Residents #41, #263 and #163) of three residents observed during blood glucose monitoring, out of 19 diabetic residents in the facility and a total of 34 residents in the sample. The findings include: 1. An observation of the 160 hall medication cart on 11/12/19 at 1:08 p.m., revealed two glucometers stored in a clear, plastic [MEDICATION NAME] bin on top of the cart. Upon closer inspection, each device was observed with a visible dark stain/spot on the testing port end of the device. On 11/12/19 at 3:45 p.m., two glucometers were observed on the 100 hall medication cart. They were stored in the same style plastic bin, each wrapped in a small white cloth. Employee A, Licensed Practical Nurse (LPN), was interviewed at 3:47 p.m. on 11/12/19. She confirmed she was assigned to the 160 hall medication cart. She stated the two glucometers in her tray were clean, and she had already performed all six scheduled blood glucose tests on the hall. An observation found she had two glucometers in a clear storage tray. A label on the tray instructed, Wrap for four minutes. Employee A explained she rotated between the two glucometers on the cart for blood glucose testing. She was interviewed about her technique for cleaning and disinfecting shared glucometers. She explained that after testing a resident's blood glucose level, she wrapped the glucometer with a sani-wipe/bleach wipe for three minutes and placed it back in the storage tray. Employee A was asked to observe each of her devices, and she confirmed the presence of the spots (the same spots as observed at 1:08 p.m.). Employee B, LPN, was interviewed on 11/12/19 at 3:53 p.m. She confirmed she was assigned to the 120 hall medication cart. The cart was observed with two glucometers stored in the same type of plastic bin. When asked to describe her cleaning and disinfecting technique of the glucometers used for more than one resident, she explained she cleaned each device before use, then wrapped it in a sani-wipe/bleach wipe and stored it in the plastic tray. She was asked if she used the same wipe to clean and wrap the device. She said, sometimes. When asked how long she left the device wrapped, she said for a little while. Upon observation of one of the two glucometers on her cart, a spot/stain was located in the center of the device under the test strip port. She stated she did not see the mark even after it was pointed out to her. Employee D, LPN, was interviewed on 11/12/19 at 4:05 p.m. He was assigned to the 100 hall medication cart. One of the two glucometers observed earlier on his cart (3:45 p.m.) was now unwrapped and stored in the plastic bin. The second device was wrapped in a white cloth and stored in the plastic bin. Employee D stated he had just used the wrapped device to obtain a blood glucose reading. Upon inspection of both devices, one was observed with a stain/spot on the bottom corner of the device. The nurse acknowledged the spot. Employee D stated he had not seen the spot when he stored device. He explained that after each use he wrapped the glucometer(s) in sani-wipes/bleach wipes and stored them in the plastic storage tray. An interview was conducted with the Director of Nursing (DON) on 11/12/19 at 4:14 p.m. She was asked what her expectation was for cleaning and disinfecting shared glucometers. She stated a sani-wipe/bleach wipe should be used to wipe the device, then it should be wrapped in a sani-wipe/bleach wipe and remain wrapped for four minutes. She explained if there was visible blood on the device, two separate wipes should be used to clean and disinfect. The DON was not aware that three of four staff nurses interviewed could not properly describe cleaning by wiping prior to the disinfection of shared glucometers. A review of the facility's Glucometer Protocol, Revised 8/23/19, revealed blood glucose meters (glucometers) must be disinfected with bleach solution or sani-wipes between each use. Wipe all surfaces of the glucometer, leave the glucometer wrapped in the wipe for at least four minutes (wet contact time), then allow to air dry. The policy also provided instructions to alternate the two glucometers on the carts. The DON provided the user manual for the Assure Platinum Blood Glucose meter at 4:35 p.m. on 11/12/19. The manual offered two different options for cleaning and disinfecting. Option 1 was the technique used by the facility nurses at the time of survey. Option 1: .follow instructions to disinfect the meter . Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; one wipe to clean and a second wipe to disinfect. A review of facility records found there 19 residents in the facility who required blood glucose testing. Personnel records revealed there were 24 licensed nurses working in the facility. Employee file reviews found that of the 24 nurses, six had not completed blood glucose testing return demonstration competencies. Step nine of the Competency Checklists used for the glucometers asked if proper cleaning/disinfecting of the meter was demonstrated. The physician was interviewed on 11/13/19 at 12:35 p.m. She stated the facility was considering moving towards individual glucometers for each resident. The physician stated nurses should be wiping the devices, then wrapping them and letting them sit, before repackaging them. A review of the cleaning procedures for the PDI SaniCloth Bleach germicidal disposable wipes (sani-wipes) instructed: All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Open, unfold and use first wipe to remove heavy soil. Use a second wipe to thoroughly wet surface. Allow to remain wet for one minute, let air dry. a four-minute contact time must be used for [MEDICAL CONDITION] (TB) and pathogenic fungi. A review of the CDC Injection Safety Guidelines (https://www.cdc.gov/injectionsafety/) found an article entitled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration. It read: Summary The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: . Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. 2. An observation of Employee E, Registered Nurse (RN), was conducted at 3:31 p.m. on 11/13/19. She was working on the medication cart in the 140 hall and said she was preparing to perform blood glucose testing. She donned gloves and placed two lancets, two alcohol wipes and a bottle of test strips in a plastic cup. She placed one glucometer in the cup and entered Resident #41's room. She placed the cup on an overbed table, removed a test strip from the bottle and placed the test strip bottle back into the cup. She cleansed the resident's right finger and obtained a blood glucose reading of 108. The nurse stopped the bleeding by using an alcohol wipe and pressure applied to the resident's finger, then she placed the blood-stained wipe back into the cup with the bottle of unused test strips. She dislodged the blood-tinged test strip from the glucometer directly into Resident #41's uncovered trash can. After disposing of the used lancet into a sharps container in the bathroom, she washed her hands and returned to the medication cart. Employee [NAME] then disposed of the unused lancet, the cup and the used alcohol wipes in the trash can. She placed the contaminated bottle of unused test strips back in the medication cart. An interview was conducted with Employee [NAME] at this time. After she was shown the unused lancet in the resident's trash can, she confirmed that she had discarded it there. At 3:42 p.m. on 11/13/19, Employee D, RN, was observed at the 120 hall medication cart. She stated she would be conducting blood glucose testing for Resident #263. She donned gloves, wiped the glucometer and replaced it on the medication cart with no barrier underneath. She repeated this with the second device, but dropped it on the floor. She picked up the device and placed it back on top of the medication cart next to the first one, still with no barrier underneath. Employee D stated she would need to clean the device again, as it was dropped, however, she picked up the first (clean) glucometer and re-cleaned and disinfected it instead. Employee D donned clean gloves, took necessary items into Resident #263's room and obtained a blood glucose reading of 305. After stopping the resident's bleeding, she wrapped the used lancet and test strip in a paper towel and took them into the bathroom. Employee D placed the lancet into a sharps container, but discarded the remaining items including the blood-tinged test strip and alcohol wipe into the medication cart's trash can. An interview was conducted with Employee D at this time, and she confirmed she threw the blood-tinged items in the trash. At 3:56 p.m. on 11/13/19, Employee A, LPN, was observed at the 160 hall medication cart. She stated she would perform blood glucose testing for Resident #163. Stating she had already washed her hands, she donned gloves, retrieved a test strip and inserted it into the glucometer. She picked up alcohol wipes and a brown paper towel. Employee A entered the resident's room, placed the paper towel on the overbed table and placed the glucometer and wipe on the towel. She cleansed Resident #163's left index finger, pricked her finger, and attempted to obtain a blood sample, but realized the device had timed out. Employee A discarded the blood-tinged test strip onto the paper towel, removed her gloves and left the room to get another test strip. She re-entered the room with a test strip in the meter, donned gloves and obtained a blood sugar reading of 523. Employee A stopped the resident's bleeding with an alcohol wipe, then without removing her gloves, walked out of the room. Without changing her gloves, she retrieved a sani-wipe/bleach wipe and cleaned and wrapped the glucometer. In an interview at this time, Employee A confirmed she failed to change her gloves before leaving the room and cleaning the meter, stating she thought about that, but didn't know what to do. A review of the Sharps Disposal Policy, revised 11/1/18, noted: The facility shall discard contaminated sharps into designated containers. The policy did not address disposal of unused sharps into trash cans accessible to residents. A review of the facility's policy on Biohazard Labeling, revised 11/1/18, read: Materials contaminated with blood or body fluids shall be labeled and discarded appropriately. Policy Interpretation and Implementation: 1. All wastes containing blood or body fluids will be identified by a red bag, Biohazard tag, label or sign. 2. The primary purposes of identifying and labeling biohazardous waste are to warn about possible occupational exposure and prevent accidental injury or illness to hazardous or potentially hazardous material. A review of the facility's Infection Prevention and Control Program, revised 11/1/18, read: 7. Prevention of Infection. a. Important facets of infection prevention include: .3. Educating staff and ensuring they adhere to proper techniques and procedures. .7. following established general and disease-specific guidelines such as those of the CDC

Based on record reviews, interviews and observations, the facility failed to provide adequate assistance to one (Resident #54) of one resident observed for activities of daily living, from a facility sample of 37 residents. The findings include: A record review was conducted for Resident #54, which revealed an [AGE] year-old female admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. A review of her MDS (Minimum Data Sheet) Admission Assessment, dated 10/25/19, revealed the following: Section C: Mental BIMS (Brief Interview for Mental Status) Score of 3. A score between 0-7 equals severely impaired cognition. Section J: Functional Status Bed mobility - Extensive assistance of two staff members Transfer - Extensive assistance of two staff members Dressing - Extensive assistance of one staff member Eating - Extensive assistance of one staff member Toileting - Total dependence with assistance of two staff members Impairment on one side - left elbow fracture On 11/12/19 at 10:17 a.m., an interview was conducted with the resident's husband at bedside. He stated that ever since she fell and broke her elbow, she has required extensive assistance with everything. He stated that before she fell and fractured her elbow she could take care of herself, however after the fall and fracture she had declined. She required total care now and couldn't do anything for herself. On 11/13/19 at 11:24 a.m., Resident #54 was observed in her room during the lunch meal. She was receiving no assistance. She was sitting up in bed with the bedside table in front of her and the meal tray on the table. Her spoon was filled with pureed food and was on her lap. She stated, I lost my utensil. She started picking up her food with her fingers, but she did not bring her fingers up to her mouth. As she attempted to feed herself the food missed her mouth and ended up on her cheek. On 11/13/19 at 11:37 a.m., an interview was conducted with Employee H, Certified Nursing Assistant (CNA), and Employee G, Licensed Practical Nurse (LPN), who were both assigned to the resident. Employee H stated that Resident #54 was a set-up only for meals and that she could feed herself. She then retrieved the resident's Kardex (care card with instructions), and it revealed the resident required set-up only. Employee H stated that the resident's husband usually fed her, and that she did not realize he left and went to a doctor's appointment. Employee G was asked what the resident's care plan indicated. She reviewed the care plan and stated, She is a physical assist with meals. Employee H was asked by Employee G to go help the resident eat her lunch. On 11/13/19 at 11:00 a.m., a second review of the Kardex was conducted. The facility had changed the instructions for meals to include mod (moderate) assistance required.

Based on a review of resident and facility records and interviews with staff, the facility failed to provide medications in a timely manner and in accordance with physician's orders [REDACTED]. The findings include: 1. A record review for Resident #24 revealed active [DIAGNOSES REDACTED]. A record review of the physician's orders [REDACTED].>[NAME] [MEDICATION NAME] 20 milligrams (mg), 1 tablet by mouth daily for [MEDICAL CONDITION] at 9:00 am. A review of the (MONTH) Medication Administration Record [REDACTED] 11/2/19 medication was administered at 12:24 pm. 11/3 /19 medication was administered at 10:45 am. 11/4/19 medication was administered at 11:42 am. 11/5/19 medication was administered at 11:35 am. 11/8/19 medication was administered at 12:12 pm. 11/9/19 medication was administered at 10:51 am. 11/10 /19 medication was administered at 10:50 am. 11/11/19 medication was administered at 10:45 am. 11/12/19 medication was administered at 11:33 am. B. [MEDICATION NAME], 30 mg twice a day at 900 am and 900 pm. A review of the (MONTH) MAR found multiple instances of late administration of the medication on the following dates: 11/2 /19 medication was administered at 12:24 pm. 11/3/19 medication was administered at 10:45 am. 11/4/19 medication was administered at 11:42 am. 11/5/19 medication was administered at 11:35 am. 11/7/19 medication was administered at 10:27 am and 10:46 pm. 11/8/19 medication was administered at 12:12 pm and 10:13 pm. 11/9/19 medication was administered at 10:51 am and 10:54 pm. 11/10 /19 medication was administered at 10:50 am. 11/11/19 medication was administered at 10:45 am. 11/12/19 medication was administered at 11:33 am. C. [MEDICATION NAME] 25 mg daily at 9:00 am. A review of the (MONTH) MAR found multiple instances of late administration of the medication on the following dates: 11/2/19 medication was administered at 12:24 pm. 11/3/19 medication was administered at 10:45 am. 11/4/19 medication was administered at 11:42 am. 11/5/19 medication was administered at 11:35 am. 11/9/19 medication was administered at 10:51 am. 11/10/19 medication was administered at 10:50 am. 11/11/19 medication was administered at 10:45 am. 11/12/19 medication was administered at 11:33 am. 11/13/19 medication was administered at 10:28 am. 2. A record review for Resident #17 revealed [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. [NAME] [MEDICATION NAME] 10 mg tablet, 1 tablet by mouth twice daily for anxiety at 9:00 am and 9:00 pm. A review of the (MONTH) and (MONTH) MARs found multiple instances of late administration of the medication on the following dates: 10/17/19 - medication was administered at 10:40 am. 10/19/19 - medication was administered at 11:21am. 10/21/19 - medication was administered at 10:53 am 10/24/19 - medication was administered at 10:29 am. 10/28/19 - medication was administered at 10:13 am. 11/02/19 - medication was administered at 10:44 am. 11/09/19 - medication was administered at 10:27 am. 11/10/19 - medication was administered at: 10:11am. B. Carvedilol 3.125 mg tablet, 1 tablet by mouth two times per day with food, hold for heart rate less 60, hold for systolic blood pressure less than 110 for hypertension at 9:00 am and 9:00 pm. A review of the (MONTH) and (MONTH) MAR found multiple instances of late administration of the medication on the following dates: 10/17/19 - medication was administered at 10:40 am. 10/19/19 - medication was administered at 11:21 am. 10/21/19 - medication was administered at 10:53 am. 10/24/19 - medication was administered at 10:29 am. 10/28/19 - medication was administered at 10:13 am. 11/02/19 - medication was administered at 10:44 am. C. [MEDICATION NAME] Oxalate 10 mg tablet, 1 tablet by mouth daily for anxiety at 9:00 am. A review of the (MONTH) MAR found multiple instances of late administration of the medication on the following dates: 10/17/19 - medication was administered at 10:40 am. 10/18/19 - medication was administered at 10:22 am. 10/19/19 - medication was administered at 11:21 am. 10/21/19 - medication was administered at 10:53 am. 10/24/19 - medication was administered at 10:29 am. 10/28/19 - medication was administered at 10:13 am. D. [MEDICATION NAME] U-100 Insulin solution, inject 10 units by subcutaneous route once daily for type 2 diabetes mellitus at 9:00 am. A review of the (MONTH) and (MONTH) MARs found multiple instances of late administration of the medication on the following dates: 10/17/19 - medication was administered at 10:40 am. 10/18/19 - medication was administered at 10:27 am. 10/19/19 - medication was administered at 11:21 am. 10/21/19 - medication was administered at 10:53 am. 10/24/19 - medication was administered at 10:29 am. 10/28/19 - medication was administered at 10:13 am. 11/02/19: - medication was administered at 10:44 am. 11/09/19 - medication was administered at 10:27 am. 11/10/19 - medication was administered at 10:11 am. E. [MEDICATION NAME] U-100 Insulin Apart solution 100 unit/ml per sliding scale twice a day for type 2 diabetes mellitus at 11:30 am and 4:30 pm. A review of the (MONTH) MAR found multiple instances of late administration of the medications on the following dates: 10/07/19 - medication was administered at 12:44 pm. 10/12/19 - medication was administered at 1:49 pm. 10/21/19 - medication was administered at 1:43 pm. 10/31/19 - medication was administered at 6:25 pm. F. [MEDICATION NAME] (quetiapine) 50 mg tablet, 1 tablet by mouth twice a day for dementia in other disease classified elsewhere with behavioral disturbances at 9:00 am and 9:00 pm. A review of the (MONTH) and (MONTH) MARs found multiple instances of late administration of the medication on the following dates: 10/17/19 - medication was administered at 10:40 am. 10/19/19 - medication was administered at 11:21 am. 10/21/19 - medication was administered at 10:53 am. 10/24/19 - medication was administered at 10:29 am. 10/28/19 - medication was administered at 10:13 am. 11/02/19 - medication was administered at 10:44 am. 11/09/19 - medication was administered at: 10:27 am. 11/10/19 - medication was administered at 10:11am. G. [MEDICATION NAME] 40 mg tablet, give 1 tablet by mouth daily for [MEDICAL CONDITION] at 9:00 am. A review of the (MONTH) MAR found multiple instances of late administration of the medication on the following dates: 11/02/19 - medication was administered at 10:44 am. 11/09/19 - medication was administered at 10:27 am. 11/10/19 - medication was administered at 10:11 am. Further review of the MARs found there were no documented reasons the above medications were administered late. In an interview on 11/15/19 at 10:13 am, Employee G, Licensed Practical Nurse (LPN), explained the Matrix Care process for medication administration using the electronic MAR. She stated there was an option to sign all mediations off at the end of the medication pass for all residents, but it was typically done after each resident. There was a sign-off button for when medications were all prepped, then another for administration. There were options to enter for late documentation or for late administration, but one had to enter a reason for late administration. In an interview on 11/15/19 at 10:33 am, Employee K, LPN, stated that the long-term hallway (160 rooms) could get hectic, but for the most part there was no problem getting medications passed on time. She explained that once she prepped the medications, she did not sign them off as provided until the resident took them, as sometimes residents refused or administration was delayed. Then she signed the medications as given once the resident took them. She was not sure why the administration times for residents would be documented so late. In an interview on 11/15/19 at 11:25 am, the Director of Nursing (DON) explained the system for prepping and administering medications. She stated it was possible for nurses to sign for all residents at one time once all medications were given on the hallway. She stated that she had not done any time audits of medication administration times. The DON returned at 11:58 am and was interviewed again. She was shown the late administration times for Resident #24. She stated she knew the resident liked to sleep in and was particular about her routine, but the order is what it is. She was not aware of the late administration times and stated she would address that. Perhaps the physician needed to change the order times. A review of the facility's policy and procedure entitled 6.0 General Doses Preparation and Medication Administration, revised on 01/01/2013. Section 4.1.1 states, Facility staff should verify each time a medication is administered that is the correct medication at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident as set forth in Appendix 17: Facility Medication Administration Time Schedule: Further review of Appendix 17 found the facility was to complete standard Administration Time for each wing/ unit per facility policy. For example, medication with once a day frequency should be administered at 9:00 am, medications with 2 times a day frequency should be administered at 9:00 am and 9:00 pm etc. for all facility locations (unit 1, Unit 2, Unit 3, and Unit 4).

Based on observations, record review and interviews, the facility failed to provide oxygen as ordered by the physician for one (Resident #262) of one resident reviewed for respiratory care, from a total of 31 sampled residents. The findings include: On 11/13/2019 at 10:50 AM, an observation was made of the resident in her room. She was lying in her bed with a nasal cannula applied. Her eyes were closed. She was positioned on her right side and the head of the bed was elevated. The cannula was attached to a wall oxygen unit, which was set at a flow rate of 2 liters per minute. She did not arouse easily and would not answer any questions. A record review revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. The resident required assistance with activities of daily living and received oxygen therapy. A review of the current physician's orders [REDACTED]. A review of the comprehensive care plan revealed a care plan titled Risk of complications related to respiratory disease with an intervention of oxygen per physician's orders [REDACTED]. A review of the resident's recorded vital signs was conducted. An entry dated 11/09/2019 at 2:07 PM, indicated an oxygen saturation of 92% and an oxygen flow rate of 3.5 liters per minute. An entry dated 11/13/2019 at 12:02 PM, indicated an oxygen saturation of 94% and an oxygen flow rate of 3 liters per minute. A review of the resident's nursing progress notes was conducted. An entry dated 11/09/2019 at 4:13 PM, indicated an oxygen saturation of 92% and an oxygen flow rate of 3.5 liters. The note also stated, The resident continues to be lethargic. A review of the resident's Medication Administration Record [REDACTED]. An order read, Oxygen continuous at 4-5 LPM (liters per minute) via nasal cannula. Keep >93% with a frequency of every shift. The order start date was 11/07/2019. The administration record was signed routinely each shift. On 11/13/2019 at 2:02 PM, a second observation was made of the resident in her room. She was again lying in her bed and the nasal cannula remained in place. Her eyes were closed. She was positioned on her back and the head of the bed was elevated. The wall oxygen unit was set to a flow rate of 3.5 liters per minute. On 11/14/2019 at 10:58 AM, a third observation was made of the resident in her room. She was again lying in her bed and positioned on her back. Her eyes were closed. The head of the bed was elevated. She was wearing her nasal cannula. The wall oxygen unit was set to a flow rate of 3.5 liters per minute. On 11/14/2019 at 12:36 PM, a review of the facility's policy and procedure titled Oxygen Administration was conducted. Step number two of the procedure indicated, Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the ordered rate. On 11/14/2019 at 12:40 PM, a fourth observation was made of the resident in her room. She was lying in her bed, positioned on her back, and the head of the bed remained elevated. Her eyes were closed. The nasal cannula was in place and the wall oxygen unit was set to a flow rate of 3.5 liters per minute. On 11/14/2019 at 2:36 PM, a fifth observation was made of the resident in her room. This observation was conducted while accompanied by the resident's assigned nurse (Employee I, LPN). The resident was again lying in bed, positioned on her back and the head of the bed was elevated. Her eyes were closed and she remained difficult to arouse. The nasal cannula was appropriately placed. The wall oxygen unit was set to a flow rate of 3.5 liters per minute. The nurse was asked to verify the current oxygen flow rate. She stated, It looks like 3.5 to 4 liters. On 11/14/2019 at 2:40 PM, an interview was conducted with the assigned nurse (Employee I, LPN). She was asked to verify the resident's current oxygen orders. She acknowledged that the current order was oxygen at 4 to 5 liters per minute to keep oxygen saturations above 93%. The nurse was then asked what the resident's oxygen saturations were on the current shift. She pulled up a vital sign entry dated 11/14/2019 at 1:32 PM, which displayed a result of 92%. The nurse acknowledged this result was outside of the parameters prescribed by the physician, and stated that she had not contacted the physician. The nurse was then asked what she would typically do if a resident's oxygen saturations were below the prescribed parameters. She stated she would notify the physician. On 11/14/2019 at 2:45 PM, the nurse (Employee I) was asked to evaluate the resident's oxygen saturation. The results fluctuated between 87-91% on the pulse oximeter. The nurse increased the oxygen to 4.5 liters per minute and administered a nebulizer treatment by mask. The nurse then asked the resident whether she was short of breath and the resident shook her head no. The saturation results continued to fluctuate between 87-91%. After approximately ten minutes the saturations increased to 92% briefly before falling again to 90% and remaining. The nurse stated she would have the desk nurse contact the physician regarding the findings. On 11/14/2019 at 3:15 PM, the surveyor was notified that the physician had been contacted and the order was being changed to indicate, for comfort measures only, because the resident's saturations would likely never be above 93%. On 11/15/2019 at 10:00 AM, an observation was made of the resident in her room. She was lying in bed and her eyes were open. The nurse was at her bedside assisting her with taking fluids. The resident was observed answering yes/no questions appropriately. The nasal cannula remained appropriately placed and the wall oxygen unit was set to 4.5 liters per minute.

Based on a review of clinical records and interviews with staff, the facility failed to ensure anti-depressant drugs were used only with behavioral interventions and adequate monitoring for two (Residents #22 and #54) of five residents reviewed for unnecessary medication, from a total of 37 residents in the sample. Monitoring of [MEDICAL CONDITION] drugs and associated behaviors or symptoms for which they are prescribed is critical for clinical review and decision-making regarding the appropriateness of continued use, and for consideration for gradual dose reductions. The findings include: A record review for Resident #24 found a quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/18/19. The resident had a brief interview for mental status (BIMS) score of 13, indicating the resident was cognitively intact, and required extensive assistance with activities of daily living. Active [DIAGNOSES REDACTED]. Resident #24 received antidepressant medication on seven of seven days during the assessment lookback period A review of the physician's orders [REDACTED]. A review of the current Medication Administration Record [REDACTED]. An interview was conducted with Employee K, Licensed Practical Nurse (LPN), on 11/15/19 at 10:33 a.m. She was asked about the monitoring for Resident #24's [MEDICATION NAME] use. Employee K replied she typically saw behavior and side effects monitoring sheets for the use of anti-depressant medication. She could not explain why there were none for Resident #24's [MEDICATION NAME]. In an interview with the Director of Nursing on 11/15/19 at 11:25 a.m., she was asked about monitoring for the use of anti-depressant medication. She stated she used to have monitoring sheets in place, but stopped using them a month ago for anti-depressants. She stated she was told they were not required. 2. A record review was conducted Resident #54, revealing an [AGE] year-old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's current Medication Administration Record [REDACTED] [MEDICATION NAME] tablet (depression medication) 7.5 milligrams at bedtime for depression/appetite, start date 10/18/19. Further review of the record revealed the facility had no documentation in place for the effectiveness of the medication and/or any depression behaviors for the resident.

Based on observations, record reviews and staff interviews, the facility failed to provide treatment and care in accordance with professional standards of practice, by (1). not providing bowel protocol for 1 (Resident #8) of 23 sampled residents; (2). not administering insulin as ordered to 1 (Resident #27) of 2 sampled residents reviewed for insulin use; and (3). not following policies and procedures for the self-administration of medication for 1 (Resident #27) of 5 sampled residents reviewed for unnecessary medications, out of a total of 23 residents in the sample. The findings include: 1. A record review was conducted for Resident #8, which reported an admisison date of 12/6/13 and a re-enty date of 2/8/18. The resident's [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record (MAR), revealed that bowel movements were to be documented every shift. This was ordered on [DATE]. The MAR was documented with an asterisk on (MONTH) 19, 20, 21, 22, and 23rd as the resident not having had a bowel movement. An asterisk was also documented (MONTH) 25, 26, 27, 28, and 29th identifying that the resident had not had a bowel movement. Physician's orders on the MAR were noted for [MEDICATION NAME] sodium 100 milligram (mg) capsule, give one daily as needed for constipation, dated 12/21/17, and milk of magnesia 400 mg/5 milliliters (ml), give 30 ml orally if no bowel movement within three days, dated 12/6/13. Neither of these medications were documented as having been administered during the time frames above related to absence of a bowel movement. A review of the care plan, dated 2/5/18, noted that the resident was at risk for constipation related to medication use. One of the interventions documented was to provide a bowel regimen to assist the resident in having a bowel movement every three days. A review of the policy and procedure for Bowel Elimination, dated 10/2/17, reported that if the resident did not have a bowel movement, the entry would be documented as Not Administered (*). If the resident had not had a bowel movement in three days, nursing staff were to initiate the bowel protocol per the physician's orders on the resident's MAR. The bowel protocol may consist of milk of magnesia, ducolax suppository, fleets enema, or other medication as specified per physician's orders. An interview was conducted with Employee E, Certified Nursing Assistant (CNA), at 8:34 AM on 8/2/18. The CNA stated that he told the nurse when residents had a bowel movement and it was recorded by the nurse. An interview was conducted with Employee D, Licensed Practical Nurse (LPN), at 8:48 AM on 8/2/18. The LPN stated that CNAs reported whether a resident had a bowel movement, and it was recorded on the MAR. If the resident did not have a bowel movement in three days, a bowel protocol was started, which may include milk of magnesia or a laxative, whatever the physician ordered. An interview was conducted with the Director of Nursing (DON), a registered nurse (RN) at 9:05 AM on 8/2/18 concerning the bowel protocol for Resident #8. The DON reviewed the MAR for (MONTH) (YEAR), and confirmed that the resident did not have a bowel movement from (MONTH) 19-23rd, had a bowel movement on (MONTH) 24, and on (MONTH) 25-29th did not have a bowel movement until (MONTH) 30th. The DON stated a bowel protocol should start after three days of not having a bowel movement. The DON confirmed that if there was an asterisk documented on the MAR, the resident did not have a bowel movement. 2. An interview was conducted with Resident #27 on 7/31/18 at 11:38 AM. When asked about medications, she stated that sometimes insulin was not received on time; that it was sometimes late. She stated that it just depended on who was working. On 8/02/18 at 8:32 AM, Resident #27 was observed alone in her room. She was interviewed at this time, and during a conversation about pain, she held up both hands and complained that the left hand was no longer functioning well. She further stated that her pinky and ring fingers were largely unresponsive, and were no longer able to move. The thumb on the left hand was also immobile. Now, the middle finger on this hand was starting to become affected. A small, graduated, plastic medicine cup was observed on Resident #27's over-bed table. Inside was a small amount of white cream that appeared to have been used. Resident #27 explained that the container held the hand cream that helped with her pain. The nurses brought it. The gel had a pleasant but medicinal scent. Resident #27 applied the cream herself once provided by the nurses. No nurse entered the room during the interview. (Photographic evidence obtained) A record review for Resident #27 revealed a 30-day Minimum Data Set (MDS) assessment with an assessment reference date of 6/23/18. She had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderately impaired cognitive functioning. She received insulin injections on seven of seven days over the assessment look-back period. Her active [DIAGNOSES REDACTED]. Resident #27 was care planned on 7/27/18 for a potential for pain related to arthritis, and was described to experience pain with activity. The goal was to verbalize acceptable relief with provided interventions. She was care planned on 6/12/18 for blood sugar management related to diabetes. Interventions included receiving insulin as ordered. Resident #27 had physician's orders for [MEDICATION NAME] U 100 Insulin (a long-acting insulin), 100 milligrams (mg)/milliliter (ml), inject 25 units subcutaneously every day at 8:00 AM. The resident received a second form of insulin, [MEDICATION NAME] (a fast-acting insulin), on a sliding scale before meals and at bedtime. She had a physician's order for [MEDICATION NAME] gel (a non-steroidal anti-[MEDICAL CONDITION] medication) to the hands twice daily (BID) for osteoarthtitis (OA). Further review of the record found no physician's order allowing for the self-application of the [MEDICATION NAME]. A review of the Medication Administration Record's (MAR's) documentation history for Resident #27's 8:00 AM daily dose of [MEDICATION NAME] revealed the following late administration times: 7/29/18 at 11:03 AM 7/28/18 at 10:25 AM 7/27/18 at 10:06 AM 7/26/18 at 10:46 AM 7/24/18 at 11:13 AM 7/23/18 at 10:05 AM 7/22/18 at 10:31 AM 7/21/18 at 10:44 AM 7/18/18 at 10:42 AM A review of physician's progress notes found a 6/25/18 report reflecting the addition of the [MEDICATION NAME] gel to Resident #27's medication regimen. A report dated 6/29/18 noted pain in Resident #27's hands along with weakness. The physician's progress note, dated 7/20/18, indicated Resident #27's blood glucose level was up to 400 (dangerously high), and that she had been observed snacking on the porch. The physician increased the sliding scale insulin ([MEDICATION NAME]) at this time. An interview was conducted with the Director of Nursing (DON) on 8/2/18 at 11:07 AM. She reviewed the MAR and [MEDICATION NAME] administration times for Resident #27. She confirmed the late administration times on (MONTH) 18, 21, 22, 23, 24, 26, 27, 28, and 29, (YEAR). She stated each of the doses were given outside of the permitted one-hour before and one-hour after window for administration. The DON stated that Employee D, Licensed Practical Nurse, was the employee who had administered most of the late insulin doses. She had no explanation as to why this was occurring, stating she would speak with Employee D to determine what the problem might be. The DON was asked for the facility's policy regarding the self-administration of topical and oral medications. She explained at this time that any resident assessed to be capable of self-administration would have the Self Administration of Medications Informed Consent and Assessment in their clinical record. In a second interview with the DON on 8/2/18 at 1:29 PM, she confirmed there was no Self Administration of Medications Informed Consent and Assessment form completed for Resident #27 to apply the [MEDICATION NAME] gel. She stated she was working on completing that now. The DON stated she spoke with the physician, who had no problem with this resident self-administering the gel, and modified the order to reflect this. The expectation will be that the nurse remains in the room during the application process. A review of the facility's policy on Self-Administration of Medication, dated (MONTH) (YEAR), revealed residents have the right to self-administer medications if the Interdisciplinary Team has determined that it is clinically appropriate and safe to do so. 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate . 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skills assessment, including the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time . c. Ability to remove medications from a container d. Ability to recognize risks . 8. Self-administered medications must be stored in a safe and secure place not accessible by other residents. If safe storage is not possible in the room, . medication will be stored on a central medication cart or in the medication room. 9. Staff shall identify and give to the Charge Nurse any medication found at the bedside of residents that are not authorized for self-administration . Review of the facility's General Dose Preparation and Medication Administration Policy #6.0, effective 12/1/07, was reviewed. It stated under section 4. 1 that staff should: 4.1.1 Verify that each time a medication is administered that it is . at the correct time . 5. During medication administration, facility staff should . 5.4 Administer medications within timeframes specified by facility policy.

Based on record review and staff interview, the facility failed to ensure the monthly drug regimen reviews were addressed by attending physicians, with the rationale for no medication changes documented for one (Resident #35) of five residents sampled for unnecessary medications from a total sample of 23 residents. The findings include: A record review for Resident #35 revealed an [AGE] year-old female admitted with [DIAGNOSES REDACTED]. A review of the monthly drug regimen review for (MONTH) (YEAR) found the Consultant Pharmacist (CP) had documented two drug irregularities with recommendations to the physician. The CP documented the resident was receiving [MEDICATION NAME][MEDICATION NAME], a high risk medication due to strong [MEDICATION NAME] effects, and was not recommended for use as a hypnotic in the elderly. The resident also had an order to administer an anti-hypertensive medication, [MEDICATION NAME], as needed. The recommendation was to consider discontinuing the [MEDICATION NAME] as-needed order, and adjust routine anti-hypertensive therapy to reach goal blood pressure. The report also included that if the therapy was to continue, it was recommended that the prescriber document an assessment of risk versus benefit. A review of the report indicated the physician signed the report; however, declined the recommendations without any rationale. An interview was conducted with the Director of Nursing on 8/2/18 at 12:10 pm. When asked whether the physician had reviewed the (MONTH) recommendations for Resident #35, she stated she would review the record. After review, she stated the physician had reviewed the recommendations; however, declined the two recommendations. When asked if the physician had documented rationale as to why the recommendations were declined, she stated no.

Based on record review and staff interview, the facility failed to ensure reconstituted intravenous medications added to intravenous fluid bags were labeled appropriately for safe administration for one (Resident #221) of one sampled residents receiving intravenous medications out of a total of 23 residents in the sample. The findings include: During observation of medication administration on 8/1/18 at 8:40 am, the Licensed Practical Nurse (LPN), Employee G, stated that Resident #221 was due a dose of Intravenous (IV) antibiotics. She said that because she was an LPN, she needed to have a Registered Nurse (RN) prepare and hang the medication. She went to inform the Assistant Director of Nursing (ADON). Observation of Resident #221 at 8:45 am found there was an IV pole with pump attached next to the bed. Also, there was an empty IV bag hanging on the pole. Upon observation of the label on the bag, it did not include the name of the medication, the time the medication was reconstituted, or the time it was hung. It also did not include the initials of the nurse who prepared and hung the medication. An interview with Employee G on 8/1/18 at 8:45 am confirmed the label did not contain the information. A review of the facility's policy Admixing Medications revealed the following: IV admixtures are routinely prepared in the pharmacy. Admixed IV solutions must have a completed medication added label attached, expiration date assigned to the mixture is calculated from the time of preparation. Label IV solution container with medication added label to include the following: Name, IV solution, medication added, medication dose, route and rate, directions, time added, date added, date and time of administration, expiration date and initials of nurse preparing and administering medication. On 8/1/18 at 8:55 am, the ADON was observed preapring IV antibiotics for administration. He added the medication into a 100 milliliter (ml) bag of Normal Saline. A pharmacy label was affixed to the IV bag that stated the name of the antibiotic, Meripenum 2 grams (gm) to be infused over one hour. The bag did not contain any medication until the nurse added it to the bag. There was no label attached that stated medication added. The ADON hung the IV bag with medication at 9:10 am. During an interview at 9:00 am, he was asked if the pharmacy provided labels that indicted medications were added, and he said no. He documented the medication's name and date and time hung in the corner of the pharmacy label. When asked where he documented the time the medication was prepared, expiration date, and initials, he stated they were not included.

Based on observations, record reviews, and staff interviews, the facility failed to ensure the kitchen, and 1 of 1 nourishment rooms and its equipment were maintained and sanitary during two of two days observed (7/18/2016 and 7/20/2016), and related to (1) frozen foods not stored at recommended temperatures; (2) one walk-in refrigerator fan was not maintained clean and sanitary; (3) microwaves were not maintained sanitary and at manufacturer's recommendations; and (4) food thermometer was not sanitized to prevent cross contamination. The findings include: During the initial kitchen tour on 7/18/2016 at 10:20 a.m., the following was observed and confirmed by Employee F: 1. The freezer had several boxes of frozen ice cream that included four 1.5 quarts and 3 3-gallon tubs. All boxes were checked and the contents were completely defrosted. 2. One refrigerator fan had built-up, caked-on blackish dust along the entire grill of the fan. 3. The microwave had a 1/8 inch lining of a brownish, golden in color substance along the back of the unit. During the comprehensive kitchen tour on 7/20/2016 at 11:50 p.m., the following was observed and confirmed by Employee E: 4. During the tray line temperature observation with Employee E at 11:55 pm, as he recorded the food temperatures, observation revealed Employee E dropped the food thermometer on the floor and it rolled under the tray line. At this point, Employee E attempted to retrieve the food thermometer with a large mixing whisk, but was unable to. Employee G came to his assistance and retrieved the food thermometer and handed it back to Employee E. Employee E then walked over to the coffee machine and dispensed the hot water on the food thermometer for 1 second, wiped it with an alcohol wipe, and continued to take the food temperatures of the green peas, white rice, and hash brown potatoes. In addition, at the nourishment station on 7/18/16 at 11:40 p.m., the following was observed: 5. The microwave was observed with a brownish golden in color substance lining along the entire back base of the unit. Interview with Employee E on 7/20/2016 at 12:10 pm revealed he correctly sanitized the food thermometer and he stated it was cleaned. Interview with the Certified Dietary Manager on 7/20/2016 at 1:00 p.m. confirmed Employee E had dropped the food thermometer and revealed the rinse of the hot water and the use of the alcohol wipe sanitized the food thermometer during the cross contamination. He provided the facility policy which revealed, Temperature Control, dated 6/1/2002 and revised on 4/1/2008. The purpose of the policy stated temperature control affects the food product in every phase from food manufacturing through transport, receiving, storage, thawing, cooking, holding, and serving. Temperatures will be checked using an appropriate sanitized thermometer to ensure food safety. Number #4 of the policy detail indicated, All thermometer probes shall be washed, rinsed, sanitized, and air dried before and after each use to prevent cross contamination. Thermometers should be washed, rinsed, and sanitized when the probe has been touched, makes contact with an un-sanitized surface, or otherwise contaminated. He also confirmed the above listed areas of concerns.

Based on observations, staff interviews, and facility policy review, the facility failed to discard an expired insulin for Resident #55. The facility also failed to store all drugs and biologicals under proper temperature controls for 16 residents (Residents #100, #215, #126, #210, #207, #216, #158, #213, #32, #212, #196, #35, #205, #14, #214, and #6) in 4 of 4 medication carts (100 hall, 120 hall, 140 hall, and 160 hall), for a total of 17 out of 37 sampled residents. The findings include: On [DATE] at 9:00 a.m., a medication observation pass was observed with Employee A, a Licensed Practical Nurse(LPN). He stated that the medication carts had a pan in the bottom drawer that they could put refrigerated medications in. He stated that they have been using them for about 2 years. On [DATE] at 3:30 p.m., the Medication Cart on the 160 hall was observed to have a vial of Novolog insulin belonging to Resident #55. The insulin label had an opened date of [DATE]. Instructions from the manufacturer revealed to discard after 28 days. On [DATE] at 3:32 p.m., Employee A confirmed the date was past 28 days, and the resident received insulin just yesterday (which was still over the 28 days). Further review of the 160 Hall's medication cart revealed a black ColdFest pan in the bottom drawer. This pan had no lid and felt warm to the touch. Employee A stated the pan was to keep refrigerated medications in it. On [DATE] at 3:35 p.m., the other three medication carts (Halls 100, 120, and 140) had the same ColdFest pan in the bottom of the drawer. In these ColdFest pans, bottles of open Acidophilus-Pectin capsules were observed. The label on these Acidophilus-Pectin bottles revealed that these medications had to be refrigerated after opening. On [DATE] at 3:40 p.m., Employee B (LPN), was the nurse on the 140 Hall and was asked about the ColdFest pans. She stated that these pans were to keep some refrigerated medications in them. Each shift was supposed to switch out the pan for a new one in the freezer. She was asked if she knew how long these pans kept the appropriate temperature for refrigerated medications. Employee B stated she did not know if these ColdFest pans kept medications cold enough. On [DATE] at 3:44 p.m., the ColdFest pan had been removed from the 140 Hall Medication Cart, and one minute later, the Maintenance Assistant, Employee C, took the temperature of the pan and it read 69 degrees. On [DATE] at 3:45 p.m., the Director of Nursing (DON) was asked if she knew how long the ColdFest pans would stay cold, she stated she did not have any information at this time. On [DATE] at 9:00 a.m., the Assistant Director of Nursing provided the manufacturer's information regarding the ColdFest pans. It revealed these pans hold contents cold up to 8 hours (keeping below 41 degrees). She stated the Director of Nursing was doing a Quality Assurance (QA) review on these pans right now. At 9:14 am on [DATE], the DON stated that she was doing QA on the refrigerated Acidophilus-Pectin capsules in the ColdFest pans, and determined that they were not keeping the proper temperature. She stated that this morning, while checking the temperatures, the ColdFest pans already were reaching 47 degrees. The facility's [DATE] policy for Storage and Expiration Dating of Medications, Biological, Syringes and Needles revealed once the medication is opened, the facility should follow manufacturer guidelines with respect to expiration dates. Also, the refrigerated medications should be maintained between ,[DATE] degrees Fahrenheit.

Based on observations, record reviews, and staff interviews, the facility failed to develop a comprehensive plan of care with measurable goals for wound care for 1 of 37 sampled residents (Resident #17). The findings include: Review of the clinical record for Resident #17 revealed a Wound Care Specialist Evaluation, dated 7/19/2016. It revealed Resident #17 had a Stage 3 pressure ulcer to his coccyx. Review of the 5/13/2016 care plan for Resident #17 revealed the resident was at risk for impaired skin integrity. It had no goal listed. An open area on the coccyx was identified on 7/1/2016, and a goal was still not developed for this concern. On 7/21/2016 at 2:00 pm, an interview was conducted Employee D, one of the care plan nurses. She confirmed there was not a goal on the pressure ulcer care plan for this resident. On 7/21/2016 at 2:30 pm, Employee I, a Licensed Practical Nurse (LPN) was observed to perform a wound treatment for [REDACTED]. Two pressure ulcers were observed on Resident #17's coccyx.

Based on record review and staff interviews, the facility failed to revise the care plan for 1 of 37 residents (Resident #98). Resident #98 did not have the care plan revised to show discontinuation of a [MEDICAL CONDITION] medication and failed to have appropriate interventions. The findings include: Upon record review for Resident #98, there was a 7/5/2016 physician's orders [REDACTED]. The resident's most recent Minimum Data Set (MDS) Assessment, dated 6/3/2016, revealed a Brief Interview Mental Status (BIMS) score of 4 (1-15) scale, indicating severe memory impairment. Review of the 3/30/2016 care plan for Resident #98 revealed the resident was taking [MEDICAL CONDITION] for [MEDICAL CONDITION] and depression, with the goal to receive the lowest effective dose through next review. The plan of care did not show the discontinuation of the [MEDICATION NAME]. The care plan also had interventions that the resident would be able to inform the nurse if she was feeling depressed, was anxious, or could not sleep. An interview was conducted with the Care Plan Coordinator (Employee D) on 7/21/16 at 12:27 pm. She stated, We run a report of discharge orders daily or weekly, and in the morning meeting, we review them and discontinue them from the residents' care plans. She stated the [MEDICATION NAME] should have been removed. Upon interviewing the Care Plan Coordinator regarding Resident #98's interventions being appropriate, she stated, No, they are probably not appropriate. She would not be able to tell us how she feels.

Based on record reviews of the Medication Administration Records (MARs), and staff interviews, the facility failed to provide pharmaceutical services for 3 out of 37 residents, (Residents #98, #139, and #184). The findings include: Review of the MARs revealed the following: 1. Resident #98's Xarelto was not administered on 7/19/16 at 4:00 PM (awaiting delivery from pharmacy); Namenda XR was not administered on 5/2/16 at 8:00 AM (awaiting delivery); and Donepezil was not administered on 5/3/16 at 8:00 PM (awaiting delivery). 2. Resident #139 was not administered Diltiazem on 7/12/16 at 8:00 AM (in route from pharmacy); and Erythromycin was not administered on 7/15/16 at 6:30 AM, 11:30 AM, or 5:00 PM, or on 7/16/16 at 6:30 AM (awaiting delivery). 3. Resident #184 was not administered Naproxen Sodium on 5/9/16 at 8:00 PM (enroute), 5/10/16 at 8:00 PM (to be ordered), or 5/11/16 at 8:00 PM (being ordered). An interview was completed with the Assistant Director of Nursing (ADON) on 7/21/16 at 11:00 AM, and she stated, Xarelto was ordered at 7/19/16 at 3:52 PM, and was delivered the next day in the morning. She stated that the procedure for reordering medication depended on the frequency of the medication, and she further stated, It is appropriate to wait until the last day to reorder and that there is no specific day to reorder. An interview was completed with Director of Nursing (DON) on 7/21/16 at 11:05 AM, and she stated, I have not had any issues with medications being given or pharmacy delivering the meds. The facility's Medication Availability Policy and Procedure, revised 1/11/2016, was reviewed. It revealed prescription medications are to be reordered via the electronic system. If a medication was not available to be given within one hour of the scheduled time, notify MD. If over the counter medications are not available, notify DON so arrangements can be made to obtain medication. There were no specific instructions listed for a time frame for reordering medications.

Based on observations, record reviews, and staff interviews, the facility failed to provide a sanitary environment and prevent the transmission of disease and infection during wound treatment for 1 of 37 sampled residents (Resident #17). The findings include: On 7/21/2016 at 2:30 p m., Employee I, a Licensed Practical Nurse (LPN) was observed to perform a wound treatment for [REDACTED]. Employee H had donned gloves and was holding the resident's buttocks to the side so Employee I could perform this dressing change. Employee H's gloves were about 2-3 inches longer than her fingers. Employee H, while holding the resident's buttocks, touched the resident's wounds on his coccyx. Employee I ran out of gloves so she asked Employee H to get her more. Employee H removed her gloves and went to the treatment cart in the hallway. Employee H did not wash her hands or sanitize them after removing her gloves. She was observed to touch the resident's door and medication cart (in the hallway) with potentially contaminated hands. On 7/21/2016 at 3:25 p.m., Employee H confirmed she did not wash her hands or sanitize them when she went into the hallway. The facility's 10/1/2014 Infection Control Protocols for Wound Care was reviewed. It revealed that appropriate hand hygiene was to be performed upon removing gloves.

Based on record review and staff interview the facility failed to update the care plan related to multiple falls and changes in condition for 1 of 3 sampled residents. (Resident #2) The findings include: Record review for Resident #2 revealed a [AGE] year-old female with [DIAGNOSES REDACTED]. The nursing notes revealed that Resident #2 was alert and oriented with periods of confusion. She required assistance with all activities of daily living. She went to [MEDICAL TREATMENT] three times a week. She was admitted to the facility with a stage IV wound and required the use of a [DEVICE]. She used a wheelchair for mobility, and was up out of bed everyday. Resident #2 had multiple hospitalization s related to her many medical conditions. She required frequent replacement of the [MEDICAL TREATMENT] catheters, had episodes of serious bleeding from shunt sites, fall with head injury, [MEDICAL CONDITION] (infection). The most recent fall assessment for Resident #2 was performed on 12/20/15 with a score of 12, indicating high risk for falls. The resident had documented falls on 12/7/15, 12/15/15 and 12/20/15. There were no injuries documented. Review of Resident #2's care plan revealed she was at risk for falls related to weakness, decreased mobility and range of motion, and use of [MEDICAL CONDITION] medications. The care plan had not been updated to reflect her multiple falls or new interventions, the use of [DEVICE], or bleeding related to [MEDICAL TREATMENT] catheter and discontinued use of anticoagulant medication. An interview was conducted on 12/22/15 at 11:10 am with the Minimum Data Set/Care Plan nurse. When asked how often the residents' care plans were updated, she stated whenever there were changes. When asked if Resident #2 had any recent changes in condition, she stated she had multiple hospitalization s. When asked if the care plan had been updated to reflect the changes, she stated, No.

Based on record review, and staff and resident interview the facility failed to ensure pain medication was administered per the physician's orders for 1 of 3 sampled residents. (Resident #5) The findings include: The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Additionally, the Act defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or informed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. During an interview on 12/22/15 at 6:20 am with the 11-7 shift Licensed Practical Nurse (LPN, Employee A), she was asked if any residents had requested pain medication during the night. She stated, Yes, it is constant most nights. After review of her notes, she stated that six residents had asked for pain medication during her shift. The LPN added that she gives Resident #5 one tablet of Tylenol for pain. She said the resident had stronger pain medication ordered, however she she stated the resident was very elderly and stronger medication could contribute to falls. When asked if Resident #5 had specifically requested Tylenol, she stated No, she just asked for her pain pill. She further added that she was familiar with the resident, and was aware she had a fall in the past and complained of hip pain. Record review for Resident #5 revealed a [AGE] year-old female with [DIAGNOSES REDACTED]. The nursing notes revealed that Resident #5 was alert and oriented with periods of forgetfulness. Review of physician's orders for the resident revealed [MEDICATION NAME] 5/325 mg (narcotic pain medication) 1 tablet every 4 hours as needed for pain. Review of the staffing schedule revealed that Employee A was assigned to the medication cart for Resident #5 on 12/22/15 on the 11-7 shift. Review of the resident's Medication Administration Record [REDACTED]. Further review of physician's orders for the resident revealed there was no order found for Tylenol. An interview was conducted with Resident #5 on 12/22/15 at 1:10 pm. When asked if she had requested pain medication during the night, she said she did and the nurse gave her a pill. She was not sure of the time, but stated she asked for another pain pill this morning before breakfast because she had hip pain. The resident's MAR indicated [REDACTED]. An interview was conducted on 12/22/15 at 2:50 pm with the Director of Nursing. When asked if the facility had standing orders for over the counter medications, she stated No, all medications are physician ordered only. Nursing Standard of Practice Protocol: Pain Management in Older Adults Horgas, A. L., Yoon, S. L., & Grall, M. (2012). Pain management in Older Adults. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker, (Eds.) Evidence-based geriatric nursing protocols for best practice (4th ed.) (pp. 258-263). New York: Springer Publishing Company, LLC. Standard: All older adults will either be pain free, or their pain will be controlled to a level that is acceptable to the patient and allows the person to maintain the highest level of functioning possible. Nurses have a key role in pain management. The promotion of comfort and relief of pain is fundamental to nursing practice. Nurses need to be knowledgeable about pain in late life to provide optimal care, to educate patients and families, and to work effectively in interdisciplinary health care teams. Assessment parameters: Older adults with cognitive impairment experience pain but are often unable to verbalize it. Assess older adults who present with acute pain of moderate-to-severe intensity or who appear to be in distress. Assess pain localization, intensity, duration, quality, and onset. Assess pain regularly and frequently to facilitate appropriate treatment. .