Every finding on record at Solaris Healthcare East Orlando

Based on interview, and record review, the facility failed to act promptly upon the grievances and recommendations of the resident council; and failed to demonstrate an active response for resolution of their complaints in a timely manner. Findings: On 6/02/25 during the initial resident screening, concerns about repeated complaints made to the facility without resolution were found. Multiple residents expressed they had previously complained at the resident council meetings, but nothing had changed and they felt the facility had never addressed their grievances. Review of the resident council meeting minutes for the prior six months from December 2024 to May 2025, revealed complaints about temperatures inside the facility being too cold were brought up by members during both the December 2024 and January 2025 meetings. The response from the facility revealed minutes from the January meeting indicated maintenance staff were aware to check the room thermostats. Complaints regarding food/nutrition services were brought up during the March 2025 meeting, but review of the April 2025 and May 2025 minutes revealed the facility did not address any resolutions for these grievances initiated during the resident council meeting. On 6/03/25 at 1:04 PM, the Activities Director stated about 12-15 residents regularly attended the monthly resident council meeting. She explained the major issues the council had complained of included issues with food/dietary services and call lights not being answered timely. The Activities Director stated she had informed the Maintenance Director and the Dietary Manager of the issues brought up in the resident council meetings, and they had been working on them. She expressed staff offered blankets and jackets to the residents when they were in other areas of the facility other than their room, and added, when they had 15-25 people in the dining room she didn't think it was cold. The Activities Director explained she invited the department managers to the resident council meetings in order to address issues when they arose. On 6/03/25 at 2:30 PM, the Certified Dietary Manager (CDM) and the Assistant Dietary Manager stated they were not aware of residents having issues with the food at the facility. The CDM stated she was invited to the resident council meeting when she first started at the facility eight months ago in order to introduce herself to residents. The Assistant Dietary Manager stated she had been to one of the meetings a few weeks ago. They acknowledged neither of them regularly attended the resident council's monthly meeting, and had not been aware of the issues resident council members had brought forward. On 6/04/25 at 12:45 PM, the Activities Director explained she took notes and talked to the department managers for the areas where issues were brought up by the resident council. She said if not, she would bring the issues to the facility's morning meeting. The Activities Director conveyed that she learned about the resident council meetings when she was trained to become an Activities Director. She confirmed she had not filed any grievances on behalf of the resident council's concerns and had only filed a grievance for an individual resident once, last year. The Activities Director acknowledged that filing a grievance would leave a paper trail that indicated what the action and resolution was to an issue but said she had never considered writing a grievance for resident council concerns. She confirmed she had invited the dietary department to the resident council meeting twice to discuss food issues, but acknowledged they did not regularly attend. On 6/04/25 at 3:33 PM, the Grievance Officer stated she had not received any grievances from resident council since she was started working at the facility, so she figured they did not have any complaints, and the facility was doing a good job. She recalled, the Activities Director brought up a resident's issue at the morning meeting a couple of weeks previous but could not recall any other issues/concerns from the resident council being brought to the morning meetings. The Grievance Officer confirmed she trained staff regularly to file a grievance if there were any issues that could not be resolved immediately, but she had not received any grievances from the resident council group. On 6/05/25 at 9:34 AM, the Activities Director stated she responded to resident council issues in person by telling them what was done about their concerns. She acknowledged she didn't file an actual grievance for them nor did she always document any action taken. The Activities Director confirmed that repeated issues brought up by residents at the monthly meeting did not have documentation to indicate the issues were addressed or resolved. She acknowledged she should have detailed meeting notes and documentation of grievances for any issues brought up by the resident council meeting in order for the department managers to respond timely and appropriately to the residents' concerns. The facility's policy entitled Filing Grievances and Complaints dated January 2024, indicated the facility would help residents, their representatives and advocates file a grievance; a written summary of the investigation would be provided to the resident; and a copy would be maintained in the grievance log. The facility's policy entitled Resident Council dated January 2024, indicated the facility supported residents' desire to be involved and have input in the operation of the facility. The policy added, grievance/concern forms would be utilized to track issues, their resolution and the facility department related to the issues would be responsible to address the items of concern. The policy indicated minutes from the meetings would include follow-up on prior issues with responses being presented at the next meeting, or sooner if indicated.

Based on interview, and record review, the facility failed to provide evidence that an abuse allegation was thoroughly investigated for 1 of 3 residents reviewed for abuse, of a total sample of 3 residents, (#3). Findings: Review of resident #3's medical record revealed an annual Minimum Data Set, dated dated dated [DATE] which indicated a Brief Interview for Mental Status score of 9 out of 15, mild to moderate cognitive impairment. On 10/30/24 at 12:30 PM, resident #3 was in her room alert and oriented to herself and place. She recalled an incident that occurred sometime in the past month or two when she reported to staff that a male staff member was rough with her. She was unable to recall who she had told or other details about what happened afterwards. On 10/31/24 at 8:00 AM, the Nightshift Supervisor stated he could recall, a couple of weeks ago resident #3 reported a staff person, whom she described as Certified Nursing Assistant (CNA) A, was rough with her. He said he did not ask resident #3 to explain what she meant by the word rough or to clarify any details of the alleged incident. The Nightshift Supervisor said he did not do a skin assessment for resident #3 at the time of the allegation. He said he did not direct resident #3's assigned female nurse, Registered Nurse (RN) A to do a skin assessment at the time of the allegation either. He said he put the paperwork he completed about resident #3's abuse allegation under the Risk Manager's office door at the end of his shift at approximately 7:00 AM. On 10/31/24 at 11:00 AM, the Risk Manager concurrently reviewed the investigation statements provided by facility staff persons, CNA A, CNA B, RN A, and the Nightshift Supervisor. She verified that resident #3's abuse allegation occurred on 10/23/24 and acknowledged there was no evidence of the time when resident #3's abuse allegation was made to the Nightshift Supervisor, or when the alleged incident occurred. The Risk Manager acknowledged they did not have evidence of verifying with the Nightshift Supervisor, RN A, CNA A, or CNA B regarding the time resident #3's alleged abuse incident occurred, or why the Nightshift Supervisor failed to immediately initiate any investigation into the alleged abuse incident. The Risk Manager did not say how the facility would be able to report any allegations in the required timeframe if they did not know what time the alleged abuse allegation was made. Review of the policy titled Resident Mistreatment, Neglect, and Abuse Prohibition Guidelines most current revision date 1/24/23 indicated that all employees were required to immediately report suspected instances of abuse to their supervisor, Abuse Coordinator, Administrator, and/or Director of Nursing so that the facility could protect the residents and promptly investigate the occurrence. If the alleged violation involved abuse the State Agency, Adult Protective Services, and local law enforcement must be reported to within two hours of the alleged violation.

Based on interview and record review, the facility failed to notify emergency contacts of changes in condition for 2 of 4 residents reviewed for falls, of a total sample of 5 residents, (#1 and #4). Findings: 1. Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including right side sciatica, osteoarthritis, difficulty walking, and generalized muscle weakness. The Admission Record or face sheet contained essential information including resident #1's selected emergency contacts with their associated telephone numbers. The document listed the resident's husband as emergency contact #1 and her daughter was emergency contact #2. Review of the hospital to facility transfer form, dated 5/16/24, revealed resident #1's emergency contact was her husband and his telephone number was the same number transcribed to the facility's Admission Record. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date (ARD) of 5/22/24 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which showed she had moderate cognitive impairment. The MDS assessment indicated resident #1 felt it was very important to have her family involved in discussions regarding her care. The document revealed the resident, her significant other, and her family were active participants in the assessment process. Review of a Nurses Note dated 6/15/24 at 7:50 PM, revealed the Weekend Registered Nurse (RN) Nursing Supervisor conducted a post-fall assessment for resident #1. The note indicated the resident's husband was notified of the fall incident. A Nurses Note dated 6/15/24 at 10:50 PM, revealed the Weekend RN Nursing Supervisor received an order from the physician for x-rays of resident #1's bilateral hips and pelvis. The medical record did not show resident #1's emergency contacts were notified of the new physician order. On 9/23/24 at 1:22 PM, in a telephone interview, resident #1's daughter stated the facility did not notify the family of her mother's fall on 6/15/24. She explained the resident's husband, emergency contact #1, was made aware of the incident when he visited the facility the following morning, approximately 15 hours after the fall. The resident's daughter stated she informed the facility that nobody called them, and she verified the facility's emergency contact information was correct. She stated she checked family phone records and neither emergency contact received a phone call at the time of the fall or during the overnight shift. Review of the family's phone records from 6/15/24 to 6/16/24 revealed no incoming telephone calls for resident #1's husband and daughter at the time the Weekend Nursing Supervisor indicated she notified the husband, or after she received a new physician order for diagnostic testing. The document showed there were no incoming calls to the resident's emergency contacts during the 7:00 PM to 7:00 AM shift. On 9/23/24 at 2:21 PM, in a telephone interview, the Weekend RN Nursing Supervisor confirmed the facility's protocol was to notify the family after a fall. She explained if she was unable to speak to the family, she would leave a voicemail and inform the nurse on the next shift to follow up. The Weekend RN Nursing Supervisor acknowledged she wrote that she notified the resident's husband but she could not recall details of the conversation. However, she stated she remembered resident #1 had a cell phone and she had verbalized she wanted to call her husband. On 9/24/24 at 10:55 AM, the Administrator, Director of Nursing (DON), and the Director of Quality Management were informed resident #1's family provided phone records that showed they were not notified of her fall. The Administrator reviewed the resident's face sheet and explained there was a home telephone number listed and the nurse might have called that number. The Administrator explained she called the home phone number once and left a message on the answering machine. When informed the home telephone number was listed as a previous phone number, and not an emergency contact number, the Administrator maintained she felt it was appropriate and acceptable to utilize a number provided for resident #1's home. The Director of Quality Management interjected that when the nurses pulled up a resident's information on the electronic medical record, they did not see a printed face sheet with previous addresses and phone numbers. She retrieved resident #1's medical record and validated the spouse and daughter were listed as emergency contacts. The Director of Quality Management stated her expectation was after a fall incident, nurses would call the emergency contacts in the order noted in the medical record. She explained if the resident's first emergency contact was not available, the nurse should attempt to notify the second contact. On 9/24/24 at 11:40 AM, the Admissions Coordinator stated the facility always received residents' emergency contact information with the referral from the hospital, prior to admission. She stated to her knowledge, emergency contacts would be called in the order selected by the resident. She said, We start calling the numbers from the top down. Number 1, then number 2, as many as they have listed. 2. Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included fractures of the right humerus and left radius, right hip osteoarthritis, chronic gout, and generalized muscle weakness. The Admission Record or face sheet contained essential information including resident #4's selected emergency contacts with their associated telephone numbers. The document listed the resident's nephews as emergency contacts #1 and #2. Review of the hospital to facility transfer form, dated 7/31/24, revealed resident #4's emergency contacts were his nephews, whose telephone numbers were transcribed accurately onto the facility's Admission Record. Review of the MDS Admission assessment with ARD of 7/18/24 revealed resident #4 had a BIMS score of 15 which indicated he was cognitively intact. The MDS assessment showed resident #4 felt it was very important to have his family involved in discussions regarding his care. The document revealed the resident was an active participant in the assessment process. Review of a Nurses Note dated 9/22/24 at 5:00 PM revealed resident #4 lost his balance as he walked in his room and fell to the floor. A Change in Condition Evaluation note dated 9/22/24 revealed resident #4's assigned nurse, the Sea Breeze unit's Licensed Practical Nurse (LPN) Unit Manager (UM) documented she notified the resident's physician and his nephew, emergency contact #1, of the fall. The document indicated she notified the resident's nephew on 9/22/24 at 6:00 PM. On 9/23/24 at 10:34 AM, the Sea Breeze LPN UM confirmed resident #4 fell on Sunday, 9/22/24. She explained even though he was not injured, notification of the physician and chosen emergency contact was required. On 9/23/24 at 1:03 PM, in a telephone interview, resident #4's nephew confirmed he was his uncle's health care surrogate and first emergency contact in the event of an accident. He stated he was made aware that his uncle fell yesterday when the facility called this morning, between 8:00 AM and 10:00 AM. He verified he had no voicemail messages from the facility yesterday. On 9/23/24 at 1:36 PM, the DON was informed although resident #4's Change in Condition Evaluation form indicated the Sea Breeze LPN UM notified his nephew of the fall on 9/22/24 at 6:00 PM, the nephew stated he was not notified until the following morning, approximately 14 hours after the incident. On 9/23/24 at 1:41 PM, the Sea Breeze LPN UM explained she called resident #4's nephew yesterday, but he did not answer. She confirmed she did not attempt to call the other listed emergency contact. When asked if she left a voicemail, the LPN UM said, I did not leave a voicemail. I don't know why I didn't leave a voicemail. I don't have an answer. I just don't know. She acknowledged proper notification was therefore not made at the time of the fall. The LPN UM stated her expectation as a UM was nurses would attempt to notify the first emergency contact, and if there was no response, then contact the second person listed. She explained if nurses were unable to contact the family, that information should be documented in the medical record. On 9/23/24 at 1:44 PM, the DON validated the Sea Breeze LPN UM should have left a voicemail message for the nephew since he was emergency contact #1. She indicated the LPN UM could have told the oncoming night shift nurse to attempt notification again. Review of the facility's policy and procedures for Change in a Resident's Condition or Status, revised on 1/25/23, revealed the facility would promptly notify the resident, the attending physician, and the representative of changes in the resident's medical condition or status. The policy indicated the Nursing Supervisor would notify the resident's family or representative when the resident was involved in an accident or incident that resulted in injury.

Based on observation, interview, and record review, the facility failed to administer blood pressure medication as per plan of care to prevent the systolic blood pressure from rising above 160 for 1 of 1 resident reviewed for unnecessary medications out of a total sample of 44 residents, (#80). Findings: Review of the medical record revealed resident #80 was admitted to the facility on [DATE] from the hospital. His diagnoses included type II diabetes, congestive heart failure, hypertension, and paroxysmal atrial fibrillation. The Minimum Data Set (MDS) 5-day assessment with the assessment reference date (ARD) of 9/14/23 revealed resident's cognition was intact with a Brief Interview Mental Status (BIMS) score of 15 out of 15. Review of resident #80's medical record revealed a care plan related to hypertension, initiated on 9/23/2023. The interventions directed nurses to administer medications as ordered by the physician and monitor the dose to achieve desired effects and minimize adverse consequences, especially when multiple antihypertensives are prescribed simultaneously. Review of the facility's Order Summary Report dated 10/5/2023 revealed resident #80 had a physician order dated 9/22/23 for Clonidine tablet 0.1 milligram (mg) to be administered every 8 hours as needed for hypertension if the resident's Systolic Blood Pressure (SBP) was greater than 160. Review of resident #80's Blood Pressure Summary Report revealed the resident's Systolic Blood Pressure was greater than 160 twelve times from 9/22/23 to 10/5/23 documented by 7 different nurses. Review of the facility's Medication Administration Record (MAR) for 9/22/23 to 10/5/23 revealed the resident never received Clonidine tablet 0.1 mg every 8 hours as needed for hypertension with systolic blood pressure that was greater than 160 as ordered by the physician. ON 10/5/2023 at 2:36 PM, Licensed Practical Nurse (LPN) A stated if a resident had blood pressure medication order with parameters, he would check the resident's blood pressure, administer the blood pressure medication if the blood pressure is within the parameter as ordered, and go back to retake the blood pressure to see if it was affective. LPN A acknowledged the Medication Administration Record noted that resident #80 had Clonidine prescribed as needed if the systolic blood pressure (SBP) was greater than 160 with a start date of 9/22/23. LPN A reviewed the resident's Blood Pressure Summary Report and verified the resident's SBP was over 160 twelve times from 9/2/23 to 10/5/23. He confirmed that on the days he worked, 10/5/23 at 7:51 AM, the resident's blood pressure (BP) was 168/81, on 9/27/23 the BP was 161/81, and on 9/26/23 the BP was 164/82. LPN A stated he did not offer or give the resident the Clonidine 0.1 as prescribed by the provider. He did not provide an answer as to why he did not administer the Clonidine as prescribed. On 10/5/2023 at 3:25 PM, the Unit Manager (UM) on the Cypress Court unit stated that if a resident had a blood pressure medication order with parameters, the nurse should check the BP and administer the prescribed blood pressure medication as ordered. She stated the resident could experience serious complications such as a stroke, chest pain, and/or shortness of breath if the medication was not given for the high blood pressure. The UM reviewed resident #80's provider orders, Blood Pressure Summary Report, and the MAR. She stated the resident's SBP was greater than 160 twelve times from 9/22/23 to 10/5/23, and the resident should have been given the Clonidine as ordered by the physician. On 10/5/2023 at 3:55 PM, the Director of Nursing verified the resident's SBP was greater than 160 twelve times from 9/22/23 to 10/5/23. She acknowledged the resident was not given the blood pressure medication as ordered on the days the resident's SBP was greater than 160 and that the nurses should have followed the physician orders and administered the BP medication. The DON stated it is very important that nurses followed the physician orders if a resident was prescribed BP medication with parameters. The facility's Physician Services Policy noted physician orders will be followed by the center staff. If a physician order is not followed for clinical concerns or per patient's wishes, the physician should be notified and the reason for not following the order must be documented.

Based on interview, and record review, the facility failed to provide Corona Virus Disease 2019 (COVID-19) vaccine for 1 of 5 residents and failed to offer the COVID-19 vaccine to 2 of 5 residents out of a total sample of 44 residents reviewed for immunizations, (#33, #64). Findings: 1. Review of resident #33's medical record showed no COVID-19 consent for the year 2022. The care plan initiated 7/24/20 and revised on 1/12/23 revealed a problem for COVID-19 infection with a goal and intervention to administer the COVID-19 vaccine through the pharmacy vaccine clinic. The medical record did not reveal a COVID-19 2022 consent for resident #33. On 10/06/23 at 4:13 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist stated there was no COVID medication administration record from the previous facility where the resident resided. She noted administration would be documented on resident #33's COVID card if she received the COVID-19 vaccine. Review of the COVID-19 card for resident #33 revealed no administration of the vaccine for 2022. The ADON/Infection Preventionist confirmed documentation on the COVID-19 card showed the resident received the vaccine in 2021, not 2022. On 10/06/23 at 4:41 PM, the ADON/Infection Preventionist stated there was no 2022 consent for the COVID-19 vaccine. She validated she did not know if the COVID-19 vaccine was offered to the resident or her representative in the year of 2022. Further review of the medical record revealed no physician orders and no documentation of administration of COVID-19 vaccine being administered in 2022. 2. Review of the medical record revealed resident #64's COVID 19 consent form dated 4/21/22 with comment Verbal consent via daughter . at 7:30 PM, witnessed by 2 nurses on 4/21/22. Review of the facility immunization report revealed COVID-19 vaccine was consented to be received, but there was no documentation of the vaccine being administered. The facility was unable to provide documentation of the medication administration record (MAR) showing administration of the COVID-19 vaccine in 2022. There was no documentation of a physician order to administer the COVID-19 vaccine in 2022. On 10/4/23 at 6:16 PM, the ADON/Infection Preventionist stated newly admitted residents were offered immunizations including COVID-19 vaccine at admission. She explained she kept track of the immunizations and vaccines by printing the census, and then comparing the consent to the residents that received or declined the vaccine. She stated it was her responsibility to ensure COVID-19 vaccine was administered to the residents, and the consents were current. Review of the medical records revealed no consent for the COVID-9 vaccine being offered in 2022 for resident #33. Resident #64's medical record revealed a signed consent for COVID-19 vaccine but no physician order for the vaccine to be administered in 2022. Review of the facility's policy, Vaccination of Residents revised on 8/3/23 showed all residents will be offered vaccines that aid in the preventing of infectious diseases. If vaccines are refused they shall be documented in the medical record.

Based on observation, interview, and record review, the facility failed to verify placement of a gastric feeding tube prior to medication administration for 1 of 2 residents reviewed for Tube Feeding of a total sample of 44 residents, (#68). Findings: Review of the medical record revealed resident #68 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 8/23/23 with diagnoses that included anoxic brain damage, respiratory failure, malnutrition, dependence on ventilator, and gastrostomy (feeding tube) status. The Minimum Data Set Admission assessment with Assessment Reference Date of 9/12/23 noted the resident was rarely/never understood, had severely impaired cognitive skills for daily decision making, and did not have any behavioral symptoms. The resident was totally dependent, required two staff to complete Activities of Daily Living (ADLs), and he received nutrition and hydration through a feeding tube. The Comprehensive Care Plan included medication administration with crushed medications administered through a feeding tube, dependency on a feeding tube for nutrition, hydration, and medications with goals the resident would remain free of complications. The interventions instructed nurses to verify the feeding tube placement prior to its use with checks for gastric contents/residual volume. The Order Summary Report showed physician orders from 6/14/23 to 8/24/23 for Enteral (Feeding tube) Check Placement (Continuous/Intermittent and Bolus) check placement before each medication administration, and active physicians orders for nothing by mouth, continuous enteral nutrition with Nepro (Nutrition formula) at 55 ML per hour for 20 hours, and enteral flushes after medication administration. The Medication Administration Record for October 2023 showed from 10/1/23 to 10/5/23, nurses administered medications through resident #68's feeding tube that included Levothyroxine 100 Micrograms (MCG) for thyroid disorder, magnesium oxide 400 Milligrams (MG), Potassium Sodium phosphates, 280-160-250 MG, and Potassium Chloride 20 Milliequivalents (MEQ) for deficiencies, Zinc 50 MG, Juven (supplement), Vitamin C 500 MG, and House Protein 30 Milliliters (ML) for wound healing, Hydrocortisone 10 MG for itching, Keppra 250 MG for seizures, Metoprolol Tartrate 25 MG for blood pressure, Pantoprazole Sodium 40 MG for gastroesophageal reflux disease, Midodrine HCI 15 MG for blood pressure, Renal-Vite multivitamin for kidney failure, and Miralax, 17 Grams (GM), for constipation. On 10/4/23 at 11:53 AM, Registered Nurse (RN) B was observed for Medication Administration for resident #68. RN B did not check for proper feeding tube placement by residual gastric (stomach) contents with a syringe or by listening for gurgling noises with a stethoscope before she manually pushed medications followed by water flushes with a syringe, nine times. On 10/4/23 at 12:19 PM, RN B said nurses were expected to check for proper placement before they administered medications into a feeding tube. RN B acknowledged she had not confirmed proper tube placement before she administered the medications. She said, you're correct I forgot. On 10/4/23 at 2:09 PM, the Seashell Unit Manager said the facility policy instructed nurses to check residual gastric contents prior to medication administration through a feeding tube. She said the normal process was to administer medications by gravity, and not by push. On 10/4/23 at 2:49 PM, the Director of Nursing said she expected nurses to check for proper placement prior to feeding tube use, and gravity administration was preferred. She explained the use of a syringe by manual push could rupture the balloon. Review of the facility's policy titled, 17.2 Checking Gastric Residual Volume (GRV), read, Steps in the Procedure . 4. Attach sixty (60) ml syringe to end of catheter tube. 5. If catheter is clamped, unclamp catheter. 6. Aspirate stomach contents (GRV)

Based on observation, interview and record review, the facility failed to accurately document medications/creams, ointments according to prescribed orders for 1 of 3 sampled residents reviewed for skin conditions (#24), failed to accurately document Physician's Orders for 1 of 3 sampled residents reviewed for pressure ulcers (#28), and for 1 of 1 resident reviewed for [CONDITION(S)] (#52), and failed to accurately document a partial bath instead of showers for 1 of 2 sampled residents reviewed for activities of daily living (ADLs) (#86), out of a total sample of 44 residents. Findings: 1. Resident #24 was admitted to the facility on [DATE] with the most recent readmission on 8/16/21. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These spots usually develop on the chest or back, but may also form on other parts of the body that also causes itching. (https://rarediseases.info.nih.gov/diseases/6551/Grovers-disease a history of infectious and parasitic diseases and atopic [CONDITION(S)]). Her Minimum Data Set quarterly assessment reference date 9/09/21, signed as complete on 9/13/21, identified the application of ointments and medications other than to feet. The plan of care for skin impairment, related to rash on back and groin, general body rashes Atopic [CONDITION(S)] to back and bilateral upper extremities, was initiated on 2/21/21 and updated most recently 10/12/21. On 11/30/21 at 9:49 AM, resident #24 had a visible reddened and bumpy rash on her exposed right lower arm. The resident said her skin itched and it kept her awake at night. On 11/23/21, the Dermatology Advanced Practice Registered Nurse prescribed [MEDICATION(S)] 5% cream - apply head to toe. Wash off 8 hours later. Repeat application in one week. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Followed by [MEDICATION(S)] 0.1% cream two times a day for 4 weeks to itchy skin. Review of the order entries for the prescriptions were as follows: 11/23/21 [MEDICATION(S)] Cream 5% apply to skin topically one time a day starting on the 11/24 and ending on the last day of the month for itching until 11/30/21. Apply head to toe wash off 8 hours later. Repeat application in 1 week. 11/23/21 Halobetasol Propionate Cream 0.05% Apply to skin topically two times a day for itching until 12/09/21 to itchy skin. 11/23/21 [MEDICATION(S)] [MEDICATION(S)] 0.1% cream apply to skin two times a day for itching until 12/25/21 to itchy skin times 4 weeks. Proof of delivery from the Pharmacy on 11/24/21 at 8:03 AM reflected that Halobetasol Propionate Cream 0.05% and [MEDICATION(S)] Cream 5% was delivered to the facility. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/30/21 at 1:15 PM, the Sea Shell Unit Manager was asked about multiple doses of [MEDICATION(S)] given to resident #24 as well as two additional creams ordered by the dermatologist and approved by the physician on 11/23/21. She was not aware that the order for the [MEDICATION(S)] was incorrect. She verbalized that [MEDICATION(S)] was signed as given daily from 11/24 to 11/30/21 by three different nurses as well at the two creams. On 11/30/21 at 3:20 PM, the Director of Nursing (DON) validated that there was an error on the transcription regarding the multiple medication/creams administered. The DON said the nurse faxed the order from the dermatologist to the pharmacy. The pharmacy only delivered one dose of [MEDICATION(S)]. Staff were signing off as given even though the resident did not receive the additional treatments. The orders for Halobetasol and [MEDICATION(S)] were also faxed to the pharmacy which only delivered the Halobetasol. Two of the three nurses signed off that [MEDICATION(S)] cream was given even though no supply was delivered. The DON contacted Licensed Practical Nurse (LPN) C by phone. LPN C explained to the DON that she gave the medications even though she did not give them. LPN C told the DON that she asked the treatment nurse if she did her treatment and LPN C assumed the treatment nurse did it the creams, so she signed off that it was done. On 12/01/21 at 9:18 AM, RN A said that she signed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/01/21 09:50 AM, the nurse said, I try to check the orders. I know the first day [11/24/21] I gave her the [MEDICATION(S)] cream and took her to the shower after 8 hours, and discarded the medication. I do not know why the next day it was signed as done. I know it should be given every 14 days. Resident #24 had three different creams for the itching plus [MEDICATION(S)]. On 12/02/21 at 10:59 AM, LPN B said she never provided [MEDICATION(S)] even though she signed that she gave it. She also validated that resident #24 had a lot of skin treatment creams and powders. 2. Review of resident #28's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28's physician's orders included to apply [MEDICATION(S)] ointment to the sacrum topically every day shift, cleanse with Normal Saline solution, pat dry, apply skin prep to periwound, apply Santyl, Puracol plus, foam dressing, change daily and as needed. This order was started on 10/29/21. The Wound Follow-Up forms, dated 11/23/21 and 11/30/21 and signed by the physician, showed treatment to follow included ¼ Dakin's Solution, Skin Prep, [MEDICATION(S)], Collagen, Santyl, Puracol, foam dressing and tape. Resident #28's Treatment Administration Record for November and December 2021 showed treatments were done every day with Normal Saline solution. Resident #28's care plan for pressure ulcer, revised on 7/13/21 included an intervention: Administer treatments as ordered and monitor effectiveness. On 12/02/21 at 2:59 PM, LPN J explained she followed residents with wounds in the facility. LPN J indicated her responsibilities included to inspect every admission, obtaining digital pictures of any wounds, calling the physician to obtain orders for treatments, determine the best specialty mattress for the resident, perform weekly skin assessments and notify families of her findings. LPN J explained she rounded with the Wound Care Physician on Tuesdays. She explained she entered wound care orders using the physician's Wound Follow-Up form and confirmed entering resident #28's wound care order. LPN J stated the physician and herself used Dakin's Solution when providing wound care. She stated the order was transcribed incorrectly and confirmed nurses would have followed the physician's order as she entered it. Review of the facility policy Physician Orders reviewed on 1/19/18 read, Physician orders will be transcribed, noted, implemented, and followed in a timely manner. Review of the Job Description for the LPN Staff, not dated, revealed duties and responsibilities that read, Maintains accurate and complete records of nursing care provided. 3. Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated an intact cognition. Resident #52's physician's orders included [CONDITION(S)] on Tuesday, Thursday and Saturday, chair time at 11:40 AM, transport pick up between 10:30 and 11 AM, return between 4 and 4:30 PM. The order started on 7/13/21. Resident #52's Treatment Administration Record (TAR) for November and December 2021 showed treatments for [CONDITION(S)] marked complete on Tuesdays, Thursdays and Saturdays. Resident #52's care plan for renal insufficiency due to [CONDITION(S)] and HD, initiated on 2/07/21, had interventions that read, [CONDITION(S)] . T [Tuesday], TH [Thursday], S {Saturday] . [CONDITION(S)] meals to be sent on [CONDITION(S)] days . Tues, Thu, Sat . On 11/30/21 at 10:12 AM, resident #52 sat in a wheelchair near the door of her room and stated she was waiting for transportation to be taken to [CONDITION(S)]. The resident indicated her [CONDITION(S)] chair time was 11:40 AM and she went on Tuesdays and Saturdays. On Thursday, 12/02/21 at 1:29 PM, the resident was asleep in her bed. On 12/02/21 at 1:37 PM, the 100-Hall Unit Manager (UM) explained they have a binder for new residents on [CONDITION(S)] that includes information about chair and pick up times. The UM stated the binder helped the Certified Nursing Assistants (CNAs) be aware of the days and times, so they got the residents ready timely. The UM reviewed resident #52's medical record and indicated resident went to [CONDITION(S)] on Tuesday, Thursday, and Saturday. When asked why resident was sleeping in her room at this time as it was Thursday. The UM reviewed the Pre-Post [CONDITION(S)] Evaluation forms from 11/02/21 to 11/30/21, and indicated the forms were only completed on Tuesdays and Thursdays. The UM explained the TAR check marks on Tuesday, Thursday, and Saturday during the month of November meant resident went to [CONDITION(S)] those days as there were no exemption code if it was not done. On 12/02/21 at 2:46 PM, the UM contacted the [CONDITION(S)] center to clarify resident #52's [CONDITION(S)] days. She stated she was told resident #52's scheduled [CONDITION(S)] days were Tuesdays and Saturdays since 8/03/21. The UM confirmed there were no progress notes with this information or a physician order that reflected those days. The UM explained if the resident was not picked up or missed [CONDITION(S)], the nurse would have called the [CONDITION(S)] center and entered a progress note. The UM indicated transportation would had been contacted by the [CONDITION(S)] center. The UM stated there were no notes documenting changes. On 12/02/21 at 5:23 PM, the DON explained the facility coordinated with [CONDITION(S)] any changes of schedule and transportation. The DON indicated [CONDITION(S)] would have contacted the transport company about the changes for resident #52 from 3 to 2 days. The DON indicated she could not remember seeing anything regarding change of days for resident #52. The DON stated a nurse should had called the [CONDITION(S)] center and updated the orders. Review of the facility policy Hemodialysis, reviewed on 4/17/13, read, Orders will be obtained from the attending physician for residents receiving hemodialysis. The procedure included, Communication with be maintained between the facility and the hemodialysis service provider. 4. Resident #86 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #86's Admission MDS assessment, dated 11/10/2,1 revealed her Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated intact cognition. The MDS also showed the resident's functional abilities and activities of daily living as needing extensive assistance for bed mobility, transfer, toilet, and dressing. The MDS revealed resident #86 needed limited assistance for personal hygiene. The MDS indicated the resident did not reject evaluation or care needed to achieve her goals for health and well-being. Resident #86's medical record revealed shower preferred days were Monday and Thursdays during the 3-11 shift. Review of tasks showed showers were given to resident #86 on the following days: 11/08, 11/11, 11/15, 11/18, 11/22, 11/25, 11/29/21. Resident's #86 care plan included impaired vision, impaired physical mobility and ADL self-care performance deficit initiated on 11/9/21. Interventions included resident required extensive assistance with bathing/showers as scheduled and as necessary. On 11/29/21 at 5:04 PM and 11/30/21 11:44 AM, resident #86 stated she had not received any showers in the time she had been in the facility. Resident #86 explained she had received a bed bath once or twice each week and would prefer more often. On 12/01/21 at 4:35 PM, CNA I stated she usually gave showers to her assigned residents after they had dinner. CNA I explained if a resident refused showers, she informed the nurse and documented the refusal but she would offer a bath by the sink or a bed bath. CNA I explained resident #86 had been refusing showers but she had received a bed bath instead. CNA I indicated resident #86 was supposed to get showers on Mondays and Thursdays but the resident had refused, and she had documented the refusal in the computer. On 12/02/21 at 2:27 PM, the 100 Hall UM explained the DON and UMs get alerted of any residents' refusal of showers, among other things, through a dashboard in computer. The UM indicated showers for resident #86 were documented as given. On 12/02/21 at 4:29 PM, CNA I confirmed resident #86 refused showers and had received bed baths. CNA I explained she had the option to select partial or bed bath when documenting the task, but had been entering as showers as a mistake. The CNA I stated she sometimes notified the nurses but knew she was supposed to tell the nurse each time.

Based on observation, interview and record review, the facility failed to adequately manage pain for 1 of 3 sampled residents reviewed for pain management, of a total sample of 44 residents (#959). Findings: Resident #959 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Vertebrae are the 33 individual, interlocking bones that form the spinal column (retrieved on 12/03/21 from www.spinehealth.com). An admission evaluation note dated 11/23/21 at 4:40 PM revealed the resident had lower back pain that he described as a score of 4 on a 0 to 10 pain scale. The resident's chart revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . every 8 hours as needed for muscle spasms. An Occupational Therapy progress note, dated 11/25/21, revealed resident #959 rated his pain as 10 during activity and 3 at rest. Resident #959's care plan for pain, initiated 11/30/21, revealed a goal that he would verbalize adequate relief of pain or the ability to cope with incompletely relieved pain . On 11/29/21 at 11:52 AM, the resident stated he received only Tylenol for his pain, and it was not effective. He explained he asked the nursing staff to get a stronger medication for his pain. He stated the Physical Therapist (PT) applied ice to his back and it helped his pain, but when he asked a nurse if she could provide ice for his back pain, she refused. Resident #959 stated the nurse told him she did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/01/21 at 8:52 AM, resident #959 was in bed. He stated he had been awake since 3:30 AM because he was in pain. He said, I asked for pain medication and the CNA [Certified Nursing Assistant] came back to the room and said the nurse told her I could not have any medication until 9 AM. I could not eat breakfast because I am in too much pain to sit up. Resident #959 rated his current pain level as 9 out of 10, and described it as feeling like someone was stabbing him. He stated he was not able to take a shower on Monday evening, 11/29/21, because of the pain. Two PTs entered the room at that time, and the resident told them he could not participate in therapy because of his pain. The Assistant Director of Nursing (ADON) entered the room and resident #959, informed her of how much pain he was experiencing, and explained he needed stronger pain medication. The ADON stated she thought the resident's physician ordered new pain medication for him on the previous day and offered to check the medical record. The resident's medical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . twice a day for muscle spasms and a [MEDICATION(S)] 5% patch for pain. However, review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/01/21 at 12:30 PM, resident #959 stated no one ever asked him what an acceptable pain level would be, and he did not recall anyone asking if the Tylenol he received was effective. He said, The doctor came in yesterday and ordered additional medication for me, and so far it is working well. On 12/01/21 at 1:01 PM, CNA H stated resident #959 had complained of pain since admission. She said, I know he did not eat his breakfast this morning because he was having pain. On 12/01/21at 2 PM, Licensed Practical Nurse (LPN) G acknowledged she was assigned to care for resident #959 on Sunday, 11/28/21. She said, When the night nurse gave me report, she said she called the on-call doctor to try to get stronger pain medication for the resident, but the on-call doc [doctor] did not feel comfortable doing that, and told me to call the on-call for day shift to see if I could get something stronger for his pain. I called, but the covering doctor would not prescribe anything because he did not know the resident. On 12/02/21 at 1:39 PM, the Director of Nursing (DON) stated her expectation was that residents' reports of pain would be addressed, and if not controlled with existing medication, the physician should be notified and another order should be obtained. The policy Pain Management Program, reviewed 2/14/18, read, The effectiveness of the interventions implemented to manage the residents pain will be observed and adjustments will be made accordingly based on the resident responses and/or preference.

Based on observation, interview, and record review, the facility failed to document medication administration accurately, failed to follow physician's orders for blood glucose monitoring for 1 of 10 sampled residents reviewed for medication administration (#42), and failed to obtain and document a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #42's Brief Interview for Mental Status (BIMS) score was 13, which indicated intact cognition. The MDS showed the resident did not reject evaluation or care needed to achieve her goals for health and well-being. Review of resident's #42's medical record revealed a physician's order, dated 11/23/21, which indicated 6 units of [MEDICATION(S)] to be administered before meals and at bedtime for diabetes, and to hold for blood glucose less than 150. There was a second order for [MEDICATION(S)], dated 10/06/21, to inject per sliding scale before meals and at bedtime. [MEDICATION(S)] mealtime insulins are used to treat people with type 1 or type 2 diabetes for the control of high blood sugar. (Retrieved from www.[MEDICATION(S)].com on 12/10/21). Review of resident #42's care plan included diabetes and the risk for further complications, initiated on 10/04/21. The care plan listed interventions that included, Administer insulin . per MD order. Blood glucose checks and notifications per MD orders. On 12/01/21 at 8:46 AM, during observation of medication pass, resident #42 told license practical nurse (LPN) G her blood glucose needed to be checked before breakfast,but it was now too late because she had eaten. The resident said, every day was the same thing. LPN G listened to the resident and responded she needed to check her blood glucose and administer the insulin as ordered. The LPN collected the blood sample with result of 396. LPN G stepped out of the resident's room, checked the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN G returned to resident #42's room and told her she was going to administer 10 units of insulin, to which the resident responded, 10 won't do it. However, LPN G administered insulin on the right upper posterior arm. On 12/01/21 at 9:21 AM and 11:30 AM, LPN explained she was late checking resident #42's blood glucose because 5 of her 19 assigned residents also required blood glucose monitoring. LPN G indicated the order to check insulin was at 8 AM, and breakfast usually came between 7:30 and 8 AM. LPN G verified the order for insulin, stated it was before meals and at bedtime, and indicated it was not checked before the meals as ordered. LPN G indicated it was important to give insulin before meals to accurately determine how much the resident needed to better control her blood glucose level. LPN G confirmed she gave 10 units of [MEDICATION(S)] and stated she only saw one order and documented administration of the 10 units. On 12/01/21 at 11:05 AM, the 100-Hall Unit Manager (UM) explained if a physician's order stated to obtain blood glucose before meals it needed to be done before meals. If a resident had already eaten, the nurse could still check the blood glucose then call the physician and report the results and find out if the insulin was to be given or obtain a new order. The UM reviewed resident #42's orders and confirmed she had two orders for [MEDICATION(S)], one for 6 units if blood glucose results were above 150, and another where the amount to be administered was based on a sliding scale. On 12/01/21 at 12:52 PM, the Director of Nursing (DON) explained nurses were to follow physician's orders for insulin administration and blood glucose monitoring. The DON stated a nurse was to obtain blood glucose before meals if that was the physician's order. The DON explained in the event a resident had eaten, she would notify the physician with blood glucose results and get a new order. On 12/01/21 at 2:50 PM, the Advanced Practice Registered Nurse (APRN) explained her expectation would be nurses contact her or the physician if an order could not be followed. The APRN explained she saw resident #42 in the morning and when reviewing the blood glucose readings, she noted the high trends so she entered an order to increase insulin from 6 to 8 units. The APRN explained she based her decision on the review of the blood glucose results documented by the nurses. The APRN stated she wasn't contacted regarding blood glucose checked and insulin administered after the resident had eaten on that morning. The APRN indicated if blood glucose is checked inconsistently, the results will be higher and she would base her treatment on before meals results, as it was ordered. The APRN stated the changes made to insulin were based on the documentation from the nurses, and inconsistent review would result in an inaccurate treatment. Review of the facility policy Physician Orders reviewed on 1/19/18 read, Physician orders will be transcribed, noted, implemented, and followed in a timely manner. Review of the facility policy Dose Preparation and Medication Administration, revised on 1/01/13, read, Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications. The procedure included, Administer medications within timeframes specified by facility policy. 2. Resident #68 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 11/29/21 at 12:10 PM and on 12/01/21 at 4:24 PM revealed a foam dressing to the resident's right forearm. The dressing was not dated. The resident stated his arm was ripped open during transfer from his bed to his wheelchair. Review of the weekly skin evaluation dated 11/22/21 revealed the resident had a skin tear to his right forearm, and ecchymosis of his right and left forearms. A nurse's progress note, dated 11/22/21, read, observed the resident right forearm bleeding. He has a small skin tear . the resident stated he rubbed it on the arm rest of the wheelchair. This writer cleansed the right forearm with normal saline and applied a dry dressing. Provider informed and new order to apply dressing until heal. An Interdisciplinary Team review note, dated 11/23/21, read that the resident had a skin tear to right forearm . treatment initiated. On 12/01/21 at 4:27 PM, Registered Nurse (RN) A stated a skin assessment was completed for the resident on the 11 PM-7 AM shift weekly and would be documented on the weekly skin assessment evaluation. Any new skin issues would be documented as a change in condition, the physician would be notified and order for treatment obtained. RN A stated she was not sure why resident #68 had the foam dressing to his right forearm. On 12/01/21 at 4:37 PM, observation of the resident's right forearm was conducted with the wound care nurse and the Regional Nurse Consultant. The wound care nurse stated she was not aware of any wound/skin impairment for the resident. The foam dressing was removed by the wound care nurse, and the resident reported he scratched his arm on his wheelchair during transfer. On 12/01/21 at 4:43 PM, the Seashell Unit Manager (UM) stated on 11/22/21, documentation revealed the nurse noted the resident's right arm bleeding, the physician was notified, and a dry dressing was placed. She stated the protocol for any change in condition included skin assessment of the resident, notification of the physician, obtaining treatment orders, documentation of an incident report, and a progress note. A review of the resident's physician orders was conducted with the UM. She verbalized a treatment order was not entered for the resident's skin tear. The UM said the facility did not have standing orders/order for skin tears, and that a physician's order would have to be obtained for treatment. The UM stated LPN B documented in the nurse's notes but did not obtain a physician's order. On 12/02/21 at 9:28 AM, LPN B stated on 11/22/21 she identified the skin tear to the resident's right forearm. She notified the physician, cleansed the area with Normal Saline solution, and applied a foam dressing to the area. LPN B explained the facility's protocol for skin tears included notification of the physician and obtaining orders for treatment. She stated she forgot to enter the physician's order in the resident's electronic clinical record. On 12/02/21 at 11:18 AM, the Director of Nursing (DON) stated LPN B explained to her that she called the physician and initiated treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the absence of a physician's order for the resident's skin tear was missed. The DON verbalized she documented that treatment was initiated, and updated the resident's care plan, for actual skin impairment, but did not check the physician's order sheet to ensure an order was obtained. The DON stated a physician's order for treatment was required. The facility's policy Skin & Wound Care, reviewed on 3/2021, read, The staff nurse will describe and measure the wound, notify physician, obtain orders and notify resident and resident representative when a skin alteration is identified.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected health conditions regarding insulin for 1 of 3 sampled residents reviewed for resident assessment (#97), and failed to accurately assess for antipsychotic medication for 1 of 5 sampled residents reviewed for unnecessary medications (#94), of a total sample of 44 residents. Findings: 1. Resident #97 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) subcutaneous in the morning every Monday for diabetes. [MEDICATION(S)] ([MEDICATION(S)]) is an injectable medication used to lower blood sugar and is not considered insulin. (Retrieved from www.[MEDICATION(S)].com on 12/10/21). Section N, Medications of the Admission MDS assessment, with assessment reference date 11/15/21, revealed resident #97 received insulin one day during the last 7 days or since admission. On 12/02/21 at 11:08 AM, the MDS Lead nurse explained she reviewed the pharmacological classification when unfamiliar with a medication. After she reviewed her pharmacological classification resource, she stated [MEDICATION(S)] was not considered an insulin. She indicated resident #97 was not receiving any insulin and confirmed the MDS assessment coded as insulin was inaccurate. On 12/02/21 at 11:20 AM, Registered Nurse (RN) E explained he reviewed the resident's medication orders and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN E stated he used the internet when unsure about a medication. RN E indicated there were many new medications he was unfamiliar with and confirmed he coded the MDS assessment incorrectly. RN E stated, It should not be marked as insulin and stated he knew the MDS was supposed to be accurate. RN E indicated accuracy of the MDS was very important to ensure an accurate care plan. Review of the facility policy titled, MDS revised on 9/16/19 read, Each Interdisciplinary Team member will sign and date the portion of the MDS that he/she completed to certify accuracy. 2. Resident #94 was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's order dated 8/05/2021 noted [MEDICATION(S)] 25 mg. every 12 hours for [CONDITION(S)]. This medication is used to treat certain mental/mood conditions . [MEDICATION(S)] is known as an anti-psychotic drug. (Retrieved from Webmd.com 12/03/21). The resident's annual MDS assessment, with assessment reference date 11/13/21, section N0410 Medications Received read, Indicate the number of DAYS the resident received the following medications by pharmacological classification . durng the last 7 days . Enter 0 if medication was not received by the resident during the last 7 days. Antipsychotic was coded 7, indicating the resident received antipsychotic medication during the review period. Section N0450 Antipsychotic Medication Review read, Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA (Omnibus Budget Reconciliation Act) assessment, whichever is more recent? This was coded 0 and read, No-Antipsychotics were not received. A review of the resident's MAR for the period November 1-30, 2021, revealed the resident received [MEDICATION(S)] two times daily, at 9 AM, and 9 PM. On 12/01/21 at 3:05 PM, and on 12/02/21 at 9:30 AM, Advanced Practice Registered Nurse (APRN) F, and RN M stated the resident received antipsychotic medication daily. On 12/02/21 at 10:03 AM, the MDS Licensed Practical Nurse (LPN) stated the MDS assessment was completed by doing a seven-day look back, which included a review of the resident's physician's orders, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's annual MDS and MAR for the period November 1-30, 2021 was reviewed with the MDS nurse. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS nurse stated the resident's annual MDS was assessed incorrectly, and section N0450 should have been coded 1 Yes- Antipsychotics were received on a routine basis only. The facility's policy MDS, revised on 9/16/2019, read, It is the policy of this facility to provide a comprehensive assessment of the resident's needs . that is completed accurately . according to the Resident Assessment Instrument (RAI) guidelines.

Based on observation, interview and record review the facility failed to provide nail care for 2 of 7 dependent residents reviewed for Activities of Daily Living (ADL), (#80, #51). Findings: 1. Resident #80 was initially admitted on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. His quarterly Minimum Data Set ((MDS) dated [DATE] revealed he had short term and long-term memory problems, his cognition was moderately impaired with disorganizing thinking. He had no behaviors or rejection of care. He required extensive assistance of 2 staff for all ADL's, and was totally dependent on staff for personal hygiene and bathing. On 2/03/20 at 12:04 PM, resident #80 was observed in bed connected to a ventilator via a [MEDICAL CONDITION] and receiving oxygen. He responded to verbal questions with slight nods of his head. His fingernails on both hands were observed to be long, 0.5 centimeters in length. The fingernails were yellowed, and some were cracked and jagged. There was black debris under the nails. When asked if he would like his fingernails cleaned and trimmed, he nodded yes. On 02/05/20 at 9:58 AM, the resident was in bed. His fingernails remained the same. There was black debris under the nails and some were cracked and jagged. When asked again if he would like his nails cleaned and trimmed, he nodded yes. On 2/05/20 at 10:52 AM, certified nursing assistant (CNA) C said residents in this unit required a lot of care. They were given bed baths every day and their hair was washed twice a week. CNA C said that nail care was part of the bed bath. She added that if a resident refused care, they would work around that to give them care. I don't know about resident #80, sometimes it's the nurse's duty because they may be diabetic or on blood thinners. On 2/5/20 at 11:02 AM, the resident was observed with CNA C. She stated, I will have to ask the nurse if I can cut them, they are dirty and long and need cutting. I'm not sure if he is diabetic. I was here yesterday and gave him a bath. I did notice his nails needed care yesterday, but I didn't see any nail clippers. On 2/5/20 at 11:05 AM, registered nurse (RN) D stated, I worked yesterday but CNA C did not let me know the resident's nails were long. The CNA will do the ADL care, but if they need some clarification or assistance they will get a nurse. On 2/5/20 at 11:22 AM, the assistant director of nursing (ADON) stated, they should be cutting his nails and keeping them clean. it's part of their normal ADL care. On 2/5/20 at 4:24 PM, CNA [NAME] stated, all the residents get 2 scheduled bed baths a week and as needed. When I clean anyone, I do head to toe, including nails and hair. I do oral care daily too, its charted under personal hygiene. A review of resident #80's CNA documented tasks for monitoring behaviors and personal hygiene indicated no refusals of care. A review of progress notes provided for resident #80 revealed no refusals of care. Resident #80's plan of care for ADL read, Requires extensive to total staff assistance with his ADL care. Check nail length and trim and clean on bath day and as necessary. Review of facility policy, Hand/Foot Care, dated, 10/17/18, read, . It is the policy of this facility to ensure that residents receive proper treatment and care to hands and feet to promote good hand and foot health and mobility. Procedure: 1. Facility will provide hand/foot care and treatment in accordance with professional standards . 5. Basic hand/foot care is included as part of routine bathing practice. 6. Routine fingernail/toenail care shall be provided by the appropriate health care provider 2. Resident #51 was initially admitted on [DATE] then readmitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) 5-day assessment dated [DATE] indicated he required extensive assistance of 1 person for bed mobility, dressing, toilet use and personal hygiene. He needed physical help of 1 person for bathing and did not reject care. Review of resident #51's care plan for ADLs dated 12/16/19 and last revised on 1/4/20 revealed that he had an ADL self-care performance deficit related to medical conditions. He required assistance of 1-2 staff with bathing/showering and 1 person assistance for personal hygiene. On 02/04/2020 at 9:37 AM, resident #51 was observed resting in bed with his eyes closed. His fingernails were noted to be dirty with dark debris under the nails. On 02/05/2020 at 9:14 AM, resident #51's nails remained the same. His fingernails were 1/4 inch long and had black debris under the nails. On 02/05/2020 at 09:24 AM, licensed practical nurse (LPN) A stated that resident #51's finger nails were long, dirty and needed to be cleaned. He stated he had no idea how long his finger nails had been that way. He also stated that the certified nursing assistants (CNAs) were supposed to trim them during showers. LPN A added that sometimes, the activity staff did nail care as well. He said that CNAs were supposed to clean up residents' hands after each meal. On 02/05/2020 at 1:52 PM, CNA B stated that resident #51 received bed baths daily. The 3-11 PM shift CNA provided showers. She said the CNAs were supposed to provide finger nail care during bathing. She said she was aware that his finger nails were long and dirty but she did not have enough time during her shift to clean and trim them. On 02/05/2020 at 2:00 PM, the unit manager (UM) explained that finger nails were to be checked by CNAs since they were the ones who cared for the residents daily. If there were issues they were supposed to report them to the nurse on duty. She also stated that nurses interacted more often with the residents so they should know if a resident needed nail care.

Based on observation, interview and record review the facility failed to ensure nail hygiene was provided to 2 of 3 dependent residents reviewed for activities of daily living (ADL) of 37 total sampled residents (#88, #99). Findings: Resident #88 was admitted to the the facility on 09/26/18 with [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) assessment dated [DATE] documented that his cognition was moderately impaired and he required extensive assistance of 1 person with personal hygiene and total assistance of 1-2 persons with bathing. Review of resident #88's ADL plan of care documented he required assistance with ADL's as evidenced by medical conditions, [MEDICAL CONDITION], [DIAGNOSES REDACTED]s, [DIAGNOSES REDACTED], and dementia. Interventions documented he required total assistance of 1-2 persons with bathing and extensive assistance of 1 person with personal hygiene. On 10/16/18 at 10:03 AM resident #88 was observed with long fingernails with brown substance under the nails. The resident stated, Sure I want my nails cut, I just had a shower this morning. On 10/17/18 at 9:25 AM resident #88 was again observed with long fingernails with a brown substance under his nails. On 10/17/18 at 9:28 AM Certified Nursing Assistant (CNA) C stated that resident #88 required assistance with his ADL care. CNA C then confirmed that his nails were long and need to be cleaned. On 10/17/18 at 9:35 AM the Assistant Director of Nursing (ADON) stated that resident #88's last shower was on 10/15/18. Showers include hair care, body and making sure fingernail are trimmed and cleaned. Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30 day Minimum Data Set (MDS) assessment dated [DATE] documented he had severe cognitive impairment, required extensive assistance with personal hygiene and total assistance with bathing. On 10/15/18 at 3:52 PM, resident #99's fingernails were observed to be long and unclean with brown substance under the nails. The resident stated that he wanted his fingernails cleaned. Observations conducted on 10/16/18 at 11:05 AM, and on 10/17/18 at 9:45 AM revealed resident's fingernails on both hands remained long and unclean with brown substance under the nails. On 10/17/18 at 10:19 AM CNA E stated that resident #99 required assistance with ADL's and he had a shower on Tuesday, 10/16/18. Nails should be done on shower days. but we can do nail care at any time. I did give him a bath in his bathroom this morning. At 11:17 AM CNA E stated It is all in the approach with him. When he is confused and refuses care I let the nurse know. I reapproach him and document the refusal of care in the computer. I will then go back to the resident to see if he will allow care. On 10/17/18 at 10:06 AM the ADON confirmed that resident #99's fingernails were long and needed to be trimmed and cleaned. She confirmed that he had a shower on 10/16/18 at 2:47 PM. Resident #99 at this time stated, Yes, I would like my nails cut and cleaned. On 10/17/18 at 10:52 AM the Director of Nursing (DON) stated, We do not have a policy for ADL care but the facility follows the Clinical Nursing Skills Basic to Advanced Skills. Review of the Clinical Nursing Skills Basic to Advanced Skills, read, . 10. c. Wash the client's hands by soaking them in a basin or with wash cloth. Nails can be cleaned now or after the bath On 10/17/18 at 3:46 PM Licensed Practical Nurse (LPN) D caring for resident #99 stated he required 1 person assistance with his ADL's and the CNA's were responsible for shaving residents, incontinent care, showers and nail care. Review of the resident's plan of care for ADL dated 09/12/18 documented he required assistance with ADL's as evidenced by medical conditions, dementia, and recent right shoulder arthroplasty. Interventions included extensive 1-2 person assistance, encourage the resident to participate in their ADL's as tolerated. Personal hygiene required extensive 1 person assistance, and to reproach if resistive to care. A Non Compliant care plan documented occasional refusal of ADL care with goals that resident #99 will respond to encouragement and redirection to comply with plan of care through next review date of 01/15/19. Interventions included to evaluate and identify reason for non-compliance, determine situations to avoid that will increase his compliance with care, identify times when care is better accepted by resident and to offer encouragement to comply with basic care needs. The resident's shower schedule noted showers to be given on Tuesdays and Fridays on the 7 AM - 3 PM shift. Review of the CNA ADL Verification Worksheet documented he refused care on 09/24/18 at 3:57 AM, 10/05/18 at 2:49 PM, 10/06/18 at 10:18 PM, and 10/12/18 at 6:56 PM. He received showers on 09/25/18 at 10:08 AM, 10/05/18 at 2:49 PM, 10/09/18 at 2:10 PM, and 10/16/18 at 2:47 PM. The Nurse Aide Data Sheet (Information to provide care) for resident #99 documented physical assist of 1 for bathing, resident may refuse showers, re-approach at different times when resident refused care. On 10/18/18 at 3:00 PM the DON revealed that nail care was part of daily care, with showers and as needed. The DON had no response when asked why resident #99 did not receive nail care as part of his shower on 10/16/18. She could not provide an answer when asked what had been identified as the reason for resident's non-compliance with care or what times had been identified as better for his care or situations to be avoided to increase compliance with his care? The DON stated that she had reviewed the resident's nurses notes and there was no documentation for non-compliance with care. On 10/18/18 at 5:35 PM an interview was conducted with the resident's wife. She stated that she came to the facility about every third day and she liked her husbands fingernails cut and clean because he scratches his face.

Based on observation, interview and record review the facility failed to ensure respiratory therapy was provided as per physician orders [REDACTED].#51). Findings: Resident #51 was admitted to the facility with [DIAGNOSES REDACTED], chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. A physician telephone order dated 8/23/18 read, Oxygen (O2) at 3 liters per minute (L/min) via nasal cannula. On 10/16/18 at 9:51 AM resident #51 was observed sleeping in bed with a nasal cannula for oxygen via an oxygen concentrator. The tubing from the concentrator to the humidifier bottle was crimped. The oxygen concentrator was set at 1 1/2 liters per minute. The hospice nurse was present. She checked the resident's oxygen level with a pulse oximeter showing saturation of 91-92 %. An observation at 2:21 PM on 10/16/18 showed the oxygen concentrator setting remained at 1 1/2 L/ min. An observation on 10/17/18 at 10:57 AM revealed a different concentrator with the oxygen set at 2 1/2 L/ min. The tubing was no longer crimped. An observation on 10/17/18 at 2:24 PM revealed the oxygen concentrator remained at 2 1/2 L/min. The licensed practical nurse (LPN) A at that time stated that the oxygen concentration was set at 3 L/min. The respiratory therapist B confirmed that the oxygen level was set at 2 1/2 L/ minute and not at 3 L/min. A review of the clinical nursing note dated 10/16/18 at 3:55 PM read, assisted back to bed, .O2 at 2 Liters per minute in progress. Further review of the clinical nursing notes from 8/23/18 to 10/17/18 documented oxygen being administered anywhere from 2 liters to 4 liter per minute. On 10/17/18 at 4:12 PM, the director of nursing stated that the nurses needed to be reeducated on the proper setting of the oxygen levels on the concentrators.

Based on observation, record review and interview the facility failed to ensure that potentially hazardous foods were in temperature control for 1 of 2 sampled outpatient [MEDICAL TREATMENT] residents (#62). Findings: Review of resident #62's medical record revealed that the resident went out to the [MEDICAL TREATMENT] center three times a week. The resident's [DIAGNOSES REDACTED]. On 10/17/18 at 3:54 PM the resident was in bed and his [MEDICAL TREATMENT] meal/snack was in a clear plastic ziplock style gallon bag on the overbed table. The meal consisted of egg salad sandwich, fruit cup, fruit juice, animal crackers and graham crackers. At this time the resident's direct care nurse, Licensed Practical Nurse A (LPN A), was asked to come into the room. He stated the resident was going out to [MEDICAL TREATMENT] and that he received his meal/snack to take with him from the dietary department. LPN A added that the resident would be returning to the facility later this evening. On 10/17/18 at 4:00 PM the Certified Dietary Manger (CDM) was shown the resident's [MEDICAL TREATMENT] meal on the overbed table. The CDM stated that the Certified Nurse's Assistant (CNA) usually retrieved the [MEDICAL TREATMENT] meals/snacks from the kitchen and that the meal/snack should have been in an insulated lunch bag with a cold pack. This would have kept the resident's meal/snack in cold temperature control. The CDM confirmed that there were insulated lunch bags in the kitchen. At this time the CDM asked her staff who gave out the [MEDICAL TREATMENT] meal. One of the kitchen staff stated she gave the meal to the CNA earlier in the afternoon. A few minutes later the CDM returned to the nursing unit and spoke with LPN A. The LPN A said the lunch was sitting on the overbed table as the nursing staff wanted to make sure the resident had his meal when he went to [MEDICAL TREATMENT]. He said the transport company picked up the resident anytime between 2:30 PM and 4:00 PM. He could not provide an explanation as to why the meal was not in an insulated bag. Chapter 3 of the Food & Drug Administration's Food Code notes that potentially hazardous cold food items need to be maintained at at temperature of 41 degrees Fahrenheit. The Food Code does allow for Time to be used as a Public Health Control but stipulates that this method cannot be used with highly susceptible populations. Nursing home residents are considered to be highly susceptible and therefore potentially hazardous cold food items need to be in temperature control for the this resident.

Based on observation, interview and record review, the facility failed to follow the manufacturer's instructions for cleaning a glucometer to prevent cross-contamination before and after testing 2 of 3 residents who received blood glucose monitoring (#29 & 99). Findings: On 6/26/17 at 12:22 PM, licensed practical nurse (LPN) E removed a glucometer from the Shell Lane medication cart and placed a test strip in the device. LPN E donned clean gloves and wiped resident #29's finger with an alcohol wipe, pricked her finger with a needle and placed a test strip to catch a drop of blood. LPN E obtained the reading and then used an alcohol wipe to clean the device for about 10 to 15 seconds and returned it to the front of the top drawer of the medication cart. A glucometer, or blood glucose meter, is a device used to measure sugar levels in the blood. To use most glucometers, a test strip is inserted into the device. Then, after pricking a clean fingertip with a special needle to get a drop of blood, the test strip is touched to the blood. The blood glucose reading appears on the screen. (www.mayoclinic.org). A few minutes later, at 12:31 PM, LPN E opened the top drawer of the medication cart and removed the same glucometer that was used for resident #29 from the front of the drawer. She donned clean gloves and checked resident #99's blood sugar using the same procedure. LPN E again used an alcohol wipe to clean the glucometer for 10 to 15 seconds, and immediately returned it to the same location in the front of the top drawer of the medication cart. On 6/26/17 at 1:48 PM, LPN E informed the director of nursing (DON) she used alcohol wipes to clean the glucometer shared by residents #29 and #99 after the device was used for both residents. LPN E explained she did not have the correct type of wipes on the medication cart at the time. LPN E acknowledged the glucometer should have been cleaned with disinfectant wipes rather than alcohol wipes. On 6/29/17 at 2:33 PM, the assistant DON/staff development coordinator (SDC) stated all nurses should use disinfectant wipes to thoroughly clean the glucometer. The ADON/SDC explained the glucometer must remain wet with the disinfectant for 2 minutes and then be left to air dry. Review of the glucometer manufacturer's Cleaning and Disinfecting Procedures for the Meter revealed the glucometer should be cleaned and disinfected between each patient. The document provided a list of products approved for use on the glucometer. Review of the facility's policy and procedure for Infection Prevention and Control, revised 12/19/13, read, The facility will provide precautionary measures to prevent the spread of potential infection, while monitoring resident's progress. The Centers for Disease Control and Prevention (CDC) has identified risks for transmitting bloodborne diseases such as hepatitis B and other infectious diseases during blood glucose monitoring with shared glucometers. The CDC recommends if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents (www.cdc.gov/injectionsafety/blood-glucose-monitoring).

Based on observation, interview and record review, the facility did not provide privacy during care for 1 of 41 sampled residents (#29). Findings: Resident #29 had [DIAGNOSES REDACTED]. The Minimum Data (MDS) quarterly assessment with assessment reference date (ARD) of 3/24/17 revealed resident #29 had a brief interview of mental status (BIMS) score of 3, which indicated severe cognitive impairment. On 6/26/17 at 12:22 PM, LPN E stood at her medication cart in the Shell Lane hallway, and resident #29 was seated in a wheelchair beside the medication cart. LPN E donned clean gloves, wiped resident #29's finger with an alcohol swab, pricked her finger and placed a test strip to catch a drop of blood. The procedure was conducted while resident #29 sat in the hallway. During the fingerstick procedure, the Maintenance Director and a visitor walked to the end of the hallway, passing within 3 feet of LPN E and resident #29. A few minutes later, both men returned to the area opposite the medication cart and stood in the alcove to speak with a CNA. LPN E then prepared to give resident #29 an insulin injection. With both men and the CNA standing about 5 feet away across the hallway, LPN E lifted resident #29's shirt, exposed an area about 4 inches wide above the waistband of her pants and gave the insulin injection to the left side of her abdomen. LPN E did not attempt to provide privacy for resident #29 who faced the hallway throughout the procedure. On 6/26/17 at 12:35 PM LPN E stated she thought it was acceptable and private enough to give resident #29's insulin injection in the hallway. On 6/26/17 at 1:48 PM, the director of nursing (DON) stated nurses should not give medication in the hallways unless it was part of the resident's plan of care. The DON stated she was not aware of a care plan for resident #29 for medication administration in the hallway, and acknowledged residents should always be provided with privacy. On 6/26/17 at 2:04 PM the Sea Shell unit manager (UM) confirmed resident #29 was not care planned for the intervention of medication administration in the hallway. The Sea Shell UM explained the intervention was added to the care plan this afternoon after the dignity concern was brought to her attention. She acknowledged LPN E should not have lifted resident #29's shirt in the hallway. Review of the policy General Dose Preparation and Medication Administration revised 1/01/13, read, During medication administration, Facility staff should take all measures (to) . Observe each resident's privacy and rights . Review of the facility's Admission Agreement that included a list of Resident Rights - Federal and Florida revealed each resident had the right to have privacy in treatment and in caring for personal needs Privacy of the resident's body shall be maintained

Based on observation, interview, and record review, the facility failed to promote dignity in dining for 4 of 18 sampled residents (#7, 22, 27 & 145). Findings: 1. During initial dining observation on 6/26/17 at 12:33 PM, certified nursing assistants (CNAs) placed the lunch meal with a covered plate in front of resident #27, #145 and resident #7 but staff did not sit next to them to assist with the meal. Eighteen minutes later, at 12:51 PM, residents #27, #145, and #7 were assisted to eat. 2. On 6/26/17 at 12:52 PM, CNAS moved resident #7 and resident #145 from their dining spaces without staff telling the residents why they were being moved, so that staff could remove resident #108 from the dining room. 3. On 6/26/17 at 12:36 PM, resident #22 ate lunch seated in a wheelchair with her shoulders 3 inches above the top of the dining room table. She ate her vegetable in a bowl on top of the plate with her fingers. The table top was above her armpit and her mouth was parallel with the table top. On 6/28/17 at 12:22 PM, resident #22 sat in the restorative dining area in the Coastal Dining Room. Resident #22 has to lift her right elbow above her shoulder to place it on table to eat. On 6/29/17 at 12:48 PM, resident #22 sat at a different table in the Coastal dining room, in a wheelchair pushed up to a non-adjustable tabletop height eating her lunch. At 12:51 PM, the occupational therapist and the director of rehab observed resident #22 eating lunch and stated her plate and mouth were parallel to one another and resident #22 was not proportional to the table. On 6/28/17 at 12:37 PM, interview with Licensed Practical Nurse (LPN) A regarding CNA assistance with dining for lunch in the Coastal Dining Room stated there were 2 CNAs to assist the restorative residents and 3 CNAs for the regular more independent dining. There were a total of 18 residents in the room at that time and 5 staff. LPN A said there were more residents in the Coastal Dining Room at lunch than breakfast or dinner. She said usually the assistant director of nursing (ADON) does not help with the meal like she was that day.

Based on observation and interview, the facility did not discard resident food in the refrigerator after 3 days (Coastal dining room). Finding: On 6/26/17 at 11:55 AM, the Coastal dining room nourishment refrigerator had a plastic Popeye's Louisiana Chicken bag with a plastic bag grocery bag wrapped around the handle with a resident name and was dated 6/13/17. On 6/26/17 at 12:01 PM, certified nursing assistant (CNA) B said she did not know the policy for how long food could be kept in the refrigerator, and said to ask the kitchen because the kitchen does things with that refrigerator. On 6/26/17 at 12:05 PM, staff D said the policy for how long items are kept in the refrigerator for 1 week if it is a resident's personal food. On 6/26/17 at 12:09 PM, LPN A said the name on the food was a discharged resdient and the policy for food items kept in the refrigerator for 3 days. On 6/28/17 at 11:40 AM, the Food Service Director (FSD) said the policy for keeping food in the nourishment refrigerator in the Coastal dining room was to keep residents' food for 3 days. She said the policy was to keep food in the refrigerator for 76 hours/3 days. The FSD stated the dietary department throws away food from that refrigerator.

Based on observation, interview and record review, the facility failed to ensure that a tube feeding was administered at the accurate rate according to physician's orders [REDACTED]. A total of twenty-two residents were receiving nutrition via tube feeding (#87). Findings: Resident #87 was a long term resident at the facility. On 4/22/16 she was discharged to the hospital for convulsions. She returned to the facility on [DATE]. Nurse's note dated 4/26/16 at 7:50 AM documented: Resident in bed tolerating tube feeding well. Glucerna 1.0 at 80 milliliters/hour (ml/hr). head of bed kept elevated. Nothing by mouth (NPO). A dietary progress note by the consultant dietitian dated 4/26/16 at 2:01 PM was completed for re-admission/quarterly and April review. The resident was sent to the hospital on [DATE] secondary to [MEDICAL CONDITION] activity and altered mental status. The resident returned on 4/25/16 NPO with Glucerna 1.0 (Enteral tube feeding) running 80 milliliters/hour (ml/hr) x 18 hours. The administration of the formula was scheduled down (off) 1 hour before and 2 hours after [MEDICATION NAME] twice a day. On 3/07/16 speech upgraded resident diet to mechanical soft with thin liquids. Per the MD, resident will remain NPO and speech will reevaluate. Recommendation: 1) discontinue Glucerna 1.0 2) Start Glucerna 1.5 60 ml/hr. x 18 hours 3) Clarify flushes to 300 ml every 6 hours- 1200 ML per day. Total nutrition 1260 ML, 1890 calories, 104 grams of protein, . 126% of recommended dietary intake, meeting needs, Will monitor, May need to make tube feeding adjustments. The resident was observed in her bed on 4/26/16 at 4:56 PM. She was receiving a tube feeding of Glucerna 1.0 in an open bag system. There was no start time on the bag or if additional formula was added to the bag. The pump was infusing at 80 ml/hr. The nurse's note dated 4/26/16 at 10:30 PM read, Tube feeding patent, tolerated well. There was no further progress note documentation regarding the administration of the tube feeding. An observation on 4/27/16 at 10:26 AM revealed the resident was in her bed. She was awake and positioned on her left side. She was being fed via feeding pump, Glucerna 1.5 in a closed bottle system running at 80 ml/hr. At that time there was 650 ml left in the bottle. The start time noted on the bottle was 3:34 AM on 4/27/16. Observation at 3:34 PM on 4/27/16 revealed the resident was receiving the same bottle of Glucerna 1.5 via feeding pump at the rate of 80 ml/hr. At that time there was approximately 320 ml remaining in the bottle. Review of the physician order [REDACTED]. An interview with the consultant dietitian on 4/27/16 at 3:34 PM confirmed that the Glucerna 1.5 was currently being administered at 80 ml/hr. On 4/27/16 at 3:40 PM, nurse A was interviewed regarding resident #87's tube feeding. She confirmed that she had checked the resident when she came on shift and that the tube feeding was being administered at 80 ml/hr. She was asked to confirm the order in the medication administration record. She said that it was supposed to be at 60 ml/hr. She was not aware that the rate of administration was reduced when it was changed from the Glucerna 1.0 to Glucerna 1.5. The resident did not received the tube feeding formula at the rate ordered by the physician for 3 shifts and it was not identified by 3 nurses on 4/27/16. The 11-7 AM nurse that started the formula, the 7 AM-3 PM that nurse that provided medications and water tube flushes to the resident, and the 3-11 PM nurse when she checked on the resident at the beginning of her shift.

Based on observation, interview and record review, the facility failed to assess and monitor the condition of the foot after it was bumped on the door frame for 1 of 3 sampled residents (#1). Findings: Review of the incident log indicated that resident #1 had an incident on 5/10/15 at 1:35 p.m. when a certified nursing assistant (CNA) was transporting her from the shower room using a shower chair back to her room. The resident complained of left foot pain at that time but refused pain medication offered. The nurse applied ice pack which was effective. Review of the nurses' progress notes did not indicate that the staff nurse documented the incident and assess the condition of the foot. There was no description of the appearance of the foot. There was no further documentation of the condition of the foot until 5/13/15 when the resident complained of a bruise on the left foot. The physician was notified and there were no new orders given. After the resident was identified with a bruise on 5/13/15, staff did not assess and monitor the size of the bruise and if there was swelling and increase pain. On 5/16/15 at 6:30 p.m., the resident complained of left foot pain, and at this time the staff documented that there was a green bruise on the foot. In a telephone interview with the staff nurse on 6/09/15 at 1:10 p.m., she verified that she did not document in the nurses' notes that an assessment was conducted but said she did complete an incident report. The condition of the left foot was not assessed, evaluated and monitored until the resident complained of increased pain. A mobile X-ray was conducted on the left foot on 5/16/15 at 11:36 p.m. which indicated a non-displaced left anterior calcaneous fracture with minimal angular deformity. Conclusion: fracture. The resident was sent out to the hospital on [DATE]. At the hospital, a repeat left foot X-ray was conducted. The results indicated mild soft tissue [MEDICAL CONDITION], impression: no acute osseous finding. The resident was returned to the facility with hospital notes indicating it was a contusion on the left foot.