Every finding on record at Solaris Healthcare Plant City

Based on record review and interview, the facility failed to ensure one (Resident #165) of three residents reviewed for hospitalization was coded correctly on the minimum data set (MDS) at discharge. Findings included: A review of Resident #165's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses included but not limited to Unspecified dementia, unspecified severity, with psychotic disturbance, muscle weakness (generalized), Unspecified lack of coordination, chronic kidney disease, stage 3b, bipolar disorder, unspecified, Major depressive disorder, recurrent, moderate and generalized anxiety disorder. A review of the Discharge - Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed under Section A- Identification Information A. 2105 Discharge Status Resident #165 was discharged to 04 Short Term General Hospital. A review of progress notes revealed the following: - A progress note dated 01/23/2024 showed, Family has decided to transfer resident to [another local long term care facility] memory care unit on Friday 1/26/24 between 1 and 2 PM. Unit manager is aware. - A progress noted date 01/26/2024 showed, Resident sitting quietly in B wing TV room. Pt [patient] alert with confusion. Pt [patient] compliant with medications and care from staff. No s/s [signs or symptoms] of pain or distress noted. No negative behaviors noted at this time. Resident continues with PT [Physical Therapy] services. Resident scheduled to be transferring to another facility today between 11:00 am-12:00 pm. Will chart when pt leaves facility. No further issues noted at this time. - A progress note dated showed, Resident left facility via transport arranged by insurance to [local long term care facility] in [city, state]. [Family Representative] present as pt [patient] was being transferred. Report given to [Family Representative]. [Family Representative] will return back to facility for pt's [patient's] things tomorrow 1/27/24. - A progress note date 01/27/2024 showed, The [Family Representative] came to the facility, to collect resident's personal belongings, TV and mount. She stated, Thank you for all you have done for my mother. - A progress note dated 01/29/2024 showed, Social services spoke with [Family Representative]and memory care unit to ensure all needs were met. They ensured all belongings were received and there were no issues since arrival. Resident is settling in nicely. Encouraged family and resident to reach out with any questions or concerns. No concerns at this time. Will follow up if needed. During an interview on 02/28/24 at 10:04 a.m., Staff A, MDS Coordinator/RN stated Resident #165 was discharged to another skilled nursing facility for their memory care unit. Staff A reviewed the Discharge - Return Not Anticipated MDS dated [DATE] MDS that showed Resident was discharged to the hospital. Staff A stated that the MDS was coded wrong as Resident #165 was not discharged to the hospital but rather discharged to another skilled nursing facility. Staff A stated she would have to amend the MDS to reflect the correct discharge.

Based on observation, interviews, and record review, the facility failed to revise a care plan to reflect a resident's condition for one (Resident #151) of 33 sampled residents. Findings included: Review of Resident #151's Face Sheet revealed he was admitted to the facility on [DATE] from an acute care hospital. His medical diagnoses included dementia, psychosis, anxiety disorder, encephalopathy, major depressive disorder, and insomnia. An observation conducted on 02/26/24 at 10:08 a.m. revealed Resident #151 sitting in a chair in the C-wing hallway with his eyes closed. An interview was conducted on 02/26/24 at 10:33 a.m. with Staff B, Licensed Practical Nurse (LPN). She said Resident #151 was pleasantly confused but redirectable. She said he did not push on doors or talk about leaving he will just walk the unit. The exit doors at the end of the hallway were not used and they had alarms on them if they were opened. A review of Resident #151's Elopement Risk assessment with a an observation date of 1/9/2024 and a completion date of 2/3/2024 revealed he was not an elopement risk. 1. Prior to admission, did patient have a history of elopement or exit seeking behavior? No 2. Has patient exhibited wandering or exit seeking behavior in the last 90 days? No 3. Select patient's mobility status. Independently Ambulatory 4. Has patient exhibited new behavior that would cause concern related to wandering exit seeking or safety? No 5. Was or is patient resistive to Nursing Home placement. No 6. Does patient verbally express desire to leave center or go home? No A review of Resident #151 care plan last reviewed on 1/9/24 revealed the following: Problem: I tend to wander aimlessly up and down the halls going to and from door to door. I push on door at times, I Have severe Dementia with cognitive deficits and confusion. I am at risk for elopement .Goal: I will not harm myself or others due to my wandering through next review date. Interventions included the following: Ensure temperature is comfortable in my room Ensure proper fitting of my clothes and shoes Ensure lighting is adequate for me Assist me to bed when fatigued Be calm and self assured Provide opportunities for positive interaction, attention - stop and talk with me passing by. Intervene as needed to protect the rights and safety of others; approach me in a calm manner; divert my attention, remove me from situations and take me to another location as needed Administer and monitor the effectiveness and side effects of medications ordered for me - see physicians orders and MAR [Medication Administration Record] Address wandering behavior by walking with me; redirect me from in appropriate areas; engage in diversional activity. Reinforce positive behavior Provide me with no-confrontational environment for care Report to my physician changes in my behavioral status. Place my photo at from lobby and on all wings so others will recognize me and redirect me. An interview was conducted on 02/28/24 at 9:37 a.m. with the Director of Nursing (DON). She said, the resident was a wanderer and would wander around the unit. He was not exit seeking and he did not push on exit doors. She said, I don't think he has ever even been off the unit. She reviewed the elopement risk assessment dated [DATE] and reviewed Resident #151's wander care plan and said I think the care plan needs to be updated. The DON said she had been in the building for [AGE] years and she had not known Resident #151 to push on doors. She said we should monitor him because he was confused and he walked the unit but he was not exit seeking. An interview was conducted on 02/28/24 at 9:50 a.m. with Staff A, Minimum Data Set (MDS) Coordinator. She said, I have been in this position for about five years. I don't feel like he [Resident #151] is an elopement risk, he does not try to exit seek, I have not seen him pushing on doors, he does not try to follow people out of the doors. He uses the door as a boundary, he walks to the end of the hall turns around, walks down another hallway, and turns around. She said she would not want to remove the portion of the care plan where it says he is at risk for elopement because although his elopement assessment says he's not at risk I want the staff to know if the door is open that he usually uses as a boundary he is at risk to keep going out the unit door. She confirmed the care plan should have been revised to remove I push on door at times. She said care plans are reviewed quarterly, yearly, and with any change. Review of the facility's Care Plans- Comprehensive policy reviewed on 1/30/24 revealed the following: Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes.

Based on observation, record review, and interview, the facility failed to ensure sufficient staffing was available on one (C-wing) of three wings as evidenced by call lights not answered in a timely manner, failed to ensure residents received timely care and services in accordance with preferences and professional standards for six (Resident #3, #4, #5, #6, #7 and #8) of seven residents, and failed to address call light grievances presented in six of six resident council meetings held on 02/22/23, 01/25/23, 01/09/23, 12/28/22, 11/30/22, and 10/28/22, affecting three (A,B,C) of three wings Findings included: During a facility tour on 03/27/23 at 10:00 a.m., Resident #3 was observed in her room. She stated she had been waiting for 30 minutes to be toileted. She stated she had turned on her light, and a CNA, (Certified Nursing Assistant) came and turned it off and told her she would be back after finding someone to assist her with the transfer. A family member visiting Resident #3's roommate stated she had witnessed the incident that morning. She stated Resident #3 had been waiting close to 30 minutes at the time. The roommate's family member said, This is not the first time. She stated she had witnessed this several times. She stated the facility did not seem to have enough staff to care for the residents. She stated she visits her family member daily and assists to get her out of bed and care for her. She stated they were paying a lot of money and hardly receiving the care the residents deserved. This family member stated she had witnessed Resident #3 turning on her call light and just sitting there waiting. A review of Resident #3's electronic medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of unspecified fracture of upper end of left humorous, subsequent encounter for fracture with routine healing and difficulty in walking. A minimum data set (MDS) dated , 02/20/23 Section C cognitive patterns showed the resident had a brief interview for mental status (BIMS) score of 14 indicating intact cognitive response. Section G Functional Status showed Resident #3 required extensive assistance for bed mobility and toilet use with two + persons physical assist. A care plan for Resident #3 with a problem start date of 02/15/23, showed a category ADL (Activities of Daily Living) functional/rehabilitation potential, indicating the resident is unable to complete ADL's independently due to decreased mobility and weakness related to history of falls with fracture. Interventions included to assist me with repositioning, transfers, bathing, grooming, toileting, dressing and oral care . On 03/27/23 at 10:04 a.m., Staff B, Physical Therapist Assistant (PTA) walked into Resident #3's room. He noted Resident #3's call light was on. He stated he was supposed to have a session with Resident #3's roommate but could assist if Resident #3 needed assistance. He stated if a CNA needed help transferring a resident, therapists can help. Staff B stated the CNA assigned to this room was in another room and would assist the resident when she was done. He stated to the resident, Your CNA is across the hall. She will be here shortly. The resident stated to the Staff B, I have waited a while. Staff B left the room and did not return. On 03/27/23 at 10.10 a.m., Resident #3 was observed in her room with her feet hanging off the bed. The resident stated, I really have to go. Resident #3's call light was still on. On 03/27/23 at 10.12 a.m., the Advanced Registered Nurse Practitioner (ARNP) responded to Resident #3's call light. After walking out of the room, she stated the resident was waiting for the CNA to assist her to the toilet. She stated she was not a staff at the facility. She stated she stopped to see what the resident needed. She stated the CNA was assisting other residents. She stated, it may take her a while, but she will be here. On 03/27/23 at 10:15 a.m., Staff A, CNA assigned to Resident #3 responded to the call light. She walked into the room without a second person to assist her. On the way to the resident's room she said to this surveyor, I will offer her a bad pan or have her just go on her brief. I will clean her up afterwards. There is no one to help me get her up. She is a two-person assist. She stated the other CNA was assisting another resident and would not be available for a transfer. She stated she first saw the call light on about 30 minutes earlier. The CNA stated residents should be assisted sooner. The CNA said, It is not my fault. I need help. During this time, an observation was made of two staff members sitting at the nurse's desk. They did not respond to the call light. On 03/27/23 at 10.15 a.m., an observation was made of Staff E, Licensed Practical Nurse (LPN) assigned to Resident #3. She was noted in the hallway two doors down from Resident #3's room standing in front of her medication cart. She stated she did not know the resident needed help. She stated she had not paid attention to the call light. She stated Resident #3 should not have been waiting for toileting assistance. She stated their protocol was for CNAs to ask other staff, including nurses, to assist with transfers if needed. Staff E stated, this is unacceptable. I will go in and assist her. She stated the expectation would be to get someone else to assist. On 03/27/23 at 10:21 a.m., an interview was conducted with Staff E, LPN. She stated she had walked into Resident #3's room and found the CNA already in process of offering the resident a bed pan. She stated they could not transfer the resident to the toilet at the time. Staff E said, when I got there, it was too late. She stated she assisted the CNA with the clean-up and educated the CNA. She stated she had told the CNA to always ask for help. She stated she had not noticed the call light herself. On 03/27/23 at 10:45 a.m., a follow-up interview was conducted with Staff A, CNA. She stated she did not mean to have Resident #3 wait. She said, I had a lot going on. I assisted two other residents. I was waiting for someone to help me. I could not find anyone. She stated she was also assisting the Restorative aide with transfers during weighing. Staff A said, It can be lot. I do my best. On 03/27/23 at 10:15 a.m., a call light was noted on in room C12. At 10:22 a.m., the call light was still on. At 10:26 a.m., no one had answered the call light. On 03/27/23 at 10:23 a.m., an observation was made of Staff J, Speech Therapist (ST) donning a gown and going into a room opposite room C12. She noted the call light was on but did not respond to it. In an immediate interview, Staff J stated she was going in for a therapy session. She stated someone should answer the call light. On 03/27/23 at 10:24 a.m., an observation was made of Staff K, Physical Therapist (PT) in the hall. Staff K was observed going into room C14 and did not answer the call light in room C12. On 03/27/23 at 10:28 a.m., the call light in room C12 was answered by Staff . The resident waited approximately 15 minutes. During this time, an observation was made of two staff members sitting at the nurse's desk. They did not respond to any call lights. On 03/27/23 at 10:28 a.m., an interview was conducted with Staff I, CNA, Restorative Aide. She responded to the resident's call light. Staff I stated the resident was waiting to get off the bed pan. Staff I stated she had assisted the resident to the bedpan and had notified the CNA to get her off. She stated the resident appeared to have sat on it for approximately a half hour. She stated, the resident should not wait that long. She stated she was trying to juggle her responsibility of getting weights and assisting the other CNAs with their responsibilities. On 03/27/23 at 10:30 a.m., an interview was conducted with Resident #4. Resident #4 stated she had been waiting to be assisted out of bed. The resident stated she had waited for approximately one hour. The resident said, The CNAs are nice they will come. They have a lot to do. The resident stated she had pulled her call light at approximately 9:30 a.m. At 10:50 a.m., Resident #4 received assistance to get out of bed. The resident waited for an hour and 20 minutes. A review of Resident #4's electronic medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side. An MDS dated , 02/15/23 Section C cognitive patterns showed the resident had a BIMS score of 13 indicating intact cognitive response. Section G Functional Status showed Resident #4 required limited assistance for bed mobility and toilet use with one-person physical assist. A care plan for Resident #4 with a problem start date of 11/16/22, showed a category for ADL functional/rehabilitation potential, indicating the resident is unable to complete ADL's independently due to recent CVA (cerebrovascular accident) with left sided hemiparesis, weakness, and vision defect. I need assistance with mobility and hygiene tasks. Interventions included to assist me with repositioning, transfers, bathing, grooming, toileting, dressing, oral care and care for my glasses. On 03/27/23 at 10:32 a.m., during this tour, it was noted there was only one CNA in the hall, Staff A, CNA. On 03/27/23 at 10:35 a.m., an interview was conducted with Staff G, LPN Unit Clerk. She stated there should be a second CNA assigned the hall. She stated she would look for her and notify her there were some call lights on. She stated she could not have taken her lunch yet. She proceeded to look for the other CNA. Staff G was observed at the nurse's station with another CNA, and they did not respond to any call lights. On 03/27/23 at 10:38 a.m., an interview was conducted with Staff H, CNA, the second staff assigned to the C-wing. She stated she was assisting another resident around the corner and was not aware Resident #3 was waiting for transfer assistance. She stated she was assisting another resident get dressed and was also helping him pick up his room. Staff H stated sometimes she did not get through to all her assignments. She stated it was kind of hard to get through her assignments because of the workload. Staff H stated she normally had 10 to 19 or 10-13 residents depending on call -ins. She stated the CNAs try really hard, but other staff were not quick to assist with call lights. Staff H said, they assume it is the CNAs sole responsibility. On 03/27/23 at 10:40 a.m., an on-going beeping sound was noted coming from Resident #5's room. The beeping had been going on for approximately 10 minutes. In an interview, the resident stated her IV (intravenous) had been beeping since around 10:30 a.m. The resident stated it took the nurses a long time to respond to her with her medications. The resident stated the IV noise was annoying. Resident # 5 said, It is not okay. I'm sure my roommate does not like it. She stated the staff took their time to respond to call lights. The resident stated she had filed a grievance related to delayed staff response recently. The resident said, A couple weeks ago I filed a grievance. They just don't answer call lights. CNAs make you wait to be assisted. The nurses do not respond to your request for medications. It is awful. On 03/27/23 at 10:44 a.m., the IV beeping was still on-going and heard from the hallway. A review of Resident #5's electronic medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of other chronic osteomyelitis, right ankle and foot, type 2 diabetes, and difficulty in walking. An MDS dated , 03/08/23 Section C cognitive patterns showed the resident had a BIMS score of 14 indicating intact cognitive response. Section G Functional Status showed Resident #5 required limited assistance for ADLs with one-person physical assist. A care plan for Resident #5 with a problem start date of 03/03/23 showed, I have IV medication ordered for right ankle abscess with a goal to have reduced risk of complications related to IV medication IV fluid IV access site /device. A category for ADL functional/rehabilitation potential showed, I am unable to complete my ADL's independently due to right ankle abscess and NWB (non-weight bearing status). I need assistance with mobility and hygiene tasks. On 03/27/23 at 10:46 a.m., Staff L, LPN walked into the room and said to the resident, sorry for the wait. The nurse disconnected the IV and walked out of the room. Resident #5's IV was alarming, waiting to be silenced for 15 minutes. On 03/27/23 at 10:48 a.m., Resident #6's family member stated the resident had not been assisted to therapy. The family member stated they usually got her before lunch started. The family member said, it's now 11 a.m. we have been waiting for 45 minutes and no one had said anything. The family member stated it took staff a long time to respond to resident's needs. Resident #6 was observed in bed waiting to be assisted out of bed and escorted to therapy. A review of Resident #6's electronic medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of nondisclosed oblique fracture of shaft of left fibula, subsequent for closed fracture with routine healing. A care plan for Resident #6 with a problem start date of 03/22/23, showed a category for ADL functional/rehabilitation potential, indicating the resident is unable to complete ADL's independently due to decreased mobility and weakness secondary to recent falls at home and has a left ankle fracture . I need assistance with my ADL 's. Interventions included to assist me with repositioning, transfers .', PT (physical therapy) and OT (occupational therapy) as ordered. On 03/27/23 at 11:00 a.m., an interview was conducted with Resident #7 and a family member. The resident stated she had had gone for two weeks without showers. The family member stated they have had problems with call lights not being answered. The family member stated the previous weekend, Resident #7 had waited for her call light to be answered for 1.5 hours . She stated this was an on-going occurrence. The family member stated they had asked an aide for coffee and water earlier that morning. She never came back. The family member said, I had to get it myself. The family member stated Resident #7 had been left in soiled briefs for hours. She stated the residents linens were not changed for weeks. The family member said, It is appalling the conditions they leave the residents in. I am surprised they have a five- or four-star rating. This was why we came here. It does not match the care the residents receive. The family member stated communication was lacking. She stated Resident #7 and many other residents had filed grievances about call lights not being answered. She stated she had addressed her concerns with the unit manager. She stated nothing was being done. The family member stated, They know there is a problem, and no one is doing anything about it. A review of Resident #7's electronic medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. An MDS dated , 02/26/23 Section C cognitive patterns showed the resident had a BIMS score of 14 indicating intact cognitive response. Section G Functional Status showed Resident #7 required limited assistance for bed mobility, bathing and toilet use with one-person physical assist. A care plan for Resident #7 with a problem start date of 02/23/23 showed a category for ADL functional/rehabilitation potential, indicating the resident is unable to complete ADL's independently due to left femoral fracture. I need assistance with mobility and hygiene tasks. Interventions included to assist me with repositioning, transfers, bathing, grooming, toileting, dressing, oral care, denture care, care of my hearing aids and care for my glasses. On 03/27/23 at 11:08 a.m., an observation was made of two call lights on, in the C-wing hall, without a CNA in sight. Staff L, LPN was observed in front of her medication cart preparing medications. She stated she had two CNAs assigned her hall. She stated one of them was probably in another resident's rooms. She stated it took them too long to answer call lights when one CNA was on break. She stated the nurses should answer call lights on behalf of the CNAs. Staff L stated some nurses think they were above the task. She stated the CNAs had quite a few residents on the assignment, anywhere from 11 to 13 residents per CNA. The nurse stated she did not believe they accounted for acuity during staffing. Staff L stated residents should not be waiting to be assisted for 30 minutes or longer. She stated an appropriate response would be no more than 10 minutes. Staff L said anything above that was unacceptable. On 03/27/23 at 1:05 p.m., an interview was conducted with Resident #8, Resident Council President (RCP). He stated the facility had on-going issues with call lights. The RCP stated the issue of call lights was brought up during almost every meeting. The RCP said, in my opinion the CNAs have way too many residents to one person. Sometimes they have 13 -15 residents per aide. You cannot possibly answer all call lights and meet every need when you are assisting that many residents. Some people need lot of help. He stated that sometimes he waited up to an hour to be assisted, especially at night. He stated there had been no true resolution to their grievances related to call lights not being answered. The RCP stated the administration had not necessarily responded to the issue. A review of Resident #8's electronic medical record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of ulcerative chronic proctitis with rectal bleeding among other diagnoses. An MDS dated , 02/22/23 Section C cognitive patterns showed the resident had a BIMS score of 15 indicating intact cognitive response. Section G Functional Status showed Resident #8 required extensive assistance for bed mobility, transfers and toilet use with two +-persons physical assist. A care plan for Resident #8 with a problem start date of 07/16/20 showed a category for ADL functional/rehabilitation potential, indicating the resident is unable to complete ADL's independently due to decreased mobility, weakness, and morbid obesity. I had a recent hospital stay with endocarditis had new pacemaker. Interventions included to assist me with repositioning, transfers, bathing, grooming, toileting, dressing, oral care . Review of a facility document tilted, Grievance Log, dates Mach 2023 through January 2023 revealed 21 grievances had been filed related to call lights not answered and delayed responsiveness. Review of facility documents titled, Grievance Forms showed: On 03/20/23: Resident stated that no one came and answered his light, and he was trying to get some help for 45 minutes. On 03/13/23: Resident stated my call light was on for an hour. I needed my CNA to put me on the bedpan. I do not even know who my CNA is today. On 03/13/23: Resident states call light is on long periods of time 7 a.m. - 3 p.m. shift and 3 p.m. - 11 p.m. shift. On 03/04/23: Resident stated there is not enough staff to answer call lights. Delay in getting pain meds. On 02/22/23: Call lights not being answered timely. On 01/31/23: Call light was on for 30 minutes. On 01/26/23: Patients reports 1/22/23 she helped herself to her wheelchair and went the restroom on her own because it took over 30 minutes and no one answered the call light. On 01/26/23: Call bell found in drawer out of her reach. She said I guess the 11 - 7 CNA didn't want to be bothered. Was upset that the 3-11, 11-7 nurse give her medications to a family member to bring it to her. On 01/26/23: Call light response on 3-11 pm on 1/25/23. Left the resident in shower alone to make his bed. On 01/25/23: Resident council meeting held (A, B, C units) and resident complaining about call lights. On 01/03/23: room rounds - resident voiced concerns with call light response times. No specific shift. On 03/27/23 at 1:15 p.m., an interview was conducted with the Social Service Director (SSD). She stated call lights grievances had come up several times during resident council meetings. She stated they were also submitted by individual residents. The SSD stated families had brought up the same concern during care plans meetings. She stated when the families brought it up, she initiated a grievance. She stated she gave the grievances to the respective unit manager who conducted call light audits and then initiated education . The SSD stated she felt the grievances had been resolved in certain units. She stated, The response fluctuate, they get better and then the problem starts all over again. When they resolve the issue on one shift , the same issue starts on the next. She stated she would not consider the grievance resolved if it was for the same resident or the same unit. The SSD said, I would consider the grievance unresolved if the problem still persists. On 03/27/23 at 1:22 p.m., an interview was conducted with the Activities Director, (AD) She confirmed the residents had expressed on-going concerns related to delayed call light responses. She stated, The residents say it takes staff a long time to answer . their concerns are documented in the resident council meeting minutes . their complaints were still on-going because there were concerns on all wings. She stated after council meetings, she did her follow-up by writing up a grievance. She gave it to the SSD who sent it to unit managers so they could try to resolve the issue. She stated the call light issues were not specific to one shift, but more of the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts. The AD stated the Unit Managers had attended resident council meetings and were always trying to see what they could do. The AD said, this is an on-going issue. On 03/27/23 at 1:30 p.m., an interview was conducted with Staff M, LPN/ Unit Manager (UM), C-wing, Staff C, LPN/UM, B-wing, and Staff D, LPN/UM, A-wing. Staff C said, we have attended resident council meetings and the issue of call lights is voiced by residents. The residents report it takes staff a long time to respond to call lights. They say sometimes it takes 30 minutes or more. Staff C stated the issue was not so much on her shift., but other shifts. She stated her response to the grievances was to in-service staff, continue to talk to them about responding to call lights. She stated the issue was not just for CNAs it also included the nurses. Staff C said, This is an issue for all. We need all hands on the deck, including administrative team members. No one should walk past a call light. Staff M stated her experience was similar. She stated she had received grievances showing it took longer than 30 minutes to respond to a call light. She stated her focus was education. She said, I teach CNAs about focusing on all aspects of care. Sometimes the call light has to do with little things like a resident has dropped something on the floor. Anyone can respond including maintenance or Housekeeping. They can then alert the nurse if it something was beyond their responsibility. She stated the call light problem was an on-going issue, especially when they have new patients with high acuity. She stated staffing assignments depended on census. She said, all staff have to be all eyes on. I don't know that it will ever change. Staff D, LPN/UM A -wing stated the residents in her hall complain often. She said, they like calls answered in a timely manner. Timely means 7 minutes or less. She stated they did their best to respond to the resident's needs. On 03/27/23 at 2:02 p.m., an interview was conducted with Staff F, Staffing Coordinator. She stated she did scheduling and assignments. She stated the CNAs signed up for their schedule. She stated she pulled her daily shift report, reviewed where she needed a staff member, and then reached out to staff to assign them the shift. She stated her staffing numbers were determined by the census. She stated she followed a worksheet that calculated the number of staff needed. She stated the DON would let her know if she needed to adjust the staffing. On 03/27/23 at 2:02 p.m., an interview was conducted with the DON. She stated sometimes the census would be low and depending on acuity she might pull back. She stated they assign 1 CNA to 10 residents and 1 nurse to 20 residents on the skilled side and 1 nurse -30 residents on the long-term care side. She stated these numbers did not include the charge nurse and unit managers. The DON stated a unit manager had notified her that a CNA told a patient to go on her brief. She stated that was not their practice. She said, I have in-serviced staff on that, I can't believe this is still happening. The DON said, Numbers wise we have enough staff, the unit clerk is also a trained CNA. She should answer call lights and assist with tray passing as well. A resident should not have to wait or be asked to go in their brief. It is not acceptable to me, they should reach out if they need help. The DON stated they were continually auditing call bell and responses. She stated she was aware of the call light concerns because of on-going grievances. She said, We are all expected to stop and answer the call light and/or find someone to take care of the need if we could not. The DON stated their response to the call light grievances was in servicing staff on an on-going basis. The DON said, We are doing everything we can. When we have call-offs we can't control the issue. When peopled don't show up there is nothing you can do. We address the staff who are not responding to call lights. The DON stated they talked about all grievances in QAPI (Quality Assurance Performance Improvement). She stated they had identified they had work to do. The DON said, It is a work a progress. On 03/27/23 at 2:28 p.m., an interview was conducted with the SSD. She stated some residents said their grievances were resolved but for some, the call light issues were on-going. The SSD stated she participated in QAPI. Grievances related to call light had not come up for discussion. The SSD said, I go over the grievances. I give them a count of the number of complaints submitted related to a certain area. I break them up per care area. She stated they had not talked about an action plan, and they had not conducted a root cause analysis. On 03/27/23 at 2:37 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated she was aware there was a problem with call lights not being answered. She stated they had initiated an investigation and had suspended the CNA in question pending investigation. She stated she was waiting for statements from the staff who were involved. She stated the in-service coordinator had initiated in-services about abuse neglect and exploitation. The NHA said, asking are resident to go on a brief was completely unacceptable. That CNA is a really good staff. She probably felt nervous and did not want to go out of the room and ask for help. She had the resident use her brief. She is normally a good aide. It is unacceptable. The NHA stated she would also be addressing other staff who could have responded to the call lights and did not. The NHA stated her expectation was for every staff member regardless of position to answer call lights and provide immediate assistance or response. The NHA stated they had noted concerns with staffing response to call lights being slow. She stated their plan would be to have SSD give more insight to specific grievance care areas so they could actually address the issues. The NHA stated she had participated in resident council meetings but had not specifically gone to the meeting to discuss call lights. She stated, I do participate and spend time on the floor, I assist with call lights, I conduct call light audits and give recognition to staff who are responding to call lights. She stated during the last QAPI on 02/23/23, they had mentioned call lights issue. They had received 10 grievances related to call lights. She stated 10 grievances was a significant number. She stated they should have had a better response. The NHA said, we will do a PIP (Performance Improvement Plan). We will do audits. We will go into the room and turn on call lights and wait for staff response. We will actually see how staff respond and how long it takes them. A review of a facility document titled, Facility Assessment Tool, dated 08/18/17 showed the purpose is to determine what resources are necessary to care for residents competently during day-to day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the facility assessment is for the facility to evaluate its resident population and identify resources needed to provide the necessary person-centered care and services the residents require. A review of a facility policy titled, Personal Care, dated 01/07/20, showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of an undated facility policy titled, Filing Grievances/complaints, showed upon receipt of a grievance and/or complaint, the grievance officer will investigate the allegations and submit a written report of such findings to the administrator. (7.) The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any to be taken. Review of a facility policy titled, Staffing Policies and Procedures, dated 01/25/23, showed it is the policy of the [facility] to assure that sufficient qualified nursing staff are available on a daily basis to meet resident's needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being, thus enhancing their quality of life. The facility shall provide services by sufficient numbers of each of the following types of personnel (RNs, LPNs, and CNAs on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans as determined by resident assessments and the facility assessment. Nursing staff shall be sufficient in quantity and quality to provide nursing services for each resident as needed .

Based on interviews, record reviews, and review of facility policy, the facility failed to properly document and address a resident grievance for one (Resident #21) of one resident sampled for grievances out of a total sample of 43 residents. Findings included: An interview was conducted on 11/16/2021 at 2:07 PM with Resident #21 in her room. Resident #21 stated that she had several personal items that had gone missing since her admission to the facility on [DATE], including a pink blanket that a family member had made for her and some personal clothing items. Resident #21 also stated that she informed the facility staff regarding her missing items but the items were not found. A review of Resident #21's Minimum Data Set (MDS) Assessment, dated 08/23/2021, under Section C - Cognitive Patters, a Brief Interview for Mental Status (BIMS) score of 13, which indicated that Resident #21 was cognitively intact. A review of Resident #21's Progress Notes revealed a note, dated on 09/11/2021 at 8:29 PM, which documented that Resident #21 expressed concerns of personal items missing and that Social Services would speak with Resident #21 on the following Monday, 09/13/2021. A review of Resident #21's Progress Notes did not reveal a follow up note related to Resident #21's missing personal items or any investigation related to the missing personal items. A review of the facility's grievance logs dating from February 2021 to November 2021 was conducted on 11/17/2021 at 2:10 PM with the facility's Nursing Home Administrator (NHA) and the facility's Social Services Director (SSD). The review of the logs did not reveal a grievance filed for Resident #21 related to missing personal items. On 11/18/2021 at 1:43 PM, Staff A, Licensed Practical Nurse (LPN) Unit Manager, stated that when a resident reported that a personal item was missing, the facility staff would review the resident's inventory log and attempt to see if the resident had that item inventoried. Facility floor staff would then attempt to find the missing item and if they were unable to find a missing item the concern would be brought to the SSD so that a grievance could be filed. A requested was made to review Resident #21's inventory sheet. Staff A, LPN stated that they did not have an inventory sheet filed for Resident #21. An interview was also conducted with the facility's Regional Nurse Consultant (RNC), who was nearby at the time of interview. The RNC stated that if an item was reported missing and the resident did not have an inventory sheet filed, then the concern would be written up as a grievance. Staff A, LPN addressed Resident #21's Progress Notes, which revealed that Resident #21 brought up a concern related to missing personal items. Staff A, LPN stated that a grievance should have been filed for Resident #21 in order to locate her missing items. An interview was conducted on 11/18/2021 at 1:57 PM with the SSD, who was also serving as the facility's Grievance Official. The SSD stated that when a resident or resident representative expressed a concern related to the facility, the staff member who received the concern would fill out a grievance form. The grievance would then be discussed in the morning meeting by the care team and be assigned to the related department. Once the concern was investigated, the grievance would be returned to the SSD in order to be filed. The SSD stated that when the concern related to a missing personal item, all care team members look to locate then missing items. The SSD also stated that the nursing staff on the floor could attempt to locate the item initially, but a grievance should be filed for the resident. The SSD reviewed the facility grievance logs from August 2021 to October 2021, but was not able to locate a grievance filed for Resident #21 related to missing personal items. The SSD addressed that a grievance should have been filed for Resident #21 related to her concerns. An interview was conducted on 11/18/2021 at 2:08 PM with the facility's NHA. The NHA stated that a resident of the facility could express concerns to any staff member, who would then report the concern to their supervisor. The staff member that received the concern would usually be the person who fills out the grievance form for the resident. Resident grievances were discussed in the morning meeting with the care team and would then be assigned to the related department. A concern related to missing items would typically be assigned to the housekeeping or laundry department. The NHA stated that Resident #21's concern related to her personal items should have been communicated properly by the facility staff so that the concern was investigated thoroughly. A review of the facility policy titled Grievance Policy, with no effective date, revealed the following policy statement: - All persons are encouraged to make requests, share concerns, and file grievances regarding care and/or services without fear of retribution or negative treatment. Customer Service/Grievance forms are provided on admission and are available throughout the facility in the lobbies and nursing units. A concern or grievance may be given orally or in writing. If you have a concern or grievance, you may contact our Grievance Official.

Based on observations, record reviews, and interviews, the facility failed to ensure assessment, consent, and proper fitting of bed rails for one (#115) of four residents sampled for accidents out of a total resident sample of 43. Findings included: According to the Food and Drug Administration (FDA), accessed at https://www.fda.gov/medical-devices/consumer-products/bed-rail-safety, indicated that Bed rails are used by many people to help create a supportive and assistive sleeping environment in homes, assisted living facilities and residential care facilities. This type of equipment has many commonly used names, including side rails, bed side rails, half rails, safety rails, bed handles, assist bars, or grab bars, hospital bed rails, and adult portable bed rails. On 11/16/21 at 10:28 a.m., Staff Member D, Agency Registered Nurse (RN), identified that Resident #115 had both left-sided and right-sided side rails. Observation with Staff D revealed the side rails were approximately 8-10 inches, shoulder level, and the middle portion of one rail held the bed controller. The left side rail was observed to have a gap of approximately 5 inches between the mattress and the rail. Staff D confirmed that the bed rail on the left side of the bed was not properly spaced. Staff D stated, it should be like that one pointing to the right side rail. On 11/17/21 at 1:45 p.m., Resident #115 was observed lying in bed on a scoop mattress, with her eyes closed. The bed was above knee-level, and the bilateral 1/8 side rails were raised. Staff Member C, Agency Licensed Practical Nurse (LPN) stated, at 1:47 p.m. on 11/17/21, that she had not done any admissions while at the facility. The staff member confirmed the gap between the mattress and the left side rail but was not sure how to move it inwards. The side rail was attached to the bed frame at the bottom. The Director of Nursing (DON) stated on 11/17/21 at 1:59 p.m., that the facility did do side rail assessments at the time of admission and that consents for use were obtained. She viewed the rails attached to the side of Resident #115's bed and confirmed that the side rail could be moved inward and that it did not fit like the right side rail. The side rail swung toward and away from the bed and could not be lowered. The DON called maintenance staff to the residents' unit for assistance. Staff Member E, Maintenance Assistant, was able to adjust the side rail by unlocking it from the bottom of the bed frame and moving it inwards. The DON stated that she wondered if the gap was due to the scoop mattress as this was not the original mattress. The DON stated that the original mattress had been changed to a bolstered one following a fall. Both Staff Member E and the Maintenance Director identified, at 2:17 p.m. on 11/17/21, that all side rails need to be observed and reported if needing to be adjusted. A review of Resident #115's clinical record revealed an original admitted in October of 2021. The Face Sheet for the resident included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #115's Face Sheet identified a family member as the Healthcare Surrogate. Resident #115's Admission Minimum Data Set (MDS) dated [DATE], indicated that the Brief Interview of Mental Status score for the resident was 4, indicating severe cognitive impairment. The MDS identified the resident required extensive 2-person assistance for bed mobility and transfers and that a bed rail was not used. The clinical record of Resident #115 revealed that the Admission Observation, completed at 6:24 p.m. on 10/12/21, did not include a side rail assessment. Subsequent observations from 10/12 to 11/16/21 did not identify a side rail assessment had been completed for Resident #115. A review of attached documents for the resident did not include a consent was given by the resident representative for the use of side rails. The Care Plan Approval Form, completed on 10/18/21 at 3:11 p.m., indicated that the care plan approval was obtained by a telephone discussion and that the Health Care Surrogate and resident had signed it on 10/18/21. The Approval form identified I DO NOT consent to the use of side rail(s) and understand the related liabilities. The Director of Nursing (DON) stated, on 11/17/21 at 4:30 p.m., that the devices on the sides of Resident #115's bed were not side rails so there was not an evaluation done and consents were not needed. On 11/18/21 at 12:58 p.m., the DON reiterated that Resident #115 did not have side rails, she stated that a side rail was able to move down or up, the resident's did not, and they were attached to the head of the bed. She identified that the facility had received 100 beds that came with assist bars. A review of the Care Plan Approval form and the portion of side rails was conducted with the DON. She stated that yes, consents were given for side rails but again, identified that the devices on Resident #115's bed were not side rails. The definition of a side rail was reviewed with the DON. The DON stated, okay and stated that, very few persons have side rails within the facility. An interview was conducted , on 11/18/21 at 1:42 p.m., with Staff Member F, RN and Staff Member G, Agency RN. They identified that neither knew where a side rail evaluation was documented (in the record). The Care Plan for Resident #115 identified the following problems and approaches: - At risk to develop impaired skin integrity due to decreased mobility, need for assistance with mobility tasks, and risk of incontinence. The approaches included assist me to turn and reposition regularly using assist rails as an enabler, started 10/13/21 and edited on 11/18/21. Review of the facility policy titled Proper Use of Side Rails revised 1/17/2018, 2/10/2019, and 01/07/2020, indicated The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. The guidelines identified the following: .3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When the side rails are used for mobility or transfer, an assessment will include a review of the resident's: --a. bed mobility; and --b. ability to change positions, transfer to and from bed or chair, and to stand and toilet . 8. The risks and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. (Note: Federal regulations do not require written consent for using restraints. Signed consent forms do not relieve the facility from meeting the requirements for restraint use, including proper assessment ad care planning. While the resident or family (representative) may request a restraint, the facility is responsible for evaluating the appropriateness of that request . 12. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used.) .

Based on observation, interview and record review the facility failed to ensure the Certified Nursing Assistant's documentation was complete and accurate for 2 of 3 sampled residents (#2, #3). Findings included: 1. Resident #3 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Resident's ADL (Activities of Daily Living) care plan showed she was unable to complete the ADLs independently due to decreased mobility and weakness secondary to recent open reduction internal fixation (hip surgery). She needed assistance with ADL care. Approaches included but not limited to ADL training as ordered; assist to maintain weight bearing status as ordered; and assist with repositioning, transfers, bathing, grooming, toileting, dressing, oral care. Review of the Bath Report / Skin Integrity (Pink sheets) showed she received a shower on 11/13, 11/21, and 11/25. The DON stated that the residents are scheduled (1) for showers twice a week. She stated that the bath sheets are filled out when a resident has a shower and / or refuses. Based on this, there were Bath Reports missing for the week of 11/03 to 11/07 (2), 11/09 to 11/14 (1), 11/16 to 11/21 (1), and 11/23 to 11/28 (1). Review of the CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2017 showed Personal Hygiene included combing hair, brushing teeth, shaving, applying make-up, washing / drying face and hands (excludes baths and showers). Bathing is how the resident takes a full body bath, shower, or sponge bath, including transfers in and out of the tub or shower. It does not include the washing of back or hair. It also showed a Code of 8 means the activity did not occur. During an interview on 12/03/20 at approximately 5:00 p.m. the Director of Nursing (DON) stated that the ADL Tracking Log (Aide charting) was based on the MDS (Minimum Data Set) / RAI. Review of the ADL Tracking Log for Resident #3 showed she received bathing on 11/13, 11/17, 11/30, which does not match the Bath Reports and vice versa. All other dates for Bathing showed 8 or the activity did not occur which would include bed baths or a sponge bath. 2 Resident #2 was admitted on [DATE]. Review of her [DIAGNOSES REDACTED]. Review of the ADL (Activities of Daily Living) care plan showed she was unable to complete her ADL's independently due to weakness, unsteady gait. She needed assistance with mobility and hygiene tasks. Approaches included but not limited to ADL training as ordered, assist to maintain weight bearing status as ordered, assist with bathing and grooming. Review of Bath Report / Skin Integrity (Pink sheets) showed she received a shower on 11/03, refused on 11/10 and 11/13; received a shower on 11/17, 11/20, 11/24, 11/27, 12/01. The DON stated that the residents are scheduled for showers twice a week. She stated that the bath sheets are filled out when a resident has a shower and / or refuses. Based on this, there is a Bath Report missing for the week of 11/2 through 11/07. During an interview on 12/03/20 at approximately 5:00 p.m. the DON stated the ADL Tracking Log / Dart Chart (Aide charting) was based on the MDS (Minimum Data Set) / RAI. Review of the ADL Tracking Log for Resident #2 showed she received bathing on 11/3, 11/17, 11/20, and 11/24. Bathing on 11/27 showed the activity did not occur. All other dates for Bathing showed 8 or the activity did not occur which would include bed baths or a sponge bath. On 12/03/20 at approximately 5:00 p.m. reviewed ADL Tracking Logs (aide charting) with Staff A, Registered Nurse (RN) Unit Manager (UM) for C Wing, Staff B, RN, UM for A Wing and the Director of Nursing (DON). All three agreed that the Bath Report / Skin Integrity (pink sheets) were not part of the chart, that they were tools. All three stated that they did not know how the aide documentation system worked (ADL Tracking Log). They all agreed that the ADL Tracking Logs were missing the documentation as to how the residents received their bathing / showers. Staff A, UM stated that the unit secretary on C wing was not verifying nor telling her, the UM, that the Bath Report / Skin Integrity (pink sheets) were missing nor consistently being done by the aide staff. Staff A stated that it was discovered last week, and they started a Quality Assurance Performance Improvement (QAPI) plan for the lack of Bath Reports (pink sheets) being turned in. Staff A, UM stated that they did not address the documentation in the ADL Tracking Logs (aide charting). When asked who was responsible for the aide and their documentation, the DON stated the nurse, the UM's, the supervisors. The DON stated that none of them knew the system, nor had access to the system. The DON stated that Staff D, Licensed Practical Nurse (LPN), MDS, was supposed to be educating the aide staff on how to fill out the ADL Tracking Log. Staff C, Certified Nursing Assistant (CNA) was called into the conference room by the DON to show how the ADL Tracking Log was supposed to be used. Staff C CNA stated that she thought the nurses input the shower information into the ADL Tracking Log from the Bath Reports (pink sheets). Staff C, CNA stated that she did not know how to fill out the ADL Tracking Log correctly. Staff C, CNA stated that if the resident refused a shower that she would document the bed bath, if given instead, under the hygiene section. Staff A UM of C wing stated repeatedly that they did not know anything about the ADL Tracking Logs (aide charting) system. When asked if anyone was reviewing the aide's documentation, the DON stated that Staff D, LPN, MDS was overseeing it. The DON stated that she spoke with Staff D, MDS, who told her that if 8 was the only documentation in the bathing section that she would ask the CNA what type of bath the resident required. Staff D, MDS also told the DON she would review the Bath Reports (pink sheets). The DON stated that Staff D, MDS had not addressed the lack of correct documentation in the ADL Tracking Log with her. The DON stated again that Staff D, MDS was responsible for educating the aide staff on their documentation. The DON stated that she had been in the system for over [AGE] years and did not know how to use the ADL Tracking Log. Both the DON and Staff A repeated many times how they nor the nurses knew anything about the ADL Tracking Logs (aide charting). The Nursing Home Administrator (NHA) joined the interview at 5:40 p.m. and stated that they were changing the aide documentation system she thought in January. Staff A, UM of C wing confirmed again that they had only spoken with the aides and the nurses on the C wing regarding filling out the Bath Reports (pink sheets). She confirmed again that they had not educated the aide staff regarding their documentation in the ADL Tracking Logs because they had not looked at it. They all confirmed that they had not performed an audit to see if it was a facility wide problem or just Unit C. On interview Staff A UM of C wing stated that they had not had a formal in-service on how to fill out the Bath Reports (pink sheets). She stated that she told the aides they needed to turn in the Bath Reports and the nurses needed to sign off on them. At 6:00 p.m. Staff A, RN, UM of C wing stated that since 11/24/20 the staff on C wing had been being educated on the Bath Reports which included being called back-in if they did not complete a Bath Report. Staff A stated that from today, 12/03/20, they would do the following for the facility, not just the C wing. They would educate the aide staff on how to fill out the Bath Reports (pink sheets), discuss the Bath Reports in the morning meeting which would include the number of reports turned in and the number of outstanding reports. If they found a pattern with a specific aide, they would address it with the individual aide. She stated that during the monthly QAPI meeting they will review how many Bath Reports were done, how many were missing, and the percentage of staff that had been educated. When asked about the education for the ADL Tracking Logs (aide charting) Staff A, UM for C wing stated that she could educate the staff to not document showers and bed baths under hygiene. 4. Record review of the facility's policy, Activities of Daily Living (ADL), Supporting, undated showed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. ADL assistance provided may be documented in the medical record.

Based on observations, interviews, record review and review of the current CDC (Centers for Disease Control and Prevention) guidelines the facility failed to implement and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases. The facility failed to: 1) store a suction machine and tubing in a clean and sanitary manner for one resident (#1) out of one resident with orders for suctioning, 2) follow CDC guidelines for the use and re-use of N-95 respirator masks with exhalation valves by staff for two shifts (7:00 a.m. -3:00 p.m. and 3:00 p.m.-11:00 p.m.) out of three shifts observed on 8/18/2020, 3) ensure staff performed hand hygiene after cleaning resident care areas for one wing (A) out of three wings, 4) follow standards of practice for setting up and isolation area to maintain clean equipment from dirty equipment on one isolation wing (C) out of one isolation wing identified by the facility. Findings included: 1. A review of the facility policy titled, Suctioning the Upper Airway (Oral Pharyngeal Suctioning), revised on October 2010, documented under Steps in the Procedure, 27 Place catheters in clean, dry area. An observation was conducted on 8/18/2020 at 10:13 a.m., in Resident #1's room there was a black suction machine with the connection and resident tubing wrapped around the suction machine sitting out uncovered on the nightstand. (Photographic Evidence Obtained). A review of the medical record for Resident #1 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. An interview was conducted on 8/18/2020 at 2:23 p.m., with the NHA and DON who reviewed the photographic evidence and confirmed that the suction machine and tubing were not stored properly. The DON said, Resident #1 does have current orders for suctioning as needed. 2. A review of the facility policy titled, Protocols for PPE (personal protective equipment) use with Suspected or Confirmed COVID-19 Individuals, with an effective date of 1/31/2020 and a revision date of 5/05/2020 documented, This document provided comprehensive guidance for respiratory protection of facility colleagues, specifically in reference to caring for COVID-19 Persons Under Investigation (PUIs) or confirmed cases. N-95 Respirator Limited Re-Use Guidelines: Limited re-use refers to the practice of using the same N-95 for multiple encounters but removing it ('doffing') after each encounter. The N-95 in question is stored in-between encounters to be out on again ('donned') prior to the next encounter with a resident. Reuse of a single N-95 respirator is limited to a single caregiver for up to 7-days. The facility policy does not address N-95 respirators with an exhalation valve use or source control. A review of the CDC guidelines on Personal Protective Equipment updated August 8, 2020 Questions and Answers documented, An N-95 respirator with an exhalation valve does provide the same level of protection to the wearer as one that does not have a valve. The presence of an exhalation valve reduces exhalation resistance, which makes it easier to breathe or exhale. Some users feel that a respirator with an exhalation valve keeps the face cooler and reduces moisture build up inside the face piece. However, respirators with exhalation valves should not be used in situations where a sterile field must be maintained (e.g., during an invasive procedure in an operating or procedure room) because the exhalation valve may allow unfiltered exhaled air to escape into the sterile field. If you only have a respirator with an exhalation valve available, cover the exhalation valve with a facemask (surgical or procedure mask) that does not interfere with the respirator fit. Wear a respirator without an exhalation valve when both source control and respiratory protection are required. If only a respirator with an exhalation valve is available and source control is needed, cover the exhalation valve with a surgical mask, procedure mask, or a cloth face covering that does not interfere with the respirator fit. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html. During the initial tour of the facility all direct care staff were observed wearing N-95 filter face masks with an exhalation valve on all wings, A, B and on C the isolation wing. An observation was conducted on 8/11/2020 at 10:21 a.m., Staff C, Licensed Practical Nurse (LPN), was on the A wing (near room A21) with only a N-95 filter face mask with an exhalation valve on. An interview was conducted on 8/18/2020 at 10:23 a.m., Staff C, LPN, confirmed she was wearing a N-95 filter face mask with an exhalation valve on. Staff C said, We wear these N-95 mask for 2- 3 days. No, we have not been told to wear another mask on top of it. An observation was conducted on 8/18/2020 at 1:47 p.m., on the C Wing- Isolation, Staff F, RN was wearing only a N-95 filter face mask with an exhalation valve. An interview was conducted on 8/18/2020 at 1:47 p.m., Staff F, RN said, We wear the N-95 filter masks for 2 days. This is what we are told to wear. An observation was conducted on 8/18/2020 at 2:00 p.m., Specialty Manger for the C-Wing (Isolation Wing) was observed wearing only a N-95 filter face mask with an exhalation valve on, and face shield. An interview was conducted on 8/18/2020 at 2:00 p.m., Specialty Manger for the C-Wing said, We wear these N-95 filter masks for up to 5 days with a face shield on. An interview was conducted on 8/18/2020 at 2:25 p.m., the Director of Nursing and the Nursing Home Administrator said, We were not aware of the CDC changes for the N-95 filter masks. We have 500- N-95 masks and 4050 KEN masks as well as cases of surgical masks. 3. A review of the facility policy titled, Handwashing/Hand Hygiene, revised on August 2015, revealed, Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. The Policy Interpretation and Implementation documented: 7. Use an alcohol-based hand rub containing at least 62% alcohol ; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; . i. After contact with the residence intact skin; . l. After contact with objects (e.g., medical equipment )in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precautions settings . An observation was conducted on 8/18/2020 at 10:23 a.m., Staff B, Housekeeping was cleaning room A23 and entered and exited the room several times without peforming hand hygiene. Staff B, Housekeeping came out of the room a third time and picked up the broom and dustpan and went back into the resident room. Staff B, Housekeeping did not have on gloves. Staff B walked into the resident's bathroom and swept the bathroom floor and picked up the debris off the bathroom floor using the dustpan. Staff B walked out of the bathroom and out of the resident's door and placed the broom and dustpan back on her cart without performing hand hygiene. An interview was conducted on 8/18/2020 at 10:31 a.m. and the Director of Housekeeping confirmed that it was Staff B, Housekeeping cleaning room A23 and said, Yes, (Staff B) should have had gloves on and cleaned her hands after leaving the room. An interview was conducted on 8/18/2020 at 10:32 a.m., Staff D, Housekeeping said, Yes, we are to have gloves on when we are cleaning a resident's room and bathrooms. We clean our hands after we take off our gloves. 4. A review of the CDC guidelines dated June 9, 2020 on how to Don and how to Doff personal protective equipment located at https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf revealed: How to Put On (Don) PPE Gear More than one donning method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of donning. 1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training). 2. Perform hand hygiene using hand sanitizer. 3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. 4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.* o Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator. o Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. 5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece [MEDICATION NAME] respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 6. Put on gloves. Gloves should cover the cuff (wrist) of gown. 7. Healthcare personnel may now enter patient room. How to Take Off (Doff) PPE Gear More than one doffing method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of doffing. 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. * 3. Healthcare personnel may now exit patient room. 4. Perform hand hygiene. 5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles. 6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.* o Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. o Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front. 7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is [MEDICATION NAME] reuse.* A tour of the C-wing (isolation wing), on 8/18/2020 beginning at 10:40 a.m., revealed the following resident rooms on Contact/Droplet Precautions rooms: C15, C19, C24, C25, C26, C28, C32, C30, C29, C44, C42, C40, C39, C36, C37 with PPE for donning and plastic bins for doffing side by side in the resident rooms without a clear designated of the clean and decontamination areas. The rooms were set up with the PPE inside the resident rooms where staff had to cross the threshold of an isolation room to don PPE. An interview was conducted on 8/18/2020 at 1:47 p.m., Staff F, RN confirmed that the PPE bins and the dirty bins for taking off personal protective equipment should be separated. Staff F said, Yes, I see they are both on the same side of the room with the residents and side by side. An interview was conducted on 8/18/2020 at 1:49 p.m., with the Director of Housekeeping and the Specialty Manger for the C-Wing who were in the hall on C-Wing discussing where to put the PPE and dirty bins. They both confirmed that the PPE bins, either the free- standing ones or the bins on the wall, had the dirty linen bins together. The Specialty Manger for the C-Wing said, What if the privacy curtain was pulled to separate the clean area as staff entered the room from the dirty area on the resident side of the room? Both managers confirmed that staff still had to walk into the room to don PPE. The Housekeeping Manager said, I think we should move the PPE bins outside of the room so they can put it on before they enter the patient's rooms. The Specialty Manger for the C-Wing said, I see what you are saying. But we consider the threshold to the room after you have passed the bathroom. We thought it was a great set up because they can walk into an isolation room go into the bathroom and wash their hands and then walk over and put on their PPE. But they still are entering an isolation room without PPE on. An interview was conducted on 8/18/2020 at 2:45 p.m., with the NHA who reviewed the observations with photographic evidence and confirmed the findings. The NHA said, Yes, we see what you are saying.

Based on observation, interview, and facility record review, the facility failed to ensure proper food storage and labeling of food items stored in the main kitchen area and a clean and sanitary nursing unit pantry on one of three nursing units. Findings included: An initial tour of the kitchen was conducted on [DATE] at 09:22 a.m. with the Certified Dietary Manager (CDM). She stated the facility had a full-time Registered Dietician (RD). Today, there are 8 staff members manning the kitchen details. A tour of the Walk-in refrigerator commenced at 09:42 a.m. with a registered temperature of 37 degrees Fahrenheit. The CDM asked Staff Member H, Dietary Aide, to observe the storage area. The tour revealed unwrapped heads of lettuce, cantaloupes, cucumbers, and cabbage stored in plastic baskets with no dates and no labels. Photo evidence was taken. An opened bag of green onions with an expiration date of [DATE] was observed. Photo evidence was taken. A bag of opened peppers revealed no dated opened and unlabeled. A loosely wrapped bag of shredded carrots revealed no label and no date opened. Photo evidence was taken. Further observation revealed leaking milk on floor of the walk-in refrigerator. Photo evidence was taken. The CDM stated, Milk delivery is on Mondays/Thursdays. Groceries are delivered on Tuesdays and Fridays. The CDM verified expired food items, loose vegetables, an undated bag of shredded carrots, and leaking milk on floor. The CDM asked Dietary Aide Staff Member H to discard the food and mop up the floor. She stated she expects her staff to follow the procedures for labeling and storing food after opening food and keeping the floor clean. At 9:58 a.m., a tour of the walk-in freezer was conducted with the CDM. The freezer registered minus 8 degrees Fahrenheit. An observation was made of boxes of frozen foods on floor. CDM stated the food delivery just came in and the staff would be putting the items away. Further observation revealed a bag of opened chicken patties with no label and no date of when opened. Photo evidence was taken. A brief interview was conducted on [DATE] at 11:12 a.m. with Staff Member E, Dietary Aide for 5 years. She stated, When you open something, it has to have a date on it; wrap items and date. She stated other education in-services have been with hand sanitizing, hand washing, storage of food, and meal tickets. She stated the in-services are ,[DATE] times per month and as needed. A tour of the B wing pantry on [DATE] at 11:37 a.m. was conducted with the CDM. An observation revealed (3) Styrofoam water pitchers with plastic lids on the floor underneath and behind the ice machine. Photo evidence was taken. Further observation of the pantry room revealed garbage (napkins and crushed Styrofoam pieces) on the floor on the side of refrigerator. Photo evidence was taken. On [DATE] at 2:21 p.m., a second tour of the B-Wing pantry with the CDM revealed the 3 Styrofoam pitchers were removed from underneath the ice machine. Further review of the room revealed the garbage had not been picked up alongside of the refrigerator. The Housekeeping Supervisor verified and stated it was his expectation for his staff to clean behind the ice machines and refrigerators. He stated once a week on Mondays, the refrigerators are pulled out and cleaned. There was a person assigned to do this task. He stated the task was not on the housekeeper's task list/ assignment sheet. An interview was conducted with the Administrator on [DATE] at 4:15 p.m. She verified and stated her expectation would be for dietary staff to label and date food items consistently and for the nursing unit pantries to be cleaned thoroughly by Housekeeping. [DATE] 07:47 a.m., an interview was conducted with Staff Member F, Housekeeper for 1 year. She stated she goes to see if trash needs to be removed, wipes down cabinets, sweeps under the ice machines and behind the refrigerators. She stated she was a Floater and if she had the assignment to clean the pantry, You were responsible to clean the whole area. There was a lot of trash in the pantries and it had to be removed. A review of the facility policy and procedure for Food Receiving and Storage, revised date of [DATE], revealed as Policy Statement, Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation #1. stated Food Services, or other designed staff, will maintain clean food storage areas at all times. #7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. #10. The freezer must keep frozen foods solid. Wrappers of frozen foods must stay intact until thawing. A review of the facility policy and procedure for Sanitization, dated [DATE], revealed as Policy Statement, The food service area shall be maintained in a clean and sanity manner. The Policy Interpretation and Implementation #1 revealed, All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.

Based on observations, record reviews, and interviews, the facility failed to ensure appropriate infection control measures were followed related to the usage of Personal Protective Equipment (PPE), signage for isolation rooms, and failed to use best practice measures for infection control during medication administration for three (# 1, #35, 280, and #324) of seven sampled residents. Findings included: 1. The policy provided by the facility Isolation- Categories of Transmission Based Precautions revealed the following: Policy Interpretation and Implementation 1. Transmission-Based Precautions will be used whenever measures are more stringent than Standard Precautions are needed to prevent or control the spread of infection. 2. Based on CDC definitions, three types of Transmission-Based Precautions (airborne, droplet and contact) have been established. Droplet Precautions 1. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. 4. Masks a. In addition to Standard Precautions, put on a mask when entering the room or cubicle. 7. Signs- The facility will implement a system to alert staff and visitors to the type of precaution the resident requires. A review of the Resident Face Sheet for Resident #324 revealed that he was admitted into the facility on [DATE] at 4:15 p.m. with a primary [DIAGNOSES REDACTED]. The Admission Report Sheet dated 02/26/20 revealed isolation: [MEDICAL CONDITION] droplet. The form also indicated that Resident #324 was on the antibiotic, [MEDICATION NAME] two times per day. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated and signed by the phsycian/designee on 2/25/20, revealed that the resident [MEDICAL CONDITION] in the sputum and isolation precautions included contact and droplet. A review of the Physician order [REDACTED].>A review of the care plans revealed that Resident #324 had a care plan initiated on 02/27/20 related to respiratory infections: Pneumonia [MEDICAL CONDITION] in the sputum. The approaches included but were not limited to isolation/precautions as ordered. On 02/27/20 at 9:32 a.m., the surveyor observed the Registered Dietitian (RD) in Resident #324's room The RD was not wearing PPE. The Surveyor stopped and asked the RD from the doorway if the resident was on contact isolation and she stated, Yes. The surveyor asked her how she knew the resident was on contact isolation. The RD stated because the box with the PPE was on the wall inside the room. There was no signage observed on the door or outside the door (photographic evidence obtained). At 9:34 a.m., the Director of Nursing (DON) confirmed that there should be signage on the door. The DON stated that she would have to talk to the nurse that admitted him last night to see why signage was not posted. On 02/27/20 at 1:12 p.m., the surveyor observed from the hallway, a staff member in the room assisting Resident #324. The staff member was not wearing PPE. The staff member walked Resident #324 into the restroom and closed the door. At 1:13 p.m., the staff member came out of the restroom, took off gloves, and used the sanitizing dispenser near the door. The surveyor verified the staff member's name as she stood in the doorway of the room. Staff A, Occupational Therapist Assistant, stated that she saw the call light on and Resident #324 stated that he needed to go to the restroom really bad, so she helped him go to the restroom. On 02/27/20 at 1:19 p.m., the Surveyor observed a staff member go into the room. When the staff member exited the room, the Surveyor verified the staff member's name. Staff B, Certified Nursing Assistant (CNA), reported that the resident was on droplet precaution. Staff B stated that a gown, gloves, and a mask must be worn when entering the room. Staff B then stated she did not wear the gown or mask because she did not touch him. 2. Resident #280 was admitted on [DATE]. The Face Sheet included [DIAGNOSES REDACTED]. On 2/25/20 at 9:58 a.m., an observation revealed a red and white magnetic sign attached to the upper right hand of the door frame. The sign was very similar to other signs noted on other resident door frames that read No Smoking, Oxygen in Use. The sign attached to the outside of Resident #280's room read Isolation See Nurse, the sign did not indicate what type of transmission-based precautions were being utilized. The observation revealed two bins; one yellow and one red, inside of the room with a small plastic drawers next to the bins. A review of Resident #280's physician order, dated 2/15/20, included an order for [REDACTED]. The Infection Control Preventionist stated, on 2/28/20 at 4:09 p.m., the facility was ordering new isolation signs due to realizing how similar they are to the No Smoking signs, but the isolation bins in the room should give people pause. 3. Resident # 35´s active medication orders included blood glucose monitoring before meals and at bedtime with insulin coverage using an insulin delivery pen. During the administration of a subcutaneous injection on 02/27/20 at 11:33 a.m. for Resident # 35, Staff C, Licensed Practical Nurse (LPN) was observed to bring the injection supplies into the room. The supplies included the injection pen and a plastic baggie that was used to store the pen in the medication cart. When preparing the pen for the injection, Staff C removed it from the plastic baggie, placed the baggie on the resident´s overbed table, and placed the primed pen on the foam tray that she used as a barrier. After delivering the injection, Staff C, LPN returned the pen to the baggie and the baggie to the medication cart. During a medication administration observation on 02/28/20 at 12:10 p.m. Staff D, LPN stated that she had two residents that she would be performing glucose testing for. Review of Resident # 324´s active medication orders included blood glucose monitoring before meals and at bedtime. The nurse entered the first room with two glucometers (# 1 and # 2) on a foam tray along with testing supplies, one meter was wrapped (# 2) with a disinfecting wipe, and the other meter was unwrapped (# 1). The nurse performed hand hygiene, donned the appropriate Personal Protective Equipment (PPE) for the droplet isolation room, and performed resident # 324´s test using meter # 1. After removing her PPE and performing hand hygiene, she unwrapped the other meter (# 2) to let it air dry. She cleaned the meter she had just used (# 1), wrapped it in a disinfecting wipe, and placed it in a cup. Staff D, LPN then proceeded to the second resident´s room. Resident # 1´s active medication orders included blood glucose monitoring before meals and at bedtime. Staff D, LPN entered the room with both glucometers on her foam tray. She performed hand hygiene and donned the appropriate PPE for the contact isolation room. Staff D, LPN then performed the test for resident # 1 using the second meter (# 2). After the test, she removed her PPE, performed hand hygiene and returned to her medication cart. She obtained a new disinfecting wipe to clean and wrap meter # 2 and then placed it in a cup. Staff D, LPN then unwrapped meter # 1 and returned it to the drawer in her cart. The DON was interviewed on 02/28/20 at 4:06 p.m. and she stated that only the supplies needed should be brought into the resident rooms, she stated that the staff was trained on infection control measures and that medication was prepared, including removing its wrapping, at the cart and only the medication should be brought into the room. The DON also stated that a nurse should not enter a resident room with two glucometers for the performance of a glucose test, the nurse should return to the medication cart to clean the used meter and to exchange it for another before performing another test.

Based on observations, record reviews, and interviews the facility failed to ensure the physician response to pharmacy recommendations were implemented as written by the physician for two (#125 and #151) out of seven residents reviewed for the task of unneccessary medications. Findings included: Resident #125 was admitted on [DATE] and readmitted [DATE]. The Face Sheet included [DIAGNOSES REDACTED]. On 2/26/20 at 10:20 a.m., an interview was attempted with Resident #125. Resident #125 was upset, became tearful, and reported pain. A review of the pharmacy recommendation, dated 1/23/20, identified Resident #125 had an order for [REDACTED].#125 had been on it for a long time. The review of Resident #125's physician order, indicated an order, dated 2/17/20, for [MEDICATION NAME] - Schedule IV tablet 0.5 mg oral every 6 hours as needed for anxiety. The order did not include an end date. The (MONTH) Medication Administration Record [REDACTED]. On 2/28/20 at 4:27 p.m., the Director of Nursing (DON) reviewed the order for [MEDICATION NAME] and shook her head in response to it not having an end date as written by the physician in response to the pharmacy recommendation. The DON changed the order to indicate an end date of 3/5/20, 30 days from the date of the physician response to the pharmacy recommendation. The care plan identified Resident #125 was at risk for developing adverse effects of [MEDICAL CONDITION] medications; receiving antidepressant and antianxiety medications for history (hx) of depression and anxiety. The interventions included administer medications as ordered. Resident #151 was admitted on [DATE]. The Face Sheet included [DIAGNOSES REDACTED]. An observation on 2/25/20 at 12:23 p.m., indicated Resident #125 was sitting at an over-the-bed table eating lunch. A review of the Consultant Pharmacist recommendation, dated 1/21/20, identified Resident #151 was receiving [MEDICATION NAME] 15 mg every bedtime as needed (QHS PRN) and [MEDICATION NAME] 0.5mg every 8 hours as needed (Q8H PRN). The Pharmacist recommended to discontinue the PRN use of the medication or reorder for specific number of days. The physician response was to continue PRN use for this order for 30 days as benefit outweighed the risk. The physician, on 2/4/20, indicated the following: - [MEDICATION NAME] 15 mg q hs. - [MEDICATION NAME] ([MEDICATION NAME]) q 8 hour prn The prescription order for Resident #151's [MEDICATION NAME] indicated a start date of 2/2/20 and was open ended. The residents' prescription order for [MEDICATION NAME] indicated a start date of 2/14/20 and was open ended (no end date). The special instructions of the [MEDICATION NAME] instructed staff to administer 0.5 mg oral (po) every 8 hours as needed for anxiety for 30 days. The (MONTH) Medication Administration Record [REDACTED]. During an interview with the Director of Nursing, on 2/28/20 at 1:39 p.m., she confirmed the order for [MEDICATION NAME] was written for 30 days and not open ended as it was put into the computer (electronic MAR). The policy titled Consultant Pharmacist Reports, dated 2006 and revised (MONTH) (YEAR), indicated the findings are phoned, faxed, or emailed within 24 hours to the Director of Nursing or designee and the prescriber is notified if needed.

Based on observation, interview and record review, the facility failed to investigate bilateral wrist discoloration for one Resident #101 of 59 sampled residents after documenting the bilateral discoloration on Bath Reports and Weekly Skin Reviews dating back to 11/6/18. Findings Included: During observation of wound care with Resident #101 on 11/30/18 at 10:05 a.m., Resident #101 was observed with dark purple markings to the top of the left and right wrist with similar pattern and length. The resident stated, the nurse did it while moving me a couple weeks ago. The marks on the top of the wrist were varying shades of dark purple to light purple with a wider base close to the hand and narrowing away from the hand. The length of the discoloration was approximately the length of a thumb with similar markings and placement on both wrists. Findings included: Review of the Weekly Skin Review dated 11/28/18 did not document discoloration to wrist. Review of the Bath Report/Skin Integrity dated 11/27/18 did not document discoloration to wrist. Review of the Bath Report/Skin Integrity dated 11/23/18 did not document discoloration to wrist. Review of the Weekly Skin Review dated 11/21/18 revealed resident with Bilateral wrist discoloration. Review of the Bath Report/Skin Integrity dated 11/20/18 did not document discoloration to wrist. Review of the Bath Report/Skin Integrity dated 11/16/18 revealed the resident had Bilateral wrist discoloration. Review of the Weekly Skin Review dated 11/14/18 revealed resident with Right back of hand small bruise. Review of the Bath Report/Skin Integrity dated 11/13/18 revealed resident with Right back of wrist and hand with redness. Review of the Bath Report/Skin Integrity dated 11/6/18 revealed resident with Bilateral back of wrist discoloration. Review of the care plan dated 9/27/18 revealed the resident had alteration in skin integrity with approaches to report changes in skin to the physician. Complete a skin assessment of my body weekly and as needed. During an interview with Resident #101 on 11/29/18 at 1:57 p.m., the resident introduced her son who was visiting. The resident was wearing long sleeves. During an interview with Staff member M, RN on 11/30/18 at 10:07 a.m., the staff member stated, Resident #101 did have markings on her legs that were not bruising which the doctor was monitoring but was unsure of the wrist discoloration and why someone would try to use the resident's wrist to sit her up and move her. Staff member M, stated she would inform the unit manager. During an interview on 11/30/18 at 10:18 a.m. , with staff member G, RN, she stated, We have weekly skin assessments that vary during day and shift. Nurses are responsible for weekly skin checks, if a new area is observed we have an on call doctor and we fill out an incident report and put them in the Unix systems and make sure they are documented in progress notes, family and physician notified. If the wound is open we call the doctor to get an order to put something on it. Staff member G, stated that the shower sheets are completed by the CNA then the nurse signs off on it. During an interview with the ADON (Assistant Director of Nurses) on 11/30/18 at 10:46 a.m., The ADON stated, we just started the investigation as she had a skin check two days ago and did not have any bruising on her wrist. The ADON confirmed the resident told her it was from a nurse a couple weeks ago. During an interview with the DON on 11/30/18 at 11:50 p.m., The DON stated, the shower sheet should be signed off by the CNA and the nurse and that the nurse should have started the investigative process on the 16th when the documentation was made. The DON stated that the CNA will be written up for not telling the nurse and having the nurse sign the shower sheets. During an interview with the ADON on 11/30/18 at 2:07 p.m., the ADON confirmed another skin check completed today and stated they are doing the investigation and interviewing the nurses. Review of the weekly skin assessments policy without a label or date revealed: Assessment will be documented on the weekly skin assessment nurses note. Review of the Abuse Prevention Coordinator Concerns & Grievances not dated with Solaris Healthcare. org, 11 pages revealed: 1. Injuries of unknown source: An injury for which both of the following conditions exist: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the patient. AND 2. The injury is suspicious because of; the extent of the injury, or location of the injury, or the number of injuries observed at any particular point in time, or the incidence of injuries over time.

Based on observation, interview and record review, the facility failed to provide one Resident #101 of two residents sampled with wound care consistent with professional standards by failing to separate the cleaning of two wounds and performing hand hygiene between the cleaning and application of medication for the wounds. Findings Included: During observation of wound care for Resident #101 on 11/30/18 at 09:36 a.m., with Staff member M, RN, the nurse gathered her supplies of mupirocin/Santyl 1:1 mix for the right scapula, Santyl for the coccyx sacral area, normal saline, 4x4 gauze, Allevyn with date and initials on a barrier and a red bag. The staff member knocked and entered the room, washed her hands and donned gloves, spoke to the resident to alert to the removing of the brief, Staff member M, removed the dressings in all three areas, doffed gloves and washed hands. Staff member M, donned gloves and cleaned the right scapula with normal saline and gauze, then cleaned the sacral coccyx wound with normal saline and gauze. Staff member M with the same gloves dried the two areas and applied the Santyl to the sacral coccyx area with a tongue depressor, then applied the mupirocin/Santyl 1:1 to the right scapula. Staff member M then applied the Allevyn to the right scapula, sacral coccyx and the bony prominence. Doffed gloves and washed hands. Applied gloves to reapply the brief and get the resident comfortable. Doffed gloves and washed hands. During an interview with Staff member M on 11/30/18 at 10:08 a.m. she confirmed that she should have changed gloves after hand washing before applying the medication and should have treated each wound separately. During an interview on 11/29/18 at 1:57 p.m. with Resident #101, the resident stated, when she is moved with the lift it really hurts her backside. Review of the physician orders [REDACTED]. Review of the physician orders [REDACTED]. Review of the physician orders [REDACTED]. Review of the Wound Care visit dated 11/29/18 revealed the resident with Right inferior scapula cyst-burst measuring 1.5cm x 1.7cm x 0.2cm with slough and a Sacro-coccyx facility acquired pressure wound measuring 1.8cm x 1.0cm x 0.2cm. During an interview with the DON on 11/30/18 at 10:46 a.m., she confirmed Staff member M should have cleaned the wounds separately and should have washed between cleaning and reapplying the medication. Review of the Handwashing/hand hygiene policy from Infection Control with a revised date of (MONTH) (YEAR) from Nursing Services Policy and Procedure Manual for Long term Care @2001 Med-Pass, two pages, revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. 7. g. Before handling clean or soiled dressings, gauze pads, etc; h. Before moving from a contaminated body site to a clean body site during resident care.

Based on observation, interview and record review, the facility failed to provide one Resident (#42) of one sampled resident with oxygen as prescribed during two of four days of observation in the facility. Findings Included: During observation on 11/27/18 at 11:39 a.m., Resident #42 was observed sitting in the dining area with an oxygen concentrator plugged into the wall. The humidified bottle was not bubbling; the concentrator could be heard running. The resident was observed with nasal cannula worn correctly. During an interview with Resident #42 on 11/27/18 at 11:46 a.m., Resident #42 stated that the staff take the oxygen concentrator with him in the facility. He stated the staff disconnect it and move it where he goes. He stated the staff do not use the portable tank on his wheel chair unless he goes out of the facility or where they can not use a plug. Review of the 9/21/18 MDS (Minimum Data Set) the resident had a BIMS (Brief Interview of Mental Status )score of 12, indicating moderately impaired cognition. During an interview on 11/27/18 at 11:48 a.m. with staff member G, RN, she stated, the concentrator is taken with the resident due to the cost of the Etank and the facility would prefer the resident be on the concentrator if they have a place to plug it in. Staff member G, confirmed the concentrator was not giving the full two liters of oxygen due to the water bottle not attached correctly. Staff member K, CNA put the cannula up to her hand and stated that she could not feel air coming through the cannula until staff member G attached the bottle. Staff member K, CNA then removed Resident #42 and took him to his room leaving the oxygen concentrator turned off with the cannula secured in the bag. Resident #42 was without oxygen while in his room. Resident #42 was observed returning to the table on 11/27/18 at 12:09 p.m. without the oxygen turned on. Staff member F, LPN was observed picking up tissue around the resident without connecting the oxygen. During observation on 11/27/18 at 12:13 p.m., staff member O, CNA was observed turning the oxygen on for Resident #42. During observation on 11/29/18 at 1:54 p.m., Resident #42 was observed going back to his room with staff member I, CNA without oxygen. The oxygen concentrator was observed turned off in the dining area. During an interview on 11/29/18 at 2:35 PM with staff member I, CNA, she stated that she disconnects the resident's oxygen concentrator when moving him from one room to another room and if he goes to the main dining room then she would connect him to his portable tank. Review of a physician order [REDACTED]. Resident #42 was readmitted on [DATE] with a history of pneumonia and [MEDICAL CONDITION]. During an interview on 11/29/18 at 4:53 p.m., with the DON (Director of Nurses), she confirmed that residents on oxygen concentrators can be moved around the facility with the concentrator as long as the concentrator is going with them and they are not going for periods of time without it. The DON confirmed that the staff should assure the concentrators are being reconnected appropriately to assure the resident is receiving the oxygen. Review of the Oxygen Administration policy dated 1/18/18 from the Nursing Services Policy and procedure manual for Solaris Health Care, two pages, revealed: Steps in the Procedure: 6. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.

Based on observation, review, and interview the facility failed to ensure one (#17) out of 10 residents sampled for medication use received medications as ordered by the mental health provider and that the medication regimen review was accurately assessed by the pharmacy. Findings included: Resident #17 was admitted on [DATE]. The active [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set, dated dated [DATE], indicated no score for Brief Interview of Mental Status. A review of physician orders [REDACTED]. A review of Resident #17's April, May, June, July, August, and (MONTH) MARs identified the resident received [MEDICATION NAME] 125mg daily at 6p.m., started 4/5/18. A nursing progress note dated 4/5/18 stated Resident #17's behaviors and psychiatry recommendations were discussed during the care plan meeting and family agreed to restart [MEDICATION NAME] as resident was noted to be more agitated in the evening hours. The Psychiatry ARNP (Advanced Registered Nurse Practitioner) note, dated 5/31/18, stated, Stopped [MEDICATION NAME] due to the fact resident stating she sleeps a lot durning (during) the day and can not sleep at night. The note identified Resident #17's current medications: [REDACTED]. Additional notes for 7/13/18 visit stated the evaluation of resident included a detailed review of medical records, MAR's, nursing and MD notes. The psychiatry visit note, dated 11/8/18, identified chief complaint: IDT met to determine use of [MEDICAL CONDITION] meds and its effectiveness. The total encounter time was 10 minutes, 5 minutes were spent in coordinating activities with psych IDT to review medications. The note indicated current medication for Resident #17 as [MEDICATION NAME] 20mg daily and a detailed patient evaluation included, detailed review of medical records, MAR's, nursing and MD notes. A follow up visit for moderate review by psychiatry ARNP was done on 11/29/18. The note identified current medications as [MEDICATION NAME] 20mg daily, [MEDICATION NAME] 125mg daily at 6p.m., and [MEDICATION NAME] XR 14mg daily. The assessment plan portion of note stated DC (discontinue) [MEDICATION NAME]. The history of present illness stated, Resident stated she sleeps off and on in her bed during She has appropriate behaviors according to the staff. A review of the progress notes for Resident #17 indicated a dietary note dated 5/25/18. The next progress note was from Physician Assistant (PA), dated 6/5/18. The review revealed no nursing notes from 5/2 - 7/2/18. The bi-annual physical exam and comprehensive review of chronic conditions note by ARNP, dated 9/29/18, indicated resident's psychiatry record, medical record and MAR indicated [REDACTED]. The ARNP progress note did not indicate a [DIAGNOSES REDACTED].#17. The review of Resident #17's comprehensive assessments on 3/20, 6/8, and 9/3/18 did not reveal an active [DIAGNOSES REDACTED]. The comprehensive assessments did reveal Resident #17's active [DIAGNOSES REDACTED]. The care plan for resident revealed resident received [MEDICAL CONDITION] meds (medications) for [DIAGNOSES REDACTED]. The review of progress notes from 4/2 to 11/25/18 did not reveal resident suffered any [MEDICAL CONDITION] activity. A review of the Medication Regimen Review (MRR) for August, September, and (MONTH) (YEAR) stated no irregularities were noted for Resident #17. The pharmacy review for (MONTH) (YEAR) indicated resident received [MEDICATION NAME], no mention of [MEDICATION NAME]. On 11/30/18 at 9:47a.m., Staff Member C, Licensed Practical Nurse (LPN), confirmed Resident #17 received [MEDICATION NAME] daily at 6p.m. The LPN removed a blister card from the medication cart which contained [MEDICATION NAME] and prescribed to resident. The pharmacy dispensed the medication on 11/20/18, according to the blister card. An interview was conducted on 11/30/18 at 3:01p.m with the DON, she stated psychiatry comes weekly but does not see each resident each week. The interview was continued at 3:06p.m., with the DON, Staff Member D, LPN UM (Unit Manager), and Staff Member N, Social Service Director. Staff member N stated the psychiatry ARNP had meant to discontinue the resident's [MEDICATION NAME] on 11/8/18 at the pharmacy management meeting so the facility called and was awaiting a call from family regarding the psychiatry recommendation. The DON and Staff Members stated the family is contacted with recommendations and if an okay is given, a call to the primary care physician is made to receive an order. When the psychiatry note dated 5/31/18 was mentioned which indicated [MEDICATION NAME] stopped, the three staff members gasped. The DON stated the ARNP had not mentioned stopping resident's [MEDICATION NAME]. The DON and Staff Member N stated the ARNP had not brought to their attention that the recommendation had not been followed. Staff Member N stated during the psychiatry management meeting the unit managers add all meds on the first page of report and the ARNP puts the recommendations on the second page then transmitted to Staff Member N, who gives to the UM's. The UM's call the family, explains the recommendations, then the primary care physician are called. Staff Member D stated if the physician agreed to discontinue the medications, the resident is placed in the acute charting book. The DON reviewed the psychiatry note dated 5/31/18 and stated she thought the previous UM probably thought the [MEDICATION NAME] had been discontinues, as the note read, [MEDICATION NAME] stopped was past tense. The DON reviewed the MRR log and stated she didn't know why Resident #17's [MEDICATION NAME] was not listed. During an interview on 11/30/18 at 4:01p.m., Resident #17's primary care physician (PCP) stated he was aware resident was taking [MEDICATION NAME] and unaware of any recommendation to discontinue the [MEDICATION NAME]. The PCP stated VPA ([MEDICATION NAME] acid) levels are done a couple times a year, he goes back and forth on it but if [MEDICATION NAME] was used as a mood stabilizer VPA levels would be done. A review of the electronic record and floor chart did not indicate laboratory results for [MEDICATION NAME] acid (VPA) - [MEDICATION NAME]. The physician orders [REDACTED]. She followed up during the interview, and stated levels for [MEDICATION NAME] were not done if used for behaviors. At 4:20p.m. on 11/30/18, the DON stated the facility missed the recommendation for the discontinuation of [MEDICATION NAME] on 5/31/18. She stated she could not find any documentation. The DON stated the pharmacist stated the possible reason the system had not picked up [MEDICATION NAME] for Resident #17 was the diagnosis.

Based on observation, record review, and interviews the facility failed to provide medications as physician ordered for one (#25) out of 4 residents sampled for residents receiving antipsychotic medications with the [DIAGNOSES REDACTED]. Findings included: Resident #25 was admitted on [DATE] and readmitted on [DATE]. The active [DIAGNOSES REDACTED]. unspecified, and unspecified anxiety d/o. The Significant Change in Status Minimum Data Set ((MDS) dated [DATE] identified 00 for Brief Interview of Mental Status (BIMS). A review of (MONTH) Medication Administration Record (MAR) indicated the following medications due at 9p.m.: [MEDICATION NAME] 50mg (milligram) by oral route once daily at bedtime. Diagnosis: [REDACTED]. Levetiracetam 250mg by oral route every 12 hours. Diagnosis: [REDACTED]. [MEDICATION NAME] 10mg by oral route once daily at bedtime. Quetiapine 25mg by oral route once daily at bedtime Tamsulosin 0.4mg - Give 2 capsules by oral route daily at bedtime. Diagnosis: [REDACTED]. A review of the MAR identified Resident #25 did not receive Quetiapine 25mg on 11/2 and 11/8/18 at 9:00p.m., per nursing documentation, awaiting delivery. The review of progress notes on 11/2 and 11/8/18 did not identify the pharmacy or primary care physician was notified of the inability to administer the antipsychotic medication, Quetiapine. Further review of the (MONTH) MAR for Resident #25 indicated on 11/16/18, the resident did not receive Levetiracetam, tamsulosin, [MEDICATION NAME], quetiapine, and [MEDICATION NAME]. The MAR nursing comments indicated resident was asleep. The progress notes did not identify if the primary care physician was notified of non-administration of the medication. On 11/29/18 at 3:54p.m., Staff Member D, Licensed Practical Nurse Unit Manager (LPN UM), stated if medication is not available in the Emergency Drug Kit (EDK) staff is to call pharmacy, have medication sent stat, call MD to let them know, and possibly get a time change for the administration. Nurses have been told to check the EDK before calling pharmacy. On 11/29/18 at 5:19p.m., the DON (Director of Nurses) stated staff would call pharmacy to stat medication. If a missed dose, staff was to call physician. The DON stated staff are to wake up residents to administer medications. She stated nurses are to call the doctor and tell them the meds were not given or wake the resident up to give medications. On 11/30/18 at 7:56a.m., the DON stated she spoke with the nurses involved with awaiting delivery and asleep. She reported the nurse from 11/2 did not remember the incident but stated she would have called the pharmacy and check the EDK for medications. The nurse from 11/6 informed the DON, the EDK was not checked but the medication was reordered. The DON confirmed neither nurse called the physician to notify of non-administration of medication. The DON stated the nurse from 11/16/18 episode of asleep reported the resident had not been sleeping well so she did not wake resident up. At 9:05a.m. on 11/30/18, the DON stated during morning meetings for two years the facility went through a non-administered report line-by-line to make sure UM's addressed the issues. She stated she was comfortable so stopped doing line-by line reviews approximately mid-2017. She stated in each narcotic book on each medication cart (facility had 7) was a worksheet detailing the procedure for medication not available and policy for medication administration. She confirmed one cart had the medication not available worksheet available. The medication not available worksheet stated: 1. Check every card in your med cart to make sure it has not been misplaced 2. Check your overflow medications 3. Check the EDK, if medication is in the EDK take from the EDK, administer medication. Contact the pharmacy and have it sent out before the next scheduled medication pass. 4. If medication is not here and not in the EDK, contact pharmacy and have medication sent STAT. 5. If the resident is going to miss a scheduled dose of the medication, you MUST contact the prescribing physician, notify him/her that the medication is not available for this scheduled medication pass. Inform the physician of what is available in the EDK and write any orders the physician prescribes. 6. Document in the nurses notes the physician has been notified. 7. If the prescribing physician is not available, you MUST contact the Medical Director for orders or further action to be taken. The Medication Administration policy, undated, stated Not Administered-Sleeping: If a medication is scheduled the resident is to be awakened and medication administered. Scheduled medications are not to be held because a resident is asleep unless there is an order to hold the medication when asleep. The care plan for Resident #25 identified resident had an altered pattern in urinary elimination. The approaches included but not limited to meds as ordered. Resident was at risk for [MEDICAL CONDITION] with the approach of med as ordered. The care plan identified resident exhibits s/s (signs and symptoms) of mood as evidenced by difficulty adjusting to current physical functions status, increased anger towards staff, exit-seeking, poor safety awareness, and unable to express thoughts and words which make him more frustrated. One of the goals for resident was to exhibit fewer episodes of altercation with others. Resident #25 was ordered [MEDICAL CONDITION] medications, initiated 11/23/18, the problem identified the drug classes of antidepressant, antianxiety, and antipsychotic. The approach included administer my medication as prescribed by the physician. The care plan revealed three falls (10/5, 10/15, and 11/22/18) and one incident of found on floor (11/3/18). The (MONTH) MAR and progress notes were reviewed and indicated ongoing behaviors, including aggression with staff and other residents.

Based on observation, interview and record review the facility failed to ensure pharmaceutical services to meet the needs of each resident related to the calibration of blood glucose meters for one (Resident #623) of one sampled residents. Findings included: On 11/29/18 at 11:20 a.m. a blood glucose testing (Accucheck) observation was conducted with Staff A, a Registered Nurse (RN), responsible for the C unit (medication cart #7) of the facility. Staff A was preparing to do a blood glucose test for Resident #623. The blood glucose test was performed without incident and Resident #623 did not receive any insulin coverage for a blood glucose level of 101 per orders for sliding scale coverage. A request to review the Quality Assurance (QA) testing log for the blood glucose meter #1 which was used to do the test, revealed no documentation that the meter had been tested for accuracy prior to use had been completed since 11/20/18. Staff A, RN stated that the testing of the meters is supposed to be done on the 11-7 shift nightly. She stated that the accucheck machines are shared by the residents and that there are two meters in each medication cart within the facility. Staff A verified that the only testing logs available for cart #7 meters revealed no testing for accuracy of the meters had been done since 11/20/18. She stated she could not say whether the testing completed for Resident #623 was an accurate test. On 11/29/18 at 11:40 a.m. an interview was conducted with Staff B, Licensed Practical Nurse (LPN) Unit Manager. Staff B stated that the machines are to be checked by the night shift for accuracy and documented on the logs. She verified that the last testing was done on 11/20/18 as seen in the logs. She was asked for a policy related to the testing of the machines and she stated she would bring it to the surveyor. On 11/29/18 at 11:55 a.m. the Director of Nursing (DON) was asked to provide the policy for accucheck testing, the manufacturer's book, and the logs for the medication carts #1-6. On 11/29/18 at 1:02 p.m. all logs were provided for review. On 11/29/18 1:04 p.m. the DON stated that the night shift is to complete the testing on all accucheck machines at least 2-3 times a week according to policy and whenever there is a new bottle of testing strips opened. She stated she should have seen that the testing was not being conducted. She stated that there was a breakdown in the way the testing was being done and that it would need to be done regularly and some education for staff would to be completed. She confirmed that the meter testing was not being completed according to guidelines. She verified that the log indicated that testing was not completed on the cart #7 accucheck meters. She verified that she reviewed the logs for carts #1-6 and there were indications the glucometer testing was not being completed per policy on other carts in the facility. On 11/30/18 at 7:56 a.m. the DON spoke with the team lead for the survey and stated she spoke with all the nurses responsible for carts 2, 3, and 7. She stated that she reprimanded and in-serviced the nurses related to the glucometer meter testing and she stated the nurses told her that they don't know why they did not monitor them as they should have. A review of Manufacturer's Instruction Manual for Assure Platinum Blood Glucose Monitoring System P. 21 Use Assure Dose Control Solutions to check if: The meter and test strips are working correctly as a system You are testing correctly P. 22 Perform a Control Solution Test Before testing with the Assure Platinum System for the first time When you open a new bottle of test strips Whenever you suspect the meter or test strips may not be functioning properly If test results appear to be abnormally high or low or are not with clinical symptoms A review of Policy titled: Finger Stick 8/7/2005 Purpose: To obtain a blood sample to determine the resident's blood glucose level Pre-Procedure: Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility. Glucometers should be calibrated nightly on 11-7 shift (REQUIRED minimally 2-3 times per week)

Based on observations, interviews and record review the facility failed to maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner in two of seven medication carts. Findings included: On 11/30/18 at 12:00 p.m. an observation of the B Wing medication cart #3 was conducted. Staff C, Licensed Practical Nurse (LPN), was present during the observation. A round yellow pill and a round white pill were observed in drawer #3 of the medication cart. Photographic evidence was obtained. Two white round pills, a white capsule, a round yellow pill, an oval white pill and an oval blue pill were observed in two different areas of drawer #4 of the medication cart. Photographic evidence was obtained. An interview was conducted with Staff C, LPN. The nurse stated that she was responsible for checking and cleaning her medication cart. The nurse then removed the loose pills from the drawers and disposed of them. On 11/30/18 at 12:10 p.m. an interview was conducted with Staff D, LPN Unit Manager. She stated the nurses were expected to check their carts for loose pills. She stated that when loose pills are found they need to be disposed of by the nurse according to policy. She stated that disposal was to be done in the medication room and placed in the liquid disposal jar. On 11/30/18 at 12:25 p.m. an observation of the C Wing medication cart #6 was conducted. Staff E, Registered Nurse (RN) was present during the observation. A round white pill was observed in the over the counter (OTC) medication drawer of the medication cart. Photographic evidence was obtained. Two white oval pills and two white round pills were observed in Drawer #1 of the medication cart. Photographic evidence was obtained. An interview was conducted with Staff E, RN. The nurse stated he was responsible for checking and cleaning out the medication cart. The nurse then removed all the loose pills from the drawers and disposed of them. On 11/30/18 at 12:30 p.m. the DON approached surveyor and stated that she had personally checked all of the medication carts in the morning and had not seen any loose pills. She verified that loose pills pop out of the medication packets and that they are to be cleaned out by the nurse and disposed of properly according to policy. A review of the Medication Storage Policy provided by the facility on 11/30/18 at 4:40 p.m. with no dates on document revealed the following: Title: Storage of Medications Purpose: The purpose of this procedure is to ensure that medications are stored in a safe, secure, and orderly manner. General Guidelines: 1. Medications are stored in the containers in which they are received. 6. Medications are stored in an orderly manner in cabinets, drawers or carts.

Based on review of the Resident Care Plan Conferences and interview with the Minimum Data Set Coordinator, the facility failed to facilitate the participation or inclusion of the physician and C.N.A. in care plan meetings for 8 (#101, #57, #120, #39, #184, #173, #275, #222) of 27 sampled stage II residents. Findings included: 1. On 09/29/2017 beginning at 12:45 p.m., in an interview with the MDS (Minimum Data Set) Coordinator, it was revealed that usual attendees at the care plan meetings included the resident and/or family or responsible parties, the unit manager, social services, dietitian or diet technician and therapy manager. When asked if the physician was usually invited and attended, the Coordinator reported that they weren't invited and she didn't think they would attend. When asked if the nursing aide who usually worked with the resident attended, the Coordinator said no. Interview with the Director of Nursing on 09/29/17 beginning at 1:45 p.m. revealed that she was aware of facility staff that should attend the care plan. She reported the facility was working on how to have all required staff attend, but they were not including the aide or physician yet. 2. Resident # 101 was admitted to the facility on [DATE], per the facesheet. His care plan meeting was held on 08/09/17, and per the sign in sheet, his family attended, as well as the Therapy Director, the Registered Dietitian, the unit manager and the Social Services Director. Neither the physician nor the resident's usual aide attended. 3. Resident # 57 was admitted to the facility on [DATE] with the most recent care plan meeting held on 06/22/2017. Per the sign-in sheet, the resident's daughter attended, as well as the unit manager, the Diet Technician and the Activities Director. The physician and the aide did not sign as having attended. 4. Resident # 120 was admitted to the facility on [DATE] with the most recent care plan meeting held on 08/16/2017. Per the sign in sheet, the resident signed as having attended. Also in attendance was the Unit Manager, the Activities Director and the Diet Technician. The physician and the aide did not sign as having attended. 5. Resident #39 was admitted on [DATE] with readmission on 10/9/15, 9/6/16, and 9/16/16, per the facesheet. Review of the clinical record indicated [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS), dated [DATE], found a Brief Interview for Mental Status (BIMS) score of 6 (severe impairment). Record review of the Care Plan Conference, held on 8/29/17, reflected that the following attended the meeting: Unit Manager, daughter, resident, resident's spouse, Activities Director, and social services. The physician, direct-care nurse and certified nursing assistant (CNA) were not, however, involved in the care planning process. 6. Resident #184 was admitted on [DATE], per the facesheet. The clinical record indicated [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS), dated [DATE], found no BIMS score for resident. Record review of the Care Plan Conference, held on 7/6/17, reflected the following attended: Activity Director, Dietary Technician, and previous Unit Manager and revealed the physician, direct-care nurse and the CNA were not involved in the care planning process. 7. Resident #173 was admitted on [DATE] with readmission on 1/18/17, per the facesheet. Review of the clinical record reflected [DIAGNOSES REDACTED]. Record review of the quarterly MDS, dated [DATE], indicated no BIMS score for resident. Record review of the Care Plan Conference, held 9/27/17, showed the following attended the meeting: Unit Manager, Social Services Director and Dietary Technician. The attendees listed revealed the physician, direct-care nurse, and CNA were not involved in the care planning process. 8. Resident #275 was admitted on [DATE] with readmission on 3/17/17, 5/22/17, and 9/5/17, per the facesheet. The clinical record reflected [DIAGNOSES REDACTED]. Record review of a quarterly MDS, dated [DATE], indicated a BIMS of 13 indicating intact cognition. Record review of the Care Plan conference, held 9/18/17, showed the following attended the meeting: Registered Dietitian, Director of Rehabilitation, family member, and Unit Manager. The attendees list revealed the physician, direct-care nurse, and CNA were not involved in the care planning process. 9. Resident #222 was admitted on [DATE] with readmission on 9/21/16, 12/25/16, and 1/7/17, per the facesheet. The clinical record indicated [DIAGNOSES REDACTED]. Record review of the care plan conference, held 7/13/17, showed the following attended: Social Service Director, Activity Director, Dietary Technician, and Unit Manager. The attendee list revealed the physician, direct-care nurse, and the CNA were not involved in the care planning process.

Based on observation, interview and policy review, the facility failed to ensure that during the laundering process linens were handled according to policy and in a way that would prevent cross-contamination of clean and dirty laundry, during one (09/28/2017) of four survey days. Findings included: On 9/28/17 at 11:31 a.m., an observation of the facility laundry with the Housekeeping Director revealed laundry from soiled linen barrels was being loaded into washers. An observation was noted of staff member A, wearing gloves, pink scrub pants and top, with no apron or gown covering clothes, filling the washer with white linens. Continued observation was made of the laundry area with the Housekeeping Director in the dryer room, which was separated from the washer room by a door. Staff member A entered the dryer room, removed her gloves and began emptying tan-colored towels from the dryer. The Housekeeping Director stated that the staff washed her hands after handling the dirty laundry and before entering the dryer room. When asked if staff wore any barrier when dealing with clean or dirty laundry, both Housekeeping Director and staff member A replied no. Staff member A confirmed that she did not wear a clothing barrier, and she tried not to have dirty laundry touch her uniform but on occasion it does . Staff A opened the dryer door, stood to the side with a clean laundry bin in front of the dryer and reached into the dryer to remove towels which touched the front of her shirt. The Housekeeping Director confirmed the Surveyor's concern by saying, I see what you mean. Staff member A stepped further back from the clean laundry bin and continued to pull towels from dryer. The Housekeeping Director asked staff member A if the protective gowns were still present in the room, while looking on the shelving unit behind laundry bin. Staff member A stated she did not know if the gowns were there. The Housekeeping Director indicated when an isolation room has a soiled linen barrel in it, staff bring the barrel to laundry and bags holding the linens are emptied straight into washer. Review of the facility's Social Services Manual, revised in November 2010, revealed the section entitled, Laundry and Bedding Soiled, with the policy statement: Soiled laundry-bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. The Policy Interpretation and Implementation, point #4 stated : Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely). Review of the facility's Housekeeping Policy and Procedure, dated 10/01/2000, revealed the Laundry manual, section entitled, Contamination Sources In Linen, stated: Once soiled linen has been deposited it can serve as a source of contamination to clean linen and the center by: #2, people who handle both soiled and clean linen. In an interview conducted with Director of Nursing (DON) and Infection Control Assistant Director of Nursing on 9/29/17 at 9:46 a.m. the observation made in the laundry area on 9/28/17 was described. Both facility staff stated that staff are supposed to wear isolation gowns and gloves when handling dirty laundry. The DON stated that she would speak with the Housekeeping Director regarding the incident.

Based on observation, interviews, policy review, and record review the facility did not ensure it followed professional standards for medication administration for 3 (#18, 175, and 189) of 4 residents observed during medication administration, on 2 (#B and C) of 3 nursing units. Findings included: 1. The 2015 Florida Nurse Practice Act; Florida Statutes chapter 464.003 includes: (16) Licensed practical nurse means any person licensed in this state to practice practical nursing. (19) Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist; and the teaching of general principles of health and wellness to the public and to students other than nursing students. A practical nurse is responsible and accountable for making decisions that are based upon the individual ' s educational preparation and experience in nursing. (b) 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. 2. Review of the Omnicare Policy, General Dose Preparation and Medication Administration, dated 2013, revealed the following: Procedure: 3. Dose Preparation: Facility should take all measures required by Facility policy and applicable Law, including, but not limited to the following: 3.7 Facility staff should verify that the medication name and dose are correct and should inspect the medication for contamination, particulate matter, discoloration or defects. 3.10 Staff should not split tablets. 3.10.1 The pharmacy should be contacted to provide the correct dose. 4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1 Facility staff should; 4.1.1 Verify each time a medication is administered that it 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 Administration Times Schedule. 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 5.4 Administer medications within timeframes specified by Facility policy; 5.8 Follow manufacturer medication administration guidelines The Policy, Medication Administration Times, dated 2013 revealed: Applicability: This policy 6.2 sets forth the procedures related to medication administration times. 1. Facility should ensure that authorized personnel, as determined by Applicable Law, administer medications according to times of administration as determined by Facility's pharmacy committee and/or Physician/Prescriber. 2. Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed by sixty (60) minutes after the designated times of administration. 3. Resident # 189 was admitted to the facility with [DIAGNOSES REDACTED]. Inject per sliding scale AC+HS (before meals and at bedtime) Everyday at 7:30 a.m. 11:00 a.m. 4:00 p.m. 9:00 p.m. 0-180=0U (units) 181-240=2U. On 01/31/2017 at 11:40 a.m., an observation was conducted during insulin administration with Staff V, LPN (Licensed Practical Nurse). Staff V, LPN reviewed Resident #189 ' s MAR (medication administration record) for the insulin sliding scale orders, and stated the resident needed 2 units of insulin. She pulled the insulin, [MEDICATION NAME], from the medication cart. She obtained a capped, sealed needle, an alcohol wipe, and gloves. She sanitized her hands, removed the seal from the container with the needle in it and screwed it onto the insulin pen. She wiped the residents left upper outer arm with the alcohol wipe after asking him which arm he preferred to receive the insulin in. She dialed the [MEDICATION NAME] to 2 units. She removed the cap and administered the insulin in his left upper outer arm, subcutaneously. She did not prime the insulin pen before giving him the injection. In an interview with Staff V, LPN on 01/31/2017 at 11:57 a.m., revealed: she said the insulin pens are prefilled; they are pre-primed. Review of the resident's MAR (medication administration record) dated 1/31/2017 revealed his 11:00 a.m. blood sugar was 186. Staff V, LPN documented 2 units had been given. Review of the manufacturer's instructions for [MEDICATION NAME], at www.[MEDICATION NAME].com revealed the following: Instructions: Step 2: Doing the airshot before each injection. Turn the dose selector to 2 units. Hold your [MEDICATION NAME] with the needle pointing up, and tap the cartridge gently a few times, which moves the air bubbles to the top. Press the push-button all the way in in until the dose selector is back to 0. A drop of insulin should appear at the tip of the needle. Step 3: Selecting your dose The dose selector should be set at 0. Turn the dose selector to the number of units you need to inject. The pointer should line up with your dose. The following information was found on https://www.drugs.com: Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin [MEDICATION NAME] ([MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about an hour, and keeps working for 2 to 4 hours. It is used to improve blood sugar control in adults. 4. Resident #175 was admitted to the facility with [DIAGNOSES REDACTED]. [MEDICATION NAME] Hcl 0.1 mg tablet give 1 tablet (0.1mg) by oral route 2 times per day for SBP (systolic blood pressure) greater than 120 Every day at 9:00 a.m. and 5:00 p.m. [MEDICATION NAME] 1 mg tablet give 1 tablet (1 mg) by oral route 2 times per day Every day at 9:00 a.m. and 5:00 p.m. [MEDICATION NAME] ER 60 mg tablet, extended release 24 hour give 1 tablet (60 mg) by oral route every 12 hours Everyday at 9:00 a.m. and 9:00 p.m. [MEDICATION NAME] 20 mg tablet give 1 tablet (20 mg) by oral route every 12 hours Hold for SBP less than 110 or HR (heart rate) less than 60. Every day at 9:00 a.m. and 9:00 p.m. On 02/01/2017 at 11:43 a.m., an observation during medication administration with Staff W, LPN for Resident #175, revealed she had administered the above medications 2 hours and 43 minutes past the scheduled administration time on the physician's orders [REDACTED]. The following information was found on https://www.drugs.com: [MEDICATION NAME] lowers blood pressure by decreasing the levels of certain chemicals in your blood. This allows your blood vessels to relax and your heart to beat more slowly and easily. It is used to treat hypertension. [MEDICATION NAME] is a diuretic that inhibits the sodium and chloride resorption. It is used to treat [MEDICAL CONDITION] (fluid retention) and high blood pressure. [MEDICATION NAME] ER is a Calcium channel blocker and antihypertensive drug used to treat high blood pressure and chest pain ([MEDICAL CONDITION]). [MEDICATION NAME] is an ACE (angiotension converting enzyme) inhibitor. It is used to treat high blood pressure and [MEDICAL CONDITION]. 5. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. [MEDICATION NAME] 10 mg tablet give 1 tablet (10 mg) by oral route once daily hold SBP less than 100. Every day at 9:00 am. [MEDICATION NAME] 25 mg tablet give 1 tablet (25 mg) by oral route 2 times per day Every day at 9:00 a.m. and 5:00 p.m. [MEDICATION NAME] 40 mg tablet give 1 tablet (40 mg) by oral route once daily (give with 20 mg to equal 60 mg) Every day at 9:00 a.m. [MEDICATION NAME] 20 mg tablet give 1 tablet (20 mg) by oral route once daily (give with 40 mg to equal 60 mg) Every day at 9:00 a.m. The following information was found on https://www.drugs.com: [MEDICATION NAME] is an ACE (angiotension converting enzyme) inhibitor. It is used to treat high blood pressure and [MEDICAL CONDITION]. [MEDICATION NAME] is a beta-blocker that affects the heart and circulation. It is used to treat [MEDICAL CONDITION], hypertension, and for the treatment or prevention of a [MEDICAL CONDITION]. [MEDICATION NAME] is a loop diuretic (water pill) that prevents your body from absorbing too much salt. It is used to treat fluid retention ([MEDICAL CONDITION]) in people with [MEDICAL CONDITIONS], liver diseases, or a kidney disorder. On 02/01/2017 at 12:05 p.m. an observation during medication administration with Staff W, LPN for Resident # 18 revealed she had administered the above medications 3 hours and 5 minutes past the scheduled administration time on the physician's orders [REDACTED]. On 02/01/2017 at 12:38 p.m., during an interview with Staff W, LPN she confirmed the medications were due at 9:00, and stated the residents can be difficult to find. She was asked if there was anything else she needed to do when she was late with the medications and she said no. Review of the Facility Medication Administration Times Schedule, dated 2013, revealed: Once a day/Daily 9 AM 2 times a day/BID 9 AM, 5 PM Every 12 hours 9 AM, 9 PM.