Every finding on record at Solaris Healthcare Windermere

Based on observation, interview, and record review, the facility failed to ensure implementation and performance of appropriate isolation precautions including standard and enhanced precautions for infection prevention and control, for 3 of 3 residents reviewed for transmission-based precautions, of a total sample of 38 residents, (#132, #134, and #5).Findings: 1. Resident #132 was admitted to the facility on [DATE] with diagnoses that include Enterocolitis due to Clostridium difficile, hypertensive chronic kidney disease, adult failure to thrive, immunodeficiency and malignant neoplasm (cancer) of the left kidney. Review of the medical record revealed resident #132 had a current physician order for Contact Precautions. Review of the current Plan of Care reflected an approach for Contact Isolation Precautions as ordered. On 6/15/26 at 11:25 AM, the signage outside resident #132's room indicated the resident was on Contact Precautions. The sign instructed staff to put on gowns and gloves before room entry. Licensed Practical Nurse (LPN) A was observed in resident #132's room without a gown and gloves and upon her exit, she stated she did not need to wear Personal Protective Equipment (PPE) because she was just giving the resident a drink. The nurse explained in the presence of the Staff Educator/Developer nurse who was also the Risk Manager, that she only wore PPE when giving direct care to residents. Contact precautions are intended to prevent transmission of pathogens that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment (e.g., C. difficile, norovirus, scabies), and requires the use of appropriate PPE, including a gown and gloves before or upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed and hand hygiene is performed, (retrieved on 6/19/26 from State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities). On 6/17/26 at 1:30 PM, in a joint interview with the Director of Nursing (DON), the Infection Preventionist (IP) nurse and the Staff Educator/Risk Manager, they acknowledged the expectation for a resident on contact precautions, was for staff including LPN A to wear the appropriate PPE regardless of the task performed and regardless of whether she provided direct care to the resident to avoid the spread of infectious agents. 2. Resident # 134 was re-admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer) of connective and soft tissue of right lower limb, including hip, osteoarthritis of knee, unspecified; secondary malignant neoplasm of unspecified lung, anxiety disorder and chronic viral hepatitis. Review of resident #134's medical record revealed no current orders for isolation precautions. Review of the current plan of care for resident #134 revealed an approach for Contact Isolation precautions as ordered on 6/12/26. On 6/15/26 at 10:06 AM, resident # 134 had an intravenous (IV) midline to his right upper arm and said he received antibiotics through the midline. The resident had a dressing on his right lower leg. No isolation precaution sign was outside the resident's door to indicate to staff or visitors that precautions were needed. Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi drug resistant organisms (MDRO) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs, (retrieved on 6/19/26 from State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities). On 6/15/26 at 4:23 PM, assigned nurse LPN B explained resident #134 had a wound and received antibiotics through a midline IV. The nurse acknowledged due to the midline and wounds that resident #134 should be on isolation precautions. She confirmed there were no signs outside the resident's door nor were there any orders for isolation precautions, earlier that morning when she assumed care. Review of the physician's orders revealed an order was placed on 6/15/26 at 1:50 PM for EBP. On 6/17/26 at 1:30 PM, during a joint interview with the DON, the IP nurse and the Staff Educator/Risk Manager, they acknowledged the order for EBP was not placed until Monday 6/15/26 in the afternoon. They all confirmed the expectation was for EBP to be ordered and implemented upon admission and not five days later. They were unaware of the current care plan that showed an approach for Contact Isolation and said they would look into it. 3. Resident #5 was admitted to the facility on [DATE] with diagnoses to include Klebsiella pneumoniae, urinary tract infection (UTI), and extended spectrum beta lactamase (ESBL) infection. Klebsiella pneumoniae is a type of bacteria that can cause pneumonia, UTIs, wound infections and other illnesses. Some can be severe and hard to treat with antibiotics. Klebsiella naturally lives in your gut and respiratory tract. It most often spreads from person to person or through contaminated medical devices, (retrieved on 6/18/26 from www.myCleveland clinic.org). Extended-spectrum beta-lactamases are enzymes or chemicals produced by germs like certain bacteria. These enzymes make bacterial infections harder to treat with antibiotics, (retrieved on 6/18/26 from www.webmd.com). On 6/15/26 at 1:15 PM, the signage outside resident #5's door indicated the resident was on EBP. The sign detailed PPE was required to be used by staff during high contact activities with the resident. On 6/16/26 at 10:30 AM, the signage outside resident #5's room had been changed to Contact Isolation. The new sign indicated PPE was required to be used anytime from entrance to the room until exit from the room. On 6/18/26 the signage outside resident #5's room was again changed to EBP. Review of the physician orders on 6/17/26 revealed an order for Contact Isolation (for ESBL) from 6/15/26 to 6/17/26. On 6/18/26 at 11:30 AM, the Infection Preventionist nurse stated, nurses were responsible for the signs being placed for the type of isolation ordered by the physician for the residents. She said that wound or other cultures usually took two days and the results were sent to the physician who might change the orders based on the results. The nurse explained resident #5's culture came back and the EBP was changed to Contact Precautions. She stated it was changed back to EBP on 6/17/26 because resident #5's antibiotics were completed. She confirmed she was not aware resident #5 had a physician order for Contact Precautions from 6/15/26 to 6/17/26. The facility's policy on transmission-based precautions, reviewed 12/08/25 indicated Contact precautions were intended to prevent transmission of pathogens that spread by direct or indirect contact with the resident or the resident's environment. PPE utilized included gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. The facility's policy for Enhanced Barrier Precautions, reviewed 12/08/25 indicated Enhanced Barrier precautions was an approach of targeted gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition.

Based on observation, interview, and record review, the facility failed to ensure physician orders were obtained for safe self-administration of medications for 2 of 4 residents reviewed for choices, of a total sample of 47 residents, (#46, and #81). Findings: 1. Resident #46, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including epilepsy, depression, and adjustment disorder with anxiety. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference date (ARD) of 4/23/24 revealed the resident's cognition was intact with a Brief Interview of Mental Status (BIMS) score of 14/15. The assessment noted the resident was independent, and only needed supervision or touching assistance from staff for her activities of daily living (ADL), and mobility needs. On 7/08/24 at 11:58 AM, and on 7/09/24 at 9:29 AM, resident #46 was sitting on the side of her bed. Noted on her tray table was a plastic bag with a pharmacy label that contained a tube of Hydrocortisone cream 2.5 %. Resident #46 said she applied the cream herself twice daily, and she needed a refill as the current tube would be completed soon. Review of the medical record revealed a physician's order dated 5/15/24 for Hydrocortisone 2.5 %. The order directed one application could be given twice daily as needed, to be applied to the affected areas of the body for itching. Hydrocortisone cream is used to treat a variety of skin conditions (such as . eczema, dermatitis, .rash). Hydrocortisone reduces the swelling, itching, and redness that can occur (retrieved on 7/12/24 from webmd.com). On 7/09/24 at 10:41 AM, observation of the Hydrocortisone cream on the resident's tray table was conducted with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) B, the resident's primary nurse. They acknowledged the findings, and the resident reiterated that she applied the cream herself twice daily. On 7/09/24 at 10:45 AM, a review of the resident's physician's orders was conducted with the DON which revealed the order for Hydrocortisone cream twice daily as needed. The DON verbalized there were no directives or order for self-administration of the medication. On 7/09/24 at 10:46 AM, LPN B stated in order for residents to self-administer medications, they were supposed to have a physician's order for self-administration. She explained the resident had to demonstrate the ability to perform the task, then the medication would be placed in a locked drawer in the resident's room. She said, the resident would then administer the medication in the presence of the nurse. LPN B acknowledged resident #45 did not have a physician's order for self-administration of the Hydrocortisone cream. On 7/09/24 at 11:17 AM, the DON stated a medication self-administration evaluation was completed for resident #46 in May 2024, however, a physician's order was not obtained for self-administration of the Hydrocortisone cream. A review of the resident's Medication Administration Summary for the period 5/14/24 through 7/09/24 revealed no documentation by nurses to indicate the Hydrocortisone cream was ever administered, either by staff or the resident. This was in conflict with resident #46's verbalizations she had applied the cream twice a day. This finding was acknowledged by the Unit Manager, and LPN B. 2. Resident #81, an [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on 5/31/24. Her diagnoses included Parkinson's disease, respiratory failure, chronic pulmonary edema, dementia, fibromyalgia, stage 4 pressure ulcer, and osteoarthritis. Review of the resident's discharge- return anticipated MDS assessment with ARD of 5/26/24, revealed the resident's cognitive skills for daily decision making was moderately impaired, and she required substantial/maximal assistance from staff for some ADLs, and mobility needs. Review of the medical record revealed a physician's order dated 5/31/24 was for acetaminophen (Tylenol) 325 milligrams (mg) three times daily, as needed for mild pain. On 7/08/24 at 12:08 PM, resident # 81 was sitting up in bed. The resident's family member stated he had fast acting Tylenol locked in a drawer, and he had permission to give the Tylenol to the resident as needed. On 7/09/24 at 10:19 AM, LPN A stated for a resident to self-administer medications, the resident would be assessed for competency to give the medication, a physician's order had to be obtained, and a care plan would be developed for self-administration of medication. LPN A stated if a family member was allowed to administer medication to the resident, the family member would have to inform the nurse when the medication was given. The LPN reviewed the resident's physician orders and acknowledged there was an order for Tylenol three times daily, as needed and verbalized there was no documentation to indicate the family/resident could self-administer the medication. She stated she was not aware the family had administered Tylenol to the resident. On 7/09/24 at 10:30 AM, an observation was conducted in the resident's room with the DON, and LPN A. The resident's family member was in the room, and stated the DON gave him permission to give the resident the Tylenol as needed and shared the Tylenol was in the bedside table drawer. After the observation and interview with resident #81's family member, the DON stated when the resident was first admitted , orders were in place for the family to self-administer the resident's medications. The resident's physician's orders were reviewed by the DON, and she stated the Tylenol order currently in place, was for staff to administer the medication. She acknowledged a physician's order for family administration of the medication was not present. The facility's Admission handbook revealed documentation pertaining to the facility's policies regarding self-administration of medication and medication storage at bedside. The document directed that, A physician's order is required for all medications being administered or self-administered .includes over-the-counter medications and patches, lotions/creams, inhalers, eye drops, etc.

Based on observation, interview, and record review, the facility failed to follow the individualized plan of care to maintain and prevent decline in range of motion (ROM) for 2 of 3 residents reviewed for limited ROM from a total sample of 41 residents, (#1, #49) Findings: 1. Review of resident #1's medical record revealed the resident was admitted [DATE] and readmitted to the facility from the hospital on 1/03/2023 with diagnoses of right hand contracture, functional quadriplegia, paraplegia, Parkinson's disease, osteomyelitis, and dementia. The Minimum Data Set (MDS) significant change assessment with Assessment Reference Date (ARD) 1/07/2023 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment showed the resident did not have any behaviors or reject care. The assessment indicated the resident was dependent on staff for activities of daily living (ADL), had functional limitations for ROM in his arms and legs on both sides of his body, and on 1/04/2023 the resident began treatment and services for Occupational Therapy (OT). On 3/20/2023 at 12:57 PM, resident #1 was observed with his eyes closed lying in bed. Both arms were placed across his chest. Both wrists were bent inward and the fingers on both hands were very close to his forearms. Review of resident #1's care plan dated 4/04/2016 to 3/23/2023 read, at risk for continued decline in functional mobility . , noted impaired ROM to bilateral upper and lower ext (extremities). The care plan included Interventions to provide ROM to maintain joint mobility, and splint treatment for contractures. Review of the Occupational Therapy Discharge Summary completed by Occupational Therapist C showed the resident was discharged from OT services on 2/01/2023. The note indicated the resident was to continue an established ROM program through trained nursing services for passive range of motion to both upper extremities to prevent further contractures, pain and maintain ROM. On 3/22/2023 at 11:58 AM, Restorative Certified Nursing Assistant (CNA) A said she was responsible for providing restorative nursing services to residents for ROM. She explained individualized treatment plans were created by therapy services and she kept a copy of each resident's plan in a binder with paper monthly logs to document dates she provided care. She stated the logs were scanned to the medical record at the end of each month. She recalled resident #1 had contractures and had required a splint that was recently discontinued by therapy services. She could not recall if the resident received ROM care and services. Review of the electronic medical record showed a scanned form titled, Referral to Restorative - Occupational Therapy signed by Occupational Therapist C on 2/01/2023 and Restorative CNA A on 2/07/2023. The form outlined resident #1's individualized plan of care that included education for passive ROM provided to both upper extremities for 15 repetitions, 3 to 5 times per week so the resident will, maintain ROM to continue to assist with ADL's, prevent pain, further contractures, and increased perceived quality of life. The electronic medical record did not include scanned monthly logs to show if restorative therapy was provided for resident #1. On 3/23/2023 at 2:32 PM, the facility could not provide any monthly log forms for resident #1. 2. Review of resident #49's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses of hemiplegia and hemiparesis following stroke affecting left non-dominant side, osteoarthritis, vascular dementia, and anxiety. The MDS quarterly assessment with ARD 2/10/2023 noted the resident had moderate cognitive impairment with a BIMS score of 8 out of 15. The assessment showed the resident did not have behavioral symptoms or reject care, was dependent on staff for ADL, and had functional limitations for ROM in his arms and legs on one side of his body. The assessment indicated resident #49 did not receive therapy, ROM, or splint/brace assistance during the look back period. On 3/22/2023 at 9:54 AM, resident #49 was observed awake while lying in bed. A splint was observed sitting on the resident's overbed table. Review of resident #49's care plan dated 9/19/2017 to 3/23/2023 read, noted with self care deficit r/t (related to) CVA (stroke) with left side weakness; at risk for further decline in functional mobility . The care plan included Interventions, hand splint during waking hours . Review of the Occupational Therapy Discharge Summary completed by Occupational Therapist C showed the resident was discharged from OT services on 1/27/2023. The note indicated the resident was to continue an established restorative program through trained nursing services for ROM, left hand splint and brace so the resident will, continue to benefit. Review of the Physical Therapy Discharge Summary completed by Physical Therapist D showed the resident was discharged from Physical Therapy services on 1/09/2023, and was to continue a bedside exercise program through trained nursing services for ROM. The note read resident #49 had, made substantial functional gains in response to skilled interventions. Review of the electronic medical record showed Referral to Restorative - Occupational Therapy form signed by Occupational Therapist C on 1/27/2023 and Restorative CNA A on 1/31/2023. The form outlined resident #49's individualized plan of care included education for Active ROM for right upper extremity and passive ROM for left upper extremity provided to both for 2 sets of 15 repetitions, and a splint/brace program for a left hand splint so the resident will, maintain ROM to continue to assist and participate from desired ADLs, and increase perceived quality of life. Review of the Restorative Therapy binder provided by CNA A contained a document with resident #49's name titled, Restorative Nursing Program Record dated 3/01/2023 to 3/22/2023. The form was signed by Restorative CNA for dates, 3/2/2023, 3/6/2023, 3/13/2023, 3/14/2023, 3/17/2023, 3/21/2023, and 3/22/2023 noting under a column titled minutes, 30/12 was provided. Review of the electronic medical record did not include any other scanned monthly log forms to document individualized ROM or splint/brace services were provided to resident #49. On 3/22/2023 at 11:46 AM, the [NAME] Unit Manager said nurses did not oversee the restorative therapy program. She explained a restorative CNA received the tasks from therapy and nursing did not document if those services were provided. On 3/23/23 at 10:46 AM, the Director of Nursing (DON) said nursing provided general ROM during ADL assistance for all residents with no individualized directions or plan of care. On 3/23/23 at 10:47 AM, the MDS Coordinator stated the MDS assessments reviewed for residents #1 and #49 were coded correctly, and there was no documentation to show restorative services for ROM or splint/brace were provided. On 3/23/2023 at 2:32 PM, the DON said there were no other restorative program monthly logs of services provided for residents aside from the March 2023 logs contained in Restorative CNA A's binder. On 3/23/2023 at 11:25 AM, the Therapy Director said therapy services established restorative programs for ROM that were individualized to the resident's needs to establish a baseline, maintain functioning, and prevent decline. He stated the expectation was that the treatment plan continued per the recommendations, and explained the risk of decline and decompensation was high if a resident did not receive the services. The facility's policy and procedure titled, Restorative Nursing Services, read, 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. The Facility's Assessment read, Part 2. Services and Care We Offer Based on our Residents' Needs . Activities of daily living . supporting resident independence in doing as much of these activities by himself/herself., and Therapy. management of braces, splints.

Based on interview, and record review, the facility failed to accurately reflect the resident's life expectancy and hospice services on the Minimum Data Set (MDS) Assessment for 1 of 41 sampled residents, (#62). Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and heart failure. The facility had a care plan in effect for Hospice since 11/2/21. The physician certified most recently from 12/27/22 to 2/24/23 and 2/23/23 to 4/25/23 that resident #62 had life expectancy of 6 months or less if the disease takes its natural course. Review of the most recent quarterly MDS assessment dated [DATE] section J-Prognosis reflected that she did not have life expectancy of less than 6 months and section O-Special Treatments, Procedures, and Programs indicated the Hospice was not checked to indicate she received services. On 3/22/23 at 4:21 PM, the MDS Coordinator acknowledged that sections J and O of the MDS quarterly assessment dated [DATE] were not accurate. Review of the Resident Assessment Instrument version 3.0 Manual instructions for completing Section J 1400: Prognosis should be marked Yes if the medical record includes physician documentation that resident is terminally ill or the resident is receiving hospice services. The instructions pertaining to Section O 100K: Hospice Care read, Code residents identified as being in a hospice program for terminally ill persons .

Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent accidents for 1 of 6 residents reviewed for falls with injuries out of 49 sampled residents, (#7). Findings: Resident #7 was admitted to the facility on [DATE], with diagnoses that included history of falls, right [CONDITION(S)], dementia and adjustment disorder with anxiety. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], indicated resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. He required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit and toilet use. Resident #7 was assessed to have unsteady balance and was only able to stabilize with staff assistance for transfers. Resident #7 used an assistive device, a walker, for ambulation. A Significant Change in Status MDS assessment dated [DATE], was completed after resident #7 sustained a fall on 4/20/21, resulting in a left humerus fracture. At that time, the resident was assessed to have a BIMS score of 5 decreased from 7 on the previous assessment. Resident #7 now required more assistance from staff and was totally dependent on two staff for transfers and toileting. Review of the Fall Care Plan dated 2/4/21, revealed resident #7 had been assessed to be a fall risk related to history of falls, impaired cognition, poor safety awareness, unsteady balance, incontinence and required extensive assistance with care. Intervention dated 2/4/21, included remind the resident to call for assistance by using the call bell and cue for safety awareness even though the care plan indicated he had impaired cognition and poor safety awareness. The Care Plan directed staff to assist with mobility, transfers and locomotion but did not specify number of staff required to assist. Review of resident #7's Resident Profile under Falls, the instruction sheet for Certified Nursing Assistants (CNAs) to provide care indicated staff were to keep call light in reach and encourage resident to call for assistance. On 5/10/21 at 10:37 AM, resident #7 was observed lying in his bed with a sling around his left shoulder and arm. He stated he fell and hurt his shoulder, but was unable to recall when, where or how the accident happened. During an interview and review of Incident Reports and Investigations on 5/13/21 at 8:30 AM, the Risk Manager (RM) stated resident #7 had 5 falls in the facility on 2/5/21, 2/11/21, 4/11/21, 4/19/21 and 4/20/21. The facility's investigation revealed on 2/5/21 at 10:36 AM, CNA F transferred resident #7 from bed to wheelchair as a 1-person transfer. The resident started to fall, and the CNA F lowered the resident to the floor. CNA F then left the resident to get help to make the transfer from the floor to the bed. The resident was assessed by Licensed Practical Nurse (LPN I), transferred back to bed with help from rehab staff. The resident later complained of back pain and the physician ordered a mobile x-ray of the pelvis/lumbar spine. The result was no acute fractures or dislocation. Review of the care plan and the facility's investigation report revealed no new interventions were developed and implemented to prevent resident #7 from falling during transfers. The report did not provide a detailed account of the last time the resident had been observed by staff or how often the resident was monitored for safety due to his risk for falls. Review of the Progress Note dated 2/9/21, at 8:40 PM, indicated resident (#7) had a history of recent falls in the facility and was assessed to be confused at times. The note revealed the resident was re-educated to not ambulate without assistance from staff. Six days later, on 2/11/21 at 9:30 PM, LPN G found resident #7 on the floor next to his bed. The resident was assessed by LPN G and transferred back to bed with help from 3 CNAs. He complained of right leg pain and a mobile x-ray of the right leg was ordered and reviewed by the physician, who ordered a follow-up with the orthopedic surgeon The Fall intervention added after the fall was continue to make frequent room rounds. The intervention did not include the required frequency of room round to prevent subsequent falls. The report showed the last time the resident had been observed by staff was at 7:30 PM, two hours prior to fall. Review of the Progress Note dated 2/12/21 at 4:02 PM, the day after the second fall indicated resident #7 was to be reminded to use call light for assistance. The intervention was not appropriate due to the resident's cognitive status and was ineffective in preventing his falls on 2/5/21 and 2/11/21. On 4/11/21 at 11:45 PM, the investigation report showed resident #7 suffered a third fall. LPN H found resident #7 on the floor next to his bed. When asked what happened, the resident stated he did not know. The resident was assessed to have no injuries and transferred back to bed. No documentation was available regarding staff who transferred the resident back to bed. The care plan was updated to include labs to rule out an infection and provide a high low bed. The incident report showed a new intervention to reconfigure the room but there was no indication this was done. Eight days later, on 4/19/21, at 7:00 PM, LPN J was called to the room by resident #7's roommate's visitor. LPN J observed the resident leaning on the bed with his feet resting against the wall. LPN J lowered the resident to the floor, assessed him to have no injuries and assisted him back to bed. The new fall care plan intervention noted in the investigation report was a scoop mattress for his bed which was not transcribe to the care plan that day. The report did not provide a detailed account of the last time the resident had been observed by staff. Less than twenty-four hours later, on 4/20/21 at 3:00 PM, LPN I was called to resident #7's room by his roommate. The resident was on the floor lying on his back and stated he was trying to go to the bathroom. LPN I assessed the resident, who had a bulge to his left shoulder and was not able to lift his left arm. The resident was transferred back to bed by 4 staff members. The physician was called and ordered the resident be sent to the hospital. The care plan was updated on 4/20/21, to include a scoop mattress and restated the existing intervention of frequent room checks. The intervention did not include the required frequency of room rounds to prevent subsequent falls. Review of a Progress Note dated 4/24/21 at 6:28 PM read the resident returned to the facility with a diagnosis of left humerus fracture. Surgery had not been performed related to the arm being too swollen. A sling was in place along with an order to follow up with the orthopedic surgeon. Review of the care plans revealed no new fall prevention interventions were developed on readmission. On 5/13/21 at 8:30 AM, the RM was asked how the facility staff would know how often to observe resident #7 as related to the term frequent checks. The RM was unable to be specific as a definite time frame had not been determined by the Interdisciplinary Team. The Risk Manager also stated she failed to get witness statements from all staff involved in resident #7's falls regarding frequency of safety checks by staff. The Risk Manager was unable to explain how staff would have been able to determine how often the resident needed to be observed. She said, staff need to check on the resident when they pass water, deliver meal trays and answer call lights. The Risk Manager was unable to explain how a resident (#7) with severely impaired cognition was going to remember to use his call light for assistance before getting out of bed unassisted. On 5/13/21 at 10:27 AM, LPN H said she was assigned to resident #7 on the night of his third fall but she did not remember when she last observed the resident before finding him on the floor. She said, We are supposed to check on the resident every two hours and as needed. She did not explain what as needed meant. On 5/13/21 at 10:39 AM, LPN J stated she was assigned to the resident on the evening of the fourth fall and did not remember the last time the resident had been observed before the fall. On 5/13/21 at 11:45 AM, Registered Nurse (RN) O stated she understood there needed to be a predetermined time frame for staff to do the safety checks to ensure safety of resident #7. She was not able to define frequent room checks and unable to state how staff would know how often to check on the resident. On 5/13/21 at 11:50 AM, LPN P stated the definition of frequent was not explicit enough to determine how often staff were required to check on resident #7. Review of the facility's policy Safety and Supervision of Residents reviewed 1/7/20, read Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance are provided as facility-wide priorities. The document indicated staff would be trained and in serviced to prevent avoidable hazards. The policy read, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident.

Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 residents reviewed for IV care of a total sample of 49 residents, (#42). Findings: Resident #42 was readmitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a Midline IV line in the right arm for administration of IV antibiotics. He received [MEDICATION(S)] (IV antibiotic) daily through 5/9/21. He had additional orders in effect dated 4/7/21 for nurses to document the IV site appearance every shift (days and nights) and order dated 4/8/21 to flush IV every shift (days and nights). A midline catheter is put into a vein by the bend in the elbow or the upper arm .midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments .(www.drugs.com). On 5/10/21 at 1 PM, resident #42 was sitting in a wheelchair in his room. He had a transparent dressing on his right upper arm midline IV site dated 4/30/21. The transparent dressing had dime sized brown substance around the site, under the dressing. The resident was not able to be interviewed and his daughter was present at the bedside. She said the resident had been in/out of the hospital due to pneumonia and urinary tract infections. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses documented IV flushes and observations of the IV site and administered IV antibiotic on the day and night shifts. There was no documentation of any further attempts to change the outdated and soiled IV dressing. Resident #42's care plan initiated on 4/29/21 noted at risk of developing complication related to midline right upper extremity with goal the resident will not develop signs and symptoms of complications related to IV line. Interventions included to change IV site dressing as ordered and observe IV site every shift as needed for signs and symptoms of complications such as warmth, redness, [CONDITION(S)], drainage or pain. On 5/10/21 at 1:25 PM, Licensed Practical Nurse (LPN) B was in resident #42's room and observed his right upper arm midline dressing dated 4/30/21 with brown substance under the dressing. She said she flushed the IV today but did not look at the dressing. She stated the standard of practice was to change IV dressings every week or more often if soiled. On 5/11/21 at 3:38 PM, the Director of Nursing (DON) said that although the resident refused IV dressing change on 5/6/21, the nurses should have attempted to change the dressing again when they administered antibiotics and flushes. On 5/13/21 at 8:45, LPN C stated she worked nights and was assigned to resident #42 from 5/7 to 5/9/21. She said she had flushed the IV, checked the site and administered the antibiotics. LPN C said she did not change the dressing as it was not assigned to her. She acknowledged the standard of practice was to change dressings every 7 days to reduce chances of complications and infection. According to the facility policy and procedure for Midline Catheter Dressing Change revised 8/15/2008, The catheter insertion site is a potential entry site for bacteria that may cause a catheter related infection Licensed nurses caring for residents receiving infusion therapies are expected to follow infection control and safety compliance procedures Dressing changes using transparent dressings are preformed At least weekly Assessment of venous access site is performed before and after administration of intermittent infusions. At least once every shift when in use

Based on observation, interview and record review, the facility failed to ensure respiratory therapy was provided as per physician orders for 2 of 4 residents of a total sample of 49 residents, (#209, #210). Findings: 1. Review of resident #209's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/21 at 9:30 AM, resident #209 was observed in her room sitting up in wheelchair. She was alert and oriented to person, place, and time. She received oxygen via nasal cannula attached to a portable oxygen concentrator set at 2.5 liters per minute (LPM). Review of the medical record revealed orders on the Agency for Health Care Adminstration (AHCA) Form 5000-3008 from the hospital dated 5/6/21, for oxygen rate of 2 LPM via NC (nasal cannula). A care plan initiated on 5/6/21 for risk of complications related to history of respiratory failure included interventions to provide oxygen as ordered. On 5/10/21 at 4:10 PM, the resident's assigned Licensed Practical Nurse (LPN) A checked the orders and said, resident #209 was ordered oxygen at 2 LPM. LPN C then went into the resident #209's room and checked the flow rate setting on the oxygen concentrator. He looked at the setting at eye level. The surveyor read 2.5 and LPN A read 2.25 LPM. He then adjusted the setting to 2 LPM and said this was the first time today he had looked at the resident's setting on the concentrator. He added that he worked 7 AM to 7 PM and was having a busy day. LPN C acknowledged the resident was admitted to the facility on [DATE] and did not receive oxygen as ordered by the physician. He explained that although the orders were on the AHCA 5000-3008 form, the oxygen orders had not been entered into the EMR (Electronic Medical Record) yet. On 5/11/21 at 3:38 PM, the Director of Nursing (DON) said the oxygen orders should have been entered in the EMR at admission. 2. Review of resident 210's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan initiated on 5/7/21 noted at risk for respiratory complications and included interventions to give oxygen as ordered with goal the resident will not develop signs and symptoms of respiratory complications. On 5/10/21 at 10:45 AM, resident #210 was in his room. He was alert and oriented to person and place. The resident received oxygen via concentrator. The flow rate was set at 1.5 LPM. On 5/10/21 at 4:05 PM, LPN A said he was assigned to resident #210's care on the 7 AM to 7 PM shift. LPN A checked the EMR and said the resident was to have continuous oxygen at 2 LPM. LPN A then went into resident #210's room and checked the setting on the oxygen concentrator. He said it was set at 1.5 LPM. LPN A said he had not checked the oxygen setting until now and acknowledged the resident was not getting oxygen as ordered by the physician. Review of the policy titled, Oxygen Administration read, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at ordered rate Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated

Based on observation and interview, the facility failed to ensure soup was prepared in a method to reduce the potential for food borne illness. Findings: On 10/21/19 at 11:12 AM, initial tour of the kitchen revealed the tilt fryer filled with approximately one inch of water. There was a steam table insert and a deep soup kettle with chicken and rice soup. The water only reached the first inch of the pans. The center of the soup measured 138° Fahrenheit. The morning cook verified that she was cooking the soup in the tilt fryer at approximately 8:30 AM. She was not aware that cooking the soup in only one inch of water was not an acceptable method for cooking soup. The soup was prepared in a method that should be used for holding the food item. The method used increased the potential for food safety hazard that could result in foodborne illness to those residents that consumed the soup. By not using safe food preparation techniques or having a system to adhere to critical control points that can reduce the risk of food contamination increased the risk of foodborne illness. (U.S. Department of Health and Human Services, Food and Drug administration Food Code (YEAR)).

Based on observation, interview and record review, the facility failed to prevent the potential for urinary tract infection by failing to provide appropriate incontinence care for 1 of 5 residents reviewed for urinary catheter/urinary tract infections, (#78). Findings: Resident #78 was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] revealed she had total dependence for toilet use and needed extensive assistance with personal hygiene. Resident #78 was assessed as frequently incontinent of bladder and always incontinent of bowel. A review of the medical record revealed that she recently had labs that were positive for urinary tract infection and antibiotic was ordered on [DATE]. On 10/23/19 at 10:10 AM, incontinent care observation was conducted with resident #78's assigned certified nursing assistant (CNA) [NAME] CNA A was observed in the resident's room doing incontinence care by herself. CNA B later came in to assist. CNA A set up a basin at the bedside 1/3 full of soapy water and verified that she had put body wash into the water and had approximately 6 cleaning wipes. CNA A explained to the resident what she was going to do and proceeded to provide perineal care with gloved hands. CNA A took a cleaning wipe from the basin of soapy water and cleaned the resident's front perineal area with downward stroke from front to back and then put the wipe in the trash bin. CNA A proceeded to do the same again with another cleaning wipe from the basin of soapy water and discarded it again into the trash bin. At this time CNA B entered the room to assist with positioning resident #78 onto her right side. CNA A proceeded to wash the residents' back side with a wipe taken from the basin of soapy water. Without rinsing the resident's perineal area and buttocks with clean water, CNA A dried the resident with a clean towel. Without performing hand hygiene, CNA A and CNA B applied a new incontinence brief and re-positioned the resident in bed. CNA A failed to rinse the resident's perineum and buttocks with fresh water. She did not remove her gloves or perform hand hygiene prior to application of incontinence brief, repositioning or adjusting the resident's linens. On 10/24/19 at 10:52 AM, an interview was held with CNA A and the 100 Wing Unit Manager (UM). CNA A verified that she had used cleaning wipes that were moistened with soapy water to clean resident #78's perineal area and had not rinsed the areas with clean water and did not change her gloves or perform hand hygiene prior to application of new brief and adjusting her linens. The UM verified that CNA A did not follow the facility policy for perineal care. On 10/24/19 at 12:30 PM, the Director of Nursing (DON) verified that CNA A should have used just the cleaning wipes or body wash alone and should not have mixed the two. She also should have rinsed with clean water and performed hand hygiene when perineal care was completed and prior to application of new brief. Review of the facility's policy and procedures for Perineal Care revised 2/10/19, read, Fill wash basin ½ full of warm water. Place the wash basin on the beside stand .For female resident: Wet wash cloth and apply soapy or skin cleansing agent .Rinse perineum thoroughly in same direction, using fresh water and clean washcloth .Remove gloves and discard in designated container. Wash and dry your hands thoroughly. Reposition the bed covers

Based on observation, interview, and record review, the facility failed to ensure residents were assessed and evaluated for physical restraints regarding the use of side rails on beds for 9 of 10 residents (#268, 42, 187, 95, 116, 30,168, 156 & 175) of 120 total beds. The residents had beds with full side rails along the side of the bed that block three-quarters of the length of the mattress from top to bottom out. Findings: Cross to F278 1. An observation of the bed for resident #268 on 04/17/2017 at 04:07 PM revealed side rails that were three-quarters of the length of the mattress on both sides of the bed. When the rails were in the raised position, there was approximately an 18-inch space from the end of the rail to the foot of the bed. In an interview with resident #268 on 4/19/17 at 5:45 PM, she said when she was in bed, the certified nursing assistants (CNAs) put the side rails up on both sides of the bed since she was admitted . She said, I cannot get out of bed when the side rails are up. I cannot put them down. I have to wait for the staff to answer the call bell for help because I need 2 CNAs to help me to the bathroom. She said she is able to move around in the bed without assistance and she does not need the rails to help her turn in bed. Review of the clinical record revealed resident #268 was admitted to the facility on [DATE] after a hospitalization . The Florida form 3008 patient transfer form identified the primary [DIAGNOSES REDACTED]. The primary admission [DIAGNOSES REDACTED]. One of her medications was [MEDICATION NAME] 40 milligrams (mg) once a day. This medication is a diuretic that increases urine output (www.drugs.com) The physician order [REDACTED]. Side rails will not prevent resident from attempting any activity or action. The order did not include any medical symptom. Review of the admitting psycho/social assessment completed on 4/10/17 identified Resident #268 was able to complete a brief interview for mental status (BIMS). The BIMS is a brief screener that aids in detecting cognitive impairment. She was cognitively intact and her short and long-term was memory intact. She had no [MEDICAL CONDITION]. An assessment to determine the medical symptom or reason for using three-quarter length bilateral side rails was not present in the medical record. The minimum data set (MDS) assessment dated [DATE] signed as completed on 4/19/17 identified the resident as requiring extensive assist with transfers. The section for physical restraints for bed rail indicated it was not used. The resident did not have a plan of care for the use of three-quarter side rails. An interim care plan for fall risk dated 4/06/17 noted the problem for at risk for falls as evidenced by a history of falls past 31-180 days. The goal was that the resident will have reduced opportunities for falls. One of the possible interventions listed an evaluation of the need for and provide safety devices if indicated, but it was not selected on the care plan. The care plan did not include any information regarding the use of side rails for positioning devices or restraints. 2. Observation of resident #42 on 4/19/17 at 4:15 PM revealed the resident was transferred into bed with a stand and lift transfer device. Her bed had side rails three-quarters of the length of the mattress on both sides of the bed. When in the up position, there was approximately 18 inches from the bottom of the side rail to the footboard on the bed. There was no space between the headboard and the side rail. On 4/19/17 at 5:20 PM, CNA B said she puts both rails up when the resident is in bed. She said the resident does not try to get out of bed and uses the rails to turn to both sides. Review of the physician order [REDACTED]. The order did not include a medical symptom. An assessment to determine the medical symptom or reason for using three-quarter length bilateral side rails was not present in the medical record. Review of plan of care initiated 12/20/16 identified she was at risk for falls as evidenced by decreased mobility and unable to use call light. One of the approaches on the care plan was to keep bed in lowest position, observe for unsafe actions and intervene as needed, and assess the need for and provide safety devices. The care plan was reviewed on 2/28/17 with no changes. An update on 3/29/17 was for restorative nursing for ambulation as tolerated. Document progress. The care plan did not include any information regarding side rails as restraints or the effect of the side rails for resident #42. It did not address any risk for entrapment regarding the use of side rails. A quarterly MDS assessment was completed on 2/21/17. She had moderate cognitive impairment. Her functional status for activity of daily living (ADL) and bed mobility indicated she required extensive assist with 1 person. She required extensive assist of two persons for transfer. Section P: restraints indicated bed rails were not used. 3. On 04/20/17 at 2:44 PM, resident #187's bed had one three-quarter length side rail up. The resident was not in bed at that time. In an interview with CNA D on 04/20/17 at 2:45 PM, she stated that she puts both side rails up when the resident is in bed because she climbs out of bed. The resident required a 2-person assistance with physical transfer using a manual transfer. She said the resident had a history of [REDACTED]. She said she receives report from the previous shift regarding the resident's actions. Review of the progress note dated 4/14/17 by the advanced registered nurse practitioner (ARNP) documented no agitation and to keep resident on fall precautions. It not address the use of side rails. A physician admission order was dated 9/16/16 and was updated on 4/14/17, Side rails will be used only to treat the cause of the medical symptoms and assist the resident in reaching his or her highest level of physical and psychosocial well-being by assisting with bed mobility and repositioning only. Side rails will not prevent resident from attempting any activity or action. An assessment to determine the medical symptom or reason for using three-quarter length bilateral side rails was not present in the medical record. The order did not include any medical symptom. The MDS quarterly assessment dated [DATE] noted the resident had short and long-term memory loss and was severely impaired for making decisions regarding tasks of daily life. She was totally dependent for bed mobility with one physical assist and was total dependence with 2-person physical assist for transfers. The section for bed rail restraints indicated they were not used. as a restraint. Review of the care plan initiated 10/06/16 and updated 2/28/17 identified the resident at risk for falls due to history of falls, decreased safety awareness, and cognitive impairment. The last documented fall was 11/26/16. The goal was that the resident will not sustain significant injury due to fall. Approaches included: keep bed in lowest position, make frequent rounds when resident is in her room due to not understanding call system, and dependent on 2 staff for transfers using standing lift. It did not address the use of three-quarter length side rails. Review of the fall prevention policy dated 10/22/1999 did not include any identifying information for the facility. The procedure did not include the use of side rails to prevent accidents and/or falls. 4. Resident #95 was admitted to the facility with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Side rails will not prevent resident from attempting any activity or action. The annual minimum data set (MDS) assessment dated [DATE] showed that the resident had moderate cognitive impairment and she required extensive assistance for bed mobility, transfers, toilet use and personal hygiene. Section P of the assessment for Restraints showed bed rails were not used. A Care plan for falls last updated on 3/28/17, did not document any side rails. A care plan for self care deficit dated 3/28/17 had a hand written note, side rails to enable, without a date or any other details about enable. The care plan did not indicate how many rails or the type of rails to be used. There was no documentation of side rail assessment. The resident was observed on 4/19/17 at 9:35 AM in bed, with both side rails up. She was observed on 4/20/17 at 3:15 PM resting in bed with both rails up for three-quarters of the length of the mattress. On 4/20/17 at 3:10 PM CNA D stated that the resident did not try to get out of bed, but she always puts both rails up as she did not want the resident to fall out. She stated that the side rails were always up when the resident was in bed to keep her safe. 5. Resident #116 was admitted to the facility with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Side rails will not prevent resident from attempting any activity or action. The quarterly MDS assessment dated [DATE] showed that the resident required extensive assistance for bed mobility, transfers, toilet use and personal hygiene. Section P of the assessment for Restraints showed bed rails were not used. A care plan for cognition dated 3/28/17 noted that the resident was able to make needs known with gestures and nodding. There was no documentation of side rails on the resident's plan of care or any side rail assessment. The resident was observed in bed on 4/18/17 at 9:45 AM. Both rails were up for three-quarters of the length of the mattress. On 4/20/17 at 2:30 PM the resident was able to communicate that staff put both side rails up when he is in bed. He gestured that he only wanted one side rail up as he cannot lower the rails or get out of bed by himself when they are both in the raised position. On 4/20/17 at 2:55 PM, CNA D stated that she puts both rails up for safety. She said the resident did not try to get out of bed, but she wanted to keep him safe by putting both rails up. When asked if the resident wanted this, she said that it was for his safety. 6. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was received hospice services. A physician order [REDACTED]. Side rails will not prevent resident from attempting any activity or action. A Falls Risk Report dated 2/13/17 showed that resident #30 was assessed as a moderate risk for falls. A care plan for falls dated 2/28/17 noted side rails as enablers. It did not include any information as to how the side rail was and enabler. The admission MDS assessment dated ,[DATE]//17 showed that the resident required extensive assistance for bed mobility and personal hygiene. He required total assistance with toilet use. Section P of the assessment for Restraints showed bed rails were not used. The resident was observed on 4/17/17 at 12:12 PM. He had both rails up for three-quarters of the length of the mattress. On 4/20/17 at 2:45 PM, the resident was in bed with both side rails up. He stated he did not know why they were up. He said did not like them as he felt, caged. He said he did not need them as he did not get out of bed by himself. He asked for staff help when he wanted to be out of bed. An interview with CNA D on 4/20/17 at 3:00 PM revealed that she knew the resident well. She said she always put both side rails up when resident was in bed to keep him safe. She said she did not want the resident to fall out of bed so both said rails were always up. 7. Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician order [REDACTED]. Side rails will not prevent resident from attempting any activity or action. The quarterly MDS assessment dated [DATE] showed resident # 68's cognition was severely impaired. She required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Section P-restraint showed bed rails were not used. On 04/17/17 at 12:31 PM the residents' day shift licensed practical nurse A said full side rails were used for the resident, requested by her husband. She did not acknowledge the husband's request for side rails could be in violation of the regulation without an assessment for the use of side rails. Observations on 04/19/2017 at 3:26 PM, and on 4/20/17 at 2:00 PM revealed resident # 168 was lying in a low bed with three-quarter bilateral side rails in the raised position. On 4/19/17 at 5:40 PM CNA B said she had resident #168 in her assignment, and assists her to bed in the evening. The CNA said resident# 168 had the long side rails, and she raises both side rails when the resident is in bed. CNA B said the side rails were used for positioning, not for falls. She did not explain how the resident used the side rails. In an interview with the director of nursing (DON) on 4/19/17 at 5:45 PM, she said full side rails for resident #168 were not used as restraint, but as an enabler. She did not provide any other information on how the use of three-quarter side rails were assessed as an enabler. On 04/20/17 at 2:00 PM resident #168's husband was in the resident's room. Resident # 168 was lying in bed on her back, asleep, and bilateral three-quarter side rails were raised. When asked if he requested bilateral 3/4 side rails, he said the resident had the same bed since admission, and both side rails were raised when the resident was in bed. He said he noticed other beds had shorter rails, and he was not aware that he could request the use of side rails. He said resident #168 has not tried to get out of bed. Care plans initiated for the resident included the following: 1. self-care deficit, intervention: SR (side rails) to aide with positioning. 2. At risk for falls, intervention: SR as an enabler. The medical record did not reveal any assessment for the use of side rails. 8. Resident #156 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident # 156 was receiving hospice services for end stage [MEDICAL CONDITION] cardiovascular disease. The significant change MDS assessment dated [DATE] showed the resident's cognition was intact and that he required extensive assistance of one person for bed mobility, personal hygiene, and dressing, and had total dependence for toilet use. The fall risk report dated 4/04/17 showed resident #156 was a low risk for falls. A physician order [REDACTED]. Side rails will not prevent resident from attempting any activity or action. Care plans initiated for resident #156 included the following: 1. self-care deficit r/t (related to) general weakness, pain, incontinent of bowel and bladder, on hospice services dated 1/26/17, interventions included side rails to aide with repositioning. 2. At risk for falls as evidenced by history of falls, use of anxiety, cardiac and narcotic medications, general weakness and impaired mobility. Side rails were not addressed. Observations on 04/18/17 at 9:23 AM, on 4/18/17 at 11:08 AM, on 4/20/17 at 9:22 AM, and on 4/20/17 at 10:45 AM, and at 1:55 PM revealed resident #156 was in bed with bilateral 3/4 side rails raised. On 04/18/17 at 9:40 AM the assistant director of nursing/Unit manager 200 Unit said bilateral full side rails were used for positioning for resident #156. In another interview on 04/20/17 at 10:14 AM the ADON said she asked the resident when he was readmitted to the facility, and he wanted both full side rails up. When asked if full side rails were considered a form of restraint, she said resident # 56 had rails up as an enabler, and it was not considered a form of restraint, the rails were not preventing him from getting out of bed, and the resident was not physically capable of getting in and out of bed on his own. As assessment for the use of three-quarter side rails was not provided. On 04/18/17 at 11:02 AM CNA C said full side rails, 'the long one' was used for the resident, he holds on to it when he turns during ADL (activities of daily living). She verified that bilateral 3/4 rails were up, although ADL care was not being given at that time. In an interview with resident # 156 on 04/18/2017 at 11:08 AM, he said as long as he is in the bed, the full side rail on each side of the bed were up. Resident #156 said he has never fallen out of bed, does not try to get out of bed, and was told by the staff that he should not try get out of bed without calling for help. 9. Resident #175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set used for comprehensive assessment dated [DATE] revealed resident is cognitively intact, incontinent of bowel and bladder at night, requires extensive assistance with bed mobility, transfers, dressing, toilet use, and uses walker and wheel chair for mobility. Section P for physical restraints revealed physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Under used in bed: Bed rail documented -not used. Review of the 03/28/17 plan of care for self-care deficit related to general weakness, impaired mobility, history of [MEDICAL CONDITION] and requires staff assistance with activities of daily living. Approaches included a hand written entry for side rails per her request which was not dated. It did not include the type of side rails or how it was to be used. A physician order [REDACTED]. On 04/20/17 at 2:50 PM resident #175 stated that she has been in the facility for about a year and a half and her bed has always had big rails on both sides. She stated that when she is in bed the staff put both the rails up and she has to ask them to put the rails down otherwise she cannot get out of the bed. On 04/20/17 at 3:08 PM CNA D stated the resident is confused at times and sometimes tries to get out of bed. She stated that the resident has had 2 long side rails on her bed and we put the 2 side rails up so the resident does not get up and fall. Some of the beds have short side rails and some have long side rails, I don't know why she has the long side rails on her bed. During an interview with the director of nursing and administrator on 04/20/17 at 4:00 PM, they revealed that there was no other type of side rail assessment on the MDS other than restraint. They confirmed the three-quarter side rails had not been assessed as to whether or not they were restraints. The administrator stated he did not realize the facility had 10 resident beds with bilateral three-quarter side rails in use. He said they had been replacing some of the beds and did not intend to use full three-quarter side rails on those that were left. They could not provide any evidence that the policies and procedures for the use of side rails and restraints were followed. They did not address the potential risk for entrapment for the use of full bilateral three-quarter length side rails. All nine residents had the identical order as follows: Side rails will be used only to treat the cause of the medical symptoms and assist the resident, in reaching his or her highest level of physical and psycho-social well being by assisting with bed mobility and repositioning only. Side rails will not prevent resident from attempting any activity or action. They could not explain why the residents had the same order for the full three-quarter length side rails. The facility policy and procedure for Proper Use of Side Rails from Nursing services Policy and Procedure manual for Long-term care © 2001 Med-Pass, Inc. (revised October 2010) read, Purpose: 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. General guidelines included: 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. 4. The use of side rails as an assistive device will be addressed in the resident care plan. Review of the facility procedure for use of restraints revealed it did not include any identifying information for the facility and it did not have any date. The purpose was listed as. To protect from injury to himself or other. The Principle: Positions must be changed and personal needs met at least every 2 hours. All restraints must be the type that can be removed promptly in case of emergency. Otherwise, restraints will be released every 2 hours for 10 minutes and recheck every 30 minutes. Equipment: specific to type ordered. It did not include any examples of restraints. Procedure: 1. Initiate enable form and begin with least restrictive. 2. Obtain order. 3. Check written order for restraint. Use the specific restraint that is ordered, i.e. belt. 4. Apply restraint. 8. Remember only restraints of the type that can be removed promptly in an emergency may be used.

Based on observation, interview and record review, the facility failed to ensure a coordinated, accurate assessment was completed for side rails for 9 of 10 residents reviewed for the use of full three-quarter length side rails out of 120 total beds. (#268, 42, 187, 95, 116, 30, 168, 156, 175, 95 &116). Findings: Cross reference to F221 An interview with the minimum data set (MDS) coordinator on 4/20/17 at 2:30 PM revealed that she had viewed all 9 residents with the 3/4 side rails as enablers. She said as part of her review, she did not observe the side rails in the raised positon to see the effect on the residents, nor did she assess the residents' ability to remove/ lower the side rails. She said she did not think of them as restraints. She did not complete an accurate assessment to determine how the side rails were used to determine whether or not the side rails were restraints She stated she thought the full three-quarter side rails were for residents who did not try to get out of bed. When she was asked why they were up at all times when residents were in bed, she could not provide an answer. Review of the documentation and physician orders [REDACTED]. Side rails will not prevent resident from attempting any activity or action. None of the resident records for the 9 residents with bilateral three-quarter side rails included a medical reason or as assessment of how the side rails assisted with bed mobility or repositioning. Resident #268 was admitted to the facility on [DATE]. Review of the minimum data set (MDS) assessment reference date 4/12/17 signed as completed on 4/19/17 Section P- Restraints was coded, as (0) which included bed rail, trunk restraint or limb restraint were not used in bed. Interview with Resident #268 on 4/19/17 at 5:45 PM revealed that when she was in bed the certified nursing assistants put up both side rails. The side rails were three-quarters of the length of the mattress on both sides of the bed. When the rails were in the raised position, there was approximately an 18-inch space from the end of the rail to the foot of the bed. Observation of resident #42 on 4/19/17 at 4:15 PM. The resident was being transferred into bed with a stand and lift transfer device. Her bed had 3/4 side rails on both sides of the bed. When in the up position, there was approximately 18 inches from the bottom of the side rail to the footboard on the bed. There was no space at the headboard. A quarterly MDS assessment was completed on 2/21/17. She had moderate cognitive impairment, activity of daily living (ADL) extensive assist with 1 person bed mobility, and had extensive assist of two persons for transfer. Section P- for restraints: identified that bed rails were not used. Resident #95 was admitted to the facility with [DIAGNOSES REDACTED]. The annual minimum data set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance for bed mobility, transfers, and toilet use. Section P for physical restraints documented a physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Under used in bed A. Bed rail, documented a 0. (Coding: 0. Not used) The resident was observed on 4/19/17 at 9:35 AM in bed, with both 3/4 side rails up. She was observed on 4/20/17 at 3:15 PM resting in bed with both 3/4 side rails up. On 4/20/17 at 3:10 PM CNA D stated that the side rails were always up when the resident was in bed to keep her safe. Resident #116 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] showed that the resident required extensive assistance for bed mobility, transfers, toilet use and personal hygiene. Section P of the assessment for Restraints showed bed rails were not used. The resident was observed in bed on 4/18/17 at 9:45 AM. Both 3/4 side rails to his bed were up. On 4/20/17 at 2:30 PM the resident was able to communicate that staff put both side rails up when he is in bed. He gestured that he only wanted one side rail up as he cannot get out of bed by himself. On 4/20/17 at 2:55 PM, CNA D stated wanted to keep him safe by putting both rails up. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment dated [DATE] showed Section P of the assessment for Restraints-bed rails were not used. The assessment also noted that the resident required extensive assistance with bed mobility, personal hygiene and total dependence with toilet use. The resident was observed on 4/17/17 at 12:12 PM. He had both 3/4 rails to his bed up. On 4/20/17 at 2:45 PM, the resident was in bed with both 3/4 side rails up. He stated he did not know why they were up. He did not like them as he felt, caged. Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] showed resident # 168 cognition was severely impaired, and she required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Section P -restraint showed bed rails were not used in bed. Observations on 04/19/2017 at 3:26 PM, and on 4/20/17 at 2:00 PM resident # 168 was lying in a low bed asleep, three -quarter (3/4) side rails bilaterally were up. In an interview the director of nursing DON on 4/20/17 at 4:00 PM, she said, the facility did not do side rail assessment, and there was no written instructions for the CNAs regarding the type and use of side rails. Resident #156 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] showed the resident's cognition was intact and he required extensive assistance of one person for bed mobility, personal hygiene, dressing, and had total dependence for toilet use. Section P restraint showed bed rail was not used in bed. Observations on 04/18/2017 at 9:23 AM, on 4/18/17 at 11:08 AM, on 4/20/17 at 9:22 AM, and on 4/20/17 at 10:45 AM , and at 1:55 PM resident # 156 was in bed with bilateral 3/4 side rails raised. Resident #175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (used for comprehensive assessment) dated 02/21/17 revealed Section P for physical restraints documented a physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Under used in bed A. Bed rail, documented a 0. (Coding: 0. Not used). On 04/20/2017 at 2:50 PM resident #175 stated that she has been in the facility for about a year and a half and her bed has always had big rails on both sides. She stated that when she is in bed the staff put both the rails up and she has to ask them to put the rails down so she can get out of the bed. On 04/20/2017 3:08 PM CNA D Some of the beds have short side rails and some have long side rails, I don't know why she has the long side rails on her bed. The facility's policy and procedure for Proper use of side rails from Nursing services Policy and procedure manual for Long-term care © 2001 Med-Pass, inc. (revised October 2010) read, Purpose: 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. General guidelines included: # 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When 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.

Based on observation, interview, and record review the facility failed to ensure a trunk restraint used for one of one residents observed with truck restraint was removed during activities. (#173) Findings: Resident #173 was observed on 04/17/17 at 4:14 PM sitting in front of the nurses' station of the 100 hall with her back to the dining room. She had a clip belt around her waist while sitting in the wheelchair. The resident was not able to be interviewed. On 04/18/17 at 4:52 PM, resident #173 was sitting in her wheelchair in the activity/dining room. The clip belt was attached around her waist. Two certified nursing assistants (CNAs) were sitting on each side of her. CNA-E stated that they were waiting for supper. On 04/19/17 at 9:26 AM, the resident was sitting in the wheelchair with a cloth activity apron with buttons, zippers, and pockets. She was holding the zipper and looking around. The clip-belt was attached around her waist under the apron. At 9:30 AM, CNA-F asked her if she wanted her fishes. The CNA brought the bag out to her. The resident pushed them away, she did not want them. The CNA offered her water. CNA-F was asked how she communicates with the resident since resident #173 only speaks Spanish. The CNA said that she knew a few words and watches facial expressions. Further observation on 04/19/17 at 10:30 AM revealed the resident was sitting in activity/dining room on the 100 wing. She was listening to the church service. The clip belt was in place. She attempted to stand and was pulled back into the chair due to the restraint. She then dropped her bag of plastic fish. She leaned forward and attempted to pick them up. CNA-F came over to assist the resident pick up the objects. At 04/19/17 at 11:00 AM the belt was still in place while the resident was in activity room. Observation on 04/19/17 at 12:19 PM, resident #173 was sitting outside the activity/dining room in her wheel chair. The clip belt was still attached and the activity apron was around her waist covering the belt. She was speaking Spanish, and staff did not respond. At 2:32 PM, resident # 173 was in the music program in the main dining room. Her clip belt was still attached. An interview with activity director 04/19/17 at 3:20 PM, confirmed self-release belt was in place. She said the resident always had it on. She said was not aware that it was supposed to be released when in activities. She said she did not take the belt off in activities because the resident stands up. Interview with CNA F on 04/19/17 at 3:24 PM confirmed that the belt was not released in either the church program or musical program activity. She said she was aware that it was supposed to be done and had just forgot to do it.

Based on observation, interview, and record review the facility failed to ensure the actual hours worked by licensed and unlicensed staff providing direct resident care was included on the posted nurse staffing information. Findings: On 04/19/17 at 5:12 PM revealed the Nursing Staff Directly Responsible For Patient Care Form posted at the reception area. The form included the facility name, date, census, number of registered nurses (RN), number of licensed practical nurses (LPN), number of certified nursing assistants (CNA) on the 6 AM-2 PM and 2 PM-10 PM shifts, and the number of hours for the RN's, LPN's and CNA's on the 6 AM-2 PM, 2 PM-10 PM shifts. The 10 PM-6 AM shift revealed no information for the number of staff or number of staffing hours. On 04/19/17 at 5:15 PM the Accounts Payable (AP)/Payroll/Human Resources employee stated she is responsible for daily completion of the Nursing Staff Directly Responsible For Patient Care Form with the number and hours for the RN's, LPN's, and CNA's on each shift. She stated the number of hours documented on the form is the estimated staffing hours and does not reflect the actual hours that the RN's, LPN's and CNA's have worked. She stated that she has worked at the facility for 4 months and the only education she has received on how to complete the Nursing Staff Directly Responsible For Patient Care Form was from the previous AP/Payroll/Human Resource person. Review of the Nursing Staff Directly Responsible For Patient Care Forms dated 04/02/17-04/08/17 with the Calculated Staffing for Long Term Care Facilities Form (report of staffs actual hours worked) dated 04/02/17-04/08/17 revealed the staffing hours for the RN's, LPN's and CNA's did not match. On 04/20/17 at 9:32 AM the Director of Nursing confirmed that the RN, LPN, and CNA staffing hours on the Nursing Staff Directly Responsible For Patient Care Forms were not accurate and did not reflect the actual hours for the staff providing direct care to the residents. Review of the facility Staffing Policies and Procedures, dated 09/01/15 . Procedures . 16. The facility will post the following information on a daily basis: . The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, and certified nursing assistants

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent avoidable falls for 1 of 3 sampled residents reviewed for falls (#3). Findings: Resident #3 was observed on 3/30/16 at 3:05 PM in bed. His bed was a low bed with mats on the floor on both sides of the bed. The resident makes good eye contact, however he was not able to say where he is from or why he is at the facility. He had a visitor at that time who indicated he has good and bad days in regards to his memory. The visitor said the resident fell a couple of times at home and broke his neck. Record review revealed resident #3 was admitted to the facility on [DATE] with a known history of falls with fracture of the cervical spine. His [DIAGNOSES REDACTED]. Review of the hospital records History and Physical dated 12/17/15, indicated the resident had recurrent falls at home and presented with neck pain and confusion to the emergency room . He is a very poor historian with confusion. CAT (computerized axial tomography) scan of the head and neck showed results of a cervical fracture. Hospital records indicated on 12/23/15 that resident #3 was confused and unable to provide history, patient placed on cervical collar. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment. The resident's decisions were poor and he required reminders, cues and supervision. His functional status showed that he required extensive physical assistance with 1-2+ persons for all activities of daily living (ADLs). He was only able to stabilize with 2+ person assisting him to move on and off the toilet. He was frequently incontinent of bladder and wore an incontinent brief. He had a history of [REDACTED]. On 3/31/16 at 4:00 PM, the Licensed Practical Nurse (LPN) MDS coordinator said that resident #3 had a Fall Risk Report one week after admission on 12/31/15. The resident's status/condition was listed on the report with a total score of 12 which would indicate that he is a level 2 which is high risk for falls. The resident had Fall Risk Interim Plan of Care dated 12/26/15. It indicated the resident was at risk for falls as evidenced by history of fall in past 30 days with cervical fracture and is on psychoactive medication. Interventions included, keep bed in lowest position, mats at the bedside, self-release belt to wheelchair, cervical collar, bed alarm, and assist to the toilet as needed. On 1/05/16 the interim care plan indicated the resident was constantly attempting to exit w/c (wheelchair) unsafely. On 1/05/16 the interim care plan listed a self release belt when out of bed to the w/c. The belt was discontinued on 1/07/16, but the entry was rewritten on 1/08/16 for self release belt when out of bed to the w/c. The interim care plan noted the resident was found on the floor on 1/10/16. Another entry dated 1/10/16 read, stand outside br (bathroom) door to monitor. A handwritten undated entry read, asked for privacy to use br. Review of the nurses' notes dated 1/10/16 indicated resident #3 fell at 1:00 PM, Resident alert with confusion .Certified Nursing Assistant (CNA) placed resident on toilet and left resident on toilet to answer an emergency light, upon returning to the room resident was found on bathroom floor, no apparent injuries noted . The Complete Patient Care Plan was developed on 1/12/16. The care plan for falls was dated 1/12/16 with a review date of 3/22/16. The problem was listed as at risk for falls as evidenced by history of falls with C1 fracture, attempts to get up an ambulate independently despite frequent redirection, use of psychotropic medications, and [DIAGNOSES REDACTED]. The goal was that the resident will not sustain a significant injury related to a fall. The goal did not address prevention or reduction of avoidable falls. Interventions included, but were not limited to, assist with transfers as needed and assist to toilet as needed. The entry to assist to toilet had a hand written entry without any date that read, upon awakening, before meals, after meals, at bedtime, and as needed. On 2/20/16 the complete falls care plan noted the resident was found on floor, stated attempting to go to bathroom. An approach dated 2/20/16 was to continue with floor mats/alarms, redirection for safety. The new approach did not address toileting. On 3/09/16, the resident was found on the floor attempting to go to the bathroom. The approach dated 3/09/16 was to continue alarms to bed. It did not include any approach regarding toileting or any change for toileting. The nurses notes dated 3/09/16 indicated, resident observed lying on floor on left side next to bed. On 4/01/16 at 10:54 AM, LPN A said that she was assigned to the resident #3's care that day and she is familiar with the resident. She indicated that he is a fall risk and fell ,[DATE] times since she has been caring for him. She said that she was assigned to resident #3 on 1/10/16 when he fell in the bathroom. LPN A said that the CNA left him in the bathroom and stepped 1-2 feet out of the room because she heard a call light go off for another resident. LPN A said that she took care of the resident who put the call light on, but when the CNA returned to the bathroom for resident #3, he had already fallen. LPN A indicated that she would not have left the resident in the bathroom unsupervised. She indicated that resident #3 would demand his privacy during toileting, so she would have stood just outside the ajar bathroom door, close enough to keep an eye on him and assist him to avoid a fall. On 4/01/16 at 11:13 AM, the Physical Therapy Assistant (PTA) B said that he was the primary therapist working with resident #3 and he reviewed the therapy evaluation done on 12/26/15. PTA B said that the resident has a known history of falls with cervical fracture and wears a cervical collar. PTA B indicated resident #3 had poor memory and instructions would have to be broken down into one step at a time. He said the resident required multiple re-instructions. PTA B indicated resident #3 needed maximal assistance with all transfers, including going to the bathroom, due to weak muscles from the hips down. He could not get up safely from a sitting position without assistance and was not able to go to the bathroom by himself. On 4/01/16 at 11:51 AM, Occupational Therapy Assistant (OTA) A said that she was familiar with resident #3's care and reviewed the therapy evaluation that was done on 12/27/15. She said that he was a fall risk due to history of multiple falls and has dementia. She indicated that initially during therapy, she was helping him with all of his ADLs and that he needed assistance of 1 person to take him to the bathroom. She said that she would not be comfortable with leaving him in the bathroom by himself and that she would stand just outside the door with it open a small crack so that she could give him instructions. On 3/31/16 at 5:30 PM the Director of Nursing (DON) said that resident #3 wanted privacy when going to bathroom and that he would get upset with staff and become combative at times if they did not leave the bathroom. Review of the current care plans for resident #3 from 1/22/16 and after the review date of 3/22/16 revealed they did not address combative behavior if the resident became upset. The care plan for fall risk did not address any interventions to provide safety and privacy when the resident needed to use the bathroom.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to life expectancy for 1 of 1 sampled resident reviewed for hospice (#48). Findings: Review of the record for resident #48 revealed on her quarterly MDS assessment dated [DATE] and significant change assessment dated [DATE], showed she did not have less than 6-months life expectancy and was under hospice care while a resident at the facility. Record review revealed that Hospice physician certified and recertified resident #48 for hospice care with life expectancy of 6 months or less starting on 7/14/15 thru 3/09/16. In an interview conducted on 1/13/16 at 3:33 PM with MDS Coordinator Licensed Practical Nurse (LPN) #A and MDS Coordinator LPN #B, they confirmed the MDS assessment was not accurate for a resident #48 who has continuously been on hospice care since 7/14/15 to the present.

Based on observation and interview, the facility failed to ensure that dignity was maintained for 1 of 29 sampled residents (#156). Findings: During an interview conducted with the resident #156 on 10/20/14 at 12:15 PM, she stated that an incident happened approximately a month ago. She said that she was in bed using a female urinal and had her pants down. A male housekeeping staff came into her room without knocking and walked in, behind the closed curtain. She stated that he came around the bed and took the trash can, emptied it, and brought it back. She said she covered herself with a pillow and told a certified nursing assistant what had happened. Later that day, a supervisor from housekeeping came and apologized for what had happened and said that the male housekeeper did not speak any English. During the same interview on 10/20/14 at 12:37 PM, a physician came into the resident's room without knocking. She came around the closed curtain, saw the surveyor and said, "sorry, I will come back later." The resident stated, "see what I mean. They all just come in without knocking, it doesn't matter whether I am naked, they just walk in without knocking."

Based on observation, interview and record review, the facility failed to ensure that hospice and facility services were coordinated to ensure resident's highest practicable well being for 1 of 1 hospice residents reviewed in total sample of 29 residents (#191). Findings: A review of the clinical record showed that resident #191 had advanced dementia. A brief interview for mental status score read 1/15 indicating severe cognitive impairment. A review of the care plan for hospice showed that services started on 2/19/13. The care plan did not indicate which days the hospice nurse and certified nursing assistant visited the resident. An interview was conducted with staff #A (licensed practical nurse, LPN) on 10/22/2014 at 12:43 PM. She stated that the hospice certified nursing assistant (CNA) comes in twice a week to bathe resident and arrives about 10:00 AM. She said she did not know which days he comes, but said the facility CNA knew as they both organize the visit days. An interview was conducted with staff #B (CNA) at 10/22/2014 12:52 PM. She stated that CNA from hospice visits usually on Tuesdays and Thursdays, but not always. She said that he did not come yesterday, Tuesday October 21,2014. She said that if she does not see him by 10:00 AM, she bathes the resident and gets her up. When asked what days the resident gets showers, she said on Tuesdays and Thursdays. When asked if the resident received a shower yesterday (Tuesday), she said she would have received a shower from the facility staff. When asked if the hospice CNA calls to inform the facility if he is coming or not, she said he does not call, he either shows up or does not come. An interview was conducted with the unit manager on 10/22/14 at 1:25 PM. She said she was not aware of the days the CNA comes, he usually arrives by 9:30-10:00 AM. When asked about shower days, she said the resident gets showers on Wednesdays and Saturdays on the day shift. She was not aware of which days the hospice nurse visited, but said it was usually once per week. She said the nurse usually lets her know when she is in the facility and will inform her of any changes in treatment or orders. On 10/22/14 at 2:35 PM, the unit manager stated that she was changing the resident's scheduled shower days to Tuesdays and Thursdays, as those were the days the hospice CNA bathes the resident. An interview was conducted with staff #C on 10/23/2014 11:42 AM. She was asked if the hospice CNA came in today and she stated no, he should have come today, but he did not. She said that if he does not show up by 10:00 or 10:30 AM, the facility CNA will provide care for the resident. An interview was conducted with staff #D (CNA) at 10/23/2014 11:46 AM. She stated that the resident was still in bed because the hospice CNA had not yet arrived. She stated that he will show up at some time and then she will help him bathe resident and get her up. An interview was held with the hospice CNA and the hospice case manager on 10/23/2014 at 12:10 PM. He stated that he had come in last Tuesday before 7:00 AM and showered resident and dressed her and left her in geri-chair. When asked if he had communicated with any of the facility staff, he stated that he had spoken to one of the CNAs, but she was not the CNA assigned to resident #191. He then stated that he came late today, as he had a team meeting at the facility. He said that he will bathe resident after lunch, then get her up. When asked if he had called the facility to let them know that he was coming late, he stated no. When asked if he had called on Tuesday to let facility know he was coming in early, he said no. He said that he organizes his visits with one of the facility CNAs. He was asked what the resident's preference was for bathing or getting up out of bed, he said he did not know. When the case manager was asked if she was aware of the timings that the hospice CNA was coming to the facility, she stated no, it was at their discretion.

Based on observation and interview, the facility failed to ensure equipment was maintained properly and proper thawing techniques were used for potential hazardous products. Findings: During an initial kitchen tour on 10/28/13 at about 9:55 a.m. the following issues were observed: 1. At 9:55 a.m. the microwave oven had rust on the inside of the door. The cart that housed the microwave oven had brown substances on the bottom. Food particles were in front of the oven and all over the cart. The cart was sticky to the touch. The dietician manager and the cook observed the same issues at that time. 2. At 10:00 a.m., several packages of frozen meats to be thawed were submerged in a bucket of water. The bucket was in a sink without cold running water to agitate and float off loose ice particles. The water in the bucket was at room temperature to the touch. The dietitian and the cook stated at 10:00 a.m. that those meats were to be cooked 'tomorrow", Tuesday 10/29/13. The dietitian instructed the cook to move the bucket of meats to the refrigerator. According to FDA Food Code 2009 (Section 3-501.13 (B)), potentially hazardous food shall be thawed completely submerged under running water at a water temperature of 21 degree Celsius (70 degree Fahrenheit) or below, with sufficient water velocity to agitate and float off loose particles in an overflow.

Based on observation and interview, the facility failed to ensure residents are assessed to self-administer medications for 1 of 41 sampled residents (#77). Findings: During initial tour in the Buckingham wing on 11/26/12 at 9:45 a.m., resident #77 was in bed, alert, and able to respond verbally. One full bottle of [MEDICATION NAME] and "Freeze Roll On" for fast pain relief was observed at her bedside. An interview was conducted with the unit manager on 11/26/12 at 9:50 a.m. and she removed medications. She stated the resident is not to have those medications at her bedside. The medications were not prescribed by the physician. In a further interview with the unit manager on 11/28/12 at 2:08 p.m., she stated the resident was not assessed by the interdisciplinary team (IDT) to self-administer her own medications. Review of the facility policy and procedure for self-administration of medications indicated that the IDT should assess and determine with respect to each resident, whether self-administration of medications is safe and appropriate.

Based on observation, interview, and record review, the facility failed to ensure residents were informed of new or change of roommate for 3 of 3 sampled residents. (87, 299 & 305) Findings: 1. An interview was conducted with resident #87 on 11/27/12 at 11:00 a.m. She stated that two and half months ago a new mattress arrived in the room and was placed in the bed next to her. She asked the staff what it was for. She was informed that a new resident was moving in to the next bed. She was not formally informed of the new roommate until she asked what the new mattress was for. An interview was conducted with the Admission Coordinator and social worker (SW) on 11/27/12 at 4:00 p.m. who confirmed that they "forgot to inform resident of new roommate." The resident indicated that the new roommate makes noise at night and it bothers her, however she has not complained to anyone about it. Review of the medical records revealed the new roommate was admitted to the facility on [DATE]. There was no documentation that the resident was informed of the new admission/roommate. 2. An observation was conducted with resident #299 who just came back from an appointment with the surgeon on 11/26/12 at approximately 11:30 a.m. When she walked inside her room, there was a new roommate on the other bed and the resident introduced herself. An interview was conducted with the resident on 11/26/12 at 2:00 p.m. and she verified that when she got back from the doctor's appointment, there was a new resident in the next bed. She was not informed previously that a new roommate would be coming in that day. In an interview with the admissions coordinator on 11/27/12 at 4:00 p.m., he stated they have recently changed their policy and procedure by documenting in the progress notes that they have informed the resident if there is a new roommate coming in. Review of the progress notes of the resident dated 11/26/12 did not indicate that facility staff had informed her of an impending roommate. 3. During an interview on 11/27/12 at 10:20 am, resident #305 indicated that she was not notified of a new roommate change. Review of the resident's clinical record on 11/27/12 revealed no documentation that she was notified prior to a change in roommate assignment. Interview with the admission coordinator on 11/27/12 at 4:12 p.m. validated that he failed to notify resident #305 before she received a change in roommate assignment.