Every finding on record at Sunnyside Nursing Home

Based on resident record review, Health Care Representative and staff interviews, the facility failed to ensure the facility's binding arbitration agreement informed the resident or their representative they were not required to agree with arbitration agreement as part of the resident admission to the facility and they could rescind the arbitration agreement within 30 days of signing for 3 (Resident #8, #40 and #404) of 3 residents reviewed who had signed the facility binding arbitration agreement. The findings included: On 5/29/25 a review of the Agreement For Care contract signed by the resident or their representative prior to admission to the facility, #12 stated the arbitration clause is optional and if the parities to the agreement do not wish to include the following arbitration provision, are required to indicate so by marking an X through this clause. Any controversy or claim arising out of or relating to the Agreement, or the breach shall be settled by arbitration, with the provisions of the Florida Arbitration Code found at Chapter 682, Florida Statutes. Further review of the Agreement For Care contract revealed the Arbitration Clause noted it did not indicate the arbitration agreement was not required as part of the admission to the facility, and the arbitration agreement may be rescinded within 30 calendar days of signing. 1. Review of Resident #40's medical record revealed his initial admission to the facility was on 12/20/24. Resident #40's wife, signed by Resident #40's Agreement For Care contract on 12/20/24. The arbitration clause in section #12 of the Agreement For Care contract was not X out. On 5/29/25 at 9:51 a.m., in an interview with Resident #40's wife, she confirmed she had signed her husband's Agreement For Care contract on 12/20/24 as one of multiple documentation she was required to sign the day her husband (Resident #40) was admitted to the facility. She said she did not remember the Social Service Assistant explaining to her she was not required to agree with the arbitration clause in section #12 in the Agreement For Care contract and she was not informed she could rescind the arbitration agreement within 30 days of signing the Agreement For Care contract. 2. Review of Resident #404's medical record revealed she was admitted to the facility on [DATE]. Resident #404's Agreement For Care contract was signed by Resident #404 on 5/24/25. The arbitration clause in section #12 of the Agreement For Care contract was not X out. On 5/29/25 at 10:05 a.m. during an interview with Resident #404 said she was admitted a couple of days ago and she had not been informed that she didn't have to agree to the arbitration clause in the Agreement For Care contract nor did the staff explain to her that if she changed her mind, she could rescind the arbitration agreement within 30 days of admission. 3. Review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. Resident #8's Agreement For Care contract was signed by Resident #8 on 4/20/25. The arbitration clause in section #12 of the Agreement For Care contract was not X out. On 5/29/25 at 10:20 a.m. during an interview with Resident #8 said she was admitted in April 2025, she stated she had not been informed that she didn't have to agree to the arbitration clause in the Agreement For Care contract nor did the staff explain to her that if she changed her mind, she could rescind the arbitration agreement within 30 days of admission. On 5/29/25 at 10:27 a.m., in an interview the Social Service Assistant (SSA) said as part of her job she was required to have the resident or their Health Care Representative sign multiple admission documentation to include the Agreement For Care contract. She said because she did not know all the components of the arbitration agreement, she was unaware the resident, or the Health Care Representative could rescind the arbitration clause within 30 days of signing the Agreement For Care contract therefore she did not provide information to residents or their Health Care Representative on how to rescind the arbitration clause if they had changed their mind after signing. On 5/29/25 at 11:40 a.m., in an interview with the Administrator, she said as part of a resident being admitted to the facility, they were required to sign the Agreement For Care contract. The Administrator stated that the SSA was the primary employee responsible for the completion of the admission forms which includes the Agreement For Care. She confirmed the Agreement For Care contract and/or other admission documentation did not explain to the resident or their Health Care Representative they were not required to sign the arbitration clause in Agreement For Care contract as part of their admission to the facility and did not explain that they could rescind the arbitration agreement within 30 days of signing.

Based on observation, staff interviews, medical record and policy review, the facility failed to ensure proper Personal Protective Equipment (PPE) was worn for 2 (Residents #32 and #40) of 5 residents observed for enhanced barrier precautions. Enhanced barrier precautions (EBP) are used to prevent the transmission of multi drug resistant organisms (MDRO) and protect vulnerable residents who are at a greater risk of infection transmission during high contact care. The findings included: Review of the facility policy # 4-400-17 titled, Enhanced Barrier Precautions, dated 4/9/24, implemented to enhance barrier precautions for the prevention of multi-resistant organisms. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions; An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds, and/or indwelling medical devices. Make gowns and gloves immediately near or outside of the resident's room. High-contact resident care activities include: Dressing, Bathing, Transferring, Providing hygiene, Changing linen, Changing briefs or assisting with toileting, Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, Wound care: any skin opening requiring a dressing. 1. Resident #32 was admitted to the facility on [DATE]. His primary admitting diagnosis was Displaced Intertrochanteric fracture of the right femur. His BIMS (Brief Interview for Mental Status) score was 15 which indicated cognitively intact. Physician orders included Enhanced Barrier Precautions every shift for right femur surgical incision with dressing; Gown and Glove with all hands-on care and bed/lines/towels handling. Order was initiated on 5/6/2025. Care Plan for Resident #32 initiated on 5/7/2025 with problem of right hip fracture related to fall implemented intervention of Enhanced Barrier Precautions as directed related to potential wound exposure. Sign posted at door. On 5/27/25 at 11:35 a.m. during an interview Staff C, Registered Nurse (RN) said the Sunflower signs on the residents' doors mean they are on Enhanced Barrier Precautions. On 5/27/2025 at 11:40 a.m., Occupational Therapist Staff A was observed interacting with Resident #32 who had a sign on his doorway identifying him as being on Enhanced Barrier Precautions. Activities observed included Staff A positioning the residents' legs as well as working with his upper body. Staff A did not wear the required infection Prevention equipment including gloves. In an interview Occupational Therapist Staff A stated she did participate in hands-on activities with the resident. Staff A said she was working with the resident to improve his upper body strength. She said she was aware of the Enhanced Barrier Precautions but said she did not need Personal Protection Equipment (PPE) because the resident's hip wound was covered. She said the PPE required for Enhanced Barrier Precautions depends on the diagnosis of the resident. On 5/27/2025 at 11:50 a.m. During an interview Licensed Practical Nurse (LPN) Staff B said she has worked at the facility for 5 years. She said the Enhanced Barrier Precaution signs meant precautions are used based on the resident's diagnosis (catheter; wound; etc.). On 5/27/2025 at 12:30 p.m., Observed Certified Nursing Assistant (CNA) Staff D enter Resident #32's room without donning PPE. She proceeded to the resident's bedside and assisted him out of bed and stabilizing his arm as he ambulated to the bathroom. She did not have on a gown or gloves. She was wearing gloves when she came out of the bathroom. Staff D admitted she did not donned gloves when she was supposed to but said she was not required to wear gowns. On 5/29/2025 at 1:20 p.m., in an interview with the Infection Preventionist, she said the goal of Enhanced Barrier Precautions was to reduce caregivers transmitting MDRO's from resident to resident. She said herself and nursing staff are in charge of monitoring residents on EBP. She said if the Enhanced Barrier Sign is on a resident's door there are no circumstances a staff member should provide care without following the requirements. She said PPE supplies are usually kept for Enhanced Barrier Precautions on the counter. On 5/29/2025 at 2:45 p.m., in an Interview the Director of Nursing (DON) said gowns should be on counters in the residents' rooms. She said all staff should follow the PPE requirements for EBP if the sign is on the door. The DON provided Annual CNA skills Event for March 2025. No education was documented as provided for any other staff. There was no documentation of spot checks as told by the IP. The DON said the IP just walks through and checks on things but doesn't keep records. 52390 2. Review of medical record revealed Resident #40 had an admitted [DATE] with a diagnosis including fracture of left femur, malnutrition, unspecified dementia, obstructive and reflux uropathy. Review of Minimum Data Set (MDS) Assessment with a target date of 4/2/25 revealed Resident #40 scored an 8 on the Brief Interview for Mental Status (BIMS), indicating impaired cognition. Review of Resident #40's care plan dated 12/23/24 with a revision date of 5/16/25 identified the resident had indwelling catheter related to obstructive uropathy. Interventions included enhanced barrier precautions as directed. Sign posted at door. Review of Resident #40 Physician order dated 4/4/24 documented enhanced barrier precautions every shift for Foley catheter. Review of Resident #40 Certified Nursing Assistant (CNA) Facility tasks dated 1/8/25 documented enhanced barrier precautions every shift for Foley catheter. On 5/29/25 at 9:23 a.m., in an interview with CNA Staff E said he bathed and dressed Resident #40, and did not wear a gown. He confirmed there were gowns in the room, but thought the precautions were discontinued. CNA Staff E said he emptied the Foley catheter bag for Resident #40 earlier that morning and said he did not need a gown to do that. On 5/29/25 at 10:00 a.m. in an interview with Licensed Practical Nurse (LPN) Staff F said Resident #40 was on enhanced barrier precautions which requires staff to wear a gown and gloves while performing care. LPN Staff F confirmed there was a sunflower sign on Resident's #40's door, indicating enhanced barrier precautions.

Based on observation, record review, review of facility policy and procedures, resident and staff interview, the facility failed to implement necessary restorative care to prevent the decline in range of motion or mobility for 1 (Resident #17) of 3 residents reviewed with limited range of motion. The findings included: The facility policy,10-1140 (4/23/18) for Nursing Services Restorative/Maintenance Program specified, the facility shall have a Restorative/Maintenance Program for the purpose of restoring and maintaining optimum level of function for residents at risk. The policy specified the Restorative Care Coordinator shall attend weekly Minimum Data Set (MDS) (a clinical assessment of all residents to assess a resident's functional capabilities) meeting to maintain current communication relating to resident mobility or related problems. Maintain ongoing communication with the interdisciplinary team. Review of the clinical record revealed Resident #17 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) admission assessment completed on 3/9/21 noted Resident #17 had functional limitation in range of motion of both upper extremities. Resident #17 required extensive physical assistance of 1 for activities of daily living. Review of the functional maintenance program dated 3/19/21 revealed instructions to provide range of motion (ROM) to bilateral upper and lower extremities during activities of daily living and to keep a rolled cloth in hand for skin integrity. The Certified Nursing Assistant (CNA) Kardex (provides direction for care) noted to keep a rolled cloth in hand for skin integrity. On 5/17/21 at 2:18 p.m., 5/18/21 at 9:02 a.m., 5/18/21 at 1:42 p.m., and 5/19/21 at 1:42 p.m., Resident #17's right hand's fingers were observed curled toward his palm. Resident #17 did not have the rolled cloth in his hand. On 5/18/21 at 9:02 a.m., in an interview Resident #17 said he could not remember the last time anyone placed the rolled cloth in his hand. On 5/19/21 review of the daily charting revealed the CNAs placed their initials from 5/1/21 through 5/19/21 indicating the rolled cloth was in place in the resident's hand for skin integrity. On 5/19/21 at 3:00 p.m., Registered Nurse (RN) Staff A verified Resident #17 did not have a rolled cloth in his hand. She said the nurses and CNAs were responsible to place the rolled cloth in the resident's hand and she checked to ensure it was in place. RN Staff A said although she oversaw the restorative program, she did not have set meetings to review the residents' progress. She said she also participated in stand-up meetings in the morning but did not discuss or review residents on a restorative program.

Based on observation, review of facility policy and procedure, resident and staff interview, the facility failed to store continuous positive airway pressure ([CONDITION(S)]) machines masks in a sanitary manner for 1 (Resident #37) of 1 resident who use a [CONDITION(S)] machine (helps you breathe more easily when you sleep). This has the potential to cause respiratory infection. The findings included: A review of the clinical record documented a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order specified, wash [CONDITION(S)] weekly with soap and water and obtain new storage bag every day shift every Tuesday for infection control. On 5/17/21 at 11:58 a.m., during an observation, Resident #37's [CONDITION(S)] mask and tubing were stored uncovered in the open drawer of the nightstand with other personal items. **Photographic Evidence Obtained** Observations on 5/18/21 at 9:00 a.m., and 5/19/21 at 9:07 a.m., Resident #37's [CONDITION(S)] mask remained uncovered in the opened nightstand drawer. **Photographic Evidence Obtained** On 5/19/21 at 10:12 a.m., in an interview, Licensed Practical Nurse (LPN) Staff B said the nurse was responsible to place the [CONDITION(S)] mask in a plastic bag when not in use. On 5/19/21 at 10:24 a.m., during an observation and interview, Registered Nurse (RN) Unit Manager Staff A confirmed the [CONDITION(S)] mask for Resident #37 was in the open nightstand drawer and was uncovered. RN Staff A verified the [CONDITION(S)] mask should be in a plastic bag and not in contact with other items in the drawer. On 5/19/21 at 11:12 a.m., in an interview, the Director of Nursing said the facility had no policy on the care of [CONDITION(S)] machines.

Based on observation, record review, review of the facility's policies and procedures, and staff interview the facility failed to identify and implement interventions to ensure the environment was free of potentially avoidable accidents for 1 (Resident #1) and the 15 other residents residing on the second floor of the facility. The findings included: Facility Policy: Elopement/Wandering Management (Policy # 2-202-8, Date:12/4/19, Supersedes: 2/18/19) Policy: Sunnyside Health Services ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Resident #1 had a history of [REDACTED]. Wandering Risk Scale -V2, dated 9/6/20, Resident #1's score number 9.0. Scores 9-10 were in the Category: At Risk to Wander Care Plan: (Resident #1) is an elopement risk/wanderer r/t (related to) history of leaving facility unattended looking for Son. Self-propels her wheelchair into other Resident rooms. Date initiated: 6/22/20. Revision on: 9/3/20. Goal: The resident's safety will be maintained through the review date. Date initiated: 6/22/20. Revision on: 9/11/20. Target Date: 12/9/20. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, etc. Date initiated: 6/22/20. Revision on: 6/22/20 Identify pattern of wandering: Is wandering purposeful, aimless? Is resident looking for her family? Intervene as appropriate. Date initiated: 6/22/20. Revision on: 6/22/20 Provide 1:1 supervision. Date initiated: 6/22/20. On 9/22/20 at 10:40 a.m., observation of the second-floor fire exit door that lead to a stairway which was located on the left side of the unit. The 15 second delayed egress, (a locking feature that delays the opening of a door) alarm on the fire exit door was tested . The door sounded an alarm that was not auditable unless standing a short distance from the exit door. Fire Protection Specialist, (FPS) notified. On 9/22/20 at 10:45 a.m., during an interview Staff A Certified Nursing Assistant, said Resident #1 was allowed out of her room when wearing a face mask. She said the resident required redirecting because she was confused. She said the resident was able to independently open the doors and had seen her open the outdoor balcony doors. On 9/22/20 at 10:55 a.m., observation of Resident #1 in the unit hallway. Resident #1 was able to effortlessly propel herself in her wheelchair by using her feet in a walking motion while seated in the wheelchair. Resident #1 was alert but confused repeatedly asking what day it was. On 9/22/20 at 11:15 a.m., the Director arrived on the unit and explained the windows in the resident's rooms have guards that allow the window to only open 4 inches at the bottom of the window. He measured the windowsill distance to the floor at 31 inches. The window opening width, measured at 36 inches. He said the windows in the common areas of the unit do not have the opening guards and he said they were not required. He demonstrated that the common area windows open to approximately half the window length (appeared to be approximately 30 inches). The window openings had a mesh screen exposed when opened and no other barrier. Below the windows was an outdoor garden two floors below. On 9/22/20 at 2:23 p.m., FPS arrived on the second-floor unit and observed the windows located in the common areas with the Administrator and the Director. The windows did not have safety guards. The fire exit door alarm was tested for alarm volume from inside a resident room with the door closed approximately 25 feet away from the fire door. The alarm was not able to be heard inside the room. The Administrator acknowledged the alarm volume was not loud enough to alert the staff to someone exiting the door leading to the stairwell. The Administrator and Director discussed removing the door alarm and using the keypad lock to exit the fire door. FPS reviewed the safety requirements with the Administrator and Director.

Based on observation, review of the facility's policies and procedures and staff interview the facility failed to identify and implement interventions to ensure the facility provided an environment that was functional and safe for 16 of 16 residents residing on the second floor of the facility. The findings included: Facility Policy: Elopement/Wandering Management (Policy # 2-202-8, Date:12/4/19, Supersedes: 2/18/19) Policy: Sunnyside Health Services ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. On 9/22/20 at 10:40 a.m., observation of the second-floor fire exit door that lead to a stairway which was located on the left side of the unit. The 15 second delayed egress, (a locking feature that delays the opening of a door) alarm on the fire exit door was tested . The door sounded an alarm that was not auditable unless standing a short distance from the exit door. Fire Protection Specialist, (FPS) notified. On 9/22/20 at 11:15 a.m., the Director arrived on the unit and explained the windows in the resident's rooms have guards that allow the window to only open 4 inches at the bottom of the window. He measured the windowsill distance to the floor at 31 inches. The window opening width, measured at 36 inches. He said the windows in the common areas of the unit do not have the opening guards and he said they were not required. He demonstrated that the common area windows open to approximately half the window length (appeared to be approximately 30 inches). The window openings had a mesh screen exposed when opened and no other barrier. Below the windows was an outdoor garden two floors below. On 9/22/20 at 2:23 p.m., FPS arrived on the second-floor unit and observed with the Administrator and the Director, the windows located in the common areas that did not have the safety guards. The fire exit door alarm was tested for alarm volume from inside a resident room with the door closed approximately 25 feet away from the fire door. The alarm was not heard inside the room. The Administrator acknowledged the alarm volume was not loud enough to alert the staff to someone exiting the door leading to the stairwell. The Administrator and Director discussed removing the door alarm and using the keypad lock to exit the fire door. FPS reviewed the safety requirements with the Administrator and Director.

Based on staff interviews and record reviews, the facility failed coordinate the transfer for 1 (Resident #1) of 24 residents reviewed who were transferred into the facility. There facility failed to obtain the correct medication orders when Resident #1 was admitted and continued through his stay. This situation was determined to be past noncompliance at the immediate jeopardy level. On [DATE] Resident #1 was transferred from a local hospital to a skilled nursing facility (SNF) for rehabilitation. The hospital discharge orders included 3 medications for [MEDICAL CONDITION] ([MEDICAL CONDITION], heart failure in which the heart is unable to maintain adequate circulation of blood in the tissues of the body). On [DATE] the resident's daughter removed the resident from the SNF without notice and moved him to another facility. This facility failed to correctly reconcile Resident #1's medications. As a result, on [DATE], Resident #1 suffered an exacerbation of [MEDICAL CONDITION] and subsequently died on [DATE] due to [MEDICAL CONDITION]. The facility completed corrective actions to resolve the deficient practice by [DATE]. The findings included: On [DATE] review of Resident #1's closed record showed he was admitted to the facility from another SNF on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's records were obtained from the local hospital. The records included the [DATE] medication reconciliation for discharge. The list had instructions to continue taking these medications: [REDACTED].drugs.com/ ). Some documents from a local hospital stay dated [DATE] were found in the clinical record at the facility. These records show the primary hospital [DIAGNOSES REDACTED]. The hospital medication reconciliation pages 2 and 3 did not include [MEDICATION NAME], Entresto, and [MEDICATION NAME] (the medications for [MEDICAL CONDITION]). Page 1 of this form was not found among the facility's records. On [DATE] at 1:03 p.m., the Director of Nursing (DON) said when a resident transfers into the facility from another, an admission packet is given to the facility containing orders and transfer forms. The facility's long term care (LTC) policy #[DATE] titled, Admission of a Resident to LTC' (in effect from [DATE] through Resident #1's stay) noted medication orders were processed as follows: 2. admission orders [REDACTED] 7. Notify physician via fax to verify orders. A history and physical from the prior SNF was found with the patient transfer form in the facility clinical record. The history and physical contained a list of all medications including [MEDICATION NAME], Entresto, and [MEDICATION NAME]. The Order Summary Report from the prior SNF listed Resident #1's medications. Although nearly illegible, the report included [MEDICATION NAME], Entresto, and [MEDICATION NAME]. In an interview on [DATE] at 2:50 p.m., Licensed Practical Nurse (LPN) Staff D said when a resident is admitted , the DON or supervisor enters the medications into the system. She said she compared Resident #1's discharge medications from the local hospital and verified they matched what was put into facility's medication system. She said she never saw the prior SNF's medication sheet. She said the former DON is the one who entered the medications into the system. Review of the Physician order [REDACTED].#1 for [DATE], signed [DATE], listed 9 routine medication orders. The sheets did not include orders for [MEDICATION NAME], Entresto, or [MEDICATION NAME] and continued through his facility stay. In an interview on [DATE] at 11:49 a.m., the Administrator said the Medication Administration Record [REDACTED]. The Administrator explained the nurse used the medication list from the local hospital that included pages 2 and 3 (but not page 1) to reconcile medications for Resident #1. She said the nurse did not pursue obtaining page 1 of the orders. The medication orders noted on the history and physical from the prior SNF were not used to transfer the medication orders. In a telephone interview on [DATE] at 12:50 p.m., Assistant Director of Nursing (ADON) Staff F said a list of medications did come from the prior SNF. She said the medications were reconciled at the facility from the patient transfer form from the local hospital. She said at the time of admission, the transfer form was still within an acceptable timeframe. She said the Medical Director reviewed the history prior to seeing Resident #1. In an interview on [DATE] at 1:13 p.m., the Medical Director (who was Resident #1's physician upon admission) said he reviewed the medications that the nurse had entered into the facility medication record for Resident #1. He said [MEDICATION NAME], Entresto, and [MEDICATION NAME] were not on the form. He said he was not aware the resident was previously taking these medications. He said initially there were no signs of cardiac problems, and that may be because the resident was on cardiac medication before coming into the facility. He said the resident was put on these medications for a good reason and withdrawing them may have placed the resident at risk. On [DATE] at 1:24 p.m., the Administrator said the pharmacist reviewed Resident #1's medication orders on [DATE] (the day after admission) and had made no recommendations. On [DATE], review of records from the local hospital readmission of [DATE] revealed Resident #1 presented at the hospital on [DATE] with decreased oxygen saturation. The hospital [DIAGNOSES REDACTED]. The record noted the resident expired at 7:30 a.m. on [DATE] due to [MEDICAL CONDITION]. On [DATE] at 3:45 p.m., the Administrator said after the resident expired, Resident #1's daughter informed the facility about the issue of the missing medications. The facility began putting corrective actions into place on [DATE]. The corrective actions included an update to the admission policy (#[DATE]) on [DATE]. The update added: Assure that the family reviews medications that the resident received prior to admission to (facility). The revised policy also included, Two nurses will sign off on medication administration record. (If resident comes from a facility other than the hospital, use the MAR from the facility). The facility developed a new admission checklist to reflect these policy updates. Review of QA/Risk Management meeting Agenda dated [DATE] included: New risk concerns/new procedures as of [DATE] Assure that families are notified regarding the medications the residents were previously on prior to admission to (facility). Assure that when new admits are coming from another facility, only the MAR from that facility is used to document medications. Two staff to sign off on reconciliation form. In-service to nursing staff was documented as completed during the Nurses Meeting on [DATE] removing the immediate jeopardy. The facility conducted audits of records of current residents for 3 months to ensure medications were correct compared to the transfer orders to assure continued compliance. Admission medication audits were documented on [DATE], [DATE], and [DATE].

Based on staff interviews and record reviews, the facility failed to obtain accurate medication orders on admission for 1 (Resident #1) of 24 residents reviewed who were transferred into the facility. Those admission orders [REDACTED]. On [DATE] Resident #1 was transferred from a local hospital to a skilled nursing facility (SNF) for rehabilitation. The hospital discharge orders included 3 medications for [MEDICAL CONDITION] ([MEDICAL CONDITION], heart failure in which the heart is unable to maintain adequate circulation of blood in the tissues of the body). On [DATE] the resident's daughter removed the resident from the SNF without notice and moved him to another facility. This facility failed to correctly reconcile Resident #1's medications on admission. The error continued until [DATE] when Resident #1 showed exacerbation of [MEDICAL CONDITION]. He returned to the hospital where he subsequently died on [DATE] due to [MEDICAL CONDITION]. The facility began corrective actions to resolve the deficient practice and completed them by [DATE]. The findings included: On [DATE] a closed record review found Resident #1 was admitted to the facility from another SNF on [DATE] with the [DIAGNOSES REDACTED]. Resident #1's records obtained from the local hospital admission included the [DATE] medication reconciliation for discharge. The list with instructions to continue taking these medications: [REDACTED]. (These medications are used for heart failure, reference: https://www.drugs.com/ ) On [DATE] at 1:03 p.m., the Director of Nursing (DON) said when a resident transfers into the facility from another, an admission packet is given to the facility containing orders and transfer forms. The facility's long term care (LTC) policy # [DATE] titled, Admission of a Resident to LTC' (in effect from [DATE] through Resident #1's stay) was reviewed. The medication orders were managed as follows: 2. admission orders [REDACTED] 7. Notify physician via fax to verify orders. The documents from a local hospital stay dated [DATE] were found in the clinical record at the facility. The primary hospital [DIAGNOSES REDACTED]. The hospital medication reconciliation pages 2 and 3 did not include [MEDICATION NAME], Entresto, and [MEDICATION NAME] (medications for [MEDICAL CONDITION]). Page 1 of this form was not found among the facility's records. These documents from the local hospital apparently were used by the facility to reconcile the medications for Resident #1. A history and physical from the prior SNF was found with the patient transfer form in the facility clinical record. The history and physical contained a list of all medications including [MEDICATION NAME], Entresto, and [MEDICATION NAME]. The Order Summary Report from the prior SNF listed Resident #1's medications. Although nearly illegible, the report included [MEDICATION NAME], Entresto, and [MEDICATION NAME]. During a telephone interview on [DATE] at 12:50 p.m., Assistant Director of Nursing (ADON) Staff F said a list of medications did come from the prior SNF. She said the medications were reconciled at the facility from the transfer form from the local hospital. She said at the time of admission, the transfer form was still within an acceptable timeframe. She said the Medical Director reviewed the history prior to seeing the resident. In an interview on [DATE] at 2:50 p.m., Licensed Practical Nurse (LPN) Staff D said when a resident is admitted , the DON or supervisor enters the medications into the system. She said she compared Resident #1's discharge medications from the local hospital and verified they matched what was put into facility's medication system. She said she never saw the prior SNF's medication sheet. She said the former DON is the one who entered the medications into the system. Review of the facility Physician order [REDACTED].#1 dated [DATE] and signed [DATE] included routine medication orders, but [MEDICATION NAME], Entresto, and [MEDICATION NAME] were not included. In an interview on [DATE] at 11:49 a.m., the Administrator said the Medication Administration Record [REDACTED]. The Administrator said the nurse used the medication list from the local hospital that included pages 2 and 3 (but not page 1) to reconcile medications for Resident #1. She said the nurse did not pursue obtaining page 1 of the orders. The medication orders noted on the history and physical from the prior SNF were not used to transfer the medication orders. On [DATE] at 1:13 p.m., the Medical Director (and Resident #1's physician upon admission) said he reviewed the medications the nurse had entered into the facility medication record for Resident #1. He said [MEDICATION NAME], Entresto, and [MEDICATION NAME] were not on the form. He said he was not aware the resident was previously taking these medications. He said initially there were no signs of cardiac problems, and that may be because the resident was on cardiac medication before coming into the facility. He said the resident was put on these medications for a good reason and withdrawing them may have placed the resident at risk. On [DATE] at 1:24 p.m., the Administrator said the pharmacist reviewed Resident #1's medication orders on [DATE] (the day after admission) and had made no recommendations. On [DATE], records from the local hospital readmission on [DATE] were reviewed. The records note the resident presented to the hospital from the facility on [DATE] with decreased oxygen saturation. The [DIAGNOSES REDACTED]. The hospital record indicated the resident expired due to [MEDICAL CONDITION] at 7:30 a.m., on [DATE]. On [DATE] at 3:45 p.m., the Administrator said after the resident expired, Resident #1's daughter informed the facility of missing medication problem. The facility began putting corrective actions into place on [DATE]. The corrective actions included an update to the admission policy (#[DATE]) on [DATE]. The update added: Assure that the family reviews medications that the resident received prior to admission to (facility). The revised policy also included, Two nurses will sign off on medication administration record. (If resident comes from a facility other than the hospital, use the MAR from the facility). The facility developed a new admission checklist to reflect these policy updates. Review of QA/Risk Management meeting Agenda dated [DATE] included: New risk concerns/new procedures as of [DATE] Assure that families are notified regarding the medications the residents were previously on prior to admission to (facility). Assure that when new admits are coming from another facility, only the MAR from that facility is used to document medications. Two staff to sign off on reconciliation form. In-service to nursing staff was documented as completed during the Nurses Meeting on [DATE] removing the immediate jeopardy. The facility then conducted audits of records of current residents for 3 months to ensure medications were correct compared to the transfer orders to assure continued compliance. Admission medication audits were documented on [DATE], [DATE], and [DATE].

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a sanitary manner. The facility also failed to ensure eating surfaces/utensils were being handled in a manner to prevent contamination, before serving the food to residents. This deficient practice can cause the spread of harmful microorganisms, which has the potential of causing food borne illness to residents receiving an oral diet. The findings included: 1. On 9/14/15 at 9:20 a.m., during the initial tour of the kitchen, the hood over the stove and oven had an accumulation of dust/grease along the metal slats and dust was also noted to be hanging off the sprinkler lines. There was a heavy accumulation and clumps of dust along the top front of the stove, around the knobs of the stove and in the open areas around the knobs. Staff J, kitchen manager, said the hood had been scheduled to be cleaned over the last couple of days but would be done tonight by a cleaning company. Staff J said staff are to clean this area every 2 weeks but may need to increase the cleaning frequency as they now have a fryer that causes more grease. During a second tour of the kitchen at 11:15 a.m., the following was observed: The temperature knobs of the steam table were heavily stained/soiled and being handled by Staff P, cook. The sides and legs of a metal cart being stored under a food prep area were heavily soiled. The legs of the metal table for the coffee/beverage station were heavily soiled and/or rusted, creating an unclean surface. The floor along the cove base was observed to be soiled with debris. ***Photographic evidence on file*** On 9/16/15 at 9:06 a.m., a tour of the kitchen was conducted with Staff J who also observed the heavy accumulation of dust directly under the top lip of the stove surface and around the control knobs. Staff J said he had not noticed this, but would take care of it immediately. Staff J pulled out the drip trays under stove surface and the foil was heavily soiled with spillage and debris. Staff J confirmed the knobs of the steam table were soiled, and the legs of the metal carts, initially observed on 9/14/15, were heavily soiled. Staff J also acknowledged the floor along cove base was soiled with debris, and said the tables were moved and that area cleaned was on a monthly schedule. Staff J confirmed all floor areas of the kitchen should be maintained in a clean and sanitary manner. 2. On 9/14/15 at 11:14 a.m., Staff M, dietary aide, was observed standing next to the steam table wrapping silverware in linen napkins. Staff M was observed to have long finger nails with purple polish on them. Staff M was handling the flatware with her bare hands and the tips of her fingernails were frequently touching the inside eating surface of the utensils. On 9/16/15 at 11:07 a.m., Staff N, dietary aide, was observed to have long fingernails with white tipped nail polish. On 9/16/15 at 11:12 a.m., Staff M was observed next to the steam table taking silverware from containers and placing them into linen napkins. Staff M was not wearing gloves and the tips of her fingernails were frequently touching the eating surface of the flatware. Staff M was also noted to have the front half of her hair uncovered. On 9/16/15 at 11:29 a.m., Staff I, Certified Dietary Manager confirmed Staff M did not have her hair properly covered. On 9/16/15 at 2:24 p.m., in an interview with Staff I and Staff J, they confirmed staff were to have their fingernails at a presentable length not to extend past the end of their fingers. Staff I said staff are in-serviced on not handling the inside surface of eating utensils and tableware and Staff M should have been wearing gloves when she was wrapping the utensils in linen napkins. 3. On 9/17/15 at 11:35 a.m., during a main dining room/restorative dining observation, Staff F was observed serving rolls, using tongs to place the rolls on plates she was carrying. She was observed placing her entire thumb, on the top of each plate, when she served it to each resident. She was also observed resting the plates at her side and touching the top of the plates against her pant leg. In addition, Staff B was observed resting her thumb on top of the main entree plate when serving it to residents. On 9/17/15 at 8:30 a.m., Staff B was observed serving the breakfast meal to Resident #48 in her room. Staff B served the main entree by placing her thumb across the top of plate.

Based on record review, observation and interview, the facility failed to ensure the proper use of gloves, proper cleaning of commode chairs and a process that effectively analyzes data to identify trends and monitors staff performance in the area of preventing Urinary Tract Infections (UTI)/Acute [MEDICATION NAME]. The findings include: 1. On 9/15/15 at 1:30 p.m., Staff B was observed toileting Resident #48. She wore gloves during the procedure and did not wash hands after removal of the gloves. Staff B left the resident's room and was observed entering several utility rooms, touching the door knob and touching a key pad to unlock a door with her bare unwashed hands. 2. On 9/16/15 at 10:00 a.m., Staff C was observed not to have a clean jacket, covering the front of her uniform, while she was folding clean laundry in the facility laundry room. Although she was wearing a jacket, it was not buttoned in the front to cover her uniform. During the folding process, clean laundry was observed touching the front of her uncovered uniform. In addition, a clean blanket was hanging out of a bin behind Staff C. Staff C's pant legs were observed touching the blanket while she was folding other clean linen. 3. On 9/15/15 at 1:30 p.m., a cleaning of the shower/commode chair was observed after being used by Resident #48 for toileting in her room. Staff B was observed in the shower room wetting the chair and bucket, (holding urine) with water from the shower hose. She then rubbed the arms and seat, of the shower/commode chair with a PDI (brand of disinfectatnt wipe) wipe for approximately 15 seconds and then rinsed the chair again with water from the shower hose. Staff B proceeded to fill the urine bucket with water and used the same PDI wipe to rub the inside of the bucket (filled with water). She then rinsed the bucket with water. The instructions, on the PDI wipe container said for disinfection, areas must remain wet (with the product) for 2 minutes. On 9/17/14 at 11:00 a.m., when asked for the procedure, used by nursing staff to clean a commode chair after use, the DON stated We don't have a procedure. Did you see the disinfectant in the room where they are cleaned? That is what we use. 4. On 9/16/15 at 9:45 a.m., the Infection Control Nurse said she gathers statistics, regarding any resident infections, on a monthly basis. Review of the statistics, recorded for August 2015, revealed there were 8 cases of Acute [MEDICATION NAME] recorded, as well as one case of a UTI. When asked if any investigation had been done regarding these infections, the Infection Control Nurse said she looked at where the resident rooms were, who had the UTI's, but did not see any correlation. Review of the statistics revealed that all 8 cases of Acute [MEDICATION NAME] were nosocomial (acquired in the facility) infections. The resident rooms involved were 24W, 30W, 30D, 10W, 12D, and 14W; all within close proximity of each other. One resident was listed without a room number. When questioned regarding the 8 Acute [MEDICATION NAME] infections in August 2015, the Infection Control Nurse said she looked at the statistics and did not see any trends regarding room locations and the possible need to reinforce proper staff hand washing, use of gloves or use of commode/shower chairs. She continued to state We do stand up meetings with staff when there is an identified need. We do a refresher of what the policy is and what the issues are. We also discuss not to cut corners. When questioned regarding the difference in UTI and Acute [MEDICATION NAME], the Infection Control Nurse stated she was told (by the facility) that it was based on the location of the infection (upper or lower) in the urinary tract. Further review of the recorded statistics for Urinary Tract nosocomial infections, occurring during 2015, revealed that the facility averaged 8 of this type of infection each month. There is no documented evidence that the facility analyzed this data to identify trends and/or monitored staff performance related to procedures that prevent the spread of infections.

A review of the facility records finds only four grievances listed on the grievance log from January 1, 2015 through September 14, 2015. A review of the resident council minutes, for the same period, finds sixteen issues/concerns were expressed by residents in the resident council meeting. The concerns were recorded on a form and passed on to the appropriate department head. The comments from the department head were reviewed at the next council meeting. There is no documentation that the individual in the council meeting who expressed the concern was specifically contacted for details about the concern or regarding a resolution. During an interview on 9/16/15 at 3:30 p.m., the administrator confirmed there are only 4 grievances documented on the grievance log for the year 2015. The administrator stated the Social Services Director is to keep the log up to date and will be reminded of the requirement. The administrator stated that on many occasions if a resident has an issue that is corrected immediately or within a short period of time the concern is not documented and logged. The administrator said many of the residents have dementia or cognitive impairment, so the staff sometimes discount their concerns as ramblings. The administrator stated the documented grievances are investigated and resolved with the resident. Based on interview and record review, the facility failed to ensure 1 (Resident #79) of 2 residents who had a grievance/complaint was investigated timely and given a resolution to their investigation related to the grievance/complaint. The facility failed to log resident grievances. The findings include: On 9/14/15 at 12:45 p.m., Resident #79 said he was admitted to the facility in March 2015 and the nurse did an inventory sheet noting he had $40.00 dollars in cash and credit cards in his wallet. When he went to check his wallet a couple of days later the $40.00 was missing. He told the Social Service Director (SSD) who told him he needs to tell the Director of Nursing (DON). Resident #79 went to the nursing station and told the DON someone has taken $40.00 from his wallet. The DON told Resident #79 there was nothing she could do about the missing money, but will investigate to see if she could find out what happened to the money. She told me the missing money was my fault because I did not put the money into the facility safe when admitted . Neither the DON nor the SSD have come back to tell me what happened to the missing money. Resident #79 then said he doesn't think they ever investigated what happened to the missing money because they blamed me for not putting the $40.00 in the facility safe. Review of their Grievances Policy and Procedure #2-233 noted a Complaint Form should have been initiated by the SSD or a staff member on behalf of the resident and/or his family in response to a complaint/grievance. A prompt effort should have been made to resolve the grievances that the resident/family may have had. On 9/15/15 at 1:17 p.m., the DON said, during a care plan meeting in June 2015, Resident #79 told them he was missing money. The daughter-in-law shook her head and said she would bring some pocket money in for him to have while at the facility; therefore an investigation did not happen. Review of Resident #79's medical records revealed he was admitted to the facility 3/18/15. An Inventory of Personal Effects was done on 3/18/15 and the word wallet was circled. The form does not list how much cash money and/or credit cards were in the wallet upon admission to the facility in March. Review of Resident #79's Minimum Data Set (MDS) a tool used to assess a resident's medical condition was done on 8/27/15. Section C (Cognitive Patterns) a Brief Interview for Mental Status was done and Resident #79 scored 13 out of 15. A score of 13 to 15 means the resident is cognitive intact and has no impairments. Review of the Admission MDS dated [DATE] revealed for Section C (Cognitive Patterns) a Brief Interview for Mental Status for Resident #79 scored 15 out of 15. On 9/16/15 at 2:01 p.m., the DON, confirmed she was made aware of Resident #79's grievance of $40.00 missing from his wallet but did not write the grievance on a complaint form and did not investigate because the daughter in-law said she would bring some money to the facility for Resident #79 to use. She confirmed the Grievance policy states any grievance/complaint should be written on a complaint form, an investigation should be completed and the resident and/or the family should be informed of the findings, which was not done as per the grievance policy. Review of Resident #79's inventory sheet with the DON confirmed the word wallet was circled but the form did not list how much money and/or credit cards was in the resident's wallet. She said the facility staff was responsible to complete the inventory form for each resident including how much money and credit cards was in the wallet which was not done as required when Resident #79 was admitted . On 9/16/15 at 5:00 p.m., Resident #79's daughter in-law, said she remembers the care plan meeting in June 2015 where Resident #79 said he was missing money from his wallet. The DON had told her in the care plan meeting they had done a full investigation and there was no money in Resident #79's wallet when he was admitted . She said she was unaware an investigation was not completed related to the missing $40.00 and that was why she offered to bring money to the facility for Resident #79 to use when he wanted. On 9/17/15 at 9:15 a.m., a second interview was conducted with the DON and she confirmed after she reviewed Resident #79's medical records the facility had not investigated Resident #79's missing $40.00 dollars because she did not think she had to do an investigation.

Based on record review and interviews, the facility failed to insure the recommendations of the Consultant Pharmacist were acted upon in a timely manner for 1 (Resident #54) of 5 residents reviewed for medications. The findings included: Resident #54's clinical record contained a Consultant Pharmacist's monthly medication review sheet that documented on 8/13/15, the Pharmacist had made a recommendation to the resident's physician to consider a gradual dose reduction for the antidepressant medication Remeron. There was no evidence in the clinical record that this recommendation had been responded to by the resident's physician. On 9/17/15 at 11:23 a.m., the Director of Nursing (DON) had her copy of the Pharmacist recommendation, but did not think the resident's physician had reviewed it yet. The DON said she did not know why the August recommendation had not been reviewed by the resident's physician. On 9/17/15 at 12:27 p.m., the Consultant Pharmacist said she does give the recommendations to the facility right after her visit. She said she emailed them to the Assistant Director of Nursing (ADON) and then checked back with the DON who said she had received them. The Pharmacist said when she was in the facility last week, she could not find a response for some of the recommendations she had made in August so she resent them to the facility. On 9/17/15 at 12:49 p.m., the ADON said she did get a summery of all the recommendations made by the Consultant Pharmacist for August. The ADON said she reviewed the recommendations from August with the physician. The ADON confirmed a recommendation for Resident #54 was listed in the summary she received from the Consultant Pharmacist. The ADON said she did not verify that all the recommendations listed in the summary were responded to.

Based on interview and record review, the facility failed to follow its policies and procedures for properly investigating and reporting allegations of abuse for 4 (Resident #56, #38, #44 and #71) of 4 residents from a total sample of 27 residents. The facility failed to report allegations immediately to the administrator and all required state agencies, failed to report the results of the investigations to the administrator and required state agencies within 5 working days, and failed to take corrective actions set forth by state law and facility policy and procedures. The findings included: 1. Record review on 10/16/14 of the facility's Resident Rights - Abuse and Neglect policy #2-232 dated 2/16/11, page 3, documented all alleged violations involving mistreatment, neglect or abuse are reported immediately to the administrator and officials in accordance with state law. The results of all investigations must be reported to the administrator and to other officials in accordance with state law including the certification agency within 5 working days of the incident. 2. Review of the abuse investigation for Resident #56 dated 8/18/14 documents the resident told the staff she was pinched by a staff member on her right hand and right arm. The investigation form documented the abuse hotline was called on 8/18/14. The hotline accepted the report and documentation noted the allegation would be investigated by the Department of Children and Families (DCF). The form did not state whether DCF had done an investigation. The form did not state if the administrator and all state agencies including the Agency for Health Care Administration (AHCA) were notified the day of the incident, and then within 5 working days, the results of the investigation. 3. Review of the abuse investigation for Resident #44 dated 8/26/14 documented the resident told a staff member they were thrown on the toilet during the night when she asked if they could help her go to the bathroom. The investigation form documented the abuse hotline was called on 8/26/14 and accepted the allegation. The form did not document whether the administrator and all state agencies, including AHCA, were notified the day of the incident and then within 5 days working days, the results of the investigation. 4. Review of the abuse investigation for Resident #38 dated 9/06/14 documents two nurses had punched the resident in the stomach. The investigation form documented the abuse hotline was called on 9/06/14 and accepted the allegation. The form did not state if the administrator and all state agencies, including AHCA, were notified the day of the incident and then within 5 days working days, the results of the investigation. 5. Review of the abuse investigation for Resident #38 dated 9/08/14 documented the resident informed a staff member they were punched again by a staff member "last night". The investigation form documented the abuse hotline was called on 9/08/14 and the hotline accepted the allegation. The form did not document whether the administrator and all state agencies, including AHCA, were notified the day of the incident and then within 5 days working days, the results of the investigation. 6. Review of the abuse investigation for Resident #71 dated 9/24/14 documents the resident told her husband she had been slammed by staff during her care. The investigation form documented the abuse hotline was called on 9/25/14 at 8:56 a.m. and the hotline accepted the call. The form did not document the administrator, all required state agencies, or AHCA were notified. There was no documentation to support the results of the investigation within 5 working days. 7. During an interview on 10/16/14 at 2:50 p.m. with the Director of Nursing (DON) and Social Service Director (SSD), who is also the Risk Manager, they stated they were the ones who investigated the abuse allegations and filed the reports with the abuse hotline. They both confirmed the policy for abuse and neglect requires the administrator and official agencies to be immediately notified of any allegation. They also confirmed they are required to inform the administrator and official agencies of the results of their investigations within 5 days. The DON and SSD stated they thought all they had to do was call the abuse hotline and they (representatives from the abuse hotline) would notify all the required agencies. They also stated they did not know they had to notify the administrator and official agencies within 5 days of the results of their abuse investigations and confirmed they had not followed the facility's policy and procedures for investigating abuse and neglect.

Based on observation, record review and interview, the facility failed to revise the plan of care related to injuries sustained from a wheelchair for 1 (Resident #89) of 3 residents reviewed for skin condition. The failure to update the plan of care increases the risk for repeated injuries to the resident's skin. The findings included: 1. During an observation 10/14/14 at 9:50 a.m., Resident #89 was ambulating with two staff from physical therapy. Leg protectors were observed on the resident's lower calves. Two areas of red drainage were observed on the left leg protector. Therapist "A" assisted the resident to a chair and lowered the leg protectors. Two band-aids and steri strips were adhered to the left lateral leg. Therapist "B" acknowledged the band-aids and steri strips and stated, "He (Resident #89) wiggles in the wheelchair and rubs his legs." Therapist "B" pointed to the wheelchair and stated they applied foam to the wheelchair to protect the resident. Electronic record review on 10/14/14 documented Resident #89 was to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]." Review of the nursing progress notes dated 10/13/14 included the following: "Present on the left middle calf is a Skin Tear/Laceration. The following findings were documented, General Comments: after lunch, resident sitting in his w/c (wheelchair), CNA (certified nursing assistant) noted small amt. blood on leg. The area was cleaned with NS (normal saline), has two skin tears to left lateral calf, each measure 1 cm, steri-strip applied to each site, left OTA (open to air). Monitor daily til resolved per protocol...pressure reducing or relieving device(s) are in place, devices used on the bed surface, devices used on the chair surface." A second observation was made of Resident #89 on 10/15/14 at 10:42 a.m. The resident was sitting in his recliner with his legs elevated and his eyes were closed. Two band-aids were observed on the left lateral leg. Scattered small reddened areas were observed on the left lower calf. A certified nursing assistant (CNA) entered the room and said the resident does not wear leg protectors. He said it wasn't on his work assignment and it wasn't on the resident's plan of care. Care plans developed on 10/06/14 identified the resident at risk for skin problems due to incontinence and decreased mobility. The goal, "Any skin issues I might have will be identified and treated in a timely manner to prevent further deterioration." The plan of care was not updated to reflect the resident's tendency to wiggle and rub his legs on his wheelchair causing injury. Interventions did not include ensuring the wheelchair was protected with foam nor did it include applying leg protectors to the resident's lower legs. Interview with the restorative nurse on 10/15/14 at 10:50 a.m. confirmed Resident #89 was not wearing leg protectors. She said the resident wasn't wearing them because they weren't "care planned." She stated therapy applied soft foam to the wheelchair due to the resident banging his leg against the footrest and they felt this took care of the problem at the time, therefore, there was no need to apply the leg protectors. The care planned was not updated. In an interview with the MDS (Minimum Data Set) Coordinator on 10/15/14 at 12:22 p.m., she said she did not get a communication form from the therapy department related to the placement of foam on the wheelchair. If she did, she would've updated the care plan. She was not aware of the resident's tendency to wiggle and rub his legs on the wheelchair which resulted in injury. She confirmed she did not update the resident's care plan. She felt the plan of care the facility already had in place for his skin would suffice. She acknowledged the failure to update the plan of care contributed to the CNA's lack of awareness to monitor the resident, ensure the foam remained on the wheelchair, and increased the potential for additional injuries to occur. She stated she would revise the plan of care related to the resident injuring his legs on the wheelchair as well as revise the goal and approaches appropriate to monitoring the resident for safety to prevent additional injuries.

Based on observation, record review and interview, the facility failed to ensure requirements for staff posting were met. The findings included: 1. Observation on 10/13/14 at 9:59 a.m. during the initial tour of the facility showed a white magnetic board hanging across from the nurse's station. The board listed the census. The board failed to list whether staff on duty were RNs (Registered Nurses) or LPNs (Licensed Practical Nurses). The board posted various numbers next to words entitled, "day", "evening", and "night", but did not indicate what the numbers represented. The board failed to delineate the actual and total hours worked by the registered and licensed staff on duty for the day. Next to this magnetic bulletin board was a clip board holding the nursing home daily staffing report sheet. This document, dated 10/13/14, listed names of staff which did not delineate whether they were RN's or LPN's. There were numbers next to the names. The numbers did not indicate what they represented. The document lacked the total number of hours worked by RN's and LPN's. Observations on 10/13/14, 10/14/14, 10/15/14 and 10/16/14 showed the same discrepancies in the same areas for those dates throughout the survey. An interview was conducted on 10/16/14 with Staff C who is responsible for posting the staffing. When asked which posting the visitors and residents are to view for staffing, she stated, "Well, it's a little bit of both." When reviewing the regulatory requirements for staff posting, she acknowledged she failed to ensure the information was properly listed and in a clear, readable format.

Based on record review, observation and interview, the facility failed to ensure sufficient nursing staff to meet the needs of the residents for timely answering of call lights, and for providing appropriate personal care for 9 (Resident #7, #14, #19, #28, #47, #64, #68, #78, #85) out of a sample of 34 residents. Failure to provide sufficient staff has the potential to lead to staff burn out which may contribute to resident safety and potentially neglect and abuse. The findings include: 1. Upon interview, 5 residents complained that it took a long time for the staff to answer call lights as follows: Resident #7 on 9/17/13 at 9:42 a.m., stated, "Have to wait for the call light to be answered. There should be more staff. " Resident #19 on 9/17/13 at 8:29 a.m., stated, "One time I waited an hour in the day time and had to urinate and had an accident. One time it happened on the night shift (that I waited one hour) and had an accident urinating. She makes we wait a long time when I call for help." Resident #19 also reported to the surveyor that a staff member threw a pillow at him when she answered his call light on the night shift. This was reported to the Administrator by the surveyor. This staff member (Staff A) had repeated documentation of unsatisfactory job performance including "slow to answer call lights" documented in her personnel folder. Staff A was in a permanent resident assignment, on this corridor, on the night shift. Resident #47 stated on 9/17/13 at 11:46 a.m., that she feels she has to wait a long time for someone to come and help her, sometimes it's an hour wait to get out of bed. Resident #68 on 9/17/13 at 10:51 a.m., stated, "One time I waited 2 hours for them to answer my call light. They take a long time to come." Resident #85 on 9/17/13 at 9:15 a.m., stated he waits 20 to 25 minutes for someone to come when he puts the light on. "When you got to pee, you got to have someone (come)." The foregoing residents reside on the same corridor/hallway in the facility. 2. Resident #64 also resides on this corridor/hallway. There was documentation dated 5/19/13 and 5/20/13, submitted by Staff A's supervisor on the night shift, stating that Staff A was rough with the repositioning of this resident. This issue was not documented as being discussed with the resident or Staff A by the night supervisor. The Director of Nursing (DON), who received a copy of the concern, did not document that this concern was addressed. 3. Resident #14 complained regarding Staff F giving him a shower. No action was taken to resolve the complaint and the grievance was not documented in the grievance log or in the minutes of the care plan meeting. Staff F continued to give the shower to Resident#14. Upon interview on 9/19/13 at 11:25 a.m., the Director of Nursing (DON) stated the nurse supervisor (on the evening shift) should have made other arrangements. 4. Interview of the nursing supervisor (Staff H) at 4:00 p.m., on 9/19/13 revealed that she was unaware of what to do if she believed the facility did not take action when she reported that she observed a staff member slap a resident in the face. The surveyor then asked Staff G if there was a bulletin board in the facility that would tell her what to do. Staff G said she did not know. The surveyor showed the bulletin board, with the abuse hotline number posted, to Staff G who stated she did not think of that and "Yes, I should call myself (the hotline) in that situation." 5. Resident #28 has a care plan documenting alarms on the bed and chair. A review of the facility's fall policy noted alarms are to be checked by the nurse each shift. A review of the Mattress Alarm Check - South Hall revealed there was no evidence of the resident's alarms being checked for of total of 28 shifts during the time period 8/12/13 through 9/15/13. During interview, with the Restorative Coordinator on 9/19/13 at 1:00 p.m., it was stated, "When I am working during the week and on the day shift, it is my responsibility to check the safety devices and sign the mattress and alarm sheet." She continued to state that when she is not working, it is the responsibility of the individual nurses to check their resident's safety device and document. She confirmed there were shifts when Resident #78's safety devices were not documented as being checked to be operational.

Based on record review, observation and interview the facility failed to implement procedures to ensure the reporting of possible abuse, neglect and mistreatment related to Resident #19. The findings include: 1. Record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Minimum Data Set (MDS) assessment dated [DATE] states the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15. An MDS assessment dated [DATE] identifies the resident having a BIMS score of 9 (representing a decrease in mental status); and requiring extensive assistance of 1 for bed mobility, personal hygiene, walking in corridor, and dressing; requiring extensive assistance of 2 for transfer and toileting; and is frequently incontinent of urine and occasionally incontinent of bowel. Review of the Comprehensive Assessment, dated 7/15/13, revealed a problem stating "I am at risk for skin problems due to my urinary incontinence and decreased mobility;" with an approach to "Use incontinent pads as indicated to draw moisture away from my body." The approaches did not include toileting the resident. On 9/17/10 at 8:20 a.m., when asked, during an interview, if any staff member, resident or anyone else in the facility abused him verbally, physically or sexually; Resident #19 stated "Yes, it was on the night shift. I called her (the staff) back (to my room) because I had to go to the bathroom again. She threw a pillow at me and it hit me in the chest. (Resident pointed to his left upper chest.) It happened a couple of weeks ago and it was at 2:00 a.m., in the morning. I could tell she was really mad because she didn't like that I called her back. That is why she threw the pillow at me. I still see her and she still takes care of me on the night shift. I do not know her name but would recognize her if I see her." The resident continued to state "She is pretty slow with answering my call light." When asked if anyone else was with the staff member when she threw the pillow, he said "Yes, someone else was with her." The resident continued to state "I have to urinate frequently; I have that problem; that is why I had to call her again. I didn't want to have any accident." When asked if he reported this to anyone, Resident #14 said "Yes, some staff; but no one ever came to talk to me about it." The surveyor requested to see the Administrator on 9/17/13 at 8:35 a.m. At the onset of the meeting, the surveyor advised the Administrator that Resident #19 said something that needed to be reported to her. The Administrator stated "You know the resident is not reliable to give accurate information." The surveyor stated "I do not know that," and continued to report what the resident said during the interview regarding a staff member throwing a pillow at him. The Administrator was advised of the time of the reported occurrence, the reason a staff member was in the room and that another staff member was reported to be present and may have witnessed the event as reported by the resident. The Administrator was also advised that the resident said he told some staff members about the incident but no one ever came to talk to him about what happened. The Administrator said she would investigate the incident. Interview of the facility Social Worker, at 10:45 a.m., on 9/18/13, revealed that he is the Risk Manager and is in charge of handling and investigation of any abuse, neglect and mistreatment. He stated he presents an annual in-service on abuse, neglect and mistreatment; which is mandatory for all staff to attend. The Social Worker mentioned the incident of possible abuse (that was identified on 9/17/13 at 8:30 a.m., by the surveyor regarding Resident #19) and said he would be doing an in-service, later this week, to address the issue. When asked if he reported this incident (related to possible abuse) to any state agency, he stated he thought the Director of Nursing (DON) reported the staff member involved. He also stated that he did not report anything to the hotline yesterday and that he has not had any experience in that type of reporting at this facility. He also stated "You were here." The Social Worker was advised that the surveyor interviewed Resident #19 as part of the survey process (state/federal) and immediately reported what the resident said to the Administrator; and, it was up to the facility to run an investigation and report to the appropriate agencies. The surveyor advised the Social Worker to consult with the Administrator relating to reporting the incident. At 11:45 a.m., on 9/18/13 the Risk Manager/Social Worker stated that he, and the Director of Nursing (DON), would be reporting to the regulatory agencies related to Resident #19. The facility failed to report the allegation of Abuse to the States ' Agencies within 24 hours after the facility became aware of the possible abusive event. 2. Interview of Staff E at 9:30 a.m., on 9/19/13 revealed that Resident #19 requires extensive assistance with all activities of daily living (ADL), uses a gait belt to transfer, and uses the toilet at his request. She also stated that she found Resident #19 very wet with urine in the bed, on 3 occasions, when she arrived on duty for the day shift (at 7:00 a.m.). When asked if she reported this to anyone, Staff E stated "Yes, I told the night shift Certified Nursing Assistants (CNA); and they responded "we made our rounds." She continued to state "I told them you have to check more closely; the resident was cold and wet with urine." When asked if she thought this may be neglect, Staff E said "Yes", and acknowledged that she did not report the possible neglect to her supervisor.

Based on family and resident interview, staff interview and record review the facility failed to document complaints/grievances and failed to resolve grievances in a timely manner regarding complaints raised by the resident and family members for 1 (Resident #14) of 34 residents reviewed. The findings include On Monday 9/16/13 the facility provided a copy of the 'Problem/Grievance Tracking Log'. The log documents 'No Grievances Reported' since the last Recertification survey conducted 8/12. On Thursday 9/19/13 at 10:30 a.m., the son of Resident #14 approached this surveyor and stated he feels his father, generally, is receiving good care, but has two complaints, both of which have been brought to the attention of the facility staff. The son stated he attended the last quarterly care plan meeting. He also stated he has been away from the area for 5 weeks and has just returned. The son stated his sister had come to visit the resident and on one occasion walked up to the room, found the door open and the resident lying on the bed naked. The resident is in the bed closest to the door. The son stated his sister complained to nursing about the resident not being covered and he is still concerned about the lapse in maintaining dignity. He feels the nurse left the room, got busy with something else and failed to return. The son stated, that secondly, the resident complained about the showers given by the male nurse aide, (F). The son stated the resident complained he is not getting a proper shower; 'more like a sprinkle than a shower' and the son reported, the resident states his private area does not get a thorough cleaning particularly his backside. The son stated he brought the residents concern to the quarterly care plan meeting in July. The son stated that when he complained of the showering at the care plan meeting, the director of nursing (DON) told him he should not wait for the care plan meeting to express a complaint; he was told he should tell the nurse right away. The son stated he told the nurse again, before going on vacation, that the resident was not happy with the showers provided by nurse aide F. The son stated nursing was told twice about the shower complaint. In an interview on 9/19/13 at 11:00 a.m., the administrator confirmed the 'Grievance Tracking Log' documents that no grievances have been reported in 2012 and 2013. The administrator stated there is a difference between a grievance and a complaint. She stated a grievance is a formally documented form submitted to the facility. The administrator stated a complaint that is resolved is not recorded on the grievance log. Guidelines in the federal regulations state: "'Voice grievances' is not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff." A review of the facility's Grievance Policy states the duty of Administration: 1. To allow the resident and/or family member to voice grievances with respect to treatment, care or services that are, or are not, being furnished. Grievances may be processed through: a. Resident Council, under the responsibility of Activity Director b. Complaint Form - initiated by Social Services Director in response to complaint by resident and/or family member 2. Make prompt efforts to resolve grievances that resident/family may have. 4. To encourage participation and communication between staff, residents and family members in the common goal of providing quality care. A review of the resident council minutes reveals only two concerns were recorded in the past year; 1) not having the day room television tuned to the news in the evening and 2) a resident expressed a personal concern. The specifics of the personal concern were not documented, no complaint form was initiated, and the complaint was not documented on the Grievance Log. There is no documentation that the resident's personal concern was resolved. In interviews on 9/18/13 at 5:15 a.m., on the 11:00 p.m., to 7:00 a.m., shift, the two nurses and three nurse aides stated a complaint or concern does not have to be in writing to be a grievance. The nurses stated the only complaints or resident issues to arise on the Night shift have been a resident wanting breakfast including eggs at 2:00 a.m., and some residents wanting coffee as soon as they wake up around 5:00 a.m. The nurses stated they explained to the resident the food items that are available at that time of night; yogurt, cookies, milk, fruit and sometime a sandwich if the resident has requested it before and the request was put on the dietary department list. Coffee is made early and is available around 5:00 a.m. The nurses state they would report grievances to the nursing supervisors coming on, on the day shift. However, the nurses acknowledged they did not document or report the before mentioned resident complaints. The nurse aides stated the residents seldom have any complaints at all on their shift. They stated they would take any complaints or concerns directly to the nurse on duty. On 9/19/13 at 1:00 p.m., two nurses Licensed Practical Nurses (LPN) and three nurse aides, on the day shift (7:00 a.m. to 3:00 p.m.) were interviewed regarding grievances and complaints. All stated that complaints are to be reported and should be documented. There are no completed complaint forms on file in the facility. In an interview on 9/19/13 at 11:05 a.m., the director of nursing (DON) stated the privacy issue was resolved. The DON stated the resident was left uncovered in the bed when the nurse was changing a blocked catheter and had to leave the room to get supplies. The DON stated the nurse reported she pulled the door closed when she left the room but it must have swung back open. The DON stated the nurse was counseled and the issue resolved. When asked for documentation of the resolution of the privacy complaint, the DON stated the complaint was not logged and the complaint and follow-up were not documented. The DON stated the nurse aide assisting Resident #14 with showers was counseled about accommodating the residents. The DON stated resident's requests for change of staff are honored and that the male aide F was taken off shower duty for Resident #14. In an interview on 9/19/13 at 11:10 a.m., Resident #14 stated he receives showers on Tuesdays and Fridays in the evening. He stated he was assisted this past Tuesday, 9/17/13, with his shower by nurse aide F. The resident stated there has not been any improvement in the aide's ability to assist him the way he likes. The resident stated nurse aide's F is fair - less than adequate. The resident stated he would rather have assistance with his showers from the other nurse aide. In an interview on 9/19/13 at 11:20 a.m., nurse aide G, pulled up on the computer the activities of daily living (ADL) flow sheet for Resident #14. The flow sheet shows that, this week, on Tuesday 9/17/13 at 8:54 p.m. nurse aide F gave the resident his shower. A review of the resident's record finds the resident had a Brief Interview for Mental Status (BIMS) score of in July 2013 of 13. The April 2013 BIMS score was 15 indicating the resident is alert and oriented and competent to make his needs known. The sign-in sheet for the 7/11/13 care plan meeting documents Resident #14 and the son attended the care plan meeting. Hand written notes of the care plan meeting by the DON, titled 'Recommendations for up-dating the care plan' state nurse aide F to receive education in giving showers, indicating the resident's concern about inadequate showers. However, the write up of the care plan meeting in the computer states: "No concerns expressed at this time. Resident very pleased with his care." In an interview on 9/19/13 at 11:05 a.m., the director of nursing (DON) confirmed the resident complained about the assistance he was receiving with his showers. She stated it was going to be taken care of so she did not document the complaint. In an interview on 9/19/13 at 11:25 a.m., the DON confirmed nurse aide F had given Resident #14 a shower on Tuesday 9/17/13. The DON stated nurse aide F was to be taken off of assisting with showers for Resident #14 but the newly assigned nurse aide is on vacation. The DON stated the nurse supervisor should have known nurse aide F is not to be assigned to Resident #14 for showers and should have made other arrangements. The DON stated there is no documentation of the shower complaint or documentation of the resolution of the complaint. There is no documented communication regarding restrictions on nurse aide shower assignments. In an interview on 9/19/13 at 1:15 p.m., the administrator acknowledged resident/family complaints are not documented. She stated there is no documented follow-up to resident complaints. The administrator stated that going forward all complaints will be documented and resolved in a timely manner.

Based on record review, observation, and interview the facility failed to perform the safety monitoring measures for 1 (Resident #78) of 2 residents sampled for accidents/falls. Findings included: Review of Resident #78's medical records revealed an admission date of [DATE], resident is documented to have the following [DIAGNOSES REDACTED]. The medical record documents the resident had a fall on 9/10/2013. An updated assessment and care plan revision were completed. Further medical record review revealed a care plan documenting alarms on bed, and chairs, it is also noted the bed is to be lowered with mats on both sides. The resident, non-verbal, was able to point to the alarm pads as the restorative nurse demonstration how the alarms work. A review of the facility's Fall Policy it is noted the Alarms are to be checked by the nurse each shift. A review of the Mattress Alarm Check - South Hall revealed between 8/12/2013 through 9/15/2013, there are no evidences of the resident's alarm being checked for a total of 28 shifts. The facilities failed to monitor safety equipment, the alarms, are correctly and consistently working. During interview with the Restorative Coordinator on 9/19/2013, at 1:00 p.m., it was stated, "When I am working during the week and on the day shift it is my responsibility to check the safety devices and sign the Mattress and Alarm sheet." She continued to state when she is not working it is the responsibility of the individual nurses is to check their resident's safety device and document. She confirmed there were shifts Resident #78's safety device were not documented.

Based on interview, record review and observation the facility failed to ensure residents' rooms were kept in good repair and failed to provided good housekeeping services. The findings include: 1. On 8/06/12 at 11:00 a.m., during the Stage 1 interview with Resident #30, it was observed the pull cord for the over the bed light bar was short and could not reach the bed. Resident #30 stated the staff does not put the pull cord in reach when he is in his bed. He further stated he would like to be able to turn the light on and off at night but since the cord is to short he has to call the staff to turn on and off the light bar. 2. On 8/06/12 at 11:25 a.m., during the stage 1 interview with Resident #38, it was observed the pull cord for the over the bed light bar was too short to reach Resident #38 when she is in her bed. Resident #38 stated the pull cord is too short and she is unable to reach the pull cord to turn on and off her light. She further stated the staff will tie a trash bag to the pull cord sometimes but the trash bag can be hard to pull at times. 3. During inspection of the Sara-Lifts in the East and South shower rooms it was noted they had dark brown matter on the foot pads, white powder and what appear to be food particles. During the tour it was also noted several rooms to have damage doors, missing base boards and some wall damage all listed below. Recheck of both Sara-Lifts 8/07/12 and 8/07/12 noted the same dark brown matter on the foot pads, white powder and what appears to be food particles. 4. On 8/10/12 at 9:30 a.m., a tour of the facility was done with the Director of Environmental Services (DES). The following was observed during this tour: ? Rooms #5, #10, #13, #22, #25, #26 and #31 front entry door wood was chipped and was damaged. ? Rooms #9, #10, #14, #20, #23, #26, #27, and #31 bathroom doors and the door frames were chipped, the paint was pealing and doors had deep groves in the wood. ? Room #5 by the air conditioner unit the wall was damage and the paint was peeling. ? Room #3 the baseboard behind the toilet was peeling away from the wall. ? Room #13 the wall by the air conditioning (A/C) unit was damage and the base board was missing. ? Room #23 the wall was patched but the patch was not painted to match the room. The wall by the a/c unit was soft to the touch and the DES stated the wall appears to have some water damaged. Inspection of both Sara-Lifts located in the South and East shower rooms the DES confirmed both Sara-Lifts still had a dark brown matter on the foot pads, white powder and what appear to be food particles. She confirmed all of the areas noted on the environmental tour 8/06/12 as listed above. 5. On 8/09/12 at 10:10 a.m. during an interview the DES stated it is the facility staff responsibility to report any room damage they observed and report their observation to her department verbally or in writing. Her department then makes a work order for each observation so they can track each work order and insure they are done in a timely manner. She also stated the staff is required to clean each Sara-Lift between residents and cleaning crew is responsible to clean the Sara-Lifts twice a day which was not done as required by the facility staff. She also confirmed rooms #9D&W, #12A, #22W, #29W and #31D pull cords for the over the bed lights were short and could not be reached by the resident when they are in their bed.