Every finding on record at Surrey Place Nursing Center

Based on observation, interview, and record review, the facility failed to ensure staff followed enhanced barrier precautions while providing high-contact care to residents in 2 of 3 units reviewed for infection control to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 9/29/2025 at 9:51 AM, there was an enhanced barrier precautions signage posted on Resident #31's room door. Resident #31 was lying in bed. Staff A, Certified Nursing Assistant (CNA), entered Resident #31's room with a clear plastic bag that contained towels. Staff A provided peri-care to Resident #31. Staff A was wearing gloves, but no gown.Review of Resident #31's physician order dated 6/30/2025 read, Enhanced Barrier Precautions R/T MRSA [related to Methicillin-resistant Staphylococcus aureus] every shift.During an interview on 10/1/2025 at 2:02 PM, Staff A, CNA, stated, For residents that are on enhanced barrier precautions, we need to wear gloves and gown when providing care. The personal protective equipment is only stored in the hallway. I should have worn a gown when providing care for [Resident #31's name].2) During an observation on 9/29/2025 at 1:43 PM, there was an enhanced barrier precautions signage posted on Resident #4's room door. Staff B, CNA, and Staff C, CNA, were providing care to Resident #4 at bedside, wearing gloves but no gown. Staff D, CNA, was collecting linen in Resident #4's room. Staff D was wearing gloves but no gown. Staff C was making Resident #4's bed, wearing gloves but no gown.Review of Resident #4's physician order dated 7/8/2024 read, Enhanced Barrier Precautions R/T MRSA. Order Status: Active.During an interview on 10/1/2025 at 12:54 PM, Staff B, CNA, stated, I was not aware [Resident #4's name] had orders for enhanced barrier precautions. I did not see a sign posted on the door. I might have missed it. When a resident has enhanced barrier precautions, you are to wear gloves and gown when providing care.During an interview on 10/1/2025 at 1:39 PM, Staff D, CNA, stated, I must have missed it [enhanced barrier precautions signage on the door]. I should have donned a gown.3) During an observation on 9/29/2025 at 1:55 PM, there was an enhanced barrier precautions signage posted on Resident #19's room door. Resident #19's call light was on. Resident #19 was sitting in the toilet seat in his room. Resident #19 verbalized he needed assistance with putting his brief and pants up. Staff E, CNA, entered Resident #19's room and donned gloves. Staff E provided toileting assistance to Resident #19. Staff E did not wear a gown.Review of Resident #19's physician order dated 9/26/2025 read, Enhanced Barrier Precautions R/T Hx [History of] MRS [Sic.] every shift.During an interview on 10/1/2025 at 1:26 PM, Staff E, CNA, stated, I only put up his pants, He [Resident #19] does everything else by himself. I cannot recall if I saw the sign [enhanced barrier precautions] posted outside his [Resident #19] room.4) During an observation on 9/30/2025 at 8:35 AM, Staff E, CNA, and Staff F, CNA, were transferring Resident #61 out of bed. Staff E and Staff F had gloves but no gown. There was an enhanced barrier precautions signage posted on Resident #61's room door.Review of Resident #61's physician order dated 9/29/2025 read, Enhanced Barrier Precautions R/T Suprapubic catheter, wounds every shift.During an interview on 10/1/2025 at 1:26 PM, Staff E, CNA, stated, I was assisting [Staff F's name] get [Resident #61's name] out of bed to his chair. We forgot to put a gown on.During an interview on 10/1/2025 at 1:30 PM, Staff F, CNA, stated, We were getting [Resident #61's name] out of bed into his wheelchair. I forgot to wear the gown. We always have signs on the door. The personal protective equipment is stored outside in the hallways.During an interview on 10/1/2025 at 3:09 PM, the Infection Preventionist stated, Staff should wear gowns and gloves during any close contact with the resident or any close contact with their linens for any residents on enhanced barrier precautions. The staff have to read the signs posted on the resident's doors and follow them.During an interview on 10/1/2025 at 3:38 PM, the Director of Nursing stated, Staff should follow enhanced barrier precautions, which mean they are expected to wear gown and gloves when providing direct care to any resident that have enhance barrier orders. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 4/24/2025 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines. 4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting.

Based on record review and interview, the facility failed to ensure residents had an accurate Level I Preadmission Screening and Resident Review (PASRR) completed for 2 of 3 residents reviewed for mood and behavior (Residents #27 and #31).Findings include:1) Review of Resident #27's admission record showed the resident was admitted on [DATE] with diagnoses to include major depressive disorder with an onset date of 9/9/2025 and post-traumatic stress disorder with an onset date of 9/9/2025.Review of Resident #27's PASRR) dated 9/9//2025 showed no depressive disorder or post-traumatic stress disorder documented as mental illness under Section I: PASRR Screen Decision Making.During an interview on 10/1/2025 at 2:16, the Minimum Data Set (MDS) Coordinator stated, [Resident #27's name] PASRR does not include depressive disorder or PTSD [Post Traumatic Stress Disorder]. It will need to be updated.2) Review of Resident #31's admission record showed the resident was admitted on [DATE] with diagnoses to include other specified anxiety disorders with an onset date of 3/26/2025 and adjustment disorder with depressed mood with an onset date of 3/26/2025.Review of Resident #31's PASRR dated 9/9/2025 showed no mental illness including anxiety disorder documented as mental illness under Section I: PASRR Screen Decision Making.During an interview on 10/1/2025 at 2:17 PM, the MDS Coordinator stated, [Resident #31's name] original PASRR does not include anxiety or adjustment disorder. It will need to be updated.During an interview on 10/2/2025 at 10:15 AM, the Social Services Director stated, PASRRs are uploaded from admission. I am required to check them [PASSR] within 24 to 48 hours. Making sure that resident diagnoses are all accurate. If the diagnoses are not accurate, I will update them. Once I have completed the PASSR, I submit them to [the MDS Coordinator's name] and she will review them and submit them. I think with these two residents [Residents #27 and #31], you have to put the code twice and I think there was a mix up and the code was not input again.Review of the facility policy and procedure titled Resident Assessment- Coordination with PASARR Program with the last review date of 4/24/2025 read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting to their needs. Policy Explanation and Compliance Guidelines: 1. a. PASARR Level I- initial pre-screening that is completed prior to admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASSAR screening status, and referring to the appropriate authority.

Based on record review and interview, the facility failed to ensure medications were administered as per the parameters ordered by physician for 2 of 7 residents reviewed for medication management (Residents #7 and #27).Findings include:1) Review of Resident #27's physician order dated 9/10/2025 read, Metoprolol Tartrate Oral Tablet 25 MG [milligram] (Metoprolol Tartrate), Give 1 tablet by mouth two times a day for afib [atrial fibrillation] Hold for SBP [Systolic Blood Pressure] less than 110, hold for heart rate less than 60.Review of Resident #27's Medication Administration Record (MAR) for September 2025 for administration of Metoprolol Tartrate 25 mg showed the resident was administered the medication on 9/18/2025 at 9:00 PM for the blood pressure (BP) of 107/68, and on 9/23/2025 at 9:00 PM for the BP of 109/68.Review of Resident #27's physician order dated 9/11/2025 read, Clonidine HCl Oral Tablet 0.1 mg (Clonidine HCl), Give 1 tablet by mouth two times a day for HTN [Hypertension] Hold for SBP < [less than] 110.Review of Resident #27's MAR for September 2025 for administration of Clonidine HCl 0.1 mg showed the resident was administered the medication on 9/18/2025 at 9:00 PM for the blood pressure (BP) of 107/68, and on 9/23/2025 at 9:00 PM for the BP of 109/68.During an interview on 10/1/2025 at 2:26 PM, Staff I, Licensed Practical Nurse (LPN), stated, If there is a check documented, it means I gave the medication. I document the blood pressure, and the parameters are listed. I should have not given the medication.2) Review of Resident #7's physician order dated 9/17/2025 read, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 6 hours as needed for non acute pain, pain level 6-10.Review of Resident #7's MAR for September 2025 for administration of Hydrocodone-Acetaminophen 5-325 mg showed the resident was administered the medication on 9/17/2025 at 10:00 PM for the pain level of 0, 9/18/2025 at 6:24 AM for the pain level of 0, 9/19/2025 at 12:01 AM for the pain level of 0, at 6:34 AM for the pain level of 0, and at 11:19 PM for the pain level of 4, 9/20/2025 at 6:31 AM for the pain level 0 and at 10:59 PM for the pain level of 4, 9/21/2025 at 6:44 AM for the pain level of 4 and at 11:08 PM for the pain level of 4, 9/22/2025 at 6:52 AM for the pain level of 4 and at 11:44 PM for the pain level of 1, 9/23/2025 at 11:11 PM for the pain level of 5, 9/24/2025 at 11:12 PM for the pain level of 4, 9/25/2025 at 6:49 AM for the pain level of 4 and at 11:12 PM for the pain level of 4, 9/26/2025 at 6:24 AM for the pain level of 4, 9/28/2025 at 11:41 PM for the pain level of 1, 9/29/2025 at 10:57 PM for the pain level of 4, 9/30/2025 at 6:32 AM for the pain level of 4, and at 11:17 PM for the pain level of 4.During an interview on 10/2/2025 at 8:07 AM, the Director of Nursing (DON) sated, After reviewing [Resident #7's name and Resident #27's name] medication record, the medications were administered out of parameters. Nurses should check parameters and physician orders and follow the doctors' orders.During an interview on 10/2/2025 at 8:08 AM, Staff G, LPN, stated, I do not recall [Resident #7's name] medication order. I do not have the record in front of me. I don't recall.During an interview on 10/2/2025 at 8:12 AM, Staff H, LPN, stated, It was an oversight on my part. I gave him [Resident #7] the medication and did not follow the parameters.Review of the facility policy and procedure titled Medication Administration with the last review date of 4/24/2025 read, Policy: Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review, the facility failed to ensure staff cleaned and sanitized the thermometer probe between testing temperatures of different food items.Findings include:During an observation on 9/30/2025 at 7:40 AM in the main kitchen, the Dietary Manager tested the internal temperature of pureed eggs by a food temperature probe. The Dietary Manager used the same probe to test the pureed ham without cleaning or sanitizing between uses.During an interview on 9/30/2025 at 7:41 AM, the Dietary Manager stated she should not have tested the pureed ham without cleaning the probe first.Review of the document provided by the facility for taking food temperature read, Taking Accurate Temperatures using Metal Stem Thermometers. 3. The thermometer must be sanitized between uses in different foods. 4. Thermometers should be sanitized according to manufacture's instructions. In between uses at one meal, an alcohol swab may be used to sanitize. (Use a new swab for each sanitizing.)

Based on record review and interview, the facility failed to provide the residents with the Notice of Medicare Non-coverage (NOMNC) within the required time frame for 1 of 3 residents reviewed for beneficiary notification (Resident #18).Findings include:Review of Resident #18's Notice of Medicare Non-Coverage (NOMNC) showed the resident's Medicare coverage for current skilled services would end on 6/11/2025.Review of Resident #18's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) read, Beginning on 6/12/2025, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The care(s) you have been receiving during the Inpatient Skilled Nursing Facility include: Physical Therapy. The resident acknowledged the receipt of the notice and signed it on 6/10/2025.During an interview on 10/1/2025 at 11:37 AM, the Administrator stated, The business staff was training and felt that it had to be two days from 6/12/2025, which is the day the resident would be responsible for services instead notices have to be given to the resident two days before the last covered day of services will end. [Resident #18's name should have received the notices two days before 6/11/2025.Review of the facility policy and procedure titled Advance Beneficiary Notices with the last review date of 4/24/2025 read, Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines: 7. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The notices must not be provided while resident/representative is under duress or in an emergency situation.

Based on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed for respiratory services (Resident #14) and 1 of 3 residents reviewed for behavioral health (Resident #31).Findings include:1) Review of Resident #14's physician order dated 9/22/2025 read, O2 [Oxygen] PRN [as needed] at 2 L [liter] via n/c [nasal cannula] to maintain an O2 sat [saturation] of greater than 92%.Review of Resident #14's Weights and Vital Summary documented the resident's oxygen saturation as 97% (Oxygen via nasal Cannula) on 8/29/2025 at 2:22 AM, 98% (Oxygen via nasal cannula) on 8/29/2025 at 6:30 PM, 97% (Oxygen via nasal cannula) on 8/29/2025 at 11:43 PM, 98% (Oxygen via nasal cannula) on 8/31/2025 at 1:46 AM, and 97% (Oxygen via nasal cannula) on 9/1/2025 at 12:47 AM.Review of Resident #14's Medicare 5-Day MDS assessment dated [DATE] showed no information documented for oxygen therapy under Section O. Special Treatments, Procedures, and Programs.During an interview on 10/1/2025 at 2:15 PM, the MDS Coordinator stated, [Resident #14's name] MDS Section O, the oxygen coding, needs to be corrected. The nurses were not documenting the use of oxygen, but it was being documented in the vitals oxygen saturation.2) Review of Resident #31's admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to adjustment disorder with depressed mood and other specified anxiety disorders.Review of Resident #31' MDS assessment for significant change dated 8/18/2025 showed no anxiety disorder and adjustment disorder with depressed mood documented in Psychiatric/Mood Disorder or other additional active diagnoses parts of Section I. Active Diagnosis.During an interview on 10/1/2025 at 2:10 PM, the MDS Coordinator stated, [Resident #31's name] MDS did not include the diagnosis of anxiety or adjustment disorder. It will need to be corrected.Review of the facility policy and procedure titled MDS 3.0 Completion with the last review date of 4/24/2025 read, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards during medication administration for 2 of 5 residents observed, Resident #35 and Resident #7, and during wound care for 1 of 2 residents observed, Resident #32, and failed to ensure staff disinfected the reusable medical equipment to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 7/2/2024 at 7:57 AM, Staff A, Licensed Practical Nurse (LPN), was preparing medications for Resident #35. A dark colored capsule fell on to the top of the medication cart while popping the medication blister pack. Staff A picked up the capsule from the top of the medication cart with an ungloved hand and placed it into the medication cup. Staff A entered Resident #35's room and administered the medication. During an observation on 7/2/2024 at 8:05 AM, Staff A, LPN, poured medications into a medication cup for Resident #7. Staff A asked Resident #7 if she would like her potassium tablet to be cut in half and the resident replied Yes. Staff A, without donning gloves, removed the potassium tablet from the medication cup with her hands and cut the potassium tablet in half and placed the two halves of the medication back into the medication cup. Resident #7 asked Staff A to take her blood pressure one more time. Staff A placed a wrist blood pressure monitor on the resident's right wrist. Staff A read the blood pressure reading to the resident. Resident #7 asked Staff A if she could take her blood pressure manually. Staff A exited the room and walked towards the vital signs monitor covered with a plastic bag and removed the manual blood pressure cuff from the basket. Staff A returned to Resident #7's room and took Resident #7's blood pressure manually. Staff A read the blood pressure reading and Resident #7 accepted to take the medications. Staff A administered the medications to Resident #7. Staff A exited Resident #7's room and without sanitizing the manual blood pressure cuff, placed it back into the basket and covered the vital signs monitor with the plastic bag. During an interview on 7/2/2024 at 8:25 AM, Staff A, LPN, stated, I should have probably worn gloves when touching the medication and the one capsule that fell . I should have discarded and given another capsule. I should have sanitized the blood pressure cuff after using it with [Resident #7 name]. During an interview on 7/2/2024 at 9:28 AM, the Director of Nursing stated, If the staff drops the medication, they should dispose of it and get a new one. The staff should always wear gloves when handling medication and should clean the medical equipment in between patient use. If the patient vitals machines out in the hallway are covered with the plastic bag, it means they are clean and ready to be used on the next resident. Review of the facility policy and procedure titled Cleaning Blood Pressure Cuffs with the last review date of 2/15/2024 showed the policy read, Purpose: The purpose of this procedure is to prevent cross contamination when cleaning a blood pressure cuff. Procedure Guidelines . 2. Obtain alcohol prep pad or swab and use firm pressure to clean the blood pressure cuff before and after each resident use. Review of the facility policy and procedure titled Oral Medications with the last review date of 2/15/2024 showed the policy read, Protective Barriers That May Be Required: Handwashing, Gloves (as indicated) . Steps in the Procedure . 5. For unit dose tablets/capsules put packaged tablet/capsule directly into medicine cup. During an observation on 7/2/2024 at 9:40 AM, Staff B, LPN, Unit Manager, performed hand hygiene and entered Resident #32's room. Staff B donned gloves and removed a dressing dated 7/2/2024 from Resident #32's left heel. Staff B removed gloves and, without performing hand hygiene, donned a new set of gloves. Staff B cleansed the left heel wound area, pat the area dry, applied the ordered treatment and applied a new dressing without performing hand hygiene in between any of the wound care steps. During an interview on 7/2/2024 at 9:48 AM, Staff B, LPN, Unit Manager, stated, I should have washed my hands when I took off my gloves after removing the dressing. I forgot. During an interview on 7/2/2024 at 10:00 AM, the Director of Nursing (DON) stated, The nursing staff should perform hand hygiene after removing gloves and when hands are considered contaminated. The nurse should have washed her hands in between the wound care steps. Review of the facility policy and procedure titled Dressing, Non-Sterile with the last review date of 2/15/2024 showed the policy read, Purpose: The purposes of this procedure are to provide guideline for non-sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria . Steps in the procedure . 10. Put on disposable exam gloves. 11. Loosen tape and remove soiled dressing. 12. Pull glove over dressing and discard into appropriate receptacle. 13. Wash hands or sanitize with ABHR [Alcohol Based Hand Rub] (if not visibly soiled). 14. Put on clean gloves. 16. Cleanse the wound. Use separate gauze for each cleansing stroke. Clean from the most contaminated area to the least contaminated area. 17. Use dry gauze to pat the wound dry. 18. Wash hands or sanitize hands with ABHR (if not visibly soiled) and apply new gloves. 19. Supply the ordered dressing and secure with tape.

Based on record review and interview, the facility failed to ensure medical records were accurate for 1 of 6 residents reviewed for medication administration, Resident #36, and for 1 of 3 residents reviewed for accidents, Resident #3. Findings include: 1. Review of Resident #36's physician order dated 5/1/2024 showed the order read, Cardizem Oral Tablet 30 mg [milligrams] (Diltiazem HCl) Give 1 tablet by mouth every 8 hours for HTN [Hypertension] Hold for HR [Heart Rate] <60 [less than 60] or SBP [Systolic Blood Pressure] <100 [greater than 100]. Review of Resident #36's Medication Administration Record (MAR) for June 2024 for administration of one Cardizem oral tablet 30 mg (Diltiazem HCl) every 8 hours for hypertension (Hold for HR <60 or SBP <100) with the start date of 5/1/2024 and discontinuation date of 6/6/2024 showed the resident received the medication on 6/4/2024 at 2:00 PM with blood pressure and pulse coded as NA (not applicable). Review of Resident #36's physician order dated 6/6/2024 showed the order read, Cardizem Oral Tablet 30 mg (Diltiazem HCl) Give 1 tablet by mouth every 8 hours for HTN Hold for HR <60 or SBP <110. Review of Resident #36's MAR for June 2024 for administration of one Cardizem oral tablet 30 mg (Diltiazem HCl) every 8 hours for hypertension (Hold for HR <60 or SBP <110) with the start date of 6/6/2024 showed the resident received the medication on 6/16/2024 at 10:00 PM with blood pressure and pulse documented as X, and on 6/18/2024, 6/21/2024, 6/22/2024, and 6/26/2024 at 2:00 PM with blood pressure and pulse coded as NA and 10 (Vitals/blood sugar out of parameter). During an interview on 7/3/2024 at 9:09 AM, the Director of Nursing (DON) stated, I reached out to the staff that were involved in the medication administration. The medication was given, but the staff did not go back to put the vitals in. I tried to look for the vitals and I could not locate them. The staff should be inputting the parameters in the electronic record if the medication ask for parameters. 40559 2. Review of Resident #3's physician order dated 6/5/2024 showed the order read, RNP [Restorative Nursing Program]: Splinting- one time daily. Review of Resident #3's task sheet for assistance to apply left hand splint for at least 4 hours daily from 6/3/2024 through 7/1/2024 showed it was documented as Not Applicable on 6/7/2024 at 2:31 PM, 6/14/2024 at 2:54 PM, 6/17/2024 at 5:03 PM, 6/18/2024 at 6:59 PM, 6/21/2024 at 3:21 PM, 6/24/2024 at 3:05 PM, 6/29/2024 at 3:18 PM, 6/30/2024 at 3:12 PM, and 7/1/2024 at 3:57 PM. During an interview on 7/2/2024 at 10:30 AM, the DON stated, The staff should not be recording the splint application as not applicable. It should be either time applied or that the resident refused. Review of the facility policy and procedure titled Charting with the last review date of 2/15/2024, showed the policy read, Policy Interpretation and Implementation: 1. Medications given, services performed, etc. are recorded in the resident's chart. Review of the facility policy and procedure titled Administration of Drugs with the last review date of 2/15/2024, showed the policy read, Policy Interpretation and Implementation . 9. The nurse administering the drug must record such information on the resident's eMAR [electronic medication administration record] before administering the next resident's drug.

Based on record review and interview, the facility failed to ensure the resident or resident representative received the refund due the resident within 30 days from the resident's date of discharge from the facility for 1 of 3 residents sampled for financial status review, Resident #1. Findings include: Review of Resident #1's admission record showed the resident was initially admitted to the facility on [DATE]. Review of Resident #1's physician order dated 10/13/2023 showed the resident will be discharged to an assisted living facility on 10/16/2023. Review of Resident #1's financial statement dated 2/21/2024 showed the resident has made a payment of $1,614.00 on 10/3/2023. The statement showed the resident was due $1,093.35 on 1/17/2024. During an interview on 2/21/2024 at 8:49 AM, Resident #1's Daughter stated that the resident had moved out on October 16, 2023, and she had not received a refund from the facility for unused days. During an interview on 2/21/2024 at 11:00 AM, the Business Office Manager (BOM) stated, [Resident #1's name] discharged to hospital on 10/16/23. I sent refund status to [Third Party [NAME] Company's Staff] on 1/17/24 at 1:26 PM. I called third party billing company on 2/1/24 and asked the status of account for [Resident #1's name]. She told a prior employee left with no access to email with ledger for $1,093.35 due to a liability payment. Payment refund will be sent to [Resident #1's name] daughter. It was signed as accepted status on 1/17/24. During an interview on 2/21/2024 at 12:11 PM, Third Party [NAME] Company's Staff stated, [Resident #1's Name] refund has not been processed due to several employees quitting with no notice and no access to her email. It has been approved, processed and will be mailed today. Review of the facility contract signed by Resident #1 on 3/21/2023 reads, 13. Refunds payable shall be confirmed by audit by the Center's accounting office. All refunds due to the resident: a) shall be made regardless of the reason for the resident leaving.c) refunds will be made for any prepaid room and board services for which payment has been received. The refund of the unused portion of prepaid fees and charges will be made within 30 days following resident's death, refunds will be made in accordance with state and federal law) in cases where third party coverage is involved (Medicare, Medicaid, Insurance) refunds may be delayed until formal determination and documentation of a resident's eligibility is received by the Center from the appropriate agency.

Based on observation, interview, and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility by allowing unqualified facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 1 of 1 residents, Resident #197, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. This can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, which can occur from a poorly administered IV infusion. Phlebitis can cause blood clots, which can block important blood vessels, causing tissue damage or even be life-threatening. Lack of proper training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into the patient's vein) can increase the spread of infection. Lack of training and verified competency to assess the insertion site for signs and symptoms of phlebitis or infection, fluid leaking (resulting in the treatment not being administered as ordered), redness, pain, tenderness, and swelling can result in the likelihood of increased risk of serious harm and/or death. Findings include: Review of the job description titled, Administrator read, Summary: Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and company policies to maintain excellent care for the residents while achieving the facility's business objective. Essential Duties and Responsibilities: Planning Function: Work with the facility management staff and consultants in planning all aspects of facility operations, including setting priorities and job assignments. Monitor each department's activities, communicate policies, evaluate performance, provide feedback, and assist, coach and discipline as needed. Continuous Quality Improvement Function: Conduct regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of facility, morale of staff and to ensure residents needs are being addressed in a proactive manner. Regulatory Compliance Function: Maintain a working knowledge of and ensure compliance with all governmental regulations. Educational Function: Supervise, conduct, and participate in department and facility education activities and staff meetings. Maintain professional competence through participation in continuing education programs, seminars, and training programs. Review of job description titled, Director of Nursing [DON] read, Summary: Lead and direct the overall nursing operation of the Center in accordance with residents' needs, government regulations, and company policies to maintain excellent care for the residents while achieving the Center's business objectives. Essential Duties and Responsibilities: Work with the nursing management staff, Administrator, and Consultants in planning all aspects of the nursing operation, including setting priorities and job assignments. Monitor each unit's activities, communicate policies, evaluate performance, provide feedback, and assist, coach, and discipline as needed. Conduct regular rounds to monitor delivery of nursing care, effective coordination with other support services, cleanliness and appearance of the residents, and morale of staff and to ensure residents' needs are being addressed in a proactive manner. Maintain a working knowledge and ensure compliance with all governmental regulations. Monitor medical records to assure the documentation reflects the skilled services provided and complies with policies and regulations. Monitor associate relations practices key nursing staff to ensure compliance with employment laws and company policies and to ensure practices that maintain high morale and staff retention to include effective communication, prompt problem resolution, positive supervisory practices, and maintaining a positive work environment. Manage turnover and ensure current and future staffing through development of recruiting sources and through appropriate selection, orientation, training, and staff education. Review of job description titled Assistant Director of Nursing [ADON], RN [Registered Nurse] read, Summary: To assist the Director of Nursing in leading and directing the overall nursing operation of the Center in accordance with residents' needs, government regulations, and company policies to maintain excellent care for the residents while achieving the Center's business objective. Essential Duties and Responsibilities: Assist the DON in working with management staff, Administrator, and Consultants in planning all aspects of the nursing operation, including setting priorities and job assignments. Conduct regular rounds to monitor delivery of nursing care, effective coordination with other support services, cleanliness and appearance of the residents, and morale of staff and to ensure residents' needs are being addressed in a proactive manner. Carry out, coordinate, and manage administrative functions in areas or programs related to nursing services, which may include departmental documentation or medical records; nursing supplies; ancillary supplies or services; center CQI [Continuous Quality Improvement]; care plan; MDSs [Minimum Data Sets]; Infection control programs; skin care program; Medicare; special programs; staff scheduling; selection, training, and orientation; and related functions. Maintain a working knowledge and ensure compliance with all governmental regulations. Monitor associate relations practices key nursing staff to ensure compliance with employment laws and company policies and to ensure practices that maintain high morale and staff retention to include effective communication, prompt problem resolution, positive supervisory practices, and maintaining a positive work environment. Manage turnover and ensure current and future staffing through development of recruiting sources and through appropriate selection, orientation, training, and staff education. Review of job description titled, Staff Developer-RN read, Summary: To plan and implement Center orientation, job skills training, and in-service education programs in accordance with Company policies and regulations. The primary function of this position is recruiting and training associates and to monitor and guide these positions throughout the course of employment. Work with the Administrator, Director of Nursing, and Center staff in assessing training needs and plan programs that meet priority needs and regulatory requirements. Review of Medical Director Agreement effective [DATE] reads, Section 1. Medical Director Duties . 13. Assuring that the medical standards of the facility comply with applicable laws, licensing, certification, and accreditation and professional standards. During an observation on [DATE] at 9:03 AM Resident #197 was in his room lying in bed. There is a double lumen peripherally inserted central catheter (PICC) covered with a transparent observed to the resident's upper right arm. The transparent dressing was dated [DATE] written with a black marker. During an interview on [DATE] at 9:04 AM Resident #197 stated, I have this IV [intravenous catheter] for antibiotics to treat the infection I have in my big toe. Review of the physician order report for [DATE] through [DATE] documented an order dated [DATE] for Resident #197 that read, Normal Saline Flush [sodium chloride 0.9% flush] syringe; amt [amount to administer]: 10 ml [milliliters]; injection. Special Instructions: Flush before and after each IV medication administration. Every shift. [Dated] [DATE] Meropenem recon soln [reconstituted solution]; 1 gram; amt]: 1 gram; intravenous. Dx [diagnosis]: Other [osteomyelitis, ankle and foot]. Every 8 hours. [Dated] [DATE] Vancomycin recon soln; 1.25 gram; amt: 1.25 gram; intravenous. Dx Other [osteomyelitis, ankle and foot]. Once a day. Review of the Medication Administration History for Resident #197 documented Staff A, License Practical Nurse (LPN), administered 10 ml of sodium chloride 0.9% before and the administration of Meropenem 1 gram on [DATE] at 3:32 PM and on [DATE] at 2:00 PM. Review of the Medication Administration History for Resident #197 documented Staff G, LPN, administered 10 ml of sodium chloride 0.9% before and after the administration of the IV medication Meropenem 1 gram reconstituted solution on [DATE] at 11:56 PM, [DATE] at 10:00 PM, [DATE] at 6:00 AM, [DATE] at 10:00 PM and [DATE] at 6:00 AM. Dated [DATE] Staff G, LPN administered 1.25 grams of Vancomycin reconstituted solution IV on [DATE] at 5:31 AM. During an interview on [DATE] at 10:09 AM the Director of Nursing (DON) stated, We have no IV certification records for Staff A, LPN. He was contacted and cannot produce a certification. If the MAR [Medication Administration Record/Medication Administration History] is initialed by a nurse, it means the medication was given by that nurse unless if there is parenthesis which means they made a note. The Staff Developer and Human Resources are responsible for verification of staff certification. During the interview a request was made for the IV Certification for Staff G. During an interview on [DATE] at 10:30 AM Staff C, Unit Manager LPN, stated, LPNs need to have IV certification. The Human Resource staff and Staff Development is responsible for making sure staff have all certifications upon hire. During an interview on [DATE] at 10:41 AM Staff A, LPN, stated, Yesterday I helped administer medication. The Assistant Director of Nursing was in the room with me. I hung medication, flushed, and cleaned the port. I was supervised. I am always supervised by an RN [Registered Nurse]. The facility did not request IV certification from me upon hire. I did not know I needed IV certification. I have done IV medication administration before. I do not know how to place an IV in an arm [to insert an IV] but I know how to hang medication. When I was hired, I was trained and shown how to administer medication via IV. The first time the nurse showed me [how to administer IV medications]. After that, she has always supervised me doing the administration and flushes. The RN is always with me at all times. Normally I will do it and chart under my name since he is my resident. During an interview on [DATE] at 12:55 PM the Human Resource/ABOM (Assistant Business Office Manager) stated, The IV certification would be kept in the employee file only if provided, it is not requested. During an interview on [DATE] at 12:55 PM the Staffing Coordinator stated, Staff is assigned to halls. I leave it up to the nursing staff to tell me if they are capable or not of treating the resident. I hold a CNA [Certified Nursing Assistant] license. I am aware that the RN is the only one who is able to do PICC lines. I do not have copies of all the nurses' certifications. I am the only one who schedules. The head nursing department is responsible to verify certifications. I assume that all the credentials have been verified by the head of nursing. We do not have a 24-hour RN on the schedule. From 7 PM to 7 AM that we do not have an RN. During an interview on [DATE] at 1:21 PM the Staff Developer stated, Upon hire, I will request the license, CPR [cardiopulmonary resuscitation], and any certifications. Prior to me, it was [name of the previous owner company] who was in charge of all the onboarding. Upon hire, I request the IV certification and give them up to 30 days. If the staff does not provide the certification, I have to readdress. During orientation, I asked [Staff A's name] for his certification. [Staff A's name] stated he had it. When [Staff A's name] did not provide it in the 30-day time frame, I readdressed, and we were in the process of a teachable moment. Review of the personnel record for Staff A, LPN documented the LPN's hire date as [DATE]. During an interview on [DATE] at 1:21 PM the DON stated, Newly hired staff are told upon hire if there is something that they are not able to do or do not feel comfortable there is a 24-hour RN that is on call that is able to assist. We stress constantly that if a task is not in their scope of practice or they are unable to complete ask for assistance. Upon hire, the Staff Development will do the competency and skills fair. My expectation for [Staff A's name] would be to get an RN that was on duty and assist and perform the task for him. It is not the practice of the facility to allow a non-IV Certified LPN to administer IV medications supervised. That was not the case there was no RN in the building that approved of [Staff A's name] to administer IV medications. It would be falsification of documentation to only initial; an LPN will not be allowed to initial the task if they had not performed the task themselves. During an interview on [DATE] at 1:40 PM the ADON stated, I have not been in the room with an LPN to supervise or walk through IV medication administration for [Resident #197's name]. Onboarding is done by Staff Development and Human Resources goes behind with a checklist. I don't get an official notification of who is certified. I understand that someone will learn in school what their scope is that would be my expectation. The Staff Developer is the one who should be checking the paperwork and verifying that all LPNs have all certifications. I don't know if the Staff Developer reports to the DON since everything in the building falls under her. I will find out who is responsible for verifying agency [LPNs]. I have provided emergency cover for 7 PM-7 AM. During an interview on [DATE] at 2:05 PM the Medical Director stated, If nursing staff is non-IV certified, they should not be doing medication administration via IV. I was not aware that LPNs were administering medications via IV and were not certified. If the staff is not certified they might not know what they are doing and there is a risk for infection, mishandling of the IV port, bleeding, pain, the list can go on, but it is only a potential. During an interview on [DATE] at 10:35 AM, the DON stated, The facility does not have IV Certification for [Staff A's name] and [Staff G's name]. During an interview on [DATE] at 2:56 PM, Staff G stated, I became a nurse in the 1990s and while working at [Name of facility], I took a [Name of pharmacy] IV certification course in [Name of City], but I have not been able to locate the paperwork. During an interview on [DATE] at 2:58 PM, the DON, stated, There was an IV certified LPN, but I don't know why [Staff G's name] didn't ask for assistance. Ultimately, as far as the nursing department, I oversee nursing staff qualifications and the Staff Developer. [Staff G's name] verbally told us that she is IV certified. IV certification was requested. No documentation was provided of IV certifications for Staff A or Staff G. During an interview on [DATE] at 7:20 AM the Administrator stated, I understand there is a certification LPNs need to obtain that certifies them for IVs. The hiring process is new with all the corporate buy outs. Now we have a Human Resource Manager. Upon hire employees are ask for any and all certificates they have; if they do not produce the certifications, we assume they do not have them. During an interview on [DATE] at 9:30 AM with DON stated, It is not up to me to determine what neglect is. I would have to refer to my neglect policy. During an interview on [DATE] at 9:30 AM with Administrator stated, It would be neglect if we were aware and condoned it. Our policy does not condone. This was a [NAME] employee. We expect the staff to work within their scope of practice. As the facility Administrator I oversee the facility. My responsibilities are listed in my job description. During an interview on [DATE] at 9:34 AM the Director of Clinical Services, stated, I would consider it neglect if the staff worked outside their scope. We did not have a system in place to check for qualifications. We expect staff to work within their scope of practice, we trusted them. During an interview on [DATE] at 12:57 PM with the Administrator stated, We didn't have a process in place for verification of staff qualifications. The previous company took care of the onboarding and now the new company has HR [Human Resource] in house. We have weekly meetings and daily staff meetings. During an interview on [DATE] at 12:57 PM the Staffing Coordinator stated, I depend on higher nursing staff for qualifications. I am responsible for the hours per resident care and PBJ [Payroll Based Journal, a system for facilities to submit staffing information]. I rely on the head of nursing to verify staff certifications and qualifications. I was trained on hours per resident care and PBJ. Review of the facility policy and procedure titled, Abuse, Neglect and Misappropriation of Property with a last review date of [DATE], read, Definitions of Types of Abuse: Neglect - Is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Policy Components . C. Prevention: Ensuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Responsibilities with a last reviewed date of [DATE], read, Policy . 6. Maintain records of personnel qualified by education and experience who may provide infusion therapy in the facility. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Policies and Procedures with a last review date of [DATE], read, The policies and procedures of a facility may be more stringent, and duties may be more restrictive than what is permitted by state regulations but may never be more lenient. For example: The State Board of Nursing may indicate that it is within the scope of practice for LPNs to flush Central Venous Catheters in long term care facilities, but it is the individual facility's decision to allow or not allow LPNs to perform the procedure. On the other hand, if the State Board of Nursing prohibits LPNs from flushing Central Venous Catheter in long term care facilities, then a facility may NEVER allow an LPN to perform that procedure. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Legal Issues with a last review date of [DATE], read, Legal Issues . Rule of Personal Liability: No Nurse, LVN [Licensed Vocational Nurse]/LPN or RN, should perform any procedure that he or she has not been specifically trained to do. Review of the facility policy and procedure titled, Nursing Services with a last review of [DATE], read, Policy . 5. The facility will ensure that licensed nurse have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Board of Nursing Rule Chapter 64B,d+[DATE] titled Administration of Intravenous Therapy by Licensed Practical Nurse reads, Section 64B,d+[DATE].005 - Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy .(2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B,d+[DATE].002(2), F.A.C. [Florida Administrative Code] Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL [central venous catheters] site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnessed by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. (3) Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the Board pursuant to Rule 64B,d+[DATE].005, F.A.C. To be qualified to teach any such course, the instructor must be a currently licensed registered nurse in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying completion of the requisite number of hours and course content. (4) Educational Alternatives. The cognitive training shall include one or more of the following: (a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S. [Florida Statutes], for practical nursing programs are extensive and that every licensed practical nurse will not administer IV therapy. The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B,d+[DATE].005(1), F.A.C.(b) Credit for Previous Education. The continuing education provider may credit the licensed practical nurse or graduate practical nurse for previous IV therapy education on a post-graduate level, providing each component of the course content of subsection 64B,d+[DATE].005(1), F.A.C., is tested by and competency demonstrated to the provider. (c) Nontraditional Education. Continuing education providers may select nontraditional education alternatives for acquisition of cognitive content outlined in Rule 64B,d+[DATE].005, F.A.C. Such alternatives include: 1. Interactive videos; 2. Self-study; 3. Other nontraditional education that may be submitted to the Board for consideration and possible approval. Any continuing education providers using nontraditional education must make provisions for demonstration of and verification of knowledge. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed registered nurse. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the likelihood of harm and/or possible death as evidenced by the following: On [DATE] during interviews, 6 RNs, 4 LPNs and 5 CNAs confirmed education for abuse/neglect, scope of practice and the 30 hour IV certification requirement for LPN's, the Director of Nursing, Assistant Director of Nursing, Staff Development, Human Resources and the Scheduler confirmed education for abuse/neglect, scope of practice, the 30 hour IV certification requirement for LPN's, and the new system for scheduling per residents needs according to staff qualifications. Review of staff training documented 100% of staff were educated on abuse/neglect and 100% of RNs and LPNs were educated on scope of practice. On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and/or receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On [DATE] all LPN personnel records were audited to verify training credentials. On ,d+[DATE] - [DATE], the facility educated all nursing staff related to neglect, scope of practice, and the 30-hour IV certification requirement for LPNs prior to IV medication administration. On [DATE], the Director of Clinical Services provided training to the facility administration on verification of staff competency, working within their scope of practice and abuse/neglect policy. On [DATE], the Director of Clinical Services provided training to the Staff Developer and Staff Scheduler on neglect, scope of practice and supervision of staff. On [DATE], a new system for scheduling per residents needs according to staff qualifications was developed and implemented. On [DATE] the Director of Clinical Services educated the nursing managers on the new scheduling system.

Based on observation, interview and record review the facility failed to ensure licensed practical nurses (LPNs) had the appropriate skills and competencies to administer intravenous (IV) medication via central line access devices for 1 of 1 residents, Resident #197. The lack of IV certification and validation of competency for IV medication administration can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, causing tissue damage or even be life threatening. The lack of training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into patients' veins) can increase the spread of infection and can result in the likelihood of increase harm and/or death. Findings include: During an observation on [DATE] at 9:03 AM Resident #197 was in his room lying in bed. There is a double lumen peripherally inserted central catheter (PICC) covered with a transparent observed to the resident's upper right arm. The transparent dressing was dated [DATE] written with a black marker. During an interview on [DATE] at 9:04 AM Resident #197 stated, I have this IV [intravenous catheter] for antibiotics to treat the infection I have in my big toe. Review of the physician order report for [DATE] through [DATE] documented an order dated [DATE] for Resident #197 that read, Normal Saline Flush [sodium chloride 0.9% flush] syringe; amt [amount to administer]: 10 ml [milliliters]; injection. Special Instructions: Flush before and after each IV medication administration. Every shift. [Dated] [DATE] Meropenem recon soln [reconstituted solution]; 1 gram; amt]: 1 gram; intravenous. Dx [diagnosis]: Other [osteomyelitis, ankle and foot]. Every 8 hours. [Dated] [DATE] Vancomycin recon soln; 1.25 gram; amt: 1.25 gram; intravenous. Dx Other [osteomyelitis, ankle and foot]. Once a day. Review of the Medication Administration History for Resident #197 documented Staff A, License Practical Nurse (LPN), administered 10 ml of sodium chloride 0.9% before and the administration of Meropenem 1 gram on [DATE] at 3:32 PM and on [DATE] at 2:00 PM. Review of the Medication Administration History for Resident #197 documented Staff G, LPN, administered 10 ml of sodium chloride 0.9% before and after the administration of the IV medication Meropenem 1 gram reconstituted solution on [DATE] at 11:56 PM, [DATE] at 10:00 PM, [DATE] at 6:00 AM, [DATE] at 10:00 PM and [DATE] at 6:00 AM. Dated [DATE] Staff G, LPN administered 1.25 grams of Vancomycin reconstituted solution IV on [DATE] at 5:31 AM. During an interview on [DATE] at 10:09 AM the Director of Nursing (DON) stated, We have no IV certification records for Staff A, LPN. He was contacted and cannot produce a certification. If the MAR [Medication Administration Record/Medication Administration History] is initialed by a nurse, it means the medication was given by that nurse unless if there is parenthesis which means they made a note. The Staff Developer and Human Resources are responsible for verification of staff certification. During the interview a request was made for the IV Certification for Staff G. During an interview on [DATE] at 10:30 AM Staff C, Unit Manager LPN, stated, LPNs need to have IV certification. The Human Resource staff and Staff Development is responsible for making sure staff have all certifications upon hire. During an interview on [DATE] at 10:41 AM Staff A, LPN, stated, Yesterday I helped administer medication. The Assistant Director of Nursing was in the room with me. I hung medication, flushed, and cleaned the port. I was supervised. I am always supervised by an RN [Registered Nurse]. The facility did not request IV certification from me upon hire. I did not know I needed IV certification. I have done IV medication administration before. I do not know how to place an IV in an arm [to insert an IV] but I know how to hang medication. When I was hired, I was trained and shown how to administer medication via IV. The first time the nurse showed me [how to administer IV medications]. After that, she has always supervised me doing the administration and flushes. The RN is always with me at all times. Normally I will do it and chart under my name since he is my resident. During an interview on [DATE] at 12:55 PM the Human Resource/ABOM (Assistant Business Office Manager) stated, The IV certification would be kept in the employee file only if provided, it is not requested. During an interview on [DATE] at 12:55 PM the Staffing Coordinator stated, Staff is assigned to halls. I leave it up to the nursing staff to tell me if they are capable or not of treating the resident. I hold a CNA [Certified Nursing Assistant] license. I am aware that the RN is the only one who is able to do PICC lines. I do not have copies of all the nurses' certifications. I am the only one who schedules. The head nursing department is responsible to verify certifications. I assume that all the credentials have been verified by the head of nursing. We do not have a 24-hour RN on the schedule. From 7 PM to 7 AM we do not have an RN. During an interview on [DATE] at 1:21 PM the Staff Developer stated, Upon hire, I will request the license, CPR [cardiopulmonary resuscitation], and any certifications. Prior to me, it was [name of the previous owner company] who was in charge of all the onboarding. Upon hire, I request the IV certification and give them up to 30 days. If the staff does not provide the certification, I have to readdress. During orientation, I asked [Staff A's name] for his certification. [Staff A's name] stated he had it. When [Staff A's name] did not provide it in the 30-day time frame, I readdressed, and we were in the process of a teachable moment. Review of the personnel record for Staff A, LPN documented the LPN's hire date as [DATE]. During an interview on [DATE] at 1:21 PM the DON stated, Newly hired staff are told upon hire if there is something that they are not able to do or do not feel comfortable there is a 24-hour RN that is on call that is able to assist. We stress constantly that if a task is not in their scope of practice or they are unable to complete ask for assistance. Upon hire, the Staff Development will do the competency and skills fair. My expectation for [Staff A's name] would be to get an RN that was on duty and assist and perform the task for him. It is not the practice of the facility to allow a non-IV Certified LPN to administer IV medications supervised. That was not the case there was no RN in the building that approved of [Staff A's name] to administer IV medications. It would be falsification of documentation to only initial; an LPN will not be allowed to initial the task if they had not performed the task themselves. During an interview on [DATE] at 1:40 PM the ADON stated, I have not been in the room with an LPN to supervise or walk through IV medication administration for [Resident #197's name]. Onboarding is done by Staff Development and Human Resources goes behind with a checklist. I don't get an official notification of who is certified. I understand that someone will learn in school what their scope is that would be my expectation. The Staff Developer is the one who should be checking the paperwork and verifying that all LPNs have all certifications. I don't know if the Staff Developer reports to the DON since everything in the building falls under her. I will find out who is responsible for verifying agency [LPNs]. I have provided emergency cover for 7 PM-7 AM. During an interview on [DATE] at 2:05 PM the Medical Director stated, If nursing staff is non-IV certified, they should not be doing medication administration via IV. I was not aware that LPNs were administering medications via IV and were not certified. If the staff is not certified they might not know what they are doing and there is a risk for infection, mishandling of the IV port, bleeding, pain, the list can go on, but it is only a potential. During an interview on [DATE] at 10:35 AM, the DON stated, The facility does not have IV Certification for [Staff A's name] and [Staff G's name]. During an interview on [DATE] at 2:56 PM, Staff G stated, I became a nurse in the 1990s and while working at [Name of facility], I took a [Name of pharmacy] IV certification course in [Name of City], but I have not been able to locate the paperwork. During an interview on [DATE] at 2:58 PM, the DON, stated, There was an IV certified LPN, but I don't know why [Staff G's name] didn't ask for assistance. Ultimately, as far as the nursing department, I oversee nursing staff qualifications and the Staff Developer. [Staff G's name] verbally told us that she is IV certified. IV certification was requested. No documentation was provided of IV certifications for Staff A or Staff G. During an interview on [DATE] at 7:20 AM the Administrator stated, I understand there is a certification LPNs need to obtain that certifies them for IVs. The hiring process is new with all the corporate buy outs. Now we have a Human Resource Manager. Upon hire employees are ask for any and all certificates they have; if they do not produce the certifications, we assume they do not have them. During an interview on [DATE] at 9:34 AM the Director of Clinical Services stated, We did not have a system in place to check for qualifications. We expect staff to work within their scope of practice, we trusted them. During an interview on [DATE] at 12:57 PM with the Administrator stated, We didn't have a process in place for verification of staff qualifications. The previous company took care of the onboarding and now the new company has HR [Human Resource] in house. We have weekly meetings and daily staff meetings. During an interview on [DATE] at 12:57 PM the Staffing Coordinator stated, I depend on higher nursing staff for qualifications. I am responsible for the hours per resident care and PBJ [Payroll Based Journal, a system for facilities to submit staffing information]. I rely on the head of nursing to verify staff certifications and qualifications. I was trained on hours per resident care and PBJ. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Responsibilities with a last reviewed date of [DATE], read, Policy . 6. Maintain records of personnel qualified by education and experience who may provide infusion therapy in the facility. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Policies and Procedures with a last review date of [DATE], read, The policies and procedures of a facility may be more stringent, and duties may be more restrictive than what is permitted by state regulations but may never be more lenient. For example: The State Board of Nursing may indicate that it is within the scope of practice for LPNs to flush Central Venous Catheters in long term care facilities, but it is the individual facility's decision to allow or not allow LPNs to perform the procedure. On the other hand, if the State Board of Nursing prohibits LPNs from flushing Central Venous Catheter in long term care facilities, then a facility may NEVER allow an LPN to perform that procedure. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Legal Issues with a last review date of [DATE], read, Legal Issues . Rule of Personal Liability: No Nurse, LVN [Licensed Vocational Nurse]/LPN or RN, should perform any procedure that he or she has not been specifically trained to do. Review of the facility policy and procedure titled, Nursing Services with a last review of [DATE], read, Policy . 5. The facility will ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Board of Nursing Rule Chapter 64B,d+[DATE] titled Administration of Intravenous Therapy by Licensed Practical Nurse reads, Section 64B,d+[DATE].005 - Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy .(2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B,d+[DATE].002(2), F.A.C. [Florida Administrative Code] Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL [central venous catheters] site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnessed by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. (3) Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the Board pursuant to Rule 64B,d+[DATE].005, F.A.C. To be qualified to teach any such course, the instructor must be a currently licensed registered nurse in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying completion of the requisite number of hours and course content. (4) Educational Alternatives. The cognitive training shall include one or more of the following: (a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S. [Florida Statutes], for practical nursing programs are extensive and that every licensed practical nurse will not administer IV therapy. The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B,d+[DATE].005(1), F.A.C.(b) Credit for Previous Education. The continuing education provider may credit the licensed practical nurse or graduate practical nurse for previous IV therapy education on a post-graduate level, providing each component of the course content of subsection 64B,d+[DATE].005(1), F.A.C., is tested by and competency demonstrated to the provider. (c) Nontraditional Education. Continuing education providers may select nontraditional education alternatives for acquisition of cognitive content outlined in Rule 64B,d+[DATE].005, F.A.C. Such alternatives include: 1. Interactive videos; 2. Self-study; 3. Other nontraditional education that may be submitted to the Board for consideration and possible approval. Any continuing education providers using nontraditional education must make provisions for demonstration of and verification of knowledge. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed registered nurse. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the likelihood of harm and/or possible death as evidenced by the following: On [DATE] during interviews, 6 RNs, 4 LPNs and 5 CNAs confirmed education for abuse/neglect, scope of practice and the 30 hour IV certification requirement for LPN's, the Director of Nursing, Assistant Director of Nursing, Staff Development, Human Resources and the Scheduler confirmed education for abuse/neglect, scope of practice, the 30 hour IV certification requirement for LPN's, and the new system for scheduling per residents needs according to staff qualifications. Review of staff training documented 100% of staff were educated on abuse/neglect and 100% of RNs and LPNs were educated on scope of practice. On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and/or receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On [DATE] all LPN personnel records were audited to verify training credentials. On ,d+[DATE] - [DATE], the facility educated all nursing staff related to neglect, scope of practice, and the 30-hour IV certification requirement for LPNs prior to IV medication administration. On [DATE], the Director of Clinical Services provided training to the facility administration on verification of staff competency, working within their scope of practice and abuse/neglect policy. On [DATE], the Director of Clinical Services provided training to the Staff Developer and Staff Scheduler on neglect, scope of practice and supervision of staff. On [DATE], a new system for scheduling per residents needs according to staff qualifications was developed and implemented. On [DATE] the Director of Clinical Services educated the nursing managers on the new scheduling system.

Based on observation, interview, and record review the facility failed to ensure all residents were free from medical neglect. The facility failed to ensure licensed practical nurses had the appropriate skills and competency to administer intravenous (IV) medication via central line access devices for 1 of 1 residents, Resident #197. The lack of IV certification and validation of competency for IV medication administration can result in an increased risk of infection, damage to veins and the injection sites, an air embolism (a blood vessel blockage cause by one or more bubbles of air or other gas in the circulatory system), phlebitis (inflammation of a vein), and blood clots. The lack of training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into patients' vein) can increase the spread of infection and can result in the likelihood of increased harm and/or death. Findings include: During an observation on [DATE] at 9:03 AM Resident #197 was in his room lying in bed. There is a double lumen peripherally inserted central catheter (PICC) covered with a transparent dressing observed to the resident's upper right arm. The transparent dressing was dated [DATE] written with a black marker. During an interview on [DATE] at 9:04 AM Resident #197 stated, I have this IV [intravenous catheter] for antibiotics to treat the infection I have in my big toe. Review of Resident #197's admission record documented the resident was admitted to the facility on [DATE] with a diagnosis including paroxysmal atrial fibrillation (irregular heart rhythm, osteomyelitis of ankle and foot (infection of the bone), cerebral aneurysm (a weak or think spot on an artery in the brain), depression, heart failure unspecified, and type 2 diabetes mellitus. Review of the physician order report for [DATE] through [DATE] documented an order dated [DATE] for Resident #197 that read, Normal Saline Flush [sodium chloride 0.9% flush] syringe; amt [amount to administer]: 10 ml [milliliters]; injection. Special Instructions: Flush before and after each IV medication administration. Every shift. [Dated] [DATE] Meropenem recon soln [reconstituted solution]; 1 gram; amt]: 1 gram; intravenous. Dx [diagnosis]: Other [osteomyelitis, ankle and foot]. Every 8 hours. [Dated] [DATE] Vancomycin recon soln; 1.25 gram; amt: 1.25 gram; intravenous. Dx Other [osteomyelitis, ankle and foot]. Once a day. Review of the Medication Administration History for Resident #197 documented Staff A, License Practical Nurse (LPN), administered 10 ml of sodium chloride 0.9% before and the administration of Meropenem 1 gram on [DATE] at 3:32 PM and on [DATE] at 2:00 PM. Review of the Medication Administration History for Resident #197 documented Staff G, LPN, administered 10 ml of sodium chloride 0.9% before and after the administration of the IV medication Meropenem 1 gram reconstituted solution on [DATE] at 11:56 PM, [DATE] at 10:00 PM, [DATE] at 6:00 AM, [DATE] at 10:00 PM and [DATE] at 6:00 AM. Dated [DATE] Staff G, LPN administered 1.25 grams of Vancomycin reconstituted solution IV on [DATE] at 5:31 AM. During an interview on [DATE] at 10:09 AM the Director of Nursing (DON) stated, We have no IV certification records for Staff A, LPN. He was contacted and cannot produce a certification. If the MAR [Medication Administration Record/Medication Administration History] is initialed by a nurse, it means the medication was given by that nurse unless if there is parenthesis which means they made a note. The Staff Developer and Human Resources are responsible for verification of staff certification. During the interview a request was made for the IV Certification for Staff G. During an interview on [DATE] at 10:30 AM Staff C, Unit Manager LPN, stated, LPNs need to have IV certification. The Human Resource staff and Staff Development is responsible for making sure staff have all certifications upon hire. During an interview on [DATE] at 10:41 AM Staff A, LPN, stated, Yesterday I helped administer medication. The Assistant Director of Nursing was in the room with me. I hung medication, flushed, and cleaned the port. I was supervised. I am always supervised by an RN [Registered Nurse]. The facility did not request IV certification from me upon hire. I did not know I needed IV certification. I have done IV medication administration before. I do not know how to place an IV in an arm [to insert an IV] but I know how to hang medication. When I was hired, I was trained and shown how to administer medication via IV. The first time the nurse showed me [how to administer IV medications]. After that, she has always supervised me doing the administration and flushes. The RN is always with me at all times. Normally I will do it and chart under my name since he is my resident. During an interview on [DATE] at 12:55 PM the Human Resource/ABOM (Assistant Business Office Manager) stated, The IV certification would be kept in the employee file only if provided, it is not requested. During an interview on [DATE] at 12:55 PM the Staffing Coordinator stated, Staff is assigned to halls. I leave it up to the nursing staff to tell me if they are capable or not of treating the resident. I hold a CNA [Certified Nursing Assistant] license. I am aware that the RN is the only one who is able to do PICC lines. I do not have copies of all the nurses' certifications. I am the only one who schedules. The head nursing department is responsible to verify certifications. I assume that all the credentials have been verified by the head of nursing. We do not have a 24-hour RN on the schedule. From 7 PM to 7 AM we do not have an RN. During an interview on [DATE] at 1:21 PM the Staff Developer stated, Upon hire, I will request the license, CPR [cardiopulmonary resuscitation], and any certifications. Prior to me, it was [name of the previous owner company] who was in charge of all the onboarding. Upon hire, I request the IV certification and give them up to 30 days. If the staff does not provide the certification, I have to readdress. During orientation, I asked [Staff A's name] for his certification. [Staff A's name] stated he had it. When [Staff A's name] did not provide it in the 30-day time frame, I readdressed, and we were in the process of a teachable moment. Review of the personnel record for Staff A, LPN documented the LPN's hire date as [DATE]. During an interview on [DATE] at 1:21 PM the DON stated, Newly hired staff are told upon hire if there is something that they are not able to do or do not feel comfortable there is a 24-hour RN that is on call that is able to assist. We stress constantly that if a task is not in their scope of practice or they are unable to complete ask for assistance. Upon hire, the Staff Development will do the competency and skills fair. My expectation for [Staff A's name] would be to get an RN that was on duty and assist and perform the task for him. It is not the practice of the facility to allow a non-IV Certified LPN to administer IV medications supervised. That was not the case there was no RN in the building that approved of [Staff A's name] to administer IV medications. It would be falsification of documentation to only initial; an LPN will not be allowed to initial the task if they had not performed the task themselves. During an interview on [DATE] at 1:40 PM the ADON stated, I have not been in the room with an LPN to supervise or walk through IV medication administration for [Resident #197's name]. Onboarding is done by Staff Development and Human Resources goes behind with a checklist. I don't get an official notification of who is certified. I understand that someone will learn in school what their scope is that would be my expectation. The Staff Developer is the one who should be checking the paperwork and verifying that all LPNs have all certifications. I don't know if the Staff Developer reports to the DON since everything in the building falls under her. I will find out who is responsible for verifying agency [LPNs]. I have provided emergency cover for 7 PM-7 AM. During an interview on [DATE] at 2:05 PM the Medical Director stated, If nursing staff is non-IV certified, they should not be doing medication administration via IV. I was not aware that LPNs were administering medications via IV and were not certified. If the staff is not certified they might not know what they are doing and there is a risk for infection, mishandling of the IV port, bleeding, pain, the list can go on, but it is only a potential. During an interview on [DATE] at 10:35 AM, the DON stated, The facility does not have IV Certification for [Staff A's name] and [Staff G's name]. During an interview on [DATE] at 2:56 PM, Staff G stated, I became a nurse in the 1990s and while working at [Name of facility], I took a [Name of pharmacy] IV certification course in [Name of City], but I have not been able to locate the paperwork. During an interview on [DATE] at 2:58 PM, the DON, stated, There was an IV certified LPN, but I don't know why [Staff G's name] didn't ask for assistance. Ultimately, as far as the nursing department, I oversee nursing staff qualifications and the Staff Developer. [Staff G's name] verbally told us that she is IV certified. IV certification was requested. No documentation was provided of IV certifications for Staff A or Staff G. During an interview on [DATE] at 7:20 AM the Administrator stated, I understand there is a certification LPNs need to obtain that certifies them for IVs. The hiring process is new with all the corporate buy outs. Now we have a Human Resource Manager. Upon hire employees are ask for any and all certificates they have; if they do not produce the certifications, we assume they do not have them. During an interview on [DATE] at 9:30 AM the DON stated, It is not up to me to determine what neglect is. I would have to refer to my neglect policy. During an interview on [DATE] at 9:30 AM with Administrator stated, It would be neglect if we were aware and condoned it. Our policy does not condone. This was a [NAME] employee. We expect the staff to work within their scope of practice. During an interview on [DATE] at 9:34 AM the Director of Clinical Services, stated, I would consider it neglect if the staff worked outside their scope. We did not have a system in place to check for qualifications. We expect staff to work within their scope of practice, we trusted them. During an interview on [DATE] at 12:57 PM with the Administrator stated, We didn't have a process in place for verification of staff qualifications. The previous company took care of the onboarding and now the new company has HR [Human Resource] in house. We have weekly meetings and daily staff meetings. During an interview on [DATE] at 12:57 PM the Staffing Coordinator stated, I depend on higher nursing staff for qualifications. I am responsible for the hours per resident care and PBJ [Payroll Based Journal, a system for facilities to submit staffing information]. I rely on the head of nursing to verify staff certifications and qualifications. I was trained on hours per resident care and PBJ. Review of the facility policy and procedure titled, Abuse, Neglect and Misappropriation of Property with a last review date of [DATE], read, Definitions of Types of Abuse: Neglect - Is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Policy Components . C. Prevention: Ensuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Responsibilities with a last reviewed date of [DATE], read, Policy . 6. Maintain records of personnel qualified by education and experience who may provide infusion therapy in the facility. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Facility Policies and Procedures with a last review date of [DATE], read, The policies and procedures of a facility may be more stringent, and duties may be more restrictive than what is permitted by state regulations but may never be more lenient. For example: The State Board of Nursing may indicate that it is within the scope of practice for LPNs to flush Central Venous Catheters in long term care facilities, but it is the individual facility's decision to allow or not allow LPNs to perform the procedure. On the other hand, if the State Board of Nursing prohibits LPNs from flushing Central Venous Catheter in long term care facilities, then a facility may NEVER allow an LPN to perform that procedure. Review of the facility policy and procedure titled, Administrative Policies for Infusion Therapy Legal Issues with a last review date of [DATE], read, Legal Issues . Rule of Personal Liability: No Nurse, LVN [Licensed Vocational Nurse]/LPN or RN, should perform any procedure that he or she has not been specifically trained to do. Review of the facility policy and procedure titled, Nursing Services with a last review of [DATE], read, Policy . 5. The facility will ensure that licensed nurse have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Board of Nursing Rule Chapter 64B,d+[DATE] titled Administration of Intravenous Therapy by Licensed Practical Nurse reads, Section 64B,d+[DATE].005 - Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy .(2) Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B,d+[DATE].002(2), F.A.C. [Florida Administrative Code] Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL [central venous catheters] site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnessed by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse's ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse's personnel file. (3) Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the Board pursuant to Rule 64B,d+[DATE].005, F.A.C. To be qualified to teach any such course, the instructor must be a currently licensed registered nurse in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying completion of the requisite number of hours and course content. (4) Educational Alternatives. The cognitive training shall include one or more of the following: (a) Post-graduate Level Course. In recognition that the curriculum requirements mandated by Sections 464.019(1)(b), 464.019(1)(f), and 464.019(1)(g), F.S. [Florida Statutes], for practical nursing programs are extensive and that every licensed practical nurse will not administer IV therapy. The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduate level course teaching aspects of IV therapy containing the components enumerated in subsection 64B,d+[DATE].005(1), F.A.C.(b) Credit for Previous Education. The continuing education provider may credit the licensed practical nurse or graduate practical nurse for previous IV therapy education on a post-graduate level, providing each component of the course content of subsection 64B,d+[DATE].005(1), F.A.C., is tested by and competency demonstrated to the provider. (c) Nontraditional Education. Continuing education providers may select nontraditional education alternatives for acquisition of cognitive content outlined in Rule 64B,d+[DATE].005, F.A.C. Such alternatives include: 1. Interactive videos; 2. Self-study; 3. Other nontraditional education that may be submitted to the Board for consideration and possible approval. Any continuing education providers using nontraditional education must make provisions for demonstration of and verification of knowledge. (5) Clinical Competence. The course must be followed by supervised clinical practice in intravenous therapy as needed to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing a licensed practical nurse based on institutional protocol. Such verification shall be given through a signed statement of a Florida licensed registered nurse. The Immediate Jeopardy (IJ) was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of the likelihood of harm and/or possible death as evidenced by the following: On [DATE] during interviews, 6 RNs, 4 LPNs and 5 CNAs confirmed education for abuse/neglect, scope of practice and the 30 hour IV certification requirement for LPN's, the Director of Nursing, Assistant Director of Nursing, Staff Development, Human Resources and the Scheduler confirmed education for abuse/neglect, scope of practice, the 30 hour IV certification requirement for LPN's, and the new system for scheduling per residents needs according to staff qualifications. Review of staff training documented 100% of staff were educated on abuse/neglect and 100% of RNs and LPNs were educated on scope of practice. On [DATE], the facility assessed the residents involved in the IJ situation and conducted a facility-wide audit of all current residents with a PICC line and/or receiving IV medications to identify possible harm, side effects, and injury to the resident due to IV administration. On [DATE], the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis. On [DATE] all LPN personnel records were audited to verify training credentials. On ,d+[DATE] - [DATE], the facility educated all nursing staff related to neglect, scope of practice, and the 30-hour IV certification requirement for LPNs prior to IV medication administration. On [DATE], the Director of Clinical Services provided training to the facility administration on verification of staff competency, working within their scope of practice and abuse/neglect policy. On [DATE], the Director of Clinical Services provided training to the Staff Developer and Staff Scheduler on neglect, scope of practice and supervision of staff. On [DATE], a new system for scheduling per residents needs according to staff qualifications was developed and implemented. On [DATE] the Director of Clinical Services educated the nursing managers on the new scheduling system.

Based on observations, interviews, and record review the facility failed to maintain equipment to be in a safe and clean operating manner. Findings include: An observation of the meat slicer equipment was conducted on 02/28/23 at 6:45 AM when the Certified Dietary Manager (CDM) removed the covering for observation. The meat slicer had a rust-colored debris and food particles on a center connector of the blade. During an interview with the CDM on 2/28/23 at 6:53 AM the CDM confirmed that the meat slicer had a rust-colored debris and food particles on a center connector of the blade. The CDM stated that a covered piece of equipment should designate that the equipment is clean and ready for use. During a follow-up tour conducted on 02/28/23 at 6:45 AM with the Certified Dietary Manager, an observation was made of 24 trays with sharp and broken edges being used for room trays. An observation was made of heated metal insert being used in dome bases that were not designed to need a heated metal insert therefore was sitting above the base exposing the heated metal. An observation was made of a knife holder on the wall that had a clear plexiglass covering that had food crumbs in the base. An observation was made of the convection oven with a buildup of food and debris on the external and internal part of the oven. An interview was conducted with the CDM on 3/01/23 at 1:45 PM related to the observation made during the follow up visit to the dietary department. The CDM confirmed that the trays with broken and sharp edges should not be used. The CDM verified that the convection oven should be cleaned and not have a buildup of food and debris inside or outside. The CDM confirmed that the heated metal inserts should only be used in designated bases to prevent the potential of burns to the staff and residents. The CDM stated that there should not have been breadcrumbs in the knife container. A policy titled Equipment dated September 2017 read, policy statement, all foodservice equipment will be clean, sanitary, and in proper working order. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use.

Based on observations, interviews, and record review, the facility failed to ensure food is stored, covered, labeled, and discarded in the kitchen and failed to maintain sanitary standards for equipment used to prepare, cook, and serve the residents. (Photographic evidence obtained). Findings include: A walk-through tour of the kitchen was conducted on 02/27/23 at 09:10 AM with the Certified Dietary Manager (CDM). The walk-in cooler had a large container labeled Chili and labeled with a prepared date of 02/19/23 and a use by date of 02/22/23. A sheet pan was located on the bottom shelf of the walk in cooler and the sheet pan was observed to have a bag of thawed raw chicken and a roll of raw ground beef with no separation of the two items to prevent cross contamination. An observation was made of two quart containers of raw liquid eggs stored directly over an opened box of raw bacon. An observation was made in the walk-in freezer of ice buildup and open boxes exposing food. There was an observation in the dry storage area of three dented cans stored on the ready to use shelving and not in the designated dented can area. There was an observation of four storage bins with black garbage bags being used as liners to hold the bulk foods. There was a soiled, wet cloth resting on the stainless table next to the food tray line. An interview was conducted with the CDM on 2/27/23 at 9:30 AM. The CDM confirmed the walk-in cooler had a large container labeled Chili and showing a prepared date of 02/19/23 and with a use by date of 02/22/23. The CDM stated the chili should have been discarded after 2/22/23. The CDM confirmed the sheet pan containing the large bag of thawed raw chicken and a five pound roll of raw ground beef did not have a separation of the two items to prevent cross contamination. The CDM confirmed the raw ground beef and raw chicken should not be stored together on the same pan. The CDM confirmed there were two-quart containers of raw liquid eggs stored directly over an opened box of raw bacon and that eggs should be stored below other raw foods to prevent cross-contamination. The CDM verified in the walk-in freezer there is an ice buildup and open boxes exposing food with the potential for freezer burn and compromising the integrity of the food stored for preparation of menu items. The CDM confirmed in the dry storage area, the three dented cans stored on the ready to use shelf and not in the designated dented can area. The CDM confirmed four storage bins had black garbage bags being used as liners to hold the bulk foods and garbage bags were not a food grade container for bulk products. The CDM confirmed that all wiping cloths should be kept in a sanitizer bucket when not in use. A review of the policy and procedure titled, Food Storage: Cold Foods last reviewed on 02/16/23 read, Procedures: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the policy and procedure titled, Receiving last reviewed on 02/16/23 read, Procedures: 4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal as appropriate. During an observation on 2/28/23 at 6:45 AM with the CDM the meat slicing equipment was covered. The CDM removed the covering and the meat slicer was observed to have rust-colored debris and food particles on the center connector of the blade. An observation was made of a knife holder on the wall that had a clear plexiglass covering. Food crumbs were observed in the base of the knife holder. An observation of the convection oven showed it had a thick buildup of food and debris on the external and internal parts of the oven. During an interview with the CDM on 2/28/23 at 6:53 AM the CDM confirmed the meat slicer had a rust-colored debris and food particles on the center connector of the blade. The CDM stated that a covered piece of equipment should designate that the equipment is clean and ready for use. During an interview with the CDM on 3/01/23 at 1:45 PM the CDM verified the convection oven had a thick covering of debris and food on the inside and outside of the oven and stated it should be cleaned and not have a buildup of food and debris. The CDM stated there should not be breadcrumbs in the knife container. Review of the policy and procedure titled, Equipment was last reviewed on 02/16/2023 read, Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use.

Based on interview and record review the facility failed to ensure an advanced directive was formulated for 1 of 3 residents, Resident #198. Findings include: During an interview conducted with Resident #198 on [DATE] at approximately 10:17 AM regarding her advanced directives, Resident #198 stated she wished to be a DNR [do not resuscitate]. Review of the Social Services Director's (SSD) progress note dated [DATE] read, Went to [Resident name's] room for her to sign dnr [DNR]. She [Resident #198] stated she wanted to talk to her daughter before she signed it and requested, I come back tomorrow. I [SSD] explained that was not a problem. Explained at this time if she were to stop breathing or her heart stopped, we would initiate CPR [Cardio Pulmonary Resuscitation] at this time. She [Resident #198] acknowledged understanding. During an interview conducted on [DATE] at approximately 3:10 PM the SSD and she confirmed she did not go back and revisit for the DNR Advanced Directive paperwork for Resident #198. During an interview conducted with the Administrator (ADM) on [DATE] at 11:03 AM, the ADM confirmed that there was not an advanced directive for Resident #198. Review of the policy and procedure titled, Advanced Directive Policy read, the facility will provide a written description of the facility's policy to implement advance directives and applicable state law, evaluate and document each resident's advance care planning decision.

Based on observation, interview, record review the facility failed to ensure the residents environment remained free of accident hazards as is possible for 1 of 3 residents, Resident #28. Findings include: Review of Resident #28's medical record documented on the Electronic Face Sheet the resident's diagnoses of: type II diabetes mellitus, schizophrenia, cognitive communication deficit, bipolar disorder, central pain syndrome, and hypertension. Resident #28 was observed on 02/27/23 at 11:15 AM smoking in the facility's smoking area without a smoking apron. Review of Resident #28's care plan dated 1/6/23 read, [Resident #28's Name] prefers to smoke requires smoking apron. Review of Resident #28's medical record did not document a safe smoking assessment was completed which would determine the resident's safety needs while smoking. During an interview conducted on 03/02/23 at 10:33 AM, the Administrator confirmed they did not have a safe smoking assessment completed for Resident #28. Review of the policy and procedure titled, Surrey Place Nursing Center Facility Smoking Policy last reviewed on 2/16/23, read, 1. The facility will complete a safe smoking evaluation within 24 hours of admission for all residents who desire to smoke.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 1 of 2 medication carts (East Cart) and unsecured medications observed at resident's bedside, Resident #33. (Photographic evidence obtained). Findings include: During an observation on 02/27/2023 at 9:25 AM of the East Medication Cart with Staff A, License Practical Nurse (LPN), there were three dark color circular pills in an unlabeled medication cup in the top draw of the cart. During an interview on 2/27/2023 at 9:37 AM Staff A, LPN, stated, These are iron pills. I didn't place them there. I don't know why the medication is there. During an observation on 2/27/2023 at 9:25 AM of Resident #33's room there was a bottle of Nutribiotic throat spray with grapefruit seed extract plus zinc and menthol, a medicated anti-itch spray, a calamine clear lotion, a round orange circular unlabeled pill on top of the bedside table, and a clear plastic cup with a lid, on the lid it was labeled 2/25 For Rash and contained a white cream. During an interview on 2/27/2023 at 9:26 AM Resident #33 stated, I am itchy and my throat is sore at times. This pill on my bedside table is gum. During an interview on 2/27/2023 at 9:55 AM the Director of Nursing (DON) stated, Medication should not be out unlabeled. The DON confirm Resident #33 had unsecure medications in the room and stated, I am not able to say where the labeled cup came from. Review of the policy and procedures titled, Self-Administration of Medication with a last reviewed date of 2/16/2023 read, General Guidelines .2b. storage of medications in the resident's room must be such that it will prevent access by other residents; 2c. Only the medications permitted for self-administration shall be left at the bedside; .

Based on observation, interview, and record review the facility failed to ensure assistive adaptive devices for provided for 1 of 1 residents, Resident #145. Findings include: During an observation on 02/28/23 at 12:31 PM of Resident #145 for the adaptive equipment of a high sided separated or divided plate was not provided and was listed on the meal tray ticket. During an observation on 3/01/23 at 8:35 AM of the breakfast tray served to Resident #145 for the adaptive equipment of a high sided separated or divided plate showed it was not provided and was listed on the tray ticket. During an interview with the Certified Dietary Manager (CDM) conducted on 3/01/2023 at 1:30 PM related to the adaptive equipment for Resident #145. The CDM stated the dietary department did not have a high sided divided or separated plate for Resident #145. The CDM verified that orders for adaptive equipment allows residents to maintain independence while dining and should be provided as ordered. The CDM confirmed she had not discussed the lack of adaptive equipment or an alternative with the Registered Dietician (RD) or therapy department. During an interview with the Speech Therapist (ST) on 3/02/23 at 12:11 PM related to adaptive and assistive devices. The ST confirmed that adaptive or assistive devices are ordered to promote independence for a resident that has restricted movement, visual impairment, tremors, or other conditions that may benefit from adaptive or assistive devices. The ST stated that her expectations would be for the therapy department to be notified if equipment is not available in the dietary department so that an equivalent substitute can be recommended until the needed equipment can be ordered. Review of the document titled, Resident Adaptive Equipment Report, dated 2/27/23 read, Resident #145 [resident named] adaptive equipment high-sided partition plate, breakfast, lunch and dinner.

Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan to identify a problem and approach for 1 of 5 residents, Resident #28, reviewed for unnecessary medications. Findings include: Review of the electronic face sheet documented Resident #28 was admitted to the facility with diagnoses to include type II diabetes mellitus. Review of Resident #28's physician orders documented dated 12/28/22 - Levemir FlexTouch U-100 insulin (100unit/ml (milliliter) (3ml)-inject 45 units subcutaneously once a day. Dated 12/27/22-Trulicity pen injector, 1.5mg (milligrams)/0.5ml-inject 1.5mg subcutaneously once a day on Friday. Review of Resident #28's care plan did not provide for documentation of a problem and approach related to the resident's diagnosis of type II diabetes mellitus and the use of insulin and other medications to treat diabetes. During an interview conducted on 3/2/23 at 2:30 PM with the facility's Corporate Director of Clinical Services, confirmed Resident #28's care plan did not address the resident's diagnosis of type II diabetes mellitus and the use of insulin and other diabetic medications. Review of the facility's policy titled, Care Plan-Comprehensive, last reviewed on 2/16/23 read, Policy Interpretation. 1. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident .2. The Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas, b. Incorporate risk factors associated with identified problems, and d. Reflect treatment goals and objectives in measurable outcomes .

Based on observation, interview, and record review, the facility failed to ensure the menus were reviewed by a registered dietitian or other clinically qualified nutrition professional for nutritional adequacy. Findings include: During an interview on 1/18/2023 at 10:00 AM, the Assistant Dietary Manager stated that the facility was using the hcsg2southern 2022-23 week 2 menus for this week's offerings and today's lunch and dinner entrees were going to be substituted due to supply issues. She confirmed the meatloaf, dinner roll and sweet potato pie was to be substituted with sliced ham and marble cake with no roll being served and the Italian sausage sub with pepper and onion for dinner was to be substituted with egg salad sandwiches. During an observation of the tray line service for the lunch meal on Wednesday 1/18/2023 at 12:00 PM, the main entree being served included sliced ham and marble cake. No dinner roll was being served. Review of the menus presented as the facility's current menus showed they were labeled as hcsg2southern 2022-23 week 2 and were not signed as being reviewed by a registered dietitian. The entree for Wednesday was homestyle meatloaf with ketchup glaze 4 ounces, capri vegetables (no portion noted), au gratin potatoes 1/2 cup, dinner roll/ bread 1 each and sweet potato pie 1 slice. During an interview on 1/18/2023 at 12:47 PM, the Registered Dietitian stated, The food service director makes changes due to the availability. The substitutions list has not been given to me for November and December of 2022. I have not been given the opportunity to sign off on the menus that they are using now. Review of the most current substitution list provided by the facility was dated October of 2022. Review of the facility policy and procedure titled, Menus revised in 9/2017 reads, Policy Statement: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines . Procedures . 5. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus . 7. A substitution log will be maintained on file.

Based on observation, record review and interview, adequate supervision and assistive devices were utilized to prevent accidents for one (#113) of 26 sampled residents related to skin tears and supervision while eating. The facility's failure to adequately supervise resident #113 while eating resulted in the resident sustaining 1st and 2nd degree burns to her thighs as a result of spilling hot soup in her lap during a meal. Finding: Resident #113 was observed on 4/2/13 at 3:15 PM on a gurney being transported to her room after returning from the emergency room (ER). Interview with the Licensed Practical Nurse (LPN) at this time revealed the resident sustained [REDACTED]. She stated the resident was prescribed silvadine cream at the ER and the resident's daughter was notified of the injury. Continued interview with the treatment nurse on 4/3/13 at 10:34 AM revealed she was in the cafeteria when resident #113 knock a bowl of hot soup in her lap resulting in burns on 4/2/13 at approximately 11:50 AM. She stated the resident has 1st degree burns approximately 6-8 centimeters (cm) to the top of her right thigh and approximately 10 cm to the left inner thigh which is a 2nd degree burn and is getting silvadine 1% cream and dressings every 12 hours. She added that the resident needs cueing during most of her meals and is aware that the resident required a Certified Nursing Assistant (CNA) to sit with her the past week as the resident would not eat. The LPN explained that the resident should have been monitored with the hot soup and that the facility has now placed resident #113 in restorative dining which will entail the resident having an aide to assist her at each meal. Review of the Interim plan of care upon admission for resident #113 dated 3/11/13 revealed the resident problem areas as "self-care deficit provide assistance as needed and monitor weight and meal intake." Review of the Full Life conference dated 3/13/13 revealed documentation of assist with ADLs:"set up help" Review of the care plan dated 3/26/13 included problem care areas as follows: Activities; Bowel elimination; Dehydration; Nutrition (meal intake and weights); Terminal Illness (3/13/13) malignant neo-uterine isthmus with comfort measures only. Continued record review revealed no mention of assistance with meals in resident #113's care plan. Interview with LPN, Minimum Data Set (MDS) Coordinator, on 4/3/13 at 10:48 AM, revealed that the standard form Activities of Daily Living (ADLs) report for dates 3/14/13 to 3/20/13 for eating document that the resident was in need of supervision 6 times, 2 times limited assistance, and 8 times totally dependent, with the the resident having to be fed by a CNA. She added the ADL report informs her what to code the resident on her MDS form regarding assistance with eating. She added the resident was coded as an extensive 1 person assist for meals. Further interview with the MDS coordinator on 4/3/13 at 11:51 AM revealed the resident is under Hospice care, but does not receive CNA care from Hospice and that hospice staff do not assist the resident with eating. The MDS coordinator confirmed that the resident did not have a care plan area identified for ADL (eating) care until 4/2/13, after the resident returned from the emergency room . Review of the MDS dated [DATE] revealed the resident as coded for eating as requiring extensive assistance with 1 person physical assist. Interview with the Risk Manager (RM) on 4/3/13 at 10:57 AM revealed she was called in when the incident occurred (soup spillage in lap of resident). She confirmed resident #113 had a care plan area for nutrition due to constipation and disease process of cancer of the uterus with interventions related only to dietary intake and weight with no care plan related to assistance/supervision with eating prior to the 4/2/13 incident.

Based on interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of 26 sampled residents (#7, and #88) related to pain, administration of medication for a resident receiving [MEDICAL TREATMENT], and skin tears. Facility staff failed to provide care and services upon complaints of pain by resident #7 who sustained a large hematoma to ensure appropriate action was taken to alleviate the resident's pain. Finding: 1) Review of resident #7's clinical record revealed that the phlebotomist attempted to draw blood on 1/14/13 and again on 1/15/13, but was unsuccessful. Review of the facility's documentation dated 1/15/13 at 12:30 pm revealed that resident #7 complained to the nurse, who was on duty as the treatment nurse on 1/15/2013, that her left arm was hurting from where the phlebotomist tried to draw blood that morning. The treatment nurse documented that the resident had a large purple hematoma. During the interview with the nurse, to who the resident complained of pain, on 4/3/13 at 12:30 PM, she revealed that she was on duty as the treatment nurse that day (1/15/13) and was unable to give the resident medication. She stated that she did inform the medication nurse, who was on duty, of the resident's complaints of pain. Continued review of the documentation revealed that the treatment nurse only documented to monitor the resident. No documentation was identified that she informed the medication nurse of resident #7's complaints of pain related to the large hematoma on her left arm. Review of the nurses notes and the medication administration record (MAR) did not reveal any documentation that resident was administered any pain medication on 1/15/13 despite a physician's orders [REDACTED]. Review of resident #7's care plan revealed that the resident has chronic pain and that the approaches include for staff to administer and monitor for effectiveness of the medication. Review of the nurse notes dated 1/16/13 at 12:50 PM revealed that emergency medical services (EMS) was called to transport resident #7 to the emergency room . The note documented that the resident had a large, blood filled hematoma measuring 9 inches x 4 inches to left forearm which was hard and swollen, and that the resident continued to complain of pain. Additionally, review of resident #7 clinical record revealed the resident received a skin tear on the left forearm on 12/1/12, the right forearm on 12/17/12, and the right thigh on 2/20/13. Review of the resident's care plan dated 12/17/12 included an approach for the use of protective sleeves for arms and legs as needed (PRN). During the interview with minimum data set (MDS) coordinator on 4/3/13 at 11:00 AM, she stated that, although the approach was listed on the care plan, it was not checked off as being an active approach; therefore, staff did not use the sleeves. During the interview with one of the resident's assigned certified nursing assistants (C.N.A.) on 4/3/13 at 11:30 AM she stated that she did not use the protective sleeves for the resident because her arms were always bandaged. 2 ) Review of the medical record of resident #88, revealed the resident receives [MEDICAL TREATMENT] treatments off-site 3 days a week at 12:45 PM. Review of the Medical Administration Record (MAR) for February 2013, March 2013, and April 2013 indicates the resident is scheduled to receive [MEDICATION NAME] 325 milligrams (mg.) every day at 12:00 PM. Continued review revealed the MARs were circled and/or documented as "LOA" on 02/11/13, 02/13/13, 02/15/13, 02/18/13, 02/20/13, 02/25/13, 02/27/13, 03/01/13, 03/04/13, 03/08/13, 03/22/13, and 04/01/13. The explanation documented on the MARs indicated the reason this medications was circled and/or written as "LOA" was due to the medication not being administered as the resident was at [MEDICAL TREATMENT]. Continued review of the Medical Administration Record (MAR) for February 2013 indicates the resident is scheduled to receive [MEDICATION NAME] 500 mg. four times a day at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. The documentation revealed that the MAR was circled and/or documented as "LOA" on 02/11/13, 02/15/13, 02/25/13, and 02/27/13 for the 9:00 AM and 1:00 PM administration doses. The explanation documented on the MARs indicated the reason this medications was circled and/or written as "LOA" was due to the medication not being administered as the resident was at [MEDICAL TREATMENT]. Review of the Medical Administration Record (MAR) for March, 2013 indicates the resident is scheduled to receive [MEDICATION NAME] 250/10 mg. three times a day at 9:00 AM, 1:00 PM, and 5:00 PM. The MAR revealed circles and/or documentation as "LOA" on 03/15, 03/18, 03/20, 03/25 and 03/29/2013 for 1:00 PM administration doses. The explanation documented on the MARs indicated the reason this medications was circled and/or written as "LOA" was due to the medication not being administered as the resident was at [MEDICAL TREATMENT]. Interview with Registered Nurse (RN) on 04/03/11 at 9:30 AM, revealed resident #88 usually leaves the facility around 10:30 AM for [MEDICAL TREATMENT] treatments on Monday, Wednesday, and Friday (M-W-F). In continued interview with the nurse, she indicated that the 1:00 PM medication that was circled or written as "LOA", on the MAR was not given by nursing on those days because resident #88 was at the [MEDICAL TREATMENT] Center for treatment, and an explanatory note should have been documented on the MAR. No additional information was provided on how the facility ensured that resident #88 was provided medications on [MEDICAL TREATMENT] days. Interview on 04/03/2013 at 4:00 PM with the Clinical Coordinator at the [MEDICAL TREATMENT] Center revealed that they were not administering any medications sent from the facility, nor was the facility sending medications with resident #88 to the [MEDICAL TREATMENT] center on his/her days of treatment.

Based on interview, observation, and record review, the facility failed to ensure a care plan was developed for 1 (#113) of 26 sampled residents with measurable goals and interventions to address the supervision needs of the resident to prevent accidents and provide the necessary level of assistance with eating. Resident #113 sustained 1st and 2nd [MEDICAL CONDITION] her thighs as a result of spilling hot soup in her lap during a meal. Finding: Resident #113 was observed on 4/2/13 at 3:15 PM on a gurney being transported to her room after returning from the emergency room (ER). Interview with the Licensed Practical Nurse (LPN) at this time revealed the resident sustained [REDACTED]. She stated the resident was prescribed silvadine cream at the ER and the resident's daughter was notified of the injury. Continued interview with the treatment nurse on 4/3/13 at 10:34 AM revealed she was in the cafeteria when resident #113 knock a bowl of hot soup in her lap resulting [MEDICAL CONDITION] 4/2/13 at approximately 11:50 AM. She stated the resident has 1st [MEDICAL CONDITION] 6-8 centimeters (cm) to the top of her right thigh and approximately 10 cm to the left inner thigh which is a 2nd degree burn and is getting silvadine 1% cream and dressings every 12 hours. She added that the resident needs cueing during most of her meals and is aware that the resident required a Certified Nursing Assistant (CNA) to sit with her the past week as the resident would not eat. The LPN explained that the resident should have been monitored with the hot soup and that the facility has now placed resident #113 in restorative dining which will entail the resident having an aide to assist her at each meal. Review of the Interim plan of care upon admission for resident #113 dated 3/11/13 revealed the resident problem areas as "self-care deficit provide assistance as needed and monitor weight and meal intake." Review of the Full Life conference dated 3/13/13 revealed documentation of assist with ADLs:"set up help" Review of the care plan dated 3/26/13 included problem care areas as follows: Activities; Bowel elimination; Dehydration; Nutrition (meal intake and weights); Terminal Illness (3/13/13) malignant neo-uterine isthmus with comfort measures only. Continued record review revealed no mention of assistance with meals in resident #113's care plan. Interview with LPN, Minimum Data Set (MDS) Coordinator, on 4/3/13 at 10:48 AM, revealed that the standard form Activities of Daily Living (ADLs) report for dates 3/14/13 to 3/20/13 for eating document that the resident was in need of supervision 6 times, 2 times limited assistance, and 8 times totally dependent, with the the resident having to be fed by a CNA. She added the ADL report informs her what to code the resident on her MDS form regarding assistance with eating. She added the resident was coded as an extensive 1 person assist for meals. Further interview with the MDS coordinator on 4/3/13 at 11:51 AM revealed the resident is under Hospice care, but does not receive CNA care from Hospice and that hospice staff do not assist the resident with eating. The MDS coordinator confirmed that the resident did not have a care plan area identified for ADL (eating) care until 4/2/13, after the resident returned from the emergency room . Review of the MDS dated [DATE] revealed the resident as coded for eating as requiring extensive assistance with 1 person physical assist. Interview with the Risk Manager (RM) on 4/3/13 at 10:57 AM revealed she was called in when the incident occurred (soup spillage in lap of resident). She confirmed resident #113 had a care plan area for nutrition due to constipation and disease process [MEDICAL CONDITION] of the uterus with interventions related only to dietary intake and weight with no care plan related to assistance/supervision with eating prior to the 4/2/13 incident.