Every finding on record at Tampa Lakes Health and Rehabilitation Center

Based on record reviews and interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level II were completed to ensure recommended services were provided for residents with mental illness (MI) or suspected MI for four residents (Resident #49, Resident #111, Resident #131, and Resident #40) of sixty-seven sampled residents. Findings included: Review of Resident #49's Admission Record showed Resident #49 was admitted to the facility on [DATE] with a primary diagnosis of senile degeneration of the brain. Other diagnoses include major depressive disorder, visual hallucinations, and delusional disorders. Review of Resident #49's Level I PASRR screen dated 09/07/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, under question 5: Does the individual have a primary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease)?: No, was marked. Section II also showed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). The screen showed under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. Review of Resident #111's Admission Record showed Resident #111 was admitted to the facility on [DATE] with a primary diagnosis of senile degeneration of the brain. Other diagnoses include major depressive disorder and post-traumatic stress disorder. Review of Resident #111's Level I PASRR screen dated 09/07/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, under question 5: Does the individual have a primary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease)?: Yes, was marked. The screen showed in Section II, under question 7: Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)?: Yes, was marked. Section II also showed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). The screen showed under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. Review of Resident #131's Admission Record revealed an original admitted [DATE], and a re-admitted [DATE]. Resident #131's Admission Record revealed diagnoses including Alzheimer's disease, restlessness and agitation, unspecified dementia, unspecified severity, with other behavioral disturbance, panic disorder [episodic paroxysmal anxiety], major depressive disorder, recurrent, moderate, other specified persistent mood disorders, and generalized anxiety disorder. Review of Resident #131's Level I PASRR screen dated 01/06/2025 showed in Section II: Other Indications for PASRR Screen Decision-Making, under question 5: Does the individual have a primary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease)?: Yes, was marked. The screen showed in Section II, under question 7: Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)?: Yes, was marked. Section II also showed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). The screen showed under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. Review of Resident #40's Admission Record revealed Resident #40 was admitted on [DATE]. Resident #40's Admission Record revealed diagnoses including senile degeneration of the brain, major depressive disorder, bipolar disorder, dementia, and anxiety disorder. Review of Resident #40's Level I PASRR screen dated 10/24/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, under question 5: Does the individual have a primary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease)?: Yes, was marked. The screen showed in Section II, under question 7: Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)?: Yes, was marked. Section II also showed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). The screen showed under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. Review of the facility policy titled Admission/Social Services-Pre-Admission Screening for Resident Review (PASRR), revised October 2015 revealed the following: Overview: The purpose of PASRR is to ensure individuals who are being considered for placement in a nursing facility are evaluated for serious mental illness and/ or intellectual disability and are offered the most integrated setting appropriate for their long-term care needs (including determining whether a nursing facility is appropriate). All persons, regardless of payer or age, needing admission to a nursing facility must first be screened for possible mental illness (MI) or the presence of an intellectual disability (ID) or both (Level I). If a mental illness (MI) or intellectual disability (ID) appears to exist, the person must be referred for further evaluation (Level II) before nursing facility admission The Level II PASRR screen must be done prior to admission for all persons seeking admission except when the following exemption applies for a provisional admission: - Individuals who are discharged from a hospital into a nursing facility after receiving acute impatient care, and require NF services, for which they receive an inpatient hospital care, may be admitted to the nursing facility if a physician certifies on the AHCA 3008 form before admission that the individual is likely to require less than 30 days of NF services. Policy for PASRR: The Admissions Coordinator is responsible for ensuring that the Level I PASRR Screen and Level II PASRR evaluation and determination, if applicable, are completed prior to admission. Procedure: . 2. When applicable, our request for a Level II evaluation is made using the attached [State Survey Agency] Medserv I Form 004, Part B, November 2011. This request must be sent to the comprehensive assessment and review for long-term care services (CARES) unit. CARES will make the referral to the substance abuse and mental health (SAMH) and/ or agency for persons with disabilities (APD) and they should complete the evaluation within 7 to 9 days and forward it to the admitting nursing facility .

Based on observations, interviews, and record review, the facility failed to follow professional standards for food service safety in the facility kitchen, three of six dining areas, and two of six nourishment rooms. Findings included: On [DATE] at 9:23 a.m., a tour of the facility's kitchen was conducted with the Assistant Food Service Director. Observations revealed a white foam cup with a straw and lunchbox on the drying rack, where clean kitchenware and other items were stored. The Assistant Food Service Director stated the cup and lunchbox belonged to a staff member. She motioned to the staff member and stated, it's her breakfast. On [DATE] at 9:47 a.m., three staff members were observed in the dish machine area. Observations revealed one dietary aide was scraping and discarding food off of plates. A second staff member, Staff H, Dietary Aide, was observed rinsing off kitchenware and putting the items into the dish machine. Staff E, Dietary Aide was placing clean plates and other kitchenware on the rack to dry. Staff H, Dietary Aide was asked which type of dish machine it was, she responded it was a high temperature dish machine. The Assistant Food Service Director corrected her and stated it was a low temperature dish machine. A review of the sanitizing log for the dish machine was conducted with Staff E, Dietary Aide and the Assistant Food Service Director. Staff E, Dietary Aide stated he did not take or record the sanitizing temperatures. He stated if he were to do them, he would check what the sanitizing solution buckets indicated and record that information for the temperatures. Further observations of the sanitizing solution log for the dish machine, with the date of [DATE], revealed the initials written down were not his. The Assistant Food Service Director stated those initials were the day cooks. She confirmed Staff E, Dietary Aide should be taking and recording the sanitizing solution temperatures on the log. The Assistant Food Service Director was observed demonstrating and educating Staff E, Dietary Aide on how to test the sanitizing solution, what parts per million (ppm) they are looking for, and what she expected to be recorded on the log. On [DATE] at 9:29 a.m., observations and interviews regarding the holding freezer were conducted with the Assistant Food Service Director. The holding freezer contained two cases of food that were not labeled or dated and appeared to be opened. One of the boxes observed was frozen hamburger patties and the other box contained French fries. The Assistant Food Service Director confirmed they should have been labeled and dated when they were opened. At 9:35 a.m., observations of the walk-in cooler revealed a container of black olives had approximately three penny sized white spores in the liquid. The Assistant Food Service Director proceeded to throw away the container of olives. She stated the olives were not going to be used for resident meals as they were not on the menu today. At 9:36 a.m., further observations of the walk-in cooler revealed a box containing loose lettuce pieces stored in a plastic bag, open, and exposed to the air. Two fruit plates were observed on a mobile rack in the walk-in cooler, with a date of [DATE]. The Assistant Food Service Director could not confirm if [DATE] was the use by date or the prepared date. She proceeded to remove the two fruit plates. On [DATE] at 12:21 p.m., observations of the nourishment room in the 100 unit were conducted. The refrigerator and freezer temperature log was observed to be filled out through [DATE]. Observations of the refrigerator revealed one carton of Glucerna 1.5 with an expiration date of [DATE], one carton of Peptamen Intense Very High Protein (VHP) with a use by date of [DATE], and a cup of what appeared to be macaroni and cheese labeled [DATE]. At the time of the observation, the cup of macaroni and cheese did not indicate a resident name or room number. (Photographic Evidence Obtained) On [DATE] at 12:23 p.m., observations revealed Staff E, Dietary Aide entered the 100-unit dining area with a meal cart and proceeded to put prepared food on the steam table. At 12:33 p.m., he was observed putting on gloves before starting to handle food. Throughout the dining observation, Staff E, Dietary Aide wore the same gloves while also touching and opening cupboards. At 12:47 p.m., he was observed wiping his gloved hands with a napkin as it appeared to have food particles on them, but did not take the gloves off. From approximately 12:33 p.m. to 12:55 p.m., Staff E, Dietary Aide, was not observed changing gloves while serving food and doing other tasks. On [DATE] at 12:29 p.m., observations of the 200-unit dining area revealed no food temperatures were taken or recorded by the dietary staff. At 12:38 p.m., observations revealed soup started to be served. Observations of a dietary aide revealed they were not wearing gloves while handling and serving the soup to residents. A few minutes after the initial observation, another staff member provided gloves to the dietary aide. An observation was conducted on [DATE] at 12:37 p.m. of a staff member serving food on the BB unit food line with a hairnet on with two braids pulled out of the hairnet on each side of her face, leaving her hair uncovered while scooping food onto resident plates. The food was observed being delivered to the food line from the kitchen until the end of service. During that time, no temperatures were taken, however, after service, the temperature log at the BB unit food line had food temperatures documented for that meal. On [DATE] at 12:55 p.m., an interview with Staff E, Dietary Aide revealed he does not take or record food temperatures on the tray line in the dining area. He confirmed he did not take or record food temperatures for the [DATE] lunch meal in the 100-unit dining area. On [DATE] at 4:08 p.m., observations of the nourishment room in the 200-unit were conducted. Observations of the refrigerator revealed resident food not dated to include a pie, broccoli salad, unknown item from [Vendor name], and a container of dessert dated [DATE]. Further observations of the refrigerator revealed a lunch box containing food items and beverages with no date identified. A to-go container was observed with a date of, ,d+[DATE], but no resident name or room number was identified on the container. The refrigerator and freezer temperature log was observed to be filled out through [DATE]. (Photographic Evidence Obtained) On [DATE] at 9:38 a.m., a review of the food temperature log for the 100-unit dining area was conducted. Observations of the log revealed food temperatures on [DATE] were completed for lunch. (Photographic Evidence Obtained) On [DATE] at 10:26 a.m., a review of the 100-unit nourishment room refrigerator revealed the same concerns identified on [DATE]. (Photographic Evidence Obtained) On [DATE] at 12:02 p.m., observations revealed Staff D, Dietary Aide entered the 100-unit dining area with a meal cart. At 12:05 p.m., Staff D, Dietary Aide was observed washing his hands and putting on gloves. At 12:08 p.m., he was observed putting food on the steam table and started serving soup at approximately 12:11 p.m. At 12:12 p.m., Staff D, Dietary Aide was observed touching various drawer handles to obtain placemats. He was observed putting placemats on the dining tables in front of seated residents, while wearing the same gloves he put on at the beginning of the meal service. From 12:05 p.m. to 12:32 p.m., Staff D, Dietary Aide wore the same gloves and there was no observation of him changing them. On [DATE] at 12:04 p.m., an observation revealed Staff R, Dietary Aide entered the 600-unit dining area with a meal cart. Observations revealed she opened the meal cart, removed the covered food trays, and placed them on the steam table. Staff R, Dietary Aide was observed removing aluminum foil covering a tray of lasagna with ungloved hands. She was not observed performing hand hygiene before removing the aluminum foil from the tray of lasagna. Further observations of Staff R, Dietary Aide revealed she discarded the aluminum foil in the garbage and put serving ware on top of the covered food trays on the steam table. After that task, she was observed putting on gloves and started to serve soup. Staff R, Dietary Aide was observed at the sink running water over a scoop and using a rag to wipe it off. Her hands were observed to be ungloved throughout this task. Another observation in the 600-unit dining area revealed, Staff S, Dietary Aide pulled down her hair band, touched her face, and left the dining area. Upon her return to the dining area, she was observed passing a bowl to another staff member with an ungloved hand. She was observed removing aluminum from a covered food tray and putting the tray on the steam table. Staff S, Dietary Aide did not have gloves on and was not observed performing hand hygiene when these tasks were conducted. On [DATE] at 10:44 a.m., an interview with the Assistant Food Service Director regarding the process for taking and recording the food temperatures revealed they are completed in the kitchen, before the meal carts go out to the units. She stated one of the reasons temperatures are not taken and recorded on the units is due to an audit. The Assistant Food Service Director stated there was an audit taking place, requested by the Nursing Home Administrator (NHA), from [DATE] - [DATE]. She stated the NHA was asking for random checks of meal temperatures on the units. A review of the audit logs was conducted with the Assistant Food Service Director to reveal the 200, 300, and 400 units were included in the audits. On [DATE] at 10:47 a.m., a follow up interview with the Assistant Food Service Director revealed dietary staff are responsible for everything in the nourishment room, except for formula and, Med pass items. She stated dietary staff responsibilities included cleaning the refrigerator, stocking, dating, reviewing expiration dates, and rotating items. The Assistant Food Service Director stated every morning she completed rounds of the nourishment rooms, To make sure everything is up to par. She also stated her rounds included restocking if needed, review of refrigerator and freezer temperatures, and review of expiration dates and labeling of resident's personal food items. The Assistant Food Service Director confirmed during her rounds she checked if formula was expired. She stated if she saw expired formula she would discard them. A review of dish machine competencies/education provided by the Assistant Food Service Manager revealed a date of [DATE]. The staff members in the observation on [DATE] are not indicated on the attendance log. On [DATE] at 2:20 p.m., an interview with the Director of Nursing (DON) revealed food that belongs to the resident, brought to the facility by a family member, should be discarded after three days. A review of the facility policy titled Food Holding and Service, undated, revealed the following Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the Florida Food Code and HACCP (Hazard Analysis and Critical Control Points) guidelines. Further review of the policy revealed under Procedure, the facility will take and record the temperatures of all food prior to service. A review of the facility policy titled Food Storage, undated, revealed the following Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the Florida Food Code and HACCP guidelines. Further review of the policy revealed the following Procedure: . 2. Refrigerators . c. Date and label all refrigerated foods. d. Use all leftovers within 48 hours. Discard items that are over 48 hours old. A review of the facility policy titled Employee Sanitation, undated, revealed the following Policy: The kitchen employees of the facility will practice good sanitation practices in accordance with the Florida Food Code in order to minimize the risk of infection and food borne illness. Further review of the policy revealed the following, Procedure: . d. Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped utensils, or where utensils are cleaned or stored. 5. Hand washing a. Employees must wash their hands at designated hand washing facilities at the following times: i. After touching bare human body parts other than clean hands . v. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. vii. After engaging in other activities that contaminate the hands . 6. Use of Gloves . c. Change gloves: i. Between each food preparation task. ii. After touching items, utensils or equipment not related to task. iii. After touching a source of contamination v. When damaged, soiled or when

Based on observations, interviews, and record review, the facility did not ensure proper infection control practices related to 1.) failing to ensure proper hand hygiene was conducted after exiting the room of one resident (Resident #578) of one resident on contact precautions for clostridium difficile (C. diff), 2.) failing to ensure proper storage of respiratory masks on one unit (AB/100 unit) of six units, and 3.) failing to ensure appropriate hand hygiene was performed by staff and offered to residents on two units (AB/100 unit and BB/200 unit) of six units during meal service. Findings included: 1. An observation was conducted on 1/6/25 at 12:23 p.m. of Resident #578's room, which had a contact precaution sign posted on the door. A staff member was observed donning personal protective equipment (PPE), removing it while exiting the room, then using alcohol-based hand rub (ABHR). The contact precaution sign showed everyone must: perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting. Review of Resident #578's January 2025 Order Listing Report showed the resident was on contact precautions for C. diff starting 12/27/24. Review of Admission Records showed Resident #578 was admitted on [DATE] with diagnoses including acute respiratory failure, sepsis, and bacteremia. Review of Resident #578's Lab Results Report showed a positive result for C. diff antigen and C. diff toxins on 12/28/24. An interview was conducted on 1/8/25 at 3:30 p.m. with Staff F, Certified Nursing Assistant (CNA) and Staff L, CNA. They both confirmed Resident #578 was on contact precautions, but they did not know why. They said for contact precaution rooms, they wear a gown and gloves to enter the room and then either wash their hands or use alcohol-based hand rub when they exit. They both stated they followed the sign on the door for what to do with the precaution rooms. An interview was conducted on 1/9/25 at 12:15 p.m. with Staff J, Registered Nurse (RN). She said Resident #578 was on contact precautions for C. diff. She also said staff wore a gown and gloves to enter the room and can use hand sanitizer (ABHR) to clean their hands. Staff J, RN said they follow the sign on the door. 2. An observation was conducted on 1/6/25 at 10:29 a.m. in room [ROOM NUMBER] of a respiratory mask on the bedside table uncovered. An additional mask was in the top drawer, unbagged, with the end of the resident's oxygen tubing lying on the floor. The mask remained on the bedside table, unbagged, and uncovered on 1/8/25 and 1/9/25. An observation was conducted on 1/6/25 at 12:21 p.m. in room [ROOM NUMBER] A of a respiratory mask on the bedside table uncovered. The mask remained unbagged and uncovered on the bedside table on 1/9/25. An interview was conducted on 1/9/25 at 11:26 a.m. with Staff Q, Licensed Practical Nurse (LPN). She said residents with respiratory masks should have a clear bag at their bedside and the masks should be stored in the bag when not in use. Staff Q, LPN also said if staff see the masks out they should place them in a bag. An interview was conducted on 1/9/25 at 11:44 a.m. with the facility's Respiratory Therapist (RT). She said all respiratory masks should be bagged when taken off the resident, which helps prevent them from getting dirty and/or falling on the floor. The RT said she had placed bags in all the rooms that needed them with the resident's name for staff to place the masks in. The RT also said she had just come from room [ROOM NUMBER] where she saw the respiratory mask uncovered on the bedside table. 3. An observation was conducted on 1/6/25 at 12:37 p.m. of lunch service on the BB/200 unit. Residents were observed being brought into the dining room for lunch. At no point were the residents offered hand hygiene wipes, alcohol-based hand rub, or hand washing prior to eating their lunch. There was a sink with soap available in the dining room. An additional observation was conducted on 1/8/25 at 12:35 p.m. of lunch service on the BB/200 unit. Residents were observed being brought into the dining room for lunch. No hand hygiene options were offered to residents before the meal. 50570 On 1/6/25 from 12:16 p.m. to 1:03 p.m., the AB/100 unit dining area was observed for lunch. Observations of the dining area revealed four dining tables with three to four residents at each table. Staff members were observed in the dining area included Staff G, CNA, Staff F, CNA, and Staff C, CNA. Residents were not observed being offered hand sanitizer or hand washing before eating. Staff were not observed performing hand hygiene prior to meal service or between passing of individual resident meals. At 12:46 p.m., Staff F, CNA was observed assisting Resident #718 with eating. Staff F, CNA did not perform hand hygiene before assisting this resident with eating her meal. Prior to assisting Resident #718, Staff F, CNA was observed assisting with passing of meal trays to the residents sitting in the AB/100 unit dining area. On 1/8/25 at 12:02 p.m., the AB/100 unit dining area was observed for lunch. The same concerns, observed on 1/6/25, related to hand hygiene not being offered to residents before eating or during the lunch meal service was observed. At 12:08 p.m., Staff B, RN was observed reviewing and writing on meal tickets, directly to the left of the steam table, as Staff D, Dietary Aide was serving food. From 12:08 p.m. to 12:32 p.m., Staff B, RN was observed touching plates with food and handing them to another staff member to provide to residents. Staff B, RN was not observed performing hand hygiene after handling the meal tickets and touching the plates with food being provided to residents. On 1/8/25 at 12:51 p.m., an interview with Resident #569 revealed staff don't offer or provide hand hygiene to her before meals. She stated she has wipes located in the bathroom she uses to clean her hands before eating. She confirmed she was not offered hand hygiene for breakfast or lunch that day. On 1/9/25 at 12:16 p.m., an interview with Staff C, CNA revealed hand hygiene is offered and performed in resident's rooms before they come to the dining area. She stated hand hygiene is also offered to residents who dine in their rooms. Staff C, CNA stated staff perform hand hygiene, All the time. On 1/9/25 at 12:23 p.m., an interview with Resident #19 revealed staff don't offer or provide hand hygiene to her before meals. She stated, I could do it myself, but it would be hard, and pointed to her right arm. Resident #19 stated, It would be nice if it was offered. On 1/9/25 at 12:28 p.m., an interview with Staff B, RN revealed the CNA's offered and perform hand hygiene for residents. She confirmed she sometimes helps with the dining meal service, including feeding residents who need assistance or passing trays. Staff B, RN stated when she assisted with the dining meal service the residents are already seated at the table, therefore, they had hand hygiene completed in their rooms. She stated when she passes meal trays to resident rooms she washes her hands, every three rooms. On 1/9/25 at 12:32 p.m., an interview with Staff A, Unit Manager (UM) for the AB/100 unit revealed hand hygiene should be offered to residents during morning care, before and after meals, if they touch their wheelchairs, and as needed. She stated her expectations for staff is to perform hand hygiene when they care for residents and remove personal protective equipment (PPE) in between passing trays and when they are working in the kitchen/dining areas. On 1/9/25 at 12:37 p.m., an interview with Resident #153 revealed staff don't offer or provide hand hygiene to her before meals. An interview was conducted on 1/9/25 at 12:24 p.m. with the facility's Infection Preventionist (IP). He said if a resident was on contact precautions for C. diff, staff should wear a gown and gloves, then wash their hands with soap and water. He confirmed Resident #578 tested positive for C. diff and staff should have been using soap and water to clean hands, not alcohol-based hand rub. He also confirmed the sign posted on the resident's door did say alcohol-based hand rub could have been used. He said they did not have a sign with enteric contact precautions. The IP said when he placed the sign, he told staff the resident was on precautions for C. diff, and they should have passed it along to the next shift so staff would know to use soap and water when exiting Resident #578's room. The IP confirmed all respiratory masks should be stored in a bag and not left uncovered on the bedside tables. He said if staff see a mask uncovered, they should place it in a bag. When asked about residents being offered hand hygiene before meals the IP said, that would be a great practice. He confirmed they did not offer residents hand hygiene options prior to eating. Review of a facility policy titled Clostridium Difficile, revised July 2014, showed the following: Policy Statement Preventative measures will be taken to prevent the occurrence of Clostridium difficile infections among residents and precautions will be taken while caring for residents with C. difficile (to prevent transmission of C. difficile to others). Policy Interpretation and Implementation 11. When caring for residents with diarrhea or fecal incontinence caused by C. difficile, staff will maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR for the mechanical removal of C. difficile spores from hands 12. Glove use when caring for residents with C. difficile infection, washing hands with soap and water upon exiting the room of a resident with C. difficile infection and strict adherence to hand hygiene in general is considered best practice. Review of a facility policy titled Use of CPAP/BIPAP/APAP, undated, showed: Purpose: To provide guidance for use of CPAP (continuous positive airway pressure therapy) or BIPAP (bi-level positive airway pressure therapy) or APAP (auto-adjusting positive airway pressure therapy) for the treatment of obstructive sleep apnea (OSA). Care and Maintenance: - Store equipment when not in use. Photographic Evidence Obtained

Based on observations, interviews, and record review, the facility failed to monitor blood pressure before administering medication ordered for increased blood pressure for one resident (Resident #36) of six residents reviewed for medication regimens. Findings included: During an interview and observation on 1/6/25 at 11:51 A.M., Resident #36 was lying in bed and said he was outside and recently returned to his room. He also said he was feeling lightheaded. Resident #36 said the lightheaded occurs at least twice each week and he reported feeling lightheaded to the nurses several times. Review of Admission Record showed Resident #36 was admitted to the facility on [DATE], with a diagnosis of essential hypertension. Review of Resident #36's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14, indicating cognition is intact. Review of Resident #36's Order Summary Report, active orders as of 1/1/25, showed an order dated 10/28/24 for Metoprolol Succinate ER (Extended Release) Oral Tablet 24 Hour 50 mg (milligrams) give 1 tablet by mouth in the morning for increase blood pressure. Review of the Medication Administration Report for December 2024 showed vital signs every evening shift and blood pressures ranged from 109/70 to 161/56. During an interview on 1/8/25 at 9:56 A.M., Staff O, Registered Nurse (RN), Unit Manager (UM) said the order for metoprolol for Resident #36 should have an order to check supplemental blood pressure, they should be checking it and there are no parameters ordered. Review of Resident #36's Order Summary Report, active orders as of 1/8/25, showed an order dated 1/8/24 with a start date of 1/9/24 for Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 mg give 1 tablet by mouth in the morning for HTN (high blood pressure) hold for systolic BP (blood pressure) less than 110 mmHg (millimeters of mercury) and/or heart rate less than 60. During an interview on 1/9/25 at 1:44 P.M., Staff P, Licensed Practical Nurse (LPN) said he always checks blood pressure before administering medications if they're ordered for increased blood pressure. During an Interview on 1/9/25 at 1:46 P.M., the Director of Nursing (DON) said her expectations for orders without listed parameters are for staff to verify parameters do not exist and notify the resident's physician. Review of Medline Plus article (https://medlineplus.gov/druginfo/meds/a682864.html#how) titled Metoprolol, last revised on 9/15/23, showed Side Effects may include dizziness or lightheadedness.

Based on observations and interviews, the facility did not ensure the privacy of resident information on three (AB, BB, and EB) of six units in the facility. Findings included: An observation was conducted during a facility tour on 1/6/25 at 10:15 a.m. of a list posted, facing the main hall, on the AB unit nurses' station with resident names, room numbers, and the type of therapy they are receiving. There was also a paper lying on the counter with a resident name and doctor's order, and another paper showing the resident census with medical information. The tour also revealed the document with resident names, room number, and type of therapy was posted, facing the main halls on the BB and EB units. The documents remained posted all on three units on 1/7/25 and 1/8/25. An observation was conducted on 1/7/25 at 9:37 a.m. of a computer screen on the wall on the BB unit, open, with a resident's medical record visible. No staff were in the vicinity at the time. An observation was conducted on 1/8/25 at 10:00 a.m. of a medication cart computer on the BB unit, open, with resident information on the screen. No staff were at the cart and a visitor was observed walking past the open screen. Staff J, Registered Nurse (RN) returned to the medication cart. She confirmed the screen should have been locked and said staff are educated to make sure the screen is closed. An interview was conducted on 1/8/25 at 4:22 p.m. with Staff M, Licensed Practical Nurse (LPN) and Staff F, Certified Nursing Assistant (CNA). They both stated computer screens should be locked, and papers should be turned over so resident information is not visible. Both staff members reviewed the posted document with resident names, room number and types of therapy being provided and agreed the document contained personal resident information and should not be posted. Staff M, LPN said the document is supposed to be in the nurses station, not facing the hall. An interview was conducted on 1/8/25 at 4:30 p.m. with the Director of Nursing (DON). She said staff should always lock their computers when they are not at them working and paperwork should not be left on the nurses' station counter where it could be seen by others. The DON also confirmed the document with resident, names, rooms, and therapy posted on the AB, BB, and EB nurses' stations should be in the nurses' station, not visible to residents or visitors. Review of a facility policy titled HIPAA [Health Insurance Portability and Accountability Act] Guidelines-Computer Terminals/Workstations, effective 11/1/2013, showed: Policy Computer terminals and workstations will be positioned/shielded to ensure that resident and facility information is protected from public view or unauthorized access. Interpretation and Implementation 1. Insofar as practical/feasible, computer terminals/workstations will be positioned or shielded so that screens are not visible to the public or to unauthorized staff. Encryption of ePHI [Electronic Protected Health Information] will be implemented if reasonable and appropriate. 2. Only authorized users are granted access to resident and facility information. Such access is limited to specific, defined, documented and approved applications and level of access rights. 3. A user may not leave his/her workstation or terminal unattended for long periods of time (e.g., breaks, lunch, meetings, etc.) unless the terminal screen is cleared, and the user is logged off. Each user must log off at the end of his/her work shift. 4. A user must clear the terminal screen if the workstation or terminal is left briefly unattended. 5. All hard copy printed information must be positioned in such a manner that it cannot be viewed or read by the public or unauthorized staff. . Photographic Evidence Obtained

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs related to wheelchair use for one (Resident #3) of four sampled residents. Findings included: On 5/15/24 at 10:18 a.m., Resident #3 was observed using his phone while lying down in bed. Resident #3 reported he had resided at the facility for 2 years. Resident #3 stated his concern of not having a wheelchair at that time. He stated he had spine surgery and had difficulty walking. Resident #3 revealed he was dependent on the wheelchair to ambulate. He stated he relied on staff to get him in and out of bed and into the wheelchair. He stated staff used the [Mechanical] lift with two people assisting him. Resident #3 stated he did not have a wheelchair at that time because it was being borrowed. He stated one staff member asked for his permission to take the wheelchair because it was needed for measurements. He stated he could not remember who the first staff member was. He said a second occurrence of borrowing the wheelchair happened two days ago. He stated Staff D, Unit Manager (UM)/Registered Nurse (RN) asked for his permission to borrow the wheelchair he used. Resident #3 stated the wheelchair had not been returned for his use. A second interview with Resident #3 on 5/15/24 at 10:46 a.m. revealed he had not been able to get out of bed for two days. He stated if he wanted to get out of bed he could not because he did not have access to the wheelchair at that time. He stated his family came to visit and they did not take him out because he did not have his wheelchair. Resident #3 stated, I feel like I'm being picked on. Why did they take this wheelchair and not someone else's? A review of the Admission Record for Resident #3 showed an admitted to the facility of 7/18/22 and diagnoses to include history of falling, low back pain, unspecified, muscle spasm of back, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness (generalized), contracture, left knee, and pain in left knee. A review of Resident #3's care plan initiated on 7/19/22 showed a focus of, [Resident #3] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] morbid obesity, history of CVA [Cerebrovascular accident] with left side weakness, activity intolerance, deconditioning. The goal, with an initiated date of 12/23/22, a revision date of 5/13/2024, and a target date of 5/25/24, revealed the following: The resident will maintain current level of function in ADLS through the review date. The interventions included the following: LOCOMOTION: The resident uses a wheelchair for locomotion. A review of the medical record to include progress notes and current care plan showed there was no documentation of Resident #3 refusing to get out of bed. A review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Section GG - Functional Abilities and Goals showed the following: - Mobility Devices - B. Wheelchair, response: yes. A review of Resident #3's Therapy Screen dated 5/2/24 showed the current level of transfer is dependent and ambulation is none. An interview conducted on 5/15/24 at 11:02 a.m. with Staff D, UM/RN. She revealed she asked permission from Resident #3 to borrow the wheelchair and her intention was not to take it indefinitely. She stated before borrowing the wheelchair from Resident #3, she confirmed with the Director of Therapy/Physical Therapist (PT), it belonged to the facility . She stated Resident #3 was hesitant at first and told her, It's mine. She stated after explaining to Resident #3 that it was to try on another resident, then he gave permission. She stated the wheelchair was borrowed to see if it fit another resident who resided in another room on the unit. Staff D confirmed it was therapy's role to evaluate if the wheelchair fit or not. Staff D confirmed Resident #3 needed assistance with ADLs and ambulating. Staff D was aware Resident #3 had not been out of bed since she took the wheelchair out of his room. She stated the resident sometimes refused to get up. Staff D stated she had not returned the wheelchair yet. An interview conducted on 5/15/24 at 11:25 a.m. with the Director of Therapy/PT. He revealed Resident #3's wheelchair was borrowed to assess another resident. He stated, Taking [Resident #3's] wheelchair was the quickest way to do it. The Director of Therapy stated the trial/assessment should not take long to complete. He confirmed therapy staff normally did the trial/assessment for residents. The Director of Therapy stated [the other resident] was on the caseload today, 5/15/24, for assessment with Resident #3's wheelchair. He stated, We haven't got to that point yet. The plan is to do it today. The Director of Therapy stated he was not aware Staff D removed the wheelchair from Resident #3 ahead of the assessment with therapy and that it was not returned. He stated Resident #3 did not like to get out of bed. The Director of Therapy stated if the wheelchair was Resident #3's personal property he would not have taken it and would have respected his wishes if Resident #3 said no to taking the wheelchair. For residents that need to be evaluated by therapy, the Director of Therapy stated there was a therapy referral form. He stated staff also communicated face to face or by phone with himself and his team. An interview was conducted on 5/15/24 at 4:16 p.m. with the Director of Nursing (DON). She stated for residents that needed a wheelchair assessment, she expected that the nursing staff would communicate with therapy. The DON stated she spoke to Staff D. She stated therapy wanted to try a specific wheelchair and that was why Staff D borrowed Resident #3's wheelchair. She stated in the conversation with Staff D, she asked Resident #3 if it was okay to remove the wheelchair from his room. The DON agreed that the wheelchair was not returned in a timely manner. She stated she was not sure where the wheelchair was these past two days. She agreed that it was not acceptable that the resident would not have his wheelchair accessible to him. Review of the facility policy titled, Resident Rights, revealed the following in section (a) Resident Rights: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. The policy further revealed in section (1), A Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .

Based on observations, interviews, and record review the facility failed to ensure kitchen equipment was maintained in a clean manner for 1 of 1 ice machines located in the kitchen and related to ice/water dispensers located on 6 of 6 (Cabana Bay, Anchor Bay, Blueray Bay, Dolphin Bay, Emerald Bay, Florida Bay) living units. Findings included: An interview with the Dietary Manager (DM) on 3/13/24 at 8:59 AM revealed the main kitchen housed a large ice machine. She reported that there were ice/water dispensers in each of the 6 Chef Kitchens. A tour of the facilities kitchen and 6 Chef Kitchens revealed a large ice machine in the kitchen. Inspection of the ice machine revealed a white substance lining the inner left side of the ice machine walls. The ice machine had a wire rack located on the inside of the unit used to store the scoop. The scoop was noted to be lying sideways on the ice with the handle touching the ice. The Dietary Manager took the scoop off the ice and placed it on the rack. She did not notify any of the kitchen staff about the contaminated ice. She reported the scoop should have been on the rack when it was not in use. Tour of Chef Kitchens on each of the 6 living units revealed the following: -Cabana Bay-Ice/water dispenser noted with white and brown substance around the spout and white substance in the spill tray. -Anchor Bay-Ice/water machine with white and brown substance around the spout and white substance in the spill tray. - Blueray Bay-Ice/water machine with white substance around the spout and white and brown substance in the spill tray and settled water in the spill tray. -Dolphin Bay-Ice/water machine with brown and white substance around the spout and white substance in the spill tray. -Emerald Bay-Ice/water machine with white and brown substance around the spout. -Florida Bay-Ice/water machine with white and brown substance around the spout and white substance in the spill tray. An interview on 3/13/24 at 9:30 AM with the Dietary Manager revealed the substance is lime scale and the maintenance department is responsible for maintaining and cleaning the ice/water dispensers. An interview on 3/13/24 at 9:48 AM with the Maintenance Director revealed the maintenance department is responsible for maintenance and cleaning of the ice/water machines on all six units and the ice/water machines are cleaned weekly by maintenance. He reported for the one ice machine in the kitchen the maintenance department checks the filter and checks for mold, mildew and limescale once a month. He reported if there is mold, mildew or white lime scale present they empty the ice machine, clean it and then set it back up. A review of the facility policy titled Ice Machine, with a date of 2016 revealed the following: The facility will maintain the ice machine, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day.

Based on record review, staff interview, and family interview, the facility failed to provide a requested medical record for one Resident (#2) reviewed for access to medical records. Findings included: Resident #2 was originally admitted on [DATE], hospitalized on [DATE], and discharged home on [DATE] according to the clinical record. During an interview with the facility Medical Records Coordinator on [DATE] at 3:21 PM, she was asked to explain the procedure for a resident or family requesting a copy of their medical record. The Medical Records Coordinator stated she gives the resident or family an authorization for release form, she will scan the paper record, and send it up to Corporate. The facility medical records consists of both electronic information and paper information. The Medical Records Coordinator would wait for the response from corporate and then would forward the medical record to corporate. Corporate sends the medical record from their headquarters with a letter of approval. The Medical Records Coordinator stated it normally takes about 3 days. The Medical Records Coordinator said that the facility would charge for copies of the medical record. The resident or family would have to pay up front before receiving the medical records. After payment, the resident or family would receive a paper copy of their medical record. The facility Medical Records Coordinator provided a copy of the Authorization for Release of Health Care Information signed by Resident #2's family member on [DATE] to request Resident #2's medical records and billing records for continued medical care and insurance. Additionally, the Medical Records Coordinator provided a copy of a letter dated [DATE] from the facility's attorneys that was sent via email to the Medical Records Coordinator regarding the Authorization for Release of Health Care Information. The letter documented that the request for the medical records was determined to be HIPAA (Health Insurance and Portability and Accountability Act (federal health care privacy of information rule)) and the facility attorneys would send further correspondence and an invoice for copy reproduction and postage charges. The Medical Records Coordinator showed a copy of a letter sent via email to the facility Risk Manager on the same date to authorize the facility to send the resident's paper record to attorneys. The facility Medical Records Coordinator was asked for documentation that Resident #2's family member received the medical record that they requested. The Medical Records Coordinator could not find any proof that the medical record was sent to the resident's family. The Medical Records Coordinator tried to call the attorney group several times, but did not ask to speak to anyone. The surveyor asked the Medical Records Coordinator if the family paid the facility for the copy reproduction and postage charges for the medical record. The Medical Records Coordinator stated the Business Office would have documentation of payment by the family. On [DATE] at 3:25 PM, an interview was conducted with the Business Office Manager (BOM). The BOM was asked if they have a receipt or documentation of Resident #2's payment for copies of their medical record. She looked through several receipt books, but could not find it. She said she would have to look for the information. At 4:20 PM, on [DATE], the Medical Records Coordinator provided a copy of the receipt for $20.22, dated [DATE] for payment by Resident #2's family for copies of the requested medical records. At that time, the Medical Records Coordinator stated that they are still looking for documentation to show that the family of Resident #2 received the requested medical record from corporate. During an interview with the Director of Nursing (DON), on [DATE] at 4:23 PM, the DON was asked if she knew if Resident #2's family received a copy of the medical record they requested. She said she would try to find out. At the exit on [DATE] at 4:50 PM, the facility Administrator stated that they could not find any proof that the family of Resident #2 received a copy of the medical record they requested. During an interview with Resident #2's daughter on [DATE] at 9:24 AM, the day after the investigation survey, she stated that they still have not received a copy of the medical record they requested. Resident #2's wife stated during a telephone interview on [DATE] at 10:50 AM, that she has not received the copy of the medical record and that she went in person to the facility to pay for a copy of the medical record in [DATE]. In an email from the Administrator to the surveyor on [DATE] at 11:58 AM, documented the following: The Administrator did not hear back from the attorney group. They did not have proof that they had sent records to the requestor. The Administrator requested they do so and the firm [attorneys] confirmed with the Administrator that they have sent the records. Unfortunately the Administrator was unable to prove otherwise, The facility policy for Medical Records - Access and Release (not dated and no facility name) included the following: AUTHORIZED ACCESS . . 2. All requests for medical records shall be directed to the Medical Records Department. The facility Administrator and/or Risk Manager shall be notified of any attorney request for records. 3. Release of information from the medical record shall be carried out in accordance with all applicable legal, accrediting and regulatory agency rules and requirements. . 6. Patients and their legal representatives shall have access to their medical records in accordance with state law. RELEASE OF RECORDS (General) . 1. All requests for information contained in the medical record shall be directed to the Medical Records Department for processing. 2. The Medical Records Department shall review each request and verify the following: -The legitimacy of the request. The purpose for the request must be described in the request along with the part(s) of the record to be released and to whom. - The authenticity of the signature. The signature on the request should be compared with the patient or responsible party. - Return inappropriate request to the requesting party with a cover letter explaining the reason the request was rejected. Include with the letter a blank authorization form (a sample is attached) if appropriate. 3. Review the medical record for completeness and any documentation of drug/alcohol abuse, psychiatric care and HIV information. 4. Photocopy the part(s) of the record to be released. 5 Calculate the fee for copying, if appropriate. 6. Forward the copied record and the bill for copying to the requesting party. 7. The request for record and signed authorization shall be placed, under a separate tab in the patient's medical record. RELEASE OF RECORDS (By Requesting Party) . .9. Patient/Family Member/Responsible Party - Request must be in writing and accompanied by written authorization if the requesting party is someone other than the patient. - Release information as requested according to State regulation. - Charge for copies according to current schedule. The facility policy for Medical Records - Response to Request for Medical Records (not dated and no facility name) included the following: POLICY . Any request for medical records should be made in writing and directed to the facility Administrator or Designee. The Administrator or Designee will ensure that a copy of the request is forward to the facility attorney for review. The facility is required by state and federal law to protect the confidentiality of every resident's private health information. No record shall be released to any party until advised to do so by facility attorney. PROCEDURE . Prior to sending the request for medical records to the facility attorney for review, the Administrator or Designee will ensure the request includes: 1. Completed Authorization for Release of Medical Information form 2. Resident face sheet 3. Evidence of authority to receive private health information (if request is not made by the resident): a. Power of Attorney (for living resident) b. Health Care Surrogate or Health Care Proxy (with statement of incapacity) c. Guardianship documents d. Letter of Administration (for a deceased resident) The Administrator or Designee will send the request to the facility attorney in a secure format. NO FURTHER ACTION SHOULD BE TAKEN AT THIS TIME UNTIL DIRECTED TO DO SO BY FACILITY ATTORNEY. The facility attorney will review the request to determine whether it complies with all applicable Federal and State regulations regarding the release of medical records. If the request does not comply with the applicable regulations, the attorney will inform the requesting party, in writing, advising of the reason(s) why the record cannot be released. A copy of that email will be forwarded to the facility. If the request complies with the applicable regulations, the facility attorney will advise the facility in writing the request is HIPAA compliant and instruct the facility on how to proceed. Upon receipt of written instruction from the attorney to release the record, the Administrator or Designee will coordinate the preparation of the record. Any record that is in paper form at the facility should scanned into an electronic format. The facility should report the time spent to produce the record in electronic form to the attorney. The facility attorney will use this to generate an invoice. If records are requested in paper form, copy work will be completed at the facility for records of 100 pages or less. If the number of pages exceeds 100 the record may be taken to a copy service for copying. A facility employee will remain with the record at all times. After copying, the original record and one copy of the record will be stored in a secure location in the facility. The second copy of the record will be sent to the facility attorney that can be tracked. The facility should keep a copy of the record that was sent to the facility attorney regardless of the format it was produces as. The facility attorney will generate an invoice and send it to the requesting part and copy the facility. The facility attorney will release records to the requestor only after payment has been made. It is the facilities [sic] responsibility to notify the facility attorney when payment has been made for the requested records. The facility attorney will notify the facility administrator or Designee when the record has been sent to the requestor. The facility Administrator or Designee is responsible for maintaining a log of all record request and a file for each request. The log should contain the following information: 1. Resident name 2. Date request was received 3. Name of requesting party 4. Date request was sent to the facility attorney 5. Disposition of request (e.g. record released on [DATE] or record not released at discretion of facility attorney).

Based on observations, record review, and interviews, the facility failed to review and revise the care plan related to behaviors for one resident (Resident #98) out of the sampled five residents. Findings included: On 10/26/22 at 10:02 a.m., Staff G, assigned Certified Nursing Assistant (CNA), reported Resident #98 was on 1:1 due to an altercation she had with Resident #52. She tore his skin on his arm. Resident #98 had been on 1:1 for about three months. She was put on 1:1 after the incident occurred. On 10/27/22 at 11:00 a.m., Resident #98 was observed in bed sleeping. Staff J, assigned (CNA), was in the room at that time and stated Resident #98 was on 1:1 due to her behaviors. He reported she was very calm today but was very aggressive with other residents on Tuesday. Staff J, CNA, reported Resident #98 was mostly aggressive with residents in the dining room. She likes to grab at people. On 10/27/22 at 10:45 a.m., Staff H, assigned Licensed Practical Nurse (LPN) stated Resident #98 was aggressive and would aim for anyone. One time she pulled her hair and wouldn't let go stated Staff H, LPN. She goes after everyone. She looks sweet but she was very aggressive. She's on 1:1 and had been for a few months stated Staff H, LPN. On 10/27/22 at 10:50 a.m., Staff I, LPN, Unit Manager, confirmed Resident #98 was on 1:1 due to being aggressive. A review of the Admission Record revealed Resident #98 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated 99 in the section for the Brief Interview for Mental Status (BIMS) score. 99 indicated the resident was unable to complete the interview. Section E Behavior of the MDS indicated Resident #98 did not exhibit physical or verbal behavioral symptoms. A review of the Progress Notes revealed the following notes: 09/20/22 08:34 Medication Administration Note indicated the resident was on 1:1 but not aggressive that morning 08/26/22 08:37 Physician Note indicated recent aggression towards neighbor. Physically contacted fell ow resident with trauma to that resident's arm 07/04/22 15:52 Nursing Note revealed Resident #98 was having aggressive behavior 07/04/22 10:39 Nursing Note revealed the family was notified about the resident's aggressive behavior towards another resident A review of the care plans for Resident #98 revealed: -a care plan in place related to Activities of Daily Living (ADL) self-care performance deficit related to aggressive behavior initiated on 09/22/20. The latest intervention for this care plan was revised 05/20/22. -a care plan in place related to behaviors of cursing at staff and biting and hitting during care. The latest intervention for this care plan was revised 10/05/20. -a care plan in place related to dementia with behaviors. The latest intervention for this care plan was revised 09/22/20. The care plans were not revised related to aggressive behavior towards staff and residents after the incident that occurred on 07/04/22. The care plans did not reflect that Resident #98 was on 1:1. On 10/27/22 at 11:15 a.m., the Risk Manager confirmed Resident #98 had been on 1:1 since the incident happened in July. On 10/27/22 at 11:45 a.m., the Director of Nursing (DON) reported Resident #98 was put on 1:1 to keep her separated from Resident #52. She reported she was not aware that the resident was aggressive with staff and other residents. She would expect the care plan to include interventions related to her aggressive behaviors after the incident occurred. A review of the policy provided by the facility Person Centered Care Plan revised 12/2016 revealed the following: The facility's IDT, in coordination with the resident, the resident's family or representative, develops and maintains this care plan in an effort to attain and/or maintain the highest level of function the resident may be expected to reach.

Based on observation, record review and interview the facility failed to provide activities of daily living (ADL) tasks to residents who required assistance to address elongated and soiled fingernails for 3 of 6 (#22, #24, #76) residents sampled for ADL's. Findings included: 1. Review of Resident #22's record revealed that he was admitted to the facility on [DATE], with diagnosis that included Hemiplegia and Hemiparesis following cerebral infraction affecting right dominant side. Observations of Resident #22 on 10/24/22 at 10:06 AM revealed the resident sitting up in his bed watching television. Closer observation of the resident revealed his fingernails on his bilateral hands were noted to be elongated approximately .03 centimeters above the top of his fingers the several of the fingernails were noted to be soiled with a brown substance. Interview with the resident at this time revealed the resident does not like his nails long, and would like them cut. Observations of Resident #22 on 10/25/22 at 02:40 PM revealed the resident seated seated round the table in the common area. The resident was noted to still have elongated fingernails on his bilateral hands. Interview on 10/25/22 at 02:48 PM with Staff A, Certified Nursing Assistant (CNA) revealed she has been working at the facility for 5 years and typically gets the same assignments each time she works. She reported that nail care is provided everyday and as needed and CNA's cut, clean and file the residents fingernails. Staff A reported that Resident #22's fingernails are not that long. Interview on 10/25/22 at 02:54 PM with Staff B, Licensed Practical Nurse (LPN) revealed that the CNA's will typically cut resident fingernails and sometimes activities will trim nails. She reported the CNA's are responsible to cut and file resident nails daily or as needed and the task can be done on shower days. Observations and interview of Resident #22 on 10/25/22 at 02:56 PM with Staff B, LPN present, the resident confirmed that his nails are long. He reported that It doesn't matter because the staff wont do anything about it. He reported that he prefers his nails trimmed like when he was in the military. He reported Short and neat to go with my uniform. At this time Staff B, LPN explained to the resident that she would ensure that his nails are trimmed by tomorrow. Review of Resident #22's Minimum Data Set (MDS) dated [DATE] revealed that the resident requires extensive assist of one person for personal hygiene. Review of Resident #22's care plan initiated 4/27/21 related to ADL self-care performance deficit r/t [related] right sided hemiparesis following CVA. revealed interventions that included Personal Hygiene: The resident requires assistance by staff with personal hygiene and oral care. 2. Review of Resident #24's record revealed that he was admitted to the facility on [DATE], with diagnosis that included Toxic Encephalopathy, Hemiplegia and Hemiparesis following cerebral infraction affecting left dominant side. Observations of Resident #24 on 10/24/22 at 10:20 AM revealed the resident laying in his bed watching television. Closer observation of the resident revealed his fingernails on his bilateral hands were noted to be elongated approximately .04 centimeters above the top of his fingers the residents fingernails were noted to be soiled with a brown substance. When asked if he likes his nails long, the resident shook his head from side to side, waved his right hand from side to side and said No like wants cut. Observations of Resident #24 on 10/25/22 at 10:29 AM revealed the resident was lying in bed with the television on. The resident was noted to still have soiled elongated fingernails on his bilateral hands. Observations of Resident #24 on 10/25/22 at 02:42 PM revealed the resident lying in bed. The resident was noted to still have soiled elongated fingernails on his bilateral hands. Interview on 10/25/22 at 02:48 PM with Staff A, CNA revealed that she has been working at the facility for 5 years and typically gets the same assignments each time she works. She reported that nail care is provided everyday and as needed and that CNA's cut, clean and file the residents fingernails. Staff A reported that this resident sometimes will refuse, but she has not gotten to his nails yet. Interview on 10/25/22 at 02:54 PM with Staff B, LPN revealed that the CNA's will typically cut resident fingernails and sometimes activities will trim nails. She reported that the CNA's are responsible to cut and file resident nails daily or as needed and the task can be done on shower days. Observations of Resident #24's fingernails on 10/25/22 at 03:02 PM with Staff B, LPN present, she confirmed that his nails were long and soiled. She reported that the CNA's are about to leave for the day and will ensure the fingernails get groomed tomorrow. Review of Resident #24's MDS dated [DATE] revealed that the resident requires extensive assist of one person for personal hygiene. Review of Resident #24's care plan initiated 7/26/22 related to ADL self-care performance deficit r/t toxic encephalopathy, deconditioning, activity tolerance, history of CVA with residual left sided weakness, pneumonia. revealed interventions that included Personal Hygiene: The resident requires assistance by staff with personal hygiene and oral care. 3. Interview on 10/25/22 at 03:07 PM with the Director (DON) revealed residents nail care should be done by the CNA's daily when providing care and as needed. She reported if the resident refuses the aide should let the nurse know. She reported that the residents nails will be addressed today, and should not wait until tomorrow. Review of the facility policy titled Nursing-Nail Care with an effective date of January 1999 revealed that the purpose is To promote cleanliness, safety, and neat appearance 16723 4. During an interview with Resident #76 on 10/24/2022 beginning at 02:52 PM, the resident's left hand was noted to be contracted with his fingertips curled into his hand. The resident held his right hand out and his fingernails were observed to extend beyond his fingertips. The nails were noted to be dirty under the nail. The resident reported that sometimes the staff cleaned and trimmed his nails when he had a shower. On 10/25/22 at 9:40 AM the resident was observed sitting in his electric wheel chair eating his breakfast. During the conversation with Resident #76, he was observed to pick up his sausage patty with his right hand to finish eating it. On 10/26/22 at 10:22 AM Resident #76 was observed sitting up in bed, just finishing his breakfast. His finger nails on his right hand were observed and noted to remain jagged and with brown debris under the nails. When a comment was made about the jagged nails with visible brown under the tips, the resident confirmed they could be cleaner. When asked about his showers, he took a minute to think and then answered that he had an aide that gave him his showers that was very good. Just as he was referring to his aide, she walked into his room. The resident continued by saying his shower was usually on a Monday. The aide (Certified Nursing Assistant G) confirmed she gave him showers on Mondays, but she was off on Monday (10/24/2022). The aide confirmed the resident's preferred shower days were Monday, Thursday and Saturday on the day shift. Review of the resident's shower schedule confirmed his shower preference was Monday, Thursday and Saturday during the 7a to 3p shift. A review of documentation for bathing, which included bed baths or showers provided to Resident #76 revealed during the week of 10/09/2022, only two showers were documented. During the week of 10/23/2022, only one shower was documented (10/27/2022). (No bed baths were documented during these weeks.) A review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident's score on the BIMS (brief interview for mental status) was a 13, indicating the resident's cognition was intact. The resident was assessed as needing one person for total assistance with his personal hygiene and being totally dependent for bathing on one staff assisting. A review of the care plan developed from the quarterly assessment for the resident's self care performance deficit included the resident's generalized weakness and his contracted left hand. An intervention on the care plan identified the resident's need for assistance with bathing. An interview was conducted on 10/27/2022 beginning at 1:05 PM with Resident #76. He confirmed he had his shower that morning which he enjoyed. When asked about his nails, the resident held out his right hand and said no they hadn't been trimmed. The nails remained long, jagged, and with noted dark areas under the nails. The resident then held out his left hand and commented that these nails were dangerous. He attempted to pull his pinkie finger out straight to demonstrate the nail length and the nail was observed to be longer than the nails on the right hand. The resident was able to pull his pointer finger out almost straight so the nail could be observed. The nail was close to one inch beyond the fingertip. When asked why he called his nails dangerous, the resident reported because they were long and hard. When asked if they were digging into his left palm, he answered, not yet. An interview was conducted with Staff I, Nurse Supervisor, on 10/27/22 at 1:20 PM. She reported she had spoken with Resident #76 that morning (on 10/27/2022) and told him that she would need to clean out under his nails for him and to clip them. She confirmed she had noted how long the nails were on both hands and agreed they probably had been that way for a longer period of time than just since his last shower.

Based on observations, record reviews, and interviews, the facility failed to ensure a skin condition was assessed, a physician ordered wound care for the area, and the responsible party was notified for one (#123) out of 48 sampled residents. Findings included: Resident #123 was admitted on [DATE]. The Admission Record included diagnoses not limited to Type 2 Diabetes Mellitus with ketoacidosis without coma, adult failure to thrive, contracture of right knee, and unspecified muscle wasting and atrophy not elsewhere classified. The Weekly Skin Sweep, dated 10/25/22, for Resident #123 identified that a treatment to the residents' left great toe remains in progress and that the skin was not impaired. The purpose of the skin sweep was To document skin condition following weekly examination and to identify new areas of concern or breakdown. The skin assessment did not identify any other skin condition affecting the resident. An observation was conducted, on 10/27/22 at 10:36 a.m., with Staff Member L, Certified Nursing Assistant (CNA), of Resident #123. The resident was lying on an air mattress with borders. Resident #123 was dependent upon the staff member in all repositioning maneuvers. As Staff L provided incontinency care for the resident, a foam dressing was noted on the residents' left ankle area. The staff member peeled back the dressing slightly and an abrasion-type skin condition with a pink wound bed was observed that appeared to be approximately 1 centimeter by 2 centimeters. The dressing had an area of dried sangriserous drainage on the pad and was undated. Staff Member C, Licensed Practical Nurse (LPN) stated, 10/27/22 at 11:13 a.m., she did not know anything about an area to the Resident #123's left ankle. The Unit Manager, Staff D, and Staff C left the nursing station and went to Resident #123's room. Staff D removed the foam dressing, confirmed it was not dated, and observed the open area to the residents left ankle. Staff C stated she did not know anything about it and the last skin sweep was (completed) on 10/25/22. Staff D stated she would start an investigation and both staff member applied bilateral sheepskin heel protectors on the resident. On 10/27/22 at 11:28 a.m., the Unit Manager informed Staff C the physician had not been notified (of Resident #123's skin condition). A Skin Sweep Weekly, dated 10/27/22 at 11:20 a.m., indicated that Resident #123 had an identified abrasion to side of the left lower leg. The skin sweep was created approximately seven minutes after Staff C had reported not knowing of any skin issue on the residents left ankle. A review of Resident #123's progress notes did not identify any physician order had been received to apply a dressing to the residents' left lower extremity from 10/21 to 10/27/22. A progress note, dated 10/27/22 at 11:30 a.m., identified that the physician was called to report an open area to left outer ankle. The Advanced Practitioner Registered Nurse (APRN) returned the call at 10/27/22 at 11:41 a.m. and the facility received new orders. The progress notes indicated calls were placed to the residents' family member on 10/27/22 at 11:43 a.m. and 12:00 p.m., to notify them of an abrasion to the residents' left lower extremity. The Situation, Background, Appearance, and Review (SBAR), dated 10/27/22, indicated that Resident #123's change in condition was a skin wound or ulcer and the facility was unable to determine when the issue started. The review of Resident #123's October Treatment Administration Record (TAR) instructed staff to Cleanse abrasion to Left (L) lower shin with normal saline (ns), pat dry, apply dry clean dressing every (q) day and as needed (prn), every day shift for impaired skin integrity. The TAR identified this order was to start on 10/28/22. The facility documented that an as needed dressing change to the left lower extremity had been done for the first time at 11:45 a.m. on 10/27/22. The TAR did not include any prior physician order to apply a dressing to Resident #123's left lower extremity. Resident #123's care plan was updated on 10/27/22 to identify that the resident had an abrasion to the left lower shin. The care plan had previously identified, initiated 3/22/22 and revised 10/27/22, that the resident had a potential for pressure ulcer development related to (r/t) Immobility, incontinence, history of Pressure ulcer to left buttock. The interventions instructed staff to Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs/symptoms (s/sx) of infection, wound size (length x width x depth), (and) stage. The care plan identified, on 11/8/19, that the resident was at risk for skin breakdown r/t decreased mobility, incontinence, (and) contractures. The interventions indicated that the resident was to wear heel protectors in bed as tolerated and follow facility protocols for treatment of injury. The Director of Nursing stated, on 10/27/22 at 11:47 a.m., that her expectation was for staff to fill out an incident report at that time and call physician to get an order for the dressing. The DON stated that she had (just been) notified of the area and had just given an in-service regarding getting physician orders for dressings and dating them.

Based on record review and interview, the facility failed to ensure collaborative communication with Hospice Services for one (#60) of two residents reviewed. Findings included: A review of the Admission Face Sheet for Resident #60 revealed an admitted to the facility of 8/22/22 and a readmitted [DATE]. Documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Admit to [Name of Hospice] on 09/21/2022 related to [CONDITION(S)]. Review of the Care Plan showed the following: -Terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Continued review of the clinical record revealed no hospice notes or hospice care plans. On 10/26/2022 at 10:07 AM an interview was conducted with Staff E, Medical Records. Staff E stated hospice notes are either in the hard chart or the resident would have a separate hospice binder. The hard chart was reviewed with Staff E, and she confirmed hospice notes were not present. At that time Staff E reviewed the electronic medical record (EMR) and confirmed the resident was admitted to hospice on 09/21/2022 and there were no hospice records contained within the EMR. An interview was conducted on 10/26/2022 at 10:15 AM with Staff F, Licensed Practical Nurse (LPN). The LPN said there was no hospice binder for this resident and she was unaware who visited the resident from hospice. On 10/26/2022 at 10:22 AM an interview was conducted with the Director of Nursing (DON). The DON confirmed hospice notes should be in chart or the resident should have a separate hospice binder containing the hospice notes and hospice care plans. A subsequent interview was conducted on 10/26/2022 at 12:47 PM with the DON. The DON stated it is her expectation hospice notes and care plans be located within the resident's facility record. The DON also confirmed Resident #60 had been under care of hospice at the facility for greater than 30 days. Review of a facility-provided policy, undated and titled 'Nursing-Hospice Communication' revealed: Purpose: To promote continuity of care, the facility will facilitate regular and comprehensive communication with the Hospice provider for each resident receiving Hospice Care. Policy: hospice communication may be done through meetings with member(s) of the IDT [interdisciplinary team] team, and/or physician or nursing documentation. Documentation provided through Hospice services.

Based on record review and interviews, the facility failed to notify residents, families, and representatives following the admission of two (#61 and #100) out of two residents who tested positive, and were cared for, with COVID-19 precautions. Findings included: During an interview, on 10/27/22 at 1:03 p.m., the Infection Preventionist (IP) reported that the facility currently had two residents who had been admitted to the facility after testing positive at the hospital. The IP identified Resident #61 had been admitted on [DATE] and Resident #100 was readmitted on [DATE]. The Director of Nursing stated, during the IP interview, the Nursing Home Administrator was responsible for the automatic calls regarding COVID and was unsure if a call was made after either Resident #61 or Resident #100 were admitted . The facility had provided a copy of the last automatic calls made to families, residents, and representatives that was done at 2:44 p.m. on 10/19/22. The facility identified in the update on 10/19/22 that the last identified COVID-19 positive person was on 10/10/22, that there was no new positive staff and one resident was isolating with COVID-19. The listing of positive staff members identified a Certified Nursing Assistant had tested positive on 10/22/22. The Admission Record for Resident #61 indicated that the resident was readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The lab results from an acute facility indicated that the resident PCR COVID-19 test was positive on 10/21/22. The Admission Record for Resident #100 indicated that the resident was readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The lab results from an acute facility indicated that the resident had a positive PCR COVID-19 dated 10/25/22. The policy - COVID-19 Pandemic Plan, dated 3/2/20 and most recently revised 10/2022, included the following: - Residents and resident representatives will be notified: -- Following the occurrence of either a single confirmed infection of COVID-19 OR three or more residents or staff with new-onset of respiratory symptoms occurring with 72 hours of each other. The Nursing Home Administrator (NHA) stated, on 10/27/22 at 1:52 p.m., stated they (the facility) did not have to notify residents, families, and/or representatives if a resident was admitted with it (COVID-19), only if they had a positive in the building. She reported she does an automatic call weekly to update. On 10/27/22 at 2:16 p.m., the NHA stated the policy said they had to notify following an occurrence of a confirmed case. She reported if she misinterupted the policy and the facility can notify moving forward and that the weekly updates contain information regarding COVID admissions.

Based on observations, record review, and interview, the facility failed to maintain resident equipment in a functional manner for four (Residents #4, #5, #6, and #7) of five residents sampled for the use of air mattresses. Findings included: 1. Observations on 6/1/22 at 10:10 a.m. of the 400 hall, revealed Resident #6 lying in her bed with her eyes closed. Attempts to communicate with the resident were unsuccessful as the resident did not respond to her name being called. The resident was noted to have an alternate pressure air mattress on her bed. Closer observation of the air mattress revealed that the unit had the ability to be set based on the resident's weight from 50 pounds to 450 pounds, which went up in increments of 50 pounds from 50 pounds to 350 pounds and then went up in increment of 100 pounds to 450 pounds. It was noted that Resident #6's air mattress was set at a weight of 450 pounds. (Photographic evidence obtained) Review of Resident #6's record revealed she was admitted to the facility on [DATE] and had long and short-term memory problems with severely impaired cognitive skills for daily decision making. Review of the resident's most recent weights revealed a current weight of 95.0 pounds as of 5/17/22. Review of Resident #6's physician orders revealed the following: -Low air loss mattress. No directions specified for order. Order date 1/14/22 -Low air loss mattress with bolsters when in bed. Check placement and function every shift. Order date 10/22/20 Review of Resident #6's care plans revealed the following: -Related to risk of falls, with intervention LAL (low air loss) mattress with bolsters as ordered, initiated 11/30/2020 -Care plan related to pressure sores, with intervention Low Air Mattress initiated 5/27/22 -Care plan related to skin integrity, with intervention Low Air Mattress initiated 1/17/22 2. Observations on the 500 hall on 6/1 22 at 10:20 a.m., revealed Resident #7 lying in her bed with her eyes open. Attempts to communicate with the resident were unsuccessful as the resident did not respond to her name being called. The resident was noted to be lying on an alternate pressure air mattress attached to her bed. Closer observation of the air mattress revealed the unit had the ability to be set based on the resident's weight from 50 pounds to 450 pounds, which went up in increments of 50 pounds from 50 pounds to 350 pounds and then went up in increment of 100 pounds to 450 pounds. It was noted that this resident's air mattress was set at a weight of 50 pounds. (Photographic evidence obtained) Review of Resident #7's record revealed on 3/24/22, she had a Brief Interview For Mental Status (BIMS) which indicated she had long and short-term memory problems with severely impaired cognitive skills for daily decision making. Review of the resident's most recent weights revealed a current weight of 121.0 pounds as of 5/6/22. Review of resident #7's current order summary report revealed no current physician orders related to the use of an alternate pressure air mattress. Review of Resident #7's care plans revealed the following: -Related to risk of falls, with intervention LAL mattress with bolsters. Setting 2 or as ordered, initiated 4/20/18. -Care plan related to pressure sores, with intervention Low Air Mattress initiated 2/8/22 -Care plan related to alteration in comfort, with intervention LAL mattress with bolsters as ordered initiated 12/28/20. -Care plan related to skin integrity, with intervention Low air loss mattress with bolsters as ordered initiated 7/16/20. 3. Observations on the 500 hall on 6/1/22 at 10:28 a.m., revealed Resident #4 lying in her bed with her eyes closed. Attempts to communicate with the resident were unsuccessful as the resident did not respond to her name being called. The resident's granddaughter was in the room and reported the resident ate breakfast and went back to sleep. The resident was noted to be lying on an alternate pressure air mattress attached to her bed. Closer observation of the air mattress revealed the unit had the ability to be set based on the resident's weight from 35 pounds to 350 pounds, which went up in increments of 35 pounds. It was noted that this resident's air mattress was set at a weight of 175 pounds. (Photographic evidence obtained) Review of Resident #4's record revealed she was admitted to the facility on [DATE] and had a BIMS dated 4/24/22 with score of 03 (severe cognitive impairment). Review of the resident's most recent weights revealed a current weight of 118.8 pounds as of 5/2/22. Review of Resident #4's current order summary report revealed no current physician orders related to the use of an alternate pressure air mattress. Review of Resident #4's care plans revealed the following: -Care plan related to pressure sores, with intervention Low Air Loss Mattress initiated 2/18/22 -Care plan related to skin integrity, with intervention Low air loss mattress initiated 3/7/22. 4. Continued observations on the 500 hall on 6/1/22 at 10:48 a.m., revealed Resident #5 lying in her bed with her eyes closed. Attempts to communicate with the resident were unsuccessful as the resident did not respond to her name being called. The resident was noted to be lying on an alternate pressure relieving air mattress attached to her bed. Closer observation of the air mattress revealed that the unit had the ability to be set based on the resident's weight from 35 pounds to 350 pounds, which went up in increments of 35 pounds. It was noted that this resident's air mattress was set at a weight of 210 pounds. (Photographic evidence obtained) Review of Resident #5's record revealed she was readmitted to the facility on [DATE], and had a BIMS dated 2/27/22 with a score of 02 (Severe Cognitive Impairment). Review of the resident's most recent weights revealed a current weight of 130.6 pounds as of 5/15/22. Review of Resident #5's physician orders revealed the following: -Low air loss mattress. No directions specified for order. Order date 1/14/22 Review of Resident #5's care plans revealed the following: -Care plan related to skin integrity, with intervention Low air loss mattress initiated 1/17/22. An interview with the Director of Nursing (DON) on 6/1/22 at 3:02 p.m., revealed when the air mattress was on, if it beeps, there was a malfunction. She reported when they (facility staff) rent air mattresses, they give the vendor the resident's weight and height. She reported once in the building, she believed the vendor set up the mattress and the nurses monitor and report if there were any issues. The DON reported she believed the air mattresses were care planned, but not sure if they required a physician order. The DON reported when monitoring the mattresses, the nurses would just check to see if the mattress was deflated or lopsided. She added the nurses did not check the settings as that was already set up and did not need to be changed. An interview on 6/1/22 at 3:17 p.m. with Staff A, Central Supply, Certified Nursing Assistant, revealed when a request was made for an air mattress, she contacted the vendor and provided the vendor with the resident's height and weight. The vendor would deliver the mattress and set it up based on the height and the weight of the resident. She reported hospice orders their own mattresses from their own vendors. Staff A reported that once the weight setting was set it could not be changed once it was locked. In an interview on 6/1/22 at 4:29 p.m. with the DON, she reported she did not know about the settings of an air mattress as that was not her expertise. She reported she was not sure who in the building had that knowledge. An interview on 6/1/22 at 4:48 p.m. with the Wound Care Physician, revealed she typically recommended an air mattress for a Stage 3 pressure wound. She reported the air mattress did not need a physician order. She reported the dial set was based on weight increments of 100 pounds or at 2nd level. She reported that the air mattresses could be unlocked, and that someone should be monitoring them. An interview on 6/2/22 at 12:35 p.m. with the DON, revealed last evening (6/1/22), she completed an audit of air mattresses to ensure that all were on and functioning. She reported she contacted the medical director to request to adjust all air mattresses to the parameters for the resident's weight and height until the vendor was able to come to the facility. The DON reported that she was able to change some of the settings on the air mattresses to meet the weight closest to the resident's actual weight. Continued interview with the DON at this time, revealed the air mattresses were able to be unlocked and new settings placed. She reported, moving forward, the mattress would be monitored but she was not sure by whom at this point. She reported she had no estimated date or time the vendor would come in and check the air mattress and provide training regarding the air mattresses. A phone interview on 6/2/22 at 1:34 p.m. with the Durable Medical Equipment (DME) vendor representative, revealed when equipment orders were received by his company, the resident's height and weight were required. He reported, regarding the air mattresses, his company would set them up at the time of delivery. He said staff at the facility should know how the system worked and how to adjust it. He reported typically the weight was set within 10 pounds on either side of the resident's weight. The representative said the mattresses would automatically lock, and if there was a power surge, it would reset the mattresses to the manufacturers settings. He said the facility had the ability to change settings and ensure they monitored the air mattresses accordingly. He reported his company did not monitor the air mattresses once set up; that would be the responsibility of the facility. A request was made for a policy related to the use of the air mattresses and a policy related to maintenance of resident equipment, however neither policy was not provided.

Based on record review, family interview, staff interview and facility policy and procedure review, the facility failed to ensure that it provided appropriate incontinence care for one (Resident #4) of seven sampled residents. Findings included: A review of Resident #4's clinical chart, the Admission Record, reflected an admission of 01/21/2022. Resident #4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's Progress notes, 01/24/2022, 17:33 (5:33 p.m.): SS (Social Service) met with resident and wife. Pt's (patient's) ability to communicate is very limited. Pt is able to make eye contact and nod his head yes and no to some questions. Pt is non-verbal . On 02/17/2022 at 10:30 a.m., Resident #4 was observed in his room, sitting in a wheelchair , his spouse was sitting on the bed, holding his hand. Resident #4's spouse agreed to answer questions. She stated that she had submitted a grievance yesterday (02/16/2022) to Social Services. She stated that she had come in on Saturday (02/12/22), Monday (02/14/22), and Wednesday (02/16/22), and that she had found her husband soaked. The diaper and all the bedding, all soaked. She stated that she usually came in at 10:30 a.m. She stated that he [Resident #4] never complained, but he motioned. She showed the surveyor the motion that the resident had made, by the motion pointing at her bottom and rubbing her bottom. Then she stated it was in a way that would indicate irritation on his bottom. She stated that, I have submitted four grievances. Initially, they seemed to step it up. The first weekend he was here was a nightmare. I tried to get someone to change him. They said they had to serve lunch. He had a line on his brief that showed the wetness. Review of Resident #4's Care Plan, Focus: Resident #4 has an ADL (Activity of Daily Living) self-care performance deficit r/t left side [CONDITION(S)] following [CONDITION(S)]/craniotomy, [CONDITION(S)], confusion, initiated on 01/22/2022. Interventions included: Eating: The resident is dependent on one staff to eat, initiated 01/22/2022. Toilet Use: The resident requires assistance by staff for toileting, initiated on 01/22/2022. Transfer: The resident requires assistance by two staff with a Total Mechanical Lift to move between surfaces as necessary, initiated 01/22/2022. A review of 01/2022, ADL-Toilet Use, which indicated toilet use-self performance; and Toilet use Support provided. The following dates were initialed off by staff as having provided toileting assistance for the time period of 01/21/22 through 01/31/22: 01/21, 21:24 (9:24 p.m.) 01/24, 6:07, and 14:59 (2:59 p.m.) 01/25, 13:58 (1:58 p.m.) 01/26, 11:28 01/28, 23:48 (11:38 p.m.); 18:37 (6:38 p.m.) and 11:24. 01/29, 12:05 01/30, 11:10 01/31, 17:51 (5:51 p.m.) and 12:45 All other times on the sheet were either marked NA or blank. For the time period, 01/21/22 through 01/31/22, 10 days with 3 shifts each=30 shifts, plus the date of admission =31. The resident was documented to have received toileting assistance 12 times during the latter period, i.e., 12 times out of 31 shifts. A review of 02/2022, ADL Toilet Use, which indicated toilet use-self performance; and Toilet use Support provided. The following dates were initialed off by staff as having provided toileting assistance for the time period of 02/01/22 through 02/16/22: 02/01, 14:59 (2:59 p.m.) 02/03, 15:43 (3:43 p.m.) 14:39 (2:39 p.m.) 02/04, 14:14 (2:14 p.m.) 02/05, 14:27 (2:27 p.m.) 02/06, 10:15 02/07, 12:35 02/08, 14:48 (2:48 p.m.) 02/09, 13:38 (1:38 p.m.) 02/10, 14:58 (2:58) 02/11, 6:59, 12:08, 15:35 (3:35 p.m.) 02/12, 5:20, 14:43, 21:59 (2:43 p.m.), (9:59 p.m.) 02/13, 13:03 (1:03 p.m.) 02/14, 6:27, 15:42, (3:42 p.m.) and 14:59, (2:59 p.m.) 02/16, 01:10, 14:28 (2:48 p.m.) All other times on the sheet were either marked NA or blank. For the time period, 02/01/22 through 02/16/22, 16 days with 3 shifts each=48 shifts. The resident was documented to have received toileting assistance 22 times during the latter period, i.e., 22 times out of 48 shifts. On 02/17/2022 at 12:44 p.m. an interview was conducted with the Social Worker (SW). She said the grievance for Resident #4 received on 02/16/2022 was related to concerns that on 02/12/2022, 02/14/2022, and 02/16/2022, in the morning, the resident was soaked in urine from infrequent diaper changes during the night. The SW reported for the facility's response to the concern, We just got it yesterday. On 02/17/2022 at 1:47 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Risk Manager (RM). The RM reported that she became aware today of the grievance that was submitted yesterday (02/16/2022) by the Resident #4's spouse. The RM reported, that at this point, I went and spoke to her. We talked about what her concerns were. I talked to her about what exactly happened. The RM confirmed that the resident had not been assessed. The RM stated, The standard for this facility is that the resident should be checked and changed if needed, every two hours. On 02/17/2022 at 3:28 p.m., in an interview with the Director of Nursing (DON) and the NHA, the DON stated that the toileting protocol was to check the patient every 2 hours. For the briefs, there was a band on them that changed color, located on the front / back of the brief. If the brief was wet, the color would change. The NHA stated, she thought that the color was yellow to blue. She would have to confirm with central supply. A review of the facility's Nursing-Incontinence Care, Bowel, Purpose and Procedure, undated, documented: The purpose of this procedure is to provide guidelines that will aid in preventing exposure to fecal matter. Equipment & Supplies: Gloves; Gown or apron (as indicated); Diaper (disposable or cloth); Underpad (disposable or cloth); Soap and water (or incontinence preparation; and Barrier creams and lotions (as indicated.) Procedure: 1. Use high degree of caution when turning residents who are known to be incontinent. 2. If resident is found to be incontinent, gather supplies. 3. Put on gown or apron, if there is the likelihood of soiling of clothing. 4. Put on gloves. 5. Wipe feces from the resident's skin with edge of diaper or underpad. 6. Wash the resident's skin with soap and water or incontinence preparation. 7. Provide catheter care as indicated, if catheter is soiled with feces. 8. Rinse will and pat dry. 9. Apply barrier creams or lotions as indicated. 10. When evaluating the condition of the resident's skin, note the following: Breaks in the skin; Excoriation; Pressure ulcers; and Signs of infection (heat, swelling, pain, redness, purulent exudate, etc.) 11. Remove soiled items. Replace with clean dry diapers or underpad, as indicated. 12. Drop solid fecal matter into toilet or hopper and flush. 13. Place disposable diaper or underpad into special waste container. 14. Place cloth diaper or underpad into designated linen hamper. 15. Remove gown or apron (if worn). 16. Remove gloves and discard into appropriate receptacle. 17. Wash hands. 18. Document actions and findings on chart.

Based on observations, staff interview and facility record review, the facility failed to ensure kitchen equipment was operating to meet manufacturer specifications regarding one of one mechanical dish washing machine on one of four days observed (5/4/2021). It was determined the facility had a High Temperature dish machine and the wash and rinse temperatures were below the minimum requirements. Findings included: On 5/4/2021 at 9:15 a.m. a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). In the dish machine room the CDM and employee A revealed that they operated a High temperature Dish Cleaning Machine. During the time of the observation, employee A was operating the machine and there were several crates of clean dishes that had run through. Interview with employee A revealed that the Wash temperature should reach at least 165 degrees F., and the Rinse temperature should reach at least 180 degrees F. This was confirmed by the CDM. Observations of the temperature read out gauges located on the machine, revealed print that read, Wash High Temp - 150 degrees F., and Rinse High temp - 180 degrees F. At 9:18 a.m. the CDM asked employee A to run the machine to demonstrate the wash and rinse temperatures. Employee A placed a crate of dishes in the washing compartment, closed the door/lid and the machine turned on and began to wash. Reading the gauges on the machine, the wash temp reached 147 degrees F. and did not go higher. After the wash cycle, the machine then made a heavy click and hot water is then filled in to start the rinse cycle. Once the rinse cycle began the gauges were observed and the rinse gauge reached only 175 degrees F. and did not go higher. This surveyor asked employee A if they have to prime the machine every day and in between meal services to ensure the water was heated appropriately. Employee A and the CDM both confirmed that they do and that they had already did that this a.m. She said the machine was fine because she had already run several crates of dishes. The surveyor at 9:24 a.m. asked for another opportunity to observe the machine during its wash/rinse process. Employee A then ran another crate of dishes in the machine. After the door was closed, the machine began its wash cycle. The wash cycle only reached 148 degrees F. and did not go any higher. Once the wash cycle was completed and the rinse cycle clicked over, the rinse temperature only reached 178 degrees F. and did not go any higher. This was confirmed by both employee A and the CDM. Employee A and the CDM were asked how they monitor the wash and rinse temperatures for each meal service. Employee A pointed to the Dish Machine Temperature Log, which was hanging on the wall. She confirmed that before each wash service to include Breakfast, Lunch and Dinner, they log wash and rinse temperatures. She and the CDM both confirmed there were no documented temperatures for this a.m. on 5/4/2021 and no documented temperatures logged for all three meal services for the day before, on 5/3/2021. Neither employee A and the CDM could show if the machine was working appropriately since the dinner meal service on 5/3/2021. Photographic evidence was taken of both the temperature log and the dish machine temperature gauges. At 12:22 p.m. the CDM revealed that the facility maintenance department was responsible for maintaining the machine and ensuring the temperatures are as per machine specifications. She also revealed that the maintenance man came in this a.m. to check on the machine, tried to make adjustments and could not get the required 150 degrees F. for wash and 180 degrees F. for rinse. She did say however, that moving on they will be using paper until a machine repair company can come out and repair it. She further confirmed that she does not know if the machine was not working properly this a.m. before the observations, and there were no indications of log temperatures from the day before on 5/3/2021. Interview with the Maintenance Director confirmed that the Dish Machine was not running according to machine specifications and would have to have a repair company come out and look at it and repair it. Review of the facility's Dish Machine Temperature Log dated for two months reviewed to include 5/2021 and 4/2021, revealed: Minimum Wash temperatures should reach at least 150 degrees F. Also revealed Minimum Final Rinse temperatures should reach at least 180 degrees F. Review of the 4/2021 month log for all three meal services revealed 4/1/2021 through 4/16/2021 had appropriate wash and rinse temperatures documented. However, dates 4/17/2021 through to 4/27/2021 revealed out of service, paper in use. It was verified from the Certified Dietary Manager that the machine received some maintenance that was not temperature related and had to wait for a part to be installed before using, and therefore the machine was out of service for eleven days. She further confirmed they used paper and plastic during those days. However, further review of the 4/2021 Dish Machine temperature log revealed there were no documented temperatures during all three meal services on 4/28/2021 and 4/29/2021. This was confirmed by the CDM. There were appropriate temperatures for both wash and rinse documented for the last day, 4/30/2021. Review of the 5/2021 month log for all three meal services revealed 5/1/2021 - 5/2/2012 had appropriate wash and rinse temperatures documented. However, there were no documented temperatures for all meal services on 5/3/2021. The CDM confirmed that staff must not have documented on that date, which was just one day ago, and one day prior to observing machine not meeting required wash and rinse temps. The CDM and dietary aide (employee A) did not know if the machine was not running appropriately the day before as there was no documented evidence. Both confirmed that the machine is not at optimum wash and rinse temps for today 5/4/2021. On 5/6/2021 the Nursing Home Administrator provided the facility's Mechanical Cleaning and Sanitizing of Utensils policy and procedure with date 2016, for review. The policy states: The facility will follow the cleaning and sanitizing requirements of the Florida Food Code for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Under the procedure section of the policy #1, revealed: Use only an approved dish machine that is properly installed and maintained. Operate the dish machine as instructed in the manufacturer's directions. Schedule and complete regular maintenance inspections. #8 of the procedure section revealed: If a machine that uses hot water for sanitizing is in use, follow these guidelines; (b) Water must be maintained at not less than the temperatures stated below, depending on the type of machine; ii. Single tank, sanitary rack, single temperature machine: Wash temperature 165 degrees F., and Final rinse temperature 165 degrees F.; (c) Temperatures must be monitored and recorded during each wash/rinse cycle. A sample Dish Machine Temperature and Sanitizing Log follows this policy. On 5/7/2021 the Nursing Home Administrator provided the (Brand name) SERIES Installation, Operation, and Service Manual for its in house Dish Cleaning Machine and dated 6/6/2015. Page #2 of the manual and under the Specifications section revealed the following: (Brand name) HH NB/(Brand name) HH S: Wash Temperature (minimum) 150 degrees F.; and Rinse Temperature (minimum) 180 degrees F.

Based on observation, interview and record review, the facility failed to ensure three Residents (#27, #13 and #85) received restorative therapy of five residents sampled. Findings Included: 1) During an interview with Resident #27 on 5/4/21 at 10:50 a.m. he stated he has not had restorative therapy in at least 3 weeks. The resident said staff told him they are short staffed and that's why he has not had restorative therapy. The resident stated the staff lost parts to his boots he used to wear in bed with the kickstand on them and wore them once or twice. He stated he has not had any one ask or put on his splint that goes on his right hand in weeks. Review of the treatment administration record reflected on 5/4/21 the resident was administered the right wrist/hand splint for 4 to 6 hours 5 days per week or as tolerated During an interview with Resident #27 on 5/5/21 at 5:04 p.m. he stated no one has asked him or applied his hand splint today and has not seen it in several weeks. Resident #27 stated he wears the soft boots to protect his heels but they are not the boots with the kickstands he used to wear before the staff lost the pieces. Review of the treatment administration record reflected on 5/5/21, the resident was administered the right wrist/hand splint for 4 to 6 hours for 5 days per week or as tolerated. Review of the treatment administration record from 4/20/21 to 5/5/21 reflected Resident #27 having the right wrist/hand splint applied every day as checked off by the nurses. Review of the Restorative Nursing program referral/plan revealed therapy referral for restorative nursing program 3 to 5 times per week with the splint 5 times a week. Referred for Range of motion and splints/braces. Problem/assessment: at risk for increased contracture in Bilateral upper extremities and at risk of functional decline. Interventions: right wrist/hand splint 4 to 6 hours as tolerated 5 times a week. Active range of motion for bilateral upper extremity joints, 10 reps for 2 sets. Passive range of motion for bilateral upper extremity joints with sustain stretching at the end range, 10 reps for 1 set as tolerated. Goal to reduce risk for progression of joint contracture. Signed by the restorative aide and Restorative nurse on 4/9/21. Review of the Restorative nursing flow sheet for May was blank and April did not show the right wrist hand splint applied after 4/12/21. Active range of motion and passive range of motion completed 8 times after 4/9/21. The Resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physicians orders revealed: Apply bilateral podus boots 4 hours daily or as tolerated, use knee wedge to right knee area every night and as tolerated dated 3/5/21. Apply right wrist/hand splint for 4 to 6 hours, 5 days per week or as tolerated, every day shift and as needed dated 4/19/21. Bilateral heel protectors when in bed as tolerated, may remove for skin checks and hygiene, every shift to protect dated 8/17/20. Restorative nursing program for a minimum of 3 days per week as tolerated. Bilateral upper extremity active range of motion (AROM) for 2 sets of 10 reps or as tolerated. Bilateral upper extremity passive range of motion (PROM) with sustain stretching at end range for 1 set of 10 reps or as tolerated, dated 4/19/21. Review of the Minimum data set (MDS) dated [DATE] revealed the resident had a brief interview of mental status (BIMS) score of 15, cognitively intact. Review of the care plan revealed the resident had a self-care deficit related to limited mobility, limited range of motion. Interventions included: apply bilateral podus boots as ordered/tolerated. Apply knee wedge to right knee area as tolerated every evening. Bilateral hand/wrist splints as ordered and as tolerated, revised on 4/20/21. Bilateral heel protectors while in bed. Restorative nursing as ordered revised on 5/5/21. During an interview on 5/07/21 at 12:54 p.m. with Staff member W, CNA restorative, she stated she has not done restorative care this week. She confirmed she has been getting monthly resident weights and working as a CNA on the units every day that she has worked. She stated she worked as a restorative aide about 3 full days last week. Resident #27 receives upper and lower extremity range of motion. Staff member W, CNA confirmed the last time she worked with him was last Friday. Staff member W, CNA confirmed he has hand splints, and that he used to refuse to wear the right hand splint because it hurt so therapy was supposed to make him a new one. Staff member W, CNA said she saw him with it the other day, maybe last week. Staff member W, CNA confirmed she has not documented on restorative care. Staff member W, CNA stated the right hand splint is kept in the drawer, closet or the chair and he will have restorative today. Staff member W, CNA confirmed he is supposed to wear the podus boots(hard boots) every day but since working the floor as an aide he has not had them on since April. On 5/7/21 at 1:15 p.m. Staff member W, CNA asked the resident where his splint was and did not observe the splint in the 4 drawer dresser. She asked the resident again and he said it should be in the drawers. After looking again the CNA found a bag with a splint and stated, Is this It?, I have not seen this one! Resident #27 stated, That's my new splint therapy ordered that no one has put on me. Staff member W, CNA asked if she could go ahead and put the splint on and the resident agreed. During an interview on 5/07/21 at 1:32 p.m. with the Director of Rehabilitation (DOR), he stated Resident #27 was referred to restorative on 4/7/21. The DOR stated he was not tolerating his right hand splint and they made home another one. The DOR said they do not follow the residents placed on restorative and was not aware the resident was not getting restorative therapy as ordered. During an interview with Staff member U, RN on 5/5/21 at 4:45 p.m., she stated the facility has one certified nurse assistant (CNA) that completes restorative care and another restorative aide on medical leave. Staff member U, RN stated the schedule for restorative varies and when she is not working then restorative does not get done. Staff member U, RN stated she recently took on the restorative program and was not aware that it was not getting done. She stated that so far for the month of May she did not have any real time documentation on record for any residents and confirmed that April was not complete either. She said she will start a plan of correction and come up with a plan for the restorative program. Review of the policy for restorative nursing effective 9/2010, two pages, reflected: Restorative Nursing Program flow sheet: 1. The restorative nurse will initiate documentation of each completed restorative nursing referral/ plan by implementing the restorative nursing program flow sheet. 2. The restorative nursing program flow sheet will indicate the resident's name, room number, and restorative plan. 3. The restorative nursing assistant will initial the corresponding box to indicate completion of interventions of the program and will record minutes spent in that activity. Should the resident refuse to participate for any reason, the Restorative nurse or designee should be notified. Refusal will be indicated by placing the letter R in the corresponding box on the flow sheet. 4. The restorative nursing assistant will also complete a narrative restorative nursing program summary each week. The weekly summary will include the resident's level of participation, ability and willingness to continue with program and progress toward goals. 5. The restorative nurse will complete a monthly summary of the resident/patient's level of participation, ability and willingness to participate, progress toward goals and will note whether the current program will be continued, revised or discontinued. 7. The resident/patient's physician will be notified of changes and written orders will be obtained if the program is discontinued. Review of the facility policy for documentation, clinical, revised 4/19, 3 pages, reflected: Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. Documentation in the medical record of each resident should provide: 1. A complete account of the resident's care treatment and response to the care. 2. Information for the physician when prescribing medications and managing care and treatments. 3. A description of care and services that can be used for measuring the quality of care provided to the resident. Documentation Guidelines: 1. All entries in the medical record should be accurate, legible, dated, and timed. 2) Resident #13 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS assessment dated [DATE] revealed that Resident #13 had a BIMS score of 99, indicating severe cognitive impairment. Further review of the assessment reflected Resident #13 required extensive assistance to total dependence of two persons for ADLs (activities of daily living). Review of the physician's orders in the electronic medical record reflected an order dated 3/7/21 apply bilateral knee splints daily as tolerated every shift. A review of the care plan dated 3/6/21 indicated Resident #13 had an ADL self care performance deficit. Interventions included bilateral knee splints as ordered and as tolerated. Review of the care instructions for CNAs (certified nurse's assistants), Dressing/Splint Care, reflected Bilateral knee splints as ordered and as tolerated. A review of the TAR (treatment administration record) in the medical record for the month of May showed electronic signatures for each shift (7a-3p, 3p-11p, and 11p-7a) indicating the splints had been applied. On 5/04/21 at 10:35 AM an observation was conducted. Resident #13 was lying in his bed with the head of the bed lower than than foot. His knees were both contracted and bent to his left side. There were no splinting devices observed and there was no support between his knees. On 5/06/21 at 8:58 AM an observation was conducted. Resident #13 was in his bed sitting in an upright position. His knees were both contracted and bent under him positioned to his left side. A pillow was positioned behind the left leg. There wasn't any support between the knees or any splinting devices on his legs. There was a pair of contracture boots sitting in the wheel chair across from the end of his bed. On 5/07/21 at 10:36 AM an observation was conducted. Resident #13 was in bed with the head of the bed elevated to about forty-five degrees. The bilateral knee contracture boots were sitting on the wheel chair across from the foot of the bed. On 5/07/21 at 10:38 AM an interview was conducted with Staff W, restorative CNA. Staff W, CNA said she is a restorative CNA. She is pulled to the floor a lot so she can't do restorative, so she hasn't been putting Resident #13's splints on. Staff W, CNA said since Monday this week she hasn't done any restorative. She doesn't know if the CNAs put the splints on. She confirmed Resident #13 was not wearing his splints. She said she is going to put them on him now. On 5/07/21 at 11:47 AM an interview was conducted with Staff X, RN (registered nurse) unit manager. Staff X, RN said restorative or therapy puts the splinting devices on. CNAs can put them on if they have been trained to. If they haven't, they can ask for assistance from one of the nurses or other staff who are able to help with them. Staff X, RN unit manager was not aware that Resident #13 wasn't getting the splints. 3) Resident #85 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders in the electronic medical record reflected an order dated 3/521, apply bilateral hand splints for up to 6 hours daily as tolerated daily as needed and every day shift. A review of the 4/7/21 MDS assessment revealed a BIMS score of 3, indicating severe cognitive impairment. Further review of the assessment showed Resident #85 required extensive assistance to total dependence of two persons for ADLs. Additional review showed Resident #85 had impairment on both sides of her upper extremities. A review of the TAR in the medical record reflected the hand splints were scheduled on the 7a-3p shift, and had been signed during the month of May. Review of the care instructions for CNAs under Dressing/Splint Care revealed Bilateral hand splints as ordered/ or as tolerated by patient. Bilateral hand splints per restorative program. A review of the care plan dated 7/10/18 reflected Resident #85 has impaired physical mobility and/or joint impairment. Interventions included bilateral hand splints per restorative program. Further review showed Resident #85 had a self care deficit with dressing, bathing, and grooming related to impaired mobility and cognitive deficit. Requires staff assistance with ADL care. Decreased ROM (range of motion) to BUE (bilateral upper extremities). An intervention dated 1/7/21 reflected bilateral hand splints as ordered or tolerated by patient. On 5/04/21 at 1:54 PM an observation was conducted in Resident #85's room. Resident #85's right wrist was noted to be contracted. The left hand was not observed at the time because it was beneath the covers. A splinting device for a hand was observed in a chair at the foot of the bed. On 5/05/21 at at 12:13 PM an observation was conducted in Resident #85's room. A wrist splint was noted in the chair at the foot of the bed. The right wrist was observed to be contracted. The left wrist was not visible during the observation, due to being beneath the covers. On 5/05/21 at 1:45 PM an interview was conducted with the resident's CNA, Staff FF. Staff FF, CNA said Resident #85 only gets the splint when she is up. On 5/05/21 at 4:52 PM an interview was conducted with Staff U, RN, the resident's nurse. Staff U, RN said if the splint doesn't feel right or it's uncomfortable and they want it off at two hours than it's ok to remove it. They would document if they applied it and if they refused it would be documented. On 5/06/21 at 9:14 AM another observation was conducted in Resident #85's room. Resident #85 was in her bed with her eyes closed. Her right wrist was observed again to be contracted and without any splinting device. The left hand was also not observed since it was under the covers. A wrist splint was observed in a chair at the foot of the bed. On 5/06/21 at 9:29 AM an interview was conducted with Staff T, RN unit manager. Staff T, RN said there are residents with multi podus boots, hand splints, and one with a shoulder brace. They are all scheduled under restorative. She said she wasn't sure about Resident #85's hand splint. The order is categorized as restorative. There are some residents that put their own on. Resident #85's order indicates bilateral hand splints for up to six hours as tolerated daily, every day shift. She was up a couple days ago when she was out here and she had them on. She is up when she is alert. That is not always. Her mentation fluctuates. Sometimes she is just very sleepy and other times she will be alert and talking to you. The CNAs put the splints on. They are in the kardex (care instructions for CNAs). The nurse signs it on the TAR. They both see the order. She opened the TAR and showed it had been documented for the month of May. On 5/07/21 at 11:14 AM an interview was conducted with Staff V, CNA, the resident's CNA. Staff V, CNA said Resident #85 required total care. She is not really alert. Sometimes she says things, but she is not all the way alert. She wears a hand splint. We use the hand splint only when she is up. We put splints on, and restorative does too. Review of the policy, Restorative Nursing - Contracture Prevention and Management - Splint/Brace Assistance, dated September 2010, reflected the following: Purpose The contracture prevention and management program is designed to assist the resident by promoting normal joint alignment and positioning, preventing or reducing contractures and facilitating daily living skills and mobility. Clinical conditions that may place a resident at risk for decreased range of motion (ROM) are immobilization, weakness or deformities arising out of neurological deficits (strokes, [CONDITION(S)], [CONDITION(S)], and polio), pain, spasms, and immobility associated with arthritis or late stage Alzheimer's disease. In addition, a reduction in range of motion may occur because of injury or surgical procedures, weakness or paralysis. Procedure: 4. Should skilled therapy not be indicated or skilled goals have been met with the likelihood of continued improvement, the OT (occupational therapist) or PT (physical therapist) will assist in the development of a restorative splinting/brace program. 5. Verify that the resident is able and willing to participate and obtain a physician order. 6. Record the program in the resident's comprehensive plan of care. 7. The program should be carried out as ordered by the resident's physician.

Based on observations, and staff interview, the facility failed to ensure dignity was maintained during dining for one (#50) of 46 sampled residents. On one of four days observed a staff member administered medications to a resident while dining on the 600 unit dining room. The resident had to stop eating in order to receive these medications. Findings included: On 5/5/2021 at 8:20 a.m. Resident #50 was observed seated in her wheelchair, positioned at a table in the 600 unit (Florida Bay) dining/activity room. She was just served and set up with her lunch meal tray. A Certified Nursing Assistant (CNA), employee G was observed to get resident #50 started with her meal and then walked away to assist other residents. Resident #50 began to self feed slowly and was able to bring spoonfuls of food to her mouth on her own. While she was self feeding, and at 8:32 a.m. a Registered Nurse, employee J was observed at a medication cart parked/positioned in the hallway across and in-between resident rooms [ROOM NUMBERS]. The medication cart was positioned just outside the dining/activity room. Employee J was observed to prepare and pour medications in various cups to include liquids and pill form. Also, she prepared a small cup of applesauce. At 8:33 a.m. she walked from her medication cart, through the dining/activity room to resident #50. When Employee J arrived at the table, resident #50 was spoon feeding herself with food items. There was another resident seated at the same table, across from resident #50. Further, there were nine other residents in the same room during the time of the observation. Employee J asked resident #50 if she could give her her medications. Resident #50 did not answer. Employee J waited until resident #50 took another spoonful of food and then proceeded to gently hold the resident's hand down so she could assist giving medications to the resident both via liquid form and pill form. The resident took all the medications, however she did have to stop eating for approximately five minutes while taking all the medications. At 8:46 a.m. Employee J was interviewed. The nurse indicated that resident #50 did not need to take the medications directly with food and said I just needed to give her the medications. The nurse confirmed that she does not normally work on this (600) unit and that she is a Floating nurse. She also confirmed that when she did bring the medications to the resident, that she did ask her to stop eating so she could take the medications. The nurse also confirmed that there were other residents in the dining room and in the area when she provided and assisted the resident with her medications. On 5/5/2021 at 1:00 p.m. an interview with the Director of Nursing (DON) revealed that the expectations when passing medications are to do so while residents are in their rooms and not out in the open, and not while dining and in a space with other residents. The DON revealed unless the resident has an order to take medications with meals, it is not acceptable for nurses to provide medications during dining service, while residents are dining with others. The DON later confirmed Resident #50 does not have any type of medications that have to be provided at and during meals. The DON did not have any specific policy/procedure related to medication pass during meal service. Review of resident #50's medical record revealed resident #50 was admitted to the facility 12/3/2019 and readmitted on [DATE]. Review of the admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the current Minimum Data Set (MDS) Quarterly dated 3/10/2021, revealed, Cognition/Brief Interview Mental Status score 3 of 15, which indicates very low cognitive function. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, review of the current care plans with next review date 6/15/2021 also did not indicate any interventions to pass and give medications at or during meals. Resident #50 was unable to say if she was ok with receiving and taking medications during meal service, while in the dining room with others.

Based on observations, staff interview and medical record review, the facility failed to ensure eight (#50, #66, #7, #22, #39, #109, #8, and #35) of thirteen sampled residents who were ordered and to receive drinking adaptive equipment, were provided with that equipment during four of four days observed (5/4/2021, 5/5/2021, 5/6/2021, and 5/7/2021), for six meal service observations. According to the residents' care plans, they should have received 2 handled cups or built up eating utensils with each meal. Findings included: On 5/4/2021 at 9:50 a.m. it was determined through tour of the kitchen and interview with the Certified Dietary Manager (CDM), that the facility's dish washing machine was broken and the facility was using paper and plastic ware and would continue with that during all foreseeable meal services. 1) On 5/4/2021 at 12:15 p.m. resident #50 was observed seated in a high back wheelchair, positioned at a table in the 600 unit dining/activity room. She was served her meal on plastic and paper utensils and dishware. Further observations revealed she was served liquid in a white Styrofoam cup. She did not drink from it. Staff occasionally asked her if she wanted to drink her juice. Review of the meal ticket revealed resident #50 should have received a 2 handled cup with nosey lid. She did not receive this drinking adaptive equipment. On 5/5/2021 at 7:38 a.m. the resident was observed in the 600 unit dining/activity room. She was seated in a high back wheelchair and positioned at a table with one other resident seated across from her. Resident #50 was observed dressed for the day and well groomed. Resident #50 had a small plastic cup with colored liquid in it. She could not reach it should she want to get it on her own. There were no handles on this plastic cup. At 8:20 a.m. the resident was served her meal and the meal tray was placed in front of her by Certified Nursing Assistant (CNA) employee G. The meal was served on paper and plastic containers and consisted of: Eggs, French Toast, Sausage Gravy, Styrofoam cup of orange juice. The cup had no handles or nosey lid. During the meal service, employee G picked up a plastic fork and knife and began to cut up the resident's food into bite sized pieces. While cutting up the food, the Aide stood up and at the right side of the resident. She cut up food for four minutes from 8:22 a.m. to 8:26 a.m. Review of the meal ticket placed next to the resident's meal, revealed: Utilize Two handled cup with Nosey lid. The resident was not served any type of handled cup for breakfast meal. This was confirmed by employee G. At 8:28 a.m. resident #50 picked up the cup with her hands shaking. She brought the Styrofoam cup to her mouth and tried to drink the orange juice. She was observed to spill orange juice on her shirt collar area. Employee G walked by and assisted the cup back to the table. At 8:34 a.m. the 600 (Florida Bay) Unit Manager sat down next to resident #50 and assisted her with her meal. She at times brought the Styrofoam cup to the resident's mouth and the resident took sips from it. It was determined that the resident could not take sips of liquid form the Styrofoam cup on her own without spilling it on her. The Unit Manager sat with her for about three minutes and then left to assist another resident. On 5/6/2021 at 8:20 a.m. resident #50 was observed assisted out from her room and positioned at a table in the 600 unit dining/activity room. She was brought out to the dining room so she could eat her breakfast meal. At 8:33 a.m. resident #50 received her breakfast tray, which served on paper and plastic. She received two liquid drinks in white colored Styrofoam cups. Neither had nosey lids or handles. After an aide, employee F set up the meal for the resident, she walked away and resident began to eat on her own but very slowly. At 8:40 a.m. resident #50 was observed dropping food onto her upper shirt while using a spoon. She then grabbed her cup with shaking hands and tried to take a sip. She spilled some orange juice out on her shirt. Review of the meal ticket revealed: To use two handled cup with nosey lid On 5/6/2021 at 12:35 p.m. resident #50 was observed in the 600 dining/activity room and was seated in her high back wheelchair and at a table with her lunch meal in front of her. She was served her meal on paper and plastic and received two Styrofoam cups with liquid. None of the cups had handles or nosey lid. She was observed a times trying to bring the cup to her mouth and spilled liquid onto her shirt. She did not receive a 2 handled cup with nosey lid. On 5/7/2021 at 8:22 a.m. employee G served and set up resident #50 with her meal, while in the 600 unit dining/activity room. The meal was served on paper and plastic with divided Styrofoam container. Further, resident #50 was served two cups of liquid, one orange juice and one water, which were both in Styrofoam cups. Neither had handles on them. Also, cups did not have any type of cut out device. Interview with the aide employee G provided the meal ticket for review. The meal ticket indicated resident was to receive a 2 handled nosey cup with a cut out during all meals. She confirmed that she had not seen the adaptive drinking equipment and that there were several others on this unit that required eating or drinking adaptive equipment. She confirmed that the entire facility has been using paper and plastic the past few days and she just realized that residents do not get the adaptive eating and drinking equipment. Further observations from 8:25 a.m. through to 8:32 a.m. revealed that the resident did pick up the Styrofoam cup of liquid and brought to her mouth. She was observed to spill liquid on her shirt when doing so. An aide removed the Styrofoam cup from the resident's reach at 8:35 a.m. Staff never returned during this meal service with another drink for the resident. At 8:30 a.m. an interview with an aide employee K, who set up all the meal trays for the residents this a.m. in the 600 unit, revealed she was aware the dish machine was not working for the past few days and that the facility was and is using paper and plastic only for meal services. She was asked if residents utilized adaptive eating equipment, what do they do to ensure they are using it. She was not sure at this time because the facility was on paper and plastic eating ware. Then the dietary aide employee L, who was at the steam table and serving plates, revealed, I know that we are using paper and plastic, but I need to make sure the adaptive equipment comes from the kitchen. She was asked if the kitchen had a three compartment sink to wash dishes and she confirmed that they do. She also confirmed that adaptive eating/drinking equipment could be washed in the three compartment sink. She was not sure why for the past few days there was no adaptive eating/drinking equipment for residents to use when the dish washing machine was broken. Review of resident #50's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed the resident had a responsible party in place. Review of the dx. sheet revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed, (Cognition/Brief Interview Mental Status/ BIMS score 3 of 15, which indicated very low cognition and not interviewable); (Activities of Daily Living/ADL - Supervision and Set up only for Eating Review of the Nutrition Screening and Data Collection for Skilled Nursing Facilities assessment dated [DATE] revealed in Feeding ability, resident is set up with assist/adaptive equipment. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plans with next review date 6/15/2021 revealed: *ADL self care performance deficit related to CVA, Dementia, Impaired balance with interventions in place to include: EATING - Adaptive equipment as ordered. *Nutrition problems or potential nutrition problem related to low BMI, variable PO intake, Diet restrictions, comfort measures with interventions to include but not limited to: Adaptive equipment as ordered. On 5/7/2021 at 10:30 a.m. the Director of Nursing provided the following information, OptimaSolutions Adaptive Device Master dated 5/7/2021 with names of residents who require and utilize eating adaptive equipment, and what type of equipment they are to utilize. The report included the following residents: 1. Resident #66 - use of 2 Handled Sippy Cup (admitted on [DATE]) 2. Resident #7 - use of Bent Handled Fork, Bent Handled Spoon, Two Handled Cup (admitted on [DATE]) 3. Resident #22 - use of Nosey Cup (admitted on [DATE]) 4. Resident #50 - use of Plate Guard, Two Handled Cup w/Nosey Lid (admitted on [DATE]) 5. Resident #39 - use of Rocker Knife (admitted on [DATE]) 6. Resident #109 - use of Transparent Two Handle Mug With Concave Lid (admitted on [DATE]) 7. Resident #8 - use of Weighted Cup, Weighted Utensils (admitted on [DATE]) 8. Resident #35 - Weighted Utensils (admitted on [DATE]) Interview with Occupational Therapist employee M on 5/7/2021 revealed that when a resident is assessed and therapy recommends with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further confirmed that there should not be any meal services missed with regards to use of adaptive eating equipment. Employee M confirmed that she found out this a.m. that all residents to include #66, #7, #22, #50, #39, #109, #8, and #35 had not received their adaptive drinking equipment since 5/4/2021. On 5/7/2021 at 9:45 a.m. an interview with the Kitchen Dietary Manager confirmed that residents who required use of adaptive drinking equipment, did not receive that adaptive equipment since 5/4/2021, the same date as when the dish washing machine broke. The Dietary Manager revealed that they should have provided them out on the floor and there would be no reason that they could not be washed after each use by using the three compartment sink. She revealed, it just got away from me and I didn't think about the adaptive eating/drinking equipment., and I was just concerned getting paper and plastic out to the floor. It was verified through the current care plan review and current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5/6/2021, and 5/7/2021).

Based on observation, interview and record review, the facility failed to ensure one Resident #27 received showers according to the shower schedule. Resident #27 did not receive any showers for the last 30 days of 5 sampled residents. Findings Included: During an interview with Resident #27 on 5/4/21 at 10:50 a.m. he stated his last shower was about two to three weeks ago and his last bed bath was almost two weeks ago. He stated his skin gets very flaky and dry if he does not get washed and shaved daily or every other day. Resident #27 stated his face was last shaved at least a week ago and he stated that he is itchy on his head, face and chest from not getting washed. He stated that he has asked for a shower but his shower days are on Tuesday and Thursday from 3 to 11 shift and they don't even ask him to shower or get a bed bath. During a interview on 5/05/21 at 12:15 p.m. Resident #27 stated that he will demand a shower if he doesn't get one by tomorrow since he has only had a few baths in the last month. The resident stated again he is supposed to get a shower on the 3 to 11 shift but that does not happen often. The resident stated he has flaky skin and really needs to have his face shaved. During an interview with Staff member X, RN unit manager on 5/5/21 at 12:17 p.m. She asked the resident when he received a shower last and he stated it was at least a couple weeks or so ago. During an interview with Resident #27 on 5/5/21 at 5:04 p.m. He stated he is very happy that he finally got a shower. He was observed without white flaky skin on his chest, face and head. He stated that he was even told if he wanted another one tomorrow (Thursday) he could get one. The resident was so happy and stated he felt so clean and no longer itchy. Resident #27 stated his head feels so much better too. During an interview with Resident #27 on 5/7/21 at 9:40 a.m. he stated he did get a shower last around 9 p.m. and wanted to be shaved but it was late so he will ask today since he has not been shaved yet and has family coming on Saturday. Review of the activities of daily living documentation for the last 30 days of showers revealed from 4/7/21 to 5/4/21, Resident #27 did not receive a shower and received 7 bed baths. One shower was completed on 5/5/21. Review of the Minimum Data Set (MDS) for Brief interview for mental status (BIMS) revealed the resident with a score of 15, cognitively intact. Section G0120. Bathing reflected the resident required physical help in part of bathing activity with one person physical assist. Resident #27 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan focus area revealed: The resident has a self-care deficit related to activity intolerance, limited mobility, limited range of motion. Interventions include: bathing and showering to provide a sponge bath when a full bath or shower cannot be tolerated. Personal Hygiene: the resident requires assistance by 1 staff with personal hygiene and oral care. During an interview on 5/06/21 at 3:03 p.m. with the Director of Nursing (DON), she stated that her expectation would be to have showers twice a week and as needed. Review of the facility policy for Bathing/Shower, effective January 1999, one page reflected: Purpose to promote cleanliness, stimulate circulation, and assist in relation. Review of the facility policy for bathing/bed bath, effective January 1999, one page reflected: Purpose to cleanse the skin, provide circulation, and provide an opportunity for observation and assessment.

Based on interviews, observations, and record review, the facility failed to ensure that a resident received urinary catheter care in accordance with professional standards of practice for 1 (Resident #95) of 4 residents reviewed for catheter/incontinence care in regards to a catheter reinsertion that resulted in observed blood clots shortly afterwards which was not reported to the physician. The staff waited until the next shift to reevaluate the resident at which time the bleeding was still present, the resident was sent to the emergency room , the catheter balloon was found to be inflated in the penis portion of the urethra and the resident required hospitalization to [MEDICAL CONDITION]. Findings included: Review of Resident #95's Admission Record revealed: admitted : 6/12/19, with an initial admission date of [DATE]. His medical [DIAGNOSES REDACTED]. His physician's orders [REDACTED].#16 French (fr), with balloon size 30 milliliters (ml) (6/13/19), change urinary catheter every evening shift every 30 days (6/13/19). His Minimum Data Sheet ((MDS) dated [DATE]; revealed a Brief Interview for Mental Status (BIMS) score of 13; which indicated the resident was cognitively intact. His bladder/bowel assessment indicated Resident #95 had an indwelling urinary catheter. Review of Resident #95's care plan revealed Resident has a catheter related to [MEDICAL CONDITION]: catheter care each shift and PRN (as needed), change catheter as ordered and as needed, cover catheter bag for privacy/dignity, check placement of catheter securement devices (stat lock) as ordered for anchoring catheter and tubing, prevent tension on catheter tubing to prevent injury to urinary meatus, keep catheter tubing free from kinks, and keep drainage bag below the level of the bladder. Review of Resident #95's admission and discharge records reflected that Resident #95 was sent to the emergency roiagnom on [DATE] due to blood in his catheter bag and tubing. Review of a written statement to the facility by Staff L, RN, the night shift nurse, revealed on (MONTH) 5th 2019 I cleansed area with Iodine, deflated balloon, and removed the old catheter, and a small blood clot came out I inserted the catheter and inflated the balloon .and a small amount of yellowish blood tinged colored urine drained into the bag. He did not complain of pain at this time. Review of progress note labeled LATE ENTRY by Staff L, RN written on 6/5/19 at 5:53 am, revealed (without mention of the time) I proceeded to remove the old catheter by deflating the balloon and gently pulling out, noting a small amount of jelly like red fluid. Catheter came out without difficulty .I inserted the catheter and a small amount of yellow tinged colored urine drained out. I inflated the balloon, secured the catheter to the leg strap, and hung the bag on the side of the bed . I returned to the patient's room and noted a small amount of blood clots had flowed into the tube and down into the bag. Review of a written statement by Staff K, LPN the day shift nurse, to the facility revealed: After writer received report from 11-7 nurse, I entered the resident's room and noted blood on the towel covering the resident's groin, with blood in the Foley tubing and drainage bag. Writer changed Foley catheters and irrigated per PRN orders and a got a scant amount of urine output. A progress note from the day shift nurse, Staff K, LPN on 6/5/19 at 08:28 a.m., revealed resident noted to have blood in Foley catheter tubing and Foley catheter bag. He stated I'm feeling discomfort in my abdomen. Flushed catheter per PRN (as needed) order, with some resistance. Resident continued to complain of discomfort to abdomen. Call placed to doctor's answering service; awaiting response. Staff K also entered a note at 8:48 a.m., which stated New order received from Nurse Practitioner (NP) to send resident to (local hospital). Review of the emergency room (ER) Record at (a local hospital) reflected that the resident arrived in theER on [DATE], and was evaluated at 10:46 a.m. According to the record [AGE] year old male with history of chronic indwelling Foley due to [MEDICAL CONDITION] (benign prostatis hypertrophy) and retention, presents with acute hematuria. According to the EMS (emergency medical services) report, the Foley was changed early this a.m., and patient is having some cramping. Patient states that he has had pain before, but today is more. Today they noticed some pink tinged urine which has now turned to gross hematuria. It is unclear if this has happened before or not. Neurological assessment: oriented x 4. Medical decision making: CT (cat scan) reviewed, Foley removed with 30 cc/ml balloon. Re eval after Foley removed, it was noted that the patient had a small laceration to the tip of his penis, inferior to the urethra, from approximately 5-7. There is bleeding that stopped with direct pressure. There is also bleeding from the urethra. At 1:30 p.m. Case discussed with the Urologist on call, he recommends reinserting the Foley to tamponade off bleeding. He made some recommendations for dressings externally, and to hold the Eliquis (Apixaban). At 2:40 p.m.: bleeding has stopped for the most part. There is small oozing from the laceration. Microfibular collagenous [MEDICATION NAME] powder and surgical applied directly, and bleeding has stopped completely. Findings and plan discussed with patient, and patient verbalized understanding and was appreciative of ED care. Visit Diagnoses: [REDACTED]. Review of the hospital records showed under Discharge summary: Admission 6/5/19, Discharge 6/12/19, History and Physical dated 6/5/19, history is from chart review since patient is altered, [AGE] year old man presented to hospital with acute hematuria. Patient has chronic indwelling catheter which is changed and today there was hematuria noted. It was noted on CT scan that the catheter had initially had the balloon inflated in the penile part of the urethera. Discharge Diagnoses: [REDACTED]. Review of the hospital records showed CT abdomen 6/5/19, The Foley catheter balloon is inflated within the penile portion of the urethra and should be deflated and repositioned. During an interview with Resident #95 on 7/9/19 at 10:30 a.m., he said I just know that the night nurse, came in to change my Foley at night, and something happened. I don't know what she did. I was out of it, because it was so early in the morning. I just know that the next nurse came on, and there was blood, and she tried to fix it. She couldn't and I had to go to the ER. By that time, I was really out of it, and didn't really know what was going on. He was asked if the night shift nurse had inserted his Foley prior to this date, and he said yes, many times, so I don't know what happened. I do remember she came in and was in a big rush that morning, so maybe she made a mistake. When asked if he felt the day shift nurse had done anything different, Resident #95 said No, it wasn't the day shift nurse, she was very good and caring. It was the night shift nurse. I asked that she not do the catheter changes after that all happened. When asked if he and any long term effects, any skin irritation, on his penis from using the catheter for so long, he said No. I don't think so. During a phone interview with the night shift nurse, Staff L, on 7/10/19 at 7:45 a.m., she said I'm a Registered Nurse. The resident did look different on the top part of his penis. His penis head had a split, with a flap hanging over the opening. He had that for a long time. Well, it was about 5:30 or 6 a.m., and I went into his room, and he was sleepy, and I informed him that I needed to change his catheter. He consented. I had done it many times before on him. I used a 16 fr, with 30 ml syringe for his balloon, as per the doctor's order. I removed the old Foley, and there was maybe a dab of blood, but no blood clot that came out. It was jelly like fluid. I then cleaned his meatus, you know, I did catheter care. When asked if she measured the amount of urine already in the catheter bag, and if there was already blood in it, she said No, I didn't measure it, since there was no order to measure output. But there was only yellow urine in the bag before I emptied it. Staff L was asked to continue with her statement. Staff L said Well, I lubricated the tip of the new catheter, and inserted it without any resistance. I got about 100 ml of yellow tinged urine out. When asked to clarify if she had any towel or washcloth with blood, or if there was any blood in the tubing, on the meatus, or in the new catheter bag, Staff L said No, there was no blood at all, except for that small dab of blood when I removed his Foley. There was no bloody washcloth or towel. When asked if she had changed his catheter bag or catheter in June, prior to 6/5/19, she said No, his bag and catheter are scheduled to be changed the 5th day of each month. That's why I did everything on the 5th. When asked when she returned to work, she said I went back 2-3 days later, and they gave me education on catheter insertion procedure and care. When asked if she had been taking care of the resident since returning, and whether she was restricted from changing his Foley, she said I have had him in my assignments since then, but no, I wasn't told I couldn't change his catheter. I haven't done it since he returned from the hospital, but I wasn't told that I couldn't do it. During a phone interview with the day shift nurse, Staff K, on 7/10/19 at 8 p.m., she said Yes, I am a LPN. My last day of work at (the facility) was 6/5/19, I had already turned my resignation in two weeks prior to the incident. I remember the resident. What happened, was that when I got report that morning from the night shift nurse, she said that she had changed his Foley, blood came out, and there was blood in the tubing and Foley bag, and she didn't know why. So, I went to take a look for myself. When I entered the room, the resident was in bed, which the sheets down over his lower legs. There was only a towel covering his penis. The resident was upset, saying there is blood everywhere. I tried to calm him down. I removed the towel covering his penis, and there was a moderate amount of blood on the towel, about the size of your palm. There was about 300 ml's of urine mixed with blood in the tubing and bag. I tried to flush the catheter, per the order, but there was resistance. So I changed the Foley, inflated the balloon with 30 ml, and a small amount of urine mixed with blood also drained out. Soon after that, the resident told me he was having abdominal pain, and I could see more blood draining. So I called the doctor, left a message, and got return orders to send the resident to the ER. I took his vitals and did an assessment on him before he left. When asked how much she deflated the balloon with before removing the catheter, she said whatever the order was, I can't remember, but I deflated it with whatever the amount ordered, I think 30 ml. When asked how much urine with blood was in the catheter bag before departing to the ER, she said about 200 milliliters. When asked if there was any abnormality or difference noted on the head of his penis at any time, on that day or otherwise, Staff K said No, absolutely not. It was just like any other penis in shape, and there was no skin erosion. An interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 7/9/19 at 5:30 p.m. The DON stated I would expect any nurse who removed or inserted a urinary catheter to document on the Treatment Administration Record. The DON confirmed that there was no documentation of a catheter change on 6/5/19, by either nurse. She confirmed that there was no catheter change documented at all in the (MONTH) TAR. The DON stated the day shift nurse, (Staff K), reported that she had irrigated the old catheter and then inserted a new one. The DON confirmed that the progress note written by the day shift nurse, Staff K, only indicated that she irrigated the Foley. There was no mention of insertion of the Foley in the progress note. When asked if either nurse recorded the output of urine before removal/disposal of the Foley, the DON stated the day shift nurse reported that there was a scant amount of blood tinged urine in the catheter bag, but they didn't measure the output. Not everyone with a Foley needs to have the output measured with removal, unless there is a doctor's order for it. When asked about the facility's investigation into the urethral tear, the ADON stated Yes, the ER Nurse called the facility and told us that the CT scan showed the balloon inflated in the urethra instead of the bladder. She suspected a urethral tear. However, the resident has had a chronic indwelling catheter from admission, and he has had erosion on his penis for a long time. She must have mistaken that for the tear. Review of the facility's policy titled Foley Catheter Removal, revealed Purpose: The purpose of this procedure is to provide guidelines for the approved method of removing a Foley catheter. Reporting and Documentation: The following information should be reported to the staff/charge nurse, and should be documented in the resident's medical record: 1) the date and time that the procedure was performed. 2) The name and title of the individual who performed the procedure. 3) The amount of urine drained. 4) The character, clarity, and color of the urine. 5) All assessment data obtained during the procedure including assessment for UTI, abdominal distention . Review of facility's policy titled Catheter, Indwelling Urinary, Insertion, Male Resident dated (MONTH) 2009 revealed, Purpose: The purpose of this procedure is to provide for and maintain constant urinary drainage, to monitor the kidney function of the seriously ill resident, and to obtain a urine specimen for diagnostic purposes. The procedure included: 30. Insert the catheter gently into the meatus (approximately 5-7 inches) or until urine begins to flow from the bladder. When urine begins to flow, advance the catheter another 2 inches. Inflate balloon and remove syringe. Pull gently on catheter to check placement. 31. If slight resistance is met, instruct the resident to take a slow deep breath to relax the perineal muscles. If resistance continues, do not force the entry. Stop the procedure and notify your supervisor.

Based on observation, interview and record review the facility failed to ensure that three of six sampled residents (#2, #6, and #1) with a history of falls received adequate supervision and interventions to prevent falls. Resident #2 was admitted with a history of falls and sustained two falls within two days of admission. The second fall resulted in a [MEDICAL CONDITION]. Findings Included: 1. The facility provided a copy of their policy titled Risk Management- Fall Risk Reduction Program that contained an effective date of (MONTH) (YEAR). Policy: The facility strives to reduce the risk for resident falls while promoting and supporting resident independence and mobility. Residents at risk for falls will be identified and the Interdisciplinary Team will work with the resident, caregivers and family to reduce the risk of falls while maximizing dignity and independence. Components of the fall risk reduction program include, not are not limited to; Identification of resident specific risk factors for falls and injuries Implement of individualized interventions to minimize risk factors for falls and injuries. Addressing underlying medical issues that may contribute to fall risk. Evaluating the effectiveness of the interventions in minimizing fall risk factors. Identification of residents with recent falls. Interdisciplinary review of each resident fall, using the Interdisciplinary Team Notes: fall form Post fall care and management Resident/responsible party/family education Analysis of facility fall data for quality improvement opportunities. A. Fall Risk Evaluation and care plan 1. A fall risk evaluation is completed on each resident on admission/readmission, quarterly, upon change of condition and following a fall. 2. A resident identified as at risk for falls at any time during his/her stay will be care planned for fall for the duration of the stay unless their risk assessment score declines below at risk level. C. Intervention If a resident falls, the following steps should be taken. Monitor the resident condition and document findings each shift and for the next 72 hours using the 72 hour Fall Monitor form. Implement new falls risk strategies based upon fall investigation and IDT recommendations. Update residents care plan. D. Documentation E. 1. Document all resident's falls in the resident's medical record, including objective and factual statements regarding: a) Circumstances of the fall in nursing notes For the witnessed fall-where it occurred, what time it occurred, resident's condition just prior to the fall, position after the fall, resident's activity just prior to the fall and any other precipitation factors, and statement from witness. The unwitnessed fall- how and where the resident was found, position after the fall, what time was he/she found, time and condition last noted by the staff, footwear, environmental factors, last activity known to staff and other precipitating factors, and statement from the resident. b) Results of the evaluation and condition of the resident. c) Care rendered. d) Notification of physician and family, EMS if necessary, giving as much detail of discussion as is possible and response. e) Physician orders f) Strategies' or new interventions to reduce the risk of recurrence 2. A closed medical record review was conducted for Resident #2 which revealed she was admitted to the facility from the hospital on [DATE] and discharged to the hospital 2 days later, 1/6/2018. A review of the hospital patient transfer form (AHCA Form 5000-3008) dated 1/3/2018 revealed a primary [DIAGNOSES REDACTED]. The resident's mental/cognitive status at the time of transfer was noted as alert, disoriented but can follow simple instructions. A review of the hospital History and Physical dated 12/30/2017 for an inpatient date of 12/29/2017 revealed the chief complaint was weakness and fatigue for two days since discharged from the hospital. Fall this evening in bathroom. This is a [AGE] year old female with a past history for dementia whom is a poor historian . She presented to the emergency room for a fall which she sustained just prior to arrival. Patient does not have the ability to confirm whether she lost consciousness during fall. She just knows that she was sick yesterday and does not know how to describe it . Continued review of the clinical record revealed a facility form titled Pre-Admission Fall Risk Evaluation which was dated 1/13/2018 (resident was discharged on [DATE]). The form states Policy: During the pre-admission review, a risk evaluation will be completed to ensure that the facility will be aware of any special care or equipment needs. The instructions state check all areas that apply and the form contained 10 different areas that could have been checked. The form was only checked for the following three areas: 1) Age 65 or above; 2) Physical disabilities affecting mobility (unsteady, weakness, old [MEDICAL CONDITION], ect.) and 3) History of hypertension. It should be noted that the following areas were not checked but would be applicable based on the information contained in the resident's record from the admitting hospital: **Recent or previous (in hospital or home) falls** **Confused, disoriented, sundow[DIAGNOSES REDACTED], or impaired judgement** The bottom of the form stated Resident is at risk if: 1. Any starred items are checked (two should have been checked but were not) 2. Any combination of 5 items are checked. This form was improperly completed and did not accurately evaluate the resident's risk for falls. On 2/18/18 at 2:00 p.m. the Risk Manager was asked to review the 'Fall risk evaluation' form and confirmed that it was not an accurate evaluation of the resident. Continued review of the resident's clinical record revealed a Nursing Admission/Readmission Screening/History dated 1/4/2018 at 15:58 (3:58 p.m.). Admission Details: A. Reason for admission according to resident /POA: Resident confused. Reason for admission from paper work: Frequent falls. B. L[NAME]/Orientation/ Neurological: Alert & Oriented x 1. Very confused/disoriented. the nursing admission assessment continued on to note the resident has unsteady gait, history of falling/recent fall, confused, short term and long term memory problem, and disorganized thinking. The resident was noted as independent with bed mobility, needed assistance of staff for transfers, dressing and eating. The following Activities of Daily Living (ADL's) were marked as not assessed: walking, locomotion, personal hygiene, toilet use, and bathing. A review of a physician progress notes [REDACTED]. Alert with confusion. Unable to answer simple questions appropriately . Review of systems; Unable to complete review of systems due to underlying dementia. Plan: status [REDACTED]. Physical Therapy (PT)/Occupational Therapy (OT) for evaluation and treatment. Maintain fall precaution Ordered floor mats to be placed on both sides of the bed Maintain bed lowered. A review of the physician orders [REDACTED]. 1. Place floor mats, 1 on each side of bed 2. Keep bed in low position when patient in bed. According to the physician progress notes [REDACTED]. However, the order indicates that these measures were not processed until the following day. A review of Resident #2's Nursing Notes revealed the following entries: 1/4/2018 at 15:53 (3:53 p.m.) Resident admitted this shift. Signed for paperwork from receiving transportation company. Went to introduce self and resident was noted sitting upright on floor. Next to bed. Bed in low position. When questioned, resident states sitting on the floor. Resident believes she is in my living room. Res is Alert and Oriented X 1. Confused and disoriented. Full active Range of Motion (ROM) noted. No complaints of pain. No signs or symptoms of injury. Clean gown and linens to bed and assisted back to bed. Vital Signs: 98.1, 81, 18, 158/84, 93% on room air (RA). 1/5/2018 at 7:37 a.m. Alert with confusion, respirations even and unlabored, denied discomfort, resident wanted to sleep in the TV room. No complaints made. Vitals within normal limits. 1/5/2018 at 1536 (3:36 p.m.) Resident alert and confused. States she is going home today. Multiple reminders to stay in wheelchair (w/c) given. Sitting at nursing station with a snack at this time. Resident pleasant with others. Poor safety awareness. 1/5/2018 at 18:54 (6:54 p.m.) Resident discovered on floor near the television area on Anchor Bay unit. Resident assessed, complaint of pain in left hip. Nurse paged the physician and obtained an order for [REDACTED]. Call bell within reach. 1/6/2018 at 7:46 a.m. Received final report from lab regarding view of left hip. Left hip shown to be a Fracture. Called Medical Doctor (MD). Resident sent to hospital. Family aware. 1/6/2018 at 21:41 (9:41 p.m.) Nurse notified by another resident's family members that resident had fallen to the floor. Nurse saw that resident was right side lying on floor in front of her wheelchair. Resident assessed, physician paged and orders obtained for 2 view x-ray of bilateral hips. Family notified of situation. A review of the X-Ray Report revealed Findings of an acute moderately displaced left intertrochanteric [MEDICAL CONDITION]. Old healing left sided pubic fractures noted. Bony mineralization is within normal limits for age. No evidence of osteo[DIAGNOSES REDACTED]. Remainder of the visualized pelvis and right hip is grossly intact. Impression: 1. Acute left intertrochanteric [MEDICAL CONDITION]. Follow up recommended. 2. Arthritic changes of the right without evidence of obvious fracture. No baseline or admission care plan was located in the clinical record. On 2/16/2018 at 2:54 p.m. a family interview was conducted with Resident #2's daughter who stated my mother needs someone with her so she doesn't attempt to stand up and fall. My mother was only at the facility for two days and fell two times when she was there. She said that the first day just before the dinner meal my mother needed help using the bathroom. The daughter stated she spoke to a certified nursing assistant who told the daughter that she could not help her mother to the bathroom or with her meal because she was too busy and they were short staffed. The daughter stated she went and told this to the nurse who not happy with that. The nurse told the daughter we are never supposed to tell the family that we're short staffed. The daughter said the next day (1/5/18) I went to the facility and sat with my mother. I told the nurse in the afternoon that I had to leave and my daughter was on her way to sit with my mother. The nurse told me to keep my mom in the TV room where she could be watched. I hadn't even driven halfway home when I got a call from the facility stating that my mother had fallen. They said they would watch her. I don't understand how that happened. The daughter continued on to state that from the first day my mother was admitted , I told everyone that she was a high fall risk. They told me that they could not use any devices because that would be a restraint. They said they don't use alarms. They said that they would make sure her bed was low to the floor. The bed didn't help when she fell from her wheelchair and broke her hip. On 2/18/2018 at 3:00 p.m. an interview was conducted with the Risk Manager (RM) she was asked about the fall investigation report for Resident #2 for the first fall on 1/4/2018. The RM said that she was observed on the floor by bed at 1320 (1:20 p.m.) and then read the nursing progress note on the day of the fall out loud to the surveyor. The RM was asked if the facility had a process in place for when a resident was admitted with a high risk for falls. She stated that we can't use all of our interventions right away because we will run out of them. Then we wouldn't have any interventions to use if they fall. The RM was asked if any statements were taken for the investigation. She stated that the nurse wrote what had happened. The RM was asked if the certified nursing assistant had written a statement and the RM stated she did not have one from the certified nursing assistant. The RM was asked what interventions were put in place after the first fall. She said that a PT evaluation was written. She said that after every fall that's what we do, write an order for [REDACTED]. The Risk Manager stated that the investigation report indicated the daughter states she will not use the call light. We had several residents on that unit that required enhanced supervision. She was asked what the process was of enhanced supervision. She stated that there should be an order for [REDACTED]. The RM was asked if she could show documentation of enhanced supervision. She said that it didn't work that way. The RM went on to state that we have gotten away from 1:1 supervision because a facility of ours was cited for it. She said that if you have a 1:1 with a resident and the certified nursing assistant assigned has to answer a call light or go to the bathroom then it's not a 1:1 and we can't take that chance. The RM was asked about the resident's second fall that occurred on 1/5/2018. She again read the nurse progress note out loud to the surveyor. She then said it was a witnessed fall by another family. She was asked if the family had written a statement. She said that they said they seen her stand and fall. The RM did not provide a statement from the family. She was asked what intervention was put in place after the resident had fallen a second time. She said that we called the MD and received an order for [REDACTED]. The granddaughter was on her way in. She went on to read the nursing progress notes to the surveyor again to include the multiple reminders for her to stay at nursing station and she had a snack. The RM then stated that we enhanced supervision. The RM was reminded that enhanced supervision was what she had indicated they initiated after the first fall and it did not appear to be effective based on a second fall the following day. The RM said we had a low bed with mats on the floor and her call light in reach. The RM was reminded that the daughter had informed the facility that her mother could not use the call light. The RM stated it doesn't matter if she can use it or not it has to be in reach! The RM was reminded that the physician had ordered the low bed and mats to the floor on her day of admission before fall #1. The RM stated well then I have it wrong. We started the enhanced supervision on the second fall and the PT/OT eval for the first fall. She went to the hospital the next day. A 72 hour fall monitor form was located in the paper record. The form started with DAY 1 1/4/2017 at 1245 level of pain: 0. Interventions: changed put back to bed call light use encouraged. 1/4/2018 shift 3-11. Pain: 0/10. Close observation. 1/4/2018 shift 11-7. Pain: 0. Close observation. DAY 2 1/5/2018 shift 7-3. Pain: 4/10 Interventions: NA 1/5/2018 shift 3-11. Pain 3/10. Interventions/ additional comments. Left hip pain. No further documentation was on the 72 hour fall monitor. No documentation of resident assessment or treatment after the second fall on 1/5/2018 at 6:54 p.m. was located in the clinical record. 3. On 2/18/2018 beginning at 11:00 a.m. observations were made of Resident #1 sitting in her wheel chair in the TV room and in the dining room. She was observed to frequently stand up from her wheelchair. Peers that were sitting with her were overheard redirecting her to sit down. Staff members were observed stopping their duties and responding to the resident from across the room. The resident was seen responding after several cues and sitting back down. The wheel chair brakes were in the locked position. Resident #1 was observed in the dining room eating her lunch after being set up from staff. The resident was observed standing three different times as her peer told her to sit down. Her wheel chair brakes were locked. At 6:02 p.m. the resident was observed standing up at the dinner table. Her wheel chair breaks were in the locked position as she was noted attempting to leave the table. Her plate of food was empty. A staff member approached the resident and asked her to sit down. She then unlocked the resident's wheel chair breaks and removed her from the dining area. Medical record review for Resident #1 revealed a hospital History and Physical dated 12/26/2017 which noted patient was in her mid-eighties and presents to the emergency department for evaluation of left hip pain status [REDACTED]. Her health history included advanced [MEDICAL CONDITION]. The radiographic imaging revealed compacted sub capital left [MEDICAL CONDITION]. A review of the facility's face sheet revealed the resident was admitted to the facility on [DATE]. The facility Incident Log was reviewed and revealed Resident #1 had fallen on 1/20/2018 at 0415 in her room. Injury description was documented as a 0. A review of the nursing notes revealed the following: 1/20/2018 at 5:15 a.m. Patient found in sitting position unwitnessed in living room area. Patient has no injuries and denies pain at this time. 1/21/2018 at 3:00 a.m. alert with confusion, resp. unlabored, denies discomfort, call bell within reach, needs attended. 1/21/2018 at 1426 resident is confused standing up out of w/c every few moments. Dozens of reminders given to sit down and be safe. Res is tearful after husband left. Difficult to redirect. A Nursing to Therapy Communication Form was located on the paper record. Listed under the comments section it stated observed on floor in dayroom [ROOM NUMBER]/20 0418 (4:18 a.m.) Rehab comments: patient on caseload, will assess for further interventions. An interview was conducted with the RM and was asked at the time about Resident #1's fall investigation. She provided a documented tilted Root Cause Analysis Worksheet. Time Line Detailed. Sequence of events. The resident's name was on the form and indicated the event or incident was a fall. The date was written in as 1/20 and the time section was blank. Occurrence: refer to nurses notes and & Activities of Daily Living sheets. A second Root Cause Analysis Worksheet was provided. The RM stated that it was filled out with all questions that were answered as no. The RM was asked what new intervention was put in place after the resident's fall. The RM stated, a therapy evaluation. 4. On 2/18/2018, Resident #6's daughter was observed at the facility helping the resident with her with her lunch and again at 6:15 p.m. with her dinner meal. The daughter was receptive to an interview and stated that she has been at multiple Long Term Care (LTC) facilities during her career as she had worked for a pharmacy. She stated that about a week ago she had left her mother in the afternoon so she could pick up her daughter from school. She said that not long after she left, she received a phone call that her mother had fallen. My mother was sent out to the hospital after the fall. I was so afraid that she had re-injured her new hip that she had her surgery on, but she hadn't. She was left alone in her room and she had attempted to stand up on her own. I don't know why she was left alone in her room. I went to a 5 day meeting with the facility staff and had asked them what had happened with my mother's fall, and why she was put in her room alone. They could not tell me what happened. I'm still waiting for them to tell me what had happened. I don't think they know. A medical record review was conducted for Resident #6 which revealed she was originally admitted to the facility on [DATE] for short term rehabilitation with a primary [DIAGNOSES REDACTED]. The face sheet also indicated she was in her late seventies and had a history of [REDACTED]. A review of Nursing Notes revealed the following: 1/30/2018 at 7:02 a.m. alert with confusion, resp. even and unlabored, no c/o pain, call bell within reach, patient is on fall precautions. 2/2/2018 at 2:33 a.m. alert with confusion, resp. even and unlabored, denies discomfort, slept outside at the dining table with her wheelchair. 2/5/2018 at 1521 resident alert and confused up in w/c, to DR for meals. Daughter in to visit. C/o hip pain after therapy and medicated with [MEDICATION NAME] with positive results. Attempted to take resident's b/p this afternoon. Res informed this nurse I was mistaken, she is not a patient here. 2/9/2018 at 1433 roommate heard a loud bang on the floor. Alerted staff to pt. being found on the floor laying sideways on back. Pt. has a large gash to head and blood noticed to the rear scalp. UM and DON made aware and present. Pt. alert but in severe pain to lower back. MD made aware. Pt. to be sent out to hospital for further evaluation. A review of the hospital History and Physical dated 2/9/2018 revealed present illness: she was brought in to the emergency room from the skilled nursing facility after another fall, and in the ER, she was found to be in [MEDICAL CONDITION] with rapid ventricular response with sever [DIAGNOSES REDACTED] as well. She is very frail, cachectic and has difficulty with eating. Daughter now states that she would like to take her home and not have her back in rehab. She has no fever, chills, nausea, vomiting but overall she is doing poorly, functional decline, not adequate oral intake, weak, frail alert and awake but demented. Continued review of the facility's nursing notes revealed on 2/12/2018 at 1447 Patient arrived back to the facility. No symptoms of pain or discomfort. Call bell and fluids within reach. On 2/13/2018 at 10:48 a.m. patient alert with confusion. Patient has a lump to Left side of forehead. Denies pain working with therapy. On 2/18/2018 at 6:40 p.m. an interview was conducted with the Risk Manager (RM) about the investigation of Resident #6's fall that had occurred in the facility. The RM read off the nursing progress notes to the surveyor. She said that the Interdisciplinary Team notes just stated observed on the floor. The RM could not provide any information as to why the resident was on the floor. She showed the surveyor the IDT notes that indicated a therapy screen. With Recommendation to ER. The RM was then asked after the resident had returned to the facility from the hospital with a lump to the left side of her forehead what new interventions were put in place. The RM was not able to provide any new interventions for the resident. The RM was asked for the resident's care plan related to her safety and falls. The RM stated there was not a care plan in place. She provided the only care plan that was in place for the resident and this related to a nutritional problem.