Every finding on record at Westminster St Augustine

Based on resident and staff interviews and resident/facility record reviews, the facility failed to record, address, and resolve grievances for two (Residents #4 and #7) of two residents reviewed for grievances from a total survey sample of 15 residents. The findings include: 1. On 08/04/2025 at 10:50 AM, an interview was conducted with Resident #4, who reported the facility had lost three of her nightgowns purchased with her own money for $69.00 each that she reported to the laundry supervisor who was no longer working for the facility. She stated she purchased the nightgowns to keep her warm and without them, the facility staff would place her in a hospital gown, and she got cold easily. One nightgown was found, but the other two, a cream-colored gown and a blue-colored gown were not. She was never reimbursed and no one from the facility had followed up with her to provide an update. She reported also speaking with someone from the social services department, but she didn't know their name. A record review for Resident #4 revealed she was most recently re-admitted to the facility on [DATE] and was initially admitted on [DATE]. Her medical diagnoses included nonrheumatic aortic (valve) stenosis, encounter for palliative care, anxiety disorder, and obstructive reflux uropathy. A review of the most recent Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/15/2025, revealed that the resident's Brief Interview for Mental Status (BIMS) score was documented as 15 out of 15 possible points, indicating intact cognition. No hallucinations, delusions, or behaviors were noted over the assessment reference period. On 08/05/2025 at 12:01 PM, an interview was conducted with the Social Services Director (SSD) who confirmed that she was also the facility's Grievance Officer. When asked about the facility's grievance process, she stated there was a form completed when a grievance was reported. This was discussed by the Interdisciplinary Team (IDT) to determine who would be assigned to investigate the grievance. The SSD further stated if something came up that could be resolved immediately, she wouldn't complete a grievance form. For missing clothes, the laundry was contacted and the lost-and-found with Activities was checked. If the items were not located, she would complete a grievance form so the facility could start the reimbursement process. She reported being familiar with Resident #4, and stated she was aware of her missing nightgowns. She further stated the resident had reported her nightgowns missing before but usually they were found in the laundry, so a grievance form was not completed. A review of the facility's Grievance Log during the period of July 2024 - July 2025 revealed no recorded grievances for Resident #4 alleging she was missing items. Further, the facility had no reported grievances to review during this period of time. On 08/06/2025 at 10:13 AM, Resident #4 reported that the Social Services Department visited her, and her cream-colored nightgown was returned, but her blue one was not found and the facility agreed to replace it. She was already wearing the returned cream-colored nightgown and reported being happy that the facility met with her to address this concern. A review of the facility's admission Packet titled Westminster Communities of Florida, Health Center Admissions Comprehensive Form Acknowledgments (Revised 3/2024), Page 5 read: A log will be maintained of all complaints and grievances showing progression of resolution. On 08/06/2025 at 12:25 PM, an interview was conducted with the Administrator, who explained the grievance process and stated their facility had a unique situation as the community was extremely small, allowing staff the opportunity to quickly resolve issues brought up to the resident or the resident's family's satisfaction. She said the issues were received and resolved verbally and then asked what the definition of a grievance was. A review of the facility's policy and procedure titled Resident and Family Grievances (revised 5/2025) revealed: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and activity working toward resolution of that complaint/grievance. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than three years from the issuance of the grievance decision. (Copy Obtained) 2. On 08/04/2025 at 1:03 PM, an interview was conducted with Resident #7, who reported her wheelchair didn't fit her well. She stated she told her Certified Nursing Assistant (CNA) and her nurse that she wasn't comfortable in her wheelchair. A record review for Resident #7 revealed she was admitted to the facility on [DATE]. Her medical diagnoses included unspecified abnormalities of gait and mobility, muscle weakness (generalized), nonexudative age-related macular degeneration, bilateral, stage unspecified, age-related osteoporosis without current pathological fracture, and unspecified osteoarthritis. A review of the most recent Comprehensive Minimum Data Set (MDS) assessment, dated 06/23/2025, revealed that the resident had a BIMS score of 15 out of 15 possible points, indicating intact cognition. No hallucinations, delusions, or behaviors were noted. On 08/06/2025 at 10:56 AM, an interview was conducted with Certified Nursing Assistant (CNA) E who stated she had worked at the facility for approximately 20 years. She confirmed being familiar with Resident #7 but could not recall whether or not the resident ever complained about her wheelchair. On 08/06/2025 at 11:06 AM, an interview was conducted with Licensed Practical Nurse (LPN) B who reported she had worked at the facility for a little over two years. She confirmed being familiar with Resident #7 and was aware that she had complained about her wheelchair to the therapy department approximately three to four weeks ago. On 08/06/2025 at 11:14 AM, an interview was conducted with the Therapy Program Director, who reported she had worked for the facility in her role for 4 1/2 years. She confirmed that Resident #7 was on her case load and the first time she received a complaint about her wheelchair was earlier this year in January. She explained the process when a complaint was received; they notified Social Services, who oversaw grievances and the grievance process. When asked if she reported the complaint about the wheelchair to Social Services, she confirmed she did not report it to Social Services. A review of the facility's Grievance Log for the period of July 2024 - July 2025 revealed no recorded grievances for Resident #7 alleging that she was uncomfortable with her wheelchair. Further, the facility had no reported grievances to review during this period of time. A review of the facility's admission Packet titled Westminster Communities of Florida, Health Center Admissions Comprehensive Form Acknowledgments (Revised 3/2024), Page 5 read: A log will be maintained of all complaints and grievances showing progression of resolution. A review of the facility's policy and procedure titled Resident and Family Grievances (revised 5/2025) revealed: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and activity working toward resolution of that complaint/grievance. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident . 8. Grievances may be voiced in the following forum: a. Verbal complaint to a staff member or Grievance Official . 10. Procedure: b. The staff receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. (Copy Obtained)

Based on observation, interview and record review, facility staff failed to 1) Properly perform hand hygiene between disposable glove changes for one (Resident #1) of six residents observed during medication administration, and 2) Ensure to don the proper personal protective equipment for accessing a Peripherally Inserted Central Catheter (PICC) line for one (Resident #1) of one resident with a PICC line.The findings include: During an observation on 08/05/2025 at 11:10 AM, Licensed Practical Nurse (LPN) A completed Resident #1's blood glucose monitoring and removed the gloves from both hands. LPN A disposed of the used gloves and donned a new pair of gloves without performing hand hygiene in between. During continued observation on 08/05/2025 at 11:10 AM, LPN A flushed Resident #1's PICC line wearing gloves only. Resident #1 had a sign posted outside of his room door advising of Enhanced Barrier Precautions and that a gown and gloves were to be utilized when accessing an internal dwelling device. During an interview on 08/05/2025 at 11:20 AM, LPN A stated, I forgot to wash my hands. After prompting, LPN A stated, I'm supposed to wear a gown when I deal with his (Resident #1's) PICC line. During an interview on 08/06/2025 at 9:00 AM, the Director of Nursing (DON) stated, I expect them to perform hand hygiene in between glove changes. I also expect them to wear a gown and gloves and observe Enhanced Barrier Precautions for any resident with a PICC line. A review of Resident #1's active physician's orders dated 07/11/2025 revealed, Enhanced Barrier Precautions-staff to wear gloves and gown while performing high-contact care activities. Further review of Resident #1's active physician's orders dated 7/11/2025 revealed, Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 10 ml [milliliters] intravenously every shift for maintenance. A review of the facility's policy titled Enhanced Barrier Precautions (reviewed January 16, 2025), revealed, Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi-drug resistant organism] as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). Policy Explanation 4. Showed to read High-Contact resident care activities include g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. A review of the facility's policy titled Hand Hygiene (reviewed January 16, 2025), revealed, Policy Explanation and Compliance Guidelines: 6.a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on record review and interviews, the facility failed to adequately monitor resident behaviors for one resident (#16) receiving antipsychotic medications from a total sample of 11 residents. The findings include: A review of Resident #16's medical record revealed an admitted [DATE] with a readmission on 11/29/19. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the May 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record did not reveal any orders for behavior monitoring for the ordered medication. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/2/22, revealed that Resident #16 received antipsychotic medication on seven of seven days during the assessment lookback period. She also received antidepressant, hypnotic and opioid medications during that time. A review of the May 2022 Medication Administration Record (MAR) revealed no monitoring of behaviors for the administration of antipsychotic ([MEDICATION(S)]/[MEDICATION(S)]) medication. A review of the active care plan revealed a focus area for: Intermittent confusion, delusions, behaviors, related to Alzheimer's dementia with interventions for medications as ordered; document for side effects and effectiveness; review medications and records for causes of cognitive deficit. Prescribed [CONDITION(S)] medications, related to behavior management, dementia, neuropathic pain, and chronic pain, anxiety, history of delusional thinking; administer medications as ordered by physician, monitor for side effects and effectiveness every shift; monitor/record occurrence of target behavior symptoms, refer to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/31/22 at 10:48 a.m., an interview was conducted with Agency Licensed Practical Nurse (LPN) A. When asked if monitoring of behaviors was expected for residents receiving antipsychotic medications, LPN A stated, yes. She stated side effects and behaviors were two separate orders and they were to be documented on the MAR. On 6/2/22 at 10:50 a.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #16. She stated there should be an order and documentation for side effects and behavior monitoring for antipsychotic medications. She stated she did not see current documentation for behavior monitoring but there had been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if reviews of antipsychotic monitoring had occurred, she stated they had been in the past but not recently. .

Based on observations, record reviews and a staff interview, the facility failed to implement the comprehensive, person-centered care plan in order to meet residents' needs for one (Resident #14) of one resident reviewed for use of supplemental oxygen, from a total of 17 residents in the sample. The findings include: 1. On 3/22/2021 at 11:25 am, Resident #14 was observed lying in bed in his room. An oxygen concentrator was present with a clear nasal cannula, which was inserted in the resident's nostrils. The concentrator was set to administer oxygen at 2 liters per minute. A second observation of Resident #14 on 3/22/2021 at 3:06 pm, revealed the resident sitting in a recliner in his room with the nasal cannula applied. The oxygen concentrator was actively running and set to administer oxygen at 2 liters per minute. During a third observation of Resident #14 on 3/23/2021 at 10:52 am, he was observed lying in bed with the nasal cannula applied. Again, the oxygen concentrator was actively running and remained set to administer oxygen at 2 liters per minute. During a fourth observation of Resident #14 on 3/23/2021 at 2:16 pm, he was observed sitting in his room watching television. The oxygen concentrator was actively running and remained set to administer oxygen at 2 liters per minute however, the nasal cannula was displaced and under the resident's right eye. A record review for Resident #14 revealed he was admitted on [DATE]. His last readmission was on 12/2/2020. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's care plan revealed the following: FOCUS ONSET: 2/2/2021 Resident uses oxygen continuously. Desats when O2 is off. At risk for respiratory distress. He has a history of shortness of breath and lung mass. GOALS: Resident will have comfort in breathing. Will not show any signs or symptoms of respiratory distress through the review period 6/11/2021. INTERVENTIONS: Oxygen saturation per medical doctor order. Apply oxygen per medical doctor order. See Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . FOCUS ONSET: 9/24/2019 Resident is at risk for respiratory distress. He has a history of fatigue. He has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . GOALS: Resident will have comfort in breathing, will not show any sign and symptom of respiratory distress through next review date 6/11/2021. INTERVENTIONS: administer prescribed medication, observe for effectiveness, possible adverse effects and notify medical doctor as needed; observe for shortness of breath; administer medications as ordered; apply oxygen per medical director order; see Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly minimum data set (MDS) assessment, signed by a Registered Nurse (RN) on 3/5/2021, revealed: Resident #14 had minimal difficulty hearing with clear speech and adequate vision. He usually understood others and was understood. He scored 1 out of a possible 15 points on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. He was documented as totally dependent with transfers, locomotion on/off the unit and toilet use. He required extensive assistance with dressing, eating and bed mobility. He had shortness of breath, required oxygen and received hospice care while a resident in the facility. A review of the facility's Oxygen Administration policy (reviewed and revised in July 2020) revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. During an interview with RN A on 3/23/2021 at 3:07 pm, she stated she had worked in the facility for nearly six months and was familiar with Resident #14. He received hospice care and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility nurses were responsible for making sure that the oxygen concentrator was operable and set at the appropriate setting. The facility certified nursing assistants (CNAs) were responsible for ensuring that the nasal cannula was properly inserted. She stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated this information was in the resident's hard chart as well as in the electronic record. On 3/23/2021 at 4:11 pm, another observation of Resident #14's oxygen concentrator was made in the presence of RN A. She confirmed that the concentrator was set for 2 liters per minute. She confirmed that the setting was incorrect and that it should have been set for 3 liters per minute as ordered. .

Based on observations, interviews and record reviews, the facility failed to adequately manage pain for one (Resident # 17) of one resident reviewed for pain management, from a total of 17 residents in the sample. The findings include: A review of Resident #17's medical record revealed she was admitted on [DATE]. Her admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive Minimum Data Set (MDS) assessment, dated 3/9/21, indicated the resident's cognition was impaired and she required extensive to total assistance with activities of daily living. She also received hospice services. On 3/22/21 at 10:24 AM, Resident #17 was observed lying in bed. She could be heard from the hallway yelling out repeatedly. Her speech was incoherent. Upon entering the resident's room, she was observed lying in her bed and was restless. She was moving all of her extremities in repeated motions while yelling out. Her brow was furrowed. She was not able to answer any questions. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 3/19/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 3/19/21. Continued review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) A review of the resident's comprehensive care plan revealed a focus area indicating the resident was at risk for pain and that she had an alteration in communication. She would need staff to observe for non-verbal signs of pain. Interventions included monitoring for effectiveness of pain medication, observing for pain when assisting with activities of daily living (ADLs), and that the resident may have pain medications as needed as prescribed by the physician. The care plan also indicated that collaboration with hospice services was required. (Photographic evidence obtained) A comprehensive MDS assessment, dated 3/9/21, indicated the resident did present with behavioral symptoms such as rejection of care. Continued review of the resident's care plans revealed a focus area for hospice. Interventions included collaboration with hospice services as needed, observe effectiveness of pain medication, report unrelieved pain to the physician, request further orders in an effort to attain a level of comfort for the resident, and coordinate communication with the hospice provider. (Photographic evidence obtained) On 3/23/21 at 3:25 PM an observation was made of Resident #17. Upon approaching her room, her door was closed. Upon entering the room, the resident was noted to be lying in bed. She was positioned on her back. Her bed linens were lying on the floor and she was repeatedly moving both legs in the bed while yelling incoherently. Her brow was furrowed and facial grimacing was noted. A second interview with the resident was attempted, however, she was unable to answer any questions. On 3/24/21 at 11:15 AM, an interview was conducted with Employee C, Registered Nurse (RN). She confirmed that she was assigned to Resident #17, but that she was not familiar with the resident. She had just begun working at the facility as an agency employee. When asked whether she had conducted any pain assessments for Resident #17, RN C explained that she didn't think the resident had complained of any pain. When asked whether the resident would be able to verbalize complaints of pain, the nurse stated, I'm not sure. A review of the facility's policy titled, Pain Management, directed the staff to evaluate the resident for pain when residents presented with changes in behavior or mental status. The policy indicated behavioral signs and symptoms that may suggest the presence of pain included but were not limited to: fidgeting, increased or recurring restlessness, facial expressions, changes in behavior or decreased participation in activities of daily living, sighing, groaning, crying, whimpering, breathing heavily or screaming. The policy further directed staff to reassess residents with pain regularly, and to revise the pain management regimen if assessment findings indicated pain was not adequately controlled. (Photographic evidence obtained) On 3/24/21 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). She explained that she had recently started working at the facility and that she was continuing to learn each resident's behaviors and routines. The DON acknowledged that Resident #17 frequently presented with episodes of yelling and restlessness, and that despite several adjustments to her [CONDITION(S)] medications, her behaviors continued. During the interview, the resident's medication regimen was reviewed. The DON explained that she had discontinued the resident's [MEDICATION(S)] and Tylenol as part of the facility's policy to discontinue as-needed medications if they hadn't been used in a thirty-day period. On 3/24/21 at 2:40 PM, the DON entered the conference room and explained that the resident had been reassessed and that a scheduled pain medication regimen had been ordered. She then provided a copy of a newly obtained physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained)

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of 5 percent or less. There were 25 opportunities for error with four errors identified, resulting in a medication error rate of 16% and involving three (Residents #5, #20 and #11) of three residents observed during medication administration. The findings include: 1. On 3/23/21 at 9:48 AM, an observation of medication administration was conducted for Resident #5 with Employee C, Registered Nurse (RN). Resident #5 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was scheduled for 6:00 AM and 6:00 PM. The medication was administered at 9:48 AM. Resident #5 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was scheduled for 6:01 AM and 6:01 PM. The medication was administered at 9:48 AM. 2. On 3/23/21 at 9:56 AM, an observation of medication administration was conducted for Resident #20 with RN C. Resident #20 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was scheduled for 8:00 AM and 8:00 PM. The medication was administered at 9:56 AM. 3. On 3/23/21 at 10:05 AM, an observation of medication administration was conducted for Resident #11 with RN C. Resident #11 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were parameters to hold the medication for a systolic blood pressure of less than 100 or a heart rate of less than 60. The nurse prepared the medication and entered the room. She did not check the resident's blood pressure or pulse. She then stated, I have your pills for you and handed the medication cup to the resident. As the surveyor was preparing to interject, the resident exclaimed, No blood pressure medicine! My blood pressure was really low this morning! On 3/23/21 at 10:10 AM, an interview was conducted with RN C. The nurse reviewed the [MEDICATION(S)] order for Resident #11 and acknowledged that the order contained parameters. She further acknowledged that she had not checked the resident's blood pressure or pulse prior to attempting administration of the medication. She explained that this was her second shift at the facility, and she was an agency employee. The nurse explained that she had received some training on the facility's electronic medication administration system, but she was still learning it. On 3/24/21 at 10:43 AM, an interview was conducted with the Director of Nursing (DON) regarding the findings of the medication administration observations. She stated she would conduct further training with the nurse immediately. She explained that the nurse was employed by an agency, and that the facility relied upon the agency's training to the nurse. A review of the facility's policy titled, Medication Administration, directed staff to obtain and record vital signs when applicable or per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further directed the staff to administer the medication within 60 minutes prior to or after scheduled times unless otherwise ordered by the physician. (Photographic evidence obtained)

Based on observations of medication administration, interviews, a review of policies and procedures and a review of Medication Administration Records (MARs), the facility failed to ensure it provided accurately documented MARs for two (Residents #4 and #5) of four residents sampled. The findings included: An interview was conducted with Employee A, Registered Nurse (RN), on 11/26/2019 at 10:18 AM. She stated she was completing her medication administration for a couple of residents. On 11/26/2019 at 10:21 AM, Employee A was observed taking medications mixed in applesauce and administering them to Resident #4. On 11/26/2019 at 10:23 AM, Resident #4 was interviewed. She stated she just took her medications, provided by Employee A, crushed in applesauce. On 11/26/2019 at 10:27 AM, an observation was made of Employee A taking medications to Resident #5. Employee A was observed passing medication to Resident #5 in a small medication cup with multiple pills. An interview was conducted with Resident #5 on 11/26/2019 at 10:28 AM. She reported that Employee A just gave her medication and she took all of it. An interview was conducted with Employee A on 11/26/2019 at 12:22 PM. She stated she had only been at the facility for five days and did not have computer access to the residents' medical records. An interview was conducted with the Director of Nursing (DON) on 11/26/2019 at 1:26 PM. The DON reviewed the current MARs for Residents #4 and #5 and confirmed that the documentation revealed Employee B, Licensed Practical Nurse (LPN) was represented as the nurse who administered the 9:00 AM medications on 11/26/2019 indicated by the initials of Employee B, LPN. The DON stated Employee A, RN, should have been able to document herself. The DON stated that she expected the nurse who administered the medication to document the medication administration. A review of the current MARs for Residents #4 and #5 was conducted. The date reviewed for 11/26/2019 at 9:00 AM medication administration revealed that Employee B, LPN, signed the document which indicated that Employee B, LPN, had administered the medications provided. The MAR for Resident #4 documented on 11/26/2019 at 9:00 AM that Employee B, LPN, had administered [MEDICATION NAME] Sodium, 1 tablet, which was on hold for diarrhea; Memantine 5 milligrams, Quetiapine [MEDICATION NAME] 25 milligrams, Vitamin B-12 250 micrograms and Vitamin D3 1,000 units. This was indicated by the initials of Employee B, LPN, that appeared in the documentation field. The MAR for Resident #5 was reviewed and documented on 11/26/2019 at 9:00 AM that Employee B, LPN, had administered [MEDICATION NAME] 150 capsule, [MEDICATION NAME] 25 milligrams, [MEDICATION NAME] Complete Multivitamin, Losartan 25 milligrams, and Aspirin 81milligrams. This was indicated by the initials of Employee B, LPN, that appeared in the documentation field. A review of the facility's policy Documentation in Medical Record at line 2. Principles of documentation included: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's health status requiring an alteration in treatment for one (Resident #8) of three residents reviewed for urinary tract infections (UTIs), out of a total of twelve residents sampled. The facility failed to appropriately assess and follow up with the physician after at least three instances during which the resident complained of abdominal pain and the failure of his catheter to drain urine. The findings include: On 04/16/19 at 10:07 AM, Resident #8 was observed sitting in his wheelchair wearing shorts. His catheter bag was observed strapped to the top of his left thigh and was protruding about halfway out from under the hem of his shorts. He tapped on the empty bag and told the nurse it wasn't draining. He stated his abdomen was painful. She asked him to go to his room, and she would be right there. A record review revealed Resident #8 was a [AGE] year-old male with [DIAGNOSES REDACTED]. He once had an indwelling Foley catheter and a history of blockages and urinary tract infections (UTIs). The most recent UTI was diagnosed on [DATE]. The resident's urologist recommended changing the Foley catheter to a suprapubic catheter. The resident received a suprapubic catheter on 3/18/19 and the Foley catheter was removed on 3/19/19. On 04/16/19 at 3:04 PM, an interview was conducted with Resident #8. He stated there had been two separate incidences when his Foley would not drain, but he was unable to provide dates. He stated the last time this occurred, he had to stand up in order for the catheter to drain. This relieved the pressure/pain he was experiencing in his abdominal area. On 04/17/19 at 12:44 PM, an interview was conducted with Employee A, Registered Nurse (RN). She confirmed that on Monday (4/15/19) the resident's catheter was not emptying. The thigh bag tubing was too short, and the bag was at the same level as his bladder. If he stood it would drain. She had not entered a progress note regarding his abdominal pain or the catheter's failure to drain. She had not contacted the resident's physician. After returning from the hospital earlier this day, Resident #8 had a long tube and standard hanging bag which replaced the thigh bag. On 04/18/19 at 10:05 AM, a telephone interview was conducted with Employee D, RN. She was the evening shift nurse who worked with Resident #8 on 4/16/19. She stated a couple of weekends ago Resident #8 had complained about abdominal pain. Since he did not usually have abdominal pain except when he had urine retention or a UTI, she tried changing his position to see if drainage would start. When it did not start, she had him stand up. At that point, the catheter drained and the resident's pain was relieved. Employee D stated she had not entered a progress note or notified the physician, because the situation was not critical and the resident's abdominal pain had been relieved. She confirmed that Employee A had informed her on Monday that the resident's catheter was not draining, and she too had him stand and this relieved the pain. She had not written a nurse's note or notified the physician concerning this event either. On 04/18/19 at 12:07 PM, a telephone interview was conducted with the Medical Director's Physician's Assistant (PA). She stated her expectation was that facility staff would keep the suprapubic site, the tubing and the bag clean, and watch the suprapubic site for any signs of infection. She further stated they should be palpating the abdominal area to ensure it was supple, and there was no pain or symptoms of discomfort. They should monitor for proper drainage and the amount being passed and notify the physician's office of any issues or concerns. A telephone interview on 04/18/19 at 1:15 PM with Resident #8's personal care physician, revealed that with regard to the resident's suprapubic catheter, his expectation was that the nursing staff notify the urologist if the catheter was not draining or the resident expressed pain. He expected the staff to notify his office first and then the urologist, so they could coordinate the required care. A review of the resident's care plan revealed a 03/19/19, New Suprapubic Catheter care plan. It stated a goal of Maintain urinary flow without obstruction or discomfort. The approaches included: 1. Cleanse supra pubic site with normal saline and apply a dry gauze dressing every day; 2. Assess for pain and medicate as needed; 3. Observe urine for color, consistency, presence of sediment - keep physician informed. On 04/18/19 at 2:03 PM, a telephone interview was conducted with Employee G, RN, MDS Coordinator. She confirmed she wrote the care plan segment for Resident #8's new suprapubic catheter. She stated the approach followed the standard of nursing. The approach was to observe urine for color, consistency, presence of sediment; keep physician informed. She stated this meant the nurse should follow nursing standards for color, consistency and sediment of urine. She also stated that a lack of output or urine drainage would fall under consistency, and should be reported to the physician. A review of nursing progress notes dated 3/19/19 through 3/29/19 revealed no indication of abdominal pain or failure of the catheter to drain properly. No nursing progress notes were recorded between 3/29/19 and 4/17/19, when the resident was sent via emergency medical services to the hospital. There was no documentation during that time that the resident had complained of abdominal pain or had trouble with his catheter draining, despite the resident's 4/16 complaint to the nurse about the concern at 10:07 AM; Employee A's interview on 4/17 at 12:44 PM, when she stated the resident had the pain and trouble with the catheter draining on 4/15/19, and Employee D's interview on 4/18/19 at 10:05 AM stating the resident had the same complaints a couple of weeks ago. There was no documentation to verify that the staff had notified the resident's physician. At the hospital, Resident #8 was diagnosed with [REDACTED]. A review of resident's post-operative instructions from the hospital revealed an instruction to Get Help Right Away If: * You have no urine flow. A review of Policy and Procedure for Notification of Changes, Reviewed/Revised 06/18 stated under Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. life-threatening conditions, or b. Clinical complications.

Based on observations and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings include: During a tour of the main kitchen on 4/15/19, the following observations were made between 10:34 AM and 11:00 AM in the presence of the Dining Services Manager (DSM). 1.The floor mixer which was found near the back door was observed with food debris and dust. The equipment, which was on the floor, was left uncovered in the foot traffic area. 2.The walk- in refrigerator was littered with dirt and onion skin debris. The floor was significanty soiled. 3.The chemical room door was wide open. 4. A cooking spoon was observed on the stove element without a barrier. The cook stated that he was using the spoon to stir the soup. 5. The stove elements and grids were impacted with food debris, which is a fire hazard. 6. The grill was impacted with burnt grease and food debris, which is a fire hazard. The grease traps under the grill were observed burnt to a charcoal color. 7. The flat-top grill was burnt and soiled. 8. The oven was observed with dried spillage. 9. The bottom of the reach-in refrigerator was observed with dried-on spilt milk. 10. One of the reach-in refridgerators was observed at 48 degrees Fahrenheit instead of 40 degrees Fahrenheit. 11. In the dishwashing room, the clean plates holder was observed with dust and dirt, and the plates, which were at floor level, were not covered. 12. The can opener casing was observed with debris at 10:54 AM. 13. The center of the dry storage room floor was observed with a large area of dried, hardened, caked-on dirt. The DSM stated that the dishwasher staff should have mopped that floor the previous night. (Photographic evidence of observations noted above was obtained.) The DSM observed and acknowledged all of the above-mentioned areas. He stated that this was his first survey in this facility.

Based on observations, record reviews and interviews, the facility failed to ensure a medication error rate of less than 5% for three (Resident's #11, #118, and #13) of five sampled residents during medication administration. There were 31 opportunities for error with three errors identified for a medication error rate of 9.68 %. The findings include: 1. On 4/16/19 at 1:55 PM, an observation was made of medication administration and blood glucose testing with Employee A, Registered Nurse (RN), for Resident #11. Employee A was observed obtaining all of her supplies at the medication cart. She removed the glucometer (blood glucose testing device) from the pouch with the resident's name on it. She then placed three lancets, two alcohol wipes, and two blood test strips in a medication cup and the glucometer in a small, clear plastic cup. She entered the room and asked the sitter at the bedside to get her a paper towel from the bathroom and place it on the table as a barrier. She placed all the items on the barrier and washed her hands. She returned and donned clean gloves. She opened an alcohol wipe and cleansed Resident #11's right thumb. She pricked her thumb, however only a very small amount of blood appeared. She then turned and obtained a second alcohol wipe and cleansed the small finger of the resident's right hand. She pricked that finger with a second lancet and was able to obtain a blood droplet. She removed the test strip from the glucometer, removed her gloves and threw them in the trash, along with the two lancets. On 4/17/19 at 8:37 AM, an interview was conducted with Employee A, RN, and she confirmed that she had thrown the test strip and lancets in the trash can in the resident's room. 2. On 4/17/19 at 9:11 AM, a medication administration observation was conducted with Employee A, RN, as she administered medications to Resident #118. Employee A administered Desemafaxine [MEDICATION NAME] ER (extended release) 50 mg (milligrams) one tablet, by mouth, crushed in chocolate pudding. (antidepressant) On 4/17/19 at 1:45 PM, an interview was conducted with Employee A regarding the crushing of the Desemafaxine [MEDICATION NAME] ER 50 mg. She confirmed that the pill should have not been crushed because it was an extended-release medication. The Director of Nursing (DON) approached at this time and stated that her answer to the question was that they had an order stating (MONTH) crush meds. It was explained that a generalized order to crush medications did not pertain to extended-release medications with warnings not to crush. The Physician's Assistant (PA) then came to the unit to see residents and confirmed that the medication could not be crushed. The PA stated, We will call pharmacy, and see what we can get ordered that will be equivalent to that, that we can crush. 3. On 4/17/19 at 4:32 PM, and observation was conducted with Employee B, Registered Nurse (RN), during blood glucose testing for Resident #13. The nurse removed two lancets, two alcohol wipes, and two blood test strips and placed them in a medication cup. A glucometer was then placed into a second plastic cup. The nurse entered the room and placed a barrier on the bedside table. She washed her hands. She returned and donned clean gloves. She then cleansed the resident's right index finger with an alcohol wipe, and placed the test strip into the glucometer. She picked up the corner of the barrier paper and dried the residents finger off, before pricking it with the lancet. She then placed a drop of blood on the strip and obtained a blood glucose reading. She placed the used lancet back in the medicine cup, removed the blood test strip from the glucometer and placed it in her glove. She then returned to her cart and placed the glucometer in the cup that was set up with the bleach wipe. She disposed of the soiled gloves and the used blood test strip in the garbage can on her medication cart. On 4/17/19 at 4:38 PM, an interview was conducted with Employee B, RN, regarding the blood glucose testing for Resident #13. She confirmed that she broke infection control by picking up the barrier and wiping off the resident's finger. She also confirmed that she threw away the used blood strip in her regular garbage, and it should have been disposed of in the sharps box due to it having blood on it. On 4/18/19 at 10:14 AM, the DON was asked for the facility's policy and procedure for blood glucose testing as well as cleaning and disinfecting of the glucometers. She stated, Can you please come to my office, and I will show you what I have. Upon entering the DON's office, the Regional Nurse Consultant was there. She stated that she had no policies or procedures for blood glucose testing or cleansing glucometers. She stated that the facility went by Standards of Care. She further stated that it was a competency to ensure the staff knew what to do. Competencies were requested for the two nurses observed testing blood glucose for Residents #11 and #13 (Employees A and B). She produced a form that she stated she randomly used to ensure facility nurses were completing the blood glucose testing correctly. When she was asked for the last three months of her completed audit forms, she stated, I just use this form for guidance, I don't document anything.

Based on observations and interviews, the facility failed to store medications under proper temperature controls in one out of one medication refrigerators in the facility. Failing to properly store medication can change its molecular form, potentially resulting in decomposition of the medication. This can change the medication's potency and/or result in new or different effects. The findings include: On 4/18/19 at 11:10 AM, an observation was made of the medication room with Employee C, Registered Nurse (RN). She unlocked the refrigerator and upon review of the thermometer, the temperature was 34 degrees Fahrenheit (F). Employee C verified the temperature. The refrigerator temperature logs were then reviewed, and on several occasions the temperatures were incorrect, but there were no adjustments/corrections made. Further review of the logs revealed the facility had utilized meat/dairy temperature logs instead of medication temperature logs for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019. The meat/dairy temperatures range from 34-38 degrees Fahrenheit. The acceptable temperature range for medication storage is 36- 46 degrees Fahrenheit. The facility medication refrigerator temperatures were too cold for medications on the following dates: November (YEAR) - meat/dairy temperature log utilized 11/2/18 - 34 degrees F 11/10/18 - 34 degrees F 11/12/18 - 34 degrees F 11/13/18 - 34 degrees F 11/14/18 - 34 degrees F 11/17/18 - 34 degrees F 11/21/18 - 34 degrees F 11/22/18 - No temperature recorded 11/23/18 - No temperature recorded 11/24/18 - No temperature recorded 11/25/18 - No temperature recorded 11/26/18 - No temperature recorded 11/27/18 - No temperature recorded 11/28/19 - 34 degrees F 11/29/18 - 34 degrees F December (YEAR) - meat/dairy temperature log utilized 12/9/18 - 34 degrees F January 28, 2019 - No temperature documented February 2019 - meat/dairy temperature log utilized 2/2/19 - 40 degrees - refrigerator lowered 2/16/19 - 40 degrees - refrigerator lowered 2/17/19 - 40 degrees - refrigerator lowered 2/18/19 - 40 degrees - refrigerator lowered 2/24/19 - 40 degrees - refrigerator lowered 2/25/19 - 40 degrees - refrigerator lowered 2/26/19 - 40 degrees - refrigerator lowered 2/27/19 - 40 degrees - refrigerator lowered For all of the temperatures in (MONTH) that were documented as 40 degrees, the refrigerator thermostat was lowered due to the facility utilizing the wrong temperature log. On 4/18/19 at 1:35 PM, an interview was conducted with the Director of Nursing (DON), and she reviewed the refrigerator logs at that time. She verified that on several occasions they should have implemented a correction for the temperatures. She then reviewed the week that no temperatures were taken, and stated, That's the week I was on vacation. She then verified that they had used the wrong log over several months, and the temperature ranges on the two logs were not the same.

Based on observations, record reviews and interviews, the facility failed to maintain and observe an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, by failing to properly dispose of one used needle and three used lancets as well as used blood glucose test strips and gloves which were in contact with these items. The facility staff also failed to adhere to infection control practice by using a corner of a barrier to wipe off the finger of one (Resident #2) of two residents who were observed during blood glucose testing. The findings include: 1. On 4/16/19 at 1:51 PM, and observation of the medication cart was made which revealed a used needle that was lying on top of the sharps/biohazard container. (Photographic evidence obtained) On 4/16/19 at 2:07 PM, an interview was conducted with Employee A, Registered Nurse (RN), and she confirmed that the used needle was left lying on top of the sharps/biohazard box. She stated she must have been in a hurry, and did not realize that it did not go into the box. She stated that the lock did not work, so the box was not secure in there anyway. She was asked how long the lock had been broken, and she stated for at least four months. (Photographic evidence obtained) 2. On 4/16/19 at 1:55 PM, an observation was made of medication administration and blood glucose testing with Employee A, Registered Nurse (RN), for Resident #11. Employee A was observed obtaining all of her supplies at the medication cart. She removed the glucometer (blood glucose testing device) from the pouch with the resident's name on it. She then placed three lancets, two alcohol wipes, and two blood test strips in a medication cup and the glucometer in a small, clear plastic cup. She entered the room and asked the sitter at the bedside to get her a paper towel from the bathroom and place it on the table as a barrier. She placed all the items on the barrier and washed her hands. She returned and donned clean gloves. She opened an alcohol wipe and cleansed Resident #11's right thumb. She pricked her thumb, however only a very small amount of blood appeared. She then turned and obtained a second alcohol wipe and cleansed the small finger of the resident's right hand. She pricked that finger with a second lancet and was able to obtain a blood droplet. She removed the test strip from the glucometer, removed her gloves and threw them in the trash, along with the two lancets. On 4/17/19 at 8:37 AM, an interview was conducted with Employee A, RN, and she confirmed that she had thrown the test strip and lancets in the trash can in the resident's room. 3. On 4/17/19 at 4:32 PM, and observation was conducted with Employee B, Registered Nurse (RN), during blood glucose testing for Resident #13. The nurse removed two lancets, two alcohol wipes, and two blood test strips and placed them in a medication cup. A glucometer was then placed into a second plastic cup. The nurse entered the room and placed a barrier on the bedside table. She washed her hands. She returned and donned clean gloves. She then cleansed the resident's right index finger with an alcohol wipe, and placed the test strip into the glucometer. She picked up the corner of the barrier paper and dried the resident's finger off, before pricking it with the lancet. She then placed a drop of blood on the strip and obtained a blood glucose reading. She placed the used lancet back in the medicine cup, removed the blood test strip from the glucometer and placed it in her glove. She then returned to her cart and placed the glucometer in the cup that was set up with the bleach wipe. She disposed of the soiled gloves and the used blood test strip in the garbage can on her medication cart. On 4/17/19 at 4:38 PM, an interview was conducted with Employee B, RN, regarding the blood glucose testing for Resident #13. She confirmed that she broke infection control by picking up the barrier and wiping off the resident's finger. She also confirmed that she threw away the used blood strip in her regular garbage, and it should have been disposed of in the sharps box due to it having blood on it. On 4/18/19 at 10:14 AM, the DON was asked for the facility's policy and procedure for blood glucose testing as well as cleaning and disinfecting of the glucometers. She stated, Can you please come to my office, and I will show you what I have. Upon entering the DON's office, the Regional Nurse Consultant was there. She stated that she had no policies or procedures for blood glucose testing or cleansing glucometers. She stated that the facility went by Standards of Care. She further stated that it was a competency to ensure the staff knew what to do. Competencies were requested for the two nurses observed testing blood glucose levels for Residents #11 and #13 (Employees A and B). She produced a form and stated she randomly used this to ensure facility nurses were completing the blood glucose testing correctly. When she was asked for the last three months of her completed forms, she stated, I just use this form for guidance, I don't document anything.

Based on observation, interviews and record review, the facility failed to provide the texture consistency specifications of a pureed diet for six (Residents #4, #5 , #12, #24, #29 and #32) of six residents with an order for [REDACTED]. Thie findings include: Observations during the kitchen visit on 7/7/2017 at 12:15 p.m., revealed that the pureed lunch consisted of pureed salisbury steak with pureed sweet potato and pureed cauliflower blend vegetables. A closer examination of the pureed salisbury steak revealed various sizes of pieces of steak which were not pureed. A finger test confirmed the unsmooth textures of the pureed Salisbury steak. During an interview with Employee F, Dietary, and the Food Service Director on 7/7/2017 at 12:20 p.m., the texture of the pureed salisbury steak was confirmed. A review of the procedure for making puree section titled, Puree meats/fish: Thicken broth (beef for beef) or use gravy or sauce provide for entrée. Pour thickened broth into processor and puree until smooth/no lumps remain, reheat to 165 degrees F and place in warmer until needed. Residents #24 and #29's meal trays were brought back to the kitchen, because of the unsmooth texture of the pureed salisbury steak.

Based on medical record review and staff interviews, the facility failed to develop a plan of care for 2 of 17 sampled residents (Residents #2 and #29) for a urinary tract infection and hospice services. The findings include: 1. A medical record review was conducted for Resident #2 which revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. Reviewed the Minimum Data Set (MDS) Significant change assessment dated [DATE] with a urinary tract infection coded. The Resident was discharged out to the hospital 1/18/17 with coffee ground emesis and returned to the facility on [DATE] with a physicians order [MEDICATION NAME]([MEDICATION NAME] - antibiotic) 500 mg (milligrams) orally, twice a day for the urinary tract infection for 10 days. The care plan was reviewed and there was no documentation of a plan of care addressing a urinary tract infection. An interview was conducted with Employee C, Registered Nurse (RN), Minimum Data Set (MDS) Coordinator on 7/7/17 at 12:20 PM . Employee C confirmed that Resident #2 was diagnosed with [REDACTED]. Employee C reviewed the care plan and confirmed there was not a plan of care for the urinary tract infection. 2. On June 18, 2017, Resident #29 was readmitted to the facility with [DIAGNOSES REDACTED]. His Brief Interview for Mental Status (BIMS) score was 1/15, indicating significant cognitive impairment. On June 2, 2017, the resident elected Florida Medicaid Hospice care services with a [DIAGNOSES REDACTED]. On July 7, 2017 at 11:59:36 AM, a review of the Care Plan revealed the resident was not care planned for hospice care services. On July 7, 2017 at 12:09:03 PM, during an interview with Employee C, Licensed Practical Nurse (LPN)/MDS Coordinator, she reviewed the resident's care plans and confirmed there was no care plan initiated for hospice since the resident elected hospice services on 6/2/17.

Based on record review and staff interview, the facility failed to provide the services if a registered nurse for at least eight consecutive hours a day, seven days a week. The findings include: A review of the facility's two-week staffing calculation form dated 6/18/17 through 7/1/17, revealed that there was no registered nurse hours for 6/18/17 (Sunday). A review of the two-week staffing form dated 6/4/17 through 6/17/17, revealed that there were no registered nurse hours for 6/12/17 (Monday) or 6/17/17 (Saturday). During an interview with the Director of Nursing on 7/7/17 at 1:04 PM, she confirmed that the facility did not have a registered nurse scheduled on Sunday, June 18, 2017. One of the registered nurses had resigned, and another was on vacation. During an interview with the Director of Nursing on 7/7/17 at 2:30 PM regarding registered nurse hours for 6/12 and 6/17, she confirmed that the facility did not have a registered nurse scheduled on either day. On 6/12, the Director of Nursing and Employee B were in the facility to assist the nurses as needed throughout the day.

Based on staff interviews and record reviews, the facility failed to maintain complete, accurately documented medical records for 2 (Residents #3 and #29) of 17 sampled residents related to medications administered per the Medication Administration Record [REDACTED] The findings include: 1. A medical record review was conducted for Resident #3, which reported an admission date of [DATE] with the following Diagnoses: [REDACTED]. A review of the physicians' orders for June 2017, revealed [MEDICATION NAME] 10 mg (milligrams) orally twice a day for severe pain dated 3/8/17, and [MEDICATION NAME] 0.25 mg orally three times a day dated 3/14/17 for anxiety. The Medication Administration Record [REDACTED]. [MEDICATION NAME] 0.25 mg was not documented as having been administered on June 9 at 6:00 AM or 10 PM, June 15 at 2:00 PM, June 22 at 2:00 PM, or June 28 at 10:00 PM. An interview was conducted with Employee A, Licensed Practical Nurse (LPN), at 11:30 AM on 7/7/17. Employee A stated Resident #3 was usually asleep at 2:00 PM, and [MEDICATION NAME] was not given if she didn't wake up. Employee A stated, A note would be documented in the computer if Resident #3 refused, or if it was held or whatever the reason it was not given. If the resident was lethargic the medication would not be given. An interview was conducted with Employee A, LPN, on 7/7/17 at 2:27 PM, and she confirmed the resident did not receive the [MEDICATION NAME] on June 10 th and 28th at 9:00 PM, or the [MEDICATION NAME] 0.25 mg on June 9th at 6:00 AM or 10:00 PM, June 15th at 2:00 PM, June 22nd at 2:00 PM, or June 28th at 10:00 PM. Employee A confirmed a explanatory note was not documented on the days above, and reviewed the nursing notes but could not find any documentation as to why the medications were not given. An interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 7/7/17 at 3:00 PM. The DON and ADON confirmed the medications were not documented as having been given, and a note should have been written explaining why it was held or refused. 2. On February 5, 2016, Resident #29 was admitted to the facility, and on June 18, 2017, Resident #29 was readmitted to the facility with [DIAGNOSES REDACTED]. On July 7, 2017 at 4:16:31 PM, a review of the June 2017 Medication Administration Record [REDACTED]. On 6/1/17, the resident did not receive his 5:00 PM scheduled dose of [MEDICATION NAME] 125 mg, give 2 tabs two times daily. On 6/24/17, the resident did not receive his 5:00 PM scheduled dose of [MEDICATION NAME] 125 mg tab two times daily. On 6/7/17, the resident did not receive his 8:00 PM scheduled dose of [MEDICATION NAME] 30 mg softgel daily. On 6/23/17, the resident only received 1/2 the total dose of [MEDICATION NAME] 37.5 mg at 9:00 AM, and did not receive his 5:00 P.M scheduled dose of [MEDICATION NAME] 37.5 mg two times daily. On 6/9/17, the resident did not receive his scheduled dose of [MEDICATION NAME] OTC (Over the Counter) 20 mg tab at 6:30 AM, and on 6/7/17, the resident did not receive his scheduled 9:00 PM dose of [MEDICATION NAME] 600 mg tab every 12 hours per the charting on the MAR. Reasons why Resident #29 did not receive his medication were not located in the chart. On July 7, 2017 at 5:03:59 PM, an interview with employee H, Licensed Practical Nurse (LPN) revealed she could not explain or find a nurse's note why the resident did not receive his scheduled dose of [MEDICATION NAME] on June 1 or his [MEDICATION NAME] on June 7, 2017. On July 7, 2017 at 5:05:14 PM, an interview with employee E, Social Services, revealed she searched the nurses notes, but was unable to find a note or an explaination as to why the resident did not receive his scheduled dose of [MEDICATION NAME] on 6/1/17 and [MEDICATION NAME] on 6/7/17.

Based on observation, record review and staff interviews, the facility failed to dispose of expired medications for 6 residents ' (Resident's #5, #17, #26, #21, #15 and #16) out of 22 residents who receive medication administration in the facility. The findings include: An observation of the medications in Medication Cart 2 on 6/8/16 at 10:08 AM with Employee A found the following: 1. An unopened vial of Cyanocobalamin 1000 micrograms (MCG) belonging to Resident #5 found manufacturer's expiration date of 3/2016. 2. A bottle of Spironolactone 25 milligram tablets with manufacturer's date to discard 2/28/2016 was found belonging to Resident #17. 3. A one-pint bottle of Robafen Syrup opened 11/28/15 and a manufacturer's expiration date of 05/2017 was found for Resident #17. 4. A vial of Humulin R/Novolin belonging to Resident #21 was observed in the medication cart. The vial had an open date of 5/2/16. Observations of the vial found it was 1/8th full. Employee A was interviewed at the time of observation. She stated she was not sure how long the insulin should be kept after opening. She stated the pharmacist had directions to follow in the medication room. She provided insulin storage recommendations from the medication storage room that showed the Humulin R/Novolin should be discarded after opened for 28 days when stored at room temperature. Employee A confirmed that the vial of Humulin R/Novolin in the medication cart was the insulin that had been used for Resident #21 for sliding scale orders since it was opened on 5/2/2016. 5. A bottle of Calcitonin 200 units Nasal Spray belonging to Resident #15 was observed. Review of the label found it had an opened date of 4/23/16. Record review of the manufacturer recommendations for the Calcitron Nasal Solution found the bottle when opened and stored at room temperature should be stored up to 35 days. Employee A confirmed on 6/8/16 at 10:30 AM the medications were expired and stated she would get rid of them. 6. An observation of the medications in Medication Cart 1 on 6/8/16 at 2:00 PM with Employee B found a bottle of Latanoprost 0.005% eye drops 2.5 milliliters (ML) bottle with orders for 1 drop in each eye at bedtime for Resident #16. Record review of the label found it was opened on 4/8/16. Record review of the manufacturer's instructions found the eye drops should be discarded when opened after 42 days. Employee B reviewed the manufacturer's recommendations with the surveyor during the observation and confirmed they should be discarded.

Based on interview and record review, the facility failed to provide 1 of 3 sampled residents (Resident #13) with a notification of liability and appeal rights prior to her discharge from the facility. The findings include: At 2:00 PM on 06/08/2016, Employee D was asked to provide the CMS form for three randomly selected residents. (This form is used to inform residents of their potential liability and rights to appeal a discharge under Medicare guidelines). She was able to provide 2 of 3 forms requested, but she could not locate Resident #13's. She confirmed this was a planned discharge and she went back home to her prior living arrangement in the community, following her rehab here for knee surgery. A review of Resident #13's closed chart shows she was here for rehab and the discharge was planned, but the form could not be located in her closed chart either. There is no documentation that the form was given. In a second interview with Employee D at 10:40 AM on 06/09/2016, she confirmed she could still not locate the for Resident #13. She said she normally gets it done 3 days prior for planned discharges. She confirmed she is supposed to get it done for everyone with a planned discharge under Medicare guidelines.

Based on observation, interview, and record review, the facility failed to ensure safe self-medication practices were implemented for 1 of 19 residents reviewed. The findings include: Resident #25 was interviewed on 06/07/2016 at 9:43 AM. During that time a white bottle of cream was observed sitting next to her chair. Closer inspection of the bottle showed it had a prescription label and she confirmed her dermatologist ordered it for the skin on her legs. She confirmed she uses it herself as needed when her skin gets dry, and the staff is aware she has it. She said she does not inform them when she uses it, nor is she aware of any documentation on how often she is using it. Her physician's orders [REDACTED]. Order received from physician. Original order date: 05/17/2016. In an interview with Employee B, a floor nurse, on 06/08/2016 at approximately 12:00 PM, she stated nobody here self administers medications that she is aware of. In an interview with Employee C at 9:20 AM on 06/09/2016, also a floor nurse, she stated nobody here self administers medication to her knowledge. She stated they would have to have it locked in their rooms and tracking would have to be done. In an interview with the Director of Nursing (DON), Nurse Consultant, and Administrator (simultaneously) at 9:50 AM on 06/09/2016, they stated there is no self administration here. Residents would have to have an order, it would need to be care planned, and tracking would have to be done. There would have to be screening to ensure safety. When asked about Resident #25's cream, they confirmed none of this had been done for her. They confirmed there is a policy on self administration and they were asked to produce it. Review of policy shows that if the resident desires to self administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care plan process. Instructions are to be given to the resident on the purpose and usage of the medication. Staff is also to ask the resident to demonstrate proper usage as part of the assessment process. Following assessment, the policy continues on to state the self medication usage should be documented in the medical record. Bedside storage is allowed when nursing staff routinely observes or otherwise (e.g. communication with resident) validate appropriateness of self administration of medications, and once a month record such information on the Medication Administration Record [REDACTED] Review of the MAR for the months of May and June 2016 shows no such documentation in her MAR. The MAR indicated [REDACTED].

Based on staff interview and record review, the facility failed to develop a comprehensive care plan to meet the needs of a resident on anti-psychotic and anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications (Resident #31) in a sample of 22 residents. The findings include: Record review for Resident #31 found he was originally admitted to the facility on [DATE] with his most recent readmission on 3/3/16. Record review of the June 2016 physician order [REDACTED].#31 found the following orders: [MEDICATION NAME] 25 milligrams (MG) twice a day for behavioral disturbance. [MEDICATION NAME] 1 mg tab Q 8 hours hold if lethargic. [MEDICATION NAME] 0.5 MG give three times a day as needed anxiety/agitation. Further record review found Resident #31 had orders for [MEDICATION NAME] .25 mg once a day beginning 3/15/16 that was increased to twice a day on 5/24/16. Resident #31 started receiving the as needed [MEDICATION NAME] on 3/17/16 and received the medication 9 times in June. During an interview with the Minimum Data Set (MDS) Coordinator on 6/8/16 at 3:00 PM she was asked to provide the care plan for Resident #31 ' s anti-anxiety medication. On 6/9/16 at 9:20 AM she stated she did not have a care plan for the resident ' s anxiety medication as he had started receiving the as needed medication after his last care plan meeting. She was asked on 6/9/16 at 10:20 AM if she had care plans for the resident scheduled anti-anxiety medication or his antipsychotic medication. She stated she did not. The Director of Nursing and the Nursing Consultant were also asked for the care plans. The Nurse Consultant stated during interview on 6/9/16 at 10:25 AM they did not have any care plans to provide and were in the process of trying to contact the last MDS coordinator to see if care plans had been done in the past. .