FORT MYERS REHABILITATION AND NURSING CENTER
For profit - Corporation
120 Beds
JONATHAN BLEIER
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
48/100
#350 of 690 in FL
Photo by Fort Myers Rehabilitation and Nursing Center
Photo by Joan A Tribulas PA
Photo by Joan A Tribulas PA
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Fort Myers Rehabilitation and Nursing Center has received a Trust Grade of D, which indicates below-average performance and raises some concerns about the quality of care provided. Ranked #350 out of 690 facilities in Florida, they fall in the bottom half, and #8 out of 19 in Lee County suggests there are better local options available. The trend is worsening, with the number of issues found increasing from 5 in 2022 to 10 in 2025, which highlights a growing concern for oversight. Staffing is a notable strength, rated 5 out of 5 stars with a turnover rate of 34%, lower than the state average, indicating a stable workforce that knows the residents. However, there have been critical issues, such as failure to properly disinfect blood glucose meters, which could lead to the spread of infections, and inadequate sanitation procedures that might risk foodborne illnesses, both of which are serious concerns for potential residents and their families.
- Trust Score
- D
- In Florida
- #350/690
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 34% turnover. Near Florida's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Florida facilities.
- Skilled Nurses ✓ Good
- Each resident gets 50 minutes of Registered Nurse (RN) attention daily — more than average for Florida. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 50%
Review needed
5 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 5 issues
2025: 10 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Florida average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Florida average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 34%
12pts below Florida avg (46%)
Typical for the industry
Chain: JONATHAN BLEIER
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 23 deficiencies on record
1 life-threatening
Apr 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a clean, comfortable, homelike environment tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a clean, comfortable, homelike environment that allows the resident to use the physical layout to maximize independence and does not pose a safety risk for 4 (#52, #57, #273, #274) of 5 residents reviewed.
The findings included:
Review of an admissions agreement (no date) revealed, The facility will provide resident with room and board, nursing service, and laundering of linens.
1. Record review of Resident #52 was admitted on [DATE] a Brief Interview for Metal Status (BIMS), with a score of 10 on 3/5/25, indicating that he has moderately impaired cognition. Resident #52's diagnoses included Schizophrenia and Schizoaffective disorder.
On 3/31/25 at 9:25 a.m., Resident #52 was observed sitting on the side of his bed dressed in personal clothing. A blue incontinent brief soiled with feces like substance was observed on the bathroom floor.
On 3/31/25 at 9:25 a.m., during an interview and continuous observation Resident #52 gestured to his wheelchair, side table and dresser and stated, It's too tight, there's not enough room, some of this clutter in the drawer, these wipes, it's not my stuff, it's their stuff. I don't use any of what's in the drawer, so my stuff has to go on top of the drawer, and they (facility staff) said I have to keep the wheelchair here between the bed and the bathroom door, but it is hard for me to get in. When asked how he gets to the bathroom, Resident #52 said, I have to get up and walk past the wheelchair and squeeze into the bathroom. Resident #52 stated, I had to change myself (gestured to the soiled brief). I was dirty, I did the best I could while standing up but it was hard and I left the diaper on the floor because where else would it go, there was no trashcan. Resident #52 said that he has requested to have the wheelchair or the bed moved, but he was told the wheelchair must be next to the bed, and the bed can't be moved.
On 3/31/25 at 9:35 a.m., during an observation, the Assistant Director of Nursing (ADON) came to the room of Resident #52 and was unable to walk directly into the bathroom. The ADON turned and side stepped into the bathroom through the narrow opening of the bathroom doorway created by the obstruction and then addressed the soiled brief that was sitting on the floor. He did not make any attempts to move the wheelchair or the bed.
2. Record review of Resident #57 showed an admission date of 11/26/24. Diagnoses icluded fracture of the left clavicle, pain in left hip and right hip, protein-calorie malnutrition, cutaneous abscess of the chest wall, history of bacterial infection, heart failure, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 3/7/25 revealed the resident's cognition was intact with a BIMS score of 13.
Review of the care plan initiated on 11/28/24 and revised on 12/3/24 noted the resident was dependent on 1-2 staff assistance for bed mobility and transfer.
On 3/31/25 at 9:45 a.m., an observation of Resident #57's room showed there were multiple personal possessions on the floor out of reach of the resident. A duffel bag was sitting on the floor, tucked behind an oxygen concentrator in the back corner of the room. There was a dresser to the left of the resident, which was filled with incontinence care items. In an interview Resident #57 said, They put their stuff in here, so there's no room for my stuff. On the floor at the end of the bed, there was a cardboard box sitting on the floor with miscellaneous possessions which were also out of reach of the resident. Next to the box was a tall closet that contained very few personal possessions. When asked if he preferred having his possessions out in the open, Resident #57 said, Nobody would help me put my things away, nobody has time, or they have no idea what I'm talking about.
On 4/1/25 at 11:00 a.m., in an interview, Certified Nursing Assistant (CNA) Staff LL said that he checks on Resident #57 like he is supposed to, but since he can speak for himself, all he has to do is ask if he needs help.
3. Review of the clinical record for Resident #273 revealed an admission date of 3/25/25. Diagnoses included squamous cell carcinoma of skin, protein-calorie nutrition, weakness, muscle wasting, and gastrointestinal hemorrhage.
Resident #273 requires assistance with Activities of Daily Living (ADL's) and requires a mechanical lift to be transferred to a wheelchair.
On 3/31/25 at 10:00 a.m., during an observation of Resident #273, there was moderate sized mucous like stain on the pillowcase behind his head, that was brown, yellow and slightly green. The fitted sheet had come off one corner of the mattress, and Resident #273's bare legs were touching the mattress. A portion of the fitted sheet was bunched under his body. In an interview, Resident #273 stated that the bed was hurting him which was surprising to him because he was supposed to be on an air mattress. He described his room accommodations as, It's not home.
Registered Nurse (RN) Staff E was at the resident's bedside during the observation. In an interview on 3/31/25 at 10:00 a.m., RN Staff E said that bedding should be changed every day. He said the resident's bedding had likely been changed already.
On 3/31/25 at 10:05 a.m., in an interview CNA Staff FF assigned to Resident #273 stated, I am not changing that resident's bedding today, I will change bedding of residents who go to Dialysis and Therapy today.
On 3/31/25 at 11:00 a.m., in an interview Resident #273's spouse said she did not feel the staff understood what he was asking for. She said Resident #273 felt that staff did not understand him. She said, He has also been saying all weekend that the bed is hurting him.
4. Review of the clinical record for Resident #274 revealed an admission date of 3/25/25. Diagnoses included muscle wasting and atrophy, pressure ulcer of sacral region, dysphagia, urinary retention, protein-calorie malnutrition, and cardiomyopathy.
Review of the nursing assessment dated [DATE] revealed Resident #274 was alert and oriented with periods of confusion.
On 3/31/25 at 9:50 a.m., observed Resident #274 lying in bed watching television. In an interview Resident #274 said he wished the staff would move his bed so he could reach his own phone charger rather than having to rely on them because, I can't reach it over there, and when they plug it in, I can't get to it. He also said he couldn't reach the room phone.
On 3/31/25 at 9:50, Resident #274 was observed asking RN Staff G to help him to charge his phone. The resident asked, Can you please move my bed because I can't reach my phone charger.
RN Staff G said, The charger won't reach, you will have to call us and ask us to plug in your phone for you. RN Staff G did not attempt to reposition the bed or find an alternative option for charging the phone.
On 3/31/25 at 3:00 p.m., in an interview Resident #274 said, No, they didn't move anything for me.
On 3/31/25 at 11:26 a.m., a clear plastic bag containing a bedpan and several pieces of paper towel was observed tied to the siderail across from the toilet in Resident #274's shared bathroom. Resident #274 said he wasn't sure who the bedpan belonged to.
On 3/31/25 at 11:39 a.m., in an interview CNA Staff H said the bedpan in the plastic bag was, garbage and it has not been there very long, I just came back from my break.
Photographic Evidence Obtained
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 (Resident #96) of 3 residents with newly evident or possib...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 (Resident #96) of 3 residents with newly evident or possible serious mental disorder, or related condition was referred to the appropriate state-designated mental health or intellectual disability authority for review for a Level II screening.
The findings included:
Resident # 96 was admitted to the facility on [DATE] with a Level I Preadmission Screening and Resident Review (PASRR) with a diagnosis of Anxiety but did not indicate a need for further review.
On 7/29/24 a new Level 1 PASRR was completed with mental illness or suspected mental illness including mental disorder, psychosis, and adjustment disorder with anxiety added and indications of lack of focus and adapting to typical change. The new Level 1 PASRR from 7/29/24 was sent for a second level review, with a response on 8/5/25 that Resident #96 was not considered to have a serious mental illness.
A review of Resident #96 record revealed the Medication Administration Record contained an order dated 1/14/25 for Seroquel two times a day for schizophrenia. (Seroquel is an antipsychotic medication used to treat schizophrenia). Further review of Resident #96's record revealed a progress notes from the psychiatric provider on 1/14/25 and 4/2/25 in which both notes the medical decision making said dementia with behavioral delusional ro (rule out) schizophrenia and Seroquel for diagnosis of schizophrenia.
Record review of Resident #96's chart on revealed the PASRR had never been updated and sent for review for the newly diagnosed/suspected condition of schizophrenia.
On 4/3/25 at 9:33 a.m., in an interview the Social Services Director said they had sent a Level II for him in the past, but this time missed the new diagnosis. She said she would follow through and get a new one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs for personal hygiene, nail care, assistance with dressing, and toileting for 1 (R...
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Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs for personal hygiene, nail care, assistance with dressing, and toileting for 1 (Residents #28) of 5 dependent residents reviewed.
The findings included:
On 3/31/25 at 4:22 p.m., Resident #28 was observed lying in bed. The nails of the resident's right and left hand extended approximately ¾ inch from the fingertips. The fingers of the left hand were curled with the nails pressing into the resident's palm.
On 4/1/25 at 12:31 p.m., observation of Resident #28's fingernails revealed they remained untrimmed and extended approximately ¾ inch from the fingertips. In an interview Resident #28 said he guesses staff would trim his nails if he asked.
On 4/1/25 at 5:16 p.m., in an interview Resident #28 said staff asked maybe once or twice if they could trim the fingernails. He said he was not able to trim his own nails due to reduced dexterity and limited range of motion to the left hand.
On 4/2/25 at 10:32 a.m., Resident #28 was observed in bed. His fingernails nails remained long, untrimmed and extended approximately ¾ inch from the fingertips. The left-hand fingernails were pressing into the palm.
Review of the clinical record for Resident #28 revealed an admission date of 9/22/21. Diagnoses included cerebral infarction, dementia, amputation of right leg above the knee, and legal blindness.
Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 2/21/25 revealed Resident #28 had functional limitations in range of motion on one side of the lower extremities. The resident was dependent on staff for bathing and personal hygiene. Resident #28's cognition was moderately impaired with a Brief Interview for Mental Status score of 09. The MDS noted the resident refused care. The behavior occurred 1 to 3 days.
Resident #28 was transferred to an acute care hospital on 2/10/25 and returned to the facility on 2/12/25.
Review of the care plan initiated on 9/28/21 and revised on 9/5/24 revealed to check nail length, trim and clean on bath day and as necessary. The care plan noted the resident required assistance from 1-2 staff for personal hygiene.
The care plan initiated on 10/4/21 revealed Resident #28 had behaviors of refusing care including labs (laboratory) and therapy. The care plan did not include refusal of nail care.
Review of the Certified Nursing Assistant (CNAs) documentation (Documentation Survey Report V2) for January 2025, February 2025 and March 2025 revealed Resident #28 refused personal hygiene on 1/27/25 (Day shift), on 2/13/25 (evening shift), and on 3/20/25 (day shift). No other refusal of care was documented for January 2025, February 2025 and March 2025.
On 4/3/25 at 10:19 a.m., in an interview Activity Assistant Staff CNA Staff X said Resident #28's left hand has been that way since he came to the facility. Staff X said he refuses to get out of bed and refuses to get a shower. CNA Staff X said Resident #28 does not want to do anything.
On 4/3/25 at 11:00 a.m., in an interview Licensed Practical Nurse (LPN) Staff Y said Resident #28 can be resistant to care and was care planned for refusing care. She said Resident #28 was not as bad now with refusing. She said when she checked the resident this week she did not see his nails, they were covered by the blanket. She said if the resident refuses care, the CNA documents on the Documentation Survey Report V2 and tells the nurse. She said the resident tended to cooperate with his current nurse.
On 4/3/25 11:09 a.m., LPN Staff Y went to the resident's room and observed Resident #28's fingernails. In an interview LPN Staff Y confirmed the resident's fingernails were long and needed to be trimmed. Resident #28 told LPN Staff Y the CNA did not offer to trim his nails and he has not refused to have his nails trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to maintain ongoing communication, coordination and colla...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to maintain ongoing communication, coordination and collaboration between the nursing home and the dialysis staff for 1 (Resident #87) of 1 sampled resident receiving dialysis services reviewed.
The findings included:
Record review of Resident #87 revealed an admission date of [DATE]. Diagnoses included End Stage Renal Disease.
Review of the admission Minimum Data Set (MDS) assessment with a target date of [DATE] revealed Resident #87's cognition was mildly impaired with a Brief Interview for Mental Status score of 12.
1. Review of the physician's orders in the Electronic Medical Record (EMR) revealed Resident #87 dialysis days were scheduled for Monday, Wednesday and Friday.
The physician order dated [DATE] noted the resident's code status was Do not resuscitate (DNR) meaning not to initiate Cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
Review of a Circle of Care meeting dated [DATE] revealed documentation, A circle of care meeting was held today with team: DON opened . Resident at dialysis, his son (name) in attendance. Collaboration with dialysis center. Recommendations noted.
On [DATE] at 11:28 a.m., Resident #87's dialysis communication binder (used to exchange information between the dialysis center and the facility) was reviewed. It did not include the resident's current DNR code status. A green sheet of paper in the binder read, FULL CODE (administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest). The binder contained Physician's Orders and a Medication List that was printed on [DATE].
On [DATE] at 11:35 a.m., in an interview, Licensed Practicing Nurse (LPN) Staff I stated that the Dialysis Communication Binder travels with Resident #87 three times a week to the dialysis center. LPN Staff I stated, It's the nurse's responsibility to make sure the communication binder is updated. If there are new orders and I am working, then I put them in the binder. I don't know what happens to the binder when I am not here, and I don't go to care rounds. I am the desk nurse and the admissions nurse. This is the only way that the nursing staff communicates with the dialysis staff is through the binder. LPN Staff I reviewed the electronic and physical clinical record. She verified that Resident #87 has an active advanced directive for Do Not Resuscitate order dated [DATE]. LPN Staff I also verified that that the Physician Orders and Medication List in the communication binder were out of date. She stated, These are his admission meds (medications) and orders.
On [DATE] at 3:00 p.m., during a concurrent interview the Director of Nursing (DON) and Regional Nurse were asked whether it was concerning to them that the Dialysis Communication Binder was not up to date for advanced directives and orders. The DON said, It would be up to the dialysis center to do their own thing for advanced directives, we can tell you that for sure, our record wouldn't matter. The Regional Nurse agreed with the statement.
On [DATE] at 7:45 a.m., in a telephone interview a dialysis nurse working at the Dialysis Center for Resident #87 stated, The dialysis communication binder is how we communicate with the facility, I can show no record of a meeting held on [DATE] with the facility in his chart here. If our Social Worker were part of the meeting they would have their notes, but the nurses look in the communication binder and, in our chart, which has no record of advanced directives planning.
2. Review of the progress notes for Resident #87 revealed a psychiatry note dated [DATE] which noted Resident #87 was unaware of his medical condition and has breaks with reality and confusion at dialysis.
On [DATE] at 9:30 a.m., Resident #87 was observed freely propelling himself throughout the facility. Resident #87 appeared calm. He was not answering to questions appropriately. The resident was using inappropriate words to respond to questions.
On [DATE] at 11:00 a.m., Record Review of the Dialysis Communication Binder for Resident #87 showed an information with letters written in bold stating Sevelamer (medication) sent to dialysis with resident on T-TH-S (Tuesday-Thursday-Saturday) for self-administration x 1 dose.
Record review of Resident #87's assessment for self-administration of medications dated [DATE] showed that the resident may not self-administer medications.
Review of the Medication Administration Record (MAR) for [DATE] revealed an order dated [DATE] to send Sevelamer to dialysis with resident one time a day every Monday, Wednesday, Friday for ESRD (End Stage Renal Disease).
On Wednesday [DATE] the nurse entered 13 (At dialysis with meds) for the 12:00 p.m. dose of Sevelamer.
On [DATE] at 11:10 a.m., an observation of Resident #87 dressed in personal clothing with a bagged lunch packed hanging from his wheelchair.
On [DATE] at 12:00 p.m., an interview with staff J LPN, said that she only prepped him for dialysis because she doesn't know him that well, not because the paper in the binder said he goes on Tuesday-Thursday-Friday.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #274 was admitted to the facility on [DATE]. He has a diagnosis of muscle wasting and atrophy, pressure ulcer of sac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #274 was admitted to the facility on [DATE]. He has a diagnosis of muscle wasting and atrophy, pressure ulcer of sacral region, dysphagia, urinary retention, protein-calorie malnutrition, and cardiomyopathy. He was last assessed by a nursing assessment as alert and oriented with periods of confusion on 3/27/25.
On 3/31/25 at 9:25 a.m., during an interview, Resident #274 said, I have a Foley connected to the end of the bed. Observation of Urinary Catheter bag connected to the bedframe, where the drainage bag, tubing, and valve stem were laying on the floor.
On 3/31/25 at 9:30 a.m., during an interview Registered Nurse (RN) Staff G said that he knew the Urinary Catheter should not be touching in the floor, It belongs in a dignity bag (bag for privacy and cleanliness).
3. On 4/1/25 at 10:30 a.m., an observation of wound care was conducted for Resident #278. The Resident's door has a sign posted that read, STOP Enhanced Barrier Precautions. Licensed Practical Nurse (LPN), Staff A, Certified Nursing Assistant (CNA) Staff N, and CNA Staff O entered the room. Hand Hygiene was performed and gloves worn, no gowns were worn by any staff. CNA Staff N and CNA Staff O assisted the resident to turn to his side and removed Resident #278's brief while LPN Staff A used Normal Saline and Gauze to clean the resident's wound. LPN Staff A removed her gloves, performed hand hygiene and donned new gloves. LPN Staff A who then opened clean dressing onto clean surface. LPN Staff A applied clean Xeroform gauze and sacral dressing to the resident's wound. CNAs Staff N and Staff O were observed leaning over the bed to assist repositioning the resident. Their scrubs were touching the bed at the hip level. LPN Staff A changed her gloves and applied barrier cream to the resident's groin.
On 4/1/25 at 10:45 a.m., in an interview LPN Staff A said she was not sure which resident in the room was on Enhanced Barrier Precautions, or why, and that she didn't need to use a gown to provide wound care.
On 4/1/25 at 10:47 a.m., in an interview the Assistant Director of Nursing (ADON) who is also the Infection Preventionist, walked towards the wound care cart and explained that any resident receiving contact care activity, including wound care, would require Enhanced Barrier Precautions, including anyone in the room who is observing, even if they are not touching anything.
On 4/1/25 at 10:48 a.m., the Director of Nursing (DON) informed the ADON and Staff A that the only person who is required to wear a gown during wound care is the person who is performing the wound care, because wound care is a high-contact resident care activity.
On 4/1/25 at 11:00 a.m., the Personal Protective Equipment (PPE) drawer closest to the room of Resident #278 was observed to be empty.
On 4/1/25 at 11:15 a.m., during a follow up interview LPN staff A stated, I know better, it's just only me that needs to wear the gown and I do. I was just nervous, it's not that there wasn't PPE available, I should have gotten some.
Based on observations and staff interviews, the facility failed to establish and maintain an effective infection prevention and control program, which increased the risk of communicable diseases and infections for 3 (Residents #23, #274 and #278) of 3 residents reviewed for catheter care and enhanced barrier precautions.
The findings included:
1. The policy for Catheter-Foley Care provided by the facility, last revised on 4/25/22, stated, Keep the bag below the level of the bladder at all times to prevent the backflow of urine and decrease the risk for infection. Never leave the catheter hanging to be pulled by the weight of the bag. Do not leave the catheter bag/tubing laying on the floor. Place the catheter bag in a dignity bag. To avoid this issue and avoid infection control issues, the catheter bag/dignity bag may also be placed in a wash basin to avoid direct contact with the floor.
Clinical record review revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included a past medical history of bacterial infection and urinary tract infection. Resident #23 required a Foley catheter. Physician orders dated 2/15/25 stated, Foley catheter care every shift, and as needed every day and night shift and Secure catheter tubing to thigh with cath secure or leg strap at all times every day and night shift for Foley care. He was also under Enhanced Barrier Precautions every day and night shift ordered on 3/17/25, and there was a sign posted on his room door.
On 3/31/25 at 3:47 p.m., observation revealed Resident #23 lying in his bed, awake, alert, and oriented. His urinary catheter drainage bag was observed on the floor under his bed, outside of a dignity bag.
Photographic evidence obtained
On 4/1/25 at 9:15 a.m., Resident #23 was observed sitting in his wheelchair; his urinary catheter was observed unsecured and lying on the floor beneath the wheelchair
Photographic evidence obtained
On 4/1/25 at 9:19 a.m., in an interview, Registered Nurse Staff G said he had worked at the facility for 10 years. Staff G said the urinary catheter requires keeping the catheter clean, placed in a dignity bag, and off the floor. Resident #23 was observed in his room. Staff G verified that the Foley catheter bag was lying on the floor, not in a dignity bag. Staff G said, It shouldn't be on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of the facility job description of the Activity Director and staff i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of the facility job description of the Activity Director and staff interviews, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident's physical, mental, and psychosocial well-being for 2 ( Resident #3 and #91 ) of 3 residents reviewed for involvement in the activity programs. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being.
The findings included:
The facility Job Description and Performance Evaluation for the Activity Director documented Responsible for the planning, developing, organizing, implementing, evaluating and directing of activity programs in accordance with current exiting federal, state and local standards. Plan develop, organize, evaluate and direct activity programs to ensure all patients/residents assessed needs are met. Record and maintain activity progress notes as well as a record of resident activities.
1. Review of the clinical record revealed Resident #3 had an admission date of 1/4/24 with diagnoses including dementia with restlessness, anxiety disorder, delusional and adjustment disorder.
The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 5/19/24 documented Resident #3's preference for routine and activities specified it was very important for Resident #3 to have books, newspapers, and magazines to read, to listen to music she likes, and to keep up with the news. It was somewhat important for Resident #3 to be around animals such as pets, and to do her favorite activities.
The MDS noted Resident #3's cognitive skills for daily decision making were moderately impaired.
Review of the care plan initiated 10/8/20 documented The Resident needs encouragement and assistance in pursuing activities. The care plan interventions included, Invite and assist resident to music related activities. Offer foods that comply with the residents' ordered diet. Offer pet therapy to resident.
On 3/31/25 during random observations at 10:24 a.m., 11:32 a.m., 1:20 p.m., and 3:25 p.m., Resident # 3 was observed in her room with the door open. She was in a wheelchair (w/c) facing the side of the closet. She had a tray table in front of her, that was pushed up against the side of the closet. There was nothing on the table for the resident to eat, drink or to occupy her time. She was not meaningfully engaged and had no radio or television on.
Review of the March 2025 Activity Calendar specified the activities on 3/31/25:9:00 a.m., Rise and Shine, 10:00 a.m., What's cooking, 1:00 p.m., Arts and Crafts, 2:00 p.m., Room Visits, 3:00 p.m., Gulf Coast Baptist.
On 4/1/25 at 10:00 a.m., Resident # 3 was in her room, in w/c facing the side of the closet with the tray table in front of her and pushed against the closet. She has no liquids, food or items on the table. There was no music and no television on.
Review of the April 2025 Activity Calendar specified the activities on 4/1/25: 9:00 a.m., Rise and Shine, 10:00 a.m., Pokeno, 11:00 a.m., Trivia, 1:00 p.m., Movie and Popcorn, 1:45 p.m., room visits.
On 4/2/25 at 1:31 p.m., a review of the electronic record for the previous 30 days revealed documentation Resident #3 attended one activity on 3/25/25 at 2:24 p.m., and 3/27/25 at 2:49 p.m.
2. Review of the clinical record revealed Resident #91 was [AGE] years old with diagnoses including senile degeneration of the brain, adjustment disorder, delusional disorder, severe protein calorie malnutrition, dementia, anxiety disorder, restlessness and agitation.
The Annual MDS dated [DATE] documented Resident #91's preference for routine and activities specified it was very important to have books, newspapers, and magazines to read, to participate in religious services or practices and do her favorite activities. It was somewhat important for Resident #91 to listen to music she likes and to keep up with the news.
The MDS noted Resident #93's cognitive skills for daily decision making were severely impaired.
The care plan initiated 1/5/24 identified The Resident requires staff assistance with involvement of activities related to dementia and/or impaired thought process. The interventions for the resident included, invite and assist the resident to group activities, religious services and music related activities and offer the resident pet therapy.
During random observations on 3/31/25 at 12:07 p.m., and 3:24 p.m., Resident #91 was observed in her room in her w/c. The bedside table was in front of her and it was push up against a blank wall. No activity items, water or snacks were available on the table for her. She said she was waiting to go to school and looking for her teacher.
Observations on 4/1/25 at 9:56 a.m., Resident #91 was in her w/c with a tray table over her and it was pushed up against the blank wall. There were no liquids or food or activity items on the table for the resident. She was anxious repeating, I'm cold and I don't know what I'm doing. At 12:11 p.m., Resident #91 was observed in the w/c in her room with a tray table in front of her that was pushed up against the blank wall. There was a Styrofoam cup of ice water on the table.
Continued observations on 4/1/25 at 1:13 p.m., 1:34 p.m., and 3:41 p.m.,
Resident # 91 was observed in her room in the same position facing a blank wall and yelling out Help me, I want to go to bed. Help me.
On 4/2/25 at 9:58 a.m., a review of the electronic record documented in the previous 30 days Resident #91 participated in no activity programs.
On 4/2/25 at 9:06 a.m., in an interview Activity Assistant Staff C said she did not have a certification and no training for the position of activity aid. She said she follows the activity calendar on the wall. For residents who don't come out of the room or to activities, I do room visits every day but I can't see everyone in one day. I talk to them, if they need anything I make up packets with word search, coloring and puzzles. I do nail care and hand massage. I can't get to many of the residents, and I spend about 10 minutes with each resident.
On 4/2/25 at 9:42 a.m., in an interview Activity Director Staff A said she was the Activity Director here for 4 years. Staff A said we take the residents to the activity room or the day room on the [NAME] Unit. The day room is for the lower functioning residents. We did have activities here on 3/31/25 and 4/1/25 in the [NAME] day room. This writer mentioned that no one was observed in the day room on 3/31/25 and 4/1/25. Staff A replied it is because only 1 resident showed up and we did not do the activity for just one person. For the residents who do not get out of bed or don't come to activities, I do room visits. We are here 9-5 Monday to Sunday. There are 3 of us, but right now one is out sick. The main activity room is for higher functioning residents. Staff A said she documents participation in the activity program in the electronic record for each resident and she maintained no paper documentation. Staff A said Resident #3 is in the main activity room daily and Resident #91 is in the [NAME] Unit Day room daily for activities. The Activity Director said there was documentation in the electronic record Residents #3 and #91 attend all day activities. This writer showed the Activity Director the previous 30 day documentation for both residents and she confirmed Resident #3 attended 2 activities and Resident #91 attended no activity programs. The Activity Director said I don't know why there is no documentation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected multiple residents
Based on review of the facility job description for the Activity Director and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a q...
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Based on review of the facility job description for the Activity Director and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all 131 current residents residing in the facility.
The findings included:
The facility Job Description and Performance Evaluation documented Responsible for the planning, developing, organizing, implementing, evaluating and directing of activity programs in accordance with current exiting federal, state and local standards. Plan develop, organize, evaluate and direct activity programs to ensure all patients/residents assessed needs are met. Record and maintain activity progress notes as well as a record of resident activities. Qualifications Education College specialization, certification preferred.
On 4/2/25 at 9:06 a.m., in an interview Activity Assistant Staff C said she did not have a certification for the position of the Activity Director and no training for the position. She said she had no qualifications for the position of Activity Director, and said I am her assistant.
On 4/2/25 at 9:37 a.m., a request was made to Director of Nursing for documentation of the qualifications of the Activity Director.
On 4/2/25 at 9:42 a.m., in an interview Certified Nursing Assistant Staff A said she has been the Activity Director for the facility for four years. She said she had not completed training and did not have a certificate for the position of Activity Director.
On 4/2/25 at 1:16 p.m., in an interview, the Administrator confirmed Activity Director Staff A did not have the required qualifications for the position of Activity Director.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedures, record review and staff and resident interviews, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedures, record review and staff and resident interviews, the facility failed to ensure urinary catheters were secured to prevent pulling and injury and failed to maintain the catheters in sanitary manner for 3 (Resident #50, #423, and #274) of 3 residents reviewed with an indwelling urinary catheter.
The findings included:
The facility policy Catheter-Foley documented Completing the procedure, Secure the catheter to the residents thigh (i.e , Stat Lock or Catheter Strap) to prevent movement, irritation and decrease risk of infection. Never leave the catheter hanging to be pulled by the weight of the bag. Place catheter bag in a dignity bag.
1. Review of the clinical record revealed Resident #50 had a readmission date of 7/20/25 with diagnoses including morbid obesity, paraplegia, type 2 diabetes, chronic kidney disease, urinary retention, dementia, anxiety and delusional disorder.
The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 3/15/25 documented Resident #50 was dependent for personal hygiene and toileting.
The MDS noted Resident #65's cognitive skills for daily decision making were moderately impaired.
The care plan initiated 7/21/21 specified the resident wanted to have toileting needs met with dignity and promptly.
On 3/31/25 at 11:00 a.m., Resident #50 was observed in bed. She was noted to have an indwelling urinary catheter, that was not secured to her leg. The catheter tubing was noted to be taunt and pulling, the drainage bag was attached to the bed frame and was not in a privacy bag. Resident #50 said sometimes the catheter pulls and she has to hold the tube when the staff are caring for her.
On 4/1/25 at 11:47 a.m., Resident #50 was observed in bed and she removed the bed covers to show she did not have a securement device for the catheter. The drainage bag was attached to the bed frame and the tubing was noted to be taunt and stretched.
On 4/2/25 at 9:22 a.m., Resident #50 was observed in bed and said she did not want anyone to touch her catheter. She said the staff pour water on it and wash it every day. Resident #50 said she did not have anything on her leg to secure the catheter and said it just hangs there and it hurts. She pulled back the covers to show this writer the catheter was not secured. Resident #50 said I usually hold it when they provide care and if I hold it, then it doesn't hurt when they do the care.
2. Review of the clinical record revealed Resident #423 was admitted [DATE] with a readmission on [DATE]. Resident #423 had diagnoses including urinary retention, senile degeneration of the brain and acute cystitis with hematuria (inflammation of the bladder with blood in the urine).
Review of the physician orders specified to secure catheter tubing to thigh with catheter secure or leg strap.
On 3/31/25 at 12:00 p.m., Resident #423 was observed in his bed with a indwelling catheter and the tubing was noted to be pulling taut and was and not secured to his leg to prevent the pulling. The urinary drainage bag was secured to the bed frame and the catheter bag had no privacy cover.
On 4/1/25 at 10:07 a.m., Resident #423 was observed in bed with the catheter securement device on the catheter, but it was not secured to his leg. The drainage bag was pulling, and the tubing was stretched tightly.
On 4/3/25 at 9:48 a.m., Resident #423 was observed in bed and he did not have a catheter securement device in place. The catheter tubing was pulled tightly and wrapped around the leg of the bedside table.
Photographic evidence obtained.
On 4/3/25 at 9:49 a.m., Licensed Practical Nurse Staff D observed the resident's catheter and verified in an interview Resident #423's catheter tubing was unsecured and wrapped around the bedside table.
On 4/3/25 at 9:55 a.m., in an interview Certified Nursing Assistant (CNA) Staff B said when cleaning the catheter you wipe from front to back and you place the catheter bag in a privacy bag attached to the bed frame. She said she never applies a leg strap; the nurse does that.
3. Resident #274 was admitted to the facility on [DATE] with a diagnosis of muscle wasting and atrophy, pressure ulcer of sacral region, dysphagia, urinary retention, protein-calorie malnutrition, and cardiomyopathy. The resident was last assessed by a nursing assessment as alert and oriented with periods of confusion on 3/27/25.
On 3/31/25 at 10:05 a.m., in an interview Resident #274 stated, I have a Foley connected to the end of the bed. Observation of Urinary Catheter bag connected to the bedframe, where the drainage bag, tubing, and valve stem were laying on the floor.
On 3/31/25 at 10:10 a.m., an observation was made of a conversation between Registered Nurse (RN) Staff G and Resident #274. Resident #274 asked Staff G, for a dignity bag for his Foley catheter so he can get out of bed. Resident #274 told RN Staff G, You know, if I had a special bag, I could get up and walk around. Can you get me out of bed?
Staff G said that he knew the Urinary Catheter should not be touching in the floor, It belongs in a dignity bag.
On 4/2/25 at 2:00 p.m., in an interview the Infection Preventionist and Staff Development Coordinator said that maintaining the urinary catheter off the floor is included in staff training for Foley Care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of the facility job description of the Activity Director and staff i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of the facility job description of the Activity Director and staff interviews, the facility failed to ensure resident records were maintained in accordance with accepted professional standards and practices, that are complete, and accurately documented for 2 (Residents #3, and #91) of 28 residents records reviewed.
The findings included:
The facility Job Description and Performance Evaluation for the Activity Director documented Responsible to Record and maintain activity progress notes as well as a record of resident activities.
1. Review of the clinical record revealed Resident #3 had an admission date of 1/4/24 with diagnoses including dementia with restlessness, anxiety disorder, delusional and adjustment disorder.
The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 5/19/24 documented Resident #3's preference for routine and activities specified it was very important for Resident #3 to have books, newspapers, and magazines to read, to listen to music she likes, and to keep up with the news. It was somewhat important for Resident #3 to be around animals such as pets, and to do her favorite activities.
The MDS noted Resident #3's cognitive skills for daily decision making were moderately impaired.
Review of the care plan initiated 10/8/20 documented The Resident needs
encouragement and assistance in pursuing activities. The care plan interventions included, Invite and assist resident to music related activities. Offer foods that comply with the residents' ordered diet. Offer pet therapy to resident.
On 3/31/25 during observations at 10:24 a.m., 11:32 a.m., 1:20 p.m., and 3:25 p.m., Resident # 3 was observed in her room with the door open. She was in a wheelchair (w/c) facing the side of the closet. She had a tray table in front of her, that was pushed up against the side of the closet. There was nothing on the table for the resident to eat, drink or to occupy her time. She was not meaningfully engaged and had no radio or television on.
Review of the March 2025 Activity Calendar specified the activities on 3/31/25: 9:00 a.m., Rise and Shine, 10:00 a.m., What's cooking, 1:00 p.m., Arts and Crafts, 2:00 p.m., Room Visits, 3:00 p.m., Gulf Coast Baptist.
On 4/1/25 at 10:00 a.m., Resident #3 was in her room, in w/c facing the side of the closet with the tray table in front of her and pushed against the closet. She has no liquids, food or items on the table. There was no music and no television on.
Review of the April 2025 Activity Calendar specified the activities on 4/1/25: 9:00 a.m., Rise and Shine, 10:00 a.m., Pokeno, 11:00 a.m., Trivia, 1:00 p.m., Movie and Popcorn, 1:45 p.m., room visits.
On 4/2/25 at 1:31 p.m., a review of the electronic record for the previous 30 days revealed documentation Resident #3 attended one activity on 3/25/25 at 2:24 p.m., and 3/27/25 at 2:49 p.m.
2. Review of the clinical record revealed Resident #91 was [AGE] years old with diagnoses including senile degeneration of the brain, adjustment disorder, delusional disorder, severe protein calorie malnutrition, dementia, anxiety disorder, restlessness and agitation.
The Annual MDS dated [DATE] documented Resident #91's preference for routine and activities specified it was very important to have books, newspapers, and magazines to read, to participate in religious services or practices and do her favorite activities. It was somewhat important for Resident #91 to listen to music she likes and to keep up with the news.
The MDS noted Resident #93's cognitive skills for daily decision making were severely impaired.
The care plan initiated 1/5/24 identified The Resident requires staff assistance with involvement of activities related to dementia and/or impaired thought process. The interventions for the resident included, invite and assist the resident to group activities, religious services and music related activities and offer the resident pet therapy.
During random observations on 3/31/25 at 12:07 p.m., and 3:24 p.m., Resident #91 was observed in her room in her w/c with the bedside table in front of her that was pushed up against a blank wall. No activity items, water or snacks were available on the table for her. She said she was waiting to go to school and looking for her teacher.
Observations on 4/1/25 at 9:56 a.m., Resident #91 was in her w/c with a tray table over her and it was pushed up against the blank wall. There were no liquids or food or activity items on the table for the resident. She was anxious repeating, I'm cold and I don't know what I'm doing. At 12:11 p.m., Resident #91 was observed in the w/c in her room with a tray table in front of her that was pushed up against the blank wall. There was a Styrofoam cup of ice water on the table.
Continued observations on 4/1/25 at 1:13 p.m., 1:34 p.m., and 3:41 p.m.,
Resident # 91 was observed in her room in the same position facing a blank wall and yelling out Help me, I want to go to bed. Help me.
On 4/2/25 at 9:58 a.m., a review of the electronic record documented in the previous 30 days Resident #91 participated in no activity programs.
On 4/2/25 at 9:06 a.m., in an interview Activity Assistant Staff C said she did not have a certification and no training for the position of activity aid. She said she follows the activity calendar on the wall. For residents who don't come out of the room or to activities, I do room visits every day but I can't see everyone in one day. I talk to them, if they need anything I make up packets with word search, coloring and puzzles. I do nail care and hand massage. I can't get to many of the residents, and I spend about 10 minutes with each resident.
On 4/2/25 at 9:42 a.m., in an interview Activity Director Staff A said she was the Activity Director here for 4 years. Staff A said we take the residents to the activity room or the day room on the [NAME] Unit. The day room is for the lower functioning residents. We did have activities here on 3/31/25 and 4/1/25 in the [NAME] day room. This writer mentioned that no one was observed in the day room on 3/31/25 and 4/1/25. Staff A replied it is because only 1 resident showed up and we did not do the activity for just one person. For the residents who do not get out of bed or don't come to activities I do room visits. We are here 9-5 Monday to Sunday. There are 3 of us, but right now one is out sick. The main activity room is for higher functioning residents.
Staff A said she documents participation in the activity program in the electronic record for each resident and she maintains no paper documentation. Staff A said Resident #3 is in the main activity room daily and Resident #91 is in the [NAME] Unit Day room daily for activities. The Activity Director said there was documentation in the electronic record Residents #3 and #91 attend all day activities. The Activity Director reviewed the previous 30 day documentation for Residents #3 and #91. She confirmed Resident #3 attended 2 activities and Resident #91 attended no activity programs. The Activity Director said, I don't know why there is no documentation.
A second review of the documentation for participation in the activity programs for the previous 30 days, showed the documentation was updated and showing that Resident #3 and #91 had participated in one or two activities daily.
On 4/2/25 at 1:40 p.m., in an interview the Activity Director confirmed the activity records at this time, for participation in activities documented Resident #3 and #91 attended daily programs in the previous 30 days. When asked why there was now documentation for Resident #3 and #91 participating in daily activity programs, she replied, Late Entries. When asked how Resident #91 was in activity programs on 3/31/25 and 4/1/25 when this writer was monitoring her, she replied I had Resident #91 in the activity room on the [NAME] Unit all day, she was in activities. When asked how the resident could be in the activity programs when she was observed in her room the Activity Director replied, I don't know.
On 4/2/25 at 2:39 p.m., Review of the activity participation record documented Resident #3 participated in daily activity programs for the previous 30 days that were not documented when reviewed that morning. The documentation revealed Resident #3 was attending activities daily including Monday 3/31/25 when Resident #3 was monitored and observed in her room all day.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interviews, the facility failed to follow proper sanitation procedures for the 3-compartment sink, increasing the risk of cross-contamination and foodborne illness with ...
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Based on observation and staff interviews, the facility failed to follow proper sanitation procedures for the 3-compartment sink, increasing the risk of cross-contamination and foodborne illness with the potential to impact residents receiving cooked food out of the dietary department.
The findings included:
The policy for the 3-compartment sink provided by the facility, with no effective date, stated, Sink 1= Wash, sink 2= Rinse, sink 3= Sanitize. Three-compartment sink steps:
1. Preparation: Fill sink (1) with warm Pot and Pan Detergent Solution. Fill Rinse sink (#2) with warm water. Fill the Sanitize sink (#3) with warm sanitizer solution to 200 PPM.
2. Pre-wash: Pre-scrape and rinse all items prior to washing in sink #1.
3. Wash: Scrub all surfaces (including handles).
4. Rinse: Submerge item in rinse water. Let rinse water run back into rinse sink.
5. Sanitize: Submerge item in sanitizer sink for a minimum of 60 seconds. Remove item from sink and let air dry. Do not wipe dry.
On 4/2/25 from 11:15-11:25 a.m., during a 3-compartment sink observation, Staff O, a full-time Dietary Aide, was observed submerging dishes into the third compartment (containing the sanitizing solution) of the sink for 1-2 seconds. The employee then shook off the excess water and placed the dishes to the side of the sink on a rubber dry mat to dry.
On 4/2/25 at 11:28 a.m., during an interview with Staff O, she was unable to speak to the process for washing, rinsing and sanitizing dishes using the 3-compartment sink. She read aloud the instructions posted on the wall that said, the dishes should be soaked for 60 seconds.
**Photographic evidence obtained**
On 4/2/25 at 4:50 p.m., during an interview with the Assistant Certified Dietary Manager (ACDM) she said, the procedure for the 3-compartment sink was the first sink was to scrub, the second was to rinse, and the third one was to sanitize. Then they are placed on the metal rack above the sink to air dry. When asked how long the dishes should soak in the third compartment, she said 5-15 minutes. The Certified Dietary Manager then read through the posted instructions on the wall above the sink. She read out loud, The dishes should be submerged for 60 seconds.
On 4/3/25 at 8:36 a.m., the ACDM said during an interview that Dietary Aide, Staff O incorrectly sanitized the dishes. They should not be submerged for less than 60 seconds.
Aug 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interviews, the facility failed to implement adequate supervision for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interviews, the facility failed to implement adequate supervision for 1(Resident #78) of 19 residents reviewed with known unsafe wandering behaviors.
The findings included:
Review of the clinical record for Resident #78 revealed an admission date of 7/15/22 with diagnoses including altered mental status, and anxiety.
The admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #78 scored a 10 on the Brief Interview for Mental Status, indicative of moderately impaired cognition.
On 7/28/22 the psychiatric Advanced Practice Registered Nurse (APRN) documented Resident #78 had poor insight or judgement, was constantly pacing the halls, and had significant cognitive processing deficits. The APRN ordered to start Xanax 0.25 mg twice a day, and Xanax 0.25 milligram (mg) every two hours as needed for anxiety.
On 8/5/22 at 9:57 p.m., the psychiatric APRN documented Resident #78 was very agitated, exit seeking, not responding to the current medication regimen. The APRN ordered to administer Ativan (medication that acts on the brain and nerves to produce a calming effect) intramuscularly (IM) as needed for 14 days.
On 8/11/22 at 9:24 a.m., the psychiatric APRN documented Resident #78 overall was restless, behavioral sundowning (worsening of restlessness, agitation as daylight begins to fade), impulsive not responding to redirection. The IM Ativan had moderate effectiveness. The plan was to add routine Ativan and discontinue the Xanax (Antianxiety). Staff support behavioral interventions have been tried and are not successful.
On 8/11/22 at 3:02 p.m., the psychiatric APRN documented an urgent telephone call with the director. Resident #78 was now combative, paranoid (feelings of extreme distrust, suspicion), not responding to any behavioral interventions. The plan was to resume Ativan 1 milligram (mg) IM every eight hours as needed.
On 8/11/22 the Social Service Director documented in a grievance form a concern of Disruptive roommate voiced by Resident #78's roommate. A room change was initiated.
On 8/15/22 at 9:33 a.m., Resident #78 was observed barefoot wandering in the 400 hall. Resident #78 was going in and out of other residents' rooms with no staff intervention or redirection.
On 8/15/22 at approximately 9:40 a.m., Licensed Practical Nurse (LPN) Staff E confirmed Resident #78 was wandering unsupervised into other residents' rooms. She said Resident #78 wandered all the time and was combative.
On 8/15/22 at 9:45 a.m., Resident #16 said he used to share a room with Resident #78. He said three or four days ago, Resident #78 placed his hands around his throat and tried to choke him. Resident #16 said he punched Resident #78 in the face to protect himself. He reported the incident to the staff on duty, and an incident report was filed.
On 8/15/22 at 10:00 a.m., LPN Staff E was informed Resident #16 said three or four days ago Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. LPN Staff E said Resident #78 was combative and wandered in and out of other residents' rooms.
On 8/15/22 at 10:10 a.m., Resident #78 was observed barefoot at the back hallway exit door. Resident #78 pushed the exit door, activating the alarm. Three staff members were observed in the hallway conversing and did not attempt to redirect Resident #78. Approximately three minutes later, LPN Staff E redirected Resident #78 away from the exit door.
On 8/15/22 at 4:00 p.m., Resident #78 was observed wandering unsupervised in the hallway and going in and out of other residents' rooms.
LPN Staff E said Resident #78 was combative and wandered. A wandering device was applied to alert staff of attempts to exit the facility.
On 8/16/22 at 12:00 p.m., Resident #98 said during the night, between 2:30 a.m., and 3:30 a.m., Resident #78 wandered in and out of her room, dressed in a hospital gown. He was rummaging through her belongings and got close to her face. She said Resident #78 tried to get in her bed which frightened her. She activated the call light, but no one responded for over an hour. Resident #98 said she was frightened and was screaming. Finally, the nurse came and removed him from the room. The nurse just kept saying Resident #78 was confused.
On 8/16/22 at 12:10 p.m., Resident #16 said Resident #78 wandered into his room several times last night and was going through his belongings. He said, I told him to get out. I get upset because I don't want him going through my things. I want to sleep, and he comes in and will go through my things. Resident #16 said he reported it to the nurse on duty.
On 8/16/22 at 12:15 p.m., LPN Staff D said she did not know anything about Resident #78 wandering. LPN Staff D was informed Resident #16 said three or four days ago Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. LPN Staff D was also informed Resident #98 complained the night before Resident #78 wandered in her room and tried to get in her bed.
On 8/16/22 at 12:25 p.m., Resident #78 was observed wandering in the hallway on the unit by the back door attempting to exit the facility. Resident #78 wandered into another resident's room and then back to the exit door.
Patient Care Assistant (PCA) Staff A was observed attempting to redirect Resident #78 away from the door. PCA Staff A said she was assigned to sit with the resident after lunch due to the wandering.
On 8/16/22 1:15 p.m., Occupational Therapist (OT) Staff M said Resident #98 complained to her about Resident #78 wandering in and out of her room. OT Staff M said Resident #78 constantly wanders and goes in and out of resident rooms.
On 8/16/22 at 1:20 p.m., Unit Manager Staff L said sometimes Resident #78 wanders in other residents' rooms. Unit Manager Staff L was informed Resident #16 said Resident #78 placed his hands around his throat and tried to choke him. He had to punch Resident #78 in the face to protect himself. She was also informed Resident #98 complained about Resident #78 wandering in her room and trying to get in her bed. She said she was not aware of the incidents.
On 8/17/22 at 9:15 a.m., Resident #98 said the previous evening (8/16/22) Resident #78 wandered in her room and tried to get into her bed again. She said, I had the call light on, and no one came. I called my daughter in law, and she called the facility last night to report it. They removed him and then they had a staff member stand guard at my room to keep him out.
On 8/17/22 at 9:38 a.m., in a telephone interview, Resident #98's daughter in law said Resident #98 called her on 8/16/22 at approximately 6:30 p.m. and complained there was a man in her room who was trying to get into her bed. She called the facility and reported the incident to Registered Nurse (RN) Supervisor Staff I. RN Supervisor Staff I called her back and verified Resident #78 was found in her mother in law's room.
The care plan initiated on 7/15/22, and revised on 7/21/22 did not include individualized interventions, and supervision to address the wandering behavior.
On 8/18/22 at 12:45 p.m., the Social Service Director said on 8/11/22 she wrote a grievance noting Resident #16 complained of a disruptive roommate but did not elaborate on it. She said Resident #16 complained on 8/11/22 at approximately 4:00 a.m., his roommate (Resident #98) was acting crazy, knocking things off the wall, pulling cords off the wall. He knocked over his tray table and Resident #98 fell on his bed.
On 8/18/22 at 1:20 p.m., the Director of Nursing (DON) said Resident #78 should have been supervised to prevent the multiple incidents of wandering into other residents' rooms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, review of facility policy and procedure, and record review, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, review of facility policy and procedure, and record review, the facility failed to ensure 4 (Residents # 16, #69, #78 and #98) of 5 residents reviewed for accidents were assessed for alternative interventions prior to the use of bed rails. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized.
The findings included:
The facility policy Side Rail Use/ Enabler Use revised 3/22, documented, The policy addresses safety measures to reduce the risk of bed entrapment related to the use of side rails/enablers. Side rails/enablers will only be used by a resident to assist his or her bed mobility in accordance with the individual's interdisciplinary team assessment. Side rails/enablers will not interfere with the residents' ability to egress from the bed.
Review of the facility's Consent for use of side rails showed, . It is the policy of this facility to use side rail(s) only after evaluation and care planning deem it appropriate to assist the resident in attaining or maintaining his or her highest practicable physical and psychological well-being, and other methods or interventions are inadequate. In all instances the least restrictive device, which is effective will be used .
1. On 8/15/22 at 9:45 a.m., Resident #16 was observed in his bed with 1/4 side rails in the raised position on both sides of the bed. Resident #16 said he did not request the rails but used them to move in bed.
Review of Resident #16's clinical record showed on 5/17/22 Resident #16 signed the Consent for Use of Side Rails.
The clinical record showed an admission side rail assessment dated [DATE] recommending the use of bilateral enablers. The form documented alternatives have been discussed with the resident. The form did not document the alternatives attempted prior to the use of the enablers.
2. On 8/16/22 at 1:45 p.m., Resident #69 was observed in bed, with ½ side rails on both sides of the bed in the raised position. Resident #69 said the rails were on the bed when she was admitted , and she used the rails for mobility in bed.
Review of Resident #69's clinical record showed a Consent for Use of Side rails dated 6/28/22 and signed by the resident.
The record showed an admission side rail assessment dated [DATE], documented side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails.
3. On 8/16/22 at 1:45 p.m., Resident #78 was observed in bed with ½ side rails on both sides of the bed in the raised position. Resident #78 was confused and not able to answer questions.
Review of Resident #78's clinical record showed a Consent for Use of Siderails dated 7/17/22 and signed by the resident's family member. The record showed an admission side rail assessment dated 7/15/ 22, documented side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails.
4. On 8/15/22 at 10:10 a.m., Resident #98 was observed in bed with side rails in the raised position on both sides of the bed.
Review of Resident #98's clinical record showed a Consent for Use of Side rails dated 7/27/22 and signed by the resident's family member. The record showed an admission side rail assessment dated [DATE] documenting side rails or enablers were recommended and alternatives to side rails were discussed with the resident. The form did not document alternatives attempted prior to the use of the side rails.
On 8/17/22 at 12:57 p.m., the Director of Nursing confirmed the side rail assessments did not show documentation of the interventions attempted prior to the use of the side rails for Residents #16, #69, #78 and #98.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, clinical record review and staff interviews, the facility failed to ensure its medication error rate remains below 5%. Five licensed nurses on two different shifts with 27 opport...
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Based on observation, clinical record review and staff interviews, the facility failed to ensure its medication error rate remains below 5%. Five licensed nurses on two different shifts with 27 opportunities were observed. Four medication errors were observed resulting in a 14.81% error rate.
The findings included:
The facility policy 1.0, Medication Dispensing System (No effective date), documented, . Crushing oral medications requires a physician's order since some medications are not designed to be crushed (e.g., time release capsules, coated tablets, etc.). Medications are to be crushed in accordance with pharmacy guidelines and /or facility policy . Prior to medication administration:
Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. Verify that the MAR [Medication Administration Record] reflects the most recent medication order.
1. On 8/15/22 at 4:25 p.m., Licensed Practical Nurse (LPN) Staff F was observed administering two different medications to Resident #2, including one tablet of Xifaxan (antibiotic) 550 milligrams (mg), and three tablets of Sevelamer Hydrochloride 800 mg (medication used to treat too much phosphate in the blood for dialysis patients). LPN Staff F placed the four tablets into a plastic medication bag and crushed them. LPN Staff F mixed the crushed medications with pudding and administered them to Resident #2.
LPN Staff F discarded the medication cup leaving a portion of the medication mixture in the cup.
A review of the manufacturer's guidelines for the use of Xifaxin and Sevelamer Hydrochloride specified Do not crush or chew tablets.
2. On 8/15/22 at 5:06 p.m., LPN Staff J was observed administering 14 different medications to Resident #63, including two tablets of Baclofen (a muscle relaxer) 20 mg, and two tablets of Gabapentin (medication used to treat seizures and nerve pain) 800 mg.
On 8/15/22 at 5:30 p.m., review of the clinical record revealed a physician order specifying to administer one tablet of Baclofen 20 mg four times a day for muscle spasms and one tablet of Gabapentin 800 mg three times a day for neuropathic pain.
On 8/15/22 at 7:00 p.m., in an interview, LPN Staff J confirmed she had administered two tablets of Baclofen 20 mg and two tablets of Gabapentin 800 mg to Resident #63.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of the Minimum Data Set (MDS) with Assessment Reference Date of 8/4/22 indicated Resident #108 had a Brief Inte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of the Minimum Data Set (MDS) with Assessment Reference Date of 8/4/22 indicated Resident #108 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS revealed several active diagnoses for Resident #108 including Non-Alzheimer's Dementia, Depression, Psychotic Disorder, and Schizophrenia.
On 8/15/22 at 4:30 p.m., during an observation and interview with Resident #108 she said she keeps her medicine in her chest drawers. Resident #108 stood up from bed, walked to the chest of drawers across from her bed and removed a red, 7-day pill organizer from the top drawer. She opened one section of the pill organizer and placed several pills in her hand, including a large pink pill identified as Depakote 500 milligrams (mg), which is used to treat seizures and mood disorders. Resident #108 confirmed the chest drawer was not locked and she possessed no key for access to the contents inside.
Photographic evidence obtained.
Review of the medical record indicated Resident #108 was admitted to the facility on [DATE]. Resident #108's Medication Administration Record for August 2022 indicated the facility was administering medication to the resident daily, including Depakote 500 mg for mood stability.
On 8/17/22 at 9:24 a.m., Licensed Practical Nurse (LPN) Staff W said she gave Resident #108 her medication this morning. Staff W said Resident #108 was diagnosed with Stage 3 Kidney Disease and Paranoid Schizophrenia and was sometimes confused.
On 8/17/22 at 9:33 a.m., during an observation, Resident #108 was lying in bed dressed in street clothes. Resident #108 said she takes both the pills in the organizer and the ones the staff give her at the facility. The red pill organizer was in a plastic bag in the top drawer of the dresser.
On 8/17/22 at 9:37 a.m., LPN Staff W entered Resident #108's room. Staff W shook the pill organizer. The pill organizer contained pills in each section except for 2 sections.
On 8/17/22 at 9:50 a.m., Registered Nurse (RN) Unit Manager Staff L entered Resident #108's room and acknowledged the medications in the pill organizer.
RN Unit Manager Staff L told Resident #108 she was not allowed to have the medication in her room because the facility administers her medication.
RN Unit Manager Staff L left the room with the pill organizer.
Review of Resident #108's electronic record including assessments, care plans, miscellaneous records, progress notes, and MARs did not indicate Resident #108 was deemed safe for to keep or self-administer medication while she was admitted to the facility.
Review of Resident #108's paper chart revealed no indication Resident #108 had been deemed safe to keep or self-administer medications while at the facility.
On 08/17/22 at 12:56 p.m., RN Unit Manager Staff L verified Resident #108 was not evaluated to keep or self-administer medications.
Based on observation and staff interview, the facility failed to ensure proper storage/labeling of medications for 1 (Resident #108) of 1 resident observed with unsecured medications at the bedside, 2 (100 odd and even medication carts) of 3 medication carts and 1(East unit) of 2 medication rooms. This has the potential for expired medications to be administered to residents.
The findings included:
The facility policy 5.0 Medication Storage (Undated), documented Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and in accordance with FL (Florida) Department of Health Guidelines. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy .
1. On 8/15/22 at 10:40 a.m., observation of the 100 odd numbered hallway medication cart with Licensed Practical Nurse (LPN) Staff F revealed the following:
One box of [NAME]/Opium suppositories expired 7/31/22.
One unopened bottle of Aspart (Novolog) insulin with directions to keep refrigerated until opened. The medication was warm to touch.
One opened bottle of glargine (Lantus) insulin with no date to indicate when the insulin was opened.
One unopened bottle of Lantus insulin with directions to keep refrigerated until opened. The insulin was warm to touch.
LPN Staff F verified the findings in the medication cart.
2. On 8/15/22 at 10:45 a.m., observation of the 100 even numbered hallway, medication cart with Registered Nurse (RN) Staff G, revealed the following:
One opened bottle of lispro insulin with no open date.
One insulin Glargine (Lantus) pen not opened with directions to keep refrigerated until opened for Resident #26.
One unopened bottle of Lispro insulin stored in the cart. The label specified to keep refrigerated until opened.
One bottle of Lispro insulin opened and undated.
One Levemir insulin pen not opened with directions to keep refrigerated until opened.
One opened bottle of Lispro insulin with no date.
One unopened insulin Glargine pen with directions to keep refrigerated until opened.
One open insulin Glargine pen with no date open.
One unopened bottle of Novolog insulin with directions to keep refrigerated until opened for Resident #83.
3. On 8/15/2022 at 11:00 am, observation of the medication storage room of the East Unit with the Unit Manager revealed the following:
One bottle of Two Cal HN tube feeding solution with an expiration date of July 1, 2022.
One bottle of Senna Syrup with an expiration date of 1/22.
One bottle of regular strength antacid and anti-gas with expiration date of 3/22.
The Unit Manager verified the Two Cal HN solution, the Senna Syrup and the bottle of antacid were expired.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation, resident council, and staff interview, the facility failed to keep the most recent survey results in a place readily accessible to residents, visitors, and the public.
The findi...
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Based on observation, resident council, and staff interview, the facility failed to keep the most recent survey results in a place readily accessible to residents, visitors, and the public.
The findings included:
On 8/17/22 at 10:02 a.m., a resident council meeting was conducted with six residents (#103, #73, #40, #37, #65 and #31) who regularly attend resident council meetings.
Members of the resident council stated they did not know where to locate the results of the State inspections, including the most recent survey of the facility.
On 8/17/22 at 11:23 a.m., a joint observation of the facility lobby with the Resident Council President failed to show a posting of the most recent State survey report. Receptionist Staff P present during the observation said she keeps all survey results in a binder behind the reception area. She said the survey results are available upon request.
On 8/18/22 at 4:10 p.m., the Director of Nursing said the binder will be moved to an accessible area.
Feb 2021
8 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
Based on observation, policy review and staff interview, the facility failed to follow the manufacturer's specification to clean and disinfect multiuse Evencare G3 blood glucose meters for 5 (Resident...
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Based on observation, policy review and staff interview, the facility failed to follow the manufacturer's specification to clean and disinfect multiuse Evencare G3 blood glucose meters for 5 (Residents #16, #24, #63, #116 and #371) of 5 residents observed with a physician's order for blood glucose monitoring (test that measures the amount of sugar in the blood).
The facility failed to apply the disinfectant necessary for the minimum wet contact time per manufacturer's instructions to kill bloodborne pathogens on shared multiuse blood glucose meters.
Inadequate disinfection may result in indirect contact transmission (the transfer of an infectious agent through a contaminated inanimate object) of pathogens through the improperly disinfected glucometers.
The facility had a total of 12 blood glucose meters used for 42 diabetic residents with orders for blood glucose checks.
The failure to properly disinfect the blood glucose meters used for multiple residents resulted in a pattern of noncompliance at Immediate Jeopardy (IJ), scope and severity of K starting on 2/23/21. The Administrator was notified of the IJ on 2/25/21 at 7:20 p.m.
The Immediate Jeopardy was removed on 2/26/21 at 4:22 p.m., and the scope and severity lowered to E after the facility provided an acceptable removal plan.
The findings included:
According to the Journal of Diabetes Science and Technology (March 2009, Volume 3, Issue 2): Finger-stick devices, blood glucose testing meters, or even a health care worker's hands may all become vehicles for indirect transmission of viruses if they become contaminated with blood. Since Hepatitis B Virus (HBV) is highly infectious and environmentally stable, even invisible amounts of blood are sufficient to spread infection.
According to the Food and Drug Administration (Content current as of 12/27/2017): For blood glucose meters, the primary viruses of concern for bloodborne pathogen transmission between multiple patients are Human Immunodeficiency Virus (HIV), HBV, and Hepatitis C Virus (HCV). However, due to its robust nature, HBV is the most common virus in the observed outbreaks to date. Therefore, Blood Glucose Monitoring System sponsors should demonstrate that their disinfection protocol is effective against human Hepatitis B Virus. Studies have demonstrated that viruses can remain infective on surfaces for different time periods. The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill.
The Food and Drug Administration, https://www.fda.gov/medical-devices/vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda, accessed on 2/25/21.
According to the Centers for Disease Control and Prevention: Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include:
. Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. [Blood glucose meters are devices that measure blood glucose levels.] .
.Whenever possible, blood glucose meters should be assigned to an individual person and not be shared.
.If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents.
The Centers for Disease Control and Prevention, https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, accessed on 2/25/21.
Review of facility's policy titled Blood glucose monitoring, last revised September 2020 read . Clean and disinfect blood glucose meter after each use according to manufacturer's specifications. (See Cleaning of Glucose Monitoring Device Policy) . Train the licensed staff on the use of the glucose monitors and cleaning process.
The facility's policy and procedure titled Blood Glucose Monitor/Prothrombin Time Meter Cleaning and Disinfecting last revised on September 2020 read . Remove a disposable disinfectant wipe from the storage container. Clean the outside of the meter with a disposable disinfectant wipe. Avoid coming in contact with the electronic components and/or strip insertion area. Follow manufacturer's label regarding time disinfectant must remain in contact with meter (visibly wet) for effectiveness. Place meter on protective surface/towel/paper towel and allow the meter to air dry.
On 2/22/21 at 4:40 p,m., in an interview the Director of Nursing (DON) said the facility uses the Evencare G3 glucometer and the Micro-Kill Bleach wipes to disinfect the blood glucose meters.
The Evencare G3 user manual procedure for disinfecting the Evencare G3 meter read Clean the meter with a disinfecting wipe. All external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then wipe meter or allow to air dry .
The Micro-Kill Bleach germicidal bleach wipes directions for use read In health care settings or other settings in which there is an expected likelihood of soiling of inanimate surfaces/objects likely to be soiled with blood/body fluids can be associated with the potential for transmission of HIV-1 (associated with AIDS), HBV (Hepatitis B virus) and HCV (Hepatitis C virus) . Special instructions for cleaning and decontamination against HIV-1, HBV, and HCV on surfaces/objects soiled with blood/body fluids . Allow surface(s) to remain wet for 30 seconds to kill all of the bacteria and viruses . Photographic evidence obtained.
1. On 2/23/21 at 3:38 p.m., Licensed Practical Nurse (LPN) Staff C (training with Registered Nurse Staff E) was observed doing a blood glucose check for Resident #24. LPN Staff C and Registered Nurse (RN) Staff E performed a fingerstick, used the blood glucose meter and left Resident #24's room at 3:40 p.m. LPN Staff C used a Micro-Kill bleach wipe, wiped the blood glucose meter for 6 seconds and placed it on a Styrofoam tray. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. Staff C did not reapply the Micro-Kill wipe to ensure a 30 seconds wet contact time as per the manufacturer's specification.
On 2/23/21 at 3:44 p.m., observed LPN Staff C preparing to perform the next blood sugar check. She said since the blood glucose meter had been drying three minutes, I can check the next blood sugar.
On 2/23/21 at 3:55 p.m., LPN Staff A was observed removing a blood glucose meter from a plastic bag. She wiped the meter for 5 seconds with a Micro-Kill bleach wipe placed it on the medication cart. LPN Staff A said, and dry to 3 minutes. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. The nurse did not reapply the Micro-Kill bleach disinfectant to the blood glucose meter to ensure a 30 seconds wet contact time as per the manufacturer's specification.
2. On 2/23/21 at 4:00 p.m., LPN Staff A was observed doing a blood sugar check for Resident #371. LPN Staff A performed a fingerstick, used the blood glucose meter and left the resident's room at 4:02 p.m. LPN Staff A wiped the blood glucose meter with a Micro-Kill bleach wipe for 10 seconds and placed the meter on the medication cart. Continued observation of the meter from the time the nurse started to wipe the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. LPN Staff A made no attempt made to reapply the Micro-Kill bleach wipe to the glucometer to ensure a 30 seconds wet contact time as per the manufacturer's specification to ensure proper disinfection.
On 2/24/21 at 9:49 a.m., in an interview Registered Nurse (RN) Staff B said she was assigned to 2 diabetic residents receiving blood sugar checks. She said she cleans the blood glucose meter between residents. She said the process was to wipe the glucometer and let air dry for 30 seconds to 3 minutes. She said to ensure the meter is really clean she lets it dry the longer time.
3. On 2/24/21 at 11:32 a.m., RN Staff D was observed doing a blood sugar check on Resident #116. RN Staff D performed a fingerstick, used to blood glucose meter and left the resident's room at 11:39 a.m. RN Staff D wiped the blood glucose meter for 6 seconds with a Micro-Kill bleach wipe and placed it on the medication cart. Continued observation of the meter from the time the nurse wiped the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. Staff D made no additional attempts to reapply the Micro-Kill bleach wipe to ensure a wet contact time of 30 seconds to properly disinfect the glucometer.
4. On 2/24/21 at 11:55 a.m., RN Staff B was observed doing a blood sugar check for Resident #63. She left the resident's room at 11:58 a.m. She wiped the glucometer for 8 seconds with a Micro-Kill bleach wipe. Continued observation of the meter revealed the meter progressively drying and completely dry without residual moisture by 30 seconds. RN Staff B made no attempt to reapply the Micro-Kill bleach disinfectant to ensure a 30 seconds contact time to disinfect the meter.
5. On 2/25/21 at 4:39 p.m., LPN Staff F was observed performing a blood sugar via fingerstick for Resident #16 (dialysis resident). After performing the blood sugar, she donned a pair of gloves and wiped the blood glucose meter for 5 seconds with a Micro-Kill bleach wipe. She placed the meter on a Styrofoam tray on the medication cart. She said she would allow it to air dry for 2 minutes. Continued observation of the meter from the time the nurse started to wipe the meter revealed the meter progressively drying. The meter was completely dry at 20 seconds. LPN Staff F said she alternates the use of both blood glucose meters on the medication cart. She said she usually lets the meters dry for 2 minutes except when the resident has an infection such as C-diff (infection that causes severe diarrhea). In that case she lets the meter dry longer.
6. On 2/25/21 at 3:50 p.m., the Nurse Educator said she has been employed at the facility since 8/1/19. She described the process to disinfect the blood glucose meters as follows:
Pull a wipe out of the tub. Make sure to wipe the whole glucometer. Don't get any water on the port. Wipe the glucometer and then put it on the Styrofoam tray to dry.
The Nurse Educator said, the contact time is the time you allow the glucometer to dry to kill the pathogens.
The Nurse Educator said she routinely conducts audits of the nurses disinfecting the blood glucose meters but she did not have a piece of paper to show.
The Nurse Educator said the CDC (Centers for Disease Control and Prevention) says the contact time is the time to allow the glucometer [also known as glucose meter] to dry.
The Nurse Educator provided a competency (not dated) titled Disinfecting of blood glucose testing machine which she said she used to teach the licensed nurses. It read .To disinfect the meter, use Germicidal Cloth. Remove wipe from container and thoroughly wipe down the meter.
Allow the meter to dry for at least one (1) to five (5) minutes to gain full benefit of the disinfecting.
Note: If the wipe is very saturated (wet), squeeze or gently wring excess liquid before use.
*CLEAN and disinfect daily between patient use.
The education did not address the wet contact time for proper disinfection of the glucometers.
7. On 2/25/21 at 4:00 p.m., the DON who was present during the interview said, The nurses are basically doing it the way they were instructed to.
The Immediate Jeopardy was removed on 2/26/21 at 4:22 p.m., and the scope and severity lowered to E after verification the facility completed a removal plan which included:
All facility glucometers were disinfected according to manufacturer's specification on 2/25/21.
Documentation that 32 licensed nurses were educated and demonstrated competency on proper disinfection of the glucometers on 2/26/21.
Documentation of an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting on 2/25/21 to develop a new competency checklist that specified To disinfect the meter: Use Germicidal Cloth to wipe down the meter, then wrap the meter in the Germicidal cloth. Allow the surface of the meter to remain wet at room temperature for 3 minutes or reference the manufacturer recommended time.
Observation on 2/26/21 of 6 licensed nurses, including the Staff Educator disinfecting the blood glucose meters according to manufacturer's specification of wet contact time to ensure disinfection of the shared blood glucose meters.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Clinical record review revealed Resident #116 was admitted to the facility on [DATE].
The MDS admission assessment with a ta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Clinical record review revealed Resident #116 was admitted to the facility on [DATE].
The MDS admission assessment with a target date of 2/4/21 indicated it was very important for the resident to choose what clothes to wear and take care of his personal belongings or things.
Review of the inventory of personal effects dated 1/30/21 showed Resident #116 had one T shirt, one jacket, one pair of shorts and one pair of underpants. On 1/31/21 additional items including three shirts, two briefs, two shorts were inventoried. On 2/1/21 the facility added one shirt, one sweater and one short to the inventory of personal effects.
On 2/23/21 at 11:12 a.m., in an interview Resident #116 said his son brought him clothes weeks ago. He said he asked many times, but no one gave him his clothes.
On 2/24/21 at 11:37 a.m., in an interview Resident #116 said he had no idea where his clothes were. He said when he asks for his clothes, staff ignore him.
On 2/24/21 at 3:25 p.m., in an interview Registered Nurse (RN) Staff D said he was not aware Resident #116 had additional clothing items.
On 2/25/21 at 9:14 a.m., in an interview Resident #116 said he still did not have his clothes. He said he asked staff for his clothes again and no one addressed it.
On 2/26/21 at 9:35 a.m., Resident #116 said he was being discharged at 10:30 a.m., but they still had not given him his clothes.
On 2/26/21 at 11:29 a.m., in an interview the East Unit Manager RN Staff S said she assisted RN Staff D with Resident #116's discharge. She said a certified nursing assistant (CNA) escorted Resident #116 out of the facility with about 3 bags of clothes. RN Staff S said they don't document that, and he didn't sign his inventory sheet.
On 2/26/21 at 11:38 a.m., in a telephone interview Resident #116 said when they came to discharge him, a CNA brought in some bags of clothes but not all the clothes were his. He got some of his clothes, but not all of them.
On 2/26/21 at 3:05 p.m., in an interview the Housekeeping Director said when family brings clothes into the facility, the receptionist at the front desk inventories them. The clothes are then sent to laundry services to be labeled and then taken to the resident's room. The Housekeeping Director said Resident #116's clothes had been stored in the laundry room since the beginning of the month when they were brought into the facility. She said she found out the day before (2/25/21) Resident #116's clothes were mislabeled. She said she took Resident #116's clothes to him this morning before his discharge.
Based on record review, resident and staff interview, the facility failed to promote residents right to dignity and provide care and services to maintain self-esteem and self-worth for 2 (Residents #318, and #116) of 3 sampled residents. This has the potential to cause psychological harm, frustration, and discomfort.
The findings included:
Facility policy CB-14 (creation date 9/17) titled Bladder and Bowel Training Program read All residents will be given the opportunity to obtain or maintain their highest practicable ability with regards to toileting and continence.
The policy's objectives included to minimize episodes of incontinence through a planned intervention program; to improve dignity, maintain self-esteem and self- respect.
Review of the Minimum Data Set (MDS) admission assessment with an assessment reference date of 2/18/21 revealed Resident #318 scored 15 (intact cognition) on the Brief Interview for Mental Status (BIMS). Resident #318 required extensive assistance of one person for transfer, walking, personal hygiene, and toileting.
1. On 2/22/21 at 11:00 a.m., in an interview Resident #318 said she could use the bathroom if staff helped her to get up. Resident #318 said she preferred to use the bathroom rather than use the incontinent briefs they provided to her. Resident #318 said at night when she called for help to use the restroom, staff told her they will come back to assist her but to go in the diaper if needed. Resident #318 was tearful and said it made her feel terrible to go in a diaper like that. She said It's embarrassing. I am not a baby.
On 2/23/21 at 9:30 a.m., in an interview Resident #318 said she was very upset since she missed therapy this morning. She said she was still in a wet diaper when Physical Therapist (PT) Staff O came to assist her to the therapy room. Resident #318 said I put the call bell on after breakfast this morning and no one paid attention. Resident #318 said she heard staff being paged to come help but they did not come. She said she put the call bell on again. Resident #318 said PT Staff O assisted her get to the bathroom and ensured she had assistance from staff before leaving the room. Resident #318 said that it was embarrassing to not have help to go to the bathroom, when all she needed was some assistance. Resident #318 became tearful.
On 2/23/21 at 9:45 a.m., Resident #318 said on more than one occasion after using the call bell to get help with going to the bathroom, staff told her to just go ahead and use the brief. Resident #318 started crying and said she didn't want to use a diaper like a baby, I am an adult. Resident #318 said during the overnight hours she sometimes did not bother requesting assistance since they do not come and knows the staff won't help her but will encourage her to go in the incontinent brief.
On 2/23/21 at 3:05 p.m., in an interview PT Staff O said when he went to get Resident #318 for therapy this morning she said she was in a dirty diaper and needed to use the bathroom to be cleaned up before therapy. PT Staff O confirmed Resident #318 raised the concern to him regarding the staff not helping her to the bathroom. PT Staff O confirmed Resident #318 told him using a diaper makes her feel like a baby.
On 2/24/21 at 9:54 a.m., in an interview Certified Nursing Assistant (CNA) Staff V said resident #318 was very alert and able to call for help to use the bathroom when needed. CNA Staff V said Resident #318 was not on a bowel or bladder retraining program. She said residents are offered toileting assistance every 2 hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0917
(Tag F0917)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interview, the facility failed to provide private closet space for 2 (Resident #94 and #116) of 2 residents reviewed for physical environment. The failure to p...
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Based on observation, resident and staff interview, the facility failed to provide private closet space for 2 (Resident #94 and #116) of 2 residents reviewed for physical environment. The failure to provide private closet space inhibits the ability to protect personal effects from casual access by others and allow items to remain clean and accessible to residents.
The finding included:
1. Observation on 2/24/21 at 11:37 a.m., revealed Resident #94 and Resident #116 shared a room. The room had one dresser but no private closet space.
Resident #94's personal items, including incontinence care items, were observed stacked on a chair in the corner of the room and on the floor.
The same observation was made on 2/25/21 at 9:14 a.m. Resident #116 said the facility had not given him his clothes, but he would have nowhere to put them if they did.
2. On 2/25/21 at 9:26 a.m., the Maintenance Director said there were no work orders for closets for the shared room for Resident #94 and Resident #116. He acknowledged the double occupancy room had no closet or armoire with individual closet space with clothes racks and shelves.
On 2/26/21 at 12:43 p.m., the Maintenance Director said he is the one responsible for ensuring residents have closets. He said sometimes he just puts something in the middle of the room, so they have something to put something in.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews the facility failed to ensure they considered the views of Resident Cou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews the facility failed to ensure they considered the views of Resident Council and act promptly upon their grievances, concerns, and recommendations for 7 (8/2020, 9/2020, 10/2020, 11/2020, 12/2020, 1/2021 and 2/2021) of 7 months reviewed.
The findings included:
On [DATE] at 3:50 p.m., the Director of Activity (DOA) said because of Coronavirus Disease 2019 (COVID-19) and the death of the Resident Council President, the facility residents elected Resident #16 as the Interim Resident Council President (IRCP) in the [DATE] resident council meeting. Since the facility stopped all group meetings, they determined Resident #16 would be the representative for all the residents in the monthly resident council meetings starting [DATE]. The DOA said Resident #16 talked with most of the residents in the facility and when they had the monthly resident council meeting, he voiced all the residents' concerns and grievances for that month.
On [DATE] at 10:05 a.m., Resident #43 said Resident #16 is the IRCP and the residents tell him all their concerns, grievances, and recommendations. She has told the IRCP and facility staff over the past 5 to 6 months her room floor was sticky, and her wheelchair was dirty and not being cleaned. She also said she told the IRCP sometimes the meals arrived cold and she did not always get her clothes back from laundry.
On [DATE] at 10:30 a.m., Resident #16 said he became the IRCP in [DATE] after the Resident Council President died. He said the facility told him he would be the voice for the facility residents and every month the DOA would do a monthly resident council meeting with him. He said over the past few months he had expressed to the DOA in the resident council meetings and the Administrator (AD) during his weekly routine rounds, all the concerns, grievances, and recommendations the facility residents had told him during the month. He said residents told him their rooms and wheelchair were not cleaned on a routine basis, laundry did not always return their clothes, staff was slow answering call lights and meals were cold when delivered to the residents' rooms. He said he asked the DOA and AD several months ago if the residents could start having resident council meetings outside while practicing social distancing but as of this time neither the DOA and AD had gotten back to him related to any of his concerns, grievances or recommendations.
On [DATE] review of the Resident Council Minutes dated [DATE], [DATE] and [DATE] noted the minutes were divided into sections that covered the Nursing department, Dietary department, Maintenance department, Housekeeping/Laundry, Activity department and Other Discussions. The minutes revealed the residents had multiple areas of concerns, grievances, and recommendations which the facility addressed at that time. Resident #16 was elected as the Interim Resident Council President in the [DATE] resident council meeting.
Review of the Resident Council Minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] revealed it had 2 sections, the first section talked about COVID-19 testing and monitoring of all residents and staff were ongoing and the second section said the activity department was ongoing. The resident council minutes from [DATE] to [DATE] did not note any of the facility residents' concerns, grievances and/or recommendations.
On [DATE] at 11:44 a.m., in an interview the Administrator said Resident #16 has been the IRCP since [DATE]. He confirmed Resident #16 had talked with him during his routine weekly rounds related to concerns and recommendations he had as the facility IRCP. He said if he thought the concerns and recommendations were true grievances, he would have filled out a grievance form. The AD said he did not document any of the IRCP concerns or recommendations.
On [DATE] at 4:26 p.m., the DOA said the IRCP had spoken to her related to some concerns and recommendations over the past several months but did not document them on the resident council meeting minutes. She confirmed the resident council meeting minutes reviewed from [DATE] to [DATE] noted she talked with the IRCP about COVID-19 testing and monitoring and the activity program was ongoing but didn't note any concerns or recommendations mentioned by the IRCP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on interview and staff and resident interviews the facility the facility failed to ensure 10 (#43, #12, #23, #97, #9, #95, #90, #113, #40 and #98) of 14 resident's wheelchairs were clean and kep...
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Based on interview and staff and resident interviews the facility the facility failed to ensure 10 (#43, #12, #23, #97, #9, #95, #90, #113, #40 and #98) of 14 resident's wheelchairs were clean and kept in a sanitary condition to prevent the spread of disease-causing organisms.
The findings included:
1. On 2/22/21 at 9:49 a.m., Resident #43 said the housekeeping staff did not always mop her floor causing it to be sticky. She further said her wheelchair had not been cleaned in the past several months and the wheelchair was very dusty and sticky. Observation of Resident #43's wheelchair noted a thick layer of dust on the frame of the wheelchair.
2. On 2/22/21 at 10:06 a.m., observation of Resident #12's wheelchair revealed a thick layer of dust and dried food on the frame of the wheelchair. Resident #12 said his wheelchair had not been cleaned in a long time even though he had asked staff several times to clean his wheelchair.
3. On 2/25/21 at 9:25 a.m., observation of Resident #23 and Resident #97's wheelchairs revealed a thick layer of dust on the frames of their wheelchairs. Resident #97 said he had not seen the facility staff clean their wheelchairs in the past several months.
4. On 2/25/21 at 9:45 a.m., observation of Resident #9's wheelchair revealed a thick layer of dust on the frame of her wheelchair. Resident #9 said the facility had not cleaned her wheelchair in the past several months.
5. On 2/25/21 at 9:53 a.m., observation of Resident #95's wheelchair revealed a thick layer of dust on the frame of their wheelchair.
6. On 2/25/21 at 9:55 a.m., observation of Resident #90's wheelchair revealed a thick layer of dust on the frame of his wheelchair. Resident #90 said the facility had not cleaned his wheelchair in the past several months.
7. On 2/25/21 at 10:01 a.m., observation of Resident #113's wheelchair revealed a thick layer of dust on the wheelchair.
8. On 2/25/21 at 10:08 a.m., observation of Resident #40 and Resident #98's wheelchairs revealed a thick layer of dust on their wheelchairs. Resident #98 said the facility had not cleaned his wheelchair since his admission to the facility several weeks ago.
9. On 2/25/21 at 3:46 p.m., the Housekeeping/Laundry Director (HLD) said the Housekeeping Department was responsible to clean the entire facility to include all resident's wheelchairs. She said every 2 weeks all wheelchairs in the facility were taken out to the courtyard where they were washed/cleaned and scrubbed with a brush to remove the dust and grime which builds up on the wheelchairs over time. She said this was the week all the wheelchairs in the facility would be cleaned/washed. On Monday (2/22/21) all the wheelchairs on the 100 hallway and part of the 300 hallway were washed, Tuesday (2/23/21) all the wheelchairs on the 200 hallway, and on Wednesday (2/24/21) all the wheelchairs on the 400 hallway to include the rest of the 300 hallway were washed. Thursday (2/25/21) the wheelchairs on the back end of the 200 hallway, rooms 217 to 228 will be washed and then they will repeat the same schedule in 2 weeks. She said she did not keep any paperwork on what wheelchairs were completed but was positive all the wheelchairs were cleaned this week as required.
10. On 2/25/21 at 4:00 p.m., a tour of the facility was conducted with the HLD and we inspected Residents #43, #12, #23, #97, #9, #95, #90, #113, #40 and #98's wheelchairs. She confirmed all 10 wheelchairs we reviewed had a thick layer of dust on the frame, wheels, and the brakes. She stated it appeared the wheelchairs had not been washed/cleaned in several weeks. She said the pressure washer had been broken for a long time and the staff were required to use the scrub brush to clean all parts of the wheelchairs to include the frame, brakes, and wheels. She confirmed the 10 wheelchairs we reviewed were not washed/cleaned as required. She said she didn't have any documentation/paperwork stating the last time all the wheelchairs in the facility were washed/cleaned by the housekeeping department on a 2-week rotation.
11. On 2/25/21 at 5:50 p.m., the Administrator said all the wheelchairs in the facility are pressure washed every 2 weeks. He said he was unaware the pressure washer was broken, and the housekeeping staff were not using the pressure washer to clean the resident's wheelchair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
Based on observation, resident and staff interview, the facility failed to accommodate the food allergies and offer appropriate alternative for 1 (Resident #28) of 3 residents reviewed for food allerg...
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Based on observation, resident and staff interview, the facility failed to accommodate the food allergies and offer appropriate alternative for 1 (Resident #28) of 3 residents reviewed for food allergies, intolerances, and preferences.
The findings included:
Review of the clinical record revealed a Patient demographic form from a local hospital printed on 2/9/21 with documentation Resident #28's had an allergy to tea. The reactions to the tea were hives and itching.
Review of the progress notes revealed on 10/6/20 the advanced practice registered nurse (APRN) documented Resident #28 was allergic to tea.
On 2/23/21 at 3:03 p.m., in an interview Resident #28 said he was given iced tea daily. Resident #28 said he was allergic to tea, it caused him to itch.
On 2/23/21 at 3:04 p.m., in an interview resident #93 (Resident #28's roommate) said he had heard Resident #28 tell staff he was allergic to tea. He said Resident #28 was only given options if he raises hell.
On 2/24/21 at 12:07 p.m., Resident #28 was observed having lunch. He exclaimed they did it again. He pointed to the cup of liquid on his tray and said it was iced tea.
On 2/24/21 at 12:15 p.m., Resident #28's lunch tray was observed with Registered Nurse (RN) Staff D. RN Staff D said all drinks come from the kitchen, he could not speculate what drink was served on the lunch tray.
On 2/24/21 at 12:24 p.m., Dietary Aide Staff U said iced tea was on the lunch trays. She said all lunch trays were served with iced tea.
On 2/24/21 at 12:41 p.m., the Dietary Director said iced tea was the house beverage and all residents received iced tea if they didn't request otherwise.
On 2/24/21 at 1:36 p.m., the Dietary Director said he and Registered Dietician dealt with food allergies. The process was to identify an allergy and add the allergy to the resident's meal ticket.
On 2/25/21 at 8:26 a.m., the Dietary Director said he was familiar with Resident #28 and believed he had an allergy to tea. He said he believed his staff were placing tea on Resident #28's tray because there was no other beverage selected. The Dietary Director said he would speak with Resident #28 to discuss his preferences and alternatives to the tea.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On [DATE] clinical record review showed Resident #40 was medicated with Ativan 1 milligram (mg) intramuscularly for anxiety o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On [DATE] clinical record review showed Resident #40 was medicated with Ativan 1 milligram (mg) intramuscularly for anxiety on [DATE] at 3:53 p.m., 2/8 at 7:40 p.m., [DATE] at 12:30 a.m., [DATE] at 9:17 p.m., [DATE] at 09:37 a.m., [DATE] at 12:00 a.m., and [DATE] at 07:26 a.m.
On [DATE] at 9:32 a.m., in an interview Licensed Practical Nurse (LPN) Staff J said Resident #40 sometimes is aggressive, yelling and can occasionally hit.
Staff J said, the behavior was worse when Resident #40 was up in the wheelchair.
LPN Staff J said staff document aggressive behaviors on the Treatment Administration Record (TAR) in the behavior monitoring section each time the Ativan is administered.
On [DATE] at 10:27 a.m., review of the treatment administration record (TAR) for resident #40 showed a behavior monitoring guide used to document the behaviors, interventions, outcome, and side effects of the Ativan use.
The behavior monitoring guide did not document the behavior for the Ativan administered on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].
5. Review of the clinical record for Resident #122 revealed the resident expired at the facility on [DATE]. The death record document dated [DATE] at 2:30 p.m., did not note the time of death, the time the physician was notified; the time the funeral home was notified. The form did not note the name of Funeral Home Personnel.
Based on record review and interview the facility failed to maintain complete and accurately documented medical records for 5 (Resident #2, #30, #40, #59, and #122) of 27 residents records reviewed. Accurate and complete records are necessary to document the course of a resident's care provided by the facility.
The findings included:
Review of the facility's policy (CN-3) with a revision date of 2/2019 revealed pertinent information should be documented in the individual's record in an accurate, timely, and legible manner.
1. On [DATE] at 8:49 a.m., review of the clinical record for Resident #30 showed multiple missing documentation on the Treatment Administration Record (TAR) for [DATE].
Resident #30 had a daily wound care order with Bactroban ointment 2% to the left and right buttock on the day shift. The treatment was not recorded on the TAR [DATE] through [DATE].
Resident #30 also had daily wound care orders with Santyl ointment to the right buttock. The treatment was not recorded on the TAR [DATE] through [DATE].
On [DATE] at 9:56 a.m., in an interview Licensed Practical Nurse (LPN) Staff G said when you are done the treatment, you check the box. If you don't check the box, you haven't done the treatment. I don't know why those aren't done.
2. A review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE] revealed the resident had one stage 3 (partial thickness skin injury) and two stage 4 (full thickness skin injury) pressure injuries. The MDS noted the pressure injuries were all present on admission.
A review of Resident #2's Wound Care Assessment/Consultation forms for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] noted the wounds were not present on admission.
On [DATE] at 10:20 a.m., in an interview RN Staff N said the physician incorrectly filled out the wound care notes from [DATE] through [DATE]. The resident was sent to the hospital and was readmitted with the wounds in October of 2020.
On [DATE] at 10:23 a.m., in an interview Resident #2's physician said the wound care notes were not documented correctly.
3. A review of the resident record for Resident #59 revealed missing or incomplete vital sign entries for [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] resident did not have documentation of administration for 2 doses of intravenous fluids for abnormal labs. No behavior monitoring, barrier cream treatment, and skin prep treatment to heels were documented for the evening of [DATE].
The resident record did not note Resident #59 was out of the facility on these dates.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
Based on observation and residents and staff interview the facility failed to ensure 4 (Residents #44, #34, #90 and #49) out of 10 siderails checked out of a possible 129 bed with siderails installed ...
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Based on observation and residents and staff interview the facility failed to ensure 4 (Residents #44, #34, #90 and #49) out of 10 siderails checked out of a possible 129 bed with siderails installed were in safe operating condition at all times.
The findings include:
1. On 2/25/21 at 9:00 a.m. revealed Resident #49 has 2-upper quarter siderails attached to her bed. Resident #49 said all the residents are required to have siderails/bedrails on their bed. She said she uses the 2-upper quarter siderails to assist her in repositioning herself in bed but due to them being loose she is scared they might break if she pulls to hard. She said she has asked the nurses and housekeeper staff several times if someone could ask the maintenance department to tighten the siderails to her bed but as of this time no one has tighten the siderails as requested.
2. On 2/25/21 at 9:19 a.m. revealed Resident #44 has 2-upper quarter siderails attached to his bed. The left upper siderail is leaning on the mattress and the right upper siderail is loosely attached to the bed.
3. On 2/25/21 at 9:35 a.m. revealed Resident #34 has 2-upper quarter siderails attached to her bed. The left upper siderail is leaning on the mattress and the right upper siderail is loosely attached to the bed.
4. On 2/25/21 at 9:55 a.m. revealed Resident #90 has 2-upper quarter siderails attached to his bed. Resident #90 said both his siderails are very loose and he is worried they are a potential safety hazard. He said he has asked multiple staff if they could tighten the siderails to the bed but no one at this time has tighten his siderails to his bed as requested.
5. On 2/25/21 at 10:16 a.m. the Maintenance Director (MD) said his department is responsible to ensure all facility and resident equipment are always in good working order and the equipment remain safe for resident use. He said siderails/bedrails, and bed enablers were all considered critical resident equipment which have to remain in good working order at all times due to the potential safety and entrapment hazards. He said all staff are required if they note any facility or resident equipment not in good working order and/or not safe for resident or staff use to create a work order in the TELS system on the computer. He reviews the TELS computer program daily and prioritize all workorders by severity. Siderails/bedrails and bed enablers are a high priority due to the risk/hazard they represent to the residents. He said due to the risk of resident entrapment, the resident's siderails/bedrails and bed enablers are checked twice yearly to ensure they are safe for resident use.
He said the last time he checked all the beds with siderail/bedrails in the facility was 12/29/20. He said since there were 129 beds in the facility with siderails/bedrails or bed enablers he relied on the facility staff to inform him and/or document in the TELS system if a siderails becomes unsafe and/or is a hazard to the residents.
The Maintenance Director said the facility had multiple types of siderails/bedrails in the facility, he thought they have 3 to 4 different types of siderails/bedrails in the facility. The Maintenance Director said he did not have the manufacturer's recommendation and specifications for installing and maintaining the siderail/bedrails for the multiple different types of siderail/bedrails in the facility.
On 2/25/21 at 10:35 a.m., the Maintenance Director confirmed Residents #49, #44, #34 and #90 siderails were loose and were a potential safety hazard to the residents. He said the staff did not create a work order in the TELS system about the loose siderails as required and he was unaware Residents #49, #44, #34 and #90 were loose and needed to be repaired.
6. On 2/25/21 at 4:50 p.m., the Maintenance Director said he did an audit of all the beds with siderails in the facility and it appeared there were 7 different types of siderails/bedrails or bed enablers in the facility. He said he did not have the manufacturer's recommendation and specifications for installing and maintaining the siderails/bedrails or bed enablers in the facility at this time.
7. On 2/25/21 at 5:15 p.m., the Administrator said the Maintenance Director did an audit of all the beds with siderails in the facility and they have 5 different types of siderails in the facility at this time. He confirmed the staff are required to inform the Maintenance Director and create a work order in the TELS computer program of all loose or malfunctioning siderails to ensure the siderails/bedrails or bed enablers remain safe for the residents use at all time.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Florida facilities.
- • 34% turnover. Below Florida's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 23 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Fort Myers Rehabilitation And Nursing Center's CMS Rating?
CMS assigns FORT MYERS REHABILITATION AND NURSING CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Fort Myers Rehabilitation And Nursing Center Staffed?
CMS rates FORT MYERS REHABILITATION AND NURSING CENTER's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 34%, compared to the Florida average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Fort Myers Rehabilitation And Nursing Center?
State health inspectors documented 23 deficiencies at FORT MYERS REHABILITATION AND NURSING CENTER during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 21 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Fort Myers Rehabilitation And Nursing Center?
FORT MYERS REHABILITATION AND NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by JONATHAN BLEIER, a chain that manages multiple nursing homes. With 120 certified beds and approximately 118 residents (about 98% occupancy), it is a mid-sized facility located in FORT MYERS, Florida.
How Does Fort Myers Rehabilitation And Nursing Center Compare to Other Florida Nursing Homes?
Compared to the 100 nursing homes in Florida, FORT MYERS REHABILITATION AND NURSING CENTER's overall rating (3 stars) is below the state average of 3.2, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Fort Myers Rehabilitation And Nursing Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Fort Myers Rehabilitation And Nursing Center Safe?
Based on CMS inspection data, FORT MYERS REHABILITATION AND NURSING CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Florida. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Fort Myers Rehabilitation And Nursing Center Stick Around?
FORT MYERS REHABILITATION AND NURSING CENTER has a staff turnover rate of 34%, which is about average for Florida nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Fort Myers Rehabilitation And Nursing Center Ever Fined?
FORT MYERS REHABILITATION AND NURSING CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Fort Myers Rehabilitation And Nursing Center on Any Federal Watch List?
FORT MYERS REHABILITATION AND NURSING CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.