Every finding on record at Abernathy Laurels

Based on observation, record review, and Medical Director and staff interviews, the facility failed to provide care in a safe manner when a dependent rolled out of bed while care was being provided. She was sent to the hospital for evaluation and was identified with a subdural hematoma (a collection of blood between the brain's outer covering and the surface of the brain). She required no treatment at the hospital, was sent back to the facility the same day, did not experience pain as a result of the injury, and was not receiving a blood thinner. This deficient practice affected for 1 of 5 residents reviewed for supervision to prevent accidents (Resident #39).The findings included:Resident #39 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, neurocognitive disorder with Lewy bodies dementia with mood disorder, Parkinson's disease, hallucinations, and history of falling.Resident #39's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 was severely cognitively impaired and was dependent on others for bed mobility and transfers. Resident #39 was coded as not having a fall since the prior assessment. Resident #39 was coded as not having any pain indicators, had not received scheduled or as needed pain medications, and received no anticoagulants or antiplatelet medication. The resident weighed 179 pounds and was receiving hospice services. Review of Resident #39's care plan revealed she required assistance with activities of daily living (ADL) related to weakness, had impaired cognition related to diagnoses of Parkinson's disease and Alzheimer's, required assistance from staff to ensure ADL needs were met as the resident did not recognize or report her needs, and was experiencing an overall decline in condition. Interventions in the care plan included offer and assist the resident with transfers, bed mobility, and toileting needs and ensure safety; and re-approach later if the resident refuses assistance.Resident #39's undated Kardex (a form which indicated what Resident #39's care needs were and how many staff were required to complete the indicated care) revealed Resident #39 was a one person assist with bed mobility and personal hygiene.Resident #39's active physician orders on 02/23/25 did not include anticoagulant or antiplatelet medication.Resident #39's progress notes revealed a note dated 02/23/25 written by Nurse #1 that indicated she was notified by Nurse Aide (NA) #1 that Resident #39 had fallen and was on the floor. NA #1 reported Resident #39 was on the floor, face down next to the bed with NA #1 underneath Resident #39. Unit Manager #1 was immediately notified and she and Nurse #1 assessed Resident #39, rolled her to her back and was placed back into her bed. Resident #39 was noted to have facial swelling on the right side of her head. Resident #39's responsible party, the physician, and hospice were notified of the fall. The resident was sent out for further evaluation.An interview with NA #1 via telephone call on 09/05/25 at 8:24 AM revealed she was in Resident #39's room on 02/23/25 providing incontinence care with the bed at the height of NA #1's waist, and when she rolled Resident #39 toward her to continue changing her, the upper half of Resident #39's body rolled off the edge of the bed with her lower half remaining in bed. NA #1 stated she tried to catch Resident #39 to prevent her from falling onto the floor but due to her positioning, she was only able to get ahold of Resident #39's waist which resulted in both Resident #39 and NA #1 falling to the floor. NA #1 stated Resident #39's head struck the floor when they fell. She reported when she and Resident #39 came to rest on the floor, Resident #39 was lying on top of her, in her lap, and was facedown. NA #1 stated she screamed for help and Nurse #1 came to the room. NA #1 stated when Nurse #1 arrived to the room she told NA #1 to not move and went and retrieved Unit Manager #1. She stated Nurse #1 and Unit Manager #1 returned to the room and Resident #39 was assessed for injuries, rolled onto her back and they used a mechanical lift to get Resident #39 back into her bed. She stated Resident #39 had suffered a hematoma to the right side of her head, just to the right of Resident #39's right eyebrow. NA #1 described the swelling to be the size of a tennis ball. NA #1 reported that despite the injury to her forehead Resident #39 did not appear to be in any pain and she was not crying. NA #1 reported based on Resident #39's Kardex that was in place at the time of the 02/23/25 fall, she was a one person assist with bed mobility. She explained that due to Resident #39 being bedbound, she had not been identified as a fall risk, and therefore, there were no fall mats to the side of Resident #39's bed. NA #1 indicated that Resident #39 was ultimately sent out to the hospital.An interview with Nurse #1 via telephone call on 09/04/25 at 2:37 PM revealed she no longer worked at the facility. Nurse #1 proceeded to state that she recalled Resident #39 but stated she was not sure she recalled Resident #39's fall that resulted in her going to the hospital.An interview with Unit Manager #1 via telephone call on 09/05/25 at 9:27 AM revealed she did respond to Resident #39's fall on 02/23/25 and stated when she arrived at the room, Resident #39 was lying face down on top of NA #1 in a horizontal position to the bed. She reported when she asked NA #1 what happened, NA #1 reported she was providing care and when she rolled Resident #39 towards her, momentum carried Resident #39 out of the bed, on top of NA #1, and onto the floor. Unit Manager #1 reported she completed a full assessment and rolled Resident #39 onto her back and that was when she noted a hematoma on the right temporal side of Resident #39's head that she described as larger than a golf ball and was probably approaching the size of a tennis ball. She stated she informed Nurse #1 to notify the physician, family, and hospice provider, and to begin periodic neurological checks. Unit Manager #1 reported Resident #39's vital signs were within normal limits and that Resident #39 did not appear to be in any distress post fall. Unit Manager #1 reported Resident #39 was nonverbal and was only alert to herself. She stated Resident #39 was dependent on others for the completion of her activities of daily living and Resident #39 required a one-person assist with incontinence care at the time of the fall but has since been downgraded to a two-person assist. Unit Manager #1 stated Resident #39 was ultimately sent out to the hospital for further evaluation and treatment.Resident #39's hospital records dated 02/23/25 revealed Resident #39 had a head CT (computed tomography) scan while at the hospital. This scan uses a series of X-rays and computer processing to create detailed, cross-sectional images of bones, soft tissues, and blood vessels within the body. The results of Resident #39's head CT scan indicated there was a very thin subdural hematoma layering about the lateral right convexity anteriorly (collection of blood that has formed a crescent shape over the front side of the right cerebral hemisphere) measuring approximately 4 millimeters, potentially subacute (not life threatening) as it does not appear particularly hyperdense. There was no associated sulcal effacement (loss of normal spaces between the folds of the brain) or midline shift (displacement of the brain's midline structures from their normal symmetrical position) or acute intracranial hemorrhage (bleeding within the skull that puts pressure on the brain) identified. Resident was given ice and was sent back to the facility the same day via facility transportation.The medical record indicated Resident #39 returned to the facility with an order for morphine concentrate (opioid pain medication) dated 02/23/25 with instructions to take 5 milligrams of morphine concentrate (100milligrams/5 milliliters) orally every 4 hours as needed.Review of Resident #39's Medication Administration Record (MAR) revealed she had not received any doses of the ordered morphine supplement upon return to the facility.An observation of Resident #39 on 09/02/25 at 3:54 PM revealed she was nonverbal and in a lean back wheelchair. Resident #39 did not respond to verbal stimuli and did not appear to be in any distress.Resident #39's progress notes revealed a note written by the Medical Director dated 02/25/25 that indicated while at the hospital resident was given a head CT scan and was found with a very thin subdural hematoma layering about the lateral right convexity anteriorly measuring approximately 4 millimeters that was potentially subacute. The Medical Director noted that after speaking to the hospital physician he felt the injury was most likely acute based on Resident #39's history and physical findings. Resident #39 was not on any anticoagulant medications at that time.An interview with the Medical Director via telephone on 09/05/25 at 2:19 PM revealed he did not recall much about Resident #39's fall that occurred on 02/23/25 but stated that an acute injury would be defined as one occurring within the past day or two and that subacute would be within the past few weeks, though he stated that a radiologist may have different definitions. He also reported that he would consider a subdural hematoma a significant injury and indicated that Resident #39 was not on any anticoagulant medications at the time of the fall. An interview with the Director of Nursing on 09/05/25 at 12:31 PM revealed she was aware of Resident #39's fall on 02/23/25 and had investigated it. She reported NA #1 reenacted the incident and that NA #1 showed her that when she rolled Resident #1 over to provide care, Resident #39's upper body came off the bed and that Resident #39 and NA #1 fell to the floor. She reported Resident #39 was found face down on top of NA #1. The Director of Nursing reported Nurse #1 and Unit Manager #1 responded to the fall and Resident #39 was assessed, determined to have facial swelling and returned to her bed. She also stated that Resident #39's responsible party, the physician, and hospice care were notified. The Director of Nursing reported at the request of hospice; Resident #39 was sent out to the hospital for further evaluation and treatment. She stated when Resident #39 arrived at the hospital, she was diagnosed with an acute subdural hematoma and contusions to her face. The Director of Nursing continued, stating after her investigation into the fall, she determined the root cause to be due to Resident #39's poor trunk control. She stated at the time of the 02/23/25 fall; Resident #39 was a one person assist with care and was subsequently downgraded to a two-person assist after the fall. The Director of Nursing reported Resident #39 was not taking any anticoagulant medications at the time of the fall and reported she could not recall if Resident #39 had been identified as a potential fall risk prior to the fall. The Director of Nursing reported she did not believe that NA #1 had done anything wrong when providing incontinence care to Resident #39 but stated a resident should not fall out of bed during care. An interview with the Administrator on 09/05/25 at 12:58 PM revealed she was familiar with Resident #39 and the 02/23/25 fall. She reported it was her understanding that Resident #39 was being provided with incontinence care when NA #1 rolled Resident #39 towards her to continue care and due to Resident #39's poor trunk control, the top half of Resident #39 came off the bed. The Administrator stated NA #1 tried to gain control of Resident #39 but due to her weight, Resident #39 continued to roll off of the bed and onto NA #1 and both ended up on the floor. She stated as far as she knew, Resident #39 was assessed before being moved back into bed. The Administrator continued, stating Resident #39 was subsequently sent to the hospital for further evaluation and treatment and that the only injury she was aware of was a hematoma to Resident #39's head. She reported upon review of the hospital report; it appeared as though Resident #39 had a very thin subdural hematoma with no other injuries noted. The Administrator reported Resident #39 was not admitted to the hospital and had returned to the facility via facility transportation. The Administrator stated upon Resident #39's return to the facility, there were no ongoing indicators of pain or mental anguish. She also stated a resident should not fall during care but stated that NA #1 was doing what she expected her to do, that NA #1 had the bed at the correct height to prevent falling, rolled Resident #39 towards her while she provided care, and obviously attempted to prevent Resident #39 from falling as evidenced by NA #1 being underneath Resident #39 after the fall.

Based on observations, record reviews and interviews the facility failed to post cautionary safety signs that indicated the use of oxygen for 5 of 6 residents reviewed for respiratory care (Resident #79, #93, #136, #137 and #161). The findings included: 1) Resident #136 was admitted to the facility on [DATE] with a diagnosis of shortness of breath. A review of a significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #136 was cognitively intact with no behaviors and no rejections of care. Resident #136 was coded for oxygen therapy. Review of a physician's order dated 7/8/2024 revealed an order for Resident #136 was to have oxygen administered at 2 liters per minute via nasal canula continuously. An observation was conducted on 7/8/2024 at 12:02 pm. Resident #136 was observed lying in bed with oxygen being administered at a rate of 2 liters per minute. There was no oxygen signage outside of Resident #136's room or on the doorframe. An observation was conducted on 7/8/2024 at 2:09 pm. There was no oxygen signage on the unit doors or outside of Resident #136's unit. An observation was conducted on 7/9/2024 at 9:42 am. Resident #136 was observed lying in bed with oxygen being administered at a rate of 2 liters per minute. There was no oxygen signage outside of Resident #136's room or on the doorframe. An observation was conducted on 7/10/2024 at 8:47 am. Resident #136 was observed lying in bed with oxygen being administered at a rate of 2 liters per minute. There was no oxygen signage outside of Resident #136's room or on the doorframe. An interview was conducted on 7/10/2024 at 3:57 pm with Nurse #3. Nurse #3 stated when a resident was on oxygen there would be an order for oxygen in the computer, there would be an oxygen concentrator in their room, and an emergency tank of oxygen on their wheelchair. Nurse #3 stated nurses had not put oxygen in use signs outside of resident's doors because it was a privacy issue. An interview was conducted on 7/10/2024 at 4:24 pm with the Staff Development Coordinator (SDC). The SDC stated when a resident was on oxygen the nurse should verify the order on the Medication Administration Record (MAR). The SDC reported oxygen signage was not required in the facility except outside of the oxygen storage room. An interview was conducted on 7/11/2024 at 4:03 pm with the Director of Nursing (DON). The DON stated when a resident is on oxygen the nursing staff changes the tubing weekly on night shift and there is an oxygen company that comes to the facility and cleans the filters. The DON reported the nurse on the hall is responsible for verifying the oxygen is being delivered at the correct rate based on the physician's order. The DON stated the facility had not used signage outside of resident rooms because the facility was smoke free and reported there was oxygen signage only outside of the oxygen storage rooms. The DON stated she was not aware there had to be signage outside of resident rooms. 2) Resident #161 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with hypoxia. Review of a physician's order dated 6/28/2024 revealed an order for Resident #161 was to have oxygen administered at 2 liters per minute via nasal canula continuously. A review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #161 was severely cognitively impaired and was coded for oxygen therapy. An observation was conducted on 7/8/2024 at 11:49 am. Resident #161 was observed lying in bed with oxygen being administered at a rate of 2 liters per minute. There was no oxygen signage outside of Resident #136's room or on the doorframe. An observation was conducted on 7/8/2024 at 2:09 pm. There was no oxygen signage on the unit doors or outside of Resident #161's unit. An observation was conducted on 7/9/2024 at 9:24 am. Resident #161 was observed lying in bed with oxygen being administered at a rate of 2 liters per minute. There was no oxygen signage outside of Resident #161's room or on the doorframe. An observation was conducted on 7/10/2024 at 8:44 am. Resident #161 was observed lying in bed with oxygen being administered at a rate of 2 liters per minute. There was no oxygen signage outside of Resident #161's room or on the doorframe. An observation was conducted on 7/11/2024 at 10:27 am. Resident #161 was observed lying in bed with oxygen being administered at a rate of 2 liters per minute. There was no oxygen signage outside of Resident #161's room or on the doorframe. An interview was conducted on 7/10/2024 at 3:57 pm with Nurse #3. Nurse #3 stated when a resident was on oxygen there would be an order for oxygen in the computer, there would be an oxygen concentrator in their room, and an emergency tank of oxygen on their wheelchair. Nurse #3 stated nurses had not put oxygen in use signs outside of resident's doors because it was a privacy issue. An interview was conducted on 7/10/2024 at 4:24 pm with the Staff Development Coordinator (SDC). The SDC stated when a resident was on oxygen the nurse should verify the order on the Medication Administration Record (MAR). The SDC reported oxygen signage was not required in the facility except outside of the oxygen storage room. An interview was conducted on 7/11/2024 at 4:03 pm with the Director of Nursing (DON). The DON stated when a resident is on oxygen the nursing staff changes the tubing weekly on night shift and there is an oxygen company that comes to the facility and cleans the filters. The DON reported the nurse on the hall is responsible for verifying the oxygen is being delivered at the correct rate based on the physician's order. The DON stated the facility had not used signage outside of resident rooms because the facility was smoke free and reported there was oxygen signage only outside of the oxygen storage rooms. The DON stated she was not aware there had to be signage outside of resident rooms. 35789 3. Resident #93 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure. Review of a physician order dated 04/20/24 read oxygen at 3 liters per minute continuously via nasal canula. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #93 was moderately cognitively impaired and required the use of oxygen. An observation of Resident #93 was made on 07/09/24 at 9:27 AM. Resident #93 was resting in bed with oxygen being administered at 3 liters per minute via nasal canula. There was no cautionary sign noted to her door, door frame, or environment. An observation of Resident #93 was made on 07/10/24 at 4:11 PM. Resident #93 was resting in bed with oxygen being administered at 3 liters per minute via nasal canula. There was no cautionary sign noted to her door, door frame, or environment. An observation of Resident #93 was made on 07/11/24 at 11:28 AM. Resident #93 was resting in bed with oxygen being administered at 3 liters per minute via nasal canula. There was no cautionary sign noted to her door, door frame, or environment. An interview was conducted with Nurse #5 on 07/11/24 at 1:46 PM who confirmed she was caring for Resident #93. Nurse #5 stated that she had been working at the facility since November 2023 and knew that oxygen tubing was assigned to be changed weekly on third shift. She stated that she thought it was third shift but just knew that it was not assigned to be completed on her shift. Nurse #5 stated that she checked Resident #93's oxygen concentrator throughout her shift to ensure that the correct dose of oxygen was being delivered. Nurse #5 stated that the facility utilized the red no smoking signs on doors and was then asked to go and observe Resident #93's room. Nurse #5 confirmed that there was no cautionary sign on the door or on the door frame or in the environment where Resident #93 resided, and oxygen was being delivered. The Director of Nursing (DON) was interviewed on 07/11/24 at 4:03 PM. The DON stated that oxygen tubing, oxygen cannulas and nebulizer sets were changed out weekly by the nurse on third shift. The nurse was responsible for checking the dose routinely throughout the shift. The DON stated that the facility utilized cautionary no smoking signs on the oxygen storage rooms only and added that something was posted on the front door of the facility about the facility being tobacco free. The DON stated that she believed that the cautionary signs only needed to be where oxygen was stored but added they could add the cautionary signs where oxygen was administered as well. 4. Resident #137 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and congestive heart failure. Review of a physician order dated 06/13/24 read; oxygen via nasal cannula at 3 liters per minute continuously. Review of a significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #137 was cognitively intact, had shortness of breath with exertion and when lying flat and required the use of oxygen. An observation of Resident #137 was made on 07/08/24 at 3:18 PM. Resident #137 was resting in bed with oxygen being delivered at 3 liters per minute via nasal canula. There was no cautionary sign noted to her door, door frame, or environment. An observation of Resident #137 was made on 07/09/24 at 9:20 AM. Resident #137 was resting in bed with oxygen being delivered at 3 liters per minute via nasal canula. There was no cautionary sign noted to her door, door frame, or environment. An observation of Resident #137 was made on 07/10/24 at 9:15 AM. Resident #137 was resting in bed with oxygen being delivered at 3 liters per minute via nasal canula. There was no cautionary sign noted to her door, door frame, or environment. An observation of Resident #137 was made on 07/11/24 at 1:47 PM. Resident #137 was resting in bed with oxygen being delivered at 3 liters per minute via nasal canula. There was no cautionary sign noted to her door, door frame, or environment. An interview was conducted with Nurse #5 on 07/11/24 at 1:46 PM who confirmed she was caring for Resident #93. Nurse #5 stated that she had been working at the facility since November 2023 and knew that oxygen tubing was assigned to be changed weekly on third shift. She stated that she thought it was third shift but just knew that it was not assigned to be completed on her shift. Nurse #5 stated that she checked Resident #137's oxygen concentrator throughout her shift to ensure that the correct dose of oxygen was being delivered. Nurse #5 stated that the facility utilized the red no smoking signs on doors and was then asked to go and observe Resident #93's room. Nurse #5 confirmed that there was no cautionary sign on the door or on the door frame or in the environment where Resident #137 resided, and oxygen was being delivered. The Director of Nursing (DON) was interviewed on 07/11/24 at 4:03 PM. The DON stated that oxygen tubing, oxygen cannulas and nebulizer sets were changed out weekly by the nurse on third shift. The nurse was responsible for checking the dose routinely throughout the shift. The DON stated that the facility utilized cautionary no smoking signs on the oxygen storage rooms only and added that something was posted on the front door of the facility about the facility being tobacco free. The DON stated that she believed that the cautionary signs only needed to be where oxygen was stored but added they could add the cautionary signs where oxygen was administered as well. 37280 5. Resident #79 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and respiratory failure. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79's cognition was moderately impaired, and she wore supplemental oxygen. A review of Resident #79's medical record revealed an order dated 07/08/24 for supplemental oxygen via nasal cannula at 2 liters per minute. An observation was made on 07/08/24 at 11:55 AM of Resident #79's room. In the room sat an oxygen concentrator with the nasal cannula lying on the Resident's bed. The concentrator was infusing oxygen at 2 liters per minute. Resident #79 was not in the room. There was no oxygen cautionary sign posted on the Resident's door or near her room to indicate oxygen was in use. An observation on 07/08/24 at 12:37 PM was made of Resident #79 sitting in the dining room wearing oxygen via nasal cannula delivered from the E-tank which was mounted on the back of the Resident's wheelchair. On 07/08/24 at 1:30 PM an observation and interview made with Resident #79 revealed the Resident was sitting in the doorway of her room but would not respond to simple questioning. Resident #79 wore oxygen via nasal cannula delivered at 2 liters via E-tank which was mounted on the back of her wheelchair. An interview was conducted with Nurse Aide (NA) #1 on 07/09/24 at 3:00 PM. The NA explained that the facility did not post cautionary signs for oxygen near the residents' door, but they did post the no smoking signs on the door where oxygen was stored. On 07/10/24 at 10:05 AM Resident #79 was sitting up in bed wearing oxygen via nasal cannula at 2 liters from an oxygen concentrator. There was no oxygen cautionary sign posted on or near the Resident's door. An interview was conducted with Nurse #2 on 07/10/24 at 10:24 AM. The Nurse explained that the facility did not post oxygen cautionary signs on the residents' rooms, and they only posted the signs on the rooms where oxygen was stored. On 07/11/24 at 4:05 PM during an interview with the Director of Nursing (DON) she explained that the facility was a smoke free facility and did not allow smoking in the building or the grounds. The DON stated the cautionary signs were posted where oxygen was stored in the building, but the signs were not posted on the residents' doors where oxygen was in use. She indicated she thought having the smoke free facility sign posted on the front entrance was sufficient for the regulation.

Based on record review, staff interview, and Nurse Practitioner (NP) interviews the facility failed to ensure a resident's (Resident #32) code status election was accurate throughout the medical record for 1 of 2 residents (Resident #32) reviewed for advanced directives. The findings included: Resident #32 was admitted to the facility on [DATE] with a diagnosis of heart disease. A review of a physician's order dated [DATE] revealed Resident #32 was a full code. A review of a Medical Orders for Scope of Treatment (MOST) form dated [DATE] indicated Resident #32 wanted cardiopulmonary resuscitation (CPR, chest compressions), limited scope of treatment which included to use medical treatment, intravenous (IV) fluids and cardiac monitoring as indicated, do not use intubation (breathing tube) or mechanical ventilation (ventilator); also provide comfort measures, transfer to the hospital if indicated, and avoid intensive care. The MOST form was signed by Nurse Practitioner (NP) #1 and completed by the Social Worker (SW). A review of the advanced directives book at the nurse's revealed Resident #32 had a Medical Orders for Scope of Treatment (MOST) form dated [DATE] which indicated Resident #32 wanted cardiopulmonary resuscitation (CPR, chest compressions), limited scope of treatment which included to use medical treatment, intravenous (IV) fluids and cardiac monitoring as indicated, do not use intubation (breathing tube) or mechanical ventilation (ventilator); also provide comfort measures, transfer to the hospital if indicated, and avoid intensive care. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively intact. A review of a physician's progress note dated [DATE] written by the Medical Director (MD) revealed Resident #32 wanted a full scope of treatment. An interview was conducted on [DATE] at 1:37 pm with Nurse #1. Nurse #1 stated when a resident was admitted a nurse manager would complete the MOST form and/or DNR form and place the form in the advanced directives book at the nurse's station. Nurse #1 verified not all residents have a MOST form and in the event of an emergency, she would refer to the order in Electronic Health Record (EHR). Nurse #1 verified Resident #32 was a full code in the EHR. An interview was conducted on [DATE] at 8:55 am with the SW. The SW stated when a resident was admitted to the facility, she was responsible for discussing code status with the resident and/or representative and completed the MOST form. The SW stated that she would ask the resident or resident representative if they wanted to have CPR and would elect either CPR or Do Not Resuscitate (DNR). The SW stated she then would read the scope of treatment options and elect the one the resident desired. The SW stated the facility did not require residents to have a MOST form. The SW stated after she completed the MOST form, she had a provider review and sign the form and she then would take the MOST form to medical records where it was scanned into the chart. The SW stated after Medical Records scanned the form into the chart, she delivered the form to the appropriate nursing unit, would have the resident's nurse review the form for accuracy and completion, and would put the completed form in the advanced directives book at the nurse's station. The SW stated she completed Resident #32's MOST form on [DATE]. The SW stated Resident #32 had elected to have CPR and she was unsure of what limitations, if any, that Resident #32 wanted. The SW verified Resident #32 had an order for full code in the Electronic Health Record (EHR) and agreed that the code status should match and reflect limitations. The SW stated the admitting nurse was responsible for entering the code status order into the computer. An interview was conducted on [DATE] at 8:32 am with the Admission Nurse. The Admission Nurse stated she would ask residents about their code status and preferences on admission. The Admission Nurse reported after she verified the MOST form, she would enter the code status order in the chart. The Admission Nurse stated that if a MOST form indicated CPR with limited scope of treatment, she would enter the code status as full code and reported the facility does not enter limitations because the facility does not intubate or place residents on mechanical ventilation. The Admission Nurse stated the MOST form, active code status order, and code status on the progress note should have been consistent. NP #2 was unavailable for interview. The MD was unavailable for interview. An interview was conducted on [DATE] at 11:15 am with Resident #32. Resident #32 stated he was able to remember someone, unsure of name, going over code status information on admission. Resident #32 expressed he wished to have CPR but he was not sure if he wanted any additional interventions because he was not sure what limitations were allowed. An interview was conducted on [DATE] at 11:53 am with NP #2. NP #2 stated on admission, the SW reviewed and completed a MOST form with the resident. NP #2 stated when she conducted her visit with the resident upon admission, code status was reviewed with the resident and resident representative. NP #2 stated she was familiar with Resident #32 but was unaware that Resident #32 had a MOST form that indicated CPR with limited scope of treatment. NP #2 stated the facility would still enter in a full code order, but verbalized the progress note should not have said full scope of treatment if the resident wanted limited interventions. NP #2 stated she was not sure what limitations Resident #32 wanted. An interview was conducted on [DATE] at 4:36 pm with the Director of Nursing (DON). The DON stated she thought nursing was responsible for completing the MOST forms and was unaware the SW had been completing them. The DON stated not all residents had a MOST form, but it was recommended. The DON stated code status was discussed on admission with nursing staff and the medical provider. The DON stated if a resident had elected CPR and limited scope of treatment on the MOST form, nursing staff would enter a full code order into the EHR. The DON stated limited scope of treatment included everything that would be performed in the facility because we do not intubate or ventilate. The DON stated she was not aware of what limitations Resident #32 would want and stated that limitations should be written in under the instructions portion of the MOST form. The DON was unsure why the MD progress note dated [DATE] revealed Resident #32 wished to receive a full scope of treatment. The DON stated the MOST form, code status order, and medical provider's progress note should indicate the resident's wishes. An interview was conducted on [DATE] at 5:20 pm with the Administrator. The Administrator reported the SW was responsible for going over code status wishes with the resident and/or resident representative upon admission and completed the MOST form at that time. The Administrator was not aware that Resident #32 had a MOST form that indicated CPR with limited scope of treatment, an order for full code in the EHR, and a physician progress note dated [DATE] that revealed Resident #32 wished to have a full scope of treatment. The Administrator verbalized Resident #32's code status should be consistent throughout the medical record.

Based on resident council meeting minutes, resident, and staff interview the facility failed to resolve dietary grievances that were reported in the resident council meeting for 8 out of 10 months (June 2021, July 2021, August 2021, September 2021, October 2021, December 2021, January 2022, and February 2022). a. Review of the 06/03/21 Resident Council (RC) minutes revealed the following dietary concern: the council commented on vegetables such as green beans and potatoes sometimes being undercooked. The response to the concern of vegetables such as green beans and potatoes being undercooked read in part: will address with staff in kitchen. The response was signed by the Administrator. b. Review of the 07/01/21 RC minutes revealed the following dietary concerns: the group had the following concerns about food such as beans, potatoes, carrots, rice, and noodles being undercooked and too hard to eat. They were often served something other than what was on the menu. The response to the concern of food quality read in part: will follow up with individual resident on food preferences. The response was signed by the Administrator. c. Review of the 08/19/21 RC minutes revealed the following dietary concerns: meals are cold and tough, and they were not being served what was on the menu. The response to the concern of food/dining read: being addressed by Dietary Manager (DM). The response was signed by the Executive Director (filling in for the Administrator). d. Review of the 09/02/21 RC minutes revealed the following dietary concerns: poor communication when menu changes occur, they would like to be notified when the menu changed, and vegetables were still undercooked. The response to the dining and food service concerns read: response from DM noted in green (no attachment was included that indicated the DM's response to the concerns). The response was signed by the Executive Director. e. Review of the 10/07/21 RC minutes revealed the following dietary concerns: still not getting items listed on the menu and baked and sweet potatoes are served undercooked. The response to the food service concerns were in an attached email that read in part: We are experiencing supply challenge from vendors. Regarding the baked and sweet potatoes being served undercook the response read: we will look into that and correct it. The response was signed by the Administrator. f. Review of the 12/02/21 RC minutes revealed the following dietary concerns: potatoes and green beans were not cooked long enough, and food was served cold in the rooms. The response to the food concerns read: addressed by staff who attended the meeting. The response was signed by the Administrator. g. Review of the 01/03/22 RC minutes revealed the follow dietary concerns: the council expressed concerns about not having condiments requested in the dining room like ketchup, honey mustard or ranch. The DM reminded them of the supply issues they were having. The response form was blank and was signed by the Administrator. h. Review of the 02/10/22 RC minutes revealed the following dietary concerns: the council expressed concerns about not having everything needed on their meal tray or when being served in the dining room such as water, salt, pepper, and other condiments. The response to the concerns of not having needed items such as water, salt and other condiments on meal trays read: staff educated to ask if anything else was needed before leaving room/dining table. Spoke with DM about stocking cabinets and assigned duties of staff. The response was signed by the Administrator. A RC meeting was held on 05/05/22 at 10:19 AM with 13 members of the RC. The council reported having food concerns with cold food and as well as the food not being good. A follow up interview was conducted with Resident #117 on 05/05/22 at 2:15 PM. Resident #117 confirmed that she regularly attended resident council and she continued to have issues with not having condiments on her meal tray and the vegetables were hard and undercooked. Resident #117 stated that last week the baked potato was not done and was so hard you couldn't put the spoon through it. The Activity Director (AD) was interviewed on 05/05/22 at 2:11 PM who confirmed that she took notes during each RC meeting and then sent an email to the department head that was affected and copied the Administrator on the email as well. The AD stated that food was always a major discussion in RC, but it was never a consistent issue. Sometimes the council would complaint that the food was undercooked and sometimes it was overcooked. She added that they seemed to resolve one topic and move on to something else and sometimes a resolved issue would come back up later. The AD stated she always received a response from the department head, and she would take that response to the RC meeting the following month. The DM was interviewed on 05/05/22 at 3:01 PM and stated that he or a member of his staff attended the RC meetings. He stated that after the RC meeting he would receive an email from AD with any concerns voiced during the meeting and he was responsible for responding to and determining how to address the concern. Once the concern had been investigated and resolved it was sent to the Administrator for approval. The DM stated that sometimes the council would complain of the vegetables being undercooked and hard and then it would be too soft and mushy. He stated he had switched to green beans because the residents seemed to like those. The DM stated that he did not believe the issues voiced in resident council represented a concern of the majority of the residents and he could not alter the menu as a whole so he tried to correct individual concerns. He added the vegetables were cooked to a point where they were palatable and further explained he had his staff interacting with the residents after meals to see if they enjoyed the meal and they always received positive feedback. The DM stated he had no additional documentation to the resolutions provided to the RC except what was documented in the RC meeting minutes. The Administrator was interviewed on 05/05/22 at 2:26 PM. The Administrator confirmed that the AD took notes during the RC meeting and would send an email to the department head and to her. The Administrator stated she generally gave the department head a couple of days to submit their response and follow up and if she agreed with the response then the response was signed off. The Administrator stated she would have expected the DM to identify who was complaining and see if it was a mastication (chewing) issue and to see why the vegetables were undercooked. The Administrator confirmed that she had no other documentation and if the follow up was provided via email the email was attached to the RC minutes. She added that the AD attended the Quality Assurance (QA) meeting quarterly but did not always bring the RC minutes which she stated might be helpful in resolving some of the dietary issues.

Based on observations, staff interviews, and record review, the facility failed to label, date, and seal stored food items in 2 of 2 kitchens (main kitchen and satellite kitchen located on the first floor at the front of the facility). The facility also failed to discard stored foods after the manufacturer's expiration date in 2 of 2 kitchens (main kitchen and satellite kitchen). These practices had the potential to affect all residents who receive oral food nutrition. The findings included: 1. A brief tour of the satellite kitchen located on the first floor in the front of the facility on [DATE] at 10:59 AM with Cook #1 and Dietary Supervisor #1 revealed the following items which had all been removed from their original packaging: In the mini freezer located under the toaster: - A press and seal plastic bag with 3 frozen hamburger patties unlabeled or dated with visible ice crystals on the surface - A partially used and unsealed bag containing 8 frozen chicken tenders unlabeled or dated - A partially used and unsealed bag of potato wedges unlabeled or dated - A partially used and unsealed bag of French fries unlabeled or dated - A metal steam table container which held 4 frozen fish filets with a prepare by date of ,d+[DATE] - A clear plastic bag of frozen chicken tenders unlabeled or dated which showed visible ice crystals on the surface In the two-glass door reach-in cooler: - 5 cartons of chocolate milk with no manufacturer's expiration date - An open sleeve of pasteurized American cheese unlabeled with an open/expiration date In single-door solid front reach-in refrigerator: - 2 containers of probiotic yogurt with an expiration date of [DATE] - 1 container of strawberry yogurt with an expiration date of [DATE] An interview on [DATE] at 11:15 AM with Cook #1 and Dietary Supervisor #1 revealed they did not realize the food items located in the freezer and cooler were unlabeled and undated nor did they realize the food items located in the refrigerator had expired. Both had been trained all items should be labeled and dated when removed from their original packaging and items should be discarded if they have reached their expiration dates. 2. A follow-up observation of the satellite kitchen located on the first floor at the front of the facility on [DATE] at 10:30 AM with the Food Service Director (FSD) revealed the following items which had all been removed from their original packaging: In the mini freezer located under the toaster: - A partially used and unsealed bag of French fries unlabeled or dated - A metal steam table container which held 3 frozen fish filets with a prepare by date of ,d+[DATE] Under the food preparation counter, a pan was on the lower shelf which contained multiple spices: - A smaller metal container which held an unidentifiable reddish-orange spice with clear plastic wrap partially covering the container and the other portion exposed to air unlabeled or dated 3. An observation of the main kitchen on [DATE] at 10:45 AM with the FSD revealed the following: In the milk cooler: - 5 cartons of chocolate milk with no manufacturer's expiration date In the side-by-side freezer: - A clear plastic bag of frozen chicken tenders unlabeled or dated which showed visible ice crystals on the surface - 4 hotdog [NAME] wrapped in a clear plastic wrap unlabeled or dated - A large partially used and unsealed plastic package of hotdog [NAME] which contained visible ice which had formed were unlabeled or dated - An opened white paper box with a clear plastic lining containing an unidentifiable breaded food item. The clear lining was not resealed, showed visible ice crystals on the surface, and the packaging did not contain a label or date 4. A follow-up observation to the main kitchen on [DATE] at 2:15 PM with the FSD revealed the following: In the side-by-side refrigerator: - A paper box of raisins with an opened lid was labeled [DATE] with no expiration date. - A large clear plastic bag which was unsealed containing a head of lettuce. The lettuce showed signs of spoilage with the leaves which had turned from its original color to a yellow-brown discoloration. - A cardboard egg tray which contained 15 whole eggs with no label or use by date on the crate In the walk-in fridge: - A plastic container of sliced cheddar cheese which was opened and contained no labels with an open or discard date. When the package was lifted, the bottom of the orange cheese showed 3 large areas of a white and green circular fuzzy substance attached. - 2 large plastic bags of spinach leaves which contained a visible reddish brown liquid substance seeping through the bag and onto the spinach leaves. When the bags were lifted, the bags of spinach leaves contained small pin holes in the plastic from the manufacturer. An interview with the FSD on [DATE] at 2:45 PM revealed he was unable to explain why items were found in the kitchen and available for use/resident consumption were unlabeled or dated, expired, or with signs of spoilage. The FSD stated all dietary staff should label, store, rotate and discard items when they have reached their expiration date or show signs of spoilage. The FSD indicated the coolers, refrigerators, and freezers should be checked at least weekly and items discarded appropriately. An interview with the Administrator on [DATE] at 11:21 AM revealed she was made aware the satellite on the first floor and main kitchen had food items observed which were unlabeled or dated. She also indicated she had been made aware of item which were expired and that showed signs of spoilage that were available for staff usage and resident consumption. The Administrator stated the dietary staff should label all food items stored and all items should be discarded by their expiration dates, storage dates, or if they show signs of soilage.

Based on observation, record review, and staff interview, the facility failed to ensure staff donned Personal Protective Equipment (PPE) according to the Center of Disease Control and Prevention (CDC) to include a gown, gloves, eyewear, and a N-95 mask when Nurse Aide #1 (NA #1) entered a resident's room who was under transmission-based precautions (TBP) labeled Quarantine Enhanced Barrier Precautions for 1 of 1 residents reviewed for infection control (Resident #331). Findings included: The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 2/2/22 indicated the following statement under Section 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection: HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Resident #331 was admitted to the facility on [DATE] for short term rehabilitation. An observation and interview on 05/02/22 at 12:18 PM revealed NA #1 knock on Resident #1's door and speak to the resident from the doorway. The signage on the door indicated Resident #1 was under the transmission-based precautions: Quarantine Enhanced Barrier Precautions which indicated a gown, gloves, eyewear, and a N-95 mask were to be worn when in entering the room. NA #1 entered the room wearing only a surgical mask and retrieved two clear plastic bags and exited the room carrying them in his ungloved hand. One bag was observed to contain facility linen and the other contained trash. The surveyor immediately stopped NA #1 when he exited Resident #1's room and asked him about the observation. NA #1 indicated he had been educated to don a gown, gloves, eyewear, and N-95 mask when he went in a resident's room who was on Quarantine Enhanced Barrier Precautions. NA #1 stated he had not intended to go in the room and completely forgot to don the PPE on when he entered. An interview on 05/05/22 at 1:40 PM with Medication Aide #1 (MA#1) revealed she was assigned to the medication cart where Resident #1 resided on 05/02/22 during day shift. MA #1 indicated Resident #1 was a new admission and was on TBP: Quarantine Enhanced Barrier Precautions because he was unvaccinated upon admission. MA #1 stated she was not aware staff had entered Resident #1's room without PPE but had been educated to stop staff and remind them to don full PPE to include a gown, gloves, eyewear, and a N-95 mask before entering the room of all residents on Quarantine Enhanced Barrier Precautions and alert the nurse if she saw. An interview on 05/05/22 at 2:02 PM with the Director of Nursing (DON) revealed she was not aware NA #1 had been observed to not don his PPE when he entered Resident #1's room; however, confirmed Resident #1 was on TBP: Quarantine Enhanced Droplet Precautions due to his vaccination status upon admission. The DON stated all staff had been educated to don full PPE to include a gown, gloves, eyewear, and a N-95 mask before entering the room of a resident on Quarantine Enhanced Droplet Precautions and wondered what NA #1 was doing with the bags since Resident #1 is continent of bowel and bladder and performs his own personal Activities of Daily Living (ADL) care and asked that we speak with NA #1 together. A follow-up interview on 05/05/22 at 2:10 PM with NA #1 and the DON revealed NA #1 stated on 05/02/22 during day shift he had approached Resident #1's room to speak to Resident #1 and his family member to see if they needed anything which he did from the threshold of the door when he noticed a soiled towel near the sink in Resident #1's room. NA #1 stated without a second thought, he entered the room to retrieve it and noticed the trash also needed to be emptied, so he quickly grabbed both bags and exited Resident #1's room when the surveyor approached him. NA #1 explained he immediately realized he had not donned on the PPE according to the signage posted on both Resident #1's room and the isolation cart placed directly outside Resident #1's room. NA #1 elaborated to say, Had I not saw the linen, I wouldn't have ever gone in the room. I've thought about it all week and feel terrible about it. It won't happen again. An interview on 05/05/22 at 2:15 PM with the Administrator revealed she was familiar with Resident #1 and expects all staff to don the appropriate PPE posted on all TBP signage. She stated staff should don full PPE once they cross the doors threshold to include: a gown, gloves, eyewear, and a N-95 mask before entering rooms labeled Quarantine Enhanced Barrier Precautions.

Based on observation, staff interview, and record review the facility failed to ensure that frozen fish, stored ready for use, was within the use by date. The facility accepted frozen fish more than 2 years past the production date. This practice had the potential to affect residents. The findings included: An inital tour of the kitchen was made on 12/16/19 at 9:47 AM with the Dietary Manager (DM). Observations made of the freezer revealed 3 boxes of frozen Flounder. The frozen Flounder was labeled with a production date of 07/05/17. During the observation, the DM was interviewed and reported he was unaware of the date and when the fish should be used. A document titled Shelf Life Guidelines revised on 01/12/17 taped on the wall in the kitchen area specified safe storage frozen fish was 6 months. Review of the weekly menus revealed Flounder was listed as an entrée for service. In a follow-up interview with the DM on 12/19/19 at 10:15 AM he explained that the policy for frozen fish was to store for 6 months. The DM stated that the frozen Flounder was delivered on 12/10/19 out of date. He added that he had contacted the food vendor and verified the fish was out of date. The DM also explained that when food was delivered to the facility, a staff member was designated to randomly inspect one or two boxes before accepting the delivery and rated the delivery as good or damaged and temperatures were taken of food. The DM stated he had never been presented with this type of problem before.

Based on record review and staff interview the facility failed to accurately code the Minimum Data Set to reflect a resident bowel movement (Resident #121) for 1 of 1 resident reviewed for respiratory care. The findings included: Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility document titled Activity of Daily Living Worksheet dated 11/21/19 through 12/17/19 revealed that Resident #121 had a bowel movement on 11/25/19 at 12:34 PM. Review of the comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #121 was moderately impaired for daily decision making and required extensive assistance of one staff member with toileting. The MDS further revealed that Resident #121 was not rated for bowel continence (no bowel movement in the 7-day reference period) and constipation was noted. The MDS was completed by MDS Nurse #1. An interview was conducted with MDS Nurse #1 on 12/18/19 at 11:57 AM. MDS Nurse #1 stated that she had a sheet that she collected information to complete the MDS assessment. She indicated that she used that sheet, conducted a resident interview, nurses notes, and the bowel report. She indicated that she printed the bowel report for Resident #121's MDS dated [DATE] and the bowel movement that was recorded on 11/25/19 did not appear on her report. MDS Nurse #1 indicated she would have captured the bowel movement if it had appeared on her report. An interview was conducted with the Director of Nursing (DON) on 12/18/19 at 4:16 PM. The DON stated that MDS Nurse #1 printed a report that was only completed by the Nursing Assistants (NAs) and the report that she provided was a report completed by both the Nurses and the NAs. The DON stated that MDS Nurse #1 should have pulled the report completed by both the Nurses and NAs so she had the most accurate information and should have coded the bowel movement correctly on the MDS. A follow up interview was conducted with MDS Nurse #1 on 12/19/19 at 10:25 AM. She stated that the DON had educated her on how to the pull the report that included all the documentation. She added that she believed that the 2 reports were combined and did not realize they were not. MDS Nurse #1 stated that if she would have caught the bowel movement on 11/25/19 she would have coded the MDS correctly, but she was not aware of the 2 different reports. An interview was conducted with the Administrator on 12/19/19 at 12:47 PM. The Administrator stated that she expected the staff to pull the correct information to code the MDS accurately.

Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed follow up on an order to check on a resident's ambulation program and honor a resident's wish to ambulate daily in the hallway for 1 of 3 residents investigated for choices (Resident #99). The findings included: Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #99 was cognitively intact and had no rejection of care. The MDS further revealed that Resident #99 required limited assistance of 1 staff member with ambulation in his room and ambulation on the unit did not occur during the assessment reference period. The MDS also revealed that Resident #99 required extensive assistance of one staff member with toileting. No restorative ambulation program was recorded during the assessment reference period, however physical therapy was identified as having occurred during the assessment reference period. An undated care plan read in part, due to my chronic illness and generalized weakness I would benefit from a restorative nursing ambulation program. The goal read, I will be able to ambulate 50 feet with assistance through next review. The intervention read, ambulation program, allow for frequent rest periods as I become short of breath at time with ambulation. The status of the care plan indicated it was active and current. Review of a Nurse Practitioner (NP) progress note dated 12/10/19 read in part, denied any concerns today with the exception of wanting to walk more if possible. He was put to therapy services and was discharged . He is requesting to walk daily with staff if possible. The orders read, nursing please check into restorative program. Would like to ambulate daily if possible. The note was signed by the NP. Review of a nurses note dated 12/10/19 read in part, progress note received. Nursing to please check into restorative program for Resident #99. Resident would like to ambulate daily. No new orders at this time. Will continue to observe. Signed by Nurse #1. An interview was conducted with Nurse #1 on 12/19/19 at 1:20 PM. Nurse #1 confirmed that she had received the NP progress note about Resident #99's request to walk more. She added that she was just filling in on the unit that day and was not familiar with how things ran on the unit. She was instructed to let the Supervisor know about the order and she would take care of it. Nurse #1 stated that she did report the issue to the Nurse Supervisor (NS) that day. An interview was conducted with the NS on 12/19/19 at 1:27 PM. The NS stated should could not recall if Nurse #1 reported the order written by the NP on 12/10/19 regarding Resident #99's ambulation program. Typically, she would have reported the order to the ADON, especially if it was a new program. She added that she would have checked to make sure Resident #99 did not have a current restorative program and if he did not then definitely, she would have notified the ADON. An observation and interview with Resident #99 were conducted on 12/16/19 at 10:29 AM. Resident #99 was observed to be in the bathroom and had finished using the bathroom. He was noted to clean himself up and using the grab bars attached to the wall, pulled himself up to a standing position and transferred himself to the wheelchair sitting directly in front of the toilet. Resident #99 propelled himself to the sink to wash and dry his hands and then propelled himself out of the bathroom. Resident #99 stated that he had finished working with therapy and the staff were supposed to walk him, but they did not. He indicated that he got around in his room independently but no one was helping him walk out in the hallways. Resident #99 stated that he did not refuse to ambulate but stated that he had to have help with his oxygen tank. An interview was conducted with Nurse Aide (NA) #1 on 12/18/19 at 10:58 AM. NA #1 confirmed that she worked with Resident #99 frequently and was familiar with his needs. NA #1 indicated that she assisted him with getting up and dressed and once he was in his wheelchair, he was pretty self-sufficient. NA #1 indicated that Resident #99 would go into the bathroom to wash his face, shave, and brush his teeth. She added that he was supposed to alert the staff when he went into the bathroom but did not always do that. NA #1 stated that Resident #99 had worked with therapy and was scheduled for some type of restorative but could not recall which program. She added that on the days that there were no Restorative Aides (RA) to complete the schedule programs, she counted his transfers as restorative, but she was not comfortable walking him long distances by herself, so she counted his steps in the room as ambulation but did not walk Resident #99 out on the hallways. During a resident council meeting on 12/18/19 at 2:14 PM, Resident #99 stated that he would like to walk more but stated he thought the lack of be assisted with walking was due to him requiring the use of oxygen. A follow up interview was attempted with Resident #99 on 12/19/19 at 9:30 AM but was unsuccessful as he was out of the facility with his family. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/19/19 at 10:39 AM. She confirmed that she was responsible for the restorative program at the facility. The ADON stated that Resident #99 was currently on restorative for ambulation, transfers, and active range of motion and was scheduled at least 6 days a week but added they strive to do the programs daily. She added that Resident #99 ambulated in his room daily and the staff on the unit could document that as ambulation if they wanted to because all nursing staff were trained to provide restorative. The ADON added that Resident #99 did become short of breath often and his goal was to ambulate 50 feet with frequent rest breaks. An interview with the Restorative Aide (RA) was conducted on 12/19/19 at 11:19 AM. The RA confirmed that she assisted Resident #99 when she was working at the facility depending on how many RAs the facility had. She stated that she had a list of the residents that received programs and once they were completed then she would document them in the computer system. The RA stated that she documented the number of minutes Resident #99 walked when she assisted him and if he refused then she would indicate that in her documentation. The RA indicated that Resident #99 got short of breath a lot during activity and was very active in the activity program and at times would want to the ambulation at a different time. The RA added that the staff on the hall could ambulate Resident #99 as well and they would document it in the same place. An interview was conducted with the Physical Therapist Assistant (PTA) on 12/19/19 at 11:44 AM. The PTA confirmed that she treated Resident #99 during his time on therapy caseload from 09/26/19 through 11/15/19. She indicated that when Resident #99 was discharged from therapy on 11/15/19 he was referred to restorative for ambulation and exercise 15 minutes 6 days a week for each program. The PTA added that the biggest barrier for Resident #99 was his oxygen tank, he continued to need assistance with the tank. When Resident #99 was discharged from therapy he was walking 210 feet x 2 with 1 seated rest break which was no more than 3 minutes. She added he was very motivated to walk and never refused therapy. She added that at times he would want to go to activities and do his therapy at a later time but never refused to participate. An interview was conducted with the Director of Nursing (DON) on 12/19/19 at 12:06 PM. The DON stated that she expected the staff to meet Resident #99's need in regard to his ambulation or as he requested. A follow up interview was conducted with the ADON on 12/19/19 at 12:19 PM. The ADON stated that a lot of times during Resident #99 ' s range of motion he would get short of breath and want to do his ambulation later. She added the NAs on the unit walked him to/from the bathroom every day and maybe he did not perceive that as walking. The ADON stated that Resident #99's goal was 50 feet and she had never seen him walk 200 feet. She added that the NAs on the unit have attempted to walk him and he was meeting his goals just walking in shorter periods. The ADON stated the staff meet weekly and there were no concerns brought to her attention about Resident #99 ' s ambulation. She also was unaware of the NPs progress note regarding his ambulation but stated she could go and talk to him and see what he wanted to do. An interview was conducted with the NP on 12/19/19 at 1:13 PM. The NP recalled the visit with Resident #99 on 12/10/19 and he conveyed to her that he wanted to walk daily. She stated that he was previously on therapy caseload and was walking 2-3 times a day out on the units and wanted something like that. She added that she did not have access to the restorative program, so she put an order in for the nursing staff to check and follow up.

Based on observations, record reviews, staff, Nurse Practitioner, and Medical Doctor Interviews the facility failed to administer the correct antianxiety medication to the correct resident as ordered for 1 of 5 residents sampled for unnecessary medications (Resident #89). Resident #89 was administered [MEDICATION NAME] (antianxiety medication) instead of [MEDICATION NAME] (antianxiety medication) as he was prescribed. The findings included: Resident #89 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly minimum data set ((MDS) dated [DATE] indicated Resident #89 was cognitively intact. The MDS also indicated Resident #89 had received 7 days of antianxiety medication during the assessment reference period. Review of the physician order [REDACTED].#89 was prescribed [MEDICATION NAME] 0.5 milligrams (mg) by mouth twice a day and every 4 hours as needed. An observation of the narcotic count on the Harmony Court where Resident #89 resided was made on 01/25/18 at 11:00 AM with Nurse #3 and revealed a discrepancy. The declining narcotic sheet indicated Resident #89 had 14 [MEDICATION NAME] pills remaining and there were 15 [MEDICATION NAME] pills in the medication cart. Nurse #3 confirmed the discrepancy and stated she would notify her supervisor immediately. An interview was conducted with Nurse #3 on 01/25/18 at 11:04 AM. Nurse #3 confirmed she had counted her medication cart at shift change that morning with the off going nurse and to her knowledge the narcotic count was correct. Review of a Medication Error Form dated 01/25/18 indicated on 01/24/18 Nurse #1 administered Resident #89 [MEDICATION NAME] 0.5 mg by mouth that was prescribed for another resident instead of the [MEDICATION NAME] 0.5 mg by mouth that was prescribed for Resident #89. The form indicated there was no adverse side effects noted and the physician had been notified. An interview was conducted with the Assistant Director of Nursing (ADON) on 01/25/18 at 2:18 PM. The ADON confirmed that she was Nurse #3's supervisor and after researching the discrepancy determined that on 01/24/18 Nurse #1 had administered the [MEDICATION NAME] that was prescribed for another resident by accident and not the [MEDICATION NAME] that was prescribed for Resident #89. The ADON stated she determined the error had been made by reviewing the declining narcotic sheet for Resident #89 and the other resident and after speaking to Nurse #1 determined that the error had occurred. An interview was conducted with Nurse #1 on 01/25/18 at 5:05 PM. Nurse #1 confirmed she had worked Harmony Court where Resident #89 resided on 01/24/18 from 7:00 PM to 11:00 PM. Nurse #1 stated she was not aware she had made the error until she was notified by the ADON. She stated she did not have to administer a lot of narcotics and remembered medicating Resident #89 but stated that if she had given him [MEDICATION NAME] instead of his [MEDICATION NAME] then it was completely by mistake. She stated she did recall medicating Resident #89 and the other resident fairly close together so it was possible that she just grabbed the wrong card of medication. An interview was conducted with the Nurse Practitioner (NP) on 01/26/18 at 9:57 AM. The NP confirmed the staff had made her aware of the medication error with Resident #89. She added there was no change in his mentation or his vital signs and she did not feel like there was any adverse reactions. She stated she did ask the staff to continue to monitor him closely but did not feel like there was any potential for harm because Resident #89 was on a similar antianxiety medication. The NP also stated that she expected the staff to administer the correct medications to the correct patient as prescribed. An interview was conducted with the Medical Doctor (MD) at 01/26/18 at 2:45 PM. The MD stated she expected the staff to administer the correct medications to the correct resident as prescribed. The MD added that she did not feel like Resident #89 had any signs of adverse reactions. An interview was conducted with the Director of Nursing (DON) on 01/26/18 at 4:05 PM. The DON stated she would expect the Nurses to administer the correct medications to the correct residents as prescribed by the MD.

Based on observations, record reviews, and staff interviews the facility failed to keep an accurate account of controlled medications on the Controlled Medication Utilization Record for 2 of 5 residents sampled for unnecessary medications (Resident #89 and Resident #93). The findings included: 1. Review of Resident #89's physician order [REDACTED]. An observation, interview and reconciliation of the narcotic medications on the Harmony Court neighborhood where Resident #89 resided was made on 01/25/18 at 11:04 AM with Nurse #3. The reconciliation revealed Resident #89 had 15 tablets of [MEDICATION NAME] and the Controlled Medication Utilization Record indicated he had 14 tablets. Nurse #3 stated she had counted the narcotics at the beginning of her shift with the off going nurse which was Nurse #2. She added that to her knowledge the narcotic count was correct and stated she had a nursing student from the local community college who also observed the narcotic count. Nurse #3 stated she would alert her supervisor immediately of the discrepancy. Review of the Shift Change Controlled Substance Inventory Count Sheet for the Harmony Court Medication cart revealed on 01/25/18 at 7:00 AM both Nurse #2 and Nurse #3 had signed the sheet indicating the narcotic count was correct at that time. An interview was conducted with Nurse #2 on 01/25/18 at 4:56 PM. Nurse #2 confirmed she had worked 11:00 PM to 7:00 AM on 01/25/18 on Harmony Court. Nurse #2 stated at 7:00 AM on 01/25/18 she had counted the narcotics on the medication cart with Nurse #3 and to her knowledge the narcotic count was correct. She added she had also counted the narcotics at 11:00 PM on 01/24/18 with Nurse #1 and to her knowledge the narcotic count on Harmony Court was correct at that time as well. Nurse #2 stated there was nursing student from the local community college that had observed the narcotic count on 01/25/18 at 7:00 AM. She added that during 3rd shift she did not have to administer any narcotic medications to the residents on Harmony Court. Review of the Shift Change Controlled Substance Inventory Count Sheet for the Harmony Court Medication cart revealed that on 01/24/18 at 11:00 PM both Nurse #1 and Nurse #2 had signed the sheet indicating the narcotic count was correct at that time. An interview was conducted with Nurse #1 on 01/25/18 at 5:05 PM. Nurse #1 confirmed she had worked Harmony Court on 01/24/18 from 7:00 PM to 11:00 PM and had counted the narcotic's at 11:00 PM with Nurse #2 and to her knowledge the narcotic count was correct. Nurse #1 stated she had given Resident #89 his [MEDICATION NAME] as prescribed last evening and had documented that on the Controlled Medication Utilization Record. Nurse #1 again confirmed that when she had counted the narcotics at 11:00 PM on 01/24/18 all were accounted for. An interview was conducted with the Consultant Pharmacist (CP) on 01/26/18 at 10:25 AM. The CP stated she visited the facility monthly. She stated the narcotics on each medication cart should be kept under lock and key and should be counted with each shift change and then the staff should sign the Shift Change Controlled Substance Inventory Count Sheet indicating that both shifts had verified the count and it was correct. She added the facility could notify her of any discrepancies in narcotics but they had policies and procedures in place on how to handle the issue. An interview was conducted with Nursing Student (NS) #1 on 01/26/18 at 11:39 AM. The NS student confirmed he had been working on Harmony Court on 01/25/18 and had observed Nurse #2 and Nurse #3 count the narcotic's on 01/25/18 at 7:00 AM. The NS stated during the narcotic count Nurse #3 stated to Nurse #2 there was a discrepancy but he was not sure what the discrepancy was or for which resident. The NS stated he recalled it was a pill they were referring to but was not sure which pill. NS #1 further stated after Nurse #2 and Nurse #3 had counted the narcotics on the medication cart they discussed checking the medication room for the missing pill but that was the last he had heard about the discrepancy that was discovered while they were counting the narcotics. An interview was conducted with the Director of Nursing (DON) on 01/26/18 at 4:05 PM. The DON stated she expected the narcotic count to be accurate at all times and for the staff to count the narcotic's at the beginning and ending of their shift and at any time staff changed positions to a different unit. 2. Review of Resident #93's physician order [REDACTED]. An observation, interview and reconciliation of the narcotic medications on the Harmony Court neighborhood was made on 01/25/18 at 11:04 AM with Nurse #3. The reconciliation revealed Resident #93 had 4 tablets of Klonopin and the Controlled Medication Utilization Record indicated she had 5 tablets. Nurse #3 stated she had counted the narcotics at the beginning of her shift with the off going nurse which was Nurse #2. She added that to her knowledge the narcotic count was correct and stated she had a nursing student from the local community college who also observed the narcotic count. Nurse #3 stated she would alert her supervisor immediately of the discrepancy. Review of the Shift Change Controlled Substance Inventory Count Sheet for the Harmony Court Medication cart revealed that on 01/25/18 at 7:00 AM both Nurse #2 and Nurse #3 had signed the sheet indicating the narcotic count was correct at that time. An interview was conducted with Nurse #2 on 01/25/18 at 4:56 PM. Nurse #2 confirmed she had worked 11:00 PM to 7:00 AM on 01/25/18 on Harmony Court. Nurse #2 stated that at 7:00 AM on 01/25/18 she had counted the narcotics on the medication cart with Nurse #3 and to her knowledge the narcotic count was correct. She added she had also counted the narcotics at 11:00 PM on 01/24/18 with Nurse #1 and to her knowledge the narcotic count on Harmony Court was correct at that time as well. Nurse #2 stated there was nursing student from the local community college that had observed the narcotic count on 01/25/18 at 7:00 AM. She added that during 3rd shift she did not have to administer any narcotic medications to the residents on Harmony Court. Review of the Shift Change Controlled Substance Inventory Count Sheet for the Harmony Court Medication cart revealed on 01/24/18 at 11:00 PM both Nurse #1 and Nurse #2 had signed the sheet indicating the narcotic count was correct at that time. An interview was conducted with Nurse #1 on 01/25/18 at 5:05 PM. Nurse #1 confirmed she had worked Harmony Court on 01/24/18 from 7:00 PM to 11:00 PM and had counted the narcotic's at 11:00 PM with Nurse #2 and to her knowledge the narcotic was correct. Nurse #1 stated she had given Resident #93 her Klonopin as prescribed last evening and had documented that on the Controlled Medication Utilization Record. Nurse #1 again confirmed when she had counted the narcotic at 11:00 PM on 01/24/18 all were accounted for. An interview was conducted with the Consultant Pharmacist (CP) on 01/26/18 at 10:25 AM. The CP stated she visited the facility monthly. She stated the narcotic's on each medication cart should be kept under lock and key and should be counted with each shift change and then the staff should sign the Shift Change Controlled Substance Inventory Count Sheet indicating that both shift had verified the count and it was correct. She added the facility could notify her of any discrepancies in narcotics but they had policies and procedures in place on how to handle the issue. An interview was conducted with Nursing Student (NS) #1 on 01/26/18 at 11:39 AM. The NS student confirmed he had been working on Harmony Court on 01/25/18 and had observed Nurse #2 and Nurse #3 count the narcotic's on 01/25/18 at 7:00 AM. The NS stated during the narcotic count Nurse #3 stated to Nurse #2 there was a discrepancy but he was not sure what the discrepancy was or for which resident. The NS stated he recalled it was a pill they were referring to but was not sure which pill. The NS further stated after Nurse #2 and Nurse #3 had counted the narcotics on the medication cart they discussed checking the medication room for the missing pill but that was the last he had heard about the discrepancy that was discovered while they were counting the narcotics. An interview was conducted with the Director of Nursing (DON) on 01/26/18 at 4:05 PM. The DON stated she expected the narcotic count to be accurate at all times and for the staff to count the narcotic's at the beginning and ending of their shift and at any time staff changed positions to a different unit.

Based on observations, record reviews, family, resident, and staff interviews the facility failed to provide care in a manner to maintain the resident's dignity by not answering a call light timely for a resident that required assistance with toileting for 1 of 1 residents reviewed for incontinent care (Resident #45). This led to the resident soiling herself after waiting excessively for assistance to the bathroom. The finding included: Resident #45 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive minimum data set ((MDS) dated [DATE] revealed Resident #45 was cognitively intact and required extensive assistance of 2 staff members with toileting. The MDS also revealed Resident #45 was frequently incontinent of bladder and no rejection of care or behaviors was identified during the assessment reference period. An observation was made on 01/25/18 at 11:00 AM. Resident #45's family member approached Nurse #3 at the medication cart and stated her call light has been on for 45 minutes and she needs to use the bathroom. Nurse #3 stated she would get someone to assist Resident #45. The family member then stated she has waited so long that she has already went in her pants. Nurse #3 then entered Resident #45's room and stated to the family member and the resident that the Nursing Assistants (NAs) were in another room assisting with care and they would be with her as soon as possible. An interview was conducted with Nurse #3 on 01/25/18 at 11:03 AM. Nurse #3 stated she was not aware of how long Resident #45's call light had been on but stated she had gone and found the NAs on the unit and they were providing care to another resident and they would get to Resident #45 as soon as possible. She added they were really busy with several resident's needing assistance at one time. An interview was conducted with Resident #45 and her family member on 01/25/18 at 11:07 AM. The family member stated Resident #45 had turned her call light on and then picked up the phone and called the family member at 10:30 AM. The family member further stated during the conversation on the phone Resident #45 stated she had turned the call light and was still waiting for the staff to assist her to the bathroom. The family member stated she hung up with Resident #45 and drove over to the facility and upon entering the unit Resident #45's call light was still turned on. The family member stated she had turned the call light off and then immediately turned it right back on and had waited an additional 15 minutes and the staff still had not answered the call light and that was when the family member approached Nurse #3 at the medication cart. Resident #45 stated that she had waited so long that she had already wet herself and stated it really hurts my pride when I go in my britches. The family member stated Resident #45 had to wait a long time on a frequent basis and she had shared her concerns with the facility social worker. Resident #45 confirmed she had turned her call light on at 10:30 AM and then called her family on the telephone and when the family arrived 30 minutes later the call light was still on and she was still waiting to be assisted to the toilet. An observation was made on 01/25/18 at 11:15 AM. NA #1 and NA #2 entered Resident #45's room. NA #1 stated I am so sorry, we answer the call lights in the order in which they come on and there was 5 people in front of you. Resident #45 stated to NA #1 I have waited so long and already wet myself, I am not sure if I will go or not. NA #1 and NA #2 assist Resident #45 to the bathroom, stood her up and removed the pull up she was wearing. When NA #1 threw the pull up in the trash can it made a loud thud due to the excessive weight of the soiled pull up. Resident #45's skin was intact with no breakdown noted, she sat on the commode and was able to urinate again before standing up and a new pull was applied. An interview was conducted with NA #1 on 01/25/18 at 2:44 PM. NA #1 confirmed she routinely cared for Resident #45 but stated she was still fairly new to the unit and indicated she was still learning all of Resident #45's needs. NA #1 stated Resident #45 required extensive assistance with most activities of daily living and stated she did ambulate in short distances but it was a very slow pace. NA #1 stated Resident #45 was mostly continent of bladder but as soon as she stood up she would start to urinate. She added she was not aware of how long the call light had been on but stated she was toileting another resident when Nurse #3 came and told her Resident #45 needed to use the bathroom. NA #1 stated she had already toileted Resident #45 at 2 other times that morning and each time she was able to urinate. She added most of the time Resident #45's pull up was dry but when she toileted her at 11:15 AM the pull up was heavily wet. NA #1 further stated Resident #45's family had informed her numerous times that Resident #45 only had 1 kidney and had to be toileted frequently. NA #1 stated she toileted Resident #45 as frequently as possible. Again NA #1 explained she answered the call lights in the order in which they came on and there was 5 other people in front of Resident #45 and she got to her as quickly as possible. An interview was conducted with the Administrator on 01/25/18 at 3:00 PM. The Administrator confirmed that the facility had the capability to measure call bell response time but since moving into the new building they were not aware of how to perform the task. She explained the new system would not be fully functioning until the entire new facility was complete and that would be another year or so. The Administrator again confirmed that she could not pull a report to identify how long Resident #45's call light had been on. An interview was conducted with the Director of Nursing (DON) on 01/26/18 at 4:05 PM. The DON stated she expected the nursing staff to toilet Resident #45 when she requested and further stated that waiting 45 minutes to be toileted was not acceptable. She added she expected the staff to make each resident feel dignified and respected while providing care to them. The DON stated she had tried to pull the call bell response time report but with the new system they had not fully implemented the features of the new system and would not until the building was complete in the future.

Based on observations, record reviews and resident and staff interviews the facility failed to use hand sanitizer or wash hands with soap and water after removal of gloves after trash was discarded from an isolated resident room for 1 of 1 resident who had physician orders [REDACTED].#29). Findings included: A review of physician's treatment orders dated 01/20/18 indicated isolation droplet precautions till the end of [MEDICATION NAME] ([MEDICAL CONDITION] medication used for the treatment of [REDACTED]. During an observation on 01/23/18 at 3:49 PM a sign on Resident #29's door indicated isolation droplet precautions. The sign also indicated to wash hands, wear mask and gloves to enter room and a cabinet hanging from the door contained masks and gloves. During an interview on 01/23/18 at 3:55 PM Resident #29 stated she was sick with the flu and everyone had to wear masks and gloves when they came into her room. During an observation on 01/26/18 at 11:10 AM, Housekeeper #1 put gloves on and was standing in the hallway next to a trashcan outside of Resident #29's room. She picked up a plastic trash bag from inside the trashcan with discarded gloves and masks that were visible and loosely tied the top of the bag and set the plastic bag on the floor. She then placed a clean plastic bag inside the trashcan and carried the trash bag from the floor to a linen cart and deposited the bag into a larger plastic bag with other trash. She removed her gloves and put them into the trash bag on the linen cart and then put on another pair of gloves without washing or sanitizing her hands and picked up housekeeping supplies from her cart and walked across the hall and started to enter another resident's room which did not have isolation precautions. During an interview on 01/26/18 at 11:13 AM, Housekeeper #1 confirmed she was getting ready to clean her next resident room. She explained this was only her 2nd week as housekeeper on resident hallways and she was new to housekeeping duties because she had been working in the laundry. She stated she thought a resident had the flu in the room next to where the trashcan was sitting in the hallway at Resident #29's room because there was an isolation sign on the resident's door. She explained she checked the trashcan about every 30 minutes and routinely carried the trash from the trashcan to her housekeeping cart and she changed her gloves after she touched the trash bag. She stated she was aware she was supposed to use hand sanitizer or wash her hands with soap and water after she removed her gloves but she was focused on emptying the trash and had forgotten to sanitize or wash her hands after she had removed her gloves. During an interview on 01/26/18 at 11:23 AM, Nurse #5 confirmed she was assigned to Resident #29 and the resident was on isolation droplet precautions because she had the flu. She explained and all staff were expected to discard their masks and gloves in the trashcan and it was her expectation for staff to use hand sanitizer and then wash their hands with soap and water after they removed their gloves. She further stated staff should sanitize or wash their hands before they went into another resident's room. During an interview on 01/26/18 at 11:38 AM, the Environmental Services Manager explained he was responsible for housekeeping, laundry and floor technician staff. He stated if a resident had isolation precautions then housekeepers were supposed to look at the box on the resident's door with the sign to know what type of personal protective equipment to wear. He stated it was his expectation for housekeepers to take the trash bag from the trashcan next to Resident #29's room to the linen cart and then remove their gloves and use hand sanitizer to clean their hands. He stated then they should go into the spa which was a bath/shower room and wash their hands with soap and water. During an interview on 01/26/18 at 12:26 PM, the Director of Nursing stated it was her expectations for staff to dispose of masks and gloves from a resident's room who was ordered isolation precautions into a trashcan. She explained staff should then use hand sanitizer or soap and water to clean their hands after they removed their gloves. She further stated she was not familiar with housekeeping procedures but expected for them to empty trash and remove their gloves and use hand sanitizer or use soap and water to clean their hands before they put on clean gloves and went into another resident's room. During an interview on 01/26/18 at 4:02 PM, the Treatment Nurse who was also in charge of infection control explained approximately 2 weeks ago some residents at the facility had influenza and now Resident #29 was positive for influenza. She stated it was her expectation for staff to remove their gloves after they handled trash from Resident #29's room and they were supposed to wash their hands with soap and water. She explained they could use hand sanitizer but after they had used it 3 times they had to wash their hands with soap and water. She confirmed infection control training had been done for housekeeping staff and Housekeeper #1 should have sanitized or washed her hands after she removed her gloves after she had handled trash from Resident #29's room. She stated it was her expectation for all staff to follow policy and procedures for infection control.

Based on observations, record reviews, and staff interviews the facility failed to remove expired medication from 2 of 4 medication rooms (Friendship and Faith Household medication rooms). The findings included: Review of a facility policy titled Storage and Expiration of Medications, Biologicals, Syringes, and Needles dated 12/01/07 read in part, the facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with the Pharmacy return/destruction guidelines or other applicable law. 1a. An observation of the Friendship Household medication room and refrigerator was conducted on 01/24/18 at 4:42 PM with Medication Aide (MA #1). The observation revealed a unopened bottle of Oyster Shell calcium 500 milligrams (mg) that expired 08/17 and a whole unopened bottle of liquid pain relief that expired 11/17 both were in the medication room cabinets and available for use. There was an open bottle of [MEDICATION NAME] (TB) serum that was dated as being opened on 10/18/17. An interview was conducted with MA #1 on 01/24/18 at 4:47 PM. MA #1 confirmed she was working on the Friendship household and stated that every Wednesday the Nurses or the MA's would go through the medication carts and remove any expired medication. She added she was unsure of who monitored the medication room but thought it was the nurses. MA #1 stated the expired medications should have been removed from the medication room and she was not sure how long the TB serum was good for but would have to ask her nurse. An interview was conducted with Nurse #4 on 01/24/18 at 4:49 PM. Nurse #4 stated she was responsible for overseeing MA #1 and she would discard the expired medication. She added the TB serum was only good for 30 days after opening and it should have been discarded. Nurse #4 stated she only worked as needed but to her understanding the Nurses on the medication carts went through the medication carts and medication rooms weekly and removed any expired medications. Nurse #4 stated she would discard the expired medications and TB serum. b. An observation of the Faith Household Medication room was conducted on 01/24/18 at 5:00 PM with Nurse #4. The observation revealed: 1 bottle of 16 ounce (oz.) Mineral Oil that expired 11/17, 1 unopened fleet enema that expired 12/17, 1 opened box of Nasal decongestant that expired 02/17, 1 unopened box of nasal decongestant that expired 11/17 and 2 unopened bottles of Vitamin D that expired 12/17. All the expired medications were in the medication room in the cabinets and available for use. An interview was conducted with Nurse #4 on 01/24/18 at 5:10 PM. Nurse #4 stated she was responsible for the Faith Household medication room and that she would discard the expired medication. Nurse #4 stated she only worked as needed but to her understanding the Nurses on the medication carts went through the medication carts and medication rooms weekly and removed any expired medications An interview was conducted with the Consultant Pharmacist (CP) on 01/26/18 at 10:25 AM. The CP stated she visited the facility every month and each month she checked 1 medication room and 1 medication cart and looked for expired medications and any regulatory items that related to medication storage. She added the TB serum was only good for 30 days after opening and should have been discarded. The CP stated that her expectation was the facility staff would routinely check the medication room and medication carts and promptly remove any expired medications. An interview was conducted with the Director of Nursing (DON) on 01/26/18 at 4:05 PM. The DON stated she expected the nurses to go through the medication carts and rooms weekly and remove any expired medications and return them to the pharmacy for destruction.

Based on observations and staff interviews the facility failed to label and date multiple portion food items and left over prepared foods in the kitchen walk in freezer and a reach in freezer. The findings included: During the initial tour of the kitchen on 11/28/16 at 1:23 PM the following unlabeled and undated items were observed on shelves in the walk in freezer: - a clear plastic bag containing frozen dough for approximately 10 dinner rolls - a clear plastic bag containing approximately 8 frozen dinner rolls - a clear plastic bag containing approximately 12 frozen ravioli - a gallon sized recloseable bag of dark red sauce - an opaque blue bag containing approximately 3 cups of a frozen food item An interview with the Dietary Manager (DM) on 11/28/16 at 1:23 PM revealed all of the observed food items in the freezer needed to labeled and dated. Observations of a reach in freezer on 11/28/16 at 1:36 PM revealed an unlabeled and undated clear plastic bag containing frozen dough for approximately 12 cookies. The DM was present during this observation and stated the bag needed to be labeled and dated. Signage was affixed to the kitchen's refrigerator and freezer doors which stated, All Foods Must Be Covered And Labeled And Dated- No Exceptions. An interview was conducted with the Director of Culinary Services on 11/28/16 at 2:00 PM. The Director of Culinary Services stated that he and the Executive Chef and the Sous Chef checked the refrigerators and freezers daily for unlabeled and undated food items but they were all scheduled off today because they had worked Thanksgiving Day. The Director of Culinary Services further stated all of the dietary staff were trained to date and label food items before placing them back in the freezer.

Based on observations and staff interviews the facility failed to label a comb and bed pans and bath basins in 3 resident bathrooms (Room #302, #705 and #711) on 2 of 9 resident halls. The facility also failed to repair 13 resident room doors with broken and splintered laminate and wood on the lower edges of the doors (Room #209, #302, #304, #309, #411, #504, #505, #701, #703, #705, #711, #805 and #902) on 7 of 9 resident halls (200, 300, 400, 500, 700, 800 and 900 halls), failed to repair 1 resident's bathroom door with broken and splintered laminate on the lower edges of the door (Room #807), failed to repair a spa door with broken and splintered laminate on the lower edges of the door (700 hall), failed to repair a door to a multipurpose room with broken and splintered laminate on the lower edges of the door (900 hall) and failed to repair smoke prevention doors in the locked unit near the nurses station with broken and splintered laminate on the lower edges of the doors (on 1 of 1 locked unit). The findings included: 1. a. Observations on 11/30/16 at 4:45 PM in the bathroom of Room #302 revealed a comb lying on the sink with no resident name on it. Observations on 12/01/16 at 4:50 PM in the bathroom of Room #302 revealed a comb lying on the sink with no resident name on it. Observations on 12/02/16 at 10:00 AM in the bathroom of Room #302 revealed comb lying on the sink with no resident name on it. b. Observations on 11/28/16 at 04:33 PM in the bathroom of Room #705 revealed 2 bed pans and a bath basin that were each inside a plastic bag and were stacked on top of each other on the floor in the bathroom with no resident names on them. Observations on 11/30/16 at 4:40 PM in the bathroom of Room #705 revealed 2 bed pans and a bath basin that were each inside a plastic bag and were stacked on top of each other on the floor in the bathroom with no resident names on them. Observations on 12/01/16 at 12:38 PM in the bathroom of Room #705 revealed 2 bed pans and a bath basin that were each inside a plastic bag and were stacked on top of each other on the floor in the bathroom with no resident names on them. c. Observations on 11/29/16 at 11:00 AM in the bathroom of Room #711 revealed a bed pan and a bath basin were each inside plastic bags and were hanging from a handrail in the bathroom with no resident name on them. Observations on 11/30/16 at 4:43 PM in the bathroom of Room #711 revealed a bed pan and a bath basin were each inside plastic bags and were hanging from a handrail in the bathroom with no resident name on them. Observations on 12/01/16 at 12:39 PM in the bathroom of Room #711 revealed a bed pan and a bath basin were each inside plastic bags and were hanging from a handrail in the bathroom with no resident name on them. During an interview on 12/02/16 at 9:56 AM Nurse #1 explained resident hygiene products were supposed to be labeled with the resident's name and personal care equipment such as bed pans or bath basins were supposed to be labeled with the resident's name and stored in plastic bags. During an interview on 12/02/16 at 12:21 PM with Nurse Aide #1 she stated staff were expected to label resident care equipment with the resident's name and they were expected to put resident's personal care equipment such as bed pans or bath basins in a plastic bag. She further stated a resident's personal hygiene products were supposed to be labeled with the resident's name. During an interview and tour on 12/02/16 at 10:36 AM with the Director of Nursing she stated resident care equipment should be stored in a plastic bag and tied to the handrail in the bathroom and the items were not supposed to be stored on the floor. She confirmed there was no resident name on the comb in the bathroom of room #302 and there was no resident name on the bath basins and bed pan in the bathroom in room #705 and there was no resident name on the bed pan or bath basin in the bathroom of room #711. She explained labeling of a resident's personal care equipment was discussed in orientation with each new employee and she expected for staff to label all personal care equipment. 2. a. Observations of Room #209 on 11/28/16 at 4:54 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:48 PM revealed the door of resident room #209 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:42 PM revealed the door of resident room #209 had broken and splintered laminate on the edges of the bottom half of the door. b. Observations of Room #302 on 11/28/16 at 04:35 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:51 PM revealed the door of resident room #302 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:38 PM revealed the door of resident room #302 had broken and splintered laminate on the edges of the bottom half of the door. c. Observations of Room #304 on 11/28/16 at 4:13 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:52 PM revealed the door of resident room #304 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:39 PM revealed the door of resident room #304 had broken and splintered laminate on the edges of the bottom half of the door. d. Observations of Room #309 on 11/29/16 at 10:34 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:53 PM revealed the door of resident room #309 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:40 PM revealed the door of resident room #309 had broken and splintered laminate on the edges of the bottom half of the door. e. Observations of Room #411 on 11/29/16 at 1:46 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:56 PM revealed the door of resident room #411 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:43 PM revealed the door of resident room #411 had broken and splintered laminate on the edges of the bottom half of the door. f. Observations of Room #504 on 11/29/16 at 1:47 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:57 PM revealed the door of resident room #504 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:44 PM revealed the door of resident room #504 had broken and splintered laminate on the edges of the bottom half of the door. g. Observations of Room #505 on 11/28/16 at 4:12 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:58 PM revealed the door of resident room #505 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:45 PM revealed the door of resident room #505 had broken and splintered laminate on the edges of the bottom half of the door. h. Observations of Room #701 on 11/29/16 at 12:11 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 4:59 PM revealed the door of resident room #701 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:46 PM revealed the door of resident room #701 had broken and splintered laminate on the edges of the bottom half of the door. i. Observations of Room #703 on 11/29/16 at 11:21 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:00 PM revealed the door of resident room #703 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:47 PM revealed the door of resident room #703 had broken and splintered laminate on the edges of the bottom half of the door. j. Observations of Room #705 on 11/28/16 at 4:37 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:01 PM revealed the door of resident room #705 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:48 PM revealed the door of resident room #705 had broken and splintered laminate on the edges of the bottom half of the door. k. Observations of Room #711 on 11/29/16 at 11:00 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:02 PM revealed the door of resident room #711 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:49 PM revealed the door of resident room #711 had broken and splintered laminate on the edges of the bottom half of the door. l. Observations of Room #805 on 11/29/16 at 2:48 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:04 PM revealed the door of resident room #805 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:50 PM revealed the door of resident room #805 had broken and splintered laminate on the edges of the bottom half of the door. m. Observations of Room #902 on 11/28/16 at 4:20 PM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:06 PM revealed the door in resident room #902 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:52 PM revealed the door in resident room #902 had broken and splintered laminate on the edges of the bottom half of the door. 3. Observations of Room #807 on 11/29/16 at 2:35 PM revealed the bathroom door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:05 PM revealed the bathroom door in resident room #807 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:51 PM revealed the bathroom door in resident room #807 had broken and splintered laminate on the edges of the bottom half of the door. 4. Observations on 11/28/16 at 4:22 PM on the 700 hall revealed the door of the spa room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:07 PM on the 700 hall revealed the door of the spa room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:53 PM on the 700 hall revealed the door of the spa room had broken and splintered laminate on the edges of the bottom half of the door. 5. Observations on 11/28/16 at 4:23 PM on the 900 hall revealed the door of a multipurpose room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 11/30/16 at 5:08 PM on the 900 hall revealed the door of a multipurpose room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/01/16 at 12:54 PM on the 900 hall revealed the door of a multipurpose room had broken and splintered laminate on the edges of the bottom half of the door. 6. Observations on 11/28/16 at 4:24 PM in the locked unit revealed the smoke prevention doors near the nurse's station had broken and splintered laminate on the edges of the bottom half of the doors. Observations on 11/30/16 at 5:09 PM in the locked unit revealed the smoke prevention doors near the nurse's station had broken and splintered laminate on the edges of the bottom half of the doors. Observations on 12/01/16 at 12:55 PM in the locked unit revealed the smoke prevention doors near the nurse's station had broken and splintered laminate on the edges of the bottom half of the doors. During an interview and tour on 12/02/16 at 10:04 AM with the Director of Facility Management he stated the facility utilized a work order system and staff could access work orders on any computer. He explained when staff put in a work order in the computer system they got a confirmation number and the work order was sent to the maintenance department. He further explained there were 3 maintenance staff who covered the skilled nursing units and work orders were prioritized and assigned to maintenance staff to do the repairs. He stated if a Nurse or Nurse Aide saw something that needed to be repaired he expected for them to report it to their supervisor and the supervisor could put the work orders in the computer system. He explained most work orders were completed within a day but sometimes within hours depending on how complicated the repair and it was everybody's responsibility to report things. He confirmed the doors observed during the tour needed to be repaired to remove the rough edges. During an interview and tour on 12/02/16 at 10:33 AM with the Administrator she stated it was her expectation for staff to call and report when repairs needed to be made. She explained Administrative staff made rounds routinely and the safety committee addressed concerns monthly and she expected for maintenance staff to be proactive to fix things.

Based on record review and staff interviews, the facility failed to accurately code resident ' s MDS for 2 of 20 residents (Resident #102 and #203). Resident #102 dental status did not code the resident as having any dental concerns and Resident #203 MDS did not code the [DIAGNOSES REDACTED]. The findings included: #1. Resident #102 was admitted to the facility 5/1/2012. Cumulative [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated the resident had no dental problems; her missing teeth/edentulous status was not coded. The Care Area Assessment (CAA) did not include any documentation of her poor oral/dental status and/or missing teeth. Her care plan dated 8/27/15 did not include her dental status. 10/15/2015 9:44:48 am, an interview with the MDS Coordinator was conducted. The MDS Coordinator stated she completed the MDS dated [DATE] for resident #102, and she did complete section L- Oral/Dental Status. She stated she had made a mistake on the MDS assessment dated [DATE], and would do a MDS correction assessment to ensure the correct dental status is coded for resident #102. Example #2: Resident #203 was readmitted [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] showed resident had moderately impaired cognitive skills. Section I of the MDS did not include [DIAGNOSES REDACTED]. A review of the physician's order [REDACTED]. During an interview on 10/15/2015 10:30 AM, MDS Nurse # 1 stated she had to use the [DIAGNOSES REDACTED]. During an interview on 10/15/2015 11:15 AM, MDS Nurse # 2 stated that Resident 203 does take [MEDICATION NAME] for depression and it should have been coded in section I of the MDS, it was overlooked. During an interview 10/15/2015 11:32 AM, the Director of Nursing (DON) stated she expected the [DIAGNOSES REDACTED].

Based on record reviews and staff interviews, the facility failed to immediately notify 3 of 3 cognitive impaired residents family members (Resident #1, #2 and #3) of an incident in which a confused and cognitively impaired resident (Resident #4) was reported to have sexually inappropriate behavior towards the residents by touching their breasts. The findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had severely impaired cognition, required extensive assistance with mobility and transfers and needed limited assistance with walking and locomotion. An interview was conducted on 4/29/14 at 3:32 PM with the unit manager for the secure memory unit (where Resident #1 resided). During this interview, the unit manager reported that there was a recent incident in which a male resident was observed with sexually inappropriate behaviors. The unit manager reported that about 2 weeks ago, when she came on duty the morning of 4/17/2014, it was reported to her that Resident #4 (admitted the day before) had wondered into three different female residents ' room and fondled the residents ' breast. The unit manager indicated she contacted the director of nurses (DON), the administrator and the executive director. Further discussion revealed that she, the nurse on duty during the incident, the DON, the administrator and executive director all meet that morning to discuss the incidents. When asked about notification to families regarding the incident the unit manager replied " I was told by the executive director that she would take care of it. " The unit manager indicated that families for residents on this unit were notified when ever anything out of the ordinary occurred. An interview was conducted with a Nurse Aid (NA), who reported routinely working with Resident #1 on 4/29/2014 at 3:42 PM. During this interview, the NA reported that on the late evening hours before midnight on 4/16/2014, he witnessed Resident #4 to go into Resident #1 ' s room. He stated that he followed behind Resident #4 into the room of Resident #1. He stated that he observed Resident #4 standing over Resident #1 who was in bed. He stated Resident #4 had his hands inside of Resident #1 ' s jacket, but on top of the pajamas with his hands on the breast of Resident #1. The NA stated that Resident #1 was observed to tell Resident #4 to " stop, get out of here " . The NA reported that he reported the incident to his supervisor and had a telephone conversation about the incident on 4/17/2014 with the Executive Director, the Director of Nursing and the Administrator. An interview was conducted with the Nursing Home Administrator, the Director of Nursing (DON), Executive Director and Administrator in training on 4/29/2014 and began at 4:37 PM. During his interview the Administrator sated that on the morning of the 4/17/2014, he met with the Night shift Nurse supervisor, the DON and the Executive Director. He stated that the meeting was pertaining to Resident #4 ' s sexually inappropriate behaviors on the night of 4/16/2014 and early morning hours on 4/17/2014. The Director of Nursing stated that she was told by her nurse supervisor that Resident #4 was observed to go into Resident #1 ' s room by a Nurse Aid. She stated they spoke to the Nurse Aid who observed the incident via telephone on 4/17/2014. The DON additionally stated that the NA stated Resident #4 ' s hands were under the jacket, but on top of the pajamas of Resident #1. When asked where Resident #4 ' s hands were on Resident #1 ' s body, the DON stated that she was not sure and that she " just assumed the stomach area " . When asked if they notified the family, the Administrator stated yes, and reviewed his note with this surveyor where he told a son on 4/22/14. The Administrator was unable to state which son of Resident #1 he talked to on 4/22/2014. The Administrator stated the police department showed up on 4/21/2014 with concerns about the incident and stated the family of Resident #1 wanted to have the resident sent to the emergency room (ER) for evaluation. He stated they sent her out (after the police told him the family wanted Resident #1 to go to the ER) and then notified the family of the incident. The notification was on 4/22/2014. When questioned as to why they did not notify the family of Resident #1 prior to 4/22/2014, the Executive Director stated that they wanted to make sure the staffs were not " over exaggerating " and further stated they wanted to be sure they had accurate information before they notified families. A review of the medical chart on 4/29/14 for Resident #1 revealed there was no documentation on 4/16 or 4/17, 2014 regarding the family being notified of resident #4 ' s touching resident #1 ' s breast. Continued review of the nurse ' s notes for Resident #1 revealed a notation on 4/22/2014 that stated the resident returned from a local hospital emergency room (ER). The note did not indicate what the ER visit was for An additional general noted dated 4/22/2014 by the Nursing Home Administrator, revealed he met with a son of Resident #1 and explained that Resident #1 was being monitored for sins and symptoms of " mental distress " . The note did not indicate why Resident #1 was being monitored for " mental distress " . There was no mention of the incident in Resident #1 ' s record to include any report or documentation about notification to family members of the incident, prior to 4/22/2014. 2. Resident # 2 was originally admitted on [DATE] and re-admitted on [DATE]. Current [DIAGNOSES REDACTED]. A review of the most current quarterly Minimum Data Set ((MDS) dated [DATE] revealed residents cognitive skills were severely impaired. Further review of the MDS revealed the resident required extensive assistance for bed mobility and activities of daily living. An interview was conducted on 4/29/14 at 3:32pm with the unit manager for the secure memory unit. During this interview, the unit manager reported that there was a recent incident in which a male resident was observed with sexually inappropriate behaviors. The unit manager reported that about 2 weeks ago, when she came on duty the morning of 4/17/2014, it was reported to her that Resident #4 (admitted the day before) had wondered into three different female residents ' room and fondled the residents ' breast. The unit manager indicated she contacted the director of nurses (DON), the administrator and the executive director. Further discussion revealed that she, the nurse on duty during the incident, the DON, the administrator and executive director all meet that morning to discuss the incidents. When asked about notification to families regarding the incident the unit manager replied " I was told by the executive director that she would take care of it. " The unit manager indicated that families for residents on this unit were notified when ever anything out of the ordinary occurred. An interview was conducted with the Nursing Home Administrator, the Director of Nursing (DON), Executive Director and Administrator in training on 4/29/2014 and began at 4:37PM. During this interview the Administrator sated that on the morning of 4/17/2014, he met with the Night shift Nurse supervisor, the unit manager, the DON and the Executive Director. He stated that the meeting was pertaining to Resident #4 ' s sexually inappropriate behaviors on the night of 4/16/2014 and early morning hours on 4/17/2014. . During this interview the DON went to get the notes and staff written statement so she could provide accurate information. The DON indicated the staff reported that a staff member had witnessed Resident #4 touching the breast of Resident #2 during the 3:00pm -11:00pm shift. The DON indicated the staff placed Resident #4 on 1-1 observation/care after the incident and called her to report incident. Further discuss revealed that the DON, and the administrator wanted to be sure they had accurate information before they notified families. Staff members provided written statements to the administrative staff on 4/22/14 regarding resident #4 ' s behavior on 4/16-17, 2014. The DON read the staff statements during the interview. The families of the female residents involved were notified at that time. The administrator indicated that on 4/21/14 he received a visit from members of the local police force regarding the sexual behavior of resident #4. A review of the medical chart on 4/29/14 for Resident #2 revealed there was no documentation on 4/16 or 4/17, 2014 regarding the family being notified of resident #4 ' s touching resident #2 ' s breast. A review of the medical chart on 4/29/14 for Resident #2 revealed a series of nurse ' s notes dated 4/22/14 which referred to the incident that had occurred 7 days prior. The first note was at 10:35am. The note documented an attempt to notify family of reported touching of breasts by another male resident. It also stated other female residents were being interviewed and that the male resident was in the facility for approximately 12 hours with 1-1 care before being discharged from the facility. The next note at 1:38pm documented family member had been informed of the incident. The next note at 2:35pm indicated the resident was " alert and responsive. Confused due to dementia. Quite affect smiling. No signs & symptoms of mental distress. " The next note at 2:36pm documented a phone call to ----------------- (person ' s name) with Department of Social Services to inform him of the " occurrence as described in previous note left message on voice mail. " Resident taken to emergency room by facility for a physical exam. The next note at 7:41pm documented the residents return to the facility and that the physical exam was negative. 3. Resident #3 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. A review of the admission minimum data set ((MDS) dated [DATE] revealed the residents cognitive skills were severely impaired. Further review of the MDS revealed the resident required limited assistance for bed mobility. An interview was conducted on 4/29/14 at 3:32pm with the unit manager for the secure memory unit. During this interview, the unit manager reported that there was a recent incident in which a male resident was observed with sexually inappropriate behaviors. The unit manager reported that about 2 weeks ago, when she came on duty the morning of 4/17/2014, it was reported to her that Resident #4 (admitted the day before) had wondered into three different female residents ' room and fondled the residents ' breast. The unit manager indicated she contacted the director of nurses (DON), the administrator and the executive director. Further discussion revealed that she, the nurse on duty during the incident, the DON, the administrator and executive director all meet that morning to discuss the incidents. When asked about notification to families regarding the incident the unit manager replied " I was told by the executive director that she would take care of it. " The unit manager indicated that families for residents on this unit were notified when ever anything out of the ordinary occurred. An interview was conducted with the Nursing Home Administrator, the Director of Nursing (DON), Executive Director and Administrator in training on 4/29/2014 and began at 4:37PM. During this interview the Administrator sated that on the morning of 4/17/2014, he met with the Night shift Nurse supervisor, the unit manager, the DON and the Executive Director. He stated that the meeting was pertaining to Resident #4 ' s sexually inappropriate behaviors on the night of 4/16/2014 and early morning hours on 4/17/2014. . During this interview the DON the DON went to get the notes and staff written statement so she could provide accurate information. The DON indicated the staff reported that a staff member had witnessed Resident #4 touching the breast of Resident #3 during the 3:00pm -11:00pm shift. The DON indicated the staff placed Resident #4 on 1-1 observation/care after the incident and called her to report incident. Further discuss revealed that the DON and the administrator wanted to be sure they had accurate information before they notified the families. Staff members provided written statements to the administrative staff on 4/22/14 regarding resident #4 ' s behavior on 4/16-17, 2014. The DON read the staff statements during the interview. The families of the female residents involved were notified at that time. The administrator indicated that on 4/21/14 he received a visit from members of the local police force regarding the sexual behavior of resident #4. A review of the medical chart on 4/29/14 for Resident #3 revealed there was no documentation on 4/16 or 4/17, 2014 regarding the family being notified of resident #4 ' s touching resident #3 ' s breast. The only documentation available in Resident #3 ' s medical record was dated 4/22/14. The general note was dated 4/22/14 at 10:36am and signed by the administrator. The note stated the family member had been called to report " touching of breasts by a male resident " to resident #3. It was explained that this was witnessed by staff. It took place between the doorway between the hall and her room. Resident was immediately separated. " Your ------ (resident) does not ' t recall the event and seems happy. We are monitoring for any signs of mental anguish and currently we are not seeing any signs of distress or mental anguish. "

Based on record review, and resident and staff interviews, the facility failed to accommodate residents' preference for the frequency of showers per week (Resident #26, #30, #190) and preference for time of day shower was given (Resident #26) for 3 of 3 residents reviewed for choices. The findings included: 1. Resident #26 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] stated bathing required assistance but did not indicate preference for frequency or time of day for showers. An annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #26 was cognitively intact, was able to make her needs known, and required extensive assistance with bathing. The annual MDS noted rejection of care was not exhibited. The Care Area Assessment (CAA) Summary for Activities of Daily Living (ADL) Functional Status dated 05/20/13 stated Resident #26 was dependent on staff for assistance with daily personal care tasks and required extensive assistance with transfer, bathing, and toileting. Review of Resident #26's current care plan for ADL revealed she required assistance with ADL due to dementia with the goal to participate in her ADL as able. Interventions included: assist with showers twice weekly. Review of the shower schedule revealed Resident #26 had showers scheduled for Wednesday and Saturday during the 3:00 PM to 11:00 PM shift. An interview was conducted with Resident #26 on 07/23/13 at 9:28 AM. Resident #26 stated she did not have a choice regarding how many times a week she was showered or the time of day they occurred. Resident #26 further stated the staff told her when she was would have a shower and often times it was very late in the evening. The interview further revealed Resident #26 would like to shower every day and during the morning or early afternoon. An interview with nurse aide (NA) #2 on 07/24/13 at 2:50 PM revealed residents received two showers a week and they were assigned by room number. NA #2 stated if a resident requested additional showers she would notify the nurse. NA #2 was not sure how the time of day residents received showers was determined. During an interview on 07/25/13 at 11:10 AM NA #3 stated she worked Monday through Friday during the day shift (7:00 AM to 3:00 PM) and was given a list every morning of which residents needed showers during the day shift. NA #3 further stated the unit managers put the residents on the shower schedule and she was not sure how the time of day a shower was given was determined. An interview was conducted on 07/25/13 at 1:05 PM with the Director of Nursing (DON). The DON stated residents received two baths/showers per week and if they requested more they could be scheduled. The DON stated prior to yesterday residents' preference for frequency of showers was not assessed. An interview was conducted with Nurse #2 (Unit Manager) on 07/25/13 at 2:10 PM. Nurse #2 stated residents were assessed for their preference regarding a shower or bath during the admission process. Nurse #2 further stated frequency and time of day for bathing was not formally addressed during the admission process but if the resident wanted more showers the request would be accommodated. 2. Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #190 had moderately impaired cognition, was able to make her needs known, and required extensive assistance with bathing. The Care Area Assessment (CAA) Summary for Activities of Daily Living (ADL) Functional Status dated 03/12/13 stated Resident #190 was dependent on staff for assistance with daily personal care tasks and was totally dependent on staff for bathing. Review of Resident #190's current care plan for ADL revealed she required assistance with ADL due to dementia, [MEDICAL CONDITION] joint disease with nerve impingement, [MEDICAL CONDITION], and chronic pain. The goal was for her to participate in her ADL as able. Review of the shower schedule revealed Resident #190 had showers scheduled for Tuesday and Friday during the 7:00 AM to 3:00 PM shift. An interview was conducted with Resident #190 on 07/23/13 at 11:52 AM. Resident #190 stated she would like more than two showers a week but no one had ever asked her what her preference was regarding frequency of showers. An interview with nurse aide (NA) #2 on 07/24/13 at 2:50 PM revealed residents received two showers a week and they were assigned by room number. NA #2 stated if a resident requested additional showers she would notify the nurse. During an interview on 07/25/13 at 11:10 AM NA #3 stated she worked Monday through Friday during the day shift (7:00 AM to 3:00 PM) and was given a list every morning of which residents needed showers during the day shift. NA #3 further stated the unit managers put residents on the shower schedule and if a resident requested additional showers she would notify the unit manager or nurse. An interview was conducted on 07/25/13 at 1:05 PM with the Director of Nursing (DON). The DON stated residents received two baths/showers per week and if they requested more they could be scheduled. The DON stated prior to yesterday residents' preference for frequency of showers was not assessed. An interview was conducted with Nurse #2 (Unit Manager) on 07/25/13 at 2:10 PM. Nurse #2 stated residents were assessed for their preference regarding a shower or bath during the admission process. Nurse #2 further stated frequency and time of day for bathing was not formally addressed during the admission process but if the resident wanted more showers the request would be accommodated. 3. Resident #30 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #30's most recent Quarterly Minimum Data Set (MDS) assessed her as being cognitively intact. The MDS further assessed Resident #30 as needing limited assistance with most activities of daily living and needing the physical assistance of one person with bathing. An interview was conducted on 07/23/13 at 8:03 AM with Resident #30. Resident #30 stated she received two showers per week but she would like to have a shower every night. She stated she told the staff but she was told it was the rule she could only have two per week. An interview was conducted on 07/24/13 at 3:01 PM with Nursing Assistant (NA) #1. NA #1 stated she works with Resident #30 on 2nd shift (3:00 PM to 11:00 PM). NA #1 stated she knew what to do for residents just by having worked with them for some time. She further stated there was an index in the computer kiosk which tells exactly what needs to be done for each resident. She stated showers were assigned and the shower schedule tells who gets showers on each day. NA #1 revealed showers were typically given twice per week though one resident gets one three times per week because it is needed. NA #1 went on to explain if a resident requested more than two showers per week they would get a sponge bath because there is a limit to what they can get done. She stated there were two NAs who work the 200 hall and they give 2 to 3 showers during 2nd shift. An interview was conducted on 07/24/13 at 3:18 PM with Nurse #1 (Unit Manager). Nurse #1 stated the shower schedule was twice per week based on the resident's room number. She went on to explain that the schedule can change due to resident preferences regarding day or evening shower. Nurse #1 explained that during the admission process residents are asked if they would like a tub bath or a shower but not how frequently they would like a shower or a bath. Nurse #1 stated residents were told what their shower days were and if they requested more they would receive more. An interview was conducted with Resident #30 on 07/25/13 at 10:10 AM. Resident #30 stated she has told several people she was wanted a shower every night. She stated she told NA#1 but was not sure if she told the nurses. She stated she wanted her showers every night because she likes to feel clean before she goes to bed. An interview was conducted on 07/25/13 at 1:05 PM with the Director of Nursing (DON). The DON stated residents receive two baths per week and if they want more they can schedule more. She stated a resident can get a tub bath or a shower. The DON stated prior to yesterday residents' preference for frequency of showers was not something they assessed.

Based on observations and staff interviews the facility failed to remove dented canned food stored ready for use. The findings included: An initial tour of the facility's kitchen was made on 07/22/13 at 12:35 PM with the Food Service Director (FSD). During the tour, observations of the dry good storage area revealed 5 cans of fruit with rim dents. The dents were approximately 3-4 inches long just above the bottom rim of the canned goods. The FSD was present for the observation and reported that the canned goods were stored ready for use. He added that food service employee #1 had been trained on the procedure for stocking canned goods. He added that the employee was trained to inspect stock and remove damaged canned goods. The FSD removed the 5 damaged cans. He stated the damaged cans should have been stored on the shelf ready for use in food production. Food service employee #1 was not available for an interview. On 07/24/13 at 11:50 AM the Food Service Manager was interviewed and reported that she expected all dented cans to be removed and placed on a shelf designated for damaged cans. She added that food service employee #1 had been out and that food service employee #2 had also helped with stocking canned goods. She added that she wasn't sure which employee failed to remove the dented cans but that both employees had been trained to remove dented canned goods from use.

Based on observations, staff interviews and record reviews facility staff failed to assess or reassess for pain before or during a dressing change and failed to provide wound treatment according to physician's orders [REDACTED].#6). The findings are: Resident #6 was admitted with [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set ((MDS) dated [DATE] indicated impairment in short and long term memory and moderate impairment in cognition for daily decision making. The MDS also indicated under section J titled "pain" that Resident #6 received scheduled pain medication, frequently had pain, pain affected her functioning and the pain intensity over a five (5) day period was eight (8) out of ten (10) on a pain scale. A review of a care plan with goals dated through 8/31/12 indicated a problem statement that resident had developed a venous stasis ulcer to the right (R) lower extremity. The goals indicated Resident #6 would show signs of improvement in the next 90 days. The approaches indicated to provide treatment as ordered and assess for pain and medicate as needed or ordered. A review of a post-op/follow-up surgeon's note dated 7/6/12 indicated resident returned in follow-up to help control infection in the ulcers of her (R) lower extremity and continued to have significant pain. The plan indicated to continue [MEDICATION NAME] daily and add [MEDICATION NAME] 800 milligrams orally twice a day. A review of a nurse's note dated 7/11/12 at 5:10 PM indicated a treatment nurse assessed Resident #6's (R) lower extremity with increased slough (a layer of dead tissue) with an area that measured 2 centimeters (cm) x 0.5 cm x 0 cm at one (1) to three (3) o'clock with black eschar (a black scab) on back of lower leg wound and odor. Also noted a new open area 8 cm x 7 cm x 0.1 cm to (R) lower leg on (R) side. Will notify surgeon in the morning because office was closed. A review of a nurse's note dated 7/12/12 at 10:45 AM indicated the treatment nurse called the surgeon's office regarding her assessment of Resident #6's right lower leg on 7/11/12 and was informed that the surgeon saw Resident #6 this morning and she had a follow up appointment next week. A review of a physician's progress note dated 7/13/12 indicated Resident #6 had an ischemic (R) leg with progressive ulceration and worsening with eschar (a black scab) and odor and complaints of pain in (R) lower extremity. The resident is followed by a surgeon and no longer on antibiotics. The notes further indicated worsening wound and awaiting surgeon's instructions. A review of monthly physicians orders dated 7/1/12 through 7/31/12 indicated [MEDICATION NAME] 800 milligrams by mouth twice a day for leg pain; [MEDICATION NAME] 10-325 milligrams by mouth every eight (8) hours for pain; [MEDICATION NAME] 5-325 milligrams by mouth one (1) to two (2) tablets every four hours as needed for pain and [MEDICATION NAME] 50 milligrams by mouth twice daily as needed for pain. The orders further indicated to apply [MEDICATION NAME] cream daily to (R) lower extremity, cover with cepafoam and kerlix. A review of the monthly Medication Administration Record (MAR) dated 7/1/12 through 7/31/12 indicated Resident #6 received [MEDICATION NAME] 800 milligrams by mouth at 8:00 AM and 4:00 PM daily and [MEDICATION NAME] 10-325 milligrams by mouth at 6:00 AM, 2:00 PM and 10:00 PM daily. A review of "Nurse's Medication Notes" on the MAR dated 7/4/12 through 7/18/12 indicated Resident #6 had not received any doses of [MEDICATION NAME] 50 milligrams by mouth for pain but received [MEDICATION NAME] 5-325 milligrams by mouth for (R) leg pain. There was no documentation on the MAR of Resident 6's pain levels according to a pain scale of one (1) least pain to ten (10) worst pain before the pain medication was given. The medication was given as follows: 7/4/12 (1) tablet at 9:00 AM 7/5/12 (1) tablet at 10:30 AM 7/7/12 two (2) tablets at 8:45 AM 7/8/12 (2) tablets at 8:50 AM 7/9/12 (1) tablet at 12:00 PM 7/10/12 (2) tablets at 9:00 AM 7/11/12 (2) tablets at 9:30 AM 7/15/12 (1) tablet at 7:00 PM 7/17/12 (2) tablets at 10:10 AM 7/18/12 (2) tablets at 9:45 AM A review of the monthly Treatment Record dated 7/1/12 through 7/31/12 indicated venous stasis ulcer (R) leg, cleanse with normal saline, skin prep, [MEDICATION NAME] and gauze. Treatment nurse to change on Wednesday 7AM - 3 PM shift. During an observation on 7/18/12 at 10:43 AM Licensed Nurse (LN) # 1 verified the treatment on the monthly treatment record and carried supplies for a dressing change into Resident #6's room and washed her hands and put on gloves. Resident #6 was sitting in her wheelchair and a large gauze dressing surrounded her (R) lower leg and extended from below her knee to the top of her ankle. LN #1 sat down on a chair facing the resident and Resident #6 stated "the back of my (R) leg is so sore." LN #1 began to remove the dressings on the resident's (R) leg and Resident #6 clenched her teeth, squinted her eyes closed, clenched her fists and shifted from side to side in her wheelchair. The dressings were loose and were not stuck to the wounds but Resident #6's (R) leg was bright red with raw, oozing skin and open sores on the front and back of her leg. A small area of greenish drainage was on the back of her lower (R) leg. LN#1 saturated gauze with saline and started to clean the open areas and Resident #6 grasped each wheel of her wheelchair with her hands, closed her eyes, was groaning and stated "oh, it hurts." LN#1 stated to Resident #6, "I'm trying to hurry" and continued to place four (4) large foam dressings on the front of the resident's leg, (4) large foam dressings to the back of her leg and started to wrap them with a gauze roll dressing. Resident #6 closed her eyes tightly, was breathing rapidly and stated "oh" and started groaning. LN#1 secured the dressing with tape and repositioned the resident. LN #1 then picked up her supplies and walked out to the treatment cart in the hallway. During an interview on 7/18/12 at 10:52 AM with LN #1 she explained she was assigned to do wound care because the treatment nurse was on vacation this week. She further explained this was the first time she had seen Resident #6's (R) leg and it was "one, open multiple wound." She stated she did not know and had not checked to see if Resident #6 had received pain medication prior to the dressing change but should have because "it's hurting her a good bit." She stated she heard the resident make several sounds while she changed the dressing but she was trying to get the dressing off and back on as quickly as she could and did not think to re-assess her pain. She further stated she was not aware the resident was grimacing, clenching her fists or grabbing the wheels of her wheelchair during the dressing change. LN #1 explained Resident #6's surgeon had discussed the possibility of amputation of her (R) lower leg with Resident #6 but she refused to discuss or consent to amputation. She further explained she did the dressing change according to the instructions on the treatment record which indicated to use saline and apply foam and gauze dressings. During a follow-up interview with LN #1 on 7/18/12 at 11:12 AM she stated she would go check Resident #6's MAR to see if she had pain medication that morning. She verified Resident #6 had been given two (2) [MEDICATION NAME] 5-325 milligram tablets orally at 9:45 AM by the medication nurse. LN #1 further stated she was not aware of this until now because she had not checked the MAR or talked with the medication nurse. During an interview on 7/18/12 at 1:55 PM Resident #6 stated her (R) lower leg was very sore because it was all open skin. She stated the slightest touch was painful and the dressing changes were very painful. During an interview on 7/18/12 at 2:00 PM the Nurse Manager explained documentation of pain was on the MAR under the "Nurse's Medication Notes" She stated the treatment nurse should talk with the medication nurse to ask about the resident's pain medication before starting a dressing change. During an interview on 7/18/12 at 1:17 PM the Director of Nurses (DON) stated it was her expectation that wound care be done according to physician's orders [REDACTED]. She explained it was her expectation that a resident's pain level according to the pain scale should be documented on the MAR before the resident received the pain medication and again when they reassessed the resident for the effects or response of the medication.

Based on observations, staff interviews and record reviews facility staff failed to assess or reassess for pain before or during a dressing change and failed to provide wound treatment according to physician's orders [REDACTED].#6). The findings are: Resident #6 was admitted with [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set ((MDS) dated [DATE] indicated impairment in short and long term memory and moderate impairment in cognition for daily decision making. The MDS also indicated under section J titled pain that Resident #6 received scheduled pain medication, frequently had pain, pain affected her functioning and the pain intensity over a five (5) day period was eight (8) out of ten (10) on a pain scale. A review of a care plan with goals dated through 8/31/12 indicated a problem statement that resident had developed a venous stasis ulcer to the right (R) lower extremity. The goals indicated Resident #6 would show signs of improvement in the next 90 days. The approaches indicated to provide treatment as ordered and assess for pain and medicate as needed or ordered. A review of a post-op/follow-up surgeon's note dated 7/6/12 indicated resident returned in follow-up to help control infection in the ulcers of her (R) lower extremity and continued to have significant pain. The plan indicated to continue [MEDICATION NAME] daily and add [MEDICATION NAME] 800 milligrams orally twice a day. A review of a nurse's note dated 7/11/12 at 5:10 PM indicated a treatment nurse assessed Resident #6's (R) lower extremity with increased slough (a layer of dead tissue) with an area that measured 2 centimeters (cm) x 0.5 cm x 0 cm at one (1) to three (3) o'clock with black eschar (a black scab) on back of lower leg wound and odor. Also noted a new open area 8 cm x 7 cm x 0.1 cm to (R) lower leg on (R) side. Will notify surgeon in the morning because office was closed. A review of a nurse's note dated 7/12/12 at 10:45 AM indicated the treatment nurse called the surgeon's office regarding her assessment of Resident #6's right lower leg on 7/11/12 and was informed that the surgeon saw Resident #6 this morning and she had a follow up appointment next week. A review of a physician's progress note dated 7/13/12 indicated Resident #6 had an ischemic (R) leg with progressive ulceration and worsening with eschar (a black scab) and odor and complaints of pain in (R) lower extremity. The resident is followed by a surgeon and no longer on antibiotics. The notes further indicated worsening wound and awaiting surgeon's instructions. A review of monthly physicians orders dated 7/1/12 through 7/31/12 indicated [MEDICATION NAME] 800 milligrams by mouth twice a day for leg pain; [MEDICATION NAME] 10-325 milligrams by mouth every eight (8) hours for pain; [MEDICATION NAME] 5-325 milligrams by mouth one (1) to two (2) tablets every four hours as needed for pain and [MEDICATION NAME] 50 milligrams by mouth twice daily as needed for pain. The orders further indicated to apply [MEDICATION NAME] cream daily to (R) lower extremity, cover with cepafoam and kerlix. A review of the monthly Medication Administration Record (MAR) dated 7/1/12 through 7/31/12 indicated Resident #6 received [MEDICATION NAME] 800 milligrams by mouth at 8:00 AM and 4:00 PM daily and [MEDICATION NAME] 10-325 milligrams by mouth at 6:00 AM, 2:00 PM and 10:00 PM daily. A review of Nurse's Medication Notes on the MAR dated 7/4/12 through 7/18/12 indicated Resident #6 had not received any doses of [MEDICATION NAME] 50 milligrams by mouth for pain but received [MEDICATION NAME] 5-325 milligrams by mouth for (R) leg pain. There was no documentation on the MAR of Resident 6's pain levels according to a pain scale of one (1) least pain to ten (10) worst pain before the pain medication was given. The medication was given as follows: 7/4/12 (1) tablet at 9:00 AM 7/5/12 (1) tablet at 10:30 AM 7/7/12 two (2) tablets at 8:45 AM 7/8/12 (2) tablets at 8:50 AM 7/9/12 (1) tablet at 12:00 PM 7/10/12 (2) tablets at 9:00 AM 7/11/12 (2) tablets at 9:30 AM 7/15/12 (1) tablet at 7:00 PM 7/17/12 (2) tablets at 10:10 AM 7/18/12 (2) tablets at 9:45 AM A review of the monthly Treatment Record dated 7/1/12 through 7/31/12 indicated venous stasis ulcer (R) leg, cleanse with normal saline, skin prep, [MEDICATION NAME] and gauze. Treatment nurse to change on Wednesday 7AM - 3 PM shift. During an observation on 7/18/12 at 10:43 AM Licensed Nurse (LN) # 1 verified the treatment on the monthly treatment record and carried supplies for a dressing change into Resident #6's room and washed her hands and put on gloves. Resident #6 was sitting in her wheelchair and a large gauze dressing surrounded her (R) lower leg and extended from below her knee to the top of her ankle. LN #1 sat down on a chair facing the resident and Resident #6 stated the back of my (R) leg is so sore. LN #1 began to remove the dressings on the resident's (R) leg and Resident #6 clenched her teeth, squinted her eyes closed, clenched her fists and shifted from side to side in her wheelchair. The dressings were loose and were not stuck to the wounds but Resident #6's (R) leg was bright red with raw, oozing skin and open sores on the front and back of her leg. A small area of greenish drainage was on the back of her lower (R) leg. LN#1 saturated gauze with saline and started to clean the open areas and Resident #6 grasped each wheel of her wheelchair with her hands, closed her eyes, was groaning and stated oh, it hurts. LN#1 stated to Resident #6, I'm trying to hurry and continued to place four (4) large foam dressings on the front of the resident's leg, (4) large foam dressings to the back of her leg and started to wrap them with a gauze roll dressing. Resident #6 closed her eyes tightly, was breathing rapidly and stated oh and started groaning. LN#1 secured the dressing with tape and repositioned the resident. LN #1 then picked up her supplies and walked out to the treatment cart in the hallway. During an interview on 7/18/12 at 10:52 AM with LN #1 she explained she was assigned to do wound care because the treatment nurse was on vacation this week. She further explained this was the first time she had seen Resident #6's (R) leg and it was one, open multiple wound. She stated she did not know and had not checked to see if Resident #6 had received pain medication prior to the dressing change but should have because it's hurting her a good bit. She stated she heard the resident make several sounds while she changed the dressing but she was trying to get the dressing off and back on as quickly as she could and did not think to re-assess her pain. She further stated she was not aware the resident was grimacing, clenching her fists or grabbing the wheels of her wheelchair during the dressing change. LN #1 explained Resident #6's surgeon had discussed the possibility of amputation of her (R) lower leg with Resident #6 but she refused to discuss or consent to amputation. She further explained she did the dressing change according to the instructions on the treatment record which indicated to use saline and apply foam and gauze dressings. During a follow-up interview with LN #1 on 7/18/12 at 11:12 AM she stated she would go check Resident #6's MAR to see if she had pain medication that morning. She verified Resident #6 had been given two (2) [MEDICATION NAME] 5-325 milligram tablets orally at 9:45 AM by the medication nurse. LN #1 further stated she was not aware of this until now because she had not checked the MAR or talked with the medication nurse. During an interview on 7/18/12 at 1:55 PM Resident #6 stated her (R) lower leg was very sore because it was all open skin. She stated the slightest touch was painful and the dressing changes were very painful. During an interview on 7/18/12 at 2:00 PM the Nurse Manager explained documentation of pain was on the MAR under the Nurse's Medication Notes She stated the treatment nurse should talk with the medication nurse to ask about the resident's pain medication before starting a dressing change. During an interview on 7/18/12 at 1:17 PM the Director of Nurses (DON) stated it was her expectation that wound care be done according to physician's orders [REDACTED]. She explained it was her expectation that a resident's pain level according to the pain scale should be documented on the MAR before the resident received the pain medication and again when they reassessed the resident for the effects or response of the medication.

Based on observations, medical record review and staff interviews the facility staff failed to implement care measures to prevent a pressure ulcer from developing for one (1) of four (4) residents reviewed with pressure ulcers, Resident #99. The findings are: Resident #99 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #99's most recent Minimum Data Set for significant change dated 05/18/12 assessed her as being cognitively intact. The physical therapy initial assessment dated [DATE] was reviewed and read in part, "Precautions: non weight bearing right lower extremity, use knee immobilizer at all times, skin bruises and tears easily." Review of the Weekly Skin Assessment Detail Report completed by nursing dated 4/9/12 revealed there was no new skin problem. A Physician consult dated 4/12/12, revealed the following orders: 1.Observation and nonweightbearing on the right lower extremity. 2. Work on range of motion to full extension as well as flexion to tolerance. 3. Otherwise she will remain in the knee immobilizer except for range of motion and bathing. Resident #99's Braden Scale (scale used to assess risk for skin breakdown) dated 4/13/12 was scored at fourteen (14). Review of the Braden Scale revealed a score of twelve (12) or less represents high risk for skin breakdown. Review of the Weekly Skin Assessment Detail Report completed by nursing dated 4/16/12 revealed there were no new skin problems. Resident #99's Care Area Assessment (CAA) dated 4/17/12 read in part, "Hemoglobin of 8.9 adds to her risk and susceptibility to skin complications. Also to consider is the leg immobilizer she is currently wearing and the potential also for it to cause pressure/friction. She will need frequent repositioning in wheelchair and bed, routine checks for incontinence and toileting opportunities. Also regular skin checks for any indication of pressure and prompt intervention to prevent skin breakdown. This area will most likely prove the most challenging in what will be an extended period of limited mobility. Proceed to care plan." Review of physical therapy notes dated 4/19/12 read in part: "Today patient complained of right lower extremity pain and discomfort. Knee brace was strapped too tight. Physical therapy assistant (PTA) discovered an open blister at heel cord of right lower extremity and several blood blisters up lateral side of right lower extremity. Nursing notified and PTA (Physical Therapy Assistant) showed nursing areas." Review of nursing notes dated 4/19/12 read in part, "1 X 1 (one by one) centimeter (cm) dark red fluid filled blister noted on right lower lateral calf and 1 X 1 (one by one) cm dark red fluid filled blister noted on right lower posterior calf. Resident denies pain. No drainage noted from areas. Areas left open to air. Right leg immobilizer padded with a towel for protection of blisters." Review of physical therapy notes dated 4/20/12 read in part: "Blister areas on right lower extremity without dressing. Nursing notified again today and also shown the areas of interest." Resident #99's care plan dated 4/20/12 indicated she was at risk for pressure ulcers due to immobility. The goal was she would not develop any pressure ulcers for ninety (90) days. Interventions included monitor skin daily with activities of daily living, bathe twice per wk and frequently reposition in bed and chair. There was no mention of the leg immobilizer in the care plan or the resident's leg wound. Review of the Weekly Skin Assessment Detail Report completed by nursing dated 4/23/12 revealed there was no new skin problem. Review of the Nursing Discharge Summary dated 4/30/12, revealed Resident #99 was discharged to the hospital emergency room . This form completed prior to the resident being sent to the hospital, read in part, "Skin Conditions: left upper arm skin tear." There was no mention of the wound on Resident #99's right lower leg. The discharge summary was signed by the Unit Manager. An interview was conducted on 6/1/12 at 8:38 AM with Licensed Nursed (LN) #4 who is a certified wound nurse. She stated that the resident came here because she had a right tibial fracture. She stated the resident went back to the hospital and when she returned from the hospital she had a wound on her right lower leg. She reported the wound measured 15 X 3.6 cm. She stated she had not seen the resident prior to her readmission to the facility on [DATE]. She further reported that an immobilizer has to be taken off everyday and the skin inspected. She specified necrosis can develop with that type of fracture. She stated checking the skin is a standard of care. An interview was conducted on 6/1/12 10:26 AM with Physical Therapy Assistant (PTA) #1. She stated that on 4/19/12 while providing range of motion exercises for Resident #99 she felt her leg was wet and saw that she had a blister on right lower lateral aspect of her leg. She reported there were other blisters as well in this area of her leg. She specified she reported this to the LN #6 who was caring for Resident #99 that day. She stated when the resident came back for physical therapy the next day she did not have a dressing on her leg. She stated she told nursing about the wounds again. She reported she told her supervisor on 4/26/12 that the wounds were getting worse. An observation was made on 6/1/12 at 12:40 PM LN #4 performing a dressing change to Resident #99's right lower extremity wound. The wound measured 9 X 1.5 X 0.4 cm. with 2.5 cm of tendon showing. The wound was cleaned with normal saline, a clear dressing was applied to the area around the wound and ointment was applied to the wound bed. The showing tendon was covered with white foam dressing and black [MEDICATION NAME] was inserted into the wound bed, covered with a clear dressing and the wound vac was attached. During the dressing change on 6/1/12 at 12:40 PM LN #4 explained she is usually notified if a blister is found on a resident. She further reported that a clear blister is automatically a stage II pressure ulcer and a bloody blister is automatically a stage III pressure ulcer. An interview was conducted on 6/1/12 at 1:17 PM with the Unit Manager she stated she did not assess the wound blisters when she learned of them. She stated the wound nurse should have been notified. She further stated she could have missed the wounds on Resident #99's leg when she filled out the discharge summary. She further reported she wrote Resident #99's care plan. She stated the care plan should have involved specific care regarding the leg immobilizer. An interview was conducted on 6/1/12 at 1:26 PM with the Assistant Director of Nursing. She stated that when a wound was discovered it should be reported to the wound nurse. An interview was conducted on 6/1/12 at 2:57 PM with the Director of Nursing (DON). The DON stated her expectation was that skin assessments were done. When a wound was found she expected there would be communication between staff that needed to know. She stated she was never informed when the wounds were originally found on 4/19/12. She stated her expectation was for the Nurse Manager to report the wound during the morning stand up meeting. She stated she thought that when Resident #99 returned from the hospital that it was a new wound. She stated the process broke down when the wound was not reported originally in morning stand up. She would have expected for skin checks to have been done daily. She stated a dressing should have been applied per wound care protocol.