Every finding on record at Bainbridge Nursing & Rehabilitation Center

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility did not ensure medications and biologicals were stored in accordance with currently accepted professional principles. This was evident for 1 (5th floor) of 5 units observed. Specifically, during observation on the 5th Floor, a box filled with medications labeled with residents' names were found stored under the table at the nurse's station. These medications were not secured and were accessible to unlicensed staff and residents. The findings include:The facility policy titled Proper Storage and Return of Medications with a revised date of 05/02/2025 documented the medications must be secured, temperature controlled, and accessible only to authorized personnel. All medications and other drugs, including treatment items, shall be stored in a locked cabinet inaccessible to residents and visitors. During observation on 07/18/2025 between 12:45 PM to 1:36 PM, a cardboard box filled with multiple medications labeled Return was observed under the table in the nurses' station. The nurse's station was an open area with a walk in entry. A resident was observed wandering by the nurses' station. The contents of the cardboard box was examined with Registered Nurse #5, who was the Unit Manager, and the following medications were observed, to name a few: 6 tablets of sulfamethoxazole and trimethoprim, 29 tablets of memantine 10 milligrams, 2 tablets of metformin 500 milligrams, 6 tablets of quetiapine 25 milligram, 30 tablets of memantine 10 milligrams, 2 tablets of metformin 500 milligrams, 20 tablets of ketorolac tromethamine 10 grams, 22 tablets of mirtazapine 15 milligrams, a bottle of atorvastatin calcium 80 mg bottle, 28 tablets of mirtazapine 15 mg, 30 tablets loratadine 10 milligrams. During an interview on 07/18/2025 at 4:46 PM, Licensed Practical Nurse #3 stated the medications were supposed to be returned to the medication room for storage. They stated medication should be kept in the medication room for resident safety. During an interview on 07/18/2025 at 1:37 PM, Registered Nurse #4 stated those medications in the box should have been in some place secured for safety of the resident since they have residents who are confused and can pick up and swallow those medications. They stated the medications are for return to the pharmacy and it is the night shift nurse's responsibility to return the medications. During an interview on 07/18/2025 at 2:31 PM, Registered Nurse #5, who was the Unit Manager, stated they did not notice the box filled with medications stored at the nurse's station this morning. They stated those medications should be stored in the medication room and should not be out in the open and not accessible to non-healthcare staff and residents. During an interview on 07/18/2025 at 3:55 PM, the Director of Nursing stated the box filled with medications that were found in the nursing station are medications for return to the pharmacy. They stated these medications were scanned by the night shift nurse and should have been put back in the medication room. The Director of Nursing stated all medications must be secured for safety as they have residents who wander. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews during the Recertification survey conducted from 07/16/2025 to 07/23/2025, the facility failed to ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed. This was evident for 1 (Resident #43) of 3 residents reviewed for Dental. Specifically, Resident #43's the Comprehensive Care Plan for oral/dental conditions was not reviewed and revised quarterly after each assessment. The findings include:The facility policy and procedure titled Comprehensive Care Plan with a revised date of 03/2025 documented that comprehensive care plans will be reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments. Resident #43 was admitted to the facility with diagnoses of Diabetes Mellitus, Anemia, and Heart Failure. The Quarterly Minimum Data Set, dated [DATE] and 04/18/2025 documented Resident # 43 was cognitively intact and had no dental issues documented. During observation on 07/16/2025 at 11:21 AM, Resident # 43 was observed with cracked teeth. Resident #43 stated they do not have mouth pain at this time.A comprehensive care plan for oral/dental conditions as evidenced by broken natural teeth was initiated on 08/07/2023. The facility interventions include inspecting mouth for any abscess, sores, or sign of infection; and to monitor food intake. The care plan was last reviewed on 07/09/2024; the care plan notes documented resident remained free from any sign and symptom of oral/dental problems, will continue plan of care for 90 days. A nursing progress note dated 01/13/2025 documented by the Former Registered Nurse Registered Nurse # 6 was called to assess Resident # 43 for tooth falling out, according to resident tooth fell out. Resident # 43 complained of no pain will continue to monitor resident dental appointment was attempted to be made but no dental appointment was secured I will call again documented. There was no documented evidence that the comprehensive care plan for oral/dental condition was reviewed and revised after each quarterly review assessments on 01/08/2025 and 04/09/2025. During an interview on 07/18/2025 at 3:14 PM, Registered Nurse #4, who was the Unit Manager, stated they do not check care plans for the residents, and they still have yet to learn how to look for and revise the resident care plans. During an interview on 07/18/2025 at 3:50 PM, the Director of Nursing stated that care plans should be completed on resident's admission, readmission, quarterly, when there is significant change, and episodic changes in a resident's clinical condition. The Director of Nursing stated that Resident # 43's dental care plan should have been reinitiated when the resident was readmitted and should have been updated. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility did not ensure that all potentially hazardous foods were stored, prepared, distributed, and served in accordance with professional standards of food safety. This was evident for 1 (Unit 1) of 5 units observed. Specifically, the dairy refrigerator in Unit 1 was observed to be above 40 F and the items inside of it, including multiple cartons of milk, sandwiches, and cheese, were not immediately disposed of.The findings include:The facility policy titled Food Storage-Potentially Hazardous Food which was last revised on 05/01/2025 documented that it is the facility's policy to ensure the safe storage of potentially hazardous foods to prevent foodborne illnesses and maintain a clean, safe, and sanitary storage area for both food and non-food items. Refrigerators must maintain food at 41 F or below. Potentially hazardous foods, which includes dairy products, are foods that require strict temperature control to prevent the growth of harmful bacteria. For items requiring cold storage such as dairy/eggs, the recommended temperatures are 32-40 F. Any potentially hazardous foods found outside of safe temperature ranges must be discarded immediately.The Main Kitchen Refrigerator/Freezer Temperature Sheets for Unit #1 documented that the minimum acceptable temperature for the refrigerator was 40 F. It also documented that on 07/16/2025, the refrigerator was not working.On 07/16/2025 at 9:11 AM, the dairy refrigerator in Unit 1 was observed to be 45 F. The dairy refrigerator contained multiple items including crates of individual milk cartons, peanut butter sandwiches, cheese sandwiches, and individual cream cheese portions. The Food Service Director was interviewed and stated that on the evening of 07/15/2025, they observed the dairy refrigerator to be above 40 F and contacted a technician to repair it.On 07/16/2025 at 11:54 AM, a milk carton was removed from the dairy refrigerator and the temperature was tested to be at 47.6 F. The Food Service Director was interviewed and stated that the milk and other items in the refrigerator remained in the refrigerator and would not be disposed of despite it being broken because they did not believe that the refrigerator's temperature had been out of range for over two hours. They further stated that milk cartons from the broken dairy refrigerator had been served for lunch.On 07/16/2025 at 02:00 PM, the dairy refrigerator was observed to be 56 F. The Food Service Director stated that they were going to move the items in the dairy refrigerator to a different refrigerator and was then observed removing items from the dairy refrigerator with the assistance of a dietary aide.On 07/23/2025 at 10:54 AM, the Food Service Director was interviewed and stated that the dairy refrigerator was repaired on 07/18/2025. They stated that while the refrigerator was broken, the items inside of it were transferred to a different refrigerator and served to residents from that refrigerator. The milk and other potentially hazardous food items that had been inside of the broken refrigerator had not been disposed of because the Food Service Director did not believe they had been exposed to unsafe temperatures for a prolonged period of time.On 07/23/2025 at 11:32 AM, the Administrator was interviewed and stated that the Food Service Director made them aware of a problem with the dairy refrigerator's temperature. The Administrator stated that they were unsure if there had been a problem with the refrigerator's cooling ability, or if the problem was with the temperature gauge reading incorrectly. The Administrator stated that they were unaware that the milk in the refrigerator had been tested to be above 40 F. They also stated that they were unsure of whether the items in the dairy refrigerator had been immediately disposed of after the temperature was found to be out of range. 10 NYCRR 415.14(h)

Based on record review and interview during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility did not ensure the Binding Arbitration Agreement granted the residents and/or their designated representatives the right to rescind the agreement within 30 calendar days of signing it. This was evident for 3 (Resident # 146, #161, and #165) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Residents #146, #161, and #165 did not grant the residents and/or their designated representatives 30 calendar days to rescind the agreement. The findings include:The facility policy titled Arbitration Agreements which was effective on 10/17/2024 and last reviewed 10/18/2024 documented that the arbitration agreement shall explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it. 1. Resident #146 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] documented Resident #146's cognition as intact. The resident signed a Binding Arbitration Agreement with the facility on 07/12/2024.2. Resident #161 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] documented Resident #161's cognition as moderately impaired. Resident #161's designated representative signed a Binding Arbitration Agreement with the facility on 04/23/2024. 3) Resident #165 was admitted to the facility on [DATE].The admission Minimum Data Set assessment dated [DATE] documented Resident #161's cognition as intact. The resident signed a Binding Arbitration Agreement with the facility on 05/30/2024.Upon review of the signed Binding Arbitration Agreements for Residents #146, #161, and #165, it was noted that there had been no documented evidence that the facility provided the residents and/or their designated representatives 30 calendar days to rescind the agreements. On 07/22/2025 at 2:06 PM, the Assistant Director for Admissions, who was responsible for the binding arbitration agreements, was interviewed and stated that they explained the admission and binding arbitration agreements to the residents and/or their designated representative on admission. They stated most of the residents chose not to sign the arbitration agreement. They stated for those residents who signed, they have thirty days to rescind their signature. They stated their policy states that the residents have thirty days to rescind the agreement, but it is not in the signed arbitration agreement.On 07/22/2025 at 2:15 PM, the Director of Operations was interviewed and stated that the residents have thirty days to rescind the arbitration agreement. They stated the signed arbitration agreement before October 2024 did not include the thirty days to rescind the agreement. The Director of Operations stated they updated their arbitration agreement in October 2024 to include thirty days to revoke the agreement. On 07/22/2025 at 2:25 PM, the Administrator was interviewed and stated that the arbitration agreement states that they can rescind their signatures. They stated they revised the arbitration policy last year and that the time frame was included in the new arbitration agreement.10 NYCRR 415.30

Based on observation, record review, and interviews conducted during a Recertification survey from 4/3/23 through 4/11/23, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team to reflect changes in the resident's needs. This was evident in 1 out of 1 resident(s) reviewed for Urinary Catheter out of 38 total sampled residents (Resident # 154). Specifically, Resident # 154's CCP was not reviewed and revised to reflect that the resident performs self-catheter care. The findings are. The facility policy titled Interdisciplinary Care Planning dated March 2023 documented that the facility utilizes an interdisciplinary team to provide an individualized comprehensive resident assessment and a person-centered care planning process to maximize and maintain every resident's functional potential and quality of life. Each resident's care plan identifies goals that reflect the resident's unique needs. The care plan is revised when appropriate to reflect the resident's current needs, based on the evaluation of progress toward goals, response to care, and treatment. The facility did not have a policy for self-catheter care. Resident # 154 had diagnoses of obstructive reflux uropathy, acute kidney failure, and bladder neck obstruction. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #154 was cognitively intact, was independent in Activities of Daily Living (ADL), and had an indwelling catheter. On 4/06/23 at 8:48 AM and 04/07/23 at 2:44 PM, Resident #154 was interviewed and stated they have a Foley catheter connected to a leg bag. Resident #154 empties the leg bag and changes the bag without staff assistance. The staff showed them how to change the leg bag. The leg bag is changed once a week and when the leg bag plastic gets loose. The Comprehensive Care Plan titled Bladder Continence/Indwelling Catheter was initiated on 10/26/21 and documented interventions to monitor for signs and symptoms of urinary tract infection (UTI), pain, increased temperature, and confusion. The quarterly review care plan note dated 1/14/23 documented that Foley is in place, draining well, and remains free from UTI. The physician orders dated 3/26/23 documented Foley care every shift. There was no documented evidence Resident #154's CCP related to Bladder Continence/Indwelling Catheter was revised to include interventions for self catheter care. On 4/7/23 at 2:45 PM, an interview was conducted with the Certified Nursing Assistant (CNA) #3 who stated Resident #154 had a Foley catheter. The resident is independent and empties the leg bag themselves. The resident does not allow them to empty the leg bag. On 4/11/23 at 9:47 AM, an interview was conducted with Licensed Practical Nurse (LPN) #1 who stated Resident #154 is alert and empties the catheter bag themselves. Resident #154 asks for a new bag when they need it. LPN #1 has not changed Resident #154's leg bag. LPN #1 has never seen Resident #154 changing or emptying the leg bag and does not know if the resident uses a glove. On 04/07/23 at 2:51 PM, an interview was conducted with Registered Nurse Manager (RNM) #2 who stated Resident # 154 emptied and changed the leg bag themselves. It is not included in the CCP that the resident can change the bag themselves. There should have been an education and intervention documented in the resident's CCP. On 04/11/23 at 12:54 PM, an interview was conducted with the Director of Nursing (DNS) who stated Resident #154 has a care plan for indwelling catheters, but it did not reflect that the resident is doing self-catheter care. The CCP should have reflected Resident #154's self-catheter care. 415.11(c)(2)(i-iii)

Based on interviews and record review conducted during the Recertification/Complaint survey (NY00291223) from 4/3/2023 to 4/11/2023, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident # 58) out of 3 residents reviewed for Abuse. Specifically, the facility did not report Resident #58's right hip fracture to the NYSDOH within 2 hours. The findings are: The facility's policy titled Abuse Prohibition- Prevention and Reporting last revised January 2023 documented injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #58 had diagnoses of bipolar disorder and paraplegia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #58 was cognitively intact, required the assistance of 2 people to complete activities of daily living. The MDS also documented behavioral, verbal, and other behavioral symptoms occurring daily, putting Resident #58 at significant risk for physical illness or injury and rejection of care occurring daily. A Nursing Note dated 02/13/22 documented that resident #58 called 911 and reported their hips were broken while being turned during care. The Nursing Supervisor was notified, and Resident #58 was transferred to the hospital. The Accident/Incident (A/I) report dated 02/13/22 documented Resident #58 was overheard calling 911 after care was provided and complained their hip was broken. Resident #58 was transferred to the hospital. The Hospital After Visit Summary dated 02/14/22 revealed Resident # 58 sustained an impacted comminuted right intertrochanteric fracture. The NYSDOH intake dated 02/15/22 at 12:31PM documented the date and time of Resident #58's hip fracture as 02/13/22 at 11:20PM, more than 24 hours after the incident occurred. On 04/11/23 at 11:07 AM, the Director of Nursing (DNS) was interviewed and stated the DNS is responsible for reporting injuries of unknown origin to the NYSDOH. The DNS could not recall what transpired and the reason the case of Resident #58 was reported late. The incident occurred 2/13/22 and was reported to the NYSDOH on 2/15/22. The DNS stated they do their best to ensure incidents involving injury of unknown origin are reported to the NYSDOH within2 hours. The Administrator is made aware of reports being submitted to the NYSDOH. On 04/11/23 at v11:22 AM, the Administrator was interviewed and stated that they are aware of the time frame for reporting and that the DNS collaborates with them when a report must be made. The Administrator stated they knew they had to report the allegation of injuries of unknown source to NYSDOH within 2 hours after the allegation was made. 415.4 (b)(2)

Based on observations, record reviews, and interviews conducted during the Recertification survey, the facility did not ensure a resident's physical restraint was used for the least amount of time. Specifically, a resident's rear buckle restraint seat belt was not released every 2 hours for 15 minutes for a range of motion and during meals as ordered and periodic re-evaluation of the ongoing need for the restraint was not completed. This was evident for 1 of 2 residents reviewed for Physical Restraints out of a total sample of 38 residents. (Resident #137) The finding is: The facility policy entitled: Physical Restraints, dated 09/20/11, documented that: all residents with restraints will be monitored for continued need, and justification, as needed, arises. Documentation by nursing and physician shall state the medical symptom requiring the need for the restraint and the need for continued use in the CCP and all other relevant documentation. Seatbelts with buckle or Velcro closures that can be self-released by the resident at will are not considered restraints. The resident must be cognitively able to do so and can release the belt at will. Each individual with a restraint must have the restraint released every two (2) hours between fifteen (15) thirty to (30) minutes for the prescribed exercise and activity (e.g., ROM, feeding, hygiene, etc.). The resident's response must be documented appropriately by nursing on an ongoing basis. Restraints will be released at meals and during care. In addition, the clinical record shall include documentation of periodic re-evaluation of the need for the restraints and efforts made to substitute alternate measures. Resident #137 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented that Resident #137 had severely impaired cognition with short and long-term memory problems. The resident required extensive assistance of 2 staff persons for bed mobility, transfer, and toilet use. On 9/9/2020, from 11:38 AM to 2:27 PM, the resident was observed seated in a reclining wheelchair (w/c) with a rear buckle restraint seat belt in place in their room. The seat belt was not released during this time frame. At 12:24 PM, the resident was observed eating lunch in their room with the seat belt in place. On 9/10/2020, from 11 AM to 2:34 PM, the resident was observed in their room seated in a reclining w/c with the restraint seat belt in place with no release. At 12:30 PM, the Certified Nursing Assistant (CNA#1) was observed entering the residents room with the lunch tray. CNA #1 placed a clothing protector on the resident, placed the meal tray in front of the resident, and exited the room without releasing the seat belt. On 9/11/2020, from 10 AM to 2 PM, the resident was observed in their room seated in a reclining w/c with the seat belt in place. The seat belt was not released during this time frame. At 12:32 PM, CNA #1 entered the room with the resident's lunch tray, placed a clothing protector on the resident, and left without releasing the seat belt. The Comprehensive Care Plan (CCP) Restraint/Seat Belt dated 6/16/2020 documented that the resident was unaware of safety boundaries and had poor trunk and body control. Interventions included releasing the restraint every 2 hours for 15 minutes for range of motion exercise, toileting, ambulation, and at mealtimes. The physician's orders [REDACTED]. The orders documented the seat belt restraint should be released every two (2) hours for 15 minutes for range of motion, toileting, hygiene, nourishment, and mealtimes. The Restraint Initiation/Reduction document dated 4/3/2019 and completed on 4/6/2019 documented that lap buddy removal assessment was done for three days. The resident made numerous attempts to stand and was redirected by staff. The Restraint Initiation/Reduction document dated 4/6/2019 and completed on 4/10/2019 documented that lap buddy removal assessment was done for three days. The resident continues to get out of the chair unassisted needing continuous monitoring. The Restraint Initiation/Reduction document dated 4/10/2019 and completed on 4/14/2019 documented that resident continued to stand up from the chair and was redirected by staff for safety numerous times. The Restraint Initiation/Reduction document dated 2/20/2020 documented that resident is alert and oriented and seatbelt removal trial day 1 to 3 was performed. The resident continues to stand up despite the seatbelt. The Restraint Evaluation Monthly document dated 3/31/2020 documented that resident is alert with confusion with [DIAGNOSES REDACTED]. Continued use and needs Quarterly review. The evaluation further documented the rationale for rear seatbelt restraints was that the resident continued to rock back and forth and attempted to stand and move locked wheelchair. This was discussed with resident legal/designated representative including discussion of risk, benefits and alternatives. The Restraint Removal Assessment and Observation dated 7/29/2020 completed by the RN/Manager documented that the resident continued to require seatbelt daily as per plan of care. Restraint removal unsuccessful. There was no documented evidence that ongoing need for restraint had been re-evaluated periodically between April 2019 and February 2020. The Resident Medication Administration Record (MAR) dated July 2020, August 2020, and September 2020, documented a rear-facing seat belt was in place while in a wheelchair and should be released every 2 hours for 15 minutes for range of motion, toileting, hygiene, nourishment, and mealtimes due to the history of falling. The time frames listed were 7:30 to 3:30 PM, 3:30 PM to 11:30 PM, 11:30 PM to 7:30 AM. There was no documentation on the MAR that seat belt had been released every two (2) hours. The CNA Accountability Records (CNAAR) dated August 2020 and September 2020 contained no documentation regarding the use of the rear buckle restraint seat belt. On 9/10/2020 at 12:38 PM, an interview was conducted with CNA #1. CNA#1 stated that the resident is always strapped with the restraint seat belt at all times, and she did not know when it would be released. The CNA looked at her CNA Accountability instructions and stated there was nothing mentioned regarding when the seat belt should be released. The CNA did not know how often or when the seat belt needed to be released. On 9/10/2020 at 12:50 PM, an interview was conducted with Registered Nurse (RN#1). RN#1 stated that the resident should be released every two hours as per the care plan. RN #1 also stated that when she look at the CNAAR and CNA Documentation History Details there is no task for releasing the resident's seat belt restraints, therefore the CNAs would not know it needed to be done because it is not on their task. RN#1 further stated the only restraint evaluation documents for the resident were completed on 4/6/19, 4/10/2019, 4/14/2019, 2/23/2020 and 3/31/2020 and could not explain why it had not been completed between April 2019 and February 2020. On 9/11/2020 at 12:50 PM, the Registered Nurse (RN#1) was interviewed after observing Resident #137 eating lunch in their room with the rear buckle seat belt restraint in place. RN #1 stated the seat belt should be released during mealtimes and every two hours. On 09/14/2020 at 10:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that Resident #137's physician order [REDACTED]. The DON also stated that the resident should be evaluated and assessed every month for the continued use of the restraint. The restraint order for every two hours release can be found on the Medication Administration Record. The DON stated that the restraint release schedule should have been documented on the MAR every two hours under restraint monitoring, not as 7:30 to 3:30 PM, 3:30 PM to 11:30 PM, and 11:30 to 7 30 AM which would only be documentation once per shift. The DON further stated that the CNA's would not know when to release the resident's seatbelt restraint because it is found only in the Medication Administration Record. On 09/14/2020 at 11:28 AM, an interview was conducted with the Attending Physician (AP). The AP stated that the resident had a history of [REDACTED]. The physician ordered the rear buckle seat belt restraint for the resident, and it is to be released every two hours for a range of motion, care, and during mealtime. The AP also stated that the last monthly restraint evaluation was completed on 3/31/2020. The AP further stated the resident was evaluated during this period but he had not completed the monthly restraint evaluation form until 9/12/20. 09/14/2020 at 12:07 PM, an interview was conducted with the Rehabilitation Director (RD). The RD stated that the resident used to have a lap buddy, which was ineffective. The rear buckle seat belt helped prevent the resident from falling. The RD added that during their care plan meetings, it was very clear that the resident had to be released every two hours for a range of motion when receiving care and during meals. The Interdisciplinary Team decided that the resident will have a rear seat belt restraint that should be released every two hours. 415.4(a) (2-7)

Based on staff interviews and record review conducted during an abbreviated survey (NY 631), the facility failed to notify a resident's designated representative, of changes in treatment. This was evident in 1 out of 3 residents reviewed (Resident #1). Specifically, Resident #1 had an order for [REDACTED].#1 was administered a nerve block (an injection to decrease inflammation or turn off a pain signal along a specific distribution of nerve) medication under local Anesthesia, and Resident #1's designated representative was not notified. The findings include: The Facility's Policy and Procedure titled Family/Designated Representative Notification of Change in Resident Condition state that it is the policy of the facility to inform the resident's family or designated representative of any significant changes in his/her condition and/or treatment plan. The policy further states that for any other significant change of condition or treatment/discharge plan, the attending physician/designee will call the family or designated representative to discuss resident's condition and treatment status and document in the progress notes. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 07/13/2018 documented that Resident #1 had short/long-term memory problems. Resident # 1's Cognitive Skills for Daily Decision Making recorded a score of 3 - Severely impaired - never/rarely made decisions. Review of Resident #1 Face Sheet revealed that the complainant was listed on the Face Sheet as Resident #1's primary contact. The Comprehensive Care Plan (CCP) for Cognition Loss/Dementia initiated on 12/06/2016; revised on 03/08/2017, documented that Resident #1 had an actual cognitive loss. A physician's orders [REDACTED].#1 had Pain Management Consult. An Operative Report document (Consult document) dated 07/31/2018, revealed that a Physician Consultant evaluated Resident #1 on 07/31/2018 for [DIAGNOSES REDACTED]. The report documented that Resident #1 had nerve block injection at the right femoral area under local Anesthesia for Hip necrosis. The consultant also recorded that verbal consent was obtained from Resident #1 before performing the procedure. Review of the Facility's Physician Monthly Progress Note dated 07/31/2018 at 3:22 PM, documented that Resident #1 had a nerve block done on 07/31/2018. Record review of Resident #1 medical record revealed no further documentation regarding the nerve block injection administered to Resident #1 on 07/31/2018. No family notification was documented. Licensed Practical Nurse #1 (LPN #1) was interviewed on 04/11/2019 at 11:09 AM and stated that Resident #1 is confused and believes that she lives at home. Resident #1 does not remember recent events. The Registered Nurse Supervisor (RNS) was interviewed on 04/11/2019 at 11:15 AM and stated that Resident #1 is confused and alert to names only. The resident was able to verbalize when she was in pain. Resident #1 had progressive Dementia and poor memory. She would not be able to consent to procedures. Resident #1's designated representative makes all medical decisions for Resident #1, and that included signing or giving consent for a medical procedure. She said that the facility staff did not obtain the consent, the pain management team obtained the consent and gave the nerve block injection. The RNS stated that the doctor was responsible for notifying the family. The Primary Medical Doctor (PMD) was interviewed on 04/11/2019 at 11:22 AM and stated that Resident #1 was Demented and that he would have obtained consent from the resident's designated representative. He does not believe that Resident #1 can give consent as the resident was demented. The Pain Management Doctor (consultant) gave Resident #1 the nerve block injection. A follow-up interview was conducted with the PMD on 04/15/2019 at 3:06 PM. He stated that he does not recall if he spoke with Resident #1's designated representative about the pain management consult. The Pain Management Doctor was interviewed on 04/11/2019 at 4:00 PM and stated that the facility's policy at that time was to obtain verbal consent from the resident before the procedure. He verbalized that he does not call residents' family for consent if a resident can say yes. He said that he does not remember if the staff ever told him that the resident could not make a medical decision. The Director of Nursing was interviewed on 04/11/2019 at 2:52 PM and stated that Resident #1's designated representative should have been notified of the changes in the resident condition and any new orders. She said that if a resident does not have the capacity to make medical decisions, the designated representative would be notified for consent. The nerve block injection was not part of the routine treatment, and that notification and approval was required from the resident's representative. She said that there was no psych consult done to determine Resident #1 capacity to make medical decisions. A follow-up interview was conducted with the DON on 05/01/2019 at 11:07 AM. She stated that Resident #1 does not have a Health Care Proxy (HCP), but there is an indication of next of kin on the resident's face sheet. She said that Resident #1's designated representative is responsible for making medical decisions for the resident. She stated that the primary physician and Registered speaks with the family regarding changes in conditions. However, she was not sure if Resident #1's family member was notified before the nerve block injection was administered. There was no documentation of notification in the progress notes for Resident #1. 415.3(e)(2)(ii)(c)

Based on observation, interview and record review the facility did not ensure that 1) Two Novolog Insulin fles pens and 2) One vial of Purified Protein Derivative (PPD) were labeled by nursing staff with a date of opening. 1) On [DATE] at 11:29AM during the initial tour of the 4th floor Medication Room two Novolog Insulin Flex pens were observed in the medication refrigerator. The flex pens were opened but not labeled with an opening date on the pen itself. One flexpen was labeled with Lot mumber EZF0626 with an expiration date of ,[DATE]. The second flexpen was labeled with Lot number EZF0611 with an expiration date of ,[DATE]. On [DATE] at 11:28AM the Registered Nurse (RN) supervisor was interviewed and stated,The pens and the plastic bags are supposed to be labeled with an opening date. On [DATE] at 11:38AM the Licensed Practical Nurse (LPN) was interviewed and stated, The nurse who opens the flex pen is supposed to put the date that it is opened on the pen. There is a date on the plastic bag holding the flex pen, but I do not check the flex pen itself. I do not check the insulin pen itself if I do not give it. It was an oversight. On [DATE] at 11:10:AM the 4th floor RN Supervisor was interviewed and stated, When we start a bottle or pen of insulin they should label the date of opening on the vial or pen and on the ziplock plastic bag we keep it in. I was taught when you start an insullin pen you date the pen and the plastic bag holding it if there is one. The facility policy says to date the plastic bag that holds the pen. The facility policy does not say to label the insulin pen with a start date. The policy says to label the insulin pen with an expire date. Once an insulin pen is opened it is good for 28 days. 2) On [DATE] at 10:49AM during a check of medication storage one bottle of PPD approximately 90% full was found in the medication refrigerator in the 1st floor Nursing Office. The vial was open and in use. The vial was not labeled with a date of opening by the nursing staff. The vial was labeled with lot number 3 and an expiration date of ,[DATE]. On [DATE] at 10:55AM the Assistant Director of Nursing (ADON) was interviewed and stated. I checked the refrigerator last week. There was no open medication that was not dated in the refigerator. I checked the temperature of the refrigerator yesterday but I did not look and check the bottles. All the Nurses have access to this refrigerator and can go in and take out what they need. All the nurses have the responsibility that if they take out a bottle PPD, or insulin or any vaccine flu or pneumovax they are supposed to date the vial and the box. It is my rsponsibility to check this refrigerator every day for the proper temperature, for expired medication and to make sure the vials are properly labeled with a date of opening . I see the vial is appeoximately 90% full and not labeled with an opening date. On [DATE] 10:00 AM ADON was interviewed and stated, Once a vial of PPD is opened it is good for 30 days. If I find a vial that is not dated I would throw it out. I can't determine that 30 days have passed if there is no date on the bottle. For Novolog pen insuin if it is opened it is good for 30 days. If it is not labeled there is no way to know that the 30 days are up. The manufacturers labeling on the box containing the vial of PPD documents, Once entered, vial should be discarded after 30 days. The manufacturers package insert for Novolog FlexTouch Pens documents, The NovologFlexTouch Pen you are using should be thrown away after 28 days, even if it still has insulin left in it. 415.18(d)

Based on observation, record review, and staff interview the facility did not ensure that a resident with missing and broken carious teeth had a care plan intiated. (Resident #12) The findings are: On 3/22/16 at 2:13 PM Resident #12 was observed to have missing teeth. The resident has nutritional supplements on tray in a cup next to him. On 3/23/16 at 12:20PM Resident #12 was observed in the hallway by the main dining room. ( MDR) The resident was sitting in same spot as usual. The resident was seen eating her meal and tolerating food. It was observed the resident has missing teeth on the lower jaw. On 3/24/16 at 1 PM the resident was observed sitting in the hallway by the Main Dining Room. The resident stated she wanted to be left alone. It was observed that her lower jaw had missing teeth. This is a [AGE] year old with the [DIAGNOSES REDACTED]. The quarterly MDS on 2/26/16 documents severely impaired with long and short term impairment. The resident's functional status for bed mobility, transfer, locomotion on and off unit, dressing, personal hygiene and eating is extensive assist of one person. In the area titled Oral/Dental Status there is no checkmark to indicate any issues. None of the above present. On previous Annual MDS dated [DATE] next to the area titled, Oral/Dental Status no indication of anything. None of the above present. There is no documented evidence for an oral/dental care plan. On 3/24/16 at 1:15 PM the Registered Nurse Supervisor (RNS) was interviewed and stated, The RNS is responsible to intiate and update the Care Plan yearly and quarterly and it was not done. The RNS did not complete the comprehensive care plan until March 24, 2016.

Based on record review and interview, the facility did not ensure that a comprehensive care plans were reviewed and revised for a resident. Specifically, there was no revised care plan for a resident whose Foley Catheter was discontinued and also improved in functional status in the Activities of Daily Living. (ADL'S). The findings are: Resident is a [AGE] years old admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. The Minimum Data Sets 3.0 (MDS) quarterly assessment dated [DATE] documented the following: Cognitive status is intact, resident required limited assistance in dressing and personal hygiene. The MDS also documented resident is always incontinent of bowel and bladder. The Prior admission MDS assessment dated [DATE] documented the following: Cognitive status is intact, resident required total assistance in dressing and personal hygiene. The admission MDS further documented the resident has a Foley Catheter. The Foley Catheter was discontinued in 12/2015. A review of medical record reveals no documented evidence that care plans were reviewed for this resident who's quarterly MDS assessment reveals improvement in ADLS and no longer has a Foley Catheter. On 3/23/16 at 10AM the Nurse Manager was interviewed and stated, I am still in the process of updating and developing care plans and as well as the new admission. The facility does not revise care plans every quarter unless there's a change in the residents status. We do it annually. On 3/23/16 at 11:44AM an interview was conducted with the MDS coordinator who stated, Quarterly assessment and we don't necessarily meet. We don't revised care plans every quarter unless there is a change in the residents condition. We do it annually but not on quarterly schedule. 415.11(c)(2)(i-iii)

Based on observation, record review, and staff interview the facility did not ensure that a resident with missing and broken carious teeth was seen annually by the dentist. The findings is: On 3/22/16 at 2:13 PM resident #12 was observed to have missing teeth. The resident has nutritional supplements in a cup on a tray next to him. On 3/23/16 at 12:20PM the rersident was observed in the hallway by the main dining room. The resident was sitting in same spot as usual. The resident was observed eating her meal and tolerating food. The resident was observed with missing teeth on her lower jaw. On 3/24/16 at 1 PM the resident was observed sitting in the hallway by the main dining room and stated she wanted to be left alone. It was observed that her lower jaw had missing teeth. This is a [AGE] year old with the [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The last consult for dental was done in 10/20/14 which documented oral tissue within normal limits, pt has missing teeth and broken carious teeth, no pain. Pt does not want dental work On 3/24/16 at 1:15 PM the Registered Nurse Manager was interviewed and stated, I am responsible to ensure a dental consult is done yearly. I would put a consult in the dental box in the nursing office and the dentist would pick up the consult and see the resident in the facility. There is a standing order for dental consults on a yearly basis. The last dental consult was 10/20/14. The RNS asked the medical records clerk if there was any other consult to be reviewed by the physician and filed. The medical records clerk stated there was none. The RNS stated there was a physician order [REDACTED]. The RNS continued to state that the resident would be seen by the dentist on 3/25/16 when the dentist comes to the facility. 415.17(a-d)

Based on observations and interviews, the facility did not ensure medical supplies and equipment were stored properly. Specifically supplies were stored under sinks in the Medication rooms. This was evident for three (3) of (6) units. (Units 6, 5 and 4) This resulted in no actual harm with potential for more than minimal harm. The findings are: During the initial tour of the resident ' s units on 2/17/15 the following was observed under the sinks in the medication rooms. 6th floor medication room: Opened box containing specimen bags Opened box containing sterile urine specimen collection cups 6 urinals 4 water pitcher 1 suction machine 5th floor 5 boxes of disposable aprons 2 boxes of cleansing towelletes 1 box of gloves Multiple boxes of facial tissues Multiple toothbrushes Hand and body lotion Mouth wash Multiple Combs Multiple Hair brushes Urethral catheterization trays Multiple bottles of Shampoo & body wash Dominoes 4th floor 1 container of shampoo & body wash On 2/17/15 at 1:37pm the nursing supervisor on the 5th floor stated that the ' floaters ' placed supplies under the sink. Also stated that he randomly check under the sink to ensure supplies are not stored there. On 2/17/15 at 2:05pm the LPN charge nurse on the 6th floor stated that she was aware that supplies and/or equipment should not be stored under the sink in the medication room and that the nursing supervisor ' s usually ensure compliance. On 2/20/15 at 2:44pm the Assistant Director of Nursing/Infection control coordinator stated that supplies should not be stored under the sink in the medication rooms and it is the responsibilities of the Nursing supervisors to ensure that the staff do not store supplies under the sink. The Facility ' s Policy and procedure for storage of supplies indicated that supplies are stored according to infection and fire safety guidelines. Resident care items such as dressings and wound supplies will be stored in Central supply: when needed for resident care, they will be stored in the unit treatment carts. General resident care supplies will be stored in supply cabinets which are set up in each unit.

Based on observation,record review and staff interviews, the facility did not ensure that services provided to residents is in accordance with each resident's written plan of care . Specifically, a physician's orders [REDACTED]. This was evident for 1 out of 26 sampled residents. (Resident #163) . This resulted in no harm with the potential for more than minimal harm . The finding is: Resident #163 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS 3.0 ( minimum data set ) assessment dated [DATE] identified the resident 's cognition as intact and requires assistance with most activities of daily living. On 2/20/2015 at 2:00PM, resident was observed in her room. Alert , oriented to all conversant and cooperative. The physician's orders [REDACTED].>(more than ) 250 and <( less than ) 70 mg/dl ( milligram per dilution ). Review of the MAR ( Medication Administration Record [REDACTED] 1/29/2015 ----4:00PM----288 mg/dl 2/06/2015 ----4:00PM- ---356 mg/dl 2/10/2015 ----4:00PM-----362 mg /dl 2/11/2015-----4:00PM-----309 mg/dl 2/14/2015-----4:00PM-----285 mg/dl 2/17/2015 ----4:00PM -----375 mg/dl 2/20/2015-----4:00PM------329 mg/dl There was no documented evidence in either the Nurse's notes, physician's notes or MAR indicated [REDACTED]. The Charge LPN on 2/20/2015 at 2:00PM was interviewed and stated " The Licensed Nurse should have informed the physician but I don't see any documentation". The 3-11 LPN was not available for interview at the time of the survey. 415.11 (c) (3)(ii) OBSERVATION; 2/19/2015-----2:00PM -- RESIDENT IN SINGLE BEDDED ROOM WITH 2 1/2 SR UP WITH RW AND WC AT BEDSIDE . AT TIME OF VISIT RESIDENT WAS TAKING A NAP. 2/20/2015 ----9;00AM -- RESIDENT WAS REVISITED -- STILL ASLEEP. LPN IN CHARGE STATED " SHE IS A LATE MORNING PERSON . TV IN THE ROOM IS ON . RECORD REVIEW; DOB;03/23/1968 DOA;11/26/2014 FLU; REFUSED DRUG REGIMEN REVIEW ;1/20/2015-- SEE REPORT -- REPORT RECOMMENDATION TO DECREASE VS TAKING TO WEEKLY FROM DAILY . ATTENDING MD ; JONATHAN CHANG MD ORDERS; 1/26/2015 [MEDICATION NAME] 1 UNIT Q 6 HRS CALCUIM 600 WITH VIT. D 1 TAB BID [MEDICATION NAME] 20 MG 1 TAB OD [MEDICATION NAME] 5 MG 1 TAB OD [MEDICATION NAME] 25 MG 1 TAB Q 8 HRS [MEDICATION NAME] 100 MG 1 TAB OD [MEDICATION NAME] INSULIN 30 U SQ OD HS LORATIDINE 10 MG HS [MEDICATION NAME] ER 25 MG 1 TAB OD [MEDICATION NAME] 15 MG 1 TAB OD HS NEPHRO 0.8 MG 1 TAB OD NIFEDIAC CC 90 MG OD -- HOLD FOR BP< 110 [MEDICATION NAME] -- [MEDICATION NAME] 5MG /325MG Q 4 HRS PRN [MEDICATION NAME] 10 MG 1 TAB OD [MEDICATION NAME] 150 MG 1 TAB OD HS FS BID AC -- INFORM MD IF BS IS >250 <70 BP PR DAILY X 1 MONTH THEN WEEKLY MONITOR ORTHOSTATIC BP 1 X M O2 VIA NASAl CANNULA @2 L/MIM PRN DIETARY; NAS,DIABETIC LOW FAT /LOW CHOLESTEROL/RENAL REGULAR CONSISTENCY 2/11/ --- WT. 160 LBS WITH 12 LBS INCREASE IN 1 MONTH . WILL DISCUSS WITH MD AND REVIEW OF MEDICATIONS . PHYSICAL THERAPY 6X A WEEK X 8-12 WEEK FOR THERAPEUTIC EXERCISES AND BED MOBILITY ,TRANSFER,GAIT ,BALANCE, MAY AMBULATE WITH RW IN HER ROOM OOB TO WC OCCUPATIONAL THERAPY --- 6 X A WEEK X 6-12 WEEKS FOR THERAPEUTIC EXERCISES /ADL RETRAINING /BED MOBILITY/BALANCE PHYSICAL THERAPY ---6 X AWEEK THERAPEUTIC EXERCISES /MOBILITY /TRANSFERS /GAIT/BALANCE /MOBILITY MODALITIES INTERDISCIPLINARY NOTES ; RESIDENT STILL ON OT/PT FOR GAIT BALANCE AND [MEDICATION NAME] --.CURRENTLY REQUIRES LIMITED ASSIST OF 1 FOR TRANSFER AND ADLS ,AMBULATES IN ROOM WITH RW WITH SUPERVISION . RESIDENT IS CONTINENT OF BLADDER AND BOWEL. WILL CONTINUE TO MONITOR . CNA INSERVICE -- DONE ON 1/14/2015 --- PROPER TRANSFER TECHNIQUES /1 PERSON ASSIST FOR SAFE TOILETING WITH USE OF WALKER . SPEECH DYSPHAGIA STUDY --11/26/2014--- RESIDENT WITH ORAL MOTOR STUCTURES AS UNREMARKABLE . WITH MILDLY DECREASED MASTICATION . PT. TOLERATING REGULAR FOODS WITH NO S/SX OF ASPIRATION . LABORATORIES AMMONIA LEVEL Q WEEK ---MONDAYS - 2/16/2015--- NA- 138 /POTASSIUM-- 4.9 CHLORIDE --109 --GLUCOSE --231 ( VH) -- CREATININE --3.07 ( vh) -- BUN-- 68 (VH) --- RESIDENT HAD ACUTE CRF WITH NEPHOSTOMY TUBE INPLACED . AMMONIA--- 29.0 (NORMal) BMP 3XW(M-W-F) --- RESULTS WITH SIGNIFICANT DECREASED ON ELEVATED FINDINGS . AMMONIA AT 29 .HOWEVER -- BUN /CREATININE AND GLUCOSE REMAINS ON THE HIGH SIDE OF THE RESULTS . CONSULTATIONS ; DENTAL---SEEN 12/1/2014 PODIATRY--SEEN 12/14/2014 PSYCHIATRIC SEEN 12/1/7/2014 ---DX; MAJOR [MEDICAL CONDITION] /CHRONIC INSOMMIA . RECOMMENDATION; INCREASE [MEDICATION NAME] TO 45 MG HS /INCREASE ACTIVITY /GET OUT OF BED IN CHAIR . WOUND CONSULT -- SEEN 12/30/2014 WITH RECOMMENDATION TO D/C TRETAMENT TO AREA - HAS HEALED . PRESSURE ULCERS ; WITH MULTIPLE SITES FROM ADMISSION AS FOLLOWS ; RIGHT SCAPULAR AREA --STAGE 4 -- 4 X 2 / SACRAL-- STAGE 2 --4 X 2 -- LEFT HEEL --DTI 1 X 1 ---RIGHT FOOT -STAGE 2 --4 X 2 2/20/2015 --- WOUNDS SITES WERE MONITORED AND OBSERVED TO HAVE HEALED . ACTIVITIES : 12/5/20O14 -- THERAPEUTIC EVALUATION --- RESIDENT PREFERS ARTS AND CRAFTS - BOARD GAMES - PET -MUSIC --RELIGIOUS ACTIVITIES AND TV

Based on record review and interview, the facility did not ensure the assessment accurately reflected residents status. Specifically, The resident's most recent comprehensive assessment did not document that a resident had experienced a significant weight loss. This was evident for 1 of 3 residents reviewed for Nutrition (Resident #86). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #86 is an [AGE] year-old, readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8 out of 15. The MDS further documented the resident weighed 146 pounds (lbs.) and had no significant weight loss or gain in the last 6 months. The resident's "monthly/weekly Weight Record Sheet" dated 2013-2014 documented the following weights for this resident: 10/5/13- 148.6 lbs 11/11/13- 145.8 lbs 1/6/14 - 137.2 lbs The record of weights reflect that the resident sustained [REDACTED]. On 2/18/14 at 11:35 am, the Registered Dietician was interviewed and stated that she did not know where she got the weight of 146 lbs. for the completion of the assessment. She further stated that the facility policy is to document the weights in the weight book, including reweighs, and that she may have re-weighed the resident and did not document the new weight on the weight record sheet. . 415.11(b)

Based on record review and interview, the facility did not ensure that the comprehensive care plan for Nutrition was reviewed and revised. Specifically, A comprehensive care plan was developed to address a resident at risk to be nutritionally compromised. The resident experienced a significant weight loss and the CCP was not revised to identify the weight loss or to implement new goals and interventions to prevent further loss. This was evident for 1 of 3 residents reviewed for Nutrition. (Resident #86). The findings are: Resident #86 is an [AGE] year-old, readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] quarterly assessment documented the resident had moderately impaired cognition (Brief Interview of Mental Status score of 8 out of 15). The Monthly/weekly Weight Record sheet for 2013-2014 documented the following weights: 10/5/13 148.6 lbs 11/11/13 145.8 lbs 1/6/14 137.2 lbs The resident sustained [REDACTED]. The Comprehensive Care Plan for Nutrition dated 11/14/13 documented "steady weight gain noted good progress so far". There was no documented evidence in the medical record that the Comprehensive Care Plan for Nutrition was reviewed and revised with new interventions when the resident sustained [REDACTED]. On 2/18/14 at 11:35am, the Registered Dietician was interviewed and stated that she was not aware of the resident's significant weight loss, and she did not re-assess the resident. 415.11(c)(2)(i-iii)

Based on record review and interviews, the facility did not ensure that physician's orders were followed. This was evident for 1 of 3 residents reviewed for Nutrition (Resident #63). This result in no actual harm with potential for minimal harm that is not immediate jeopardy. The findings are: Resident #63 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented that the resident is cognitively intact (Brief interview of Mental Status score of 15) The Physician's order dated 11/08/12 documented "Consultation dental f/u (follow up) annually". A review of the resident's medical record indicated no documented evidence that a Dental Consult was done. On 2/14/14 at 1:30pm, the assistant Director of Nursing was interviewed and stated that she did not see a dental consult for 2013. She further stated that dental consults are done annually. On 2/14/14 at 2:30pm the Licensed Pratical Nurse was interviewed and stated "I thought she had a bedside dental consult visit. I never saw the consultation request." 415.11(c)(3)(ii)

Based on observation, record review, and interview the facility did not ensure that a resident maintained acceptable parameters of nutritional status. Specifically, A resident at risk for weight loss had a significant weight loss that was not identified and interventions were not implemented in a timely manner. . This was evident for 1 of 3 residents reviewed for Nutrition (Resident #86). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #86 is an [AGE] year-old, readmitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8 out of 15). The MDS further documented the resident weighed 146 pounds (lbs) and had no significant weight loss or gain in the last 6 months. The MDS also documented the resident required supervision with set-up help for eating. On 2/18/14 at 12:20 am the resident was observed eating lunch. The resident appeared thin and was eating independently. The resident ate 90% of the meal, which included 1/2 cup of juice, 6 oz (ounces) of soup, 3 oz meat, 1/2 cup of starch, 1/2 cup of vegetables, 1/2 cup of fruit, 1 slice of bread and 1 margarine pat. The Monthly/weekly Weight Record sheet dated 2013-2014 documented the following weights: 10/5/13 148.6 lbs 11/11/13 145.8 lbs 1/6/14 137.2 lbs There was no documented weight for December 2013. The resident sustained [REDACTED]. The CNA (Certified Nursing Assistant) Accountability Record Care Guide Nursing Orders dated February 2013 documented the resident had a 2 gm (grams) NA (sodium), mechanical soft diet. The Accountability further documented the resident's intake for breakfast, lunch, and dinner as (G) good which indicates 75-100% of the meals were consumed. The Dietary assessment dated [DATE] documented the resident was on a Chopped, 2 grams of sodium diet and required 65-70 grams of protein and 2000 ml (milliliters) of fluid. The assessment documented the resident weighed 147 lbs . The assessment documented the following interventions: monitor weights monthly, encourage food, visit at mealtime, assess need for supplements, encourage completion of meals, monitor for bowel movements, monitor appetite, monitor signs and symptoms of fluid imbalance. There was no documented evidence in the medical record that the resident's significant weight loss was addressed. The policy and procedure for weight monitoring documented that residents will be weighed monthly, and any weight loss or gain of 3 lbs or more will be added to a weight monitoring log. The policy further documented that a interdisciplinary team meeting will be held to address weight concerns documented in the weight monitoring log. On the Certified Nurses Assistant (CNA) was interviewed and stated that resident feeds himself after setup, and he usually eats 75-100% of all meals. She further stated the resident is weighed on the digital scale in the bathroom, and she documents the weight on the weight sheet for the nurse. On 2/1814 at 2:58 PM, the Licensed Practical Nurse (LPN) was interviewed and stated that the CNA takes the monthly weights and records them in the Weight book on the weight sheet. She further stated that the charge nurse or nurse supervisor reviews the weight sheets and initial them to indicate the weights have been observed. She also stated that if there is a weight change of 3 lbs. or more, the resident should be re-weighed. The LPN stated that the re-weigh should also be documented on the weight sheet. She stated that she did not remember if she informed the dietician of the resident's weight loss, but the dietician does check the weight book and address weight losses. The LPN stated that she did not remember the resident having any swelling to the extremities since readmission from hospital. On 2/18/14 at 11:35 AM, the Registered Dietician was interviewed and stated that she checks the weight book daily to monitor weights. She further stated that she was not aware of the resident's significant weight loss and did not re-assess the resident. She stated that she did not understand the discrepancy between the weights in her notes and those documented in the weight book. She stated the resident was moved to a different floor after admission, and the scale gives different results. She further stated that she does meal observations, and the resident eats well. On 2/18/14 at 2:44 PM, the Director of Nursing (DON) was interviewed and stated that they have not been doing the weight monitoring log per the facility policy, and the Dietician should be reviewing the weight book and addressing weight loss or gain concerns with the team. 415.12(i)(1)

Based on observation, it was determined that the facility did not ensure that the kitchen areas and equipment are maintained in good repair and clean, so as to afford good production under sanitary condition. Reference is made to the following: - Dusty/sooty surfaces around the compressor fan panels, in the dairy walk-in refrigerator. - Broken door gasket of the dairy reach - in refrigerator. - Broken loose ceramic tiles and accumulation of debris immediately outside of the dairy refrigerator. - Broken/missing wall tiles adjacent to the juices holding refrigerator. - Corrodel metal surfaces of the milk holding refrigerator. - Dusty/sooty lighting fixtures above the cooking range area, on the dairy and meat side. - Unprotected lighting fixtures above the cooking range areas. - Dust ladden storage pallets/shelves in the paper goods storage area. -Stained/dirty ceiling surfaces in the food preparation area. - Broken/missing wall tiles in the pot washing area. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy. The findings include: On January 28, 2013, at 10:00 AM to 11:00 AM, the following was observed; (1) In the dairy "walk-in" refrigerator, the surfaces around the compressor fan panels were heavily coated with black sooty dust. (2) The door gasket was completely broken (held with sticky tape) around the door to the dairy refrigerator. (3) The wall tiles were broken and there was an accumulation of loose debris immediately outside of the dairy refrigerator. (4) The wall tiles were broken and/or missing adjacent to the juices' holding refrigerator. (5) The metal surfaces at the exterior of the milk holding refrigerator was corroded with rust. (6) The lighting fixtures above the cooking range equipment were coated with dusty line. (7) The lighting bulbs above the cooking range equipment were not provided with covers so as to protect the broken glass falling into food or onto food preparation surfaces. (8) The storage pallets/shelves were dust ladden, in the paper goods storage area. (9) The ceiling surfaces and the low ledge surfaces adjacent to the meant side food preparation area, were stained with brownish food spills. (10) The wall surfaces had broken tiles, in the pot washing area. On January 29, 2013, at approximately 1:30 PM, the facility's director of building services stated that all noted areas in the kitchen are being cleaned/repaired. 415.29 (j)(1); 415.14 (b)

Based on observation, record review, and interview, the facility did not ensure that the clinical record accurately documented the status of a resident's pressure ulcer. This was evident for 1 of 30 sampled residents (Resident #6). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident # 6 is an [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] documented the resident had severely impaired cognition. The MDS further documented that the resident had no pressure ulcers. On 1/31/13 at 10:40 AM a wound care observation was conducted and revealed a small, unstageable opening on the sacrum. The surrounding skin on the sacral area was reddened. A Nursing Note dated 12/12/12 documented: "Resident noted c (with) (R) (Right) buttock open area 0.75 cm (centimeters) x (by) 1cm in size. Wound base pink with shiny granular appearance. " Nursing Notes dated 12/13/12 to 1/31/13 were reviwed. The resident's sacral pressure ulcer was consistently documented as a ( R) buttock pressure ulcer. The Weekly Physician's Pressure Ulcer Record sheets from 12/13/12 to 1/31/13 were reviewed. The sheets documented the resident had a Stage 3 pressure ulcer on the (R) buttock for that time-frame, except 1/17/13 when the wound was described as unstageable. The latest entry was 1/31/13. On 1/31/13 at 1:12 PM, the Registered Nurse Supervisor (RNS), who documented the initial note on 12/12/12, was interviewed and stated that she informed the Nurse Practitioner (NP) that the resident had a sacral wound. The RN further stated that the NP conducts wound rounds and stages the pressure ulcers. 415.22(a)(1-4)