Every finding on record at Bethesda Health Care Facility

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of diabetes and anxiety diagnoses for 1 of 24 residents reviewed for MDS accuracy (Resident #5).Findings include:Resident #5 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Her medical history was significant for type 2 diabetes mellitus and generalized anxiety disorder.Resident #5's care plan created 1/10/25 indicated Resident #5 had a diagnosis of diabetes. Anxiety was not included as a care focus area in Resident #5's care plan.A physician encounter note dated 10/28/25 indicated Resident #5 had a diagnosis of diet-controlled diabetes mellitus.Resident #5's physician order dated 11/19/25 indicated to administer 0.5 milligram Ativan (antianxiety medication) once a day in the evening for anxiety and unspecified mood disorder. Resident #5's annual MDS dated [DATE] coded Resident # 5 as cognitively severely impaired and as taking an antianxiety medication. The MDS did not indicate that Resident #5 had a diagnosis of diabetes or anxiety.During an interview with the MDS Nurse on 2/11/26 at 3:04 PM, she reported that Resident #5 had documented diagnoses of diabetes and generalized anxiety disorder, which should have been coded on the annual MDS. The MDS Nurse verbalized that she had missed coding the MDS to indicate that Resident #5 had diabetes and anxiety diagnoses when she completed the annual MDS on 12/23/25 and that the omission was an oversight.During an interview on 2/12/26 at 10:22 AM, the facility Administrator stated that the MDS should include all of a resident's diagnoses, and that diabetes and anxiety should have been coded on Resident #5's annual MDS to accurately reflect her current condition.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with serious mental health diagnoses for 1 of 1 resident reviewed for PASRR (Resident #4). Findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses which included hypertension, hyperkalemia and hyperlipidemia. The PASRR history report dated 11/01/2021, provided by the facility, revealed Resident #4 had one Level I PASRR review, completed on 11/01/2021 and the review did not meet level II criteria. The PASRR review revealed Resident #4 was noted to have no mental health diagnosis at the time of the review.A review of the active diagnosis list revealed Resident #4 had a diagnosis of generalized anxiety disorder and depressive disorder both noted as active on 03/26/2025. Review of the Psychiatrist note dated 01/20/2026 indicated Resident#4 had a chief complaint/ nature of presenting problem as mood disorder with psychosis/bipolar. The note documented medication prescribed for mood disorder with psychosis /bipolar was Zyprexa 5 milligrams one tablet by mouth (po) every bedtime.Review of Resident #4's electronic and paper medical record revealed no evidence a request was submitted for an evaluation for level II PASRR determination. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS indicated the resident had a diagnosis of bipolar disorder.During an interview on 02/11/2026 at 11:01 AM, MDS Coordinator stated that her usual practice was to notify the Business Office Manager (BOM) of the resident's new mental illness diagnoses and the BOM was responsible for sending the request to the state agency for evaluation for the level II PASRR. The MDS Coordinator stated that when the provider added the new mental illness diagnoses for Resident#4 in March 2025 she failed to notify the BOM so she could submit request for level II PASRR evaluation. During an interview on 02/12/2026 at 8:44 AM, the Business Office Manager (BOM) confirmed she was responsible for requesting level II PASRR evaluations for residents at the facility. She stated the MDS Coordinator did not notify her of the new mental health diagnoses of anxiety disorder, and depressive disorder for Resident #4 in March 2025. The BOM also stated she was not made aware of the bipolar disorder diagnosis in January 2026. She further stated that she would continue to communicate with the MDS Coordinator about the new mental health diagnoses and request level II PASRR evaluations. An interview was conducted with the Administrator on 02/12/26 at 8:57 AM who revealed the facility received Resident #4's level I PASRR information after his admission to the facility on [DATE] indicating she did not have any mental illness. She added the MDS Coordinator was responsible for notifying the BOM of Resident #4's new mental health diagnoses in March 2025 and the BOM would have requested a level II PASRR evaluation. She added Resident #4's level II PASRR evaluation should have been completed in March 2025 when the new mental illness diagnoses were added in the medical records.

Based on observations and staff interviews, the facility failed to discard expired food items and food items with signs of spoilage and failed to label and date resident's personal food items stored in 2 of 2 nourishment room refrigerators (Main Unit and Locked Unit). This practice had the potential to cause foodborne illnesses.Findings included:a. Observation of the Main Unit nourishment room refrigerator with the facility's Dietary Manager (DM) on 2/11/26 at 2:05 PM revealed the following: - A jar of strawberry preserves that was approximately a third full with a use by date of 1/19/26; - An unopened 8 ounces bottle of high protein milkshake with a best if used by date of 1/30/26; - Three unopened bottles of nutritional energy drink with a use by date of 10/9/25; - A 2-liter soft drink bottle that was half full of an orange liquid that was not labeled or dated; - A 500-milliliter disposable water bottle with a purplish liquid that was not labeled or dated; - A 500-milliliter soft drink bottle that was approximately half full of a brownish liquid that was not labeled or dated. The Unit Manager who came into the nourishment room during the observation placed the above food items in the trash can. The Unit Manager stated that nursing staff were supposed to ensure that all food items in the nourishment refrigerator were dated and labeled and that expired food items were discarded.b. Observation of the Locked Unit nourishment room refrigerator with the DM on 2/11/26 at 2:20 PM revealed the following: - A cup of yogurt with an expiration date of 1/9/26; - A pack of 3 prepackaged apples with an opened by date of 12/15/25 and best by date of 1/29/26. Two apples in the packet were observed to have grayish fuzz. The Locked Unit Charge Nurse who was present during the observation placed the items in the trash can. The Locked Unit Charge Nurse indicated that nurses were responsible for labeling the food items and checking the expiry dates and that she should have checked the refrigerator at the beginning of her shift at 7:00 am and ensured that expired food items were discarded to prevent food borne illnesses. During an interview on 2/11/26 at 2:40 PM with the Director of Nursing (DON), she stated that she expected nursing staff to inspect the nourishment room refrigerators to ensure expired food items were not left in the refrigerator and that all food items were labeled and dated.During an interview with the facility Administrator on 2/11/26 at 2:45 PM, she indicated that her expectation was to have all food items in the nourishment room refrigerators dated and labeled, have no outdated food items in the refrigerator and that any expired food items should have been thrown out by nursing staff.

Based on record review and staff interviews, the facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) (form 10123) for 1 of 3 sampled residents reviewed for beneficiary protection notification review (Resident #49). The findings included: Resident #49 was admitted to the facility on [DATE] with Medicare Part A skilled services. Resident #49's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #49's Medicare Part A skilled services ended on 4/08/2024 and her Medicare Part A Skilled Nursing Facility benefit was not exhausted. She remained in the facility. Record review revealed no evidence that Resident #49 or the resident's Responsible Party (RP) was provided with the NOMNC. During an interview with the Secretary Assistant on 11/31/2024 at 10:51AM, she stated she provided the RP with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) on 03/25/2024 but she failed to provide NOMNC notice. The Secretary Assistant stated she was not aware she should have provided the RP with the NOMNC notice due to the resident remaining in the facility and still having Medicare Part A days remaining. The Secretary Assistant indicated moving forward she would provide the NOMNC notice to the residents or RP as required by the federal guidelines. During an interview with the Administrator on 11/31/2024 at 11:05 AM, she stated Resident #49 remained in the facility after being discharged from rehab services and the RP should have received the NOMNC as required by the federal guidelines.

Based on record review and staff interview, the facility failed to refer a resident with a newly evident [DIAGNOSES REDACTED]. (Resident #24 and #76). Findings included: 1. Review of Resident #24 ' s PASARR Level I Determination Notification letter dated 01/08/16 revealed the resident was assessed to be Level I. There were no further PASARR referrals for Resident #24 in the medical record. Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #24 had no mental health related [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24 ' s cognition had been severely impaired. Resident #24 was not currently considered by the State Level II PASARR process to have a serious mental and/or intellectual disability or a related condition. She had behavioral symptoms daily. She was administrated antipsychotic medication and antidepressant medication on 7 of 7 days. Her active [DIAGNOSES REDACTED]. Resident #24 ' s plan of care, updated 12/04/18, included the problems of the [DIAGNOSES REDACTED]. It included a focus of cognition loss with [DIAGNOSES REDACTED]. Review of Resident #24 ' s psychiatric progress notes dated 01/24/19 revealed Resident #24 had been seen for follow-up per staff request. The progress notes specified facility staff had reported increased crying spells for Resident #24. The [DIAGNOSES REDACTED]. Review of Resident #24 ' s (MONTH) 2019 physician's order [REDACTED].#24 continued to receive antipsychotic medications and antidepressant medications. During an interview with the Administrator on 01/30/19 at 2:56 PM, the Administrator stated the PASARR screen in (MONTH) (YEAR) was the last PASARR screen performed on Resident #24. She stated this was a PASARR Level I. She further stated Resident #24 had not been referred to have a new screening with the new onset [DIAGNOSES REDACTED]. The Administrator expressed the front office clerk at that time had not been told to refer Resident #24 for a PASSAR Level II referral. The Administrator indicated her expectation was for the screening to be completed. 2. Review of Resident #76 ' s PASARR Level I Determination Notification letter dated 02/28/17 revealed the resident had been assessed to be Level I. There had been no further PASARR referrals for Resident #76 in the medical record. Resident #76 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 ' s cognition had been severely impaired. Resident #76 had been inattentive consistently and had behavioral symptoms 4 to 6 days of the assessment period. She had been administrated antipsychotic medication and antidepressant medication on 7 of 7 days. Her active [DIAGNOSES REDACTED]. Review of Resident #76 ' s psychiatric progress noted dated 01/10/19 revealed Resident #76 had been seen for follow-up medication review. The progress notes specified facility staff reported no changes in mood or behaviors with the last medication changes. The current noted [DIAGNOSES REDACTED]. Resident #76 ' s plan of care, updated 01/24/19, included the problems of Resident #76 will resist care and become combative at times and had history of falls and receiving [MEDICAL CONDITION] drug. It included additional focus areas of wandering in her wheelchair on the unit, dementia and not being aware of her needs, depending on staff for her care and the risk for side effects related to [MEDICAL CONDITION] medication. Review of Resident #76 ' s (MONTH) 2019 physician's order [REDACTED].#76 continued to receive antipsychotic medications and antidepressant medications. During an interview with the Administrator on 01/30/19 at 2:56 PM, the Administrator stated the PASARR screen in (MONTH) (YEAR) was the last PASARR screen performed on Resident #76. She stated this was a PASARR Level I. The Administrator further stated Resident #76 had not been referred to have a new screening. She stated the added [DIAGNOSES REDACTED]. The Administrator expressed the front office clerk at that time had not been told to refer Resident #76 for a PASSAR Level II referral. The Administrator indicated her expectation was for the screening to be completed.

Based on record review and staff interviews, the facility failed to invite the resident in the care plan conference for 1 of 1 sampled resident (Residents # 17). Findings included: Resident #17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident # 17's cognition was intact. The resident had no short or long term memory problems. Review of the interdisciplinary care conference attendance record dated 1/4/2018 revealed that Resident # 17 had a care plan conference .The record did not indicate that the resident had attended the conference. On 4/3/2018 at 11:46 AM, Resident # 17 was interviewed. The resident stated that she had not been invited to a care plan conference for the last 3 months. She also indicated she wanted to be discharged home but no staff had discussed with her about her goals and progress in her health. She indicated she was feeling much better compared to the time she was admitted to the facility. On 4/4/18 at 10:59 AM, The MDS coordinator indicated she was responsible for inviting the residents and residents' representative to the care plan conference. She further indicated she did not invite Resident # 17 to the last care planning conference on 1/4/2018. She added that next time the resident's conference is due she will make sure she is invited. On 4/4/2018 at 12:25 PM, the Administrator was interviewed. She stated that she expected the care plan meeting to be held every 3 months and the residents or resident's representative should be invited in the care plan conference every 3 months.

Based on observation and staff interview, the facility failed to store 5 of 5 items in the walk-in freezer, to allow for adequate air circulation and to label and date 4 of 4 opened and resealed bags of dry pasta. Findings Included: A review of the facility's General Sanitation Procedures: Dietary Services dated 6/5/86, showed in part, Sanitation in Food Storage: (1) All containers of food are stored above the floor in such a manner to be protected from splash or other contamination and to permit cleaning. Shelving unit construction and placement and storage practices must allow for proper air circulation . All opened packages are securely fastened by a tie or other closure to protect the contents from contamination. An observation of the dry storage area of the facility kitchen with the facility Dietary Manager on 6/14/2017, at 12:05pm revealed 4 bags of dry pasta in the dry storage area that had been opened and resealed with no label of the date opened. On 6/14/2017 at 12:15pm an observation of the walk-in freezer with the facility Dietary Manager revealed 5 three gallon containers of ice cream stored on floor of walk-in freezer. An interview with the facility Dietary Manager on 6/14/2017 at 12:30pm was conducted, she stated her expectation was that any opened product should be dated when opened and all products in walk-in freezer stored at least 6 inches off the floor. On 6/14/2017 at 3:00pm, an interview was conducted with the facility Administrator. The Administrator stated that her expectations for dry storage items that were opened and resealed be dated when opened. The Administrator stated that her expectation for storage of frozen foods in the walk-in freezer was that no foods be stored on the floor.

Based on observations, staff interviews and record review, the facility failed to identify a medical symptom to justify the use of a physical restraint (trunk restraint) and failed to implement systemic approaches to reduce the restraint to the least restrictive method for 2 of 3 sampled residents (Resident #66 and Resident # 81) reviewed for physical restraints. Findings included: 1. Resident #66 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. A review of a physical therapy discharge summary dated 10/6/15 indicated Resident #66 was seen for abnormal posture and wheelchair positioning. Resident #66 was discharged using a high back wheelchair to achieve improved posture. A nursing note dated 12/7/15 indicated a fall at 5:50 PM in which Resident #66 leaned forward and fell from the wheelchair and a physician order [REDACTED]. A review of the Restraint Log completed by the restorative nurse indicated on 12/8/15 at 8:00 AM, wedge cushion was placed in Resident #66 ' s wheelchair for positioning purposes. At 1:30 PM, Resident #66 was noted to leaning over and throwing legs over the foot pedals while the wedge cushion was in place. A lap buddy was then placed in the wheelchair for correct positioning. The next Restraint Log note was dated 3/1/16 and indicated the lap buddy was used while Resident #66 was up in the wheelchair due to poor positioning and leaning forward. The last Restraint Log note dated 6/10/16 indicated the lap buddy was utilized to provide correct positioning in the wheelchair. Resident #66 ' s repeatedly slides hips forward to the edge of the wheelchair and the lap buddy correct the spine and hip alignment. A Fall Risk assessment dated [DATE] indicated Resident #66 was coded at a high risk for falls with no falls in the last 3 months. The annual Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment with no behaviors. Resident #66 was coded as having one fall without injury, no impairment to the upper or lower extremities and as using a walker or wheelchair. There was no restraints coded on the MDS. Resident #66 was care planned for falls on 6/27/16 with the intervention for a lap buddy to assist with positioning. In an observation on 8/22/16 at 3:30 PM, Resident #66 was observed sitting with a lap buddy applied to her wheelchair in the common area of the secured unit. In another observation on 8/23/16 9:45 AM, Resident #66 was observed eating breakfast at the dining with a lap buddy to her wheelchair. At 10:36 AM, nursing assistant (NA) #1 removed the breakfast plate while Resident #66 was attempting to remove the lap buddy from the wheelchair. NA #1 stated you know you can't take that off. In an interview on 8/23/16 at 9:50 AM, NA #1 stated she had known Resident #66 since her admission and was very familiar with her. NA #1 stated the lap buddy was placed on Resident #66 ' s wheelchair because she was able to walk but had a history of [REDACTED].#1 stated Resident #66 was able to take off the seat belt she had on her wheelchair once before but she could not take the lap buddy off. NA #1 stated she was told to take the lap buddy off every few hours to toilet Resident #66. In an observation on 8/23/16 at 12:00 PM, NA #1 and NA #2 were observed preparing to toilet Resident #66. NA #2 stated she knew Resident #66 since his admission to the facility. NA #2 asked Resident #66 to remove the lap buddy from the wheelchair. Resident #66 required redirection to attempt to remove the lap buddy four times before she made an attempt to remove it. Resident #66 was unable to remove the lap buddy from the wheelchair with prompting from NA #2. NA #1 stated Resident #66 was not able to take the lap buddy off by herself when asked. In an observation on 8/24/16 at 10:30 AM, Resident #66 was taken off the secured unit to a music activity with the lap buddy in place to her wheelchair. She was returned to the secured unit at 10:41 AM. In an interview on 8/24/16 at 11:20 AM, the Administrator stated the lap buddy was an intervention initiated for positioning either by therapy or by the restorative nurse. In an interview on 8/24/16 at 11:45AM, the rehabilitation director stated Resident #66 had not been seen for positioning since she was last seen in October 2015. He stated therapy did not recommend the lap buddy but it likely was initiated as a result of a fall team meeting after a fall. He also stated he was not aware of an attempt discontinue the lap buddy because the restorative nurse was over the restraints. In an interview on 8/24/16 at 12:00 PM, restorative nurse recalled discussing the lap buddy as a fall intervention. She stated she was told during a fall team meeting that the lap buddy was for positioning to keep her from falling from the wheelchair. The restorative nurse stated there had been no attempt to remove the lap buddy or try a less restrictive intervention since it was apply last December. The restorative nurse stated she was not trained restraint usage or the need for reduction attempts. In an interview on 8/25/16 at 2:00 PM, the Administrator stated it was her understanding that if the physician ordered the lap buddy for positioning, it was not considered a restraint. She stated that since Resident #66 was unable to remove the lap buddy, she understood it would be considered a restraint and attempts to use a less restrictive device should have been attempted. 2. Resident #81 was admitted [DATE] with dementia and benign prostate hypertrophy. A review of the last fall incident was 3/28/16 at 1:50 PM when Resident #81 was ambulating in the hall and lost his balance. Rest periods were encouraged. A review of the physician orders [REDACTED]. Resident #81 was sent to the hospital due in issues unrelated to the fall in March on 4/7/16 and returned on 4/20/16 with orders for therapy. A review of the physical therapy plan of care dated 4/21/16 indicated wheelchair mobility/management was not indicated as a functional deficit or did the occupational therapy plan of care dated 4/29/16. A review of the Restraint Log completed by the restorative nurse indicated on 6/9/16 the wedge cushion was used to correct Resident #81 ' s positioning in the wheelchair. Without the wedge cushion, Resident #81 ' s hips slid forward and made self propelling in the wheelchair difficult. He was correctly and efficiently propelling self in the wheelchair with the wedge cushion. Another Restraint Logs note dated 6/23/16 indicated Resident #81 was leaning forward in the wheelchair. A Velcro alarming seat belt was applied but Resident #81 continued to lean forward. A lap buddy was applied and noted to provide correct positioning of hip and he was not leaning forward. The quarterly MDS assessment dated [DATE] indicated severe cognitive impairment with verbal and physical behaviors, limited assistance with walking on the unit, unsteady gait with impairment to his lower extremities and the use of a wheelchair. Resident #81 was not coded for any falls or a trunk restraint. A review of the care plan indicated the last review was 6/25/16 and Resident #81 was originally care planned for falls on 9/15/15. The application of the lap buddy was initiated as an intervention on 6/23/16. A nursing note dated 6/13/16 at 4:00 PM indicated Resident #81 was restless and made multiple attempts to transfer himself without assistance. Constant wandering was observed while in his wheelchair on the secured unit. A nursing note dated 6/16/16 at 4:40 PM read physical therapy and occupational therapy continue to work with the Resident #81 on gait and transfers. There was no observed loss of balance. A nursing note dated 6/17/16 at 5:00 PM read Resident #81 propels in the wheelchair without difficulty. A nursing note dated 6/22/16 at 2:30 PM read physical and occupational therapy continue to work on gait and transfers. Resident #81 can ambulate 150 feet with hand held assistance. A nursing note dated 6/22/16 at 4:00 PM read Resident #81 was observed multiple times leaning forward. The note did not specify if the leaning was noted while ambulating or while sitting in his wheelchair. A nursing note dated 6/23/16 read at 7:30 AM and 8:30 AM read Resident #81 was observed leaning forward in his wheelchair. A nursing note dated 6/23/16 at 9:00 AM read a lap buddy was in place and Resident #81 was noted in upright proper sitting position. The lap buddy was discussed with the interdisciplinary team and orders were obtained for the lap buddy. A review of the physician orders [REDACTED].#81 ' s wheelchair for positioning. A review of the occupational therapy discharge summary dated 6/23/16 indicated at the time of discharge, Resident #81 was able to maintain proper postural alignment while standing for ten minutes without a recovery period and able to bend to pick up items on the floor while maintaining balance. A review of the physical therapy discharge note dated 6/30/16 Resident #81 was ambulating 300 feet with contact guard assistance to stand by assistance and able to maintain head and trunk balance. He was discharged to restorative nursing for ambulation. In an observation on 8/25/16 at 8:47 AM, Resident #81 was observed sitting at the dining room table eating breakfast with a lap buddy applied to his wheelchair. In an interview on 8/25/16 at 8:47 AM, Nursing Assistant (NA) #2 knew Resident #81 since his admission to the facility. NA #2 stated she had not received any training on the use of restrains but she was told the lap buddy needed to be removed every few hours for toileting. In an interview and observation on 8/25/16 at 9:22 AM, NA #1 stated she knew Resident #81 since his admission to the facility. She asked Resident #81 to remove the lap buddy from his wheelchair. Resident #81 required redirection to attempt to remove the lap buddy two times and made no effort to attempt to remove the lap buddy. NA #2 stated she had never observed Resident #81 leaning while in his wheelchair but rather was known to constantly stand up from his wheelchair up and fell a few times. In an interview on 8/24/16 at 11:45 AM, the rehabilitation director stated Resident #81 was discharged from therapy on 6/30/16. He stated there was no therapy documentation regarding Resident #81 leaning while up on his wheelchair but it must have been discussed in a fall or Medicare meeting for restorative to have applied a lap buddy to his wheelchair. In an interview on 8/24/16 at 12:00 PM, the restorative nurse stated she was unsure why she initiated the lap buddy but he must have been leaning that day and the group in the morning meeting decided to use a lap buddy. The restorative nurse stated she was told that if the lap buddy was for positioning, it was not considered a restraint. The restorative nurse stated there had been no attempt to remove the lap buddy or try a less restrictive intervention since it was apply last in June. The restorative nurse stated she was not trained restraint usage or the need for reduction attempts. In an interview on 8/25/16 at 2:00 PM, the Administrator stated it was her understanding that if the physician ordered the lap buddy for positioning, it was not considered a restraint. She stated that since Resident #81 was unable to remove the lap buddy, she understood it would be considered a restraint and attempts to use a less restrictive device should have been attempted.

Based on staff interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment on 1 (Resident #81) of 24 residents reviewed for a MDS accuracy. Findings included: Resident #81 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. He was sent to the hospital on [DATE] and returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. A review of the MDS assessments submitted indicated an discharge with expected return MDS dated [DATE], an entry MDS dated [DATE], a quarterly MDS dated [DATE], 14 day MDS dated [DATE] and a 30 day MDS dated [DATE]. The most recent MDS was a quarterly MDS dated [DATE]. There was no evidence of a significant change assessment with Care Area Assessments (CAAs). In an interview on 8/25/16 at 11:15 AM, the MDS nurse stated there should have been a significant change MDS with CAAs completed when Resident #81 was readmitted due to the change in condition. In an interview on 8/25/16 at 2:00 PM, the Administrator stated she would have expected a complete MDS assessment that would have captured the changes in Resident #81 ' s condition upon readmission on 4/20/16.

Based on observations, staff interviews and record review, the facility failed to correctly code the most recent comprehensive Minimum Data Set (MDS) assessment for physical restraints for 2 of 3 Resident #66 and Resident #80) residents reviewed for restraints. Findings included: 1. Resident #66 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. The most recent MDS was an annual assessment dated [DATE]. She was coded with severe cognitive impairment with no behaviors. Resident #66 was coded as having one fall without injury, no impairment to upper or lower extremities and as using a walker or wheelchair. There was no Care Area Assessment (CAA) completed for a physical restraint either. In an observation on 8/22/16 at 3:30 PM, Resident #66 was observed sitting in a wheelchair with a lap buddy (a cushion that fits snuggly in a wheelchair) applied to the chair. In another observation on 8/23/16 at 9:45 AM, Resident #66 was sitting at the table eating breakfast with a lap buddy applied to her wheelchair. In an observation on 8/23/16 at 12:00 PM, Resident #66 was asked by nursing assistant (NA) #2 to remove the lap buddy from her wheelchair. Resident #66 required multiple request and redirection to attempt to remove the lap buddy. She was unable to remove it. NA #1 stated Resident #66 was not able to take the lap buddy off her wheelchair and it was applied to her wheelchair to keep her from falling. In an interview on 8/24/16 at 12:00 PM, the MDS nurse stated Resident #66 ' s 6/20/16 annual MDS should have been coded for a trunk restraint since she was unable to remove the lap buddy when asked. The MDS nurse also stated that had the MDS been correctly coded, a CAA would have been completed. In an interview on 8/25/16 at 2:00 PM, the Administrator stated she would have expected the annual MDS assessment dated [DATE] would have been properly coded for the trunk restraint on Resident #66. 2. Resident #80 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. The most recent Minimal Data Set (MDS) was an annual assessment dated [DATE]. She was coded with moderately impaired cognition and inattention and disorganized thinking behaviors present. Resident #80 was coded as having no falls, no restraint, and no impairments to upper or lower extremities. There was no Care Area Assessment (CAA) completed for a physical restraint. During an observation on 8/22/2016 at 4:02 PM, Resident #80 was observed sitting in her Merrichair (enclosed framed wheeled walker) watching television in the Dayroom. In another observation on 8/23/2016 at 10:24 AM, Resident #80 was observed sitting in her Merrichair playing catch with a beach ball with other residents during activities. At lunchtime on 8/23/2016, Resident #80 was observed sitting in her Merrichair eating her lunch in the dining room. During an observation on 8/24/2016 at 3:45 PM, Resident #80 was asked by nursing assistant (NA) #2 to open the latch for the Merrichair. Resident #80 was asked several times and was redirected several times to open the latch on the Merrichair. She was unable to open the latch. NA #2 stated Resident #80 was not able to open the Merrichair latch. She stated the Merrichair assisted Resident #80 with her ambulation and positioning, but she had not seen her ever open the latch. In an interview on 8/25/2016 at 9:30 AM, the MDS Nurse stated Resident #80 ' s annual MDS dated [DATE] should have been coded for a restraint since she was unable to remove the Merrichair latch when asked. The MDS nurse also stated that had the MDS been correctly coded, a CAA would have been completed. In an interview on 8/25/16 at 11:00 AM, the Facility Administrator stated she would have expected the annual MDS assessment dated [DATE] would have been properly coded for the restraint used for Resident #80.

Based on observations, staff interviews and record review, the facility failed to administrator ordered three times daily (TID) and four times daily (QID) medications within the administration timeframe for 1 (Resident #18) of 3 residents observed during a medication administration. Findings included: During a medication pass on 8/24/16 Nurse #1 was restocking her medication cart with drinking cups. She began pulling medications for Resident #18 at 9:09 AM. Nurse #1 administered Resident #18 ' s prescribed 8:00 AM medications at 9:34 AM. The following medications were not given with the prescribed time frame: [MEDICATION NAME] 400 milligrams (mg) by mouth three times daily at 8:00 AM, 12:00 PM and 4:00 PM [MEDICATION NAME] 25-100 mg by mouth four times daily at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM [MEDICATION NAME] one drop in each eye four times daily at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM In an interview on 8/24/16 at 9:37 AM, Nurse #1 stated she was aware she could administer medications ordered at 8:00 AM between 7:00 AM and 9:00 AM but after 9:00 AM, Resident #18 ' s medications were considered late. Nurse #1 stated she started her medication pass after she got report a little after 7:00 AM and nothing unusual occurred the cause her to be behind on her medication pass. In an interview on 8/24/16 at 3:30 PM, the Charge Nurse stated she supervised the nurses on the hall and she observed Nurse #1 passing medications on the hall at approximately 7:20 AM when she arrived at work. The Charge Nurse stated she was not aware of any issues regarding timeliness of medication administration or anything that occurred unusual early in the shift to cause Nurse #1 to be late passing the 8:00 AM medications. In an interview on 8/25/16 at 9:56 AM, the Administrator stated she expected all resident medications be given within the ordered time frames. If the medications were not administrated at the times ordered, the physician should be contacted for orders to adjust medication administration times for medications given more than once daily.

Based on observation and staff interviews, the facility failed to maintain the resident ' s privacy by posting signs that indicated the type of diet, fluid restrictions and thickened liquids for 35 residents, on 1 of 1 supplement carts located in the hallway, the facility failed to provide privacy for 1 of 1 sampled residents (resident #58), by not pulling a privacy curtain between two residents during a gastrostomy medication administration observation, and by leaving a Medication Administration Record [REDACTED]. Findings included: 1) During the initial tour on 9/21/15 at 4:15pm 1 supplement cart was observed sitting in the hallway by room [ROOM NUMBER]. The cart had signs posted which displayed 35 resident names and room numbers, and the type of diet, fluid restriction and thickened liquids for each listed resident. During an observation on 09/24/2015 10:30:28 AM the dietary manager was observed pushing 1 supplement cart out of the dietary department, which is located near the entrance of the building, down the 100 hall, and onto the locked unit 200 hall, which is located near the back of the building. The cart had signs posted on the top of the cart with resident ' s names, room numbers, and types of diet, fluid restrictions and thickened liquids. 09/24/2015 10:33:28 AM During an interview with nursing assistant (NA) #2, she stated that the facility used the signs so the staff would know what type of diet residents are on. She stated that it probably shouldn ' t be there because it ' s a HIPAA thing . She stated that the signs were always there . 109/24/2015 10:45:23 AM During an interview with Nurse #2, she stated she did not even realize that the resident information was displayed on the supplement cart. Stated I really don't remember seeing it up there before, but I do not usually pass the supplements out . She stated the resident's private information should not be displayed for others to see. 09/24/2015 10:49:04 AM During an interview with the dietary manager, he stated that the resident information is not supposed to be displayed. Stated the reason we use it is because we have had a recent turnover of nursing assistants and we want to make sure that the staff do not give the wrong supplements out to the wrong resident . Stated it's probably been about a week we have been using the sign, because the nursing assistants do not know the resident's diets, so we wanted to make sure they don't give out the wrong thing . 09/24/2015 11:03:00 AM During a joint interview with the director of nursing (DON) and administrator (ADM), both stated they expect all resident private information to be covered and not prominently displayed for the public to view. The DON stated we wanted to make sure everyone gets the right thing, but all the signs should be covered so the residents ' personal information is not displayed . 2) 9/22/2015 4:44:19 PM During an observation of nurse #4 of medication administration, the nurse raised the head of the bed for resident #58, and pulled up the resident ' s gown, exposing her abdomen to begin to administer her medications via her gastrostomy tube. She did not pull the privacy curtain located between the residents during the medication administration. Upon completion of the medication administration, nurse #4 pulled the gown back down in place for resident #58 and exited the room. 9/24/15 12:05 PM During a phone interview with nurse #4 she stated she realized after the medication observation that she had forgotten to pull the privacy curtain between resident #58 and resident #38 during her medication administration. She stated that she knew better than that, but had just gotten nervous during the observation. 09/24/2015 10:57:36 AM During an interview with the DON, Assistant director of nursing (ADON) and ADM. They jointly stated that the expectation is to provide the resident with privacy during any medication administration that may expose the resident. The DON stated the curtain should have been pulled when she administered the medications . 3) 9/23/15 9:35:16 AM During an observation of nurse #3 of medication observation, she left the the Medication Administration Record [REDACTED]. 09/24/15 10:25:50AM During an interview with nurse #3 she did not recall leaving MAR indicated [REDACTED]. 09/24/2015 10:57:36AM During an interview with DON she stated that all private information, including the MAR, should be covered at all times. 09/24/2015 10:57:36 AM During an interview with ADM, she agrees that resident private information is to remain confidential at all times.

Based on observation, staff interview and the medication storage policy review, the facility failed to discard expired medications for 1 of 2 medication rooms (100 hall medication room), the facility failed to properly store medications to be administered to the residents for 2 of 3 nurses administering medications, and failed to date multidose tuberculin vial for 1 of 2 refrigerators. Findings included: The facility ' s medication policy, (no date provided) was reviewed. Page #48 of medication policy under discontinued drugs states contrary to the instruction on the drug returned to pharmacy or released to the patient form, the nurse must list all controlled substances on the form along with other medications. The pharmacy complete the form supplied by the State Drug Authority . #4 states return medications and forms to the pharmacy , and #5 states if medications are to be discharged with the resident, have the responsible party sign the form then forward to the pharmacy . A review of the manufacturer ' s instruction for storage and use dated November 2013 indicated that Tuberculin vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 1) 09/24/2015 9:03:40 AM observation of 100 hall medication room revealed outdated medications of Warfarin 7.5mg filled on 11/18/2013 & Warfarin 7.5 mg filled on 9/4/2014 stored in a cabinet. 09/24/2015 9:07:30 AM During an interview with nurse #1 regarding the facility policy of medication storage, states we usually give the meds back to the family, we can't use them because they are mixed pills in one bottle of meds . She stated that another evening shift nurse is responsible for checking the medication rooms for expired medications . 09/24/2015 10:19:14 AM During an interview with DON regarding the facility policy of expired medications and medications brought from the resident ' s home, she stated that is the facility expectation to send back any expired medications to the pharmacy, and unidentified medications brought from the residents home back should be sent back home with the residents family. The DON stated that two weeks is too long of a time frame to return the medications; the medications should be sent back immediately. 09/24/2015 10:19:14 AM During an interview with the Administrator (ADM) regarding the facility policy of expired medication and medications brought from the resident ' s home, she stated that it was her expectation that expired medications should be discarded and medications brought from the resident ' s home should be returned to the resident ' s family. 2a) On 9/22/2015 4:44:19 PM During an observation of nurse #4 of medication administration, she pulled the medications from medication cart for resident #58, prepared medications by diluting them in water for gastrostomy tube administration, locked cart, and then went to another residents room, turning her back on the cart and leaving the medications on top of the cart unattended. She came back to the cart, gathered the medications she had prepared for resident #58 and then entered the semi-private room for resident #58 and resident #38, and shut the door. She was preparing to begin to administer her medications via her gastrostomy tube, but stated she forgot something , so she left the medications on the bedside table, exited the room and shut the door. Upon returning to the room, she began to administer the medications. 9/24/15 12:05 PM During a phone interview with nurse #4 stated she would not normally leave medications unattended on the cart or in the resident ' s room. 2b) 9/23/15 9:35:16 AM During an observation of nurse #3 of medication administration, she pulled out a bag containing topical medications of Voltaren gel from the medication cart, 1 Voltaren gel that was opened and 1 that had not been opened, and placed them on top of her cart for resident #28. She collected the medications for resident #28, including 1 opened vial of the Voltaren gel, but left the second unopened vial of Voltaren gel on top of her medication cart unattended while she went into resident #28 room, shut the door, and administered the medications to resident #28, the medications were not in her view. 09/24/15 10:25:50AM During an interview with nurse #3 regarding medications left unattended on her cart. She stated that I can totally remember the 2 tubes of Voltaren, one tube was new and the other was old, I completely forgot about leaving them on the medication cart . States it is not okay to leave medications unattended and you should never leave medications on top of the medication cart unattended. States I open the MAR indicated [REDACTED] . 09/24/2015 10:57:36AM During an interview with DON regarding unattended medications. The DON states that the nurse is to have their eyes on the medication cart at all times , the cart should be locked when the nurse is not within reach and medications should never be left unattended at any time. 09/24/2015 10:57:36 AM During an interview with ADM regarding unattended medications. She stated that it is her expectation that medications should never be left unattended and should be kept locked on the medication cart. 3) On 9/24/15 9:16 AM During an observation of medication storage on the locked unit (200 hall), an open multidose vial of Tuberculin 5TU/0.1ml was found with no date of opening. 09/24/2015 9:16 AM Staff interview with Nurse #2 on the unit revealed that it was missed. Stated she would discard it. 09/24/2015 10:21 AM Interview with DON/ADON stated, it was expected that staff would date when opening multidose vials.

Based on record review and staff interviews, the facility failed to accurately code section A of the Minimum Data Set (MDS) to reflect the Level II Preadmission Screening and Resident Review (PASRR) determination for one of one resident reviewed as Level II PASRR resident. (Resident #5). Findings included: Resident #5 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of section A1500 (Preadmission Screening and Resident Review (PASRR)) of Resident #5's annual Minimum Data Set ((MDS) dated [DATE] was conducted. Section A1500 indicated the resident was evaluated by Level II PASRR and determined not to have a serious mental illness and/or intellectual disability. The results of this screening and review are used to determine needs, appropriate care setting and a set of recommendations for services to help develop an individual's plan of care. A review of the facility's list of Level II PASRR residents revealed that Resident #5 was included among the residents named on the list. During an interview on 09/24/2015 at 8:51 AM, the facility Office Manager confirmed Resident #5 did indeed have a Level II PASRR status. The review of Resident ' s PASRR II form revealed that Resident #5 had Level II PASRR status. The MDS Coordinator was interviewed on 09/24/2015 at 10:05 AM, regarding the accuracy of Resident #5's annual MDS. When it was revealed the MDS did not reflect the Level II PASRR determination for this resident, the MDS Coordinator reported the information on the Level II PASRR was read wrong and the MDS was not coded correctly. On 09/24/2015 at 10:50 AM, the Director of Nursing indicated it was her expectation that the Level II PASRR determination would be coded accurately on each resident's MDS.

Based on observation, record review and staff interviews, the facility failed to provide nail care for one of four residents sampled for Activities of Daily Living (ADLs). (Resident #64). Findings included: Resident #64 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] noted Resident #64 was severely cognitively impaired and needed extensive to total assistance for all Activities of Daily Living (ADLs), with the physical assistance of one or two persons. On 9/22/2015 at 5:00 PM, Resident #64 was observed in her wheelchair. All of Resident #64's nails were long on both hands and had black matter underneath the nails. At 11:03 AM on 9/23/2015, in an interview, Nurse Aide (NA) #2 stated residents received showers or bed baths according to their schedule. ADL care, including washing hair and trimming nails, was provided during that time to residents. NA #2 stated Resident #64 was scheduled for a shower during 3-11 PM shift. On 9/23/2015 at 11:48 AM, Resident #64 was observed with untrimmed fingernails with black matter underneath. On 9/23/2015 at 2:51 PM, Resident #64 was observed again with Nurse #1. The resident had untrimmed fingernails with black matter underneath. Nurse #1 reported the resident was scheduled for shower on Mondays and Fridays for 3-11 PM shift, and nail care should be provided during shower or as needed. Nurse #1 also reported NAs were responsible for the resident ' s nail care as needed as somedays the resident needed set up only help with eating. At 3:23 PM on 9/23/2015, in an interview, the Director of Nursing (DON) stated her expectation was ADL care including nail care would be provided as scheduled and as needed.

Based on record review, observation, and staff interviews, the facility failed to update the care plan with specific interventions attempted for a resident who was at risk and had continued falls (Resident #8). Findings included: Resident #8 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) completed on 6/24/14 indicated Resident #8 had short and long term memory problem. Decision making was severely impaired. Extensive assistance of one person physical assist was required with bed mobility and two persons with transfers. Falls was listed as one fall without injury and one fall with injury. The care plan identified Resident #8 was at high risk for falls related to a history of falls, unsteady gait at times, continuously walk when awake, and not aware of her needs due to impaired cognition. The care plan further revealed the following falls: ? 1/31/14 fall without injury with no intervention for prevention specified ? 4/6/14 fall with skin tear with no intervention for prevention specified ? 4/20/14 fall without injury with no intervention for prevention specified ? 5/18/14 fall with laceration over left eyebrow with no intervention for prevention specified On 8/5/14 at 12:00 pm, Resident #8 was observed walking with a supportive ambulation device and required redirection periodically by the facility staff due to unaware of her surroundings. On 8/6/14 at 12:14 pm, Nurse #1 who participates in the development of the care plan for Resident #8 in the presence of Nurse #2 who oversee the care plan, reviewed the care plan and indicated she (Nurse #1) did not see specific care plan interventions for falls on 1/31, 4/6, 4/20 and 5/18/14. Nurse #2 stated she expected the care plan to reflect interventions or approaches implemented for the falls.

Based on staff interviews and record review, the facility failed to notify the physician for 1 of 2 residents (# 18) reviewed for accidents that sustained a laceration to the hand that required medical evaluation. The findings included: Resident # 18 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the facility skin tear protocol updated 10/14/2011 indicated "skin tear protocol will be part of the physician's standing order and used unless otherwise specified by the attending physician. Skin tear protocol stated "Cleanse skin tear with normal saline. Apply [MEDICATION NAME] according to the size of skin tear. Check skin tear everyday, change [MEDICATION NAME] every 5-7 days and prn (as needed) until healed. For large skin tear or skin tear with copious drainage may clean with normal saline, use Steris trips if needed and cover with dry dressing. Change prn until healed. Review of the Minimum Data Set ((MDS) dated [DATE], indicated Resident #18 was severely cognitively impaired. Review of an incident report for Resident #18 dated 9/4/2013 at 11:45 pm indicated the resident received a laceration to the index finger on the right hand. The Nurse's descriptive note stated "Resident resistant to ADL care-grabbing the bed rail-skin tear to right pointer finger at the base of finger." Review of a physician's telephone order dated 9/4/2013 indicated "Cleanse skin tear to right pointer finger at base of finger with normal saline. Pat dry. Apply (TAO) triple antibiotic ointment cover with nonstick dressing wrap with kling. Change daily until healed." Review of a physician's telephone order dated 9/5/2013 untimed indicated "May send to urgent care clinic at Hospital #1 or to Hospital #2 ER (emergency room ) for stitches to right index finger base, unable to maintain closure to this moveable joint with steristrips or dressing." Review of the hospital Express Care Record for Hand/Wrist Injury sheet dated 9/5/2013 revealed a wound description of 2.5cm laceration to the right hand index finger. The narrative notes on the hand/wrist injury sheet indicated "wound older than 8 hours. Cleaned and dressed. Wound must be rechecked in 3 days." During a phone interview with Nurse #3 on 9/10/2013 at 3:48 pm, she stated "resident had a gash. I could not tell how deep. There wasn't much blood. I passed it on to the treatment nurse the next day that the area may need more treatment. I didn ' t know if it needed stitches or Steris trips." Nurse #3 indicated she did not call the physician because it was not an emergency. In an interview on 9/10/2013 at 3:57 pm, the Director of Nursing (DON) indicated her expectation was for the nurse to call the doctor for an injury that required a treatment that was not included in the standing order protocol or that could not be provided in the facility. During an interview with the Charge Nurse on 9/11/2013 at 10:40 am, she stated her observation of the wound was that the wound possibly needed stitches and she notified the physician immediately on 9/5/2013 at 10:30am and obtained an order to send the resident out for medical evaluation and treatment. In an interview with Nurse # 3 on 9/12/2013 at 7:30 am, she stated she notified the physician of the incident report on 9/5/2013 at 7:30 am via fax machine. During a phone interview with the Attending Physician on 9/12/2013 at 9:55 am, he stated his expectation was for the nurse to call the doctor on call for anything that was not listed in the protocol. The Attending Physician stated "In this situation, she should have called whoever was on call. We are on call 24 hours a day, 7 days a week."

Based on observation, staff interviews and facility policy review, the facility failed to remove two vials of stock supply of Pneumonia Vaccines from use in one of two medication refrigerators. The findings included: Review of the facility policy guidelines entitled Vials and Ampules of Injectable Medications dated January 1, 2008 indicated medication in multidose vials may be used until the manufacturer's expiration date/ for the length of time allowed by state law/according to the facility policy for thirty days if inspection reveals no problems during that time. On 9/10/2013 at 11:35 am, one medication refrigerator on the Alzheimer's Unit was observed to contain the following: Two vials of Pneumonia Vaccines dispensed on 8/9/2012 with a manufacturer's expiration date of 8/5/2013. The medication was in active stock for resident use. In an interview with Nurse #5 on 9/10/2013 at 11:40 am, she indicated she recalled the consultant pharmacist had marked the box with the expiration date for the vials to be removed in August but it was overlooked. Nurse #5 indicated the medication was expired and should have been discarded. During an interview with the Director of Nursing on 9/12/2013 at 11:47 am, she stated her expectation was for the licensed nursing staff to remove expired medications from storage and return them to the pharmacy for disposal.

Based on observation, staff interviews and record review, the facility failed to validate Nursing Assistant II (NAII) skill competency level prior to performing wound care on the facility residents for 2 of 2 NAII's (NAII #1, NAII #2). The findings included: 1. Resident # 18 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. [MEDICAL CONDITION](Cardiovascular Accident), [MEDICAL CONDITION] and [MEDICAL CONDITION]. A review of a telephone physician order [REDACTED]. index finger daily with soap and water, then dry. Apply [MEDICATION NAME] three times a day." A review of a telephone physician order [REDACTED]. right hand need to be covered with a 2 by 2 gauze, secured with Kling wrap around the finger and around the hand. Cover the dressing with open finger mesh or glove or gerisleeve." A review of a telephone physician order [REDACTED]. to right index finger to clean wound with soap and water, pat dry. Apply hydrogel AG (silver). Cover with collagen and nonstick dressing, wrap around kling around the hand and second finger and cover the dressing with mesh or glove or gerisleeve." A review of the Treatment Administration Record (TAR) revealed the signature of Nursing Assistant II (NAII) #1 on four entries, 9/6/13 for the 7-3 and 3-11 and on 9/9/13 for the 7-3 and 3-11 shifts. A review of the facility's undated skills and performance checklist for Nursing Assistant II indicated NAII skills should be validated by an LPN (Licensed Practical Nurse) or a RN (Registered Nurse). During an observation of wound care for Resident #18 on 9/11/2013 at 12:20 pm, NAII #1 started in the room with Hydrogel. The physician's orders [REDACTED]. stated Hydrogel AG (silver). NAII #1 confirmed with Nurse #1 that Hydrogel was not the same product as Hydrogel AG. A review of the employee file for NAII #1 did not reveal a signed copy of the facility's checklist for skills and performance for NAII. During an interview on 9/11/2013 at 12:35 pm, NAII #1 indicated she was trained by NAII #2. She further indicated she signed the TAR for Resident #18 on 9/6/13 7-3 and 3-11 and 9/9/13 7-3 and 3-11 shifts but she did not perform the treatment as ordered. NAII #1 stated she checked the dressing to see if it was dry and intact as she had been instructed to do. NAII #1 indicated she could not recall who had given her the instructions to check the dressing. In an interview on 9/11/2013 at 12:50 pm, NAII #2 stated she trained NAII #1 on wound care but she was not able to complete the last day of the training due to conflicts in the schedule. NAII #2 further indicated she was trained on wound care by another NAII. On 9/11/2013 at 1:10 pm, the administrator was unable to provide evidence of validation of skills and performance for NAII #1. The Administrator further indicated a signed copy of the NA II skills and performance checklist should be filed in the employee file jacket. During an interview on 9/12/2013 at 11:10 am, NAII #1 indicated she was trained to sign off on the treatment orders for the 3-11 shift and it was understood that someone else would do the treatment later. NAII #1 stated "I am confused and don't know what I should and should not be doing." During an interview on 9/12/2013 at 11:31 am, Nurse #1 stated the NAII's were trained by other NAII's that had worked in the treatment aide position. In an interview with the Administrator and Director of Nursing (DON) on 9/12/2013 at 11:49 am, the DON stated the skills and evaluations performance checklists should have been signed off by the treatment nurse for the NAII's. 2. Review of the facility's undated skills and performance checklist for Nursing Assistant II ' s (NAII) indicated NAII skills should be validated by an LPN (Licensed Practical Nurse) or an RN (Registered Nurse). A review of the employee file for NAII #2 did not reveal a copy of the facility's skills and performance checklist for NAII. In an interview on 9/11/2013 at 12:50 pm, NAII #2 stated she was trained on wound care by another NAII in the treatment aide position. During an interview on 9/12/2013 at 11:31 am, Nurse #1 stated the NAII's were trained by other NAII's that had worked in the treatment aide position. In an interview with the Administrator and Director of Nursing (DON) on 9/12/2013 at 11:49 am, the DON stated the skills and performance checklist should have been signed off by the treatment nurse for the NAII's.

Based on record review and staff interviews, the facility failed to ensure the clinical record reflected care provided to an unstageable pressure ulcer for 1 of 5 residents reviewed for pressure ulcers (Resident #17). The findings included: Resident #17 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. A significant change minimum data assessment completed on 6/14/13 indicated that Resident #17's mental status was severely impaired. Total dependence on the staff was required with activities of daily living. One unstageable pressure ulcer was indicated that measured 1 cm (centimeter) length x 1 cm width. The care plan date 6/18/13 listed an unstageable pressure ulcer to the right toe as a problem area. Approaches to care read in part "monitor skin during care and report changes to treatment nurse, treatments as ordered." A review of the treatment administration record (TAR) for September 2013 read "1) apply [MEDICATION NAME] powder topically to right second toe dorsal aspect wound bed after cleaning with normal saline daily. 2) Apply santyl ointment nickel thick layer to same area (second toe) dorsal aspect after [MEDICATION NAME]. Cover with hydrogel gauze, then border foam clean first with normal saline, change every day as one treatment." Further review of the TAR for September 2013 revealed treatment to the right second toe was not signed as completed nor an explanation provided on the back of the TAR from 9/1/13 through 9/9/13. A review of the weekly skin assessment revealed no clinical notation regarding the specific care provided to the ulcer to the second right toe from 9/1/13 through 9/9/13. In an interview on 9/10/13 at 11:00 am Nurse #1 indicated that she oversaw ulcer treatments and that she was not sure why the TAR was not signed to reflect the care provided. She concluded that she was not aware until today. In an interview on 9/10/13 at 11:15 am nursing assistant II (NA II) #1 acknowledged that she worked 9/3/13 through 9/6/13 and forgot to sign off on the TAR that she completed ulcer care to the second right toe. In an interview on 9/10/13 at 2:45 pm Nurse #2 acknowledged that she worked on 9/8/13. She stated that she thought she performed the treatment to the right toe but was not sure. She indicated sometimes Resident #17 refused the treatment to be done. If so, she would have documented on the back of the TAR that the resident refused. In an interview on 9/10/13 at 2:55 pm NA II #2 acknowledged that she worked on 9/1/13 and 9/7/13. She indicated she forgot to initial on the TAR that she provided ulcer care to the second right toe. In an interview on 9/10/13 at 3:00 pm the administrator concluded that she expected the clinical record "treatment administration record" to have been signed each day to reflect the care provided by the nursing staff.