Every finding on record at Charlton Place Rehab and Healthcare Center

Based on interviews, medical record review, and review of a facility policy titled, ABUSE, PREVENTION AND PROHIBITION POLICY, the facility failed to ensure an allegation of physical abuse, made by RI (Resident Identifer) #3, was reported to the State survey agency (SA) on 07/09/2022 within the two hour time frame. This had the potential to affect RI #3, for one of six abuse allegations reviewed. Findings include: The State agency received a complaint on 07/18/2022 regarding RI #3's allegation of abuse of being whipped with a wet wash cloth at the facility that caused bruises to RI #3's arms. A facility policy titled, ABUSE, PREVENTION AND PROHIBITION POLICY, with a reviewed date of 2021, documented: . Reporting/Response: . All alleged violations involving abuse, . will be reported immediately to the administrator. The person made aware of allegations of abuse . OR the administrator will report the allegations of abuse . to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours after the allegation is made . RI #3 was admitted to the facility on [DATE]. Review of RI #3's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/06/2022 documented RI #3 required physicial assistance of one staff for bathing. RI #3's progress notes with an entry dated 07/09/2022 at 5:22 PM signed by EI #3 Licensed Practical Nurse (LPN) documented . Hospice Nurse . was in resident room with resident family doing . (RI #3's) assessment. (the Hospice Nurse) stepped out of the room and told writer that family member asked resident how did . (he/she) get bruises on . left and right arm, resident stated that . (he/she) was hit with a wet towel. On 07/19/2022 at 4:07 PM a telephone interview was conducted with RI #3's family member who said during a visit with RI #3 on 07/09/2022, RI #3 had bruises on both arms. The family member said, RI #3 reported obtaining the bruised arms when RI #3 was beaten with a rag at the facility. The family member said, the Hospice nurse reported this to the nurse on duty. On 07/19/2022 at 4:30 PM a telephone interview was conducted with another family member of RI #3 who confirmed that during a visit with RI #3 on 07/09/2022 RI #3 had bruises on both arms. The family member said, RI #3 reported obtaining the bruised arms when RI #3 was hit with a wash cloth during a bath at the facility. The family member stated, the Hospice nurse also observed the bruised arms and reported it to the nurse in charge. On 07/20/2022 at 10:14 AM an interview was conducted with a Hospice agency nurse. She stated she did the admission assessment on RI #3 on 07/09/2022. The Hospice agency nurse said she did a body audit and observed bruising RI #3's left upper arm and right forearm. She said, the family told her, RI #3 said someone had hit RI #3 with a wet wash cloth. The Hospice nurse stated, she reported it to the nurse at the facility, Employee Identifier (EI) #3, LPN. On 07/22/2022 at 2:56 PM EI #3 was asked what happened on 07/09/2022, when the family visited and the Hospice nurse came to do the assessment. EI #3 said, at about 2:50 PM the nurse came to her and said she was in the room and the family said RI #3 reported being hit on the arms with a wet rag. EI #3 was asked what type of allegation it was considered when the family reported the allegation made by RI #3. EI #3 said, abuse allegation. EI #3 was asked what the facility's policy was for abuse allegations. EI #3 said, to document it, report it and call the Director of Nursing (DON). EI #3 was asked if she documented it and called the DON. EI #3 said yes, she documented it in the progress notes and called the DON who said she was coming to the facility. On 07/21/2022 at 11:13 AM an interview was conducted with EI #2, DON. EI #2 was asked how she become aware of the abuse allegation made by RI #3 on 07/09/2022. EI #2 said the charge nurse EI #3, called her and reported the hospice nurse was questioned by RI #3's family about bruises on RI #3's arms, that RI #3 had reported were caused by being hit with a wet towel. EI #2 was asked when RI #3 made the abuse allegation. EI #2 said, it was on Saturday 07/09/2022. EI #2 was asked what type of abuse was alledged. EI #2 said the family reported RI #3 made the allegation of being hit on the arms with a wet towel. EI #2 was asked if this abuse allegation was reported to the SA on 07/09/2022. EI #2 said, she informed EI #1, the Administrator about the abuse allegation and she did not know if it was reported. EI #2 was asked when an allegation of abuse was to be reported to the SA according to the facility abuse policy. EI #2 said, physical abuse should be reported within two hours. EI #2 was asked if this allegation of abuse should have been reported to the SA. EI #2 said, yes. On 07/21/2022 at 2:06 PM an interview was conducted with EI #1, Administrator. EI #1 was asked when she become aware of the allegation of abuse regarding RI #3. EI #1 said on July 9, 2022 at 3:39 PM. EI #1 was asked what type of allegation it was. EI #1 said, it was an abuse allegation. EI #1 was asked what she was told about the abuse allegation. EI #1 said the DON called her and said RI #3 made the abuse allegation to the Hospice nurse of having been hit with a wet towel. EI #1 was asked if the abuse allegation was reported to the SA. EI #1 said, no, it was not reported. EI #1 was asked what type of alleged abuse should be reported to the SA according to the facility policy on abuse. EI #1 said, physical. EI #1 was asked when should an allegation of abuse be reported to the SA. EI #1 said, within two hours. This deficient practice was cited as a result of the investigation of complaint/report # AL 927.

Based on record review and interviews, the facility failed to ensure a plan of care was implemented for Resident Identifier (RI) #3's use of a Foley catheter. This affected RI #3, one of three residents whose plans of care were reviewed. Findings Include: A review of the medical record for RI #3 revealed a re-admitted [DATE] and an original admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS) for RI #3, with an Assessment Reference date of, 04/01/2022 shows the resident was coded to have an Indwelling Catheter. A review of the May 2022 Physicians Orders for RI #3, with an order date of 04/11/2022, revealed orders for Foley catheter (FC) to closed drainage system, change catheter drainage bag as needed for leaking, and change FC monthly/prn (as needed). A review of the care plans for RI #3 revealed RI #3 had a catheter related to obstructive [CONDITION(S)], with an initiated date of 05/03/2022. During an interview on 05/05/2022 at 9:16 AM, EI (Employee Identifier) #2, the Registered Nurse (RN) supervisor was asked should a resident having a Foley catheter be care planned for the FC. EI #2 stated yes. EI #2 was asked why would it be important for the resident with a FC be care planned for the FC. EI #2 stated, when any sort of procedure you have to have a care plan to follow care. EI #2 was asked who would be responsible for implementing a care plan for a resident with a Foley catheter. EI #2 stated she really could not answer that question. During an interview on 05/06/2022 at 10:07 AM, EI #1, the Director of Nursing (DON) was asked, when a resident has a Foley catheter, should there be a care plan for the Foley catheter. EI #1 stated there should be. EI #1 was asked was she familiar with RI #3. EI #1 stated she was. EI #1 was asked how long had RI #3 had a FC. EI #1 stated since RI #3 came into the building. When asked how long has that been EI #1 stated, since 03/28/2022. EI #1 was asked should a care plan have been implemented for the FC. EI #1 stated, it should have. EI #1 was asked, looking at RI #3's care plans, when was a FC catheter care plan implemented for RI #3. EI #1 stated, looks like on 05/03/2022. When asked what would be the rationale for a resident having a FC care plan EI #1 stated, so it would be know how to take care of the resident, be aware of RI #3 having the catheter, and be aware of what was needed to be done as far as RI #3's incontinent status.

Based on interviews and record review, the facility failed to ensure a Physicians Order was obtained to insert a Foley catheter for Resident Identifier (RI) #1. This deficient practice affected RI #1, one of three residents sampled with Foley catheter's whose Physicians Orders were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's care plans revealed RI #1 had a care plan, with an initiated date of 04/18/2022, for . The resident has Catheter . On 05/04/2022 at 2:24 PM, the surveyor conducted an interview with Employee Identifier (EI) #2, a RN (Registered Nurse)/supervisor. The surveyor asked EI #2 did RI #1 have a Foley catheter. EI #2 said she thought RI #1 did. On 05/05/2022 at 9:16 AM, the surveyor conducted a follow-up telephone interview with EI #2. When asked who inserted RI #1's Foley catheter, EI #2 said she remembered she got an order from RI #1's physician and she inserted the Foley catheter. The surveyor asked EI #2 where would there be evidence a doctor's order was obtained for the Foley catheter. EI #2 said that should be on the Physicians Order. RI #1's Order Summary Report (Physicians Orders) for April 2022, did not reveal RI #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/06/2022 at 10:07 AM, the surveyor conducted an interview with EI #1, The Director of Nursing (DON). The surveyor asked EI #1 where would there be evidence a Physicians Order was obtained to insert a Foley catheter. EI #1 said there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor asked EI #1 why should there be a Physicians Order to insert a Foley catheter. EI #1 said you had to have a Physicians Order to perform any type procedure. This deficiency was cited as a result of the investigation of complaint/report #AL 800.

Based on interviews, record review and review of facility policy titled CHARTING AND DOCUMENTATION, the facility failed to document the insertion of a Foley into Resident Identifer (RI) #1, due to [CONDITION(S)]. This deficient practice affected RI #1, one of three residents sampled for Foley catheters. Findings Include: Review of a facility policy titled CHARTING AND DOCUMENTATION, with a reviewed date of 02/2021, revealed the following: Policy 1. Chart all pertinent changes in the resident's condition, reaction to treatments . 2. Be concise, accurate, and complete . Document only the facts . Procedures . 3. Catheter Insertion a. Type of procedure (urethral catherization . etc ) and who performed it. b. Date and time the procedure was performed. c. Type and size of catheter used. Include balloon size. d. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] e. Resident's response to the procedure. f. Changes in resident's condition. (i.e. [for example], swelling, discomfort, change in output, amount, color, odor, any sediment, patency of the catheter, etc.) g. Urine output. h. Other pertinent data as necessary . RI #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/05/2022 at 9:16 AM, the surveyor conducted a telephone interview with Employee Identifier (EI) #2, a RN (Registered Nurse)/supervisor. EI #2 said she obtained an order from RI #1's physician and inserted a Foley catheter due to RI #1 having [CONDITION(S)]. EI #2 said she believed RI #1 had 900 cc's (centimeters) of urine output when she put the Foley catheter in. When asked where would there be evidence of RI #1's Foley catheter insertion, EI #2 said she would have documented that under the progress notes (nurses notes). A review of RI #1's Progress Notes, from 04/12/2022 through 04/21/2022, did not reveal any documentation of RI #1 having a Foley catheter inserted. On 05/06/2022 at 10:07 AM, the surveyor conducted an interview with EI #1, The Director of Nursing (DON). The surveyor asked EI #1 where would there be documentation of the insertion of RI #1's Foley catheter. EI #1 said she would have put it in the progress notes, which was the same as the nurses notes. The surveyor asked EI #1, looking at RI #1's progress notes, did she see where it was documented RI #1's Foley catheter had been inserted. EI #1 said she did not see where it was documented. This deficiency was cited as a result of the investigation of complaint/report #AL 800.

Based on medical record review, interviews and review of a facility document titled, 10.2 Medication-Related Errors, the facility failed to ensure Resident Identifier (RI) #1's order for [MEDICATION(S)] 200 milligrams (MG) by mouth (PO) twice a day (BID) was administered from 9/17/2021 through 9/22/2021. This medication error was significant due to the drug's classification as an anticonvulsant and as a result of not receiving the prescribed medication, RI #1 had a Grand mal [CONDITION(S)] requiring hospitalization on [DATE]. This affected RI #1, one of four sampled residents reviewed for medication administration. Findings included: A review of a facility document titled, Medication-Related Errors, with Revision Date: 05/01/2010, documented: . Procedure: 1. Medication Errors: If a medication reaches a resident in error, Facility should: 1.1 Notify Pharmacy . 1.2 Notify Physician/Prescriber and obtain further instructions and/or orders. Facility staff should monitor the resident in accordance with Physician's/Prescriber's instructions. 4. Administration Errors: In the event of an administration error, Facility staff should follow Facility policy relating to medication administration errors. Examples of administration errors include, but are not limited to: . 4.9 Omission error: Facility fails to administer an ordered dose to the resident, . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's medical record revealed an Order Summary Report, dated 09/16/2021 - 09/23/2021, containing the following order: . [MEDICATION(S)] Tablet 200 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day related to [CONDITION(S)] . Active 09/16/2021 . A review of RI #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's progress notes dated 9/23/2021 at 13:27 (1:37 PM) revealed the resident (RI #1) was experiencing a change in condition. This note indicated the change in condition the resident was currently experiencing was Grand mal seizures. On 11/03/2021 at 10:27 AM, an interview was conducted with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN). EI #3 was asked if she was aware of any concerns with RI #1 not receiving any of (his/her) medications. EI #3 said yes. EI #3 was asked what medication it was. EI #3 said [MEDICATION(S)]. On 11/03/2021 at 10:49 AM, an interview was conducted with EI #2, Registered Nurse (RN)/Previous Director of Nursing (DON). EI #2 was asked was she aware of any concern with RI #1 not receiving any medication while in the facility. EI #2 said yes, (name of EI #4) called her to tell her that RI #1 was having a [CONDITION(S)] and had not been getting [MEDICATION(S)] and was being sent to the hospital. On 11/17/2021 at 9:27 AM, an interview was conducted with the facility's Medical Director. When asked what the concern was with RI #1 not receiving (his/her) [CONDITION(S)] medications as ordered, the Medical Director responded that someone with seizures was more likely to have seizures if they did not get their [CONDITION(S)] medications than if they did get them. When asked if RI #1 not receiving [MEDICATION(S)] for six days contributed to (him/her) having a Grand mal [CONDITION(S)] on 9/23/2021 requiring hospitalization , the Medical Director stated not taking all [CONDITION(S)] medications as prescribed could have caused RI #1 to have a [CONDITION(S)]. On 11/17/2021 at 2:43 PM, a follow-up interview was conducted with EI #3, LPN, assigned nurse for RI #1. EI #3 was asked what the concern was with RI #1, a resident with [CONDITION(S)], not receiving (his/her) anticonvulsant medication from 09/16/2021 to 09/22/2021. EI #3 said seizures. EI #3 was asked why RI #1 was transported to the hospital on 09/23/2021. EI #3 stated [CONDITION(S)] activity. On 11/18/2021 at 11:06 AM, during a follow-up telephone interview, EI #3 was asked what was the concern with the omission of RI #1's [MEDICATION(S)], a significant anticonvulsant medication, for six days. EI #3 said medication errors. On 11/17/2021 at 3:58 PM, an interview was conducted with EI #8, LPN/Minimum Data Set (MDS) Coordinator. EI #8 was asked what she remembered regarding RI #1's diagnoses/condition. EI #8 stated RI #1 was in the facility on three different occasions and had a [CONDITION(S)] (TBI) and [CONDITION(S)] Disorder that stemmed from the [CONDITION(S)]. EI #8 said when she arrived on 09/23/2021, during RI #1's second stay, he/she was having seizures and the doctor was there and ordered [MEDICATION(S)] to stop the seizures. EI #8 further stated that RI #1 was admitted to the Intensive Care Unit (ICU) for several days and returned with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #8 said RI #1 was on multiple [CONDITION(S)] medications and she was aware that there were issues with one of them. EI #8 was asked what the concern was with RI #1 not receiving ordered [MEDICATION(S)] for six days. EI #8 said obviously if residents were ordered medications and did not receive them it would put them at risk for an adverse medical event. EI #8 further stated in RI #1's case there was risk for seizures. EI #8 was asked why RI #1 was transported to the hospital on 09/23/2021. EI #8 said because (he/she) had uncontrolled seizures that they could not stop. On 11/18/2021 at 11:25 AM, a follow-up telephone interview was conducted with EI #2, Registered Nurse (RN)/Previous Director of Nursing. EI #2 was asked what were the omission of medications considered. EI #2 said in her nursing judgment, they were medication errors. Review of a document for RI #1 from the hospital with an admitted and time of 09/23/2021 at 09:26 AM states: Chief Complaint: [CONDITION(S)] activity History of present illness: . patient who presents to (local hospital) ED (Emergency Department) after having 6 reported seizures at (his/her) rehab (rehabilitation) facility this morning. EMS (Emergency Medical Service) reports that these were grand mal seizures, and 2mg (milligrams) of IM (intramuscular) [MEDICATION(S)] was given at the facility ([NAME] Rehab) . (He/She) has a significant history of [CONDITION(S)] and [CONDITION(S)] activity for which (he/she) takes several medications including [MEDICATION(S)]. (he/she) had received all of (his/her) prescribed medications except [MEDICATION(S)]. An addition document from the hospital revealed RI #1 was discharged on [DATE] after an admission to ICU (Intensive Care Unit) with neuro (neurological) checks. RI #1 was discharged back to the facility in a stable condition.

Based on interviews, review of Resident Identifier (RI) #1's medical record and review of facility policies titled, Significant Condition Change & Notification, the facility failed to ensure Resident Identifier (RI) #1's medical doctor was notified when the resident did not receive his/her prescribed [MEDICATION(S)], an anti-epilectic/anticonvulsant medication from 09/17/2021-09/22/2021. This deficient practices affected RI #1, one of four sampled residents sampled for notification. Findings Include: A review of an undated facility policy titled, Significant Condition Change & Notification, documented, Purpose To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as . medication error . Procedure .the licensed nurse will contact the resident's representative and their medical practitioner .Each attempt will be charted as to the time the call was made, who was spoken to and what information was given to the medical practitioner . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the facility's Medical Director on 11/17/2021 at 9:27 AM. The Medical Director stated, he wasn't notified RI #1 had not received his/her [MEDICATION(S)] for 6 days until the morning of 09/23/2021, the day he/she had a Grand mal [CONDITION(S)] and was sent to the hospital. The Medical Director stated, his expectation is that residents receive medication as prescribed and the facility to notify him if that does not happen. An interview was conducted with EI #3, Licensed Practical Nurse (LPN) on 11/17/2021 at 2:43 PM. EI #3 stated she ordered/created RI #1's orders for his/her readmission on 09/16/2021. EI #3 stated, it should be documented in the nurses notes when the Medical Director was notified about RI #1 needing a written prescription for his/her [MEDICATION(S)]. EI #3 reviewed nurses notes and stated, the Medical Director was not contacted until 09/21/2021 and this contact was only requesting a prescription. There was no documentation notifying the Medical Director that RI #1 had not received his/her [MEDICATION(S)] since being readmitted on [DATE]. An interview was conducted with EI #4, Registered Nurse (RN) on 11/17/2021 at 5:20 PM. EI #4 stated she attempted to contact the Medical Director on 09/19/2021 regarding RI #1's [MEDICATION(S)] not being available, however she was unsuccessful in contacting him. The facility could not provide documentation that a call was made to the physician. An interview was conducted with EI #7, RN (assigned to RI #1) on 11/18/2021 at 9:03 AM. EI #7 stated she remembered RI #1 not having his/her [MEDICATION(S)] on 09/22/2021 and she called the pharmacy but did not notify the Medical Director regarding RI #1 not having his/her [MEDICATION(S)].

Based on observations, interviews, medical record reviews, and review of the facility policy titled Administering Medications, the facility failed to ensure the medications error rate was less than five percent. During medication administration observations from 3/11/20 through 3/12/20 two errors were observed out of twenty-five total opportunities, equaling a medication error rate of eight percent. This affected Resident Identifier (RI) #4 and RI #59, two of three residents observed for medication pass. Findings Include: A facility policy titled Administering Medications, revised December 2012, revealed: Policy Statement Medications shall be administered . as prescribed. 3. Medications must be administered in accordance with the orders . 7. The individual administering the medication must . verify the . right medication .before giving the medication. RI #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 3/11/20 at 9:40 a.m., an observation was made of Employee Identifier (EI) #5, Licensed Practical Nurse (LPN), administering medication to RI #4 from the Station Two Medication Cart. EI #5 administered Senna Plus, containing 50 milligrams (mg) [MEDICATION NAME] sodium and 8.6 mg sennosides, to RI #4. However, when reconciling the medications administered to RI #4 by EI #5 with the physician's orders, it was noted that RI #4's Order Summary Report listed an active order with a Start Date of 9/14/2019 for [MEDICATION NAME] Tablet 8.6 milligrams (mg) (Sennosides) Give 8.6 mg by mouth one time a day for constipation. There was no order for the Senna Plus. RI #59 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 3/11/20 at 4:28 p.m., an observation was made of EI #6, LPN, administering medications to RI #59 from the Rehab Medication Cart. EI #6 administered Senna Plus, containing 50 mg [MEDICATION NAME] sodium and 8.6 mg sennosides, to RI #59. However, when reconciling the medications administered to RI #59 by EI #6 with the physician's orders, it was noted RI #59's Order Summary Report listed an active order with a Start date of 2/22/2020 for Senna Tablet 8.6 MG (Sennosides) Give one (1) tablet via PE[DEVICE] (Percutaneous Endoscopic Gastrostomy Tube) two times a day for Constipation. There were no active orders for Senna Plus or [MEDICATION NAME] sodium. On 3/12/20 at 12:09 p.m., an interview was conducted with EI #7, Registered Nurse (RN). EI #7 was asked, what the active ingredients listed on the bottle of medication in which Sennosides or Senna was administered. EI #7 found the bottle and stated, the bottle was labeled Senna Plus and contains sennosides 8.6 mg and [MEDICATION NAME] 50 mg. EI #7 was asked, when sennosides 8.6 mg and [MEDICATION NAME] 50 mg were administered when sennosides 8.6 mg tablet was ordered, what did she call that. EI #7 replied, it was a medication error. On 3/12/20 at 12:19 PM, EI #8, LPN, was asked to check the Rehabilitation Medication Cart. EI #8 was asked, when Sennosides 8.6 mg is ordered, what bottle was used. EI #8 replied, Senna Plus. EI #8 was asked, what were the active ingredients in Senna Plus. EI #8 replied, sennosides 8.6 mg and [MEDICATION NAME] 50 mg. EI #8 was asked, when sennosides 8.6 mg and [MEDICATION NAME] 50 mg were administered when sennosides 8.6 mg tablet was ordered, what did she call that. EI #8 replied, it would be a medication error. On 3/12/20 at 12:27 PM, an interview was conducted with EI #2, RN/Director of Nursing. EI #2 was asked, what was [MEDICATION NAME] sodium. EI #2 replied, in a facility like this it was a medication. EI #2 was asked, did administration of [MEDICATION NAME] sodium at a skilled nursing facility require a physician's order. EI #2 replied, yes. EI #2 was asked, when sennosides 8.6 mg was ordered, and then [MEDICATION NAME] sodium 50 mg with sennosides 8.6 mg was administered, what was that called. EI #2 replied, a medication error. EI #2 was asked, why was that a medication error. EI #2 replied, because something was being administered that was not ordered. EI #2 was asked, who was responsible for administering medications as ordered. EI #2 replied, the nurses.

Based on observations, interviews, review of medical records, review of Certified Nursing Assistant job description and review of a facility training document, the facility failed to ensure staff provided Activities of Daily (ADLs) assistance to ensure facial hair was removed for Resident Identifier (RI) #s 11 and 22. This affected RI #s 11 and 22, two of five residents sampled for ADLs. Findings Include: A review of an undated Certified Nursing Assistant job description revealed, . Purpose of Your Job Position The primary purpose of you job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Job Functions . Duties and Responsibilities . Personal Nursing Care Functions . Keep hair on female residents clean shaven (i.e., facial hair, under arms, on legs, etc.) . A review of an undated (Name of Corporation) training manual revealed, . Resident Hygiene . SHAVING - All male residents are to be shaved daily unless they have a trimmed beard. This includes facial hair on female residents. RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #11's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/24/18, indicated RI #11 had severely impaired cognition and required limited assistance of one person for personal hygiene, including shaving. An observation was made on 3/12/19 at 11:32 AM of RI #11 in the activities room in a wheelchair positioned at a table. A moderate to heavy amount of hair was observed on this/her upper lip and chin. Most hairs were approximately 1/2 inch long and light colored. There were three dark brown ones on his/her chin and one dark hair on the right side of RI #11's mouth that was approximately one inch long. On 3/12/19 at 6:09 PM, RI #11's facial hair was visible from approximately four feet away, during observations in the Dining Room. Another observation was made on 3/13/19 at 11:08 AM. RI #11's facial hair remained unchanged and visible. An interview was conducted on 3/13/19 at 2:45 PM with Employee Identifier (EI) #6, a Certified Nursing Assistant (CNA). EI #6 was asked to observe the facial hair on RI #11's face. EI #6 was asked what she saw on RI #11's upper lip, and she answered hair. EI #6 was asked to please describe what she saw. EI #6 described the hair as being about a half an inch long across the upper lip and a patch on the right side of RI #11's mouth. EI #6 was asked what she noticed on RI #11's chin. EI #6 answered the hairs were shorter than a half inch and were all the way across the bottom of the chin. EI #6 was asked who was supposed to remove the facial hair for RI #11. EI #6 answered RI #11's showers were on the 11-7 shift and they were supposed to do all the grooming care at that time. EI #6 was asked if staff do not do it at that time, who should do it. EI #6 answered anyone that sees it. EI #6 said she was assigned to RI #11 on 3/13/19. When asked why RI #11 was not shaved, EI #6 answered she was busy and did not notice it. An interview was conducted on 3/14/19 at 7:42 AM with EI #4, a CNA. EI #4 was asked when did RI #11 get a shower. EI #4 answered on the 11-7 shift on Tuesday, Thursday, and Saturday. EI #4 was asked who should remove RI #11's facial hair. EI #4 answered it should be done by whoever notices it, but it would usually be done with their shower. EI #4 was asked who cared for RI #11 on Tuesday night. EI #4 answered she thought she did. EI #4 was asked why was RI #11's facial hair not removed. EI #4 answered she did not remember seeing any, but said it was hard for her to see the hairs. EI #4 was asked if she had shaved RI #11 last night or Tuesday night. EI #4 answered no. RI #22 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #22's Significant Change MDS assessment,, with an ARD of 1/12/19, documented RI #22 had severe cognitive impairment and required extensive assistance of one person for personal hygiene, including shaving. An observation was made on 3/12/19 at 10:55 AM of RI #22 in a recliner in his/her room, dressed, with white facial hair across his/her upper lip and three white hairs observed on his/her chin. The hair was approximately 1/2 inch long. On 3/12/19 at 10:57 AM, RI #22 was asked if staff were supposed to take care of his/her facial hair. RI #22 answered, Yes. An observation was made on 3/12/19 at 6:34 PM during the evening meal observation. RI #22's facial hair was visible from approximately three feet away from the resident. An observation was made on 3/13/19 at 11:14 AM of RI #22. RI #22's facial hair remained visible, and there were numerous hairs that were dark black and more noticeable at this time. An interview was conducted on 3/13/19 at 2:22 PM with EI #8, a CNA. EI #8 was asked to observe the facial hair on RI #22's face. EI #8 was asked to describe what she saw on RI #22's lip and chin. EI #8 answered she saw fuzzy hairs that were black on the top and the bottom. EI #8 was asked approximately how long were the hairs on the lip. EI #8 answered about one quarter of an inch. EI #8 was asked approximately how long were the hairs on RI #22's chin, and she answered about the same. EI #8 was asked who was supposed to remove the facial hair for RI #22. EI #8 answered the CNA working with him/her on the day that it (facial hair) was noticed. EI #8 was asked when should it be done. EI #8 answered in the morning when RI #22 was being groomed to get up. EI #8 was asked why was that not done this morning (3/13/19). EI #8 answered the 11-7 shift gets RI #22 dressed and they should have done the hair removal. EI #8 was asked if they don't do it, who should. EI #8 answered the first shift CNA or whoever notices it. EI #8 said she was assigned to RI #22. When asked why she had not shaved RI #22's facial hair, EI #8 said she had not noticed it. During a follow-up interview with RI #22 on 3/14/19 at 2:18 PM, RI #22 said he/she expected staff to remove facial hair. RI #22 indicated he/she did not want visible facial hair. An interview was conducted on 3/14/19 at 2:48 PM with EI #9, a CNA. When asked what should be done for residents with facial hair, EI #9 answered if they have facial hair, staff should shave them with shaving cream and a razor. EI #9 said facial hair should be removed as needed. EI #9 was asked who was supposed to groom RI #22's facial hair. EI #9 answered the CNA, anytime, even if it is not shower day. EI #9 added if they (residents) have facial hair, that is when you do it. EI #9 was asked why RI #22's facial hair was long and highly visible Tuesday and Wednesday. EI #9 answered she did not notice. EI #9 was asked should a CNA notice long white hairs on a residents upper lip and or chin. EI #9 answered yes. EI #9 was asked what was the concern of not providing ADL assistance for residents dependent for that care. EI #9 answered it would be a problem because the ADL care is supposed to be done. An interview was conducted on 3/14/19 at 3:21 PM with EI #2, a Licensed Practical Nurse (LPN). EI #2 was asked if she was the nurse caring for RI #22 on 3/12, 3/13, and 3/14/19. EI #2 answered yes. When asked what the concern was of staff not providing ADL assistance for residents dependent on staff for that care, EI #2 answered the concern was the residents not being able to do it for themselves, especially the nonverbal ones. EI #2 was asked who was responsible for ensuring ADL care was provided for dependent residents. EI #2 answered the CNAs, then the LPNs and on up the chain of command. An interview was conducted on 3/14/19 at 3:34 PM with EI #1, the Director of Nursing (DON). EI #1 was asked what were staff trained about grooming of facial hair of residents. EI #1 answered whenever they (staff) give care, they are to provide that grooming as it is needed. EI #1 was asked what was the concern of residents found with facial hair 1/2 to 1 inches long on their lips and/or chins. EI #1 answered it should have been cut. EI #1 was asked what was the facility's expectations for staff to provide ADL assistance for dependent residents. EI #1 answered all residents will be treated equally and make sure the residents do not have hair on their face. EI #1 was asked who was responsible for ensuring residents receive ADL care that they require. EI #1 answered the charge nurses and up the chain of command.

Based on observation, interview, review of a facility policy titled Food Storage: Cold and the Food Code (YEAR), the facility failed to ensure: 1. nectar thickened tea, in the reach in cooler, was not expired, 2. sliced carrots, in the reach in refrigerator, were dated with a use-by-date, 3. lemon pudding, in the reach in refrigerator, was not expired, and 4. nectar thickened water, in the nourishment room refrigerator on nursing station 1, was dated with a use-by-date. This was observed on 2 of 2 days of the survey and had the potential to affect all 56 residents receiving meals from the kitchen, out of a total facility census of 57. Findings Include: A review of a facility policy titled, Food Storage: Cold, with a revised date of ,[DATE], included: . Policy Statement It is the center policy to insure . refrigerated food items, will be appropriately stored in accordance with guidelines of the . Food Code 5 food items are . labeled and dated A review of The Food Code (YEAR) revealed: . ,[DATE].17 . (A) .READY-TO-EAT .FOOD prepared and held . for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed . or discarded when held . for a maximum of 7 days 1.) On [DATE] at 07:52 a.m. the surveyor observed, three glasses of a dark brown liquid and one glass of a white liquid in the reach in cooler dated [DATE] and labeled nectar drink. On [DATE] at 08:00 a.m., an interview was conducted with Employee Identifier (EI) #1, Dietary Manager. EI #1 was asked, what substance was in the three glasses of dark brown liquid, and one glass of white liquid, inside the cooler. EI #1 stated they were three eight ounce glasses of nectar thickened tea and one eight ounce glass of nectar thickened water. EI #1 was asked, what does the date of [DATE] on top of the four eight ounce glasses in the drink cooler mean. EI #1 stated that [DATE] meant the thickened drinks should have been used or discarded by that date and the drinks should have been taken out of the cooler. EI# 1 was asked why should the nectar thickened drinks with a use-by-date of [DATE] have been discarded. EI #1 stated there could be a possibility of making someone sick. The surveyor asked EI#1, does the facility have a policy on dating food/drink items to be stored in the cooler/refrigerator. EI#1 stated, yes. EI #1 was asked, was the facility policy followed. EI #1 stated, no. 2.) On [DATE] at 08:04 a.m., the surveyor observed a clear plastic container filled with an orange colored item. There was no label or date on top of the lid. On [DATE] at 08:05 a.m., an interview was continued with EI #1, Dietary Manager. The surveyor asked EI #1 what was the orange colored item in the clear plastic container. EI #1 stated carrots. EI #1 was asked, what was the use-by-date on the carrots. EI #1 stated, there was no use-by-date or description of the food item. The surveyor asked EI #1, should the carrots have a label with a use-by-date. EI #1, replied yes. 3.) On [DATE] at 08:25 a.m. the surveyor observed, a plastic container with a yellow substance labeled Lemon Pudding and dated [DATE] and [DATE] in the reach in refrigerator. On [DATE] at 08:29 a.m., an interview was conducted with EI #1. EI #1 was asked, what do the dates [DATE] and [DATE] mean on top of the yellow substance in the reach in refrigerator. EI#1 replied, the substance was lemon pudding and the dates meant the pudding was opened on [DATE] and the use-by-date was [DATE]. EI #1 further stated this container should have been discarded after [DATE]. EI #1 was asked if there was a facility policy on use-by-dates. EI #1 replied, yes. EI#1 was asked if the policy was followed. EI#1 stated, no. 4.) On [DATE] at 08:09 a.m., in the refrigerator in the nourishment room on nursing station one, seven glasses of a white liquid substance with letters MN on top of the lid,were observed with no date. On [DATE] at 08:10 a.m., an interview was conducted with EI #2, Licensed Practical Nurse (LPN). EI #2 was asked, what was in the seven glasses in the refrigerator. EI #2 answered, nectar thickened water. EI#2 was asked, how long could the nectar thickened liquid be used. EI #2 replied, she did not know. The interview was concluded with EI #3, Director of Nursing (DON). EI #3 was asked, was there a use-by-date on top of the seven glasses of nectar thickened water. EI #3 replied, no. EI #3 was asked, should there be a use-by-date on top of the seven glasses of nectar thickened water. EI #3 answered, yes.

Based on observations, interviews, medical record reviews and review of facility policies titled, Eye drop administration, MEDICAL ADMINISTRATION/USE OF INHALANTS and Nebulizer treatment, the facility failed to ensure licensed staff: 1. did not touch Resident Identifier (RI) #14's privacy curtain and bed control and retrieve a thickened beverage from the refrigerator before applying gloves to administer eye drops for RI #14. Further staff failed to wash hands after removing gloves and before applying clean gloves, between administering eye drops in the right and left eye for RI #14; and 2. rinsed the mouthpiece of RI #54's inhaler before returning it to the medication cart. Further staff failed to rinse RI #54's nebulizer reservoir before storing it in a plastic bag. These deficient practices affected RI #14 and RI #54, two of five residents and two of four nurses observed during medication administration observation. Findings Include: 1.) A review of a facility policy titled, Eye drop administration with no date, documented: .If eye drops are to be put in both eyes remove your gloves wash hands and put on new gloves .for second eye . RI #14 was admitted to the facility on [DATE]. On 03/29/18 at 8:53 a.m., Employee Identifier (EI) #4, Licensed Practical Nurse (LPN), was observed administering RI #14's medications. EI #4 washed her hands and was then observed getting a thickened beverage from RI #14's refrigerator and pulling RI #14's privacy curtain. EI #4 then applied gloves without washing her hands, placed a straw in the thickened beverage and operated RI #14's bed control. Wearing those same gloves, EI #4 was observed to administer RI #14's right eye drop. EI #4 then removed her gloves and applied a clean pair of gloves without washing her hands to administer RI #14's left eye drop. On 03/29/18 at 9:03 a.m., an interview was conducted with EI #4. EI #4 was asked when should she wash her hands when using gloves. EI #4 said before she puts them on and when she takes them off. EI #4 was asked should she touch the privacy curtain, refrigerator or bed control after washing her hands before she put on gloves to administer RI #14's eye drops. EI #4 replied no, she should have washed her hands after touching any potentially contaminated object before she applied gloves. EI #4 was asked did she wash her hands when she removed her gloves after administering the eye drop in RI #14's right eye before she put on clean gloves for administration to the left eye. EI #4 answered no. EI #4 was asked what was the concern with touching the privacy curtain, refrigerator and bed control and not washing her hands when removing gloves. EI #4 said infection control. 2.) A review of a facility policy titled, MEDICAL ADMINISTRATION/USE OF INHALANTS with a revised date of 08/16/01, revealed: .12.run warm water through the mouthpiece to clean and prevent clogging. 13. Return medication to cart . A review of a facility policy titled, Nebulizer treatment with no date, documented: .rinse nebulizer reservoir out and let dry on a paper towel . RI #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/29/18 at 9:09 a.m., EI #5, LPN, was observed administering RI #54's medications. EI #5 was observed administering RI #54's inhaler. EI #5 placed the inhaler back into the medication cart without rinsing the mouthpiece. EI #5 was then observed administering RI #54's nebulizer treatment. After the medication was administered, EI #5 placed the nebulizer mask back into a plastic bag without rinsing or drying the reservoir. On 03/29/18 at 3:17 p.m., an interview was conducted with EI #5. EI #5 was asked what should she do after an inhaler has been administered. EI #5 said rinse it and wipe it off. EI #5 was asked did she rinse and wipe off RI #54's inhaler before she put it back into the medication cart. EI #5 said no. EI #5 was asked what should she do after administering a nebulizer treatment. EI #5 replied clean out the reservoir and dry it before putting it back in the plastic bag. EI #5 was asked did she rinse and dry RI #54's nebulizer reservoir before she stored it in a plastic bag. EI #5 said no. EI #5 was asked what was the concern in not rinsing RI #54's inhaler before returning it to the medication cart and not rinsing and drying RI #54's nebulizer reservoir before storing it in a plastic bag. EI #5 answered infection control. On 03/29/18 at 3:32 p.m., an interview was conducted with EI #6, LPN/Infection Control Coordinator. EI #6 was asked when should a nurse wash her hands during glove use. EI #6 said before she puts them on and after she takes them off. EI #6 was asked during eye drop administration to both eyes, what should a nurse do between eyes. EI #6 replied take the gloves off after the first eye wash her hands and put on a clean pair of gloves for the other eye. EI #6 was asked after a nurse washed her hands should she pull the privacy curtain and use the bed control before putting her gloves on for eye drop administration. EI #6 replied no, she should wash them again after doing those things and then put on the gloves. EI #6 was asked what should a nurse do before storing an inhaler after a resident has used it. EI #6 said clean it before putting it away. EI #6 was asked what should be done after a nebulizer treatment was administered. EI #6 replied the reservoir should be separated rinsed and dried before putting it in the plastic bag. EI #6 was asked what was the concern with these things not being done or being done incorrectly. EI #6 answered infection and harboring bacteria.

Based on record review, interviews, Charge Nurse Job Description, Practical Nursing Standards and Lippincott Manual of Nursing Practice, the facility failed to ensure a licensed staff member assessed Resident Identifier (RI) #1, when notified by a family member of a change in RI #1's condition. This deficient practice affected RI #1, one of three residents, sampled for assessment after change in a resident condition. Findings include: The State Agency received a complaint from RI #1's family member regarding a visit on 6/30/2017 at 9:45 AM. The family member found RI #1 to be unresponsive and asked Employee Identifier (EI) #2, a licensed staff member, to check on RI #1. After no assessment of RI #1 by EI #2, the family member left at 10:30 AM only to be called around 3:00 PM that RI#1 was being sent to the ER for unresponsiveness. After reviewing the chart and interviewing the staff the incident occurred on 6/29/2017. A review of a job description for the Charge Nurse, no date, documented: . Nursing Care Functions . Implement and maintain established nursing objectives and standards. Make periodic checks to . evaluate the resident's physical and emotional status. A review of a document titled, . Standards of Nursing Practice, dated 9/30/16, documented: . 610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice). (1) The practice of practical nursing includes, but is not limited to: . (d) Conducting . focused nursing assessments, to include the patient's health status. A review of Lippincott Manual of Nursing Practice 10th Edition, copyright 2014, pages 16-17 documented: . Standards of Practice General Principles . 5. Documented in the patient's chart with clear, concise statements of the nurse's decisions, actions and reasons for the care provided . Box 2-1 Common Legal Claims for Departure from Standards of Care . Failure to monitor and observe a change in a patient's clinical status . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/18/2017, revealed the resident had short-term and long-term memory problems and further indicated RI #1 cognitive skills for daily decisions making was severely impaired. A review of RI #1's Progress Notes dated 6/29/2017 revealed: . 1030 AM Health Status Note RESIDENT HAD VISITORS THIS MORNING. RESIDENT WAS VISUALLY SEEN SITTING OUTSIDE WITH FAMILY. FAMILY WAS CONCERNED AND TOLD THAT WRITER WOULD CONTINUE TO MONITOR. At 1:50 PM Health Status Note RESIDENT SLEPT THROUGH LUNCH, WAS ASSESSED . RESIDENT WAS UNABLE TO BE AROUSED, RESPIRATION AT EASE AND NON LABORED. RESIDENT WAS UNRESPONSIVE TO STERNUM RUB, PAIN, OR VERBAL COMMANDS. VITAL SIGNS 100/62, 18, 98.2, 72 BS (Blood Sugar) 144. UNABLE TO GET O2 STAT . The entries was signed by EI #2, the LPN (Licensed Practical Nurse) who cared for RI #1 during the 7 AM-3 PM shift on 6/29/2017. At 2:56 PM, RI #1 was transported to the hospital by Ambulance Services. On 7/18/2017 at 1:55 PM, the Surveyor conducted an interview with EI #2. EI #2 was asked what did she do when a family member informed her RI #1 was not right and to check on RI #1. EI#2 said she looked at RI #1 and RI #1 was asleep. In a phone interview with EI #2 on 7/19/2017 at 3:30 PM, EI #2 was asked if she could have done more than just look at RI #1 when informed by the family to check on RI #1. EI #2 stated, Yes, I could have done more. In another interview with EI #2 on 7/20/2017 at 10:05 AM, EI #2 was asked what more could she have done other than look at RI #1 when informed by a family member a change was recognized. EI #2 said she could have called another Nurse to look or obtain vital signs. EI #2 was asked what action did she take. EI #2 replied She just let her slept. EI #2 was asked if it was an acceptable practice of this facility for a licensed staff member to only visually look at a resident when informed there is a change in their condition. EI #2 said more was supposed to have been done. EI #2 was asked, what harm can occur when informed there is a reported change in the resident's condition and the resident was only looked at by a licensed staff nurse. EI #2 said his/her condition can decrease and worsen. On 7/19/2017 at 10:21 AM an interview was conducted with EI #1, the DON (Director of Nursing). EI #1 was asked what her Nurse are expected to do when a change in a resident condition is reported. EI #1 said a more thorough evaluation and open an SBAR (Situation, Background, Assessment, Recommendation). EI #1 was asked if it was an acceptable practice of this facility for a licensed staff member to only visually look at a resident when informed there is a change in their condition. EI #1 said no. EI #1 was asked, what harm can occur when informed there is a reported change in the resident's condition and the resident was only looked at by a licensed staff nurse. EI #1 said first assessment should be physical and a complete assessment because there could have been a decline.

Based on record review, interview, and review of Job Descriptions, the facility failed to ensure a licensed staff member followed Resident Identifier (RI) #1's Cognitive Care Plan to monitor and document any change in RI #1's cognitive function. This deficient practice affected RI #1, one of three residents, sampled for assessment after change in a resident condition. Findings include: The State Agency received a complaint from RI #1's family member, regarding a visit on 6/30/2017 at 9:45 AM. The family member found RI #1 to be unresponsive and asked Employee Identifier (EI) #2, a licensed staff member, to check on RI #1. After no assessment of RI #1 by EI #2, the family member left at 10:30 AM only to be called around 3:00 PM that RI#1 was being sent to the ER for unresponsiveness. After reviewing the chart and interviewing the staff the incident occurred on 6/29/2017. A review of a job description for the Charge Nurse, no date, documented: . Nursing Care Function . Ensure that . care the residents are providing . in accordance with the resident's care plan . A review of RI #1's Cognitive Care Plan, with an initiated date of 12/8/2014 and revision on 2/21/2017 documented, . Interventions . Monitor/document . any changes in cognitive function, specifically . level of consciousness, mental status. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/18/2017, revealed the resident had short-term and long-term memory problems indicated RI #1 cognitive skills for daily decisions making was severely impaired. RI #1 Current MDS further revealed RI #1 required extensive to total care of one person assist with ADLs (Activities of Daily Living). A review of RI #1's Progress Notes dated 6/29/2017 revealed: . 1030 AM Health Status Note RESIDENT HAD VISITORS THIS MORNING. RESIDENT WAS VISUALLY SEEN SITTING OUTSIDE WITH FAMILY. FAMILY WAS CONCERNED AND TOLD THAT WRITER WOULD CONTINUE TO MONITOR. At 1:50 PM Health Status Note RESIDENT SLEPT THROUGH LUNCH, . RESIDENT WAS UNABLE TO BE AROUSED, . RESIDENT WAS UNRESPONSIVE TO STERNUM RUB, PAIN, OR VERBAL COMMANDS. VITAL SIGNS 100/62, 18, 98.2, 72 BS (Blood Sugar) 144. UNABLE TO GET O2 STAT . The entries was signed by EI #2, the LPN (Licensed Practical Nurse) who cared for RI #1 during the 7 AM-3 PM shift on 6/29/2017. At 2:56 PM, RI #1 was transported to the hospital by Ambulance Services. On 7/20/2017 at 3:15 PM, an interview was conducted with EI #1, the DON (Director of Nursing). EI #1 was asked what staff members are involved with writing a care plan. EI #1 responded, SW (Social Worker), MDS Coordinator, it's a team approach. EI #1 was asked if she had a policy for following the care plan. EI #1 said not one that states to follow care plan. EI #1 was asked if EI #2 monitored and documented on RI #1, as directed in the Cognitive Care Plan . EI #1 said documentation did not occur consistently from 10:30 (AM) until time of transfer.

Based on record review, interviews, a facility policy titledCharting and Documentation, Charge Nurse Job Description, and Lippincott Manual of Nursing Practice, the facility failed to ensure a licensed staff member provided evidence she monitored and documented a change in Resident Identifier (RI) #1's cognition status when informed by a family member a change in RI #1's condition. This deficient practice affected RI #1, one of three residents, sampled for assessment after change in a resident condition. Findings include: The State Agency received a complaint from RI #1's family member regarding a visit on 6/30/2017 at 9:45 AM. The family member found RI #1 to be unresponsive and asked Employee Identifier (EI) #2, a licensed staff member, to check on RI #1. After no assessment of RI #1 by EI #2, the family member left at 10:30 AM only to be called around 3:00 PM that RI#1 was being sent to the ER for unresponsiveness. After reviewing the chart and interviewing the staff the incident occurred on 6/29/2017. A review of the facility policy titled, CHARTING AND DOCUMENTATION, with a reviewed date of 01/2017 documented: Policy 1. Chart all pertinent changes in the resident's condition . as well routine observations. A review of a job description for the Charge Nurse, no date, documented: . Charting and Documentation . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. Nursing Care Functions . Make periodic checks to . evaluate the resident's physical and emotional status. A review of Lippincott Manual of Nursing Practice 10th Edition, copyright 2014, pages 16-17 documented: . General Principles . 5. Documented in the patient's chart with clear, concise statements of the nurse's decisions, actions and reasons for the care provided . Box 2-1 Common Legal Claims for Departure from Standards of Care . Failure to . document a . change in a patient's condition . A review of RI #1's Cognitive Care Plan, with an initiated date of 12/8/2014 and revision on 2/21/2017 documented, . Interventions . Monitor/document . any changes in cognitive function, specifically changes in . level of consciousness, mental status. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/18/2017, revealed the resident had short-term and long-term memory problems and further indicated RI #1 cognitive skills for daily decisions making was severely impaired. A review of RI #1's Progress Notes dated 6/29/2017 revealed: . 1030 AM Health Status Note RESIDENT HAD VISITORS THIS MORNING. RESIDENT WAS VISUALLY SEEN SITTING OUTSIDE WITH FAMILY. FAMILY WAS CONCERNED AND TOLD THAT WRITER WOULD CONTINUE TO MONITOR. At 1:50 PM Health Status Note RESIDENT SLEPT THROUGH LUNCH, WAS ASSESSED . RESIDENT WAS UNABLE TO BE AROUSED . RESIDENT WAS UNRESPONSIVE TO STERNUM RUB, PAIN, OR VERBAL COMMANDS. VITAL SIGNS 100/62, 18, 98.2, 72 BS (Blood Sugar) 144. UNABLE TO GET O2 (Oxygen) STAT . The entries was signed by EI #2, the LPN (Licensed Practical Nurse) who cared for RI #1 during the 7 AM-3 PM shift on 6/29/2017. At 2:56 PM, RI #1 was transported to the hospital by Ambulance Services. On 7/19/2017 at 10:55 AM, EI #2 was interviewed and asked, what did she do when a family member informed her RI #1 was not acting right. EI#2 said she looked at RI #1 and RI #1 sleeps a lot. EI #2 was asked where did she document her assessment of RI #1. EI #2 replied she just told the family she would continue to monitor her. She didn't document it. On 7/20/2017 at 10:17 AM, EI #2 was interviewed and asked, what do they (nursing staff) document. EI #2 replied, antibiotics, change in condition, anything out of the norm, IV (Intravenous) fluids, dressings. We chart in the nurses notes. EI #2 further explained things are charted daily they see. On 7/20/2017 at 10:10 AM, EI #2 was interviewed and asked, if she documented in RI #1's chart that RI #1 often slept . and was difficult to aroused. EI #2 replied, We don't document that. No. Residents sleeps harder sometimes in the morning. EI #2 was asked, should she have documented in RI #1 chart regarding her condition and her response when the family stated she had made a change. EI #2 replied, I could have. On 7/19/2017 at 15:30 PM an interview was conducted with EI #1, the DON (Director of Nursing). EI #1 was asked should EI #2 done more than just look at RI #1. EI #1 replied she should have documented what she was monitoring. EI #1 further said she wouldn't have left a large gap of time from 9 (AM) - 2 (PM). On 7/20/2017 at 3:15 PM, E #1 was interviewed and asked if EI #2 monitor and document on RI #1. EI #1 replied, Documentation did not occur consistently from the 1030 (AM) until time of transfer.

Based on observation, medical record review of Resident Identifier (RI) #7 and staff interviews, the facility failed to ensure RI #7's fingernails were not long and rough to the touch. Findings Include: RI #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #7's Quarterly Minimum (MDS) data set [DATE] documented RI #7 had long and short term memory problems and was severely impaired in cognitive skills for daily decision making. RI #7 was totally dependent of staff for Activities of Daily Living Skills which included personal hygiene and nail care. During the initial tour on 05/02/17 at 3:35 p.m., RI #7 was observed in bed asleep. The fingernails on both hands were beyond the tip of the nail and some were jagged. Another observation was made on 05/04/17 at 9:35 a.m., RI #7's thumb fingernail on the right hand was long and jagged; all fingernails on the left hand were long and the 5th digit fingernail was jagged. On 05/04/17 at 10:20 a.m., Employee Identifier (EI) #5, Certified Nursing Assistant/CNA was asked to describe what RI #7's fingernails. EI #5 stated the fingernails were long and not smooth. EI #5 was asked when was the last time RI #7's fingernails were cut. EI #5 replied she did not know. EI #5 was asked which ones were long and not smooth. EI #5 replied the left hand fingernails. EI #5 was asked who was responsible to cut RI #7's fingernails. EI #5 replied she thought it was EI #6, the Treatment Nurse. On 05/04/17 at 11:00 a.m., EI #6 was asked who was responsible to cut residents' fingernails. EI #6 replied the CNAs unless the resident is a diabetic. EI #6 further explained she would on occasion if she saw the resident's fingernails needed to be cut. EI #6 was asked had she seen RI #7's nails. EI #6 replied she had not seen them recently. EI #6 was asked if RI #7 was a diabetic. EI #6 replied no he/she was not a diabetic.

Based on observation, interview and record review the facility failed to ensure a staff person did not pick up a washcloth off the floor and put it in the hands of Resident Identifier (RI) #5. This affected RI #5 one of nine sampled residents. Findings Include: RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/08/16 at 1:30 p.m., RI #5 was observed sitting in a wheelchair at the nurses station. RI #5 dropped a washcloth that he/she was holding. Employee Identifier (EI) #1, Activity Assistant, walked by, picked the washcloth off the floor with her bare hand and put it in RI #5's hands. On 11/08/16 at 1:37 p.m., EI #1 was asked why RI #5 needed a washcloth. EI #1 replied because of drooling. EI #5 was asked could RI #5 wipe his/her mouth by himself/herself. EI #1 replied sometimes. EI #1 was asked when she saw the washcloth on the floor what did she do. EI #1 replied she picked it up and gave it to RI #5. EI #1 was asked what could be a concern with giving a resident a washcloth off the floor. EI #1 replied it could be contaminated. On 11/08/16 at 3:10 p.m., EI #2, Infection Control Nurse, was asked why RI #5 used a washcloth. EI #5 replied because of drooling. EI #5 was asked would there be a concern if RI #5 dropped the washcloth on the floor and it was picked up off the floor and given back to him/her. EI #2 replied that should not have happened. EI #2 was asked why not. EI #2 replied because it was on the floor and should not be picked up with bare hands and could cause contamination.

Based on observation and interview the facility failed to maintain the walk-in freezer in safe operational condition. ring the initial tour of the kitchen the external thermometer on the freezer section of the walk in freezer registered 60 degrees on the external thermometer. There was no working internal thermometer. There was an ice bank noted on the floor of the freezer as well as cascading down three stacked boxes of frozen food adjacent to the cooling unit. This had the potential to affect all residents receiving foods from the kitchen. Findings include: On 11/07/16 at 3:10 p.m., during the initial tour of the kitchen the external temperature on the walk-in freezer was noted to register 60 degrees. Upon entering the unit the cooling unit was noted to be on. The internal thermometer was broken and did not work. There was an ice bank noted on the floor of the freezer as well as ice cascading down three boxes of frozen foods adjacent to the cooling unit. It was also noted to have a small water leak (drip) coming from the cooling unit pipe. At 3:40 p.m. the freezer was once again checked after the facility put new thermometers in the unit. At that time the external temperature registered 30 degrees outside and 28 degrees internally. At 3:42 p.m. the external temperature had dropped to 28 degrees. A review of the maintenance history for the unit revealed there had been problems with the unit that had been addressed. The latest check done on 09/15/16 indicated the unit was low on freon and there was a bad thermostat which was replaced. In an interview with the administrator, when Employee Identifier (EI)# 3 was asked if he was aware the walk-in freezer had a problem. EI #3 stated, yes, it was condensation. When asked what the potential harm could occur if the freezer cooler/fan was not working, EI #3 stated the safety factor, ice builds up and you could slip. The food could get wet from the condensation. If something is not working then it needs to be fixed .

Based on observation, interviews and record reviews, the facility failed to ensure on 12/16/2015 Resident Identifier (RI) #1 was checked and changed every two hours and as needed per the care plans. RI #1 was observed from 10:00 AM to 1:52 PM without staff checking and changing the resident during that time frame. This affected RI #1, one of fourteen residents whose care plans were reviewed. Findings include: A facility policy titled Care Plans - Preliminary with a revision date of August 2006 documented: . Policy Interpretation and Implementation - Preliminary Care Plan 1. To assure that the resident's immediate care needs are met and maintained, . 2. The Interdisciplinary Team will review . and implement a nursing care plan to meet the resident's immediate care needs . RI #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/06/2015 revealed that RI #1 had a BIMS (Brief Interview for Mental Status) score of 1 out of 15, indicating RI #1 was severely impaired in cognition. The MDS further revealed that RI #1 was always incontinent of bowel and bladder and was totally dependent with one person assist for toileting needs. RI #1's care plan for ADL (Activities of Daily Living) documented the following intervention: .The resident requires extensive assistance of one staff participation to use toilet . RI #1's care plan for the potential for Pressure Ulcer documented interventions as follows: .Check and change Q (every) 2 hours or more frequently if requested . RI #1's care plan for frequent bladder incontinent episodes documented the following intervention: .Check the resident every two hours and as required for incontinence . A continuous observation of RI #1 was made on 12/16/2015 from 10:00 AM to 1:52 PM. RI #1 was initially observed sitting in a wheelchair in the Activity Room. The surveyor continued to observe RI #1 in the Activity Room attending different activities. RI #1 was then escorted to the Restorative Dining Room at 12:00 PM (noon) for lunch. After lunch, RI #1 was escorted to the Nurses Station at 1:46 PM. At 1:52 PM, Employee Identifier (EI) #2 a Certified Nursing Assistant (CNA), went to the nurses station and wheeled the resident to the bed room and put RI #1 to bed. EI #2 then checked and changed RI #1. At no time during the continuous observation was RI #1 checked or changed, nor asked if she needed to be checked or changed. On 12/17/2015 at 09:25 AM, the surveyor interviewed EI #2, CNA. EI #2 stated that she was assigned to RI #1 on 12/16/2015. She stated RI #1 was to be checked and changed every two hours according to the care plans. EI #2 stated if the resident was in activities, they would have checked and changed her but also stated that the CNA's were responsible for checking and changing. EI #2 was asked why it was important to follow care plans. She replied so that staff would know how to take care of the resident, and give the care they need. EI #2 was asked what the potential for harm was in not checking and changing RI #1 every two hours as care planned. EI #2 said the resident could have skin break down, get rashes and could get an infection. On 12/17/2015 at 10:37 AM, the surveyor interviewed EI #3, Activities Director. EI #3 stated that RI #1 had attended activities on 12/16/2015. When asked who was responsible to check and change RI #1, EI #3 stated the CNAs would go to the Activity Room and get the residents and take them to their rooms to be checked and changed. On 12/17/2015 at 11:05 AM, the surveyor interviewed EI #4, Registered Nurse (RN) for First Station. EI #4 was asked how did staff know what care a resident required. EI #4 stated the residents have care plans. EI #4 was asked how RI #1 was care planned for incontinence and pressure ulcers. She stated RI #1 was to be checked and changed every two hours. EI #4 was asked who was responsible for checking and changing the residents. She stated the CNAs were. When asked why was it important to check and change RI #1 per the care plans, EI #4 stated it was to prevent pressure ulcers. When asked what the harm was in not checking and changing RI #1 as care planned, EI #4 stated the resident could develop pressure ulcers from urine acidity.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #1 was assisted with her ADL (Activities of Daily Living) needs on 12/16/2015. RI #1 was not checked or changed from 10 AM to 1:52 PM. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/06/2015 revealed that RI #1 had a BIMS (Brief Interview for Mental Status) score of 1 out of 15, indicating RI #1 was severely impaired in cognition. The MDS further revealed that RI #1 was always incontinent of bowel and bladder and was totally dependent with one person assist for toileting needs. RI #1's care plan for ADL (Activities of Daily Living) documented the following intervention: .The resident requires extensive assistance of one staff participation to use toilet . RI #1's care plan for the potential for Pressure Ulcer documented interventions as follows: .Check and change Q (every) 2 hours or more frequently if requested . RI #1's care plan for frequent bladder incontinent episodes documented the following intervention: .Check the resident every two hours and as required for incontinence . A continuous observation of RI #1 was made on 12/16/2015 from 10:00 AM to 1:52 PM. RI #1 was initially observed sitting in a wheelchair in the Activity Room. The surveyor continued to observe RI #1 in the Activity Room attending different activities. RI #1 was then escorted to the Restorative Dining Room at 12:00 PM (noon) for lunch. After lunch, RI #1 was escorted to the Nurses Station at 1:46 PM. At 1:52 PM, Employee Identifier (EI) #2 a Certified Nursing Assistant (CNA), went to the nurses station and wheeled the resident to the bed room and put RI #1 to bed. EI #2 then checked and changed RI #1. At no time during the continuous observation was RI #1 checked or changed, nor asked if she needed to be checked or changed. On 12/17/2015 at 09:25 AM, the surveyor interviewed EI #2, CNA. EI #2 stated that she was assigned to RI #1 on 12/16/2015. She stated RI #1 was to be checked and changed every two hours according to the care plans and that RI #1 wore briefs. EI #2 was asked when was the last time RI #1 had been checked and changed on 12/16/2015 prior to the surveyor observing EI #2 putting RI #1 to bed. EI #2 replied that if the resident was in activities, the activity staff would ask her if she needed to be checked and changed. The Activity staff would get a CNA to change the resident. EI #2 further stated she did not remember if the Activity staff came and got her to check and change RI #1. EI #2 was asked what the potential for harm was in not checking and changing RI #1 every two hours. EI #2 said the resident could have skin break down, get rashes and could get an infection. On 12/17/2015 at 10:37 AM, the surveyor interviewed EI #3, Activities Director. EI #3 stated that RI #1 had attended activities on 12/16/2015. When asked who was responsible to check and change RI #1, EI #3 stated the CNAs would go to the Activity Room and get the residents and take them to their rooms to be checked and changed. EI #3 was asked if RI #1 had been taken from the Activity Room on 12/16/2015 to be checked and changed. EI #3 replied she thought they did. But further stated that CNAs take residents to and from the room all the time. When EI #3 was asked why was it important to check and change residents, she stated to make sure that the residents did not have skin breakdown and for personal hygiene reasons. On 12/17/2015 at 11:05 AM, the surveyor interviewed EI #4, Registered Nurse (RN) for First Station. EI #4 was asked how did staff know what care a resident required. EI #4 stated the residents have care plans. EI #4 was asked how RI #1 was care planned for incontinence and pressure ulcers. She stated RI #1 was to be checked and changed every two hours. EI #4 was asked who was responsible for checking and changing the residents. She stated the CNAs were. When asked why was it important to check and change RI #1, EI #4 stated it was to prevent pressure ulcers. When asked what the harm was in not checking and changing RI #1, EI #4 stated the resident could develop pressure ulcers from urine acidity.

Based on observations, record review and interview, the facility failed to ensure the State Survey Results were posted in a manner identifiable to residents and visitors. This affected all residents and visitors in the facility. Findings include: A review of the facility's document titled, RESIDENT RIGHTS, revealed . (g) Examination of survey results. A resident has the right to - (1) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors . The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability . Postings of the State Survey Results were not observed at the location of the survey book or throughout the facility from 12-14-15 through 12-17-15. On 12/17/15 at 8:39 AM, an interview was conducted with EI (Employee Identifier) #1, Administrator. EI #1 was questioned regarding the posting for the location of the State Survey book and how residents and visitors were made aware of the survey results. EI #1 said there was no posting and the admission packet states where the State Survey book was located. When EI #1 was asked who was responsible for posting the survey results, EI #1 said the Administrator.

Based on observations and interviews, the facility failed to ensure the sprinkler heads in the ceilings of residents' rooms, A through M, were free of an accumulation of dust-like particles on 2 (two) of 2 days of the survey. This affected 13 (thirteen) of the 26 rooms observed on 1 (one) of the 2 units at the facility. Findings Include: The following observations were made: Room A On 07/22/15 at 9:47 AM, during the initial tour of the facility, the surveyor observed a moderate amount of dust-like particles on the sprinkler head in the ceiling of the resident's room. On 07/23/15 at 11:35 AM, the dust like-particles remained on the sprinkler head. Room B On 07/22/15 at 9:21 AM, during the initial tour of the facility, the surveyor observed a small amount of dust-like particles on the vent in the ceiling of the resident's bathroom. Room C On 07/22/15 at 9:32 AM, during the initial tour of the facility, the surveyor observed a moderate amount of dust-like particles on the sprinkler head in the ceiling of the resident's room. On 07/23/15 at 10:44 AM, the dust like-particles remained on the sprinkler head. Room D On 07/23/15 at 10:50 AM, the surveyor observed a resident sitting in bed in the resident's room. There were dust-like particles observed on the sprinkler head in the ceiling of the resident's room. Room E On 07/22/15 at 3:19 PM, the surveyor observed a resident sitting in a wheelchair in the resident's room. There were dust-like particles observed on the sprinkler head in the ceiling of the resident's room. On 07/23/15 at 10:48 AM, the dust like-particles remained on the sprinkler head. Room F On 07/22/15 at 3:06 PM, the surveyor observed dust-like particles on 1 of 2 of the sprinkler heads in the ceiling of the room. On 07/23/15 at 10:46 AM, the dust like-particles remained on the sprinkler head. Room G On 07/23/15 at 10:45 AM, the surveyor observed dust-like particles on the sprinkler head in the ceiling of the room. Room I On 07/23/15 at 11:18 AM, the surveyor observed a large amount of dust-like particles on the sprinkler head in the ceiling on the A side of the room. There was also observed a scant amount of dust-like particles on the sprinkler head in the ceiling on the B side of the room. Room J On 07/23/15 at 11:12 AM, the surveyor observed a small amount of dust-like particles on the sprinkler head in the ceiling on the B side of the resident's room. Room K On 07/23/15 at 11:21 AM, the surveyor observed a large amount of dust-like particles on the sprinkler head in the ceiling of the resident's room. Room L On 07/23/15 at 11:20 AM, the surveyor observed a moderate amount of dust-like particles on the sprinkler head in the ceiling of the resident's room. Room M On 07/23/15 at 11:22 AM, the surveyor observed a moderate amount of dust-like particles on the sprinkler head in the ceiling of the resident's room. On 07/23/15 at 2:24 PM, the surveyor conducted an interview with Employee Identifier (EI) #3, the Maintenance Director. The surveyor asked EI #3 had he ever cleaned the sprinkler heads for dust-build. EI #3 replied, No. The surveyor asked EI #3 what would be some of the complications or concerns if the sprinkler heads are covered with a dust build-up. EI #3 said if they (maintenance department) saw one with a dust build-up, they would get the dust off. The surveyor asked EI #3 what complications if any would a dust build-up in a resident's room cause the resident. EI #3 replied, It would probably cause breathing problems or allergies [REDACTED]. EI #3 accompanied the surveyor to rooms A - M. The following observations were made by EI #3 and the surveyor: Room A On 07/23/15 at 2:37 PM, the surveyor asked EI #3 did he see an accumulation of dust on the sprinkler head in the ceiling of the resident's room. EI #3 replied, Yes I do. The surveyor asked EI #3 what amount of dust did he see. EI #3 replied, Moderate. Room B On 07/23/15 at 2:38 PM, the surveyor asked EI #3 did he see any dust on the vent in the ceiling of the resident's bathroom. EI #3 replied, Yes. The surveyor asked EI #3 what amount of dust build-up did he see. EI #3 replied, Small or moderate amount. Room C On 07/23/15 at 2:41 PM, the surveyor asked EI #3 what he saw on the sprinkler head in the ceiling of the resident's room. EI #3 replied, a moderate amount of dust. Room D On 07/23/15 at 2:45 PM, the surveyor asked EI #3 what he saw on the sprinkler head in the ceiling of the resident's room. EI #3 replied, Small amount of dust. Room E On 07/23/15 at 2:43 PM, the surveyor asked EI #3 what he saw on the sprinkler heads in the ceiling of the resident's room. EI #3 said he saw a very small amount of dust on both sprinkler heads. Room F On 07/23/15 at 2:42 PM, the surveyor asked EI #3 what he saw on the sprinkler heads in the ceiling of the room. EI #3 said he saw a very small amount of dust on both sprinkler heads. Room G On 07/23/15 at 2:47 PM, the surveyor asked EI #3 did what he see on the sprinkler head in the ceiling of the resident's room. EI #3 replied, A moderate amount of dust. Room H On 07/23/15 at 2:48 PM, the surveyor asked EI #3 what he saw on the sprinkler head in the ceiling of the resident's room. EI #3 replied, A moderate amount of dust. Room I On 07/23/15 at 2:50 PM, the surveyor asked EI #3 what he saw on the sprinkler heads in the ceiling of the resident's room. EI #3 replied, A moderate amount on B side. Small amount on A side. Room J On 07/23/15 at 2:42 PM, the surveyor asked EI #3 did what he see on the sprinkler head in the ceiling of the resident's room. EI #3 replied, Excessive amount (of dust) on A side. Very small amount (of dust) on B side. Room K On 07/23/15 at 2:44 PM, the surveyor asked EI #3 what he saw on the sprinkler head in the ceiling of the resident's room. EI #3 replied, Moderate amount of dust. Room L On 07/23/15 at 2:56 PM, the surveyor asked EI #3 what he saw on the sprinkler head in the ceiling of the resident's room. EI #3 replied, Moderate amount of dust. Room M On 07/23/15 at 2:58 PM, the surveyor asked EI #3 what he saw on the sprinkler head in the ceiling of the resident's room. EI #3 replied, Small amount of dust. On 07/23/15 at 4:01 PM, the surveyor conducted an interview with EI #2, the RN (Registered Nurse) Day Shift Supervisor. The surveyor asked EI #2 what would or could having dust on a sprinkler head in a resident's room potentially do to the resident. EI #2 replied, Dust can mess with the respiratory system . On 07/23/15 at 4:28 PM, the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1 what were some of the potential concerns a resident may face when there is a dust build-up on the sprinkler heads in the ceiling of a resident's room. EI #1 said it depended on the severity of the dust build-up. EI #1 further said it sounded like a life safety issue so she would say it would be maintenance who was responsible for ensuring the sprinkler heads were clean.