Every finding on record at Chatham Nursing & Rehabilitation

Based on observations and staff interviews the facility failed to maintain a closet door and trash can in good repair. This was evident in 1 of 4 rooms reviewed for environment (room [ROOM NUMBER]). Findings included: On 6/19/2023 at 1:16 PM an observation of room [ROOM NUMBER] was conducted. A closet with two doors that swung open was located on the right-hand side of the room at the entrance to the room. One of two doors on the closet was broken. The door on the left side of the closet was observed to be hanging loosely from the top hinge and was completely disengaged from the bottom hinge. There was a trash can in the bathroom with about 6 inches of broken jagged edges that were approximately 4 - 5 inches long around the top corner rim of the trash can. It was covered by a plastic trash can liner. On 6/20/2023 at 2:00 PM an observation of room [ROOM NUMBER] revealed the closet door was attached to the top hinge and completely disengaged from the bottom hinge. There was a broken trash can in the bathroom with jagged edges along the top. It was covered by a plastic trash can liner. On 6/21/2023 at 10:12 AM an observation and interview were conducted with Nurse Aide #1 (NA#1) while in room [ROOM NUMBER]. NA#1 revealed she had worked at the facility for about 3 months and that the closet door had had been broken the entire time she worked at the facility. She further revealed she had submitted a work order for the closet door to be repaired about 1 to 1.5 months ago. NA #1 was observed as she removed the trash from the broken trash can and lined the trash can with a new bag. When informed that the trash can was broken, she stated she did not realize it because she was focused on the trash. She indicated if she had known the trash can was broken, she would have asked for it to be replaced. She further indicated she needed to remove the trash can immediately as it could cut her residents if they fell against it. NA #1 removed the trash can from the room and filed a work order for the broken closet door. In an interview at 10:31AM on 6/21/2023, the Maintenance Director observed the broken closet door in room [ROOM NUMBER]. He stated he had not received a work order for the closet door to be repaired. There was no log of a request for the closet door to be repaired. The Maintenance Director stated there is a logbook at each nursing station where problems were signed in, and he and his assistant reviewed them every morning. He further stated he did a walk through every morning to assess for any problems, including closets, and fixed hazards immediately. He said that needed repairs were prioritized and emergent repairs were made as needed. He indicated the broken closet door was a hazard and would be repaired immediately. An interview was conducted on 6/22/2023 at 7:52 AM with the Account Manager for the housekeeping contract company. She revealed she was the head housekeeper in charge of housekeeping, laundry, and the floor technicians. She further revealed that resident rooms were cleaned every day and that trash cans were emptied when the room was cleaned. She explained that the NAs emptied trash cans if needed after they provided resident care. She further explained housekeeping staff should remove a broken trash can, put it in dirty linen, notify her and she would put in a work order for maintenance. On 6/22/2023 at 4:40 PM an interview was conducted with the facility Administrator and the Director of Nursing (DON). The Administrator stated that the broken trash can should have been thrown away and replaced. She further stated the closet door could have been removed and replaced or repaired if a work order had been submitted. The DON stated that the NA who stated that the closet door had been broken the entire time she worked at the facility did not submit a work order and that the NA was disgruntled. She stated staff are expected to write a work order for needed repairs and that work order boxes are located at each nursing station. A Resident and Room Audit Form was provided that revealed on 6/13/2023 an audit of resident rooms revealed the closet was orderly and there were no clothes on the floor in room [ROOM NUMBER].

Based on observations and staff interviews the facility failed to maintain a clean walk-in refrigerator from an accumulation of a brownish/blackish matter for 1 of 1 walk-in refrigerators. Additionally, the facility failed to remove expired liquids stored ready for use in 1 of 1 walk-in refrigerators. This practice had the potential to affect food served to residents. The findings included: 1a. An observation completed with the Dietary Manager (DM) in the walk-in refrigerator on [DATE] at 9:39 AM revealed a brownish/blackish matter on the ceiling of the walk-in refrigerator which included the cage covering the circulatory fan and the light protector. b. An observation completed with the DM in the walk-in refrigerator on [DATE] at 9:41 AM revealed 1 opened box of honey thick consistency milk with a use by date of [DATE] on the top shelf. The box contained 12 un-opened cartons of honey thick consistency milk. The DM stated in an interview on [DATE] at 9:43 AM that the brownish/blackish matter on the ceiling of the walk-in refrigerator was from condensation from opening the door. The DM stated that he checked expiration dates weekly on delivery days and that the milk was delivered from the food supplier expired. The DM was not certain as to why the honey thick consistency milk was still in the walk-in refrigerator. The DM communicated he last checked the walk-in refrigerator for expired items on [DATE]. In a follow up interview with the DM on [DATE] at 2:32 PM, he verbalized the walk-in refrigerator was cleaned Monday, Wednesday, and Fridays. The DM expressed the walk-in refrigerator would be scrubbed clean and Maintenance would be notified. The Administrator stated in an interview on [DATE] 04:32 PM that the walk-in refrigerator should be cleaned on a regular basis to prevent buildup of debris on the ceiling. Additionally, the Administrator voiced that any foods or beverages coming into the building needed to be checked for the expiration date before storing.

Based on record reviews, observations, and staff and transport company interviews the facility failed to transfer a resident in a manner that prevented Resident #1 from toe fractures with lacerations on an outside van company for 1 of 3 residents reviewed for supervision to prevent accidents. The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnoses of dysphagia, dementia, Alzheimer's Disease, history of falls and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 as being severely cognitively impaired and required extensive assistance of two staff for activities of daily living (ADL). A nurses note dated 04/07/21 revealed Resident #1 was found on the floor on the right side of the bed with her feet tangled in the sheets with the bed in the lowest position. The note further revealed a hematoma was on Resident #1's forehead, approximately 2 inches in diameter, a skin tear was on the right dorsal hand and left elbow. The nurses note stated all injuries were cleaned with sterile saline and Resident #1 was sent to the Emergency Department (ED). The nurse's note further stated Resident #1 was picked up by Emergency Medical Services (EMS) at 8:30 AM. A nurses note dated 04/07/21 at 5:32 PM indicated Resident #1 was injured during the transport back to the facility from the ED. The note further indicated the nurse did not witness the incident nor the injury. A nurses note dated 04/07/21 at 7:57 PM indicated the nurse received the report from the ED and Resident #1 had multiple fractures on all 5 toes on the right foot and was given intravenous antibiotics, a [CONDITION(S)] shot, and the foot was placed in a splint. The nurses note further indicated Resident #1 was being transferred back by EMS with pain medications and orders for circulation checks. A nurses note dated 04/07/21 at 10:01 PM indicated Resident #1 returned to the facility at 9:35 PM with non-emergent EMS. The right foot was bandaged and splinted and sutures were present. There was bruising noted to Resident #1's forehead and left hand from the previous fall and steri-strips were present on the left hand. There was no distress noted at this time. A physician progress note dated 04/09/21 stated it was for a follow-up from the van accident and laceration to the right foot. The note further stated to continue follow-up as directed with orthopedics. An interview on 08/09/21 at 2:55 PM with the Director of Nursing (DON) and the Clinical Nurse Liaison revealed the van driver came into the facility the morning of the accident and told the Human Resources (HR) Director the resident had blood on her foot. The HR Director got the Clinical Nurse Liaison and went out to the van. The Clinical Nurse Liaison stated Resident #1 was sitting in the van with her arms crossed and looking around with no signs of distress noted. The Clinical Nurse Liaison stated she saw blood on Resident #1's foot and she rolled the Resident#1's [CONDITION(S)]-[CONDITION(S)] deterrent stockings (ted hose) back and saw the laceration. She further stated the laceration was all the way across the foot and about 1 inch in width with some swelling and blueish tint to the toes. The Clinical Nurse Liaison indicated they got Resident #1 off the van, called EMS, and sent her back to the ED. The DON stated the Executive Director called the transport company immediately after Resident #1 was sent out to the ED and informed them of what happened. The DON further stated a full Quality Assurance and Performance Improvement (QAPI) plan was completed on this incident and the daily appointment lists were audited daily for compliance by the Executive Director for 8 weeks and then monthly thereafter. An interview on 08/10/21 at 10:20 AM with the director of the transport company indicated the first thing the transport company does when an accident happened that could have been prevented was to immediately look at the video footage, have a 1 on 1 huddle with everyone to go over loading and unloading of all clients, re-educating the van drivers on the yellow boundaries marked on the lift and the use of seat belts on the van. The director further indicated the 1 on 1 huddle was done on 04/08/21, the next day after the accident and after the video footage was viewed and everyone signed off on it. The director stated on 04/15/21 an Urgent Training was completed with all lift van drivers on proper wheelchair procedures, and the driver's responsibility to keep the client inside of the yellow lift boundaries. The director further stated each van driver signed a document acknowledging and agreeing to comply with the established procedures. The director reported he had looked at the video of the accident and felt the contributing factors included: the wheelchair didn't have footrests on it, the client did not have shoes on, a blanket was wrapped around her legs obstructing the view the van driver had of the client's feet, the client was not completely within the yellow safety boundary lines and the wheelchair lift plate lowered onto and pinned the client's foot under the plate. The director further reported the van driver should have paid better attention to the client's feet before and during loading. The director explained the van driver involved in the accident was disciplined and was not allowed to drive until successfully completing remedial training which included reviewing the video hard drive of the incident and discussed proper loading and unloading procedures, driver responsibility, and an actual hands on demonstration of proper loading, tie down and unloading of clients. The director further explained nothing new was put into place after the accident because the transport company was doing it the right way but sometimes people strayed from doing what was right. He explained the company had cameras and the videos were watched periodically and we rode with the drivers to make sure they're doing what they're supposed to be doing. The director stated he received the van driver's story of the event right after it happened. The director further stated the van driver loaded the client onto the ramp and stood behind the client as the lift was going up and the lift stopped almost at the top. The van driver explained she tried to see why the lift had stopped and tried to get the lift to go back down but the lift wouldn't move. The van driver further explained she looked under the wheelchair and saw a stuffed animal which belonged to the client and the stuffed animal appeared to be stuck between the lift and the lift plate. The van driver said she removed the stuffed animal, put the blanket back around the client's legs and feet and raised the lift and put the seatbelt back on the client. The van driver further stated when she went to wheel the client back on the lift to bring her down to the ground at the facility, she saw blood on the client's sock and called for an employee at the facility to come and look at her foot. The van driver stated she did not know her foot was what stopped the lift as she thought it was the stuffed animal. The director indicated he was aware the facility had a person in place to watch each resident load and unload. An interview on 08/10/21 at 11:20 AM with a receptionist/scheduler revealed she was the one who scheduled the appointments and completed the paperwork for transports. The receptionist/scheduler further revealed she received her training from the transport company, and she trained the other receptionist who takes her place when she's not at the facility. The receptionist/scheduler stated the HR director was also trained as there are times she's at the front desk. She further stated she checked each resident for appropriate clothing, appropriate footwear, and footrests on the wheelchair. The receptionist/scheduler explained she followed the resident to the lift and made sure the resident was between the yellow lines and the brakes were on in the wheelchair. She further explained she was with the resident until they left the facility and was there when they came back and was unloaded. The receptionist/scheduler explained the van company only transports Monday through Friday and on the weekends the facility uses EMS for transports. An interview on 08/10/21 at 12:04 PM revealed Resident #2 had used the transport van several times and never had any issues with them. Resident #2 further revealed there was always someone from the facility who watched them get on and get off the van and Resident #2 stated she felt comfortable with the driver and never felt afraid. Resident #2 stated she had an appointment that day and would be using the van for transportation to her appointment. An interview on 08/10/21 at 12:15 PM indicated Resident #3 had used the transport van several times for physician appointments and never felt afraid to use the service. He further indicated he never had any issues with them and felt comfortable on the van and had an appointment today and would be using the van. An interview on 08/10/21 at 12:45 PM with the van driver involved in the accident stated she had picked up Resident #1 at the hospital to bring her back to the facility. She further stated she had a blanket over her legs and pushed her onto the lift and rode with her up the lift. The van driver revealed as she was raising the lift it stopped before the flap went down, and the van driver couldn't figure out why it had stopped. She further revealed she saw a pink bear down where the flap was and pulled it out and the lift went up. She stated she thought that was why the lift had stopped and when she got to the facility and went to take Resident #1 off she saw blood and went and got the nurse. The van driver reported she had training right after the incident and wasn't allowed to drive until she had a refresher training course. The van driver further reported she pushed the resident forward onto the lift of the van and in my training it showed I should have pushed the resident backwards. She indicated she thought it was the stuffed animal that stopped the lift not the client's foot and I should have checked it again. An observation was made on 08/10/21 at 12:30 PM of a resident being loaded onto a van. The van driver had the van open, and the lift was sitting on the ground and the yellow stripes were marked where the resident was to be placed. The van driver stated the resident was to go in backwards unless the resident didn't feel safe. An observation was made of the receptionist/scheduler checking the footrests again and making sure the brakes were on and the wheelchair was in the middle of the yellow stripes. Once the resident was on the van, the van driver released the brakes on the wheelchair and moved the resident, so she was facing the front of the van. The van driver strapped the floor belts to the wheelchair and pulled them tight, put the seat belt around the resident and put the wheelchair brakes on and closed the van door. The van driver continued around to the back of the van, where the door was open and checked the floor belts again and made sure they were tight, and the wheelchair didn't move. The receptionist/scheduler also checked the belts and the wheelchair brakes. An interview with the Medical Director on 08/11/21 at 12:25 PM revealed Resident #1 had followed up with the orthopedic department and the laceration was fixed and doing well. He further revealed the foot was healing well with no complications. The facility's corrective actions implemented after the accident to prevent a reoccurrence included the following: the receptionist was immediately trained on the lift operation of the van and how the wheelchair and resident would be positioned on the lift prior to loading. Education was completed on 04/08/21 with all receptionists who escorted all residents out of the facility and monitored the loading of the residents and ensured proper positioning on the lift to ensure safety. Any observed would be corrected before the resident was loaded onto the van. Verifications would be documented on a daily appointment list and the list would be turned into the Executive Director at the end of each day. The Executive Director reviewed the daily appointment lists for compliance for 8 weeks and then monthly thereafter. Any issues would be addressed immediately with the transportation company director and additional training would be provided. The transportation company's education was done on 04/08/21 and follow-up training was conducted with all van drivers on 04/15/21. The facility QAPI committee would review the findings of the audits on a monthly basis x 6 months, then quarterly for 2 quarters. Any revision or reviews to the plan of action would be included in the meeting minutes with the appropriate staff being re-in serviced to the revised plan and monitoring would take place. The facility alleges the corrective action date of 04/15/21. On 04/15/21 the facility's plan for past noncompliance was validated by the following: (1) Review of in-service training records revealed all drivers were in-serviced on proper wheelchair lift operation procedures which included: the lift must always be operated from the ground, drivers are not allowed to ride up the lift with the client, drivers may ride up the lift with an unsteady standee for stability, and the driver's responsibility is to keep the client inside of the yellow lift boundaries. (2) Review of the remedial/refresher training in-service training records for the van driver who drove the van at the time of the accident included: review of the hard drive of the incident and discussion on proper loading and unloading procedure, watching a DVD on the Sure-Lok Braun Lift Operation which detailed proper loading, discussion of the policy regarding driver responsibilities and an actual hands on demonstration of proper loading, tie down and unloading clients. (3) Review of the receptionist training on how the resident should be positioned prior to loading and lift operation with an actual observation of a resident. (4) An interview with the van driver involved in the accident who validated the remedial/refresher training was received. (5) A review of the daily appointment list sent to the Executive Director daily for monitoring. Compliance was achieved 04/15/21 when all van drivers had been educated and receptionists educated on loading and lift operation of the transport van.

Based on observations, staff interviews and review of the facility's COVID-19 Infection Control Assessment and Response Tool, the facility failed to implement measures specified on the infection control tool when 5 of 5 dietary staff failed to wear a facemask or face covering when they worked in the kitchen. This failure occurred during a COVID-19 pandemic. Findings included: The facility's COVID-19 Long-Term Care Infection Control Assessment and Response Tool, updated 5/15/20, was reviewed. The tool stated, in part, Facility has implemented universal use of facemasks for all staff . During a tour on 5/18/20 at 12:06 PM there were five dietary staff observed working in the kitchen. None of the dietary staff, which included the Director of Dining Services, Cook Supervisor, Dietary Aide #1, Dietary Aide #2 and Dietary Aide #3, wore facemasks or face coverings. On 5/18/20 at 1:20 PM an observation of the hallway outside of the dining room revealed a sign was posted that stated, All staff wear masks all the time. On 5/19/20 at 9:00 AM an interview was completed with Dietary Aide #1. She said she had been educated by the facility about the COVID-19 pandemic and was told a facemask was to be worn whenever she left the kitchen and went out on the resident halls or had contact with a resident. She confirmed she had not worn a facemask when she worked in the kitchen on 5/18/20 during the surveyor's tour. In an interview with the Cook Supervisor on 5/19/20 at 10:08 AM, she verified she had worked in the kitchen on 5/18/20 and had not worn a facemask. She stated she was aware of the COVID-19 pandemic. She recalled the facility had instructed her that a facemask was to be worn when she left the kitchen and went out on the floor/hall where the residents resided. An interview was completed with Dietary Aide #2 on 5/19/20 at 10:17 AM. She explained the facility had educated her that a facemask was to be worn only when she went out on the hall from the kitchen. She said she had not been instructed that a facemask was to be worn when she worked inside the kitchen. During an interview with Dietary Aide #3 on 5/19/20 at 10:35 AM, she expressed her awareness of the COVID-19 pandemic. She verified she had not worn a facemask in the kitchen when the surveyor toured on 5/18/20. She explained she was informed by the Director of Nursing (DON) that whenever she left the kitchen and went out on the halls or was around residents she was expected to wear a facemask but when she was in the kitchen, a facemask did not have to be worn. The Director of Dining Services was interviewed on 5/18/20 at 12:08 PM. She explained the dietary staff had not worn a facemask or face covering when they worked in the kitchen but wore them when they left the kitchen and went on to the resident units or halls. She said she had been told by the DON that dietary staff were not required to wear a facemask or face covering when they were in the kitchen. On 5/18/20 at 12:56 PM an interview was completed with the DON, during which she stated all staff of all departments wore masks daily. She added the dietary staff were supposed to wear a mask whenever they left the kitchen. In an interview with the Administrator on 5/18/20 at 1:14 PM, she explained the facility followed the Center for Medicare and Medicaid Services (CMS) guidelines related to the COVID-19 pandemic, and said, I believe the CMS guidelines says everybody should be wearing a mask. She added, everyone should be wearing a mask when in the kitchen, and was unsure why the dietary staff had not worn a facemask or face covering when they worked in the kitchen.

Based on record review, family and staff interviews, the facility failed to protect private health information for 1 of 1 resident (Resident #288) by including their confidential medical and personal information into another resident's file (Resident # 279). Findings included: Resident #279 was discharged from the facility and admitted to the hospital on [DATE]. The facility provided the resident face sheet and Medication Administration Record [REDACTED]. An interview was conducted with Resident #279's family member via phone who advised that she opened the envelope given to her by facility staff and found a face sheet with personal information for Resident #288 included with the pertinent medical information for Resident #279. The face sheet information included the home address, medications, billing and insurance numbers, current diagnoses, most recent vital signs, and emergency contact information for Resident #288. This information matched the information in the facility's computer system for Resident #288. The family member stated that the folder did contain the necessary paperwork for Resident # 279 but the extra face sheet for Resident # 288 was also included. The family member did not notify the hospital or facility and stated that she removed it from the envelope and placed it in her purse before turning it over to hospital personnel. Interview with Nurses #1 and # 2 was conducted together on 11/6/2019 at 9:15 am. Each nurse was able to verbalize each resident's face sheet and Medication Administration Record [REDACTED]. Each nurse also verbalized that it is not just one staff member's job to complete that task and that whomever is available will go ahead at do it. No one was able to explain how another resident's medical information could have ended up in another resident's outgoing envelope. Neither nurse specifically remembered preparing Resident #279 for transfer or getting her envelope together and stated that anyone can do that task. An interview was conducted on 11/7/2019 at 1:30 pm with the Director of Nursing who stated that she will, at times, help the staff during emergency transfers by gathering necessary paperwork. She stated she was unaware that Resident #288's information was found in the envelope for Resident #279. Both the Administrator and Director of Nursing stated that they were not aware of any privacy issues or concerns prior to hearing about this incident. Both verbalized that it was their expectation that staff maintain the confidentiality of each resident's personal and medical information.

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set assessment in the area of continence for 1 of 3 (Resident #40) reviewed for pressure ulcers. The findings included: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #40 had severely impaired cognition, required extensive assistance of two people for bed mobility, transfers and toileting and was frequently incontinent of bowel. A care plan updated last on 6/12/19 indicated a problem of incontinence not new onset of bowel and bladder at risk for further decline and for complications associated with incontinence. The goal was for Resident #40 to have no preventable decline to continence. The interventions included: offer frequent toileting opportunities if appropriate, identify any environmental barriers to toileting and minimize or eliminate and ensure pathway to toilet is clear for resident and staff convenience/safety. A review of bowel and bladder data collection by nursing assistants during the look back period of 10/12/19 through 10/18/19 revealed Nursing Assistant (NA) #2 documented Resident #40 had a bowel movement on 10/18/19 at 2:29 PM and was continent. An observation on 11/7/19 at 8:30 AM of Resident #40 in bed revealed the resident was awake and not verbally responsive. An interview was conducted on 11/7/19 at 10:04 AM with the Minimum Data Set Nurse #1. She stated she gets information for the assessment from many ways. She watches the residents, talks to the nursing assistants and family members of residents, does resident interviews and knows the residents. She stated she also uses the nursing assistant data collection tool. An interview on 11/7/19 at 11:55 AM with NA #2 revealed Resident #40 is always incontinent of bowel and bladder and if she documented continence, that was in error. An interview on 11/7/19 at 1:03 PM with Nurse #1 revealed she had been working at the facility for about 2 years and Resident #40 had been incontinent of bowel and bladder for that time period. She stated she couldn ' t ask for assistance to be toileted.

Based on record review and staff interviews, the facility failed to revise care planned interventions for 1 of 3 (Resident #40) reviewed for pressure ulcers. The findings included: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #40 had severely impaired cognition, required extensive assistance of two people for bed mobility and transfers. A review of a care plan dated 6/12/19 for risk of skin impairment with a goal to maintain skin integrity without noted skin problems and staff to implement interventions to reduce risk for skin impairment through next review included interventions of right boot when up in wheelchair on 4 hours a day dated 6/12/19, monitor skin pre and post boot application dated 6/12/19 and left arm position on pillow under arm and elbow. An observation on 11/4/19 at 10:29 AM revealed Resident #40 out of bed to her wheelchair. There was not a boot to the resident ' s right foot observed. An observation on 11/4/19 at 3:02 PM revealed Resident #40 lying in bed. There was not a pillow under the left arm and elbow. An observation on 11/5/19 at 1:49 PM revealed Resident #40 out of bed to wheelchair. There was not a boot to the right foot. An observation on 11/5/19 at 2:37 PM revealed Resident #40 lying in bed with no pillow observed under the left arm and elbow. An interview was conducted on 11/7/19 at 3:10 PM with Med Aide #1. He stated the Kardex is where the nursing assistants would look to find out the residents needs. He stated the Kardex for Resident #40 did indicate a pillow was to be placed under her left arm and elbow. He did not know about Resident #40 having a boot. An interview was conducted on 11/7/19 at 3:17 PM with the treatment nurse. She stated Resident #40 had interventions in place to prevent pressure ulcers including low air loss mattress, barrier cream and hand splints. She stated she didn ' t know about a boot. She stated Resident #40 didn ' t have a wound to the foot. An interview was conducted on 11/7/19 at 3:52 PM with the Assistant Director of Nursing. She stated Resident #40 was on the restorative nursing program beginning in (MONTH) of 2019 and the boot was to be worn for 6 weeks. She stated the care plan should have been updated.

Based on observations, staff interviews and record review the facility failed to give a supplement as ordered by the physician for 1 of 3 residents (Resident #73) reviewed for nutrition. Findings included: Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had severely impaired cognition and needed limited assistance with one person for eating. The resident's weight was 73 pounds. A care plan problem updated 7/22/19 included nutrition. A care plan intervention revealed supplement meal intake with between meal/nourishing snacks. The care plan further revealed the discipline responsible for the task was dietary and nursing assistant. A physician's orders [REDACTED]. The (MONTH) medication administration record (MAR) indicated Ensure was scheduled to be given daily at 10:00 AM, 4:00 PM and 10:00 PM. Documentation on the MAR revealed Ensure was signed off as having been given three times daily each day in November. On 11/4/19 from 12:29 PM-1:13 PM a continuous observation was made of Resident #73 when she ate lunch in the main dining room. The meal ticket that accompanied Resident #73's lunch tray indicated she was on a mechanical soft diet and the lunch meal included a Supplement: Ensure Chocolate. An observation of the meal tray revealed there was no Ensure on the tray that had been delivered to Resident #73. Resident fed herself the lunch meal. Throughout the dining process, staff opened food containers for the resident and encouraged resident to eat her meal. At 1:13 PM the Social Services Director escorted Resident #73 from the dining room. The resident had not received the chocolate Ensure during the consumption of the lunch meal. An observation of Resident #73 on 11/4/19 at 3:25 PM revealed she was in her room, asleep in the bed. No nutritional supplements were observed to be in her room. During an interview with Nurse #4 on 11/5/19 at 2:18 PM, she explained if there was an order for [REDACTED]. Nurse #4 said if a resident ate in the dining room she asked the nurse aide if the resident received the Ensure, and if so, asked how much the resident drank and then documented the resident received the supplement. On 11/6/19 at 8:12 AM an observation was made of Resident #73 seated in the main dining room, eating breakfast. There was no Ensure on the breakfast tray. The breakfast tray ticket revealed no supplement was listed on the ticket. An interview was completed with Personal Care Assistant (PCA) #1 on 11/6/19 at 9:17 AM. She stated she worked in the main dining room during meal times and assisted residents to set up meal trays, cut up food, opened drink cartons and checked on residents throughout the meal and asked if they needed anything. PCA #1 confirmed the meal tickets came out with the meal trays for each resident. She added when she checked on a resident she looked at the tray ticket to see if it matched what was on the meal tray. PCA #1 verified she worked in the main dining room on 11/4/19 during the lunch meal and indicated she had not looked for the nutritional supplement for Resident #73, I honestly probably looked more at the food than the supplement. An observation of Resident #73 on 11/6/19 at 9:43 AM revealed she was in her room and asleep. No nutritional supplements were observed to be in her room. On 11/6/19 at 10:10 AM an interview was completed with the Registered Dietician (RD) during which she said Resident #73 had been in the facility over a year, had lost weight and was placed on a nutritional supplement of Ensure. The RD explained the Ensure was supposed to be given in between meals and not with the meal in order that the resident was encouraged to eat the meal or food first. RD said the Ensure was not to be placed on the meal tray and was unsure why it was listed on the tray ticket, The Ensure being on the tray ticket is an error. She reported the Ensure was kept in a refrigerator in the medication room and the nurse was supposed to give the Ensure to Resident #73. An interview was completed with Nurse Aide (NA) #1 on 11/6/19 at 10:27 AM. She recalled she had worked with Resident #73 on 11/5/19 and said she had not given the resident any Ensure during her shift. A second interview was completed with Nurse #4 on 11/6/19 at 10:31 AM during which she confirmed she worked with Resident #73 11/4/19-11/6/19. Nurse #4 stated she had not given any Ensure to Resident #73 during the shifts she worked with the resident. An observation of Resident #73 on 11/6/19 at 10:38 AM revealed she was in her room, asleep in a wheelchair. No nutritional supplements were observed to be in her room. An observation of Resident #73 on 11/6/19 at 3:50 PM revealed she was in her room, asleep in bed. No nutritional supplements were observed to be in her room. The MAR for 11/6/19 indicated the nurse documented that Ensure was given to Resident #73 at 10:00 AM and 4:00 PM. In an interview with the Director of Nursing (DON) on 11/7/19 at 11:11 AM, she explained when a nutritional supplement was ordered for a resident it was typically given in between meals and not with a meal. The ordered supplement was listed on the MAR and either the medication aide or nurse was responsible to give the supplement to the resident or make sure the resident received it. The DON added the supplements had been placed on the meal tray until recently (8/27/19). She reported Nurse #4 was new to the facility and had completed a medication pass for the first time during the week of 11/4/19. The DON expressed if a supplement was ordered and was on the MAR she expected the medication aide or nurse ensured the supplement was provided to the resident. On 11/7/19 at 12:30 PM an interview was completed with Nurse #4, the DON and Administrator. During the interview Nurse #4 stated she gave Ensure to Resident #73 when she gave her medication, I gave it to her on every med pass that I have for her this week. An interview with the Administrator on 11/7/19 at 1:01 PM revealed Nurse #4 had been suspended pending an investigation related to the administration and documentation of the Ensure.

Based on record review, staff and physician interview the facility failed to notify the physician of a new and worsening pressure ulcer for 2 of 7 residents (Resident #133 and Resident #40) reviewed for pressure ulcers which resulted in delayed assessment and treatment. The findings included: 1. Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During record review of the admission Minimum Data Set (MDS) Assessment for resident #133 dated for 2/13/17 documented the resident to be severely cognitively impaired. For assessment of ADL's in Section G the resident required two person extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and one person extensive assistance for eating meals. This MDS from coded that the resident was at risk for pressure ulcers but did not have any skin conditions on admission. Review of the signed physician telephone orders dated 7/13/17 indicated treatment for [REDACTED]. MD #1 requested a wound consult by Wound MD on 7/25/17. Physician note from 7/25/17 from Wound MD was his initial consult and assessment of resident #133's wounds. The wounds assessed included: large abscess to right hip with [MEDICAL CONDITION], ulcer to right foot, and pressure ulcer of left heel stage 2. The Wound MD recommended intramuscular (IM) [MEDICATION NAME] 1 gram (antibiotic) for 7 days for [MEDICAL CONDITION] and to reevaluate in a few days. No measurements or descriptions of the wounds were documented. Review of a wound assessment note by Nurse 1 from 7/25/17 revealed documentation for right hip unstageable pressure ulcer measuring 9 centimeters (cm) in length by 7 cm in width, covered with 100% eschar (dry, dark scab or falling away of dead skin) tissue. No other assessment of the stage 2 pressure ulcer identified on resident #133's feet was provided. Review of a Wound Assessment note by Nurse 1 from 7/28/17 at 7:34 PM revealed documentation for a right medial heel unstageable pressure ulcer measuring 6 cm in length by 3 cm in width covered with 100% eschar tissue. The treatment for [REDACTED]. A left medial ankle unstageable measuring 3 cm in length by 3 cm in width by 0.2 cm in depth covered in 90% eschar tissue and 10% granulation tissue (new connective tissue and microscopic blood vessels that is formed on the surfaces of a wound during the healing process). The treatment for [REDACTED]. A Deep Tissue Injury (DTI - Purple or maroon discolored localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) to resident #133's sacrum measuring 6 cm in length by 8 cm in width described as 100% purple/blue in color. There were no treatment orders for this wound. A left hip DTI measuring 4 cm in length by 4 cm in width described as 100% purple/blue in color. This wound was to be cleaned with normal saline, apply an island dressing, and change daily. The note stated that the resident's responsible party (RP) was notified and that MD #1 was updated by fax. During an interview on 9/28/2017 at 8:48 AM with the Wound MD when asked when he was consulted to treat the resident's wound he stated he was consulted by MD #1 and first assessed the resident's wound on 7/25/17. Stated after his initial assessment the resident was started on antibiotics, couldn't remember details about the wounds. Stated that the resident was on comfort measures at the time of the assessment. When asked if he had seen or assessed the wounds after the follow-up assessment on 7/27/17 until 9/1/17, he stated that he had not, and that he relied on Nurse 1 to assess and notify him of any changes that were seen, none were reported until 9/1/17. When asked if he had staged the wounds to be end of life by assessing them, he stated he made the determination based on the assessment and the information about the wounds given to him by Nurse 1. When asked if he had assessed the resident's sacrum on 7/25/17 or 7/27/17, he stated he hadn't assessed it because he wasn't told about the wound by Nurse 1 on those dates. During an interview on 9/28/2017 at 12:55 PM with the previous DON she stated that she wasn't aware of the wounds or problems with the treatments until the last week of August. Stated that Nurse 1 was supposed to let her know of wound changes, she relied on her to tell her of changes in the wounds, and that Nurse 1 was over the whole wound process. She also stated she wasn't aware of the exact time that the resident's wounds appeared or worsened. Attempted to call Nurse 1, the nurse was no longer working at the facility, and no interview was obtained. During an interview with MD #1 on 9/29/17 at 11:28 AM, when asked if he was resident #133's primary physician he stated that he and his nurse practitioner (NP 2) were his primary and secondary providers. When asked when and why he had consulted the Wound MD he stated that he assumed it was for a decubitus ulcer but consulted the Wound MD as soon as he was notified of the wounds. He did not remember who notified him and stated that it is usually sent as a fax to his office, but could not find the documentation to answer the question. When asked if he had assessed the wounds, he stated he had not seen them until 9/1/17 because he relied on the Wound MD for assessing and treating the wounds. When asked if he had received any information from the facility or from the Wound MD about worsening of the wounds he stated he had received no faxed information about the wounds. On 9/1/17 when he was notified in person (couldn't remember by who) and assessed the wounds on 9/1/17 after being told of their status. He also stated he wanted the Wound MD to continue with treatment of [REDACTED].#133's poor nutrition, his late stage dementia, and his low [MEDICATION NAME] levels, he had assumed that they were unavoidable. On 9/29/17 the facility was asked to provide information to show that MD #1 had been notified of the change in the pressure ulcers on 7/28/17 via fax and the facility did not provide any information. The facility attempted to call NP 2 on 9/29/17 at approximately 10:30 AM and 12:00 PM, but was unable to obtain her for an interview. 2. Resident # 40 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. A wound Assessment Report dated 6/26/17 read Resident #40 ' s left ischium measured 3 centimeters (cm) by 3 cm by 0.3 cm with 90% eschar and 10% granulation with a small amount of serous drainage. Orders were to treat the area with Dakin ' s Solution (solution use to kill germs) and Santyl (ointment use to clear way unhealthy tissue) daily. The wound was to be covered with [MEDICATION NAME] (a silver-based dressing use to absorb wound drainage). His admission Minimum Data Assessment ((MDS) dated [DATE] indicated Resident #40 had severe cognitive impairments, no behaviors and extensive assistance with his activities of daily living (ADLs). He was coded as incontinent of bowel and bladder and coded for pressure ulcers present on admission. The Care Area assessment dated [DATE] indicated he was at risk for the development and worsening of pressure ulcers due to his impaired mobility, contractures and poor nutritional status. Resident #40 was care planned on 7/3/17 for his left Ischial unstageable pressure ulcer with interventions to include the following: -Record appearance, amount and odor of drainage and report decline to his wound status A Wound Assessment Report dated 7/7/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but was described as having 100% eschar. The wound was documented as having no odor or drainage. The treatment was to clean with wound with Normal Saline, apply [MEDICATION NAME] daily. The wound assessment note read the Nurse Practitioner was updated via a form in his folder by Nurse #1. A Wound Assessment Reports dated 7/14/17, 7/20/17, 7/28/17 and 8/4/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but was described as having 100% eschar. The wound was documented as having no odor or drainage. The wound assessment note read the physician was updated via a form in his folder for 7/14/17, 7/20/17, 7/28/17 and 8/4/17 by Nurse #1. A Wound Assessment Reports dated 8/11/17 and 8/15/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but described as having 10% slough and 90% eschar with a scant amount of drainage with no odor. The wound was documented as having no odor or drainage. The wound assessment note read the physician was updated via a form in his folder for 8/11/17 and 8/15/17by Nurse #1. A Wound Assessment Report dated 8/24/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but described as having 10% slough and 90% eschar with a scant amount of drainage with no odor. The wound was documented as having no odor or drainage. The wound assessment note read the physician was updated via a form in his folder by Nurse #1. A nursing note dated 8/31/17 at 2:25 AM read there was new order to culture Resident #40 ' s left ischium and start [MEDICATION NAME] (antibiotic) Intramuscularly daily for 7 days. A Wound Assessment Report dated 9/1/17 read the left ischium stage 4 pressure ulcer measured 6 cm by 5 cm by 4.5 cm with undermining at 12 PM of 6 cm with 90% wet eschar and 10% granulation tissue with a moderate amount of serous drainage with noted odor.[MEDICATION NAME] started twice daily for 2 weeks and continue the [MEDICATION NAME]. A review of the Wound Culture read Resident #40 cultured Proteus mirabilis (gram-negative rod bacteria) on 9/2/17. A review of the physician orders [REDACTED].#40 ' s left ischium was to be cleaned with Dakin ' s Solution and packed with Dakin ' s Solution and covered daily. A review of the physician orders [REDACTED]. The bacteria were sensitive to the [MEDICATION NAME]. A review of the physician orders [REDACTED]. A nursing note dated 9/11/17 at 4:18 PM read Resident #40 was more lethargic. The physician was notified and ordered Stat Lab work. At 6:26 PM, Resident #40 ' s vital signs were: temperature 97.3 degrees Fahrenheit, blood pressure of 79/41 and pulse 106. At 6:26 PM, the physician ordered Resident #40 be sent to the hospital for a change in his level of consciousness. A review of the hospital discharge summary dated 9/14/17 read Resident #40 was discharged to the hospice house with cumulative [DIAGNOSES REDACTED]. In a telephone interview on 9/27/17 at 11:49 AM, Nurse #1 stated she was the treatment nurse for the facility and her last days was 9/1/17. She stated Resident #40 was admitted with multiple pressure ulcers and she updated the physician weekly in writing. Nurse #1 stated the physician nor the DON ever observed Resident #40 ' s wounds until 8/31/17 but the DON would give her advice if she asked. She confirmed the Nurse Practitioner was at the facility weekly but he did not ask him to assess Resident #40 ' s left ischium. She stated Resident #40 ' s physician also had his own wound clinic and told her what treatments to use. In a telephone interview on 9/27/17 at 2:57 PM, the Nurse Practitioner stated he was at the facility Mondays, Wednesdays and Fridays and Nurse #1 never asked him to assess Resident #40 ' s left ischial pressure ulcer and no one asked him to assess Resident #40 ' s left ischial pressure ulcer until the DON asked on 8/31/17. The Nurse Practitioner stated Resident #40 ' s left ischial pressure ulcer looked infected and had a noted odor. In an interview on 9/28/17 at 8:50 AM, the physician stated he only visually assessed wounds as needed. He stated Nurse #1 would communicate the status of Resident #40 ' s pressure ulcers by leaving him a note in his folder. The physician stated he was not notified of the worsening of Resident #40 ' s left ischial pressure ulcer until sometime after 9/1/17. He stated he ordered a PICC line and changed his antibiotics on 9/5/17. The physician stated it was his expectation that someone for the facility team would have notified him of worsening the Resident #40 ' s left ischial pressure ulcer. In a telephone interview on 9/28/17 at 12:30 PM, the previous DON stated staff reported that Resident #40 ' s left ischial pressure ulcer had developed an odor so a culture was obtained. She stated the called the physician and spoke with the Nurse Practitioner and asked if they were aware of the change in Resident #40 ' s left ischial pressure ulcer. She stated they told her they were not aware. The previous DON stated it was her expectation that Nurse #1 would have notified the physician or the Nurse Practitioner or non-healing or worsening of Resident #40 ' s left ischial pressure ulcer. In an interview on 9/29/17 at 11:30 AM, the Administrator stated it was her expectation that the nursing department notified the attending physician for any changes or worsening in Resident #40 ' s pressure ulcer.

Based on observations, physician and staff interviews and record review, the facility failed to assess for worsening of pressure ulcer, failed to assess for worsening of a facility acquired pressure ulcer and failed to prevent the development of a new pressure ulcer for 3 of 7 (Resident #40, Resident #133 and Resident # 84) residents reviewed for pressure ulcers. Findings included: 1. Resident # 40 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. A wound Assessment Report dated 6/26/17 read Resident #40 ' s left ischium measured 3 centimeters (cm) by 3 cm by 0.3 cm with 90% eschar and 10% granulation with a small amount of serous drainage. Orders were to treat the area with Dakin ' s Solution (solution use to kill germs) and Santyl (ointment use to clear way unhealthy tissue) daily. The wound was to be covered with [MEDICATION NAME] (a silver-based dressing use to absorb wound drainage). Resident #40 was ordered sugar Free Prostat (supplement) three times daily on 6/27/17 to promote wound healing. His admission Minimum Data Assessment ((MDS) dated [DATE] indicated Resident #40 had severe cognitive impairments, no behaviors and extensive assistance with his activities of daily living (ADLs). He was coded as incontinent of bowel and bladder and coded for pressure ulcers present on admission. The Care Area assessment dated [DATE] indicated he was at risk for the development and worsening of pressure ulcers due to his impaired mobility, contractures and poor nutritional status. Resident #40 was care planned on 7/3/17 for his left Ischial unstageable pressure ulcer with interventions to include the following: -Measure his wound facility protocol -Record appearance, amount and odor of drainage and report decline to his wound status -For wound drainage, obtain culture and let the physician know the results -Treatments as ordered -Pressure relieving mattress to bed and wheelchair A Wound Assessment Report dated 7/7/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but was described as having 100% eschar. The wound was documented as having no odor or drainage. The treatment was to clean with wound with Normal Saline, apply [MEDICATION NAME] daily. A Wound Assessment Reports dated 7/14/17, 7/20/17, 7/28/17 and 8/4/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but was described as having 100% eschar. The wound was documented as having no odor or drainage. The Wound Assessment Report dated 7/14/17 read the treatment order was to apply [MEDICATION NAME] (ointment use to prevent infection) twice daily. A review of the July 2017 physician orders [REDACTED].#40 ' s left ischium did not include any orders changing the treatment to [MEDICATION NAME]. There was also no evidence documented on the July Treatment Administration Record (TAR) that the left ischial unstageable pressure ulcer was treated with [MEDICATION NAME] but rather [MEDICATION NAME]. A Wound Assessment Reports dated 8/11/17 and 8/15/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but described as having 10% slough and 90% eschar with a scant amount of drainage with no odor. The wound was documented as having no odor or drainage. A Wound Assessment Report dated 8/24/17 read the left ischium unstageable pressure ulcer remained the same as far as measurement but described as having 10% slough and 90% eschar with a scant amount of drainage with no odor. The wound was documented as having no odor or drainage. The treatment was to use [MEDICATION NAME] daily. A nursing note dated 8/31/17 at 2:25 AM read there was new order to culture Resident #40 ' s left ischium and start [MEDICATION NAME] (antibiotic) Intramuscularly daily for 7 days. A Wound Assessment Report dated 9/1/17 read the left ischium stage 4 pressure ulcer measured 6 cm by 5 cm by 4.5 cm with undermining at 12 PM of 6 cm with 90% wet eschar and 10% granulation tissue with a moderate amount of serous drainage with noted odor.[MEDICATION NAME] started twice daily for 2 weeks and continue the [MEDICATION NAME]. A review of the Wound Culture read Resident #40 cultured Proteus mirabilis (gram-negative rod bacteria) on 9/2/17 which was resistant to [MEDICATION NAME]. A review of the physician orders [REDACTED].#40 ' s left ischium was to be cleaned with Dakin ' s Solution and packed with Dakin ' s Solution and covered daily. A review of the physician orders [REDACTED]. The bacteria were sensitive to the [MEDICATION NAME]. A review of the physician orders [REDACTED]. A review of a Registered Dietician note dated 9/5/17 read she recommended Resident #40 start magic cup twice daily for weight stabilization and wound healing. A nursing note dated 9/11/17 at 4:18 PM read Resident #40 was more lethargic. The physician was notified and ordered Stat Lab work. At 6:26 PM, Resident #40 ' s vital signs were: temperature 97.3 degrees Fahrenheit, blood pressure of 79/41 and pulse 106. At 6:26 PM, the physician ordered Resident #40 be sent to the hospital for a change in his level of consciousness. A review of the hospital discharge summary dated 9/14/17 read Resident #40 was discharged to the hospice house with cumulative [DIAGNOSES REDACTED]. In an interview on 9/27/17 at 11:05 AM, Nurse #3 stated she recalled Resident #40 was admitted with multiple pressure ulcers. She stated she often found Resident #40 ' s left ischium dressing missing and noted an odor from the wound one could smell in the hall. Nurse #3 stated she reported her concerns to the previous Director of Nursing (DON) but by the time the DON assessed Resident #40 ' s left ischial wound, he had gotten sicker and was ultimately discharged to the hospital. Nurse #3 stated Nurse #1 and nursing assistant (NA) #3 were responsible for doing Resident #40 ' s treatments as ordered. In a telephone interview on 9/27/17 at 11:49 AM, Nurse #1 stated she was the treatment nurse for the facility and her last day was 9/1/17. She stated Resident #40 was admitted with multiple pressure ulcers and she updated the physician weekly in writing. Nurse #1 stated the physician nor the DON ever observed Resident #40 ' s wounds until 8/31/17 but the DON would give her advice if she asked. She confirmed the Nurse Practitioner was at the facility weekly but he did not assess Resident #40 ' s left ischium. Nurse #1 stated Resident #40 ' s left ischial ulcer deteriorated quickly and Resident #40 ' s physician also had his own wound clinic and told her what treatments to use. In a telephone interview on 9/27/17 at 12:03 PM, NA #3 stated she started assisting with treatments the end of June 2017. She stated she decided to stop doing treatments a month or so ago and returned to the floor because she did not feel treatments or wound assessments were being done as ordered. She recalled Resident #40 and stated his left ischial wound started getting worse sometime in late August. She stated she reported the change in the appearance Nurse #1 but did not recall what day. In an interview on 9/27/17 at 2:33 PM, Nurse #7 stated she was doing the treatments on weekends and once Nurse #1 resigned, she began doing Resident #40 ' s treatments daily. She recalled going to the previous DON about concerns over Resident #40 ' s left ischial pressure ulcer. She stated the wound was getting worse and she felt his wound was not being accurately assessed or treated. Nurse #7 stated the previous DON stated she would assess Resident #40 ' s left ischium but she did not recall her ever going and assessing it. In a telephone interview on 9/27/17 at 2:57 PM, the Nurse Practitioner stated he was at the facility Mondays, Wednesdays and Fridays and Nurse #1 never asked him to assess Resident #40 ' s left ischial pressure ulcer. He stated the previous DON asked him to assess the wound on 8/31/17. He stated he gave new orders at that time but the physician was a wound specialist and would assess Resident #40 as needed. The Nurse Practitioner stated Resident #40 ' s left ischial pressure ulcer looked infected and had a noted odor. In a telephone interview on 9/27/17 at 3:06 PM, Nurse #8 stated she worked 8/31/17 and the aides called her in to see Resident #40 ' s ischial wound because there was no dressing. She stated she was concerned about the appearance of the wound and obtained a wound culture and left a note for the DON and physician about her concerns of the worsening of the left ischium pressure ulcer. In another interview on 9/28/17 at 8:20 AM, the Nurse Practitioner stated on 8/31/17, the previous DON asked him to assess Resident #40 ' s left ischial pressure ulcer and he started antibiotic and changed the treatment orders to Dakin ' s Solution and told the DON the physician would need to assess Resident #40 ' s left ischium since he was a wound specialist. In an interview on 9/28/17 at 8:50 AM, the physician stated he only visually assessed wounds as needed. He stated Nurse #1 would communicate the status of Resident #40 ' s pressure ulcers by leaving him a note in his folder. The physician stated he was not notified of the worsening of Resident #40 ' s left ischial pressure ulcer until sometime after 9/1/17. He stated he ordered a PICC line and changed his antibiotics on 9/5/17. In a telephone interview on 9/28/17 at 12:30 PM, the previous DON stated staff reported that Resident #40 ' s left ischial pressure ulcer had developed an odor so a culture was obtained. She stated she called the physician and spoke with the Nurse Practitioner and asked if they were aware of the change in Resident #40 ' s left ischial pressure ulcer. She stated they told her they were not aware. The previous DON stated she reviewed the weekly wound reports and met with Nurse #1 weekly to discuss the progress or worsening of all the residents with pressure ulcer but Nurse #1 reported all his pressure ulcers were the same. It was not until 8/31/17 when she and the Nurse Practitioner assessed the left ischium that concerns were evident about the assessment of the left ischium. A review of the September Treatment Administration Record (TAR) read omissions for treatments 9/5/17 through 9/8/17. During the telephone interview with the previous DON on 9/28/17 at 12:30 PM, she stated she provided the treatments after Nurse #1 resigned on 9/1/17. The previous DON stated her last day was 9/15/17. In an interview on 9/29/17 at 11:20 AM, the Interim DON stated she was the nurse who sent Resident #40 to the hospital on [DATE]. She stated she and the previous DON completed his treatment earlier in the day but he was exhibiting a change in his level of consciousness so, the previous DON got orders to send him to the hospital for an evaluation. The Interim DON stated Resident #40 was receiving IV antibiotics and the wound had an odor at the time of his discharge. In an interview on 9/29/17 at 11:30 AM, the Administrator stated it was her expectation that Resident #40 ' s pressure ulcers were assessed and treated accurately to ensure no worsening in status. 2. 3. Resident #84 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Her most recent lab work dated 6/7/17 indicated her [MEDICATION NAME] was low at 2.9 with normal ranges from 3.2 to 5.5 the and total protein was 7.30 with normal ranges from 6.0 to 7.80. These lab results are indicators of nutritional status. The Quarterly MDS dated [DATE] indicated Resident #84 had severe cognitive impairments with no behaviors and required total assistance with her ADLs. She was coded as having no skin impairment. Resident #84 was coded for a feeding tube supplying all her nutritional needs. A review of the nursing notes for August and September 2017 read a skin assessment were completed on 8/2/17, 8/16/17, 8/23/17 and on 9/6/17 and 9/13/17 with no identified skin impairments. A review if Resident #84 ' s September 2017 orders read she received [MEDICATION NAME] 1.5 at 45 milliliters (ml)/hour for 16 hours and 150 ml of water four times daily. A review of the TAR for September 2017 indicated Resident #84 received the treatments as ordered. A nursing note dated 9/18/17 at 2:59 AM, read at 2:30 AM, a 1 cm by 1 cm open area was noted to Resident #84 ' s left elbow. There was yellowish drainage present. The area was cleaned with normal saline and an island dressing was applied. The nursing note read the physician was notified. There were no documented skin assessments from 9/18/17 through 9/26/17. Resident #84 was care planned on 9/18/17 for the actual development of a left elbow unstageable pressure ulcer to her left elbow. Interventions were as follows: -skin assessment with routine care -Notify the Treatment Nurse and physician for new skin issues -Provide tube feeding as ordered -treatment as ordered -Dietician to evaluate as needed -Pressure relieving mattress to bed and wheelchair A review of the Wound Assessment Report dated 9/19/17 read the unstageable pressure ulcer to Resident #84 ' s left elbow measured 2.1 cm by 1.7 cm with 90% slough and 10% necrotic tissue. There was a small amount of purulent drainage and the peri-wound was macerated. New orders were to clean the area with Normal Saline and apply [MEDICATION NAME] daily. Offload the elbow with an elbow protector every shift. A review of a wound assessment note dated 9/22/17 read there was a moderate amount of sero-purulent drainage oozing from wound. A note was written and left for the physician. A review of a wound assessment note dated 9/25/17 read the left elbow had deteriorated. The Nurse Practitioner assessed the area and new orders were given for [MEDICATION NAME] Collagen to the left elbow [MEDICATION NAME] for 10 days via the feeding tube. In an interview on 9/26/17 at 3:10 PM, NA #1 stated Resident #84 required staff assistance for all her ADLs to include turning and repositioning. She stated Resident #84 ' s left elbow was to be elevated on a pillow for pressure relief. She stated Resident #84 was not able to move her arm enough to remove the pillow. NA #1 stated she was not aware that Resident #84 had an elbow pressure relieving device and had not seen one in her room as of 9/26/17. In an observation on 9/26/17 at 3:15 PM, Resident #84 was observed with a dressing to her left elbow and her arm resting on a pillow in bed. A review of a nursing note dated 9/26/17 read occupation therapy was to elevate the left elbow for positioning since Resident #84 did not keep her arm on a pillow provided. The note read the physician was at the facility but did not assess Resident #84 ' s left elbow. In an observation on 9/27/17 at 9:20 AM, Resident #84 was sitting up in bed. There was no observed pressure relieving device observed to her left elbow. She was on a pressure relieving mattress. Her tube feeding was not in progress. In an interview on 9/27/17 at 2:33 PM, Nurse #7 stated she was doing the treatments on weekends and but when Nurse #1 resigned, she began doing treatments daily. She stated the first of the month, two wound care nurses from other facilities came and took over the treatments. She stated she had not seen Resident #84 ' s left elbow until this past weekend but it looked infected by the appearance of the drainage. Nurse #7 stated she left a note for the Nurse #5 to ask the physician or the Nurse Practitioner to assess on 9/25/17. In a telephone interview on 9/27/17 at 2:57 PM, the Nurse Practitioner stated he was at the facility Mondays, Wednesdays and Fridays. He stated he gave orders to start an antibiotic 9/25/17 and he was asked today to assess Resident #84 ' s left elbow and gave new orders for a wound culture. In an interview on 9/27/17 at 4:20 PM, the RD stated she was only made aware of the new pressure ulcer on 9/26/17 and she saw Resident #84 today. She recommended Prostat twice daily and a multivitamin via the feeding tube. Resident #84 ' s tube feeding was also increased to promote wound healing. In an interview on 9/28/17 at 8:50 AM, the physician stated he only visually assessed wounds as needed. He stated Resident #84 developed a pressure ulcer to her left elbow and the staff requested an order to culture the area but he discontinuing the wound culture until he saw the wound. The physician stated he had not yet assessed the wound. He stated Resident #84 ' s area to her left elbow was from pressure of the elbow on her mattress and avoidable. He stated he wrote orders to therapy to evaluate for positioning needs. In another observation on 9/28/17 at 10:38 AM, there was a left elbow protector in place. In a wound care observation on 9/28/17 at 10:40 AM, the unstageable pressure ulcer to Resident #84 ' s left elbow measured 2.5 cm by 2.7 cm. There was no odor but there was moderate purulent drainage. There were no observed concerns with the wound care observation. Nurse #5 stated she was a certified wound nurse from the coast and was asked to come to the facility to assist with wound care early September 2017 when Nurse #1 resigned. In an interview on 9/29/17 at 11:20 AM, the Interim DON stated she was aware Resident #84 developed a pressure ulcer to her left elbow but the facility was quick to treat and put interventions in place. In an interview on 9/29/17 at 11:30 AM, the Administrator stated it was her expectation that Resident #84 would not have developed a pressure ulcer. 3. Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) Assessment for resident #133 dated 2/13/17 documented the resident to be severely cognitively impaired. For assessment of ADL's in Section G the resident required two person extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and one person extensive assistance for eating meals. This MDS from coded that the resident was at risk for pressure ulcers but did not have any skin conditions on admission. Review of the signed physician telephone orders dated 7/13/17 indicated treatment for [REDACTED]. During an interview on 9/28/2017 at 10:25 AM with the Director of Rehab when asked about resident #133, she stated that resident was evaluated on 7/17/17 for his wheelchair being too small related to his hip wounds. She stated that the chair was found to be too small so a new one was ordered. It was determined by facility staff that the actual cause of the wounds was because he was a side sleeper and it was not from the wheelchair that was too small for the resident. The Therapy Director stated that at that point a recommendation for a bed wedge and air mattress to be put in place was made to the treatment nurse, Nurse 1. MD #1 requested a wound consult by Wound MD on 7/25/17. The following wounds occurred from 7/13/17 to 9/1/17. The wounds were per the documentation in the medical record by the wound nurse (Nurse 1) and the Wound MD. The wounds have been assigned numbers for easy identification. Wound #1 - Began as a right hip abrasion on 7/13/ 17. It progressed to a large abscess on 7/25/17 based on the Wound MD's assessment and was documented as an unstageable pressure ulcer on 7/25/17 by Nurse 1's wound assessment. Wound #2 - Began as an ulcer to right foot on 7/25/17. Progressed to a right medial heel unstageable pressure ulcer on 7/28/17. Wound #3 - Began as a stage 2 pressure ulcer to left heel during the Wound MD's assessment on 7/25/17 and not mentioned in any documentation after that assessment. Wound #4 - Began as an ulcer to left medial ankle on 7/27/17 during Wound MD assessment. Progressed to an unstageable pressure ulcer on 7/28/17. Wound #5 - Began as a left hip abrasion on 7/13/17. Progressed to a left hip deep tissue injury (DTI - Purple or maroon discolored localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on 7/28/17. Progressed to a left hip unstageable pressure ulcer on 8/15/17. Wound #6 - Began as a Sacral Coccyx DTI on 7/28/17. Was described as a stage 4 pressure ulcer by the Wound MD on his 9/1/17 assessment. Progressed to an unstageable pressure ulcer on 9/21/17. Physician note from 7/25/17 from Wound MD was his initial consult and assessment of resident #133's wounds. The wounds assessed included: large abscess to right hip (Wound #1) with [MEDICAL CONDITION], ulcer to right foot (Wound #2), and pressure ulcer of left heel stage 2 (Wound #3). The Wound MD recommended intramuscular (IM) [MEDICATION NAME] 1 gram (antibiotic) for 7 days for [MEDICAL CONDITION] and to reevaluate in a few days. No measurements or descriptions of the wounds were documented. The left hip abrasion was not assessed. Review of a wound assessment note by Nurse 1 from 7/25/17 revealed documentation for Wound #1 as an unstageable pressure ulcer measuring 9 centimeters (cm) in length by 7 cm in width, covered with 100% eschar (dry, dark scab or falling away of dead skin) tissue. Wounds #2 and #3 were not assessed by Nurse 1. Physician note from 7/27/17 from Wound MD was a follow-up assessment of resident #133's wounds. The document stated that staff did not report any fevers or decompensation since recent evaluation (7/25/17). It also stated that resident #133 had progressive dementia with poor by mouth intake and protein calorie malnutrition per staff reports. The wounds assessed on 7/27/17 included: Wound #1 was described as an abscess to right hip, Wound #2 was described as pressure ulcer to right heel, and a ulcer of Left Medial Ankle (Wound #4). The Wound MD documented there was slight improvement with the IM antibiotics and that the plan was to continue supportive care with palliative approach per family, continue off-loading resident's feet with pressure reducing boots, and would continue to monitor. No measurements of the wounds were documented. Wound #3 was not assessed. Review of a Wound Assessment note by Nurse 1 from 7/28/17 at 7:16 PM revealed that Nurse 1 had spoken with resident #133's RP concerning his condition and decline in health. The note stated that the Responsible Party (RP) wished for the resident to remain in the facility, to be treated with comfort care measures and not sent to the emergency room (ER). Resident had several new end of life pressure wounds that included a right medial heel (Wound #2) unstageable end of life pressure injury, a left hip deep tissue injury (DTI - Purple or maroon discolored localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) end of life pressure injury (Wound #5), a left medial ankle unstageable end of life pressure injury (Wound #4), and a sacral/coccyx DTI end of life pressure injury (Wound #6). Nurse 1 stated that All of these wounds have developed within the last 24 hours. Nurse 1 documented the resident continued to have a right hip unstageable end of life pressure injury (Wound #1), and that after speaking to the resident's RP she understood his health was very poor and that he would continue to decline with the outcome of possible death. The note stated that Nurse 1 notified MD #1 of his condition and new orders were received from NP #2. Wound #3 was not described. Review of a Wound Assessment note by Nurse 1 from 7/28/17 at 7:34 PM revealed documentation for Wound #2 as an unstageable pressure ulcer measuring 6 cm in length by 3 cm in width covered with 100% eschar tissue. The treatment for [REDACTED]. Wound #4 was described as an unstageable measuring 3 cm in length by 3 cm in width by 0.2 cm in depth covered in 90% eschar tissue and 10% granulation tissue. The treatment for [REDACTED]. Wound #6 measured 6 cm in length by 8 cm in width described as 100% purple/blue in color. There were no treatment orders for this wound. Wound #5 measured 4 cm in length by 4 cm in width described as 100% purple/blue in color. This wound was to be cleaned with normal saline, apply an island dressing, and change daily. The note stated that the resident's RP was notified and that MD #1 was updated by fax. Wound #1 and #3 were not assessed or measured. Skin Conditions in Section M for a significant change MDS assessment dated [DATE] coded 3 unstageable pressure ulcers, 2 of those with slough or eschar. Review of resident's active care plan dated 7/28/17 revealed a care plan was in place for: Resident has multiple unstageable wounds with treatments in place (unstageable to sacrum, unstageable to right & left hip, and blisters to left thigh, left thumb, and left elbow); He has suffered a global decline physically and cognitively. He is now palliative care and he is at risk for multiple medical diagnoses/problems that may affect his health status due to delayed wound healing, further skin impairment, decreased ability to perform ADLs, Falls, due to immobility, incontinence, fluctuating appetite, advanced age, and declining status. Interventions put into place for his wounds included an air mattress, increased repositioning and turns by staff, supplements (Prostat 30 milliliters three times a day for skin integrity - ordered 7/12/17) and dietician consult for wound healing, treatments as ordered by the physician, pressure reducing boots, and notification of provider for worsening wounds. Review of a Wound Assessment note by Nurse 1 from 8/4/17 revealed documentation for Wound #1 that measured 9 cm in length by 7 cm in width covered in 100% eschar tissue. Treatment was to clean with normal saline and apply [MEDICATION NAME] ag (wound dressing), island dressing, and change daily. Wound #2 measured 6 cm in length by 3 cm in width covered with 100% Eschar tissue. Wound #4 measured 3 cm in length by 3 cm in width by 0.2 cm in depth covered in 90% eschar tissue and 10% granulation tissue. Wound #6 measured 6 cm in length by 8 cm in width described as 100% purple/blue in color. There were no treatment orders for this wound. Wound #5 measured 4 cm in length by 4 cm in width described as 100% purple/blue in color. This wound was to be cleaned with normal saline and apply an island dressing, change daily. The note stated that the resident's RP was notified and that MD #1 was updated by fax. Treatments ordered did not change and Wound #3 was not assessed or measured. The wound assessment by Nurse 1 on 8/11/17 for Wounds #1, #2, #4, #5, and #6 revealed no change in size, description, or treatment orders. Wound #3 was not assessed or measured. The note stated that the resident's RP was notified and that MD #1 was updated by fax. The wound assessment by Nurse 1 on 8/15/17 for Wounds #1, #2, #4 revealed no change in size, description, or treatment orders. Assessment of Wounds #5 (measured 7 cm in length by 6 cm in width) and #6 (8 cm in length by 12 cm in width) revealed they were larger. Both Wound # 5 and #6 changed from 100% blue/purple in color to 100% eschar, no new treatment orders were placed for any of the wounds. Wound #3 was not assessed or measured. The note stated that the resident's RP was notified and that MD #1 was updated by fax. The wound assessment by Nurse 1 on 8/24/17 for Wounds #2 and #5 revealed no change in size, description, or treatment orders. Assessment of Wounds #1 (measured 10 cm in length by 7 cm in width) and #6 (12 cm in length by 12 cm in width) revealed they were larger. Treatment orders did not change. Wound #3 was not assessed or measured. The note stated that the resident's RP was notified and that MD #1 was updated by fax. The wound assessment by Nurse 1 on 9/1/17 for Wounds #1, #2, and #4 revealed no change in size, description, or treatment orders. Assessment of Wound #5 (measured 7 cm in length by 7 cm in width) revealed it was larger. Wound #6 measured 12 cm in length by 12 cm in width described as 80% wet eschar and 20% slough (a white or yellow covering on the base of the wound can prevent a wound from healing properly; infection) with moderate amount of serosanguinous exudate with foul odor. Treatment orders were placed to clean with Dakin's solution and cover with [MEDICATION NAME] AG (wound dressing) and island dressing. Treatment orders did not change for Wound #1, #2, #4, and #5. Wound #3 was not assessed or measured. The note stated that the resident's RP was notified, that MD #1 was updated, and that he had stated he wanted to have Wound MD continue to treat of the resident's wounds. Record review revealed a wound assessment was completed on 9/1/17 by the Wound MD and revealed that staff had asked him to check sacral area wound due to worsening. The wounds assessed included a pressure ulcer of hip (did not specify which hip), Wound #6 was described as a stage 4, a stage 2 pressure ulcer of ankle (did not specify which ankle), a stage 1 pressure ulcer of heel (did not specify which heel), and [MEDICAL CONDITION] to sacral area. The recommendation for the [MEDICAL CONDITION] and wound infection was to start [MEDICATION NAME] (antibiotic) 500 mg IM every day for 7 days [MEDICATION NAME](antibiotic) 500 mg by mouth twice daily for a couple of weeks with Flora-Q ([MEDICATION NAME]). No assessments, measurements, or descriptions of wounds were completed after 9/1/17 until 9/21/17. Review of a Wound Assessment note by Nurse 10 from 9/21/17 revealed Wound #5 was larger in size measuring 7.5 cm in length by 7 cm in width covered in 95% eschar tissue and 5% granulation tissue, with small amount of purulent exudate. Wound #1 measured 8.5 cm in length by 9 cm in width unstageable due to 95% eschar tissue and 5% granulation tissue, with small amount of purulent exudate. Wound #6 was larger in size measuring 14 cm in length by 12 cm in width by 3.5 cm in depth and was described as unstageable due to 75% slough and 25% granulation tissue, with a large amount of purulent malodorous drainage. Wound MD was notified and a new order was received to cleanse wound with normal saline, pat dry, and pack with Dakin's 0.25% solution, cover with a dry dressing, and change daily or as needed if soiled. Wounds #2, #3, and #4 were not assessed or measured. The Medication Administration Record [REDACTED]. During an interview with Nurse 10 on 9/26/2017 11:42 AM when asked when she had started treating resident #133's wounds she stated had started on 9/21/17. She stated she had spoken with the Wound MD about changing the wound treatment for [REDACTED].#6 but the MD refused to change the order due to the resident's RP not wanting to debride the wound. When she started doing the treatments the resident was only receiving dry dressings to Wound #1 and #5 and [MEDICATION NAME] AG on Wound #6. Stated that since she started doing treatments on 9/21/17, and new orders were placed, the wounds had gotten better. When asked about the status of the wounds she stated that the wounds did not seem to be taken care of and were in poor condition when she first assessed them. She also stated that the wounds did not seem to be end of life pressure wounds but wounds that have happened over a longer period of time. During a resident observation and interview on 9/27/2017 at 9:47:3(TRUNCATED)

Based on observations, staff, family and resident interviews and record review, the facility failed to provide showers and bed baths as scheduled during a month period of time for 3 (Resident #84, Resident # 100 and Resident #53) of 9 residents reviewed for activities of daily living (ADLs). Findings included: 1. Resident #84 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #84 had severe cognitive impairments with no behaviors and required total assistance with her ADLs to include bathing. Resident #84's care plan, last revised on 8/30/17, read she required full staff assistance for all her ADLs. A review of Resident #84 ' s nursing notes from 8/1/17 to 9/28/17 included no refusals of her showers. A review of the shower schedule indicated Resident #84 was to receive a shower Tuesday and Fridays on first shift. A review of the facility documented showers provided to Resident #84 read as follows: Shower-Friday 8/4/17 (no evidence of a bed bath or shower until 8/8/17) Showers-Tuesday 8/8/17 (no evidence of a bed bath or shower until 8/15/17) Shower-Tuesday 8/15/17 Shower-Tuesday 8/22/17 (no evidence of a bed bath or shower until 8/25/17 and not another shower until 8/29/17) Shower-Tuesday 8/29/17 Shower- Thursday 8/31/17 (no evidence of a bed bath or shower until 9/12/17) Shower- Tuesday 9/12/17 (no evidence of a bed bath or shower until 9/19/17 when he received a bed bath, no evidence of a bed bath on 9/22/17 and not another shower until 9/26/17) Shower-Tuesday 9/26/17 In an interview on 9/26/17 at 3:10 PM, Nursing Assistant (NA) #1 stated due to inadequate staffing, she was often unable to complete her showers and bed baths as scheduled. She stated Resident #84 did receive her scheduled shower today. NA #1 stated for alert and oriented residents, she often asks those residents if it was acceptable to them to postpone their showers to the next day. She stated if she was unable to complete her assigned showers, she reported it to the charge nurse. NA #1 stated Resident #84 was non-verbal and never refused her ADLs. In an observation on 9/26/17 at 3:15 PM, Resident #84 was observed with a dressing to her left elbow and her arm resting on a pillow in bed. She was clean and absent of odors. In an interview on 9/27/17 at 10:22 AM, NA #2 stated she was often unable to complete her assignment when working on one half of 200 hall and all of 300 hall. She stated she was scheduled to give 6 showers and had to assist some residents with eating breakfast and dinner. She stated she often asked her alert and oriented resident if they minded having their showers postponed if she was unable to complete all her showers and some days she did not do a bed bath but reported it to the oncoming shift. NA #2 stated she always informed her charge nurse if she did not give her showers. She stated Resident #84 did not refuse showers but she often made noises when she was moved due to her contractures. In an interview on 9/27/17 at 10:33 AM, the Administrator stated it was her expectation that resident receives their showers and bed baths as scheduled. In an interview on 9/27/17 at 10:55 AM, Nurse #4 stated the aides often reported to her that they were unable to complete their assigned showers due to time constraints and staffing. She was not aware that the aides were not giving bed baths. She stated management was aware and had been working on staffing for at least six months or more. In another observation on 9/28/17 at 10:38 AM, there was a left elbow protector in place. Her family member was present and at the bedside. She stated she did not feel Resident #84 was receiving her showers as scheduled. She stated she felt it was due to inadequate staffing. 2. Resident #100 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #100 ' s quarterly MDS dated [DATE] indicated moderate cognitive impairment with a Brief Interview of Mental Status was 7. He was coded for no behaviors and as requiring total assistance with bathing. Resident #100 was care planned, and last revised on 8/1/17, for assistance with many of his ADLs. He was not care planned for refusals of showers. A review of Resident #100 ' s nursing notes from 8/1/17 to 9/28/17 did not include any refusals of his showers. A review of the facility documented showers provided to Resident #100 read as follows: No evidence of a bed bath or shower from 8/2/17 shower until a shower on 8/8/17) Shower-Tuesday 8/8/17 Shower-Friday 8/11/17 (no evidence of a bed bath or shower from 8/16/17 until a shower on 8/22/17) Shower-Tuesday 8/22/17 Shower- Friday 8/25/17 (no evidence of a bed bath or a shower until a shower on 8/29/17) Shower- Tuesday 8/29/17 Shower- Friday 9/1/17 (no evidence of a bed bath or shower until a shower on 9/5/17) Shower-Tuesday 9/5/17 (no evidence of a bed bath or shower from 9/12/17 until a bed bath on 9/25/17 and a shower on 9/26/17) Shower-Tuesday 9/26/17 In an interview on 9/27/17 at 9:25 AM, Resident #100 stated he did not receive his showers as scheduled. He stated the aides would ask him if it was acceptable to postpone showers on some days due to what the aides report and a lack of staff. He stated he did not receive a bed bath on some days. In an interview on 9/27/17 at 10:33 AM, the Administrator stated it was her expectation that resident receives their showers and bed baths as scheduled. In an interview on 9/27/17 at 10:55 AM, Nurse #4 stated the aides often reported to her that they were unable to complete their assigned showers due to time constraints and staffing. She was not aware that the aides were not giving bed baths. She stated management was aware and had been working on staff for at least six months or more. In an interview on 9/28/17 at 10:20 AM, NA #4 stated on days when she was unable to complete her assignment by not giving all her showers, she would give bed baths instead and report it to the charge nurse. She stated the days she was unable to complete her showers was due to staffing. 3. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #53 was cognitively intact. Further review revealed the resident was totally dependent and needed 2-person assistance for bathing activities of daily living. A review of the care plan updated 8/6/17 revealed Resident #53 was at risk for further decline and required assistance with activities of daily living due to the [DIAGNOSES REDACTED]. A review of the Bathing and Shower Log for Resident #53 from 5/29/2017 to 9/29/2017, had documentation that Resident #53 only received a bath or shower for 62 days out of 123 days. An observation was conducted of Resident #53 on 9/27/2017 at 6:30 PM. Resident #53's forehand appeared oily with a white flaky substance on his scalp. An interview was conducted with an involved family member of Resident #53 on 9/27/2017 at 6:50PM. During this interview, the family member stated that Resident #53 gets showers on Mondays and Thursdays, but no baths in between shower days. The family member further stated they had spoken to the Social Worker about their concern with bathing and stated the Social Worker stated she is trying to get a shower team hired. The family member further stated, there are never enough staff to bath. She also stated that Resident #53 is dependent upon staff for bathing and showering. An interview was conducted with Resident #53 on 9/27/2017 at 6:55PM. During this interview, Resident #53 stated he gets a shower on Mondays and Thursdays. The resident further stated he gets oily skin and sweats a lot due to [MEDICAL CONDITION] and needs to be bathed every day. Stated he has talked to the Social Worker and stated she told him they were hiring new staff, but Resident #53 stated that he is not getting bed baths in between his shower days. Resident #53 stated he was very dissatisfied. An interview was conducted with a NA #7 (Nurse Aide) on 9/28/2017 at 8:50 AM. NA #7 reported working with Resident #53 around 5 to 6 days a week. During this interview, NA #7 stated that there are not enough staff to give Resident #53 a bed bath in between shower days. She further stated that she will sometimes be the only aide working on Resident #53's hall. The NA stated that Resident #53 is dependent for bathing and requires 2-person assistance. She further stated that she knew Resident #53 wanted a bath every day, but stated there are not enough staff. An interview was conducted with the Social Worker on 9/29/2017 at 8:30 AM. During this interview the Social Worker stated she was under the impression the staff are giving Resident #53 bed baths in between his shower days. She further stated Resident #53 gets a shower on Monday and Thursday. A second observation was conducted of Resident #53 on 09/29/2017 at 8:50 AM . The resident was dressed, seated in his wheelchair in the dining room eating breakfast. The residents face was noted to be oily with a white crusty substance on his forehead. An additional interview was conducted with Resident #53 on 09/29/2017 9:10 AM. During this interview, Resident #53 stated that he got a shower yesterday (Thursday) but stated he has not gotten a bed bath today. Resident #53 further stated I won't get one. The resident stated if it is not a shower day, I do not get a bath. Resident #53 stated he wants a shower every day and if not a shower he wants a bed bath at the very least. Resident #53 further stated he needed his face washed today and needs help and no one has helped. An interview was conducted with NA #2, who reported working with Resident #53 about 4 days a week on 09/29/2017 at 9:57 AM. During this interview, NA #2 stated Resident #53 is supposed to get showers on Mondays and Thursday with bed baths in between. She stated he is dependent upon staff for baths and further stated Resident #53 does not get a bed bath everyday like he is supposed to. She stated there are not enough staff. NA #2 further stated she is aware Resident #53's care plan says to assist him with bathing and knows he wants a bath daily, but says there are not enough staff to bath him every day. An interview was conducted with the Administrator on 9/29/2017 at 12:55PM. During this interview, the Administrator stated her expectation was for residents to get a bed bath on the days in between shower days and further stated residents should get bathed in accordance with their preferences. .

Based on observations, resident interview, staff interviews, family interviews and record review, the facility failed to provide sufficient staff to provide showers and bed baths as scheduled for residents who required staff assistance with bathing for 3 (Resident #84, Resident #100 and Resident #53) of 7 residents reviewed for activities of daily living (ADLs). The facility failed to provide a dignified dining experience for residents in 2 of 3 separate dining areas, the main dining room and the silver spoon dining room. Findings included: This citation is cross referenced to: 1. F312-Based on observations, staff, family and resident interviews and record review, the facility failed to provide showers and bed baths as scheduled during a month period for 3 (Resident #84, Resident # 100 and Resident #53) of 9 residents reviewed for activities of daily living (ADLs). In an interview on 9/25/17 at 10:14 AM, Nurse #3 stated residents do not get their showers because there was not enough staff. She stated she often had a difficult time convincing the aides to come in or stay over due to short staffing. In an interview on 9/26/17 at 3:10 PM, Nursing Assistant (NA) #1 stated due to inadequate staffing, she was often unable to complete her showers and bed baths as scheduled. She stated Resident #84 did receive her scheduled shower today. NA #1 stated for alert and oriented residents, she often asks those residents if it was acceptable to them to postpone their showers to the next day. She stated if she was unable to complete her assigned showers, she reported it to the charge nurse. NA #1 stated Resident #84 was non-verbal and never refused her ADLs. In an observation on 9/26/17 at 3:15 PM, Resident #84 was observed with a dressing to her left elbow and her arm resting on a pillow in bed. She was clean and absent of odors. In an interview on 9/27/17 at 9:25 AM, Resident #100 stated he did not receive his showers as scheduled. He stated the aides would ask him if it was acceptable to postpone showers on some days due to what the aides report and a lack of staff. He stated he did not receive a bed bath on some days. In an interview on 9/27/17 at 10:22 AM, NA #2 stated she was often unable to complete her assignment when working on one half of 200 hall and all of 300 hall. She stated she was scheduled to give 6 showers and had to assist some residents with eating breakfast and dinner. She stated she often asked her alert and oriented resident if they minded having their showers postponed if she was unable to complete all her showers and some days she did not do a bed bath but reported it to the oncoming shift. In an interview on 9/27/17 at 10:33 AM, the Administrator stated prior to 9/15/17, the precious Director of Nursing (DON) was responsible for staffing. The Administrator she assumed the reasonability of staffing as of 9/15/17. She stated it was her expectation that resident receives their showers and bed baths as scheduled. The Administrator stated the facility has been advertising for additional help and was offering a sign-on bonus for newly hired staff. She stated the facility was hosting a job fair and stated the facility does not use any agency staff. In an interview on 9/27/17 at 10:55 AM, Nurse #4 stated the aides often reported to her that they were unable to complete their assigned showers due to time constraints and staffing. She was not aware that the aides were not giving bed baths. She stated management was aware and had been working on staff for at least six months or more. In an interview on 9/28/17 at 10:20 AM, NA #4 stated she was not able to give all her showers and offered her alert and oriented resident a bed bath instead. In another observation on 9/28/17 at 10:38 AM, Resident #84 was in bed. She appeared clean and groomed. Her family member was present and at the bedside. She stated she did not feel Resident #84 was receiving her showers as scheduled. She stated she felt it was due to inadequate staffing. 2. F241 The facility failed to serve the food to all residents seated at the same table during two meal observations. Resident # 106 waited 40 minutes for her food while a table mate ate supper, Resident #114 waited 35 minutes and Resident # 16 waited 30 minutes to be fed while her table mate was fed lunch. Failing to provide a dignified dining experience occurred in 2 of 3 separate dining areas, the main dining room and the silver spoon dining room. a. Continuous observations of the supper meal service to the residents in the main dining room on 9/24/17 from 4:30 PM to 5:05 PM, revealed there were 11 separate dining tables in the room. Resident #106 was seated at table #3 on the left side of the room. Residents # 21 and 114 were at the same table. Resident #21 received her supper meal at 4:40 PM and she began to eat her food. Residents were served randomly at other tables during the observation. Observation at 4:45 PM revealed Resident #16 was heard saying Hello, hello, where's my food? Observation at 5:00 PM revealed Resident #21 left the dining room and Resident #106 used her hand to eat some of the food left by Resident #21. Resident # 114 was observed to grab some of the food left by Resident #21. Aide # 11 came by the table at 5:03 PM and pushed the food away from both residents. Observations at 5:05 PM revealed Aide #11 removed Resident #21's plate with the remaining food from the table. Observation at 5:07 PM revealed Resident #114 received her food and at 5:12 PM Resident #106 received her food. Interview with aide #10 on 9/28/17 at 4:30 PM revealed he was not aware Resident #106 was asking for her food. He explained the trays were not in the same order as the resident tables. Aide #10 further explained they try to get the trays out as fast as possible. b. Continuous observations on 9/26/17 in the silver spoon dining room from 11:43 AM to 12:35 PM revealed there were six residents with 2 staff members in the room. Resident #16 was seated at a table with another resident and one staff member (Aide #9). Aide #9 fed the other resident and Resident #16 did not receive her tray. A visitor was observed to enter and feed the table mate while Resident #16 remained at the table without her food. Aide # 9 left the table, left the silver spoon dining room and began assisting in the main dining room (adjacent to the silver spoon dining room). Observations revealed at 11:52 a third Aide # 3 came to the silver spoon dining room with another resident, and provided the resident a tray and assisted that resident. Observations at 11:54 AM revealed Aide #5 entered the dining room and provided another resident with feeding assistance. Observations at 12:15 revealed Resident #16 received her tray and feeding assistance. An interview was conducted on 9/29/17 at 12:31 PM with aides # 8 and 9, who had worked in the silver spoon dining room on 9/26/17. Interview revealed they were supposed to have 3 aides assigned to the silver spoon dining room. They both explained there would be 2 aides on each hall. One aide from each of the halls (100, 200 and 300 halls) were to come to the silver spoon dining room. If there were only 4 total aides on for all three halls, there would be 2 aides in silver spoon dining room. The residents in that dining room required feeding assistance. The staffing for 9/29/17 was reviewed and revealed there were 3 aides for 100, 200 and 300 halls (one aide per hall). Interview with the Administrator on 9/29/17 at 12:58 revealed the trays were not in any order in the tray cart for the main dining room due to residents sitting wherever they wanted. There was not a seating assignment. The Administrator explained ideally there would be 3 aides in the silver spoon dining room, and one aide and a patient care assistant (PCA) in the main dining room. The residents in the main dining room required cueing for meals. She would expect the nurse to supervise the aides and alert management if there was not enough staff. The Administrator expected residents to receive trays at the same table within a reasonable timeframe. Interview with the charge nurse for the 100, 200 and 300 halls was conducted on 9/29/17 at 1:05 PM. Nurse # 11 explained she was from a sister facility and was not familiar with what a silver spoon dining room meant. She explained she thought it was restorative dining. Nurse #11 was not aware the silver spoon dining room did not have enough staff to provide assistance at mealtime.

Based on staff interview and record review, the facility failed to staff Registered Nurse (RN) coverage 8 consecutive hours for 3 of 28 days reviewed for RN staffing. Findings included: A review of the facility staffing hours and staffing schedules from 8/19/17 through 9/27/17 revealed no 8 hours consecutive RN coverage on 8/31/17, 9/19/17 and 9/20/17. In an interview on 9/27/17 at 10:33 AM, the Administrator stated the previous Director of Nursing (DON) was over the facility staffing and she assumed the role as of 9/15/17 when the DON was terminated. She stated she was aware of the lack of RN coverage on the days identified and it was her expectation that there be an RN for 8 consecutive hours daily.

The facility failed to serve the food to all residents seated at the same table during two meal observations. Resident # 106 waited 40 minutes for her food while a table mate ate supper, Resident #114 waited 35 minutes and Resident # 16 waited 30 minutes to be fed while her table mate was fed lunch. Failing to provide a dignified dining experience occurred in 2 of 3 separate dining areas, the main dining room and the silver spoon dining room. The findings included: 1. Continuous observations of the supper meal service to the residents in the main dining room on 9/24/17 from 4:30 PM to 5:05 PM, revealed there were 11 separate dining tables in the room. Resident #106 was seated at table #3 on the left side of the room. Residents # 21 and 114 were at the same table. Resident #21 received her supper meal at 4:40 PM and she began to eat her food. Residents were served randomly at other tables during the observation. Observation at 4:45 PM revealed Resident #16 was heard saying Hello, hello, where's my food? Observation at 5:00 PM revealed Resident #21 left the dining room and Resident #106 used her hand to eat some of the food left by Resident #21. Resident # 114 was observed to grab some of the food left by Resident #21. Aide # 11 came by the table at 5:03 PM and pushed the food away from both residents. Observations at 5:05 PM revealed Aide #11 removed Resident #21's plate with the remaining food from the table. Observation at 5:07 PM revealed Resident #114 received her food and at 5:12 PM Resident #106 received her food. Interview with aide #10 on 9/28/17 at 4:30 PM revealed he was not aware Resident #106 was asking for her food. He explained the trays were not in the same order as the resident tables. Aide #10 further explained they try to get the trays out as fast as possible. Interview with the Administrator on 9/29/17 at 12:58 revealed the trays were not in any order in the tray cart for the main dining room due to residents sitting wherever they wanted. There was not a seating assignment. The Administrator explained ideally there would be 3 aides in the silver spoon dining room, and one aide and a patient care assistant (PCA) in the main dining room. The residents in the main dining room required cueing for meals. She would expect the nurse to supervise the aides and alert management if there was not enough staff. The Administrator expected residents to receive trays at the same table within a reasonable timeframe. 2. Continuous observations on 9/26/17 in the silver spoon dining room from 11:43 AM to 12:35 PM revealed there were six residents with 2 staff members in the room. Resident #16 was seated at a table with another resident and one staff member (Aide #9). Aide #9 fed the other resident and Resident #16 did not receive her tray. A visitor was observed to enter and feed the table mate while Resident #16 remained at the table without her food. Aide # 9 left the table, left the silver spoon dining room and began assisting in the main dining room (adjacent to the silver spoon dining room). Observations revealed at 11:52 a third Aide # 3 came to the silver spoon dining room with another resident, and provided the resident a tray and assisted that resident. Observations at 11:54 AM revealed Aide #5 entered the dining room and provided another resident with feeding assistance. Observations at 12:15 revealed Resident #16 received her tray and feeding assistance. An interview was conducted on 9/29/17 at 12:31 PM with aides # 8 and 9, who had worked in the silver spoon dining room on 9/26/17. Interview revealed they were supposed to have 3 aides assigned to the silver spoon dining room. They both explained there would be 2 aides on each hall. One aide from each of the halls (100, 200 and 300 halls) were to come to the silver spoon dining room. If there were only 4 total aides on for all three halls, there would be 2 aides in silver spoon dining room. The residents in that dining room required feeding assistance. The staffing for 9/29/17 was reviewed and revealed there were 3 aides for 100, 200 and 300 halls (one aide per hall). Interview with the Administrator on 9/29/17 at 12:58 revealed the trays were not in any order in the tray cart for the main dining room due to residents sitting wherever they wanted. There was not a seating assignment. The Administrator explained ideally there would be 3 aides in the silver spoon dining room, and one aide and a patient care assistant (PCA) in the main dining room. The residents in the main dining room required cueing for meals. She would expect the nurse to supervise the aides and alert management if there was not enough staff. The Administrator expected residents to receive trays at the same table within a reasonable timeframe. Interview with the charge nurse for the 100, 200 and 300 halls was conducted on 9/29/17 at 1:05 PM. Nurse # 11 explained she was from a sister facility and was not familiar with what a silver spoon dining room meant. She explained she thought it was restorative dining. Nurse #11 was not aware the silver spoon dining room did not have enough staff to provide assistance at mealtime.

Based on record review and resident, family, staff and physician interviews, the facility failed to provide a psychiatric service recommended by the physician to evaluate one of one resident (Resident #53) reviewed for social services needs. Findings included: 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact. He did not have any problems with mood, nor did he have any psychosis or negative behaviors. A review of a social services note dated 8/2/17 revealed cognition and mood interviews were conducted by the social worker on 8/1/17. Resident was alert and oriented. He reported no mood concerns and has had no behaviors. However, Social Services Director (SSD) had a meeting earlier this week where resident stated that he felt he had outlived his usefulness and that he felt hopeless. He did not state this during this interview. He stated that 'Everyone thinks of suicide, it used to frighten me but it no longer does.' He contracted for safety today, this was also reported to the nurse practitioner (NP) that was in the building today. A review of the physician note (MD) dated 8/3/17 revealed, The social worker in the nursing facility reported that the resident felt more depressed lately. He is on multiple medications. He has not seen psychiatrist recently. After medication review will try to simplify some of his medications although he is on multiple antidepressants. Will recommend a psychiatric evaluation. A review of the care plan updated 8/6/17 revealed Resident #53 was at risk for side effects from antianxiety and antidepressant medication use. Care plan interventions included, observe for adverse side effects, document and report to physician. A review of the care plan updated 9/25/17 revealed a problem of combative behavior, hallucinations and delusions. Care plan interventions included, approach resident warmly and positively, allow resident opportunity to make choices, do not argue with resident and praise resident for demonstrating desired behavior. A review of Resident #53's medical record revealed no order or paperwork for a psychiatric evaluation and no evidence that the resident was seen by any psychiatric service. An interview was completed with the nurse practitioner (NP) on 9/28/17 at 8:18 AM. He stated he didn't recall being notified of Resident #53's mood. He said if he knew about the resident's statements about suicide he would have made a note in the chart. An interview was completed with the MD on 9/28/17 at 9:01 AM. He recalled that the SSD notified him of a change in the resident's mood and that they talked about an evaluation the next time the psychiatric service came into the building. The MD said he spoke with the resident and family member and made some medication changes. He further stated he did not have to write a specific order for a psychiatric evaluation. An interview was completed with the SSD on 9/28/17 at 9:09 AM. She said Resident #53 hadn't had any psychiatric issues since he was admitted to the facility. She recalled his statement that everyone thought of suicide was made during a resident group meeting and said He has said things like that from time to time. She said she notified the NP or MD after Resident #53 made that statement. She stated that an outside provider came in every other week and provided psychiatric services. She said the process for obtaining psychiatric services was that the primary MD wrote an order for [REDACTED]. Once she received the copy of the order an authorization form had to be completed and signed by the primary MD before the psychiatric service evaluated a resident. She stated the company that provided the psychiatric service required the primary MD's signature on the authorization form prior to seeing a resident. The SSD said she didn't have any record that Resident #53 had received psychiatric services in the facility, or that any authorization paperwork was completed. An interview was completed with Resident #53 on 9/28/17 at 10:05 AM. He stated he did not recall being offered psychiatric services after he voiced comments back in August during a resident group meeting. He could not remember if the MD spoke with him about a psychiatric evaluation. He said the SSD talked with him earlier on 9/28/17 about psychiatric services and he said he would talk to his family about it. An interview was completed with Resident #53's family member (Family Member #1) on 9/28/17 at 12:00 PM. Family Member #1 stated the SSD gave her some forms to fill out about six weeks ago to authorize psychiatric services. She stated she completed the paperwork and returned it to the SSD about 3-4 weeks ago. Family Member #1 said she thought it was a good idea for Resident #53 to be followed by psychiatry because of his history of depression. A second interview was completed with the SSD on 9/28/17 at 2:30 PM. She stated she thought the forms Family Member #1 turned in were for dental services, not psychiatric services but wasn't sure and would look for the forms A follow up interview was completed with Family Member #1 on 9/28/17 at 2:36 PM. She stated the SSD had just found the authorization forms for psychiatric services in a file. An interview was completed with the Administrator and Director of Operations on 9/28/17 at 4:34 PM. The Administrator stated she would have expected that if the MD recommended a psychiatric consult that the facility would have arranged for those services. An interview was completed with the SSD on 9/28/17 at 5:15 PM. She provided a copy of the consent agreement signed on 8/11/17 by Family Member #1. She stated she did not remember if Family Member #1 had turned in the forms to her and that Family Member #1 told her she returned the signed forms on 9/13/17. The SSD said the psychiatric provider was at the facility on 9/25/17 but did not see Resident #53 because only urgent cases were seen that day. She stated the provider would return again to the facility in two weeks.

Based on staff interviews and record review the facility failed to accurately code on the comprehensive admission Minimum Data Set (MDS) assessment a level II PASRR (Preadmission Screening and Resident Review) for 1 of 1 resident (Resident #53) reviewed for PASRR. Findings included: 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the PASRR Level II Determination Notification dated 12/11/14 revealed that Resident #53 was determined to be a PASRR level II (The purpose of the Level II screening is to assure that individuals with serious mental illness entering or residing in Medicaid-certified nursing facilities receive appropriate placement and services). A review of the admission MDS assessment dated [DATE] indicated Resident #53 was not coded as a level II PASRR. An interview was completed with MDS Nurse #1 on 9/28/17 at 11:09 AM. She stated the nurse who completed Resident #53's assessment no longer worked at the facility and probably incorrectly coded the MDS. MDS Nurse #1 said the PASRR information was located under the admissions tab in the medical record and typically she was notified of any new residents with level II PASRRs in morning meetings. MDS Nurse #1 stated she would correct the MDS to reflect the resident's level II status. An interview was completed with the Admission Nurse Liaison on 9/28/17 at 3:22 PM. She said the level II PASRR information was placed in the medical record and she assumed the MDS Nurse got the information from there. An interview was completed with Human Resources/Payroll Employee on 9/28/17 at 3:55 PM. She stated if a resident was admitted to the facility with a level II PASRR she notified the Administrator. She said she was new to the PASRR process and was not aware the MDS Coordinator was to be notified of any residents with level II PASRRs. An interview with the Administrator on 9/28/17 at 4:34 PM revealed her expectation that the level II PASRR infor mation be correctly coded on the MDS assessment.

Based on observation, record review and staff interview the facility failed to update the care plan for the use of a comfy splint for one (Resident #129) of two sampled residents with splints. The findings included: Resident #129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set, dated dated [DATE] indicated Resident # 129 had severe impairment with long and short term memory. The MDS indicated she required extensive assistance of two staff persons for transfer, dressing and hygiene. Review of the area of limitation of functional movement revealed she had no limitation in the lower extremities. Review of the care plan that was not dated revealed the use of the comfy splint for the foot drop was not addressed. Review of the Kardex (aides' care plan in the computer) did not instruct the aides to apply the comfy splint. Observations on 09/25/17 at 10:54 AM revealed Resident #129 was seated in a wheelchair and the right foot was noted to have foot drop. No devices were applied to support the left foot. A soft splint was observed in the room. Interview on 09/28/2017 at 11:41 AM with the MDS nurse revealed she did not have a communication form from therapy for the brace. These communication forms were initiated in the last two months. The MDS nurse explained there were no Care Area Assessments that included the problem of foot drop due to no contractures were present. During the interview, she explained the care plans were updated quarterly and as needed. Interview with Physical Therapist #2 on 09/28/2017 at 12:03 PM revealed the last therapy discharge note was dated 1/31/17 for a comfy splint to be applied. Interview with the MDS nurse on 09/28/2017 at 12:41 PM revealed the comfy splint was not care planned and it must have been missed by the former MDS nurse.

Based on observations, staff and physician interviews and medical record review, the facility failed to clarify an admission order for a tabs monitor or bed alarm for 1 of 4 residents (Resident #150) reviewed for accidents. Findings included: 1. Resident #150 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] after sustaining a fall. She re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #150 had moderately impaired cognition. She required extensive assistance with transfers. She had fallen once since her original admitted with no injury. She was on physical therapy (PT) caseload. A review of the care plan updated 9/12/17 revealed Resident #150 was at risk for falls related to impaired mobility, increased weakness and decreased endurance. Care plan interventions included, Provide assistance for all safety compromising activities, encourage her to summon assistance for any activity that might compromise her safety, check for needs often as she has periods of confusion, monitor for changes in condition that may warrant increased supervision/assistance and notify physician (MD) and therapy per orders. A review of admission orders [REDACTED]. A review of a nurse's note dated 9/16/17 revealed, MD order in chart as follows: 'Please order tabs monitor or bed alarm for patient safety.' An observation of Resident #150's room on 9/26/17 at 9:38 AM revealed no alarm on the bed. An observation was made of Resident #150 on 9/26/17 at 9:39 AM. She was in her wheelchair, self-propelling around the nurse's station. There was no tabs alarm on the wheelchair. An interview completed with the Administrator, Director of Rehabilitation and MDS Nurse #1 on 9/26/17 at 2:38 PM revealed the facility didn't use tab monitors or bed alarms because it caused more agitation in residents with dementia. An interview was completed with the Administrator on 9/26/17 at 3:45 PM. She stated the MD from the hospital had ordered the tabs monitor/bed alarm, not the facility MD. An interview was completed with the Interim Director of Nursing (DON) on 9/26/17 at 4:11 PM. She said when a resident was admitted to the facility from the hospital the nursing staff used the hospital discharge orders until the facility MD reviewed the information. She stated the MD would be called once the resident was admitted and notified of new orders that needed to be reviewed. She further stated if any immediate clarifications were needed the nurse called the facility MD. An interview was completed with Resident #150's MD on 9/27/17 at 12:10 PM. He stated tab monitors were not used in the facility and couldn't remember if the facility used bed alarms. He said he was not notified by the nurse about clarifying the order for tabs monitor/bed alarm. The MD stated he expected the nursing staff to contact him to clarify orders if it was something the facility didn't use or provide. An interview was completed with Nurse #7 on 9/27/17 at 2:49 PM. She was the nurse on duty when Resident #150 was readmitted to the facility. She remembered the order for the tabs monitor/bed alarm and said, I was hoping it would be followed through, I wasn't sure. She stated the facility didn't use tab monitors or bed alarms, and then clarified she thought the facility could use tab monitors, but they did not actually use them. She added that she did not know if an alarm was placed on the resident and that she should have followed up on it. An interview was completed with the Administrator and Director of Operations on 9/28/17 at 4:31 PM. The Administrator stated that staff knew the facility didn't use alarms. She said she expected the nurse would have contacted the MD to clarify the order or have the order discontinued since the facility didn't use chair or bed alarms.

Based on observations, record review and staff interview the facility failed to provide cueing and assistance while eating for one (Resident #106) of three sampled residents that required limited assistance for eating. The findings included: Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the dietician's note dated 6/19/17 indicated Resident #106 had some confusion but is alert and able to feed herself. Review of a Restorative Care Referral form dated 8/30/17 indicated she was to attend restorative dining six days a week. The interventions included for restorative to have the resident stay at the table, lock her brakes, stay close to the resident for verbal cues and please feed the resident if needed to initiate intake. Resident #106 required supervision - max (maximum) A (assistance) if pt (patient) not self feeding. The type of cues needed included up to max vc's (visual cues) to attend to task. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #129 had severe impairment with short and long term memory and required extensive assistance of one staff member for eating. The care plan that was not dated included a problem for potential weight loss related to [DIAGNOSES REDACTED]. Review of the Kardex (care plan for aides) indicated Resident #106 ate in the dining room or in her room, received a regular diet and no straws. The Kardex did not provide instructions to assist or cue the resident. Continuous observations in the main dining room on 9/24/17 from 4:45 PM to 5:30 PM revealed Resident #106 rolled away from the table at 4:48 PM and a visitor pushed her up to her table. She received her supper tray at 5:12 PM. Aide #10 delivered her tray and offered no assistance with the meal. Nurse Aide (NA) #10 continued passing supper trays in the dining room. Resident #106's meal included a piece of turkey that covered a slice of light bread with gravy, fruit cup and a frozen nutritional supplement. Observations revealed she was unable to cut up the meat and she did not receive assistance with eating. Resident #106 made 3 attempts to cut the meat. A small corner piece remained attached to the whole piece. Resident #106 was observed putting her fork in the small attached piece of turkey. The entire piece of turkey slid off the plate and onto the tray edge. Resident #106 was observed to put her fork down and not attempt to eat the turkey, slice bread or fruit cup. NA#10 came by her table and instructed her to eat her supper. No other cues or assistance was provided. Resident #106 ate the magic cup. Interview with NA #10 on 9/28/17 at 4:40 PM revealed he had started work at the facility in August. He had worked with Resident #106 and knew she needed cueing. During the interview, he was asked how he would know who needed assistance and cueing in the dining room. NA #10 explained he would ask the other staff if he had a question about a resident and if they needed assistance. Further interview revealed he did not remember if she needed assistance cutting her meat during the supper meal on 9/24/17 Observations of the main dining room on 09/28/17 at 4:59 PM revealed Resident #106 received her tray and NA #14 provided set up assistance. NA #14 cut the meat into bite size portions. Resident #106 was observed to eat independently after she received set up assistance. Interview with the Interim Director of Nursing on 9/29/17 at 4:00 PM revealed residents should receive assistance with their meals, set up assistance and feeding assistance. The Kardex system informs the NA's of the care that was to be provided. Further interview revealed she would expect the MDS nurse to update the Kardex.

Based on observations, record review, family and staff interviews the facility failed to provide the therapy recommended splint to the right ankle for treatment of [REDACTED].#129). The findings included: Resident #129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set, dated dated [DATE] indicated Resident #129 had severe impairment with long and short term memory. The MDS indicated she required extensive assistance of two staff persons for transfer, dressing and hygiene. Review of the area of limitation of functional movement revealed she had no limitation in the lower extremities. Review of the care plan that was not dated, revealed the use of the comfy splint for the foot drop was not addressed. The Restorative care plan, which was not dated, included use of the splint to the right ankle. Review of the Kardex (aides' care plan in the computer), not dated, revealed there were no instructions for the aides on the floor to apply the comfy splint. The restorative Kardex included the comfy splint to be worn when transferring and standing in the standing frame. Observations on 09/24/17 at 5:55 PM revealed Resident #129 did not have a splint on her right foot and a soft splint was observed in the room. A sign was posted on the outside of the closet door to apply a splinting device to the right ankle due to foot drop. The sign indicated the device was to be worn 24/7 except for bathing. Observations on 9/25/17 at 10:54 AM revealed Resident #129 was seated in a wheelchair and the right foot was noted to have foot drop. Her heel and bottom of her foot did not rest on the foot pedal. No devices were applied to support the right foot. A soft splint was observed in the room. Observations on 09/25/17 at 2:00 PM revealed Resident #129 did not have the splint on her right foot. Her heel and bottom of her foot did not rest on the foot pedal. There were no devices applied to support the right foot. Observations on 09/26/17 at 9:00 AM revealed Resident #129 did not have the splint on her right foot. The resident was in the bed at this observation. Observations on 09/26/17 at 10:08 AM revealed aide # 12 and aide # 13 provided morning care for Resident #129. Both aides assisted in dressing the resident and transferring her from the bed to the wheelchair. After the care was provided, aides # 12 and 13 were interviewed about the signage on the closet door indicating Resident #129 was to wear a brace 24/7 except for bathing. Neither aide was aware of a brace or a splint for the right lower leg/ankle. Interview on 09/26/17 at 10:15 AM with the restorative aide revealed the comfy splint was used during restorative treatment when Resident #129 stood in the standing frame. The restorative aide explained she was not responsible for applying the comfy splint each day, the aides on the floor would put it on the resident's ankle. Interview with the restorative aide revealed she had no further knowledge about the splint. Interview with the therapy manager on 09/27/17 at 10:20 AM revealed the resident had surgical repair of a fracture in October 2016. The resident had foot drop and a splint had been ordered. A brace had been used in the beginning after the resident was able to bear weight. Due to family request, the brace was discontinued and the splint was ordered. Resident #129 was discharged from therapy and transferred to the restorative program. Restorative worked with the resident in a standing frame and the resident wore the splint during those times. In reviewing the multiple times of being on therapy case load, the last discharge dealing with the right ankle was dated 1/31/17. On the discharge summary, the therapist indicated the resident was to wear a comfy splint on the right ankle at all times, except for bathing. The therapy manager explained the process for communication to the nursing department included using a form that was given to the Director of Nursing and the MDS nurse. Therapy would train the nursing staff on the hall. With staff turnover, the new staff should be informed by the current staff, and to look at the Kardex for the plan of care. The MDS nurse updated the Kardex Interview with aide #12 on 09/27/17 at 12:11 PM revealed she saw the sign about the leg brace but was not sure what it was or where it was kept. Aide #12 explained she had asked someone about the device, but could not remember who she asked. Aide #12 further explained she had not received instructions a splint or brace was to be applied. She explained she knew what care was to be provided by checking the Kardex in the kiosk (aide's computer chart). She further explained she did not remember seeing anything about the splint on the Kardex. The splint was in her (Resident #129)'s wheelchair this morning. After seeing the signage on the closet door, Aide #12 explained she could not find the splint on the other days (9/25 and 9/26) this week. Interview with the Interim Director of Nursing on 09/27/2017 at 3:10 PM revealed physician orders [REDACTED]. The therapy communication form had been implemented in the past two months. Further interview revealed she had no explanation why the comfy splint had been missed. The physical therapist #1 had worked with the resident most recently and was interviewed on 9/28/17 at 12:15 PM. She and the MDS nurse accompanied the surveyor to the resident's room. The device on the resident's leg was a comfy splint. She explained it was to prevent further damage to the Achilles tendon which caused foot drop after she had sustained a [MEDICAL CONDITION] leg. The therapist explained, if the splint was not used, she could have further damage to the foot which would cause her pain due to the flexion of the foot. She was supposed to wear the comfy splint 24 hours a day except for bathing. Physical therapist #1 explained she had written a telephone order for use of the splint. The telephone order for the use of [REDACTED]

Based on observation, record review and staff interview the facility failed to have two persons perform transfers for 1 of 4 sampled residents (Resident #117). The findings included: Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #117 required extensive assistance with bed mobility and transfer with the use of 2 staff. The MDS further indicate Resident #117 was moderately cognitively intact. Review of the care area assessment (CAA) dated 4/8/15 revealed Resident #117 was currently non ambulatory, dependent on staff for transfer with using maxi lift (total mechanical lift) by nursing assistants (NA). The CAA stated, Therapy was working on standing transfers but report (Resident #117) was not able. Review of Resident #117 care plan updated 6/8/15 revealed no care plan in regards to transfers. Review of the Kardex (electronic information used for a resident care guide) indicated Resident #117 required 2 + staff for transfers. Review of Resident #117 incident report dated 7/29/15 revealed Resident #117 had a fall in his room which resulted in injury. The narrative of the incident stated, Both hall NAs (nursing assistants) (NA#1 and NA#2) were in Resident #117's room. NA#1 and NA#2 had Resident #117 on the total mechanical lift. The right upper body strap came undone and Resident #117 fell about 1-2 feet to the floor. The incident report continued with Resident #117 had approximately 7cm (centimeters) in diameter round knot on right side of his head and a small abrasion under the knot on back of his bead. Trace amounts of blood were noted. The medical director was notified and ordered Resident #117 to the emergency room for evaluation and treatment. The immediate post-incident action stated, Investigating why lift pad came undone and reeducated staff on proper ways to hook lift pad to lift. The narrative of investigation stated, Both the lift and the sling were in working order. Re-education with all staff on proper use of mechanical lift and safe transfer procedure. Random audits of transfer begun. (Resident #117) is a hands on two person transfer. Their investigation indicated that all staff were re-educated on the mechanical lift with the use of 2 people on 7/30/15. Review of physician order [REDACTED].#117 to the emergency room for evaluation and treatment of [REDACTED]. Hospital discharge summary dated 7/30/15 indicated Resident #117 was sent from the nursing home for a fall. Resident #117 had a CT (x-ray procedure) and magnetic resonance imaging (MRI) of the neck which showed a C2 fracture. The discharge summary further indicated resident #117's left shoulder x-ray showed he had a dislocated shoulder. Review of Resident #117's significant change MDS assessment dated [DATE] revealed a significant change from Resident #117's 6/8/15 MDS assessment for activities of daily living (ADLs). The areas of change indicated resident went from extensive assistance with one person assistance to total assistance with the use of 2 people in the areas of locomotion. Resident #117 went from total dependence with one person physical assistance to total dependence with two person assistance in the area bathing self-performance. Resident #117 went from not steady with balance (only able to stabilize with staff assistance) to the activity did not occur with moving from seated to standing position. Resident #117 went from not steady (only able to stabilize with staff assistance) to the activity did not occur in the areas of balance: moving on and off the toilet. Review of Resident #117's physician order [REDACTED]. Interview with NA#1 on 11/4/15 at 4:27pm stated on 7/29/15, she and NA#2 were in the process of completing their last rounds for their shift. NA#1 and NA#2 had to lay down Resident #117 and his roommate that were both 2 person assist/transfer. NA#1 indicated she was in the process of providing care to Resident #117's roommate when NA#2 went ahead and hooked Resident #117's lift pad up to the mechanical lift. While NA#2 was taking Resident #117 up in the total mechanical lift one of the four hooks from the lift pad came undone. NA#1 stated the hook that goes around Resident #117's right shoulder had come undone. As a result Resident #117 went backwards and hit his head on the floor. NA #1 indicated she told NA#2 to stay with Resident #117 so NA#1 could get assistance. The Assistant Director of Nursing (ADON) assisted with getting Resident #117 off the floor. NA#1 revealed she and NA#2 were supposed to have 2 people with the total mechanical lift when hooking the resident up by the lift pad. NA#2 was the only staff transferring Resident #117 with the mechanical lift. NA#2 was unavailable for interview. Interview with the assistant director of nursing (ADON) on 11/5/15 at 7:48am revealed she was approached by NA#1 that communicated Resident #117 had fallen out of the mechanical lift. The ADON indicated she went into Resident #117's room and observed Resident #117 on the floor with the total mechanical pad underneath him. Both leg straps were hooked and one shoulder strap of the lift pad was hooked. The hook for the right shoulder strap of the lift pad was observed to be unhooked. The ADON stated she lowered Resident #117 the rest of the way to the floor due to his body still being slightly propelled by the connected lift pad. The ADON stated she rolled Resident #117 to see the back of his head to determine where the blood was coming from. Resident #117 was upset as evidenced by cursing at nursing staff and stated he said he hurt all over. The ADON stated when she questioned the 2 NAs about what had occurred it was communicated that NA#1 was providing care to Resident #117's roommate and NA#2 was putting Resident #117 in the bed also. The NAs stated they both were in the room but both were not with the lift at the same time for 2 person transfer. ADON revealed staff were instructed during training to use 2 people for a total lift. Even if one NA was doing all the work the other NA was to ensure that the hooks clicked into place (when you pull it into place they click). The ADON stated we terminated (NA#2) following the incident for not following company policy. Interview with the Administrator on 11/5/15 at 8:20am revealed he was made aware of the incident involving Resident #117's fall on 7/29/15. Upon an internal investigation it was discovered that NA#1 was helping Resident #117's roommate and NA#2 took it upon herself to transfer Resident #117 even though he needed the assistance of two persons. The Administrator indicated that the internal investigation and inspection of the mechanical lift revealed no mechanical error with the lift. The Administrator described the lift pad as having slings that had tabs that fastened to the total mechanical lift. The tabs were described as hook and eye tabs. The Administrator stated when you pull down on the tab it makes a distinct pop sound that indicates it is in place and properly hooked. The Administrator stated NA#2 was terminated as a result of not following company guidelines as it related to operating the lift with 2 people. Resident #117 was described by the Administrator as a large man who required 2 staff to ensure his safety during a transfer utilizing the mechanical list. The Administrator stated it was his expectation that staff operated the mechanical lift properly and the resident was safe during the transfer. It was further his expectation that staff followed training and guidelines when transferring any resident. Corrective action for resident affected. Immediate care of the injury was performed, the attending physician and family member were notified. The resident was sent to the hospital where he remained in observation for 24 hours for a fracture at C2. This was completed by the charge nurse on 7/29/15. The lift and lift pad were removed from service until they could be inspected for mechanical problems. None were found and the lift was put back into service. This was completed by the administrator and maintenance director on 7/29/15. A full investigation into the root cause of this fall with injury was conducted: The findings showed the resident was care planned for a 2 person assistance, and this information was also on the SmartChart (the instructions for providing care that the CNAs (nursing assistants) and Nurses see each time they provide ADL assistance, incontinence care, etc.) However, one CNA attempted a transfer with a mechanical lift with resident #117 by herself. She was suspended immediately after the fall on 7.29.15. The root cause analysis showed there was no fault with the lift or lift pad, and that the root cause of the accident was the CNA, who failed to follow facility procedure. The CNA was terminated, without ever returning to work. This was completed by the administrator, and director of nursing on 7/29/15. Upon resident #117's return to the facility, a full assessment was attempted, although he refused a skin check, saying he was fine. This was completed by the charge nurse on 7/30/15. The care plan was revised to include a neck collar and new pain medications. Use of a mechanical lift for transfers was added to the care plan, as was the need for a 2 person assistance. This was completed by the MDS Coordinator on 8/2/15. Corrective action for residents with the potential to be affected Observations of all other residents who required mechanical lifts for transfers were made. No other transfers were done inappropriately (using proper technique and following facility procedure for knowing where to look to find the level of assistance needed (1 person or two persons).This was completed by the Staff Development Coordinator on 7/29/15. All mechanical lifts and pads were removed from service until they could be inspected to identify mechanical problems or wear/tear concerns. All lifts and lift pads passed this inspection and were put back into service. This was completed by the administrator and maintenance director on 7/29/15. The care plans and SmartChart information for all residents who were transferred using a mechanical lift, were reviewed to ensure the care plan for the level of assistance (1 or two person) was correct, and the SmartChart information matched the care plan instructions. This was completed by the MDS Coordinator on 7/30/15. Measures/systems that were put into place to ensure the deficient practice does not occur again. Direct care staff were educated on the proper lift procedures, including the need for 1 or 2 persons to assist. The hand out was entitled Steps to Safe Transfer. The inservice, and the handout stated that If a resident requires 2 person assist, 2 staff members must be present during the entire lift procedure. This was completed by the Staff Development Coordinator on 7/29/15. Direct care staff were not allowed to transfer any resident until they had been educated which included a return demonstration. Any employee who failed to pass the return demonstration was not allowed to transfer any resident using a mechanical lift until he/she passed the return demonstration. None failed to pass. New employees are trained on proper procedures for transferring with mechanical lifts, including return demonstration, during their orientation period and annually. Going forward, spot audits will be conducted on all new direct care staff x 3 during their first 3 weeks of employment. Validation of the corrective action plan was conducted on 11/6/15. The inservice information was reviewed which included the use of the total lift, safety precautions to take, ensure the clip clicks , and where to find the information regarding how many staff required to transfer a resident. Direct care staff and nurses were interviewed concerning the inservice information. Interviews were conducted with administrative staff regarding the plan for education for staff not currently working. A plan was in place for the weekend to ensure staff would receive inservice training before working. Observation of direct care staff using a mechanical lift for a total care resident revealed no resident safety concern during transfer.

Based on observations, record reviews, and staff interviews the facility's Quality Assessment and Assurance Committee failed to implement, monitor and revise as needed the action plan developed for the recertification survey dated 10/09/2014 in order to achieve and sustain compliance. The facility also had a deficiency on failure to develop comprehensive care plans (F279) on the recertification survey of 10/09/2014 and, again on the current recertification survey. The facility had a deficiency on failure to update comprehensive care plans (F280) on the recertification survey of 10/09/2014 and the current recertification Survey. The findings included: 1. This tag is cross referenced to F 279: Based on record review and staff interview the facility failed to develop a care plan for the use of an antipsychotic medication for one of one sampled residents on antipsychotic medications. (Resident # 41) 2.This tag is cross referenced to F 280: Based on observations, record review and staff interview, the facility failed to update the care plan of 1 of 1 resident with current interventions due to the resident's refusals of a splinting device.(Resident #92). The facility failed to update the care plan for interventions of adaptive eating equipment for two of three residents (Residents #49 and 104). An interview was conducted on 11/05/2015 3:36 PM with the facility's Staff Development Coordinator (SDC) which revealed that the SDC was responsible for being the contact person for the facility's Quality Assessment and Assurance ( QAA) committee. She did note that she was new to the position and was not aware of the previous citations that the facility had received or the need for continued follow up to prevent future citations in the same previously cited areas. The SDC stated that the QAA committee met generally one time a month, but definitely met quarterly. Committee members included the Medical director, facility administrator, registered dietician, the activity coordinator, social worker, the DON and SDC as well as other (ancillary staff) staff members as able to schedule attendance. The SDC did reveal log books, in services and follow up on previous plans of correction follow up, and also a log book including meeting minutes for current QAA issues being addressed which included weight loss, wound management, and investigative procedures for root causes and analysis of the previously mentioned areas.