Every finding on record at Clark's Mountain Nursing Center

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 61.Review of the facility's policy titled, Sanitation Inspection, revised 2025, showed:- The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation and daily, weekly inspections. Review of the facility's policy titled, Date Marking for Food Safety, dated 2026, showed:- The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food;- The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded;- The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared;- The cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly;- The dietary manager or designee shall spot check the refrigerator weekly for compliance, and document accordingly. Observation on 05/11/26 at 9:59 A.M., and 05/13/26 at 8:30 A.M., of the kitchen showed:- The louvers on the bottoms of Refrigerator #1 and #2 with smeared white substances;- The plastic casing around the handle of Refrigerator #2 was broken. Observation on 05/11/26 at 9:59 A.M., of Freezer #3 showed:- Half a bag of opened and undated egg rolls;- Quarter of a bag of opened and undated meatballs;- One bag of 10 opened and undated brats. Observation on 05/11/26 at 10:02 A.M., of Refrigerator #1 showed:- One roll of opened and undated bologna;- One package of opened and undated smoked ham;- 16 pieces of cheese on a plate covered with plastic wrap and undated;- Half of a cucumber wrapped in plastic wrap and undated;- Half of an opened and undated bag of salad. Observation on 05/11/26 at 10:06 A.M., of the dry food storage area showed:- One opened and undated 16 ounce (oz.) bag of creamer;- One bag of six opened and undated hotdog buns;- One opened and undated gallon jug of soy sauce;- One opened and undated tub of peanut butter with peanut butter on the side and the top of the container. During an interview on 5/13/26 at 8:45 A.M., the Dietary Manager said all items should be labeled and dated. The plastic casing around the handle of Refrigerator #2 should be replaced because it was not cleanable. The louvers under the refrigerators were dirty because people spilled things and didn't clean it up. The louvers were not on the cleaning schedules. During an interview on 05/14/26 at 2:07 P.M., the Administrator said all opened food should be labeled and dated. The equipment should be clean and in good repair.

Based on interview and record review, the facility failed to include the bed-hold rate and complete the bed-hold policy upon transfer to the hospital for four residents (Residents #3, # 4, #9, and #56) out of four sampled residents. The facility census was 61.Review of the facility's policy titled, Bed-Holds and Returns, undated, showed:- The resident may request that the facility hold open a bed for the residents at the time of hospitalization or therapeutic leave;- The resident shall be given written notice of the bed hold option at the time of admission, hospitalization or therapeutic leave and should be sent with the other papers accompanying the resident to the hospital;- Bed holds or room reserves are voluntary. 1. Review of Resident #3's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 03/27/26. Review of the residents' Bed-Hold form, dated 03/27/26, showed:- No documentation of the daily bed hold rate. 2. Review of Resident #4's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 01/30/26;- Transferred to the hospital on [DATE], and returned on 04/08/26. Review of the residents' Bed-Hold forms, dated 01/28/26 and 04/03/26, showed:- No documentation of the daily bed hold rate. 3. Review of Resident #9's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 03/24/26. Review of the residents' Bed-Hold form, dated 03/20/26, showed:- No documentation of the daily bed hold rate. 4. Review of Resident 56's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 03/24/26;- Transferred to the hospital on [DATE], and returned on 03/30/26. Review of the residents' Bed-Hold forms, dated 03/20/26 and 03/30/26, showed:- No documentation of the daily bed hold rate. During an interview on 05/23/26 at 3:30 P.M., the Administrator and the Social Services Designee (SSD) said the daily rate should be written in on the bed-hold forms. However, the facility didn't actually charge anything. The nurse was responsible for putting in the rate and the SSD was responsible for ensuring it was done.

Based on observation, interview, and record review, the facility failed to store medications in a safe and effective manner when staff left the South Hall medication cart unlocked and unattended. This had the potential to affect all residents. The facility census was 61.Review of the facility's policy, Medication Storage, last reviewed 05/14/26, showed:- It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security;- All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls;- During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. Observation on 05/12/26 of the South Hall medication cart showed: - At 6:18 A.M., Certified Medication Technician (CMT) A prepared medication from the South Hall medication cart, shut the medication cart drawer, and failed to lock the medication cart when he/she left the medication cart unattended;- The unattended and unlocked medication cart sat against the outside wall of the private dining room and faced the South Hallway by the dining room and the South Hall nurse's station;- At 6:19 A.M., CMT A walked through the main dining room into the assisted dining room and the unlocked medication cart sat outside the empty private dining room in the South Hall outside the dining room and out of sight of staff; - One staff walked past the unlocked and unattended medication cart;- At 6:22 A.M., CMT A exited the assisted dining room and returned to the unlocked and unattended medication cart. 2. Observation on 05/12/26 of the medication administration showed:- At 6:51 A.M., CMT A prepared medication from the South Hall medication cart, shut the medication cart drawer, and failed to lock the medication cart;- At 6:53 A.M., CMT A entered a resident's room with the unlocked and unattended medication cart facing the South Hallway and out of sight of staff; - One staff walked past the unlocked and unattended medication cart;- At 6:54 A.M., CMT A exited the resident room and returned to the unlocked and unattended medication cart. 3. Observation on 05/12/26 of the medication administration showed:- At 7:11 A.M., CMT A prepared medication from the South Hall medication cart, shut the medication cart drawer, and failed to lock the medication cart;- At 7:13 A.M., CMT A entered a resident's room with the unlocked and unattended medication cart facing the South Hallway and out of sight of staff; - At 7:16 A.M., CMT A exited the resident room and returned to the unlocked and unattended medication cart. During an interview on 5/14/26 at 1:34 P.M., CMT C and Registered Nurse (RN) B said if the medication cart was outside of their sight, then yes it should be locked. During an interview on 5/14/26 at 1:39 P.M., RN D said the medication cart should be locked when not in view. During an interview on 5/14/26 at 2:20 P.M., the Director of Nursing (DON) said the medication cart should be locked when out of view. During an interview on 5/14/26 at 2:25 P.M., the Administrator said the medication cart should be locked when unattended and out of view. During a phone interview on 05/14/26 at 3:07 P.M., CMT A said the medication cart should be locked when unattended.

Based on interview and record review, the facility failed to ensure three nurse aides (NAs) (NA F, NA G, and NA H) out of six sampled NAs completed a nurse aide training program within four months of his/her employment in the facility. This deficient practice had the potential to affect all residents in the facility. The facility's census was 62. Review of facility's policy titled, Required Training, Certification and Continuing Education of Nurse Aides, undated, showed: - NAs may be employed as full-time and permanent, but must provide documentation of certification within 4 months of their hire date; - NAs who do not completed the required training and competency evaluation program and successfully pass the certification exams within the 4 month period will not be allowed to perform the duties of a nurse aide until certification is presented and verified with the state nurse aide registry. 1. Review of NA F's Training Record showed: - Hire date of 07/01/24; - NA F had been attending the nurse aide program; - The facility failed to ensure the completion of the program and certification within four months of the hire date. 2. Review of NA G's Training Record showed: - Hire date of 08/07/24; - NA G had completed the nurse aide program, but had not taken the test; - The facility failed to ensure the completion of the program and certification within four months of the hire date. 3. Review of NA H's Training Record showed: - Hire date of 09/20/24; - NA G had been attending the nurse aide program; - The facility failed to ensure the completion of the program and certification within four months of the hire date. During an interview on 01/31/25 at 4:25 P.M., the Administrator and Assistant Director of Nursing (ADON) said they make sure nurse aides have completed their training within four months of hire. During an interview on 01/31/25 at 4:25 P.M., the ADON said nurse aides are fired and rehired if they are not certified within four months.

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner which correctly describes the arbitration process for four residents (Resident #3, #46, #58 and #112) out of four sampled residents and had the potential to affect the other 51 residents who had signed an arbitration agreement. The facility's census was 62. Review of the facility's policy titled, Binding Arbitration Agreements, undated, showed: - Facility asks all residents to enter into an agreement for binding arbitration; - Do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care; - When explaining the arbitration agreement, the facility shall: - Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission; - Explain to the resident or his or her representative in a form and manner that he or she understands; - Ensure the resident or his or her representative acknowledges that he or she understands the agreement. 1. Review of Resident #3's Face Sheet showed: - The resident admitted to the facility on [DATE]; - The resident was his/her own responsible party for finances. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/02/22, showed the resident had moderately impaired cognition. Review of the resident's arbitration agreement showed it was signed by the resident on 09/26/22 and witnessed by a Social Service Designee (SSD). During an interview on 01/31/25 at 10:15 A.M., the resident said he/she was very sick when he/she was admitted to the facility and does not know what all he/she signed and could not define an arbitration agreement. 2. Review of Resident #46's Face Sheet showed: - The resident admitted to the facility on [DATE]; - The resident was his/her own responsible party for finances. Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's arbitration agreement showed it was signed by the resident's Power of Attorney (POA) for Healthcare on 12/05/24 and witnessed by the SSD. During an interview on 01/31/25 at 10:25 A.M., the resident said he/she was not aware of what an arbitration agreement was and is his/her own responsible party for finances. 3. Review of Resident #58's Face Sheet showed: - The resident admitted to the facility on [DATE]; - The resident was his/her own responsible party for finances. Review of the resident's admission MDS, dated [DATE], showed the resident had moderately impaired cognition. Review of the resident's arbitration agreement showed it was signed by the resident on 12/11/24 and witnessed by a SSD. During an interview on 01/30/25 at 2:00 P.M. the resident said he/she was not feeling well when he/she was admitted to the facility, and everything was cloudy. The resident said he/she does not remember signing anything and could not define an arbitration agreement. 4. Review of Resident #112's Face Sheet showed: - The resident admitted to the facility on [DATE]; - The resident was his/her own responsible party for finances. Review of the resident's admission MDS, dated [DATE], showed the resident was moderately impaired. Review of the resident's arbitration agreement showed it was signed by the resident's next of kin on 01/13/25 and witnessed by the SSD. During an interview on 01/31/25 at 2:01 P.M. the resident and the next of kin said the arbitration agreement was not explained to them and was unaware of having 30 days to rescind the agreement. During an interview on 01/29/25 at 2:48 P.M. the SSD said: - The arbitration agreement is given to the resident or the resident's representative during admission; - He/she was unaware of a set amount of time the resident has to rescind the agreement until he/she read it on the policy; - The form is given to the person and he/she kind of reviews it with them, it has to do with a Missouri law and has to do with insurance agreements, stuff like that. During an interview on 01/31/25 at 2:49 P.M., the Administrator said the SSD is responsible for going over the arbitration agreement with the resident during admission.

Based on observation, interview, and record review, the facility failed to follow infection prevention precautions for four residents (Resident #34, #38, #58 and #212) out of eight sampled residents by not performing proper hand hygiene and glove changing techniques during wound and incontinent care and failed to provide infection prevention precautions by not following enhanced barrier precautions (EBP) for one resident (Resident #40) out of two sampled residents. The facility's census was 62. Review of the facility's policy titled, Hand Hygiene, dated May 2024, showed: - All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility; - Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); - The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Review of the facility policy's titled, Enhanced Barrier Precautions, undated, showed: - It is the policy of the facility to implement enhanced barrier precautions for the prevention of, and transmission of multidrug resistant organisms; - All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions; - All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; - An order for enhanced barrier precautions will be obtained for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized; - High-contact resident care activities are dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care, and wound care. 1. Observation of incontinent care provided for Resident #58 on 01/31/25 at 11:15 A.M. showed: - Nurse Aide (NA) A and NA E, without performing hand hygiene, donned gloves; - NA E opened brief and wiped the left side peri-area front to back with clean wet cloth; - NA E folded soiled cloth and wiped right side of peri-area front to back; - NA E placed soiled cloth in bag; - NA E and NA A assisted resident onto his/her right side; - NA E, without performing hand hygiene and changing gloves, rolled up clean bed pad with a clean incontinence brief and tucked under the resident; - NA E, wearing the same soiled gloves, wiped buttocks front to back with clean wet cloth; - NA E folded soiled cloth and wiped buttocks a second time; - NA E placed soiled cloth in bag; - NA E cleaned the coccyx (tailbone) area with clean wet cloth to remove barrier cream residue; - NA E, without performing hand hygiene and changing gloves, picked up the small cup of barrier cream from the bedside table; - NA E, without performing hand hygiene and changing gloves, scooped the cream out of the cup and applied it to coccyx area; - NA E, without performing hand hygiene and changing gloves, rolled the resident to his/her left side and pulled out the soiled bed pad and brief; - NA E, without performing hand hygiene and changing gloves, smoothed out clean bed pad and clean incontinence brief and rolled the resident onto his/her back; - NA E, without performing hand hygiene and changing gloves, placed the clean incontinence brief on the resident; - NA E, without performing hand hygiene and changing gloves, reached into his/her pocket and pulled out a permanent marker; - NA E, without performing hand hygiene and changing gloves, labeled the brief with the date and time, and placed the marker back into his/her pocket; - NA E, wearing the same soiled gloves, and NA A pulled the resident's pants up; - NA E, without performing hand hygiene and changing gloves, assisted the resident to a sitting position on the side of the bed; - NA E bagged up the soiled cloths and trash; - NA E removed gloves and washed hands with soap and water. During an interview on 1/31/24 at 11:20 A.M., NA A and NA E both said glove changes with hand hygiene should be performed when going from dirty to clean and before and after resident care. 2. Observation of incontinent care provided for Resident #38 on 01/31/25 at 11:25 A.M. showed - Certified Nurse Aide (CNA) I and NA J did not perform hand hygiene, donned gloves, and entered the resident's room; - NA J raised the resident's bed; - CNA I wet wash cloths in the sink and applied peri-care wash to them; - CNA I and NA J removed the resident's wet pants and brief; - CNA I performed hand hygiene and donned new gloves; - NA J, wearing the same soiled gloves, held onto the resident while CNA I wiped the resident's buttocks four times. CNA I did not clean the peri area, and placed a new brief under the resident. NA J touched his/her glasses and hair with soiled gloves; - CNA I removed gloves, performed hand hygiene and donned clean gloves; - NA J put soiled linen in soiled linen bag; - NA J, wearing the same soiled gloves, and CNA I pulled up and fastened the clean brief; - NA J removed soiled gloves, did not perform hand hygiene, got clean pants out of closet, and donned clean gloves without performing hand hygiene; - NA J and CNA I put clean pants on the resident; - NA J retrieved the mechanical lift sling out of the resident's wheelchair; -NA J and CNA I both put the lift sling under the resident; -NA J removed gloves and did not perform hand hygiene; -NA J brought the mechanical lift to the resident's bedside; -CNA I removed gloves, performed hand hygiene and donned clean gloves; -CNA I and NA J transferred the resident into the wheelchair via mechanical lift; -CNA I combed the resident's hair and covered the resident with a blanket; -CNA I removed gloves and performed hand hygiene; -NA J removed gloves and did not perform hand hygiene. During an interview on 01/31/25 at 12:15 P.M., NA J said hand hygiene should be performed after performing peri-care on the resident and after taking gloves off. Hands should be sanitized before entering and leaving residents' rooms. NA J said he/she forgot to do these things today. 3. Observation of incontinent care provided for Resident #34 on 01/31/25 at 11:45 A.M. showed; - NA J entered resident's room and did not perform hand hygiene; - NA J wet wash cloths in the sink and applied peri-care wash to them; - NA J removed the resident's soiled brief and cleaned the resident's peri area; - NA J cleaned fecal material from the resident's buttocks, and wearing the same soiled gloves, got a clean wet wash cloth, and cleaned the resident's buttocks; - NA J, wearing the same soiled gloves, got a clean brief, got a marker out of his/her pocket, labeled the brief with the date, time, and initials, adjusted his/her glasses and touched the resident's shirt; - NA J removed gloves and did not perform hand hygiene; - NA J put the resident's pants on, combed the resident's hair and wheeled the resident to the dining room for lunch. 4. Observation of wound care provided for Resident #212 on 01/31/25 at 1:45 P.M. showed: - Licensed Practical Nurse (LPN) C performed hand hygiene and donned gown, gloves, N95 mask and goggles before entering the resident's room; - LPN C cut old dressing from around the resident's left leg with scissors; - LPN C placed scissors on bedside table; - LPN C removed the soiled dressing and placed in trash; - LPN C, without performing hand hygiene and changing gloves, picked up the cup of 4x4's dampened with wound cleanser; - LPN C, without performing hand hygiene and changing gloves, pulled a 4x4 out of the cup and wiped the wound bed; - LPN C, without performing hand hygiene and changing gloves, pulled a second 4x4 out of the cup and wiped the wound bed and around the wound; - LPN C removed gloves, washed hands, and donned a clean pair of gloves; - LPN C placed dressing over wound bed and surrounding area, covered with ABD pad (absorbent dressing) and wrapped with kerlix (rolled gauze); - LPN C, without cleaning scissors, cut the clean kerlix and secured with tape; - LPN C wrapped the resident's lower leg from foot to knee with ace bandage; - LPN C removed gloves and gown, washed hands, and left the resident's room. During an interview on 1/31/25 at 2:04 P.M., LPN C and Assistant Director of Nursing (ADON) said gloves should be changed and hand hygiene performed when going from dirty to clean. 5. Review of Resident #40's medical record showed: - An order for Enhanced Barrier Precautions (EBP), dated 11/25/24. Observation on 01/31/25 at 11:54 A.M. of the resident's mechanical lift transfer, showed: - Personal Protection Equipment (PPE) and signage for EBP on the resident's door; - NA A and NA B entered the room, did not put on gloves or a gown; - NA A moved the mechanical lift over the resident, attached the sling straps to the lift on the resident's right side while touching the right side of the bed with his/her clothes: - NA B attached the sling straps to the left side of the mechanical lift, touching the bed with his/her clothes; - NA A and NA B transferred the resident from the bed to the wheelchair using the mechanical lift; - NA B placed a blanket over the legs of the resident in the wheelchair: - NA A brushed the resident's hair; - NA A and NA B performed hand hygiene and left the room. During an interview on 01/31/25 at 12:01 P.M., NA B said EBP should be done for care of residents with catheters or wounds and should have PPE on the door to the room. During an interview on 01/31/25 at 12:02 P.M., NA A said EBP should be followed for residents with wounds or feeding tubes, would know who requires it because of the PPE hanging on the door, and was unsure if EBP was required for transferring a resident, but could find out from the charge nurse. During an interview on 01/31/25 at 12:03 P.M., Licensed Practical Nurse (LPN) C and the ADON said EBP should be used for transferring a resident in their room. During an interview on 01/31/24 at 5:55 P.M., the Director of Nursing (DON), ADON and Administrator said that they would expect staff to perform hand hygiene and change gloves between dirty and clean care. They would expect staff to wash hands after performing peri-care and to perform hand hygiene between residents, as well as wash the entire peri-area when performing peri-care. They would expect staff to wear a gown and gloves while performing a mechanical lift transfer for residents on EBP. 49999

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 52. Review of the facility's policy titled, Cleaning Instructions: Floors, Work Tables, Counter, Refrigerator, and Freezer, dated 2016, showed: - Floors will be kept clean and sanitary, washed daily or as needed; - Wipe down outside of refrigerator and freezer with a clean cloth dipped in sanitizing solution as needed; - Work tables and counters will be cleaned and sanitized on a regular basis before and after food preparation, meal service, and as needed. Observations on 12/04/23 at 9:29 A.M., and 4:01 P.M., of the dietary department showed: - The front door panels with a buildup of a milky substance located on the AdvantEdge refrigerators; - Dirt and debris on the floor under the AdvantEdge three door refrigerator; - The front door panels with a buildup of a milky substance located on the Traulsen refrigerator; - Dirt and debris on the floor under the Traulsen three door refrigerator; - The front door panels with a buildup of a milky substance located on the Traulsen refrigerator in the dry/canned goods area; - Dirt and debris on the floor under the Traulsen three door refrigerator; - A long area of scrapes, missing paint and exposed sheetrock the length of the wall behind the steam table; - Debris and dirt on top of an electrical outlet close to the wall clock by the steam table; - A trash can with miscellaneous trash and no lid located by the three compartment sink; - A white pipe with a build up grime and dirt coming out of the floor located near the three compartment sink; - A plunger lay on the floor and not contained with a build up of grime and milky residue located underneath the far left side of the three compartment sink; - A build up of grime and dried splatter on the wall underneath the far left side of three compartment sink; - A trash can overflowed with wet paper towels located under the handwashing sink; - A buildup of grime on the edges of the baseboard and the floor located under the handwashing sink; - Debris and buildup of grime on top and the sides of the [NAME] dishwasher; - Several areas of grime buildup and dirt on the floors throughout the kitchen; - A long narrow area of scrapes, exposed sheetrock and peeled paint the length of the wall located behind the steam table; - An area approximately 5 inch (in.) x 5 in. of exposed sheetrock on the bottom left-side located by the janitorial closet. Observation on 12/04/23 at 4:13 P.M., of the South Hall ice machine showed: - A buildup of a milky substance covered the entire inside of the ice lid; - A buildup of a crusty, milky substance around the edges where the ice lid sat; - A buildup of a dried, milky substance on the floor, wall and air gap pipe located at the bottom right-side area. Review of the Daily/Weekly Cleaning Checklist showed kitchen tasks initialed as completed included floors, baseboards, doors and facing, pipes under sink, counters and trash cans. During an interview on 12/05/23 at 8:23 A.M., Dietary Aide A said the floors should be free of buildup of grime and dirt. There should be no dirt and debris under the counter tops, refrigerators or other kitchen equipment. Kitchen surfaces should not have a milky buildup after cleaning. Trash cans should have lids on them when not in use. Maintenance was notified of any paint concerns and had not seen any concerns in the kitchen area. During an interview on 12/05/23 at 8:33 A.M., Dietary Aide B said the floors should be free of buildup of grime and dirt. There should be no dirt and debris under the counter tops, refrigerators or other kitchen equipment. Kitchen surfaces should not have a milky buildup after cleaning. Trash cans should have lids on them when not in use. Maintenance was notified of any paint concerns and had not seen any concerns in the kitchen area. During an interview on 12/05/23 at 8:42 A.M., the Dietary Manager (DM) said the staff were probably signing off on tasks as completed, but could be doing a better job at cleaning the kitchen overall. Kitchen cleaning duties were being done, but there needed to be a little more elbow grease put into it. During an interview on 12/05/23 at 9:42 A.M., the Administrator said the kitchen area should be free of grime, dirt, and debris including the floors, the counter tops and the surfaces, the refrigerators and the other kitchen equipment. She would expect the kitchen to be clean at all times.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 52. Review of the facility's policy titled, Homelike Environment, dated 2023, showed: - In accordance with residents' right, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible; - Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment; - Report any unresolved environmental concerns to the Administrator. Observations on 12/04/23 at 9:45 A.M., and 12/05/23 at 9:22 A.M., of the [NAME] Hall showed: - Several small areas of exposed sheetrock on the right-side of the wall of the bed near the door in Room W02; - A 3 inch (in.) x 4 in. area of exposed sheetrock above the headboard located above the bed near the door in Room W02; - Several small areas of exposed sheetrock and peeled paint under the light fixture by the bed near the door in Room W04; - Several small areas of exposed sheetrock on the left-side of the wall located by the bed near the door in Room W04; - Several small areas of exposed sheetrock on the wall under the light fixture located by the bed near the door in Room W10. Observations on 12/04/23 at 11:22 A.M., and 12/05/23 2:01 P.M., of the therapy department showed: - Four air vents approximately 6 in. x 12 in. with a dark brown substance and a buildup of dust and debris located on the ceiling; - A large air vent approximately 20 in. x 24 in. with a buildup of dust and debris located on the ceiling near the privacy curtain. Observations on 12/06/23 at 8:22 A.M., of the South Hall showed: - A 1 foot (ft.) x 1 1/2 ft. dark circle located on the ceiling near room [ROOM NUMBER]; - A 1 ft. x 1 ft. air vent located on the ceiling with a dark brown substance near room [ROOM NUMBER]; - An 8 ft. cracked area of ceiling near the dining room with exposed sheetrock and screws and approximately a 3 foot crack running east and west from the original area; - Approximately 3 in. x 4 in. piece of vinyl plank flooring missing near the dresser, a 4 in. x 5 in. piece of vinyl flooring missing under the air conditioner/heating unit, and a 3 ft. x 6 in. strip of vinyl flooring missing in front of the closet in room [ROOM NUMBER]; - A 6 in. x 1 ft. air vent located on the ceiling with a build up of a gray substance near room [ROOM NUMBER]; - A large area around a call light of peeled paint and exposed sheetrock above the resident's door of room [ROOM NUMBER]; - Approximately 20 in. x 2 ft. air vent located on the ceiling covered with a buildup of dust and debris near the double doors; - A 6 in. x 1 ft. vent located on the ceiling covered with a a dark brown substance near room [ROOM NUMBER]; - A 6 in. x 1 ft. vent located on the ceiling covered with buildup of dust and debris near room [ROOM NUMBER]. Observations on 12/06/23 at 8:40 A.M., of the South Hall shower room showed: - A 6 in. area of peeled paint around the vent in the ceiling; - 14 - 1 in. x 1 in. cracked square tiles in the shower. Observation on 12/06/23 at 8:45 A.M., of the East Hall showed several areas of peeled paint and exposed sheetrock above the bed near the window and above the sitting area of room [ROOM NUMBER]. Review of the Maintenance and/or Housekeeping Job Orders, dated 6/13/23 through 12/5/23, showed no current requests for areas of concern documented. During an interview on 12/05/23 at 8:23 A.M., Dietary Aide A said the maintenance department was notified of any concerns such as exposed sheetrock or peeled paint. He/she had not seen any concerns in the kitchen area that needed to be reported to the maintenance department or written on the maintenance job log. During an interview on 12/05/23 at 8:33 A.M., Dietary Aide B said the maintenance department was notified of any concerns such as exposed sheetrock or peeled paint. He/she had not seen any concerns in the kitchen area that needed to be reported to the maintenance department or written on the maintenance job log. During an interview on 12/05/23 at 8:36 A.M., Housekeeper C said there were maintenance logs hanging by the mechanical room door and on South Hall to write down any needed repairs or concerns. He/she had reported areas of exposed sheetrock, peeled paint, torn wallpaper and wrote the concerns on the maintenance job log. During an interview on 12/05/23 at 8:42 A.M., Housekeeper D said there was a maintenance log hanging by the mechanical room door to write down any needed repairs or concerns. He/she had not noticed any environmental concerns such as peeled paint, exposed sheetrock or any other environmental concerns to report and write down on the maintenance job log. During an interview on 12/05/23 at 9:36 A.M., the Maintenance Supervisor (MS) said he/she would expect staff to write down any needed repairs such as exposed sheetrock, peeled paint or other environmental concerns on the maintenance job log so they could be addressed in a timely manner. During an interview on 12/06/23 at 8:35 A.M., the Administrator said she would expect staff to tell maintenance and/or her about any environmental issues throughout the facility. She would expect staff to notify maintenance and/or her regarding issues related to peeled paint, peeled wall paper, exposed sheetrock, missing floor panels, cracked tiles, vents and ceiling concerns so they could be addressed in a timely manner.

Based on interview and record review, the facility failed to include all core elements of an antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility census was 67. Record review of the facility's Antibiotic Stewardship Program policy, undated, showed the policy did not include: - A procedure to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; - A procedure to promote and implement a facility-wide system to monitor the use of antibiotics including a system of reports related to monitoring antibiotic usage and resistance data; - Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; - Educate staff and residents about the antibiotic stewardship; - Documentation of a review completed annually or as needed. Record review of the facility's Census and Conditions of Residents, dated 11/19/19, showed six residents currently receiving antibiotics. During an interview on 11/22/19 at 11:39 [NAME]M., the Director of Nursing (DON) said the antibiotic information that the facility collects doesn't go to their monthly Quality Assurance and Assessment (QAA) committee to be reviewed for concerns. The facility staff do not look at the antibiotic process as a whole, they look at individual infections for the past month. She didn't realize they weren't conducting an ongoing review for the antibiotic stewardship.

Based on interview and record review, the facility failed to implement care plans with specific interventions tailored to meet individual needs for three residents (Resident #29, #51, and #61) out of 17 sampled residents. The facility census was 67. 1. Record review of Resident #29's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/13/19, showed: - admission date of [DATE]; - [DIAGNOSES REDACTED]. cells or neurons), and depression; - Received antipsychotic (a major tranquilizer) medication; - Received antidepressant medication. Physician order [REDACTED]. - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, revised on 11/7/19, showed: - [DIAGNOSES REDACTED]. - A focus of advanced [MEDICAL CONDITION]; - No individualized interventions for the [MEDICAL CONDITION] care; - A focus of the antidepressant medication use to help improve his/her mood; - A focus of the antipsychotic medication use to help control some of his/her thoughts and behaviors; - No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors. 2. Record review of Resident #51's quarterly MDS, dated [DATE], showed: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Severely impaired cognitive status; - Received antipsychotic medication; - Received antidepressant medication. Record review of the resident's POS, dated (MONTH) 2019, showed: - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, reviewed on 11/5/19, showed: - [DIAGNOSES REDACTED]. - A focus of [MEDICAL CONDITION]; - No individualized interventions for the [MEDICAL CONDITION] care; - A focus of the antidepressant medication use to help improve his/her mood; - A focus of the antipsychotic medication use to help control some of his/her thoughts and behaviors; - No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors. 3. Record review of Resident #61's admission MDS, dated [DATE], showed: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Received antipsychotic medication; - Received antidepressant medication. Record review of the resident's POS, dated (MONTH) 2019, showed: - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, undated, showed: - [DIAGNOSES REDACTED]. - A focus of the antidepressant medication use to help improve his/her mood; - No non-pharmacological interventions to help improve his/her mood; - No antipsychotic medication use with interventions. During an interview on 11/22/19 at 11:53 [NAME]M., the Director of Nursing (DON) said she would expect a resident's care plan to address Alzheimer's/dementia care, antidepressant medication usage with individualized interventions, and antipsychotic medication usage with individualized interventions. During an interview on 11/22/19 at 12:02 P.M., the MDS Coordinator said he/she is new to this position and he/she didn't realize all that needed to be addressed on each resident's individualized care plans. Record review of the facility's Care Plan policy, undated, showed: - Care planning critical to the quality of service in any care home; - The Care Plan should be the means the identified needs and wishes of the individual will be recorded; - The Care Plan ensures care will be offered consistently by well-informed staff with awareness of the individual care needs; - Care Plans will be updated with quarterly, annual and significant change MDS's; - Care Plans will be updated with any changes in direct care of the individual and reviewed upon any readmission to the facility by the interdisciplinary team (IDT).

Based on interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for three residents (Resident #4, #7, and #60) out of 17 sampled residents. The facility census was 67. 1. Record review of Resident #4's Fall List, dated 5/1/19 - 11/21/19, showed: - Four falls in (MONTH) 2019; - Five falls in (MONTH) 2019; - Four falls in (MONTH) 2019; - Five falls in (MONTH) 2019; - Four falls in (MONTH) 2019; - Seven falls in (MONTH) 2019. Record review of the resident's care plan, reviewed on 11/19/19, showed: - Last documented fall on 1/25/19; - The facility failed to update the care plan to address the 29 falls for 5/1/19 - 11/21/19. 2. Record review of Resident #7's Physician order [REDACTED]. - An order to clean open areas to medial right lower extremity with normal saline, cover with xeroform (an ointment covered dressing) and a dry dressing until healed, dated 6/12/19. Observation of the resident from 11/19/19 - 11/22/19, showed: - The resident with a dressing on his/her lower right leg and ankle. Record review of the resident's care plan, last revised on 11/5/19, showed: - Last skin care interventions dated 2/13/19; - The facility failed to update the care plan for the resident's open skin areas. 3. Observations of Resident #60 showed: - On 11/20/19 at 3:38 P.M., 11/21/19 at 8:08 [NAME]M. and 3:48 P.M., and 11/22/19 at 8:13 [NAME]M., the resident lay in bed without an indwelling catheter (a tube inserted into the bladder to drain urine) or an indwelling catheter collection bag. Record review of the resident's care plan, revised on 10/10/19, showed: - Resident with a special tube that drains his/her bladder; - The collection bag will be covered in a dignity bag; - Will need proper catheter hygiene care performed every shift and as needed; - Observations of urine output for signs of infection; - The catheter may be replaced per the doctor's orders and as needed if it becomes displaced or removed; - The facility failed to update the care plan to show the resident no longer required an indwelling catheter. During an interview on 11/22/19 at 11:50 [NAME]M., the Director of Nursing (DON) said she would expect a resident's care plan to be revised to reflect the changes of care the resident needs. She said Resident #60 has not had an indwelling catheter since he/she returned from his/her last hospitalization in (MONTH) 2019. During an interview on 11/22/19 at 12:02 P.M., the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) Coordinator said that the residents' care plans should be updated as their care changes. He/she is new to this position so he/she is still trying to learn what needs to be updated on the care plans. Record review of the facility's Care Plan policy, undated, showed: - Care planning critical to the quality of service in any home; - Care Plans will be updated with quarterly, annual, and significant change MDS's; - Care Plans will be updated with any changes in direct care of the individual and reviewed upon any readmission into the home by the interdisciplinary team (IDT); - The care plan in itself will be a guide for care, listing both strengths and weaknesses, with individual goals and interventions to accomplish them.

Based on observation, interview and record review, the facility failed to document, assess, and revise treatment for one resident (Resident #7) out of a sample of two residents. The facility census was 67. Record review of the facility's Pressure Sore Prevention policy, undated, showed: - The direct care nursing staff will observe throughout each day the condition of the resident's skin when care provided; - If skin impairment found when the resident bathed, a skin communication form will be completed and forwarded to the charge nurse; - Once a week, a licensed nurse shall perform a head to toe assessment on each resident identified; - Interventions will be evaluated on their effect on measurable outcomes. 1. Record review of Resident #7's Physician order [REDACTED]. - [DIAGNOSES REDACTED]. - An order to clean the open areas to the medial right lower extremity with normal saline, dry, cover with xerform (an ointment covered dressing) and dry dressing until healed, dated 6/12/19; - No change of treatment for the open areas. Record review of the resident's Treatment Administration Record (TAR) for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019, showed: - The treatment for the open areas performed daily. Record review of the resident's medical record showed: - No documentation of the resident's open areas on his/her right lower leg; - No communication between the facility and the physician for the reevaluation of the resident's open areas on his/her right lower leg. During an interview on 11/19/19 at 3:26 P.M., Resident #7 said he/she had open areas or sores on his/her right lower leg and ankle. Observations of the resident showed: - On 11/19/19 at 3:30 P.M. and 4:05 P.M., a kling (a type of gauze used to dress wounds) dressing on the resident's right lower leg and ankle; - On 11/20/19 at 8:25 [NAME]M. and 3:52 P.M., a kling dressing on the resident's right lower leg and ankle; - On 11/21/19 at 8:30 [NAME]M., and 3:30 P.M., a kling dressing on the resident's right lower leg and ankle; - On 11/22/19 at 8:34 [NAME]M., a kling dressing on the resident's right lower leg and ankle. Observation on 11/21/19 at 3:30 P.M., showed: - The resident lay in bed with a kling dressing to his/her right lower leg and ankle; - Licensed Practical Nurse (LPN) A removed the dressing from the resident's right lower leg and ankle; - The resident had one small opened area on the outer lower right ankle area; - The resident had a two inch (in) flat blister on the lower inner right ankle area and two opened, round areas, approximately 3/4's in. in diameter on the lower right leg. During interviews on 11/20/19 at 11:12 [NAME]M. and 11/21/19 at 10:06 [NAME]M., the wound care nurse said the resident has had blisters come up on his/her right lower leg and ankle. We have orders to treat them. The blisters form, we treat them, they dry up, and then they reappear. We keep treating them. The nurses have not been charting on them when the treatments are done. Quarterly Braden assessments (a type of skin assessment to screen for potential skin concerns) are done on each resident and if the resident is not at risk for skin issues, we do not look at the resident's skin every week. Resident #7 had a Braden score of 19 and he/she is up and about, so he/she did not qualify for a weekly skin assessment. The wound care nurse said he/she had not been notified the areas were still open or he/she would have assessed the areas weekly. During an interview on 11/22/19 at 11:33 [NAME]M., the Director of Nursing (DON) said she would expect staff to chart on treatment and skin issues found and ongoing issues. The DON said she would also expect staff to notify the proper staff for ongoing treatments and plans and would expect the wound care nurse to know about all skin issues, not just pressure ulcers (localized areas of tissue damage) on all residents.

Based on interview and record review, the facility failed to ensure residents diagnosed with [REDACTED]. level of functioning and psychosocial needs for three residents (Resident #29, #51, and #61) out of four sampled residents. The facility census was 67. 1. Record review of Resident #29's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/13/19, showed: - admission date of [DATE]; - [DIAGNOSES REDACTED]. cells or neurons), and depression; - Severely impaired cognitive status; - Received antipsychotic (a major tranquilizer) medication; - Received antidepressant medication. Record review of the resident's Physician order [REDACTED]. - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, undated, showed: - [DIAGNOSES REDACTED]. - A focus of advanced [MEDICAL CONDITION]; - No individualized interventions for the [MEDICAL CONDITION] care; - A focus of the antidepressant medication use to help improve his/her mood; - A focus of the antipsychotic medication use to help control some of his/her thoughts and behaviors; - No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors; - No identification of targeted behaviors with interventions. 2. Record review of Resident #51's quarterly MDS, dated [DATE], showed: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Severely impaired cognitive status; - Received antipsychotic medication; - Received antidepressant medication. Record review of the resident's POS, dated (MONTH) 2019, showed: - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, undated, showed: - [DIAGNOSES REDACTED]. - A focus of [MEDICAL CONDITION]; - No individualized interventions for the [MEDICAL CONDITION] care; - A focus of the antidepressant medication use to help improve his/her mood; - A focus of the antipsychotic medication use to help control some of his/her thoughts and behaviors; - No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors. 3. Record review of Resident #61's admission MDS, dated [DATE], showed: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - Severely impaired cognitive status; - Received antipsychotic medication; - Received antidepressant medication. Record review of the resident's POS, dated (MONTH) 2019, showed: - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, undated, showed: - [DIAGNOSES REDACTED]. - A focus of the antidepressant medication use to help improve his/her mood; - No non-pharmacological interventions to help improve his/her mood; - No antipsychotic medication use with interventions; - No identification of targeted behaviors with interventions. During an interview on 11/22/19 at 11:53 [NAME]M., the Director of Nursing (DON) said she would expect a resident's care plan to address Alzheimer's/dementia care, antidepressant medication usage with individualized interventions, antipsychotic medication usage with individualized interventions, and specific behaviors should be identified and documented on. During an interview on 11/22/19 at 12:02 P.M., the MDS Coordinator said he/she is new to this position and he/she didn't realize all that needed to be addressed on each resident's individualized care plans.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for the use of [REDACTED]. The facility census was 63. 1. Record review of Resident #63's Physician Order Sheet (POS), dated 12/11/18, showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. - The POS did not contain an order for [REDACTED].>Record review of the resident's progress notes, dated 11/30/18 through 12/11/18, showed: - On 12/1/18 at 12:44 A.M., the resident on oxygen at 2 liters (L) minute/(m) via nasal cannula (NC) (supplemental oxygen through tubing into the nostrils); - On 12/3/18 at 7:05 P.M., 12/4/18 at 12:45 A.M., 12/4/18 at 3:05 P.M., 12/5/18 at 12:57 A.M., 12/5/18 at 2:49 P.M., 12/6/18 at 12:15 A.M., 12/7/18 at 2:57 A.M., and 12/7/18 at 4:03 P.M., the resident on oxygen at 2 L/m via NC; - On 12/8/18 at 1:32 A.M., the resident on oxygen at 3.5 L/m via NC; - On 12/8/18 at 2:45 P.M., 12/9/18 at 12:18 A.M., 12/9/18 at 3:01 P.M., 12/10/18 at 12:42 A.M., and 12/11/18 at 12:57 A.M., the resident on oxygen at 2 L/m via NC; - On 12/11/18 at 9:57 P.M., the resident on oxygen at 3 L/m via NC. Observations of the resident showed: - On 12/10/18 at 3:53 P.M., 12/11/18 at 10:42 A.M., and 12/11/18 at 1:59 P.M., the resident lay in bed wearing oxygen at 3.5 L/m via NC; - On 12/12/18 at 8:06 A.M., the resident sat in his/her wheelchair wearing oxygen at 2 L/m via NC; - On 12/12/18 at 4:13 P.M. and 12/13/18 at 9:52 A.M., the resident lay in bed wearing oxygen at 4 L/m via NC. During an interview on 12/12/18 at 8:11 A.M., Certified Nurse Aide (CNA) A said the resident wears oxygen at 2 L/m all the time. During an interview on 12/12/18 at 11:47 A.M., Registered Nurse (RN) B reviewed the resident's POS and said the resident does not have an order for [REDACTED]. During an interview on 12/13/18 at 8:50 A.M., the Director of Nursing said she expects staff to obtain a physician's order for use of oxygen. Review of the facility's Administration of Oxygen policy, undated, showed initiation of oxygen therapy will be performed by a licensed nurse, certified medication technician, and therapist.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices for one resident (Resident #164) out of 16 sampled residents and failed to maintain proper infection control practices when passing ice in the main dining room. The facility census was 63. 1. Observation on 12/12/18 at 9:31 A.M., showed: - Resident #164 lay in bed on his/her back with an indwelling catheter (a tube inserted into the urinary bladder to drain the bladder); - Certified Nurse Aide (CNA) A and Certified Medication Technician (CMT) C provided indwelling catheter care; - CNA A, still wearing the soiled gloves, touched the resident's sheets, right arm, and right leg as he/she rolled the resident to his/her left side. During an interview on 12/12/18 at 10:05 A.M., CNA A said he/she had been taught not to touch clean items with dirty hands or gloves. He/she said he/she should have removed the soiled gloves, cleaned his/her hands, and placed new gloves on his/her hands before touching the sheets and the resident. During an interview on 12/13/18 at 8:50 A.M., the Director of Nursing (DON) said she expects staff not to touch clean items with dirty hands or gloves. She said staff should remove dirty gloves and clean hands before touching any clean items. Review of the facility's Incontinent Care policy, undated, showed staff showed removed gloves, wash hands, and reapply clean gloves. Review of the facility's Standard Precautions, dated (MONTH) 2007, showed: - Wear gloves (clean, non-sterile) when you anticipate direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material; - Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean site); - Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. 2. Observation of the dining room on 12/10/18 at 12:03 P.M., showed: - Staff scooping ice to put in cups and paying the scoop back into the ice container with the handle touching the sides of the container; - Staff holding the cups over the ice container and ice falling back into the ice container after touching the cup. During an interview on 12/12/18 at 1:00 P.M., Kitchen Aide D said there was no where to put the scoop except back in the container. During an interview on 12/12/18 at 1:10 P.M., CNA E said usually there was a tray to lay it on, but there wasn't one there that day. During an interview on 12/12/18 at 2:00 P.M., the DON said she would expect staff to pass ice per facility policy. Record review of the facility's policy on ice pass, undated, showed: - During the ice pass, care is taken to avoid touching the scoop to the carafe; - When an ice scoop is reused, it must be stored in an upright position in a clean container, the scoop handle must remain out of the ice.

Based on interview and record review the facility failed to ensure the accuracy of a resident's advance directive regarding resuscitation status for one resident (Resident #164) out of a sample of 18 residents. The facility census was 63. Record review of Resident #164's Physicians Order Sheet (POS), dated 12/10/18, showed: - FULL CODE (will allow all interventions needed to get their heart started). Record review of Resident #164's Code Status Form, dated 11/28/18, located on the first page of the resident's medical chart, showed: - Do Not Resuscitate (DNR) (does not want any resuscitation measures taken). Record review of Resident #164's baseline care plan dated 11/29/18 showed DNR status. Record review of Resident #164's facesheet showed full code. During an interview on 12/11/18 at 9:30 A.M., Resident #164 said he/she expected the staff to do everything they could in the event he/she should stop breathing. During an interview on 12/12/18 at 4:00 P.M., the Director of Nursing said she would expect the code status on each resident to be an accurate reflection of the resident's wishes and the doctor's orders. She would expect the correct code status to be on all the resident's personal and medical information. During an interview on 12/13/18 at 9:43 A.M., the Director of Social Services (SSD) said he/she obtained the Resident's code status upon his/her entering the facility. His/her spouse signed after a meeting was held with the resident, the spouse and his/her attorney to determine what the decision was going to be. The spouse has Power of Attorney. The SSD said if the resident had changed his/her mind she was unaware of it but she would go and speak with him/her immediately. During an interview with the Administrator on 12/13/18 at 12:00 P.M., he said they had spoken with Resident #164 that morning and he/she was not clear on his/her wishes at this time. The Administrator said he is going to contact the Resident's lawyer today and get clarification before changing any documentation on the Residents wishes. Facility policy on Advance Directives and Life Sustaining Treatment, undated, showed: - Every resident will be asked on admission if the resident has executed an advance directive; - When the resident or legal representative executes an advance directive, the physician will be notified of the resident's (representative's) wishes and agreement with the advance directive will be included in the physician's orders [REDACTED]. - The resident's advance directive will be reviewed on admission, with any significant change in condition and at least quarterly during the care plan conference to ensure full understanding and continued wishes of the resident/representative.

Based on interview and record review, the facility failed to update and revise care plan for two residents (Resident #56 and #42) out of 16 sampled residents. The facility census was 63. 1. Record review of Resident #56 physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. causing high blood sugar); - An order on 10/16/18 to cleanse left buttock with facility wound cleanser, pat dry and apply [MEDICATION NAME] (a wound gel), and apply dry dressing twice a day until healed; - An order on 11/26/18 to cleanse wound to right heel with normal saline, pat dry, apply [MEDICATION NAME] gel to wound bed, cover with dry dressing twice a day and as needed; - An order on 11/26/18 for left 5th toe, left heel, left dorsal foot, right dorsal foot to cleanse with normal saline, pat dry, apply santyl (a wound gel that helps to break up and remove dead skin and tissue) nickel thick and cover with dressing twice a day and as needed. Record review of Resident #56's care plan updated 6/11/18, showed: - Some open areas on lower left leg that are vascular due to poor circulation; - An open area on left 2nd toe; - A recurring area on bottom that is healed at this time. Review of the resident's wound care note, dated 12/13/18 showed: - The resident with wounds to the left 5th toe, left buttock, left heel, left dorsal foot, right heel, and right dorsal foot. During an interview on 12/12/18 at 6:12 P.M., the Minimum Data Set (MDS) Coordinator said the resident's care plan should have been updated to include all wounds 2. Record review of Resident #42's care plan updated 12/6/18, showed: - An order to wear TED ([MEDICAL CONDITION] Embolic Deterrent), a compression stocking worn to promote optimum blood flow for the prevention of chronic swelling, blood clots or [MEDICAL CONDITIONS], to both lower extremities to help with circulation. Record review of the resident's POS, dated 12/10/18, showed: - No order for TED hose. During an interview on 12/13/18 at 8:30 A.M., the MDS Coordinator said the resident's care plan should have been updated to show no order for TED hose. During an interview on 12/13/18 at 8:50 A.M., the Director of Nursing said she expects staff to update a resident's care plan within 24 hours of a change in condition. She said she expects staff to care plan a resident's wounds and when physician's orders [REDACTED]. Review of the facility's Care Plan policy, undated, showed: - Care planning is critical to the quality of service in any care home; - It is designed to inform caregivers of the individual's plan of care; - It ensures that care is offered consistently by well-informed staff, aware of the individual care needs.

Based on interview and record review, the facility failed to recognize a significant change in status for one resident (Resident #56) out of 16 sampled residents. The facility census was 63. 1. Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/27/18, showed: - Supervision with setup assist of staff for bed mobility and transfers; - Limited assistance of one staff for walking in room; - Extensive assist of one staff for dressing and personal hygiene; - Limited assist of two staff for toilet use; - Total dependence of one staff for bathing; - Always continent of bladder and bowel. Record review of Resident #56's quarterly MDS, dated [DATE], showed: - Extensive assist of two staff for bed mobility, transfers, walking in room, dressing, toilet use, and personal hygiene; - Total dependence of two staff for bathing; - Frequently incontinent of bladder and bowel. - A significant change in condition due to a decline in two or more areas. During an interview on 12/12/18 at 6:12 P.M., the MDS Coordinator said she did not think a significant change MDS was needed since the resident's condition can vary. She said the resident's quarterly MDS on 11/20/18 showed a decline in the resident's condition in more than two areas. She said a significant change MDS should be completed within 14 days after the resident's change in condition. During an interview on 12/13/18 at 8:50 A.M., the Director of Nursing said she expects staff to complete a significant change MDS within 14 days of a resident's significant change in condition. Review of the facility's Resident Assessment Instrument (RAI)/MDS policy, undated, showed: - The RAI process is coordinated by an RN and includes an interdisciplinary team (IDT); - Significant change in status as identified appropriate by the IDT and according to guidelines in the RAI manual; - Change in status is often subtle and should be considered as a possibility with any change in the resident's plan of care; - Criteria for determining a change in status is identified in the RAI manual; - When a resident meets the change in status criteria, the RN will schedule the MDS; - This is to be done within 14 days of the determination in the change in status.

Based on interview and record review, the facility failed to provide written notification regarding their bed-hold policy for six residents (Resident #56, #48, #62, #42, #58, and #23) out of six sampled residents. This deficient practice had the potential to effect all residents. The facility census was 63. 1. Record review of Resident #56's nurse notes showed: - Resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident's record showed no documentation of the bed hold policy provided to the resident or the resident's representative at the time of transfer. 2. Record review of Resident #48's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; Review of the resident's record showed no documentation of the bed hold policy provided to the resident or the resident's representative at the time of transfer. 3. Record review of Resident #62's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; Review of the resident's record showed no documentation of the bed hold policy provided to the resident or the resident's representative at the time of transfer. 4. Record review of Resident #42's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; Review of the resident's record showed no documentation of the bed hold policy provided to the resident or the resident's representative at the time of transfer. 5. Record review of Resident #58's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; Review of the resident's record showed no documentation of the bed hold policy provided to the resident or the resident's representative at the time of transfer. 6. Record review of Resident #23's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; Review of the resident's record showed no documentation of the bed hold policy provided to the resident or the resident's representative at the time of transfer. During an interview on 12/11/18 at 5:50 P.M., the Director of Nursing said the facility has not been providing any information to the resident and/or the resident's representative regarding the facility's bed hold policy at the time of transfer to the hospital. Review of the facility's Bed Hold policy, undated, showed: - The resident may request that the facility hold open a bed for the resident; - The resident shall be given written notice of the bed hold option at the time of admission, hospitalization , or therapeutic leave.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reason for the transfer for six residents (Resident #56, #48, #62, #42, #58, and #23) out of six sampled residents transferred to the hospital. The deficient practice had the potential to effect all residents. The facility census was 63. 1. Record review of Resident #56's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital and the reason for the transfer. 2. Record review of Resident #48's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital and the reason for the transfer. 3. Record review of Resident #62's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital and the reason for the transfer. 4. Record review of Resident #42's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital and the reason for the transfer. 5. Record review of Resident #58's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital and the reason for the transfer. 6. Record review of Resident #23's medical record, showed: - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital and the reason for the transfer. During an interview on 12/11/18 at 5:50 P.M., the Director of Nursing said the facility has not been providing any written information to the resident and/or the resident's representative regarding transfers to the hospital and the reason for the transfers. The facility did not provide a policy regarding transfer and discharges from the facility.