Every finding on record at Cypress Pointe Rehabilitation Center

Based on observations, record review, and resident, staff, and Physician interviews, the facility failed to remove a dressing and visually assess a resident's dialysis fistula (an arteriovenous (AV) fistula is a surgical connection between an artery and a vein, usually in the forearm or upper arm created to provide reliable access for dialysis) as ordered by the physician for 1 of 2 residents reviewed for dialysis (Resident #5).The findings included:Resident #5 was admitted to the facility 11/16/2023. Diagnoses included arteriovenous (AV) fistula, end stage renal disease, dialysis, and peripheral vascular disease.Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and was receiving dialysis.Resident #5's physician orders dated 2/2/2026, revealed an order to remove dressing to AV fistula on night of dialysis, to avoid skin breakdown and damage to AV fistula, in the evening every Monday, Wednesday, and Friday.The Care Plan for Resident #5 dated 11/29/2023 and updated on 2/27/2026 revealed a plan of care for dialysis. Interventions included checking and changing the dressing to AV fistula as ordered and to observing the site for signs and symptoms of infection.An observation and interview with Resident #5 were completed on 5/5/2026 at 11:08 AM. Resident #5 was observed to have a gauze dressing secured with tape to left upper arm AV fistula. Resident #5 stated the dressing was applied to his left upper arm AV fistula yesterday by the dialysis nurse after he completed treatment. An interview was conducted with Nurse #1 on 5/5/2026 at 3:37 PM. Nurse #1 stated she was the nurse assigned to care for Resident #5 on 5/4/2026 during the 3:00 PM to 11:00 PM shift. She stated she was supposed to remove the dressing from Resident #5's left arm AV fistula after he returned from dialysis but forgot because she was busy with another resident. She acknowledged she knew she was required to remove the dressing when the resident returned from dialysis and assess the site for complications. An interview with the Physician occurred on 5/6/2026 at 8:57 AM. The Physician stated that it was important for Resident #5 to have his dressing removed and his AV fistula assessed by the nursing staff after dialysis because he had significant vascular disease and had experienced complications with hypotension and falls after dialysis. He indicated the nursing staff needed to check his AV fistula because it was literally his lifeline.An interview with the Director of Nursing (DON) was completed on 5/6/2026 at 1:15 PM. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after Resident #5 returned from dialysis. She stated she expected nursing staff to follow physician orders, remove the dressing, and assess the site for signs and symptoms of infection.

Based on record review, and staff and Physician interviews, the facility failed to maintain complete medical records by not documenting a reweight following a significant increase in the weekly weights that were obtained for a resident admitted with acute congestive heart failure. Resident #72 experienced no significant outcome. This occurred for 1 of 1 resident reviewed for weight management (Resident #72). Findings included. Resident #72 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and fluid overload. A physician's order dated 2/27/25 for Resident #72 revealed to obtain weekly weights. Review of Resident #72's electronic medical record revealed the following weights: 2/25/25 at 5:28 PM the admission weight was 154.0 lbs. documented by Nurse #3. 3/03/25 at 9:26 AM the weight was 166 lbs. documented by Nurse #2. 3/15/25 at 3:57 PM the weight was 181 lbs. (pounds) documented by Nurse #1. Review of Resident #72's electronic medical record revealed no documentation that Resident #72 was reweighed on 3/3/25 or 3/15/25 to determine if the weights were accurate. During an interview on 3/20/25 at 4:22 PM Nurse #2 stated she checked Resident #72's weight on 3/3/25 and saw the increase and rechecked the weight but did not document the reweight that was obtained. She stated she verbally reported the weight to the Physician that day and the Physician assessed Resident #72 that day. During an interview on 3/20/25 at 12:20 PM Nurse #1 stated she checked Resident #72's weekly weight on Saturday 3/15/25 and it was up but he was not symptomatic. She reported that she weighed Resident #72 again on Sunday 3/16/25 and his weight was the same and he remained asymptomatic. She stated she did not think to document the reweight that was obtained. She notified the Nurse Practitioner of the weight increase on Monday morning 3/17/25. A physician's note dated 3/3/25 at 10:26 AM revealed Resident #72 was seen at the bedside today. He reported he was doing better. He denied any lower extremity edema or shortness of breath. A physician's order dated 3/5/25 for Resident #72 revealed a new order to obtain weekly weights due to congestive heart failure. A nursing progress note dated 3/15/25 at 1:09 PM documented by Nurse #1 revealed Resident #72's vital signs were within normal limits. There was no documentation that a reweight was obtained. A physician's note dated 3/17/25 at 10:32 AM revealed Resident #72 was seen at the bedside today. He reported doing well and without acute concerns. His weight was up but he feels well. During an interview on 3/20/25 at 10:00 AM the Physician stated that he was in the facility daily Monday through Friday. He stated that Resident #72 was admitted recently with congestive heart failure and weekly weights were ordered. He indicated that when a weight was significantly up from the previous weight, then a reweigh should occur to determine accuracy, and the weight should be documented in the medical record. During an interview on 03/20/25 at 4:05 PM the Director of Nursing (DON) stated the Physician was in the facility Monday through Friday and the nurses verbally reported to him daily. She indicated that both nurses should have documented the reweight that was obtained following the significant increase in Resident #72's weight on 3/3/25 and 3/15/25. Reweights were obtained to determine accuracy. She stated education would be provided.

Based on observations, record review, staff, Physician Assistant, Registered Dietician, and Physician interviews the facility failed to maintain a system to identify weight loss by not obtaining monthly weights on residents at risk for nutritional decline including weight loss for 3 of 7 residents ( Resident #77, 71, 37) and failed to obtain a weight and verify the accuracy of a weight for a 1 of 7 residents (Resident #13) reviewed for nutrition. Findings included: 1. Resident #77 was admitted to the facility on [DATE]. Diagnoses included above the knee amputation to left leg, congestive heart failure (CHF), chronic respiratory failure, and protein calorie malnutrition. Review of the weight log for Resident #77 revealed there was one weight recorded with the use of a mechanical lift of 125 pounds (lbs.) dated 01/16/24. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #77 was cognitively aware. She had an impairment to one side to lower extremity and received diuretic medication (medication to remove fluid from the body). Resident #77's weight was recorded as 125 lbs. She was on a therapeutic diet and required supervision with set up only with meals. Resident #77 had no rejection of care. A review of Resident #77's care plan dated 01/22/24 revealed a plan of care was in place for altered cardiovascular status related to congestive heart failure with interventions to include, in part, diet consult, monitor for edema (swelling), changes in weight and shortness of breath. Review of Resident #77's electronic medical record on 02/19/24 revealed no order was in place to obtain a monthly weight. Review of Resident #77's activity of daily living (ADL) log for oral meal intake from February 1 through February 22, 2024, revealed the following: Breakfast: Resident #77 consumed 0-25% of her meal 10 out of 22 days, 26-50% of her meal 3 out of 22 days, 51-75% of her meal 7 out of 22 days and 76-100% of her meal 1 out of 22 days. Lunch: Resident #77 consumed 0-25% of her meal 11 out of 22 days, 26-50% of her meal 5 out of 22 days, 51- 75% 4 out of 22 days, and 76 to 100 % 0 out of 22 days. Dinner: Resident #77 consumed 0-25% of her meal 7 out of 22 days, 26-50% of her meal 1 out of 22 days, 51-76% of her meal 9 out of 22 days and 76 to 100 % 0 out of 22 days. An interview with Resident #77 on 02/19/24 at 11:40 AM revealed she felt like she was losing weight and wanted to know if she could get a nutritional supplement because she was not eating very well. An interview with Nurse Aide (NA) #3 on 02/21/24 at 1:15 PM revealed she worked as a restorative aide and a nurse aide and helped obtain weights. She stated she did not get any monthly weights during the month of January or February because she was not asked to get any weights. NA #3 added, usually the Director of Nursing would give her a list of weights to be obtained at the beginning of the month. She stated she only obtained weights on the new admissions during the month of January and February. An interview with Nurse #2 on 02/21/24 at 10:26 AM was conducted. Nurse #2 stated Resident #77 could feed herself without difficulty and had a fair appetite. She indicated she believed the nurse aides obtained the weights. She was unaware if Resident #77 had weight loss. A phone interview was conducted with the Registered Dietician on 02/21/24 at 3:18 PM. The Registered Dietician stated she conducted resident evaluations on admission, readmission, annually, or for a change of condition such as significant weight loss, insidious (gradual) weight loss, or a new pressure wound. During her evaluations she reviewed the weight reports from the previous 6 months to identify any significant weight changes or trends. She indicated there had been issues with monthly weights being obtained and recorded and she had discussed this with the Administrator and Director of Nursing a few weeks ago. The Registered Dietician indicated there was no agreement made during the conversation to not obtain monthly weights. The Registered Dietician stated Resident #77 was admitted last month and she would like to have a weight for this month since she was a new admission. The Registered Dietician reported she was unaware that Resident #77 was requesting a specific nutritional supplement and indicated the facility did not provide the one she wanted, but they have another nutritional supplement that they could offer. The Registered Dietician stated that Resident #77's congestive heart failure (CHF) was stable and she would not expect a weekly weight unless there was a change in her CHF condition, but at the very least she would expect a monthly weight especially since she was a new admission and her oral intake was fair. The Registered Dietician added she utilized the monthly weights as her best measure for monitoring the resident's nutritional status and if there was a decline. An interview was conducted with the facility Physician on 02/21/24 at 10:00 AM. The Physician stated the monthly weights were needed to determine weight loss or gain and to monitor nutritional status. An interview was conducted with the Physician Assistant on 02/21/24 at 10:30 AM. The Physician Assistant stated she expected to see a monthly weight recorded for each resident to assist in determining the resident's nutritional status and to determine weight loss. The Physician Assistant stated there was a conversation with the Director of Nursing and the Administrator regarding obtaining monthly weights, but there was no agreement made regarding not getting monthly weights. The Physician Assistant stated it was important for weights to be obtained at least monthly to monitor for significant weight loss and to determine if interventions were needed such as lab work or adding medications or supplements. She indicated if a resident was on hospice, they would not require a monthly weight but for the other residents who were at risk for nutritional decline due to their diagnoses or poor oral intake she would expect to see monthly weights. During an interview on 02/21/24 at 4:35 PM, the Director of Nursing stated there was not a weight policy for residents in the facility including residents with a diagnosis of heart failure. The Director of Nursing stated weights were obtained based on clinical findings and assessments by the nurse, the PA, and the Physician and when they evaluated the resident's oral intake and lab values. The Director of Nursing added, if they identified an area of concern such as poor oral intake or abnormal lab values, she would make a list for the Restorative Aides to obtain weights. She stated it was decided by herself and the Administrator that they wanted to have a more homelike environment and not weigh every resident every month. On 02/22/24 at 11:15 AM, a weight was obtained for Resident #77 with Nurse Aide (NA) #4 and the Unit Manager using the mechanical lift. Resident #77's weight was 95.4 lbs. Resident #77 stated I knew I had lost weight, but I did not think it was this much! During an interview with Resident #77 on 02/22/24 at 11:30 AM, she reported she would like to be we weighed monthly so that she can monitor her weight. Resident #77 stated she did not recall being asked by any staff member if she wanted to be weighed or not. An interview was conducted with the Director of Nursing on 02/22/24 at 11:30 AM. The Director of Nursing reported that based on the weight obtained on the mechanical lift, Resident #77 had shown a significant weight loss of 30 lbs. and she was not sure of the accuracy. A reweight was suggested. A follow up phone interview was conducted with the Physician Assistant on 02/22/24 at 1:20 PM. The Physician Assistant revealed she was surprised to hear the resident had a significant weight loss since her lab values were within normal limits and her oral intake was adequate. She stated she agreed that the facility should be obtaining monthly weights on all the residents unless the residents requested not to and the resident was care planned to not have a weight done. The Physician Assistant added that obtaining the monthly weights was in the best interest of the residents to monitor and evaluate their nutritional status. The Physician Assistant stated although Resident #77's lab values and oral intake were adequate, she still had a weight loss and if monthly weights were not getting done, it may have been a while before realizing Resident #77 had a weight loss. A reweigh was obtained on 02/22/24 at 1:10 PM for Resident #77 with the Rehab Director from the therapy department and the DON using a wheelchair. The resident's wheelchair weight was 26 lbs. Resident #77 was transferred to the wheelchair and the weight with the resident on the wheelchair was 132 lbs. - 26 lbs. for the wheelchair totaling a 19 lb. weight loss for Resident #77. An interview was conducted with the Director of Nursing and she confirmed Resident #77 had an actual significant weight loss of 19 lbs. since admission. She confirmed that although her labs were within normal limits and her oral intake was fair, Resident #77 had a significant weight loss and she did not know if the weight loss may not have been noticed since monthly weights were not being done. 40044 2. Resident #71 was admitted to the facility on [DATE] with diagnoses including heart failure, protein calorie malnutrition, and chronic kidney disease. A care plan dated 12/05/23 revealed Resident #71 was at risk for decreased nutritional status and dehydration related to his diagnoses. The goal of care was to be free from significant weight changes through the next review date. Interventions included, in part, to obtain weights as ordered. The MDS assessment dated [DATE] revealed Resident #71 had moderately impaired cognition. He required supervision/touching assistance with eating. His weight was 169 pounds (lbs.) with no weight loss. He had no rejection of care. A nutritional evaluation note documented by the Registered Dietician on 12/19/23 revealed, in part, Resident #71 was at risk for nutritional decline. He received a regular diet. His average meal intake ranged from 26% to 76 %. He was at risk for nutritional decline due to his advanced age, variant intake, and progression of disease. The plan of care included monitoring weight, food intake, and skin integrity. Review of Resident #71's electronic medical record on 02/19/24 revealed no weight was obtained since the admission weight on 11/27/23 of 169 lbs. Review of Resident #71's electronic medical record on 02/19/24 revealed no order was in place to obtain a monthly weight. During an interview on 02/20/24 at 3:50 PM, Nurse #4 stated Resident #71 was compliant with care. He could feed himself without difficulty and had a fairly good appetite. She indicated the nurse aides obtained the weights. She stated she worked at the facility for 5 months and was not consistently assigned to Resident #71 and she was unaware if Resident #71 had weight loss. During an interview on 02/21/24 at 3:18 PM, the Registered Dietician stated she conducted resident evaluations on admission, readmission, annually, or for a change of condition such as significant weight loss, insidious weight loss, or a new pressure wound. During her evaluations she reviewed the weight reports from the previous 6 months to identify any significant weight changes or trends. She stated monthly weights were being done up until mid-December of 2023. She indicated she had discussed her concerns regarding not having monthly weights obtained since December with the Administrator and Director of Nursing a few weeks ago. The Registered Dietician indicated there was no agreement made during the conversation to not obtain monthly weights. She stated when she did the nutritional evaluations for residents in the facility in January 2024, she did not have any weights to go on and she requested weights from Unit Manager #1 and the Director of Nursing at that time. She reported there were no weights recorded after her request. She stated she did not enter weight orders into the electronic medical records, but she expected to see at least a monthly weights recorded for each resident. The Registered Dietician stated Resident #71 was on the list of weights she requested for January 2024, and she only had the resident's recent laboratory results to review during the evaluation. She stated Resident #71's BUN (blood urea nitrogen - used to determine kidney function) was slightly elevated which she attributed to his hydration status and the plan of care for Resident #71 included to encourage fluids throughout the day. The Registered Dietician stated she planned to add a nutritional supplement and wanted to see the current weight to make further recommendations. During an interview on 02/21/24 at 10:30 AM, the Physician Assistant stated she expected to see a monthly weights recorded for each resident to assist in determining the resident's nutritional status and to determine weight loss. She stated there was a conversation with the Director of Nursing and the Administrator regarding obtaining monthly weights and there was no agreement regarding not getting monthly weights. The Physician Assistant stated it was important for weights to be obtained at least monthly to monitor for significant weight loss and to determine if interventions were needed such as lab work or adding medications or supplements. The Physician Assistant added if a resident was on hospice, they would not require a monthly weight, but for the other residents who were at risk for nutritional decline and weight loss she expected monthly weights. During an interview on 02/21/24 at 4:35 PM, the Director of Nursing stated there was not a weight policy for residents in the facility including residents with a diagnosis of heart failure. She stated conversations were had with the Physician and the Physician Assistant about not having to obtain monthly weights in order to provide a more homelike environment. The Director of Nursing did not indicate that the Physician and Physician Assistant were in agreement with this and stated that the decision was made to not obtain weights between her and the Administrator. During an interview on 02/21/24 at 10:00 AM, the Physician indicated Resident #71 was at risk for nutritional decline and monthly weights were needed to determine weight loss or gain. During an interview on 02/22/24 at 1:00 PM, Resident #71 was alert to self and situation. He indicated he would not be opposed to having his weight obtained. During the investigation on 02/22/24 a current weight was requested and obtained for Resident #71. The new weight was 167 lbs. indicating a 2 lb. weight loss. 3. Resident #37 was admitted to the facility 05/20/19 with diagnoses including, in part, adult failure to thrive, nutritional anemia, and muscle weakness. A care plan dated 12/05/23 revealed Resident #37 was at risk for nutritional decline and dehydration related to adult failure to thrive, anorexia, nutritional anemia, and receiving a mechanical diet. The goal of care was to be free from significant weight changes. There was no intervention in place to monitor weights. The MDS annual assessment dated [DATE] reveled Resident #37 had moderately impaired cognition. She had impaired range of motion on one side. She required set up assistance with meals. She had no rejection of care. A nutritional evaluation note documented by the Registered Dietician on 01/25/24 revealed Resident #37's meal intake was 51% to 100%. It was noted that there was no weight available. The plan of care was to monitor intake, weight, and skin integrity. Review of Resident #37's electronic medical record on 02/19/24 revealed the following weights recorded: 08/08/23 a weight of 123.4 lbs. 09/06/23 a weight of 122.4 lbs. 10/07/23 a weight of 124.4 lbs. 12/14/23 a weight of 123.7 lbs. Review of Resident #37's electronic medical record on 02/19/24 revealed no order was in place to obtain a monthly weight. During an interview on 02/20/24 at 3:50 PM, Nurse #4 stated Resident #37 was compliant with care and she could feed herself. She indicted she was not aware if Resident #37 had weight loss or weight gain. During an interview on 02/21/24 at 3:18 PM the Registered Dietician stated Resident #37 was included in the residents that she requested weights on in January 2024. She stated she expected to see monthly weights for Resident #37. During an interview on 02/21/24 at 10:30 AM the Physician Assistant stated she expected to see a monthly weight recorded for Resident #37 in order to assess her nutritional status. During an interview on 02/21/24 at 10:00 AM, the Physician indicated Resident #37 was at risk for nutritional decline and monthly weights were needed to determine weight loss or gain. During an interview on 02/22/24 at 12:00 PM, Resident #37 was alert and was not opposed to having her weight obtained. During the investigation on 02/22/24, a current weight was requested and obtained for Resident #37. The new weight was 119 lbs. indicating a 4.7 lb. weight loss. 4. Resident #13 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident, dysphagia, and protein calorie malnutrition. A care plan dated 10/02/23 revealed Resident #13 was at risk for decreased nutritional status and dehydration related to dysphagia, protein calorie malnutrition, receiving a mechanically altered diet, and drug-nutrient interactions. The goal of care was to be free from dehydration and fluid overload through the next review date. Interventions included, in part, to weigh monthly as resident allowed. The MDS quarterly assessment dated [DATE] revealed Resident #13 was cognitively intact. She had no weight loss or gain and was independent with eating. She had no rejection of care. A nutritional evaluation note documented by the Registered Dietician on 02/20/24 revealed Resident #13's meal intake was 51% to 100%. Her blood urea nitrogen (BUN) was within normal limits. The plan of care was to monitor weight, intake, and skin integrity. Review of Resident #13's electronic medical record on 02/19/24 revealed the following weights recorded: 08/09/23 a weight of 176 lbs. 10/09/23 a weight of 190.5 lbs. 11/02/23 a weight of 193.2 lbs. 12/19/23 a weight of 193.1 lbs. 02/19/23 a weight of 205 lbs. Review of Resident #13's electronic medical record on 02/19/24 revealed no order was in place to obtain a monthly weight. During an interview on 02/20/24 at 3:50 PM, Nurse #4 stated Resident #13 was compliant with care. She could feed herself and her appetite was good. She indicted she was not aware if Resident #13 had weight loss or weight gain. During an interview on 02/21/24 at 3:18 PM, the Registered Dietician stated Resident #13 was included in the residents that she requested weights on in January 2024. She stated a new weight was not recorded until 02/19/24. She indicated the weight obtained on 02/19/24 of 205 lbs. was a 11.9 lb. gain from the December weight and she would have expected a reweigh to determine accuracy. She stated she expected to see monthly weights for Resident #13. During an interview on 02/21/24 at 10:30 AM, the Physician Assistant stated she expected to see a monthly weight recorded for Resident #13 in order to assess her nutritional status. During an interview on 02/21/24 at 10:00 AM, the Physician indicated Resident #13 was at risk for nutritional decline due to advanced age and diagnoses and monthly weights were needed to determine weight loss or gain. During an interview on 02/22/24 at 1:00 PM, Resident #13 was alert to person, place, and time. She stated she would not be opposed to having her weight obtained at any time. During the investigation on 02/22/24, a current weight was requested and obtained for Resident #13. The new weight was 205 lbs. indicating an 11.9 lb. weight gain. An interview with the Director of Nursing on 02/22/24 at 3:00 PM was conducted. The Director of Nursing indicated that the facility wanted to provide a more homelike environment and therefore were not obtaining monthly weights for all residents. She stated weights were only obtained for those residents who were reviewed to have poor oral intake, abnormal lab values or changes in their clinical assessment.

Based on record review, staff interview and Nurse Practitioner interview the facility failed to provide tube feeding management by failing to check for tube placement prior to the administration of a water flush for 1 of 1 residents observed for tube feeding management (Resident #14). Findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] documented Resident #14 was rarely or never understood with short and long term memory problems. He was dependent for all activities of daily living including eating. He received 51% or more of his daily calories from a tube feeding. Review of the care plan dated 06/29/22 for Resident #14 revealed the following focus area: At risk for aspiration related to family occasionally provides pleasure food although resident is NPO (nothing by mouth) status with 100% of nutritional needs provided by a feeding tube. One of the goals was for Resident #14 to remain free from complications related to aspiration through the next review date. An intervention was to check for tube placement and gastric contents/residual volume as ordered. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of tube feeding management was made on 09/15/22 at 12:35 PM with Nurse #8. It was observed Nurse #8 had not brought a stethoscope to check placement of the feeding tube prior to administering a free water flush through the tube. Nurse #8 stated she had checked the placement of the tube at the beginning of the shift, and this was the only time she ever checked tube placement. She reiterated she did not check tube placement each time she used the feeding tube but would on this occasion. She retrieved her stethoscope (needed to check placement of the tube) from the medication cart. She explained to Resident #14 that she was going to flush his tube. He nodded understanding by moving his head up and down. Nurse #14 pushed air through the feeding tube and auscultated with her stethoscope to confirm proper tube placement. She administered 210 ML (Milliliters) of free water through the tube using gravity. The tube was patent and flushed easily. No sign of resident discomfort was observed. In an interview with the Director of Nursing on 09/15/22 at 12:40 PM she stated she expected nurses to check placement of feeding tubes prior to the administration of medication or water. In an interview with the facility Nurse Practitioner on 09/15/22 at 1:55 PM she stated if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She concluded if a dislodged tube was used without first checking for placement, it could lead to infection or resident discomfort.

Based on record review, and staff interviews the facility failed to prevent the Director of Nursing (DON) from serving as a charge nurse and having a resident care assignment including working on the medication cart with a facility census of greater than 60 residents on 2 of 2 occasions (08/22/22 and 08/25/22). Findings included. During an interview with the DON on 09/15/22 at 12:45 PM she stated the facility was actively hiring nursing staff. She stated on a few occasions during the month of August 2022 she had to take an assignment because there were no nurses available to pick up the shift and stated the facility was not currently utilizing agency staff. She stated she was not aware of the federal regulation that prevented the DON from taking a resident care assignment with a facility census of greater than 60. She indicated that she made the schedules for the nursing staff and stated there was not an available nurse to cover the shift on those occasions and she had to take care of the residents. A review of the daily staffing sheet dated 08/22/22 revealed the DON was the assigned nurse for the evening shift from 2:45 PM - 11:15 PM. The daily staff posting on 08/22/22 revealed a facility census of 79 residents. A review of the daily staffing sheet dated 08/25/22 revealed the DON was the assigned nurse for the night shift from 10:45 PM - 07:15 AM. The daily staff posting on 08/25/22 revealed a facility census of 85 residents. An interview was conducted with the Administrator on 09/15/22 at 4:45 PM. She stated she recently informed the DON that she could not work other shifts and that she would have to start mandating or scheduling overtime. She indicated the facility census was greater than 60 during the month of August 2022. She stated her expectation was that the DON would utilize other nursing staff to cover the shifts and should not act as charge nurse when the census is greater than 60.

Based on record review, staff interview and Nurse Practitioner interview the facility failed to implement a specific plan of care for tube feeding management to check for tube placement every shift, prior to medication administration, and free water flushes for 1 of 1 residents observed for tube feeding management (Resident #14). Findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] documented Resident #14 was rarely or never understood with short and long term memory problems. He was dependent for all activities of daily living including eating. He received 51% or more of his daily calories from a tube feeding. Review of the care plan dated 06/29/22 for Resident #14 revealed the following focus area: At risk for aspiration related to family occasionally provides pleasure food although resident is NPO (nothing by mouth) status with 100% of nutritional needs provided by a feeding tube. One of the goals was for Resident #14 to remain free from complications related to aspiration through the next review date. An intervention was to check for tube placement and gastric contents/residual volume as ordered. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of tube feeding management was made on 09/15/22 at 12:35 PM with Nurse #8. It was observed Nurse #8 had not brought a stethoscope to check placement of the feeding tube prior to administering a free water flush through the tube. Nurse #8 stated she had checked the placement of the tube at the beginning of the shift, and this was the only time she ever checked tube placement. She reiterated she did not check tube placement each time she used the feeding tube but would on this occasion. She retrieved her stethoscope (needed to check placement of the tube) from the medication cart. She explained to Resident #14 that she was going to flush his tube. He nodded understanding by moving his head up and down. Nurse #14 pushed air through the feeding tube and auscultated with her stethoscope to confirm proper tube placement. She administered 210 ML (Milliliters) of free water through the tube using gravity. The tube was patent and flushed easily. No sign of resident discomfort was observed. In an interview with the Director of Nursing on 09/15/22 at 12:40 PM she stated she expected nurses to check placement of feeding tubes prior to the administration of medication or water. In an interview with the facility Nurse Practitioner on 09/15/22 at 1:55 PM she stated if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She concluded if a dislodged tube was used without first checking for placement, it could lead to infection or resident discomfort.

Based on observation, record review, and staff interviews the facility failed to accurately code the dental status of a resident for 1 of 2 residents reviewed for dental care (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE]. Resident #3's dental care visit documentation dated 8/14/19 revealed the resident was assessed by the dental hygienist to have no teeth. Resident #3's minimum data set assessment dated [DATE] revealed the resident was coded no for the question if the resident had, no natural teeth or tooth fragment(s) (edentulous). During observation on 6/22/21 at 11:43 AM Resident #3's mouth was observed to not have teeth. During an interview on 6/22/21 at 11:52 AM MDS Nurse #1 stated the minimum data set assessment dated [DATE] for Resident #3 was incorrect and the resident did not have any teeth. During an interview on 6/22/21 at 12:25 PM the Administrator stated the minimum data set should accurately reflect resident dental status.

Based on physician interview, staff interview, and record review the facility failed to communicate with the discharging hospital about medications to ensure that a resident receiving an anti-Parkinsonian medication did not miss any doses and the timing of the medication was kept consistent and failed to follow a physician order [REDACTED].#12) whose physician orders [REDACTED]. 1. Record review revealed Resident #12 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. a. Resident #12's 08/22/20 hospital History and Physical (H & P) documented, .Presents to the hospital as a transfer from ED (emergency department) with progressively worsening dizziness, speech changes, and mild confusion. Patient has a history of [DIAGNOSES REDACTED] .and [MEDICAL CONDITION]. (Has) been noted that he has speech changes with his providers in the past. Likely attributed to his [MEDICAL CONDITION]. He reports that it is just rapidly progressing (and) is concerned about his home safety Assessment and Plan: Continue home medications ([MEDICATION NAME] three times daily was one of those documented medications). A 08/25/20 Hospital Discharge Summary documented, Continue these medications which have not changed: [MEDICATION NAME]-[MEDICATION NAME] 25-100 milligrams (mg) one tablet three times daily (TID), [MEDICATION NAME] controlled release (CR) Discharge Diagnoses: [REDACTED]. The summary did not document the last time the resident received [MEDICATION NAME] at the hospital or the administration times of the medication in the hospital. Review of Resident #12's hospital Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the resident's nursing home admission assessments revealed the facility began them at 4:45 PM on 08/25/20. Review of Resident #12's nursing home August 2020 (MAR) revealed he did not receive any [MEDICATION NAME] in the facility on 08/25/20, but received a morning dose of [MEDICATION NAME] on 08/26/20. The administration times documented on the facility MAR for the resident's [MEDICATION NAME] were 8:00 AM, 12 noon, and 4:00 PM on 08/25/20 and 08/26/20. The administration times were changed to 8:00 AM, 2:00 PM, and 8:00 PM starting on 08/27/20. According to LexiComp (a comprehensive on-line drug database), Intervals between doses of [MEDICATION NAME] CR should be 4 - 8 hours while awake. Take ([MEDICATION NAME]) at the same time every day. Space doses evenly over the waking hours. The resident's 08/28/20 5-day Medicare assessment documented his cognition was severely impaired, he exhibited no behaviors including rejection of care, and he was independent to requiring extensive assistance from a staff member with his activities of daily living (ADLs). During a telephone interview with the facility's Consultant Pharmacist on 09/11/20 at 9:54 AM she stated [MEDICATION NAME] should be given at the same time daily, and for the best results in controlling abnormal movements, there should not be missed doses of the medication. During a telephone interview with the facility's Pharmacy Manager on 09/11/20 at 10:03 AM she stated on 08/25/20 the pharmacy did not receive MEDICATION ORDERS FOR [REDACTED]. Therefore, she explained the next time the facility could send out the resident's medications was at 12 noon on 08/26/20. She reported the facility obtained Resident #12's first two doses of [MEDICATION NAME] on 08/26/20 from the Omnicell (a machine system used to store, dispense, and track medications). She reported according to pharmacy records on 08/26/20 [MEDICATION NAME] was withdrawn from the Omincell at the facility at 10:16 AM and 1:07 PM. During a telephone interview with the Director of Nursing (DON) on 09/11/20 at 10:09 AM she stated sometimes the resident arrived at the facility before their orders since the hospital was right across the street. She reported that for TID medication orders the facility's medication system pre-populated administration times of 8:00 AM, 12 noon, and 4:00 PM. She commented the facility could input its own administration times only if the order was written for administration every eight hours. She stated when the resident's medication orders were reviewed with the primary physician on 08/27/20 he changed the TID administration times. After reviewing Resident #12's August 2020 MAR, she commented the resident did not receive any [MEDICATION NAME] from the facility on 08/25/20, and the morning dose on 08/26/20 was administered late. According to the DON, it was recommended to give [MEDICATION NAME] at about the same time every day. During a follow-up telephone interview with the facility's DON on 09/11/20 at 1:57 PM she stated Resident #12's primary physician was still in the building on 08/26/20, and was informed that the resident's [MEDICATION NAME] was administered late with a scheduled time of 8:00 AM and actual administration time of after 10:16 AM on 08/26/20. She reported the physician just advised the staff to provide the other two doses of [MEDICATION NAME] that day per orders that accompanied the resident from the hospital. During a telephone interview with Resident #12's primary physician on 09/16/20 at 11:06 AM he stated Resident #12 was on a low, starting dose of [MEDICATION NAME] so he did not think two missed doses, followed by late administration of the medication the next morning would have caused the resident any long-[MEDICATION NAME] harm. However, he reported there could have been better communication between the nursing home and hospital to have promoted continuity of the [MEDICATION NAME] dosing because once the most effective administration times were established for a resident the medication needed to be provided at about the same time every day without any missed doses. b. A 08/26/20 physician order [REDACTED].#12 at 3:00 PM for vital signs each shift x 7 days, then daily. Review of vital signs and progress notes revealed the following blood pressure readings for Resident #12: 08/25/20 at 4:50 PM 122/58 lying, 08/27/20 at 5:34 AM 160/108 lying, 08/27/20 at 1:45 PM 148/80 lying, 08/28/20 11:40 PM 141/64 lying, 08/29/20 2:26 AM 115/52 lying, 08/29/20 2:17 PM 136/86 sitting, 08/30/20 12:34 AM 136/84 other, 08/30/20 1:18 PM 127/68 lying, and 08/31/20 12:41 AM 126/68 other. (A blood pressure was not obtained for Resident #12 on second shift 08/26/20, on second and third shift 08/27/20, on first shift 08/28/20, on second shift 08/29/20, on second shift 8/30/20, and any shifts on 09/01/20 before the resident was discharged home against medical advice). During a telephone interview with Nurse #6 on 09/14/20 at 11:37 AM she stated that all residents admitted to the facility had the vital sign protocol order, and vital signs were documented each shift on the MAR for the first seven days in the facility and then daily thereafter. She reported blood pressure readings were part of the vital sign protocol. She explained if nursing assistants (NAs) obtained the vital signs then the nurse was supposed to transpose them onto the MAR. During a telephone interview with Resident #12's primary physician on 09/16/20 at 11:06 AM he stated residents with [MEDICAL CONDITION] often had accompanying autonomic dysfunction which involved experiencing erratic blood pressures. He explained Parkinson patients with autonomic dysfunction often registered elevated blood pressure readings when they were in the supine position (laying down), but the blood pressure frequently normalized when the residents were asked to sit or stand. He reported Resident #12 experienced autonomic dysfunction when he was alerted about a blood pressure of 160/108 in the early morning of 08/27/20. According to the physician, frequent monitoring of the blood pressure was a good practice for residents with Parkinsonian-associated autonomic dysfunction. During a telephone interview with the Director of Nursing (DON) on 09/16/20 at 12:13 PM she stated the physician order [REDACTED].

Based on observation and staff interviews the facility failed to discard expired medications stored in 1 of 1 omnicells (a machine system used to store, dispense and track medications) and failed to keep unattended medications secured by leaving them on top of a medication cart for 1 of 4 medication carts observed. Findings included: 1. Review of the Omnicell Maintenance Visits report dated 03/18/19 by the Pharmacy Technician revealed that a partial audit of the Omnicell had been performed on drawers three, five, and seven. The report indicated that medication expiration dates were not being entered correctly into the Omnicell and were also not being updated correctly. The report revealed that the former Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were present when the report was gone over by the Pharmacy Technician. In an observation and interview on 05/08/19 at approximately 10:45 AM Nurse #3 accessed the Station 2 Omnicell to remove pramipexole 1.0 mg (milligrams) from the machine. The storage drawer opened and multiple storage compartments with different medications and doses of medications were visualized. There were two doses of pramipexole 1.0 mg with the expiration date of 12/14/18 and two doses with the expiration date of 03/05/20 in the storage drawer compartment for that medication. The expiration dates were verified by Nurse #3 who proceeded to hand the expired medications to the Director of Nursing (DON). The DON stated that the pharmacist was responsible for checking the Omnicell for expired medications and removing them if they were expired. In a telephone interview on 05/08/19 at 12:07 PM the Pharmacist stated that the nurses were responsible for restocking the Omnicell when the medications were delivered from the pharmacy and that the pharmacists did not check the Omnicell. She indicated that she felt that the expiration dates were being entered incorrectly by the nurses and that this had caused there to be expired medications in the Omnicell. In an observation and interview on 05/08/19 at 4:45 PM an audit of drawer #6 in the Station 2 Omnicell was conducted with the DON. Of the 279 medications in the multiple storage compartment drawer, 29 of the medications were expired. The amount of expired medications was confirmed by the DON. The DON indicated that when the nurse received a medication from the pharmacy that needed to go into the Omnicell it was scanned into the machine and the quantity was added. The nurse was then supposed to check the medication in the storage drawer compartment for the expiration dates on those medications and enter the expiration date that was closest to the present date as those would be the medications that would be expiring first. She indicated that the expiration dates were not being entered correctly. In a telephone interview on 05/08/19 at 11:31 PM Nurse #5 stated she was the nurse who usually put the medications in the Omnicell when they came in from the pharmacy. She indicated that the process was that medications would come in about 3:30 AM and she would scan them into the Omnicell. She would then input the expiration date of the new medication that was going into the Omnicell and not the expiration date of the medication that would be expiring first from the storage drawer compartment. In an interview on 05/09/19 at 1:47 PM the Pharmacy Technician stated she was the one who checked the Omnicell, not the pharmacist. She indicated a 100% review was done annually and a quarterly spot check had been performed in (MONTH) 2019. The Pharmacy Technician stated that the nurses were supposed to sign the medications into the Omnicell, update the quantity, and input the expiration date of the medication in the storage drawer compartment that would be expiring first. She stated that entering the expiration date of the medication that had just been delivered would update the expiration date and the Omnicell would not recognize that a medication that was already in the drawer would expire before the new medication. She indicated that this practice would cause expired medications to be found in the Omnicell. In an interview on 05/09/19 at 2:26 PM the DON stated that there should never be expired medications in the Omnicell. She indicated that she thought a 100% audit of the Omnicell was performed each time the Pharmacy Technician came into the facility and not just annually. She indicated she was unaware that only partial audits were done the rest of the year. The DON stated that the nurses had been entering the expiration dates into the Omnicell incorrectly and that had caused there to be expired medications in the Omnicell. She stated that although the Maintenance Visit report showed her name, she had been busy with a resident and the ADON who was no longer employed at the facility, had gone over the report with the Pharmacy Technician. The DON stated if she had been aware of the report, training could have been done and there would not have been expired medications in the Omnicell. 2. In an observation on 05/07/19 at 10:59 AM an attended medication cart was seen outside the door of room [ROOM NUMBER]. There were two bubble packs of medications on top of the cart. Xifacan (an antibiotic that fights infections only in the intestines) 550 mg 21 tablets and [MEDICATION NAME] (a beta blocker which relaxes blood vessels, slows the heart rate, and decreases blood pressure) 10 mg 24 tablets. Nurse #6 approached the cart from around the corner of the hallway within approximately two minutes. During the time the cart was unattended two staff members were seen walking past the cart. In an interview on 05/07/19 at 11:01 AM Nurse #6 confirmed she was the nurse that was assigned to that medication cart. She indicated she was in the middle of something and that was why she left the medication unattended on top of the cart. She stated she knew she was not supposed to leave medications unattended on top of the cart because the facility had wandering residents and they could have taken the medications. Nurse #6 indicated that medications should be kept locked in the medication cart. In an interview on 05/09/19 at 2:26 PM the DON indicated that medications should be locked in the medication cart and not left unattended on top of the cart. She stated that if left on top of the cart, anyone could take the medications and the facility would not know about it.

Based on observations, record review, and staff interviews the facility failed to provide feeding assistance to 1 of 1 residents sampled (Resident #76) who required extensive one-person assistance with eating. Resident # 76 was admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set ((MDS) dated [DATE] and coded as a change of therapy assessment indicated Resident #76 had moderately impaired cognition and required extensive one-person physical assistance with activities of daily living including eating. A review of the care plan dated 4/12/19 revealed Resident #76 had increased risk for nutrition and dehydration due to a therapeutic diet with altered texture, and diagnoses. The goal was the Resident would consume 75% of meals and fluids. Interventions in part were to assist with meals as needed, observe diet intolerance and adjust as needed, dietary screening as needed, encourage fluid intake, encourage and monitor meal intake, and weekly weights. A review of the weekly weights recorded from 4/10/19 through 5/8/19 revealed a 10-pound weight loss, or 6.43% in less than one month. A review of the Nutrition Comprehensive Evaluation Risk Screen dated 4/23/19 documented Resident #76 had inadequate meal intake and needed assistance with eating. An observation was conducted on 5/7/19 at 12:45 PM. Resident #76 was lying in bed sleeping, and easily aroused. Her lunch tray with pureed foods of chicken, vegetables, and mashed potatoes were on the bedside table untouched. An unopened carton of the nutritional supplement was on her meal tray. The nurse aide who removed the meal tray from the room stated it looked as though the resident had not eaten anything. On 5/7/19 at 12:45 PM, Resident #76 stated she did not know if she had eaten anything for breakfast or lunch. An interview was conducted on 5/8/19 at 12:38 PM with nurse aide #4. She stated Resident #76 received meal tray set up, and stated nurse aides would provide feeding assistance with meals at times if the resident needed it. An observation of Resident #76 was conducted on 5/9/19 at 8:40 AM. She was sleeping and would mumble when aroused. Her breakfast tray on the bedside table with lid covered appeared untouched. An interview was conducted with Nurse #7 on 5/9/19 at 8:57 AM. She stated she was not sure how much breakfast Resident #76 had eaten and stated she did not see any nurse aides in her room during the breakfast meal to assist with her feeding. An interview was conducted on 5/9/19 at 11:30 AM with nurse aide #3. She stated Resident #76 was disoriented most of the time and eats less than 25% of meals. She stated the aides provided meal tray set up for the resident or would assist with her feeding if needed. An interview was conducted on 5/9/19 at 1:44 PM with the facility Speech Therapist. She stated Resident #76 had a significant cognitive decline since her admission to the facility. She stated the resident was pleasantly confused and did exhibit behaviors such a s yelling out at times. She agreed that the resident should be receiving staff assistance with her feeding for all meals. An interview was conducted on 5/9/19 at 9:56 AM with the facility physician. He stated he was aware of Resident #76 ' s weight loss, her appetite was poor, and that she received nutritional supplements. He stated she did exhibit behaviors at times such as yelling out. He agreed that she did require extensive assistance with feeding. An interview was conducted on 5/9/19 at 2:00 PM with the Director of Nursing. She stated its her expectation that staff are providing assistance with feeding for residents that require extensive assistance with eating.

Based on record review and staff interviews the facility failed to accurately code insulin on a Minimum Data Set (MDS) for 1 of 5 residents (Resident #79) reviewed for unnecessary medications. Findings included: Resident #79 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #79 received one insulin injection during the seven day look back period. Review of the physician orders [REDACTED].#79. However, Trulicity (a non-insulin GLP-1 receptor agonist) had been ordered to be injected weekly for diabetes. In an interview on 05/09/19 at 10:50 AM the MDS Nurse stated that when she filled out the medication section of the MDS she gathered the information from the Medication Administration Record [REDACTED]. She indicated that it was a mistake and that she would correct it. In an interview on 05/09/19 at 2:26 PM the Director of Nursing (DON) indicated that she expected the information on the MDS to be recorded accurately so that the condition of the resident during the look back period reflected the correct status of the resident at that time.

Based on observation, record review and staff interviews the facility failed to ensure it was free of medication error rates greater than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 4 residents (Resident #27 and Resident #60) observed during medication administration. Findings included: During a medication administration observation on 05/08/19 at 10:40 AM Nurse #3 produced a packaged scored tablet of pramipexole 1.0 mg (milligram). The expiration date on the package was 12/14/18. Nurse #3 indicated she had removed the medication from the omnicell (a machine that provides a secure electronic system for managing medications) for administration to Resident #27. Nurse #3 broke the tablet in half explaining that the dose ordered was for 0.5 mg by mouth as a one-time dose. Nurse #3 turned to enter Resident #27's room and indicated she was ready to administer the medication. Nurse #3 was stopped at that time. In an interview on 05/08/19 at 10:43 AM Nurse #3 checked the packaging on the pramipexole and verified that the expiration date was 12/14/18. She indicated that a resident should never be administered an expired medication because it may not be as effective and that she had not realized that the medication had expired. During a medication administration observation on 05/09/19 at 9:20 AM Nurse #4 removed an [MEDICATION NAME] 1.0 mg tablet from the locked narcotic drawer and administered the tablet to Resident #60. During a medication reconciliation on 05/09/19 at 9:35 AM Resident #60's (MONTH) 2019 Medication Administration Record [REDACTED]. In an interview on 05/09/19 at 9:40 AM Nurse #4 was asked to review the order for the [MEDICATION NAME]. After reading the order she verified that she should have administered 0.5 mg of [MEDICATION NAME] to Resident #60 and not 1.0 mg. She stated she did not read through the complete order which caused her to administer the wrong dose of medication to Resident #60. In an interview on 05/09/19 at 2:26 PM the Director of Nursing (DON) stated that nurses should never give expired medications to residents as they might not work as well. She indicated that nurses should always read through the entire order prior to administering a medication to make sure the correct dose of medication was administered. The DON indicated that the facility medication error rate should be less than 5% and that she would like for the rate to be zero.

Based on observation, staff interviews, and record review the facility's quality assurance (QA) program failed to prevent the reoccurrence of deficient practice related to the medication administration process by having a medication error rate of 8% which resulted in a repeat deficiency at F759. The re-citing of F759 during the last year of federal survey history showed a pattern of the facility's inability to sustain an effective QA program. Findings included: This tag is cross-referenced to: F759: Medication Administration: Based on observation, record review and staff interviews the facility failed to ensure it was free of medication error rates greater than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 4 residents (Resident #27 and Resident #60) observed during medication administration. Findings included: Review of the facility's survey history revealed F759 was cited during the facility's 05/25/18 annual recertification/complaint investigation survey for a medication error rate greater than 5%. The facility was re-cited during the current 05/09/19 annual recertification/complaint investigation survey for the same issue of a medication error rate greater than 5% at F759. In an interview on 05/09/19 at 3:53 PM the Administrator stated that there had been a lot of changes in the facility and that this may have caused the nurses to feel the need to hurry through the medication administration in order to be able to manage other assessment and documentation requirements. She indicated that the multiple changes may have caused the failure of the QA process.

Based on observation and staff interview the facility failed to keep a cold salad made with mayonnaise at or below 41 degrees Fahrenheit during operation of the trayline. The facility also failed to air dry kitchenware before stacking it in storage, and failed to label and date opened and repackaged food items in storage areas. Findings included: 1. Upon entering the kitchen on 05/22/18 at 5:22 PM a deep tray pan of Cole slaw was observed in a well of the steam table above a shallow pan of melting ice and next to a well housing hot foods, and five preplated dishes which included bowls of Cole slaw were sitting on the edge of the steam table waiting to be placed on resident trays. At 5:25 PM on 05/22/18 a calibrated thermometer used to check the tray pan of Cole slaw registered 46.5 degrees Fahrenheit. The same thermometer registered 68.2 degrees Fahrenheit when used to check the last bowl of preplated Cole slaw to be placed on a resident tray. At 5:28 PM on 05/22/18 the PM Cook stated the dietary staff still had 1 1/2 meal carts to send out for residents. He reported that he finished assembling the slaw at about 1:00 PM on 05/22/18, and placed it in the walk-in refrigerator to chill. He commented that all the ingredients he utilized in the preparation were chilled prior to assembly. The Cook stated that the Cole slaw contained diced cabbage, carrots, mayonnaise, vinegar, and sugar. The Cook reported that he recorded the temperature of the slaw at 40 degrees Fahrenheit when the supper trayline initially began operation at 5:00 PM. At 5:34 PM on 05/22/18 the Dietary Manager (DM) stated when he took the temperature of the Cole slaw prior to the supper trayline beginning operation the calibrated thermometer actually registered 37 degrees Fahrenheit. At 2:35 PM on 05/23/18 the DM stated the dietary staff was trained to use chilled ingredients when preparing cold salads, and that it was preferable to prepare them a day before they were served to residents. He reported staff usually placed cold salads over ice in a steam well once the trayline began operation. He commented that from a temperature control standpoint it was probably best not to place all the chilled salad in one big tray pan. According to the DM, allowing cold salads made with mayonnaise to rise above 41 degrees Fahrenheit for long periods of time could cause the spread of foodborne illness. At 2:57 PM on 05/23/18 a dietary employee stated cold salads should be prepared the day before they were served, or at the latest they should be assembled in the early morning on the day they were due to be served. Once assembled, he reported the salads were supposed to be stored in refrigeration until the meal trayline began operation, and then they were to be kept in or above ice once the trayline process began. The employee commented allowing cold salads to rise above 41 degrees Fahrenheit for long periods of time could cause bacteria and fungus to grow in the food. 2. During initial tour of the kitchen, beginning at 11:23 AM on 05/20/18, 6 of 12 tray pans stacked on top of one another on a shelving unit had moisture trapped inside of them. At this time the AM cook reported these tray pans were stacked wet on the evening of 05/19/18, and retained moisture inside of them overnight. At 2:35 PM on 05/23/18 the Dietary Manager (DM) stated dietary employees were trained to air dry all kitchenware before stacking it in storage. He reported stacking kitchenware wet overnight could cause bacterial formation and result in residents getting sick. At 2:57 PM on 05/23/18 a dietary employee stated there should be absolutely no moisture present when kitchenware was stacked in storage. He reported the dietary staff was taught to use drying racks and fans to promote the drying of kitchenware which had been run through the dish machine and three-compartment sink process. He commented that stacking kitchenware wet could cause the formation of bacteria and fungus which could make residents sick if ingested. 3. During initial tour of the kitchen, beginning at 11:23 AM on 05/20/18, hot dog buns and potato chips which were opened and stored above a food preparation table were without labels and open dates. In the reach-in refrigerator three containers of pink lemonade did not have labels and dates on them. In the dry storage room three bags of ziti pasta, 2 bags of tri-color rotini pasta, one bag of elbow macaroni, and a 5-pound container of dry/powdered milk were opened, but did not have labels or open dates posted on them. In the walk-in refrigerator one gallon of mayonnaise, one gallon of Cole slaw dressing, one gallon of lite Italian dressing, one gallon of sweet pickle relish, one gallon of Caesar dressing, and one gallon of thousand island dressing were opened, but were without labels documenting the dates on which they were initially opened up. In the walk-in freezer a brown bag of waffle fries had been opened, but was without a label and date on it. During a follow-up tour of the kitchen, at 9:48 AM on 05/23/18, one gallon of mayonnaise, one gallon of Cole slaw dressing, one gallon of lite Italian dressing, one gallon of Caesar dressing, and one gallon of thousand island dressing, stored in the walk-in refrigerator, were opened, but did not have labels on them documenting when they were initially opened. At 2:35 PM on 05/23/18 the Dietary Manager (DM) stated he and his assistant monitored storage areas daily when they were working, and that all opened food items, repackaged food items, and leftovers were supposed to have labels and dates on them. He also reported the stock person monitored storage areas once weekly for labeling and dating, and the cooks were trained to place food from opened packages in storage bags with labels and dates to be affixed to these bags. According to the DM, dating and labeling was important in the first in, first out (FIFO) concept which promoted serving the freshest food possible. At 2:57 PM on 05/23/18 a dietary employee stated all employees were supposed to monitor storage areas for labeling and dating as they went in and out of the dry storage room, reach-in coolers, and walk-in refrigerators and freezers. He reported labeling and dating was important to keep stock rotated properly.

Based on observation, record review and resident and staff interviews the facility failed to ensure a resident was assisted to the bathroom as requested causing the resident to experience incontinence and a lack of dignity for 1 of 1 residents (Resident # 15). Findings included: Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #15 was cognitively intact and needed the limited assistance of one person for transfers and toilet use. Resident #15 was occasionally incontinent of bladder. Review of the information provided to the nursing staff that directed the care of each resident (Care Guide) revealed that on 05/21/18 Resident #15 needed the limited assistance of one person for toileting needs and needed the limited assistance of one person for transfers. In an observation on 05/21/18 at 8:40 AM the call light above the door of Resident #15's room was lit up. A male staff member walked past the room without acknowledging the light. Two female staff members were at the end of the hallway speaking together. The call light was lit up on the panel at the nurse's station and the alarm was sounding. No staff members were at the nurse's station. Resident #15 was sitting on the bed with her legs thrown over the side of the bed. The head of the bed was elevated and she was leaning against the mattress in an awkward appearing position. Resident #15 was wearing a brief. She indicated she needed to use the bathroom but could not get out of the bed on her own to get to the bathroom. At 8:45 AM the MDS Nurse entered Resident #15's room and was told by the resident that she needed to use the bathroom. At 8:50 AM the MDS Nurse left the room after informing Resident #15 that she was going to check on how the resident was transferred. At 8:53 AM the MDS Nurse came back to the room with some linens. At 8:59 AM the MDS Nurse left the room after explaining to Resident #15 that a resident from the room next door was now in the adjoining bathroom and that she (Resident #15) would need to wait to use the bathroom. The MDS Nurse informed Resident #15 the aide that was helping the resident next door had been told to let staff know when the bathroom was available for Resident #15's use. At 9:06 AM the Speech Therapist (ST) came to Resident #15's room. She indicated Resident #15 had a mild stroke approximately five days prior but was recovering quickly. At 9:10 AM the Rehabilitation Aide (RA) came to Resident #15's room. She indicated she was not assigned to Resident #15 that day but had been told by a staff member (she was unable to remember who) to see if the resident needed assistance with transferring to the bathroom. The bathroom became available for Resident #15 to use. At 9:11 AM the RA left Resident #15's room stating she would find out how the resident transferred. At 9:14 AM the Rehabilitation Director came into Resident #15's room. She informed Resident #15 that the Physical Therapist (PT) (on 05/16/18) had changed her transfer status to a two person mechanical lift transfer following her recent stroke and that the lift could not be used to take her into the bathroom in her room because the mechanical lift would not fit in the bathroom. The Rehabilitation Director indicated that Resident #15 would probably feel more comfortable with the PT she was familiar with and he was sent for. Resident #15 indicated that she had not been transferred to the bathroom using the mechanical lift and did not want to use it because she was afraid it would injure her leg. At 9:20 AM Resident #15 indicated that she had already wet herself because she could no longer hold it. She stated at first it bothered her when she wet herself but now she was used to it because it always took staff a long time to help her and she was used to it. At 9:28 AM the PT came to Resident #15's room with a walker and she was assisted to sit on the edge of the bed in preparation for transfer into a wheelchair. The PT indicated that the nursing staff was supposed to use the mechanical lift for transfers and only the therapists could transfer Resident #15 using a walker. Resident #15 was still requesting to use the bathroom so the PT decided to transfer her into the wheelchair and take her to the shower room where she could be transferred to a shower chair and placed over the toilet. Resident #15 was assisted to stand in preparation for transfer to the wheelchair. The back of her gown was noted to be saturated with urine. The brief that Resident #15 wore appeared to be saturated with urine. There was a fabric lined, plastic backed, incontinence pad over a folded in quarters bath blanket on top of the bottom sheet. The bath blanket and incontinence pad were both saturated with urine. The bottom sheet was wet from the shoulder area to the mid-thigh area. The Rehabilitation Director removed the saturated linens and rivulets of urine were noted on the mattress. A strong smell of urine was noted at the time the linens were exposed. The Rehabilitation Director offered Resident #15 a shower and stated it was not acceptable that Resident #15 was found in that condition. At 9:36 AM Resident #15 was taken to the shower room where she required the assistance of three staff members to stand. At 9:39 AM the saturated brief was removed and Resident #15 was placed in a shower chair over the toilet to use the bathroom. When the brief was removed Resident #15's buttocks were noted to be red but there was no breakdown. Resident #15 stated her buttocks were red because she had laid in urine for so long. Throughout the continuous observation there had never been any offer of a bedpan or to check Resident #15's brief to see if incontinence care could be provided while her transfer status was being established. In an interview on 05/21/18 at 10:28 AM Nursing Assistant (NA) #1 indicated she had checked Resident #15 at approximately 7:30 AM by looking at the front of the brief for a color change on the moisture indicator line. There was no change in color to indicate that Resident #15 had been incontinent of urine. She indicated she fed Resident #15's roommate her breakfast and told Resident #15 she would be back to provide care. NA #1 stated Resident #15 did not tell her she was wet when she served her breakfast. She indicated she had used the mechanical lift to get Resident #15 out of bed on 05/19/18. In an interview on 05/21/18 at approximately 10:35 AM the Director of Nursing (DON) stated the care guides for each resident were only in the computer. She stated the nursing staff all had access to the information and should be going into the computer to see how to care for the residents. In an interview on 05/22/18 at 9:51 AM the Occupational Therapist (OT) stated the nursing staff was supposed to use a mechanical lift to transfer Resident #15. In an interview on 05/24/18 at 5:18 PM the MDS Nurse stated that a lot of things had been discussed about Resident #15 in clinical meetings. She indicated she remembered a discussion that Resident #15 may or may not be appropriate for therapy but did not remember any discussion about the use of a mechanical lift so was not aware Resident #15 needed one for transfers. She indicated she and the MDS Coordinator were responsible for updating the care guides but since a significant change MDS was in process Resident #15's care plans and care guide had not yet been updated. In an interview on 05/25/18 at 10:05 AM Nurse #4 stated the PT had informed her on 05/16/18 that Resident #15 needed a mechanical lift for transfers. She indicated there was a big problem with communication in the facility. Nurse #4 stated she did not update the care guide as that was up to the MDS Nurse to do. In an interview on 05/25/18 at 11:45 AM the PT stated he had informed Nurse #4 on 05/16/18 that Resident #15 required a mechanical lift for transfers by nursing staff. In an interview on 05/25/18 at 12:15 PM the Administrator stated the delay in transfer and the resident being saturated was not intentional. She indicated the facility was trying to do what was best for Resident #15 to keep her safe. She stated Resident #15 should not have had to wait that long to be taken to the bathroom and that she expected current transfer information to be readily available to the staff. In an interview on 05/25/18 at 2:05 PM the DON stated she expected the correct transfer information to be on the care guide and for staff to know how to access the information The DON stated she expected residents to be treated with dignity and that it should not have taken so long to figure out how Resident #15 transferred so she could be taken to the bathroom. She indicated a resident's mental health should be maintained and no resident should be made to feel that they were not being cared for.

Based on observation, staff interviews and record review, the facility failed to maintain a clean living environment for 2 of 12 resident areas observed that had visible feces dried on the floor in a resident's room (#20B) and on the wall in the bathroom between rooms (#4 and #6). Findings included: During the initial tour of the facility on 05/20/18 at 11:00 AM dirty, used latex gloves and two quarter size areas of dried feces were observed on the floor beside a resident's bed in room [ROOM NUMBER]B. In an interview with Nurse #7 on 05/20/18 at 11:15 AM she stated that she was the nurse assigned to room [ROOM NUMBER]B. She reported that she had been employed at the facility for one week. The feces was witnessed by herself and the Housekeeping Director. Nurse #7 reported that she would use bleach wipes to clean up the dried feces and then ask housekeeping to disinfect the floor. The Housekeeping Manager stated that it was the responsibility of nursing to clean up the initial spillage and then housekeeping's responsibility was to disinfect the area. He stated that he would not have expected feces to be dried on the floor of a resident's room at 11:00 AM. He said it should have been seen and cleaned on the first rounds after breakfast by housekeeping. A follow up observation at 1:30 PM revealed that the dried stool had been cleaned from the floor and the trash removed. An additional observation of dried feces splattered on the wall in the bathroom between resident rooms #4 and #6 was made on 05/20/18 on initial tour. The feces was again observed on the wall at 2:30 PM on 05/23/18 (3 days later). It was shown to the Housekeeping Director on 05/23/18 who stated it should have been cleaned up earlier either by nursing or housekeeping. He summoned a housekeeper who cleaned the feces off the wall. Record review of the contracted housekeeping company policy revealed: Any equipment or furniture that is contaminated with visibly large quantities of blood or other bodily fluids will be referred to nursing personnel of the client facility for decontamination and will not be handled by employees of (the housekeeping company). Employees are only to clean previously decontaminated areas or small areas requiring clean up (i.e. drips of blood or urine). In an interview with the Housekeeping Director on 5/23/18 at 2:34 PM he stated that housekeeping staff arrived at 8:00 AM each day and started cleaning the common areas because breakfast trays were still on the hallways. After the trays came off the floor he said staff began room rounds that included sweeping, emptying trash, and checking soaps and paper towel needs. The next step included going back through the rooms and wiping down horizontal surfaces, sweeping behind furniture, cleaning bathrooms, and mopping floors. He said the rooms were revisited after lunch for additional cleaning if needed. He stated that this was the 5 step method of cleaning. He said the 7 step method of cleaning was also used when rooms where scheduled to be deep cleaned. In an interview with CNA #12 on 05/23/18 at 3:05 she stated that if she saw feces on the floor she would have cleaned it up with a towel and water and had called housekeeping to disinfect the area. She said the aides had to remove it before housekeeping would disinfect the area. Interview with the Director of Nursing on 05/23/18 at 3:15 PM she said it was her expectation that as soon as feces was seen on the floor it would be cleaned up. She said the nursing staff was to clean the area first with a solution kept in the housekeeping closet and then housekeeping was to disinfect the area. She said if there were no housekeeping staff available that there was a supply room with disinfectant, a mop and a mop bucket to enable nursing to completely clean the area entirely.

Based on observation, record review and resident and staff interviews the facility failed to have the correct transfer information accessible to staff causing a 59 minute delay in toileting for 1 of 1 residents (Resident # 15). Findings included: Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #15 was cognitively intact and needed the limited assistance of one person for transfers and toilet use. Review of the 05/01/18-05/20/18 Physical Therapy and Occupational Therapy notes revealed no mention that nursing was to use a mechanical lift to transfer Resident #15. Review of the information provided to the nursing staff that directed the care of each resident (Care Guide) revealed that on 05/21/18 Resident #15 needed the limited assistance of one person for toileting needs and needed the limited assistance of one person for transfers. In an observation on 05/21/18 at 8:40 AM the call light above the door of Resident #15's room was lit up. A male staff member walked past the room without acknowledging the light. Two female staff members were at the end of the hallway speaking together. The call light was lit up on the panel at the nurse's station and the alarm was sounding. No staff members were at the nurse's station. Resident #15 was sitting on the bed with her legs thrown over the side of the bed. The head of the bed was elevated and she was leaning against the mattress in an awkward appearing position. Resident #15 was wearing a brief. She indicated she needed to use the bathroom but could not get out of the bed on her own to get to the bathroom. At 8:45 AM the MDS Nurse, who had been speaking with the staff member at the end of the hall, entered Resident #15's room. She had a short conversation with Resident #15 and was told by the resident that she needed to use the bathroom. At 8:50 AM the MDS Nurse left the room after informing Resident #15 that she was going to check on how the resident was transferred. At 8:53 AM the MDS Nurse came back to the room with some linens and had another discussion with Resident #15. At 8:59 AM the MDS Nurse left the room after explaining to Resident #15 that a resident from the room next door was now in the adjoining bathroom receiving care and that she would need to wait to use the bathroom. The MDS Nurse informed Resident #15 that she wanted to provide care at the same time she was in the bathroom and that the aide had been told to let staff know when the bathroom was available for Resident #15's use. At 9:06 AM the Speech Therapist (ST) came to Resident #15's room. She indicated Resident #15 had a mild stroke approximately five days prior but was recovering quickly. At 9:10 AM the Rehabilitation Aide (RA) came to Resident #15's room. She indicated she was not assigned to Resident #15 that day but had been told by a staff member (she was unable to remember who) to see if the resident needed assistance with transferring to the bathroom. The resident who was in the bathroom had been taken back to her room and the bathroom was available for Resident #15's use. At 9:11 AM the RA left Resident #15's room stating she would find out how the resident transferred. At 9:14 AM the Rehabilitation Director came into Resident #15's room. She informed Resident #15 that the Physical Therapist (PT) had changed her transfer status to a two person mechanical lift transfer following her recent stroke and that the lift could not be used to take her into the bathroom in her room due to its size. The Rehabilitation Director indicated that Resident #15 would probably feel more comfortable with the PT she was familiar with and he was sent for. At 9:20 AM Resident #15 indicated that she had already wet herself because she could no longer hold it. She stated at first it bothered her when she wet herself but now she was used to it because it always took staff a long time to help her and she was used to it. At 9:28 AM the PT came to Resident #15's room with a walker and she was assisted to sit on the edge of the bed in preparation for transfer into a wheelchair. The PT indicated that the nursing staff was supposed to use the mechanical lift for transfers and only the therapists could transfer Resident #15 using a walker. Resident #15 was still requesting to use the bathroom so the PT decided to transfer her into the wheelchair and take her to the shower room where she could be transferred to a shower chair and placed over the toilet. Resident #15 was assisted to stand in preparation for transfer to the wheelchair. The back of her gown was noted to be saturated with urine. The brief that Resident #15 wore appeared to be saturated with urine. There was a fabric lined, plastic backed, incontinence pad over a folded in quarters bath blanket on top of the bottom sheet. The bath blanket and incontinence pad were both saturated with urine. The bottom sheet was wet from the shoulder area to the mid-thigh area. The Rehabilitation Director removed the saturated linens and rivulets of urine were noted on the mattress. A strong smell of urine was noted at the time the linens were exposed. The Rehabilitation Director offered Resident #15 a shower and stated it was not acceptable that Resident #15 was found in that condition. At 9:36 AM Resident #15 was taken to the shower room where she required the assistance of three staff members to stand. At 9:39 AM the saturated brief was removed and Resident #15 was placed in a shower chair over the toilet to use the bathroom. When the brief was removed Resident #15's buttocks were noted to be red but there was no breakdown. Resident #15 stated her buttocks were red because she had laid in urine for so long. Throughout the continuous observation there had never been any offer of a bedpan or to check Resident #15's brief to see if incontinence care could be provided while her transfer status was being established. In an interview on 05/21/18 at 10:28 AM Nursing Assistant (NA) #1 indicated she had checked Resident #15 at approximately 7:30 AM by looking at the front of the brief for a color change on the moisture indicator line. There was no change in color to indicate that Resident #15 had been incontinent of urine. She indicated she fed Resident #15's roommate her breakfast and told Resident #15 she would be back to provide care. NA #1 stated Resident #15 did not tell her she was wet when she served her breakfast. In an interview on 05/21/18 at approximately 10:35 AM the Director of Nursing (DON) stated the care guides for each resident were only in the computer. She indicated there were no printed copies in resident closets or in binders at the nurse's desks. She stated the nursing staff all had access to the information and should be going into the computer to see how to care for the residents. In an interview on 05/22/18 at 9:51 AM the Occupational Therapist (OT) stated only the therapists could transfer Resident #15 out of bed using a walker. She indicated the nursing staff was supposed to use a mechanical lift for transfers. In an interview on 05/22/18 at 10:43 AM the Rehabilitation Director stated the RA had come to ask the PT how to transfer Resident #15. She indicated the PT was working with another resident so she came to Resident #15's room. She indicated Resident #15 had experienced a stroke recently and that a significant change MDS was underway. She stated a physical therapy evaluation was done and it was decided a mechanical lift should be used for transfers. The Rehabilitation Director stated the change to a mechanical lift was discussed in a clinical meeting which the MDS Nurse attended. She indicated that the change to a mechanical lift for transfers by the nursing staff had not been updated to the care guide. In an interview on 05/22/18 at 10:53 AM the facility Nurse Consultant stated the change in Resident #15's transfer status was discussed in a clinical meeting that the MDS Nurse attended. She stated the MDS Nurse should have updated the care guide to show that a mechanical lift was now needed for transfers. In an interview on 05/22/18 at 2:30 PM NA #2 stated the only way she knew how to take care of a resident was if she already knew them or she could ask the nurse. She indicated there were no care guides to look at. NA #2 stated when she recorded a resident's activities of daily living she would put down how she transferred a resident but there was nothing that told her how the resident should be transferred. In an interview on 05/22/18 at 3:03 PM NA #3 stated she could find the information on how residents were transferred in the electronic record. In an interview on 05/23/18 at 6:00 AM NA #4 stated she was an agency aide and this was her third time at the facility. She stated the care guides for residents hung inside their closets. In an interview on 05/23/18 at 6:05 AM NA #5 stated she was an agency aide but worked at the facility about three times each week. She indicated there was a book at the nurse's desk with the information on how to care for each resident or she could ask the nurse. In an interview on 05/23/18 at 6:20 AM NA #6 stated she was a staff aide and had worked in the facility for a few months. She indicated if she did not know how to care for a resident she would ask the nurse. She stated that before she was in-serviced yesterday she did not know the information on how to care for residents was in the computer. In an interview on 05/23/18 at 6:42 AM NA #7 stated she documented in the computer and could go there to find the information on how to transfer a resident. In an interview on 05/24/18 at 12:50 PM the Rehabilitation Director stated when a therapist documented a resident needed maximum assistance it meant something different to each therapist. She indicated that in Resident #15's case the PT meant that the nursing staff needed to use a mechanical lift for transfers. She indicated the need for a mechanical lift was discussed in a clinical meeting and the MDS Nurse was at the meeting. The Rehabilitation Director stated the care guide should have been updated with Resident #15's new transfer needs. She indicated she felt there was a problem with verbal communication between disciplines. In an interview on 05/24/18 at 3:14 PM Nurse #3 stated that until two days ago she did not know that Resident #15 needed a mechanical lift for transfers by the nursing staff. She indicated that if she had been asked by an aide how to transfer Resident #15 she would have told them that two people were necessary but not that a mechanical lift was needed. In an interview on 05/24/18 at 5:18 PM the MDS Nurse stated that a lot of things had been discussed about Resident #15 in clinical meetings. She indicated she remembered a discussion that Resident #15 may or may not be appropriate for therapy but did not remember any discussion about the use of a mechanical lift so was not aware Resident #15 needed one for transfers. She indicated she and the MDS Coordinator were responsible for updating the care guides but since a significant change MDS was in process Resident #15's care plans and care guide had not yet been updated. In an interview on 05/25/18 at 10:05 AM Nurse #4 stated the PT had informed her on 05/16/18 that Resident #15 needed a mechanical lift for transfers. She indicated she would have told the aide who should have passed the information on in report. She indicated she thought she would have put the information on the shift report and told the oncoming nurse but was not sure if she had done that. She indicated there was a big problem with communication in the facility. Nurse #4 stated she did not update the care guide as that was up to the MDS Nurse to do. In an interview on 05/25/18 at 11:45 AM the PT stated he had informed Nurse #4 on 05/16/18 that Resident #15 required a mechanical lift for transfers by nursing staff. In an interview on 05/25/18 at 12:15 PM the Administrator stated the delay in transfer and the resident being saturated was not intentional. She indicated the facility was trying to do what was best for Resident #15 to keep her safe. She stated Resident #15 should not have had to wait that long for transfer and that she expected current transfer information to be readily available to the staff. In an interview on 05/25/18 at 1:10 PM NA #8 stated she had found Resident #15 saturated before when she took over her assignment. She indicated she had informed the hall nurse and the DON. NA #8 stated there was a lack of communication in the facility. In an interview on 05/25/18 at 2:05 PM the DON stated she expected the correct transfer information to be on the care guide and for staff to know how to access the information. She indicated she expected the care guide to be updated as necessary and for there to be better communication between therapy and nursing. The DON stated she expected residents to be treated with dignity and that it should not have taken so long to figure out how Resident #15 transferred. She indicated a resident's mental health should be maintained and no resident should be made to feel that they were not being cared for. She stated that no resident should experience neglect and that the facility was trying to do what was safest for Resident #15.

Based on observations, record review and staff interviews, the facility failed to assess a resident (Resident #56) who had a change in condition and was admitted to the hospital for 1 of 1 residents observed. Findings included: Resident #56 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 30-day quarterly assessment revealed Resident #56 was cognitively aware. There were no moods or behavior indicated. Resident #56 required limited assistance with one staff assist with bed mobility, transfers, eating and toileting, supervision with one staff assist with locomotion on/off unit, extensive assist with one staff assist with dressing and personal hygiene. Resident #56 was always continent of bowel and bladder. An interview with Resident #56 on 05/20/18 at 2:30 PM revealed an alert and pleasant resident. Resident #56 was propelling herself in the wheelchair. An observation of Resident #56 on 05/21/18 at 9:15 AM revealed the resident was out of bed, dressed and propelling herself in her wheelchair. An observation of Resident #56 on 05/21/18 at 12:45 PM revealed the resident was out of bed and propelling her- self in her wheelchair. An interview with Resident #56 on 05/21/18 at 12:45 PM was conducted. Resident #56 stated she was doing fine and had breakfast and lunch. An observation of Resident #56 on 05/22/18 at 9:00 am revealed the resident was lying in bed and appeared to be sleeping. The resident was not dressed and there was no meal tray noted in her room. An observation of Resident #56 on 05/22/18 at 10:00 am revealed the resident was lying in bed and appeared to be sleeping. The resident was not dressed. An observation of Resident #56 on 05/22/18 at 11:00 am revealed the resident was lying in bed and appeared to be sleeping. The resident was not dressed and did not respond to verbal stimuli. An interview was conducted with Nurse #4 on 05/22/18 at 11:07 AM. Nurse #4 revealed the resident stated she wasn ' t feeling well and she was sleepy. Nurse #4 stated the resident was confused earlier this morning when she came out of her room in her brief and wanted to go down the hall to use a bathroom. Nurse #4 reported she did not take her vital signs or do an assessment, but she and the nursing assistant (NA) assisted her back to bed. Nurse #4 stated it was a new behavior for the resident. A review of a nursing progress note dated 05/22/18 indicted Resident #56 had a temperature of 102 degrees Fahrenheit with an irregular heart rate of 135 beats per minute and a distended abdomen. The note indicated Resident #56 was sent out to the emergency department for further evaluation. An interview was conducted with Nurse #4 on 05/22/18 at 2:15 PM. Nurse #4 stated she asked the resident this morning if she was okay about 8:30 or 8:45 AM and the resident stated she did not feel well. Nurse #4 reported the resident got out of bed shortly after and took her morning medications and was noted to be confused as she was coming out of the room in her brief and attempting to wander. She stated this was not normal behavior. Nurse #4 stated she was going to assess her when she did her afternoon medication pass at 1:00 PM. Nurse #4 stated she should have assessed her when she presented with the new behavior and reported she did not feel well this morning. Nurse #4 stated she was sent to the Emergency Department around 12:00 pm on 05/22/18 with a fever and increased heart rate. An interview was conducted with NA #2 on 05/22/18 at 2:20 PM. NA #2 reported the resident did not eat breakfast and that was not her norm. She reported the resident usually ate in the dining room or her room and would get up and about every morning and was talkative. NA #2 stated when she went to assist her in the morning, the resident cussed at her. NA #2 stated the resident did not report she did not feel well, but her lying in bed, not eating her breakfast and cussing at her were not typical behaviors for her. NA #2 stated she reported it to Nurse #4. An interview with the facility physician on 05/23/18 at 11:30 AM revealed Resident #56 was admitted to the hospital with [REDACTED]. The physician revealed that although he felt the delay in treatment would not have changed the resident ' s outcome due to her history of chronic UTI ' s, his expectation of the nurse would have been to assess the resident when the resident indicated she did not feel well and exhibited a change in condition with her behavior. The physician then stated, Clearly there was something going on and needed to be addressed. An interview with the Nurse Practioner (NP) on 05/23/18 at 12:45 PM stated that she would have expected the nurse to assess the resident based on her new behavior. An interview with the Director of Nursing (DON) on 05/24/18 at 2:30 PM revealed her expectation of the nurse would have been to assess the resident when she presented with a change of condition with her behavior and complained of not feeling well.

Based on observation, record review and resident and staff interviews the facility failed to provide incontinence care for a resident dependent on staff for transfer and care for 1 of 1 residents (Resident #15). Findings included: Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #15 was cognitively intact and needed the limited assistance of one person for transfers and toilet use. Resident #15 was occasionally incontinent of bladder. Review of the information provided to the nursing staff that directed the care of each resident (Care Guide) revealed that on 05/21/18 Resident #15 needed the limited assistance of one person for toileting needs and needed the limited assistance of one person for transfers. In an observation on 05/21/18 at 8:40 AM the call light above the door of Resident #15's room was lit up. A male staff member walked past the room without acknowledging the light. Two female staff members were at the end of the hallway speaking together. The call light was lit up on the panel at the nurse's station and the alarm was sounding. No staff members were at the nurse's station. Resident #15 was sitting on the bed with her legs thrown over the side of the bed. The head of the bed was elevated and she was leaning against the mattress in an awkward appearing position. Resident #15 was wearing a brief. She indicated she needed to use the bathroom but could not get out of the bed on her own to get to the bathroom. At 8:45 AM the MDS Nurse entered Resident #15's room and was told by the resident that she needed to use the bathroom. At 8:50 AM the MDS Nurse left the room after informing Resident #15 that she was going to check on how the resident was transferred. At 8:53 AM the MDS Nurse came back to the room with some linens. At 8:59 AM the MDS Nurse left the room after explaining to Resident #15 that a resident from the room next door was now in the adjoining bathroom and that she (Resident #15) would need to wait to use the bathroom. The MDS Nurse informed Resident #15 the aide that was helping the resident next door had been told to let staff know when the bathroom was available for Resident #15's use. At 9:06 AM the Speech Therapist (ST) came to Resident #15's room. She indicated Resident #15 had a mild stroke approximately five days prior but was recovering quickly. At 9:10 AM the Rehabilitation Aide (RA) came to Resident #15's room. She indicated she was not assigned to Resident #15 that day but had been told by a staff member (she was unable to remember who) to see if the resident needed assistance with transferring to the bathroom. The bathroom became available for Resident #15 to use. At 9:11 AM the RA left Resident #15's room stating she would find out how the resident transferred. At 9:14 AM the Rehabilitation Director came into Resident #15's room. She informed Resident #15 that the Physical Therapist (PT) (on 05/16/18) had changed her transfer status to a two person mechanical lift transfer following her recent stroke and that the lift could not be used to take her into the bathroom in her room because the mechanical lift would not fit in the bathroom. The Rehabilitation Director indicated that Resident #15 would probably feel more comfortable with the PT she was familiar with and he was sent for. Resident #15 indicated that she had not been transferred to the bathroom using the mechanical lift and did not want to use it because she was afraid it would injure her leg. At 9:20 AM Resident #15 indicated that she had already wet herself because she could no longer hold it. She stated at first it bothered her when she wet herself but now she was used to it because it always took staff a long time to help her and she was used to it. At 9:28 AM the PT came to Resident #15's room with a walker and she was assisted to sit on the edge of the bed in preparation for transfer into a wheelchair. The PT indicated that the nursing staff was supposed to use the mechanical lift for transfers and only the therapists could transfer Resident #15 using a walker. Resident #15 was still requesting to use the bathroom so the PT decided to transfer her into the wheelchair and take her to the shower room where she could be transferred to a shower chair and placed over the toilet. Resident #15 was assisted to stand in preparation for transfer to the wheelchair. The back of her gown was noted to be saturated with urine. The brief that Resident #15 wore appeared to be saturated with urine. There was a fabric lined, plastic backed, incontinence pad over a folded in quarters bath blanket on top of the bottom sheet. The bath blanket and incontinence pad were both saturated with urine. The bottom sheet was wet from the shoulder area to the mid-thigh area. The Rehabilitation Director removed the saturated linens and rivulets of urine were noted on the mattress. A strong smell of urine was noted at the time the linens were exposed. The Rehabilitation Director offered Resident #15 a shower and stated it was not acceptable that Resident #15 was found in that condition. At 9:36 AM Resident #15 was taken to the shower room where she required the assistance of three staff members to stand. At 9:39 AM the saturated brief was removed and Resident #15 was placed in a shower chair over the toilet to use the bathroom. When the brief was removed Resident #15's buttocks were noted to be red but there was no breakdown. Resident #15 stated her buttocks were red because she had laid in urine for so long. Throughout the continuous observation there had never been any offer of a bedpan or to check Resident #15's brief to see if incontinence care could be provided while her transfer status was being established. In an interview on 05/21/18 at 10:28 AM Nursing Assistant (NA) #1 indicated she had checked Resident #15 at approximately 7:30 AM by looking at the front of the brief for a color change on the moisture indicator line. There was no change in color to indicate that Resident #15 had been incontinent of urine. She indicated she fed Resident #15's roommate her breakfast and told Resident #15 she would be back to provide care. NA #1 stated Resident #15 did not tell her she was wet when she served her breakfast. She indicated she had used the mechanical lift to get Resident #15 out of bed on 05/19/18. In an interview on 05/21/18 at approximately 10:35 AM the Director of Nursing (DON) stated the care guides for each resident were only in the computer. She stated the nursing staff all had access to the information and should be going into the computer to see how to care for the residents. In an interview on 05/22/18 at 9:51 AM the Occupational Therapist (OT) stated the nursing staff was supposed to use a mechanical lift to transfer Resident #15. In an interview on 05/24/18 at 5:18 PM the MDS Nurse stated that a lot of things had been discussed about Resident #15 in clinical meetings. She indicated she remembered a discussion that Resident #15 may or may not be appropriate for therapy but did not remember any discussion about the use of a mechanical lift so was not aware Resident #15 needed one for transfers. She indicated she and the MDS Coordinator were responsible for updating the care guides but since a significant change MDS was in process Resident #15's care plans and care guide had not yet been updated. In an interview on 05/22/18 at 6:00 AM NA #4 stated incontinence rounds were conducted every two hours and as needed. In an interview on 05/22/18 at 6:20 AM NA #6 indicated she went non-stop during her shift providing care. She stated she checked on her residents more often than every two hours. In an interview on 05/25/18 at 1:10 PM NA #8 stated she had found Resident #15 saturated before when she took over her assignment. She indicated she had informed the hall nurse and the DON. She stated rounds should be done every two hours to check residents for incontinence. In an interview on 05/25/18 at 2:05 PM the DON stated she expected incontinence rounds to be completed every two hours and as needed. She indicated she would not expect aides to pull back a resident's brief to check for incontinence. She stated that visualizing a change in color to the moisture line in the brief was sufficient if there was no odor. The DON indicated it should not have taken so long for Resident #15 to be taken to the bathroom or for her to receive incontinent care.

Based on observations, record review and staff interviews, the facility failed to follow patient centered care plans to apply palm protectors to 2 of 3 residents (Resident #19 and #9) observed for range of motion and contractures. Findings included: Example #1 Resident #19 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], 14-day assessment revealed the resident was cognitively impaired. Resident #19 required extensive assistance with two staff assist with transfers, bed mobility, toileting and bathing, and extensive assistance with one staff assist with dressing, eating and personal hygiene. Resident #19 had impairments to both sides to upper and lower extremities. Resident #19 was not coded for any splinting or range of motion. A review of the physician orders [REDACTED]. A review of the care plan updated on 04/20/18 revealed the resident had a potential for skin breakdown development related to decreased mobility with an intervention to include bilateral palm protectors to be worn at all times and removed for hand hygiene and monitor for redness. An observation of Resident #19 on 05/20/18 at 1:42 PM revealed there were no palm protectors on bilateral hands. The resident ' s hands were noted to be contracted, fingernails were clean and trim and there were no signs of indentation or odor on her palms. An observation of Resident #19 on 05/20/18 at 4:45 PM revealed there were no palm protectors on bilateral hands. An observation of Resident #19 on 05/21/18 at 8:50 AM revealed there were no palm protectors on bilateral hands. An observation of Resident #19 on 05/21/18 at 10:30 AM revealed there were no palm protectors on bilateral hands. An observation of Resident #19 on 05/21/18 at 12:30 PM revealed there were no palm protectors on bilateral hands. An observation of Resident #19 on 05/21/18 at 2:30 PM revealed there were no palm protectors on bilateral hands. An observation of Resident #19 on 05/21/18 at 4:30 PM revealed there were no palm protectors on bilateral hands. An observation of Resident #19 on 5/22/18 at 8:30 AM revealed there were no palm protectors on bilateral hands. An observation of Resident #19 on 05/22/18 at 10:15 AM revealed there were no palm protectors on bilateral hands. An observation on Resident #19 on 05/22/18 at 1:20 PM revealed there were no palm protectors on bilateral hands. An interview with NA #2 on 05/22/18 at 2:30 PM revealed Resident #19 was total care and she relied on staff assistance for all of her care. NA #2 stated Resident #19 wore bunny boots to her bilateral feet, but she was not aware if the resident wore splints or anything on her hands. NA #2 stated she was fed with assistance and could use her hands to hold a special cup. NA #2 reported the only way she knew how to take care of a resident was if she already knew them or she would ask the nurse. An observation of Resident #19 on 05/23/18 at 6:00 AM revealed there were no palm protectors on bilateral hands. An interview with Nurse #8 on 05/23/18 at 6:10 AM revealed She was supposed to have them on at all times. The nurse searched the room for the palm protectors which were located in a bureau draw and applied them to the resident. Nurse #8 stated it was a nursing measure and it was up to the nurse to apply the palm protectors. An interview was conducted with the Director of Nursing (DON) on 05/24/18 at 2:30 PM. The DON reported her expectations of the nursing staff was to follow the care plan and to ensure the palm protectors were applied as ordered by the physician. Example 2 Resident #9 was admitted to the facility on [DATE] and re-entered on 03/03/18 with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) current physician orders [REDACTED]. A quarterly Minimum Data Set assessment ((MDS) dated [DATE] revealed the resident had intact cognition, required extensive assistance for all activities of daily living except eating, and had bilateral upper and lower extremity impairments. Review of the care plan dated 03/05/18 for Resident #9 stated that he was at risk for impaired skin integrity related to poor bed mobility due to [MEDICAL CONDITION] and a right hand contracture. Interventions included: palm protector to the right hand, remove for hand hygiene and monitor for redness. On 05/20/18 at 11:45 AM and on 05/23/18 at 8:30 AM Resident #9 was observed without a palm protector on his right hand. In an interview with Resident #9 on 05/23/18 at 8:30 AM he stated that his palm protector had fallen on the floor beside his bed about a week ago and he had not seen it since. He stated that he did wear it except when wheeling his wheelchair and when eating but had not had it to put on for a week. He said his hand felt better when he had it on. On 5/23/18 at 5:30 PM the resident stated that he had received a new palm protector for his hand and showed it to this surveyor. He said he had just taken it off because dinner was coming and he was going to eat. In an interview conducted with the Director of Nursing on 05/24/18 at 12:05 PM she stated that the nurse aides applied splints and palm guards. She said they documented this task in the electronic Point of Care (P[NAME]) system Kardex. She said it was her expectation that if a palm protector was ordered by the physician that it be applied by the nurse aides as ordered and care planned In an interview with Nurse Aide #9 on 05/25/18 at 7:50 AM she stated that she obtained information regarding specific patient care by looking in P[NAME] or asking a nurse. She said if a resident had a palm guard or a splint it would show in P[NAME] as a task to be done. She reported that she cared for Resident #9. She said that she remembered that he wore a palm guard and that she was pretty sure that she saw it and put it on his hand while providing care but could not say for certain. In an interview with Nurse Aide #10 on 05/25/18 at 8:05 AM she stated that she cared for Resident #9 on her assignment. She said she looked at the resident Kardex to determine the needs of each resident. She remembered that Resident #9 wore a palm guard on his right hand. She stated that she could not remember if he was wearing the palm guard the last time she took care of him. She said she did remember seeing it on his dresser but could not remember putting it on the resident.