Every finding on record at Diversicare of Shelby

Based on staff interview, record review, Payroll-Based Journal (PBJ) staffing data review and facility policy review, the facility failed to submit PBJ data accurately to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. 2nd Quarter 2025 (January 1, 2025, through March 31, 2025) Findings include: Record review of the facility policy titled, Payroll Based Journal Entry Submission, dated 2022, revealed, Procedure .7. Hours that each team member works each day must be submitted. Per CMS training hours and corporate team member hours may be included if the team member is providing direct care or performing direct care duties . Review of the PBJ Staffing Data Report revealed the facility triggered for excessively low weekend staffing for the 2nd quarter, 2025 (January 1, 2025, through March 31, 2025). During an interview on 6/30/25 at 12:40 PM, the Human Resource Coordinator revealed the facility used a phone application (APP) for their payroll time clock system. At times, the APP did not work properly and during those times, the employee's time was entered manually. The salary employees' time was also entered manually into the facility's payroll system. An interview with the Workforce Manager on 6/30/25 at 12:45 PM revealed the Administrator, Human Resource Coordinator, and Workforce Manager met every weekday morning to discuss the hours submitted by the clocking system as well as those manually entered to ensure the submitted information was accurate. She revealed the hours submitted into their payroll system were sent to herself and to corporate by the Human Resource Coordinator. During an interview and record review with the Administrator and the Workforce Manager on 7/1/25 at 7:50 AM, the working schedule and the information submitted into the Payroll Based Journal (PBJ) system revealed discrepancies. The Workforce Manager stated she felt the data was submitted into the PBJ system prior to their review and updated changes of the data. The Administrator confirmed that the information submitted during the 2nd quarter did not accurately reflect the staff present due to manually entered information not being entered timely or correctly. She confirmed the facility failed to submit accurate data into the PBJ system which led to an inaccuracy of data submission.

Based on observation, interview, record review and facility policy review, the facility failed to maintain a clean, safe, and homelike environment in one (1) of fifty-five (55) resident rooms observed. This deficient practice resulted in a room environment with visible water damage and possible mold growth, which may pose a health risk to the resident occupying the room. room [ROOM NUMBER] B. Findings include: A review of the facility ' s policy, Types of Maintenance, with no date, revealed, Routine Maintenance. This is the most frequently done activity of all and is done by performing routine and scheduled maintenance of the property . On 6/29/2025 at 11:30 AM, during an observation, room [ROOM NUMBER] on the B-side was noted to have a large, irregular-shaped light brown and black discoloration on the far wall, extending approximately two (2) feet across the ceiling and approximately two (2) feet down the wall. On 6/30/2025 at 8:38 AM, during an observation with the Infection Control Nurse, she verified the presence of the large, irregular-shaped light brown and black discoloration extending across the ceiling and wall in room [ROOM NUMBER]. She explained that the discoloration appeared to be from a water leak. She reported that she was not sure what the discoloration consisted of, but it could be mold. She agreed that a water leak and possible mold could be detrimental to the resident that lived in that area of the room, by causing an infection. On 6/30/2025 at 8:40 AM, during an observation with Maintenance and the Administrator (ADM), they verified the presence of the discoloration in room [ROOM NUMBER]. Maintenance explained that there had previously been a roof leak in that area which he had repaired, but stated he was unaware of the current issue and noted that it had recently rained. A record review of the facility's Logbook Documentation Task Name: Regular Maintenance and Safety Inspection revealed documentation completed by Maintenance. On 3/28/2025, the log noted need roof now, on 4/30/2025 it indicated need roof badly, and on 5/12/2025 it read roof needs replacing. On 6/30/2025 at 9:48 AM, during an interview with the Administrator, she verified that she was aware of the maintenance and safety inspection entries indicating the roof needed to be replaced. She explained that she had put in a request for a replacement, and in the meantime, Maintenance had patched the roof. She agreed that the discoloration observed in room [ROOM NUMBER] could have been caused by the leaking roof. She verified that she had no documentation that a request had been submitted to the corporate office for a new roof. On 6/30/2025 at 10:00 AM, during a further interview with Maintenance, he verified that he would not have documented the need for a new roof on the inspection log if a replacement was not necessary.

Based on observation, resident/staff interview, and record review, the facility failed to implement a comprehensive care plan for nail care for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead with an effective date of October 2024 that revealed, Policy: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Record review of Resident #10's Care Plan Report revealed under, Focus: Self-care deficit due to: Recent surgery for trans metatarsal amputation of left foot. Additionally revealed under, Interventions/Tasks: Nail, hair, and oral care daily as needed. On 6/29/25 at 11:55 AM an observation and interview with Resident #10 revealed fingernails on both hands were long, jagged, and measured approximately three-eighths (3/8) inches in length from the fingertip. She stated she would like them trimmed and explained that her nails had never been this long before. On 6/30/25 at 9:00 AM an observation and interview with the Administrator confirmed Resident #10's long nails. An interview with the Minimum Data Set (MDS) Nurse on 6/30/25 at 9:52 AM revealed the purpose of the care plan was to provide the necessary resident care and to ensure their needs were met while incorporating the resident preferences. She acknowledged Resident #10's care plan was not followed for nail care. Record review of the admission Record revealed the facility admitted Resident #10 on 5/15/25 with a medical diagnosis of Encounter for Orthopedic Aftercare following Surgical Amputation. Record review of the MDS with an Assessment Reference Date (ARD) of 5/22/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #10 was moderately cognitively impaired.

Based on observation, interviews and record review, the facility failed to perform nail care for a resident requiring assistance with activities of daily living (ADLs) for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead that read, Policy: Proper name of the facility uses Clinical Nursing Skills and Techniques, [NAME]. [NAME], as a supplementary policy and procedure care guide. An observation and interview with Resident #10 on 6/29/25 at 11:55 AM revealed she was lying in bed with long fingernails bilaterally that measured approximately three-eighths (3/8) of an inch long and were jagged. She admitted that staff had told her they would trim them, but no one ever came. She stated that her nails had never been as long as they are now and she wanted them trimmed. An observation and interview with Certified Nurse Aide (CNA) #1 on 6/30/25 at 8:35 AM confirmed Resident #10's long nails. She stated the treatment nurse was responsible for trimming the resident's nails and revealed the resident could scratch herself and get an infection. An observation and interview with the Administrator on 6/30/25 at 9:00 AM confirmed Resident #10's nails were long. She revealed the aides or nurses could trim the resident's nails since she was not a diabetic. She acknowledged there was a possibility the resident could scratch and injure herself. Record review of the admission Record revealed the facility admitted Resident #10 on 5/15/25 with a medical diagnosis of Encounter for Orthopedic Aftercare following Surgical Amputation. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/25 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #10 was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to use Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) for one (1) of 16 residents on EBP reviewed.(Resident #206). Findings include: Review of the policy titled, Proper Name Infection Control Guide, dated 2025, revealed Enhanced Barrier Precautions (EBP) refer to the expanded use of PPE (personal protective equipment) and involve the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug-resistant organisms). Nursing home residents with indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. Indwelling devices, e.g., (for example) central lines. Review of the Order Summary Report for Resident #206 revealed an order for Cefepime Intravenous (IV) solution 2 (two) GM/100 ML (grams/milliliter): administer two grams intravenously twice daily, with a start date of 6/26/25 and an end date of 7/06/25. IV-PICC: monitor site every shift for signs/symptoms of infection and/or infiltration every shift to maintain patent IV access and prevent infection, with a start date of 6/16/25. An observation of medication administration on 6/30/25 at 8:25 AM for Resident #206 revealed Registered Nurse (RN) #1 administered Cefepime intravenous solution 2 GM/100 ML via a PICC line to the resident's left upper arm without wearing a gown as required for EBP. In an interview with RN #1 on 6/30/25 at 8:32 AM, she confirmed she failed to apply a gown as part of EBP and acknowledged that she should have because Resident #206 has a PICC line. She stated that the purpose of EBP is to provide an extra layer of protection between staff and the resident to reduce the spread of infection, and that failing to use EBP increased the resident's risk of infection. During an interview with the Administrator on 6/30/25 at 9:48 AM, she confirmed that RN #1 should have used EBP when she administered the antibiotics to Resident #206 via his PICC line. She confirmed that EBP reduces the risk of the spread of infection between staff and residents. She confirmed that failing to use EBP could place the resident at increased risk of infection. Record review of the admission Record revealed Resident #206 was admitted by the facility on 5/02/25 with a diagnosis of acute osteomyelitis, left femur. Record review of Resident #206's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired.

Based on staff interviews, record review and facility document review, the facility failed to submit accurate staffing information into the Payroll-Based Journal (PBJ) system for one (1) of four quarters reviewed. First quarter 2024 Findings Include: Record review of a typed document on facility letterhead, dated 5/21/24 and signed by the Licensed Nursing Home Administrator (LNHA) revealed Staffing: It is the practice of (Proper name of the facility) to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Staffing expectations are based on resident acuity and needs and may fluctuate based on the center population as identified in the facility assessment. The center conducts work force management meetings daily to discuss open positions, open shifts and call ins as related to patient needs. We continue to actively recruit staff offering various incentives. Record review of the PBJ (Payroll-Based Journal) Staffing Data Report revealed the facility submitted excessively low weekend staffing data for the 1st quarter 2024 (October 1-December 31). An interview with Licensed Practical Nurse (LPN) #3 on 5/19/2024 at 12:45 PM, revealed she had witnessed staffing concerns on the weekend and stated they mostly come from call in's. She revealed management did come in to work when someone called in. An interview with LPN #2 on 5/19/2024 at 12:50 PM, revealed she had witnessed staffing concerns on the weekend. She explained that when someone calls in on the weekend, they get on the phone and start calling staff to find help. She revealed they also notify the Workforce Manager so that she can start making calls. LPN #2 explained that management always helps and comes to work when someone calls in. An interview with the Administrator (ADM) and the Director of Nursing (DON) on 5/19/2024 at 3:30 PM, revealed they were not aware they had triggered for low weekend staffing. The ADM revealed they have a Workforce Manager who always ensured the facility met the minimum requirement or above. She stated they had never fallen below that minimum requirement. She revealed they do have frequent call-ins, but all management personnel come to work to fill positions, whether it be as an aide or a nurse. The ADM stated they all rotated and took call and were responsible for coming in if they were unable to find replacement staff when someone called in. The DON revealed that management personnel were all salaried and that corporate did not have a way to add them to the PBJ (Payroll-based Journal) because they did not clock in. The ADM explained that she had several discussions with the facility Human Resource staff member and the Corporate Payroll staff and was told there was no way to add any hours for coming in and covering a shift for salaried individuals. An interview with the Workforce Manager on 5/20/2024 at 2:32 PM, revealed she had worked in the staffing position for two (2) years. She revealed call in's were the biggest concern for staffing. She stated they have a staff member on call every day. She explained when a staff member called in, they had to call in to the person on call, and it was the on-call person's responsibility to call around and try to find a replacement. She revealed on the weekends, they call in to the facility and the floor nurses were responsible for calling the staff to find a replacement. The Workforce Manager explained the on-call person must work if they cannot find someone. She stated when management worked to fill a position, she always included them in her staffing numbers even though she knew Human Resources had told her that they were unable to add it to the payroll data. She confirmed this was an error in payroll data submission. An interview with the ADM on 5/20/2024 at 3:15 PM, revealed she just hired two (2) aides and was looking to hire 2 more part-time. She stated the staff she has right now were willing to work extra and stay over to cover shifts. She revealed all management personnel come in to work to meet the staffing requirement when someone calls in. She explained she had reached out to the corporate office to notify them of the need to count salaried employees on payroll but was told they did not have a way to do it. She confirmed this was a payroll data error and would not accurately reflect the staffing numbers. An interview with Human Resources on 5/21/2024 at 9:40 AM, revealed she was responsible for completing payroll. She revealed once her information was entered into the payroll system, it went to the corporate office. She explained that the payroll system will not allow her to change the role of a salaried employee. She revealed that salaried employees' hours were pre-set in the system and could not be changed. An interview with the ADM on 5/22/2024 at 9:10 AM, revealed that the facility was without a payroll person for 4-5 months, and that would have been during the time the facility triggered for low weekend staffing. She revealed she hired someone in the middle of October 2023 to fill that position but the new hire still had to be trained. She explained that she and the Workforce Manager did payroll within that time frame. She revealed she was not familiar with payroll, but she had to step up and do what needed to be done. She acknowledged this likely caused some data errors with the accurate submission of the payroll-based Journal.

Based on observation, staff interview, and facility policy review the facility failed to provide blinds or window coverings in good repair for one (1) of 60 resident rooms observed for a clean, comfortable, and homelike environment. room [ROOM NUMBER]. Findings Include: Review of the facility policy Work Orders and Paging, effective September 1, 2014, revealed, Purpose, To establish a productive procedure for communicating and coordinating the needs of the residents and employees from the Maintenance Department . Work Orders, TELS . is a Computerized Maintenance Management System (CMMS). Employees shall complete Work Orders through TELS. When a verbal request for maintenance is received from center personnel, maintenance staff should request that a work order be submitted . An observation of room [ROOM NUMBER] on 5/19/24 at 1:00 PM, revealed the window blind had broken slats creating a 12 by six (6) inch opening on the right side through which the parking lot was visible. In an interview on 5/20/24 at 9:35 AM, with Certified Nursing Assistant (CNA) #1 she stated that if there was something broken in a resident's room, she would tell the maintenance staff. During an interview on 5/20/24 at 9:40 AM, with Registered Nurse (RN) #1 he stated that if broken equipment was found in the resident room, he would notify the maintenance staff either in person or by phone. On 5/20/24 at 10:00 AM, an observation of room [ROOM NUMBER] and interview with the Maintenance man, he verified that the window blinds were broken creating and opening on the right side. The Maintenance man stated that staff are supposed to enter work orders in TELS, but usually they just tell him. He verified that he was not aware of the condition of the window blinds. On 5/20/24 at 10:07 AM, an interview and record review, with the Maintenance man, of work orders in TELS, revealed that there was no work order for the broken window blinds in room [ROOM NUMBER]. During an interview with the Administrator on 5/20/24 at 2:00 PM, she stated that staff usually notify the Maintenance man verbally or put maintenance needs on the 24-hour report. She verified that staff have not consistently been entering maintenance requests in TELS like they should.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident receiving an enteral feeding (Resident #1), and failed to develop a comprehensive care plan for a resident receiving antipsychotic medication (Resident #54) for two (2) of nineteen care plans reviewed. Findings Include: Review of the facility policy titled Care Plans with a revision date of October 2021 revealed, Policy: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. This document was dated 5/21/24 and signed by the Licensed Nursing Home Administrator. Resident #1 Record review of Resident #1's care plan revealed, Focus: (Proper name of Resident #1) has PEG (Percutaneous Endoscopic Gastrostomy) tube placed and is at risk for complications R/T (related to) feeding tube .Interventions . every shift Jevity 1.5 @ (at) 65 ml/hr (milliliters per hour) x (times) 22 hours, 2145 kcal (kilocalories); 90g (grams) protein; and 2330 ml total fluid. An observation on 5/19/2024 at 12:25 PM, revealed Resident #1 lying in bed with his eyes closed. A bottle of Jevity 1.5 enteral feeding was hanging via feeding pump, which was turned off. An observation on 5/19/2024 at 3:15 PM revealed Resident #1 lying in bed with his eyes closed. A bottle of Jevity 1.5 enteral feeding was hanging via pump, which was turned off. On 5/19/2024 at 3:55 PM, in an interview with Licensed Practical Nurse (LPN) # 2 confirmed Resident #1's feeding pump was turned off. On 5/21/2024 at 3:30 PM, in an interview with the Director of Nursing (DON) revealed the purpose of the care plan was to identify and focus on the resident's concern or problem and to develop interventions to resolve the problem. She confirmed that the facility did not follow Resident #1's care plan for the enteral feeding. Resident #54 An observation of resident #54 on 5/19/2024 at 2:35 PM, revealed she could be heard hollering down the hallway. The resident was sitting in a wheelchair in her room and was confused, asking for the car keys and stated she was leaving to go to the store but did not want anyone to know. Record review of the Order Summary Report with active orders as of 5/20/24, for Resident #54 revealed an order dated 4/22/2024, Seroquel oral tablet 50 MG (milligrams) (Quetiapine Fumarate) Give 50 mg via PEG-Tube at bedtime for Mood Disorder. Record review of the Care Plans for Resident #54 revealed a care plan was not developed for the antipsychotic medication Seroquel for mood disorder. An interview with the Minimum Data Set (MDS) nurse on 5/20/2024 at 1:15 PM, revealed she was responsible for the care plans. She confirmed Resident #54 did not have a care plan developed for the antipsychotic medication Seroquel. She revealed a care plan should have been developed so that staff would know what care to provide. An interview with the Administrator (ADM) on 5/20/2024 at 1:32 PM, revealed antipsychotic medications should be care planned because they were high-risk medications and it would allow staff the knowledge to provide better care.

Based on observation, staff interview, and record review and facility document review, the facility failed to ensure a resident who received enteral nutrition received appropriate treatment and services, as evidenced by, the facility's failure to administer an enteral feeding according to the physician's order for one (1) of 11 residents with a feeding tube. Resident #1 Findings Include: Record review of a typed document on facility letterhead, dated 5/21/24 and signed by the Licensed Nursing Home Administrator revealed, Standards of Practice: The expectation set forth by (Proper Name of the facility) is that nurses comply with current standards of practice in terms of following physician's orders. This includes following orders for medication and enteral feedings. An observation on 5/19/2024 at 12:25 PM, revealed Resident #1 with his eyes closed lying in bed A bottle of Jevity 1.5 was hanging via pump, which was turned off. An observation on 5/19/2024 at 3:15 PM, revealed Resident #1 lying in bed with his eyes closed. A bottle of Jevity 1.5 was hanging via pump, which was turned off. An interview with Licensed Practical Nurse (LPN) #2 on 5/19/2024 at 3:55 PM, confirmed Resident #1's enteral feeding was turned off. Record review of the May 2024 MAR for Resident #1 revealed an order dated 3/12/2024, Enteral feed one time a day turn feeding pump off scheduled for 7:00 AM, signed as administered on the MAR, which indicated the resident was receiving this order. An additional order dated 3/12/2024 revealed, Enteral Feed Order one time a day turn feeding pump on scheduled for 1500 (3:00 PM) signed off as administered on the MAR, which indicated the resident was receiving this order. Record review of the May 2024 Medication Administration Record (MAR) for Resident #1 revealed an order dated 5/7/2024, Enteral feed order every shift Jevity 1.5 @ 65 ml/hr (milliliters per hour) x (times) 22 hours, 2145 kcal (kilocalories); 90g (grams) protein; 2330 ml (milliliter) total fluid which was signed off on the MAR as administered, which indicated the resident was receiving this order. During an interview with the Director of Nursing (DON) on 5/20/2024 at 8:45 AM revealed several weeks ago Resident #1 began not eating meals, and they increased his tube feeding. She revealed he was supposed to be receiving Jevity1.5 at 65 ML/HR (milliliters per hour) x (times) 22 hours. She confirmed the Jevity was not supposed to be off between the hours of 7:00 AM to 3:00 PM and stated the order should have been discontinued. The DON revealed an error was made by not removing the order from the resident's MAR. She revealed she took responsibility for the error because she put the new feeding order into the medical record and did not take out the other discontinued order. She confirmed weight loss could be a concern. An interview with Registered Nurse (RN) #1 on 5/21/2024 at 9:02 AM, confirmed he was aware Resident #1 had two enteral feeding orders on the MAR. He revealed there was a problem with communication and the old order was not discontinued. He stated he had been turning the resident's feeding pump off at 7:00 AM and re-starting it at 3:00 PM daily, and confirmed he was signing both orders. RN #1 revealed he should have questioned the order and called the doctor for clarification and confirmed he should not sign a physician's order on the medical record that was not given. He revealed that the resident was at risk for dehydration, weight loss and malnutrition by not getting the appropriate enteral feeding. An interview with the Administrator (ADM) on 5/21/2024 at 9:48 AM, revealed the nurses should have questioned two different enteral feeding orders on the MAR. She revealed they should not have signed both orders as administered, and confirmed this was a standard of practice issue. She acknowledged Resident #1 was at risk for weight loss by not getting the correct enteral feeding order. During a telephone interview with the Registered Dietician (RD) on 5/21/2024 at 10:22 AM, confirmed Resident #1 was at risk for weight loss if he did not get the prescribed enteral feeding. Record review of the Admission Record revealed the facility admitted Resident #1 on 9/8/2019 with current medical diagnoses that included Alzheimer's Disease, Dysphagia, and Gastrostomy status.

Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately complete section P of the Minimum Data Set (MDS) for one (1) of four (4) residents residing in the facility with a wander alert bracelet. Resident #24 Findings Include: Review of the facility policy titled RAI (Resident Assessment Instrument) Process Guideline undated, revealed Process: The CMS (Centers for Medicare and Medicaid Services) Long-Term Care Facility Resident Assessment User's Manual 3.0 will provide the framework and directions to completing the RAI process. All items in the MDS are to be coded per the instructions of the CMS Long-Term Care Facility Assessment User's Manual MDS 3.0. An observation of Resident #24, on 5/19/2024 at 12:16 PM, revealed she was sitting on the edge of the bed. A wander alert bracelet was observed on her left ankle. Record review of the Order Summary Report with active orders as of 5/20/24, revealed an order dated 7/03/2023, Wanderguard to left ankle. Check placement and function Record review of Resident #24's quarterly MDS with an Assessment Reference Date (ARD) of 5/3/2024, revealed in Section PO200 Alarms .Wander/elopement alarm was coded as 0 indicating Not used during the MDS look back period An interview with the MDS Nurse on 5/20/2024 at 11:01 AM confirmed a data error was made on Resident #24's quarterly MDS and the wanderguard was not captured. An interview with the Director of Nursing (DON) on 5/20/2024 at 11:06 AM, revealed her expectations was for the assessments to be completed accurately by the MDS staff.

Based on record review and staff interviews, the facility failed to refer a resident to the appropriate agency for a Level II Preadmission Screening and Resident Review (PASARR) following an inpatient Geri-psych admission with a new psychiatric diagnosis and new psychiatric medications for one (1) of four (4) sampled residents reviewed for PASARR. Resident #16. Findings include: Record review of a typed document on facility letterhead dated 1/4/22 provided and signed by the Administrator revealed (Formal Name of Facility) go by the State Guidelines on performing PASSARS. We do not have a Passar Policy. Record review of the Medical Diagnosis List for Resident #16 revealed a diagnosis of Schizophrenia, Unspecified, with a date of 11/19/19. Record review revealed there was no Change in Status Form completed for Resident #16, related to the inpatient admission to Geri-psych on 11/8/19 during which the resident received a new psychiatric diagnosis of Schizophrenia, dated 11/19/19, and a new physician's order for new psychiatric medications, Abilify and Depakene. An interview on 1/4/23 at 10:25 AM, with the Minimum Data Set (MDS) Nurse, revealed she was not able to locate a Change in Status Form, for Resident #16, related to the inpatient admission to Geri-psych on 11/8/19. The MDS Nurse revealed a Change in Status Form should have been done for the Geri-psych admission, for the new diagnosis of Schizophrenia, and the new psychiatric medicines for psychiatric treatment. An interview on 1/4/23 at 12:07 PM, with Social Services, revealed she called the mental health services agency responsible to process Change in Status Forms to inquire about a Change in Status Form submission, from November 2019, for Resident #16. She revealed the mental health services agency confirmed there was no submission of a Change in Status Form, for Resident #16, for the Geri-psych inpatient admission on 11/8/19, for the diagnosis of Schizophrenia, nor for the psychiatric medicines. Social Services confirmed that a Change in Status Form should have been submitted, in November 2019, to ensure a Level II screen was completed to evaluate Resident #16 for the possible need of additional mental health services and interventions. An interview on 1/4/23 at 12:11 PM, with the Administrator, confirmed there was not a Change in Status Form submitted in November 2019, for Resident #16, after re-admission to the facility following a Geri-psych admission with a new diagnosis of Schizophrenia and new psychiatric medications. She confirmed that a Change in Status Form should have been submitted in November 2019. This would have allowed Resident #16 to have possibly received a Level II Screen for the possible need of additional mental health services. The Administrator confirmed there is a possibility that Resident #16 may not have received all the mental health services she could have qualified for in the nursing facility. Record review of the Physician's Order Sheet, for Resident #16, revealed, 11/19/19 Readmit to [NAME] Health and Rehab Center under the care of (physician's name removed). Resume previous nursing home order, plus add: Aripiprazole (Abilify) 10 MG by mouth (PO) at bedtime and Depakene (Valproic Acid) 250 MG PO two (2) times a day (BID). Record review of the Admission History and Physical for Geri-psych, for Resident #16, revealed . admitted Nov-08-2019 . Assessments: Schizophrenia Deferred to the Geri-psych service . Identifying Data: The patient is a [AGE] year old African American female who was voluntarily hospitalized to (facility's name removed), Geri-psych facility at (hospital's name removed) transferred from [NAME] Health and Rehab where she has been showing inappropriate sexual behavior . The symptoms were unable to treated on outpatient basis which required this Geri-psych referral and admission . Record review of the Patient Discharge Summary Report from Geri-psych, dated 11/19/19, revealed . admitted : 11/8/2019 . Diagnosis: Anxiety Disorder . Discharge Medications: New Medications to start taking - Aripiprazole (Abilify) - Take 10 MG by mouth at bedtime . Depakene - Take 250 MG by mouth twice a day. Record review of the Admission Record for Resident #16 revealed an admitted [DATE].

Based on record review, staff interview, and facility policy review, the facility failed to transmit a Minimum Data Set (MDS) assessment within a timely manner for one (1) entry, Resident #205, and two (2) discharge MDS assessments for Resident #6 and #1; for three (3) of 22 residents reviewed. Findings include: On [DATE] at 11:25 AM, an interview with the Assistant Director of Nursing (ADON) revealed the facility does not have a policy and procedure for the timing of the Minimum Data Set (MDS), the facility uses the Resident Assessment Instrument (RAI) manual for guidance. The RAI - required Assessment Summary revealed a Discharge Assessment - return not anticipated should be completed by the 14th day after the discharge date . Review of a statement on facility letterhead, signed by the Administrator, and dated [DATE], revealed: All MDS assessments are completed by the direction of the RAI manual. Resident #1 Review of Resident #1's Discharge MDS, with an ARD of [DATE], revealed the MDS had not been completed and submitted. Review of the MDS history for Resident #1, revealed a Discharge MDS with a date of [DATE], with a status of export ready on [DATE]. During an interview on [DATE] at 10:24 AM, Registered Nurse (RN) #1 confirmed the discharge MDS for Resident #1 had not been completed on [DATE]. RN #1 revealed she was not the MDS nurse at that time and did not know why the MDS was not completed. RN #1 revealed a Discharge MDS should be completed by the 14th day after the ARD date. On [DATE] at 11:25 AM, an interview with the ADON confirmed the Discharge MDS for Resident #1, with an ARD of [DATE], was not completed and was 105 days late. Resident #6 Review of Resident #6's medical record revealed the resident expired in the facility on [DATE], and the Discharge Assessment has not been opened or completed as of [DATE]. Interview with RN #1 on [DATE] at 4:43 PM, revealed that she is new in the position, and is scheduled to go to the MDS training later in the month. RN #1 stated the assessment should have been completed within seven (7) days of the resident's discharge. Resident #205 Record review revealed Resident #205 was sent to the hospital on [DATE]. Resident #205 was admitted to Geri-Psych unit and was readmitted to the facility [DATE]. The MDS Entry tracking was completed [DATE], instead of [DATE]. Interview with RN #1 on [DATE] at 9:43 AM, revealed the assessments were not completed timely. She stated that Admissions and Discharges are discussed in the stand up meeting daily.

Based on record review, observation, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for four (4) of 22 MDS assessments reviewed as evidenced by inaccurate coding for: one (1) resident discharged to home (Resident #56), two (2) residents with a gastrostomy tube (Resident #51 and Resident #35), one (1) resident with Insulin injections (Resident #51), two (2)residents with pressure ulcers (Resident #51 and Resident #35), and two (2) residents without an anticoagulant ordered (Resident #51 and Resident #35). Findings include: Review of a statement on facility letterhead, signed by the Administrator, and dated 10/10/19, revealed: All MDS assessments are completed by the direction of the Resident Assessment Instrument (RAI) manual. Resident #56 Record review of Resident #56's Discharge MDS, with an Assessment Reference Date (ARD) of 9/6/19, revealed Acute Hospital was chosen as the Discharge Status. Record review of Resident #56's physician's orders [REDACTED]. During an interview on 10/10/19 at 4:43 PM, Registered Nurse (RN) #1/MDS Nurse/Care Plan Coordinator, confirmed she did enter the wrong information about the discharge status of Resident #56 on the MDS, with an ARD of 9/6/19. She stated, I was under the impression that she was discharged to another facility, a hospital. RN #1 stated she was in orientation at the time and input information into the MDS according to what the Director of Nursing (DON) told her. She stated, I've never done MDS. She stated she is scheduled to go to the State MDS training this month. Resident # 51 Review of Resident #51's MDS, with ARD of 9/18/2019, was inaccurately coded with the following: Section K0510B was not coded for a gastrostomy tube, K0710A and B were not coded for the amount of nutrition received via gastrostomy tube, M0100A and B was not coded for pressure ulcer, M0210 was coded 0 for number of stage 2 pressure ulcers, N0300 was coded 0 for injections received, N0350A was blank for insulin injections, N0410E was coded 7 for days of anticoagulant therapy. Review of the physician's orders [REDACTED].#51, all initiated on 9/6/19, revealed the resident had a gastrostomy tube and received medications and enteral feedings via this route, resident had a stage 2 pressure ulcer, resident received seven (7) days of insulin injections, and there was not an anticoagulant ordered or received during the seven (7) day look back period. Resident #35 Review of Resident #35's MDS with an ARD of 8/25/2019, revealed Section N0410E was coded 7 for days receiving an Anticoagulant. Record review of the (MONTH) 2019 MAR and physician's orders [REDACTED].#35. Resident #43 Review of Resident #43's Annual MDS, with an ARD of 9/5/2019, revealed section K0510B was not coded for a gastrostomy tube, K0710A was not coded for fluid intake, and M0300B was not coded for pressure ulcers. Review of the (MONTH) 2019 physician's orders [REDACTED].#43 had a gastrostomy tube, received flushes per tube every shift, and had two (2) facility acquired Stage 2 pressure ulcers. Interview with RN #2, on 10/8/19 at 10:24 AM, revealed Resident #43 had two (2) Stage 2 pressure ulcers that are being treated on a daily basis. Interview with RN #1 on 10/10/19 at 4:43 PM, revealed she was in orientation at the time and input information into the MDS according to what the Director of Nursing told her. She stated, I've never done MDS. She stated she is scheduled to go to the State MDS training this month. She stated she is still in training and was completing the MDS, with guidance from the previous Director of Nursing. She confirmed the MDS assessments for Residents #56, #43, #35, and #51 were coded in error.

CI MS # Based on record review, staff interview, family interview, and facility policy review, the facility failed to ensure that an order for [REDACTED].#206. Findings include: Review of the facility's Psychopharmacologic Drugs policy, dated Nov (YEAR), revealed, Unnecessary Drugs, 1. Each resident's drug regimen must be free from unnecessary drugs .2. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Review of Resident #206's (MONTH) 2019 physician's orders [REDACTED]. Give one (1) milliliter (ml). Review the Pharmacy Consultation Report, dated 12/25/18, revealed a recommendation regarding Resident # 206's PRN [MEDICATION NAME] order, related there was no stop date. The Medical Doctor declined the recommendation on 1/7/19, with the rationale: still agitated-working on changing meds. Review of the Pharmacy Consultation Report, dated 1/28/19, revealed Resident #206 continued to have a PRN order for [MEDICATION NAME] 1 ml (5 mg) PRN [MEDICAL CONDITION], which had been in place for greater than 14 days. Order started on 12/11/18. The Physician declined the request with a response: Recommend Pharmacist meet me every 14 days to examine patient. On 10/10/19, at 3:55 PM, RN #2 stated it was the facility policy that PRN antipsychotic drugs are limited to 14 days and cannot be renewed unless the physician [MEDICATION NAME] the resident. She stated, We can't write a stop date without an order and he won't write it. Record review of the Medication Record for (MONTH) 2019 revealed the resident did not receive an injection of [MEDICATION NAME] from 2/1/19 - 2/12/19. In a phone interview, on 10/09/19 at 4:47 PM, Resident #206's daughter, not the Responsible Party (RP), stated she was not happy with the care her father received at the facility, that he was admitted for rehab and was never able to participate in therapy due to, in her opinion, being over medicated and always out of it when she visited. She stated that the facility gave him [MEDICATION NAME] to make him sleep and he could hardly wake up. The Daughter stated Resident #206 was sent to the local hospital several times and the emergency room (ER) doctors always said he was over medicated. Review of Resident #206's physician's orders [REDACTED]. Review of Progress Notes for Resident #206, dated 2/6/19, at 10:10 AM, revealed family was in the facility demanding that the resident be sent to the hospital, due to the resident was asleep during her visitation hours. The resident was transported to the hospital via ambulance, where he was evaluated for Altered Mental Status. Upon return to the facility at 6:09 PM, a new order was noted by Registered Nurse #3 (RN). Resident #206's Physician Orders, dated 2/6/19, revealed an order: Cut the [MEDICATION NAME] down to one (1) pill at night, do not give a dose tonight or tomorrow morning, start it on 2/7/19 at hour of sleep (HS). Review of the (MONTH) 2019 Medication Administration Record (MAR) revealed the [MEDICATION NAME] order was not updated on the MAR to reflect the 2/6/19 order for giving one (1) pill daily. The MAR continued documentation to give [MEDICATION NAME] (Quetiapine [MEDICATION NAME] Tablet) 25 mg by mouth two (2) times a day for [MEDICAL CONDITION], Order Date- 01/16/2019. The medication had a discontinue date of 02/12/2019. The [MEDICATION NAME] was documented as not given on 2/6/19 at 6:00 PM, with the reason code 07 sleeping. The medication was documented as given at 10:00 AM, on 2/7/19, and not given on 2/7/19 at 6:00 PM, with the reason code 07 sleeping. The medication was given twice a day on 2/8/19 - 2/10/19, with only one (1) dose given on 2/11/19, at 10:00 AM. During an interview on 10/9/19 at 6:20 PM, RN #3 reviewed the order written on 2/6/19, and stated that he could not recall the order, but thought it meant that the [MEDICATION NAME] should not be given on the night of 2/6/19, and the morning of 2/7/19. RN #3 stated the [MEDICATION NAME] should have been restarted on the evening of 2/7/19, and only given one (1) pill at night thereafter. He stated that the resident would get really drowsy because of the medicine, and could not tolerate it. He stated he only worked the 3/11 shift and would not know what the resident got on the day shift. In an interview, on 10/10/19 at 3:50 PM, RN #2 stated that RN #3 entered the order on 2/6/19, in a way that would not enable it to flow to the MAR, therefore it was never changed on the MAR and confirmed the [MEDICATION NAME] was not changed and should have been cut down to one (1) pill at night. She revealed that Resident #206's behavior was up all night and slept during the day. She stated that his sleep pattern was off. She stated that Resident #206 continued to get the same dose prior to going to the hospital, so she didn't think it would have been an adverse effect for him, because he wasn't getting more than he was used to getting.

Based on observation, staff interview, facility policy review, and record review, the facility failed to initiate a care plan with appropriate interventions to monitor a lower extremity Orthotic/brace device, with the potential to cause skin breakdown in a resident who was assessed as high risk for the development of pressure ulcers (PU) for one (1) of 17 care plans reviewed, Resident #8. Resident #8 developed a PU to the right heel, which was identified on 8/22/17, from the use of the device. The PU was discovered/identified by the facility as Stage 3. A second Stage 2 pressure ulcer, was identified on 8/24/17. Findings include: Review of the facility's policy titled Care Plan - Comprehensive, dated November 2001, revealed: A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The policy noted that the Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on resident strength; d. Reflect treatment goals and objectives in measurable outcomes. e. Identify the professional services that are responsible for each element of care; and f. Prevent declines in the resident's functional status/functional levels. Care plans are revised as changes in the resident's condition dictate. Review of the facility's policy entitled Prevention of Pressure Ulcers, dated March 2015, revealed Purpose - The purpose of this procedure is to provide guidelines for residents identified to be at risk. Preventative Actions - Skin Observations 1. All residents will have a Skin Risk Observation and Record Form completed on admission, quarterly, with significant change and as needed thereafter. 2. Skin observation schedule will be completed as follows: a. C.N.A.s will complete total body skin observations at a minimum on bath days. Charge nurse will complete weekly skin observations on each resident. 'Licensed Nurse Weekly Skin Observation Form'. Other areas that may be documented include: (11) Care Plan revised/updated. A review of Resident #8's current Care Plan revealed the facility did not develop a care plan for the resident being at high risk of pressure ulcer (PU) development for the lower extremities due to the use of Orthotic devices. There was no care plan or interventions in place to monitor the resident's skin prior and after use of the Orthotic lower extremity devices until 8/24/17. This was after the facility identified a Stage 3 PU to Resident #8's right heel on 8/22/17 and a Stage 2 PU to the left heel on 8/24/17. Record review revealed the facility completed a Pressure Ulcer Risk Screen on 7/5/17, which revealed a score of 10, which placed the resident in a Category: High Risk for Pressure Ulcers. An observation during wound care with RN #1, on 8/23/17 at 12:15 PM, revealed that Resident #8 had a Stage 3 Pressure Ulcer on his right heel that measured 2.5 centimeters (cm) length x 2.5 cm width x 0.2 cm depth. RN #1 stated the resident had been wearing a prosthesis when out of bed, but had not worn since the development of the Stage 3 PU on the right heel. Bilateral Ankle Foot Orthotic (AFO) devices inside athletic type footwear was noted to be in a chair in Resident #8's room. The devices had molded dark plastic braces with Velcro that fastened around the upper calf. Interview with Resident #8 on 8/24/17 at 10:15 AM, revealed he did not know how long the wound had been on his right heel. He stated It's been there. Observation on 8/25/17, at 9:30 AM, revealed that the resident had an open area, (Stage 2 PU), to his left heel. RN #1 was summoned to the room and asked to observe the resident's left heel. RN #1 was not aware of the open area to Resident #8's left heel until that time. During an interview, on 8/25/17 at 3:17 PM, the Director of Nursing (DON) revealed there was no care plan for Resident #8's lower extremity devices. She stated that Resident #8 came in to the facility with the braces in his shoes as part of his attire, therefore the braces would not be care planned. She stated there must be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the Certified Nursing Assistants (CNAs) had been putting the braces on when the Resident got out of bed and up in his wheelchair and that they would take them off when he went to bed and during showers. The DON was asked how the CNAs knew when and how to put the braces on or take them off if there was no care plan and she stated, They have in-services on how to apply splints and braces safely. She stated for those residents who come in with orders, the order will tell them how to put braces on and when to take them off. She stated that since Resident #8 had no order for the foot braces, he would tell the CNAs when to put them on and when to take them off. The DON was asked about the Care Plan process and stated upon admission of a resident, the Minimum Data Set (MDS) nurse completed an initial care plan from the initial assessment, admission paperwork from the hospital and Physician Orders. The Care Plan would address all the issues the resident had and the Care Area Assessment Summary (CAAs) from the MDS. She stated Care Plans are updated by the MDS nurse from updates discussed in the Daily Clinical Nursing Meeting and all orders from the previous day are printed and compared to the current care plans to ensure care plans are updated. The DON was asked what type of things she would want to ensure were care planned. She stated Medication changes, interventions, wound care and updated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Administrator, on 8/25/17 at 1:55 PM, revealed there was no care plan to check Resident #8's skin due to the use of the bilateral braces because she didn't realize the lower extremity devices could cause a PU. The Administrator stated that she had researched, after the resident was identified with the PU, and found that braces could cause PUs. Record review of the face sheet revealed Resident #8 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), Section M, with an Assessment Reference Date (ARD) of 7/11/17, revealed the facility assessed Resident #8 at risk of developing pressure ulcers. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, record review, and facility policy review, the facility failed to assess, identify and evaluate the risk factors for the development of pressure ulcers related to the use of bilateral lower extremity braces/Ankle Foot Arthosis (AFO), for one (1) of nine (9) residents observed as being high risk to develop pressure ulcers, Resident #8. The facility's failure to monitor the skin on Resident #8's lower extremities during use of the lower extremity braces resulted in a Stage 3 Pressure Ulcer (PU) on the right heel and a Stage 2 PU to the left heel. Findings include: Review of the facility's policy entitled Prevention of Pressure Ulcers, dated March 2015, revealed the purpose of this procedure is to provide guidelines for residents identified to be at risk. Preventative Actions - Skin Observations: 1. All residents will have a Skin Risk Observation and Record Form completed on admission, quarterly, with significant change and as needed thereafter. 2. Skin observation schedule will be completed as follows: a. C.N.A.s will complete total body skin observations at a minimum on bath days. Charge nurse will complete weekly skin observations on each resident. 'Licensed Nurse Weekly Skin Observation Form'. Review of Resident #8's Admission Nursing Data Collection report, dated 7/5/17, revealed the resident was admitted with severe internal rotation of the right foot and generalized weakness in upper and lower extremities. The report revealed no breakdown of the heels documented. There were small scrapes on the right shin with scabs noted. There was a 0.5 x 1 centimeter (cm) pressure sore on the right buttock with white and pink skin noted. A healed pressure sore was noted at the coccyx area. The report did not include any prosthesis or supportive/assistive devices for Resident #8 other than a wheelchair. The facility completed a Pressure Ulcer Risk Screen on 7/5/17, which revealed a score of 10, which placed the resident in Category: High Risk for Pressure Ulcers. Consideration included: Observe for protective devices as needed i.e. heel protectors, positioning devices etc. Record review of Resident #8's Order Summary Report for August 2017, revealed no Physician's Order for Bilateral Orthotic Braces. Review of the Resident's Care Plan revealed the facility did not develop or initiate a Care Plan for resident's high risk for the development of Pressure Ulcers due to the use of Otrhotic Braces. There were no interventions to monitor the resident's skin related to the use of bilateral lower extremity Orthotic braces. An observation on 8/23/17 at 12:15 PM, revealed that Resident #8 had a Stage 3 Pressure Ulcer on his right heel. Wound care to the right heel was performed by Registered Nurse #1. Before removal of the border gauze dressing, it was noted that approximately 75% of the outside of the dressing was covered in a brown stain. The resident's bottom bedsheet had a two (2) by three (3) inch brown stain below the heel. Bilateral Ankle Foot Orthosis (AFO) devices inside athletic type footwear was noted to be in a chair in Resident #8's room. The devices had molded dark plastic braces with Velcro that fastened around the upper calf. RN #1 stated the resident had been wearing the prosthesis when out of bed, but had not worn them since the development of the Stage 3 PU on the right heel. An observation on 8/25/17, at 9:30 AM, revealed Resident #8 lying supine in bed. Certified Nursing Assistant (CNA) #3 was present. The dressing to the Stage 3 pressure ulcer on the right heel was absent. The resident raised his left leg and an open area with dry, flaking skin surrounding a pink center was present on the left upper heel. RN #1, Treatment Nurse, was informed of the absence of the dressing to the right heel. She came to the room with wound care supplies for the right heel pressure ulcer and confirmed the presence of the open area of skin on the left heel. She stated I have to notify your MD and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 was unaware of the open area to the resident's left heel until that time. An interview with CNA #3 on 8/25/17, at 9:35 AM, revealed that he takes care of Resident #8 about once a week. He revealed that he had noticed a reddish stain on his sheet about three (3) weeks ago and that he had reported it to the nurse about a wound. He stated that he believed the wound was on the left heel. In an interview with CNA #2, on 8/24/17, at 10:10 AM, the CNA was asked how long the resident had the wound on his right heel. He stated I saw it over a couple of weeks ago. I noticed a spot of light red pus like drainage on his sheet. I reported it to the treatment nurse, I can't remember her name. She's no longer with us. CNA #2 stated I report any skin problems such as redness, wounds, and bruises to the charge nurse immediately. An interview with Resident #8 on 8/24/17, at 10:15 AM, in regards to the wound on the right heel, the resident stated It's been there. Resident #8 did not know how long the PU had been on his heel. During an interview with Resident #8 on 8/25/17, at 9:40 AM, he stated I don't have any feeling in my feet. I had a stroke. I go to therapy to get stronger so I can go home. An interview with the Director of Nursing (DON), on 8/24/17, at 10:20 AM, revealed the 11-7 nurses do body audits and if there is a skin issue it should be reported to herself or the Assistant Director of Nursing (ADON). She stated that they are both wound certified nurses. She revealed that the CNA's should have reported skin issues to the charge nurse and if nothing had been done, they should have reported it directly to her or the ADON so that they could look at the area. She stated RN #4 may have been the nurse that CNA #2 said he reported to about the PU on Resident #8's heel, and she no longer works at the facility. She stated the Registered Nurse (RN) who discovered the wound to Resident #8's right heel staged it a Stage III because of the location on the heel. She stated We are taught to stage heels a Stage III because there is no fatty tissue in those areas. She also stated CNAs do skin assessments every time they do skin care or baths and they are to report any skin tears, bruises, redness, or wounds to the charge nurse and she will assess it and notify the MD for orders. She stated that Resident #8 had been referred to Physical Therapy (PT) for an evaluation and recommendation for the right foot brace. In an interview with the resident's Attending Physician on 8/24/17, at 3:50 PM, he was asked if he would expect the right heel ulcer to have been discovered before it became a Stage III, he stated I don't know, I'm not really sure. An interview with the Administrator on 8/25/17, at 1:55 PM, revealed that Resident #8 was admitted to the facility with braces to both lower extremities to prevent foot drop and that he wears them when he gets up in the wheelchair or goes to therapy. She stated that she feels that the braces caused the wounds to his heels. She stated that the facility did not care plan to check the skin because she didn't realize the braces could cause a pressure ulcer. She revealed she had researched braces after finding the pressure ulcer and found that braces could cause pressure ulcers. She stated she did not feel like there was a breakdown in care, so there would be no reason to bring this matter to the Quality Assurance (QA) Committee for review. When asked if it did not concern her that one (1) of her residents had developed a wound and that it was not discovered until it was a Stage III, she stated it did not concern her due to the location of the wound being in an area of no adipose tissue. She stated that there was no documentation to support there was any skin breakdown before it was discovered on 8/22/17, and the two (2) CNAs who were interviewed had not documented any skin breakdown in their records.She stated they were not very credible. An interview with the DON on 8/25/17, at 3:17 PM, revealed that upon Resident #8's admission to the facility, there was not a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident came in to the facility with the braces in his shoes as part of his clothing. She stated the CNAs had been putting them on when he got out of bed and up in his wheelchair and that they would take them off when he went to bed and during showers. The DON was asked how the CNAs knew when and how to put the braces on or take them off and she stated They have inservices on how to apply splints and braces safely. She stated for those residents who come in with orders, the order will tell them how to put braces on and when to take them off. She stated that since Resident #8 had no order for the foot braces, he would tell the CNAs when to put them on and when to take them off. The DON stated that the Admission Nurse does a head to toe assessment on admission and the charge nurse on the 11-7 shift does a weekly skin assessment called a Licensed Weekly Skin Assessment. She revealed this form notes any existing areas and any new areas. She stated that if any new concerns were discovered, the nurse would notify the on call physician for orders and that the facility had a wound care formulary signed by the Medical Director. She also stated that RN #2 found the Stage III Pressure Ulcer and notified the physician at 12:28 PM, on 8/22/17. She also stated that she felt this should be brought to the QA Committee. She stated Any problem that affects the residents in this facility, we QA it to make the process better so it won't happen again. Review of the Licensed Nurse Weekly Skin Observation (Weekly Skin Check) V 2, dated 8/16/17, revealed the only skin issue was the right buttock. The next Licensed Nurse Weekly Skin Observation was performed on 8/22/17, at 12:28 PM, and revealed a new Stage 3 acquired Pressure Ulcer to the resident's right heel. Review of a Progress Note and and Exception Report, both dated 8/22/17, revealed a Stage 3 pressure sore was observed on the resident's right heel related to scrubbing against back of shoe. The wound measured 2.5 centimeters (cm) x 5.0 cm x 0.2 cm. Mild drainage noted on resident's sock. The Exception Report documented that Resident #8 had bilateral lower extremity leg brace and the right shoe was removed. Review of a Progress note, dated 8/24/17, revealed Resident #8 was observed with a Stage 2 wound to the left heel. The wound measured 1 cm length x 1.5 cm width x 0.1 cm depth. Review of the Therapy Referral and Screening Form, date completed 8/24/17, revealed that AFO's (Ankle Foot Othosis) are effective at prevention of BLE (bilateral lower extremity) foot drop. Therapy recommended Resident #8 to wear slippers only when he is out of bed until the wounds on his heels were healed. In a record review of In-service Training, presented by the DON and ADON, dated July 25 and July 26, 2017, revealed: Report change in condition for residents (i.e. skin, respiratory, overall health) infection control, and it revealed that CNA # 2 and CNA #3 had attended. Record review of the Admission Record revealed the facility admitted Resident #8 on 7/5/17, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/17, revealed the facility assessed Resident #8 at risk of developing pressure ulcers. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, record review, and facility policy review the facility failed to ensure the possible spread of infection during medication pass for two (2) of eight (8) residents observed during med pass, Unsampled Resident A and Unsampled Resident B; and two (2) of five (5) residents during perineal care, Resident #8 and Resident #9. This involved four (4) of 13 residents observed. Findings include: A facility policy titled Eye Drops, dated November 2001, revealed the procedure may involve potential/direct exposure to blood, body fluids, and infectious disease. A facility policy titled, Cleaning Stethoscopes, dated February 2016, revealed an alcohol prep pad would be used to clean the stethoscope before and after each resident use. A facility policy titled Perineal Care, dated August 2014, revealed to remove disposable gloves, discard into designated container after the care and then reposition the covers and make the resident comfortable. Unsampled Resident A: An observation on 08/24/17 at 8:45 AM, revealed Licensed Practical Nurse (LPN) #1 placed eye drop bottles on Unsampled Resident A's bedside table without a barrier or disinfecting the table. LPN #1 also used the stethoscope on Unsampled Resident A, placed on the resident's bed without a barrier. LPN #1 then placed the stethoscope and the eye drop bottles back into the med cart without disinfecting. In an interview on 08/24/17 at 8:55 AM, LPN #1 confirmed she did set Unsampled Resident #A's eye drop bottles on the over bed table without disinfecting and did not clean the stethoscope before placing back on the med cart. LPN #1 said the policy was to use barriers to prevent cross contamination. In an interview on 08/25/17 at 9:00 AM, the Director of Nursing (DON) confirmed the policy was to use barriers for supplies brought into the resident's room. The DON said the disposable plates were available on the med carts for barriers. A review of the record titled Med Pass Technique, dated 04/20/17, revealed LPN #1 had been observed during morning medication pass and monitored for infection control/aseptic technique. A review of the facility's face sheet revealed the facility admitted Unsampled Resident A on 01/27/17. Unsampled Resident A's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/17, revealed Unsampled Resident A's Brief Interview for Mental Status (BIMS) was 11, which indicated moderately impaired cognition. Unsampled Resident B: An observation during Medication Pass on 8/24/17, at 8:45 AM, revealed that Licensed Practical Nurse #3 placed the [MEDICATION NAME] Diskus and Incruse Ellipta boxes on the toilet tank lid in the resident's bathroom while she was cleaning her stethoscope. She then took the two (2) boxes and placed them into the medication cart. In an interview with LPN #3 on 8/24/17, at 9:10 AM, she stated that sitting the medication boxes on the lid of the toilet tank was an infection control issue with cross contamination. LPN #3 stated, I can't believe I did that. Record review of Med Pass Technique check off performed on 4/14/17, for LPN #3, by Registered Nurse #3, Assistant Director of Nursing, revealed that LPN#3, Administered med timely using good technique. Washed hands thoroughly. Record review of the Admission Record revealed the facility admitted Un-Sampled Resident B on 6/9/16, with the following Diagnoses: [REDACTED]. Review of the Annual MDS with an ARD of 6/1/17, revealed Unsampled Resident B had a BIMS score of 11, indicating intact cognitive skills for daily decision making. Resident #9: An observation on 08/23/17 at 2:30 PM, revealed Certified Nursing Assistant (CNA) #1 assisted with perineal care for Resident #9. CNA #1 removed the soiled linen pads underneath the resident. CNA #1 then touched the clean linens on the bed, the bedside table, the bed rail and the feeding tube with the same gloves. In an interview on 08/23/17 at 2:50 PM, CNA #1 identified the deficient practice of not changing her gloves after perineal care for Resident #9. CNA #1 confirmed she did not change her gloves before touching the clean items. CNA #1 said she should have changed her gloves because of the spread of infection. In an interview on 08/23/17 at 3:00 PM, Licensed Practical Nurse (LPN) #2, Staff Development, said the policy was to remove the soiled gloves and wash hands after care. LPN #2 confirmed the facility training covered infection control, and the CNA's were checked off on pericare. A record review of an in-service titled Perineal and Catheter Care, dated 06/08/17, documented a signature of attendance and return demonstration given by CNA #1. A review of the facility's face sheet revealed the facility admitted Resident #9 on 02/18/16. Resident #9's [DIAGNOSES REDACTED]. The MDS with an ARD of 06/14/17, revealed Resident 9's BIMS was 9, which indicated moderately impaired cognition. Resident #8: Observation on 8/23/17, at 11:46 AM, revealed CNA #2 washed his hands and put on gloves before beginning incontinent for Resident #8. CNA #2 failed to remove his gloves and wash his hands before placing the clean cloth incontinent pad beneath the resident. CNA #2 then assisted the resident to his back and pulled the bed linens up to the resident's chest, all without changing gloves and washing hands. In an interview with CNA #2 on 8/23/17, at 2:40 PM, he stated I should have changed my gloves between dirty and clean to prevent cross contamination. In an interview with LPN #2, Staff Development Nurse, on 8/23/17 at 3:05 PM, she stated Hands should be washed and clean gloves donned between dirty and clean. She stated He (CNA #2) shouldn't have done that. He was not taught that way and has not return demonstrated that way. Record review of the Admission Record, revealed the facility admitted Resident #8 on 7/5/17, with [DIAGNOSES REDACTED]. Review of the MDS, with an ARD of 7/11/17, revealed Resident #8 was assessed with [REDACTED].

Based on record review, staff interview and policy review the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for Resident #1 for current diagnoses and Resident #11 for Hospice care. This affected two (2) of 15 residents reviewed for accurate completion of the MDS. Findings include: A review of the facility's Certifying Accuracy of the Resident Assessment policy, dated October 2010, documented the following: All personnel who complete any portion of the Resident Assessment must sign and certify the accuracy of that portion of the assessment. Resident #1: A review of the Admission Nursing Data Collection for Resident #1, dated 12/01/15, identified diagnosed including: [DIAGNOSES REDACTED]. A review of Care Plans, dated 12/01/15 -12/03/15, identified Focus areas related to [MEDICAL CONDITIONS] [MEDICAL CONDITION], Bilateral AKA (above knee amputation), [MEDICAL CONDITION] and Diabetes Mellitus. A review of the Admission MDS, with an Assessment Reference Date (ARD) of 12/08/15, did not identify any active diagnoses during the prior seven days in Section I (Active Diagnoses). During an interview on 06/16/16 at 9:40 AM Registered Nurse (RN) #2, responsible for completing Section I, said the MDS was not accurate because no diagnoses were marked. RN #2 said there must have been a glitch in the computer because the facility could not bill without a diagnosis. The facility admitted Resident #1 to the facility on [DATE]. The MDS, with an ARD of 06/05/16, identified the resident's active diagnoses which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, Anxiety Disorder, [MEDICAL CONDITION], Acquired Absence of Right and Left Leg Above Knee and [MEDICAL CONDITION]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) Score of 14 or cognitively intact. Resident #11 A review of Resident #11's physician's orders [REDACTED]. A review of care plans for Resident #11 included a Focus area which documented as follows: RESIDENT HAS BEEN admitted TO (name of Hospice). Date initiated 02/06/15. Target Date: 09/08/2016. A review of notes, provided by the facility, identified documentation of visits by hospice staff, dated 03/02/16, 03/09/16 and 03/10/16. A review of Section O (Special Programs) of the MDS, with an ARD of 03/14/16, did not identify that Resident #11 received Hospice Care during the previous 14 days. During an interview on 06/16/16 at 9:40 AM the MDS Nurse (RN #2), responsible for certifying the completion of the assessment, acknowledged the MDS of 03/14/16 was not accurate. The RN said the MDS failed to identify that Resident #11 received hospice care during the time of the assessment. The facility readmitted Resident #11 to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The MDS, with an ARD of 03/14/16, identified the resident with memory problems and severely impaired cognitive skills for daily decision making.

Based on observation, record review, staff interview and policy review, the facility failed to revise and update the care plans for Resident #2 to include goals and interventions for hospice care, specifically for wound care; for Resident #5 to include appropriate interventions to ensure the resident was NPO (nothing by mouth) as ordered by the physician. This affected two (2) of 15 residents reviewed for updating care plans. Findings include: A review of the facility's Care Plan-Comprehensive policy, dated November 2001, documented: A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. The Comprehensive Care Plan has been designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems. Care plans are revised as changes in the resident's condition dictate. A review of the facility's statement, not dated, regarding care plans in the electronic health record documented as follows: All care plans are maintained and updated in the center's electronic health record. Care plans are updated daily by members of the interdisciplinary teams. Care plans are updated as changes occur in the resident condition or care regimen. Resident #5 During the initial tour on 06/14/16 at 9:30 AM, Resident #5 was observed receiving nutrition through a feeding tube. The resident was identified as NPO (nothing by mouth). A review of the care plans for Resident #5, dated 04/13/16, identified the following Focus area: RESIDENT HAS A POTENTIAL FOR DEHYDRATION R/T (related to) [DIAGNOSES REDACTED]. Interventions included Monitor consumption at meal, Offer fluids with ADL (Activities of Daily Living) care. A review of the physician's orders [REDACTED]. was NPO and received nutrition by a feeding tube, with an initial date of 4/13/16. During an interview on 06/16/16 at 3:30 PM, Registered Nurse (RN) #2 said a care plan is a comprehensive review for all the care for the residents and identifies what staff does for the resident. RN #2 acknowledged she is responsible for care plans, although the interdisciplinary team can update the care plans. The RN confirmed Resident #5's care plan interventions were not appropriate for NPO because the resident could not have anything by mouth, according to physician's orders [REDACTED].#5's care plan should have been individualized to show the resident was NPO and could not have anything by mouth. The facility admitted Resident #5 on 04/13/16 with [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date of 04/19/16, identified the resident with both long and short term memory problems, severely impaired cognitive skills for daily decision making and absence of spoken words. Resident #2 Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Resident #2's care plans developed by the facility, dated 3/4/16, revealed Resident #2's care plan for hospice was not revised to include specific services to be provided by Hospice in the care plan, including pressure ulcer care, timeliness of visits from Hospice, or other care provided. Interview with the Hospice RN on 6/14/16 at 9:40 AM, revealed the care plan and notes for Hospice were electronic and charts were not kept at the facility; she went by the facility care plan. The Hospice RN stated she did not attend care plan meetings. During an interview with the MDS Nurse and the Administrator on 06/16/16 at 3:45 PM, revealed the care plan didn't include specific services or frequency of visits by nurses and aides.

Based on observation, record review, staff interview and policy review the facility failed to follow the plan of care to administer a tube feeding flush according to physician's orders [REDACTED].#12, one (1) of three (3) observations of residents receiving tube feeding flushes according to the plan of care. Findings include: A review of the facility's physician's orders [REDACTED]. A review of the facility's Care Plan-Comprehensive policy, dated November 2001, documented: The Comprehensive Care Plan has been designed to Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Reflect treatment goals and objectives in measurable outcomes. Resident #12 A review of Resident #12's care plan, dated 09/02/2014, documented: RESIDENT IS AT RISK FOR COMPLICATIONS R/T (related to) FEEDING TUBE. The target date documented 09/08/2016 and included the following Interventions: Provide tube feeding as ordered and provide flushes as ordered. A review of Resident #12's physician's orders [REDACTED]. Enteral Feed Order: Every shift Flush enteral tube before/after medications with 30 ML (milliliters) of H20 (water). Enteral Feed Order: five (5) times a day Flush enteral tube with 50 cubic centimeters (cc's) H20 before & (and) after feedings. Enteral Feed Order five (5) times a day Two Cal HN Bolus (tube feeding formula) 1 can 5 times per day. Enteral Feed Order four (4) times a day FLUSH PEG TUBE WITH 150 ML H20. During an observation of medication administration on 06/16/16 at 1:10 PM, Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] to Resident #12 through a feeding tube. LPN #1 checked tube placement with a syringe and administered the medication mixed with five (5) cc of water, followed by 50 cc water. (She did not flush prior). LPN #1 administered one (1) can of formula followed by 150 cc water. LPN #1 acknowledged that she administered a total of 205 cc of water during the administration of medication and tube feeding formula. During an interview on 06/16/16 at 2:25 PM, LPN #1 confirmed that she administered a total of 205 cc of water for the flush of Resident #12's enteral tube during medication and tube feeding administration. LPN #1 acknowledged she did not give the amount of water for the flush as ordered by the physician and the resident's plan of care. LPN #1 confirmed the amount of water for the flush should have been 30 cc before and after meds, 50 cc before and after feeding and 150 cc water flush as ordered for a total of 310 cc. The facility readmitted Resident #12 to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/16, identified the resident with a Brief Interview for Mental Status (BIMS) of 11, indicating Resident #12's cognitive status was moderately impaired.