Every finding on record at Golden Years Nursing Center

Based on resident and staff interview, observation, and record review, the facility failed to ensure a resident's care plan was developed related to dental needs and range of motion of the right upper extremity. This affected one (Resident #58) of 17 residents reviewed for care plans. The facility census was 69. Finding include: Review of the medical record for Resident #58 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was cognitively intact. Resident #58 was noted to have an impairment on one side for upper and lower extremity. 1. Review of Resident #58's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the plan of care dated 08/10/22 revealed Resident #58 had impaired dentition and was at risk for oral problems of pain, infection, difficulty chewing or swallowing with interventions to complete oral assessment and refer to the dentist as needed. provide all necessary items for oral care as needed and provide oral care at least daily and more frequently as needed. The care plan had no mention of significant bleeding from the mouth. Review of the progress notes dated 10/04/22 revealed the nurse was notified by the aide regarding Resident #58 having bleeding from her mouth on her lips, chin and cheek. Resident #58 was assessed and found blood in her mouth. Resident #58 was referred to see the dentist and the nurse practitioner was informed. Observation and interview on 11/07/22 at 9:38 A.M. revealed Resident #58 had blood that had run down her face from the corner of her mouth down her chin and dripped on her chest, shirt and bedding. Resident #58 stated she had gum issues and at times will having increased bleeding of her mouth. Interview and observation on 11/07/22 at 9:43 A.M. with Registered Nurse (RN) #253 revealed Resident #58 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #253 then went to resident's bedside and asked Resident #58 if her mouth bleeding was common and if she saw the dentist. Interview on 11/08/22 at 4:20 P.M. with Social Services (SS) #242 revealed she was not aware of Resident #58's bleeding prior to 11/07/22. Resident #58 saw the dentist on 10/06/22 and the dentist mentioned increased calcium on the teeth and mouth bleeding would be expected. SS #242 stated the dentist requested Resident #58 to have assistance with oral hygiene. Interviews on 11/09/22 at 9:47 A.M. with State tested Nursing Aide (STNA) #212 and STNA #233 stated Resident #58's oral bleeding was common. Interview on 11/09/22 at 10:30 A.M. with the Director of Nursing (DON) confirmed oral bleeding was not documented in Resident #58's care plan. 2. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resting hand splint should be worn at all times when out of bed as Resident #58 can tolerate it. Review of the plan of care dated 08/10/22 revealed Resident #58's care plan did not include any mention of an impairment to resident's right upper extremity or wrist and provided no guidance or plan related to receiving therapy or wearing a splint. Review of Resident #58's progress notes dated 11/07/22 revealed it stated to apply resting hand splint to right upper extremity daily. Resting hand splint was to be worn at all times when out of bed. Observation and interview on 11/07/22 at 9:38 A.M. with Resident #58 revealed she had a contracture-like hand deformity with fingers curled inward. Resident #58 was not wearing any hand device or splint. Resident #58 stated she had hand issues for a while and she was working with therapy for a splint as the previous brace was not comfortable. Resident #58 stated her new brace was kept in the therapy gym. Interview on 11/08/22 at 9:35 A.M. with RN #224 stated she was unsure if Resident #58 should be wearing a splint and the splint of the shelf was the only one she was aware of. Interview on 11/08/22 at 10:17 A.M. with Occupational Therapist (OT) #305 revealed therapy staff were working with the splint. OT #305 revealed they were working to fabricate the brace and increase residents' tolerance. Interview on 11/09/22 at 9:47 A.M. with Certified Occupational Therapy Assistant (COTA) #310 revealed she had been working with resident about three weeks with a new brace. COTA #310 revealed Resident #58 has increased her tolerance to about three hours. COTA #310 revealed she works with Resident #58 three days each week on wearing the brace. Interview on 11/09/22 at 10:30 A.M. with DON confirmed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed there was no mention of a splint or a hand deformity in Resident #58's care plan.

Based on staff interview, review of the facility's policy and contract, and medical record review, the facility failed ensure ongoing communication with Resident #43's [CONDITION(S)] center regarding [CONDITION(S)] care and services. This affected one (Resident #43) of one resident reviewed for [CONDITION(S)]. The facility identified two residents who receive [CONDITION(S)]. The facility census was 69. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact and required extensive assistance of two staff members for mobility and transfers. Review of the plan of care dated 07/25/22 revealed Resident #43 received [CONDITION(S)] treatments three times weekly for [CONDITION(S)]. Interventions included to assist with transfers to and from [CONDITION(S)], maintain communication with [CONDITION(S)] staff and physician, and monitor laboratory values and report results to physician. Subsequent review of Resident #43's medical record from 06/01/22 to 11/07/22 revealed there was no documentation of routine communication forms kept on record to indicate the [CONDITION(S)] center and the facility were routinely communicating to one another regarding Resident #43. There was one communication form dated 11/07/22 that was found during this time period. Interview on 11/08/22 at 9:40 A.M. with the Director of Nursing (DON) and Corporate Nurse #30 revealed the facility sends out [CONDITION(S)] communication forms with Resident #43 when he leaves the facility for [CONDITION(S)], but the facility does not keep a record. The DON and Corporate Nurse #30 verified the [CONDITION(S)] center does not typically complete their section and return the form to the facility. Subsequent interview on 11/08/22 at 1:40 P.M. with Corporate Nurse #30 verified the only documentation in Resident #43's medical record the facility had regarding communication with [CONDITION(S)] was from 11/07/22. Review of the facility's policy and [CONDITION(S)] contract titled LTC (long term care) Facility Outpatient [CONDITION(S)] Services Coordinated Agreement, dated 05/27/21, revealed the facility and [CONDITION(S)] agreement have a mutual obligation for collaboration of care. Both parties shall ensure there was documented evidence of collaboration of care and communication between the LTC and the [CONDITION(S)] unit.

Based on observation, staff interview, and medical record review, the facility failed to ensure narcotic medications were securely stored in the medication room refrigerators. This affected one of two medication rooms observed for medication storage. The facility had three medication rooms. This affected two (#4 and #50) of two residents prescribed narcotic medications which required refrigeration. The facility census was 69. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE]. Review of the medical record revealed Resident #50 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Review of the medical record revealed Resident #4 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/08/22 at 1:52 P.M. revealed the 200-Hall medication room's refrigerator had locked a narcotic box on a removable shelf which contained two unopened bottles of [MEDICATION(S)] (liquid [MEDICATION(S)]) for Residents #4 and #50. Interview on 11/08/22 at 1:56 P.M. with Registered Nurse (RN) #239 verified the refrigerator shelf contained a locked box with narcotic medications for Residents #4 and #50 and the locked box was not permanently affixed.

Based on review of facility staffing schedules and staff interview, the facility failed to ensure a registered nurse (RN) was physically present in the facility for eight consecutive hours per day as required. This had the potential to affect all 57 residents residing in the facility. Facility census was 57. Findings include: Review of staffing schedules from 09/01/21 through 09/27/21 revealed there was not an RN present in the facility for eight consecutive hours on 09/18/21, 09/25/21 and 09/26/21 Interview on 09/28/21 at 3:30 P.M. with the Administrator confirmed there was not an RN present in the facility for eight consecutive hours on 09/18/21, 09/25/21 and 09/26/21. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were free from unnecessary psychoactive medications when the facility failed to ensure as needed anti-anxiety medication orders had a duration for the order (stop date) and failed to ensure staff documented non-pharmacological interventions attempted prior to use of as needed doses of anti-anxiety medications. This affected three (#24, #30 and #29) out of three residents reviewed for unnecessary medications. The facility identified 23 facility identified residents with orders for anti-anxiety medications. The census was 57. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE] with a diagnosis of [NAME] Chiari Syndrome with [CONDITION(S)]. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 09/20/21 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #24 dated 09/13/21 revealed resident experienced alteration in mood and behavior including non-compliance, verbally aggressive with staff at times, history of manipulative behaviors with staff and mother, delusions at times, experiences hallucinations, yells out often. Interventions included the following: attempt to identify what triggers behavior, educate explain procedures before beginning them, offer nonpharmacological interventions for target behaviors (such as yelling out), reality orientation when clinically indicated. Review of the September 2021 monthly physician's orders for Resident #24 revealed an order dated 09/15/21 for the anti-anxiety medication [MEDICATION(S)] to be given every eight hours as needed for anxiety. The order did not include a duration/stop date. Review of the September 2021 Medication Administration Record (MAR) for Resident #24 revealed resident received [MEDICATION(S)] on the following dates/times: 09/16/21 at 5:17 A.M. and at 7:33 A.M.; on 09/17/21 at 1:06 P.M.; on 09/20/21 at 7:55 P.M.; on 09/21/21 at 2:36 A.M. and 8:10 P.M.; on 09/24/21 at 1:51 P.M. and 10:00 P.M.; on 09/25/21 at 9:31 A.M. and 8:37 P.M.; and on 09/26/21 at 12:51 P.M. Review of the September 2021 MAR and nurse progress notes dated 09/16/21 through 09/26/21 revealed administration the following doses of as needed [MEDICATION(S)] did not include non-pharmacological interventions attempted prior to medication: 09/16/21 at 5:17 A.M. and at 7:33 P.M.; on 09/20/21 at 7:55 P.M.; on 09/21/21 at 2:36 A.M. and 8:10 P.M.; on 09/25/21 at 9:31 A.M. and 8:37 P.M.; and on 09/26/21 at 12:51 P.M. 2. Review of the medical record for Resident #30 revealed an admitted [DATE] with a diagnosis of dementia with behavioral disturbance. Review of the MDS assessment for Resident #30 dated 07/06/21 revealed resident was cognitively impaired and required extensive assistance of two staff with ADL's. Review of the care plan for Resident #30 dated 06/16/21 revealed resident had diagnosis of [CONDITION(S)], depression, and paranoid [CONDITION(S)] and displayed anxious behavior at times, requires medication management ([MEDICATION(S)]) and remained at risk for associated complications. Interventions included the following: assess behaviors for which drugs are being given, monitor and record frequency of occurrence, assess for non-drug approaches to deal with problem behaviors and implement, utilize as needed medications only after non-drug measures are ineffective. Review of the September 2021 monthly physician's orders for Resident #30 revealed an order dated 08/13/21 for the anti-anxiety medication [MEDICATION(S)] to be given every six hours as needed for anxiety. The order did not include a duration/stop date. Review of the August 2021 MAR for Resident #30 revealed resident received [MEDICATION(S)] on the following dates/times: 08/17/21 at 9:36 P.M.; 08/18/21 at 10:13 A.M.; 08/21/21 at 3:55 P.M. and 11:17 PM.; 08/22/21 at 7:19 P.M.; and on 08/28/21 at 3:22 P.M. Review of the August 2021 MAR and nurse progress notes dated 08/17/21 through 08/28/21 revealed administration the following doses of as needed [MEDICATION(S)] did not include non-pharmacological interventions attempted prior to medication: 08/21/21 at 3:55 P.M.; 08/22/21 at 7:19 P.M.; and on 08/28/21 at 3:22 P.M. Review of the September 2021 MAR for Resident #30 revealed resident received [MEDICATION(S)] on the following dates/times: 09/08/21 at 9:16 A.M.; 09/09/21 at 12:01 P.M.; 09/10/21 at 3:33 P.M. and 9:23 P.M.; 09/13/21 at 1:10 P.M. and 9:04 P.M.; 09/15/21 at 9:58 P.M.; 09/19/21 at 11:30 A.M.; 09/21/21 at 11:37 A.M. and 9:59 P.M.; 09/22/21 at 8:46 P.M.; 09/23/21 at 3:54 P.M.; 09/26/21 at 9:49 P.M. and 09/27/21 at 7:22 A.M. Review of the September 2021 MAR and nurse progress notes dated 09/08/21 through 09/27/21 revealed administration the following doses of as needed [MEDICATION(S)] did not include non-pharmacological interventions attempted prior to medication: 09/08/21 at 9:16 A.M.; 09/15/21 at 9:58 P.M.; and on 09/21/21 at 11:37 A.M. and 9:59 P.M. 3. Review of the medical record for Resident #29 revealed an admitted [DATE] with a diagnosis of vascular dementia with behavioral disturbance. Review of MDS assessment for Resident #29 dated 09/11/21 revealed resident was cognitively impaired and required limited assistance of one staff with ADL's. Review of the care plan for Resident #29 dated 08/30/21 revealed resident experienced an alteration in mood and/or behavior as evidenced by being resistive to care and experienced experiences shortness of breath related to anxiety. Resident had called and threatened to call nine-one-one (911), the news and the Ombudsman. Resident had manipulative tendencies. Experienced frequent delusions was tearful at times and easily agitated. Interventions included the following: allow resident to vent, validate feelings as needed, attempt to determine what may trigger the behaviors (infection, loneliness, constipation, hunger), decrease stimulation as needed, distraction and redirection as needed, educate on negative outcomes of non-compliance provide non-pharmacological interventions when experiencing shortness of breath related to anxiety such as, but not limited to, one-on-one (1:1), distraction, food/fluids, altered lighting, deep breathing. Review of the September 2021 monthly physician's orders for Resident #29 revealed an order dated 09/01/21 for the anti-anxiety medication [MEDICATION(S)] to be given every eight hours as needed for anxiety. The order did not include a duration/stop date. Interview on 09/28/21 at 9:00 A.M. with the Administrator and the Director of Nursing (DON) confirmed the as needed anti-anxiety medication orders for Residents #24, #29, and #30 did not include stop dates/duration. Administrator further confirmed Residents #24 and #30 received as needed anti-anxiety medications without attempts by staff at non-pharmacological interventions prior to administration. Review of the facility policy titled Medication Monitoring dated 06/21/17 revealed when treating psychiatric disorders or distressed behavior it is important to seek the underlying cause of distressed behavior, either before or while treating the symptom. In additional the facility should consider non-pharmacological interventions. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interview, review of facility infection control policies and procedures, and review of an article from Centers for Disease Control (CDC) the facility failed to implement procedures regarding hand hygiene and isolation precautions in order to prevent the potential spread of the coronavirus (COVID-19). This directly affected four Residents (#3, #4, #6 and #32) of six reviewed and had the potential to affect 18 other Residents (#1 - #3, #5, #7 - #18, #30, and #31) who resided on the 200 and 400 wings at the facility. The facility had an outbreak of COVID and were in the process of transferring the COVID positive residents to a different facility. The facility census was 38. Findings include: 1. Record review revealed Resident #4 was originally admitted to the facility on [DATE] with the following diagnoses; hypertensive [MEDICAL CONDITION] with heart failure, [MEDICAL CONDITION], muscle weakness, cognitive communication deficit, muscle wasting and atrophy, irritable bowel syndrome, heartburn and generalized anxiety disorder. Resident #4 was readmitted to the facility on [DATE] after being admitted to the hospital for altered mental status. Review of Resident #4's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required supervision with with bed mobility, transfers, toileting and dressing. Resident #4 was independent with personal hygiene and eating. Review of Resident #4's orders revealed Resident #4 was ordered droplet precautions from 09/16/20 to 09/30/20 due a recent hospital visit. 2. Record review revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses;[MEDICAL CONDITIONS] of right lower limb, type two diabetes mellitus, muscle weakness, dysphagia, unsteadiness on feet, other symbolic dysfunctions, acute kidney failure and osteo[DIAGNOSES REDACTED] Review of Resident #6's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and require extensive assistance with transfers, bed mobility, dressing and toileting. Resident #6 also required supervision with eating and personal hygiene. Review of Resident #6's orders revealed no orders for precautions. 3. Record review revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses; hypertension, dementia, anxiety and depression. Review of Resident #3's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. Observation of Resident #4's bedroom door on 09/16/20 at 12:06 P.M. revealed a notice to please report to nurse before entering, and a sign that indicated droplet precautions with an explanation of what personal protective equipment (PPE) to put on before entering the room to provide care or services. The sign indicated that the following PPE was to be worn into the room: gown, mask, goggles, and goggles/face shield. There was no isolation cart containing PPE outside the residents room. At the same time, State tested Nurse Aide (STNA) #50 walked into Resident #4's room to deliver a meal tray wearing only a mask and a gown. STNA #50 delivered and set up the meal tray, sanitized her hands, then took another meal tray out and went into Resident #3's room wearing the same gown. Resident #3 did not have any precautionary signs on his door. On 09/16/20, at 12:14 P.M., after serving Resident #4 and Resident #3, STNA #50 sanitized her hands, removed a tray from the tray cart and took the meal tray into Resident #6's room. Resident #6 also had signs on his door to please report to the nurse before entering, and a sign specifying the resident was on droplet precautions with an explanation of what PPE to put on before entering the room to provide care or services. There was an isolation cart outside his door. STNA #50 did not change her gown after being in Resident #4's room, who was on isolation, or Resident #3's room, before walking into Resident #6's room. She did not don a fresh gown, or gloves, but was wearing eye protection (goggles). STNA #50 when exited Resident #6's room, she was questioned as to what PPE she was supposed to wear into the room, and confirmed at that time she did wear the same gown that she had worn into the two previous rooms, and was not wearing gloves. She reported that she thought gloves were only necessary when providing hands on care to residents. 4. Record review revealed Resident #32 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITIONS] and [MEDICAL CONDITION] following cerebral infarction affecting left non dominant side, muscle wasting and atrophy, abnormal posture, other reduced mobility, dementia in other diseases classified elsewhere with behavioral disturbance, vitamin D deficiency, constipation and major [MEDICAL CONDITION]. Review of Resident #32's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. Resident #32 also required total dependence with transfers, supervision with eating, Review of Resident #32's orders revealed no orders for precautions. On 09/16/20 at 12:25 P.M. STNA #58 was observed getting ready to enter Resident #32's room. She stated she was going into the room to see/assist in pulling the resident up in bed. She removed a gown and a surgical mask from the isolation cart outside the resident's room, and placed the surgical mask over her N95 mask STNA #58 then took her surgical mask off, and opened the biohazard trash container and lid outside the resident's room with her bare hands stating she needed gloves. Without washing or sanitizing her hands, after handling the biohazard trash can, she went to the nurses cart to get gloves and put them on, then got a surgical mask and placed over her N95 mask. At that time, STNA #58 was asked to verify that she had failed to wash her hands after handling the biohazard trash can and lid, and before donning a clean pair of gloves. STNA #58 affirmed she did not wash her hands prior to donning the clean gloves, and after handling the biohazard trash container. An interview was conducted with the Director of Nursing (DON) on 09/16/20 at 12:45 P.M. The aforementioned observations were shared with the DON at which time she confirmed there should have been an isolation cart outside Resident #4's room, that STNA #50 should have donned a fresh gown and gloves when entering Resident #4 and 6's rooms and removed them afterwards, and STNA #58 should have washed or sanitized her hands prior to getting clean gloves and donning them after handling the soiled biohazard trash container. Review of the facility's donning and doffing PPE for COVID-19 policy dated 04/14/20 revealed health care personnel should perform hand hygiene before and after all patient contact, contact with potentially infectious material and before putting on and after removing PPE including gloves. Review of CDC and Preventions article Using PPE dated 08/19/20 revealed gloves and gown are to be doffed prior to exiting the patients room.

Based on observation and staff interview, the facility failed to keep resident equipment in safe operating condition. This affected three (#2, #7 and #43) of 19 residents reviewed for equipment. The facility census was 63. Findings include: Observation of Resident #2's geri-chair on 11/12/19 at 5:20 P.M. revealed the geri-chair arms were in disrepair and torn up. Observation of Resident #7's room on 11/12/19 at 2:32 P.M. revealed the over bed light was missing a pull cord. Observation of Resident #43's wheelchair on 11/14/19 at approximately 11:00 [NAME]M. revealed the wheelchair arms were in disrepair and the vinyl was missing on the ends of the bilateral wheelchair arms. During an interview and observation with State tested Nursing Assistant (STNA) #457 on 11/14/19 at 2:51 P.M. it was confirmed there was no call light pull cord for Resident #7's over the bed light. The STNA also confirmed the arms to Resident #2's geri-chair and the arms to Resident #43's wheelchair were in disrepair and the vinyl was off the ends of the arms.

Based on medical record review, staff interview and observation, the facility failed to ensure the catheter drainage bag was covered while up in public areas. This affected one (Resident #12) of one resident reviewed for catheter care. The facility census was 63. Findings include: Medical record review for Resident #12 revealed an admission on 01/16/16 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/26/19, revealed the resident had impaired cognition and had an indwelling urinary catheter. Observation on 11/14/19 at 11:21 [NAME]M. of Resident #12 revealed the resident was sitting in the public dining area with other residents at a table. Resident #12 urinary drainage bag had dark yellow fluid visible to others. Interview with State tested Nursing Assistant #475 on 11/14/19 at 11:25 [NAME]M. verified the urinary drainage bag should have be enclosed in a protective covering to prevent visualization of bag contents. Interview on 11/14/19 at 11:27 [NAME]M. with Licensed Practical Nurse (LPN) #461 verified the urinary drainage bag should be enclosed in a protective covering.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan to address the resident [DIAGNOSES REDACTED].#48) of 18 residents reviewed for care plans. The facility census was 63. Findings include: Medical record review for Resident #48 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/21/19, revealed Resident #48 had no cognitive impairment. Review of the physician orders, dated 07/01/19, revealed orders for antihypertensive medications named [MEDICATION NAME] extended release (ER) tablet, Losartan potassium tablet, [MEDICATION NAME] and and an antianxiety medication named [MEDICATION NAME]. Review of the care plan, dated 07/29/19, revealed it was silent to addressing the resident's [DIAGNOSES REDACTED]. The care plan was updated on 11/13/19 for the anxiety medications and was silent for the hypertensive medications. Interview on 11/14/19 at 9:35 [NAME]M. with the Director of Nursing (DON) confirmed the care plan had been updated on 11/13/19 and she would have expected it should have been done at the time of admission.

Based on record review and staff interview, the facility failed to obtain laboratory testing as ordered. This affected one (Resident #352) of five residents reviewed for unnecessary medications. The facility censes was 63. Findings include: Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 10/23/19, revealed the resident was cognitively impaired and the resident received seven days of antipsychotic, antianxiety, hypnotic and anticoagulant medications. Review of the physician orders, dated 07/2019, revealed the resident had laboratory testing orders which included a vitamin D level every three months on the first Monday in the months of August, November, February, and May. Review of the laboratory results revealed the resident had not had a vitamin D level completed in (MONTH) 2019 or (MONTH) 2019 as ordered, and the last vitamin D level was completed on 06/24/19. During an interview with Corporate Clinical Specialist #491 on 11/14/19 at 12:21 P.M. it was confirmed the facility did not complete laboratory testing as ordered by the physician and the resident had not had a Vitamin D level completed in (MONTH) 2019 and (MONTH) 2019.

Based on observation, review of facility policy and staff interview, the facility failed to ensure the staff served the resident's meals in a sanitary manner. This affected two (#2 and #26) of 63 residents observed for dining observation. The facility census was 63. Findings include: Observation of the meal tray delivery on 11/12/19 at 12:48 P.M. in the memory care unit revealed State tested Nursing Assistant (STNA) #403 applied hand sanitizer prior to pulling a meal tray from the delivery cart. STNA #403 preceded to place a meal tray on the dining room table in front of Resident #26. STNA #403 then removed her personal eye glasses from her head and placed them on her face. STNA then tucked her hair behind her ears using both hands. STNA #403 then opened a wax paper bag with a dinner roll inside and placed in on the plate of food without reapplying hand sanitizer and gloves prior to handling the dinner roll. A subsequent observation on 11/12/19 at 1:01 P.M. in the memory care unit revealed STNA #403 applied hand sanitizer prior to a pulling meal tray from the delivery cart. STNA #403 preceded to place a meal tray on the dining room table in front of Resident #2. STNA #403 proceeded to remove the dinner roll from the wax paper bag and place it on the plate of food. STNA #403 then handled a facility dining room chair using both hands on the arm rests and pulled it close to Resident #2. Then, STNA #403 did not use hand sanitizer and gloves before picking up the dinner roll and proceeding to cut the roll in two and placing butter on both sides of the roll and then placing the item on the food plate of Resident #2. Interview on 11/12/19 at 2:42 P.M. with STNA #403 verified she touched her hair and the arms of the dining room chair and did not sanitizer her hands and use gloves before touching the resident's food with her bare hands. Review of the facility's policy titled Provider Services, infection control policy and procedure manual, dated 10/18/01 with a revision of 08/2016, revealed the facility failed to follow guidelines for safe food handling. The policy stated the food handlers mush wash their hands after engaging in other activities that contaminate the hands.

Based on observation, record review and resident and staff interview, the facility failed to maintain an accurate care plans for Resident #7 and #52 and failed to invite the resident and/or family members for care conferences quarterly for Resident #15. This affected three (#7, #15 and #52) of 19 residents who were reviewed for care plan accuracy. The facility census was 63. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders, dated 08/27/19, revealed to place a pummel cushion (prevents sliding further) to the resident's wheelchair and check the placement every shift, dated 08/27/19. On 08/27/18, there was an order to place a dycem (non slip pad) under the pummel cushion to the wheelchair and check the placement every shift. Review of the treatment administration record (TAR), dated 11/2019, revealed the facility staff were placing their initials on the TAR twice daily indicating Resident #7 had dycem under the pummel cushion in the wheelchair, and the pummel cushion to the wheelchair and checking placement every shift, indicating the staff were verifying the items were in place and in use. Review of the care plans revealed the resident had a care plan that indicated the resident had a pummel cushion to the wheelchair to assist with positioning. There was no mention of a geri-chair in place for the resident. Observation of Resident #7 on 11/12/19 at 9:32 [NAME]M. revealed the resident was sitting in a geri-chair which was being pushed by a staff member. Subsequent observation of Resident #7 on 11/14/19 at 8:25 [NAME]M. revealed the resident was in a geri-chair in the dining room. The geri-chair had no cushion to the chair. During an interview with State tested Nursing Assistant (STNA) #405 at 11/14/19 at 8:26 [NAME]M., it was revealed the resident only used a geri-chair and without a cushion. During an interview with Licensed Practical Nurse #410 on 11/14/19 at 9:18 [NAME]M. it was verified Resident #7 was not currently using a wheelchair with a pummel cushion, but was using a geri-chair. The LPN verified the resident was using the geri-chair for the current month and verified in the past the resident used a wheelchair with a pummel cushion. The LPN stated he/she was unsure when the changes in chairs occurred. During an interview with Corporate Nursing Consultant # 491 on 11/14/19 at 9:02 [NAME]M., it was confirmed Resident #7's care plan did not include the geri-chair the resident used when out of bed, but continued to have the wheelchair with pummel cushion included in the care plan which was no longer in use. 2. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the care plan revealed the resident was on hypnotics for short term use only with a created date of 12/18/17 and no revision date. During an interview with Corporate Clinical Specialist #491 on 11/14/19 at 12:21 P.M. it was confirmed the the care plan was not updated to reflect the non-use of a hypnotic medication. 3. Review of the medical record for Resident #15 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/23/19, revealed Resident #15 was cognitively intact. Further review of the medical record revealed the resident was offered a care conference on 01/10/19 and on 04/12/19 and declined. The record was silent to any other offer of a care conference after that. Review of the social services notes, dated 06/03/19 and 09/03/19, revealed the social services completed assessment but there was no record of offering a care conference with the resident or family members. Interview on 11/12/19 at 2:14 P.M. with Resident #15 revealed she had not been offered a care conference recently and could not recall the last time she had been offered one. Interview on 11/13/19 at 4:30 P.M. with Admissions #427 revealed the facility did offer care conferences by sending out a letter out to the residents and family members on 07/17/19 stating if they wanted a care conference they could call and set up one up.

Based on medical record review, staff interview and review of the facility's hospice contract, the facility failed to designate a facility team member for the collaborate of care between hospice services and the facility. This affected three resident (#12, #44 and #45) of three residents reviewed for hospice services. The facility identified 11 residents receiving hospice services. The facility census was 63. Findings include: 1. Medical record review for Resident #44 revealed an admission on 04/14/19. [DIAGNOSES REDACTED]. Review of the physician orders, dated 04/14/19, indicated to admit the resident into hospice care related to end stage [MEDICAL CONDITION]. Review of the plan of care, dated 04/16/19, revealed the resident was receiving hospice services related to late stage [MEDICAL CONDITION]. Interventions included for hospice to collaborate with the facility staff and to contact hospice for changes in the resident's condition. The plan of care was silent regarding the name and title of the designated facility staff member for coordination of care with hospice. 2. Medical record review for Resident #45 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 10/18/19, revealed the resident had impaired cognition and was receiving hospice services care. Review of physician orders, dated 07/11/19, revealed an order for [REDACTED]. Review of the plan of care, dated 07/29/19, revealed hospice services were in place for end stage [MEDICAL CONDITION] of the liver. Interventions included hospice to collaborate care with facility staff contact hospice for changes in the resident's condition. The plan of care was silent regarding the name and title of the designated facility staff member for coordination of care with hospice. 3. Medical record review for Resident #12 revealed an admission on 01/16/16 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 08/26/19, revealed the resident had impaired cognition and was receiving hospice services during the look back period. Review of the physician orders, dated 05/22/19, revealed an order for [REDACTED]. Review of the plan of care, dated 05/23/19 revealed the resident was receiving hospice services for end stage [DIAGNOSES REDACTED]. Interventions included for hospice to collaborate care with facility staff and contact hospice for changes in the resident's condition. The plan of care was silent regarding the name and title of the designated facility staff member for coordination of care with hospice. Review of the hospice contract with the facility, dated 11/01/17, reveals the facility will designate a member of its interdisciplinary team who will be responsible for working with hospice to coordinate care provided to the hospice patients. Interview on 11/13/19 at 4:45 P.M. with Director of Admissions verified the facility does not have a specific staff member to communicate with hospice to coordinate care. She stated if it was a new hospice referral, the social worker will set up the meeting with the family and assist with admission process. Interview with Licensed Practical Nurse (LPN) #461 on 11/14/19 at 11:45 [NAME]M. verified the hospice staff will report to the facility nurse when a visit is made and if any follow up will be needed as a result of the visit. The LPN stated she was unaware of a designated facility staff member that collaborates care and services with hospice. Interview on 11/14/19 at 2:10 P.M. with the Clinical Corporate Specialist #491 verified the facility did not designate a facility staff member for the collaboration of hospice services and determination of the services hospice will provide for Resident #12, #43 and #44. Subsequent interview on 11/14/19 at 3:08 P.M. with Clinical Corporate Specialist #491 verified the facility was now completing audits to correct the plan of cares that have been impacted with the lack of documentation regarding a designated staff member for continuation of care.

Based on record review and interview the facility failed to develop a comprehensive care plan for a resident with urinary issues. This affected one (#7) of 17 residents reviewed for care plans. The facility census was 67. Medical record review for Resident #7 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 had no cognitive impairment and was independent for most activities except for personal hygiene, she was noted as limited to one person assist. Review of physician progress notes [REDACTED]. On 01/30/18 she complaints of urinary frequency. On 02/12/18 she indicated the urinary frequency was better. Review of an urology note and orders dated 04/02/18 revealed not to treat for a urinary tract infection unless the resident had a fever or was bleeding (she was colonized). The note indicated the resident had multiple UTI's and had Extended spectrum beta-Lactamases (ESBL) six times during (YEAR). Review of physician progress notes [REDACTED]. Further review of the medical record revealed an order dated 05/11/18 for [MEDICATION NAME] (pain reliever for lower urinary tract) 100 milligrams (mg) one tablet by mouth three times per day as needed related to dysuria (painful urination). Review of the care plans for Resident #7 revealed no care plan to address urinary issues. Interview on 09/19/18 at 3:00 P.M. with State tested Nurse Aide (STNA) #8 stated Resident #7 was normally continent of urine but wore panty liners in case of an incontinet episode. STNA #8 verified the resident frequently complaint of burning. Interview on 09/20/18 at 1:53 P.M. with Licensed Practical Nurse (LPN) #44 verified there was no care plan implemented for Resident #7's urinary issues.

Based on medical record review and interviews the facility failed to investigate and reply to transportation concerns presented by the Resident Council. This affected two (#32 and #42) of 17 residents reviewed. The facility census was 67. Findings include: Review of Resident #42's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] indicated Resident #42 was cognitively intact. The resident required assist of one to two staff for activities of daily living except for eating she required supervision. Review of the care plan revealed the resident required transportation three times a week for [MEDICAL TREATMENT] Interview with Licensed Practical Nurse (LPN) #16 on 09/18/18 at 10:02 A.M. revealed there were issues with transportation always being late. Interview with Resident #42 on 09/18/18 at 11:30 A.M. revealed she had missed her appointment today for vein mapping since transportation did not show up. Interview on 09/18/18 at 1:41 P.M. with the Director of Nursing (DON) reported transportation failed to show up today for Resident #42's appointment for vein mapping and the appointment had to be rescheduled. The DON reported transportation had been an ongoing issue but it was out of their hands since managed medicaid determines what particular providers for transportation be used. Interview with Licensed Nursing Home Administrator (LNHA) on 09/18/18 at 4:05 P.M. reported calls had been made to the transportation providers to complain about the service. LNHA did not have any dates, times, or who was spoken to in order to confirm the efforts. LHNA verified residents had complained during Resident Council regarding transportation and she had no follow up for their concerns. Follow up interview with the DON on 09/19/18 at 11:26 A.M. verified Resident #42's transportation provider was facility chosen and not directed by any insurance demands. The DON stated residents had complained numerous times regarding late or missed appointments but it was out of the facilities control. Follow up interview on 09/20/18 at 8:44 A.M. with Resident #42 reported she had missed or been late to ten appointments within the last year due to transportation issues. She reported she had been late to [MEDICAL TREATMENT] but had not missed a treatment. Review of Resident Council Minutes for (MONTH) (YEAR) revealed a resident concern of transportation issues. 2. Medical record review for Resident #32 revealed an admission date of [DATE] with medical [DIAGNOSES REDACTED]. Review of Resident #32's MDS dated [DATE] revealed no cognitive impairment. Further MDS review revealed Resident #32 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #32 was noted to be frequently incontinent of urine and occasionally incontinent of bowel. Interview on 09/19/18 at 10:25 A.M. with Resident #32 revealed she had missed several appointments. Resident #32 stated the facility had made the appointments and made the transportation arrangements. She further stated twice the transportation company canceled and three times the transportation company didn't show up in time. Resident #32 stated she had missed on appointment on 09/18/18 due to issues with the transportation company. The resident stated around 10:45 A.M. the facility called the transportation company and they indicated they would be there by 11:00 A.M. By 11:12 A.M. the transportation company had not shown up and her appointment was scheduled for 11:30 A.M. Interview on 09/19/18 at 11:55 A.M. with the DON stated Registered Nurse (RN) #28 had called the transportation company, who was supposed to pick up Resident #32 at 10:15 A.M., they stated they were running late and would be at the facility between 10:45 A.M. and 11:00 A.M. At 11:00 A.M. RN #28 called the transportation company again and stated Resident #32 did not want to go to her appointment as she didn't think she had enough time to make it to her appointment. The transportation company said the driver had an emergency and the cancellation wouldn't be against the resident. RN #28 called the physician's office and left a voicemail to explain the situation about why Resident #32 was unable to make her appointment. RN #28 was waiting for a call back from the physician's office. Follow up interview on 09/19/18 at 12:50 P.M. with the DON stated this was the first time she was aware of issues related to transportation. The DON stated in regards to the resident council complaints back in (MONTH) (YEAR), the issue was transportation sent a van that was not wheelchair accessible. The resolution was the nursing supervisor would schedule all the appointments. Interview on 09/19/18 at approximately 1:45 P.M. with State tested Nurse Aide (STNA) #8 stated Resident #32 had missed appointments. Interview on 09/19/18 at 1:57 P.M. with LPN #62 stated several resident's, including Resident #32, had problems with missing appointments due to transportation concerns.

Based on record review, observation and interviews the facility failed to notify a physician of an antibiotic not being available for a resident. This affected one (#13) of 17 residents reviewed for notification. The facility census was 67. Findings include: Review of Resident #13's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #13 required extensive assist of two for activities of daily living and was cognitively impaired. Review of physician orders [REDACTED]. Review of Resident #13's Medication Administration Record [REDACTED]. A second initialing on 07/19/18 included a code that indicated the medication was not available. Review of progress notes revealed an entry on 07/20/18 at 3:56 P.M. that indicated a call was placed to the pharmacy due to eye drops not coming in yet. Per the notes the pharmacy indicated there was a national shortage of this medication. Progress notes further indicated the physcian would be notified. Further review of the progress notes revealed no evidence the physcian was notified. During an interview on 09/18/18 at 9:21 A.M., Resident #13 indicated she had an eye appointment. Resident #13 indicated she had an eye infection. The resident was observed at this time and there was no redness nor swelling noted to her eyes. Review of an ophthalmologist visit note for Resident #13 dated 09/18/18 revealed an order for [REDACTED]. Interview with the Director of Nursing and Corporate Clinical Nurse #95 on 09/20/18 at 11:30 A.M. indicated the [MEDICATION NAME] was not received for Resident #13 and verified the medical record contained no evidence of the physician being notified.

Based on record review, observation, and interview, the facility failed to assess resident devices quarterly. This affected one (#54) of 17 residents reviewed for care planning. The facility identified 10 residents as using seat belt enablers. The census was 67 residents. Findings include: Review of Resident #54's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #54 was cognitively impaired. The resident required extensive assist of one for activities of daily living except for eating she required supervision The MDS indicated Resident #54 had more than three falls. Review of a restraint enabler decision tree dated 02/12/18 and a restraint physical assessment dated [DATE] indicated the alarming Velcro seat belt was not assessed as a restraint. Review of a care plan dated 08/01/18 revealed Resident #54 was at risk for falls due to a history of falls, unsteady gait, and impaired cognition. The care plan revealed Resident #54 could release seat belt when desired but not on command due to having severely impaired cognition. Observation of Resident #54 on 09/18/18 at 2:01 P.M. revealed she was up in a wheelchair with an alarming seat belt in place. The resident made eye contact with verbal interactions but replied nonsensically. Observation on 09/18/18 at approximately 5:00 P.M. revealed Resident #54 was eating dinner in the dining room, feeding self with alarming seat belt in place. Interview on 09/20/18 at 1:11 P.M. with Licensed Practical Nurse (LPN) #44 reported Resident #54 had an alarming seat belt as a reminder to not get up unassisted. LPN #44 stated the alarming seat belt was an enabler and she assessed all enablers quarterly for appropriateness and continued use. LPN #44 stated the assessment was done via restraint enabler decision tree and verified she had not assessed Resident #54 since 02/12/18. Interview on 09/20/18 at 2:05 P.M. with the Director of Nursing reported the facility only had a care plan policy addressing advance care planning only.

Based on medical record review and staff interview, the facility failed to maintain and revise person centered care plans. This affected three Residents (#4, #17, and #60) of 17 reviewed for care plan revisions. The facility census was 67. Findings include: 1. Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #60 was cognitively intact. Her functional status was listed as independent for all activities of daily living. She was always continent of urine and bowel. Review of the weight chart dated 02/18/16 revealed an admission weight of 141.0 pounds. Her weight as of 09/16/18 was 119.6 pounds. Review of the admission care plan dated 05/23/16 revealed a plan in place for the potential for alteration in nutrition and hydration related to: nutritional risk, body mass index (BMI) of 25.0-29.9 (overweight status), hypertension, [MEDICAL CONDITION], anxiety disorder, depression disorder, heart failure, [MEDICAL CONDITION], irritable bowel syndrome (IBS), [DIAGNOSES REDACTED], and dietary calcium deficiency. Review of the comprehensive Dietary assessment dated [DATE] revealed Resident #60's complete body weight of 129 pounds, her height at 61 inches and her BMI as 24.4 pounds (normal). The resident was receiving a normal diet. Resident was able to feed self without difficulty. Resident exhibits no signs or symptoms of suboptimal hydration status as evidenced by labs and moist mucous membranes. No current pressure injuries noted. Review of the quarterly Dietary assessment dated [DATE] revealed Resident #60's complete body weight of 119.6 pounds, height 61 inches and BMI as 22.6 (normal). Resident was receiving a regular, small portions diet. The Resident was also receiving MedPass (supplement) 120 milliliters (ml) twice daily to promote weight stability and better meet the residents' needs. Resident with very slight additional weight loss, will increase MedPass to three times a day at this time. Review of the current revised care plan dated 08/29/18 revealed a plan in place for the potential for alteration in nutrition and hydration related to: nutritional risk, body mass index (BMI) of 25.0-29.9 (overweight status), hypertension, [MEDICAL CONDITION], anxiety disorder, depression disorder, heart failure, [MEDICAL CONDITION], irritable bowel syndrome (IBS), [DIAGNOSES REDACTED], and dietary calcium deficiency. Interventions in place were appropriate. This was the exact same plan of care the resident had upon admission to the facility. Interview with the Staff #88 on 09/17/18 at 3:23 P.M., confirmed the care plan was not revised and the care plan dated 08/29/18 was the exact same care plan as on admission. 2. Medical record review for Resident #4 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting and hygiene. The resident utilized a self-releasing seatbelt due to [MEDICAL CONDITION] and late effects of Polio. Review of the care plan for Resident #4 indicated the use of a safety device Velcro front release alarming seatbelt when in wheelchair but no interventions were listed. Interview on 09/20/18 at 1:53 P.M. with Licensed Practical Nurse (LPN) #44 who verified the care plan for Resident #4 was not person centered and had no interventions for use of the seatbelt. 3. Medical record review for Resident #17 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the significant change MDS dated [DATE] revealed Resident #17 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Further medical record review for Resident #17 revealed the resident had falls on 01/24/18, 06/03/18, 06/04/18 and on 06/29/18 Review of the care plan for falls for indicated the resident was at risk for falls the care plan was not person centered and was not updated after the falls Interview on 09/20/18 at 1:53 P.M. with LPN #44 verified the care plan for Resident #17 was not person centered and the care plan was not revised after the falls.

Based on observations, record review and staff interviews the facility failed to create and sustain an environment that humanizes and individualizes the quality of life for residents. This affected two (#27 and #116) of 17 residents reviewed. The facility census was 67. Findings include: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive deficit. Her functional status was listed as totally dependent on staff for all activities of daily living. Review of the care plan dated 09/11/18 revealed a plan of care for the potential for alteration in activities anxiety, cognitive impairment, impaired communication, impaired decision making, impaired mobility, progressive disease. She had a history of [REDACTED]. One on one visits, one to three times weekly were needed. Review of the physician orders [REDACTED]. Observations on 09/18/18 at 2:00 P.M., 4:00 P.M., 09/19/18 at 10:00 A.M.,12:00 A.M., 2:00 P.M. and 4:00 P.M. and on 09/20/18 at 11:00 A.M. and at 1:00 P.M. revealed only one time Resident #27 was out of her bed and in a geriatric-chair at the nurse's station. Observation was made on 09/20/18 at 1:00 P.M., after this surveyor spoke with staff, Resident #27 was observed out of bed and in a geriatric chair at the nurse's station. Interview with State tested Nurse Aide (STNA) #38 and STNA #57 on 09/19/18 at 2:00 P.M. revealed they were unaware of any time Resident #27 was gotten up out of bed. 2. Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #116 had severe cognitive impairment. Her functional status was listed as extensive one person assist to totally dependent on staff for all activities of daily living. The resident received nutrition through a tube feed of [MEDICATION NAME], 1.5 milliners (ml) times 22 hours. Review of the care plan dated 07/24/18 revealed Resident #116 had the potential for alteration in activities and impaired mobility. She was interested in television/movies and preferred doing activities in her own room. Interventions included Resident #116 would receive one on one (1:1) visits, one to three times weekly. Review of the physician orders [REDACTED]. Observations on 09/18/18 at 2:00 P.M., 4:00 P.M., 09/19/18 at 10:00 A.M.,12:00 A.M., 2:00 P.M. and 4:00 P.M. and on 09/20/18 at 11:00 A.M. and at 1:00 P.M. revealed Resident #116 was never observed out of her bed. Interview with STNA #38 and STNA #57 on 09/19/18 at 2:00 P.M. revealed they were unaware of any time Resident #116 was gotten up out of bed

Based on record review, resident interview and staff interview, the facility failed to ensure a resident received showers. This affected one (#7) of one resident reviewed for activities of daily living (ADL) care. The facility census was 67. Findings include: Medical record review for Resident #7 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 had no cognitive impairment and was independent for most activities. For personal hygiene, she was noted as limited to one person assist. Review of the baseline care plan for Resident #7 revealed under grooming Resident #7 was listed as needing assistance. Review of the shower log for 09/2018 revealed Resident #7 had refused a showered on 09/04/18, the only other shower documented was on 09/13/18. Interview on 09/18/18 at 9:22 A.M. with Resident #7 stated her shower days were Mondays, Wednesdays and Fridays. Resident #7 further stated she didn't recall what day last week she received a shower or was bathed. Interview on 09/19/18 at 3:00 P.M. with State tested Nurse Aide (STNA) #8 stated the facility gave showers three times per week. STNA #8 indicate Resident #7 was a night time shower and received her showers on Mondays, Wednesdays and Fridays according to the STNA shower log schedule in the STNA flow book. STNA #8 also indicated the resident refused her showers at times. STNA #8 stated Resident #7 was independent with most skills but needed supervision during showers for safety. Interview on 09/20/18 at 9:24 A.M. with STNA #39 verified the shower log for 09/2018 revealed Resident #7 only received one shower. STNA #39 verified Resident #7 was supposed to receive showers three times per week on Monday, Wednesday and Friday. STNA #39 stated Resident #7 was a supervision and stand by assist as the resident was unsteady. Interview on 09/20/18 at 10:48 A.M. with Corporate Clinician #94 verified Resident #7 was scheduled to receive showers three times per week. Corporate Clinician #94 provided the shower log for 08/2018. At this time the shower log was reviewed and revealed Resident #7 was documented as receiving three showers for the month and had two refusals. The resident received showers on 08/09/18 and on 08/14/18. The resident refused on 08/16/18, 08/21/18 and on 08/29/18.