Every finding on record at Guttenberg Care Center

Based on record review, resident and staff interviews the facility failed to conduct quarterly care conferences and invite resident/family to attend and provide input for 1 of 12 residents reviewed (Resident #11) The facility census was 34 residents. Findings include: Review of the documentation for Resident #11 revealed an admitted to the facility of 4/12/21. Review of the most recent Minimum Data Set MDS) assessment for Resident #11 dated 4/15/22, showed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. During an interview on 7/12/22 at 10:59 am, Resident #11 stated they have been a resident here for a little over a year now and is only aware of 2 care conferences for reviewing and updating her plan of care since her admission here and states that the second one only happened because she asked the facility Social Worker why she only had one since admission to the facility. Resident #11 went on to say that she used to work in a nursing home so she knows they are to have care conferences quarterly, Resident #11 stated the Social Worker said they could do one right then, sat in her room and asked if she had any concerns, Resident #11 told the Social Worker she had no concerns at that time. Review of the EMR (Electronic Medical Record) for Resident #11 revealed Care Conference Progress Notes for documentation of care conferences since the residents admitted d 7/22/21, 10/21/21, & 11/17/21. Further review of those Care Conference Progress Notes revealed that the Care Conference held on 7/22/21 Resident #11 attended, the Care Conference held 10/21/21 documented the resident as having attended (though the resident does not recall this), and the Care Conference documented on 11/17/21 only the facility Social Worker and Resident #11 attended, no other Care Conference Progress Notes were found in the EMR since that date to the current date of 7/14/22. During an interview on 7/13/22 at 11:16 am the facility ADON verified the Resident had no other Care Conferences since admission to the facility and stated she would expect Care Conferences to be held at least quarterly (every 3 months) and that a Resident with a BIMS score of 15 would be invited to attend their Care Conference to provide input for updating the plan of care for that resident.

Based on observation, record review, and staff interviews the facility failed to follow manufacturers recommendations for use of insulin pens for 1 of 1 residents observed receiving insulin injections (Resident #4). The facility census was 34 residents. Findings include: Review of the Physicians Orders for Resident #4 revealed current orders on 7/13/22 for the resident to receive a scheduled dose of [MEDICATION(S)] (long acting) insulin of 45 units every morning as well as an adjusted dose of [MEDICATION(S)] (short acting) insulin based on the residents blood sugar level at that time. During observation of Medication Administration on 7/13/22 at 7:00 am, Staff A (LPN) reviewed the MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A then went into the resident room and administered both doses of insulin to Resident #4 without priming the needles to ensure no air was present and accurate insulin dose administration. During an interview on 7/13/22 at 7:05 am, after administration of the 2 doses of insulin to Resident #4, Staff A stated that they were not aware that use of insulin pens required priming of the needles with 2 units of insulin prior to dialing up the ordered dose of insulin to be administered to ensure the accurate amount of insulin is administered to the residents. Review of the manufacturers information/recommendation provided to the facility by their pharmacy for the use of [MEDICATION(S)] insulin pens directs the users to use a new needle for each injection and to follow Step 3 of the Instructions for use. Step 3 of the Instructions for use directs the users to always perform a safety test before each injection, this ensures that you get an accurate dose by ensuring the pen and needle work properly and remove any air bubbles, then instructs the user to select a dose of 2 units, remove the cap, hold pen with needle pointing upwards, tap the insulin pen so any air bubble rise to the needle, then press the injection button all the way in and check that insulin comes out of the needle tip. Review of the manufacturers information/recommendation provided to the facility by their pharmacy for the use of [MEDICATION(S)] insulin pens directs the users to prime the insulin pen before each use and warns that if you do not prime before each injection you may get too much or too little insulin, then directs users to prime the pen by turning the Dose Knob to 2 units, hold the pen with the needle pointing up and tap on the pen gently to collect air bubbles at the top, continuing to hold the pen with needle pointing up and push the Dose Knob until it stops at 0 and says that you should see insulin at the tip of the needle. The information then directs the users to turn the Dose Knob to the desired number of units of insulin to be administered. During an interview on 7/13/22 at 11:18 am, the facility ADON stated that they do expect nursing staff to prime insulin pens with 2 units of insulin each time before use and that she does instruct any new nurses to the facility to follow this procedure for insulin administration using insulin pens.

Based on observation, record review and staff interview, the facility failed to notify the ombudsman for 4 of 4 residents (#6, #20, #31 and # 76) reviewed. The facility reported a census of 30. Findings include: Record review showed Resident # 6 was hospitalized [DATE] and returned to the facility on [DATE]. Resident # 6 was hospitalized [DATE] and returned to the facility on [DATE]. Resident # 6 was hospitalized on [DATE] and returned to the facility on [DATE]. Record review showed Resident # 76 was hospitalized on [DATE] and returned to the facility on [DATE]. Record review showed Resident # 20 was hospitalized on [DATE] and returned to the facility on [DATE]. Record review showed resident # 31 was hospitalized on [DATE] and did not return to the facility. Review of the ombudsman notification list for March, May and December 2020 and February 2021 does not include any information for Residents #6, 20, 31 or 76. During an interview on 4/1/2021 at 8:37 AM, the Office Manager stated the reports did not include residents that were discharged to the hospital.

Based on record review and staff, resident and family interviews, and facility policy review, the facility failed to separate the alleged perpetrator from the victim for 1 of 6 sampled (Resident #1). The facility reported a census of 29. Findings include: The Intake Information sheet revealed the facility reported an allegation to the Department of Inspections and Appeals on 12/6/20. The allegation involved Staff A and Resident #1 and occurred on 12/4/20 at 7:30 p.m. The report had a Corrective Action Description of separated the aide and resident immediately and notified the local law enforcement. Review of Staff A's timecard sheet revealed Staff A worked on 12/4/20 from 2:00 p.m. until 10:00 p.m. Review of the Abuse Prevention, Training and Investigations policy revised 2/22/11 documented the person in charge of the facility should immediately separate the alleged perpetrator, if know, from the victim and maintain this separation without exception, pending completion of the investigation. During an interview on 1/6/20 at 2:18 p.m., Staff A (Nurse Aide) reported the facility called her and informed her a Resident made an allegation that involved her and asked her to write a statement. The Administration directed her not to work with and stay away from Resident #1. Staff A reported after the allegation she worked the other side of the building. Staff A denied any contact with Resident #1 since the alleged incident and then reported said hello to him in the dining room and assisted him with a cup of coffee. Staff A reported another staff was in the dining room with her. During an interview 1/8/21 at 2:17 p.m., Staff A reported she worked had contact with Resident #1 since the alleged incident but always had another staff member present. Staff A then stated Resident #1 asked her to pick up items from him and she delivered meals to his room without another staff member present. During an interview 1/8/21 at 1:33 p.m., Staff C (Nurse Aide) reported Staff A worked directly with Resident #1 since the alleged incident. During an interview 1/8/21 at 2:16 p.m., Staff B (Nurse Aide) reported Staff A worked directly with Resident #1 since the alleged incident. During an interview 1/8/21 at 1:15 p.m., a Family Member stated he/she knew without a doubt the Staff A worked with Resident #1 since the alleged incident.

Based on observation, clinical record review, staff, resident and physician interviews and facility policy review, the facility failed to ensure residents with pressures sores received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 sampled (Resident #4, #5 and #6). The facility reported a census of 29. Findings include: The Minimum Data Set (MDS) assessment identified the following pressure ulcer definitions: a. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. b. Unstageable Ulcer: inability to see the wound bed. 1. The MDS assessment dated [DATE] indicated Resident #4 had [DIAGNOSES REDACTED]. Resident #4 required extensive assistance of 2 staff with bed mobility, transfers and ambulation in his room. Resident #4 had a risk for pressure ulcers and not on turning and repositioning program. Resident #4 admitted to the facility on [DATE]. The Brief Interview for Mental Status sheet dated 1/8/21 revealed Resident #4 scored a 15, indicating no cognitive impairments. The Care Plan documented Resident #4 had a risk for pressure ulcers and had [DIAGNOSES REDACTED]. The Care Plan directed staff to observe for skin impairments when assisting with my activities of daily living, prefers to sleep in recliner, independent with chair mobility and able to elevate and lower legs, encourage to elevate legs throughout day due to [MEDICAL CONDITION], and pressure reduction pad in recliner. The Braden Scale for Predicting Pressure Sore Risk sheet dated 8/4/15 revealed Resident #4 at risk for developing pressure sores. A Physician/Nursing Communication sheet dated 11/6/20 revealed the staff notified the Physician of Resident #4's new Stage II pressure sore to the coccyx that measured 2.0 centimeters (cm) by 0.2 cm without odor or drainage and a little red with surrounding excoriation. The Physician responded on 11/9/20 at 4:14 p.m. with an order for [REDACTED]. An Order Entry sheet dated 11/20/20 at 9:00 p.m., revealed an order to measure the area on Resident #4's coccyx weekly until healed. The Progress Notes revealed the following: a. On 11/16/20 at 10:53 a.m., treatment held due to a new treatment pad placement on 11/15/20 which had been still in place. b. On 11/20/20 at 6:41 a.m., the affected area dark pink and fragile skin with the treatment pad placement. The note failed to include the stage, size, depth, drainage, odor and the condition of the surrounding skin. c. On 11/20/20 at 8:59 p.m., new order to measure the area on the coccyx/sacral area weekly until healed every Friday. The resident had been sleeping so measurement held until tomorrow. d. On 12/5/20 at 10:39 a.m., new order to measure area on the coccyx weekly on Saturday. An Order Entry sheet dated 11/20/20 at 9:00 p.m., revealed an order to measure the area on Resident #4's coccyx weekly until healed. During an observation 1/8/21 at 4:00 p.m., the Assistant Director of Nursing (ADON) assessed Resident #4's coccyx. The ADON confirmed Resident #4 had an open area. The area had a red color and a small amount of sanguineous drainage. Resident #4 denied any pain. According to a Weekly Pressure Ulcer Progress Report form dated 1/8/21 Resident #4 had a Stage II pressure area on the coccyx measuring 0.4 cm by 0.6 cm with superficial depth, no tunneling or odor and red in color. An entry on 1/11/21 documented the area as healed. The facility lacked thorough assessments of the Stage II pressure area from 11/6/20 to 1/8/21. 2. The MDS assessment dated [DATE] documented Resident #5 had [DIAGNOSES REDACTED]. Resident #5 required assistance of 2 staff with bed mobility and transfers but non-ambulatory. Resident #5 at risk for pressure sores and no turning/repositioning program. Resident #5 admitted to the facility on [DATE]. A MDS 3.0 Resident Interview sheet dated 1/8/21 revealed Resident #5 scored a 14, indicating intact cognition. The Care Plan documented Resident #5 had a potential for pressure ulcer development and other skin impairments related to impaired mobility, incontinence and obesity. Resident #5 had a pressure ulcer on her coccyx on admission and currently had a Stage I pressure ulcer on her left heal and now a stage II. The Care Plan directed the staff to provide extensive assistance with 1 to 2 staff to turn and reposition in bed, prefers to face the wall in bed or on back, use pillows for positioning, requests frequent position changes at night, likes left side or back, utilize a pressure reduction mattress on bed and ROHO cushion on wheelchair, now utilizes an air mattress since developed ulcer on left heel, and utilize bunny boots to both feet. A Braden Scale for Predicting Pressure Sore Risk sheet dated 1/7/21 documented Resident #5 had a moderate risk for pressure ulcers. A Weekly Pressure Ulcer Progress Report sheet documented the staff noted on 12/10/20 an unstageable pressure area to Resident #6's left heel. The area measured 3 cm, round, and boggy. The staff notified the Physician of the area. The form lacked assessments of the area from 12/10/20 to 1/7/21. On 1/7/21, the unstageable area measured 5 cm by 3.5 cm and had a black color. The staff notified the Physician. The Progress Notes revealed the following: a. On 12/10/20 at 4:11 a.m., left heel had a 3 cm round pressure ulcer noted deep purple center and boggy but not open. Resident had bunny boots in place and no signs and symptoms of pain or discomfort. b. On 12/14/20 at 3:47 p.m., the staff received a fax from the Physician who approved the use of bunny boots to both feet to offload pressure and to monitor and contact if worsens. c. The Progress Notes failed to reflect assessments of the pressure ulcer from 12/15/20 to 1/6/21. d. On 1/7/21 at 4:14 p.m., the unstageable pressure area to Resident #5's heel measured 5 cm x 3.5 cm with a deep purple scab feeling type area. Resident #5 reported the area tender to touch. Resident #5 had bunny boots on sitting in wheelchair. Resident stated the area had been there for a while and caused no bother to her. A plan to continue to monitor area weekly on a Weekly Pressure Ulcer Progress sheet and the Progress Notes. During an interview 1/8/21 at 4:43 p.m., the Physician reported Resident #5's pressure area was avoidable and/or at least minimized if treated correctly. The Physician had no knowledge of the pressure area. 3. The MDS assessment dated [DATE] documented Resident #6 had [DIAGNOSES REDACTED]. Resident #6 required extensive assistance of 2 staff with bed mobility and transfers and extensive assistance of 1 staff with ambulation in her room. Resident #6 had a risk for pressure ulcers, had an unhealed stage II pressure ulcer and not on a turning and repositioning program. Resident #6 admitted to the facility on [DATE]. A MDS 3.0 Resident Interview sheet dated 1/8/21 documented Resident #6 scored 11, indicating moderately impaired cognition. The Care Plan documented Resident #6 had [DIAGNOSES REDACTED]. Resident #6 had a potential for pressure ulcer development related to diabetes and occasional bowel and bladder incontinence. The Care Plan directed the staff to complete treatments daily as ordered, observe skin for any impairments when assisting with cares, and report skin concerns to the nurse. A Weekly Pressure Ulcer Progress Report sheet documented Resident #6 had a pressure ulcer to the coccyx identified on 12/10/20. The sheet lacked a stage and measurements. The staff notified the Physician. The sheet lacked assessments of the area from 12/10/20 to 1/8/21. On 1/8/21, the area measured 0.8 (length) by 0.5 (width) by less than 0.1 cm (depth). The area had no tunneling, or odor, a small amount of blood drainage, a yellow center and red edges. The area a Stage II. A Progress Note dated 12/11/20 at 4:23 a.m., documented a pressure ulcer on Resident #6's coccyx measuring 2.0 cm by 1.0 cm. No further assessment addressed. During an observation 1/8/21 at 11:20 a.m., revealed Resident #6 had a dressing on the coccyx dated 1/5/21. The Assistant Director of Nursing (ADON) removed the dressing. The dressing contained a scant amount of dried sanguineous drainage. The ADON measured the area at 0.8 cm by 0.5 cm with a depth of less than 0.1 cm. The area had a white center and red surrounding skin. Resident #6 reported pain only with dressing changes. During an interview 1/8/21 at 12:13 p.m., Staff F (Registered Nurse) confirmed the record lacked additional skin sheets or assessments. During an interview 1/7/21 at 4:05 p.m., the Director of Nurses (DON) stated when she started at the facility the prior DON told her she had been bad with skin assessment so the assessments are probably not in the records. The Pressure Ulcer Risk Assessment and Documentation policy revised on 1/2011 directed the following for Pressure Ulcer development and documentation: 1. Assess any new pressure ulcer as soon discovered and documented the following information in the Interdisciplinary notes: location, stage, size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth, drainage, odor and color, surrounding skin condition, location extent of any undermining or tunneling/sinus tract and granulation. If eschar and necrotic tissue covered and prevented adequate staging of the pressure ulcer, the assessor would follow the Resident Assessment Instrument and guidelines and code the ulcer as unstageable-slough and/or eschar. 2. Initiate a Weekly Pressure Sore Progress Report form initiated and documentation of the results of the assessment a minimum of weekly until healed. 3. Update the Physician on the healing progress at minimum of every 2 weeks.

Based on observation, clinical record review and a staff e-mail, the facility failed to ensure staff maintained a safe and secure environment for 2 of 4 sampled (Residents #1 and #2). The facility reported a census of 29. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 12/2/20 documented Resident #1 had [DIAGNOSES REDACTED]. Resident #1 required extensive assistance of 2 staff with transfers and ambulation in his room and had one fall with no injury and one fall with a minor injury in the previous quarter. A Care Plan identified a Focus area of at risk for falls related to impaired mobility with [MEDICAL CONDITION], tremors, cognitive impairment with unawareness of safety issues, [MEDICAL CONDITION] drug use, obesity and a history of falls. The Care Plan directed staff at times thinks he can walk by self and self-transfers, and utilizes a chair alarm to alert the staff of position changes. During an observation 1/6/21 at 3:55 p.m., Staff D (Nurse Aide) and Staff E (Nurse Aide) assisted the Resident #1 with toilet use. Upon completion, the staff pushed Resident #1 to dining area in his wheelchair. The staff failed to place the chair alarm on Resident #1. Continued observation until 4:14 p.m., revealed the Director of Nursing (DON) present and staff coming and going from the dining area. After 4:14 p.m., the DON directed the staff to place the alarm on Resident #1. 2. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. Resident #2 had a memory problem, moderately impaired cognitive skills, required extensive assistance of staff with bed mobility and transfers, non-ambulatory, two falls with a minor injury, and one with a major injury. According to the Care Plan Resident #2 required assistance with my activities of daily living related to impaired mobility, unsteadiness, dementia with impaired cognition and communication, pain, and incontinence. The Care Plan identified Resident #2 at risk for falls and directed the staff to provide the following: a. Requires assistance of two staff for my toilet use needs. b. Be aware of self-transfers. c. On 9/4/20, staff had no knowledge Resident #2 got up because the alarm on the chair failed to sound. d. Transferred with staff assistance of two, no ambulation and used a wheel chair as my main form of mobility. e. On 5/16/20, utilize a chair alarm when up to alert staff of position changes, unaware of safety issues and self-transfers. Check function of the chair alarm every shift. An Incident Report dated 8/9/20 at 10:10 p.m., revealed Resident #2 on the floor without the chair alarm working. An Incident Report dated 9/4/20 at 10:00 a.m., revealed Resident #2 found on the floor without the chair alarm working. Alarm Review forms dated 6/16/20 at 10:30 a.m. and 9/11/20 at 10:30 a.m. revealed the staff assessed the functionality of the resident's chair alarm. Review of an email dated 1/12/21 at 1:31 p.m. the DON confirmed the facility policy for checking the functionality of resident alarms as a monthly alarm review form.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff utilized proper infection control technique when completing cares or assisting residents. (Resident #25 & #43) The facility census was 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #25 had [DIAGNOSES REDACTED]. The Physician order [REDACTED]. Staff were to apply calcium Alginate (an absorbent ) dressing and cover the wound with a border foam dressing. The order directed staff to change the resident's dressing every other day for a open wound on the left leg. Observation on 5/7/19 at 11:50 a.m., Staff A, Licensed Practical Nurse (LPN) cleansed the scissors with alcohol and placed them on top of the medication cart without a clean barrier. She gathered all the supplies into her hands and went into the resident's room. Staff A placed all the gathered supplies, which included 2 black plastic bags and the dressing supplies, on the room mates recliner seat without a barrier. Staff A placed a black plastic bag on top of the resident's right leg and one on the floor next to the resident's left foot. Staff A took all the supplies from the recliner's seat and placed them onto the resident's wheelchair without a barrier. Staff A moved the black plastic bag from the right leg, opened it up and placed it on top of the resident's tray table. She took the loose supplies from the wheelchair and placed them into the plastic bag on top of the tray table. Staff A donned gloves and removed the old dressing, placing it into the open plastic bag on the floor. Staff A took clean gauze and cleansed the open wound with a normal saline cleanser, without any change of gloves. The Director of Nursing (DON), Registered Nurse (RN) came into the room and Staff A removed her gloves, placing them into the plastic bag on the floor. Staff A cleansed her hands, donned gloves, and opened the sterile Calcium Alginate dressing packet. With the scissors, she cut a section from the Alginate dressing pad and put the rest of the dressing into the packet and then into a plastic bag. Staff A covered the wound with the dressing and then placed a foam dressing on top. During wound cares the resident's catheter's tubing, approximately 4 inches in length, sat directly on the floor. Observation on 5/8/19 at 9:00 a.m., the resident sat in the recliner with the feet down and the catheter tubing sat on the floor. Observation on 5/8/19 at 10:00 a.m., the resident sat in the recliner with the feet down and the catheter tubing sat on the floor. During interview on 5/8/19 at 12:30 p.m., Staff A reported she should have set up a clean barrier for the supplies and change her gloves after removing the old dressing. Staff A reported the resident's catheter tubing should not sit on the floor. The facility's policy for Appropriate Use of a Drainage Bag dated 5/2002 showed (page 2 part 4, letter L) showed the drainage bag should never touch the floor. 2. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated Resident #43 had [DIAGNOSES REDACTED]. During observation on 5/7/19 at 9:46 a.m., the resident was standing with EZ stand lift while Staff C, certified nurse aide, CNA and Staff D, CNA completed residents cares. Staff C applied lotion to the residents back and arms and without removing gloves, touched the EZ stand lift. Neither Staff C or Staff D cleansed the lift after use. 3. During dining observation on 5/6/19 at 11:05 a.m., Staff E CNA was observed lifting a residents feet to reposition them and touching foot pedals and handles of residents' wheel chairs. Staff E sat in a chair between residents and began feeding residents when lunch arrived. Staff E failed to wash their hands before feeding the residents. During interview on 5/8/19 at 12:28 p.m., the Director of Nursing (DON) stated staff complete hand hygiene before they assist residents with meals. The DON stated if staff were touching a residents feet and wheel chairs they should complete hand hygiene before feeding a resident.

Based on facility record review, staff and resident interviews the facility failed to follow policies and procedures and investigate allegations of abuse in a timely manner. Concerns were noted for one incident involving two residents (# 1 and #2) in which a delay of at least four days elapsed prior to the charge nurse/director of nursing being aware and implementing interventions. Findings include: According to the Minimum Data Set (MDS) assessment of 7/6/18, Resident #1 experienced delusions but no other behavioral symptoms. The resident required supervision with transfers and walking. The assessment documented he had a BIMS (Brief Interview for Mental Status) score of 13, indicating intact memory and cognition. The MDS assessment dated [DATE] documented Resident #2 experienced delusions but no other behavioral symptoms. The resident required the assistance of one staff with bed mobility, transfers and with walking. During an interview on 9/4/18 at 9:10 a.m. the Administrator stated a resident told Staff A (a CNA, or certified nursing assistant) she witnessed Resident #1 touch Resident #2's breast on 7/24/18. The Administrator stated Staff A later told her the behavior was documented in Resident #1's medical record/behavior sheet, but the charge nurse was busy at the time and Staff A's shift ended soon. Staff A just forgot to let the charge nurse know about the incident. The Administrator added that Staff B, LPN (licensed practical nurse) heard about the incident a few days later (7/28/18) and informed the facility Director of Nursing who stated she would take care of the situation on Monday (7/30/18). During an interview on 9/4/18 at 1:25 p.m. Resident #1 admitted he had touched another resident's breast. Resident # 1 indicated he felt they were friends and he wanted to be more than friends with Resident #2. Resident # 1 stated Resident #2 did not say no when he touched her. During an interview on 9/4/18 at 11:15 a.m. Resident #2 indicated Resident #1 had touched her inappropriately and added that she had not wanted Resident #1 to do that. Resident #2 stated she had not been hurt nor was she fearful of Resident #1. According to review of the personal file, Staff A had signed the facility Acknowledgement of Abuse Prevention & Reporting, Education, Policies and Notices form on 10/26/17. By signing this document Staff A, verified she was aware that reporting must be done within 2 hours of forming a suspicion if there is serious bodily injury and within 24 hours of forming a suspicion if there is no serious bodily injury. The facility Abuse Prevention, Training and Investigation policy revised 8/24/16 also directed staff to report allegations or suspicions of mistreatment, abuse or other crimes immediately and without hesitation directly to the person in charge of the facility at the time. If that person is not the administrator, the employee is also required to report the allegation to the Administrator with in one hour of first becoming aware.

Based on clinical record review and staff interview, the facility failed to complete a new PASSAR (Pre Admission Screening and Resident Review) screening for two of four residents with a significant change in mental health as required. (Resident #11 & #17) The facility census was 54 residents. Findings Include: 1. The significant change MDS (Minimum Data Set) assessment dated [DATE], documented Resident #11 had a [DIAGNOSES REDACTED]. The current PASARR dated 7/24/12, was a negative Level 1 and showed no mental health diagnosis. The current [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. During interview on 2/5/18 at 2:49 p.m., the Director of Nursing (DON) stated that up until now the facility had not done any significant change PASARR's on any resident. The DON further stated she understood that a significant change PASARR was done when a resident triggers for a significant change MDS. 2. The MDS assessment dated [DATE], documented Resident #17 had [DIAGNOSES REDACTED]. The current PASRR dated 4/24/15 was a negative Level 1 and listed depression (mild or situational) as the only mental health diagnosis. A History & Physical listed mental health [DIAGNOSES REDACTED]. Point Click Care [DIAGNOSES REDACTED]. During interview on 2/7/18 at 8:10 a.m., the DON acknowledged it would be an expectation to submit another PASARR for Resident #11 with a new [DIAGNOSES REDACTED]. The DON stated another PASARR should of been submitted for Resident #17 for a new [DIAGNOSES REDACTED].

Based on observation, clinical record review and staff interview, the facility failed to ensure initial and/or ongoing assessments were completed to identify, prevent and promote healing of altered skin integrity for two of five residents reviewed. (Resident #44 & #31) The facility census was 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #31 had [DIAGNOSES REDACTED]. A Podiatrist document dated 2/16/17, recommended return to clinic follow up in 2 ½ months. No follow up visit was found in the chart. On 2/5/18 at 3:10 p.m., Staff C, Licensed Practical Nurse, LPN prepared to do a foot soak for the resident with warm soapy water. Observation revealed 5 areas on the residents right foot/toes and two areas on left foot/toes in varied color from yellow to deep purple. Staff C stated the resident received foot soaks in warm soapy water and [MEDICATION NAME] treatment each night. Staff C reported the residents feet had improved since the soak had started. On 2/6/18 at 8:00 a.m., Staff D, LPN stated at times they did skin review sheets for the residents feet. Reported there had been several areas on the right foot which had been treated. Staff D expected skin assessment sheets would be completed for all treated sites. Staff D stated a foot doctor or wound nurse had not assessed the areas and stated the doctor that did rounds had seen them. During interview on 2/6/18 at 8:51 a.m., the Director of Nursing, DON stated all areas being treated on foot/ toes would be addressed on the skin sheet for monitoring weekly with each area separately identified. The DON stated the foot doctor used to come but did not any longer. During observation on 2/6/18 at 4:30 p.m., Staff C, LPN performed treatment to residents feet. Staff C swabbed [MEDICATION NAME] to 4 scabbed discolored areas on left foot, tips of toe one and three, between toes four and five and bottom of foot approximately 1 inch below toe 5. Swabbed 5 scabbed and purple areas on right foot; side of toe 5,between toe 4 &5, between toe 3&4, side of toe 1, and top of foot below toe 1. Noted that heels felt soft, boggy spongy. On 2/7/18 at 4:00 p.m., the resident laid in bed as the physician assessed the residents feet and buttocks. The physician stated they would expect to be notified if an ordered treatment had not been effective, no improvement or worsening, within a week or two of treatment start. The physician stated if the facility had been treating 2 areas on a foot and more areas of concern appeared the normal course of action would be to let the physician know by fax or other ways. At that time the ADON who had also been present stated the physician had been notified on 1/10/17 of change in foot condition by fax. Reviewed the fax dated 1/10/17, it requested to soak feet in warm soapy water x 15 min and apply [MEDICATION NAME] to scaly areas. The Physician replied OK. ADON agreed fax did not indicate how often, how long, if it was a one time order and did not notify the physician of a change in condition. On 2/8/18 07:47 a.m., the DON agreed no assessment was completed on areas to the residents feet. On 2/8/18 at 7:40 a.m. Staff D, LPN measured areas to the residents feet as follows: Right Foot a) great toe ; 0.2 cm b) below great toe top of foot; 0.4 cm c) between toe 3&4; 0.6 cm d) between toe 4&5; 0.2 cm e) side of little toe; 0.5 cm Left Foot a) great toe; 1.6 x 0.3 b) toe 3; 0.2 cm c) bottom of foot; 0.4 x 0.6 cm 2. The MDS assessment dated [DATE], documented Resident #44 had [DIAGNOSES REDACTED]. The care plan updated 1/11/18, included a problem of diabetes mellitus. The problem included an intervention for the podiatrist to follow resident for toe nail care as needed. On 2/07/18 at 4:11 p.m., Staff C, LPN assessed the residents feet upon the surveyor request. Observation revealed all nails on bilateral feet elongated and thick, right great toe nail had grown so long it had curved toward and into 2nd toe and with visible indentation of 2nd toe skin where nail growing into it. Right 2nd toe nail had grown so long it had curved toward and into side of right great toe with visible indentation of skin where nail growing into it. At that time Staff C stated the facility had not had a foot doctor for about 9 months and stated the nails needed to be trimmed but were such that a nurse would not be able to do it. Staff C verified the indentation in skin of toes from nails growing into them. At that time the resident stated their toes hurt. On 2/7/18 at 4:48 p.m., the Director of Nursing (DON) stated the resident had been scheduled for foot doctor appointment out of the facility at one point but had behaviors so the appointment had been canceled. The DON stated the resident had now been scheduled to go in March (next month). The DON stated they would not want to wait until March if the nails were growing into the toes/skin and would have expected CNAs to notify the RN if nails were growing into toe so appointment could be moved sooner. The DON stated the facility had not had a foot doctor that had come to the facility since August (6 months previous).

Based on observation, clinical record review and staff interview, the facility failed to ensure two of five residents reviewed received nutrition and hydration services as Speech Therapy recommended. (Resident #1 & #54) The facility census was 54 residents. Findings include: 1. The Minimum Data (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required supervision and set up for meals with no poor appetite in the previous two weeks and no refusal of care. The care plan updated 1/16/18, included a problem of swallowing and need a mechanically altered diet. Problems feeding self and need adaptive equipment and assistance. Depression and history of weight loss. History of [MEDICAL CONDITION]. The problem included the following interventions: a. Resident likes yogurt or whole milk and may ask for this in place of my meals. b. In the past resident would dine by the nurses station area. On 9/4/17, power of attorney requested resident eat in the dining room next to a table in the dining room. Need and will accept assistance at times or need cues to just stay awake and continue eating. On 11/8/17, power of attorney is ok with resident dining in dining room or by nurses station as long as resident eating or assisted if needed. c. Diet is pureed. d. Observe for signs and symptoms with swallowing or chewing for choking/aspiration. On 2/1/18 at 11:05 a.m., the resident sat in a Broda chair near the nurses station with a plate of pureed food. The resident had both eyes closed. A Hospice music therapist sat next to the resident and played guitar and sang. At 11:20 a.m., the resident sat with eyes open, music therapist still played. The resident had not attempted to eat any of the food which sat on the tray. At 11:31 a.m., the music therapist remained beside the resident, food remained untouched. At 11:41 a.m., the food remained untouched and no staff attempted to assist the resident. Observation revealed Staff B, Registered Nurse frequently in the area at the nurses station. At 11:57 a.m., Staff B walked by the resident and stated you better eat something girl. The resident stated the food was cold. Staff B did not stop or offer the resident a new plate or to heat up the food. The resident stated the food was cold and they did not care for cold meat. The resident stated they would find some somewhere. At 12:15 p.m., the Activity Director removed the plate of pureed food without offering a new plate or to heat the food up. The Activity Director left a bowl of pureed cake in front of the resident which had been sitting on the tray with the other plate of pureed foods. The resident requested a clothing protector and ate the cake. No other food was offered to the resident. During interview on 2/6/18 at 3:35 p.m., the Director of Nursing stated staff should have assisted and offered to warm the residents food. 2. The MDS assessment date 1/15/18, documented Resident #54 had [DIAGNOSES REDACTED]. The care plan updated 1/23/18, included a problem of nutritional risk due to advancing dementia process. History of pneumonia but swallow study showed no aspiration. The problem included an intervention to see attached speech and language pathologist recommendations from 9/5/17 (added 1/16/18). The same care plan included a problem of risk of aspiration with a [DIAGNOSES REDACTED]. See recommendation form attached. Refer to speech therapy as needed. A Speech Therapy Swallow Guidelines Recommendation sheet dated 10/17/17, included the following directives: a. pureed textures b. please allow patient time to take 2-3 breaths after providing a bite or sip. On 2/1/18 at 11:29 a.m., Staff A, Registered Nurse provided 1:1 feeding assistance to the resident. Staff A gave the resident multiple bites of pureed foods throughout the meal without waiting for two to three breaths as directed by Speech Therapy. During the observation the resident had a deep harsh cough at times. At 12:10 p.m., the surveyor asked Staff A if any of the residents at the table had specific feeding directives. Staff A stated Resident #54 could not be fed by a paid nutritional assistant. Staff A showed the surveyor a book with specific meal directives and stated the resident had no specific directive except to be fed by a Certified Nurse Aide. The Director of Nursing stated on 2/7/18 at 4:45 p.m., that Staff A was counseled on where to find the correct information on resident feeding needs after the surveyor had brought the concern to their attention.

Based on observation, record review and staff interview, the facility failed to ensure residents with pressure sores received necessary treatment and services to promote healing for 2 of 3 residents with pressure sores (Resident #6 & #7). The facility reported a census of 74 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment, dated 10/24/14, revealed Resident #6 [DIAGNOSES REDACTED]. The MDS documented the resident had a stage 2 pressure ulcer. A Nutritional Assessment signed 02/19/14 by the Dietician Resident #6 had intact skin. The Interdisciplinary Progress (IDP) Notes dated 08/14/14 at 9:00 a.m. documented Resident #6 had a stage 1 pressure ulcer of the left heel measuring 3 by 2 centimeters (cm) with the skin intact. The IDP Notes dated 09/30/14 at 10:00 a.m. documented Resident #6 had a pressure ulcer of the left heel with a dry callused area that sloughed off. The area was open with slight peri wound redness and serous drainage. The clinical record lacked a nutritional assessment regarding the development of the pressure ulcer or initiation of nutritional interventions to promote healing. A Nutrition Assessment signed 10/28/14 by the Dietician documented the description of Resident #6's skin condition as normal and failed to identify Resident #6 had a pressure ulcer. The assessment documented Resident #6 had the potential for inadequate energy intakes, with intakes becoming more variable at lunch. Resident #6's intakes had been good and able to meet estimated needs (last calculated 02/19/14) even with the lunch becoming more variable. The assessment documented Resident #6 had intact skin. The Progress Notes dated 10/28/14 at 3:53 p.m. documented a skin area noted on Resident #6's heel and he/she continued to eat and drink well at meals and adequate for skin health. Would continue current nutritional offerings. During an interview on 11/04/04 at 11:30 a.m. the Dietician stated she could not remember when she received notification regarding Resident #6's heel ulcer. It may have been after she did the assessment on 10/28/14 at the high risk meeting. She did not calculate Resident #6's needs regarding the pressure ulcer, but said she ate well enough. During an interview on 11/04/14 at 3:10 p.m., the Dietary Manager (DM) stated she didn't know if she attended the last at risk meeting, so unsure if she knew Resident #6 had a pressure ulcer. She had been in the DM position since August. During an interview on 11/04/14 at 3:20 p.m., the Dietician stated they didn't stage the ulcer at a 2 until 10/20/14, and they wouldn't do anything for a Stage 1 ulcer. (The IDP notes documented the ulcer open 09/30/14). During an interview on 11/04/14 at 3:30 p.m., the Director of Nursing (DON) stated they included Stage 1 pressure ulcers at the risk meetings and usually did the meetings when the dietician was there. She said they knew about Resident #6's pressure ulcer. She didn't know why the skin sheets didn't show a stage of the ulcer for 3 weeks after it opened. The facility policy for Pressure Ulcer Risk Assessment and Documentation directed when a new pressure ulcer was discovered staff would notify the Dietary Manager and he/she would be responsible to initiate dietary interventions. They would update the care plan to reflect new interventions to aid in the healing process (may refer to the Nutritional Care of Residents with Pressure Ulcers policy). A list of residents with pressure ulcers would be maintained by the DON for weekly review and provided to the dietary Manager, Consultant Dietician, and Administrator. The facility policy for Nutritional Care for treatment of [REDACTED]. The policy directed a nursing staff member would notify the Dietary Manager of the pressure ulcer and the following interventions may be implemented per the resident's preferences. 2) According to the MDS dated [DATE], Resident #7's [DIAGNOSES REDACTED]. The MDS revealed Resident #7 depended on staff for bed mobility, transfer, toilet use and personal hygiene and had Stage 2 and Stage 3 pressure ulcers. The Care Plan dated 07/24/14 identified Resident #7 at high risk for pressure ulcers and skin impairments. The Care Plan directed staff to use a pressure reduction pad in the resident's chair. During an observation on 11/04/14 at 8:22 a.m., staff transferred Resident #7 out of the chair which had a pommel cushion in it. During an observation on 11/04/14 at 10:43 a.m., staff transferred Resident #7 to the wheelchair onto a pillow which they had placed over the pommel cushion. The lift sling remained under Resident #1's buttocks and back. During an observation on 11/04/14 at 4:01 p.m., Resident #7 sat up in the chair with the lift sling between the resident and the seat cushion and padded back of the chair. During an observation on 11/05/14 at 6:44 a.m., Resident #7 sat in the wheelchair with a pillow and the lift sling under his her buttocks, and the lift pad at his/her back. At 7:21 a.m., Resident #7 sat in the wheelchair in the dining room, and the pillow and lift sling were not in the chair. During an interview on 11/04/14 at 11:10 a.m., the Unit Manager stated the chair and the pommel cushion provided pressure reduction, but she did not know about the pillow between the pommel cushion and the resident. During an interview on 11/04/14 at 12:31 p.m., Staff A Certified Nursing Assistant (CNA) stated they put a pillow under Resident #7 because he/she sat so low in the chair. An information page provided by the facility for Posey Wedge Foam Pommel Cushions revealed the cushions were designed to help keep hips and knees in alignment, and help reduce patient forward sliding. The information did not indicate the cushion provided pressure reduction. During an interview on 11/05/14 at 3:30 p.m., the Director of Nursing stated that was all the information they had on the pommel cushion. She acknowledged it did not say anything about pressure reduction. She said the Broda chair the resident had provided pressure reduction. During an interview on 11/06/14 at 8:29 a.m., a representative of the Posey Company confirmed the information regarding the pommel cushion said nothing about pressure reduction. During an interview on 11/06/14 at 8:47 a.m., the Unit Manager stated Resident #7 had had the pommel cushion for a long time.

Based on observation and staff interview, the facility failed to ensure that potentially hazardous items were secured as required. The facility census was 74 residents. Findings include: During the facility Environmental Tour conducted 11/5/14 at 10:35 a.m., an observation in the 1st floor storage area at 11:00 a.m. revealed an oxygen tank on the floor of the oxygen tank storage area. The tank was not secured to prevent it from being tipped over and possibly damaging the tank. A full oxygen tank is under 2,000 psi (pounds per square inch) of pressure. A break could cause the tank to become a hazardous projectile. At the time of the discovery, the facility administrator stated they were aware the tanks need to be secured at all times. The administrator immediately placed the tank in a secure area before proceeding with the Environmental Tour.

Based on observation, record review and staff interview the facility failed to transfer a resident using a safe technique for 1 out of 6 residents reviewed (Resident #1). The facility identified a census of 87 residents. Findings include: 1. Resident # 1's Minimum Data Set (MDS) assessment, dated 7/4/14, identified a Brief Interview for Mental Status (BIMS) score of 15 that revealed the resident as cognitively intact. The MDS listed [DIAGNOSES REDACTED]. The MDS showed the resident required extensive assistance of 1 or 2 persons for transfers, personal hygiene, ambulation and toilet use. The History and Physical dated 5/14/14 identified the resident with left foot drop, vertigo and neuropathy. The resident's Care Plan dated 5/23/14, showed the resident was at risk for falls with impaired mobility, shortness of breath, weakness, and a history of falls. The Care Plan showed interventions that included: transfer and ambulate with a front wheeled walker, a gait belt and 1 or 2 staff assistance, using 2 staff when weak or increased unsteadiness, pain, SOB and/or fatigue. The Care Plan directed staff to have appropriate footwear on the resident when ambulating, transferring, or mobilizing in the wheelchair daily. The Care Plan also showed the resident wore an AFO (ankle foot orthosis-a brace) to the left foot every am and off at bedtime. The Care Plan updated on 7/15/14 and 7/16/14 revealed interventions for transfer with a Hoyer lift and 2 staff assist along with non- weight bearing status. The updated care plan directed staff to apply the left leg brace on at all times. The Physicians Progress Notes dated 7/15/14 noted a transfer to the emergency room per ambulance via telephone orders. The Diagnostic Report of the CT (an X-Ray with computed tomography) from the hospital dated 7/15/14 reported the resident sustained [REDACTED]. The report noted the resident's bones showed extreme demineralization. A Diagnostic Report on 7/15/14, of the resident's knee showed profound osteopenia. Interdisciplinary Progress Notes (also Nurse's Notes) dated 7/14/14 at 9:00 a.m. reported the resident was transferred to bed with 1 staff assist, staff heard Resident #1's knee snap and the staff member called for help to get the resident to bed. Resident #1 complained of pain to the left knee on down the leg. The physician was called and staff received direction to send Resident #1 to the emergency room . The facility staff notified Resident #1's relatives of the transfer to the hospital for evaluation. Interdisciplinary Progress Notes dated 7/16/14 at 5:10 a.m., reported the resident returned from the emergency room at 11:45 p.m. The resident has a non-displaced fracture of the left tibial plateau. Resident #1 returned to the facility with an immobilizer on the left leg, to be worn at all times. The notation identified Resident #1 as non- weight bearing and the staff received direction to elevate the left leg at all times. Interdisciplinary Progress Notes revealed the following: -7/16/14 at 1:30 p.m., the resident had increased pain, with the physician notified to increase the pain medication. -7/17/14 at 3:15 p.m., an anti-coagulation injection was ordered. - 7/20/14 at 9:30 p.m., the resident was having hallucinations. -7/21/14 at 5:30 a.m., the resident had hallucinations and hollered out all night. The physician changed the pain medication. During an interview on 7/22/14 at 2:15 p.m., with Resident #1 revealed he /she didn't remember the fall, and then remarked of not falling, but noted his/her grandmother fell , with 4 other children around. Observation on 7/22/14 at 2:25 p.m. revealed Resident #1 appeared confused. The resident was in bed with the immobilizer on the left leg elevated on a pillow. During an interview on 7/22/14 at 2:35 p.m., Staff G, Licensed Practical Nurse, reported the resident was alert before the incident and fractured left leg. The resident was transferred with the walker and staff assist of 1 person and if needed, 2 persons. Staff G noted the resident now transfers with use of a mechanical lift device. Staff are changing and monitoring the resident's medication to see if the confusion can be relieved. During an interview on 7/22/14, the Director of Nursing (DON), doing the investigation, reported the resident had received a shower, was in the shower chair and in the process of transferring to the bed by Staff B, Certified Nursing Aide. The resident's feet hung from the shower chair, so the resident probably took a 'hop', lifting up and out, with Staff B's assistance of a gait belt. The DON noted, the resident's leg just snapped, and also noted the resident did not fall. After a discussion with the resident's physician, the conclusion of not using the walker, as the care plan directed, made no difference, especially if the resident had to 'hop' to get out of the shower chair. During an interview on 2/22/14, Staff C, Licensed Practical Nurse, who worked the evening of the incident, was called to the resident's room around 7:30 p.m. She found the resident, barefoot, gait belt on, lying on the bed. Staff B reported to her, of hearing the resident's knee 'snap' while standing the resident up for the transfer into bed. When Staff C lightly touched the resident's knee, the resident stating it really hurts, from the knee down to the foot. Staff C called the physician, who directed staff to send the resident to the emergency room and also called the resident's relative. During an interview on 7/22/14 at 4:15 p.m., Staff B reported of giving the resident a shower on 7/15/14 around 7:30 p.m. She could not find the usual short shower chair the resident typically used, being short in stature, so she got a tall shower chair from the shower room. Staff B noted the resident transferred into the shower chair without a problem. After the shower, she rolled the resident to the room, next to the bed. She had the resident grab onto the side rail, with both hands, and with the assistance of the gait belt, transfer to bed. Staff B, noted the resident used the walker for transfers, but, felt since transferring into bed, the resident could use the side rail. The resident's feet were not touching the floor, so there was a slight drop of the resident's feet to the floor. Staff B heard a 'snap or a pop', with the resident saying 'oh, my knee'. Staff B gently guided the resident to sit at the edge of the bed. Staff H, Certified Nursing Aide, heard the resident yell for help, came quickly and assisted with placing the resident into the bed and proceeded to get the nurse. The nurse assessed the resident, made phone calls and sent the resident to the hospital. During an interview on 7/23/14 at 3:10 p.m., Staff D, Certified Nursing Aide, remarked, if a resident's feet are not touching the floor, when doing a transfer, she would call for another person to help. Staff A, Certified Nursing Aide, noted, teaching all new staff, when things don't feel right, or you are uncomfortable, to call for help, as someone will come. During an interview on 7/23/14 at 3:30 p.m., Staff E, Certified Nursing Aide, reported of not being sure if there was staff instruction on how to use a shower chair properly. She commented of not knowing what to do if a resident's feet did not touch the floor with transfers, but would probably have the resident hang onto a bar or something. During an interview on 7/23/14 at 3:30 p.m., Staff F, Certified Nursing Aide, reported there was no inservice on how to use shower chairs, but noted it was common sense to use a shower chair that fits. Staff F noted if a resident's feet did not touch the floor for a transfer, she would call for more help with the transfer, so the resident's feet would touch the floor for the transfer. During an interview on 7/24/14 at 8:30 a.m., the DON reported of not having a policy for using a shower chair properly. She noted the usual shower chairs are already used in resident's bathroom, but if they were unavailable, then staff could use one from the shower room. During an interview on 7/24/14 at 10:10 a.m., Staff H reported passing the shower room on 7/15/14 around 7:30 p.m., noting the resident's clothing and walker were still in the shower room. Staff B, knew the resident had a shower and was carrying the walker and clothing into the resident's room when Staff B called for help. The resident sat, barely on the edge of the bed. Staff H assisted Staff B with lying the resident down in bed. The resident reported the leg hurting. Staff H went to get the nurse, who was right across the hall. Staff H reported of not having any instructions on the use of shower chairs but knew to have the resident be comfortable in them. Staff H noted if a resident's feet did not touch the floor for a transfer, she would call for help with the transfer. During an interview on 7/24/14 at 10:30 p.m., the DON and Nurse Manager nodded their heads in agreement, that standard procedure when a resident is transferred, is to have their feet on the floor. The facility's Policy for Transfer/Gait Belts/Ambulation and Use of Safety Straps/Belts updated on 11/08 included the following in the Procedure (#6): If the resident is able, encourage him/her to participate by pushing off on the chair arms (or bed), bearing weight and pivoting on the strong side to complete the transfer.

Based on observation, record review and staff interview the facility failed to verify 1 out of 14 residents with an Advanced Directive and the physician's orders [REDACTED]. The facility identified a census of 73 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 8/16/13, Resident #16 experienced both long and short term memory loss with severely impaired skills for daily decision making. The Advance Directive Acknowledgement dated 10/26/11, signed by the resident, documented the resident did not want resuscitation efforts initiated at the time of cardiopulmonary arrest. Resident #16's Admission Record dated 1/11/12 documented, "DNR (Do Not Resuscitate)" on top of the sheet. The form failed to document any directive in the area marked Advanced Directives which shows the resident's wishes for resuscitation or no resuscitation if the resident had no heartbeat or respirations. The resident's Care Plan dated 8/28/13 did not identify any Advanced Directive and did not indicate any review with the resident and/or representative regarding their choices or changes. The physician's orders [REDACTED]. The POS documented Resident #16 had [DIAGNOSES REDACTED]. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's Interdisciplinary Notes did not contain a review of the resident's choices at care conferences or on a routine basis. During an interview on 9/25/13 at 9:00 a.m., Staff A, Registered Nurse (RN), told the surveyor the resident was not interviewable. Staff A stated staff can check a resident's MARs to see whether or not a resident should be resuscitated. The RN indicated staff can also refer to a resident's record; if the chart contained a blue round sticker next to the name (on the outside of the record), it indicated the resident requested to be resuscitated. Staff A reported since the POS listed a, "Full Code" status, she would probably initiate efforts to resuscitate the resident should he/she experience cardiac or respiratory arrest. At 9:40 a.m., Staff A stated she called the resident's son and Power of Attorney for Health Care and explained the discrepancy. The son to the nurse to ask Resident #16 what he/she preferred. Staff A explained the choices to the resident who stated, "Yes, Full Code." When Staff A reported it to the son, he directed her to keep the Full Code status for now, but indicated he would check with his siblings to see what they thought would be in the resident's best interest and let the facility know what the family decided. At 9:42 a.m., Staff A reported the resident went to the hospital and returned with a full code status. Staff A stated probably not every resident is checked on a routine basis to review their code status choices. During an interview on 9/25/13 at 9:15 a.m., Staff B, Licensed Practical Nurse (LPN), reported staff checked a resident's MARs to see whether or not a resident wished resuscitation efforts to initiated on his/her behalf. Staff B also stated could check the outside of the resident's record for a blue sticker, which designated the resident wished to be resuscitated. The resident's chart did not contain a blue sticker on the outside of the record. The facility's Policy for Resuscitation dated 8/13 documented each adult resident is consulted upon admission concerning his/her wishes for resuscitation or no resuscitation in the event of cardiac or [MEDICAL CONDITION] arrest. This shall be reviewed with the resident at least annually and/or upon significant change in condition.

Based on observation and staff interview, the facility failed to ensure kitchen equipment was properly sanitized and stored dry to prevent the potential for foodborne illness. The facility census was 86 residents. Findings include: 1. Observation on 8/14/12 at 9:50 a.m., with the Food Service Manager revealed the following: a. Two cookie/bar (silver) sheet-pans on the dry rack had small spots of brown debris present. Observation revealed the debris could be easily scratched off. b. Four cream colored spatulas (non flat) in a drawer had edges that were cracked or split or missing in areas. c. Three scoops contained water in the bowl/scoop area, all were sitting in the drawer. One scoop (silver) contained multiple areas spotted of white debris. d. Three 1/3 size steam pans, stacked together on the dry rack had standing drips of water present inside and outside. The Dietary Manager stated they expected the pans to be clean and dry. During interview on 8/15/12 at 6:04 a.m., the Administrator commented on the wet, soiled cookware in the kitchen and stated new staff had just started in the kitchen.

Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary manner. The facility census was 86 residents. Findings include: 1. Observation on 8/14/12 at 9:50 a.m., with the Dietary Service Manager revealed the following: a. The white, walk in refrigerator had black, exposed steel, with yellow and tan streaks and smudges along the door handle up and down one to two feet and out one to one and one half feet (width-size) and along the corresponding door jam. b. The white, walk in freezer had black, exposed steel, with yellow and tan streaks and smudges along the door handle up and down one to two feet and out one to one and one half feet(width-size) and along the corresponding door jam. Observation on 8/15/12 at 10:50 a.m., revealed the same conditions on the outside doors of the refrigerator and freezer. During interview on 8/16/12 at 7:29 a.m., the Dietary Manager stated the refrigerator and freezer doors were cleansed on a monthly basis and had tried to clean them after tour on 8/14/12, but would check with the Maintenance Manager if another cleanser would be more effective.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to follow the nutritional recommendations for one of three residents reviewed with a weight loss. The facility census was 86 residents. (Resident #4) Findings include: 1. The minimum data set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident scored 12 of 15 on the brief interview for mental status (BIMS), indicating intact memory. The MDS assessment documented the resident required staff assistance with meal set up only, had no swallowing disorder and weighed 103 pounds. The Resident Care Plan dated 8/1/12, identified the resident did not eat a lot, had a weight loss and had specific food likes. Interventions dated 8/1/12 & 8/10/12, included assist the resident with meal set up, offer the resident Plus 2 supplement, weigh weekly and offer snacks between meals. The resident's weekly weight record for 2012 included the following: a. On 7/10/12 the resident weighed 111 pounds. b. On 7/17/12 the resident weighed 111 pounds. c. On 7/24/12 the resident weighed 105 pounds. d. On 8/1/12 the resident weighed 103 pounds. e. On 8/8/12 the resident weighed 103 pounds. f. On 8/14/12 the resident weighed 101 pounds. Interdisciplinary notes dated 7/25/12, documented the resident's weight as down 5.4 percent, 6 pounds down since admission, question if related to need for adjustment as the resident eats about 50 percent. Will work on getting some pastry favorites and follow up as needed with the usual body weight at 108 pounds. Interdisciplinary notes dated 7/27/12, documented the physician and next of kin were notified of the weight loss. Interdisciplinary notes dated 8/1/12, documented the resident's weight as 103 pounds, indicating 8 pounds down and 7.2 percent in a month. Decreasing weight was ongoing, will follow and update as needed. Plus 2 (supplement) added today. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During interview on 8/15/12 at 9:40 a.m., Staff D, Registered Nurse, RN stated the physician typically orders the supplements, which go on the resident's MAR's. Nursing staff administer the supplement and document on the MAR indicated [REDACTED] During interview 8/16/12 at 12:35 p.m., the resident stated they had not received any supplements of shakes or Plus 2 liquids. During interview on 8/16/12 at 12:50 a.m., Staff D, RN stated the Dietician would usually let staff know if a resident required a supplement and usually fills out a facsimile that goes to the physician, indicating the weight change. Staff D noted the Dietician note for a supplement (Plus 2) on 8/1/12 did not produce a facsimile form to the physician and apparently the Dietician forgot to inform staff, as the Plus 2 supplement did not get recorded onto the MAR, thus the resident did not receive any supplement since recommended on 8/1/12. During interview on 8/17/12 at 9:30 a.m., the Dietary Manager stated since the Dietician did not pass on the information for the resident's continued weight loss, it failed to get discussed at the weekly high risk meetings. The facility's Policy and Procedure for Supplement Medication Pass Protocol dated 4/11/05, documented residents who are determined to be nutritionally compromised, may receive additional calories during medication pass as per their plan of care.

Based on observation and staff interview the facility failed to maintain an environment as free of potential hazards as possible. The facility census was 69 residents. Findings include: 1. Random observations of the two newly remodeled public restrooms on 8/16, 8/17, & 8/18, revealed the restrooms are left unlocked at all times and have no emergency call light system inside the bathrooms. An interview during the environmental tour on 8/18/11 at 10:10 a.m., the Administrator verified the bathrooms are not kept locked and are available for residents to use. The doors lock from the inside and have no emergency call light system in the bathrooms. Observation on 8/18/11 at 11:35 a.m., the facility maintenance director replaced the public restroom door knobs with locking knobs and placed keys for the doors on the wall across from the bathrooms. On the Department website in the February 2004 Insight, the State Fire Marshal's Office documented clarification on use of surge protectors. The posted information documented the electrical surge protector shall be of metal or steel construction and approved by Underwriters Laboratories or another recognized laboratory. The paper documented items that could be used with an electrical surge protector and items prohibited from use with a surge protector that included clocks, lamps, personal grooming and care devices, battery chargers, and motor drive appliances, including fans. 2. Observation on 08/18/11 at 7:10 a.m., revealed in room 113 an apporved surge protector with a white fan plugged into it.