Every finding on record at Harborview Health Systems Jesup

Based on observation, interview, and document review, the facility failed to assure dietary department equipment was in safe working condition. Specifically, the steam table located in the kitchen was in disrepair. The failure to assure that the steam table worked correctly had the potential to impact 85 residents that received oral diets from the kitchen steam table. Findings include:Review of the facility's policy titled Record of Food Temperatures, last revised 06/01/2024, documented under Policy Explanation and Compliance Guidelines, number 2. Hot food will be held at 135 degrees Fahrenheit or greater; number 8. If the food temperature falls into an unsafe range, immediately follow procedures for reheating previous cooked food; number 9. Potentially hazardous food that has been cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees F for at least 15 seconds before holding for hot services; number 11. No food will be served that does not meet the food code standard temperatures.Observation on 05/06/2026 at 12:20 PM, as initial steam table temperature checks were conducted with the Dietary Manager (DM) revealed the following temperatures:- Gravy temperature was 132 degrees Fahrenheit.- Hot dog temperature was 130 degrees Fahrenheit.- Chicken tenders' temperature was 120 degrees Fahrenheit.- Chocolate bread pudding temperature was 120 degrees Fahrenheit.During an interview on 05/06/2026 at 12:48 PM, with the DM and Registered Dietary Manager (RDM), revealed the DM had not received any complaints from residents regarding food being cold. The DM confirmed the food temperatures were not within state regulatory requirements and mentioned that staff may have failed to set the steam table temperatures at the highest level. The DM stated she would prepare food in smaller containers to place in warmers and keep additional food in the oven until serving to maintain the correct temperature. She further stated staff would increase the frequency of temperature checks during meal service to residents.Observation on 05/06/2026 at 5:12 PM, during steam table temperature checks with DM and the RDM revealed, the food did not meet the required temperature standards. The following Temperature checks were confirmed with the DM and RDM: -Grilled cheese temperature was 95 degrees Fahrenheit.-Mashed potatoes temperature was 120 degrees Fahrenheit.-Puree beef temperature was 113 degrees Fahrenheit.-Chopped beef temperature was 100 degrees Fahrenheit.During an interview on 05/06/2026 at 5:20 PM, the Administrator, DM and RDM, revealed the Administrator was not aware the steam table was not functioning properly. The DM stated she was unaware the steam table was not working properly until steam temperature checks were completed for the second time today. She further reported that all previous steam temperature checks had been within the required temperature range. The Administrator instructed the DM not to serve any meals from the steam table until the issue was resolved and to ensure all food served was at the correct temperature prior to being served to residents. The Administrator instructed the DM to increase the temperature on the steam table.During an interview on 05/07/2026 at 8:17 AM, the Administrator revealed he submitted an email to the corporate office notifying them that the steam table was not functioning properly, as it was not maintaining sufficient temperatures to keep food hot. He stated the facility's plan of action was to boil water and pour it into the wells to help maintain food at the proper temperature. The Administrator further stated he requested approval from the corporate office to purchase a new steam table for the facility, and approval was pending.During an interview on 05/07/2026 at 1:20 PM, the DM revealed staff were boiling water on the stove and pouring it into the steam table wells to maintain food temperatures at or above the required level. The DM reported the Administrator made plans to purchase a new steam table. The DM stated it was her expectation that kitchen staff check food temperatures when food is initially placed on the serving line, again midway through meal service, and again when serving the final hall. She stated all temperatures should be documented. The DM further stated that she or the ADM would complete a second set of temperature checks following the Dietary Aide (DA) to verify temperatures being accurately documented. She added that if temperatures are found not to meet state regulatory requirements, meal service will be stopped, the food will be reheated, and additional boiling water will be added to the steam table.Interview on 05/07/2026 at 1:25 PM with the ADM and DM revealed, the ADM stated the steam table has not been holding the temperature on serving side of the steam table for well over a month. DM stated that she was not aware. During an interview on 05/07/2026 at 4:55 PM, the Director of Nursing (DON) revealed she was not aware the steam table was not functioning correctly, until the previous day. She stated she had not received any resident complaints regarding food being served cold. The DON further stated the Administrator had submitted a request to corporate for a new steam table and cart warmers.During an interview on 05/07/2026 at 6:20 PM, the Administrator stated that after the specifications were emailed to the corporate office, he received approval to purchase a new steam table. He stated his expectation was for dietary staff to continue boiling water to help maintain food temperatures and to monitor temperatures at the beginning of service, mid-service, and at the end of service to ensure food is served at state-regulated levels until the new steam table arrived.

Based on observations, staff interviews, record review, and review of the facility policy titled Date Marking for Food Safety, the facility failed to store and prepare food under sanitary conditions. Specifically, food items located in the dry storage were expired and kitchen equipment was not clean. This deficient practice increased the risk of foodborne illness for the 85 residents receiving an oral diet from the kitchen. Findings include:Review of the facility's policy titled Date Marking for Food Safety, last revised 06/01/2024, documented under Policy Explanation and Compliance Guidelines for Staffing, The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.)Observation with concurrent interview tour of the kitchen on 05/05/2026, beginning at 9:02 AM with the Certified Dietary Manager (CDM) revealed the following concerns: -Trash can lid next to the handwashing sink observed to have a black substance present.-Paper towel dispenser next to the handwashing sink was observed to have a slick substance present.-Handwashing sink observed to contain a gray scum-like substance present in the bowl.-Dry pantry shelf observed to have a clear plastic container of individual packages of thousand island salad dressing with an expired date of 12/26/2025.-Dry pantry shelf observed to have a clear plastic container of individual packages of golden Italian dressing with and expired date of 07/15/2025.-Dry pantry shelf observed to have a clear plastic container of individual packages of tartar sauce with an expired date of 10/17/2025.-Dry pantry shelf observed to have a container of rubbed sage with an expired date of 03/13/2026.-Dry pantry shelf observed to have a container of rubbed sage with an expired date of 04/03/2026.-Dry pantry shelf observed to have a container of ginger with an expired date of 03/20/2026.-Dry pantry shelf observed to have a container of Italian seasoning with an expired date of 03/19/2026.-Dry pantry shelf observed to have a container of ground mustard with an expired date of 04/03/2026.-Dry pantry shelf observed to have a container of crushed red pepper with an expired date 03/27/2026.-Dry pantry shelf observed to have a container of ground thyme with an expired date 01/13/2026.-Dry pantry shelf observed to have a container of chopped chives with an expired date of 04/03/2026.-Dry pantry shelf observed to have a container of freeze-dried chives with an expired date 03/06/2026.-Dry pantry shelf observed to have a container of whole tarragon leaves with an expired date of 04/03/2026.-Dry pantry shelf observed to have a container of ground nutmeg with an expired date 03/06/2026.-Can opener observed with a black substance.-Ice cream freezer observed to have an open bag of potato logs opened and unlabeled.-One trash can near the fryer observed uncovered.The Certified Dietary Manager (CDM) and Assistant Dietary Manager (ADM) both confirmed the unclean observations and expired items. The CDM stated she would re-educate staff on proper storage, labeling, disposal of expired food items and cleanliness of areas identified in the observation. During an interview on 05/06/2026 at 12:48 PM, the Registered Dietary Manager (RDM) was informed of the out-of-date food items identified during the initial tour conducted the previous day. The RDM revealed she was notified of the observations by the CDM. She stated it is her expectation that all staff be re-educated on proper storage, labeling, disposal of expired food items, and overall cleanliness in the kitchen to ensure compliance with state regulatory requirements.During an interview on 05/07/2026 at 6:10 PM, the CDM revealed she placed orders for food supplies, including seasonings, based on the menu. She reported that when seasoning deliveries are received, she rotates the older seasonings to the front. She further stated that the Dietary Aides (DA) failed to check the seasonings. The CDM stated she does not maintain a log to track seasoning expiration dates; however, she stated that moving forward she will ensure staff monitor seasonings on a weekly basis.

Based on observations, interviews, review of facility policy, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%). There were 2 errors made in 27 opportunities, resulting in a medication error rate of 7.40%. These errors affected 1 (Resident #79) out of 4 residents observed during medication pass. Findings included: A review of the facility's policy titled, Medication Administration, with an implementation date of 1/1/2023, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy further indicated the nurse should Review the MAR [Medication Administration Record] to identify medication to be administered and Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. The policy also indicated, Do not crush medications with do not crush instructions. A review of the Admission Record for Resident #79 revealed the facility admitted Resident #79 with diagnoses that included constipation and hypokalemia (low potassium level). A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #79 was unable to complete the Brief Interview for Mental Status (BIMS). The Staff Assessment for Mental Status revealed the resident had short-term and long-term memory impairment with severely impaired cognitive skills for daily decision making. Active diagnoses included hypokalemia and constipation. A review of Resident #79's comprehensive care plans revealed a care plan, revised on 11/18/2022, that indicated the resident was at risk for alteration in elimination of bowel/bladder r/t [related to] functional incontinence and constipation. This care plan directed staff to administer bowel medication as ordered. A review of Resident #79's Medication Review Report revealed an order, dated 9/13/2022, for docusate sodium capsule (a capsule used to soften stool) 50 milligrams (mg), one capsule twice a day for constipation. An observation was made on 4/26/2023 at 8:10 AM of Licensed Practical Nurse (LPN) #1 preparing morning medications for Resident #79. LPN #1 administered one 100 mg tablet of docusate sodium, instead of 50 mg as ordered by the physician. LPN #1 was also observed to crush, and then administer extended-release potassium chloride to Resident #79. On 4/26/2023 at 9:50 AM, LPN #1 was interviewed. LPN #1 reviewed the packages of medications given to Resident #79 and stated the bottle she used contained docusate sodium 100 mg. The nurse then reviewed Resident #79's docusate sodium order and confirmed the order was for 50 mg. LPN #1 also reviewed the information on the potassium chloride extended-release package, including information that indicated the medication should not be crushed. LPN #1 stated she crushed the medication because Resident #79 would not take the whole pills. The nurse confirmed she had not notified the physician the resident refused the whole pills and had not requested a different form of potassium. LPN #1 stated she considered both incidents as medication errors and would tell the Director of Nursing (DON) about the errors. An interview was held with the Director of Nursing (DON) on 4/27/2023 at 1:38 PM. The DON stated that when medications were given, the expectations included the nurse giving the right drug to the right resident in the right dose at the right time by the right route. The DON stated she expected the nurse to write a medication error report and notify the physician and Resident #79's family. The DON stated she expected the nurses to read the orders carefully and compare the order to the name and dosage of the medication in the medication cart. The DON stated LPN #1 should have double checked the docusate order. The DON stated she expected LPN #1 to inform her if the resident refused whole pills or to call the physician herself and have the form of potassium changed. The Assistant Administrator was interviewed on 4/27/2023 at 1:44 PM. He stated he expected nurses to check to make sure the medication was the right dosage, and the nurse was giving the medication to the right resident. The Assistant Administrator added if the nurse was sure the resident would not take the medication whole, the expectation would be to communicate with the DON and/or charge nurse to have the medication changed.

Based on observations, staff interviews, and facility policy review, the facility failed to follow transmission-based precautions related to wearing appropriate Personal Protective Equipment (PPE) for infection control measures for residents on isolation precaution in rooms 103, 105, 117) and failed to doff PPE when exiting a resident's room. The facility failed to remind residents to wear a mask when out of their rooms. In addition, the facility failed to ensure the indwelling catheter bag was not touching the floor for one of two sampled residents (R33). Findings include: 1. Observation on 05/24/21 at 9:02 AM, of the 100-hall during the initial tour of the facility revealed three resident rooms (Room103, 105, and117) had a clear plastic covering over the doors leading into the rooms. An isolation cart which had gloves and gowns sat outside and within proximity to the room doors. There was a sign posted by each of the rooms entrance indicating that the room had resident(s) on isolation precaution and advised staff to don full personal protective equipment (PPE-gloves, mask, gown and eye protection) before entering the room. Observation on 05/24/21 at 9:12 AM, revealed Licensed Practical Nurse (LPN)1 passed medication in rooms [ROOM NUMBERS]. LPN1 wore only a surgical mask going into the rooms. LPN1 failed to don gloves or wear a gown or an eye protection. Observation on 05/24/21 at 9:27 AM, revealed Certified Nurse Aide (CNA)5 donned appropriate PPE when she went into room [ROOM NUMBER], however, she exited the resident's room into the hallway while still wearing the full PPE. The CNA was redirected by an unidentified staff to take off her PPE. Observation on 5/24/21 at 10:15 AM, revealed CNA2 entered room [ROOM NUMBER] only wearing a surgical mask. CNA2 was in the room for approximately 25 minutes. CNA2 failed to wear the appropriate PPE recommended for use in the resident's room. Observation on 5/24/21 at 10:17 AM, revealed CNA4 exited room [ROOM NUMBER] and walked down the 100-hall towards the unit's double door while still wearing full PPE. During an interview on 5/24/21 at 9:36 AM, LPN1 stated the residents in those rooms (103, 105, 117) were on droplet and contact precautions and staff were to wear a mask, gloves, and gown when they provided care for the resident(s) in the room. LPN1 stated she thought she had donned PPE when she went to the rooms to provide care. She however acknowledged that she did not wear full PPE going into the rooms. During an interview on 5/27/21 at 8:54 AM, CNA4 said that she always struggled to remind herself of when to doff her PPE. She said she completely forgot to take off her gloves and gown when she exited the above isolated resident's room. Interview on 5/13/21 at 9:05 AM, the Infection Preventionist (IP) stated that if a newly admitted resident was vaccinated against COVID-19, or not, the resident was first admitted into an isolation room. She stated that the resident would have to be in the room by themselves, and staff would have to wear full PPE going into the Person Under Investigation (PUI) rooms, including a gown, gloves, and surgical mask. She verified that the identified residents' rooms were PUI rooms. She said staff are expected to put on PPE before they entered the rooms with PUI residents and take it off before they exited the room. The IP said that if staff came out of the room which had a PUI resident after they have been in contact with the resident or the resident's items, there was the potential for cross-contamination with whatever contaminant that was picked up in the course of being in the PUI resident's room. 2. Observation on 5/26/21 at 10:59 AM revealed resident R18 was observed on a stretcher with two ambulance attendants transporting her to [CONDITION(S)] treatment. R18 was not wearing a mask at the time of observation. Interview with LPN2 at that time confirmed the resident should have had a mask on before leaving her room. On 05/26/21 at 11:42 AM, the Medical Director was observed visiting residents. The Medical Director was observed to be wearing a surgical mask when he entered room [ROOM NUMBER]. room [ROOM NUMBER] was on quarantine status as the resident was newly admitted to the facility. The Medical Director was observed to enter and exit the room without donning and doffing proper personal protective equipment (PPE.). He did not perform hand hygiene with hand sanitizer after exiting the room. Interview with LPN2 on 05/26/21 at 11:44 AM revealed the Medical Director should have donned a gown and gloves prior to entering the room. Upon exiting the room, the Medical Director should have removed the PPE in the doorway and then completed hand hygiene with hand sanitizer. Interview with the Director of Nursing (DON) on 05/26/21 at 11:47 AM confirmed the Medical Director should have followed the facility's policy for full PPE in a quarantine room. During an interview with the Medical Director on 05/26/21 at 12:20 PM he agreed he should have donned a gown and gloves before entering the room. He stated he would try to do better in the future. On 05/26/21 at 1:15 PM, R180 was observed exiting the facility on a stretcher to return home after respite services in the facility. R180 was not wearing a mask, but the two ambulance attendants with her were wearing masks. Interview at that time of observation with LPN3 confirmed the resident should have a mask on as she was transported out of the facility. The facility did not have a policy for donning and doffing PPE. On 05/26/21 at 3:30 PM, the DON stated they had adopted the Centers for Disease Control and Prevention (CDC) as their policy for PPE. He provided the poster for proper PPE to be used with confirmed or suspected COVID-19 residents which documented that a N95 or higher or a surgical mask, shield or goggles, gloves, and a gown should be worn. 3. Review of the facility's policy titled, Catheter Care, Urinary, dated September 2014, stated, .Infection Control, be sure catheter tubing and drainage bag are kept off the floor. Review of an undated Face Sheet, for R33 located in the resident's electronic medical record (EMR), under the face sheet tab, revealed the resident was admitted to the facility on [DATE]. Review of the Diagnoses, for R33 located in the resident's EMR under the admissions tab, revealed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for R33 found under the MDS tab of the EMR with an assessment reference date (ARD) of 03/23/21, revealed a Brief Interview Mental Status (BIMS) of 9, which indicated moderately impaired cognition no behaviors, and an indwelling catheter. Review of the Physician Orders, for R33 dated 05/08/21, located under the orders tab in the resident's EMR included Foley Cath (catheter) 18 French with 10 cubic centimeter bulb. Observations in R33's room and the hallway between 05/24/21 and 05/27/21 included the following: Observation on 5/24/21 at 12:20 PM and 4:45 PM, revealed the outside of R#33's catheter bag was touching the floor. Observation on 5/26/21 at 10:40 AM and 3:52 PM, revealed R33 was sitting in his wheelchair in his room and the urinary collection bag was touching the floor. Observation on 5/27/21 at 8:50 AM, R33 was lying in bed and the urinary catheter collection bag was lying on the floor. Observation on 05/27/21 at 8:52 AM, with CNA1 revealed R33 was lying in bed with the urinary catheter bag lying on the floor. CNA1 stated that urinary catheter bags were not to touch the floor. Interview on 5/27/21 at 12:45 PM, LPN4 stated she observed R33's urinary collection bag lying on the floor, which was an infection control concern. Interview with the IP Nurse on 05/27/21 at 9:11 AM revealed that indwelling catheter bags were to be kept off the floor related to infection control issues.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) that was completed accurately for two of three residents (R61, R73) when their Medicare Part A stay was ending. The facility did not include information on how to appeal the decision made by the facility. Findings include: 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R61 was admitted on [DATE] to the facility. She received Part A Medicare services until 05/21/2021. Further review revealed she was issued a SNF ABN on 05/18/2021 and chose to remain in the facility. Review of the SNF ABD revealed it was lacking the information on how to appeal the decision made by the facility and did not fully explain the options available to a resident. The form only included two of the three available options to choose from. 2. Review of the Admission Record located in the Profile tab of the EMR revealed R73 was admitted on [DATE] for a Medicare Part A services. She elected to remain in the facility and was issued a SNF ABN on 03/22/21. Review of the SNF ABN revealed it was lacking the information on appealing the decision by the facility about ending the Part A services. An interview was conducted with the Business Office Manager (BOM) on 05/27/21 at 9:32 AM. The BOM stated she was responsible for completing the SNF ABN and agreed the form provided to residents did not include all the required information related to the appeal rights of residents. The policy for completion of beneficiary notices was requested on 05/26/21 at 3:30 PM from the DON. At the time of exit the facility had not provided a policy for review.

Based on observation, staff interviews, record review, and review of the facility's policy titled, Promoting/Maintaining Resident Dignity, the facility failed to promote care that maintains or enhances dignity and respect for one of two sampled residents (R31). Specifically, staff did not always have a cover over R31's indwelling urinary catheter collection bag, which was visible from the doorway to his room and when he was in his wheelchair. Findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 10/27/19, documented, It is the practice of this facility to care for a resident in a manner and in an environment that maintains or enhances resident quality of life.maintain resident privacy. Review of the undated Face Sheet, for R33 located in the resident's electronic medical record (EMR), under the face sheet tab, revealed the resident was admitted to the facility on [DATE]. Review of the Diagnoses, for R33 located in the resident's EMR under the admissions tab, revealed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for R33 found under the MDS tab of the EMR with an assessment reference date (ARD) of 03/23/21, revealed a Brief Interview Mental Status (BIMS) of 9, which indicated moderately impaired cognition, no behaviors, and an indwelling catheter. Review of Physician Orders, for R33 dated 05/08/21, located under the orders tab in the resident's EMR included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations in R33's room between 05/24/21 and 05/27/21 included the following: Observation on 5/24/21 at 8:50 AM, R33 was lying in bed and the urine in his urinary collection catheter bag was visible from the doorway and was not concealed in a bag. Observation on 5/26/21 at 10:40 AM and 3:52 PM, R33 was sitting in his wheelchair in his room and the urinary collection bag was not concealed inside of another bag. Observation on 05/27/21 at 8:52 AM, with Certified Nurse Aide (CNA) 1 revealed R33 lying in bed. CNA1 confirmed that the urine in the urinary collection bag was visible from the doorway and there was no bag covering the catheter bag. CNA1 stated catheter bags were to be placed in a bag to prevent other people from observing urine in a resident's catheter bag. Interview on 05/27/21 at 12:45 PM, Licensed Practical Nurse (LPN) 4 stated there was no bag covering R33's urinary collection bag, which was a dignity concern. Interview on 05/27/21 at 9:00 AM the Director of Nurses (DON) stated urinary catheter bags were to be placed in another bag to maintain a resident's dignity.

Based on record review, staff interviews, and review of the facility policy titled, Certifying Accuracy of the Resident Assessment the facility coded the Minimum Data Set (MDS) a formal assessment used for reimbursement incorrectly for one of 19 residents (R18) related to a physician ordered weight loss program. Findings include: Review of facility policy titled, Certifying Accuracy of the Resident Assessment last revised 11/2019, revealed, .The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse. Review of the Admission Record for R18 in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. The Admission Record indicated she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-Day MDS with an Assessment Review Date (ARD) of 05/07/21, Significant Change MDS with an ARD of 03/22/21, and a 5-Day MDS with an ARD of 03/15/21 revealed she was coded in .Section K Swallowing/Nutritional Status. in the section for weight loss it indicated she was .on a physician-prescribed weight-loss regimen. Interview with the Medical Director/Attending Physician on 05/26/21 at 12:10 PM revealed he had not written an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the MDS Coordinator (MDSC) on 05/26/21 at 12:25 PM revealed she did not know how to code that the resident had an amputation, so she coded the resident as being on a weight loss regimen to offset the resident's low weight. She stated she would submit a correction to all three MDS assessments.

Based on record review, policy review and interviews the facility failed to provide residents and/or their representative a copy of the baseline care plan that included instructions needed to provide effective and person-centered care for two (2) residents (R#83 and R#241) out of a sample of 32 residents to safeguard against adverse events that may occur right after admission. The facility census was 85 residents. Findings include: During a record review for Resident #83 (R#83) revealed that there was not any evidence of any documentation was found in the medical record indicating that R#83 or her representative received a copy of a base line care plan to ensure knowledge and understanding of the care and treatment for [REDACTED]. During a record review for R#241 revealed that there was not any evidence of any documentation found in the medical record indicating that R#241 or his representative received a copy of a base line care plan to ensure knowledge and understanding of the care and treatment for [REDACTED]. During a review of the facility policy on 8/23/18, Care Planning - Interdisciplinary Team, page 3, number 3, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revision to the resident's plan care plan. The facility policy, Addendum to Care plan Policy: indicates the baseline care plan is to . promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. During an Interview with BB on 8/22/18 at 10:32 a.m. she stated that she does not have any documentation to prove that a copy of the Interim Care Plan was given to the resident and/or the family representative. She stated that she has never documented that this information was given to the resident or the responsible party. During an interview with R#241 on 8/22/18 at 11:30 a.m. he confirmed that staff failed to provide him with any type of written plan of care for his admission of 8/1/18.

Based on resident and staff interview and review of facility policy, the facility failed to provide proof that one resident, (R#15) received quarterly statements for her personal fund account that the facility manages. The census sample size was 32 residents. Findings include: Resident Interview on 8/20/18 at 1:30 p.m. with R#15 revealed that she did not receive a quarterly statement for her personal funds account. R#15 had a Brief Interview for Mental Status score of 15 on her Quarterly Minimum Data Sets dated 5/24/18. Interview on 8/21/18 at 11:57 a.m. with the Business Manager and the Administrator revealed that the facility process for personal fund accounts was that the Administrator hand delivers the quarterly statement to each resident. The facility process for personal funds of residents that were not cognitively intact revealed that those quarterly statements were mailed or handed to the responsible party. When asked if she had proof that the residents had received their statements or that statements were mailed, the Administrator said that she did not have proof that they had received their statement or that statements were mailed. Review of facility policy titled Quarterly Accounting of Resident Funds documented that the facility was to provide each resident, who had funds managed by the facility on his or her behalf, with a quarterly accounting of such funds.

Based on record review and interviews the facility failed to ensure their mechanism for documenting and communicating a resident's choice related to advance directives to staff responsible for the resident's care was consistent and accurate for four (4) residents (R), R#36, R#59, R#37 and R#4. The sample size was 32. The census was 85. Findings include: 1. A review of records reveal R#36 had a monthly physician's orders [REDACTED]. This monthly order form included an order for [REDACTED]. A review of records reveal R#36 had a Georgia Advance Directives for Health Care naming a health care agent and signed by the resident on [DATE]. A review of records reveal R#36 had a Consent to Withhold CPR form signed by the health care agent and dated [DATE]. A review of records reveal R#36 had a DNR/CPR Status Order Form instructing that in the event of cardiac and/or respiratory arrest, Do Not Resuscitate (DNR). The form was signed by the physician and dated [DATE]. A review of records reveal R#36 had a physician's orders [REDACTED]. The POLST form was signed by the physician and the health care agent on [DATE]. A review of a facility policy entitled: Advance Directives and dated (MONTH) 2013 reveals: 1. DNR orders must be signed by the resident's Attending Physician on the physician's orders [REDACTED]. A review of the electronic health record (EHR) does not reflect R#36's code status on the demographic page as found in other charts;; however, there is a Full Code order dated [DATE] in the EHR with a notation that it was signed by the physician on [DATE]. During an interview with the Social Services Director (SSD) conducted on [DATE] at 2:30 p.m.she revealed that when a resident has a significant change in condition she and the interdisciplinary team (IDT) reviews the resident's code status and advanced directive (if they have one). She stated that if a resident has an advanced directive that says if they are in a terminal condition/permanent vegetative state/permanent unconsciousness, then they wish to be a DNR, the IDT will contact the resident or responsible party and the physician to confirm a terminal diagnosis; then they will make changes in the chart accordingly. The SSD confirmed the facilty policy related to the necessity of having a signed physician's orders [REDACTED]. An interview was conducted on [DATE] at 3:34 PM with Licensed Practical Nurse (LPN) CC regarding how nurses know what a resident's code status. He confirmed that the monthly physician's orders [REDACTED]. LPN CC stated that if he found any discrepency in a resident's code status (e.g. listed as a Full Code in one location and a DNR in another location), he would search through the chart for the actual DNR order or Full Code order (a separate form in the Advanced Directive tab/section of the chart). He would then make corrections as necessary and notify the Director of Nursing (DON) and the physician. During an interveiw conducted with the DON on [DATE] at 3:45 p.m., he stated the staff (nurses) all check the Advanced Directive tab/section in the charts to determine code status on a resident; they do not rely on the information in the EHR system. He confirmed the discrepancy with R#36's chart with the physician's orders [REDACTED]. He states the facility never had a situation where a resident who had a DNR order was coded or a resident with a full code order was not provided cardiopulmonary resuscitation (CPR). He could not confirm which order (Physician's monthly order for Full Code status or the DNR/CPR status order form for DNR) was active. 2. Review of Physician order [REDACTED].#59 revealed an order for [REDACTED]. Interview on [DATE] at 1:19 p.m. with family member revealed that the resident was a DNR code status. Review of care plan dated as last reviewed and initiated on [DATE] revealed that the resident had an Advance Directive with a goal of honoring the resident's wishes be honored. Review of Advanced Directive checklist revealed that R#59 had executed an Advance Directive and would provide a copy to the facility signed and dated by family member on [DATE]. Review of DNR/CPR status order form revealed that it was signed by the physician and dated [DATE]. Form titled Consent to withhold CPR was signed by the family member and dated [DATE]. Review of Durable Power of Attorney named a family member as having the authority to make medical decisions for the resident and was signed by the resident on [DATE] and was signed by a second family member. Interview on [DATE] at 3:30 p.m. with Licensed Practical Nurse (LPN)/charge nurse DD revealed that to verify a resident's code status, she would check the hard copy medical record under advance directives and in the computer under Physician Orders. She confirmed that on R#59 the hard chart had a signed DNR order and an Advanced Directive check list but the Physician order [REDACTED]. Interview on [DATE] at 3:37 p.m. with RN, unit manager EE revealed that to verify a resident's code status, she would check the sticker on the hard copy chart for DNR, check the electronic Medication Administration Record [REDACTED]. She stated the handwritten Physician order [REDACTED]. The RN/unit manager stated the charge nurse typically updated the orders when a DNR order was received after the resident had been admitted . The RN, unit manager EE confirmed that there was a discrepancy for R#59. Interview on [DATE] at 3:45 p.m. with the DON revealed that his expectation was that staff members involved in a code were to check the chart prior to starting cardiopulmonary resuscitation (CPR) for a signed order. His expectation was for the charge nurse to update the order in the computer. He stated that there had not been a resident to be resuscitated that was a DNR or a resident that was a Full Code to not be coded. 3. Review on [DATE] at 12:46 p. m. of Resident # 4's medical record revealed the following advanced directive discrepancies: Resuscitation Order on the physical chart had No CPR will be initiated signed by R#4 on [DATE] and by the physician on [DATE]. Header of all pages of the electronic-chart had Full code. Open Ended Order Sets, dated [DATE] had Do Not Resuscitate (DNR). Advanced Directive dated [DATE] had Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize. Review of Face sheet revealed R#4 admitted to facility on [DATE] with Full Code status. Review of physician order [REDACTED]. [DATE] to [DATE] [DATE] to [DATE] [DATE] to [DATE] [DATE] to [DATE] [DATE] to [DATE] Review of Social Service Director (SSD) BB, and previous SSD LL, progress notes revealed the code status by choice and documented as follows: Note dated [DATE] by BB-Full code by choice. Note dated [DATE] by BB--Full code by choice. Note dated [DATE] by BB--Full code by choice. Note dated [DATE] by LL--DNR by choice Note dated [DATE] by LL--DNR by choice. Note dated [DATE] by LL--DNR by choice. Note dated [DATE] by LL--DNR by choice. Interview on [DATE] at 3:18 p.m. with bath certified nursing assistant (CNA) FF revealed if she found a resident unresponsive, or if a resident stopped breathing while in her care, she would get the call light and call the nurse for help, shake resident and call residents name, rub their chest and try to stimulate them. Interview on [DATE] at 3:25 p. m. with CNA II revealed she would get the nurse, when asked how she would know the residents code status, she stated that is why she would get the nurse because it is in the physical chart at the nurses desk. Interview on [DATE] at 3:32 p. m. with CNA JJ revealed she would call for help and start cardiopulmonary resuscitation (CPR.) She also revealed she had only worked at the facility five days, was training and did not know for sure where to check for code status or what the policy was. Interview on [DATE] at 3:37 p. m. with LPN KK revealed what she would do if a resident stopped breathing, she would call for help, look in the physical chart before initiating anything, then start CPR if resident is a Full code. Interview on [DATE] at 3:53 p. m. with RN/Unit Manager EE confirmed discrepancies in the code status between the physical chart and electronic medical record. The header of each page in the electronic record had Full code. Physician order [REDACTED]. 4. Review on [DATE] at 12:37 p. m. of Resident # 37's medical record revealed the following advanced directive discrepancies: Advanced Directive section of face sheet in the Matrixcare electronic record dated [DATE] had Full code. Open ended order set dated [DATE] had Do Not Resuscitate (DNR). Physician order [REDACTED]. Open ended order set dated [DATE] had DNR Sticker label on physical chart had Full code. Header in the electronic record revealed DNR. Face sheet header in the Matrixcare electronic record had Full code. Interview on [DATE] at 3:18 p.m. with bath certified nursing assistant (CNA) FF revealed what she would do if she found a resident unresponsive, or if a resident stopped breathing in her care. She would first get the call light and call the nurse for help, then she would call the resident's name and rub their chest, try and stimulate them, until help came. Further interview revealed she knew the code status could be found on the chart and in the computer. Interview on [DATE] at 3:44 p. m. with CNA GG revealed what she would do if she found a resident unresponsive, or if a resident stopped breathing in her care. She would call for the nurse, then check the Kiosk system (where the CNA did documentation) for code status and if the resident was not a Do-Not-Resuscitate (DNR) she would initiate cardiopulmonary resuscitation (CPR) Interview on [DATE] at 3:48 p. m. with CNA HH revealed if she found a resident unresponsive, or if a resident stopped breathing in her care, she would check them for breathing, a pulse, then call for the nurse. Further interview revealed residents who are DNR would have on a DNR bracelet and the information would also be on the Kiosk system on the computer where they did documentation. Interview [DATE] 03:55 p. m. with RN/Unit Manager EE confirmed discrepancies between the physical chart and electronic medical record of Resident # 37's code status. The header of each page, the face sheet and physician order [REDACTED]. The open ended orders dated [DATE] and [DATE] revealed DNR. --End--

Based on staff interview, review of the resident trust account bank statements, and the Long Term Care Facility Resident's Fund Bond, the facility failed to have a surety bond to cover the amount of funds in the resident trust account. There were 61 residents in the facilty with personal funds accounts. Findings include: The facility had a Long Term Care Facility Resident's Fund Bond in the amount of $25,347.02. However, a review of the bank statements for the resident trust account from February through July 2017 revealed that the balance in the resident trust account exceeded the amount of the surety bond on the following dates: February 2017: 2/3/17 through 2/17/17 (15 days) March 2017: 3/3/17 through 3/22/17 (20 days) April 2017: 4/3/17-4/7/17 and on 4/19/17 (six days) May 2017: 5/3/17 through 5/9/17, 5/10/17, and 5/16/17 through 5/22/17 (15 days) June 2017: 6/2/17 through 6/5/17 (four days) July 2017: 7/3/17 through 7/10/17 and on 7/20/17 (nine days) During an interview on 8/16/17 at 2:40 p.m., the Administrator stated that the surety bond is overseen by the corporate office and she would contact them.

Based on staff interview and record review, the facility to provide accurate information on the Notice of Medicare Non-Coverage (Form CMS- ) for five residents (#3, #5, #2, #108 and #94) and failed to provide the skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) for two residents (#108 and #94) being discharged from medicare part A services from a total sample of six residents. Findings include: During an interview on 8/17/17 at 9:40 a.m., the Minimum Data Set (MDS) coordinator stated that Resident (R) #3, R#5 and R#2 were receiving skilled services while on Medicare Part A. 1. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#3 on 5/11/17, for skilled services ending on 5/17/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. 2. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#5 on 5/6/17, for skilled services ending on 5/8/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. 3. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#2 on 4/3/17, for skilled services ending on 4/5/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. During an interview on 8/17/17 at 11 a.m., the Social Service Director stated that R#108 and R#94 received skilled services while under Medicare Part A services. 4. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#108 on 7/24/17, for skilled services ending on 7/26/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. In addition, the facility issued Form CMS-R-131, instead of the required skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ). 5. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#94 on 8/4/17 for skilled services ending on 8/11/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. In addition, the facility issued Form CMS-R-131, instead of the required skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ).

Based on interviews and record reviews, the facility failed to include a key member of the interdisciplinary team during the care plan meetings for three of three residents reviewed out of a sample size of 23 residents. R# 31, 82 and 88 had numerous care plan meetings with documented signatures of the different disciplines in attendance. A certified nursing assistant (CNA) was not in attendance at any of the 13 meetings reviewed. Findings include: During an interview on 8/16/17 at 9:45 a.m, the RN/MDS Coordinator, BB was asked about the assessment and care planning process. While she responded that she talks with the staff including the CNAs when she is conducting a resident assessment to assist in gathering information she specifically said the CNAs do not attend the care plan meetings. When asked who attends the meeting and how they document the attendance she said the Social Services Director, the Dietary Services Director, the two Unit Manager RNs, herself and the resident and/or family member if they choose to come to the meeting. She stated they all sign a form that is kept in the chart, the Interdisciplinary Care Plan Team Sign In Sheet. Review of the Interdisciplinary Care Plan Team Sign In Sheet(s) for R#31 includes care plan meetings held on 6/21/16, 8/18/16, 11/28/16, 2/9/17 and 3/29/17 with the signatures of staff disiplines of Nursing (RN), Social Services, Activities, and Dietary in attendance at each of the five meetings. A rehab team member attended two of the meetings. The resident was in attendance at one of the meetings and a family member attended four of the five meetings. There are no signatures from a CNA for any of the dates. There is no evidence of a CNA who had responsiblity for the resident attending the care planning meetings. Review of the Interdisciplinary Care Plan Team Sign Sheet for R#82 includes care plan meetings held on 11/6/16, 2/6/17 and 5/10/17 with the signatures of staff disciplines of Nursing (RN), Social Services, Activities and Dietary in attendance at each of the three meetings. A phone conference is noted with a family member at each of the three meetings, also. There are no signatures from a CNA for any of the dates. There is no evidence of a CNA who had responsibility for the resident attending any of the care plan meetings. Review of the Interdisciplinary Care Plan Team Sign In Sheet(s) for R#88 includes care plan meetings held on 7/11/16, 9/12/16, 10/30/16, 1/30/17 and 4/30/17 with the signatures of staff disciplines of Nursing (RN), Social Services, Activities, and Dietary in attendance at each of the five meetings. A rehab team member attended one of the meetings. The resident was in attendance at one of the meetings and a family member attended three of the meetings and the remaining two by phone conference. There are no signatures from a CNA for any of the dates. There is no evidence of a CNA who had responsibility for the resident attending any of the care plan meetings. During an interview conducted on 08/17/2017 at 11:15 a.m. with CNA AA, a CNA she was asked how she knew what care each resident required; she responded that she asked the nurses and therapists for information about the residents care needs. She did not mention anything about the care plan. When asked if she knew anything about resident care plans, she indicated she did not. When asked if the CNAs attended the care plan meetings she responded no. Review of 13 pages of documents provided to the survey team leader via email after the surveyors exited the facility includes Harborview Health System Care Plan Minutes for five residents for the dates of 8/1/17, 8/10/17, 8/11/17 (two) and 8/14/17. These documents contain staff signatures including the disciplines of Activities, Social, Nursing, Therapy, Dietary and CNA. There are also spaces for signatures of resident and representative. Five of the five documents include a CNA signature; however, all five appear to be initial meetings with a resident or family member as they include a statement about welcoming the resident and that the resident or family are satisfied with the facility. The documents do not specify if these are new admission/comprehensive, annual/comprehensive or quarterly care plan meetings. These documents provided do not include anything prior to 8/1/17. · ·

Based on observation and staff interview, the facility failed to maintain an orderly and comfortable interior for nine (9) of forty-two (42) resident rooms and five (5) resident bathroom. Findings Include: During a tour conducted by the Team on 11/30/15 at 11:00 a.m. though 11:30 a.m. revealed the following rooms need repair: Room 106 - hole at bottom of closet door. Room 111- bathroom mirror discolored. Room 116 - closet door has busted across the bottom panel. Room 201 - tile middle of floor chipped and base board next to sink missing sheetrock. Room 203 - missing paint in the bathroom Room 308 - door handle bent. Room 315 - entrance door sticks to floor. Room 318 - hole at bottom of closet door During an observation with the maintenance director on 12/3/15 at 9:20 a.m. till 10:00 a.m. revealed on 100 Hall, 200 Hall and 300 Hall the following: 100 Hall Room 116 - 2nd closet door is busted across the bottom panel. Room 111 - a shared bathroom mirror discolored, and inner bathroom door panel chipped. Room 108 - shared bathroom sink basin has a hole around water pipe in the wall, and the wall panel above the sink and under the sink is chipped. The inner bathroom door (106) bottom has chipped panel Room 107 - shared bathroom wall facing sink wall panel is damage and peeling away from wall near base board. Room 104 - the first top drawer has a broken handle. 200 Hall Room 201- tile is buckle upward near the first bed in the common walkway and missing a pieces of the tile leaving a hole. Room 201- shared bathroom missing paint. However maintenance assistant was painting this bathroom during this observation. 300 Hall Room 315- the entry door is sticking to the floor when opened or closed, the shared bathroom door (315 room side) has a cracked near the door knob. Room 318 - the 1st closet door has a hole at the bottom of the panel. Room 313 - loose base board panel near the bathroom door Room 314 - a hole in the closet door Room 312 - the entry door panel is peeling away from the frame. Room 311 - the top drawer handle is broken. Room 308 - the entry/exit door (inside the room) knob is bent. Room 306 - the entry door is missing piece of panel During an interview on 12/2/15 at 10:00 a.m. with the Maintenance Director stated that he had been off for several days and the holiday and had not time to make the repairs. And that repairs were needed. And stated that the facility have a three system in place for repairs. That work orders are generated by the Corporate, Staff can initiate in the kiosk and making daily rounds. And that he was hired less than six months ago. During an interview on 12/3/15 at 7:30 a.m. with the Administrator stated resident in wheelchair continuously place holes in the doors with their wheel chairs. And after the holiday noticed multiple doors with holes. The maintenance director was giving time off last week for the holiday. The previous maintenance director is on contract and is currently helping repair these areas identified. An observation with the Maintenance Director on 12/3/15 10:55 a.m. revealed all the repairs listed above were completed prior to Surveyors exiting facility.

Based on observation, staff interviews, and record reviews, it was determined that the facility failed to consistently monitor one resident's (#10) [MEDICAL TREATMENT] access port from a total sample of 30 residents. Findings include: The facility's "Education Regarding Direct Care Giving for the Resident in [MEDICAL TREATMENT]" documented in the "Licensed Nurse Education" section that daily checks of vascular access was to be done. Documentation on treatment sheets was to include the checks for signs and symptoms of infection daily. Resident #10 had a [DIAGNOSES REDACTED]. However, there was no evidence that licensed nursing staff routinely and consistently checked the [MEDICAL TREATMENT] for resident #10. Nursing staff had documented on the 2/13/13 admission clinical health form that the resident had a left upper extremity fistula removed on 1/25/13 and a new access port implanted on his/her right upper chest wall. It was observed on 5/01/13 at 8:10 a.m. that the resident had a white dressing on his/her right upper chest wall. During an interview on 5/01/13 at 9:45 a.m., the unit charge nurse said that the nursing staff did not document routinely about the access port site, except prior to the resident going to [MEDICAL TREATMENT]. She stated that the nursing staff was supposed to complete the "[MEDICAL TREATMENT]/nursing facility communication form" prior to the resident leaving for [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. The form included two sections with the top section to be completed by the nursing home staff prior to the resident leaving for [MEDICAL TREATMENT] and the bottom section to be completed by the [MEDICAL TREATMENT] staff before leaving the [MEDICAL TREATMENT] center. However, a review of 19 "[MEDICAL TREATMENT]/nursing facility communication forms" revealed that only seven (7) included documentation by the nursing staff that the resident had an access port site. Only two (2) of those seven (7) forms (2/14/13 and 3/02/13) had any nursing home staff documentation about the condition of the access site. The 3/29/13 communication form had documentation completed by the [MEDICAL TREATMENT] staff and included instructions for the nursing home staff to keep the resident's [MEDICAL TREATMENT] access catheter area clean and dry. However, there was no evidence to indicate that the nursing staff were routinely and consistently monitoring the resident's chest wall access port. In an interview on 5/01/13 at 12:05 p.m., the Director of Nurses (DON) stated that nursing staff was supposed to inspect the resident's port site daily and document it on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Those guidelines included that the care provided by the licensed nurse for a resident receiving [MEDICAL TREATMENT] would be to check the vascular assess site daily. The types of vascular accesses included an external catheter. However, a review of the resident's medical record, including the MAR, failed to provide any evidence that the licensed nursing staff were consistently monitoring the resident's [MEDICAL TREATMENT] access port on his/her right upper chest wall.

Based on record review and staff interview, it was determined that the facility failed to revise the care plan for one resident (#10) to include care for a [MEDICAL TREATMENT] port from a total sample of 30 residents. Findings include: Resident #10 had a [DIAGNOSES REDACTED]. Nursing staff documented on the 2/13/13 admission clinical health status form that the resident received [MEDICAL TREATMENT] three times a week (Monday, Wednesday and Friday). Nursing staff documented that the resident had a fistula on his/her left upper extremity removed on 1/25/13 and a new port located on his/her right upper chest wall. The 2/14/13 nursing note documented that the resident had a right upper chest port inserted without complication and would receive [MEDICAL TREATMENT]. Although the resident's 2/13/13 care plan included that the resident received [MEDICAL TREATMENT] and was at risk for infection related to a fistula, it had not been revised to include the care and services to be provided for his/her right upper chest wall [MEDICAL TREATMENT] access port. See F309 for additional information regarding resident #10.

Based on observation, record review and staff interview, it was determined that the facility failed to ensure that the respiratory care equipment was clean for three (3) of 11 residents who received respiratory care. Findings include: Review of the facility's procedures for "Oxygen Administration" revealed that staff was supposed to check and clean oxygen equipment "at regular intervals." However, staff failed to maintain clean oxygen equipment for residents #1, #57, and a resident in room [ROOM NUMBER]A. 1. Resident #57 received [MEDICATION NAME] nebulizer treatments. It was observed on 1/30/12 at 3:38 p.m., 1/31/12 at 5:00 p.m., 2/1/12 at 2:30 p.m., and 2/2/12 at 8:10 a.m. that there were dried liquid spills on the top and inside compartment of his/her nebulizer machine. A review of the resident's clinical record revealed that there was no indication that the nebulizer was cleaned on a regular basis. 2. On 1/30/12 at 12 noon, 1/31/12 at 10:45 a.m., 2/1/12 at 7 a.m. and 2/2/12 at 9 a.m., it was observed that the filter on the oxygen concentrator being used in room [ROOM NUMBER]A was covered with lint. During an interview on 2/2/12 at 7:00 a.m., licensed charge nurse "BB" stated that oxygen filters were cleaned weekly by the night shift and recorded on the residents' Medication Administration Records (MARs). However, a review of the February MAR for the resident in room [ROOM NUMBER]A revealed that there was not any information or a schedule related to the staff cleaning his/her oxygen concentrator's filter. On 2/2/12 at 8:30 a.m., the unit manager, licensed nurse "CC" stated that the night shift nurse was supposed to check to ensure that the oxygen filters were clean. She said that if oxygen was only used on "as needed" (prn) basis, then it was not recorded on the MAR. She said that the coating on the resident's concentrator filter was due to the use of a lot of powder on the resident by his/her family and sitter and a lot of traffic in that room. 3. Resident #1 had a current physician's orders [REDACTED]. It was observed that there was a thick coating of dust on the resident's oxygen concentrator on 1/30/12 at 2:30 p.m. and 5:00 p.m., 1/31/12 at 8:30 a.m. and 11:00 a.m., and on 21/12/ at 4:00 p.m. During an interview on 2/2/12 at 8:45 a.m., Director of Nursing stated that the equipment should be cleaned at least every week.

Based on record review and staff interview, it was determined that the facility failed to complete and transmit seven residents' discharge assessments and seven residents' death assessments in a timely manner from a sample of 14 late or missing assessments. Findings include: A list of 15 residents with missing MDS 3.0 federal OBRA assessments was obtained by the State Survey Agency prior to the survey. The list of residents was reviewed with the Minimum Data Set (MDS) Coordinator, registered nurse "AA", on [DATE] at 12:40 p.m. It revealed that the facility had not completed and transmitted 14 of the 15 assessments until [DATE], after surveyor inquiry. The seven (7) of the 14 residents, who had been discharged from the facility, did not have a required federal OBRA assessment completed and transmitted by the facility until [DATE]. The seven (7) of the 14 residents, who had died , did not have the required federal OBRA assessment completed and transmitted by the facility until [DATE]. 1. One resident's discharge assessment was due to have been completed by [DATE]. 2. One resident's discharge assessment was due [DATE]. 3. One resident's discharge assessment was due [DATE]. 4. One resident's discharge assessment was due [DATE]. 5. One resident's discharge assessment was due [DATE]. 6. One resident's discharge assessment was due [DATE]. 7. One resident's discharge assessment was due [DATE]. However, those discharge assessments were not completed by the facility and transmitted to the State Survey Agency until [DATE], after surveyor inquiry. 1. One resident's death assessment was due to have been completed by [DATE]. 2. One resident's death assessment was due [DATE]. 3. One resident's death assessment was due [DATE]. 4. One resident's death assessment was due [DATE]. 5. One resident's death assessment was due [DATE]. 6. One resident's death assessment was due [DATE]. 7. One resident's death assessment was due [DATE]. However, those death assessments were not completed by the facility and transmitted to the State Survey Agency until [DATE], after surveyor inquiry.

Based on observation, staff interview and record review, it was determined that the facility failed to provide weekly treatments for a skin tear as ordered by the physician for one resident (#6), from a total sample of 18 residents. Findings include: A 4/19/10 fax notification to the physician form revealed that resident #6 sustained a skin tear on his/her right forearm on 4/15/10. There was a 4/15/10 physician's orders [REDACTED]. However, during observations on 5/4/10 at 1:30 p.m., on 5/5/10 at 9:30 a.m. and on 5/6/10 at 10:00 a.m., there was a transparent dressing dated 4/22/10 on the resident's right forearm. A review of the treatment record with the treatment nurse on 5/6/10 at 10:00 a.m. revealed that the nursing staff had failed to provide the treatment as ordered on [DATE].

Based on observations, record review and staff interviews, it was determined that the facility failed to implement interventions to promote safety and prevent falls for one resident (#7) of seven residents who had experienced falls from a total sample of 18 residents. Findings include: During the initial tour of the facility on 5/4/10 at 11:15 a.m., licensed nurse "BB" stated that resident #7 had a history of [REDACTED]. On 6/12/09, the attending physician documented that the resident had experienced several falls out of the bed after failing to notify staff of his/her need for assistance. According to documentation on a 3/6/10 "Change in Condition Report," the resident fell at 10:40 p.m. after slipping on the mat beside his/her bed when attempting to transfer his/herself to the bedside commode. Interventions after that fall included the use of a bed alarm while the resident was in bed, placing the the bedside commode away from the resident's immediate bedside, and to remind the resident to call for assistance. Those three interventions were included on the residents's 3/9/10 care plan to reduce his/her risk of falling. According to the nurse's notes and a 4/16/10 "Change in Condition Report Post Fall/Trauma," the resident fell at 5:30 a.m. while trying to get out of bed to the commode unassisted. Although care plan interventions since 3/9/10 included nursing staff putting the bedside commode away from the resident's immediate reach, the 4/16/10 "Change in Condition Report" noted the bedside commode was within the resident's reach prior to the fall. Despite the care plan intervention for the use of a bed alarm, nursing staff did not check the "Bed/Chair Alarm" box to indicate that nursing staff had put a bed alarm in place or that it was functioning at the time of the 4/16/10 fall. Resident #7 was observed transferring him/herself from the bedside commode back to bed on 5/5/10 at 4:10 p.m.. CNA "FF", who was in the room at that time, said that he/she assisted the resident or at least stood by during those transfers. On 5/6/10 at 8:35 a.m., CNA "CC" said that the resident would attempt to transfer him/herself if staff was not right there with him/her. However, after assisting the resident to the bedside commode on 5/6/10 at 8:35 a.m., CNA "CC" left the room with the resident sitting on the bedside commode. The resident finished and transferred to his/her bed without assistance before the CNA returned. It was observed that nursing staff had not attached a bed alarm to the resident's bed. On 5/6/10 at 8:35 a.m., certified nursing assistant (CNA) "CC" stated that the resident had a bed alarm at one time but currently used only the siderails and a mat at the bedside. On 5/6/10 at 9:00 a.m., licensed nurse "DD" confirmed that the bed alarm was supposed to be used for the resident. Observation of the resident's bed at that time with licensed nurse "DD" revealed that nursing staff had not attached the bed alarm to the resident or to the resident's bed. However, "DD" found two alarms in the top drawer of the resident's bedside table. Licensed nurse "DD" stated that the resident would take off the alarm. However, although "DD" said that the resident removed the alarm, there was no evidence that facility staff had attempted to address that behavior to promote the resident's safety. On the 3/6/10 and 4/16/10 "Change in Condition Reports Post Falls/Trauma" forms licensed nursing staff documented that the resident was responding to bladder or bowel urgency prior to those falls. On the 3/7/10 annual and 11/26/09 quarterly Minimum Data Set (MDS) assessments, licensed nursing staff coded the resident as being on a toileting program. The 3/6/10 care plan described the resident's scheduled toileting program as being assisted to toilet between 12 a.m. and 2 a.m., about 6 a.m. and as needed. However, on 5/5/10 at 12:50 a.m., CNA "FERE" stated that the resident was provided assistance to toilet when he/she called for it but, he/she was not on a scheduled toileting program. CNA "CC" stated on 5/6/10 at 8:35 a.m. that the resident was not on a scheduled toileting program.