Every finding on record at Ignite Medical Resort Huntersville

Based on observations, record review, and staff, Nurse Practitioner, and Medical Director interviews, the facility staff failed to follow the manufacturer's instructions for cleaning and disinfecting of a shared glucometer between resident usage for 2 of 2 residents whose blood sugar levels were checked (Resident #58, Resident #1). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There were two residents with a bloodborne pathogen in the facility at the time of the investigation. Immediate Jeopardy began on 03/12/25 when Nurse Aide #1 was observed performing blood glucose checks on residents using a shared glucometer without disinfecting per manufacturer's instructions. Immediate jeopardy was removed on 03/14/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. Findings included: The undated glucometer manufacturer's instructions for cleaning and disinfecting indicated that the blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. Additional instructions were to use a purple top wipe or an orange top bleach wipe if the resident was on enteric precautions. Review of the facility policy Glucometer Disinfection revised in September 2021 read, in part, to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The procedure for disinfecting glucometers included: The manufacturer's guidelines are as follows: put on clean gloves, clean the glucometer as below with Germicidal Disposable Wipes ([purple top] for all non-contact enteric isolation) or Bleach Germicidal Wipes ([orange wipes] if resident on contact enteric isolation) - Place the meter on a level surface and ensure meter has been powered off - Obtain appropriate wipe and squeeze excess liquid from wipe - Wipe the meter to clean by gently wiping the outside of the meter and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning - Use a fresh wipe to disinfect by gently wiping the outside of the meter three times horizontally and three times vertically and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port. - Allow the surface of the meter to remain damp with the recommended contact time (two minutes for purple-top, 4 minutes for orange-top) - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning and disinfecting. - If further testing is not needed, return the meter to the base unit to charge the battery. The purple top wipes container which was located at the nurse's station read in part to disinfect nonfood contact surfaces to thoroughly wet surface, allow treated surface to remain wet for two minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for bloodborne pathogen use. A continuous observation of Nurse Aide (NA) #1 was conducted from 03/12/25 at 11:46 AM through 12:00 PM and revealed the following: On 03/12/25 at 11:46 AM Nurse Aide #1 was observed in Resident #58's room. She stated she needed to go to the medication cart and gather necessary supplies. When she returned to Resident #58's room she was observed with a glucometer in her hand, alcohol swabs, and a lancet (used to stick the resident's finger). While in the room a second glucometer was observed on Resident #58's bedside table, NA #1 stated the first glucometer on Resident #58's table would not scan his barcode (on the resident identification bracelet), so that was why she had to obtain the second glucometer from the medication cart. NA #1 obtained Resident #58's blood sugar with a reading of 135 at 11:48 AM. She then stacked the two identical glucometers on top of one another and threw away her trash, exiting the room with both glucometers in hand at 11:50 AM. Nurse Aide #1 went over to Resident #1 with both glucometers still in her hand and pushed the resident to her room. She told Resident #1 she was going to check her blood sugar and would be right back. Nurse Aide #1 then went to the medication cart and obtained alcohol swabs, a lancet, test strip and placed one of the glucometers onto the medication cart. NA #1 kept the other glucometer in her hand and scanned Resident #1's barcode. NA #1 was not observed disinfecting the glucometer and no disinfecting wipes were observed on the medication cart. At 11:54 AM Nurse Aide #1 entered Resident #1's room with one of the two glucometers that were in Resident #58's room. NA #1 began to obtain Resident #1's blood sugar, the surveyor stopped NA #1 and asked if the glucometer was the same glucometer used on Resident #58. NA #1 stated, No, I am using the glucometer that was laying on his table, not the glucometer I used to get his blood sugar. NA #1 obtained Resident #1's blood sugar which was 244 at 11:57 AM and exited the room at 11:58 AM. At 12:00 PM the surveyor asked to see the glucometer history for the machine used to obtain Resident #1's blood sugar. The glucometer history revealed on 03/12/25 at 11:48 AM a blood sugar reading of 135 was obtained and at 11:57 AM a blood sugar reading of 244 was obtained. NA #1 was observed taking the glucometer to the nurse's station and obtaining a purple top wipe. She wiped the glucometer front and back quickly and immediately placed it onto the docking station to charge. An interview occurred with Nurse Aide #1 on 03/12/25 at 12:00 PM. NA #1 stated she had taken one glucometer into Resident #58's room and sat it on his bedside table, however it would not scan so she had to go to the medication cart and obtain another glucometer. Once in Resident #58's room she had two glucometers and used one of them to obtain his blood sugar. She stated she placed both glucometers on top of one another and thought she had placed the one she used to obtain Resident #58's blood sugar on the medication cart however made a mistake and took it into Resident #1's room and also obtained Resident #1's blood sugar using the same machine without cleaning it in between residents. NA #1 stated she knew she was supposed to clean the glucometer in between residents and had been educated on it but just made a mistake. She also stated she knew there was a wet time for the cleaning of the glucometer and thought she had cleaned the glucometer for two minutes but did not time it. NA #1 stated she thought she could just let the glucometer air dry on the docking station. An interview on 03/12/25 at 12:53 PM with the Infection Preventionist (IP)/ Director of Nursing revealed each resident household had 2 glucometers to use because not all residents admitted into the facility had their own glucometer. She stated the facility was very strict on disinfecting glucometers in between use of each resident and had just provided education on glucometer cleaning and disinfecting in January 2025. The IP stated the nurses and nurse aides should be using the disinfectant wipes after each use of the glucometer with a wet contact time of 2 minutes using two wipes and wiping the entire surface of the glucometer. After that, the nurses and nurse aide were to lay the glucometer on a towel and let it dry for a duration of 2 minutes. She stated NA #1 should have known the policy on cleaning and disinfecting the glucometers and followed it. The IP stated the negative outcome that could have occurred from not disinfecting the glucometer between resident use included the spread of bloodborne pathogens. She stated there were two current residents in the facility with a bloodborne pathogen and they were located in the same neighborhood of Resident #58 and Resident #1. The IP stated the facility did not have dedicated glucometers for each individual resident because the staff had been provided with education and training on how to disinfect the glucometers per manufacturer's instructions. An interview conducted on 03/13/25 at 2:34 PM with the Nurse Practitioner (NP) revealed all nursing staff should be disinfecting the glucometers in between each resident and according to manufacturer's instructions. The NP stated there was a risk of spreading bloodborne pathogens by using the same glucometer on both residents without cleaning it per manufacturer instructions. She stated bloodborne pathogens could be spread by blood or bodily fluid if the nursing staff were not following standard precautions by cleaning the glucometer in between residents. She stated the risk of cross contamination could be high. An interview conducted on 03/13/25 at 3:03 PM with the Medical Director (MD) revealed he felt using the same glucometer on multiple residents was an issue Administration needed to look into, including why it happened and preventative measures. The MD stated the staff could not use the same test strip for the glucometer on more than one resident. The interview revealed he felt using a test strip on multiple residents was the only likely way a bloodborne pathogen could be spread. The MD stated the nursing staff should be disinfecting the glucometer as directed by the facility. An interview on 03/12/25 at 1:00 PM with the Administrator revealed that glucometers should be disinfected according to the manufacturer's instructions. The Administrator was notified of the immediate jeopardy on 03/12/25 at 3:30 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; During an observation on 3/12/25 at 11:46 AM, the Nursing Assistant failed to follow the manufacturer's guidelines for cleaning and disinfection of one blood glucose meter used for Resident #58 and Resident #1. Following the observation, this glucometer was cleaned and disinfected based on manufacturer's guidelines by the Director of Nursing. This failure provides the high likelihood for the spread of blood borne pathogens in the facility. On 3/12/25, the Nursing Assistant was reeducated by the facility's Nurse Educator on the manufacturer's guidelines for cleaning and disinfecting blood glucose meters to include competency validation. On 3/12/25, the Nursing Assistant was provided competency validation by the Nurse Educator. On 3/12/25, 100% of the blood glucose meters were cleaned and disinfected based on manufacturer's guidelines by the Director of Nursing. The manufacturer's guidelines are as follows: put on clean gloves, clean the glucometer as below with Germicidal Disposable Wipes ([purple top] for all non-contact enteric isolation) or Bleach Germicidal Wipes ([orange wipes] if resident on contact enteric isolation) - Place the meter on a level surface and ensure meter has been powered off - Obtain appropriate wipe and squeeze excess liquid from wipe - Wipe the meter to clean by gently wiping the outside of the meter and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning - Use a fresh wipe to disinfect by gently wiping the outside of the meter three times horizontally and three times vertically and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port. - Allow the surface of the meter to remain damp with the recommended contact time (two minutes for purple-top, 4 minutes for orange-top) - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning and disinfecting. - If further testing is not needed, return the meter to the base unit to charge the battery. On 3/13/25, Resident #58 and Resident #1 were evaluated by the Medical Director. On 3/13/25, the Resident #58 and Resident #1's responsible parties were notified of the infection control breach and provided information regarding the Medical Director's evaluation. On 3/13/25 the facility's Pharmacy Consultant conducted a 100% audit of all residents who require blood sugar checks and identified that thirty residents in the facility have the potential to be affected by the deficient practice. In addition, it was determined that two residents in the facility have a diagnosis of bloodborne pathogen. It was determined that both residents who have bloodborne pathogens do not have any blood sugar checks ordered and would not have any teammate use a blood glucose monitor to obtain any blood. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/12/25 facility took immediate action by having the Nurse Educator review the manufacture's guidelines and facility's cleaning grid for cleaning and disinfecting blood glucose meters to ensure that the guidelines were accurate and did not require changes. The Nurse Educator provided education to all current nursing staff (Nursing Assistants and Nurses) to follow the manufacturer's guidelines for cleaning and disinfection of blood glucose meters, for staff competency. Any current nursing staff who do not receive education by 3/13/25 (due to FMLA, leave, etc.) will be required to complete education prior to working a scheduled shift. All nursing staff hired after 3/13/25 will be required to complete this training and education upon hire. The education will be required annually. Beginning 3/12/25, the facility's Nursing Leadership team (Nurse Educator, Director of Nursing, Licensed Practical Nurse Unit Coordinators and Clinical Supervisors) will complete competency validation to monitor for compliance of all nurses and nurse aides following the manufacturer's guidelines for cleaning and disinfecting blood glucose meters. All currently employed nurses and nurse aides will have the competency validation completed by 03/13/25. Any employed nurses and nurse aides who have not received competency validation by 03/13/25 will receive competency validation by prior to their next working shift. All nursing staff hired after 03/13/25 will be required to complete the competency validation upon hire. On 3/13/25, the facility Administrator notified the local Health Department regarding the infection control breach. Alleged IJ Removal Date: 3/14/25 On 03/13/25, the credible allegation of immediate jeopardy removal was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on provided education to follow the manufacturer's guidelines for cleaning and disinfection of blood glucose meters. Nursing staff (Nurses and Nurse Aides) were asked by educators to provide demonstration of glucometer use and cleaning during the education. The facility's in-service log and training material was reviewed. Additional observations were conducted of nursing staff obtaining residents blood sugars and disinfecting the glucometer per manufactures instructions. The IJ removal date of 03/14/25 was validated.

Based on observations, record review, and resident and staff interviews, the facility failed to maintain a resident's dignity by continuously utilizing a video and audio monitoring device in his room for 1 of 3 sampled residents reviewed for dignity (Resident #49). Resident #49 stated the video and audio device in his room did not make him feel good at all and he had to watch what he said around it because it was always watching him. Findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, hypertension, and peripheral vascular disease. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively intact and needed substantial assistance with transfers and walking. Resident #49 was not coded for any falls. Resident #49's care plan revised 1/30/25, indicated a problem area for falls and an intervention was the use of a video and audio monitoring device. A physician's order for the video and audio and monitoring device was written on 1/30/25 due to Resident #49's confusion and multiple falls. An observation on 3/10/25 at 3:55 PM revealed Resident #49 did not have a roommate and a video and audio monitoring device was visualized on a metal stand in Resident #49's room facing the bed. An interview with Resident #49 on 3/11/25 at 8:45 AM revealed he was aware of the video and audio monitoring device in his room but did not give written consent for its use. An interview with Resident #49 on 3/13/25 at 12:37 PM revealed he had the video and audio monitoring device in his room to watch him, so he didn't stand up and fall in his room. He explained the device will come on and speak to him and remind him to sit down and call for help. Resident #49 stated the device did not make him feel good at all and he couldn't even stand up before it started making loud noises. He stated that the video and audio monitoring device bothered him when it was first used but noted he had gotten used to dropping his pants and picking his nose in front of it. Resident #49 said he had to watch what he said in front of the device because it was always watching him. A second observation and second interview with Resident #49 was conducted on 3/13/25 at 4:12 PM. The surveyor asked the video and audio monitoring device for privacy and the computer screen read Privacy Mode. The monitoring technician audibly explained through system speaker to wave at the device to turn off privacy mode. Resident #49 stated one day the staff rolled in the device and it had been in his room since. He did not know who the people were monitoring the device but explained he had talked to them before through the device. Resident #49 noted he was not aware he could ask for the system to be put in privacy mode and said only staff were able to ask for that. Resident #49 stated he felt he needed to watch what he said around the device because it had ears. A review of the video and audio monitoring device's instructions found attached to Resident #49's device was conducted. The device included a camera with pan, tilt, and zoom capabilities, a monitor that enabled two-way video, and a speaker that provided two-way audio between the resident's room and viewing station. An interview with Nurse Aide (NA) #2 on 3/14/25 at 9:36 AM revealed the video and audio monitoring devices had been used about two years at the facility. She explained staff could ask for privacy mode when providing care for residents who had the devices in their room. NA #2 stated she was unsure when staff asked for Privacy mode in front of the device, if the resident and staff were actually receiving privacy, as she was unsure of what was visible on the other end of the camera. She stated family members and residents with the video and audio monitoring devices wouldn't know if there is a way to mute the device, so they are being watched in the room. NA #2 revealed she knew the monitoring technician could hear what was going on in the resident's room. An interview with Nurse #1 on 3/14/25 at 10:03 AM revealed Resident #49 had the video and audio monitoring device because he needed staff assistance, and he would often forget to call for assistance. She stated all of Resident #49's personal care was given in the bathroom, out of sight of the device. An interview with Nurse #2 on 3/14/25 at 11:13 AM revealed she managed the video and audio monitoring device unit offsite for the company. She stated she was an employee of the larger company and did not work on site at the facility. Her staff was comprised of many video and audio monitoring technicians who also worked for the company and were not on site at the facility. Nurse # 2 stated each device used in the facility had a plan for the corresponding resident and each monitoring technician would watch 10-12 video and audio feeds simultaneously at an offsite location. She stated the facility staff could ask for privacy and the device would go into Privacy Mode that lasted for 10 minutes. The video screen is blurred to the attendant during that time and staff is asked to wave to the device and the attendant would visualize the hand motion. Nurse #2 explained that the audio never turns off, but the device does not record and multiple feeds are viewed at once, so it would be hard to focus on a conversation. She stated the device used artificial intelligence to learn the movements of the resident and the video and audio monitoring technician would get an alert on their screen if a resident moved in a problematic way. Nurse #2 stated the technician would talk through the camera to the resident and if the resident was not redirected from the behavior, an alarm would sound from the device to alert staff in the facility. An interview with the Director of Nursing (DON) and Administrator on 3/14/25 at 2:34 PM revealed the video and audio monitoring device in Resident #49's room was continuously on for fall prevention, but the device did not record the feed. The DON stated she was not aware who was monitoring the devices but knew they were employees of the larger company, and they had background checks completed for their employment. The Administrator stated she was unaware Resident #49 was uncomfortable with the device in his room.

Based on observations, record review, and resident and staff interviews, the facility failed to maintain privacy and obtain written consent for the use of a video and audio monitoring device in a resident's rooms for 1 of 3 sampled residents reviewed for privacy (Resident #49). A reasonable person would expect privacy in their living area and not be monitored continuously by a monitoring technician at an offsite location. Findings included: A review of the facility's policy entitled Assignment and Use of Virtual Patient Observation (VPO) Greater [NAME] Market dated 4/12/23 revealed the administrative supervisor or designee would bring the monitoring device to the unit as needed and would contact the VPO monitoring center to enroll the resident. The nurse and/or administrative supervisor would review the virtual sitter process with the resident, family, or caregiver present. Resident #49 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, hypertension, and peripheral vascular disease. The admission MDS dated [DATE] revealed Resident #49 was cognitively intact and needed substantial assistance with transfers and walking. Resident #49 was not coded for any falls. Resident #49's care plan revised 1/30/25, indicated a problem area for falls and an intervention was the use of a video and audio monitoring device. A physician's order for the video and audio and monitoring device was written on 1/30/25 due to Resident #49's confusion and multiple falls. A review of Resident #49's medical record revealed that no written consent for video or audio monitoring was obtained. An observation on 3/10/25 at 3:55 PM revealed Resident #49 did not have a roommate and a video and audio monitoring device was visualized on a metal stand in Resident #49's room facing the bed. An interview with Resident #49 on 3/11/25 at 8:45 AM revealed he was aware of the video and audio monitoring device in his room but did not give written consent for its use. He stated when he was admitted to the facility, his spouse signed all admissions paperwork and stated he was unsure if she gave written consent. Multiple attempts were made to contact Resident #49's spouse and were unsuccessful. A second interview with Resident #49 on 3/13/25 at 12:37 PM revealed he had the video and audio monitoring device in his room to watch him, so he didn't stand up and fall in his room. He explained the device will come on and speak to him and remind him to sit down and call for help. Resident #49 noted that the device also made a loud alarm noise to alert staff before he could stand up. A second observation and third interview with Resident #49 was conducted on 3/13/25 at 4:12 PM. The surveyor asked the video and audio monitoring device for privacy and the computer screen read Privacy Mode. The monitoring techncian audibly explained through system speaker to wave at the device to turn off privacy mode. Resident #49 stated one day the staff rolled in the device and it had been in his room since. He did not know who the people were monitoring the device but explained he had talked to them before through the device. Resident #49 stated he was not aware he could ask for the system to be put in privacy mode and said only staff were able to ask for that. Resident #49 stated he felt he needed to watch what he said around the device because it had ears. A review of the video and audio monitoring device's instructions found attached to Resident #49's device was conducted. The device included a camera with pan, tilt, and zoom capabilities, a monitor that enabled two-way video, and a speaker that provided two-way audio between the resident's room and viewing station. An interview with Nurse Aide (NA) #2 on 3/14/25 at 9:36 AM revealed the video and audio monitoring devices had been used about two years at the facility. She explained staff could ask for privacy mode when providing care for residents who had the devices in their room. She stated the device would have privacy mode on the screen when they used the word privacy and sometimes the monitoring attendant would speak over the device. She stated privacy mode usually lasted about 10 minutes and if care was completed before the end of 10 minutes, she would wave and speak to the device and privacy mode would be turned off. NA #2 noted the device would alarm loudly if a resident was not responding to the person monitoring the device. She explained she was unaware of who was monitoring the devices but knew it was not someone at the facility as staff was told the monitoring technicians were at an offsite location. An interview with Nurse #1 on 3/14/25 at 10:03 AM revealed Resident #49 had the video and audio monitoring device because he needed staff assistance, and he would often forget to call for assistance. Nurse #1 stated the device would alarm loudly if Resident #49 moved without calling for assistance. She explained the staff would often get a phone call from the monitoring service at the nurse's desk after each alarm incident. She stated she did not ask for Privacy mode when working with Resident #49 as it did not include any personal care. She stated all of Resident #49's personal care was given in the bathroom, out of sight of the device. Nurse #1 stated she did not recall receive any formal training on the device. An interview with Nurse #2 on 3/14/25 at 11:13 AM revealed she managed the video and audio monitoring device unit offsite for the company. She stated she was an employee of the larger company and did not work on site at the facility. Her staff was comprised of many video and audio monitoring technicians who also worked for the company and were not on site at the facility. Nurse # 2 stated each device used in the facility had a plan for the corresponding resident and each monitoring technician would watch 10-12 video and audio feeds simultaneously at an offsite location. She stated the facility staff could ask for privacy and the device would go into Privacy Mode that lasted for 10 minutes. The video screen is blurred to the attendant during that time and staff is asked to wave to the device and the attendant would visualize the hand motion. Nurse #2 explained that the audio never turns off, but the device does not record and multiple feeds are viewed at once, so it would be hard to focus on a conversation. She stated the device used artificial intelligence to learn the movements of the resident and the video and audio monitoring technician would get an alert on their screen if a resident moved in a problematic way. Nurse #2 stated the technician would talk through the camera to the resident and if the resident was not redirected from the behavior, an alarm would sound from the device to alert staff in the facility. An interview with the Director of Nursing (DON) and Administrator on 3/14/25 at 2:34 PM revealed the facility did not use written consents for the video and audio monitoring devices used in resident's rooms as the facility did not require consent. The DON explained the staff would ask for Privacy Mode when care was given near the device. She stated she was not aware who was monitoring the devices but knew they were employees of the larger company, and they had background checks completed for their employment. The Administrator explained each time one of the devices was used, an order was written and a plan for the device was put in place. She stated if any resident or responsible party refused the device, another plan would be put in place for the resident.

Based on record review, resident, and staff interview the facility failed to treat a resident in a dignified manner by not adequately preparing her for an outside medical appointment for 1 of 3 residents reviewed for dignity (Resident #18). This made Resident #18 feel forgotten and unimportant. The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses that included seizure, history of a cerebrovascular accident (stroke), and dysphagia as late effect of a stroke. A review of Resident #18's annual Minimum Data Set assessment dated [DATE] revealed her to be cognitively intact with no psychosis, behaviors, or rejection of care. Resident #18 had indicated is was very important to choose what clothes she wore daily. Resident #18 was also coded as requiring extensive assistance with dressing and bathing and required limited assistance with toilet use and personal hygiene. During an interview with Resident #18 on 11/13/23 at 12:18 PM, she reported she had been scheduled for a follow-up appointment on 11/09/23 but she had to cancel it because she was not dressed and adequately prepared to go out when transportation showed up to take her to the appointment. Resident #18 reported when transportation arrived to take her to the appointment she was still in her pajamas and had not yet had time to get herself put together. Resident #18 reported it was very important to her to be dressed and ready to go to her appointments outside of the facility and that the incident made her feel forgotten and unimportant. A review of Resident #18's electronic progress notes revealed a note dated 11/09/23 that read: Patient states she was upset about a mix-up today pertaining to the schedule and an appointment that she missed. Patient states she was scheduled to go out, but no one informed her .Patient states she likes to be aware of her schedule . An interview with the Social Worker on 11/16/23 at 11:33 AM revealed she was responsible for scheduling follow-up appointments and transportation. She reported she was aware of the incident where Resident #18 was not gotten up and dressed before her appointment and stated because the appointment was early in the morning, the Nurse Aide (NA) that was assigned to Resident #18 on 3rd shift the night before, should have gotten Resident #18 up and assisted her in getting dressed and ready for her appointment. She stated she did not know why the NA did not get Resident #18 up and dressed and indicated that she knew Resident #18 was upset about the situation. An interview by telephone was attempted on 11/16/23 at 1:02 PM with third shift NA #4 who was the NA assigned to Resident #18 the morning of her appointment and would have been responsible for ensuring Resident #18 was up, dressed, and prepared for her appointment by 8:00 AM. Unfortunately, that interview was unsuccessful. During an interview with the Director of Nursing (DON) on 11/16/23 at 2:49 PM, her reported he was aware of the incident regarding Resident #18 not being adequately prepared to go to her appointment. He also stated that he was aware that Resident #18 was very particular and that it took some time to get her up, dressed, and ready to go to outside appointments. He stated he did not know why she was not adequately prepared to go to her appointment and that she should have been given ample and sufficient time to get up, get dressed, and prepare herself to go to her appointment. An interview with the Administrator on 11/16/23 at 2:56 PM revealed she was aware of the incident regarding Resident #18 and she reported Resident #18 should have been gotten up and dressed before her appointments. She further stated she expected all residents to be sufficiently prepared for appointments.

Based on observations, record review, and staff interviews the facility neglected to feed a dependent resident (Resident #15) her lunch meal for 1 of 2 residents reviewed for neglect. The findings included: Resident #15 was admitted to the facility on [DATE] with diagnosis that included vascular dementia with severe anxiety. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #15 was severely cognitively impaired and required total assistance with eating. The MDS further revealed no behaviors or rejection of care and indicated that Resident #15 received Hospice services during the look back period. An observation of Resident #15 was made on 11/13/23 at 4:19 PM. Resident #15 was resting in bed with head of bed elevated and was resting on her left side. Resident #15's lunch tray sat on her sink counter. The silverware on the tray had not been unrolled or taken out of the sealed plastic bag, the lids of the drink and dessert had not been removed. Once the tray lid was lifted the three scoops of puree food were undisturbed. An interview was conducted with Nurse Aide (NA) #1 on 11/13/23 at 4:20 PM who confirmed that she was one of two NAs that were working on the unit where Resident #15 resided. She stated that she had fed Resident #15 her breakfast tray and she had eaten about 33% of the meal and drank most of her supplement but stated she had not fed Resident #15 her lunch tray. She also was not aware of who had fed Resident #15 her lunch tray. An interview was conducted with NA #2 on 11/13/23 at 4:22 PM who confirmed that she was the second NA that was working on the unit where Resident #15 resided. She stated that she had not fed Resident #15 her lunch and was not sure who had fed Resident #15. NA #2 stated that maybe someone from the office fed her. Nurse #1 was interviewed on 11/13/23 at 4:24 PM who confirmed that she was the nurse on the unit where Resident #15 resided. She was asked to observe Resident #15 in her room and also her lunch tray that remained untouched on her sink counter. Nurse #1 stated she had not fed Resident #15, and she was not sure who had but she would find out who had fed her. She indicated it would have either been NA #1 or NA #2 as they were the assigned NAs to that unit. Nurse #1 also stated that Unit Manager (UM) #1 may have fed Resident #15 her lunch tray. UM #1 was interviewed on 11/13/23 at 4:37 PM who stated that she had not fed Resident #15 her lunch tray but observed the lunch tray sitting untouched on her sink counter. She stated she would find out what happened. A follow up interview was conducted with UM #1 on 11/13/23 at 4:54 PM who stated that she had spoken to the two NAs on the unit where Resident #15 resided as well as the two NAs on the other unit and it was a breakdown in communication and it got missed and no one had fed Resident #15 her lunch tray. UM #1 stated that she ordered Resident #15 an early dinner tray and was going to feed her. An observation of Resident #15 was made on 11/13/23 at 5:12 PM. Resident #15 was in bed with her head of bed elevated. UM #1 was seated next to her bed and was feeding her dinner meal. Resident #15 appeared calm and did not appear to be grabbing at the food tray but was accepting of each bite of food offered to her. UM #1 was again interviewed on 11/16/23 at 11:06 AM. UM #1 stated that Patient Safety Attendant (PSA)#1 had taken the lunch tray into Resident #15's room on 11/13/23 but she was unable to assist residents with their meals. She explained that the meal tray should not have been delivered to Resident #15's room until the staff were ready to assist her with the meal. UM #1 stated she fed Resident #15 her early dinner tray on 11/13/23 and she had eaten 25% of the meal and drank 300 milliliters (ml) of fluid. PSA #1 was interviewed on 11/16/23 at 3:27 PM who confirmed that she worked on 11/13/23 on the other unit. She stated she did not recall if she delivered Resident #15's lunch tray to her or not. She explained that she generally only delivered the trays of independent residents and just could not recall if she had accidentally delivered Resident #15's tray or not. The Administrator and Director of Nursing (DON) were interviewed on 11/16/23 at 2:41 PM. The DON stated that the staff had told him that there was a miscommunication on who was going to feed Resident #15 on 11/13/23. He further explained that they immediately got Resident #15 a tray and fed her. The Administrator stated that the meal tray should not have been taken into Resident #15's room until someone was ready to assist her with the meal.

Based on observations, record review, and staff interviews the facility failed to remove expired medications from 1 of 2 medications carts reviewed (Pine Bluff medication cart). The findings included: An observation of the Pine Bluff Medication cart was conducted on 11/15/23 at 10:38 AM along with Nurse #2 revealed the following expired medications that were on the cart and available for use: -Open bottle of Multivitamin 220 tablets that expired on 06/22. -Open bottle of Vitamin B complex 60 tablets that expired September 2022 Nurse #2 was interviewed on 11/15/23 at 10:42 AM who stated that she was a resource nurse and floated to wherever she was needed. She stated she had not been to the facility in months and was not familiar with their procedures. Nurse #2 explained the Pine Bluff Medication cart was generally assigned to the supervisor and it would their responsibility to go through the cart and look for any expired medications, but she did not know how often they did that. Nurse #2 confirmed that she had not gone through the medication cart before her shift started to check for expired medications. The Pharmacist was interviewed on 11/16/23 at 1:50 PM who stated that she did monthly inspections of each medication room and each medication cart and removed any expired medications and to ensure proper storage of each medication. The Pharmacist explained when an expired medication was found it would be pulled off the medication cart and placed in a bin to return to the pharmacy. She stated if there was no bin in the facility the medication would remain on the cart but separate from the active medications until a bin was available for return to the pharmacy. She added that she had completed her monthly review of the Pine Bluff Medication cart on 11/02/23 and again on 11/13/23 and found no expired medications. The Pharmacist explained maybe the medications were placed on the medication cart while waiting on a bin from the pharmacy to return them or they were waiting to be returned to a family member, but she was not sure who or when the medications were placed on the medication cart. The Director of Nursing (DON) was interviewed on 11/16/23 at 2:45 PM who stated the expired medication should not have been on the medication cart. If they needed to be returned to the family or to the pharmacy, it should have been pulled off the medication cart and secured in the medication room.

Based on observations, record review, and staff and resident interviews, the facility failed to ensure routine dental care for 1 of 2 residents reviewed for dental services (Resident #52). The findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses that included history of hemorrhagic stroke with residual hemiplegia, A review of Resident #52's significant change Minimum Data Set assessment dated [DATE] revealed she was cognitively intact with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #52 was coded as needing limited assistance with personal hygiene and was independent with oral hygiene. Resident #52 was coded with no noted dental issues which included no obvious or likely cavities or broken natural teeth. A review of Resident #52's care plan revealed a care plan for [Resident #52] has her own teeth, requires supervision with oral care and hygiene. Interventions included [Resident #52] will comply with oral care and hygiene and there would be no avoidable complications through the review date. An observation which included an interview with Resident #52 on 11/14/23 at 2:42 PM revealed possible poor oral dentition with presence of plaque on her teeth. Resident #52 was able to eat, was not in pain, and had not lost any unintended weight. Resident #52 reported at that time she had not seen a dentist in a while and that she was aware that a dentist came into the facility and saw residents but reported she had not been seen. Resident #52 added she had seen the facility dentist before and did not know why she had not been seen for a while. Resident #52 also indicated she would like to be seen by the facility's dentist for routine cleanings. A review of Resident #52's electronic medical record revealed the last time resident was seen by a dentist was on 12/22/21 for tooth extractions. Additional review of Resident #52's medical record revealed a note dated 04/22/22 indicating Resident #52 was discharged per Social Worker #1. During an interview with the Administrator on 11/15/23 at 3:09 PM, she verified Resident #52 had not been seen by a dentist since 2021. She reported she was unsure why Resident #52 had not been seen by a dentist since then and reported she would see if there were any notes from the contracted dental company. An interview with Social Worker #1 on 11/16/23 at 11:17 AM revealed she was the social worker in the facility from October 2019 until October 2022. She verified while she was at the facility, she was responsible for scheduling dental appointments for residents. She also stated she did not remember requesting that Resident #52 be discharged from the dental practice and stated it must have been a misunderstanding. Social Worker #1 reported Resident #52 was in and out of the hospital around that time and she most likely called to let them know Resident #52 had been discharged to the hospital. She also reported she left the facility prior to when Resident #52 would have been scheduled to be seen again. During a follow-up interview with the Administrator on 11/16/23 at 2:56 PM, she reported the facility has a dental consult binder that was maintained by the Social Worker. She indicated if Resident #52 was discharged from the dental services provider she would not be in the binder. She also reported any residents who complain about dental issues or if nursing staff report possible dental concerns, the resident's name would be placed in the binder and, to her knowledge, Resident #52 had not voiced any complaints. The Administrator stated she was unsure how Resident #52 had been overlooked for so long and that every resident should be seen by the facility's dentist or dentist of the resident's choice at least annually.

Based on observation, staff interview, record review and review of: staff screening logs; the facility policy entitled, Screener Information during COVID-19; the facility document entitled, COVID-19 SNF (Skilled Nursing Facility) Updates; and CDC (Centers for Disease Control and Prevention) guidelines, the facility 1) failed to ensure transmission based precautions were used for two (2) of two (2) new admission residents with unknown COVID-19 status (Resident #1 and #2); 2) failed to ensure two (2) of four (4) staff members (Staff # 1 and #3) were screened according to facility policy and CDC guidance; 3) failed to ensure staff consistently provided answers to all the COVID-19 symptom screening questions prior to starting their shift on five (5) of ten (10) logs sheets reviewed; 4) failed to ensure clean linens were transported properly to prevent cross contamination for one (1) of one (1) random observations; 5) failed to ensure staff assigned to screen other staff members and visitors wore eye protection while taking oral temperatures according to facility policy for one (1) of one (1) random observations; and 6) failed to monitor or record daily temperatures consistently for two (2) of nine (9) sample residents (Resident #1 and #4). The findings included: 1) Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 3/13/20 indicated Resident #1 had not been tested for COVID-19 while in the hospital. Review of the Physician admission note dated 3/16/20 revealed no documentation indicating Resident #2 was placed on contact precautions (staff wear gown and gloves) and droplet precautions (staff wear mask and eye protection) for a 14 day post admission observation period. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 3/19/20 indicated Resident #1 had not been tested for COVID-19 while in the hospital. Review of the Physician admission note dated 3/20/20 revealed no documentation indicating Resident #1 was placed on contact precautions (staff wear gown and gloves) and droplet precautions (staff wear mask and eye protection) for a 14 day post admission observation period. Review of the COVID-19 positive Resident Line List revealed that Resident #1 tested positive for COVID-19 on 3/31/20, which was 12 days after her admission from hospital. Review of the COVID-19 positive Resident Line List revealed that Resident #2 tested negative for COVID-19 on 3/31/20. Review of the progress notes for Resident #2 revealed a note to the Provider dated 4/2/20. This note indicated Resident #2 reported a dry cough and tested positive for COVID-19 on 4/2/20. During an interview with the Director of Nursing (DON) on 5/11/20 at 3:10 p.m., she stated that Resident #1, Resident #2 and the other residents on the same unit were tested for COVID-19 because a staff member who worked on that unit (Staff #1) tested positive for COVID-19. The DON confirmed that Resident #1 tested positive on 3/31/20 and was transferred to a private room on another unit and was put on contact and droplet precautions at that time. She said that Resident #2 was asymptomatic at that time and tested negative but because she had been the roommate of Resident #1, she was also transferred to a private room on the COVID-19 positive unit and placed on contact and droplet precautions. The DON also said that after being transferred to the COVID-19 unit Resident #2 started running a fever of 100.1 and was tested again. Upon inquiry the DON said that Resident #2 tested positive for COVID-19 on 4/2/20. Review of the CDC document entitled, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes last updated 4/15/20 revealed: Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended PPE (Personal Protective Equiptment) should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. 2a) Review of facility document entitled, Teammate Line List revealed Staff #1 tested positive for COVID-19 on 3/31/20. Review of the time sheet (records the dates and times a staff member signs in and out of work) for Staff #1 revealed that in the 9 days prior to 3/31/20 Staff #1 worked on 3/26/20 and 3/27/20. Review of the Teammate Screening Log for 3/26/20 revealed that Staff #1 answered Yes to the following question Absence of: SOB (shortness of breath), new or change in cough, sore throat. Review of the Teammate Screening Log for 3/27/20 revealed that Staff #1 answered No to the following question Absence of: SOB (shortness of breath), new or change in cough, sore throat. 2b) Review of facility document entitled, Teammate Line List revealed Staff #3 tested positive for COVID-19 on 5/6/20. Review of the time sheet for Staff #3 revealed in the 9 days before testing positive Staff #3 worked on 4/30/20, 5/1/20, 5/4/20 and 5/5/20. Review of the Teammate Entrance Evaluation Log for the above dates worked by Staff #3 revealed the facility was able to provide a log for 5/1/20 that had evidence of Staff #3 being screened and afebrile. The facility was unable to provide logs with evidence of Staff #3 being screened on 4/30/20, 5/4/20 and 5/5/20. During an interview with the Administrator and Director of Nursing on 5/11/20 at 3:20 p.m., the Administrator stated that the facility did have logs for the days Staff #3 worked prior to testing positive for COVID-19 but a screening for Staff #3 was not included on those logs. He confirmed that Staff #3 should have had COVID-19 symptom screening prior to every shift worked but the facility did not have evidence that this had occurred. Review of the facility document entitled, Screener Information during COVID-19 dated 5/2/20 revealed, ALL teammates should be evaluated for symptoms before the start of their shift. Please ask the following questions and check the teammate's temperature If the teammate says YES to any of the above 1) the teammate CANNOT report to work 3) Review of two (2) log forms entitled, Teammate Screening Log dated 3/26/20 and 3/27/20 revealed the following fields were to be completed: Teammate Name; shift/position; absence of: SOB (shortness of breath), new or change in cough, sore throat; temperature; hand hygiene witnessed; screening positive Y/N (yes or no); and auditor initials. Further review revealed incomplete staff screening on one (1) of two (2) log sheets. On 3/27/20 a temperature and response to the symptoms screening question was missing for one (1) of 24 staff members. In addition, there was no response regarding hand hygiene, screening positive, or auditor initials for one (1) of 24 staff members. Review of eight (8) log forms entitled, Teammate Entrance Evaluation Log for Teammates Who CANNOT Work dated between 4/30/20 and 5/6/20 revealed the screening included the following fields: Teammate Name; Facility/Department scheduled to work during the current shift; temperature greater than 100 Fahrenheit (F); worsening cough; new/worsening shortness of breath; generally ill feeling (malaise); and recent loss of sense of smell or taste. Further review revealed incomplete screening on four (4) of the eight (8) log sheets reviewed. The missing information was as follows: Review of a Teammate Entrance Evaluation Log dated 5/1/20 revealed 25 staff names and temperatures recorded on the log but only 21 staff had documentation indicating they did not have the other four (4) symptoms on the log. A Teammate Entrance Evaluation Log dated 5/2/20 revealed 37 staff names recorded on the log but there were only 34 staff temperatures recorded, and only 27 staff had documentation indicating they did not have the other four (4)4 symptoms listed on the log. A Teammate Entrance Evaluation Log dated 5/2/20 and 5/3/20 revealed 25 staff names and temperatures recorded on the log but only 22 staff had documentation indicating they did not have the other four (4) symptoms listed on the log. A Teammate Entrance Evaluation Log dated 5/3/20 revealed 35 staff names and temperatures recorded on the log but only 32 staff had documentation indicating they did not have the other four (4) symptoms listed on the log. A Teammate Entrance Evaluation Log dated 5/4/20 revealed 25 staff names and temperatures recorded on the log but only 24 staff had documentation indicating they did not have the other four (4) symptoms listed on the log. During an interview with the Administrator and Director of Nursing (DON) on 5/11/20 at 3:20 p.m., the Administrator stated that all staff were expected to complete the COVID-19 screening prior to starting their shift. Review of the facility document entitled, Screener Information during COVID-19 dated 5/2/20 revealed, ALL teammates should be evaluated for symptoms before the start of their shift. Please ask the following questions and check the teammate's temperature If the teammate says YES to any of the above 1) the teammate CANNOT report to work 4) On 5/11/20 at 1:01 p.m., Housekeeper #1 was observed dragging a large bag of clothing items along the floor and into room [ROOM NUMBER]. The clothing was in a clear, plastic, unsecured linen bag. The bag was left on the floor inside the room, near the door. There was also a contact precautions sign on the door. During an interview with Housekeeper #1 on 5/11/20 at 1:15 p.m. she stated that Resident #3 had a lot of clothes that had been washed and the bag was so heavy she was unable to carry it down the hall. She said she had to drag it all the way down the hall to get it into the resident's room. During an interview with the Administrator and Director of Nursing on 5/11/20 at 3:20 p.m., the Administrator stated that the Housekeeper should have known to use a cart to transport the clean laundry but that another staff member who usually did the resident's laundry was out on leave. 5) On 5/11/20 at 12:30 p.m., the Federal Surveyor was screened for entry to the facility. Screener #1 prepared and provided an oral thermometer probe to the Federal surveyor while she held onto the electronic monitor. Screener #1 was within two (2) - three (3) feet of the Federal Surveyor while the Federal Surveyor's oral temperature was taken. Screener #1 was not wearing eye protection. During an interview with the Administrator on 5/11/20 at 12:40 p.m., he stated that the facility had decided to use oral thermometers because the other thermometers they had tried were not accurate. The Administrator confirmed that Screening Staff should be wearing eye protection when taking oral temperatures. He also acknowledged that Screener #1 had not been wearing eye protection when the Federal Surveyor's oral temperature was taken. He added that Screener #1 was the Receptionist and had been at the screening station to relieve the regular Screening Staff temporarily. Review of the facility document entitled, COVID-19 SNF Updates dated 5/6/20 revealed the following under the heading Eye protection for teammate (visitor screening as well): Screen to use face shield or goggles when screening within 6 feet of teammate. If screener is using reusable thermometer - the screener is most likely within 6 feet. 6) Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Vital Signs flow sheet for Resident #1 from 3/25/20 - 3/31/20 revealed the resident's temperature was not recorded on 3/27/20 and 3/28/20. Review of the COVID-19 positive Resident Line List revealed that Resident #1 tested positive for COVID-19 on 3/31/20. Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the vital signs flow sheet for Resident #4 from 4/22/20 - 4/30/20 revealed the resident's temperature was not recorded on 4/24/20 - 4/27/20 and 4/29/20. Review of the COVID-19 positive Resident Line List revealed that Resident #4 tested positive for COVID-19 on 4/29/20. During an interview with on 5/8/20 at 2:20 p.m., Nurse #1 said that the facility protocol for resident screening was to take their temperature every shift. Review of the CDC document entitled, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes last updated 4/19/20 revealed: Actively monitor all residents upon admission and at least daily for fever (Temperature greater than or equal to 100.0 degrees Fahrenheit) and symptoms consistent with COVID-19.

Based on observations, record review, resident and staff interviews the facility failed to honor a resident wish to be out of bed by 10:30 AM for 1 of 3 resident reviewed for choices (Resident #125). The Findings included: Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required extensive to total assistance with activities of daily living including transfers. An observation and interview were conducted with Resident #125 on 09/23/19 at 11:49 AM. There was a sign on the wall behind the bed that read, plan of care: Resident #125 wants to be up no later than 10:30 AM. Resident #125 stated that this morning it was after 11:00 AM when the staff got her out of bed. She stated that the staff were aware of her wish to be up by 10:30 AM but a lot of times that did not happen because they did not have enough staff to help. An observation and interview were conducted with Resident #125 on 09/24/19 at 11:00 AM. Resident #125 was sitting in a shower chair in her room and had just finished her shower. She stated that the staff just got her up about 10 minutes ago and gave her a shower. Nurse Aide (NA) #1 and Nurse #2 were observed to transfer Resident #125 from the shower chair to her bed to dry her off and then get her up for the day to her wheelchair. An observation of Resident #125 was made on 09/25/19 at 11:15 AM. Resident #125 remained in bed at this time and was alert and verbal. She stated she was waiting on the staff to come and get her washed and dressed and then put her in her wheelchair for the day. An observation and interview were conducted with Nurse Aide (NA) #1 on 09/25/19 at 11:19 AM. NA #1 entered Resident #125's room and apologized for not coming to her room sooner and stated she had been busy. NA #1 confirmed that this was the first time she had been able to provide any care to Resident #125 that day because there was no staff on the other unit, and she had to go and assist with serving breakfast and then assist residents that needed help with eating. She added that she had just returned to her unit and was just getting started on providing care to her residents. NA #1 proceeded to wash Resident #125 and provide incontinent care and get her dressed. NA #1 stated that once she was dressed, she would get some help to transfer her to her wheelchair. NA #1 stated that she was aware that Resident #125 preffered to be out of bed by 10:30 AM but stated this morning she had to assist the residents on the other unit with breakfast because there was no staff to do so. NA #1 added that the previous Administrator had placed the care plan on the wall behind Resident #125's bed but stated sometimes she was not able to do that because there was not enough help. An interview was conducted with Nurse #1 on 09/26/19 at 10:10 AM. Nurse #1 confirmed that she was caring for and was familiar with Resident #125. She stated that she was aware Resident #125 preferred to be out of by 10:30 AM and they staff tried but with the lack of staff on the unit that did not always happen. She stated that a lot of time there was only 1 NA on the unit and that left the nurse to assist with the mechanical lift transfers and pass medications. A lot of times she was not out of bed by 10:30 AM because it was just not possible due to the lack of available staff. Nurse #1 stated that if Resident #125 wanted to be out of bed by 10:30 AM than the staff was expected to honor her choice. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:28 PM. The DON stated that she expected the staff to get Resident #125 out of by 10:30 AM per her choice and if they were not able to do so that they communicate that to her. She added however that should not be on a daily basis but on rare occasion when they were not able to get her up like she preferred. The DON stated she has told the staff numerous times that if things got busy and they got behind to communicate that to her, and she would do whatever they needed.

Based on record review, staff, and Medical Doctor interview the facility failed to have an advance directive available and in the medical record for 1 of 1 resident reviewed for advance directives (Resident #129). The findings included: Resident #129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #129 was moderately impaired for daily decision making and required extensive assistance with activities of daily living. Review of Resident #129's medical record including the electronic record and the hard chart record on 09/23/19 and again on 09/26/19 revealed no advance directives that indicated if Resident #129 was a full code or a DNR. An interview was conducted with the Interim Administrator on 09/25/19 at 4:44 PM. The Interim Administrator stated that the ball got dropped and no DNR had been issued for Resident #129. He added if something happened the nurse would pull up the record and verify the code status. An interview was conducted with the Social Worker (SW) on 09/25/19 at 5:11 PM. The SW stated she had been at the facility for 8 weeks and she had not had to deal with the advance directives. She stated that the Medical Director (MD) usually went over the advance directives with the resident and/or families when she visited them for the first time and then they were scanned into the electronic medical record. An interview was conducted with Nurse #1 on 09/26/19 at 10:30 AM. Nurse #1 stated that she admitted Resident #129 to the facility on [DATE]. She stated that had spoken to the family that was with him when he admitted , and they verified that Resident #129 was a DNR. She stated that the MD would have completed the DNR form when she visited with Resident #129 for the first time. An interview was conducted with the Medical Doctor on 09/26/19 at 11:20 AM. The Medical Doctor stated that she rarely visited the facility and stated that she was covering for the Medical Director on 07/10/19 when Resident #129 was admitted to the facility. The Medical Doctor stated she had verbally discussed with the family and resident his code status and it was decided that he would remain a DNR. She added that she did not complete the advance directive DNR form because she thought the SW handled those things. She added that she was really only covering that day and was not familiar with the facility practices and believed the SW would take care of the advance director DNR form. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:24 PM. The DON stated that the Medical Director completed the Advance Directives when she would visit with the resident for the first time after admission. She stated that she was unaware that Resident #129 did not have any advance directives in his either his electronic medical record or his hard chart record. The DON stated she expected that every resident would have an advance directive in their medical record.

Based on record review, Responsible Party, and staff interviews the facility failed to notify the Responsible Party of a new physician order [REDACTED]. Findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #24 as being moderately impaired cognitively and required total to extensive assistance with activities of daily living. Review of physician orders [REDACTED]. Dorzolamide (a medication used to treat [MEDICAL CONDITION]) 2% ophthalmic solution each eye twice a day started 04/30/18. Brigandine (a medication used to treat [MEDICAL CONDITION]) ophthalmic 0.2% solution each eye twice a day written on 06/24/19 for the [DIAGNOSES REDACTED].#9. During an interview on 09/25/19 at 5:29 PM the Responsible Party (RP) explained she was aware 2 different eye drops were administered to Resident #24 for [MEDICAL CONDITION]. The RP noted the nurse had a new eye drop to administer and wanted to know why she was not notified. The RP revealed she was not notified and wanted to know why the physician added a third eye drop to Resident #24's medication regimen. She was concerned the [MEDICAL CONDITION] had worsened for Resident #24. A phone interview was conducted on 09/27/19 at 10:13 AM with Nurse #9 who explained she was to notify the RP of new physician orders. Nurse #9 did not recall if she had notified the RP of the new physician order [REDACTED].>During an interview on 09/27/19 at 11:09 AM the Director of Nursing revealed it was her expectation the RP and/or family members were notified of any changes to their care which included new physician orders.

Based on record review and staff interviews the facility failed to accurately code a Minimum Data Set Assessment (MDS) for the use of antipsychotic medications for 1 of 5 residents reviewed for the use of unnecessary medications (Resident #78) The Findings Included: Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #78's most recent quarterly MDS assessment dated [DATE] revealed Resident #78 was cognitively impaired for daily decision making with physical behaviors directed towards others occurring 1-3 days during the look back period. Resident #78 was coded as receiving antipsychotics 7 of 7 days but under section M-0450A - Resident received antipsychotic medications the assessment was coded as No- Antipsychotics were not received. A review of Resident #78's physician orders [REDACTED]. During an interview with MDS Nurse #2 on 09/27/19 at 9:58 AM, she reported section M-0450A should be coded as yes - antipsychotics were received. She stated the way the system worked, unless she waited after selecting a response for it to give a green check mark, if she utilized the scroll button on her mouse, it would change the answer originally selected. She reported she would complete a modification and resubmit the quarterly MDS assessment with the corrected information. During an interview with the Director of Nursing on 09/27/19 at 1:21 PM, she reported it was her expectation that MDS Assessments be completed accurately and that the MDS Nurses take time to review their work before submitting the assessments to ensure the assessments were accurate.

Based on observations, record review, resident and staff interview the facility failed to implement a care plan to get a resident out of bed by 10:30 AM (Resident #125) and failed to use a green edged mechanical lift sling as directed by the care plan (Resident #46). This affected 2 of 4 residents sampled for accidents. The findings included: 1. Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required extensive to total assistance with activities of daily living including transfers. Review of care plan initiated on 09/05/19 read in part, Activity of Daily Living (ADL) function rehab: the goal read, functions at optima level and Resident #125 needs assistance with ADLs. The interventions included: prefers to be up by 10:30 AM. An observation and interview were conducted with Resident #125 on 09/23/19 at 11:49 AM. There was a sign on the wall behind the bed that read, plan of care: Resident #125 wants to be up no later than 10:30 AM. Resident #125 stated that this morning it was after 11:00 AM when the staff got her out of bed. She stated that the staff were aware of her wish to be up by 10:30 AM but a lot of times that did not happen because they did not have enough staff to help. An observation and interview were conducted with Resident #125 on 09/24/19 at 11:00 AM. Resident #125 was sitting in a shower chair in her room and had just finished her shower. She stated that the staff just got her up about 10 minutes ago and had just given her a shower. An observation of Resident #125 was made on 09/25/19 at 11:15 AM. Resident #125 remained in bed at this time and was alert and verbal. She stated she was waiting on the staff to come and get her washed and dressed and then put her in her wheelchair for the day. An observation and interview were conducted with Nurse Aide (NA) #1 on 09/25/19 at 11:19 AM. NA #1 entered Resident #125 ' s room and apologized for not coming to her room sooner and stated she had been busy. NA #1 stated that she was aware that Resident #125 preferred to be out of bed by 10:30 AM but stated this morning she had to assist the residents on the other unit with breakfast because there was no staff to do so. NA #1 added that the previous Administrator had placed the care plan on the wall behind Resident #125's bed but stated sometimes she was not able to do that because there was not enough help. An interview was conducted with Nurse #1 on 09/26/19 at 10:10 AM. Nurse #1 confirmed that she was caring for and was familiar with Resident #125. She stated that she was aware Resident #125 preferred to be out of by 10:30 AM and they staff tried but with the lack of staff on the unit that did not always happen. A lot of times she was not out of bed by 10:30 AM because it was just not possible due to the lack of available staff. Nurse #1 stated that the staff were expected to follow the care plan as written and assist Resident #125 out of bed by 10:30 AM. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:28 PM. The DON stated that she expected the staff to get Resident #125 out of by 10:30 AM per her choice and as directed by the care plan. 2. Resident #46 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #46 was moderately impaired for daily decision making and no transfers occurred during the assessment reference period. No falls were reported since the re-entry to the facility. The MDS further indicated Resident #46 received hospice care. Review of a care plan initiated on 08/06/19 read in part, Falls: will be free from major injury. The interventions included transfer with mechanical lift and 2 person assist using a sling with green edging. An observation of Nurse Aide (NA) #1 and #2 was made on 09/23/19 at 4:16 PM. NA #1 indicated that she and NA #2 were going to transfer Resident #46 from his wheelchair to the bed. NA #2 went to the electronic care plan and confirmed that Resident #46 required a mechanical lift with a sling pad that had green edging. NA #1 and #2 entered Resident #46 room and when asked what the sling with green edging meant NA #2 pointed to the sling pad that was under Resident #46 and pointed to the color-coded edging. When NA #2 pointed to the edging she replied this is the wrong pad he needs a green one and this one is blue. NA #2 stated that she did not get Resident #46 up that am that the hospice staff did. An interview was conducted with NA #3 and #4 on 09/25/19 at 9:12 AM. NA #3 and #4 confirmed that they worked with the hospice agency and visited Resident #46 every Monday, Wednesday, and Friday. Both NA #3 and NA #4 confirmed that they transferred Resident #46 to his wheelchair on 09/23/19 using the sling with the blue edge because it was in his room lying in his chair and they thought it was the correct sling. NA #3 stated that they did have access to the electronic care plan but had never been shown how to use it and the system located in the hallway had been broken for several months. NA #3 and #4 again confirmed that on 09/23/19 they had used the incorrect sling that was in Resident #46's chair and available for use but should have used the greed edged sling as directed by his plan of care. An interview was conducted with Nurse #1 on 09/25/19 at 5:40 PM. Nurse #1 confirmed that she routinely cared for and was familiar with Resident #46. Nurse #1 stated that all staff including hospice staff were expected to use the correct sling as directed by the plan of care. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:42 PM. The DON stated she would expect the hospice staff and facility staff to refer to the electronic care plan or written list and follow the plan of care as instructed.

Based on observations, record review, resident and staff interview the facility failed to provide incontinent care for 2 of 4 dependent residents (Resident #125 and Resident #27) reviewed for activities of daily living. The findings included: 1. Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required total assistance with toileting. The MDS further revealed that Resident #125 was always incontinent of bladder and bowel. Review of a care plan initiated on 09/05/19 read, [MEDICAL CONDITION]: the goal read, no [MEDICAL CONDITION] complications, no urinary tract infections requiring hospitalization , unable to sit on commode and prefers not to use the bed pan, and Resident #125 was at risk for recurring urinary tract infections. The interventions included: provide incontinent care routinely as needed. An observation and interview were conducted with Resident #125 on 09/25/19 at 10:20 AM. Resident #125 was resting in bed with her eyes open. She stated that her brief was soiled with urine and no one had been in to provide care to her since third shift. She further stated that no one had been into see if I was wet or soiled. She added it was uncomfortable but did not burn or hurt at this point. Resident #125 was able to pull the covers back and pointed out that the wet indicator strip on the front of her brief was dark blue indicating it was wet. An observation and interview were conducted with Resident #125 on 09/25/19 at 10:55 AM. Resident #125 remained in bed and was alert and verbal. She confirmed that she was still wet, and no one had been into provide any care to her thus far on first shift. Again Resident #125 pulled her covers back and again indicated the wet indicator strip on the front of her brief was dark blue indicating it was wet. An observation and interview were conducted with Resident #125 on 09/25/19 at 11:11 AM. Resident #125 remained in bed and alert and verbal. She again confirmed that she was wet, and no staff had been into provide care for her. Resident #125 was observed to turn the call light on, and Nurse #1 entered room and stated she would go and get someone to help her. An observation and interview were conducted with Nurse Aide (NA) #1 on 09/25/19 at 11:19 AM. NA #1 entered Resident #125's room and apologized for not coming to her room sooner and stated she had been busy. NA #1 confirmed that this was the first time she had been able to provide any care to Resident #125 that day because there was no staff on the other unit, and she had to go and assist with serving breakfast and then assist residents that needed help with eating. She added that she had just returned to her unit and was just getting started on providing care to her residents. NA #1 was observed to turn Resident #125 onto her left side and remove her brief that when open smelled heavily of urine and when thrown in the trash can made a loud thud. The inner contents of the brief were bunched together due to the excessive moisture. Resident #125's buttocks and peri area were observed and were not red or excoriated but were visibly shiny with moisture when the soiled brief was removed. NA #1 again confirmed she had not been able to provide any care to Resident #125 because there was not enough staff to feed the resident on the other unit and she had gone to assist those residents with breakfast. An interview was conducted with Nurse #1 on 09/26/19 at 10:10 AM. Nurse #1 confirmed that she was caring for Resident #125 on 09/25/19 and was familiar with her needs and stated she required a lot of assistance with her activities of daily living including incontinent care. Nurse #1 stated it was not acceptable for Resident #125 to be wet for as long as she was. She confirmed that NA #1 had gone to the other unit to assist with breakfast because for some reason the staff on that unit had not arrived at the facility yet and there was no one to assist the residents with breakfast. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:28 PM. The DON stated that she was unaware that NA #1 had to assist the other unit with breakfast and was unaware that the staff on the other unit had not shown up to work as scheduled. The DON stated it was unacceptable for Resident #125 to have been wet for as long as she was before the staff came to provide care to her. The DON stated she has told the staff numerous times that if things got busy and they got behind to communicate that to her, and she would do whatever they needed. The DON stated she expected the staff to provide incontinent care to Resident #125 and all residents when they needed it and they should not be lying in a soiled brief for very long. 2. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan initiated on 07/23/19 read, [MEDICAL CONDITION]: the goal read, no [MEDICAL CONDITION] complications, Resident #27 was incontinent of bowel and bladder, and no skin injury through the next review. The interventions included: provide incontinent care frequently and routinely and as needed. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #27 had long and short-term memory problems and was moderately cognitively impaired for daily decision making. The MDS further revealed that Resident #27 required total assistance with toileting and was always incontinent of bowel and bladder. An interview was conducted with Nurse Aide (NA) #1 on 09/25/19 at 10:09 AM. NA #1 confirmed that she was caring for Resident #27 and was familiar with her care. She stated that she had not been able to provide any care to Resident #27 thus far on the shift because there was no staff on the other unit, and she had to go and assist with serving breakfast and then assist residents that needed help with eating. She added that she had just returned to her unit and was just getting started on providing care to her residents. NA #1 again confirmed she had not changed or provided any activity of daily living care to Resident #27 thus far on her shift. An observation and interview were conducted with the Wound Nurse (WN) on 09/25/19 at 10:39 AM. The WN indicated that she was not aware of any wounds that Resident #27 had but stated she would go and observe her bottom just to make sure. The WN was observed to enter Resident #27's room and turn her onto her left side. When the covers were pulled back there was a strong smell of urine and the brief that Resident #27 had on was wet all the way to the edge of the brief. The inner contents of the brief were all bunched together from the moisture and when the brief was removed and thrown in the trash can it made a loud thud noise from the weight of the soiled brief. The WN stated she was going to provide incontinent care to Resident #27 at this time. Resident #27's buttock and peri area were observed to be of normal color for her ethnicity and was not excoriated. Resident #27 indicated that she could not recall when the last time she had been changed that day but thought it was earlier in the shift. An interview was conducted with Nurse #1 on 09/26/19 at 10:10 AM. Nurse #1 confirmed that she was caring for Resident #27 on 09/25/19 and was familiar with her needs and stated she required a lot of assistance with her activities of daily living including incontinent care. Nurse #1 stated it was not acceptable for Resident #27 to be wet and soiled for a long period of time. She confirmed that NA #1 had gone to the other unit to assist with breakfast because for some reason the staff on that unit had not arrived at the facility yet and there was no one to assist the residents with breakfast. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:28 PM. The DON stated that she was unaware that NA #1 had to assist the other unit with breakfast and was unaware that the staff on the other unit had not shown up to work as scheduled. The DON stated it was unacceptable for Resident #27 to have been wet and heavily soiled before the staff came to provide care to her. The DON stated she has told the staff numerous times that if things got busy and they got behind to communicate that to her, and she would do whatever they needed. The DON stated she expected the staff to provide incontinent care to Resident #27 and all residents when they needed it and they should not be lying in a soiled brief for very long. An interview was conducted with NA #5 on 09/27/19 at 9:32 AM. NA #5 confirmed that she had worked third shift on 09/24/19 and provided care to Resident #27. NA #5 stated that made her last round and changed Resident #27 on 09/25/19 at 6:15 AM to 6:30 AM. She added that she had been wet but was not heavily soiled because she had also changed her earlier on the shift.

Based on observation, record review, and staff interview the facility failed to transfer a resident using the correct mechanical lift sling for 1 of 4 residents reviewed for accidents (Resident #46). The findings included: Review of the mechanical lift sling recommendations contained the following information, visibly inspect sling prior to each use to ensure sling is the correct type, size, and design to handle lifting. The recommendations further indicated the following specifications: Small 75-125 pounds (lbs.) Red, Medium 125-174 lbs. Yellow, Large 175-249 lbs. green, X-large 200-399 lbs. blue, XX-large 400-600 lbs. orange, and XXX-large [PHONE NUMBER] lbs. grey. Resident #46 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #46 was moderately impaired for daily decision making and no transfers occurred during the assessment reference period. No falls were reported since the re-entry to the facility. The MDS further indicated Resident #46 received hospice care. Review of a care plan initiated on 08/06/19 read in part, Falls: will be free from major injury. The interventions included transfer with mechanical lift and 2 person assist using a sling with green edging. Review of Resident #46's medical record indicated on 09/11/19 his weight was 179 lbs. An observation of Nurse Aide (NA) #1 and #2 was made on 09/23/19 at 4:16 PM. NA #1 indicated that she and NA #2 were going to transfer Resident #46 from his wheelchair to the bed. NA #2 went to the electronic medical record and confirmed that Resident #46 required a mechanical lift with a sling pad that had green edging. NA #1 and #2 entered Resident #46 room and when asked what the sling with green edging meant NA #2 pointed to the sling pad that was under Resident #46 and pointed to the color-coded edging. When NA #2 pointed to the edging she replied this is the wrong pad he needs a green one and this one is blue. NA #1 went to the clean utility room and obtained the sling with green edging and proceed to place the correct sling under Resident #46. Once the blue edged sling was removed and the green edged sling was under Resident #46, he was safely transferred to the bed. NA #2 stated that she did not get Resident #46 up that am that the hospice staff did. An interview was conducted with NA #3 and #4 on 09/25/19 at 9:12 AM. NA #3 and #4 confirmed that they worked with the hospice agency and visited Resident #46 every Monday, Wednesday, and Friday. They confirmed that when they visited Resident #46, they bathed him, shaved him, provided mouth care, emptied his catheter and transferred him to the wheelchair. Both NA #3 and NA #4 confirmed that they transferred Resident #46 to his wheelchair on 09/23/19 using the sling with the blue edge because it was in his room lying in his chair and they thought it was the correct sling. NA #3 stated that they did have access to the electronic care system but had never been shown how to use it and the system located in the hallway had been broken for several months. NA #4 stated that a member of the staff had shown them this morning how to use the care tracker system and showed them how to find the correct sling pad for Resident #46 and indicated they had used the sling with the green edge on 09/25/19 when they transferred Resident #46. NA #3 and #4 again confirmed that on 09/23/19 they had used the incorrect sling that was in chair and available for use. An interview was conducted with Nurse #1 on 09/25/19 at 5:40 PM. Nurse #1 confirmed that she routinely cared for and was familiar with Resident #46. Nurse #1 stated that there was a list in the nursing station that indicated which sling each resident required and the staff including hospice were expected to refer to the list and use the correct sling to transfer Resident #46 and all residents. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:42 PM. The DON stated that one of the staff members had told her that NA #3 and #4 from hospice had used the incorrect lift pad to transfer Resident #46 on 09/23/19. The DON stated that there was a list of each resident and the sling that they required in each nursing station and all staff including hospice staff have access to it. I would expect them to refer to the list and use the correct sling for each resident that they transfer. She added that the list was updated each month after weights were obtained.

Based on observations, record review, resident, and staff interview the facility failed to provide sufficient nursing staff that resulted in incontinent care not being provided (Resident #125 and Resident #27), failed to have sufficient nursing staff to honor a residents choice to get out of bed by 10:30 AM (Resident #125), and failed to have sufficient staff to implement and follow a care plan that directed the staff to get a resident out of bed by 10:30 AM (Resident #125). This affected 3 of 11 sampled residents. The findings included: This tag is cross referred to F677: Based on observations, record review, resident and staff interview the facility failed to provide incontinent care for 2 of 4 dependent residents (Resident #125 and Resident #27) reviewed for activities of daily living. This tag is cross referred to F561: Based on observations, record review, resident and staff interview the facility failed to honor a resident wish to be out of bed by 10:30 AM for 1 of 3 resident reviewed for choices (Resident #125). This tag is cross referred to F656: Based on observations, record review, resident and staff interview the facility failed to implement a care plan to get a resident out of bed by 10:30 AM (Resident #125) and failed to use a green edged mechanical lift sling as directed by the care plan (Resident #46). This affected 2 of 4 residents sampled for accidents. An interview was conducted with Resident #125 on 09/23/19 at 11:55 AM. Resident #125 stated that a lot of time there was only 1 Nurse Aide (NA) to care for all the residents on her unit and indicated she had to wait awhile to receive her meal tray or any care that she needed. An interview was conducted with NA #1 on 09/25/19 at 10:06 AM. NA #1 stated that the on her unit they used to have 6 NA's and in the last year they had cut the number to 3, so in a year her work load has doubled. She stated, we do the best we can. NA #6 indicated that she was not able to complete her scheduled showers consistently and there was not enough staff on the next shift to do them so in the end the resident just missed their scheduled shower. She added that this morning she had to serve breakfast to both units and because of the lack of staff, her residents did not get incontinent care for an extended period of time. She added that they had 6 residents who required assistance with feeding and it usually took an hour and a half to complete that and left even less time for patient care. NA #1 stated they have a lot of complaints about patient care but there was just not enough of us to do everything that needed to be done. An interview was conducted with NA #8 on 09/25/19 at 2:16 PM. NA #8 stated she had worked at the facility for [AGE] years and staffing is very bad. She stated that most of the time there was 1 NA on the hall to care for 18-20 residents and when there was only 1 NA on the hall, she was only able to provide incontinent care to her residents 1 time during her shift. NA #8 stated she had 7 residents who required assistance with meals and that took most of her shift to feed them so she did the best she could. When NA #8 informed the previous administration of the staffing issue she stated she was informed that she could be easily replaced, so NA #8 stated we just keep working and doing the best we can. An interview was conducted with NA #6 on 09/25/19 at 3:20 PM. NA #6 stated that when she first came to work at the facility, they had 2-3 NAs on each hall then they dropped it to 2 NAs on each hall, then dropped it again to 1 NA on each hall with a person that went between 2 halls or a split. NA #6 added if we have 4 nurse aides on the entire unit that is good day. She added that on the evening shift she was responsible for all patient care, bathing, showering, feeding, and putting all the residents to bed. She stated that the night shift was supposed to do laundry but a lot of time she also had to do that because the residents did not have any night clothes to wear. NA #6 stated that the residents would get better care if we had more staff on the units. An interview was conducted with NA #7 on 09/25/19 at 4:01 PM. NA #7 stated that the facility had lost a lot of staff since they changed to 12-hour shifts. She stated they hire staff, but they won't stay long. 4 NAs on a on a unit is unheard of and most of the time they work with 2-3 and on occasion 1 NA per hall which is not enough to provide all the care that the residents required. NA #7 stated on the days that they only have 2 NA on each unit she hoped and prayed that the family members would not come in and find out. She added that rarely did the Nurses have time to come and help out. An interview was conducted with Nurse #3 on 09/25/19 at 4:12 PM. Nurse #3 stated staffing is pretty shabby, and we don't have much of it. She stated that the NAs were stressed to the max and most time they had 3 NAs to take care of 30 plus residents. Nurse #3 stated that the patients needed direct care and they would turn on their call light, but we just can not get there to help them. I help the NAs as much as possible but with my medication pass and wound care it is just not always feasible. An interview was conducted with Nurse #1 on 09/26/19 at 10:10 AM. Nurse #1 stated that she had worked at the facility on and off for four years and staffing is terrible. Honestly it should not happen, but we have 1 NA on the hall Nurse #1 stated that it was unacceptable for residents to be soiled for long periods of time. She stated that showers were not consistently being completed because there was not enough staff. Nurse #1 stated that there was plenty of nurses in the building and if all the nurse would take 1 resident to feed that would free up the NAs to provide better care timelier to our residents. An interview was conducted with the Director of Nursing (DON) on 09/26/19 at 4:51 PM. The DON stated that she expected the facility to maintain a level of staff to meet the needs of the resident and she felt like they had done that. She added that she had hired a lot of staff lately. The DON stated that the onboarding process was long and that was a barrier in retaining staff at times and usually took 4 to 6 weeks to get the staff in the building to work. She added that she had a good pool of nurses that were able to help out when needed and a lot of administrative nurses that would work the medication cart if needed. The DON stated that they usually did not work with 1 NA on the hall because she would put a nurse on the hall to perform patient care before she would let 1 NA work the hall alone. An interview was conducted with the Interim Administrator on 09/26/19 at 7:10 PM. The Administrator stated he had not been at the facility long enough to assess the staffing issue within the building. He stated he would expect that there was enough staff to meet the safety and welfare needs of the residents.

Based on record review, nursing, pharmacy, laboratory services staff and medical director interviews, the facility failed to provide laboratory services as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident #92) The findings included: Resident #92 was readmitted to facility on 9/10/19 with medical [DIAGNOSES REDACTED]. Resident #92's minimum data set ((MDS) dated [DATE] revealed that he was cognitively intact. A review of Resident #92's medical record revealed physician orders [REDACTED]. The medical record also revealed an order dated 9/19/19 at 11:17 am for weekly complete blood count for total 4 weeks then monthly. The start date for the order was 9/20/19 routine collection every 7 days. The order was reviewed by the nurse on 9/19/19 at 11:19 am. An interview was conducted on 9/25/19 26 at 10:02 PM with Nurse #4. She was the preceptor for a new nurse during orientation on 9/19/19. Nurse #4 instructed the new nurse of the process for checking orders for laboratory services by acknowledging and reviewing the order seen on the computer. Nurse #4 informed the new nurse that the lab draw was routine and that a label would be printed on the day of the draw, 9/20/19. Nurse #4 contacted the facility's lab and was informed by staff in the lab that the order date was 9/21/19. The lab confirmed bloodwork had not been obtained for Resident #92 on that date. On 9/25/19 at 4:32 PM, an interview was conducted with the Director of Pharmacy Services regarding orders for laboratory services with long term care drug regimen review. The director stated the specimen should have been drawn at the next routine check which would have been on 9/20/19. During an interview with Nurse #5 on 9/25/19 at 4:41 PM, he reported the process for obtaining a specimen for laboratory services once the order was reviewed by the nurse. Nurse #5 stated a label would print with the resident's name, then a nurse would place the label in the binder labeled Lakeview Inn (500 hall) Lab Draws for the date of the blood draw. Nurse #5 confirmed there was no sheet dated 9/20/19 and 9/21/19 that had a label for Resident #92. On 9/27/19 at 1:14 PM, an interview was conducted with the client service manager of the facility's lab. The service manager reported she reviewed the order put in on 9/19/19 with a request to start on 9/20/19. She reported the label did not print until 9/21/19. The service manager for the lab could not identify a reason why the label printed a day late. The service manager reported that the facility was aware that no one from the reference lab draws blood on evenings and the weekend. She also stated the facility has the understanding that blood draws should be completed by the nurse on the evening and weekend shifts. An interview with Nurse #6 and Nurse #7 on 9/27/19, both nurses reported on 9/21/19 they were assigned to residents in Lakeview Inn (500 hall) where Resident #92 resided in the facility. Both nurses reported they were aware of the responsibility to draw blood on the weekend. Both nurses stated there was no label in the binder for laboratory services that identified Resident #92 required bloodwork to be obtained on 9/21/19. During an interview with the Director of Nursing (DON) on 9/27/19 at 11:07 AM, the DON stated her expectation was bloodwork for the lab was completed as ordered. During an interview with the Medical Director on 9/27/19 at 11:46 AM, she reported that the lab work should have been drawn as ordered since Resident #92 was on an anticoagulant. She also stated that Resident #92 experienced no harm and lab work was reordered on [DATE].

Based on 6 resident interviews (Residents #72, #186, #5, #53, #31, and #125), a Resident Council Meeting, observations, a test tray evaluation and record review, the facility failed to provide food that was served at an appetizing temperature for 6 of 7 residents reviewed for palatable foods. The findings included: 1a. Resident #72 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #72 with adequate hearing, clear speech, understood by others, able to understand others and intact cognition. The MDS assessed Resident #72 as being independent with eating, requiring set up help only. Resident #72 was interviewed on 09/24/19 at 10:54 AM. During the interview Resident #72 expressed that for greater than 6 months the food served at the facility had not been good. The Resident described the food as having no taste, terrible and repetitious, especially pork giving ham and bacon as examples. Resident #72 described the last meal of the month (quiche and tomatoes) as being the worst meal of the month thus far. The Resident stated this was brought to the attention of the certified dietary manager (CDM) and other food concerns was discussed with him when he attended Resident Council meetings. A follow up interview was conducted with Resident #72 on 09/25/19 at 3:41 PM. Resident #72 stated she received a lunch meal that day that was not hot and not good (meat loaf, mashed potatoes and green peas) so she ordered a chicken sandwich from the café. Resident #72 also expressed that she had ongoing conversations with the CDM about her food concerns and all he said was What else can I get you? or told her I will take care of it., but she expressed nothing gets done. Resident #72 further stated that the lunch for the previous Monday was not good and clarified that It was ham again, we get too much pork, the broccoli was over-cooked, and the sweet potatoes had no taste. The CDM was interviewed on 09/26/19 at 10:03 AM. The CDM stated in interview that he began his role as CDM in (MONTH) (YEAR), 10 months ago. He stated that he attended Resident Council Meetings often and that he was aware of resident food concerns expressed during Resident Council meetings. He stated that when a resident expressed a concern during Resident Council, he responded to that individual resident by asking the resident what else he could get them to eat and based on their response, he updated their food preferences on their tray ticket. He also stated that he was made aware that some residents did not like the meatloaf served for lunch on 9/25/19, but further stated that an alternate entrée was available for residents to choose. The CDM stated that when he spoke to Resident #72 in the past about food, he did not ask her why she did not want a food, so he was not aware that he was updating her food preferences because she did not like the food. An interview occurred with nurse aide #8 (NA #8) on 09/26/19 at 1:45 PM. During the interview, NA #8 stated that she often returned food to the kitchen because residents complained that they did not like the food served. NA #8 stated when she returned food to the kitchen, she told the dietary staff and the CDM that she was returning the food item because the resident did like it. NA #8 stated the CDM would respond that he would update the resident's food preferences and get them something else. NA #8 further stated that residents still complained that updating their food preferences did not resolve the problem because the food did not get better and that as a result many residents ordered food out. 1b. Res #5 was admitted to the facility 10/16/18. A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #5 with minimum difficulty hearing, clear speech, able to understand others, able to be understood by others, and intact cognition. The MDS assessed Resident #5 as being independent with eating, requiring set up help only. An observation of Resident #5 having lunch occurred on 09/25/19 at 1:06 PM. During the observation, Resident #5 expressed that he discussed with staff during a recent care plan meeting that he wanted to change his diet from a no added salt diet to a low sodium diet because his food was too bland and had no taste. He further stated that even adding a little salt did not help because the food provided by the facility tasted terrible. The CDM was interviewed on 09/26/19 at 10:03 AM. The CDM stated in interview that he began his role as CDM in (MONTH) (YEAR), 10 months ago. He stated that when a resident expressed a concern he responded to that individual resident by asking the resident what else he could get them to eat and based on their response, he updated their food preferences on their tray ticket. He also stated that he was made aware that some residents did not like the meatloaf served for lunch on 9/25/19, but further stated that an alternate entrée was available for residents to choose. The CDM further stated that he had spoken to Resident #5 in the past and updated his food preferences related to sausage gravy but did not ask the Resident why he wanted to make a change to his preferences, so he was not aware that he did not like the food. An interview occurred with nurse aide #8 (NA #8) on 09/26/19 at 1:45 PM. During the interview, NA #8 stated that she often returned food to the kitchen because residents complained that they did not like the food served. NA #8 stated when she returned food to the kitchen, she told the dietary staff and the CDM that she was returning the food item because the resident did like it. NA #8 stated the CDM would respond that he would update the resident's food preferences and get them something else. NA #8 further stated that residents still complained that updating their food preferences did not resolve the problem because the food did not get better and that as a result many residents ordered food out. 1c. Resident #186 was admitted to the facility 7/27/19. An admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #186 with adequate hearing, clear speech, able to understand others, able to be understood by others, clear speech and intact cognition. The MDS assessed Resident #186 as requiring set up help and supervision during meals by 1 staff member. Resident #186 stated on 9/24/19 at 11:31 AM that the food had no taste and that she did not like the food. She expressed she shared this with the certified dietary manager (CDM) many times but that he would respond by updating her food preferences or say he would take care of it, but that the food did not get better. The CDM was interviewed on 09/26/19 at 10:03 AM. The CDM stated in interview that he began his role as CDM in (MONTH) (YEAR), 10 months ago. He stated that when a resident expressed a concern about their food he responded to that individual resident by asking the resident what else he could get them to eat and based on their response, he updated their food preferences on their tray ticket. He also stated that he was made aware that some residents did not like the meatloaf served for lunch on 9/25/19, but further stated that an alternate entrée was available for residents to choose. An interview occurred with nurse aide #8 (NA #8) on 09/26/19 at 1:45 PM. During the interview, NA #8 stated that she often returned food to the kitchen because residents complained that they did not like the food served. NA #8 stated when she returned food to the kitchen, she told the dietary staff and the CDM that she was returning the food item because the resident did like it. NA #8 stated the CDM would respond that he would update the resident's food preferences and get them something else. NA #8 further stated that residents still complained that updating their food preferences did not resolve the problem because the food did not get better and that as a result many residents ordered food out. 1d. Resident #53 was admitted to the facility 9/9/10. A quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #53 with minimum difficulty hearing, clear speech, able to understand others, able to be understood by others and intact cognition. The MDS assessed Resident #186 as independent with eating requiring set up help only. An interview occurred with Resident #53 on 09/27/19 at 12:46 PM. Resident #53 stated during the interview that she did not like the taste of the food provided by the facility. She described the food as lacking taste and seasoning, bland and that she did not like the food selections. As a result, Resident #53 stated that she ordered out 3 - 4 times per week. She further stated that she communicated her food concerns to staff. The CDM was interviewed on 09/26/19 at 10:03 AM. The CDM stated in interview that he began his role as CDM in (MONTH) (YEAR), 10 months ago. He stated that when a resident expressed a concern about their food, he responded to that individual resident by asking the resident what else he could get them to eat and based on their response, he updated their food preferences on their tray ticket. He also stated that he was made aware that some residents did not like the meatloaf served for lunch on 9/25/19, but further stated that an alternate entrée was available for residents to choose. An interview occurred with nurse aide #8 (NA #8) on 09/26/19 at 1:45 PM. During the interview, NA #8 stated that she often returned food to the kitchen because residents complained that they did not like the food served. NA #8 stated when she returned food to the kitchen, she told the dietary staff and the CDM that she was returning the food item because the resident did like it. NA #8 stated the CDM would respond that he would update the resident's food preferences and get them something else. NA #8 further stated that residents still complained that updating their food preferences did not resolve the problem because the food did not get better and that as a result many residents ordered food out. 1e. Resident #31 was admitted to the facility 5/8/15. A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #31 with adequate hearing, clear speech, able to understand others and be understood by others and intact cognition. The MDS assessed Resident #186 as independent with eating requiring set up help only. An interview was conducted with Resident #31 on 09/27/19 at 1:04 PM. During the interview, Resident #31 stated that she ate most meals in the dining room and that at times her food was cold when served and that the food was not something I want to eat every day. Resident #31 further described the food as repetitious and the lunch/dinner meals often lacked taste. Resident #31 stated she expressed these concerns to staff. The CDM was interviewed on 09/26/19 at 10:03 AM. The CDM stated in interview that he began his role as CDM in (MONTH) (YEAR), 10 months ago. He stated that when a resident expressed a concern about their food, he responded to that individual resident by asking the resident what else he could get them to eat and based on their response, he updated their food preferences on their tray ticket. He also stated that he was made aware that some residents did not like the meatloaf served for lunch on 9/25/19, but further stated that an alternate entrée was available for residents to choose. An interview occurred with nurse aide #8 (NA #8) on 09/26/19 at 1:45 PM. During the interview, NA #8 stated that she often returned food to the kitchen because residents complained that they did not like the food served. NA #8 stated when she returned food to the kitchen, she told the dietary staff and the CDM that she was returning the food item because the resident did like it. NA #8 stated the CDM would respond that he would update the resident's food preferences and get them something else. NA #8 further stated that residents still complained that updating their food preferences did not resolve the problem because the food did not get better and that as a result many residents ordered food out. 1f. A Resident Council Meeting was held on 9/26/19 at 10:00 AM. During the meeting Resident #72 stated at 10:24 AM that the food prepared by the facility was so good, that sometimes she had to order out. Resident #72 continued to report that the food was very bland, that you just can't eat it and much of the food was thrown out because the residents just did not want to eat it. Several residents who also attended the meeting shook their heads in agreement. The CDM was interviewed on 09/26/19 at 10:03 AM. The CDM stated in interview that he began his role as CDM in (MONTH) (YEAR), 10 months ago. He stated that he attended Resident Council Meetings often and that he was aware of resident food concerns expressed during Resident Council meetings. He stated that when a resident expressed a concern during Resident Council, he responded to that individual resident by asking the resident what else he could get them to eat and based on their response, he updated their food preferences on their tray ticket. He also stated that he was made aware that some residents did not like the meatloaf served for lunch on 9/25/19, but further stated that an alternate entrée was available for residents to choose. An interview occurred with nurse aide #8 (NA #8) on 09/26/19 at 1:45 PM. During the interview, NA #8 stated that she often returned food to the kitchen because residents complained that they did not like the food served. NA #8 stated when she returned food to the kitchen, she told the dietary staff and the CDM that she was returning the food item because the resident did like it. NA #8 stated the CDM would respond that he would update the resident's food preferences and get them something else. NA #8 further stated that residents still complained that updating their food preferences did not resolve the problem because the food did not get better and that as a result many residents ordered food out. 1g. Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required set up assistance with eating. An interview with Resident #125 was conducted on 09/23/19 at 11:58 AM. Resident #125 stated that her food that was served from the facility was usually cold and most of the time had no flavor. She indicated she got plenty to eat only because her family kept lots of snacks in her room. A follow up observation and interview were conducted with Resident #125 on 09/25/19 at 1:30 AM. Resident #125 was in the dining room on her unit and was eating her lunch tray that consisted of meat loaf, mashed potatoes with gravy, and green peas. She stated that it had decent flavor but was not very hot and she was looking forward to eating the dessert her family had brought into her. 1h. An observation of the lunch meal preparation was conducted on 09/25/19 at 12:30 AM. The lunch meal consisted of meat loaf, mashed potatoes, gravy, and green peas. The kitchen staff was observed to load the food onto a meal cart that would be delivered to the resident unit. An observation of the lunch meal being delivered to the resident unit was made on 09/25/19 at 12:40 AM. The dietary staff began plating each residents tray on the unit and at 1:15 PM all resident lunch trays had been plated and were being distributed to the residents. On 09/25/19 at 1:15 PM the dietary staff plated a regular test. There was no visible steam to the lunch tray and the gravy was partially congealed on top of the mashed potatoes. The Dietary Manager (DM) sampled a bite of the meat loaf, mashed potatoes, and green peas. After the test tray had been sampled the DM agreed the meat loaf was not hot and at best was room temperature. The texture and flavor were suitable but lacked an appetizing temperature. The DM stated he needed to figure out how keep and maintain the temperature of the food from the kitchen to the point of service. The DM stated that he expected the food to be hot when served to the residents.

Based on observations, record review, and staff interviews the facility failed to follow diet instructions per physician orders [REDACTED].#61 and Resident #121). Findings included: 1. Resident #61 was admitted to the facility 12/02/14 with [DIAGNOSES REDACTED]. A physician order [REDACTED].#61 receive a mechanically altered diet. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #61 to be cognitively intact with no swallowing disorders. Resident #61 required supervision with eating with a 5% or greater weight gain during the look back period of the assessment. Nutritional needs were supplemented with 26-50% of total calories and 501 or greater milliliters of daily fluid intake were provided via tube feedings. A nutrition care plan revised 08/08/19 described a goal to meet nutritional intake needs with interventions which included to provide Resident #61 with a mechanical soft diet. A nutrition note dated 09/23/19 described Resident #61 as having a history of weight loss, as being able to feed self with setup assistance, and remained on a mechanical soft diet. Resident #61 had started eating with improved meal intake. Supplemental bolus feeds were provided if meal intake was less than 50% plus a bolus at bedtime. During an observation on 09/23/19 at 12:22 PM Resident #61 was served a slice of non-mechanically altered ham which appeared to be approximately 2.5 centimeters thick. Other residents were observed to have mechanically altered ham pieces on their plates. During an interview on 09/23/19 at 12:52 PM Nurse #8 confirmed the diet card instructions for Resident #61 read in part to provide mechanical soft food. Nurse #8 revealed the ham served to Resident #61 was not the correct consistency and/or texture of a mechanically soft food. Nurse #8 did not recall which staff member served the food tray for Resident #61. An interview was conducted on 09/26/19 at 10:26 AM with the Director of Nursing (DON) who explained it was her expectation for staff to follow the instructions on the diet card when serving residents their meals. The system in place was for staff to read the instructions on the diet card to ensure the meal served was the correct consistency and/or texture. The DON felt Resident #61 was served a non-altered slice of ham due to an oversight made by the staff. During an interview on 09/26/19 at 10:29 AM the Interim Administrator revealed it was his expectation diet orders were followed by staff serving food to residents. He expected residents were served the correct recommended consistency and/or texture of food per instructions on their diet card. He explained the system in place was for staff to read the diet card. 2. Resident #121 was admitted to the facility 05/29/19 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #121 as being moderately impaired cognitively and requiring supervision with eating. No identified swallowing problems or weight loss and/or gain. The nutrition care plan revised 07/19/19 described a goal for Resident #121 to tolerate the diet as prescribed with interventions which included to provide a mechanical soft diet with nectar thick liquids. A physician order [REDACTED].#121 be provided a mechanical soft diet with nectar thick liquids. During an observation on 09/23/19 at 12:29 PM the diet card for Resident #121 read in part nectar thick liquids. Resident #121 was served tea with ice cubes which appeared to be of a non-thickened consistency and/or texture. During an interview on 09/23/19 at 12:38 PM Nurse Aide (NA) #11 checked the tea served to Resident #121 and confirmed the consistency and/or texture was not nectar thick and removed the glass of ice tea. She checks the diet card of residents to ensure the correct consistency and/or texture was served but did not recall serving tea to Resident #121. During an observation on 09/23/19 at 12:43 PM NA #12 adds 2 packets of nectar thick mix to 8 oz of tea for Resident #121 per instructions on the thickener packet. She revealed drinks were made per diet card instructions and served by staff in the dining room but did not recall serving tea to Resident #121. An interview was conducted on 09/26/19 at 10:26 AM with the Director of Nursing (DON) who explained it was her expectation for staff to follow the instructions on the diet card when serving residents. The system in place was for staff to read the instructions on the diet card to ensure they served the correct consistency and/or texture. The DON felt Resident #121 was served non-thickened tea due to an oversight made by the staff. During an interview on 09/26/19 at 10:29 AM the Interim Administrator revealed it was his expectation diet orders were followed by staff serving residents. He expected residents were served the correct recommended consistency and/or texture per instructions on their diet card. He explained the system in place was for staff to read the diet card.

Based on record review and staff and resident interviews the facility failed to accurately code Minimum Data Set Assessments for 1 of 1 [MEDICAL TREATMENT] resident (Resident #55), 1 of 1 resident coded as having a restraint (Resident #103) and 1 of 1 resident coded as requiring 2 person assistance with eating (Resident #42). Findings included: 1. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #55's most recent Minimum Data Set (MDS) assessment dated [DATE] and coded as a quarterly assessment revealed Resident #55 to be cognitively intact. Resident #55 was coded as having a [DIAGNOSES REDACTED]. A review of Resident #55's care plan revealed a care plan area that reported Resident #55 had a [DIAGNOSES REDACTED]. An interview with Resident #55 on 11/27/18 at 11:49AM revealed she had been going to [MEDICAL TREATMENT] for approximately 4 years. She reported she received treatment on Monday, Wednesday and Friday every week and that she would leave the facility around 5:00AM and return to the facility around lunch time. During an interview with Hall Nurse on 11/27/18 at 11:57AM, it was reported that Resident #55 goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday every week. She reported Resident #55 had been going to [MEDICAL TREATMENT] for many years. An interview with MDS Coordinator was completed on 11/29/18 at 11:46AM. During this interview, it was reported that Resident #55's MDS assessment dated [DATE] should have reflected that Resident #55 had received [MEDICAL TREATMENT] services while a resident in the facility. It was also reported the MDS Assessment had been completed by a temporary employee that was no longer at the facility. MDS Coordinator reported the temporary employee must have over looked the coding error. During an interview with the Director of Nursing on 11/29/18 at 11:54AM revealed Resident #55's MDS assessment dated [DATE] should have reflected the [MEDICAL TREATMENT] treatment that Resident #55 was currently receiving. She reported it was her expectation that MDS Assessments be coded accurately and reflect corresponding treatments that residents received. It was reported by the Administrator during an interview on 11/29/18 at 12:01 PM that it was her expectation that MDS Assessments be coded accurately and correctly. She reported that Resident #55's MDS assessment dated [DATE] was not coded correctly when Resident #55 was coded as not receiving [MEDICAL TREATMENT]. 2. Resident #103 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident had a limb restraint that was used less than daily when the resident was in the bed. On 11/26/18 at 10:29 AM observations were made of the resident in bed that revealed there was no limb restraint in use. On 11/27/18 at 3:32 PM the MDS Coordinator was interviewed and reported the facility had no restraints that the coding of a restraint for Resident #103 was an error. On 11/29/18 at 11:43 AM the Administrator was interviewed and stated coding a restraint on the MDS was a data entry error and would be corrected. 3. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #42's Care Area Assessment (CAA) summary for Nutrition dated 01/05/18 revealed the resident was able to feed self all her meals. A review of Resident #42's quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was assessed by the facility as being cognitively intact for daily decision making. The MDS also revealed she required extensive assistance of 2 staff members for eating. A review of a Registered Dietitian noted dated 09/07/18 revealed Resident #42 was on a regular consistent carbohydrate diet (CCD) and her intake was approximately 78 percent for her meals. The note also stated the resident had good acceptance of between meal snacks and fluids. An observation on 11/26/18 at 11:40 AM revealed Resident #42 up in her recliner with fluids on her table beside her recliner. The resident stated the food at the facility was ok and some meals were better than others. Resident #42 stated she ate her meals in her room and was able to feed herself her meals. She stated there had never been a time that she could not feed herself since she was admitted to the facility. An interview on 11/29/18 at 12:43 PM with the MDS Coordinator revealed they relied on a report generated from data entry of the nurse aides (NAs) to formulate the activity of daily living (ADL) scores utilized in their MDS reporting. The MDS coordinator stated he had not been the nurse who had keyed the score of extensive assistance with eating for Resident #42 and stated he would have questioned the documentation that led to that score because he knew her and knew she fed herself. An interview on 11/29/18 at 12:55 PM was conducted with the Director of Nursing (DON). The DON stated she would have questioned the report that stated Resident #42 required 2 staff to feed her. She stated she would have expected the MDS to have been coded correctly and stated the MDS coordinator would modify the assessment.

Based on record reviews and physician and staff interviews the facility neglected to assess a surgical incision on a resident's lower back or provide daily dressing changes according to physician's orders [REDACTED].#2) for 1 of 1 resident sampled with a surgical incision. Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 5 Day Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 was moderately impaired in cognition for daily decision making. The MDS also revealed Resident #2 required extensive assistance by staff for bed mobility, transfers, dressing, toileting, bathing and was occasionally incontinent of bladder and always continent of bowel. A review of hospital discharge instructions dated 08/26/17 indicated to continue with daily dressing changes and follow up with surgeon in 2 weeks for suture removal. A review of an interim care plan dated 08/27/17 labeled skin integrity indicated to check surgical site every day. A review of nurse's progress notes dated 08/27/17 indicated the dressing on Resident #2's back was changed per order but there was no documentation regarding the appearance of the incision. A review of a physician's orders [REDACTED]. A review of a MAR dated from 08/29/17 through 09/01/17 revealed nurse's initials were documented for daily dressing changes to Resident #2's back but there were no nurse's progress notes regarding an assessment or appearance of the surgical incision. A review of a MAR dated 09/02/17 through 09/03/17 revealed there were no nurse's initials documented for daily dressing change to Resident #2's back and there were no nurse's progress notes regarding assessment or appearance of the incision. Further review of Resident #2's medical record revealed there were no progress notes or assessment of Resident #2's back incision on 09/04/17. A review of a change in condition form titled Situation, Background, Assessment/Appearance and Recommendations (SBAR) dated 09/05/17 and signed by Nurse #3 indicated a wound to Resident #2's back had a foul smell. The section labeled assessment/appearance indicated vital signs but there was no documentation of the appearance or assessment of Resident #2's surgical incision. A section on the back of the document labeled additional notes was blank. A review of a physician's progress note dated 09/06/17 indicated in part a surgical incision bandage was removed from Resident #2's back with soiled dressing and foul odor. A section labeled plan indicated to change dressings daily to absorb any serosanguineous fluid for 5 additional days and follow up with surgeon as outpatient. A review of a hospital history and physical dated 09/07/17 indicated Resident #2 returned to the surgeon's office for a 2 week follow up appointment after back surgery and her incision was draining large amounts of serosanguineous fluid (thin, watery, pink or red drainage). A section labeled physical exam revealed Resident #2's back incision had visible eschar (dry, dark scab of dead tissue) and what appeared to be the beginning of a dehiscence mid incision (rupturing of the incision). The notes further revealed the tissue did not appear to be healthy with large amounts of serosanguineous drainage with applied pressure and was foul smelling. A section labeled assessment and plan revealed Resident #2 would be admitted to the hospital for wound irrigation, debridement, wound revision, obtain cultures and consult infectious disease for antibiotics. During an interview on 10/03/17 at 2:57 PM, the Director of Nursing (DON) explained the wound nurse was not available for interview because she was away for 2 weeks but they had a part-time wound nurse (Nurse #2) who did wound treatments when the wound nurse was not available. She further explained the nurse assigned to the resident was also responsible for doing wound treatments when a wound nurse was not working in the facility. During an interview on 10/03/17 at 3:16 PM, Nurse #2 stated she provided wound treatments when the wound nurse was not working at the facility but did not recall dressing changes or assessments of Resident #2's surgical incision on her back. She explained documentation of wounds was supposed to be done on the MAR and assessments of wounds were usually written in the nurse's progress notes. During a follow up interview on 10/03/17 at 3:33 PM the DON confirmed Resident #2 was ordered by her surgeon to have a dry dressing daily to her lower back incision for 1 week. She stated it was her expectation for nursing staff to assess surgical incisions and should document their assessments. During an interview on 10/03/17 at 3:53 PM, Physician #1 who was also the facility Medical Director explained he did not examine Resident #2 but recalled Physician #2 had examined her because of wound drainage. He stated it was his expectation for nursing staff to follow physician's orders [REDACTED]. He further stated if an incision was foul smelling or had more drainage than what the resident came to the facility with nursing staff should call the surgeon to see what they wanted them to do. During a telephone interview on 10/04/17 at 9:19 AM, Nurse #3 who had signed the SBAR on 09/05/17 stated she recalled Resident #2 but did not recall anything about the surgical incision, odor or drainage. She explained she did not recall filling out the SBAR and explained if she had done an assessment of the incision she would have documented it on the SBAR or in the nurse's progress notes. During an interview on 10/04/17 at 10:25 AM, Physician #2 confirmed she had examined Resident #2 on 09/06/17 because a nurse had completed an SBAR which indicated Resident #2 had a wound with a foul smell. She explained she examined Resident #2 who had recently had spinal surgery and the bandage on her incision was soiled with serosanguineous drainage. She stated she called the wound nurse to the room and instructed her to clean it. She further stated she expected to see the dressing dated and signed but it was not signed or dated so she was not sure how long it had been since the dressing had been changed. She explained it was her understanding Resident #2 went for a follow up appointment on 09/07/17 and from there was sent to the hospital and had not returned to the facility. During an interview on 10/04/17 at 12:00 PM the DON verified there was no nursing documentation after 08/28/17 regarding assessments or appearance of the surgical incision. She confirmed there were no staff initials on the MAR for dressing changes on 09/02/17 or 09/03/17 and she felt the dressing had not been changed on those days. During an interview on 10/04/17 at 12:30 PM with the Administrator and DON, the Administrator verified after review of the SBAR dated 09/05/17 there was documentation of Resident #2's vital signs but there was no documentation of an assessment of Resident #2's surgical incision and there was no assessment of the surgical incision documented in the nurse's progress notes on 09/05/17. The DON stated she would have expected to see nurse's progress notes and assessments to describe the length of the incision, any redness, what the drainage looked like and a description of the odor. The DON explained the nurse who should have done the dressing changes on 09/02/17 and 09/03/17 no longer worked at the facility. On 10/05/17 at 3:05 PM a telephone call was received from Resident #2's Orthopedic Surgeon. He stated Resident #2 came to his office on 09/07/17 for what was supposed to be a routine 2 week follow up visit for suture removal after spinal surgery. He explained Resident #2's surgical incision on her lower back had a foul odor and there was wound dehiscence and it was not well healed as he had expected. He stated he had to take Resident #2 to surgery that night to wash and clean it out and he cultured the wound and it was infected with bacteria from urine. He explained Resident #2 was elderly and deconditioned and had not mobilized quickly which put her at greater risk for wound contamination. He further explained Resident #2's family had told him Resident #2 wore a brief at the facility and he felt the dressing had been saturated or soiled with urine which then contaminated the wound. He stated it was his expectation for attention to have been given to the wound and it should have been kept clean and dressed according to his orders to prevent infection.

Based on record reviews and physician and staff interviews the facility failed to assess a surgical incision on a resident's lower back or provide daily dressing changes according to physician's orders [REDACTED].#2) for 1 of 1 resident sampled with a surgical incision. Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 5 Day Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 was moderately impaired in cognition for daily decision making. The MDS also revealed Resident #2 required extensive assistance by staff for bed mobility, transfers, dressing, toileting and bathing and was occasionally incontinent of bladder and always continent of bowel. A review of hospital discharge instructions dated 08/26/17 indicated to continue with daily dressing changes and follow up with surgeon in 2 weeks for suture removal. A review of a monthly Medication Administration Record (MAR) dated 08/26/17 through 08/31/17 indicated handwritten notes for dry dressing (low back) for 1 week and change every day until the last day 09/01/17. A review of nurse's progress notes dated 08/26/17 indicated Resident #2 was admitted to the facility and had a dressing to her back with no drainage noted. A review of an interim care plan dated 08/27/17 indicated in a section labeled skin integrity and check surgical site every day. A review of nurse's progress notes dated 08/27/17 indicated the dressing on Resident #2's back was changed per order but there was no documentation regarding the appearance of the incision. A review of a physician's orders [REDACTED]. A review of nurse's progress notes dated 08/28/17 indicated the dressing was changed on Resident #2's back per order and there were no signs or symptoms of infection. A review of a MAR dated from 08/29/17 through 08/31/17 revealed nurse's initials were documented for daily dressing changes to Resident #2's back but there were no nurse's progress notes regarding an assessment or appearance of the surgical incision. A review of a MAR dated 09/01/17 revealed nurse's initials were documented for a daily dressing change to Resident #2's back but there were no nurse's progress notes regarding assessment or appearance of the incision. Further review of a MAR dated 09/01/17 indicated dry dressing to surgical incision on Resident #2's back until 09/03/17. A review of a MAR dated 09/02/17 revealed there were no nurse's initials documented for daily dressing change to Resident #2's back and there were no nurse's progress notes regarding assessment or appearance of the incision. A review of a MAR dated 09/03/17 revealed there were no nurse's initials documented for daily dressing change to Resident #2's back and there were no nurse's progress notes regarding assessment or appearance of the incision. Further review of nurse's progress notes revealed there were no progress notes or assessment of Resident #2's back incision on 09/04/17. A review of a change in condition form titled Situation, Background, Assessment/Appearance and Recommendations (SBAR) dated 09/05/17 and signed by Nurse #3 indicated a wound to Resident #2's back had a foul smell. The section labeled assessment/appearance indicated vital signs were blood pressure 102/71, pulse 83, respirations 16, temperature 98 degrees Fahrenheit and pulse oximetry was 96 percent but there was no documentation of the appearance or assessment of Resident #2's surgical incision. A section on the back of the document labeled additional notes was blank. A review of a physician's progress note dated 09/06/17 indicated in part a surgical incision bandage was removed from Resident #2's back with soiled dressing and foul odor. A section labeled plan indicated to change dressings daily to absorb any serosanguineous fluid for 5 additional days and follow up with surgeon as outpatient. A review of a hospital history and physical dated 09/07/17 indicated Resident #2 returned to the surgeon's office for a 2 week follow up appointment after back surgery and her incision was draining large amounts of serosanguineous fluid (thin, watery, pink or red drainage). A section labeled physical exam revealed Resident #2's back incision had visible eschar (dry, dark scab of dead tissue) and what appeared to be the beginning of a dehiscence mid incision (rupturing of the incision). The notes further revealed the tissue did not appear to be healthy with large amounts of serosangineous drainage with applied pressure and was foul smelling. A section labeled assessment and plan revealed Resident #2 would be admitted to the hospital for wound irrigation and debridement and wound revision and obtain cultures and consult infectious disease for antibiotics. A review of a hospital discharge summary dated 09/14/17 indicated Resident #2 went for a 2 week follow up appointment on 09/07/17 and her incision had opened and was grossly infected. The summary revealed Resident #2 was admitted to the hospital for irrigation and debridement and wound revision the same day and a [DEVICE] was placed over the incision to assist with healing, a urinary catheter was kept in place to prevent wound contamination due to wound cultures revealed urine bacteria was present in the incision and caused the wound infection and antibiotics were given through a peripherally inserted central catheter (PICC line) to continue for at least 6 weeks until the infection resolved. During an interview on 10/03/17 at 2:57 PM, the Director of Nursing (DON) confirmed the facility had a full-time wound nurse who worked during the week from 7:30 AM-3:30 PM. She explained the wound nurse was not available for interview because she was away for 2 weeks but they had a part-time nurse (Nurse #2) who was trained by the wound nurse and did wound treatments when the wound nurse was not available. She further explained the nurse assigned to the resident was also responsible for doing wound treatments when a wound nurse was not working in the facility. During an interview on 10/03/17 at 3:16 PM, Nurse #2 stated she provided wound treatments when the wound nurse was not working at the facility. She explained if a resident had a surgical wound, the treatment was ordered by the surgeon and if a wound did not look good she would call and let the physician or surgeon know. She stated she did not recall dressing changes or assessments of Resident #2's surgical incision on her back. During a follow up interview on 10/03/17 at 3:33 PM the DON confirmed Resident #2 was ordered by her surgeon to have a dry dressing daily to her lower back incision for 1 week. She stated it was her expectation for nursing staff to assess surgical incisions and should document their assessments. During an interview on 10/03/17 at 3:53 PM, Physician #1 who was also the facility Medical Director explained he did not examine Resident #2 but recalled Physician #2 had examined her because of wound drainage. He stated it was his expectation for nursing staff to follow physician's orders [REDACTED]. He further stated if a wound or incision was foul smelling or had more drainage than what the resident came to the facility with nursing staff should call the surgeon to see what they wanted them to do. During a telephone interview on 10/04/17 at 9:19 AM, Nurse #3 who had signed the SBAR on 09/05/17 stated she recalled Resident #2 but did not recall anything about the surgical incision, odor or drainage. She explained she did not recall filling out the SBAR and explained if she had done an assessment of the incision she would have documented it on the SBAR or in the nurse's progress notes. She further stated she usually wrote a note in the nurse's progress notes if she did an assessment of a wound or a surgical incision. During an interview on 10/04/17 at 10:25 AM, Physician #2 confirmed she had examined Resident #2 on 09/06/17 because a nurse had completed an SBAR because Resident #2 had a wound with a foul smell. She explained she examined Resident #2 who had recently had spinal surgery and the bandage on her incision was soiled with serosanguineous drainage. She stated she called the wound nurse to the room and instructed her to clean it. She further stated she could not identify when the dressing had last been changed because it was not signed or dated so she was not sure how long it had been since the dressing had been changed. She explained she wrote orders for dressing changes to continue for 5 more days because she was trying to prevent soiling of Resident #2's clothing. She stated it was her understanding Resident #2 went for a follow up appointment on 09/07/17 and from there was sent to the hospital and had not returned to the facility. During an interview on 10/04/17 at 12:00 PM the DON verified Resident #2 had an interim care plan which indicated to check surgical site every day but there was no documentation after 08/28/17 regarding assessments or appearance of the surgical incision. She confirmed there was no documentation of dressing changes on 09/02/17 or 09/03/17 because there were no initials on the MAR and because there were no initials she felt the dressing had not been changed. During an interview on 10/04/17 at 12:30 PM with the Administrator and DON, the Administrator stated an assessment was supposed to be completed as part of the SBAR but after review of the SBAR dated 09/05/17 he verified there was only documentation of Resident #2's vital signs. He confirmed there was no additional documentation of the surgical incision and no assessment of the surgical incision in the nurse's progress notes on 09/05/17. The DON stated she would have expected to see nurse's progress notes and assessments to describe the length of the incision, any redness, what the drainage looked like and a description of the odor. She verified the back of the S-Bar was available for the nurse to use for additional nurse's notes and should have been used to describe the appearance of the surgical incision. The DON explained the nurse who should have done the dressing changes on 09/02/17 and 09/03/17 no longer worked at the facility. On 10/05/17 at 3:05 PM a telephone call was received from Resident #2's Orthopedic Surgeon. He stated Resident #2 came to his office on 09/07/17 for what was supposed to be a routine 2 week follow up visit for suture removal after spinal surgery. He explained Resident #2's surgical incision on her lower back had a foul odor and there was wound dehiscence and it was not well healed as he had expected. He stated he had to take Resident #2 to surgery that night to wash and clean it out and he cultured the wound and it was infected with bacteria from urine. He explained Resident #2 was elderly and deconditioned and had not mobilized quickly which put her at greater risk for wound contamination. He further explained Resident #2's family had told him Resident #2 wore a brief at the facility and he felt the dressing had been saturated or soiled with urine which then contaminated the wound. He stated it was his expectation for attention to have been given to the wound and it should have been kept clean and dressed according to his orders to prevent infection.

Based on record reviews and staff interviews the facilities Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the recertification survey of 10/06/16. This was for one recited deficiency which was originally cited in October 2016 and was subsequently recited on the current follow up and complaint survey of 10/05/17. The repeat deficiency was in the area to provide care to maintain well-being. The continued failure of the facility during two federal surveys of record show a pattern of the facilities inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referred to: F 309: Provide Care to Maintain Well Being: Based on record reviews and physician and staff interviews the facility failed to assess a surgical incision on a resident's lower back or provide daily dressing changes according to physician's orders [REDACTED].#2) for 1 of 1 resident with a surgical incision. During the recertification survey of October 6, 2016 the facility was cited at F 309 for failure to follow a physician order [REDACTED]. During an interview on 10/04/17 at 1:21 PM, the Administrator explained the facility conducted monthly Quality Assessment and Assurance meetings and the Administrator, Director of Nursing, Medical Director, Pharmacist and various department managers attended the meetings. He confirmed plans of correction were ongoing topics at the meetings. He stated for past deficiencies they maintained some sort of auditing either on a monthly basis or for some period of time in order to try and avoid repeat deficiencies.

Based on record reviews, staff, nurse practitioner and physician interviews the facility failed to notify the physician of a resident with difficulty breathing and the inability to collect an ordered laboratory test for 1 of 3 residents reviewed for notification of change (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Admission Cognitive Status revealed Resident #3 was alert and oriented to person, place and time. A review of physician's orders [REDACTED]. [MEDICATION NAME], a blood thinner, 3 milligrams (mg) by mouth once a day for [MEDICAL CONDITION]. [MEDICATION NAME], a blood thinner, 80 milligrams by injection every 12 hours for [MEDICAL CONDITION]. The nurse's note dated 04/03/15 at 2:30 AM revealed a late entry for 04/02/15. The note indicated Resident #3 had a black bowel movement at 7:00 PM and a second positive hemoccult was collected and the physician was notified. The new orders were for vital signs to be obtained every hour, a complete blood count (a blood test) to be drawn immediately, a [MEDICATION NAME] time (PT)/international normalized ratio (INR), (a test to monitor the effectiveness of the blood thinner to assure it is at a therapeutic level without causing excessive bleeding), to be done immediately, and withhold Resident #3's blood pressure medication. The note revealed the PT/INR was attempted 6 times and each time an error message was received with the last message stating the blood was too thin to read. The note further indicated at 1:30 AM Resident #3 had a third positive hemoccult test with the stool being a black pudding consistency and Resident #3 had complained of difficulty breathing at the 1:30 AM vital sign check. The note revealed Resident #3 had 15 plus bruises on her arms and legs and no other complaints of difficulty breathing at that time. There was no indication from the nurse's note that the physician was notified of the nurse not being able to collect the PT/INR or Resident #3's difficulty breathing at 1:30 AM on 04/03/15. Review of the nurse's note dated 04/03/15 at 10:20 AM revealed Resident #3 was diaphoretic, finger tips were blue and she was very pale with vital signs of oxygen saturation 92%, respirations 24, pulse 67, fasting blood sugar 100 and blood pressure 119/70. The note stated Resident #3's oxygen saturation dropped to 67% and oxygen was increased to 3 liters per minute via nasal cannula with the oxygen saturation not coming up. The note further revealed a call was placed to the Nurse Practitioner with an order received to send Resident #3 to the hospital for evaluation. Review of the hourly vital signs for Resident #3 on 04/02/15 through 04/03/15 from 7:30 PM to 8:30 AM revealed the vital signs to be within normal limits with no major fluctuations. There were no vital sign checks between 8:30 AM and 10:20 AM. A review of the hospital emergency department report dated 04/03/15 at 2:36 PM indicated Resident #3 was admitted with a gastrointestinal hemorrhage (bleeding) and [MEDICAL CONDITION] (a decrease in the amount of red blood cells) secondary to the hemorrhage. The records indicated Resident #3 received a unit of blood during transport to the hospital and another unit of blood upon arrival to the hospital with a hemoglobin, (a protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon [MEDICATION NAME] from the body's tissues back to the lungs), of 6.1 with the normal hemoglobin range being 11.5 to 15.0. Resident #3 was discharged from the hospital in stable condition on 04/16/15. During an interview conducted on 06/18/15 at 3:35 PM with Nurse #1 she confirmed she provided care to Resident #3 during the 7:00 PM to 7:00 AM shift of 04/02/15 through 04/03/15. She stated the nurse aide (NA) asked her to look at Resident #3's stool because it was very black. Nurse #1 stated she followed the facility Standing Orders and collected a hemoccult which was positive Nurse #3 that was going off duty called the Nurse Practitioner with the positive results and received orders for vital sign checks every hour, a stat CBC and PT/INR and to hold the blood pressure medication. She stated she attempted to collect the PT/INR 6 times and each time the machine gave her an error message with the last message stating the blood was too thin to read, she reported she did not notify the physician or the Nurse Practitioner she was unable to collect the PT/INR. Nurse #1 stated she started vital sign checks at 7:30 PM. She explained that Resident #3 complained of difficulty breathing at the 1:30 AM vital sign check and had not had any prior complaints of difficulty breathing and she assumed it was from her cracked ribs. She reported she asked Resident #3 if the difficulty breathing was from her cracked ribs and Resident #3 stated it might be. She stated she did not notify the physician of Resident #3's complaint of difficulty breathing at 1:30 AM and did not provide Resident #3 with any interventions to relieve difficulty breathing. During an interview on 06/18/15 at 3:46 PM with Nurse #2 she confirmed she was assigned to care for Resident #3 on 04/03/15 during the 7:00 AM to 3:00 PM shift. She stated she was not informed during the shift report Resident #3 had 2 positive hemoccults, difficulty breathing during the night and vital signs ordered every hour and she did not see the new order for hourly vital sign checks. Nurse #2 stated she looked in on Resident #3 from the hallway at the beginning of her shift and when she went in to see her at approximately 10:00 AM she was diaphoretic, her finger tips were blue and she was very pale. Nurse #2 stated she assessed Resident #3's vital signs and checked her oxygen saturation due to her finger tips being blue. She stated Resident #3 was receiving 2 liters of oxygen via nasal cannula per physician orders [REDACTED]. Nurse #2 stated the Nurse Leader called the Nurse Practitioner and received an order to send Resident #3 to the hospital for evaluation. The nurse aide that worked with Resident #3 on the 7:00 AM to 3:00 PM shift on 04/03/15 was not available for interview. During an interview conducted on 06/18/15 at 5:01 PM with the Nurse Practitioner (NP) she revealed it was her expectation to be notified if a resident had a change in condition or physician orders [REDACTED]. She stated she should have been notified when Nurse #1 was unable to collect the PT/INR and when Resident #3 complained of difficulty breathing with the 1:30 AM vital sign check. The NP stated she would have sent Resident #3 out for evaluation at that time due to the possibility of a gastrointestinal (GI) bleed. During an interview on 06/18/15 at 5:05 PM with the Director of Nursing (DON) she confirmed it was her expectation if an order was received to collect a stat PT/INR and the nurse was unable to obtain the PT/INR the Physician should have been notified. The DON stated vital signs should have been checked every hour until the Physician discontinued the order and she could not find any vital sign checks from 8:30 AM until 10:20 AM on 04/03/15 for Resident #3. She further stated the nurse should have completed a Situation Background Assessment Request (SBAR) Communication Form for Resident #3 for the positive hemoccults and difficulty breathing and notified the Physician and oncoming nurse. During an interview conducted on 06/19/15 at 9:07 AM with the Physician he stated he would not have been concerned if the nurse had been unable to obtain the ordered PT/INR if the resident was clinically stable but he did want to know that she was having difficulty breathing. He stated he would have sent her out for evaluation at that time due to a possible GI bleed. The Physician further stated if he ordered vital signs to be checked every hour he expected them to be checked until he discontinued the order.

Based on record reviews, staff, nurse practitioner and physician interviews the facility failed to report a resident change in condition to the oncoming shift; failed to provide ongoing assessment of a resident with difficulty breathing and failed to obtain a physician ordered laboratory test 1 of 3 sampled residents with a change in condition (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Admission Cognitive Status revealed Resident #3 was alert and oriented to person, place and time. The Minimum Data Set (MDS) had not been completed for Resident #3. Review of Resident #3's care plan dated 03/23/15 revealed she had the potential for medication side effects related to the use of blood thinners. The goal was for Resident #3 to have no side effects from the medications that resulted in injury for the next 2 weeks. Interventions included monitor for side effects as related to the medication, monitor for changes in behavior, monitor labs as ordered, monitor for change in mental status, consult Physician as needed and pharmacy to review drug regime monthly. A review of physician's orders [REDACTED]. [MEDICATION NAME], (a blood thinner), 3 milligrams (mg) by mouth once a day for [MEDICAL CONDITION]. [MEDICATION NAME], (a blood thinner), 80mg by injection every 12 hours for [MEDICAL CONDITION]. Review of the facility Physician Standing Orders for suspected bloody stools or emesis stated to collect a hemoccult and notify the Provider if positive. Review of the nurse's note dated 04/02/15 at 6:00 PM revealed Resident #3 had a dark chocolate colored stool and a hemoccult (a test for presence of blood in stool) was collected and was positive. The note indicated the physician was notified and new orders were received. The nurse's note dated 04/03/15 at 2:30 AM revealed a late entry for 04/02/15. The note indicated Resident #3 had a black bowel movement at 7:00 PM and a second positive hemoccult was collected and the physician was notified. The new orders were for vital signs to be obtained every hour, a complete blood count (a blood test) to be drawn immediately, a [MEDICATION NAME] time (PT)/international normalized ratio (INR), (a test to monitor the effectiveness of the blood thinner to assure it is at a therapeutic level without causing excessive bleeding), to be done immediately, and withhold Resident #3's blood pressure medication. The note revealed the PT/INR was attempted 6 times and each time an error message was received with the last message stating the blood was too thin to read. The note further indicated at 1:30 AM Resident #3 had a third positive hemoccult test with the stool being a black pudding consistency and Resident #3 had complained of difficulty breathing at the 1:30 AM vital sign check. The note revealed Resident #3 had 15 plus bruises on her arms and legs and no other complaints of difficulty breathing at that time. There was no indication from the nurse's note that the physician was notified of the nurse not being able to collect the PT/INR or Resident #3's difficulty breathing at 1:30 AM on 04/03/15. Review of the nurse's note dated 04/03/15 at 10:20 AM revealed Resident #3 was diaphoretic, finger tips were blue and she was very pale with vital signs of oxygen saturation 92%, respirations 24, pulse 67, fasting blood sugar 100 and blood pressure 119/70. The note stated Resident #3 ' s oxygen saturation dropped to 67% and oxygen was increased to 3 liters per minute via nasal cannula with the oxygen saturation not coming up. The note further revealed a call was placed to the Nurse Practitioner with an order received to send Resident #3 to the hospital for evaluation. Review of the hourly vital signs for Resident #3 on 04/02/15 through 04/03/15 from 7:30 PM to 8:30 AM revealed the vital signs to be within normal limits with no major fluctuations. There were no vital sign checks between 8:30 AM and 10:20 AM. A review of the hospital emergency department report dated 04/03/15 at 2:36 PM indicated Resident #3 was admitted with a gastrointestinal hemorrhage (bleeding) and [MEDICAL CONDITION] (a decrease in the amount of red blood cells) secondary to the hemorrhage. The records indicated Resident #3 received a unit of blood during transport to the hospital and another unit of blood upon arrival to the hospital with a hemoglobin, (a protein molecule in red blood cells that carries oxygen from the lungs to the body ' s tissues and returns carbon [MEDICATION NAME] from the body's tissues back to the lungs), of 6.1 with the normal hemoglobin range being 11.5 to 15.0. Resident #3 was discharged from the hospital in stable condition on 04/16/15. During an interview conducted on 06/18/15 at 3:35 PM with Nurse #1 she confirmed she provided care to Resident #3 during the 7:00 PM to 7:00 AM shift of 04/02/15 through 04/03/15. She stated the nurse aide (NA) asked her to look at Resident #3's stool because it was very black. Nurse #1 stated she followed the facility Standing Orders and collected a hemoccult which was positive Nurse #3 that was going off duty called the Nurse Practitioner with the positive results and received orders for vital sign checks every hour, a stat CBC and PT/INR and to hold the blood pressure medication. She stated she attempted to collect the PT/INR 6 times and each time the machine gave her an error message with the last message stating the blood was too thin to read, she reported she did not notify the physician she was unable to collect the PT/INR. Nurse #1 stated she started vital sign checks at 7:30 PM. She explained that Resident #3 complained of difficulty breathing at the 1:30 AM vital sign check and had not had any prior complaints of difficulty breathing and she assumed it was from her cracked ribs. She reported she asked Resident #3 if the difficulty breathing was from her cracked ribs and Resident #3 stated it might be. She stated she did not notify the physician of Resident #3's complaint of difficulty breathing at 1:30 AM and did not provide Resident #3 with any interventions to relieve difficulty breathing. During an interview on 06/18/15 at 3:46 PM with Nurse #2 she confirmed she was assigned to care for Resident #3 on 04/03/15 during the 7:00 AM to 3:00 PM shift. She stated she was not informed during the shift report Resident #3 had 3 positive hemoccults, difficulty breathing during the night and vital signs ordered every hour and she did not see the new order for hourly vital sign checks. Nurse #2 stated she looked in on Resident #3 from the hallway at the beginning of her shift and when she went in to see her at approximately 10:00 AM she was diaphoretic, her finger tips were blue and she was very pale. Nurse #2 stated she assessed Resident #3's vital signs and checked her oxygen saturation due to her finger tips being blue. She stated Resident #3 was receiving 2 liters of oxygen via nasal cannula per physician orders [REDACTED]. Nurse #2 stated the Nurse Leader called the Nurse Practitioner and received an order to send Resident #3 to the hospital for evaluation. The nurse aide that worked with Resident #3 on the 7:00 AM to 3:00 PM shift on 04/03/15 was not available for interview. During an interview conducted on 06/18/15 at 5:01 PM with the Nurse Practitioner (NP) she revealed it was her expectation to be notified if a resident had a change in condition or physician orders [REDACTED]. She stated she should have been notified when Nurse #1 was unable to collect the PT/INR and when Resident #3 complained of difficulty breathing with the 1:30 AM vital sign check. The NP stated she would have sent Resident #3 out for evaluation at that time due to the possibility of a gastrointestinal (GI) bleed. During an interview on 06/18/15 at 5:05 PM with the Director of Nursing (DON) she confirmed it was her expectation if an order was received to collect a stat PT/INR and the nurse was unable to obtain the PT/INR the Physician should have been notified. The DON stated vital signs should have been checked every hour until the Physician discontinued the order and she could not find any vital sign checks from 8:30 AM until 10:20 AM on 04/03/15 for Resident #3. She further stated the nurse should have completed a SBAR Communication Form for Resident #3 for the positive hemoccults and difficulty breathing and notified the Physician and oncoming nurse. During an interview conducted on 06/19/15 at 9:07 AM with the Physician he stated he would not have been concerned if the nurse had been unable to obtain the ordered PT/INR if the resident was clinically stable but he did want to know that she was having difficulty breathing. He stated he would have sent her out for evaluation at that time due to a possible GI bleed. The Physician further stated if he ordered vital signs to be checked every hour he expected them to be checked until he discontinued the order.

Based on observations, record review, family, and staff interviews, the facility failed to assess a resident with a healed pressure sore which progressed to a stage 4 pressure sore and failed to conduct weekly skin assessments for 1 of 3 residents reviewed for pressure sores (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition for daily decision making. The MDS also indicated Resident #1 required extensive assistance of 1 or 2 person physical assist for activities of daily living (ADLs) and Section M of the MDS titled Skin Conditions indicated Resident #1 was at risk for developing pressure sores and having 1 stage 2 pressure sore and 1 stage 4 pressure sore. A review of an updated care plan with a dated 02/28/15 indicated a problem statement of at risk for skin breakdown related to limited mobility and incontinence. The goals indicated resident would remain free of skin breakdown and the approaches were listed in part to provide incontinence care as needed, provide treatments as ordered, assist with turning and repositioning as needed, weekly and as needed skin assessments, and check skin closely during bathing. The care plan further indicated Resident #1 had a pressure sore of the coccyx which had healed as of 01/13/15. A review of the wound physician's note dated 03/03/15 read in part stage 3 pressure sore of the coccyx resolved (healed) and to follow up as needed. A review of a weekly skin integrity review dated 03/14/15 indicated in a section labeled Current Skin Condition: Redness, Open Area to the sacral area. However, there was no description of the open area. A review of a physician's orders [REDACTED]. A review of weekly wound measurements dated from 03/03/15 to 03/24/15 revealed there were no wound measurements or descriptions for the open area on Resident # 1's buttocks. A review of a physician's orders [REDACTED]. (used to wet certain types of dressings for wounds). During an interview on 06/17/15 at 12:03 PM Resident #1's family member stated the resident's skin was very fragile and tore very easily. She explained Resident #1 had a sore on her bottom that had healed in March. The family member explained the sore had re-opened around the first of April because the resident sat on in her wheelchair so much and caused pressure to the area. The family member stated it had a dressing on it and it was being changed once a day. The family member further stated she had requested to have a second opinion of the pressure sore. During an observation of wound care on 06/17/15 at 2:48 PM Nurse #3 removed Resident #1's brief and cleaned an open area on the resident's buttocks with wound cleanser. The open area was oozing a small amount of blood around the edges and Nurse #3 applied a Dakin's solution inside the open area and secured the dressing to the resident's skin with gauze and paper tape dressing. During an interview on 06/17/15 at 3:22 PM Nurse #3 explained the facility does not have a wound nurse and the hall nurses were responsible for doing there resident's wound care. Nurse #3 explained the wound on Resident #1's bottom was a large opened area with necrotic tissue (dead tissue with inadequate blood supply) and had been classified as a stage 4 pressure sore. She stated the dressing changes were supposed to be done once daily with santyl and twice daily with a Dakin's solution wet to dry dressing. She stated she did not change the dressing using the santyl ointment because she had forgotten and was nervous. She indicated she was not sure when the santyl ointment dressing was last changed and she had not measured the area because she was unaware she needed to do measurements. During an interview on 06/18/15 at 10:07 AM with Nurse #4 she stated she had changed Resident #1's dressing on her buttocks on Monday 06/15/15 because the dressing had come off. She described the wound as circular and approximately 4 centimeters long x approximately 3 centimeters wide and the wound was clean. She stated the nurses did not measure any wounds and Resident #1's wound was still classified as thick necrotic tissue. During an observation of wound care on 06/18/15 at 10:37 AM Nurse #4 showed the Nurse Mentor/Unit Manager the open area on Resident #1's buttocks and provided wound care. During an interview on 06/18/15 at 10:45 AM the Nurse Mentor/Unit Manager stated the wound on Resident #1's buttocks was a stage 4 pressure sore and was not necrotic tissue. She also verified documentation on weekly skin integrity sheets was unclear and there should have been documentation as to exactly where the wound was located and the stage of the wound. During an interview on 06/18/15 at 12:36 PM the Director of Nursing explained the nurses assessed pressure sores but did not do wound measurements each week. She explained the nurse who was assigned to the resident did the weekly skin assessments and if they saw something it was her expectation for them to report it to the nurse mentor/unit manager and she should report it at the daily meeting. She further explained she expected the nurse aides (NAs) to report concerns about resident's skin when they gave residents showers and baths and the nurses should report any new skin concerns to the physician. During an interview on 06/19/15 at 9:15 AM the facility's physician stated he was not aware of Resident #1's wound on her buttocks until staff told him about it after he had arrived at the facility that morning. He stated he assessed wounds when residents were admitted to the facility or when the nurse had questions and he expected to be called if a resident's condition worsened.

Based on observations, staff interviews, physician interviews and record reviews, facility staff failed to assess the resident's lower extremities following reports of increased pain, coldness, bluish discoloration and lack of palpable pulses in one (1) of six (6) sampled residents. (Resident #1). The findings are: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of a facility document titled "Comprehensive Pain Evaluation" dated 10/11/11 stated Resident #1 had pain in his left (L) hip and (L) leg. The pain was documented as seven (7) and described as "throbbing" based on a pain scale of one (1) "no pain" to ten" (10) "worst pain." A review of facility documents titled "Nursing Progress Summary" (weekly assessment) by Licensed Nursing (LN) staff indicated on 10/11/11 Resident #1's pain was "severe" and rated ten (10) on the pain scale. Handwritten notes indicated pain was located in his left hip. A review of Physicians Orders dated 10/11/11 stated [MEDICATION NAME] Extended Release (ER)15 milligrams orally twice a day at scheduled times; [MEDICATION NAME] 5/325 milligrams one (1) tablet orally every four (4) hours as needed for mild pain and [MEDICATION NAME] 5/325 milligrams two (2) tablets orally every four (4) hours as needed for moderate to severe pain. On 10/12/11 a physician's orders [REDACTED]. On 10/13/11 physician's orders [REDACTED]. A review of therapy notes dated 10/12/11 indicated a physical therapy evaluation was completed and the plan of care was discussed with Resident #1 for therapy to occur twice daily. The admission Minimum Data Set ((MDS) dated [DATE] indicated no impairment in short and long term memory and no impairment in cognition for daily decision making. The resident required extensive assistance by staff for transfers and supervision during ambulation with one person physical assistance. A review of a Care Area Assessment Summary dated 10/18/11 was titled "Pain" and indicated the location as left lower extremity. The document stated medications "make it better, therapy makes it worse" and it occurs "frequently." A review of a Care plan dated 10/18/11 indicated Resident #1 was at risk for pain. The interventions included to assist with repositioning to promote comfort and to assess necessity for pain medication prior to therapies to allow improved mobility and therapy participation. On 10/19/11 the nursing progress summary indicated Resident #1's pain was "severe" and the pain was rated as nine (9). There was no documentation regarding the location of the pain. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. A review of a hand-written Podiatrist note dated 10/31/11 revealed Resident #1 was seen due to long toenails and bluish discoloration on left (L) foot. The Podiatrist's notes stated in part no palpable pulses and probably will consider non-invasive arterial study of bilateral lower extremities. A review of physician's orders [REDACTED]. A review of a Licensed Physical Therapy Assistant (LPTA) note dated 11/01/11 for Resident #1 stated in part "second scheduled treatment session, left (L) foot/ankle cold to touch and with blue discolored spots." The documentation stated she reported it to the nurse who took care of the resident on 11/01/11 and documented the nurse stated the physician was already aware. Resident # 1's (L) foot pain was documented as eight (8). A review of the nurse's notes dated 11/01/11 stated "resident did complain of pain. Pain medication was given with relief." There were no nurses notes regarding an assessment of Resident #1's left (L) foot. On 11/02/11 the nursing progress summary indicated Resident #1's pain was "severe" and was rated nine (9). The hand-written notes stated "continues on pain management" but there was no documentation regarding the location of the pain. A review of the nurse's notes dated 11/07/11 at 10:45 AM revealed LN #1 documented "(L) foot cold to touch. No palpable pedal pulse and blue spots top (L) foot and bottom. (L) foot with cyanosis tip great toe." The Physician Assistant (PA) was informed and used a Doppler to check for pulses and said there was no pedal pulse. At 11:30 AM LN #1 called the resident's daughter to inform her he was being transported to the emergency room (ER) and at 11:45 AM LN #1 documented Emergency Medical Services (EMS) was transporting resident out of facility to the ER. During an interview on 12/05/11 at 2:08 PM Licensed Nurse (LN) #1 stated Resident # 1 complained to her about leg pain bilaterally. She stated the resident told her frequently that his legs just "ached and described it like restless leg syndrome." She explained on the morning of 11/07/11 she put the [MEDICATION NAME] gel on his left (L) foot and his (L) foot was cool to touch and the left (L) big toe was slightly blue. She stated she notified the Physician's Assistant (PA) who was in the facility. LN #1 stated she had never noticed his (L) foot was discolored until the morning he went to the hospital. During an interview on 12/05/11 at 3:00 PM the Nurse Manager explained on 10/28/11 Resident #1 had bilateral heel pain, had an x-ray in the facility to rule out heel spurs and the X-rays were negative. She further stated he went to see a Podiatrist on 10/31/11 for long toenails. She explained the Podiatrist sent a hand-written note regarding his evaluation back to the facility and the document was initialed on 11/01/11 as reviewed by the Family Nurse Practitioner (FNP). The Nurse Manager verified there were no nursing assessment notes in the medical record on 11/01/11 when therapy staff reported Resident #1's left (L) foot was cold and had a bluish discoloration. She further stated on 11/02/11 there was a weekly assessment in Resident #1's medical record which indicated he was having severe pain and the pain limited his day to day activities and made it hard for him to sleep. During an interview on 12/05/11 at 3:33 PM LN #2 stated Resident #1 complained of bilateral pain in his lower extremities on 10/28/11. She further stated she left a note for the physician to evaluate him and they prescribed pain cream for his heels on 10/28/11. She explained she usually applied the pain cream on her shift around eight (8) PM. She stated she checked for any swelling, discoloration or pedal pulses but did not document any assessment information in the nurses notes when she took care of the resident on November 1st, 3rd,4th, 5th, & 6th. She further stated Resident #1 complained of leg pain on November 5th and 6th and she did not document any assessment information on these dates. During a phone interview on 12/05/11 at 3:53 PM LN #3 stated she was Resident #1's nurse on the day shift on 11/01/11 and remembered he had foot problems and pain was an ongoing issue with him. She explained he had a topical ointment for pain in his feet that she put on him but later in her shift he said his feet were hurting again so she filled out a change of condition form for the Family Nurse Practitioner (FNP) but did not call the FNP to come and see the resident. She stated therapy staff talked with her on 11/01/11 and asked her to take Resident #1's Ted Hose off but she did not remember therapy staff reporting to her the resident's left (L) foot was cold or discolored. LN #3 further stated she did not document any assessment notes on 11/01/11 but gave report to the next shift about Resident #1's complaints of pain. During an interview on 12/05/11 at 4:22 PM the Nurse Manager stated she had reviewed LN #3's documentation in the medical record and verified there was no nursing assessment documented on 11/01/11. During an interview on 12/05/11 @ 4:32 PM Nursing Assistant (NA) #1 revealed she was responsible for taking off Resident #1's TED Hose at night and gave him his shower. She stated she didn't remember any discoloration on his feet but he would tell her to tell the nurse that he needed a pain pill because his legs always hurt. During an interview on 12/05/11 at 4:36 PM the Physician's Assistant (PA) stated she examined Resident #1 on 11/07/11 and sent him to the emergency room (ER) because a nurse reported Resident #1 was complaining of foot pain and his foot was discolored. She explained she went immediately to assess him and his left (L) foot was cold and blue. She further stated there was swelling in his (L) foot and she couldn't feel any pulses. She explained she used a hand held doppler to check for pulses and there were no pulses. The PA stated nursing staff did not talk to her about leg pain until the day she sent him to the hospital and the only pain he complained about to her was arthritic type hand pain. She verified a podiatrist saw Resident #1 and his hand-written notes dated 10/31/11 indicated there were no pulses in his lower extremities and he would consider further studies. She explained when they sent a resident out of the facility to see a specialist, they expected them to take care of any concerns or issues and to let them know what they recommended. She further stated if something was urgent or needed to be done immediately the consulting physician would deal with the problem themselves or ask them for a referral right away. The PA further stated nursing staff was supposed to do an assessment and complete a change of condition form when a resident had a change in condition and leave the documentation for the Physician's Assistant, Family Nurse Practitioner or Physician in a designated location at the nurses station. During an interview on 12/06/11 at 8:48 AM a Licensed Physical Therapy Assistant (LPTA) stated she provided therapy to Resident #1 in the morning on 11/01/11 and did not see anything unusal about his left (L) foot but Resident #1 stated his pain on the pain scale was a ten (10) and described the pain as sharp in his (L) foot. She stated during the afternoon therapy session his (L) foot was cold to touch as compared to the right (R) foot. She stated she went and got an Occupational Therapist to look at it and she said Resident #1's (L) foot felt cold. The LPTA stated she then went to get Resident #1's nurse (LN # 3) and reported to her that Resident #1's foot was cold. She explained the nurse stated the physician was already aware of the new complaint. During an interview on 12/6/11 at 10:33 AM a Family Nurse Practitioner (FNP) stated she remembered evaluating Resident #1 for heel pain. She explained he was having pain in both legs especially at night. She stated on 10/27/11 she ordered for him to see the Podiatrist because his toenails were long. She explained he went to the Podiatrist on10/31/11 and the Podiatrist cut the nails and documented to consider non arterial invasive studies, stockings for both extremities and there were nonpalpable pulses in his feet. She explained usually when a resident came back from a specialist visit, the specialist would write out a prescription for any additional studies or new orders. She verified there were no additional orders or prescriptions from the Podiatrist office when Resident #1 returned to the facility. The FNP stated she had not been told anything about the therapy notes that described Resident #1's foot as cold and discolored on 11/01/11. She stated nursing staff should have called her or the Physician's Assistant (PA) to evaluate the resident. During a phone interview on 12/06/11 at 11:57 AM with a Vascular Surgeon who evaluated Resident #1 in the emergency room and performed surgery stated Resident #1 had a lot of chronic disease and he attempted to open up some small arteries in the left (L) foot but there was a lack of circulation for "a significant period of time." He stated he did another surgical intervention on 11/14/11 for a [MEDICAL CONDITION] of the (L) leg. During a follow up interview on 12/06/11 at 3:10 PM the Nurse Manager explained when a resident had pain the Licensed Nurses (LNs) should medicate the resident for pain and reassess for the effectiveness of the medication and should communicate with the physician regarding any medication concerns. She stated LNs should document the as needed (PRN) pain medications on the back of the Medication Administration record (MAR) and in the nurses notes. She further stated medications documented on the MAR should also match medications documented on the pain flow sheet. She stated she expected LNs to document on the back of the MAR the name of the medication, date given, the time given, reason, results/response to the pain medication and nurse's ititials and signature. She stated LNs should document location and intensity of pain and verified that LNs did not always document pain according to the pain scale from one (1) to ten (10). The Nurse Manager verified PRN pain medications were listed on the back of Resident #1's MAR and some of the entries only stated the resident complained of pain but the location of pain was not documented on the MAR or in nurses notes or on the pain flow sheet. During an interview on 12/06/11 at 4:05 PM the Director of Nurses (DON) stated she expected licensed nursing (LN) staff to notify the physician when a resident had a change in condition.