Every finding on record at Kanawha Community Home, INC.

Based on observations, policy review, and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 18 residents. Findings include: During the initial kitchen visit on 7/24/23 at 9:43 AM, the following observations were made: Bowls and plates were stored on a cart face up and not covered. Three rubber spatulas were noted to be chipped. A bag of what appeared to be sausage patties unlabeled and undated in the refrigerator. Opened and undated gallon of milk, and jugs of orange, prune, grape, cranberry, and tomato juice in the refrigerator. Review of an undated facility document titled Food Storage revealed that all foods that have been opened and partially used shall be dated and sealed before returning to a storage area. Interview with Staff A Dietary Manager (DM) on 7/27/23 at 10:15 AM, revealed that her expectation was that all food and drink would be dated when opened. She stated that she had not thought about the dishes not being covered or face down and acknowledged that spatulas were chipped.

Based on observation, clinical record review and staff interview, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASRR) after the resident was identified to have a mental health diagnosis for 1 of 1 residents reviewed for PASRR evaluation (Resident #10). The facility reported a census of 18 residents. Findings include: The Minimum Data Set, dated dated dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 3 indicating severely impaired cognition and diagnoses including anxiety, depression and Post Traumatic Stress Disorder (PTSD). The MDS further documented the resident received an antidepressant medication for 7 out of the past 7 days. The Care Plan for Resident #10 with a target date 10/3/23, revealed the resident had the potential for behavior disturbance. The Care Plan directed staff to intervene as necessary to protect the rights and safety of others. During an observation 7/24/23 at 11:10 AM, Resident #10 requested staff not leave her during an introduction by the writer. Clinical record review revealed Resident #10 had a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 10/26/21. Review of the Level 1 PASRR completed by Ascend for Resident #10 dated 11/4/21 documented the resident had mental health diagnoses including major depressive disorder, anxiety and depression/depressive disorder and there were no indicators identified that would signify the need for further evaluation at the time. The Level 1 evaluation further documented that if there was a discrepancy in the reported information a status change should be submitted to Ascend for further evaluation. The Level 1 PASRR lacked the diagnoses of PTSD. During an interviewon 7/26/23 at 7:52 AM, the Director of Nursing (DON) acknowledged a Level II PASRR had not been completed for Resident #10 regarding her Post Traumatic Stress Disorder diagnosis. The DON further revealed the facility does not have a policy or protocol in place regarding completion of PASSR's.

Based on clinical record review and staff interview, the facility failed to notify the State Ombudsman when a resident transferred and admitted to the hospital for 1 of 1 residents reviewed for hospitalization (Resident #7). The facility reported a census of 18 residents. Findings include: The discharge Minimum Data Set (MDS) for Resident #7 dated 2/11/23 documented the resident discharged to the hospital 2/11/23. The clinical record census documented Resident #7 went on hospital leave 2/11/23 and returned to the facility 2/14/23. Review of facility form titled, Notice of Transfer Form to Long Term Care Ombudsman emailed 3/24/23 revealed Resident #7's name was not on the list of residents that transferred from the facility in February 2023. During an interview on 7/26/23 at 3:40 PM the Director of Nursing acknowledged Resident # 7's name had not been added to the list to notify the Ombudsman of the residents transfer to the hospital in February 2023 as expected.

Based on facility policy, interviews, and record review, the facility failed to ensure appropriate monitoring for one of five residents reviewed for unnecessary use of [CONDITION(S)] medication, ( Resident #17). Behaviors were not monitored related to medications administered for sleep. The findings include: Review of the facility's policy titled, [CONDITION(S)] Medication Policy dated 05/2013 read, in pertinent part, When a [CONDITION(S)] medication is ordered interventions and behaviors will be documented. Record review revealed Resident #17 was admitted to the facility on [DATE], according to the Admission Record located in the Electronic Medical Record (EMR) under the Profile Tab, with diagnoses including [CONDITION(S)] disease, anxiety, chronic pain, and [CONDITION(S)]. Review of the Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 08/16/22, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident was moderately cognitively impaired. The assessment indicated the resident exhibited behaviors including trouble falling or staying asleep or sleeping too much on half or more of the days of the assessment reference period and indicated Resident #17 received hypnotic medications (for sleep) on seven of seven days during the assessment period. Review of Resident #17's undated [CONDITION(S)] Medication Care Plan, found in the EMR under the Care Plan Tab, indicated the resident was receiving [CONDITION(S)] medications. Approaches included: Administer [CONDITION(S)] medications as ordered and monitor and document for behaviors on behavior flowsheets. Review of the resident's Medication Review Report found in the EMR under the Orders Tab and dated 09/23/22, indicated orders for [MEDICATION(S)] (a hypnotic medication used to induce sleep) 5 MG (milligrams) at bedtime for [CONDITION(S)]. Review of Resident #17's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for 09/01/22 through 09/23/22 revealed nothing to indicate hours of sleep/quality of sleep for his use of [MEDICATION(S)] was being monitored. Review of Resident #17's Behavior Intervention Monitoring documentation 09/01/22 through 09/23/22 revealed nothing to indicate hours of sleep/quality of sleep for his use of [MEDICATION(S)] was being monitored. During an interview with the MDS (Minimum Data Set)/Care Plan Nurse/Infection Preventionist (MDS/CP1/IP) on 09/23/22 at 3:44 PM, she indicated proper monitoring was not being done for the resident's use of [MEDICATION(S)] for sleep. She stated Resident #17 should be monitored for sleep. During an interview with the Director of Nursing (DON) on 09/23/22 at 4:22 PM, she stated staff should be monitoring Resident #17 for quality of sleep. She stated, We will have to develop a plan for that.

Based on observations, staff interviews and facility policy review, the facility failed to provide a sanitary environment when 3 dietary staff members did not properly restrain their hair with hairnets during food preparation/service (Staff A, B, and dietary manager). The facility also failed to prepare and serve foods in a sanitary manner and touched ready to eat foods with bare hands and with soiled gloves. The facility reported a census of 22 residents. Findings included: 1. An observation on 2/10/20 at 10:15 a.m. revealed Staff A, dietary aide, had 1/2 to 1 inch of exposed hair around the entire circumference of her head, not covered by a hairnet. An observation on 2/10/20 at 10:15 a.m. revealed Dietary Manager had a ¼ of the front of her bangs, as well as several long strands of exposed hair in the back not covered by a hairnet. During observation on 2/11/20 at 11:45 a.m., Dietary Manager prepared pureed foods for the noon meal. During the food prep process, the Dietary Manager's hairnet cinched up and around the bun in her hair, leaving the complete front and back of her hair exposed and not covered by a hairnet. An observation on 2/12/20 at 9:29 a.m. revealed Staff A, dietary aide had ½ inch of exposed hair around the entire circumference of her head, not covered by a hairnet. An observation on 2/12/20 at 9:29 a.m. revealed Dietary Manager had a ¼ of the front of her bangs, as well as several long strands of exposed hair in the back not covered by a hairnet. Interview with Staff A on 2/13/20 at 8:49 a.m. confirmed she was aware of her hair not being properly restrained in a hairnet and stated she needed to do a better job of keeping her hair secured properly. Interview with Dietary Manager on 2/13/20 at 9:42 am., confirmed she was aware of the concern with hair not being properly restrained by Staff A, as well as herself. Dietary Manager stated the hairnets the facility used, would cinch themselves up throughout the work-day and have been known to fall off completely at times. Dietary Manager stated they would need to order a different type of hairnet that worked properly. An undated facility policy titled Dietary Polices and Procedures directed dietary personnel, hair must be covered. 2. During observation of the lunch meal on 2/11/20 at 12:13 p.m. Staff B, dietary cook, handled a reuben sandwich with her bare, ungloved hands in order to cut it in half for a small portions serving. The sandwich was then immediately served to the resident for consumption. During an observation of the lunch meal on 2/11/20 at 12:23 p.m., Staff B applied gloves and served the food out of the steam table to the residents. A resident had requested to have a grilled cheese sandwich instead of a reuben sandwich. Staff B walked over to the refrigerator with her gloves still on and obtained the cheese and butter containers from the refrigerator. She placed both containers onto the food prep area. Staff B then reached into the bread sack, with her soiled gloves and obtained 2 slices of bread. Staff B buttered the bread slices and placed them on the griddle and applied the cheese on top of the bread. Staff A removed her cloves and went to wash her hands. She then returned to the griddle and removed the grilled cheese sandwich from the griddle and immediately served it to the resident. Staff B failed to maintain proper hand sanitation when preparing ready to eat foods. During an interview on 2/13/20 at 9:00 a.m., Staff B confirmed she had touched the reuben sandwich with her bare hands on 2/11/20 and she also remembered preparing the grilled cheese sandwich with her soiled gloved hands on 2/11/20. Staff B stated she knew she had made mistakes and would be working hard to correct these issues. During an interview on 2/13/20 at 9:42 a.m. the Dietary Manager confirmed she had also observed Staff B handle the reuben sandwich with her bare hands and prepare the grilled cheese sandwich with the soiled gloves on 2/11/20. Review of the Facility's undated policy, Glove use in Food Service, revealed it stated the proper procedure for glove use in part was: -Before handling ready-to-eat foods such as salads, fruits, sandwiches, cooked meats, breads or ice, put gloves on as a barrier to the bacteria on your hands. When feasible, no direct contact with food should occur, and sanitized utensils should be used for handling ready-to-eat foods. -Change gloves whenever you change activity (from making sandwiches to making change) or whenever you leave your workstation. Remove gloves and discard when not performing a food contact task and wash your hands-wear gloves only when needed (handling ready-to-eat foods).

Based on observation, record review, policy review and staff and pharmacist interviews, the facility failed to periodically reconcile the emergency medication kit and establish a system of records of the controlled medications in the emergency kit. The facility reported a census of 22. Observation of the facility's medication room on 2/12/20 at 8:15 AM, contained an emergency kit that had narcotics inside that included [MEDICATION NAME] and morphone. When reconciling the kit to ensure the numbers matched, Staff C, Registered Nurse (RN), reported a new box must have come because the numbers did not match. Review of the Emergency Kit Replacement Patient Charge Slip, showed the facility last accessed the emergency medication kit on 1/1/2020 at 8:00 AM. Interview with the Minimum Data Set (MDS) Coordinator, on 2/12/20 at 3:32 PM, revealed the facilities emergency kit had: [MEDICATION NAME], and [MEDICATION NAME] inside. During an interview on, 2/12/20 at 3:12 PM with the Pharmacist contracted to provide the emergency kit to the facility, revealed they sent the emergency kit on 2/6/20. The pharmacist reported they do not have a policy for the facility to follow on checking the lock numbers, he revealed they expect the facilities to implement their own policies for meidication emergency kits. Review of the Narcotic Count policy dated 2/13/2020, indicated the emergency kits containing narcotics will be checked at the change of each shift to be sure the seal has not been broken. During an interview with the Director of Nursing DON on 2/13/20 at 10:20 AM, she revealed they implemented a new policy on 2/12/20 titled Emergency Medication Kit and are checking the numbers on the emergency kits at change of shift. Review of the schedule for February 2020 indicated 6 nurses and the DON had access to the medication room that contained the emergency kit from 2/6/20 to 2/12/20. The facility failed to ensure emergency kits that contain narcotics lock numbers are reconciled periodically, from 2/6/20 when the new box came to the facility to 2/12/20 when the surveyor asked to check the emergency kit lock number.

Based on observation and staff interview, the facility failed to assure dietary staff wore hair restraints for facial hair for 2 staff (Staff A and Dietary Supervisor). The facility reported a census of 18 residents. Findings include: During an initial tour of the kitchen on 01/07/19 at 10:05 a.m., the Dietary Supervisor and Staff A dietary aide both had facial hair. Neither of the staff wore beard covers. At 11:26 a.m., the Dietary supervisor and dietary aide served the noon meal without wearing beard covers. During an observation on 1/8/19 at 10:00 a.m., the Dietary Supervisor DS prepared the noon meal with no beard cover. At 11:32 a.m., the DS served the noon meal with no beard cover. During an interview at the end of the meal service, the DS stated he thought if you could pinch the beard (hair) you should wear a beard cover. He acknowledged he could pinch the hair of his beard, and that Staff A had a longer beard than he did. The FDA Food Code (YEAR) directs the following regarding hair restraints, 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, food employees hall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

Based on observation, clinical record review, facility policy and procedure and staff interview, the facility failed to provide complete and proper incontinence care for one of three residents reviewed. (Resident #6). The facility reported a census 18 residents. Findings include: 1. The Minimum Data Set (MDS) assessment reference dated 11/13/18, documented Resident #6 with [DIAGNOSES REDACTED]. The MDS documented the resident with short and long term memory impairments and modified independent in decision making abilities, and required extensive assistance with all aspects of daily living. The MDS assessment documented the resident as frequently incontinent of bladder and bowel. The careplan with a focus area with a target dated 2/11/19, stated alteration in elimination related to stroke and to incontinence of bowel and bladder. Interventions include: May use bedside commode. Assist with changing incontinence brief as needed. Complete peri cares every AM/HS and as needed with each incontinence and apply moisture barrier. Toilet before and after meals and at bedtime and as needed. During an observation on 1/8/19 at 9:04 a.m., Staff C (certified nursing assistant) and Staff D (certified nursing assistant), answered the resident call light. Observation revealed the resident incontinent of stool between their legs and down inner left and right thighs. Observation also revealed the chux, and nap pad soiled with urine as well as the bottom fitted sheet. Staff C with gloved hands took wet wipes and cleansed the resident's abdomen, inner left and right thigh and down the middle of the perineal area, using a different wipe with each cleansing. Staff C changed gloves and with assistance from Staff D positioned the resident on their left side. Staff C then cleansed the resident's coccyx area, and right buttock. Staff C placed a clean brief underneath the resident and with assistance from Staff D rolled the resident on to their back, secured and fastened the brief. Staff C failed to cleanse the residents left hip, buttock and thigh area exposed to the soiled nap pad and chux. During and interview on 1/9/19 at 1:15 p.m., the facility director of nursing stated that the expectation of the staff is to cleanse all areas where the skin had touched the soiled nap pad. The Perineal Care Procedure with no dated instructed staff to: Be sure to cleanse all areas with which urine or feces may have come into contact.

Based on record review and staff interview, the facility failed to notify the physician and the family in a timely manner of a change in condition for 1 of 3 discharged records reviewed (Resident #18). The facility reported a census of 18 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated 10//30/18, Resident #18 scored 11 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. The resident's [DIAGNOSES REDACTED]. The Nurse's Notes dated 12/29/18 at 3:30 a.m. documented the resident coughing and staff checked her and she had a small bile emesis. Staff reported the resident appeared white, cool to touch. The resident responded to the nurse. Audible wheezes could be heard and the resident complained of pain in the chest area. The resident received a breathing treatment with vital signs taken before treatment and oxygen (O2) saturation (sat) at 91% on room air. At 4 a.m. the vital signs included an O2 sat of 86% (normal range 90-100%) on room air. At rest the resident had labored respirations and still pale white. Staff called the Director of Nursing (DON) and she said to call, follow protocol. At 4:20 a.m. the O2 sat registered 91%. At 6:45 a.m. Staff B Registered Nurse (RN) documented she assessed the resident. The O2 sat at 94% with O2 at 2 liters per nasal cannula, and 86% on room air. The resident utilized accessory muscles to breathe (typically only used under conditions of high metabolic demand (exercise) or respiratory dysfunction). The resident was very pale, white with skin warm and dry. The night shift voiced the resident had 3 emesis in the night. Call placed to family to notify of changes and they would like her seen. At 6:50 a.m. the doctor ordered the resident seen in the emergency room . The resident transferred via ambulance to the hospital. A late entry for 12/29/18 at 4:20 a.m. documented the resident's breathing still labored. Elevated the head of the bed, and would continue to monitor. The DON stated to monitor the resident throughout the shift and keep in her room . If the resident worsened may need an order for [REDACTED]. (The Handover Communication Tool to the hospital dated 12/29/18 documented the assessment included the resident used accessory muscles to breathe, very pale, with diminished lung sounds to bases. During an interview on 1/9/19 at 10:40 a.m. the Director of Nursing (DON) stated the night nurse called her the night the resident had the decline, but did not tell her everything she had charted. She told her to call the doctor (Dr.) or follow the protocol for calling the Dr. She said the Dr. did not want to be notified during the night of non-emergent issues. During an interview on 1/9/19 at 10:52 a.m. Staff B Registered Nurse (RN) stated she came on the day shift (12/29/18) and did things prior to receiving report. The night nurse told her the resident had some issues but it didn't sound that bad. She told her she called the DON, but not the doctor. She went to check on the resident and knew immediately there was something wrong. She was so pale, and using accessory muscles to breathe. She had O2 on and the O2 sat registered 94%. She took the O2 off to see how she did without it, and the O2 level dropped quickly, so she put it back on. She called the family, then the doctor and transferred the resident to the hospital. She stated she would have called the doctor on the night shift with the low O2 level, labored breathing and pale skin. During an interview on 1/9/19 at 11:35 a.m. the DON brought an undated education she provided to staff regarding when to notify a physician immediately versus non-immediate. A Change in Condition: When to report to the MD (physician)/NP (nurse practitioner)/PA (physician's assistant) directed immediate notification of any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed. The report directed to report immediately O2 sat less than 90%, and abrupt onset of shortness of breath with pain fever or respiratory distress. When interviewed on 1/9/19 at 11:55 a.m., the resident's physician stated they should have notified her on the night shift with the low O2 and labored breathing. She said it would not have changed the outcome for the resident. During an interview on 1/9/19 at 3:07 p.m. Staff E RN stated on 12/29/18 night shift the CNA told hear the resident breathed heavy. She said the O2 sat was up and down. She gave a breathing treatment and it went up, but back down again. She said she called the DON because she wasn't sure if she could call the doctor. She discussed it with the DON and she told her to start O2 and send a facsimile (fax) the doctor for an order for [REDACTED].

Based on observation, record review, and staff interview the facility failed to serve the menu as written for 3 of 3 residents who received pureed meat (resident #5, #9, and #10). The facility reported a census of 18 residents. Findings include: The Menu for Puree diets on Tuesday 1/8/19 at noon included 1 serving of pureed country fried steak. A Diets and Adaptive Equipment form updated 1/7/19 identified Resident #5, #9 and #10 were to receive pureed meat. During an observation on 1/8/19 at 10:00 a.m., the Dietary supervisor (DS) pureed 4 servings of meat to equal 3-1/4 cup (equal 26 ounces equal about 6.5 ounces per serving), indicating a #6 (5 plus ounces) and a #24 (1 plus ounces) scoop per serving. At 11:32 a.m., during the noon meal service the DS served Resident #5, #9 and #10 a (#10) scoop of pureed meat. At the end of the meal service the DS had served 3 servings of pureed meat. During an interview at the end of the meal service, the DS stated the #10 scoop was 3-1/4 ounces. He measured the remaining pureed meat with almost 2 cups remaining. He stated he got confused on the scoops and acknowledged the chart indicated the residents should receive a #6 and a #24 scoop of the pureed meat, and there was more meat left over than served.

Based on observation and staff interview, the facility failed to maintain clean and sanitary kitchen equipment. The facility reported a census of 25 residents. Findings include: 1. On 9/27/17 at 9:05 a.m., initial observation of the kitchen revealed the following: a. A 3 tier stainless steal cart with pots and pans had grayish, and brownish debris on the shelving units. b. The drawers holding spatulas, silverware, scoops and ladles had crumbs and debris on the bottom of the drawer. c. A fan above the clean dishes and dishwashing machine had a dark brown, and grayish debris hanging from it. d. The outside of the cabinets, and drawers had a sticky substance easily removed with a fingernail. On 9/27/17 at 11:02 a.m., observation revealed the following: a. Three (3) sprinkler heads above the stove had a grayish substance. b. The 3 tier stainless steal cart holding a stand mixer, glass measuring cup, pots and pans had a white substance around the corners of the cart and brown debris/crumbs on the shelves. During an interview on 9/27/17 at 12:10 p.m., the dietary manager confirmed the areas list above needed cleaned and stated they would be add to the cleaning schedule.

Based on observation and staff interview, the facility failed to maintain a sanitary kitchen environment in the food preparation area and failed to keep foods dated and labeled in the freezer. The facility identified a census of 25 current residents. Findings include: 1. The initial dietary tour of the kitchen on 9/6/16 at 9:08 a.m., revealed the following concerns: a. A white floor fan with grayish substance on the blades and the plastic covering blowing on clean dishes; b. A 3 tier stainless steel shelving unit with dust and grayish debris hanging over plastic containers, lids, pots and pans; c. A 1/2 filled bag of a cubed white substance in the freezer with no date of opening or label present. During interview on 9/6/16 at 9:08 a.m., the dietary supervisor stated that the 1/2 bag of cubed substance was chicken and it needed to be dated and labeled. The dietary supervisor stated she had no idea when it was used last and threw the bag away. When interviewed on 9/7/16 at 12:10 p.m., the dietary supervisor verified the shelving units and the pot and pan racks needed to be cleaned more often.

Based on observation and staff interview, the facility failed to maintain a homelike and clean environment in regards to carpet floor covering in the facility. The facility reported a census of 25 residents. Findings included: Observation of the environment on 9/7/16 at 10:15 A.M., revealed the carpet floor covering in the East and West hallways and the front room of the facility as worn and stained throughout. During interview on 9/7/16, during the environmental tour, the Administrator agreed the carpets in the hallways and the front room appeared worn and stained.

Based on clinical record review and staff interview, the facility failed to follow physician's orders for 2 of 9 current residents reviewed (Residents #3 and #7). The facility reported a census of 25 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented [DIAGNOSES REDACTED]. The MDS documented the resident required the assistance of one with dressing. The Medication Review Report, signed and dated 8/1/16, instructed staff to apply Ace wraps every day and evening shift; on in am, off at hour of sleep. Observation on 9/6/16 at 12:50 p.m., 2:22 p.m. and 3:12 p.m. revealed the resident without Ace wraps to both his/her extremities, only gripper socks; 2. The MDS assessment dated [DATE] documented Resident #7 with [DIAGNOSES REDACTED]. The assessment documented that Resident #7 required the assistance of 2 staff with bed mobility and the assistance of one staff with transfers and walking. The assessment documented that Resident #7 admitted to the facility on [DATE] after an acute hospital stay. A Discharge Summary dated 6/13/16 instructed staff to weigh Resident #7 daily. A Medication Review Report dated and signed by the physician on 8/1/16, instructed staff to obtain a blood pressure and weight daily. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] a. 8/30/16 b. 8/31/16 The MAR indicated [REDACTED]. 3rd, 4th, 5th, 6th, 7th, 9th, 10th, 11th, 12th, 13th, 14th, 16th, 17th, 18th, 19th, 20th, 21st, 23rd, 24th, 25th, 26th, 27th, 28th, 30th, and 31st. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Interview on 9/7/16 at 9:15 a.m., the MDS coordinator confirmed and verified the resident's blood pressures and weights needed to be done on a daily basis.

Based on record review and staff interview the facility failed to ensure the resident had the right to make choices about aspects of his or her life in the facility that are significant to the resident for 4 of 9 residents (Residents #1,#2, #4 and #5). The facility reported a census of 23 residents. Findings included: 1. According to the Minimum Data Set with assessment reference date of 7/27/15 Resident #2 had a BIMS score of 10, moderately impaired cognitive skills for daily decisions. Resident #2's Physician order [REDACTED]. The Nurse Notes for Resident #2 dated 9/4/15 noted at 5:30 a.m., lab tech here to draw blood from right arm for CBC and BMP. 2. According to the Minimum Data Set with assessment reference date of 9/22/15 Resident #1 had a BIMS score of 9, moderately impaired cognitive skills for daily decisions. The Nurse Notes dated 6/25/15 noted at 5:15 a.m., lab technician here and drew blood from right hand for PT/INR. Band-Aid and pressure applied by this nurse. The Nurse Notes dated 7/24/15 noted at 5:15 a.m. lab technician here and drew blood from right hand for INR. The Nurse Notes dated 8/14/15 noted at 5:45 a.m. lab technician here and drew blood for INR and BMP. The Nurse Notes dated 8/28/15 noted at 5:30 a.m. lab technician here and drew blood from right arm for PT/INR. Pressure and Band-Aid applied. The Nurse Notes dated 9/4/15 noted at 5:30 a.m. lab technician here and BMP drawn from left arm. Pressure and Band-Aid applied. The Nurse Notes dated 9/29/15 noted at 5:30 a.m. lab technician here and drew blood from right anticubital for PT/INR, WBC and BMP. Pressure and Band-Aid applied. 3. The MDS with an assessment reference dated 7/14/15, documented Resident #4 with [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS score of 5 and had signs and symptoms of [MEDICAL CONDITION]. The Nurses Notes dated 8/18/15 at 5:00 a.m., documented catheter urine analysis obtained using sterile techniques. Specimen placed on ice until transport to lab. Resident tolerated well. 4. The MDS with an assessment reference dated 8/11/15, documented Resident #5 with [DIAGNOSES REDACTED]. The MDS documented the resident with short and long term memory impairments and severely impaired decision making abilities and signs and symptoms of [MEDICAL CONDITION]. The Physicians order sheet signed and dated 10/07/15, instructed staff to administer [MEDICATION NAME] suppository insert 1 suppository rectally every 24 hours as needed for constipation. The PRN (as needed) sheet with no date, documented [MEDICATION NAME] 10 milligram suppository given rectally on 9/5/15 at 5:30 a.m., and on 9/11/15 at 5:30 a.m. Physicians orders signed and dated 10/7/15, instructed staff to obtain TSH, CMP, CBC every 6 months. The Nurse Notes dated 4/10/15 at 5:50 a.m., documented lab tech from hospital here and drew blood from antecubital area for TSH level. The Nurse Notes dated 2/20/15 at 4:00 a.m.,documented obtained catheter urine analysis. Obtained for yearly urine analysis. The Nurse Notes dated 1/30/15 at 5:30 a.m., documented blood drawn from right antecubital for CBC. Pressure and bandaid applied. During interview on 10/14/15 at 10:15 a.m. the Director of Nursing stated the facility's lab draws are done by clinic lab staff. The Director of Nursing stated she would not want lab draws to be done before 6 a.m. when the residents are still asleep.

Based on clinical record review and staff interview, the facility failed to conduct ongoing assessments of resident activity programs and needs for 2 of 9 current residents reviewed (Residents #4 and #5). The facility identified a census of 23 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had [DIAGNOSES REDACTED]. Review of the clinical record revealed the last quarterly activity assessments completed on 2/25/14 and 1/13/15, with no documentation between the dates in the clinical record. 2. The MDS assessment dated [DATE] documented Resident #5 had [DIAGNOSES REDACTED]. Review of the clinical record revealed the last quarterly activity assessments completed on 3/10/15, with no documentation prior to the assessment. Interview on 10/14/15 at 2:35 p.m., the facility administrator confirmed and verified the clinical record failed to document any activity assessments.

Based on clinical record review and staff interview, the facility failed to follow physician's orders for 2 of 9 residents reviewed. (Resident #4 and #7). The facility reported a census of 23 residents. Findings include: 1. The Minimum Data Set (MDS) assessment reference dated 7/14/15 for Resident #4 documented [DIAGNOSES REDACTED]. A Flowsheet print request signed and dated by the physician on 8/18/15, directed staff to draw a hemoglobin and hematocrit in 1 month. Review of the residents record revealed no hemoglobin and hematocrit drawn in one month. Interview on 10/14/15 at 8:00 a.m., Staff D (Registered Nurse) confirmed and verified no further labs were completed or in the residents chart. 2. The Medication Review Report dated 9/26/15 for Resident #7, documented [DIAGNOSES REDACTED]. The Medication Review Report instructed staff to obtain a CMP (comprehensive metabolic panel) every 4 months. Review of the clinical record revealed the last CMP drawn on 3/6/15. No further labs in the clinical record. Interview on 10/14/15 at 4:00 p.m., the facility director of nursing confirmed and verified no labs in the chart after the 3/6/15 labs and that the lab will be drawn on 10/16/15.

Based on record review, observation and staff interview the facility failed to ensure services provided by the facility were provided in accordance with each resident's written plan of care for 1 of 9 residents reviewed, (Resident #2). The facility reported a census of 23 residents. Findings include: 1. According to the Minimum Data Set with assessment reference date of 7/27/15 Resident #2 had a BIMS score of 10, moderately impaired cognitive skills for daily decisions. The resident required total assist with transfers and extensive assist with toilet use and personal hygiene. The resident had an indwelling catheter and frequently incontinent of bowel. Resident #2 had a Stage 2 pressure ulcer and was at risk for developing pressure ulcers. The Care Plan for Resident #2 showed the resident had a care plan problem initiated on 12/19/14 for alteration in elimination and skin impairment related to history of chronic diarrhea, involuntary incontinence of stool. A history of chronic moist yeasty open areas. Fragile scar tissue/tissue erosion/[DIAGNOSES REDACTED]/macerated eroded skin to buttocks/rectal area and upper thigh /groin creases. Interventions included pressure relieving cushion in wheel chair and recliner, and place a 4 by 4 foam between buttocks and coccyx to decrease skin contact. A skin sheet dated 9/18/15 noted on morning cares Resident #2 had an open area on coccyx that measured 1.0 centimeter by 0.6 centimeter by 0.2 centimeter. The Wound/Skin Healing Record showed the area had resolved on 10/5/15. A skin sheet showed on 10/12/15 Resident #2 had 4 open areas on buttocks, the areas measured 0.8 by 0.4 centimeters, 0.5 by 0.4 centimeters, 0.5 by 0.4 centimeters and 2.0 by 0.2 centimeters. During observations of cares on 10/13/15 at 9:55 a.m. Staff B CNA (certified nurse aide) and Staff E CNA went to Resident #2's room to take him/her to exercise activity. The resident was sitting in a recliner in his/her room. Staff used a Hoyer (mechanical) lift to transfer the resident out of the recliner. Staff noted the resident incontinent of stool and transferred the resident from the recliner to the bed. Observation showed a pressure relieving device on seat of the recliner covered with a cloth pad. Staff B and Staff E provided incontinence care observation revealed the resident did not have a 4 by 4 foam between coccyx and buttocks. Staff B and Staff E then used the Hoyer to transfer the resident to a wheel chair. The seat of the wheel chair had a cloth pad in place but did not have a pressure relieving cushion. Staff wheeled the resident out to the coffee activity at 10:22 a.m. At 12:05 p.m. Resident #2 remained in the wheelchair at the table eating lunch. At 12:46 p.m. Staff F and Staff B took Resident #2 to his/her room to lay down in bed. After staff used the Hoyer lift to transfer the resident out of the wheel chair, the Director of Nursing confirmed the seat of the wheel chair failed to have a pressure relieving cushion in place. Staff B stated there is usually a cushion in place. The Director of Nursing stated the resident was to have a pressure relieving cushion in place. During interviews on 10/13/15 at 2:20 p.m. Staff B confirmed there was no 4 by 4 foam in place during cares at 9:55 a.m. Staff C stated she had placed the foam around 6:30 a.m Staff C stated it was difficult to keep the foam in place because they cannot use tape on the resident. Staff C stated no one had told her the foam had fallen away. The Director of Nursing stated the Certified Nursing Assistants are suppose to let the nurse know if the foam needed replaced.

br>Based on observation and staff interview the facility failed to ensure each resident received and the facility provided food that is palatable, attractive and at the proper temperature. The facility reported a census of 23 residents. Findings included: During observation on 10/12/15 at 11:15 a.m. Staff A pureed one pork chop with a slice of buttered bread. When mixture was smooth placed it in a pan and set on the stove top. Staff A did not turn the burner on. Staff A then pureed one serving of broccoli with addition of cold whole milk that staff got from the refrigerator. Staff A placed the pureed broccoli in a bowl, covered with foil and said she would warm it in the microwave before serving. Staff A then pureed smooth a serving of parsley potatoes with addition of cold whole milk, placed in a bowl and covered with foil. During observation at 11:45 a.m. Staff A placed the bowls of pureed broccoli and potatoes in the microwave and turned it on. The dietary manager turned on the burner under the pan of pureed pork chop. When Staff A took the pureed food out of the microwave she stirred it and said it was too hot, Staff A did not check the temperature, and set it off to the side as she plated another meal. The dietary manager and Staff A then worked together to place the pork chop puree in a serving bowl. Staff A took the temperature of the food items, pureed pork chop 144.1 degrees, pureed broccoli 132 degrees and the pureed potatoes were 137 degrees. Staff A then set the tray of food on the service window and dietary staff took the tray to the resident at the table and nursing staff began to feed the resident. During interview at 12:35 p.m. the Dietary Supervisor stated the hot food items should be at 140 degrees when served. The Dietary Supervisor stated she had also caught that the pureed foods were not at least 140 degrees when Staff A served them.

Based on record review, observation, and staff interview the facility failed to follow the menu for residents on a ground meat diet. The facility identified a census was 21 residents. Findings include: Review of the facility menu for the 8/27/14 noon meal revealed roast pork as the entree and a serving size of 3 ounces according to the Therapeutic Spreadsheet which directs staff on how much of each menu item is to be served to residents. During observation on 8/27/14 at 11:00 a.m. Staff A prepared the ground roast pork for the 4 residents on a ground meat diet. Observation revealed 5 - 3 ounce servings of pork were ground with liquid added for proper consistency and measured out to a final volume of 2 1/2 cups or 1/2 cup per serving, review of the facility conversion chart indicates a #8 scoop would be used which is a 4 ounce scoop. During observation of noon meal service 8/27/14 ending at 12:20 p.m. revealed a blue handled scoop used for serving residents on a ground meat diet, observation of the blue handled scoop revealed the size to be 2 ounces when the scoop to be used should have been 4 ounces. During an interview with Staff A at the end of meal service 8/27/14 at 12:20 p.m. when questioned about the amount of ground meat left over and the scoop used to serve residents on a ground meat diet Staff A stated they used too small of a scoop and they knew that now.