Every finding on record at Keysville Nursing Home & Rehab

Based on staff interviews and record review, the facility failed to transmit a Discharge Minimum Data Set (MDS) within 14 days after completion for one of 17 sampled residents (R) (R20). Findings include:Review of R20's clinical record revealed resident deceased on [DATE] at 5:50 AM.Review of the MDS listing for R20 revealed a Quarterly MDS on [DATE]. Further review of the current MDS listing revealed that there were no updates or modifications to the MDS since R20's death on [DATE].During an interview with the MDS Coordinator on [DATE] at 2:10 PM, she stated that she was responsible for updating the MDS when a resident is discharged or passed away. She acknowledged that she failed to update the MDS within 14 days of R20's death.During an interview with the Administrator on [DATE] at 1:15 PM the Administrator stated that the MDS Coordinator was responsible for updating the MDS and expected the MDS Coordinator to do so within 14 days of any changes.

Based on staff interviews, record review, and facility policy review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of 12 newly admitted residents (R) (R5) reviewed for baseline care planning. This deficient practice had the potential to delay communication of the resident's immediate care needs and interventions to staff responsible for providing care. Findings include: A review of the facility policy titled, Baseline Care Plan, last reviewed May 2026, facility policy, Baseline Care Plan, revealed that the facility would develop and implement a baseline care plan for each resident within 48 hours of admission. The plan would include initial goals on admission orders, physician orders, dietary orders, therapy services, social services, and PASSAR (Preadmission Screening and Annual Resident Review) recommendations.A medical record review revealed that R5 was admitted to the facility on [DATE] with diagnosis of but not limited to, a past medical history of spinal fusion, spinal stenosis, anemia, hyperlipidemia, depression, anxiety, polyneuropathy, and hypertension.A continued review revealed that the facility failed to develop a baseline care plan until 05/18/2026.During an interview on 06/06/2026 at 12:20 PM, the MDS Coordinator stated she is responsible for creating a baseline care plan within 48 hours of a resident's admission and had failed to complete R5's baseline care plan within that required time.During an interview on 06/07/2026 at 9:16 AM with the Administrator, the Administrator explained that baseline care plans should be conducted within 48 hours of a resident's admission. She added that comprehensive assessments should be conducted by or before the next review date documented in the medical record.A medical record review revealed that R5 was admitted to the facility on [DATE] with diagnosis of but not limited to, a past medical history of spinal fusion, spinal stenosis, anemia, hyperlipidemia, depression, anxiety, polyneuropathy, and hypertension. A continued review revealed that the facility failed to develop a baseline care plan until 05/18/2026.During an interview on 06/06/2026 at 12:20 PM, the MDS Coordinator stated she is responsible for creating a baseline care plan within 48 hours of a resident's admission and had failed to complete R5's baseline care plan within that required time.During an interview on 06/07/2026 at 9:16 AM with the Administrator, the Administrator explained that baseline care plans should be conducted within 48 hours of a resident's admission. She added that comprehensive assessments should be conducted by or before the next review date documented in the medical record.

Based on staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to develop a comprehensive care plan for two of 17 sampled residents (R) (R7 and R5) related to Foley catheter. The deficient practice had the potential for R7 and R5 to have needs and services go unmet. Findings include: A review of the facility policy, Comprehensive Care Plans, last revised May 2026, revealed under Policy Explanation and Compliance Guideline: 1. That the care planning process would include an assessment of the resident's strengths and needs. 2. The comprehensive plan would be developed within seven days after the comprehensive MDS (minimum data set) assessment. All Care Assessment Areas (CAAs) triggered by the MDS would be considered in developing the plan of care. 1. Review of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE] with diagnoses of, but not limited to, hypertension, diabetes mellitus, and Alzheimer's disease, and benign prostatic hyperplasia. Review of the quarterly minimum data set (MDS) assessment, dated 05/25/2026, revealed a Brief Interview for Mental Status (BIMS) score that the resident could not complete, section H (bladder and bowel) documented that R7 required an indwelling catheter. Review of the care plan for R7 revealed no plan for an indwelling catheter. Review of the physician's orders for R7 included an order dated 02/11/2026 that specified to assess catheter site and perform catheter care every shift for urinary retention. In an interview on 06/07/2026 at 3:44 PM, the Infection Preventionist (IP) stated the care plan should show foley care. In an interview on 06/07/2026 at 11:18 AM the Director of Nursing (DON) stated nursing has oversight to be sure the care plan is accurate. The DON confirmed the paper care plan does not accurately reflect the care needs of R7. In an interview on 06/08/2026 at 09:30 AM the MDS Coordinator confirmed the care plan was not complete. 2. A review of the MDS OBRA (Omnibus Budget Reconciliation Act) admission Assessment, dated 05/20/2026, Section V-Care Assessment Area (CAA) Summary, revealed that R5's assessment triggered urinary incontinence and indwelling catheter. A review of the physician's orders (MD) dated 05/14/2026 revealed R5 had an indwelling Foley and required Foley catheter care. A review of R5's care plan revealed that R5 did not have a care plan for Foley catheter. During an interview on 06/06/2026 at 12:20 PM with the MDS Coordinator, the MDS Coordinator stated she had not yet updated the care plan but would begin working on it immediately. She explained that while she had completed the baseline care plan, the updated comprehensive care plan still needed to be completed. During an interview on 06/07/2026 at 9:16 AM with the Administrator, the Administrator explained that baseline care plans should be conducted within 48 hours of a resident's admission. She added that comprehensive assessments should be conducted by the next review date documented in the medical record, in accordance with facility policy and regulations.

Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen delivered via nasal cannula was administered at the physician-prescribed flow rate for one of 12 residents (R) (R28) receiving oxygen therapy. This deficient practice had the potential to result in inadequate or excessive oxygen delivery, placing the resident at risk for adverse outcomes.Findings Include:Review of facility policy, Oxygen Administration (reviewed/revised May 2026), states that oxygen is administered under physician orders except in an emergency. The physician's order for (R28) included oxygen at 2L/min (liters per minute) via nasal cannula continuously.Observations on 06/06/2026 at 8:17 AM and 2:52 PM, and 06/07/2026 at 9:48 AM, R28 was wearing oxygen at 3 LPM (liters per minute). Licensed Practical Nurse (LPN) BB confirmed that the ordered oxygen flow rate should be 2 LPM for R28. LPN BB verified the oxygen rate for R28 was set at 2 LPM. The nurse further stated that oxygen flow rates were checked each shift.During an interview on 06/07/2026 at 10:30 AM, LPN BB confirmed that the ordered oxygen flow rate should have been 2 L/min. After reviewing the observation, the nurse verified the oxygen was set at 3 L/min and adjusted it to the ordered rate of 2 L/min. The nurse further stated that oxygen flow rates are checked once each shift.Interview on 06/07/2026 at 11:17 AM with the Director of Nursing (DON) revealed the charge nurse should monitor oxygen levels every shift and as needed.

Based on interview, record review, facility document review, and review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to thoroughly investigate an allegation of abuse for one of 27 sampled residents (R) (R13). Findings included: A facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised 02/2025, indicated, Compliance Guidelines: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The section of the policy, Procedure for Response and Reporting Allegations of Abuse /Neglect/ Exploitation, indicated the following: When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. b. Remove the accused employee from resident care areas. c. Notify the Administrator or designee. d. Notify the attending physician, resident's family/legal representative, and Medical Director. e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. f. Document actions taken in the medical record. g. Complete an incident report is [sic] indicated. h. Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. 2. The Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. b. Obtain statements from direct care staff. The policy also indicated the Administrator would, f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. Review of R13's admission Record indicated the facility admitted R13 on 11/25/2024. Diagnoses included, but not limited to, dementia of unspecified severity, anxiety disorder, depression, and cognitive communication deficit. Review of R13's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/29/2025, revealed R13 was usually understood when they expressed their ideas and wants, and usually understood others. The MDS revealed R13 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit physical, verbal, or other behavioral symptoms towards others in the seven-day look-back period. Review of R13's Care Plan Report, included a focus area, revised 4/21/2025, that indicated the resident had socially inappropriate behavior as evidenced by yelling out. Interventions directed staff to attempt to redirect the resident when they had inappropriate behavior, and to observe the resident for inappropriate behavior and report to the charge nurse, social worker, and physician. Review of a Facility Incident Report Form, dated 2/4/2025, indicated the facility reported an allegation of abuse for R13 on 2/4/2025 at approximately 4:00 pm. The Facility Incident Report Form revealed that during a routine telephone call to the resident's family member, the facility was informed that the prior Friday [1/31/2025], the resident told the family member that someone hit them on the head with a book. The report indicated the resident was immediately assessed by staff, and no injuries were visible. According to the report, R13 was unable to recall the incident or allegation secondary to significant cognitive impairment. The report indicated an investigation was pending. The report indicated that during a review of camera footage in common areas, it was revealed that another resident (R35) was seen ambulating toward the dining room and lightly patted several residents on top of their heads. The report indicated the Director of Nursing (DON) spoke with this resident, who stated, I was just saying hey. The report indicated the resident was encouraged not to place their hands on others, even in a friendly manner, in case they did not wish to be touched. The facility's investigation documentation included a typed summary that indicated staff and R13's roommate were interviewed regarding the report; however, only two typed witness statements were included in the facility's investigation documentation, one from the nurse who received the allegation from R13's family member and one from Business Office Manager (BOM), who indicated they had spoken with the resident's family member regarding financial matters on 1/31/2025, but received no complaints or comments about the resident's care. There were no witness statements from other staff or residents. Review of R13's Progress Notes revealed no documentation on 2/4/2025 to indicate that staff conducted a skin assessment or implemented other interventions for R13. During an interview on 5/21/2025 at 11:47 am, Family Member (FM)12 revealed that while visiting the facility, R13 stated their head hurt and they were struck on the head with a book. FM12 stated they checked the resident's head and noted two very small abrasions that appeared to be new. According to FM12, R13 stated they could not see the person who hit them on the back of their head. FM12 stated they left the building without telling anyone, but when contacted by the facility the following week, they informed staff of the allegation. FM12 indicated that after the incident, R13 was moved to a different room due to not getting along with the roommate, but this was unrelated to the abuse allegation. (According to the facility's census report, the resident's room change occurred on 4/4/2025). During an interview on 5/21/2025 at 12:00 pm, Licensed Practical Nurse (LPN)1 stated she called FM12 on 2/4/2025 to provide an update regarding R13's wound care treatment. LPN1 stated during the call that FM12 stated that when they visited the facility the previous week, R13 stated someone struck them on the head, and FM12 noted two small marks on the resident's head. LPN 1 stated that after the call with FM12, she looked at R13's head and did not see red marks or anything else. LPN1 stated she informed the Assistant Director of Nursing (ADON) and also gave the ADON a written statement. LPN1 stated she did not think she wrote a progress note, but maybe she should have. During an interview on 5/21/2025 at 1:09 pm, R13 could not recall any details of the incident. During an interview on 5/21/2025 at 10:07 am, the ADON stated that when informed of an abuse allegation, she would tell the Administrator and Director of Nursing (DON). She stated the DON would then assess the resident, identify any immediate problems and injuries, or remove the resident, get statements from residents and staff, and do an environmental assessment. The ADON confirmed LPN1 received the abuse allegation in a phone call and reported it to her. The ADON stated she immediately notified the DON. During an interview on 5/22/2025 at 8:25 am, the DON confirmed LPN1 did not document that she completed an assessment or write a progress note after being informed that R13 reported being hit on the head with a book. The DON stated that when she returned to work, the day after she was notified, she interviewed R13, but the resident could not remember the details of the incident. The DON stated she reviewed camera footage and saw that on the morning of 1/31/2025, at about 7:30 am, another resident was walking in the hallway and gently tapping other residents on their heads and arms in a friendly manner. The DON acknowledged she had no documentation of interviews with the resident's day and night shift nurses, other staff, or residents. The DON stated she never kept documentation of interviews, and this was a lesson learned. The DON stated that her expectation was that all interviews and assessments would be documented and kept on file. During an interview on 5/22/2025 at 10:35 am, the Administrator stated her expectation was that investigations related to allegations of abuse would include interviews with staff, residents, the victim, and the perpetrator. She confirmed that everything must be documented. The Administrator acknowledged that R13's abuse allegation was not thoroughly investigated.

Base on observation, staff interview, and the facility policy titled Servicing Product Dispensers, the facility failed to maintain the cleanliness and sanitation of the ice machine. This had the potential to effect 61 residents receiving an oral diet. The facility census was 63. Findings include: Review of the facility policy titled Servicing Product Dispensers dated reviewed/revised 2/22 revealed: All product dispensers are to be maintained in a clean, hygienic serviceable manner. 2. Staff will ensure product dispensers are clean and fully operational. An observation and interview conducted on 5/20/22 at 7:15 a.m. revealed the ice machine in the kitchen had a dark black grime substance on the ice deflector in the back of the inside of the ice machine. Staff wiped the grime build up and it came off easily with a paper towel. Interview with Cook BB indicated the Maintenance Supervisor cleans the machine. The Dietary Manager was unavailable for interview. An observation and interview conducted on 5/20/22 at 7:30 a.m. with the Director of Nursing (DON) revealed that the ice machine had dark black grime build up in it. She indicated she will get the Maintenance Supervisor to clean it and she will ensure the ice currently in use will be discarded. She indicated she would expect it to be clean. An observation and interview conducted on 5/20/22 at 8:34 a.m. with the Maintenance Supervisor revealed the facility leases the ice machine and the company comes out every few months and cleans it and he cleans it in between. He indicated he cleans it at least monthly. He verified the dark black grime build up and will clean it. He began to empty the ice that was currently in the machine. Review of the document titled Ice Machine Maintenance Check indicated the Maintenance Supervisor cleaned the machine monthly and it was last cleaned on 4/16/22. Review of the Service Report revealed the ice machine company serviced, cleaned and sanitized the ice machine on 3/16/22.

Based on observation, interviews, and review of the facility's policy and protocol, the facility failed to have an effective Infection Prevention Control program related to the prevention and transmission of COVID-19. Specifically, an observation on December 17, 2020 revealed a nurse failed to use appropriate Personal Protective Equipment (PPE) prior to entering a resident's room to speak with the resident that was on contact and droplet precautions. The facility's failure increased the risk of COVID-19 transmission to residents and staff. Findings include: Review of the facility's policy titled Isolation Precautions, dated March 2020, revealed the definitions for Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Droplet precautions refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Further review instructs facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with infectious agents requiring additional controls to prevent transmission. Review of the facility's document titled Protocol for COVID 12/14/20revealed the following, PPE: Universal N95 for direct care staff .Universal eye protection throughout facility .All rooms are under Contact and Droplet precautions .Disposable gowns are for use in COVID Positive rooms. Positive Rooms: Don (put on) PPE in hallway (clean area) .Doff (take off) PPE in resident room near door. During the tour conducted on December 17, 2020 at 1:25 p.m. accompanied by the Director of Nursing (DON), Licensed Practical Nurse (LPN) AA was observed entering a COVID positive resident's room without donning the appropriate PPE per the facility's policy for contact and droplet precautions. During the observation of LPN AA conducted on December 17, 2020 at 1:25 p.m., the DON was questioned whether LPN AA should have put on a gown and gloves prior to going into the COVID positive room. The DON stated, Yes, that is what they have been trained to do. During an interview on December 17, 2020 at 1:35 p.m., LPN AA was asked if she should have had a gown and gloves on when she went into the resident's room. LPN AA stated, No, I just went in to find out how much the resident ate for lunch. During an interview on December 17, 2020 at 1:45 p.m., the Infection Control Preventionist (ICP) was asked what type of PPE is required of staff to wear when going into a contact and droplet precaution resident's room. The ICP stated, staff is trained that all rooms are considered to be contact/droplet precautions and that they are to wear gown, gloves, mask, and face shield. The ICP was asked if it was okay for the staff to enter the resident's room to speak to the resident without donning a gown or gloves? The ICP stated, No, it is not okay. During an interview on December 17, 2020 at 2:00 p.m., the Administrator was asked what her expectations of the staff related to wearing PPE. The Administrator stated, I expect the staff to follow the isolation precautions. Every room requires full PPE to go into it.

Based on observation, record review, review of facility policy titled Personal Care of Residents, and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for two dependent residents (R) (#21 and #25) related to nail care of 31 sampled residents. Findings include: Review of the facility policy titled Personal Care of Residents revised (MONTH) 23, (YEAR) revealed it is the policy of the facility to ensure the resident's personal care needs are met. Policy explanation and compliance guidelines: 4. Residents will have shampoo, nail care and skin inspection provided during scheduled showers. 5. Resident nails will be cleaned if soiled between showers. Nail care items are stored on the unit. 1. A review of the clinical record for R#21 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 2, which indicated severe cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for personal hygiene. Observation on 8/20/19 at 3:24 p.m., 8/21/19 at 9:25 a.m. and 8/22/19 at 2:49 p.m. revealed that fingernails on both hands had dark brown substance underneath them. 2. A review of the clinical record for R#25 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Significant Change MDS dated [DATE] revealed a BIMS was coded as 1, which indicated severe cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for personal hygiene. Observation on 8/20/19 at 2:38 p.m., 8/21/19 at 8:39 a.m. and 8/22/19 at 8:12 a.m. revealed that fingernails on both hands had brown substance underneath them. Interview on 8/21/19 at 1:41 p.m. with Certified Nursing Assistant (CNA) AA stated that she bathes between 10-12 residents each day. She stated that she takes most of the residents to the shower room, where she does a complete bath, from head to toe. During further interview, she stated that she looks at the nails on each bath day, and if they need to be cleaned or clipped, then she will do it. She further stated that she bathed R#21 and R#25 today and washed their fingernails with soap and water but did not clip them or use anything to clean underneath them. She stated she didn't see any dark material underneath the nails. Interview on 8/22/19 at 8:50 a.m. with CNA BB stated she cares for an average of 14 residents per day. She stated that she looks at residents nails every day, but the bath team is supposed to clean and clip the nails on the residents scheduled bath days. She further stated that if she notices the nails are dirty, she will clean them, if after they have had their bath for the day or are not scheduled for a bath that day. She stated that she did not notice that R#21 or R#25 nails were dirty. Interview on 8/22/19 at 9:09 a.m. with Assistant Director of Nursing (ADON) stated that her expectation is that the CNA staff keep the resident's nails cut short and clean from debris. She stated that the CNA staff are supposed to complete a bath sheet each day that the resident receives a bath and indicate on the sheet the care that was provided, including cleaning and cutting nails. She verified that R#21 and R#25 nails had dark material underneath them.

Based on observation, record review, review of the facility policy titled Comprehensive Care Plan, and staff interviews, the facility failed to follow the care plan for one dependent resident (R) (#21) related to nail care; and failed to develop a person centered care plan for one dependent resident (#25) related to nail care of 31 sampled residents. Findings include: Review of the facility policy titled Comprehensive Care Plan, revised (MONTH) (YEAR), indicated the facility will develop an individualized, comprehensive care plan for each resident that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Procedure: Ensure care plans include definitive, specific goals that address each resident's individual concerns, needs, rights, goals and preferences with appropriate approaches and corresponding review periods. Ensure care plans include services provided to obtain and/or maintain the residents highest practical level of function. 1. A review of the clinical record for R#21 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 2, which indicated severe cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for personal hygiene. Review of the care plan updated on 6/28/2019 revealed R#21 needs assistance with some activities of daily living (ADL) due to multiple health concerns. Approaches to care include encourage resident to do as much as possible for herself and observe skin for any problems during care. Observation on 8/20/19 at 3:24 p.m., 8/21/19 at 9:25 a.m. and 8/22/19 at 2:49 p.m. revealed that fingernails on both hands had dark brown substance underneath them. 2. A review of the clinical record for R#25 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Significant Change MDS dated [DATE] revealed a BIMS was coded as 1, which indicated severe cognitive impairment. Section G revealed the resident was assessed for extensive assistance for personal hygiene. Observation on 8/20/19 at 2:38 p.m., 8/21/19 at 8:39 a.m. and 8/21/19 at 8:12 a.m. revealed that fingernails on both hands had brown substance underneath them. Review of updated care plan for R#25, dated 6/24/19, did not have evidence that R#25 had a care plan problem to include assistance needed with ADL care. Interview on 8/22/19 at 9:09 a.m. with Assistant Director of Nursing (ADON) stated that her expectation is that the Certified Nursing Assistant (CNA) staff keep the resident's nails cut short and clean from debris. She stated that the CNA staff are supposed to complete a bath sheet each day that the resident receives a bath and indicate on the sheet the care that was provided, including cleaning and cutting nails. She verified that R#21 and R#25 nails had dark material underneath them. Interview on 8/22/19 at 12:07 p.m. with Administrator, stated that it is her expectation that the CNA's follow the resident's ADL care plan when providing care. She stated during further interview that the care plans need to be more specific as to the type of care that the residents need. Cross Refer F677

Based on record review and staff interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) were completed with the designation of their choice of whether or not to continue to receive skilled services after discharge off Medicare Part A, their right to appeal the decision for the termination of Medicare Part A services, and the potential liability for continued services should their appeal be denied, for two of three residents (R) reviewed (#35 and #43), who remained in the facility. Findings include: Review of a facility-completed worksheet Beneficiary Notice-Residents discharged Within the Last Six Months, revealed that R#35 and R#43 were discharged from a Medicare-covered Part A stay, still had benefit days remaining, and remained in the facility after their last covered day. 1. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form for R#35 indicated that services were initiated on 1/29/19 and discharged from Medicare Part A services on 2/17/19, and he remained in the facility with Part A benefit days remaining. Review of R#35's Advance Beneficiary Notice of Noncoverage revealed that the effective date coverage of his Skilled Part A Nursing services would end as of 2/17/19, and his responsible party signed the form, on 2/7/19. Review of the What to Do Now section of this notice revealed for him to choose an option about whether to get the care listed above Skilled Part A Nursing. Further review of the notice revealed that none of the three options were chosen (the options were to continue the care and bill Medicare; or continue the care but don't bill Medicare; or don't want the care listed). 2. Review of the SNF Beneficiary Protection Notification Review form for R#43 indicated that services were initiated on 4/11/19 and discharged from Medicare Part A services on 5/3/19, and she remained in the facility with Part A benefit days remaining. Review of R#43's Advance Beneficiary Notice of Noncoverage revealed that the effective date coverage of her Skilled Part A Physical Therapy and Speech Therapy services would end as of 5/3/19, and she signed the form on 4/29/19. Review of the What to Do Now section of this notice revealed for her to choose an option about whether to get the care listed above Skilled Part A Physical Therapy and Speech Therapy. Further review of the notice revealed that none of the three options were chosen (the options were to continue the care and bill Medicare; or continue the care but don't bill Medicare; or don't want the care listed). Review of R#43's Admission MDS dated [DATE] revealed that he had BIMS score of 14, which indicates no cognitive impairment. Interview on 8/21/19 at 8:49 a.m. with Social Services Director, stated she has always done the SNFABN since she's been at facility. She further stated that she attended a training provided by the State on how to complete the ABN notices. When questioned about the Option boxes, she replied that she would write the services resident was receiving in the blanks of the Option Boxes but had never gotten the resident or the responsible party to select which option they preferred. She stated she was not aware that she had to get them to select an option. Interview on 8/22/19 at 12:03 p.m. with the Administrator, stated she was not aware that the Social Services Director was not getting the resident or family member to choose an option box to continue services, not to receive services, or pay for services. She further stated that she looked in the ABN notebook of discharged residents, and she had gotten some of them to choose and mark an option box, so she is not sure why the ones selected for review were not completed correctly.

Based on observation and staff interview the facility failed to ensure that privacy curtains for all D (Door) beds provided full visual privacy, which included a total of 14 semi-private rooms on the A hall and 16 semi-private rooms on the B hall. Findings include: Observation on 5/30/17 at 2:00 p.m. and 5/31/17 at 11:00 a.m. of privacy curtains for all room on the A and B halls revealed that the curtain for the D (door) bed in each room, when pulled past the foot of the bed to meet the curtain from the other side of the room, left an opening allowing anyone entering the room to have full view of the D bed. In these rooms, the size of the opening varied from 15 to 25 inches. During an interview and observation on 6/1/17 9:44 a.m., the facility Administrator and the Maintenance/Housekeeping Director revealed that this issue was confirmed that the curtains failed to provide full visual privacy. Neither of them were aware of this issue and both stated that their expectation was that the privacy curtains would provide full visual privacy.

Based on record review, review of the facility policy and staff interview, the facility failed to obtain Finger Stick Blood Sugar (FSBS) levels and/or failed to administer insulin per sliding scale as ordered by the physician for 5 residents (R) (R#4, R#6, R#29, R#39, R#47) and failed to obtain a [MEDICATION NAME] (PT)/INR level as ordered by the physician for one resident #67 from a sample of 25 residents. Findings include: Review of the facility's policy Reference 15: Pertinent Techniques for Medication Administration revealed that in order to administer insulin injections safely and accurately, nursing staff should first check the physician's order. 1. R# 39 had a [DIAGNOSES REDACTED]. to the following sliding scale: For FSBS between 100-150, 2 units of [MEDICATION NAME] R Insulin; for FSBS between 151-200, 4 units of [MEDICATION NAME] R; for FSBS between 201-250, 6 units of [MEDICATION NAME] R; for FSBS between 251-300, 8 units of [MEDICATION NAME] R; for FSBS between 301-350, 10 units of [MEDICATION NAME] R; for FSBS between 351-400, 12 units of [MEDICATION NAME] R; and for FSBS between 401-450, 15 units of [MEDICATION NAME] R. Review of the May 2017 Medication Administration Record [REDACTED] A. On 5/2/17 at 4:30 p.m., the resident's FSBS was 400; however, licensed nursing staff incorrectly administered 15 units of [MEDICATION NAME] R insulin to the resident instead of 12 units as ordered. B. On 5/8/17 at 4:30 p.m., the resident's FSBS was 196; however, licensed nursing staff incorrectly administered 2 units of [MEDICATION NAME] R insulin to the resident instead of 4 units as ordered. C. On 5/26/17 at 6:30 a.m., the resident's FSBS was 123; however, licensed nursing staff did not administer any [MEDICATION NAME] R insulin to the resident at that time. Licensed nursing staff should have administered 2 units of [MEDICATION NAME] R insulin to the resident as ordered. D. On 5/26/17 at 11:30 a.m., the resident's FSBS was 124; however, licensed nursing staff did not administer any [MEDICATION NAME] R insulin to the resident at that time. Licensed nursing staff should have administered 2 units of [MEDICATION NAME] R insulin to the resident as ordered. E. On 5/29/17 at 6:30 a.m., the resident's FSBS was 145; however, licensed nursing staff did not administer any [MEDICATION NAME] R insulin to the resident at that time. Licensed nursing staff should have administered 2 units to the resident as ordered. F. On 5/29/17 at 11:30 a.m., the resident's FSBS was 261; however, licensed nursing staff incorrectly administered 6 units of [MEDICATION NAME] R insulin to the resident instead of 8 units as ordered. G. On 5/30/17 at 11:30 a.m., the resident's FSBS was 204; however, licensed nursing staff incorrectly administered 4 units of [MEDICATION NAME] R insulin to the resident instead of 6 units as ordered. Review of the medical record for R#39 revealed no abnormally high subsequent FSBS or complications due to the failure of licensed nursing staff to administer the correct dose of [MEDICATION NAME] R insulin as ordered. Interview with the Director of Nursing (DON) on 6/2/17 at 12:15 p.m., revealed that there were three different sliding scales used by the facility and that licensed nursing staff should refer to the physician orders for the sliding scale to be used for a particular resident. 2. Review of the clinical record for R#4 revealed a [DIAGNOSES REDACTED]. The sliding scale was: <200 = 0 units, 201-250 = 2 units, 251-300 = 4 units, 301-350 = 6 units, 351-400 = 8 units, 401-450 =12 units, >400 = 15 units and repeat FSBS in 2 hours. At 8:00 p.m. on 5/9/17, a FSBS glucose level of 254 was obtained for R#4, and per the physician ordered sliding scale the amount of insulin to be administered would have been four units of [MEDICATION NAME] insulin. The Medication Administration Record [REDACTED]. At 6:30 a.m. on 5/26/17 a FSBS glucose level was not obtained per the physician orders for R#4, therefore no insulin was documented as being given. There were no exception notes written on the back of the MAR. There was a statement on the MAR indicated [REDACTED]. There was no clinical documentation in the nurse's notes identifying the 6:30 a.m. FSBS value or how much [MEDICATION NAME]was administered. 3. Review of the clinical record for R#6 reveals a [DIAGNOSES REDACTED]. On 5/26/17, at 6:30 a.m. the facility failed to obtain the FSBS level for R#6. During an interview with the DON on 6/1/17 at 1:30 p.m., she confirmed the above dates that the physician orders were not followed by the nursing staff. She stated that she expects any exceptions/explanations to be written on the back of the Medication Administration Record [REDACTED]. 4. R#67 had a [DIAGNOSES REDACTED]. The resident had a physician's order for routine labs for nursing staff to obtain a [MEDICATION NAME] (PT)/INR every month. Review of the PT/INR Laboratory (Lab) Report dated 4/14/17 revealed that the PT/INR result was abnormally low at 15.9. The Lab Report was faxed to the physician who returned the Lab Report to the nursing staff with a written order on the form to increase the [MEDICATION NAME] to 4 milligrams (mg) every day and recheck (PT/INR) in two weeks. Review of the April 2017 and May 2017 Medication Administration Record [REDACTED]. However, review of the resident's medical record revealed [REDACTED]. Review of the physician's telephone order dated 4/18/17 with Licensed Practical Nurse (LPN) FF revealed that LPN FF had written the physician's order for the [MEDICATION NAME], but had failed to write the order for the PT/INR to be obtained in two weeks. Further review of the resident's medical record revealed [REDACTED]. 5. R#47 had a [DIAGNOSES REDACTED]. The [MEDICATION NAME] R sliding scale was ordered as follows: FSBS every morning and every evening with SSI subcutaneous injection if FSBS was less than 200, no insulin required; 201-250, give two units (actual order reads 291-250; this is a typographical error/confirmed with the DON); 251-300, 4 units; 301-350, 6 units; 351-400, 8 units; 401-450, 12 units; greater than 450, 15 units, re-check FSBS in two hours. Review of the MAR indicated [REDACTED] A. 5/11/17 p.m. FSBS was 247. B. 5/22/17 p.m. FSB was 216. C. 5/23/17 p.m. FSBS was 206. D. 5/29/17 p.m. FSBS was 215. Further review of the MAR indicated [REDACTED]. The Nurses' Notes and physician progress notes [REDACTED]. In a staff interview with the DON on 6/2/17 at 12:15 p.m., she confirmed the dates of documentation of incorrect dosage of insulin for 5/16/17 and the dates of omission of documentation of insulin coverage when indicated for 5/11/17, 5/22/17, 5/23/17 and 5/29/17. Continued interview with the DON revealed she could not offer any explanation for these discrepancies and took full responsibility for the record as it stands. 6. R# 29 had a [DIAGNOSES REDACTED]. Review of the physician orders for May 2017 revealed R#29 was ordered to receive [MEDICATION NAME] 10 units subcutaneous at 2:00 p.m. daily and [MEDICATION NAME] R sliding scale. The physician ordered FSBS before meals and at bedtime with sliding scale subcutaneous as follows: 151-200, 2 units; 201-250, 4 units; 251-300, 6 units; 301-350, 8 units; 351-399, 10 units; >400, call. Review of the May 2017 MAR for R#29 revealed the following: A. 5/4/17 at 12:00 p.m., FSBS of 365 and 12 units given (should have been 10 units) B. 5/4/17 at 5:00 p.m., FSBS 295 and 8 units given (should have been 6 units) C. 5/7/17 at 8:00 p.m., FSBS 194, no coverage given (MAR was signed by nursing staff acknowledging FSBS reading) D. 5/13/17 at 5:00 p.m., FSBS 214, 2 units given (should have been 4 units) E. 5/19/17 at 5:00 p.m., FSBS 148, 2 units given (no coverage should have been given) F. 5/20/17 at 8:00 p.m., FSBS 157, no coverage given (should have been 2 units) G. 5/23/17 at 12:00 p.m., FSBS 268, 4 units given (should have been 6 units) H. 5/23/17 at 8:00 p.m., FSBS 198, no coverage given (should have been 2 units) I. 5/27/17 at 8:00 p.m., FSBS 228, 2 units given, (should have been 4 units) J. 5/28/17 at 6:30 a.m., FSBS 152, no coverage given (should have been 2 units)

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan to address the [DIAGNOSES REDACTED].#4, #6 and #29) of five residents who had [DIAGNOSES REDACTED]. Findings include: 1. R#4 had a [DIAGNOSES REDACTED]. A review of the clinical record for R#4 revealed there was no comprehensive care plan with interventions to address the resident's [DIAGNOSES REDACTED]. 2. R#6 had a [DIAGNOSES REDACTED]. A review of the clinical record for R#6 revealed there was no comprehensive care plan with interventions to address the resident's [DIAGNOSES REDACTED]. During an interview with the Minimum Data Set (MDS) Coordinator on 6/2/17 at 12:35 p.m. she stated that she had never developed a care plan with interventions to address a resident's [DIAGNOSES REDACTED]. She further stated at that time that it makes perfect sense though. 3. R#29 had a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A review of the clinical record for R#29 revealed there was no comprehensive care plan with interventions to address the resident's [DIAGNOSES REDACTED].

Based on observation, staff interviews, and record review it was determined the facility failed to coordinate laboratory (lab) work related to administration of [MEDICATION NAME] as care planned for one resident (R) #67 from a sample of two residents receiving [MEDICATION NAME]. Findings include: Review of the physician's orders [REDACTED]. Review of the May 2017 Medication Administration Record [REDACTED]. However, PT/INR values pertaining to this order were not completed as ordered. Review of R#67's care plan dated 3/5/17 related to the administration of [MEDICATION NAME] includes interventions to administer anticoagulant as ordered by the physician, coordinate laboratory work as ordered, and monitor carefully for any increased bruising/bleeding and report to physician. Review of the medical record revealed the most recent lab result for a PT/INR was 4/14/17. This result had an order written [REDACTED]. Recheck 2 wks. The ordered was transcribed to a telephone order sheet by Licensed Practical Nurse (LPN) FF on 4/18/17. The telephone order stated, DC previous [MEDICATION NAME] order, 4mg QOD with 3mg QOD, start [MEDICATION NAME] 4mg po q day. This order did not include the order on the lab sheet stating recheck in 2 wks. An interview on 6/2/17 at 9:59 a.m. with LPN FF revealed that after reviewing the telephone order from the chart, she was the nurse who transcribed the order from the lab sheet to the telephone order form. She verified that the order to recheck the PT/INR in two weeks was not written on the telephone order and stated that she did not see the order while transcribing to the telephone order form. During an interview on 6/2/17 at 11:25 a.m. with LPN GG, who is responsible for the lab system for the facility, and the facility's Director of Nursing (DON), it was verified that the order for the PT/INR to be rechecked in two weeks was not entered into the system, and therefore was never completed and it was further verified that the routine order for a PT/INR to be done monthly was never entered into the lab system, which resulted in the PT/INR for the month of May 2017 not being completed. Review of R#67's medical record revealed no signs or symptoms of bleeding/bruising during the period of time from the PT/INR dated 4/14/17 until the present and no negative side effect from the PT/INR not being completed as ordered.

Based on record review and staff interview, the facility failed to report and investigate an injury of unknown origin to the State agency for one (1) resident (#1) of nine (9) sampled residents. Findings include: Record review of resident #1 medical record revealed that the resident was admitted to the facility on August of 2014 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 02/03/15 indicated that her Brief Interview for Mental Status (BIMS) score was ninety-nine (99). She was not interview able. Resident #1 required assistance of another person for bed mobility, transfers and to ambulate. Review of the Nurse's Notes dated 01/13/15 for resident #1 indicated that a family member reported a new bruise on the resident's back. Review of the Nurse's Notes dated 01/17/15 for resident #1 indicated a second family member reported bruising on the resident's left lower back. Further review of the Nurse's Notes dated 01/19/15 indicated that resident #1 was examined in the emergency room and spine and rib fractures were ruled out and chest x-rays were negative. However, the emergency room (ER) nurse reported to the facility that resident #1 had a fall in the ER and x-rays were performed to her left knee. The x-rays were negative for fractures. On 01/30/15 resident #1 was noted with some outward rotation of her left foot and she was sent to the ER. Resident #1 had a left [MEDICAL CONDITION] that required surgical repair. An interview with the Administrator on 02/11/15 at 4:00 p.m. revealed that allegations of abuse, neglect and injuries of unknown origin should be reported immediately to the State Survey Agency and thoroughly investigated. The administrator confirmed that the facility did not report and investigate resident #1's injuries of unknown origin that included the bruises on her back and a [MEDICAL CONDITION].

Based on observation, staff interview, and record review, the facility failed to ensure that the Minimum Data Set assessment accurately reflected the physical status of one (1) resident (#27), related to impairment in right hand Range of Motion and contracture, on the total survey sample of twenty-seven (27) residents. This resulted in harm for Resident #27, whose right hand experienced further contracture. Findings include: Resident #27's nursing Admission Assessment documented 07/01/2013 as the resident's date of facility admission. This nursing Admission Assessment indicated that Resident #27's right was partially closed, but that the resident could open the hand at that time. Even though Resident #27's facility nursing Admission Assessment of 07/01/2013 referenced above documented the right hand to be partially closed, Resident #27's Admission Minimum Data Set (MDS) assessment completed on 07/22/2013 inaccurately documented in Section G - Functional Status that the resident had no impairment in Range of Motion (ROM) to the upper extremities. MDS Section I-Active [DIAGNOSES REDACTED]. Additionally, Quarterly MDS Assessments of 11/17/2013, 02/16/2014, and 05/18/2014, and the Annual MDS of 08/18/2014, continued to indicate Resident #27 to have no impairment in upper extremity ROM, as had the 07/22/2013 Admission MDS referenced above. However, during an observation of Resident #27 conducted on 09/23/2014 at 1:00 p.m., Resident #27 was noted in the hallway in a reclining wheelchair, and the resident's fingers on the right had were contracted. A subsequent 09/24/2014, 5:00 p.m. observation of Resident #27 revealed the resident's fingers of the right hand to be curled inward and contracted. Certified Nursing Assistant (CNA) "EE", in attendance during this observation, attempted to open Resident #27's right hand, but the resident moaned and CNA "EE" stopped. During an interview with the MDS Nurse conducted on 09/25/2014 at 2:15 p.m., the MDS Nurse acknowledged that Resident #27 had a contracture of the right hand, stating that she had only learned of an issue with Resident #27's right hand after the resident experienced a fall on 09/16/2014. The MDS Nurse acknowledged that the MDS assessments for Resident #27 did not reflect the limitation of ROM in the right hand. Cross refer to F318 for more information regarding Resident #27.

Based on observation, clinical record review, and facility staff interview, the facility failed to ensure that services were provided in accordance with the Care Plan, which specified Restorative Nursing Program referral, related to Restorative Nursing ambulation for three (3) residents (#30, #51, and #53) of three (3) sampled residents with Functional Programs for ambulation, from a total survey sample of twenty-seven (27) residents. This failure resulted in harm for Resident #51, who walked approximately 200 feet via walker upon admission, but who was later documented and observed to have lost ambulation function after the facility failed to refer him to the Restorative Nursing Program as specified by the Care Plan. Findings include: 1. Resident #51's 06/10/2013 Admission Minimum Data Set (MDS) documented an admitted [DATE], and Section I-Active [DIAGNOSES REDACTED]. Section G-Functional Status documented Resident #51 to require staff assistance for walking. Review of Resident #51's Care Plan revealed a Problem/Need originally dated 06/10/2013 which indicated the resident to have poor safety awareness. A Care Plan Approach to address Resident #51's poor safety awareness specified that the resident would be referred to the Restorative Nursing Program as needed. Resident #51's 06/28/13 Physical Therapy Discharge Summary (PTDS) documented the resident received Skilled Physical Therapy, including gait training/ambulation, from 05/28/13 through 06/28/13. This PTDS documented Resident #51 was then discharged to Restorative Nursing, and a 06/28/13 Functional Program for Restorative Nursing form specified that Resident #51 be ambulated 200 feet via rolling walker 6 times per week. However, further record review revealed no evidence to indicate that during July, August, September, and October of 2013, Restorative Nursing staff had ambulated Resident #51 200 feet 6 times per week as specified by the Functional Program plan of 06/28/2013, after discharge from Skilled Physical Therapy. This was despite Resident #51's Care Plan Approach which specified referral to the Restorative Nursing program for the provision of Restorative Nursing services. An 11/04/2013 Nurse's Notes entry then documented that Resident #51 was no longer able to ambulate. During an observation conducted on 09/25/14 at 2:15 p.m., Certified Nursing Assistant (CNA) "JJ" attempted to get Resident #51 to stand to ambulate, but he only partially stood up, then sat back down in the wheelchair. CNA "JJ" and another CNA again tried to get Resident #51 to stand, but he only partially stood up, then sat back down. Additionally, record review for Resident #51 revealed a physician's orders [REDACTED].#51 during that period of time. During a post-survey Quality Assurance interview conducted on 10/30/2014 at 12:40 p.m., the Administrator acknowledged the lack of evidence to indicate that Resident #51 had been ambulated in accordance with the established Restorative Nursing Program plan of 06/28/2013, and acknowledged Resident #51's inability to ambulate. Cross refer to F311, example 1, for more information regarding Resident #51. 2. Resident #30's Admission MDS of 05/23/2013 documented an admission date of [DATE], and Section I - Active [DIAGNOSES REDACTED]. Review of Resident #30's Care Plan revealed a Problem/Need originally dated 05/19/2014 which indicated that the resident had poor safety awareness, and specified Approaches which included referral to the Restorative Nursing Program as needed. A PTDS documented that Resident #30 received Skilled Physical Therapy services for balance, strengthening, transfers, and gait training beginning 05/02/2014. This PTDS documented that Skilled Therapy Services were discontinued on 06/16/2014 and that Resident #30 was discharged to the Restorative Nursing Program for ambulation and Range of Motion. Resident #30's Functional Program form of 06/16/2014 specified Restorative Nursing staff were to encourage the resident to perform active Range of Motion exercises to the lower extremities, and to provide assistance for ambulation, six (6) times per week, with the resident being able to walk 300-350 feet. However, record review for Resident #30, including review of the Restorative Progress Notes and Nurse's Notes, for June, July, August, and September of 2014 revealed no evidence of Restorative Nursing staff having ambulated, or provided active Range of Motion, as specified by the Functional Restorative Nursing Program referenced above, during that period. This was despite Resident #30's Care Plan Approach which specified referral to the Restorative Nursing program for the provision of Restorative Nursing services. During a 09/24/2014, 1:30 p.m. interview, the Assistant Director of Nursing (ADON) acknowledged the lack of evidence to indicate that Resident #30 had received ambulation services, as specified by the Restorative Nursing Program and the Care Plan. Cross refer to F311, example 2, for more information regarding Resident #30. 3. Resident #53's Admission MDS of 11/11/2013 documented an admission date of [DATE], and Section I-Active [DIAGNOSES REDACTED]. Resident #53's Care Plan documented a Problem/Need, originally dating from 11/11/2013, which identified the resident to be at risk for falls. An Approach on this Care Plan for Resident #53 specified that the resident would be referred to the Restorative Nursing Program as needed. A PTDS of 12/13/2013 documented that Resident #53 received Skilled PT services including gait, balance, and safety training from 11/04/2013 through 12/13/2013, and that on 12/13/2013, the resident was discharged to the Restorative Nursing Program. A 12/14/2013 Functional Program for Restorative Nursing for Resident #53 specified that Restorative Nursing was to ambulate the resident approximately 300 feet six (6) times per week to maintain functional mobility. However, further record review, to include review of Weekly Nursing Summaries and Restorative Progress Notes from December 2013 through September 2014, revealed no evidence to indicate that Resident #53 was ambulated by Restorative Nursing staff six (6) times per week as specified by the resident's Functional Program for Restorative Nursing referenced above. This was despite Resident #53's Care Plan Approach which specified referral to the Restorative Nursing program for the provision of Restorative Nursing services. During interview on 09/24/2014 at 1:30 p.m., the ADON provided no evidence to indicate that Resident #53 had received ambulation services as specified by the Restorative Nursing Program, and in accordance with the resident's Care Plan. Cross refer to F311, example #3, for more information regarding Resident #53.

Based on observation, clinical record review, Physical Therapist interview, and facility staff interview, the facility failed to provide services as specified by the Restorative Nursing Program, related to ambulation, to maintain or improve the ambulation abilities of three (3) residents (#30, #51, and #53) of three (3) sampled residents with Functional Programs for ambulation, from a total survey sample of twenty-seven (27) residents. This failure resulted in harm for Resident #51, who could walk approximately 200 feet via rolling walker upon facility admission, but for whom the facility failed to provide ambulation per the Functional Program for Restorative Nursing, and who was later documented and observed to have lost ambulation ability. Findings include: 1. Record review for Resident #51 revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 06/10/2013 which documented the resident's facility admission Entry Date of 05/28/2013. This MDS documented in Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #51 required the limited assistance of one (1) staff person for walking. A Physical Therapy Discharge Summary (PTDS) form for Resident #51 dated 06/28/2013 documented that the resident had been referred to Skilled Physical Therapy services, with the Onset Date of Skilled Physical Therapy being 05/28/2013. This PTDS form documented that Resident #51 had received services including gait training, ambulation, and transfers, and that the resident was discharged from Skilled Physical therapy services on 06/28/2013. This PTDS further documented that at the time of discharge from Skilled Physical Therapy, Resident #51 could walk approximately 200 feet using a rolling walker, and that the resident was discharged to the Restorative Nursing program. A Functional Program form for Resident #51, signed by the Physical Therapist and dated 06/28/2013 (the date of the resident's discharge from Skilled Physical Therapy), specified that facility staff ambulate Resident #51 using a rolling walker 200 feet with Contact Guard Assistance six (6) times per week. Review of Resident #51's Nurse's Notes (NN) revealed a NN entry of 09/09/2013, labeled as a Weekly note, which documented that the resident was able to walk very short distances. NN entries of 09/24/2013 and 09/30/2013, each labeled as Weekly notes, documented that Resident #51 was able to walk short distances at times, and a NN entry of 10/20/2013 timed at 12:25 p.m. documented that the resident could walk short distances with assistance. However, further review of Resident #51's clinical record revealed no evidence to indicate that during the months of July, August, September, and October of 2013, Restorative Nursing staff had ambulated the resident 200 feet six (6) times per week, via the rolling walker, as specified by the Physical Therapist on the 06/28/2013 Functional Program Form which was written on the 06/28/2014 date of Resident #51's discharge from Skilled Physical Therapy services. A NN entry of 11/04/2013 for Resident #51 then documented that the resident was no longer able to ambulate, and that the Restorative Nursing Program was being discontinued at that time. During an observation of Resident #51 conducted on 09/25/2014 at 2:15 p.m., Resident #51 was observed to be seated in the wheelchair. Certified Nursing Assistant (CNA) "JJ" attempted to prompt Resident #51 to stand to ambulate with the rolling walker; however, the resident only partially stood up, and then sat back down in the wheelchair. CNA "JJ" then solicited the assistance of another CNA, and both CNAs attempted to prompt Resident #51 to stand using a gait belt, but again, the resident only partially stood up, and then sat back down in the wheelchair. During an interview conducted at the time of this observation, CNA "JJ" stated she could not recall the last time she observed Resident #51 ambulate. During an interview with the Administrator on 10/30/2014 at 12:40 p.m., conducted as part of the post-survey Quality Assurance review, the Administrator acknowledged that there was no evidence to indicate that Resident #51 had been ambulated six (6) times per week during as specified by the Restorative Nursing Program plan established by the Physical Therapist on 06/28/2013. The Administrator further acknowledged Resident #51's inability to ambulate. Further record review for Resident #51 revealed a physician's orders [REDACTED]. Review of the Restorative Progress Notes for Resident #51 revealed that during the months of June, July, August, and September 2014, the resident had received daily Restorative Nursing services for dressing/grooming, transfers, and toileting. However, further review of Resident #51's clinical record revealed no evidence to indicate that Restorative Nursing staff had ambulated the resident, or attempted to ambulate the resident, during that period of time. During an interview with the Administrator on 10/30/2014 at 1:45 p.m., conducted as part of the post-survey Quality Assurance review, the Administrator was questioned regarding the facility's procedure for the provision of Restorative Nursing Program services upon a resident's discharge from Skilled Physical/Occupational Therapy services. The Administrator stated that the facility's Restorative Aide had recently left facility employment. The Administrator further stated that prior to the Restorative Aide's departure, the Aide would have been the staff person to provide Restorative Nursing Program services, such as ambulation, as specified in a resident's Functional Program, and that the Restorative Aide would have been instructed on each resident's Functional Program by the Physical Therapist at the time of Physical Therapy discharge. During an interview with the Assistant Director of Nursing (ADON) conducted on 09/24/2014 at 11:55 a.m., the ADON was questioned regarding the facility's provision of Restorative Nursing Program after Skilled Physical/Occupational Therapy discharge. The ADON stated that the facility's Restorative Aide had left employment with the facility approximately two (2) months prior, and that since the Restorative Aide's departure, certified nursing assistant (CNA) staff who were assigned to work on the facility units were now responsible for providing Restorative Nursing services to residents, including ambulation. However, during an interview with Certified Nursing Assistant (CNA) "HH" conducted on 09/24/2014 at 12:00 noon, CNA "HH" stated that while CNA staff did provided Range of Motion exercises for residents during the provision of Activities of Daily Living care, CNA staff did not ambulate residents. Rather, CNA "HH" stated that Physical Therapy staff ambulated residents. During an interview with CNA "II" conducted on 09/24/2014 at 12:10 p.m., CNA "II" stated that she did not provide Restorative Nursing ambulation services to residents, further stating that she though that Physical Therapy staff ambulated residents. During an interview with CNA "JJ" conducted on 09/24/2014 at 1:58 p.m., CNA "JJ" also stated that she did not ambulate residents, but rather that Physical Therapy staff was responsible for resident ambulation. During an interview with Physical Therapist (PT) "LL" conducted on 09/24/2014 at 2:40 p.m., Physical Therapist "LL" stated that physical therapy staff did ambulate residents during the provision of Skilled Physical Therapy services, but that once a resident was discharged from Skilled Physical Therapy, physical therapy staff no longer ambulated residents. PT "LL" stated that once a resident was discharged from Skilled Therapy, the Therapist would explain the resident's Functional Program for Restorative Nursing to the ADON. During a later 09/25/2014, 9:05 a.m. interview with the Physical Therapy Aide/Director of Rehabilitation Services, she stated that upon a resident's discharge from Skilled Therapy services, the resident's Functional Program for Restorative Nursing was explained to the ADON. She further stated that for services such as Range of Motion and ambulation, the ADON was then to demonstrate to CNA staff the type of Restorative Services to be provided to the resident by the CNA staff. But, during an interview with CNA "BB" conducted on 09/25/2014 at 12:00 noon, CNA "BB" stated she had not been instructed by facility supervisory nursing staff regarding ambulation services for Resident #51. This CNA stated that she had not ambulated Resident #51 for restorative nursing, but had on occasion wheeled the resident in the wheelchair to the bathroom where the resident had taken a few steps with assistance from the wheelchair to the toilet. Based on the above, despite Resident #51 being able to walk approximately 200 feet using a rolling walker at the time of facility admission, the facility failed to provide ambulation per the Functional Program for Restorative Nursing, as specified by the PT, upon discharge from Skilled Physical Therapy. Resident #51 was later documented by the facility, and observed during the Standard Survey, to no longer be able to ambulate, thus representing actual harm for Resident #51. 2. Record review for Resident #30 revealed an Admission MDS having an Assessment Reference Date of 05/23/2013 documented an original admission Entry Date of 05/16/2013. Section I - Active [DIAGNOSES REDACTED].#30 had [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #30 was independent for walking at the time of admission. A PTDS for Resident #30 documented that the resident began receiving Skilled Physical Therapy services for balance, strengthening, transfers, and gait training, with an Onset Date of 05/02/2014. This PTDS documented that Skilled Physical Therapy was discontinued for Resident #30 on 06/16/2014, and that the resident was discharged to Restorative Nursing to receive ambulation and Range of Motion. This PTDS further documented that at the time of discharge from Skilled Physical Therapy services, Resident #30 was able to walk approximately 350 feet with a fixed-wheel walker with contact guard assist. A Functional Program form for Resident #30 dated 06/16/2014, and signed by the Physical Therapist, specified that six (6) times per week per the Restorative Nursing Program, certified nursing staff were to encourage the resident to perform active Range of Motion exercises to the lower extremities, and were also to provide assistance during ambulation. This Functional Program form documented that Resident #30 could walk 300 to 350 feet at that time. However, further record review for Resident #30, to include review of the Restorative Progress Notes for Resident #30 for the period of time from 06/16/2014 through 06/30/2014, and for July 2014, August 2014, and September 2014 (through the 09/22/2014 start date of this Standard Survey) revealed that Resident #30 received daily Restorative Nursing services for dressing/grooming and toileting only. There was no evidence to indicate that CNA staff had ambulated Resident #30, or provided active Range of Motion to the lower extremities, six (6) times per week per the Functional Program for Restorative Nursing Program established by the Physical Therapist referenced above, upon the resident's 06/16/2014 discharge from Skilled Physical Therapy. During an interview with the ADON conducted on 09/24/2014 at 1:30 p.m., the ADON reviewed Resident #30 clinical record but could provide no documented evidence to indicate that Resident #30 had received ambulation services during the months of June 2014, July 2014, August 2014, and September 2014, as specified by the Restorative Nursing Program. During an interview with CNA "JJ" conducted on 09/24/2014 at 1:58 p.m., CNA "JJ" stated she did not normally ambulate residents, but then obtained a gait belt and was observed to ambulate Resident #30 approximately 300 feet. 3. Record review for Resident #53 revealed an Admission MDS assessment having an Assessment Reference Date of 11/11/2013 which documented the resident's admission Entry Date of 11/04/2013. Section I - Active [DIAGNOSES REDACTED].#53 to have [DIAGNOSES REDACTED]. A PTDS for Resident #53 electronically signed by the Physical Therapist on 12/13/2013 documented that the resident had received Skilled PT services including gait training, strengthening exercises, and balance and safety training during the period from 11/04/2013 through 12/13/2013. This PTDS also documented that on 12/13/2013, Resident #53 was discharged from Skilled PT to the Restorative Nursing Program, and at the time of discharge from Skilled PT, the resident could walk 300 feet with a fixed wheel walker with Contact Guard Assist/Stand-By Assist. Review of the Functional Program for Restorative Nursing for Resident #53 dated 12/14/2013 revealed that CNAs were to provide services six (6) times per week which included grooming and also assistance with ambulating approximately 300 feet to maintain the resident's current functional mobility. However, further record review for Resident #53, to include review of the Weekly Nursing Summaries and Restorative Progress Notes from December 2013 through September 2014, revealed evidence indicating that Resident #53 received Restorative Nursing Program services for dressing/grooming and toileting only during that period of time. There was no documented evidence to indicate that Resident #53 was ambulated by Restorative Nursing staff six (6) times per week as specified by the resident's Functional Program for Restorative Nursing referenced above. During an interview conducted on 09/24/2014 at 12:00 noon with CNA "HH", CNA "HH" stated she had never observed Resident #53 to ambulate in the hallway. Additionally, during an interview with CNA "CC" conducted on 09/24/2014 at 3:25 p.m., she stated that she had ambulated Resident #53 to the bathroom but had not ambulated Resident #53, or any of the residents, in the hallway. During an interview with the ADON conducted on 09/24/2014 at 1:30 p.m., the ADON provided no evidence to indicate that Resident #53 had received ambulation services as specified by the Restorative Nursing Program. During an observation conducted on 09/25/2014 at 2:45 p.m., CNA "JJ" ambulated Resident #53 approximately 350 feet with a walker in the hallway.

Based on observation, record review, and staff interview, the facility failed to ensure that one (1) resident (#27), who was identified to have limited Range of Motion of the right hand at the time of facility admission, received treatment and services to prevent further decrease in Range of Motion, from the total survey sample of twenty-seven (27) residents. The facility's failure to ensure the timely provision of treatment to address Resident #27's limited Range of Motion of the right hand resulted in harm for the resident, whose right hand experienced further contracture. Findings Include: Record review for Resident #27 revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 07/22/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #27 had no impairment in Range of Motion (ROM) to the upper extremities. Additionally, Resident #27's Annual MDS having an Assessment Reference Date of 08/18/2014 also documented that Resident #27 continued to have no impairment in ROM to the upper extremities. Despite Resident #27's MDS assessments of 07/22/2013 and 08/18/2014 referenced above indicating no Range of Motion impairment in the upper extremities, Resident #27's nursing Admission Assessment completed on the resident's 07/01/2013 date of facility admission documented that assessment on the date of admission had revealed the resident's right hand to be partially closed, but that the resident was able to open the hand. Continued record review for Resident #27, to include review of nursing Monthly Summaries and Nurse's Notes, for the period of time from the resident's July 2013 admission through the September 22, 2014 start date of this standard survey revealed no documented evidence of the resident experiencing any further decline in the ROM to the upper extremities, to include the right hand. However, during an observation of Resident #27 conducted on 09/24/2014 at 5:00 p.m. with Certified Nursing Assistant (CNA) "EE" in attendance, the fingers on the resident's right hand were curled inward and contracted. When CNA "EE" attempted to open Resident #27's right hand, the resident began to moan and the CNA stopped. During an interview conducted at the time of this observation, CNA "EE" acknowledged that she could not open the fingers of Resident #27's right hand. CNA "EE" stated that staff used to be able to open Resident #27's right hand and that she was uncertain when Resident #27's right had become contracted. During interview with Licensed Practical Nurse (LPN) "GG" conducted on 09/25/2014 at 2:30 p.m., LPN "GG" stated that Resident #27's right hand could be opened about an inch or an inch-and-a-half when the LPN began working in the facility approximately nine (9) months prior. During interview with the MDS Nurse conducted on 09/25/2014 at 2:15 p.m., the MDS Nurse stated that in the past, staff had been able to open Resident #27's right hand, but further acknowledged that Resident #27's right hand was now contracted and further stated that the resident's right hand contracture must be of recent origin. During an observation conducted with the Physical Therapist (PT) on 09/25/2014 at 3:20 p.m., when the PT attempted to open the fingers on Resident #27's right hand, Resident #27 was overheard to loudly state "ouh, ouh" and withdrew her hand from the PT. During an interview conducted at the time of this observation, the PT confirmed Resident #27's right hand was contracted, further stating that she had not been made aware of Resident #27's right hand contracture or evaluated the resident for the contracture prior to this observation of 09/25/2014. A Physician's Interim Orders for of 09/18/2014 for Resident #30 specified that the Occupational Therapist (OT) provide Skilled Occupational Therapy services three (3) times per week for two (2) weeks for evaluation, therapeutic exercise, and neuromuscular re-education. An Occupational Therapy Certification form dated 09/18/2014 for Resident #30 documented that therapeutic exercise and neuromuscular re-education were to be provided to the resident three (3) times weekly for two (2) weeks (in accordance with the 09/18/2014 Physician's Interim Orders order for Skilled OT referenced above) for the Goal of assisting Resident #30 to present with the proper posture while up in the wheelchair. There was, however, no reference to OT providing any evaluation or treatment to the resident's upper extremities, including the right hand. Occupational Therapy Daily Notes then documented that Skilled OT services were provided to Resident #30 three (3) times weekly, as ordered, related to wheelchair positioning, but record review revealed no evidence of any treatment regarding Resident #30's right hand contracture. During an interview with the OT Assistant conducted on 09/25/2014 at 9:30 a.m., the Occupational Therapy Assistant reviewed the Occupational Therapy electronic record for Resident #27 and stated there was no evidence of an Occupational Therapy Assessment regarding the resident's right hand contracture as of the 09/25/2014 date of this interview. Further review of Resident #27's clinical record revealed no documented evidence after the 07/01/2013 date of the resident's facility admission (at which time the Admission Assessment had documented the right hand to be partially closed and that the resident could open the hand), through the 09/25/2014 exit date of this standard survey, of Resident #27 experiencing any further contracture of the right hand. This record review also revealed no evidence of preventative measures having been put into place for Resident #27 to prevent contracture of the right hand, or to treat the existing right hand contracture. Rather, an OT Daily Note (obtained as part of the post-survey Quality Assurance review) for Resident #27 documented that Resident #27 had been assessed by the OT on 09/26/2014 (one day after the 09/25/2014 exit date of this standard survey). The OT documented in this 09/26/2014 OT Daily Note that Resident #27 had presented with a significant contracture to the right hand, keeping the hand closed. This 09/26/2014 OT Daily Note further documented that the OT had attempted to apply a palm protector, but that Resident #27 had resisted, and a rolled washcloth was then applied to Resident #27's contracted right hand. Based on the above, Resident #27 was admitted to the facility on [DATE] with the right hand only partially closed and with the resident being able to open the hand. However, there was no evidence to indicate that the facility put measures in place in response to Resident #27's partially closed hand to prevent further loss of function. There was also no evidence to indicate that the facility identified the subsequent decline in the ROM status of Resident #27's right hand prior to this standard survey of 09/25/2014, with a post-survey, 09/26/2014 OT Daily Note then identifying that Resident #27 had a significant contracture to the right hand.

Based on observation, review of the facility's Infection Control policy, and staff interview, the facility failed to bag, label, and/or store residents' personal care items to prevent the potential spread of infection, in accordance with the facility's Infection Control policy, in ten (10) resident rooms observed (A-2, A-5, A-9, A-11, A-12, A-16, B-9, B-11, B-12, and B-14) located on two (2) of two (2) halls (Halls A and B). Findings include: Review of the facility's policy for Infection Control-Personal Care Items revealed the policy to specify the following: Bed pans and basins were to be labeled, cleaned between each use, and kept in clean trash bags in resident cabinet drawers. Urinals were to be labeled, cleaned between each use, and kept in clean trash bag accessible to residents. Oral care items such as toothbrushes, toothpaste and small emesis basins were to be kept in a Ziploc bag in resident cabinet top drawers when not in use. Other personal items such as hair brushes and combs were also to be bagged, stored separately from oral care items, and stored in resident cabinet drawers. 1. Observation conducted on 09/22/2014 at 10:30 a.m. of the bathroom for resident room A-5, which was shared by two (2) residents, revealed three (3) unlabeled and unbagged urinals on top of the handrails over the commode, rather than being labeled and bagged per the facility's Infection Control policy. Subsequent observation conducted on 09/25/2014 at 10:25 a.m. of this bathroom of resident room A-5 continued to reveal three (3) unlabeled urinals. 2. Observations conducted on 09/22/2014 at 10:30 a.m. and on 09/23/2014 at 10:30 a.m. of the bathroom for resident room A-2, a private room, revealed one (1) unbagged urinal on the floor, rather than being bagged per the facility's Infection Control policy. 3. Observations conducted on 09/22/2014 at 10:30 a.m., 09/23/2014 at 10:30 a.m., 09/24/2014 at 8:15 a.m., and 09/25/2014 at 10:25 a.m. of the bathroom for resident room A-11, which was shared by two (2) residents, revealed one (1) denture cup and one (1) 520 cubic centimeter (cc) measuring tool on top of the commode, rather than being stored in resident cabinet drawers per the facility's Infection Control policy. 4. Observations conducted on 09/23/2014 at 10:30 a.m., 09/24/2014 at 8:15 a.m., and 09/25/2014 at 10:25 a.m. of the bathroom for resident room A-16, shared by two (2) residents, revealed one (1) unbagged and unlabeled bed pan on the floor, rather than being labeled, bagged, and kept in a resident cabinet drawer per the facility's Infection Control policy. During an interview conducted on 09/25/2014 at 10:20 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that facility staff was expected to follow the facility's policy for infection control for personal care items, which included labeling and bagging the items referenced above. The ADON also acknowledged that the residents' personal items referenced above were not bagged and/or labeled, per facility policy. 5. Observations conducted on 09/22/2014 at 3:58 p.m. and on 09/25/2014 at 10:15 a.m. in the bathroom for resident room A-9, which was shared by two (2) residents, revealed an unlabeled and unbagged emesis basin, which contained a toothbrush and tube of toothpaste, on the sink in the bathroom. This was in violation of the facility's Infection Control policy, which specified that the emesis basin, toothbrush, and toothpaste be bagged and stored in the resident's cabinet drawer. 6. Observation conducted on 09/22/2014 at 11:42 a.m. in the bathroom of resident room B-11, in which one (1) resident resided at the time of this observation, revealed an unlabeled, unbagged bed pan on the floor, an unbagged emesis basin on the grab bar in the bathroom, and a graduated urine container (which had five straws and a dried yellow resident on the container bottom) stored on the shelf above the sink in the bathroom. Observation conducted on 09/22/2014 at 1:05 p.m. in this resident room B-11 bathroom revealed that the bedpan had been bagged, but placed on top of the trash can. Subsequent observation conducted on 09/23/2014 at 8:25 a.m., on 09/24/2014 at 10:20 a.m., and on 09/25/2014 at 10:00 a.m. in the bathroom of resident room B-11 revealed that the bedpan continued sitting on top of the trash can, the unbagged emesis basin remained on the bathroom grab bar, and the urine container which contained straws and having yellow residue in the bottom remained on the shelf above the sink. A second resident was admitted to resident room B-11 on the afternoon of 09/24/2014. Based on the above, facility staff failed to label and bag the bed pan, bag the emesis basin, and clean the graduated urine container between uses, and also failed to store all these items in the resident's cabinet drawer, per the facility's Infection Control policy. 7. Observations conducted on 09/22/2014 at 4:06 p.m. and on 09/25/2014 at 10:05 a.m. in the bathroom of resident room A-12, which housed two (2) residents, revealed a denture cup with dentures on the sink, an unlabeled and unbagged urinal hanging on the grab bar, and a graduated urine container sitting on top of the toilet tank in the bathroom. Thus, facility staff failed to label and bag the urinal, and failed to store the store the denture cup, dentures, and graduated urine container in the resident's cabinet drawer, per the facility's Infection Control policy. 8. Observations conducted on 09/22/2014 at 11:32 a.m., on 09/23/2014 at 8:35 a.m., on 09/24/2014 at 10:25 a.m., and on 09/25/2014 at 10:05 a.m. in the bathroom of resident room B-9, shared by two (2) residents, revealed an unbagged toothbrush on the sink behind the faucet in the bathroom, rather being bagged and stored in the resident's cabinet drawer as specified by the facility's Infection Control policy. 9. Observations conducted on 9/22/14 at 12:27 p.m., on 9/23/14 at 8:30 a.m., on 9/24/14 at 10:20 a.m. and 1 p.m., and on 9/25/14 at 10:35 a.m. in the bathroom of resident room B-14, shared by two (2) residents, revealed a denture cup on the sink in the bathroom, rather than being stored in the resident's cabinet drawer as specified by the Infection Control policy. 10. Observations conducted on 09/22/2014 at 11:53 a.m., on 09/23/2014 at 8:30 a.m., on 09/24/2014 at 10:35 a.m., and on 09/25/2014 at 10:00 a.m. in the bathroom of resident room B-12, shared by two (2) residents, revealed an unlabeled urine hat between the grab bar and the wall in the bathroom, rather than being labeled as specified by the facility's Infection Control policy. During an interview with the ADON conducted on 09/25/2014 at 11:20 a.m., the ADON stated that resident personal care equipment such as wash basins, bedpans, and emesis basins should be labeled with the resident's name, bagged, and placed in the resident's cabinet drawer. The ADON further stated that urine hats and graduated containers should be removed from the bathrooms after use.