Every finding on record at King's Grant Lacy Health Center

Based on observation, staff interviews, and facility document review, the facility staff failed to store, prepare and distribute food in the facility kitchen to prevent foodborne illnesses. The findings included: 1.The facility staff failed to discard out of date perishable food items and failed to label items when removed from the facility freezer. The kitchen contained out of date bread in the active food supply on two observations. The first observation had out of date bread dated 03/13/26 and the second observation had out of date bread of 4/7/26. On 4/14/2026 at 11:56 am, a walk through of the kitchen was conducted with the Dietary Director. Bread was observed placed on four trays in a separate area near the back of the kitchen containing sandwich breads and sandwich rolls. Two packages of bread had a date of 3/13/2026. When the Dietary Director was asked if the date was an expiration date, she stated the bread is pulled from the freezer and served each day. She could not say when the bread was pulled and could not locate a label for a used by date. The two packages with the date 3/13/2026 were thrown away by the Dietary Director. She reports receiving bread that day from the supplier. Due to the bread not being labeled with dates that the bread was received, used by dates, or dates when bread was pulled from the freezer, it was not clear when the other bread would expire or if it had expired. 4/15/2026 at 5:10pm, observation and interview with kitchen staff #1 revealed she was making sandwiches with bread that had a date of 4/7/2026. Five other loaves of bread had no date (expiration or date received) and one loaf was dated with the proper dates, not expired. When asked about why all the bread is not labeled she reports it was pulled that morning. When asked how she knows it was not expired since there is no date on the bread, she stated it is the same as using bread at home, you know when something is bad. She also reports that Serve Safe recommends six-seven days for bread to be used. This would also make the bread dated 4/7/2026 expired by one to two days. 4/15/2026 at 5:15 pm, interview with kitchen staff #2, who stated he had pulled the bread from the freezer that morning, they use what they pull each day, heat in a warmer and use by the evening. He did not have an explanation as to why some bread had a date and others did not. A facility policy titled, Food Storage, revised on 03/2015 indicated, leftover food must be stored appropriately in covered containers or wrapped carefully and clearly labeled and dated. Leftover food is to be used within three days of storage or discarded. On 04/16/2026 at 11:40 a.m., the issue with the out-of-date bread items and labeling was reviewed during a meeting with the Administrator and Director of Nursing. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. The facility dietary staff failed to ensure the sanitizing station for the three-compartment sink was maintained in proper working order. On 04/16/2026 at approximately 9:00 a.m., the dietary manager (DM) tested the sanitizing solution in the three-compartment sink using a test strip. Multiple tests were conducted, with no observable change in the color of the test strips. Dietary personnel #2 added additional sanitizing solution to the water, and another test strip was used. The strip showed only a minimal color change and remained blue in appearance. According to the labeling on the sanitizing solution bottle, this result corresponded to a concentration range of 0-170 parts per million (ppm). The test strips were confirmed to be unexpired, with an expiration date of 12/2026. Signage posted above the sink indicated that the test strip readings should fall between 272-700 ppm. An additional sign on the adjacent wall indicated an acceptable range of 200-400 ppm. The DM and dietary personnel #2 stated that the facility had recently changed vendors, and the sanitizing station had been replaced. The DM stated they would contact the vendor, they only used the three-compartment sink for plastic trays that would crack in the dish machine, and they would use bleach if they used the three-compartment sink. On 04/16/2026 at 9:15 a.m., the Director of Nursing (DON) was made aware that the sanitizing tests strips for the three-compartment sink in the kitchen were not reading within the appropriate range. On 04/16/2026 at 9:35 a.m., during an interview with dietary personnel #2 this staff stated that there was no current log in place to document sanitizing solution test results for the three-compartment sink. On 04/16/2026 at 11:40 a.m., the issue with the sanitizing station for the three-compartment sink was reviewed during a meeting with the Administrator and DON. During this meeting these staff were also informed that the dietary staff did not maintain a log documenting the results of sanitizing solution checks. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 13 current residents, Resident #6.The findings included: Resident #6's CCP included the focus area full code. The clinical record included a provider order dated 01/17/2026 indicating the resident was a Do Not Resuscitate (DNR). Resident #6's diagnoses included dementia, Alzheimer's disease, and major depressive disorder. Section C (cognitive patterns) of Resident #6's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/08/26 was coded 1/1/3 to indicate the resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. The clinical record for Resident #6 included:A DNR order dated 01/17/2026. A Durable Do Not Resuscitate (DDNR) order dated 10/18/2025, signed by Resident #6's power of attorney and physician. Resident #6's CCP included the focus area Resident's code status is a full code. Date initiated 10/02/25. On 04/14/2026 at 4:53 p.m., the Director of Nursing (DON) was notified that Resident #6's CCP listed full code while the clinical record included a provider order for DNR. At 5:00 p.m. on 04/14/2026 the DON acknowledged the CCP was inaccurate and stated it would be corrected. On 04/14/26 the facility staff updated Resident #6's CCP to reflect their DNR status. On 04/16/2026 at 8:10 a.m., during an interview with the MDS coordinator this staff stated Resident #6 was a full code upon admission, their status was later changed to DNR, and they had missed that it had been changed. On 04/16/26 at 11:40 a.m., during a meeting with the Administrator and DON the failure to revise the CCP when Resident #6's status changed to DNR was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine to 2 of 5 sampled residents for immunizations in accordance with nationally recognized standards, Residents #12 and #13. The findings included: 1. For Resident #12, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 2/13/23, read in part, .For adults [AGE] years or older who have only received PCV13, CDC recommends you either: Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after PCV13 . Resident #12's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Atherosclerotic Heart Disease, and Essential Hypertension. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/08/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #12 was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. A review of Resident #12's clinical record revealed they had received a pneumococcal conjugate vaccine 13 (PCV13) on 3/03/17 prior to admission. Surveyor was unable to locate evidence to indicate Resident #12 was offered a PCV20 or PPSV23 vaccine following admission to the facility. On 9/13/23 at 4:26 PM, surveyor spoke with the director of nursing (DON) and requested any evidence of Resident #12 receiving or being offered any additional pneumococcal vaccinations. The DON stated they would check in the Virginia Immunization System (VIS) and Care Connect for additional information. No additional pneumococcal vaccine information was provided for Resident #12. Surveyor requested and received the facility policy titled Pneumococcal Vaccines issued/revised 11/2021 which read in part, .Communicate the resident's vaccine history to his/her provider. The provider will indicate if the resident needs PCV13 or PPSV23 or both . On 9/14/23 at 1:25 PM, surveyor spoke with the DON who stated the facility focus had been on providing COVID vaccinations and they will work on providing pneumonia vaccines and will also review the facility policy. On 9/14/23 at 5:24 PM, the survey team met with the facility administrative team including the administrator and DON and discussed the concern of Resident #12 not being offered a PCV20 or PPSV23 following admission. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/14/23. 2. For Resident #13, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal conjugate vaccine 15 (PCV15) following admission to the facility. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 2/13/23, read in part, .For adults [AGE] years or older who have only received PPSV23, CDC recommends you: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination . Resident #13's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, Type 2 Diabetes Mellitus, and Malignant Neoplasm of Skin. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/31/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #13 was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. A review of Resident #13's clinical record revealed they received a pneumococcal polysaccharide 23 (PPSV23) vaccine on 5/17/18 prior to admission to the facility. Surveyor was unable to locate evidence to indicate Resident #13 was offered a PCV20 or PCV15 vaccine following admission to the facility. On 9/13/23 at 4:26 PM, surveyor spoke with the director of nursing (DON) and requested any evidence of Resident #13 receiving or being offered any additional pneumococcal vaccinations. The DON stated they would check in the Virginia Immunization System (VIS) and Care Connect for additional information. No additional pneumococcal vaccine information was provided for Resident #13. Surveyor requested and received the facility policy titled Pneumococcal Vaccines issued/revised 11/2021 which read in part, .Communicate the resident's vaccine history to his/her provider. The provider will indicate if the resident needs PCV13 or PPSV23 or both . On 9/14/23 at 1:25 PM, surveyor spoke with the DON who stated the facility focus had been on providing COVID vaccinations and they will work on providing pneumonia vaccines and will also review the facility policy. On 9/14/23 at 5:24 PM, the survey team met with the facility administrative team including the administrator and DON and discussed the concern of Resident #13 not being offered a PCV20 or PCV15 following admission. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/14/23.

Based on observations, staff interviews, and facility document review, it was determined the facility staff failed to accurately implement policies and procedures relating to DNR (do not resuscitate) status for two (2) of 30 facility residents (Resident #12 and Resident #26). The findings include: The facility staff failed to ensure Resident #12's and Resident #26's code status was correctly marked, outside the residents' room, according to the facility's process. The facility's process is that residents with an active DNR will have a blue dot sticker placed beside the resident's name that is posted on the nameplate sign outside of the resident's room. Resident #26's clinical record included a minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE]. Resident #26 was assessed as being able to make self understood and as being able to understand others. Resident #26's Brief Interview for Mental Status (BIMS) summary score was documented as a 12 out of 15. Resident #26 was documented as requiring limited assistance with bed mobility, transfers, toilet use, and personal hygiene. Resident #26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's clinical record included a minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE]. Resident #12 was assessed as being able to sometimes make self understood and sometimes being able to understand others. Resident #12 was assessed as having problems with short-term memory. Resident #12 was assessed as being dependent on others for transfers, dressing, toilet use, personal hygiene, and bathing. Resident #12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:24 a.m., the nameplate sign outside of Resident #26's room was noted to have a blue dot sticker placed beside Resident #26's name. LPN (licensed practical nurse) #21 and LPN #22 were present during this observation. LPN #21 confirmed Resident #26 had a blue dot sticker beside the resident's name. LPN #21 reported the blue dot indicated the resident had a DNR order. LPN #21 and LPN #22 reviewed Resident #26's electronic clinical record and reported a DNR order for Resident #26 was not found. LPN #22 reported the decision to start or not to start CPR is not made based on the blue dot sticker alone. LPN #22 reported the facility's process requires the blue dot sticker/code status be confirmed by two individuals and confirmed by the DNR order in a resident's clinical record. On [DATE] at 10:29 a.m., the facility's Director of Nursing (DON) was shown the blue dot sticker which was placed beside Resident #26 name; the DON was also informed a DNR order for Resident #26 was not found. Resident #26 was care planned as having a code status of Full Code. On the morning of [DATE], the blue dot stickers on the residents' nameplates outside of the resident rooms was reviewed with RN (registered nurse) #23. At 11:05 a.m., it was discovered that Resident #12's clinical documentation did not include orders for DNR although there was a blue dot sticker beside the resident's name on the nameplate outside of the resident's room. RN #23 confirmed Resident #12 had a blue dot sticker beside their name posted on the nameplate outside of the resident room. Resident #12 was care planned as having a code status of Full Code. The following information was found in a facility document titled CODE STATUS (with a revision date of ,d+[DATE]): - STATEMENT OF POLICY: It is the policy of King's Grant to support the rights of residents in making decisions regarding their care and treatment. King's Grant will honor the resident's wishes regarding the extent of measures that will be taken in the event that life saving measures are deemed necessary. - PURPOSE: To identify the process followed by King's Grant to ensure appropriate code status wishes are followed. - Residents who have an active DNR will also be identified by a blue dot on their door frame. - In the event of a code situation, a resident's code status will be verified in a three-step process: a. Nurse to check in (the electronic medical record) system and/or binder at nurses' station to verify code status b. Nurse to verify code status with another nurse c. Nurse to verify presence of blue dot on resident's door. A survey team meeting occurred on [DATE] at 4:20 p.m. with the facility's DON, Administrator, Infection Preventionist, and RN #23. During this meeting, the incorrect placement of blue dot stickers on Resident #12's nameplate and Resident #26's nameplate was discussed. The blue dot stickers indicated Resident #12 and Resident #26 had DNR orders when in actuality neither resident had DNR orders.

Based on observation, staff interview and facility policy review it was determined the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings: The facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The initial tour of the facility kitchen was on 9/18/18 at 11:24 AM. The surveyor observed stacks of baking pans on a storage rack. The pans had been stacked while still wet and moisture and water droplets were observed between the pans. The surveyor informed Chef I about the pans being stacked and stored while still wet. Chef I instructed a dietary employee to pull the pans apart and air dry them before restacking. On 9/19/18 at 3:30 PM the DON and the administrator were informed of the surveyor's observations and asked for for the facility policy for the storage of pots and dishes. On 9/20/18 at 8:30 AM the DON provided the facility policy for sanitation and infection prevention/control for the storage of pots, dishes, flatware and utensils. The policy contained the following: Air dry all food contact surfaces, including pots, dishes,flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet. No additional information was provided prior to the survey team exit.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to follow physician's orders for 1 of 16 Residents in the survey sample, Resident # 19. The findings included: The facility staff failed to follow physician's orders for Humalog sliding scale coverage and physician notification for Resident # 19. Resident # 19 was a [AGE] year-old-female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 19 was reviewed on 9/19/18 at 2:50 pm. The most recent MDS (minimum data set) assessment was a 5-day assessment with an ARD (assessment reference date) of 9/5/18. Section C assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 19 had a BIMS score (brief interview for mental status) of 15 out of 15 which indicated that Resident # 19 was cognitively intact. Section N assesses medications. In section N0350, the facility staff documented that Resident # 19 had received insulin injections during the last 7 days or since admission/entry or reentry if less than 7 days. The physician signed the orders for Resident # 19 on 9/8/18. Orders included but were not limited to: Humalog U-100 Insulin 100 unit/mL (milliliter) subcutaneous solution (see ss) (sliding scale) vial (ML) Subcutaneous Notes: Sliding Scale Insulin: Blood Sugar > 400, Notify MD (medical doctor); 201-250, 2 Units; 251-300, 4 Units; 301-350, 6 Units; 351-400, 8 Units; Greater than 400 = 10 units and notify MD. The current plan of care for Resident # 19 was reviewed and revised on 8/30/18. The facility staff documented a problem area as Resident # 19 is at risk for alteration in cardiac input r/t (related to) HTN, (hypertension) [MEDICAL CONDITION], (congested heart failure), A-fib, [MEDICAL CONDITION], type 2 diabetes. Interventions included but were not limited to: Administer medication as ordered. (See MAR) (medication administration record). On 9/20/18 at 11:15 am, the surveyor reviewed the (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 9/3/18 at 12:00 pm, the facility staff documented that Resident # 19's blood sugar was 410 and 8 units of Humalog had been administered. According to the physician's orders, 10 units should have been administered and MD notified. Upon review of the clinical notes, this surveyor did not locate any documentation that the physician had been made aware of the blood sugar of 410 for Resident # 19. On 9/5/18 at 5:30 pm, the facility staff documented that Resident #19 had a blood sugar of 402 and that 8 units of Humalog had been administered. According to physician's orders, 10 units of Humalog should have been administered and MD notified. Upon review of the clinical notes, this surveyor did not locate any documentation that the physician had been made aware of the blood sugar of 402 for Resident # 19. On 9/5/18 at 9:30 pm, the facility staff documented that Resident #19 had a blood sugar of 410. According to physician's orders, the MD should have been notified. Upon review of the clinical notes, this surveyor did not locate any documentation that the physician had been made aware of the blood sugar of 410 for Resident # 19. On 9/7/18 at 12:00 pm, the facility staff documented that Resident #19 had a blood sugar of 433 and that 8 units of Humalog had been administered. According to physician's orders, 10 units of Humalog should have been administered and MD notified. Upon review of the clinical notes, this surveyor did not locate any documentation that the physician had been made aware of the blood sugar of 433 for Resident # 19. On 9/20/18 at 11:30 am, the surveyor spoke with the RN (registered nurse) supervisor about the concerns about not following the physician's orders for sliding scale coverage and physician notification for Resident # 19. The RN supervisor stated that she would look into the issue and get back with the surveyor. According to the facility policy on Management of Blood Sugars, the guidelines incudes documentation that includes but is not limited to . 2. Staff will administer insulin as ordered by the physician. 3. Staff will monitor for changes in resident condition. Staff will monitor for signs and symptoms of hyper/hypo glycemia. Changes in condition or blood glucose readings outside of parameters, set by the physician, will be reported to the physician promptly . On 9/20/18 at 12:53 pm, the director of nursing made the surveyor aware that the facility staff did not follow physician's orders for sliding scale Humalog and MD notification as stated above. No further information was provided to the survey team regarding this issue was presented to the survey team prior to the exit conference on 9/20/18.

Based on observation, resident and staff interviews and clinical records it was determined the facility staff failed to provide oxygen administration per physician's orders [REDACTED].#7.) Findings: Facility staff failed to follow current physician's orders [REDACTED].#7. Resident #7's clinical record was reviewed on 6/15/16 at 9:00 AM. The resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #7's latest MDS (minimum data set) assessment dated [DATE] coded the resident with minimal cognitive impairment. The resident was coded as moderately impaired visually. Short & long term memory were not coded. The MDS coded the resident with required facility staff assistance for all ADLs (activities of daily living) including eating. The resident's communication ability was unimpaired. She communicated her needs effectively & understood the staff when required. The resident's MDS was coded with daily oxygen use during the 14 day look-back period. Resident #7's CCP (comprehensive care plan) implemented on 5/20/16 (and goal dated 8/24/16) included the problem At risk for alteration in cardiac/respiratory .d/t [MEDICAL CONDITION] Fib w/RVR, Acute on [MEDICAL CONDITION] .and severe [MEDICAL CONDITION] hypertension. Interventions included oxygen per order. Resident #7 had a signed physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. On 6/14/16 at 9:15 AM the surveyor observed Resident #7's nurse (LPN I)during a medication pass. The resident was seated in her room and had a nasal cannula in place. The tubing reached from the resident, across her bed, past the nitestand and was in a pile on the floor in front off the oxygen concentrator--which was running. The resident told the nurse she was not breathing well and had water running through her oxygen tubing. The nurse began to inspect the tubing. The surveyor observed the tubing had water throughout the length, yet none was caught in the trap which was lying on the bed. The surveyor pointed out to LPN I that the O2 concentrator was running at 3 L/min--but the tubing was not connected to the concentrator. LPN I obtained a new tube and attached it to a spare cylinder of oxygen in the resident's room. The surveyor requested for LPN I to take a (pulse-ox (pulse oximetry) reading on the resident. At 9:22 AM the reading was 84%. After receiving O2 for 16 minutes, at 9:38 AM, the resident's pulse ox was 98%. At this time the resident told the surveyor her breathing was better. She stated, Last the water was running into the tubing and down my neck. I was afraid to swallow it because I've been told that would cause pneumonia. Resident #7 said she had called the staff into her room twice during the middle of the night to fix the tubing. She said they just fiddled around with it and went back out. The administrator was informed of the surveyor's findings on 6/15/16 at 11:20 AM. She provided survey team with the facility policy regarding maintenance of residents using oxygen and the home health directive regarding management of humidifier bottles on O2 concentrators. The policy did not contain any directive about the air tubing, other that normal usage and cleaning. The home care directions cautioned staff, DO NOT fill the bottle over the maximum line; it will result in water getting into your tubing and possibly in your nose, or it could result in the blockage of your oxygen flow. No additional info was provided prior to exit.

2a. The facility staff failed to ensure a complete clinical record for Resident #1 by failing to document the facility investigation into a fall occurring on 5/05/15. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set (MDS) with a reference date of 4/2/15 assessed the resident with a cognitive score of 15 of 15. The resident was assessed requiring supervision of 1 person for bed mobility, transfers, ambulation, dressing, toileting, bathing, and hygiene. The clinical record contained a nursing note dated 5/5/15 the resident was fof (found on floor) in the breezeway between AL (assisted living) and HC (Health Care). She had a laceration to her left pinky, bruise on her left leg and a scratch on her forehead and one on her cheek. Resident was transported by (transport service) to hospital (named) per (physician name) to have her pinky checked. Another nursing note dated 5/6/15 noted the responsible party had been notified of the injury. The director of nursing (DON) was asked for the investigation into the fall. The DON provided the facility policy and procedure for investigation of incidents such as falls. The policy stated the investigation was to follow established procedures which included to investigate different types of incidents, identify employees responsible for initial reporting, investigation of alleged violations and reporting of results to proper authorities. The procedure noted to, Document the fall and your actions, assessment, and investigation in the nursing notes. The DON stated the investigations were to be documented in the nursing notes and the follow up was performed by the Quality Assurance (QA) Committee. The DON provided evidence of the QA investigation into incidents by showing the form the QA Committee used for documenting all investigations. The DON agreed the facility staff failed to document the actions, assessment , and investigation in the nursing notes. 2b. The facility staff failed to ensure a complete clinical record for Resident #1 by failing to document the facility investigation into a fall occurring on 12/18/14. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set (MDS) with a reference date of 4/2/15 assessed the resident with a cognitive score of 15 of 15. The resident was assessed requiring supervision of 1 person for bed mobility, transfers, ambulation, dressing, toileting, bathing, and hygiene. The clinical record contained a nursing note dated 12/18/14 the resident was fof (found on floor) at 1615 hematoma on left temple sent to ER returned to facility 2240 with orders for ice pack to affected area f/u with (physician name) in 2 days for recheck of potassium [MEDICAL CONDITION] resident denied pain neuro checks initiated. The director of nursing (DON) reviewed the clinical record. The DON agreed the facility staff failed to document the actions, assessment , and investigation in the nursing notes. 3. The facility staff failed to ensure a complete clinical record for Resident #5 by failing to document the facility investigation into a bruise occurring on 3/21/15. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set (MDS) with a reference date of 3/2/15 assessed the resident with long and short term memory deficit and requiring extensive assistance for decision making. The resident was assessed requiring extensive assistance of 1-2 persons for bed mobility, transfers dressing, eating, toileting, bathing, and hygiene. The nursing notes were reviewed. The notes contained a nursing note 3/21/15 that the resident noted to have a 2x1 cm bruise to the top of mid chest, bruise was noted during skin assessment. The notes continued that the physician and responsible party were notified. The director of nursing (DON) reviewed the clinical record. The DON agreed the facility staff failed to document the actions, assessment , and investigation in the nursing notes. The executive director, DON, and social worker were informed on 6/10/15 at 4:00 p.m. of the facility failure to complete documentation of incidents in the nursing notes per the facility policy and procedure. Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 3 of 11 residents, Residents #2, #1,and #5,. The findings include: 1. The facility staff failed to document the investigation of a fall that was not witnessed for Resident #2. Resident #2 was re- admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. A review of Resident #2 ' s clinical record included a nurse ' s note dated 1/7/15 at 2:29 p.m. that she was found on the floor in room lying on right side next to recliner chair at 1338 (1:38 p.m.) . There was no documentation in the clinical record of any investigation of the fall as per the facility policy. (The facility fall policy is referenced below.) The facility management staff were made aware of the findings on 6/10/15 at around 4:00 p.m.

Based on staff interview, and clinical record review, the facility staff failed to obtain a physician order [REDACTED]. The findings include: The facility staff failed to obtain a physician order [REDACTED].>Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with a reference date of 4/22/15 assessed the resident with a cognitive score of 5 of 15. The resident was assessed requiring extensive assistance of 1 person for bed mobility, transfers, toileting, hygiene, and bathing. The clinical record was reviewed. The record contained a physician order [REDACTED]. The lab results were reviewed. The results showed a lab test for a CRP was obtained without a physician order. The director of nursing (DON) was asked about the lab test on 6/10/15 at 8:00 a.m. The DON reviewed the lab tests and determined the CRP level was drawn in error. The executive director, DON, and social worker were informed of the finding during a meeting with the survey team on 6/10/15 at 4:00 p.m.

Based on staff interview and clinical record review, the facility staff failed to obtain physician ordered laboratory (lab) tests for 2 of 11 residents (Resident #1 and #6). The findings include: 1. The facility staff failed to obtain a physician ordered lab test for a medication level for [MEDICATION NAME] for Resident #1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set (MDS) with a reference date of 4/2/15 assessed the resident with a cognitive score of 15 of 15. The resident was assessed requiring supervision of 1 person for bed mobility, transfers, ambulation, dressing, toileting, bathing, and hygiene. The clinical record was reviewed. The record contained a physician order [REDACTED]. The clinical record was reviewed. The record contained lab results dated 5/12/15 for all lab tests ordered except the [MEDICATION NAME] level. The director of nursing (DON) was asked about the missing lab test on 6/9/15 at 3:15 p.m. The DON reviewed the lab tests and determined the [MEDICATION NAME] level was not drawn as ordered. The executive director, DON, and social worker were informed of the finding during a meeting with the survey team on 6/10/15 at 4:00 p.m. 2. The facility staff failed to obtain a physician ordered lab test for a Creatinine Phosphokinase (CPK) on 4/20/15 for Resident #6. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with a reference date of 4/22/15 assessed the resident with a cognitive score of 5 of 15. The resident was assessed requirining extensive assistance of 1 person for bed mobility, transfers, toileting, hygiene, and bathing. The clinical record was reviewed. The record contained a physician order [REDACTED]. The lab results were reviewed. The results did not contain the CPK ordered. The director of nursing (DON) was asked about the missing lab test on 6/10/15 at 8:00 a.m. The DON reviewed the lab tests and determined the CPK level was not drawn as ordered. The executive director, DON, and social worker were informed of the finding during a meeting with the survey team on 6/10/15 at 4:00 p.m.

Based on observation, staff interview, and facility document review it was determined the facility staff failed to store and prepare food in a clean and sanitary manner for facility residents. Findings: On 9/9/14 at 2:15 PM, during the initial tour of the facility the following conditions were observed in the kitchen: 1. Cook I greeted the surveyors at the door of the kitchen without a hair net on. 2. The Chef greeted the surveyors and accompanied them during the rest of the kitchen tour. 3. The kitchen was observed to have trash and debris on the floor of the kitchen and inside the refrigerators and freezers. Ice cream and pudding cups were observed on the floor under the grating. When asked how often the walk-in cooler was cleaned the Chef stated, "Apparently, not often enough." 4. A package of "wetnuts" placed in a cooler was dated, 8/29/14 after it was opened and stored there. The Chef said, "We'll toss 'em after a couple of weeks." 5. Pineapple topping, dated 8/31/14 when opened with a dispose of date 9/7/14 was still in the cooler. The Chef said the facility was supposed to date all items the date it was opened and stored and then date it with a "dispose by date" one week later. 6. Bagged ice was observed to be stored on trays on the floor of the walk-in freezer. The trays had trash and food debris including a frozen food items (?) inside them. The Chef was asked to identify one of the items lying loosely around the ice bags. He picked it up and stated, "Looks like a frozen egg roll." 7. Six previously opened frozen sausage patties, 2 frozen omelets and 20 frozen biscuits, loosely covered with cellophane that did not seal the food items were in the freezer and not dated. 8. The freezer contained previously opened (or damaged packaging) and not resealed/or dated packages of rolled dough, two packages of waffle fries, 4 bags of crinkle fries (dated 6/13/13), a box of open broccoli cuts (dated 6/19/14), bagged fried green beans (undated). 9. The shelving in the kitchen contained opened/unsealed and undated bags of Uncle Ben's rice, and pasta. The rice bag had stains on it that looked as if something had spilled onto the bag. The Chef stated, "Ordinarily we put the opened date on it--we wouldn't keep it past 6 months. It's no telling what leaked on it. We'll toss it to be sure." 10. The walk-in cooler had an unpleasant odor and the floor was littered with food debris and trash. It contained a bag of green onions (use by 8/27/14), bagged carrots (best if used by 8/25/14), bagged carrots (Use by 9/7/14), 2 five lb. bags of baby carrots (Use by 6/21/14), asparagus that was wilted and dried looking (Dated when placed in refrigerator 8/30/14). 11. Outside the refrigerator was a cart of uncovered wheat rolls. The Chef said the rolls had been placed there on the cart to thaw and rise and had been there "several hours." Since they were not covered and on very low shelving near the floor the Chef decided to discard them as he did not know what they may have been contaminated by while lying out uncovered. 12. The walls of the kitchen were smudged and dirty in places. The staff had left personal drinking cups and water bottles in the food preparation area in a window sill. 13. The ice cream freezer contained 6 bags of whipped topping with no date. 14. The 2 eyes on the gas stove were littered with food debris and the stove had build-up grease and food debris on it. The Chef commented, "It looks like it needs cleaning more often than it is." 15. The grouting in the kitchen tile floor was darkly stained in areas and completely missing and unsealed in others. The Chef said they pressure washed it to get it clean. 16. Dusty debris was observed hanging from the sprinkler system over the five burner stove. 17. The sugar bin and two flour bins housed on the floor under the shelving were observed to be dirty and have food debris and stains on the outsides. The bins were all left open/ajar. 18. The Chef said the large pans were all laid on top of the pizza oven so they could dry completely before storing them stacked on a rack. The surface of the oven was observed to be unclean and rusty looking. 19. The "cook and hold" unit was dirty and had grease built-up on the bottom of the unit. 20. In the dry goods room, a fifty lb. bag of corn meal and three bags of pasta were opened and not resealed (not dated). Kitchen staff member I stated, "If it's open--it shouldn't be back here." 21. The dry goods room also contained a plastic box of Japanese bread crumbs and three bags of vanilla wafers with no dates. A punch mix was opened and dated 7/14/14. A rusty baking powder tin was observed to be opened and dated 7/7/14. On 9/10/14 at 12:15 PM the surveyor observed two staff members, Cook II and Cook III to have hair nets on that only covered a portion of their hair. The staff had long hair that was not fully contained by the hair nets. On 9/10/14 at 3:45 PM the administrator and DON were informed of the surveyor's findings. They were asked to provide the facility policies for storing food and hair net usage. The policies contained, in part: 1. Food and stock items are to be dated and rotated. 2. Long hair (male or female) will be restrained and employees will wear head coverings that cover the entire head. 3. The food policy for refrigerated items stated specifically to cover, label and date all items. 4. The maximum time to keep any leftover food items was as follows: a. Meats; salads; or any food containing vegetables; soups containing potentially hazardous foods--3 days. b. Fruits, juices, jello - 5 days c. Puddings, custard, cream pie - 5 days

Based on staff interview and clinical record review it was determined the facility staff failed to keep complete and accurate clinical records that were systematically organized and assessable for review for 4 of 13 residents (Residents #4, 2, 1 and 3.) Findings: 1. Facility staff failed to complete and systematically organize accurate physician's orders [REDACTED]. Resident #4's clinical record was reviewed 9/10/14 at 10:00 AM. Resident #4 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment, dated 8/12/14, coded the resident with some cognitive impairment. Her communication skills were intact. The resident had a physician's orders [REDACTED]. The order included: "Diet--NAS (no added salt.)" On 9/10/14 at 8:30 AM the resident was observed to have breakfast in her room. The surveyor observed the diet card on Resident #4's tray stated her diet was supposed to be "NAS (no added salt), NCS (no concentrated sweets.)" On 9/10/14 at 12:10 PM the surveyor spoke to the RD (registered dietician) about Resident #4's diet orders and the discrepancy between the physician's signed orders and the diet being served by the dietary staff. The RD told the surveyor that the hospital physician had ordered the resident be placed on a cardiac ADA (American Diabetic Association) diet upon her return from a brief hospitalization on [DATE]. She said the resident was supposed to be receiving the NAS, NCS diet that was being delivered by the kitchen. On 9/10/14 at 15:45 PM the administrator and DON were informed of the surveyor's findings. The staff then clarified the order with Resident #4's physician. RN I said the physician wanted the resident continued on the NAS, NCS diet which staff had failed to transcribe correctly over to the current recertification orders for the physician's signature. 2. Facility staff failed to complete and systematically organize accurate physician's orders [REDACTED]. Resident #2's clinical record was reviewed 9/10/14 at 11:00 AM. Resident #2 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2's clinical record included a CCP (comprehensive care plan) section for Hospice care. The resident had been admitted to hospice care on 5/21/14. Resident #2's current physician's recertification orders, signed and dated on 8/27/14 were reviewed. The orders did not include an order from her medical doctor to admit her to hospice care. On 9/10/14 at 15:45 PM the administrator and DON were informed of the surveyor's findings. RN I said the staff had failed to transcribe the physician's orders [REDACTED]. RN provided the survey team with a copy of the physician's orders [REDACTED]. It was signed and dated by the physician on 5/9/14. 4. For Resident #3, facility staff failed to document indication and effectiveness of PRN pain medication. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3 scored 15/15 on the brief interview for mental status on the quarterly MDS assessment with ARD 7/16/14. The resident fell on During clinical record review, the surveyor noted that the resident PRN pain medications for which characteristics of pain were not assessed before and after medication administration. The May 2014 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. For the majority of doses, the nurse documented "helpful". On 5/4, the order for [MEDICATION NAME] was changed from PRN to scheduled every 4 hours. The administrator was notified of the concern on 9/11/14. 3. For Resident #1 the facility staff failed to ensure complete and accurate Physician order [REDACTED]. Resident #1 was a [AGE] year old male who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a 30 Day Medicare MDS assessment with an Assessment Reference Date (ARD) of 6/10/14. The facility staff coded that Resident #1 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #1 required extensive assistance (3/2) with Activities of Daily Living (ADL's). On September 10, 2014 at 10:15 a.m. the surveyor reviewed Resident #1's clinical record. Review of the clinical record review produced three (3) Physician's Telephone Orders. The first physician telephone order was dated 7/13/14 and read ... "D/C (discontinue) [MEDICATION NAME]." (sic) The second physician telephone order was dated 7/23/14 that read ... "1515 (3:15 p.m.) D/C (discontinue) order for Res (resident) to drink 1500 cc qd (everyday). Continue to monitor I+O (intake and outputs) D/T (due to) Foley catheter use." (sic) The third physician telephone order was dated 8/1/14 and read ... "1145 (11:45 a.m.) 1). D/C O2 (oxygen) PRN (as needed) 2). D/C ? (change) O2 tubing PRN-D/T (due to) Res (resident) not used in 60+ days. 3). Cleanse skin tear to Rt (right) ? (lower) arm c (with) NS (normal saline), apply Triple ABT (antibiotic) oint (ointment) + bandaid qd (every day) til healed 4). D/C [MEDICATION NAME] to buttocks 5). Apply [MEDICATION NAME] oint to buttocks + cover c (with) balmex q (every) shift for irritation till healed." (sic) Further review of the clinical record produced signed Physician OrderSheets (POS's) dated 8/9/14. Signed physician orders [REDACTED].*Do Not Crush,* At least 1500 cc/H20 (water) daily for hydration, Change O2 (oxygen) tubing weekly if in use, O2 at 2LPM (liters per minute) via N/C (nasal cannula) as needed for SOB (shortness of breath), Apply [MEDICATION NAME] 0.1% to buttocks and groin areas every shift for irritation." (sic) The orders had not been transcribed/discontinued from the POS's signed and dated on 8/9/14. Continued review of the signed POS's did not include the orders for the [MEDICATION NAME] oint to the buttocks, the treatment to the right lower arm with TAO and NS, or to continue I&O's due to Foley cathiter use. The orders had not been transcribed/added to the POS's signed and dated on 8/9/14. On September 10, 2014 at 11:30 a.m. the surveyor notified the Administrator (Adm) and Charge Nurse, who was a Licensed Practical Nurse (LPN #1), that Resident #1's POS's were inaccurate/incomplete. The surveyor reviewed the clinical record, signed and dated POS's, with LPN (#1) and the Adm. The surveyor pointed out the specific physician telephone orders. The surveyor pointed out that the orders had not been transcribed/added to/or discontinued from the POS's signed and dated 8/9/14. On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1), that the facility staff failed to ensure a complete and accurate clinical record for Resident #1. The surveyor notified the Administrative Team (AT) that physician telephone orders had not been transcribed to the most current POS's signed and dated 8/9/14. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure a complete and accurate clinical record, POS's, for Resident #1.

Based on staff interview and clinical record review it was determined that the facility staff failed to ensure that 2 of 13 Residents in the sample survey was free from unnecessary medications, Resident #6 and Resident #8. 1. For Resident #6, the facility staff failed to monitor for [MEDICATION NAME] use, a [MEDICAL CONDITION] medication, for effectiveness, side effects, interventions and behaviors. 2. For Resident #8, the facility staff failed to monitor for [MEDICATION NAME] use, a [MEDICAL CONDITION] medication, for effectiveness, side effects, interventions and behaviors. The Findings Included: 1. For Resident #6, the facility staff failed to monitor for [MEDICATION NAME] use, a [MEDICAL CONDITION] medication, for effectiveness, side effects, interventions and specific behaviors for September 2014. Resident #6 was a [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 7/9/14. The facility staff coded that Resident #6 had a Cognitive Summary Score of 11. The facility staff also coded that Resident #6 required limited assistance (2/2) with Activities of Daily Living (ADL's). On September 10, at 8 a.m. the surveyor reviewed Resident #6's clinical record. Review of the clinical record produced signed physician orders [REDACTED]." (sic) Continued review of the clinical record revealed the September 2014 Medication Administration Records (MAR's). The September 2014 MAR's documented that the facility staff were administering the [MEDICATION NAME] every evening as ordered by the physician. Further review of the clinical record failed to produce documentation for [MEDICATION NAME] use, a [MEDICAL CONDITION] drug, for monitoring to include behavior monitoring, effectiveness of medication, side effects of the medication and/or interventions from September 1, 2014 through September 10, 2014. On September 10, 2014 at 9 a.m. the surveyor notified a Licensed Practical Nurse (LPN #1) that Resident #6 was receiving [MEDICATION NAME] 25 mg every evening. The surveyor notified LPN (#1) that documentation for [MEDICATION NAME] use, a [MEDICAL CONDITION] drug, for monitoring to include behavior monitoring, effectiveness of medication, side effects of the medication and/or interventions could not be located in the clinical record. The surveyor reviewed the clinical record with LPN (#1). LPN (#1) was unable to locate any documentation in the clinical record for the [MEDICATION NAME] use to include specific behaviors, interventions, side effects and medication effectiveness. LPN (#1) stated that the facility had a new electronic system that started on 9/1/14 and that the system probably didn't alert/queue the facility staff to document specific behaviors, interventions, effectiveness and side effects. On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1), that Resident #6 was receiving a [MEDICAL CONDITION] medication every evening, [MEDICATION NAME] 25 mg. The surveyor notified the Administrative Team (AT) that review of the clinical record failed to produce documentation for [MEDICATION NAME] use, a [MEDICAL CONDITION] drug, for monitoring to include behavior monitoring, effectiveness of medication, side effects of the medication and/or interventions from September 1, 2014 through September 10, 2014. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure that Resident #6 was free from unnecessary medications. Resident #6 was receiving [MEDICATION NAME], a [MEDICAL CONDITION] medication, and the facility staff had not documented specific behaviors, interventions, side effects and/or effectiveness of the [MEDICATION NAME]. 2. For Resident #8, the facility staff failed to monitor for [MEDICATION NAME] use, a [MEDICAL CONDITION] medication, for effectiveness, side effects, interventions and specific behaviors for September 2014. Resident #8 was a [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment was not available due to Resident #8's recent admission to the facility. On September 11, 2014 at 8:10 a.m. the surveyor reviewed Resident #8's clinical record. Review of the clinical record produced signed physician orders [REDACTED]." (sic) Continued review of the clinical record revealed the September 2014 Medication Administration Records (MAR's). The September 2014 MAR's documented that the facility staff were administering the [MEDICATION NAME] every evening as ordered by the physician. Further review of the clinical record failed to produce documentation for [MEDICATION NAME] use, a [MEDICAL CONDITION] drug, for monitoring to include behavior monitoring, effectiveness of medication, side effects of the medication and/or interventions from September 4, 2014 through September 10, 2014. On September 11, 2014 at 12:15 p.m. the surveyor notified the Administrator (Adm) and Nursing Supervisor, who was a Registered Nurse (RN #1), that Resident #8 was receiving a [MEDICAL CONDITION] medication every evening, [MEDICATION NAME] 25 mg. The surveyor notified the Administrative Team (AT) that review of the clinical record failed to produce documentation for [MEDICATION NAME] use, a [MEDICAL CONDITION] drug, for monitoring to include behavior monitoring, effectiveness of medication, side effects of the medication and/or interventions from September 4, 2014 through September 10, 2014. The Adm stated that she had spoken with the vendor of electronic record system and that the vendor was working to resolve the issue. No additional information was provided prior to exiting the facility as to why the facility staff failed to ensure that Resident #8 was free from unnecessary medications. Resident #8 was receiving [MEDICATION NAME], a [MEDICAL CONDITION] medication, and the facility staff had not documented specific behaviors, interventions, side effects and/or effectiveness of the [MEDICATION NAME].

Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to follow provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and in accordance with the comprehensive assessment and plan of care for 5 of 13 Residents in the sample survey, Resident #1, Resident #6, Resident #8, Resident #4 and Resident #3. 1. For Resident #1 the facility staff failed to follow physician orders [REDACTED]. 2. For Resident #6 the facility staff failed to obtain a physicians order prior to Resident #6 seeing a dermatologist. 3. For Resident #8 the facility staff failed to develop an Interim Care Plan. 4. For Resident #4 the facility staff failed to follow physician orders [REDACTED]. 5. For Resident #3 the facility staff failed to obtain a pain assessment. The Findings Included: 1. For Resident #1 the facility staff failed to follow physician orders [REDACTED]. Resident #1 was a [AGE] year old male who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a 30 Day Medicare MDS assessment with an Assessment Reference Date (ARD) of 6/10/14. The facility staff coded that Resident #1 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #1 required extensive assistance (3/2) with Activities of Daily Living (ADL's). On September 10, 2014 at 10:15 a.m. the surveyor reviewed Resident #1's clinical record. Review of the clinical record review produced a Physician's Telephone Orders dated 7/23/14 that read ... "1515 (3:15 p.m.) D/C (discontinue) order for Res (resident) to drink 1500 cc qd (everyday). Continue to monitor I+O (intake and outputs) D/T (due to) Foley catheter use." (sic) Further review of the clinical record produced signed Physician order [REDACTED]. Change Foley catheter 16 Fr (French) 10 ml once monthly, Foley cath (catheter) care-cleanse with soap and water every shift. Foley cath to straight drainage-Foley 16 Fr with 10cc bulb for [MEDICAL CONDITION] every shift. Irrigate catheter c (with) NS (normal saline) PRN (as needed)." (sic) On September 10, 2014 at 11:30 a.m. the surveyor notified the Administrator (Adm) and Charge Nurse, who was a Licensed Practical Nurse (LPN #1), that Resident #1 had a physicians order for Intake and Outputs (I&O's) due to Foley catheter use. The surveyor notified the Adm and Charge Nurse (LPN #1) that review of the clinical record failed to produce I&O's since September 1, 2014. The Charge Nurse (LPN #1) stated that she would look and see what she could find. On September 10, 2014 at 3 p.m. the Charge Nurse (LPN #1) approached the surveyor and informed the surveyor that she was unable to locate any documentation of Resident #1's I&O's.. The Charge Nurse (LPN #1) stated that the facility had gone to an electronic system on September 1, 2014 and that the system had not flagged or alerted the facility staff to document I&O's for Resident #1. On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1), that Resident #1 had a physician order [REDACTED].#1 and since the initiation of the new electronic record on 9/1/14. No additional information was provided prior to exiting the facility as to why the facility staff failed to document physician ordered I&O's for Resident #1. For additional information on Resident #1 refer to F Tags 314, 315 and 514. 2. For Resident #6 the facility staff failed to obtain a physicians order prior to Resident #6 seeing a dermatologist. Resident #6 was a [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 7/9/14. The facility staff coded that Resident #6 had a Cognitive Summary Score of 11. The facility staff also coded that Resident #6 required limited assistance (2/2) with Activities of Daily Living (ADL's). On September 9, 2014 at 4:15 p.m. the surveyor observed Resident #6 sitting in a recliner at the side of her bed. The surveyor spoke to Resident #6 and introduced herself. Resident #6 asked the surveyor when her appointment to see the dermatologist was. The surveyor observed that Resident #6's face had several discolored (brown) and raised areas. Resident #6 also requested for a Band-Aid to put on her face. The surveyor told Resident #6 that she would inform the nurse that she, Resident #6, wanted a Band-Aid on her face and wanted to know when her appointment with the dermatologist was. The surveyor left the room and observed a Licensed Practical Nurse (LPN #1) standing at the medication cart. The surveyor informed LPN (#1) that Resident #6 wanted a Band-Aid on her face and want to know when her appointment was with the dermatologist. LPN (#1) stated that Resident #6 had an appointment with the dermatologist on 9/10/14 and that Resident #6's sister was taking her to the appointment. On September 10, at 8 a.m. the surveyor reviewed Resident #6's clinical record. Review of the clinical record produced signed physician orders [REDACTED]. Continued review of the clinical record revealed dermatology notes 4/22/14. The note read in part ... "Pt (patient) returns [MEDICAL CONDITION] check. No sign of recurrence ...." (sic) On September 10, 2014 at 9 a.m. the surveyor notified a Licensed Practical Nurse (LPN #1) that Resident #6 had seen a dermatologist and that a physicians order could not be located in the clinical record for Resident #6 to see the dermatologist. The surveyor reviewed the clinical record with LPN (#1). LPN (#1) was unable to locate a physicians order for Resident #6 to see a dermatologist. On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1), that Resident #6 saw a dermatologist on 9/10/14 and 4/22/14 and that a physicians order to see the dermatologist could not be located in the clinical record. The Nursing Supervisor (RN #1) stated that the sister had made the appointment. The surveyor asked why the physician wasn't notified and an order obtained to see the dermatologist. The Nursing Supervisor (RN #1) stated that she didn't think that the physician needed to be contacted as the sister had made the appointment. The surveyor asked the Nursing Supervisor (RN #1) who was responsible for directing the plan of care for Resident #6 and the Nursing Supervisor (RN #1) stated, "The physician." The Nursing Supervisor (RN #1) then stated that she understood now why the physician should have been contacted and an order received for Resident #6 to see the dermatologist. No additional information was provided prior to exiting the facility as to why the facility staff failed to obtain a physician order [REDACTED]. For additional information on Resident #6 refer to F Tags 329. 3. For Resident #8 the facility staff failed to develop/implement an Interim Care Plan. Resident #8 was a [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment was not available due to Resident #8's recent admission to the facility. On September 11, 2014 at 8:10 a.m. the surveyor reviewed Resident #8's clinical record. Review of the clinical record failed to produce an Interim Care Plan (ICP). On September 11, 2014 at 8:50 a.m. the surveyor asked the MDS Nurse where Resident #8's ICP could be located. The MDS Nurse stated that she had recently been hired on August 25, 2014 and was not sure where the ICP was located. The MDS Nurse stated that she would ask the nurses' where the ICP could be located. On September 11, 2014 at 9:50 a.m. the MDS Nurse approached the surveyor and informed the surveyor that an ICP was not in place and that she would initiate an ICP right away. On September 11, 2014 at 12:15 p.m. the surveyor notified the Administrator (Adm) and Nursing Supervisor, who was a Registered Nurse (RN #1), that the facility staff had not initiated/implemented an ICP on Resident #8. The surveyor notified the Administrative Team (AT) that Resident #8 was admitted on [DATE] and no ICP was in place. No additional information was provided prior to exiting the facility as to why the facility staff failed to implement an ICP for Resident #8. 4. Facility staff failed to follow a physician ordered diet for Resident #4. Resident #4's clinical record was reviewed 9/10/14 at 10:00 AM. Resident #4 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment, dated 8/12/14, coded the resident with some cognitive impairment. Her communication skills were intact. The resident had a physician's orders [REDACTED]. The order included: "Diet--NAS (no added salt.)" The latest updated CCP (comprehensive care plan) included the problem, "Nutrition, altered, less than body requirements....R/T therapeutic diet." The interventions included, " Question resident concerning appetite, food preferences, attitudes and beliefs about food and eating. On 9/9/14 at 4:15 PM Resident #4 was visited in her room. She told the surveyor that the facility staff kept bringing her diet foods without sugar--even though she had informed them she wanted regular food with sugar. "They keep saying I'm diabetic--I'm not. I want my sweets. I just use a little at a time. I watch what I eat." Resident #4 pulled out a package of "sugar free" cookies as an example of what the facility was making her eat. She stated, "I don't want this stuff--here, you can have it." The surveyor declined the cookies. On 9/10/14 at 8:30 AM the resident was observed to have breakfast in her room. The resident complained to the surveyor, "See this? I have french toast and no syrup--and my coffee is cold!" The surveyor flagged down CNA I in the hallway and informed her of the resident's request. CNA I heated the coffee and brought the resident some syrup for her french toast immediately. The surveyor observed the syrup was [MEDICATION NAME] maple syrup with no artificial sweetener. The diet card on Resident #4's tray stated her diet was supposed to be "NAS (no added salt), NCS (no concentrated sweets.)" On 9/10/14 at 12:10 PM the surveyor spoke to the RD (registered dietician) about Resident #4's diet orders and the discrepancy between the physician's signed orders and the diet being served by the dietary staff. The RD told the surveyor that the hospital physician had ordered the resident be placed on a cardiac ADA (American Diabetic Association) diet upon her return from a brief hospitalization on [DATE]. She said the resident was supposed to be receiving the NAS, NCS diet that was being delivered by the kitchen. The surveyor questioned if this would mean "no concentrated sweets, like the maple syrup" delivered by the CNA that AM. The RD agreed that was correct. On 9/10/14 at 15:45 PM the administrator and DON were informed of the surveyor's findings. The staff then clarified the order with Resident #4's physician. RN I said the physician wanted the resident continued on the NAS, NCS diet which staff had failed to transcribe over to the current recertification orders for the physician's signature. 5. For Resident #3, facility staff failed to monitor the effectiveness of PRN pain medication. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3 scored 15/15 on the brief interview for mental status on the quarterly MDS assessment with ARD 7/16/14. The resident fell on During clinical record review, the surveyor noted that the resident PRN pain medications for which characteristics of pain were not assessed before and after medication administration. The May 2014 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. For the majority of doses, the nurse documented "helpful". On 5/4, the order for [MEDICATION NAME] was changed from PRN to scheduled every 4 hours. The administrator was notified of the concern on 9/11/14.

Based on staff interview and clinical record review, facility staff failed to ensure the physician periodically reviewed the resident's care and wrote progress notes for each visit for 1 of 13 residents in the survey sample (Resident #5). Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the quarterly MDS assessment dated [DATE], the resident scored 5/15 on the brief interview for mental status. She was assessed with [REDACTED]. During clinical record review, the surveyor noted that the most recent physician visit was dated 4/18/14. On 9/9/14, the surveyor asked the administrator and nursing supervisor (RN#1) for documentation of a later physician visit. RN#1 reported that the physician dictates notes for transcription rather than writing them, so the latest one might not be on the chart yet. On 9/11/14, RN#1 offered a copy of a nurse's note dated 6/28/14 stating that the doctor had seen the resident and no new orders were written. She stated that the physician's office said the physician did not have a record of the physician seeing the resident on that date. The physician's office sent the transcript of the physician's 9/9/14 visit to the resident on 9/11/14. There was no record of a physician visit between 4/18 and 9/11/14. The administrator was made aware of the concern during a summary meeting on 9/11/14.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to anchor an indwelling Foley catheter to prevent excessive tension and pulling on the urinary meatus for 1 of 13 Residents in the sample survey, Resident #1. The Findings Included: Resident #1 was a [AGE] year old male who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a 30 Day Medicare MDS assessment with an Assessment Reference Date (ARD) of 6/10/14. The facility staff coded that Resident #1 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #1 required extensive assistance (3/2) with Activities of Daily Living (ADL's). In Section H. Bladder and Bowel the facility staff coded that Resident #1 had an Indwelling catheter. On September 10, 2014 at 10:15 a.m. the surveyor reviewed Resident #1's clinical record. Review of the clinical record produced signed physician orders [REDACTED]. Foley cath to straight drainage-Foley 16 Fr with 10cc bulb for [MEDICAL CONDITION] every shift. Irrigate catheter c (with) NS (normal saline) PRN (as needed)." (sic) On September 10, 2014 at 11:10 a.m. the surveyor observed a Certified Nursing Assistant (C.N.A. #1) rolling Resident #1 in his wheelchair and into his room. The surveyor observed a Foley catheter tubing exiting Resident #1's left pants leg. The surveyor asked Resident #1 if he had a strap on his catheter to prevent pulling. Resident #1 stated, "I don't think so." The surveyor asked Resident #1 if they could look to see if Resident #1 had a Foley catheter leg strap and Resident #1 stated, "Yes, okay." The surveyor asked C.N.A. (#1) to see if Resident #1 had on a leg strap. C.N.A. (#1) pulled up Resident #1's left pants leg to expose the left leg from ankle to hip area. No Foley catheter leg strap was observed. The C.N.A. (#1) then looked into Resident #1's brief and said that the Foley wasn't anchored. The surveyor asked C.N.A. (#1) why Resident #1 did not have a Foley leg strap. C.N.A. (#1) stated Resident #1 was showered the yesterday and the leg strap was probably removed to be washed/cleaned. On September 10, 2014 at 11:30 a.m. the surveyor notified the Administrator (Adm) and Charge Nurse, who was a Licensed Practical Nurse (LPN #1), that Resident #1 had a Foley catheter and that the catheter tubing was not anchored to prevent excessive tension and pulling. The surveyor requested the facility policy and procedure for Foley catheter care. On September 10, 2014 at 2:45 p.m. the Charge Nurse (LPN #1) hand delivered a policy and procedure titled, "Catheter Care, Urinary." The policy and procedure read in part ... "Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract ....15. Insure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) 16. Report unsecured catheters to the supervisor. Be observant of skin irritation ... 17. Secure catheter utilizing a leg band." On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1), that Resident #1 had a Foley catheter and that the catheter tubing was not anchored. No additional information was provided prior to exiting the facility as to why the facility staff failed to anchor the Foley catheter tubing for Resident #1 to prevent excessive tension and pulling on the urinary meatus.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess and monitor a Stage II pressure ulcer by completing weekly skin assessments for 1 of 13 Residents in the sample survey, Resident #1. The Findings Included: Resident #1 was a [AGE] year old male who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a 30 Day Medicare MDS assessment with an Assessment Reference Date (ARD) of 6/10/14. The facility staff coded that Resident #1 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #1 required extensive assistance (3/2) with Activities of Daily Living (ADL's). In Section M. Skin Conditions the facility staff documented that Resident #1 was at risk to develop a pressure ulcer. On September 10, 2014 at 10:15 a.m. the surveyor reviewed Resident #1's clinical record. Review of the clinical record produced a Physician's Telephone Orders dated 8/23/14 at 11 a.m. that read in part ... "Cleanse Rt (right) buttock c (with) NS (normal saline), apply skin prep to area, cover c (with) Duoderm dressing + (and) use hyperflex tape- change p (after) bath on Tues (Tuesdays) + Fri (Fridays) + PRN (as needed)." (sic) Continued review of the clinical record produced the "Weekly Pressure Ulcer Record" dated 8/23/14 that documented that Resident #1 had a Stage II pressure ulcer measuring 1 cm X 1 cm on the right buttock. An additional skin assessment dated [DATE] was contained in the clinical record and documented that Resident #1 had a Stage II pressure ulcer on the right buttock measuring 1 cm X 1 cm. Further review of the clinical record produced August and September 2014 Treatment Administration Records (TAR's) that documented that the staff were following the physicians order to change the dressing on the Stage II pressure ulcer on the right hip on Tuesdays and Fridays after Resident #1 received his bath. Additional review of the clinical record produced the Comprehensive Care Plan (CCP) that documented the following "Problems" and "Goals." "Problem 5/27/14 Mobility Physical mobility impaired R/T (related to) weakness, R/T dementia, R/T needs assistance W/all (with all) mobility/locomotion needs. Goals Will not develop complications of immobility EG Pressure Sores, Contractures, Pneumonia ETC (etcetera)." (sic) "Problem 5/27/14 Impaired Skin Integrity: R/T Stage 2 Pressure Ulcer of Buttocks at admission, R/T Foley catheter, R/T fragile skin, R/T decreased mobility, R/T opened area on penis. 6/6/14 R/T red, raised patches on buttocks + groin originally thought to be a Stage 2 PU (pressure ulcer). 8/28/14 1 cm X 1 cm Stage II pressure ulcer noted on R (right) buttock on 8/23/14. Goal- Will have no S/S (signs and symptoms) of infection and show signs of healing." (sic) Continued review of the clinical record failed to produce a skin assessment or monitoring of the Stage II pressure ulcer on the right buttock since 8/29/14 a total of 12 days. On September 10, 2014 at 11:30 a.m. the surveyor notified the Administrator (Adm) and Charge Nurse, who was a Licensed Practical Nurse (LPN #1), that Resident #1 had a Stage II pressure ulcer on the right buttock and that review of the clinical record failed to produce any assessment or monitoring of the pressure ulcer since 8/29/14. The Charge Nurse (LPN #1) stated that she would look and see what she could find. The surveyor asked for the facility policy and procedure for wound care treatment. On September 10, 2014 at 2:45 p.m. the Charge Nurse (LPN #1) hand delivered two policies and procedures titled, "Dressing Change Protocol" and "treatment of [REDACTED]. "Dressing Change Protocol- Purpose: The nursing staff will change dressings as ordered to promote wound healing and prevent inflammation. ... 17. Document the procedure and any assessments made." "treatment of [REDACTED]. General Guideline: 1. Assess the pressure ulcer (s) for location, size (measure length, width, and depth), sinus tracts, undermining, tunneling, exudates, necrotic tissue, and the presence or absence of granulation tissue and [MEDICATION NAME]. 2. Determine the ulcer's current stage of development ... Documentation: ... 6. All assessment data obtained when inspecting the pressure ulcer." On September 10, 2014 at 3 p.m. the Charge Nurse (LPN #1) approached the surveyor and informed the surveyor that she was unable to locate any documentation of monitoring or assessment of the Stage II pressure ulcer on Resident #1's right buttock. The Charge Nurse (LPN #1) stated that the facility had gone to an electronic system on September 1, 2014 and that the new electronic system had not flagged or alerted the facility staff to do a skin assessment. The surveyor asked the Charge Nurse (LPN #1) how often were pressure ulcers supposed to be assessed and monitored and the Charge Nurse (LPN #1) stated, "At least weekly." On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1), that Resident #1 had a Stage II pressure ulcer on the right buttock and that the facility had failed to assess and monitor the Stage II pressure ulcer since 8/29/14. No additional information was provided prior to exiting the facility as to why the facility staff failed to assess and monitor a Stage II pressure ulcer on an ongoing basis and provide a weekly skin assessment for Resident #1.

Based on observation, resident and staff interview and clinical record review it was determined the facility staff failed to honor food preferences for one out of thirteen residents -Resident #4. Resident #4's clinical record was reviewed 9/10/14 at 10:00 AM. Findings: Resident #4 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment, dated 8/12/14, coded the resident with some cognitive impairment. Her communication skills were intact. The resident had a physician's orders [REDACTED]. The order included: "Diet--NAS (no added salt.)" The latest updated CCP (comprehensive care plan) included the problem, "Nutrition, altered, less than body requirements....R/T therapeutic diet." The interventions included, " Question resident concerning appetite, food preferences, attitudes and beliefs about food and eating." On 9/9/14 at 4:15 PM Resident #4 was visited in her room. She told the surveyor that the facility staff kept bringing her diet foods without sugar--even though she had informed them she wanted regular food with sugar. "They keep saying I'm diabetic--I'm not. I want my sweets. I just use a little at a time. I watch what I eat." Resident #4 pulled out a package of "sugar free" cookies as an example of what the facility was making her eat. She stated, "I don't want this stuff--here, you can have it." The surveyor declined the cookies. On 9/10/14 at 8:30 AM the resident was observed to have breakfast in her room. The resident complained to the surveyor, "See this? I have french toast and no syrup--and my coffee is cold!" The diet card on Resident #4's tray stated her diet was supposed to be "NAS (no added salt), NCS (no concentrated sweets.)" On 9/10/14 at 12:10 PM the surveyor spoke to the RD (registered dietician) about Resident #4's diet orders and the discrepancy between the physician's signed orders and the diet being served by the dietary staff. The RD told the surveyor that the hospital physician had ordered the resident be placed on a cardiac ADA (American Diabetic Association) diet upon her return from a brief hospitalization on [DATE]. She said the resident was supposed to be receiving the NAS, NCS diet that was being delivered by the kitchen. The surveyor informed the dietician the resident was unhappy being on a sugar-free diet and that she wanted some sweets (meaning real sugar) restored. The RD noted that the resident's diabetes was controlled by diet and that she was not on any insulin. She acknowleged she got food from family members as well. On 9/10/14 at 15:45 PM the administrator and DON were informed of the surveyor's findings. The staff then clarified the order with Resident #4's physician. RN I said the physician wanted the resident continued on the NAS, NCS diet which staff had failed to transcribe over to the current recertification orders for the physician's signature. RN I said the physician had decided Resident #4 could not have concentrated sweets and would remain on the NCS diet previously ordered.

Based on observation and staff interview, it was determined that the facility staff failed to maintain the dumpster area in a clean and sanitary manner. The Findings Included: On September 9, 2014 at 2:20 p.m. the surveyor observed the dumpster area located just outside of the facility kitchen. The surveyor observed the following items littered around the dumpster: used gloves, a large piece of wet card board (approximated 1 foot by 1 foot in size), newspaper, candy wrappers, a thick plastic paper/wrapper and a wine cork. On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1), that the dumpster area had multiple items lying on the ground around the dumpster. On September 11, 2014 at 11 a.m. the surveyor made a tour of the facility with the Maintenance Director (MD). The surveyor notified the MD that the dumpster was not maintained in a clean and sanitary manner on 9/9/14. The surveyor notified the MD that the dumpster area was littered with soiled/used gloves and paper products. The surveyor asked the MD who was responsible for keeping the dumpster area clean and he stated that the maintenance department was responsible for keeping the area clean. No additional information was provided prior to exiting the facility as to why the facility staff failed to maintain the dumpster area in a clean and sanitary manner.

Based on observation, staff interview and facility document review it was determined that the facility staff failed to accurately complete the daily staffing as to totaling the number of hours worked on the daily staffing form from August 20, 2014 through September 9, 2014. The Findings Included: On September 9, 2014 at 2:45 p.m. the surveyor made a walk through of the facility. The surveyor observed that the daily staffing was posted for the facility staff at the main nursing station. The surveyor reviewed the daily staffing post from September 9, 2014. No information was documented on the daily posting to identify any staff, to include Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Nursing Assistants (C.N.A's) and to include facility census. Additionally, the facility had not totaled the total number of hours worked by each discipline. The surveyor stopped at the nurses' desk and asked why the daily staffing was incomplete and who was responsible for filling out the daily staffing. The Administrator (Adm), Charge Nurse, who was an LPN (#1), and the Unit Secretary (US) stated that the third shift was responsible for filling out the form. The surveyor notified the Adm, Charge Nurse (LPN #1) and US that having third shift fill out the daily staffing was ineffective and defeated the purpose of the daily staffing posting. The surveyor notified the Charge Nurse (LPN #1) and the US that the census and daily staffing were supposed to be posted for each shift for public viewing and that only filling out the form on the third shift defeated the purpose of posting the daily census and staffing. The surveyor requested the daily staffing posts for the past two (2) weeks. On September 10, 2014 at 3:40 p.m. the surveyor notified the Adm, Executive Director (ED) and Nursing Supervisor, who was a Registered Nurse (RN #1) that the daily staffing was not posted when the survey team entered the facility on September 9, 2014. The surveyor once again requested the daily staffing posts for the past two weeks. Within a few minutes a Secretary hand delivered the daily staffing posts from August 20, 2014 through September 8, 2014. The surveyor reviewed the August 20, 2014 through September 8, 2014 daily staffing posts. The surveyor observed that the facility staff had not totaled the number of hours worked for each discipline (RN's, LPN's and C.N.A.'s) during the 2 week look-back period. Additionally, the facility staff did not document the use and services of a RN for at least 8 consecutive hours a day, 7 days a week. The surveyor notified the Administrative Team (AT) that the staffing sheets were inaccurate that the hours were not totaled for each discipline and that an RN was not documented as working 8 hours per 24 hours on the staff posts. The Secretary then hand delivered the staffing schedule for the time frame of August 20, 2014 through September 8, 2014. The surveyor reviewed the staffing schedule with the Secretary. The surveyor notified the AT that staffing schedule documented a house supervisor (RN #1) and a Minimum Data Set (MDS) nurse, who was a RN, and several PRN (as needed) RN's scheduled to provide an RN to work 8 hours per 24 hours. The surveyor notified the AT that the staffing posts were incomplete and inaccurate. No additional information was provided prior to exiting the facility as to why the facility staff failed to accurately complete the daily staffing as to totaling the number of hours worked by RN's, LPN's and C.N.A.'s and failed to include a RN for 8 hours per 24 hour period from August 20, 2014 through September 9, 2014.