Every finding on record at Labelle Health and Rehabilitation Center

Based on observation, review of facility policy and procedure, clinical record review, resident and staff interview, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Residents #45, #57 and #63) of 4 residents reviewed for activities of daily living. The findings included: The facility policy Activities of Daily Living (ADL) implemented 11/2020 (revised 11/22/21) documented, The facility will, based on the residents comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable . Care and services will be provided for the following activities of daily living : bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good, nutrition, grooming and personal hygiene. 1. Review of the clinical record revealed Resident #45 had an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, seizures, anxiety and obesity. The Significant Change Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 3/14/24 documented Resident #45 required partial to moderate assistance for personal hygiene, dressing and bathing. The MDS revealed Resident #45 did not demonstrate refusal of care. The MDS noted Resident #45's cognitive skills for daily decision making were intact. Review of the care plan initiated 8/19/23 specified Resident #45 required assistance with transfers, toileting, grooming, hygiene, dressing, and bathing. On 5/20/24 at 11:12 a.m., Resident #45 was observed in his bed wearing a blue T-shirt and shorts. He declined to answer any questions. He was unshaven with approximately one to two days of facial hair growth. On 5/21/24 at 9:22 a.m., Resident #45 was observed in bed wearing the same clothing as the previous day. He remained unshaven and his fingernails were noted to extend approximately 1/2 inch in length with a brown substance under the nails. Resident #45 did not respond when spoken to. On 5/21/24 at 11:30 a.m., Resident #45 was observed in bed, and able to answer simple questions. He said he was fine and said he takes himself from the wheelchair to the bed. He was unshaven and said, Yeah, I could use a shave. He said he thinks he was receiving his showers but was not certain. The resident was noted to have a slight foul body odor, and his hair was greasy. Review of the certified nursing assistant (CNA) daily documentation revealed Resident #45's scheduled shower days were Mondays, Wednesdays and Fridays on the 7:00 a.m., to 3:00 p.m., shift. The CNA documentation for April 2024 revealed Resident #45 refused scheduled showers on 4/3/34, 4/5/24, 4/8/24, 4/12/24, 4/15/24, 4/19/24, 4/24/24, 4/26/24. On 4/29/24 the documentation specified not applicable. The documentation showed Resident #45 received two scheduled showers on 4/1/24 and 4/22/24. Review of the CNA documentation for May 2024 documented on 5/1/24, 5/6/24, 5/10/24 and 5/20/24 documented Resident #45 refused his scheduled showers. On 5/3/24 the CNA documented the resident was not available. On 5/8/24 the CNA documented not applicable. Resident #45 received his scheduled showers on 5/15/24 and 5/17/24. 2. Review of the clinical record revealed Resident #57 had a readmitted [DATE] with diagnoses including cerebral infarction with flaccid hemiplegia affecting the left side of the body. The Quarterly MDS dated [DATE] documented Resident #57 was dependent for bathing, toileting, dressing and personal hygiene. The MDS did not document rejection of care. The MDS noted Resident #57's cognitive skills for daily decision making were intact. On 5/20/24 at 10:44 a.m., Resident #57 was observed in his bed, he was unshaven approximately four days of facial hair growth. He said was not able to move his left hand and leg due to a stroke. His fingernails extended approximately 1/2 inch with a brown substance under the nails, and the skin surrounding the nail beds had a dry brown substance. The resident said, my nails need to be cut. He appeared unkempt; his hair was uncombed. On 5/21/24 at 8:44 a.m., Resident #57 was observed in his bed wearing a hospital gown. He said he gets up sometimes because he needs to use a lift to get into the wheelchair. He was unshaven, his fingernails remained with the brown substance under the nails and the skin surrounding the nails; he had a slight body odor of urine. Review of the CNA documentation for April 2024, and May 2024 showed Resident #57's scheduled shower days were on Tuesdays and Fridays during the 3:00 p.m., to 11:00 p.m., shift. On 4/2/24, 4/16/24, 5/10/24, 5/14/24, and 5/17/24, the CNA documented not applicable. On 4/5/24, 4/9/24, 4/12/24, 4/19/24, 4/23/24, 4/26/24, 4/30/24, 5/3/24, and 5/7/24, the CNA documented the resident refused scheduled showers. Resident #57 received no scheduled showers in April 2024, or from May 1, 2024, to May 17, 2024. On 5/22/24 at 10:14 a.m., in an interview CNA Staff C said Resident #57 does refuse showers. She said, If a resident refused I tell the nurse first and then I go back and offer it again. I try 3 times and if they refuse, I tell the nurse and I document it on the skin sheet that the resident refuses. On 5/22/24 at 10:27 a.m., in an interview Unit Manager Licensed Practical Nurse Staff A said all residents are offered a bed bath on each shift and the CNAs document it. Staff A retrieved Resident #57's electronic record of bed baths showing Resident #57 did not receive any bed baths. Staff A said, Well, it is documented as prn (as needed), not each shift but he received none. Staff A confirmed the lack of documentation that the resident received the scheduled showers for the month of April 2024, and from 5/1/24 to 5/17/24. The Unit Manager said, Well, he refuses, he is alert and oriented and it's his right. 3. Review of the clinical record revealed Resident #63 had an admitted [DATE] with diagnoses including Alzheimer's, dementia, hemiplegia and hemiparesis following cerebral infarction affecting the right side of the body and mixed expressive and receptive language disorder. Review of the Quarterly MDS with a target date of 4/4/24 documented the resident was dependent for toileting, dressing and bathing. The MDS noted Resident #63's cognitive skills for daily decision making were moderately impaired and documented no rejection of care. On 5/20/24 at 11:05 a.m., in an interview, Resident #63's family member said, My mother is not being showered. I know she likes to refuse but her hair has been greasy like this for three weeks now. I told the nurse, but nothing was done. Her nails have not been cut or cleaned. Resident #63's fingernails were observed to be approximately jagged, extended approximately 1/2 inch in length with a brown substance under the nails. Her hair was long and greasy. Resident #63 did not respond to any questions. Her daughter said the resident rarely speaks anymore. On 5/21/24 at 8:57 a.m., Resident #63 was observed in the activity room watching the television. Resident #63 had her hair pulled back in a hair clip. Her hair was greasy and her fingernails had not been cleaned or trimmed. Review of the CNA documentation showed the residents shower days were Tuesdays and Fridays on the 7;00 a.m., to 3:00 p.m., shift. Review of the CNA documentation for April 2024 documented not applicable on 4/5/24 and 4/9/24. On 4/16/24 and 4/19/24 the documentation specified the resident refused the scheduled showers. On 4/12/24 and 4/30/24 the resident received a bed bath in place of her shower. The documentation showed the resident received her scheduled showers on 4/2/24, 4/23/24 and 4/26/24. Review of the CNA documentation for May 1, 2024, to May 17, 2024, documented Resident #63 received a scheduled shower on 5/10/24 and 5/14/24. On 5/22/24 at 9:21 a.m., in an interview the Director of Nursing (DON) explained the codes on the CNA shower sheets and said if a resident refuses a shower they are offered it again. The DON was not able to provide documentation the residents were offered showers once they refused. On 5/22/24 at 9:25 a.m., Staff A said, I spoke with her daughter, she knows her mother refuses showers. The resident does not smell and when her hair looks greasy then I say ok it's time. Her nails are long because sometimes she lets me trim them and sometimes, she doesn't. Staff A said, The CNAs complete the skin sheets for each scheduled shower and turn them in everyday even if the resident refuses. This writer requested to review the shower sheets for April to May 22, 2024, and Staff A provided a total of four CNAs shower sheets. Review of the form identified as skin check form showed on 4/ 2/24 a shower was provided. On 4/5/25 and 5/9/24 documented not applicable. On 4/12/24 a bed bath was documented. On 4/16/24 and 4/19/24 documented refusal. On 4/23/24 and 4/26/24 a shower was documented. On 4/30/24 a bed bath was documented. Review of CNA documentation with Staff A confirmed Resident #63 received only five scheduled showers from 4/1/24 to 5/17/24.

Based on record review, staff interview and family interview, the facility failed to ensure advanced directives were accurately documented in the clinical record for 1 (Resident #29) of 3 residents reviewed for Advanced Directives from a total sample of 29 residents reviewed. This failure could impact quality of care at the end of life for the residents. The findings included: Review of Resident #29's Order Summary Report as of [DATE] revealed a Full Code order on [DATE], indicating the facility would initiate cardiopulmonary resuscitation (CPR) if Resident #29's heart stopped or if the resident stopped breathing. Review of Resident #29's Care Plan initiated on [DATE] revealed the Care Plan matched the Order Summary noting Resident #29 was a Full Code. Review of Resident #29's electronic health record revealed a Determination of Incapacity on [DATE] and a Health Care Surrogacy on [DATE]. A Do Not Resuscitate (DNR) order was signed by the Health Care Surrogate on [DATE]. This DNR order conflicted with Resident #29's Care Plan and the Order Summary Report (both indicating Resident #29 was a Full Code). On [DATE] at 8:41 a.m., during a telephone conversation with Resident #29's Health Care Surrogate, she said Resident #29 was incapacitated and unable to make any of his health care decisions. She confirmed she was the Health Care Surrogate and that she signed the DNR paper for Resident #29 on [DATE]. On [DATE] at 10:05 a.m., Social Services Director (SSD) Staff S said she's worked at the facility for approximately one year and has been a social worker for 3 years. She said she is responsible for auditing the residents' electronic health records for Code Status accuracy. Staff S verified the discrepancy between the Order Summary, Care Plan and the DNR order (indicating Resident #29 was not to be resuscitated.) Staff S said the Care Plan did not contain accurate information.

Based on observations, record review, review of policies and procedures, resident and staff interviews, the facility failed to ensure 1 (Resident #39) of 3 residents reviewed for continuous activities of daily living (ADLs) received completed care on a routine basis. The findings included: On 1/30/23 at 2:15 p.m., Resident #39 was observed in his bed wearing a hospital gown. Via observation Resident #39's hair appeared uncombed, and his fingernails were long, extending approximately one quarter of an inch from the base, uneven, and had dark matter underneath each nail. On 1/30/23 at 2:15 p.m., Resident #39 said he doesn't remember the last time staff washed and comb his hair and doesn't remember the last time staff trimmed and cleaned under his fingernails. On 1/31/23 review of Resident #39's medical records revealed his most recent admitted was 12/6/2022. Resident #39's plan of care for ADLs had a revision date of 12/14/22 and stated Resident #39 required assistance for most ADLs. Resident #39 required extensive assistance with bed mobility, transfers, toileting, grooming/hygiene, and bathing. On 1/31/23 at 10:38 a.m., Resident #39's son said since admission he had noted his father's hair had not been washed and combed and his father's fingernails were long and uneven with dark black matter under each fingernail. He said he had asked the nursing staff who was responsible to cut his father's hair and fingernails and the staff told him, it was the family's responsibility to cut his father's hair, and trim and clean his father's toenails and fingernails. On 1/31/23 review of the Certified Nursing Assistant (CNA) job description dated April 2020; the summary stated the CNAs were to perform direct resident care under supervision of licensed nursing personnel. One of the CNAs job duties and responsibilities were to provide personal care (i.e., grooming, bathing, dressing, oral care, etc ) of residents daily and as needed. On 1/31/23 review of the undated Activities of Daily Living (ADLs) policy, it stated care and services would be provided for the following activities of daily living to include bathing, dressing, grooming and oral care. On 1/31/23 review of the undated Care of Fingernails/Toenails policy, it stated the purpose of fingernails and toenails care is to clean the resident's nail bed, and to keep the nails trimmed/to prevent infections. On 2/2/23 at 9:48 a.m., CNA Staff T said Resident #39 was cooperative and did not refuse his daily routine ADL care. She confirmed part of routine resident's ADL care included resident nail care. She said she didn't remember when ADL nail care was completed for Resident #39. On 2/2/23 at 10:00 a.m., Licensed Practical Nursing (LPN), Staff D said the resident daily ADL care included nail care. On 2/2/23 at 10:05 a.m., Staff D's observation of Resident #39's fingers confirmed Resident #39's fingernails were very long, uneven, with a dark substance under each of Resident #39's fingernails. She said it appeared Resident #39's fingernails had not been trimmed or cleaned in a long time. On 2/2/23 at 10:30 a.m., the DON said the CNA's Job Description, the policy for Care of Fingernails and Toenails, and Activities of Daily Living stated the nursing staff were required to ensure each resident's ADL care to include fingernail and toenail care.

Based on observation, record review and staff interview, the facility failed to coordinate care and ensure 1 (Resident #33) of 1 sampled resident receiving intravenous antibiotics received care and services in accordance with professional standards of care and the physician's orders. The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses including a right sided mastectomy (surgical removal of the breast). The physician's orders with an effective date of 11/25/22 specified, No Blood Pressures or Blood Draw to right arm. Review of the progress notes revealed documentation Resident #33's blood pressure was taken on the right arm on 12/8/22, 12/9/22, 12/10/22, 12/11/22, 12/14/22, 12/16/22 and 12/17/22. On 1/30/23 at 2:00 p.m., Licensed Practical Nurse (LPN) Staff D was observed administering an intravenous antibiotic to Resident #33 through a midline catheter (catheter inserted in the upper arm with the tip located just below the axilla) inserted into the resident's right arm. On 1/31/23 at 9:36 a.m., resident #33 was observed awake, lying on her back, with a midline catheter in her right upper arm. Resident #33 was not able to answer any question related to the midline catheter. On 1/31/23 at 12:03 p.m., the nurse documented in a progress note Resident #33's right upper arm was edematous (swollen). The midline was pulled from the right arm without difficulty. On 2/1/23 at 9:34 a.m., LPN Staff D stated she was aware of the physician's order specifying, no blood pressures or blood draws on the right arm due to the mastectomy to the right side. On 2/1/23 at 9:53 a.m., the attending physician stated it was preferable not to do anything to the affected side (right mastectomy) such as blood pressure or blood draws unless we don't have a choice. On 2/1/23 at 10:25 a.m., the Advanced Practice Registered Nurse (APRN) said standards of practice would be to avoid placing a midline catheter on the affected side. She said she was not notified of the swelling to the resident's right upper arm. On 2/1/23 at 11:47 a.m., the Minimum Data Set (MDS) Coordinator verified Resident #33's care plan and the Kardex (Information of needs for each resident) did not reflect the right side mastectomy and the physician's orders for no blood pressure or blood draws to the right arm. She said, It is absolutely fair to say it should be on the care plan and I'll add it now. On 2/1/23 at 12:41 p.m., in a telephone interview Registered Nurse Staff P who inserted the midline catheter said the facility nurse did not inform her Resident #33 had a previous right side mastectomy. She said, if a resident has had a mastectomy, I can't insert the intravenous line on that side. On 2/1/23 at 3:20 p.m., The Director of Nursing (DON) verified the order for no blood pressures or blood draws had been in place to flag the nurses not to use the right side to obtain vital signs, including blood pressure.

Based on observation, interview, and record review, the facility failed to implement care and services to prevent a decline in range of motion for 1 (Resident #6) of 1 resident reviewed for the application of a splinting device. The findings included: Review of Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #6 had paralysis on the left side of his body, required extensive assistance with dressing, and was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. Review of Resident #6's Order Summary Report as of 2/2/2023 revealed an active physician's order, As of 8/9/22, elbow splint to be worn 2 hours daily on the left elbow every day shift. Review of Resident #6's Activities of Daily Living (ADL) Care Plan initiated on 6/5/22 revealed the resident required extensive assistance for bed mobility and dressing. There were no goals or interventions for applying the splint. Review of Resident #6's Care Plans did not indicate Resident #6 refused to wear the splint. Review of Resident #6's Task List Report dated 2/2/23 (a list of tasks for the Certified Nursing Assistant) did not include applying the splint. Review of Resident #6's Treatment Administration Record for January 2023 and February 2023 revealed nursing signed-off the left elbow splint was applied on 1/30/23, 1/31/23, 2/1/23, and 2/2/23. On 1/30/23 at 10:35 a.m., Resident #6 was observed in his bed, not wearing his splint. His left elbow was bent, and his hand was near his chest. He verified he could not move his left arm and the position of the elbow was permanent. Resident #6 said the facility had an elbow splint made for him, but staff do not apply the splint, and it has been a long time since he wore it. Resident #6 said he does not refuse to wear the splint and cannot apply it himself. The resident said there was a Certified Nursing Assistant (CAN) who used to work at the facility and applied the brace for him every day. On 1/31/23 at 9:29 a.m., 2/1/23 at 11:11 a.m., 2/2/23 at 8:55 a.m., 2/2/23 at 3:00 p.m. and 4:04 p.m., Resident #6 was observed in his bed, not wearing his splint. During those observations, Resident #6 reiterated staff were not applying the splint or asking him to apply it. A splint was observed on the resident's nightstand. Photographic evidence obtained. On 2/1/23 at 11:30 a.m., the Occupational Therapist (OT) Staff I said Resident #6 was discharged from therapy in December 2022 and therapy does not apply the splint. He said Resident #6 was referred to the Restorative Nursing Program. The Occupational Therapist said daily wearing of the splint would not repair the left elbow contracture, but it would help to prevent further tightening of the muscles involved in the contracture. Review of the Occupational Therapy (OT) Discharge Recommendations and Status signed by OT Staff I on 12/14/22 revealed the Restorative Nursing Program was not indicated at this time. On 2/2/23 at 1:18 p.m. Certified Nursing Assistant (CNA) Staff J said she was familiar with Resident #6 and was assigned to him from 7:00 a.m. to 3:00 p.m. Staff J said she did not know Resident #6 had a splint because it was not on her task list and the nurse did not tell her to apply it. On 2/2/23 at 1:39 p.m., Restorative CNA Staff K said Resident #6 was not in the Restorative Nursing Program and the CNA assigned to Resident #6 should apply the splint. On 2/2/23 at 3:12 p.m. Licensed Practical Nurse Staff M said she was assigned Resident #6 this week and did not apply the splint or instructed the CNA to apply it. She said she signed off on the Treatment Administration Record (TAR) the splint was applied but did not see the resident wear it. On 2/2/23 at 3:28 p.m., CNA Staff G said she was assigned to Resident #6 on 2/1/22, and she did not apply the splint to Resident #6's left elbow. She said the nurse did not tell her to apply the splint and she does not know where it is. On 2/2/23 at 3:55 p.m., LPN Unit Manager Staff C said she is responsible for updating and adding care plans according to resident needs and physician orders. Staff C reviewed Resident #6's Care Plans and verified they did not include interventions for applying the splint. Staff C reviewed Resident #6's Order Summary Report and verified the order for daily day shift application of Resident #6's left elbow splint. Staff C acknowledged the Care Plans were not reflective of the physician orders. On 2/2/23 at 4:04 p.m., Registered Nurse Staff N said he was assigned to Resident #6 and did not apply the splint. He said he did not tell the CNA to apply the splint or see the Resident #6 wearing the splint. He said he signed the TAR today indicating Resident #6 wore the splint even though the resident had not.

Based on clinical record review, review of the Florida Board of Nursing requirement for intravenous administration for Licensed Practical Nurses, and staff interview the facility failed to ensure 1 (Licensed Practical Nurse Staff D) of 3 Licensed Practical Nurses reviewed had the required certification and competency prior to administer Intravenous Medication. The findings included: The Florida Board of Nursing Chapter 64B9-12, Administration of intravenous therapy by Licensed Practical Nurses noted the course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV (Intravenous) therapy shall be not less than thirty (30) hour post-graduate level course teaching aspects of IV therapy with content as specified by the Board of Nursing. Review of the clinical record for Resident #33 showed on 1/26/23 a midline catheter (catheter inserted in the upper arm with the tip located just below the axilla) was inserted into the resident's right arm to administer intravenous (IV) antibiotics for an infected wound. On 1/30/23 at 2:00 p.m., Licensed Practical Nurse (LPN) Staff D was observed administering an intravenous antibiotic to Resident #33 through a midline catheter inserted in the resident's right arm. On 2/1/23 at 9:34 a.m., LPN staff D stated she had completed her IV competency training a long time ago but did not have record of the certification. On 2/2/23 at 11:53 a.m., The Assistant Director of Nursing (ADON) stated LPNs are required to complete a 30 hours IV certification in Florida to administer intravenous medications. On 2/2/23 at 12:26 p.m., the Director of Nursing (DON) said she was unable to provide documentation LPN Staff D completed the required training, or competency to administer intravenous medications.

Based on observation, record review, staff and resident interviews the facility failed to follow physician's orders and consistently implement therapy recommendations to prevent a decrease in range of motion for 1 (Resident # 49) of 3 residents reviewed with limited range of motion. The findings included: The facility's Policy titled Prevention of Decline in Range of Motion implemented on 11/3/2020 and revised 3/2021 noted . Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion . Based on the comprehensive assessment, the facility would provide interventions, exercises and/or therapy to maintain or improve range of motion. The facility would provide treatment and care in accordance with professional standards of practice. This included but was not limited to: 1. Appropriate services (specialized rehabilitation, restorative, maintenance). 2. Appropriate equipment (braces or splints). 3. Assistance as needed (active assisted, passive, supervision) . A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition and did not reject care. Resident #49 required extensive assistance with all Activities for Daily Living (ADL) except eating. Resident #49 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #49 received occupational therapy from 3/4/21 through 5/13/21. The Physician's order summary report dated 5/28/21 included an order dated 5/19/21 for Resident #49 to wear a left upper extremity (LUE) splint in the daytime and off at hours of sleep (HS) as tolerated. Resident #49 also had an active order dated 5/12/21 for a Restorative Nursing Program (RNP) splint program. The Care Plan initiated on 2/5/21 noted Resident #49 had a diagnosis [CONDITION(S)] (CVA) with [CONDITION(S)] of left side and required extensive assistance with activities of daily living (ADLs). The goals initiated on 5/12/21 included to maintain level of range of motion (ROM) to LUE. The listed interventions dated 5/12/21 included the Certified Nursing Assistant (CNA) to encourage the resident to participate in RNP splint program. The interventions initiated on 5/19/21 included to wear LUE splint in the daytime and off at HS as tolerated. The care plan included specific directions of how to apply the splint during the day and off at HS. The occupational therapy (OT) evaluation and plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The OT discharge summary dated 5/13/21 noted Resident #49 would safely wear a functional splint to position LUE left fingers, left hand, and left wrist for up to seven hours to decrease developing contractures and improve quality of life. The summary noted Resident #49 was discharged to a RNP with instructions on don (applying)/doffing (removing) the splint. The purpose of the splint for the LUE was to prevent further fixing contractures and soft tissue tightness, simple ADLs, and functional transfers. The discharge summary was signed by OT Staff S . The therapy referral for restorative nursing program care giver instructions for Resident #49 dated 5/12/21 noted the overall goal of the restorative program was to improve/maintain range of motion on LUE to decrease potential fixing contractures and further soft tissue tightness. On 6/21/21 at 10:30 a.m., Resident #49 was observed in bed, awake, and alert. She said she had a stroke that affected her left side. She pulled her left hand from below her blanket to display contractures of her left wrist, hand, thumb and four fingers. Resident #49 was not wearing a splint and said staff did not assist her with it. On 6/23/21 at 10:47 a.m., Resident #49 was in her room in bed, awake, and alert. She was not wearing a splint on her left hand. She said staff did not assist her to wear the splint yesterday or today and she could not apply it herself. She pointed to the splint on her nightstand. She said when she was getting therapy, the therapist applied the splint for her, but she was discharged from therapy over a month ago. She said the splint did not bother her and she wanted to wear it. *Photographic Evidence Obtained * On 6/23/21 at 2:23 p.m., Certified Nursing Assistant (CNA) Staff R said he had taken care of Resident #49 a lot. He said there was never a time when Resident #49 refused care or did not like to get out of bed. He checked the CNA Kardex (Instructions to safely care for residents) system on the wall. He said according to the computer, Resident #49 refused to wear the splint today. On 6/23/21 at 2:42 p.m., in an interview CNA Staff J said she took care of Resident #49 today and she refused to wear her splint or get out of bed. On 6/24/21 at 9:50 a.m., Resident #49 was observed in her room. She was not wearing the splint and said staff did not assist her with it. On 6/24/21 at 9:55 a.m., in an interview OT Staff S said she worked with Resident #49 and created the splint for the Resident #49's left hand contracture. She said Resident #49 completed therapy and the referral to the Restorative Nursing Program (RNP) was made on 5/12/21. She said the resident was agreeable to the splint and motivated to wear the splint to keep the contractures from progressing. OT Staff S said she instructed the nursing staff on the purpose of the splint and how to apply it. OT Staff S said Resident #49 required staff assistance to apply the splint and facility staff should be applying the splint every day. On 6/24/21 at 10:00 a.m., observed OT Staff S into Resident #49's room. She confirmed the splint was not on Resident #49's hand. She said staff must apply the brace daily or the fingers will tighten. She said Resident #49's fingers and wrist were beginning to tighten. OT Staff S used a warm damp towel to massage Resident #49's left hand and fingers open and applied the splint to the resident's hand. She confirmed Resident #49 was motivated to wear the splint when she was discharged from therapy. She said it was staffs' responsibility to ensure residents wear their splints once the resident was discharged from therapy. On 6/24/21 at 11:09 a.m., Licensed Practical Nurse (LPN) Staff M said she had been the unit manager since February 2020, and was responsible for Resident #49. She said she was aware of Resident #49's left hand contracture and the physician's order to wear the splint every day. She said it was the CNA's responsibility to assist Resident #49 with the splint every day. LPN Staff M provided the CNA task print-out for the month. She said according to the printout, Resident #49 wore the splint for a total of 50 minutes over the last 30 days. LPN Staff M said there was only one progress note where Resident #49 refused the RNP on 6/23/21. LPN Staff M said she has been to Resident #49's room during the day when she was not wearing the splint, but she did not ask the resident about it or assist Resident #49 to wear it.

Based on record review, observation, staff and resident interviews, the facility failed to have documentation of appropriate care and services to manage and prevent complication of indwelling catheter for 1 (Resident #8) of 1 resident with urinary tract infection. The findings included: The facility's policy titled Catheter Care with a revised date of March 2021, stated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy explanation stated, Catheter care will be performed every shift and as needed by nursing personnel. Document care and report any concerns noted to the nurse on duty. On 6/21/21 at 2:45 p.m., Resident #8 was observed in bed with a Foley Catheter ( Indwelling Catheter inserted in the bladder to drain urine) with a urine collection leg bag strapped to the right leg. Review of Resident #8 clinical record showed a readmitted [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's orders for June 2021 included two different intravenous antibiotics for bacteremia (bacteria in the blood stream) and UTI. The physician's orders did not include catheter care. Review of the progress notes revealed on 6/19/21 at 2:48 a.m., and 6/20/21 at 4:02 a.m., the nurse documented Foley care given as ordered. No other entry was found in the progress notes or the Treatment Administration Record (TAR) from 6/18/21 through 6/21/21 of nursing interventions related to catheter care. On 6/22/21 at 4:23 p.m., in an interview Licensed Practical Nurse (LPN) Staff A confirmed Resident #8 had an indwelling urinary catheter (Foley catheter). LPN Staff A said, All residents with urinary catheters get catheter care each shift and when completed we document the care in the TAR for the resident. On 6/22/21 at 4:40 p.m., in an interview LPN Staff N said she was unable to find any urinary catheter orders, interventions, or urinary catheter documentation on the TAR for Resident #8. LPN Staff N said, She should have had orders and documentation entered. On 6/22/21 at 4:52 p.m., in an interview the Director of Nursing (DON) said she was unable to find documentation on Resident #8's TAR for catheter care from 6/18/21 to 6/21/21. The DON said, It is expected to have the catheter care documentation each shift and the orders for the indwelling catheter entered on readmission to the facility. On 6/23/21 at 11:07 a.m., in an interview Unit Manager Staff L confirmed Resident #8 was currently on two antibiotics for a urinary tract infection and bacteremia.

Based on record review and staff and resident interview the facility failed to have a complete medical record including advance directives documentation for 1 (Resident #376) of 13 residents reviewed for advance directives. This has the potential to lead to confusion as to the proper care to be delivered. The findings included: The facility's policy titled Residents' Rights Regarding Treatment and Advance Directives dated ,d+[DATE] and revised ,d+[DATE] stated, It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives. The Policy Guidelines stated, On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive . Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to staff. On [DATE] at 12:25 p.m., clinical record review revealed Resident #376 was admitted to the facility on [DATE]. Resident #376 was a Hospice patient, and the code status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) was listed as Do Not Resuscitate (DNR). There was no yellow DNR form in the clinical record to identify Resident #376's wish to not be resuscitated in the event of respiratory or [CONDITION(S)]. On [DATE] at 12:30 p.m., Licensed Practical Nurse (LPN) Staff M said the DNR forms were kept in the hard chart. On [DATE] at 3:20 p.m., LPN Staff A stated she would check paper chart for yellow DNR. If it was not on chart, she would check EMR for doctor's order. On [DATE] at 3:21 p.m., LPN Staff O stated, we go by the yellow DNR an original order in the chart. If there is no yellow in the chart or in the computer, you start CPR (cardiopulmonary resuscitation). On [DATE] at 3:22 p.m., Staff P LPN stated, we go to the chart and look for the yellow DNR form and we look at the order. On [DATE] at 3:25 p.m., in an interview the Director of Nursing said in case of [CONDITION(S)] her nurses were trained to look in the chart for the yellow DNR. If not in the chart, they would verify by checking doctors' orders. If it was a verbal order, it must be signed by two Registered Nurses. On [DATE] at 3:28 p.m. Registered Nurse/Staffing Educator Staff Q said the nurses completed an advanced directive course on the computer. She said, We look for the yellow paper in the chart and an order. The computer will say do not resuscitate, but if we do not have that, we would do CPR.

Based on observation, record and policy review, and staff interview, the facility failed to ensure 2 (Residents #23 and #24) of 4 residents reviewed for accident hazards were assessed for the need for a bed rail, alternate interventions were attempted, and informed consent was obtained prior to the use of bed rails. The facility failed to conduct regular inspections to assess the compatibility of the bed frame, mattress, and bed rails to identify any entrapment zones. Failure to ensure bed rails are appropriate and safe puts residents at a potential safety risk for entrapment. The findings included: The facility policy, Proper Use of Bed Rails (November (YEAR)) documented, 1. Bed rails will be a last resort approach after an evaluation of risk versus benefits and entrapment risk. On 9/23/19 at 11:47 a.m., Resident #24 was observed in bed and 1/2 side rails were in the up position on the bed. On 9/23/19 at 1:55 p.m., Resident #23 was observed in bed and 1/2 side rails were in the up position. On subsequent room observations, the side rails were in the up position on both sides of the bed when the resident was in bed. On 9/25/19 at 10:00 a.m., record review of Resident #23's medical record revealed no documented evidence of informed consent and alternatives attempted prior to installation of the bed rails for Resident #23. On 9/25/19 at 10:22 a.m., record review of Resident #24's Medical record revealed no documented evidence of informed consent and alternatives attempted prior to installation of the bed rails for Resident #24. On 9/25/19 at 10:50 a.m., the Director of Nursing confirmed there were no alternate interventions attempted or signed consents for the side rails to be used for Residents #23 and #24. On 9/25/19 at 11:01 a.m., the Maintenance Director said he had no policy or manual for the side rail inspections for the beds because the beds were outdated. The Maintenance Director confirmed there was no preventive maintenance program to check for entrapment with the side rails.

Based on record review, resident and staff interview, the facility failed to properly respond to resident's grievances for one (Resident #1) of three residents grievances reviewed. The findings included: Record review for Resident #1 found a grievance dated 11/30/18. Per lost article form filed by the resident's spouse, the resident was missing four rings in total with approximate value of $1000.00. Call law enforcement if rings not found checked on lost article form On 3/26/19 at 10:39 a.m., during a telephone interview, Resident #1 had five rings when admitted to the facility. She had three rings on the left hand and two on the right. Resident #1 had four of five rings missing; they had been a plastic cup in her nightstand. The resident said multiple staff as well as her husband knew about the missing rings and they were able to find only one ring. The resident said they filed a formal grievance and the rings were still missing. Resident #1 talked to the Administrator, no reimbursement or further explanation. She said she returned to the facility sometime in (MONTH) in hopes that her rings were there. The Administrator brushed her off and told her there was nothing to be done. She was very upset because those were her wedding rings and had great sentimental value to her. The resident said she asked for reimbursement and was told her there was nothing to be done. Initial inventory list for Resident #1 identified the resident had five rings upon admission to the facility. On 3/26/19 at 10:55 a.m., the Social Services Director (SSD) said she was aware Resident #1 lost four rings and the resident's spouse filed the grievance on her behalf. The SSD said she filled out the report and gave it to the Administrator. The SSD said as far as she knew the Administrator did not do anything about the missing rings. The SSD did not replace the rings nor provide reimbursement. When asked if the police were notified of the missing items since the resident's spouse asked for law enforcement to be called, the SSD said no because the resident's husband told the SSD to hold on to the report in case the rings were found. Asked the SSD if she signed documents indicating resident or representative did not want to follow thru with the missing item report. The SSD provided only a hand written undated note by the SSD indicating resident's spouse did not want police to be called as of yet. On 3/26/19 at 12:42 p.m., the Administrator said that on 1/8/19 (one month after her discharge) Resident #1 came to the facility with her husband. The Administrator said when Resident #1 came in the facility she was wearing all four missing rings. Administrator denied she had Resident #1 sign a form stating she found her rings and no longer needed to proceed with the grievance. The administrator could not provide evidence she started an investigation when the rings were initially misplaced. The administrator did not notify the police, her husband had refused law enforcement. The only proof of this is an unsigned written note written by the social worker. The SSD wrote a note (not dated or signed) stating the husband did not want law enforcement called. Review of the Protection of residents Personal Properly policy dated (MONTH) (YEAR) revealed . the Administrator or his/her designee will log the missing items, complete an investigation on all missing items and document results of findings. The missing items log will be reviewed periodically for trending analysis. The Administrator will ensure that the resident /responsible party is informed of the results of the investigation. Should the investigation reveal misappropriation of resident's property occurred, the Administrator will report such findings to the resident/responsible party, local law enforcement as applicable and other agencies as required by state law. Record review for Resident #1's grievance found no documentation of investigation. Further review found no notification of resident or representative in regards to the outcome of the investigation. There was no documentation law enforcement was notified even though resident's spouse wanted them to be notified. Review of lost article review found on 12/8/18, Resident #6 lost a pair of golden earrings. Per lost article and record review, the resident's earrings were replaced by the facility. No documentation of an investigation found. On 3/26/19 at 1:00 p.m., during a follow-up interview, the Administrator said she did not conduct a formal investigation after the second incident or identify a trend. The Administrator also said Resident #1 was very confused, forgetful and most probably misplaced the rings herself. Resident's record revealed: Minimum Data Set (MDS) for resident found a Minimum Data Set ((MDS) dated [DATE]. Documentation of Resident #1 having a score of 14 for a Brief interview for mental status (BIMS). Follow-up MDS dated [DATE] found resident had a BIMS score of 15. There was a note on record by the SSD dated 12/8/18 indicating improvement of resident's BIMS score. On 3/26/19 at 1:25 p.m., the Administrator retracted her previous statement and said they identified a trend and a Performance Improvement Plan (PIP) was in place since (MONTH) (YEAR).

Based on observation, clinical record review, resident and staff interview, the facility failed to accurately document, monitor and notify the practitioner of a change in condition to ensure 1 (Resident # 26) of 1 selected resident with daily weight monitoring received the appropriate treatment to meet the resident's physical needs. The findings included: 1. Clinical record review revealed Resident #26 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Symptoms may include increased abdominal size, increased weight, abdominal discomfort and shortness of breath. On 7/27/18 at 6:30 p.m., the resident's weight was documented as 226 pounds (lbs). The physician's orders [REDACTED]. On 8/9/18 the Medical Director wrote a letter to the survey team indicating the daily weights were originally put in place as a safety net, without the intent of a parameter, to be reviewed weekly. He said Resident #26 is followed frequently by the physician and the Advanced Registered Nurse Practitioner (ARNP) and the weights are reviewed. On 7/30/18 at 4:41 p.m., the physician gave a telephone order for daily weight. Review of the daily weight record revealed the following weights documented: 7/26/18: 226 lbs, 7/27/18: 230.2 lbs, 7/29/18: 234 lbs, 8/1/18: 237.1 lbs, 8/2/18: 237.5 lbs, 8/3/18: 237.5 lbs, 8/4/18: 138.0 lbs, (99.5 lbs weight loss in 24 hours) 8/5/18: 134.3 lbs, 8/6/18: 144.6 lbs, 8/7/18: 242.0 lbs, and 8/8/18: 243.2 lbs. On 8/8/18 at 12:00 p.m., the Minimum Data Set Coordinator Staff A said the weights entered on 8/4/18; 8/5/18 and 8/6/18 were inaccurate and she just realized that. The corrected documented weight gain for the resident totaled 17.2 lbs in 13 days. On 8/8/18 at 12:15 p.m., in an interview with the Assistant Director of Nursing (ADON) she said there was no established protocol but they should inform the physician of any weight gain greater than 2 lbs. She confirmed there was no documentation the physician was notified of weight gain for Resident #26. She said the nurse practitioner saw the resident frequently but had been on vacation this week. Review of the ARNP progress notes revealed on 7/27/18 she documented the resident's weight was 226 lbs. The weight documented by the nurse practitioner differed from the facility's documented weight of of 230.2 lbs on the Weights and Vitals Summary for 7/27/18. On 7/31/18, the ARNP documented Resident #26's weight was 226 lbs. On 8/2/18, the ARNP documented the resident's weight was 226 lbs. The weight entry on her progress note differed from the facility's documented weight of 237.5 lbs. for 8/2/18. On 8/8/18 at 12:15 p.m., the ADON contacted the ARNP and informed her of the weight gain. On 8/8/18 at 12:17 p.m., the ARNP said during a telephone interview she would like the facility to notify her of any 2 to 3 lbs weight gain. The ARNP issued a telephone order on 8/8/18 to increase the Spironolocatone to 50 milligrams two times a day. 2. On 7/27/18 the physician issued an order to measure the resident's abdominal girth every evening shift. Review of the daily abdominal girth measurement revealed the following documentation: 8/1/18: 101.2 centimeters (cm), 8/2/18: 101.5 cm, 8/3/18: 101.5 cm, and on 8/5/18: 101.5 cm Interview on 8/9/18 at 11:00 a.m., with Resident #26 revealed his abdomen had been increasing in size. He said the nurses had not measured his abdomen for about 2 weeks. On 8/9/18 at 11:15 a.m., with the resident's permission Licensed Practical Nurse Staff C measured Resident #26's abdominal girth and found it to be 129 centimeters. This showed an increase in size of 27.5 cm (more than 10 inches) in 4 days. The failure to document accurate weights and abdominal girth measurements placed the resident at risk for inaccurate assessment and intervention to maintain his highest practicable physical well-being.

Based on record review, resident and family interviews, and staff interview, the facility failed to ensure sufficient staffing was on duty to answer resident call lights in a timely manner and residents were prevented from wandering in the facility at night. The facility failed to ensure the highest practical physical, mental, and psychosocial well-being of 6 (Residents #147, #112, #41, #78, #101, and #10) of 36 residents reviewed. The findings included: 1. Review of the Resident Council Minutes dated 1/12/17 revealed residents had expressed to staff that certified nursing assistants (CNAs) were not answering call lights quickly enough at night and residents were wandering at night into rooms that were not theirs. The Resident Council Minutes dated 3/27/17 revealed the residents expressed concern that call lights were not being answered in a timely manner and the DON was informed. The Resident Council Minutes dated 4/26/17 revealed the residents expressed concern that some residents continued to wander during the 11:00 p.m. to 7:00 a.m. shift. 2. On 7/17/17 at 9:54 a.m., Resident #10 said she did not feel there was enough staff to assist her with her needs without having to wait a long time. Resident #10 said there was not enough staff between 5:30 a.m. and 7:00 a.m. and that it takes a while for staff to respond to her during those hours. On 7/17/17 at 10:04 a.m., Resident #41 said she continually has to wait on staff to respond to the call light. She said she has waited as long as 30 minutes. Resident #41 said she would sometimes have an accident while waiting. On 7/17/17 at 11:51 a.m., Resident #112 said she had to wait 25 minutes for staff to respond to the call light. Resident #112 said there have been a couple of times she has wet herself because the staff did not respond to the light. Resident #112 said one time she called her friend who lives close by to assist her because the staff did not respond. On 7/17/17 at 2:26 p.m., Resident #101 said she felt there was not enough staff in the facility to meet her needs without her having to wait a long time. She said sometimes the staff would respond to her call light and sometimes they would not. On 7/18/17 at 9:46 a.m., Resident #78's husband said he did not feel there was enough staff to ensure his wife's needs were met without her having to wait a long time. Resident 78's husband said he felt there were not enough CNAs in the facility. On 7/20/17 at 9:24 a.m., Resident #147's husband said about three weeks prior he was getting ready for bed at about 8:00 p.m. and his wife called him crying. She told him he needed to get to the facility immediately. The resident's husband said upon arrival to the facility he observed the call light flashing. He walked into the room and found his wife soaked in urine and lying naked with only a knitted shawl covering her. The resident's husband said he was extremely upset about the issue and continues to be upset about it. He said he spoke with three staff members about the issue. They said they were going to take care of it. He said staff never responded to him again about the issue. Resident #147's husband said the staff response to call lights at night continues to be horrible. 3. On 7/18/17 at 6:35 a.m., CNA Staff I said there was too much work at night for so few CNAs. Staff I said there are times when the nurses have to help. Staff I said nurses would continue to do nursing assignments, but they would assist the CNAs with their tasks during the shift. Staff I said the nurses would not take a CNA assignment. On 7/18/17 at 1:33 p.m., Licensed Practical Nurse (LPN) Staff A said she would help out the CNAs with their assignments. She said she would do the CNA tasks, but she usually did not take a CNA assignment. On 7/18/17 at 1:57 p.m., the Administrator said the facility has had a hard time staffing CNAs for the last couple of months. The Administrator said the CNAs they hired were not staying on very long. The Administrator said the facility was in the process of holding CNA classes to try to obtain more CNAs.

Based on record review and interview, the facility failed to notify the family members of 2 (Residents #47 and #98) of 7 residents with cognitive conditions of a potentially contagious skin infestation and a [MEDICATION NAME] treatment being administered having a potential of side effects. The findings included: On 7/19/17 at 4:00 p.m., Physician Assistant Staff D verified there had been an outbreak of rashes in the months of April, May, and June of 2017. Staff D said 16 residents had been treated [MEDICATION NAME] for scabies. On 7/20/17 at approximately 1:10 p.m., the Director of Nursing (DON) said 7 cognitively impaired residents were treated for [REDACTED]. The DON said there should be documentation that representatives for these 7 residents were notified of the treatments. The DON said there were 2 residents (Residents #47 and #98) for which she was unable to determine if their representatives had been notified of the skin rash treatments. Review of the Monthly Infection Control Report revealed Resident #98 was treated with [MEDICATION NAME] 5% cream on 4/18/17. The form indicated Resident #98 had a dermatologist consult on 5/1/17. Review of the nursing notes revealed no documentation the guardian had been notified of the [MEDICATION NAME] treatment or the dermatologist consult. According to the US National Library of medicine website at: https://www.ncbi.nlm.nih.gov/pubmedhealth, [MEDICATION NAME] 1% lotion is used to treat head lice infections. It acts by destroying both the lice and their eggs. The 5% cream is used to treat scabies infections by destroying the mites which cause scabies. The common side effects of [MEDICATION NAME] include - Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing, eye irritation, fever, itching, or skin rash. Review of the significant change assessment dated [DATE] revealed Resident #98's brief interview for mental status (BIMS) score of 9. A score of 9 indicates moderate cognitive impairment. On 7/20/17 at approximately 2:00 p.m., the guardian of Resident #98 said he could not find any notes and he did not recall the facility notifying him the resident was treated with [MEDICATION NAME] 5% cream as a [MEDICATION NAME] treatment for [REDACTED]. Review of the Monthly Infection Control Report revealed Resident #47 was treated with [MEDICATION NAME] 5% cream and Ivermectin on 5/5/17. According to http://www.rxlist.com/[MEDICATION NAME]-side-effects-drug-center.htm#overview, [MEDICATION NAME] (Ivermectin) is an anthelmintic (anti-parasite) used to treat infections caused by certain parasites. Common side effects of [MEDICATION NAME] include: headache, dizziness, muscle pain, diarrhea, swelling and tenderness in the lymph nodes, and itching. Review of the Minimum Data Set assessment completed on 6/7/17 revealed a BIMS score of 11 for Resident #47. A score of 11 indicates moderate cognitive impairment. Review of the nursing notes for May, 2017 revealed no documentation that Resident #47's representative had been notified or consented to the [MEDICATION NAME] 5% cream and Ivermectin treatments for scabies.

Based on record review, family interview, and staff interview, the facility failed to implement its grievance policy. The facility failed to document verbal grievances on the grievance report, maintain a grievance log, report all grievances and corrective actions to the Quality Assurance Committee, and respond to residents with verbal grievances within a reasonable time after submission. Specifically, the facility failed to ensure the prompt resolution of the verbal grievance of Resident #147's family member, and the facility failed to ensure the prompt resolution of the Resident Council's complaints of staff not responding to call lights in a timely manner and residents wandering in the facility at night. The findings included: 1. Review of the Resident Grievance Program policy dated December, 6 read, In the case of a verbal grievance, the person receiving the grievance will document the grievance on the Grievance Report. All Grievance Reports will be forwarded to the Grievance Officer (Social Service Director) for investigation, initiation, and follow through. The Social Service Director (SSD) will maintain a log and report to the Quality Assurance Committee all grievances and the corrective actions. The Administrator or designee will respond to the grievance within a reasonable time after the submission. 2. On 7/20/17 at 9:24 a.m., Resident #147's husband said about three weeks ago he was getting ready for bed at about 8:00 p.m. and his wife called him crying. She told him he needed to get to the facility immediately. Upon arrival to the facility he observed the call light flashing. He walked into the room and found his wife soaked in urine and lying naked with only a knitted shawl covering her. He said he was extremely upset about the issue and continues to be upset about it. He said he spoke with three staff members about the issue. They said they were going to take care of it. The spouse said staff never responded to him again about the issue. Resident #147's husband said the staff response at night continues to be horrible. Review of the grievance log from February, 2017 to July, 2017 revealed only one grievance, documented on 7/17/17, which was from Resident #147 and had been logged after surveyor intervention. On 7/20/17 at 11:38 a.m., the SSD said she was not aware of Resident #147's husband reporting a grievance of his wife being left with no call light response from staff. The SSD said she keeps a concerns log for residents who verbally have a concern but did not want to file a grievance. The SSD said residents who voice concerns are asked if they want to file a grievance. Review of the Service Communication Log provided by the SSD revealed on 6/22/17 Resident #147 reported she would like a quicker response time to the light. Under the section entitled Recovery, the SSD documented, ADON (Assistant Director of Nursing) spoke with staff, followed up with (Resident #147) who is satisfied. On 7/20/17 at 12:23 p.m., the Director of Nursing (DON) verified residents who express verbal concerns are asked by staff if they want to file a grievance. The DON would not verify if asking residents expressing verbal concerns if they wished to file a grievance was reflected in the grievance policy. The DON was then asked if she felt what the husband of Resident #147 had reported to staff members was a concern or a grievance. The DON said, I see your concern. On 7/20/17 at 12:34 p.m., the Administrator said she could not verify if the staff member assigned to Resident #147 and responsible for answering her call light was ever identified and questioned as to why he/she had left the resident unattended. The Administrator said verbal concerns are reported in the daily team meetings of the staff. The Administrator said staff are instructed during every team meeting to answer call lights . On 7/20/17 at 1:00 p.m., the ADON said she spoke with the SSD about the resident and her husband reporting her call light not being answered. The ADON said Licensed Practical Nurse (LPN) Staff C had also spoken with both the resident and her husband on 6/22/17. The ADON was not aware if the certified nursing assistant (CNA) assigned to the resident had been identified and interviewed. The ADON said the facility's policy for grievances was to ask the resident if they wanted to file a grievance or report verbal concerns to the SSD. On 7/20/17 at 1:10 p.m., LPN Staff C said Resident #147 and her husband had reported to her that staff had moved the resident's bedside table and water out of her reach. Staff C said it was reported to her that Resident #147 had called her husband crying. Resident #147 reported to her that staff would tell her they were going to come back and they never did. Staff C said she asked the resident if she wanted to file a grievance, and Resident #147 said no. Staff C said she then gave the resident her cell phone number for the resident to call her if she ever had a problem. Staff C said the resident was happy after this. Staff C said she thought she knew who the aide was who was assigned to Resident #147. Staff C verified she never spoke with the staff member about the incident. Staff C said Resident #147's husband kept verbally repeating the incident after her conversation with them on 6/22/17, and he remained upset. 3. Review of the Resident Council Minutes dated 1/12/17 revealed residents had verbally expressed to staff that CNAs were not answering call lights quickly enough at night, and residents were wandering at night into rooms that were not theirs. The Resident Council Minutes dated 3/27/17 revealed the residents expressed verbally that call lights were not being answered in a timely manner and the DON was informed. The Resident Council Minutes dated 4/26/17 revealed residents verbally expressed that some residents continued to wander during the 11:00 p.m. to 7:00 a.m. shift. Review of the grievance log revealed no grievances logged in January, March, or April of 2017. On 7/20/17 at 2:04 p.m., the Risk Manager was asked to state any issues the Quality Assurance Committee had identified during the year which required quality assessment and assurance activities. The Risk Manager identified several issues. Call light response time and residents wandering the facility during the night were not mentioned by the Risk Manager as identified issues.

Based on record review and staff interview, the facility failed to post the accurate actual hours of licensed (registered nurses and licensed practical nurses) and unlicensed nursing staff (certified nursing assistants) directly responsible for resident care per shift at the beginning of each shift. The findings included: A review of the facility's federal posting for 7/2/17 showed a census of 86 residents. There were 88 hours of licensed staff posted with 4 licensed staff on the 1st shift, 4 licensed staff on the 2nd shift, and 3 licensed staff on the 3rd shift. There were 180 certified nursing assistant (CNA) hours posted. Review of the actual clock hours provided by the facility showed 93.75 actual hours of licensed staff and 214 hours of CNA staff. Comparing the federal postings to the 2 weeks of actual hours provided by the facility, 7 days were inaccurately posted: 6/26/17, 6/27/17, 6/29/17, 7/3/17, 7/7/17, 7/8/17, and 7/17/17. On 7/19/17 at approximately 9:00 a.m., after surveyor intervention the Administrator said the facility had identified they were not updating the federal posting with the actual hours every shift. The Administrator said on 7/2/17 there were 3 nurses on the 1st shift, 4 nurses on the 2nd shift, and 3 nurses on the 3rd shift. The Administrator said there were 6 licensed nurses working hours during the day without a nursing or CNA assignment. The Administrator said these nurses were floating and assisting CNAs during their shift.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records for 7 (Residents #15, #47, #53, #56, #72, #89, and #98) of 7 cognitively impaired residents surveyed out of 16 residents treated. The facility failed to ensure documentation was in the record regarding the notification of the residents' representatives of a change in treatment and the notification of the administration of medications to [MEDICATION NAME] treat potentially contagious rashes. The findings included: On 7/19/17 at 4:00 p.m., Physician Assistant Staff D verified there had been an outbreak of rashes in the months of April, May, and June of 2017. Staff D said the facility treated 16 residents [MEDICATION NAME] for scabies. On 7/20/17 at approximately 1:10 p.m., the Director of Nursing (DON) said 7 residents treated for [REDACTED]. The DON said these 7 residents (Residents #15, #47, #53, #56, #72, #89, and #98) should have had documentation in their records that their representatives were notified of the treatments. Review of all 7 of the residents' nursing notes revealed no documentation that representatives were notified of the treatments. On 7/20/17 at approximately 2:45 p.m., the DON verified she could not find documentation in the medical record the 7 residents' representatives were notified of the scabies treatments. The DON verified the medical records of all 7 residents were incomplete and inaccurate.

Based on observation, resident interview, staff interview, and review of policies and procedures for cleaning bathrooms and floors, the facility failed to provide housekeeping services to ensure resident rooms, bathrooms, floors, privacy curtains, light fixtures and blinds were maintained in a sanitary and comfortable fashion. The findings included: 1. Review of the facility's policy and procedures for cleaning bathrooms and floors indicated bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Floors shall be maintained in a clean, safe, and sanitary manner. There was no procedure provided for maintaining the cleanliness of cove bases and base boards or cleaning resident rooms. 2. During a tour of the environment on 6/29/15 between 8:30 a.m. and 4:30 p.m., resident rooms and bathrooms were noted to have dirt, dust and debris on the cove bases of the rooms, privacy curtains did not ensure full visual privacy, bathrooms smelled of urine, and the blinds in Resident #24's room were in disrepair. A follow-up tour of the environment was conducted on 7/1/15 at 1:40 p.m. in the presence of the Administrator, Director of Maintenance, and Housekeeping Supervisor which revealed the following: Room 110-(door bed) gray staining and dirt on the linoleum under the air conditioner, cracked tile in between the corner wall of the closet, dried beige residue in the resident's sink. Room 113-(window bed) privacy curtain failed to ensure full visual privacy, floor stained black and unidentified substances on the wall and floor near the air conditioner, peeling laminate from the footboard, cracked tile at bedroom door entrance. Room 114-(window bed) privacy curtain failed to ensure full visual privacy, cove base peeling away from corner of wall behind nightstand, bathroom cove base peeling away from the wall, grayish black staining around the base of the toilet, bathroom wall with large black scuff marks. At the time of the observation for Room 114, Resident #45, who has difficulty speaking, pointed to the peeling cove base and grimaced. Room-115-cove base in bathroom with brown staining, light above sink inoperable, dead insects in ceiling light in bathroom. At the time of the initial tour, Resident #49's room mate, who resides in room 115, complained about the condition of the flooring in the bathroom. Room 116-bathroom with smell of urine, dust, dirt and debris on baseboard, black furry substance in air conditioner, vertical blinds missing lever to open and close blinds, splintered wood on corner of door where door handle located. Room 119-splintered wood on door near door handle, bathroom floor stained, base board dusty, dry cracked above cove base. Room 120-back of bedroom door with dried, unidentified brown substances, wall under window and between mattress covered with beige and yellow dried substances. Room 121-urine odor in bathroom. Room 136-gray staining to cove base and around toilet in bathroom. On 7/2/15 at 8:45 a.m., during the Quality Assurance interview the Administrator said they identified the doors to the facility and the flooring in the rooms needed to be repaired. They identified this in 2/2015. They could not determine a completion date for those areas identified as they did not have specific quotes for the doors. There was no indication why the rooms identified during the follow-up tour were not maintained in a sanitary condition, why the blinds were in disrepair, why the bathrooms smelled of urine, why the cove basing and flooring in the bathrooms remained in poor condition, or why the privacy curtains failed to ensure full visual privacy.

Based on observation, record review, and interview, the facility failed to comprehensively assess a pressure sore for 1 (Resident #14) of 1 resident reviewed for pressure ulcers. The findings included: 1. Review of the facility's policy and procedure titled, Pressure Ulcer Treatment, indicated the purpose of the procedure is to provide guidelines for the treatment of [REDACTED]. Under Key Procedural Points, the policy includes the following: 1. Assess the pressure ulcer(s) for location, size (measure length, width, and depth), sinus tracts, undermining, tunneling, exudate/odor, necrotic tissue, peri wound, pain and the presence or absence of granulation tissue and [MEDICATION NAME]. 2. Determine the ulcer's current stage of development.9. Measure wound weekly, to include: a. Current measurement of the wound(s); b. Current visual stage(s) of the wound(s); c. Any drainage, odor, progress or decline of wound(s). 2. Observation on 6/30/15 at 11:35 a.m. the Wound Care Nurse (WCN) said Resident #14 was on Hospice and had a Stage III in-house acquired pressure sore to her coccyx. Review of the physician's orders [REDACTED].#14's buttocks topically every shift for skin care. ([MEDICATION NAME] skin protectant paste has a higher viscosity (thickness) than other skin pastes. It nourishes skin, helps treat and prevent diaper rash, wet and cracked skin. The [MEDICATION NAME] dries light exudates from compromised skin and the menthol cools irritated skin and calms inflamed tissue.) Record review shows physician documentation on 9/3/14 identifying Resident #14 with the following risk factors for developing pressure sores: immobility.continuous urinary incontinence.chronic bowel incontinence.pale skin and poor skin turgor (exhibits malnutrition). Wound care notes dated 11/13/14 showed Resident #14 with a pressure ulcer to the coccyx which had resolved. Review of the physician's orders [REDACTED]. Review of the 1/22/15 pressure ulcer screen showed Resident #14 at high risk for developing a pressure sore. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/15 noted the resident was unable to participate in the interview to evaluate her mental status. Resident #14 required extensive assistance of 1-2 people for activities of daily living. No pressure sores were identified on this assessment. Skin interventions on the MDS included pressure reducing device for bed, chair and an application of ointment other than to feet. Review of the 4/5/14 pressure ulcer screen showed Resident #14 remained at high risk for developing a pressure sore. On 4/14/15 and 4/21/15, weekly skin assessments noted a reddened area to Resident #14's sacrum. There was no additional assessment of the newly acquired reddened area on the sacrum. There was no indication by nursing as to whether the redness was transient, was due to a Stage I pressure sore (in accordance with the facility's Pressure Ulcer Treatment policy/procedure), or from excoriation related to incontinence. Review of the quarterly MDS with an ARD of 4/20/15 shows no changes in Resident #14's status as originally noted on 1/22/15. On 4/28/15, a weekly skin assessment was conducted by Staff A, who is a Licensed Practical Nurse (LPN). The nurse documented Resident #14's sacrum was reddened with a small open area noted. There was no further description or assessment of the newly acquired open area (type of wound, size, shape, odor or appearance of the wound and wound bed). On 4/30/15, the Hospice nurse, who is a Registered Nurse (RN), documented redness to Resident #14's coccyx. There was no further assessment of the area by the RN. There was no assessment by the RN of the open area to the sacrum previously identified by Staff A (LPN). On 5/5/15, Staff A documented the same description of the wound (reddened with small open area to sacrum). No other description or assessment of the wound was noted. On 5/12/15, a second LPN identified a small open area to Resident #14's reddened sacrum. There was no other description or assessment of the wound. Review of the WCN progress noted dated 5/14/15 documents Resident #14 with open area to the coccyx measuring 1.0 x 0.8 x 0.1cm. There was no futher description of the wound until 5/21/15 with documentation of a Stage II pressure sore to the resident's coccyx increased in size measuring 1.3 x 1.0 x 0.1 cm. The wound presented with light drainage. On 6/11/15, the WCN progress notes documented the wound increased in size measuring 2.0 x 1.8 x 0.1cm. The wound was assessed to have light clear drainage, a reddened per-wound and slough on the wound base. . On 6/25/15, the WCN documented the wound progressed to a Stage III pressure sore measuring 2.0 x 1.8 x 0.3 and with light drainage, slough, red around the wound, and the wound bed with areas of white. In an interview with the WCN on 6/30/15 at 11:40 a.m., she said she follows up on the weekly skin assessments by nursing staff if they identify any open areas. She said Resident #14 had a history of [REDACTED]. She said once an open area is identified, she, as the RN, will assess the area and if applicable, will call the family and doctor and get orders. She said the nurses didn't tell her about the reddened areas to the sacrum on 4/14 and 4/21/15. She said they did not notify her of the open area to Resident #14's sacrum on 4/28/15. Observation on 6/30/15 at 2:12 p.m. during wound care in the presence of the WCN, Unit Manager and Staff B (Certified Nursing Assistant) showed an open area, Stage III, to Resident #14's sacral-coccyxgeal area. The tissue surrounding the wound was macerated. Yellow slough was observed between the 6:00-12:00 position of the wound. Deep reddish purple tissue was observed between the 12:00-6:00 position of the wound. In an interview with Staff A, LPN, on 7/1/15 at 4:03 a.m., she confirmed she documented Resident #14 with an open area to her sacrum on 4/28/15 and 5/5/15. She did not report her findings to the WCN. She stated the wound at that time had white tissue. She did not document this. The nurse became confused and then said, I thought the white tissue was an open area. The nurse was unable to verbalize the difference between an open and closed wound. In an interview on 7/1/15 at 4:12 p.m., the Director of Nurses (DON) said he discovered a concern with the documentation related to Resident #14's pressure sore on 6/27/15. He said the Hospice nurse, who is an Registered Nurse (RN), came in between 4/21/15 and 5/5/15 for weekly skin assessments and saw a reddened area. The DON confirmed the RN did not document any further assessment of the area. He acknowledged wounds can open and close. On 7/2/15 at 10:00 a.m., the Hospice nurse said one of her aides told her about a red area on Resident #14's bottom. She said she forgot to check if the skin blanched and admitted she did not further assess the wound. The Hospice nurse did not assess the source of the wound to determine whether the wound was related to excoriation, deep tissue injury, or a Stage I verses Stage II pressure sore. Failure to accurately and comprehensively assess and the skin condition of a resident (Resident #14) identified as being high risk to develop pressure sores increases the risk of pressure ulcer development or worsening of the wound.

Based upon observation, interview and record review, the facility administered the wrong dose of a medication to 1 (Resident #28) of 10 resident records reviewed for unnecessary medications. This placed Resident #28 at risk for adverse effects from getting too little of the diuretic medication which may have contributed to fluctuations in the resident's weights, additional diuretic being administered and the potential for exacerbation of [MEDICAL CONDITION] from 1/24/13 through 5/8/13. The findings include: During a a review of Resident #28's record on 5/9/13, the written physician order [REDACTED]. An observation of the pharmacy label revealed there was a discrepancy. The resident was being administered 2 fluid pills, [MEDICATION NAME] and [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The physician order [REDACTED]. [MEDICATION NAME] Tablet 2.5 milligrams (mg), give 10 mg by mouth one time a day for [MEDICAL CONDITION] associated with [MEDICAL CONDITION]. The Medication Administration Record (MAR) dated 1/23/13 documented: [MEDICATION NAME] Tablet 2.5 mg Give 10 mg by mouth one time a day for [MEDICAL CONDITION] associated with [MEDICAL CONDITION]. The pharmacy label on the medication documented: [MEDICATION NAME] 2.5 mg tablet- sub for [MEDICATION NAME] 2.5 mg tablet. Give one tablet by mouth once daily, Diagnosis (Dx). [MEDICAL CONDITION]. During an interview on 5/9/13, at 10:00 a.m., the Director of Nursing (DON) confirmed after speaking with the pharmacy and reviewing the number of refills sent to the facility since 1/23/13, Resident #28 had been receiving one of the 2.5 mg tablets of the [MEDICATION NAME] instead of 10 mg as ordered by the physician. The [MEDICATION NAME] comes in three dosages, a 2.5 mg tablet, a 5 mg tablet and a 10 mg tablet. The DON said when she talked to the pharmacy they said the physician's orders [REDACTED]. The DON said the nurses should be looking at the MAR and the pharmacy label when administering medications to residents to ensure they match. She verbalized concern that the error was not discovered by the nurses or pharmacy during the almost 4 month period. During a phone interview on 5/9/13 at 1:31 p.m., the Physician, who prescribed the [MEDICATION NAME] 10 mg, said Resident #28 did not have any harm from receiving the incorrect dose. The Physician said a 10 mg dose is a high dose for someone who was already on [MEDICATION NAME]. He said the resident is going to continue on the 2.5 mg dose of [MEDICATION NAME]. Observation of Resident #28, on 5/9/13, in the late morning, revealed a pleasant obese resident with both lower extremities appearing dark purple with some [MEDICAL CONDITION] and both feet covered with dressings. The resident is a [AGE] year old with a history to include [MEDICAL CONDITION] and Diabetes. He has [MEDICAL CONDITION] that has contributed to the amputation of his right big toe. Resident #28 was on his way to the hospital on [DATE] to have some additional amputation to his right foot/toes. Review of Resident #28's record, the physician progress notes [REDACTED]. physician progress notes [REDACTED]. physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the dietary noted dated 4/22/13 documents Resident #28 is prone to weight fluctuations related to fluid retention due to the [DIAGNOSES REDACTED]. Review of the nursing note dated 4/24/13, at 2:45 p.m., documents Resident #28's oxygen stats are 92% on oxygen, residents lung with some crackles (indication of fluid in the lung), lethargic. The resident's physician was notified and new orders received to give resident an extra 40 mg of [MEDICATION NAME] this evening together with scheduled 40 mg of [MEDICATION NAME] to make a onetime dose of 80 mg. Review of a nursing note dated 4/24/13, at 2:48 p.m., documents Resident #28 has a productive cough with sputum and rhonchi and crackles noted to the lung. The Physician (MD) notified and increased his [MEDICATION NAME] to 80 mg today. His weight was 353.9 pounds and up 11.3 pounds this week. Call placed to MD in regards to ordering a chest X-ray. Review of the X-ray report, dated 4/24/13, documents the resident to have unchanged [MEDICAL CONDITION] congestion and infiltrate of the left lower lobe.