Every finding on record at Lutheran Senior Services at Meramec Bluffs

Based on observation, interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when facility staff failed to use a gait belt when transferring the resident from the floor to the wheelchair. The sample size was 3. The census was 67.Review of the facility's Event Reporting Policy, revised 7/29/21, showed: -Policy statement: Event reporting is essential to providing resident and client care. Events involving a resident, visitor, or other person (non-employee) that are outside of usual or normal happenings and present a potential liability, and events that are not in keeping with standards, policies, procedures or practices and may have an adverse outcome will be documented. The documentation of an event and its investigation, outside of what is documented in the medical chart, is confidential. Applicable authorities will be notified as appropriate. -A fall is an unintentional coming to rest on the ground, floor, or other lower level but not the result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention. Is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a patient or resident is found on the floor, and there is no witness to account for the event. -Procedures: Resident's physician shall be informed of any event concerning the physical care and wellbeing of the resident. Family or power of attorney (POA) shall be informed of all events defined in this policy. Review of the facility's Safe Lifting and Movement of Residents Policy, revised 10/14/19, showed: -Policy statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents;-Manual lifting of residents will be eliminated when feasible;-Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards), and mechanical lifting devices. Review of Resident #1's electronic medical record (EMR), showed diagnoses included late onset Alzheimer's dementia with other behavior disturbances, short term memory loss, status post right femur fracture surgery 12/17/25, weight bearing as tolerated, fall, and muscle weakness. Review of a video tape, dated 12/21/25 at 10:34 P.M., showed Resident #1 sat on the floor next to bed, with his/her left arm resting on top of the bed. Certified Nursing Assistant (CNA) A approached resident and said, oh he/she is on the floor. Did you hit your head? How did you fall out. Review of a video tape dated 12/21/25 at 10:35 P.M., showed the resident sat on the floor next to the bed. CNA A stood in front of the resident. CNA B entered the room and said to get him/her up and put him/her in the chair. The resident raised up both arms, as to reach for the staff. CNA A stood on the left side of the resident with his/her left arm under resident's left armpit and CNA B stood on the right side of the resident with his/her right arm under resident's right armpit and together they lifted the resident off the floor by pulling on his/her arms and transferred the resident into the wheelchair. No gait belt was used to transfer the resident from the floor to the wheelchair. Review of Resident #1 progress notes, showed the fall on 12/21/25 not documented. No fall assessment documented, and no post fall follow-up documented. During an interview on 12/23/25 at 1:48 P.M. CNA A said he/she and CNA B got on each side of Resident #1 and transferred the resident up with his/her good leg from the floor to the wheelchair. He/she does not remember if they used a gait belt for the transfer. CNA A said a gait belt should be used for transfers. During an interview on 12/23/25 at 2:01 P.M. CNA B said he/she and CNA A got on each side of the resident and transferred the resident up with his/her good leg from the floor to the wheelchair. They did not use a gait belt to transfer the resident from the floor to the wheelchair. A gait belt should have been used. During an interview on 12/23/25 at 3:15 P.M., the Director of Nursing (DON) and Executive Director (ED) said they would expect staff to use a gait belt when transferring a resident from the floor to the wheelchair after a fall. 2698306

Based on observation, interview and record review, the facility failed to notify Next of Kin (NOK) of a resident fall for one resident (Resident #1). The sample size was three. The census was 67. Review of the facility's Event Reporting Policy, revised 7/29/21, showed: -Policy statement: Event reporting is essential to providing resident and client care. Events involving a resident, visitor, or other person (non-employee) that are outside of usual or normal happenings and present a potential liability, and events that are not in keeping with standards, policies, procedures or practices and may have an adverse outcome will be documented. The documentation of an event and its investigation, outside of what is documented in the medical chart, is confidential. Applicable authorities will be notified as appropriate. -A fall is an unintentional coming to rest on the ground, floor, or other lower level but not the result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention. Is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a patient or resident is found on the floor, and there is no witness to account for the event. -Procedures: Resident's physician shall be informed of any event concerning the physical care and wellbeing of the resident. Family or power of attorney (POA) shall be informed of all events defined in this policy. Review of Resident #1's electronic medical record (EMR), showed diagnoses included late onset Alzheimer's dementia with other behavior disturbances, short term memory loss, status post right femur fracture surgery 12/17/25, weight bearing as tolerated, fall, and muscle weakness. Review of a video tape, dated 12/21/25 at 10:34 P.M., showed Resident #1 sat on the floor next to bed, with his/her left arm resting on top of the bed. Certified Nursing Assistant (CNA) A approached resident and said, Oh he/she is on the floor. Did you hit your head? How did you fall out. Review of the resident's progress notes, showed no documentation of a fall on 12/21/25 and not documentation the physician and NOK were notified. During an interview on 12/23/25 at 1:48 P.M., CNA A said, he/she discovered the resident with their elbows resting on the bed and buttocks off the floor. He/She told the resident to sit down onto the floor so he/she can get him/her up. He/she does not consider it a fall and did not report it as a fall. During an interview on 12/23/25 at 2:01 P.M., CNA B said CNA A followed him/her into the resident's room and discovered the resident sitting on the floor next to their bed. The resident denied falling. CNA B said he/she does not consider this a fall, just a slide off the bed. He/she does not know if a report was completed. During an interview on 12/23/25 at 3:15 P.M., the Director of Nursing (DON) and Executive Director (ED) said they would consider a resident sliding off the bed onto the floor and a resident holding themselves up by their elbows off the floor as a fall and should be reported. When a fall/incident happens, the physician is notified along with the NOK, and the DON or Administrator. 2698306

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #20) with limited mobility, received appropriate equipment and assistance to maintain mobility when staff failed to ensure the resident wore palm protectors properly and daily in accordance with physician orders and recommendations by therapy to address hand contractures (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement). The sample was 12. The census was 43 with 29 residents in certified beds. Review of Resident #20's medical record, showed: -Diagnoses included contracture to unspecified joint, Alzheimer's disease, and dementia; -A physician order, dated 5/23/24, for restorative - splint/brace. Please place splints on resident's hands every day and remove every night. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/24, showed: -Severe cognitive impairment; -Rejection of care behavior not exhibited; -Dependent on assistance for upper body dressing. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident has activity of daily living (ADL) self-care deficit related to decreased mobility and muscle weakness; -Goal: Resident's ADLs and self-care will be managed through the next review; -Interventions included use of braces and splints as ordered. Review of the resident's Occupational Therapy (OT) progress report, dated 9/11/24, showed: -Progress of short-term goals: -Continue: The patient will remain the same with bilateral upper extremity passive range of motion shoulder flexion; -Functional maintenance program established included splint and brace program in place. Observation on 10/7/24 at 12:20 P.M., showed the resident seated in the dining room with palm protectors on both hands with a strap with finger slots at the top of each palm protector to straighten the resident's fingers and secure the resident's hand to the base of the splint, and a strap at the bottom to secure the resident's forearm to the base of the splint. The top strap on the resident's right palm protector was not secure. Certified Nurse Aide (CNA) A sat next to the resident and provided feeding assistance. At 12:29 P.M., the top strap of the right palm protector was not secure and the resident's fingers curled into the palm of his/her hands. Throughout the meal, the right palm protector remained unsecured over the resident's hand while staff provided feeding assistance, and the resident's fingers curled into the palm of his/her hand. Observation on 10/7/24 at 5:26 P.M., showed the resident seated in the dining room next to CNA/Certified Medication Technician (CMT) G. The resident had no palm protectors on his/her hands, and the resident's fingers curled into the palm of his/her hand. Observation on 10/8/24 at 7:55 A.M., showed CNA/CMT B entered the resident's room to get the resident out of bed. The resident's palm protectors were located on the resident's bedside table. At 8:16 A.M., CNA/CMT B exited the resident's room with the resident and escorted the resident to the dining table. The resident had no palm protectors on his/her hands, and the resident's fingers curled into the palm of his/her hands. Review of the resident's administration history, showed Licensed Practical Nurse (LPN) F documented the resident's splint/brace administered on 10/8/24 at 8:00 A.M. Observations on 10/8/24, showed: -At 11:28 A.M., the resident seated in his/her room with no palm protectors on either hand. The resident's fingers curled into the palms of his/her hands. The resident was unable to be interviewed; -At 12:20 P.M., the resident seated in the dining room next to CNA/CMT B, who provided feeding assistance to the resident. The resident had no palm protectors on his/her hands, and the resident's fingers curled into the palm of his/her hands; -At 1:50 P.M., the resident seated in his/her room with no palm protectors on either hand and the resident's fingers curled into the palms of his/her hands. During an interview on 10/9/24 at 8:54 A.M., CNA/CMT C said the resident's hands were contracted and he/she had palm protectors for both hands to make sure the contractures don't get worse. The aide who is assigned to the resident is responsible for putting the resident's palm protectors on his/her hands. Staff should ensure the resident's fingers are properly inserted in the slots of the top strap, and that the straps of the palm protector are secure. The resident can pull his/her hands out of the palm protectors at times and when this occurs, staff should reapply the palm protector. Once the palm protector is applied, the nurse marks the treatment as administered in the resident's record. The nurse should not mark the treatment as completed if the palm protectors were not applied. During an interview on 10/9/24 at 9:03 A.M., LPN D said the resident wears palm protectors on his/her hands during the day to prevent his/her contractures from getting worse. The aides or nurses can put the palm protectors on the resident, and they should ensure the palm protectors are properly applied. If the resident pulls off the palm protector or it becomes loose, staff should put the palm protectors back on the resident. Nurses were responsible for ensuring the palm protectors are applied and once verified, they mark the treatment as completed in the resident's record. If the resident refuses to wear the palm protector, the nurse should document that on the administration record. Staff should not document a treatment as administered when it was not. During an interview on 10/9/24 at 9:40 A.M., LPN E said aides can put palm protectors on residents, but ultimately, it is up to the nurse to ensure the palm protectors are put on correctly and as ordered. Once the nurse verifies the palm protectors are on, they mark the treatment as completed in the administration record. If the palm protectors were not applied for whatever reason, the nurse should document this in resident's record. It was not appropriate to mark the treatment as completed if the palm protectors were not put on. During an interview on 10/9/24 at 9:27 A.M., the Assistant Director of Nurses (ADON) said the resident wears palm protectors every day to keep his/her fingers straight because they curl into his/her palms. He/She tolerates the palm protectors well. CNAs are responsible for putting the palm protectors on the resident and making sure they are on properly. If the straps become undone, it is expected that staff reposition the palm protectors to secure them. Nurses are responsible to ensure the palm protectors are applied and then marking the treatment as administered in the administration record. It was not appropriate to mark a treatment as administered if it was not completed. During an interview on 10/9/24 at 9:46 A.M. with the Director of Nurses (DON) and Administrator, they said palm protectors are used to keep the resident's hand open and fingers extended to address contractures. If the straps on the palm protectors become loose, it is expected that staff put the straps back on securely. Nurses are responsible for verifying the palm protectors are applied and marking the treatment as administered in the resident's record. It was not appropriate to mark a treatment as administered if it was not. If the palm protectors were not applied, it was expected that the nurse document why the treatment was not administered in the resident's record.

Based on observation, interview, and record review, the facility failed to answer call lights in a timely manner and to ensure all clinical nursing staff carried a call light pager per the facility's call light exception, approved by the Department of Health and Senior Services (DHSS). This affected three of three residents sampled for call light concerns (Residents #18, #8 and #1). The census was 68 with 24 residents in certified beds. Review of the facility's exception letter, approved by DHSS, dated 7/28/20, showed for each approval listed, the facility is required to comply with the stipulations that follow: -The operator will ensure that all direct care staff carry and utilize the wireless nurse call pagers at all times; -The operator will ensure that a wireless nurse call system report is available for review upon request. 1. During a group interview on 12/7/22 at 10:00 A.M., Residents #18 and #8 said they had to wait a long time for staff to answer the call light. Resident #8 said he/she needs his/her medication and sometimes staff take a long time to come. Having to wait for his/her medications for a long time makes him/her angry, anxious, and feel abandoned. Review of Resident #18's call light log for the past 30 days, showed: -On 11/9/22, elapsed time of 1 hour, 5 minutes; -On 11/9/22, elapsed time of 1 hour, 25 minutes; -On 11/12/22, elapsed time of 1 hour, 13 minutes; -On 11/13/22, elapsed time of 3 hours, 13 minutes; -On 11/13/22, elapsed time 1 hour; -On 11/13/22, elapsed time 1 hour, 18 minutes; -On 11/22/22, elapsed time 2 hours, 7 minutes; -On 11/24/22, elapsed time 1 hour, 41 minutes; -On 11/30/22, elapsed time of 4 hours, 4 minutes; -On 12/1/22, elapsed time of 3 hours, 7 minutes; -On 12/4/22, elapsed time of 1 hour, 29 minutes; -On 12/7/22, elapsed time of 1 hour, 30 minutes. Review of Resident #8's call light log, for the past 30 days, showed on 11/13/22, elapsed time of 59 minutes. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/22, showed: -Cognitively intact; -Diagnoses included Crohn's disease (a type of inflammatory bowel disease), diabetes mellitus and respiratory failure. During an interview on 12/5/22 at 10:59 A.M., the resident said night staff do not answer his/her call light in a timely manner. Staff told him/her they do not always see his/her call light. Observation on 12/7/22 at 11:57 A.M., showed the resident pushed his/her room call light. The call light above the resident's door on the outside of the resident's room showed the call light illuminated. Review of the resident's call light log for the past 30 days, showed: -On 11/7/22, elapsed time of 55 minutes; -On 11/10/22, elapsed time of 55 minutes; -On 11/10/22, elapsed time of 50 minutes; -On 11/18/22, elapsed time of 51 minutes; -On 11/26/22, elapsed time of 1 hour, 10 minutes; -On 11/29/22, elapsed time of 1 hour; -On 12/4/22, elapsed time of 53 minutes. 3. During an interview on 12/7/22 at 11:56 A. M., Licensed Practical Nurse (LPN) G said the facility uses a call light pager system. When the resident pushes their call light, the staff gets a notification on their pager. Staff then go to the resident's room and push the black button on the wall to turn the call light off. LPN G said only the certified nurse assistants (CNAs) carry a pager. 4. During an interview on 12/7/22 at 1:23 P.M., Registered Nurse (RN) H said he/she did not have a pager on him/her. 5. During an interview on 12/7/22 at 1:28P.M., RN J said he/she does not have a call light pager and never has. 6. During an interview on 12/7/22 at 1:45 P.M., Certified Medication Technician (CMT) I said he/she has a pager but it is on the medication cart at the moment. 7. During an interview on 12/7/22 at 1:41 P.M., the Director of Nurses and administrator said CNAs are the staff who carry call light pagers. If the call light is not answered within a certain timeframe, an alert is sent to the next CNA on the assignment. When the CNAs are on break, the CNA is supposed to give their call light pager to the nurse. Since the nurses do not carry a pager, they are to look for the light above the resident's door to know if the resident needs help. It is expected that call lights are answered as soon as possible. Waiting an hour or longer for a call light to be answered is considered too long. The administrator said she was aware the facility's exemption requires all direct clinical staff to carry pagers. 46970

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety, by failing to cover stored food and by failing to completely air-dry dishes before use. This had the potential to affect all residents who eat from the facility kitchen. The census was 121 with 51 in certified beds. 1. Observation on 6/18/19 at 3:21 P.M., showed a large wheeled metal storage rack with approximately six large trays filled with sliced fish, uncovered, located next to the walk in refrigerator. Two additional large metal storage racks filled with sliced zucchini and okra, uncovered, located next to the walk in refrigerator. Observation and interview on 6/19/19 at 2:13 P.M., showed a large wheeled metal storage rack with approximately six large trays filled with chopped potatoes, located in the rear of the kitchen, uncovered. Chef M said the potatoes were to be served around 4:30 P.M. Observation and interview on 6/19/19 at 2:20 P.M., showed inside the blast chiller/freezer (which allows food to cool quickly), a large pan of cooked lasagna, another pan of hash browns and a large pan of Salisbury steak, all uncovered. Chef M said staff do not cover the food in the blast chiller until it is removed, then the items are covered. These will go into the walk in refrigerator and be served tomorrow. Observation on 6/21/19 at 10:35 A.M., showed a large wheeled metal storage rack with two trays of fish, uncovered, located next to the hand washing station while staff washed their hands. During an interview on 6/21/19 at 10:46 A.M., the executive chef said food should to be covered, there is bacteria in the air and covering the food protects it from cross contamination. 2. Observation and interview on 6/19/19 at 2:16 P.M., showed stacked pans, with the inside of the pans dripping wet, next to the dish washing area. Chef M said the pans should be allowed to air dry, otherwise bacteria could grow. Observation and interview on 6/21/19 at 10:46 A.M., showed stacked pans, the inside of the pans and rims of the pans, visibly wet. The executive chef said pots and pans should be stacked dry because stacking them wet would allow for bacteria to grow. 3. On 6/21/19 at 10:46 A.M., a copy of the facility food storage and dishwashing/drying policy was requested. As of 6/26/19, none was provided.

Based on interview and record review, the facility failed to implement their written policies and procedures to identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded by failing to assess residents ability to consent to sexual activity for two residents (Residents #10 and Resident #11). The facility census was 121 with 51 in certified beds. Review of the Centers for Medicare and Medicaid services (CMS) State Operations Provider Certification, showed §483.12 Freedom from Abuse, Neglect, and Exploitation: -Sexual abuse, is defined at §483.5 as non-consensual sexual contact of any type with a resident; -Generally, sexual contact is nonconsensual if the resident either: -Appears to want the contact to occur, but lacks the cognitive ability to consent; or -Does not want the contact to occur; -A resident may have a representative that has been appointed legally under State law through, for example, a power of attorney, guardian, limited guardian, or conservatorship. These legal appointments vary in the degree that they empower the appointed representative to make decisions on behalf of the resident. While a legal representative may have been empowered to make some decisions for a resident, it does not necessarily mean that the representative is empowered to make all decisions for the resident. The individual arrangements for legal representation will have to be reviewed to determine the scope of authority of the representative on behalf of the resident; -When a resident with capacity to consent to sexual activity and his/her representative disagree about the resident engaging in sexual activity, the facility must honor the resident's wishes irrespective of that disagreement if the representative's legal authority does not address that type of decision-making for sexual activity. If the resident representative's legal authority addresses decision-making for sexual activity, then the facility must honor the resident representative's decision consistent with 42 CFR 483.10(b); -The facility must have and implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves (but is not limited to): -Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. 1. Review of the facility's policy for Supporting Resident Autonomy Related to Expressions of Intimacy, dated 1/17/15, showed: -Policy: It is the belief of this community that, based on the teachings of the Alzheimer's Association, the expression of intimacy is a human need. As long as the two people, neither of whom has been declared to be legally incompetent, as consensual, it is each person's right, including those living with dementia, to express intimacy; -It is also the belief of this community that knowing each resident, who they were, and who they are, is essential to providing quality of care and quality of life for the individual. This is best accomplished through the completion of a resident life story, in collaboration with the resident and their family. Understanding the individuals history related to desire for intimacy can assist in understanding their desires and actions as well as potential risk for themselves or others; -Procedure: When two residents express through word or action a desire to engage in intimacy, community interdisciplinary team (IDT), including the resident's physician, is to assess the appropriateness of (i.e. evidence of the level of comfort of those involved, understanding of the actions, location and impact on other residents) decision making capacity of the individuals involved as well as their response to the intimacy; -An individualized plan of care for the residents will be developed by the IDT and incorporated into the Individualized Service Plan: -The ABC approach may be utilized to support problem solving. This includes defining what triggered the behavior, including environmental factors, the details of the behaviors, and the consequence, actual or potential. When evaluating the scope or severity of a problem and defining interventions. Note: in the case of intimacy, the behavior may have potential and/or negative consequences; -If it is assessed that intimacy is not consensual on the part of both residents, the plan of care will define how the staff will monitor and intervene in providing over-sight to the non-consenting resident, as well as any other residents in the household, and to provide interventions for the resident who has initiated the intimacy. These interventions maybe include: -Fostering social and recreational activities; -Modify clothing of resident to promote modesty without restraining the resident; -Discouraging revealing clothing for staff members; -Avoiding explicit television shows; -Defining, encouraging, and reinforcing alternative behavior; -Documentation of resident encounters, including the response to the encounter and to related interventions, will be included in the clinical record. Documentation will also be included in Individualized Service Plan and the monthly review. 2. Review of Resident #11's medical record, showed no documentation of an assessment to determine if the resident has the capacity to consent to sexual contact, intimacy and/or sexual relationship. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/19, showed: -Brief Interview of Mental Status (BIMS) score of 3 out of 15; -A BIMS score of 0-7, shows the resident had severe cognitive impairment; -[DIAGNOSES REDACTED]. -Physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, and abusing others sexually): Behavior not exhibited; -Required extensive assistance with transfers; -Used a wheelchair. Review of the resident's care plan, dated 12/14/16 and in use at the time of the survey, showed: -Problem: Resident has altered thought process, he/she has long and short term memory deficits and moderate impaired decision making capabilities: -Goal: He/she will function at his/her highest level of cognition by next review date; -Interventions: Encourage involvement in activities. 1:1 for socialization; -Problem: He/she has a history of and currently trying to touch staff and other residents inappropriately: -Goal: He/she will decrease the amount of times he/she is inappropriate with staff and residents by next review date; -Interventions: Document all aggression or sexual behavior when it occurs. Provide him/her with other activities or distractions. Move him/her away from source when behavior is being noticed. Redirect behavior; -Problem: He/she demonstrated inappropriate behaviors as evidenced by him/her touching another resident in the area of his/her chest on 6/8/19: -Goal: He/she will not demonstrate inappropriate behaviors towards other residents; -Interventions: If he/she is demonstrating inappropriate behaviors, provide verbal cues to distract him/her and redirect him/her. Monitor him/her for signs/symptoms of a urinary tract infection which often accompanies increased behaviors. He/she is on routine [MEDICATION NAME] (hormone management medication) to manage sexual urges/behaviors; -No documentation of the resident's capacity to consent to sexual contact, intimacy and/or sexual relationships. Review of the resident's progress notes, showed on 6/8/19 at 10:57 P.M., the resident was found sitting in his/her wheelchair next to another resident, who was seated in a recliner chair in the common area. Resident #11 was noted to be squeezing the other resident's chest area and was immediately removed, redirected, and placed at the dining room table until further investigation could occur. A call was placed to the resident's physician, who stated Resident #11 had a history of [REDACTED]. 3. Review of Resident #10's medical record, showed no documentation of an assessment that resident has the capacity to consent to sexual contact, intimacy and/or sexual relationship. Review of the resident's quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, shows the resident was moderately impaired; -A BIMS score of 8-12, indicates moderately impaired cognition; -[DIAGNOSES REDACTED]. -No behaviors exhibited. Review of the resident's care plan, dated 10/14/16 and in use at the time of the survey, showed: -Problem: Resident has a long term memory problem: -Interventions: Encourage family/friends to bring pictures, special memories, and talk with him/her about past events. Engage him/her in talking about past events/roles. Use prompts or cues (pictures, mail, etc.) as needed. Engage in activities that remind him/her of past roles/times (music/stories); -Problem: Resident has a short term memory problem: -Interventions: Encourage/help him/her participate in recreational activities. Maintain consistent routine, introduce change slowly to reduce confusion; -No documentation of the resident's capacity to consent to sexual contact, intimacy and/or sexual relationships. 4. During an interview on 6/21/19 at 8:14 A.M., Activity Aide D said he/she had been working with Resident #11 for two years. He/she primarily sits with his/her spouse, Resident #10. The resident likes to move around in his/her wheelchair. He/she observed Resident #11 touching his/her spouse. It would be a pat on the arm or the buttocks, but that is it. Resident #10 would get embarrassed and tell Resident #11 to stop. It was kind of cute. 5. During an interview on 6/21/19 at 10:14 A.M., Social Services I said the facility has married couples. They determine the capacity to consent to sexual relationship by determining the cognition of the residents. They check the family dynamic and check the level of involvement of the family to ensure there was no harm and it was consensual. They check to see if the resident likes to be touched or if the resident is aware it is his/her spouse. The facility is expected to act responsibility if the resident does not have the capacity to consent. Social Services I did not know if there was an assessment to determine capacity to consent or if it was completed. If there was an assessment, it would be in the medical record. There was a discussion about Resident #11 and Resident #10's capacity to consent. She would expect it to be documented in the care plan. Resident #11's care plan did address his/her history with touching others. Other than eating meals together, Social Services I was not sure if there was any other interaction between Resident #10 and Resident #11. They sat together, but there was no public display of affection. One of the reasons why they were separated was because they bickered a lot with each other. There were issues with sexual behaviors between Resident #11 and other residents, but there was medication modification to treat this. Social Services I never heard anything about the spouse being embarrassed with being touched or telling him/her to stop. If they were aware that a married resident was uncomfortable, they would expect the nursing staff to contact social services. Social services would contact the family. They would put interventions in place, such as not allowing them to be alone together. 6. During an interview on 6/21/19 at 10:52 A.M., the Director of Nursing (DON) said she was unaware of how the IDT team assessed a resident's capacity to consent. She would assume that when the residents show interest, they would involve social services to determine if the resident had the capacity to consent. It is not something the facility would do on everyone when they are admitted , but only if they express interest. If a resident is touching another resident and the residents involved cannot consent, she would expect there to be a nurse's note. Resident #10 and #11's family member wanted them to meet in the common areas only. There has been no discussion about Resident #10 and Resident #11's capacity to consent to sexual contact; however, when Resident #11's inappropriate touching was discussed, it was decided to provide behavior monitoring and watch what he/she was doing. 7. During an interview on 6/21/19 at 12:15 P.M., the Administrator in Training said the facility did not have a formal capacity to consent to intimacy and sexual behavior assessment; however, if they were a married couple, they would see if they wanted to be intimate and call the power of attorney. They would look at their BIMS score, but it comes up in the care plan meeting. They would check if it was safe and if the family was ok with it. The POA would have a strong say in determining if they could be intimate. She did not know if there was any documentation on whether or not Resident #10 and Resident #11 had to capacity to consent. Resident #11 did not have a favorite or single out a particular resident. If there was intimacy with another person, then they would get the social worker involved. If there was a behavior, the resident indicated a dislike or non-permission, they would intervene. If the resident was not able to communicate or had a [DIAGNOSES REDACTED]. She did not think they would need consent for Resident #11 to swat Resident #10 on the buttocks; but Resident #10 has the right to say stop or jerk away from the resident. If it happened, she would expect staff to intervene and re-direct them.

Based on observation, interview and record review, the facility failed to ensure the services provided or arranged by the facility meet professional standards of practice by failing to ensure all physician orders [REDACTED].#108). In addition, the facility failed to follow the fall management policy for one of one sampled resident that experienced unwitnessed falls. Staff failed to complete the neurological assessments for a fall and did not care plan updated interventions to prevent future falls for one of three falls the resident experienced since admission (Resident #38). The sample size was 13. The census was 121 with 51 residents in certified beds. 1. Review of Resident #108's electronic physician order [REDACTED]. -[DIAGNOSES REDACTED]. -An order dated 6/9/19, to apply Allevyn (an absorbent foam dressing) every 3 days to the coccyx (tailbone) for redness. Review of the resident's admission skin assessment, dated 6/8/19, showed: -Reddened area to coccyx is blanchable (blood flow quickly returns after pressure applied) and pink with moisture [MEDICAL CONDITION] (skin irrigation due to moisture); -No open areas; -No size or further description of the area. Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 6/8/19, showed a score of 17 (15 to 18 = at risk). Review of the resident's progress notes, showed on 6/9/19 at 1:37 P.M., Resident and family member asked questions about a pressure relief mattress for the resident's bed. Resident had reddened area to coccyx and complaints of soreness to the area. Review of the resident's electronic treatment administration record (eTAR), showed: -An order dated 6/9/19, to apply Allevyn every 3 days for redness to the coccyx; -Staff documented they applied the Allevyn on 6/9, 6/12, 6/15, and 6/18/19. On 6/18/19, Nurse A documented he/she administered the treatment at 9:00 A.M., but then documented on the eTAR at 2:35 P.M., that he/she was unable to put the Allevyn on the resident's coccyx due to the resident in pain and requested not to be moved; -No further documentation found that the Allevyn had been changed as ordered as late as 6/20/19 at 9:25 A.M. Observation on 6/20/19 at 7:30 A.M., showed the resident lay in bed, Certified Nurse Assistant (CNA) B provided the resident with care. CNA B removed the resident's slacks and adult incontinence brief and exposed the Allevyn dressing on the resident's coccyx dated 6/15/19, with staff initials. During an observation and interview on 6/20/19 at 7:53 A.M., the Assistant Director of Nursing (ADON) verified the Allevyn dressing was dated 6/15/19. She looked at the eTAR, said it was documented as last changed on 6/18/19, and she would expect staff to change the dressing as ordered to promote healing and prevent further skin breakdown. During an observation and interview on 6/20/19 at 9:25 A.M., showed the resident lay in bed. Nurse C said the resident does not normally refuse treatments and had not heard of him/her refusing care. Nurse C told the resident he/she was going to change the dressing, washed his/her hands, put on gloves, removed the old Allevyn dressing and revealed a reddish/purple colored area on the coccyx that measured approximately 5 centimeters (cm) long by 4 cm wide without any open areas. Nurse C verified the area was red without any open areas. Nurse C cleansed the area, applied, dated and initialed a new Allevyn dressing. During an interview on 6/20/19 at 9:45 A.M., the ADON said when she printed out the eTAR, she saw the note from the nurse dated 6/15/19, where the resident refused the Allevyn dressing change. She would expect staff to tell the oncoming shift if a treatment had not been done and the treatment should be done on the next shift or rescheduled. During an interview on 6/20/19 at 9:50 A.M., the resident denied ever refusing to have the Allevyn dressing changed, even when he/she was not feeling well, because the treatment provided cushioning and made his/her tailbone feel better. During an interview on 6/21/19 at 11:30 A.M., the Director of Nursing (DON) said she would expect staff to administer the Allevyn treatment as ordered to promote healing and prevent skin breakdown. If the resident refused the treatment due to being in pain, she would expect staff to administer pain medication and administer the treatment after the pain medication was effective. 2. Review of the Centers for Medicare and Medicaid services (CMS) State Operations Provider Certification, showed: -Definitions: Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the facility's assessing falls and their cause policy, revised 1/30/18, showed: -Purpose: To provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall; -Preparation: Review the resident's care plan to assess for any special needs of the resident and identify the resident's current medications and active medical conditions; -Steps: -If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities; -Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and document findings in the medical record; -Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility, any changes in level of responsiveness/consciousness and overall function and it will note the presence or absence of significant findings. Review of the facility's neurological evaluation policy, dated 7/1/18, showed: -Purpose: To provide guidelines for neurological assessment upon physician order, when following an unwitnessed fall, subsequent to a fall with a suspected head injury or when indicated by the resident condition. Review of Resident #38's medical record, showed: -Severe cognitive impairment; -Total staff assistance required with transfers; -[DIAGNOSES REDACTED]. -Experienced a fall one month and six months before admission. Review of the admission Morse fall scale assessment (rapid and simple method of assessing a resident's likelihood of falling), completed on 5/22/19, showed a total score of 25 (a low risk for falls). Review of the resident's progress notes, showed: -On 5/26/19 at 11:15 P.M., the resident found on the floor in his/her bedroom lying on his/her abdomen. Staff assessed the resident and assisted into the bed with a mechanical lift. Skin tear noted to the left elbow, the area cleaned and treatment applied. Nurse notified the resident's spouse and physician. The resident's bed placed in low position and wedge in place to prevent him/her from rolling out of the bed while sleeping. Review of the resident's Morse fall scale assessment, completed on 5/26/19, showed a total score of 75 (a high fall risk). Further review of the resident's progress notes, showed: -On 5/30/19 at 3:37 P.M., the resident found sitting next to the side of the bed. His/her bed noted to be in low position. Staff provided assessment and no injuries noted. Staff assisted him/her back into the bed; -On 6/9/19 at 5:48 P.M., the resident found on the floor by the aide. The aide reported the resident had been transferred to his/her wheelchair. Staff had left the resident's room and when staff returned to the room five minutes later, the resident had been found on the floor. The resident lay with his/her head toward the door and under the seat of his/her wheelchair. The resident unable to state or recall if he/she had hit his/her head. He/she received skin tears to the right finger and the back of the right forearm and the left thumb. Treatment applied to all areas. The resident's nurse practitioner notified. Review of the resident's neurological check flow sheet, dated 6/9/19, showed: -The checklist should be completed at baseline, every 15 minutes x 4 and every eight hours x 72 hours; -On 6/9/19 at 1:55 P.M., baseline assessment started and within normal limits; -15 minute scheduled assessments completed on 6/9/19 at 2:10 P.M., 2:25 P.M., 2:40 P.M., and 2:55 P.M., showed normal findings; -30 minute scheduled assessments completed on 6/9/19 at 3:25 P.M., within normal limits. Scheduled 30 minutes assessments at 3:55 P.M., and 4:55 P.M., noted as incomplete and blank; -At 7:55 P.M., showed assessment within normal limits; -An eight hour assessment, dated 6/10/19 at 6:00 A.M., as within normal limits; -No further neurological assessments found. Further review of the Morse fall scale assessment, dated 6/9/19 showed a total score of 35 (a low fall risk). Review of the resident's care plan, in use at the time of the survey and updated on 6/9/19, showed: -Problem: The resident is at risk for falls/injury related to cognitive impairment and behavior; -Goal: The resident will not sustain a fall related injury by utilizing fall precautions; -Interventions: Staff will remind and reinforce safety awareness, lock the brakes on the bed, the wheelchair and remind and educate the resident to request assistance for all ambulation and transfers, maintain the bed in the lowest position, use a wedge while in bed to prevent throwing his/her legs out of the bed related to a fall on 5/26/19 and place the resident in the common area when he/she is in the wheelchair related to a fall on 6/9/19; -No updated interventions or mention of the fall on 5/30/19. During an interview on 6/21/19 at 7:53 A.M., the DON said if a fall is unwitnessed, the staff should assume the resident could have hit their head and always complete neurological assessments for 72 hours post fall. The assessment is triggered in the resident's chart when the fall event is created and should be completed. Neurological assessments are very important to complete because the assessment is used to monitor for [MEDICAL CONDITION] and missed assessments could cause the staff to miss small changes in the resident.

Based on observation, interview and record review and based upon current professional standards of practice, the facility failed to follow facility policy and ensure catheter orders contained the [DIAGNOSES REDACTED].#273). The census was 121 with 51 residents in certified beds. Review of the facility's physician orders [REDACTED]. -Policy statement: Orders for medication and treatment will be consistent with principles of safe and effective order writing. All orders will be transcribed and followed as directed; -Recording Foley catheter (brand of indwelling urinary catheter, a flexible tube that is placed into the bladder to drain urine) orders: When recording orders for Foley catheters, specify the size of the catheter, size of the balloon (inflated to hold the catheter in the bladder) and [DIAGNOSES REDACTED]. Review of Resident #34's medical record, showed: -Readmitted to the facility on [DATE]; -Cognitively intact; -Extensive staff assistance required with hygiene, transfers, toileting and mobility; -admitted with indwelling urinary catheter; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 5/2/19, showed: -Problem: At risk for infection related to an indwelling urinary catheter; -Goal: The resident will remain free of urinary tract infection [MEDICAL CONDITION] during the period of catheterization; -Interventions: Change drainage bag per current policy, clean around catheter with soap and water, keep tubing below level of bladder and free of kinks or twists, record output per shift, report any sign of infection (temperature, pain, urine that looks cloudy, dark, or with blood), cover the Foley drainage bag with a dignity bag while in the bed and the wheelchair and encourage the resident to drink fluids on meal trays; -The care plan did not address the catheter use diagnoses. Review of the resident's readmission clinical note, dated 5/19/19 at 7:13 P.M., showed the resident readmitted to the facility from the hospital. Use 18 French (size) Foley catheter in place and draining clear, yellow urine. Review of the resident's electronic physician order [REDACTED]. The order did not specify the catheter size, no catheter use [DIAGNOSES REDACTED]. Review of the resident's (MONTH) 2019, treatment administration record, showed an order dated 5/27/19 to change the Foley catheter once monthly. The order did not specify the catheter size, [DIAGNOSES REDACTED]. Observation on 6/18/19 at 9:40 A.M., showed the resident with an indwelling urinary catheter draining to gravity. During an interview on 6/21/19 at 7:58 A.M., the Director of Nursing said all catheter orders should include the catheter size, [DIAGNOSES REDACTED]. It is the nurse's responsibility to clarify orders upon admission. It is important to verify that catheter orders are complete to ensure that the catheter is changed correctly and for the correct diagnosis.

Based on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to residents to prevent the development of pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility identified two residents with pressure ulcers. Both of those residents and one additional resident, identified as having a history of pressure ulcers, were chosen for the sample. Of those three, two did not receive appropriate care and services to aide in the healing or prevention of pressure ulcers (Residents #7 and #6). The sample was 14. The census was 117 with 55 residents in certified beds. 1. Review of Resident #7's quarterly review Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/6/18, showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Cognitively intact without any short or long term memory problems; -No behaviors; -Indwelling urinary catheter (tube inserted into the bladder for the purpose of draining urine); -One Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (moist dead tissue) may be present but does not obscure the depth of tissue loss. (MONTH) include undermining (wound open underneath the border of the wound) or tunneling) facility acquired pressure ulcer and one unstageable pressure (dead tissue is present, the actual base and condition of the ulcer cannot be determined) ulcer; -Required maximum assistance from the staff for transfers, dressing and bathing. Review of the resident's care plan, dated 11/14/16 and in use at the time of the survey, showed: -Problem: Skin integrity: -Goal: Encourage to follow best practices to heal skin wounds; -Interventions: Encourage to wear heel protectors at all times. Encourage to change position and assist if allowed; -Problem: Extensive assistance required with bathing, hygiene, dressing and grooming related to disease process: -Goal: Will be odor free, dressed and out of bed daily as tolerated; -Interventions: Examine feet and trim nails. Total assist with dressing and undressing; -No problem, goals or interventions regarding the resident's pressure ulcers. Review of the resident's physician order [REDACTED]. -An order dated 1/23/17, to elevate bilateral lower extremities when sitting; -An order dated 5/16/17, for skin assessment weekly; -An order dated 5/23/18, to cleanse all wound dressings on Tuesday, Thursday and Saturday. Cleanse area with soap and water, pat dry, Xeroform gauze (a non-adherent and has antiseptic and antibacterial qualities that help keep wounds from becoming infected) and dry dressing wrap for bilateral feet/legs as such: Use 4 inch ace wrap from base of toes to above ankle, use 6 inch ace from ankles to knees. Use 1/3 stretch and 1/3 overlay; -An order dated 5/25/18, consult wound care; Review of the facility's weekly wound report, from 2/1/18 through 6/5/18, showed the resident listed as having wounds. No documentation, assessment or staging of the resident's right great toe, right fifth toe, right heel, left heel, left fifth toe, right outer foot or right inner foot pressure ulcers. Review of the resident's mobile wound clinic notes, dated 4/17/18, showed: -Wound location, fifth right metatarsal head (tip of toe). Pressure ulcer stage III. Measurement of 3.5 centimeters (cm) long by 2.5 cm wide by 0.5 cm deep; -Wound location, right heel lateral (side). Pressure ulcer unstageable. Measurement of 2.4 cm long by 1.3 cm wide by 0.1 cm deep; -Wound location, left heel plantar (bottom end). Pressure ulcer stage III. Measurement of 8 cm long by 11 cm wide by 0.1 cm deep. Review of the resident's wound clinic physician progress notes [REDACTED]. -Wound #2 - right metatarsal head of fifth toe is a chronic Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure injury pressure ulcer. Measurement of 1.7 cm long by 2.8 cm wide by 0.1 cm deep. Undermining noted at 9 o'clock (location based on the face of a clock) with a maximum distance of 2.5 cm. There is additional undermining at 12 o'clock with a maximum distance of 1 cm. There is a large amount of yellow drainage noted which has no odor. Wound bed has 76% to 100% slough. The wound is deteriorating; -Wound #3 - right heel is a chronic unstageable pressure injury obscured full-thickness skin and tissue loss. Measurement of 1.5 cm long by 3 cm wide by 0.1 cm deep. No drainage noted. Wound bed has 76% to 100% eschar (black, hard, dead tissue). The wound is deteriorating; -Wound #8 - left heel is a chronic Stage IV pressure injury pressure ulcer. Measurement of 8 cm long by 9 cm wide by 0.1 cm deep. No drainage noted. Wound bed has 1% to 25% slough, 1% to 25% granulation (new tissue growth) and 26% to 50% eschar. The wound is deteriorating; -Wound #12 - right, proximal, lateral foot (outer side of foot) is an acute Stage IV pressure injury pressure ulcer. Initial wound encounter measurement of 0.6 cm long by 0.5 cm wide by 1 cm deep. There is a copious (large amount) amount of yellow drainage noted. Wound bed has 76% to 100% slough; -Wound #13 - Right dorsal foot (inner side of foot) is an acute Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as a blister) pressure injury pressure ulcer. Initial wound encounter measurement of 2 cm long by 3 cm wide by 0.1 cm deep. There is a small amount of fresh blood drainage noted. Wound bed has 76% to 100% granulation; -Plan: Cleanse all wounds with mild soap and water, apply Xeroform gauze, secure with gauze wrap on Monday, Wednesday and Friday; -Keep weight off affected areas at all times. Pillow under right leg to keep heel off any underlying support surface. Dense pillow (e.g. memory foam) and dense wedge to support left knee and calf to keep left heel completely off the bed/floor at all times; -Return to wound clinic in 2 weeks. Observation on 5/31/18 at 8:35 A.M., at 10:54 A.M., and at 2:45 P.M., showed the resident sat on the side of his/her bed with his/her bandaged feet directly on the floor. The resident's bilateral heels were directly on the floor without any type of pillow, folded blankets, or heel protectors to try and off-load the pressure to his/her heels and feet. Observation on 6/1/18 at 6:56 A.M. and at 12:05 P.M., showed the resident sat on the side of his/her bed with his/her bandaged feet directly on the floor. The resident's bilateral heels were directly on the floor without any type of pillow, folded blanket or heel protectors to try to off-load the pressure to his/her heels and feet. Observation on 6/4/18 at 6:35 A.M., showed the resident sat on the side of his/her bed with his/her bandaged feet directly on the floor. The resident's bilateral heels directly on the floor without any type of pillow, folded blanket or heel protectors to try to off-load the pressure to his/her heels and feet. During an interview on 6/4/18 at 6:35 A.M., the Director of Nurses (DON) looked at the resident's bandaged feet directly on the floor and said it is never appropriate due to infection control issues and not aiding in the healing of the pressure ulcers. If the resident wants to sit on side of bed with feet on the floor, staff should place some type of barrier under his/her feet so that they are not directly on the floor. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Brief interview of mental status (BIMS) score, 12 out of 15 (indicates moderately impaired cognition); -No pressure ulcers or wounds marked; -Required maximum assistance from the staff for transfers, dressing, hygiene and bathing. Review of the resident's electronic POS, in use during the survey, showed: -An order dated 2/27/18, if right heel wound dressing falls off or is soiled, please cleanse with normal saline, pat dry and cover with Xeroform as needed daily; -An order dated 3/31/18, float heels - use heel protectors. The order did not specify when or how often to float heels or use heel protectors; -No further orders regarding the right heel pressure ulcer. Review of the resident's nurses notes, dated 5/21/18 at 11:58 A.M., showed right heel treatment discontinued by wound nurse. Wound healed. Review of the resident's weekly wound report, showed: -On 5/21/18 - right heel callous area measured 0 cm by 0 cm by 0 cm. Callous area re-evaluated today by the wound management company's nurse practitioner (NP). NP states alright to leave open to air and will see next week and remove callous. Healing; -On 5/28/18 - right heel callous area measured 0 cm by 0 cm by 0 cm. Callous remains to heel. NP here to see but resident eating lunch. Will re-evaluate next week. Continue to leave open to air. Healing. Observation on 5/31/18 at 5:30 P.M., showed the resident sat in his/her wheelchair in the division dining room with regular socks and tennis shoes on both feet. Observation on 6/1/18 at 6:30 A.M., showed the resident lay in bed on his/her back without any type of heel protectors on or heels floated. His/her heels sank directly into the mattress. At 6/1/18 at 8:12 A.M., Certified Nurse Assistants (CNAs) A and B provide care. CNA A removed the resident's covers and revealed a yellow/brown colored calloused area on the resident's right heel that measured approximately 0.5 cm long by 1 cm wide. CNA A put regular socks and tennis shoes on the resident's feet. Both CNAs dressed and transferred the resident into his/her wheelchair using a stand up lift (mechanical lift). Observation on 6/4/18 at 6:45 A.M., showed the resident lay in bed on his/her back without any type of heel protectors on or heels floated. Both of his/her heels lay directly on the mattress. During an interview on 6/4/18 at 6:50 A.M., Nurse C said the resident's heel pressure ulcer is healed. The treatment had been discontinued and they could put a boot on him/her at night if needed. They are not doing any type of treatment at this time. The wound nurse would check on his/her heel when he/she came to the facility. Further review of the resident's electronic POS, showed an order dated 6/4/18 at 7:17 A.M., to apply boot as needed at bedtime. The order did not specify what type of boot. Observation on 6/4/18 at 1:40 P.M., showed the resident lay in bed with a prevalon boot (soft boot that helps keep pressure off of foot) on his/her right foot. The Assistant Director of Nurses (ADON) and the wound clinic NP went into room, washed their hands and put on gloves. The ADON removed the prevalon boot from the resident's right foot and revealed a yellow brown colored, moist callous on his/her right heel. The wound clinic NP verified the moisture, scraped off the callous with a special tool and revealed a small open area. The NP measured the area and said it measured 0.2 cm long by 0.2 cm wide by 0.2 cm deep. The NP cleansed the area with normal saline, applied Xeroform and a folded 4 by 4 gauze to the area and secured it with tape. During an interview, the NP said the standard practice is to float the heels after first healed to ensure the area does not break down again. It would never be appropriate to put regular shoes on him/her as that would aggravate the newly healed tissue. Further review of the resident's electronic POS, showed: -An order dated 6/4/18, to cleanse the right heel pressure ulcer with normal saline, pat dry, apply xeroform and cover with dry dressing daily and as needed; -An order dated 6/4/18, for heel protectors at all times. 3. During an interview on 6/5/18 at 8:37 A.M., the DON said she would expect staff to follow physician orders. If a physician writes an order for [REDACTED].#7. The assessments just stopped. 4. Review of the facility's Pressure Ulcer Treatment policy, dated 1/10/18, showed: -Purpose: To provide guidelines for the care of existing pressure injuries and the prevention of additional pressure injuries; -Stage III protocol: Protect, fill dead space including tunnels and undermining, manage drainage, promote moist wound healing and choose primary dressing; -Stage IV protocol: Protect, debride (remove) slough/eschar (dry dead tissue), manage pain; -No protocol for an unstageable wound; -No definitions or descriptions of the different pressure injury stages; -No guidance on how frequently to assess, measure and/or monitor the wound.

Based on interview and record review, the facility failed to obtain a physician orders [REDACTED].#30 and #43). The census was 117 with 55 residents in certified beds. Review of the facility's Advance Directives Policy, dated 10/26/15, and revised on 1/31/18, showed: -Prior to or upon admission of a resident to the community, the Social Services Director or designee will provide written information to the resident concerning their right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives; -The Interdisciplinary Team will review annually with the resident their advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record; -The Director of Nursing Services (DON) or designee will notify the physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 1. Review of Resident #30's electronic medical record, showed: -An electronic admission face sheet, with an admission date of [DATE]; -An electronic signed code status form, dated 2/23/18, with a code status for full code (all lifesaving methods are performed); -An electronic signed code status form, dated 5/3/18, of do not resuscitate (DNR, no lifesaving methods are performed). Review of the resident's electronic physician order [REDACTED]. During an interview on 6/5/18 at 11:00 A.M., the Director of Nurses (DON) verified the resident's code status form dated 5/3/18, which showed code status of DNR. She expected there to be a physician's orders [REDACTED]. 2. Review of Resident #43's electronic medical record, showed: -An electronic admission face sheet, showed admission date of [DATE]; -An electronic signed code status form, dated 9/15/16, showed code status of DNR; -An electronic POS, in use during the survey, showed no order for a code status. During an interview on 6/4/18 at 1:00 P.M., the DON said she could not find the order for the resident's code status on the electronic POS. She thought the order got dropped off the POS when the resident switched from a different pharmacy to the current pharmacy. The POS should include a dated order for the appropriate code status. 3. During an interview on 6/5/18 at 8:37 A.M., the DON said the advance directive is completed upon admission and is reviewed quarterly during the care plan meeting. The facility's policy is to make sure it is prominently displayed in the resident's medical record. The resident's code status are checked daily on the electronic admission face sheet. The resident's code status shows up on the POS and the advance directive for the physician to sign. The DON said the resident's code status on the advance directive and code status on the POS, should always match.

Based on observation, interview and record review, the facility failed to maintain proper placement of indwelling urinary catheters (a tube inserted into the bladder for purpose of continual urine drainage). The facility identified four residents as having indwelling urinary catheters. Of those four, two were chosen for the sample. Of those two, problems were found with the positioning of the catheter tubing for both (Residents #7 and #49). The sample was 14. The census was 117 with 55 residents in certified beds. Review of the facility's Urinary Catheter Care policy, dated 12/15/17, showed: -Purpose: To prevent catheter-associated urinary tract infections [MEDICAL CONDITION]; -Maintain unobstructed urine flow; -Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks; -The urinary collection drainage bag must be held or positioned lower than the resident's bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; -Ensure the catheter tubing and collection drainage bag are kept off the floor. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/6/18, showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Cognitively intact without any short or long term memory problems; -Indwelling urinary catheter. Review of the resident's electronic physician order [REDACTED]. -An order dated 2/23/18, to provide catheter care as needed; -An order dated 4/24/18, to measure catheter output every shift; -An order dated 5/27/18, to change the indwelling urinary catheter every 30 days and as needed and to insert a #14 French (size) urinary catheter. Review of the resident's care plan, dated 11/14/16 and in use during the survey, showed: -Indwelling catheter due to [MEDICAL CONDITION] bladder (the bladder does not empty properly due to a neurological condition) with [MEDICAL CONDITION]; -A goal for the resident to remain free of a UTI; -Interventions included to keep tubing below level of bladder and free of kinks or twist. Monitor for signs and symptoms of UTI - fever, chills, pain/burning with urination, cloudy/foul smelling urine, bloody urine, lower abdominal and/or flank pain, change in cognition. Notify physician if occurring. Record output every shift. Cover drainage bag with dignity bag. Observation on 5/31/18 at 8:35 A.M., at 10:54 A.M., and at 2:45 P.M., showed the resident sat on the side of his/her bed with his/her feet directly on the floor. The indwelling urinary catheter tubing draped down the side of his/her leg with approximately 6 inches of the tubing directly on the floor. The bottom approximate 6 inches of the indwelling urinary catheter collection bag sat directly on the floor without any type of privacy bag or barrier between the floor, tubing, or the collection bag. The tubing and the collection bag contained a clear, yellow urine. A blue, plastic privacy bag hung on the rail at the bottom of his/her bed. Observation on 6/1/18 at 6:56 A.M. and at 12:05 P.M., showed the resident sat on the side of his/her bed with his/her feet directly on the floor. The bottom approximate 6 inches of the indwelling urinary catheter collection bag sat directly on the floor without any type of privacy bag or barrier between the floor and the collection bag. The collection bag contained a clear, yellow urine. A blue, plastic privacy bag hung on the rail at the bottom of his/her bed. Observation on 6/4/18 at 6:35 A.M., showed the resident sat on the side of his/her bed with his/her feet directly on the floor. The indwelling urinary catheter tubing hung down the side of his/her leg with approximately 12 inches of the tubing directly on the floor, and looped back up approximately 18 inches and into the collection bag. There was no urine in the last approximate 6 inches of the tubing where it went into the collection bag. The tubing contained a clear, yellow urine. The bottom approximate 6 inches of the indwelling urinary catheter collection bag sat directly on the floor without any type of privacy bag or barrier between the floor, the tubing, or the collection bag. A blue, plastic privacy bag hung on the rail at the bottom of his/her bed. During an interview on 6/4/18 at 6:35 A.M., the Director of Nurses (DON) looked at the catheter tubing and collection bag and said it was never appropriate due to infection control issues. The catheter tubing was not able to drain and this may result in a possibility of UTIs. The collection bag should be in the blue, plastic privacy bag. The tubing should be positioned to allow for gravity drainage from the resident's bladder directly into the collection bag. 2. Review of Resident #49's admission MDS, dated [DATE], showed: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Indwelling urinary catheter. Review of the resident's electronic care plan, dated 5/15/18 and in use during the survey, showed: -Problem: Resident has an indwelling urinary catheter; -Interventions: Staff to cover the urinary catheter drainage bag with privacy bag, keep the catheter tubing free from kinks or twists and monitor the resident for signs of urinary tract infections; -Goal: Resident will remain free of UTI. Review of the resident's electronic POS, dated (MONTH) (YEAR), showed: -An order dated 5/1/18, to clean catheter site as needed (PRN); -An order dated 5/13/18, to administer Bactrim (antibiotic) double strength (DS), one tablet by mouth twice daily (BID) for seven days for [DIAGNOSES REDACTED].>-An order dated 6/1/18, to change urinary catheter every 30 days with 16 French catheter. Review of the laboratory section of the electronic medical record, showed a urinalysis (UA, laboratory test of urine used to aid in the [DIAGNOSES REDACTED]. Observation of the resident during the survey, showed: -On 5/31/18 at 11:38 A.M., he/she sat in the wheelchair. The catheter tubing looped down and back up approximately 12 inches towards the resident's bladder. The catheter tubing contained dark, cloudy yellow colored urine; -On 6/1/18 at 12:25 P.M., he/she sat in the wheelchair. The catheter tubing looped down and back up approximately 12 to 16 inches towards the resident's bladder. The catheter tubing contained cloudy, yellow colored urine with sediment (debris); -On 6/4/18 at 8:15 A.M., he/she sat in the wheelchair. The catheter tubing looped down and back up approximately 16 to 20 inches towards the bladder with cloudy, yellow colored urine in the tubing. No urine in the catheter tubing drained from the tubing into the collection drainage bag; -On 6/5/18 at 7:30 A.M., he/she lay in the bed. The catheter tubing looped down and back up approximately 12 inches towards the resident's bladder. The catheter tubing contained cloudy, yellow colored urine with sediment. 3. During an interview on 6/5/18 at 8:37 A.M., the Director of Nurses (DON) said the catheter tubing should not be looped down, back up towards the resident's bladder, kinked and/or on the floor due to infection control purposes. The catheter tubing and collection drainage bag should be kept below the resident's bladder at all times to ensure urine does not flow back up towards the resident's bladder. The charge nurses are responsible to ensure correct positioning of the resident's catheter tubing/drainage bag. The collection drainage bag should be maintained in a dignity/privacy bag when the resident is out of the room. The privacy bag would be used as a barrier if the collection drainage bag was on the floor.

Based on interview and record review, the facility failed to maintain completed inventory sheets of the resident's personal property for seven of 14 sampled residents (Residents #1, #4, #6, #7, #11, #13 and #14), which included two closed records. The total census was 119 with 53 residents in certified beds. 1. Review of Resident #1's medical record, showed the following: -A current admission face sheet, showed admission date of [DATE] and readmission date of [DATE], with [DIAGNOSES REDACTED]. -No completed inventory sheet found in the medical record. 2. Review of Resident #4's medical record, showed the following: -A current admission face sheet, showed admitted d of 5/3/17 with [DIAGNOSES REDACTED]. -No completed inventory sheet found in the medical record. 3. Review of Resident #6's medical record, showed the following: -A current admission face sheet, showed an admission date of [DATE]; -discharged to home on 5/24/17; -No completed inventory sheet found in the medical record. 4. Review of Resident #7's medical record, showed the following: -A current admission face sheet, showed admitted d of 3/8/14 with [DIAGNOSES REDACTED]. -No completed inventory sheet found in the medical record. 5. Review of Resident #11's medical record, showed the following: -A current admission face sheet, showed admitted d of 9/1/15 with [DIAGNOSES REDACTED]. -No completed inventory sheet found in the medical record. 6. Review of Resident #13's closed medical record, showed the following: -An admission face sheet, showed an admission date of [DATE]; -discharged to a local hospital on [DATE]; -No completed inventory sheet found in the medical record. 7. Review of Resident #14's closed medical record, showed the following: -A current admission face sheet, showed admission date of [DATE] and discharged [DATE], with [DIAGNOSES REDACTED]. -No completed inventory sheet found in the medical record. 8. During an interview on 5/25/17 at 8:55 A.M., the Director of Nurses said inventory sheets are in the admission packet. When a resident is admitted , the certified nurse aide gives the inventory sheet to the family to complete, the family gives the completed inventory sheet back to the nursing staff and it should be filed in the resident's medical record. The administrator said sometimes the resident's family takes the inventory sheets home to complete and never brings the completed inventory sheet back to the facility. She does not think there is a system in place to make sure the inventory sheets are completed and filed in the resident's medical record.

Based observation and interview, the facility failed to store food appropriately by not covering cooked food when in the refrigerator and freezer for four out of four days of observation. The facility also failed to close an open container of flour. The facility census was 119 with 53 in certified beds. 1. Observation of the walk-in refrigerator, showed -On 5/22/17 at 12:35 P.M.: -Uncovered metal pan of peas; -Uncovered metal pan of broccoli; -Uncovered metal pan of squash; -Wrapped metal pan of chicken without a date; -On 5/24/17 at 11:00 A.M., an uncovered cart with 17 trays of cooked baby back ribs. 2. Observation of the kitchen at 5/23/17 at 6:20 A.M., 7:05 A.M. and 7:35 A.M., showed a large open and uncovered container of flour underneath the preparation table. 3. Observation of the walk-in freezer on 5/23/17 at 12:15 P.M., showed the following: -Uncovered metal pan of meat; -Opened box of turkey patties. 4. During an interview on 5/25/17 at 10:00 A.M., the director of dining services said he would expect all food inside the refrigerator and freezer to be covered and labeled at all times. He would expect all staff to cover the entire cart of food. Staff are expected to keep the lids closed on the container of flour at all times when it is not in use.

Based on observation, interview and record review, the facility failed to keep the kitchen floor clean, under and around the preparation counters, convection oven, tilt skillet, grill, stove, deep fat fryers, shelving units, two-compartment sink and refrigerators and freezers, on four of four days of the survey. The census was 108 with 41 in certified beds. Observation of the kitchen on 3/28/16 at 8:26 A.M. and 2:43 P.M., 3/29/16 at 12:54 P.M., 3/30/16 at 6:20 A.M. and 10:53 A.M., and 4/1/16 at 7:07 A.M., showed the following: -The floor was dull and streaked; -Crumbs, dirt and debris under and around the vegetable, meat and dessert preparation counters, convection oven, tilt skillet, grill, stove, deep fat fryers, shelving units, refrigerators and freezers and two-compartment sink; -At least five quarter-sized brown stains on the floor in front of the grill and six-burner stove. During an interview on 4/1/16 at 9:30 A.M., the dietary manager (DM) said it was the responsibility of the dishwashers to sweep and mop the entire kitchen floor daily. They were currently short a dishwasher but other staff had been stepping in to help. Review of a copy of the daily dishwasher responsibility checklist, dated March and April 2016, showed to sweep and mop kitchen, including under tables, checked as done every day. The weekly dishwasher responsibility checklist showed floor was to be scrubbed weekly. During an interview on 4/1/16 at 9:30 A.M., the DM said staff were following the cleaning checklist but could do a better job.

Based on observation, interview and record review, the facility failed to ensure all physician's orders were followed by not obtaining weights, applying protective devices and administering supplements as ordered for seven of 10 sampled residents (Residents #5, #6, #9, #10, #3, #11 and #1). The census was 108 with 41 in certified beds. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 3/1/16, showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Alert and oriented; -Required extensive assistance from staff for bed mobility, transfers, dressing and hygiene; -Gastrostomy ([DEVICE], a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications); -Admission weight of 133 pounds (lbs) without weight loss; -Incontinent of bowel and bladder; -Risk for pressure ulcer. Review of the resident's physician's order sheet (POS), dated 3/1 through 31/16, showed the following: -An order dated 3/3/16, to apply a podus boot (device worn to prevent skin breakdown and/or pressure ulcers) to the left heel; -An order dated 3/4/16, to obtain daily weights; -No order to discontinue daily weights; -No order to discontinue the podus boot until 3/31/16. Review of the resident's weight record, showed no weights documented on 3/11, 3/12, 3/22, 3/26 and 3/28/16. Observation during the survey, showed the following: -On 3/28/16 at 12:00 P.M., the resident lay in bed without a podus boot on his/her left foot; -On 3/29/16 at 7:15 A.M. and 1:25 P.M., the resident lay in bed without a podus boot on his/her left foot. The resident said he/she had not worn the boot for sometime, it was uncomfortable to wear when he/she was in bed and it was in the closet. Observation showed the podus boot was on the top shelf in the closet; -On 3/30/16 at 9:25 A.M., the resident ambulated to the dining room without a podus boot on his/her left foot; -On 3/30/16 at 1:00 P.M., the resident lay in bed without a podus boot on his/her left foot. During an interview on 3/29/16 at 1:30 P.M., the Director of Nurses (DON) said the certified nurse aides (CNAs) were responsible for applying the resident's podus boot and the charge nurses were responsible for ensuring the resident's podus boot was applied. She expected nursing staff to document if the resident was refusing to wear the podus boot and obtain an order to discontinue the boot. 2. Review of Resident #6's admission POS, dated 2/29/16 and 3/1 through 31/16, showed the following: -[DIAGNOSES REDACTED]. -An order dated 2/29/16, to obtain daily weights; -An order dated 3/1/16, to apply bilateral heel protectors (device worn to prevent skin breakdown and/or pressure ulcers); -No order to discontinue the daily weights and/or heel protectors. Review of the resident's weight record, showed no weights documented on 3/15, 3/17 through 3/22 and 3/26/16. Observations during the survey, showed the following: -On 3/28/16 at 12:10 P.M., the resident lay in bed without heel protectors on his/her feet; -On 3/29/16 at 8:00 A.M. and 12:50 P.M., the resident sat in a wheelchair without heel protectors on his/her feet; -On 3/30/16 at 6:30 A.M. and 9:25 A.M., the resident lay in bed with both feet uncovered an no heel protectors on his/her feet. The resident said he/she generally wore the heel protectors at night, but not during the day; -On 3/30/16 at 1:00 P.M., the resident sat in a wheelchair with no heel protectors on his/her feet. During an interview on 3/30/16 at 1:30 P.M., the DON said the CNAs were responsible for applying the resident's heel protectors and the charge nurses were responsible for ensuring the heel protectors were applied as ordered. 3. Review of Resident #9's medical record, showed the following: -admitted on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's physician's orders, dated 3/24/16, showed the following: -Daily weights; -Weigh one time during the day; -Document weight. Observation on 3/30/16 at 10:05 A.M., showed CNA A transported the resident to the scale to be weighed. During an interview on 3/30/16 at 10:05 A.M., CNA A said he/she was not aware daily weights were ordered for the resident. The CNA believed the resident had been weighed since admission. The unit had a weight book for staff to documented resident weights. If all seven days of the week were highlighted, under a resident's name, the resident was to be weighed daily. CNA A said he/she looked at the weight book every day, and did not believe the resident was highlighted for daily weights. He/she believed it was just highlighted earlier in the day. Review of the unit's weight book on 3/30/15, showed the following: -On 3/26/16, the resident weighed 165.8 lbs; -All seven days of the week were highlighted under the resident's name; -No further weights were documented. 4. Review of Resident #10's medical record, showed the following: -A face sheet, showed an admission date of [DATE], with [DIAGNOSES REDACTED]. -POS dated 3/17 through 31/16, showed an order dated 3/17/16, to obtain daily weights. Review of the resident's weight record, showed no weights documented on 3/18, 3/21, 3/22 and 3/26/16. 5. Review of Resident #3's initial MDS, dated [DATE], showed the following: -admitted from a local hospital on [DATE]; -[DIAGNOSES REDACTED]. -Alert and oriented to person, place and time; -Required maximum staff assistance for transfers, dressing, hygiene and bathing. Review of the resident's POS, dated 3/1 through 31/16, showed the following: -An order dated 2/18/16, to obtain a daily weight for three days and then weekly; -An order dated 3/21/16, to obtain weekly weights. Review of the resident's weight record, showed no weights documented on 2/19 through 21/16. 6. Review of Resident #11's face sheet, showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's POS, dated 3/25 through 31/16, showed an order dated 3/25/16, to obtain a daily weight for one week. Review of the resident's weight record, showed no weights documented on 3/26 and 29/16. 7. During an interview on 3/30/16 at 1:30 P.M., the DON said upon admission a resident's weight was taken daily for three days and then weekly, unless ordered by the physician. The CNAs were responsible for obtaining and recording the daily weights, and were overseen by the nurses. The nurses kept a board to document the weights and they should be documented in the computer. 8. Review of Resident #1's admission MDS, dated [DATE], showed the following: -Short and long term memory problems; -Extensive assistance required for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Lower extremity impairment on one side; -Frequently incontinent of bladder and incontinent of bowel; -Weight, 126 lbs; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 2/10/16 and in use at the time of the survey, showed the following: -Problem-resident is not concerned about weight status; -Goal-to have good nutrition and adequate fluids while maintaining weight between 140 and 150 lbs; -Approach-monitor weight weekly and report any significant changes to the physician, the registered dietician (RD) will monitor labs, weights, skin and should make any needed recommendations. Review of the resident's weekly weights, for March 2016, showed the following; -3/6/16, 126.8 lbs; -3/13/16, 121 lbs; -3/20/16, 119 lbs; -3/29/16, 121.4 lbs. Review of the resident's dietary note, dated 3/19/16, showed acute weight loss over the past two weeks, no supplements at this time, body mass index within normal limits, following weekly. Review of a fax sheet to the resident's physician, dated 3/23/16, showed the following: -The family requested a hospice evaluation; -Weight down to 119 lbs, supplement three times daily. Further review of the resident's medical record, showed the physician ordered the hospice evaluation, but no documentation about adding a supplement three times daily. During an interview on 3/30/16 at 1:30 P.M, the DON said the RD could write orders for supplements when needed. During an interview on 4/1/16 at 9:00 A.M., the administrator said Nurse B sent the fax to the physician regarding the hospice evaluation and supplement. Nurse B spoke with the physician regarding adding the supplement at the time the order for a hospice evaluation was received, the physician agreed and she thought the nurse wrote the order. No order to add a supplement three times daily was found. 9. During an interview on 3/30/16 at 1:30 P.M., the DON said she expected staff to follow physician's orders and she could not find any further documentation to show resident weights were being obtained as ordered.

Based on observation, interview and record review, the facility failed to ensure staff wore facial hair restraints, prepared pureed sausage according to the recipe and ensure the ice machine had a proper air gap, for four of four days of the survey. These deficient practices had the potential to affect all residents. The census was 108 with 41 in certified beds. 1. Observation of the care center kitchenette, on 3/28/16 at 12:22 P.M., showed the following: -A facility sous chef with a thick, full uncovered beard approximately 1/2 inch to 3/4 inch long, stood in the kitchenette, removed two pieces of cooked meat from the oven, placed them in a blender, walked throughout the kitchenette, returned to the blender, poured in a can of soup and turned the blender on. 2. Observation of the main kitchen, on 3/28/16 at 12:54 P.M., showed the following: -Two male dietary aide's moved about the kitchen and behind preparation counters. Facial hair restraints covered their beards but did not cover their approximately 1/8 inch long moustaches. 3. Observation of the main kitchen, on 3/30/16, showed the following: -At 6:42 A.M., Cook C stood at the preparation counter and pureed sausage links and no facial hair restraint covered his approximately 1/8 inch long moustache; -At 10:45 A.M., Cook C placed a tray of garlic bread slices in the oven and did not wear a facial hair restraint over his moustache; a dietary aide stood at the meat preparation counter, chopped boiled eggs for egg salad and no facial hair restraint covered his approximately 1/8 inch long moustache; a dietary aide stood at the dessert preparation counter, sliced strawberries and no facial hair restraint covered his approximately 1/8 to 1/4 inch long moustache; Dietary aide (DA) D carried covered items to the hot cart and placed them inside, then carried an uncovered pan of red sauce, placed it on the counter and no facial hair restraint covered his approximately 1/8 inch long moustache. 4. Observation of the kitchen on 3/30/16 at 10:53 A.M., showed Cook C stood at the preparation counter and said he was going to make 6 servings of pureed sausage links and two links equaled one serving. He placed 12 cooked sausage links in the blender, added three more and said he was going to make a little extra in case someone wanted another serving. Using a 3 oz. scoop, Cook C placed six scoops of applesauce into the blender, turned it on and blended until the mixture was smooth. The mixture was tangy and tasted strongly of apple, with some sausage flavor. Review of the facility's guidelines for making pureed meat, showed for every 3 oz. serving of meat, add one ounce of meat broth slurry (thin paste of liquid and starch used as a thickener). A copy of the guidelines hung over the preparation counter in front of the stove. 5. Observation of the kitchen on 3/28/16 at 8:26 A.M. and 2:43 P.M., 3/29/16 at 12:54 P.M., 3/30/16 at 6:20 A.M. and 10:53 A.M., and 4/1/16 at 7:07 A.M., showed a white pipe extended from the back of the ice machine and lay directly on top of a drain cover, with no air gap. 6. During an interview on 4/1/16 at 9:30 A.M., the dietary manager said if facial hair was longer than 1/4 inch, it should be covered with a hair restraint. Moustaches should be covered also. He expected the guidelines for making puree meat to be followed. Applesauce was okay to use but should be added in the appropriate proportions. He was aware the ice machine should have an air gap to prevent contamination should there be a back-up and would would have it taken care of by the maintenance department.

Based on observation, interview and record review, the facility failed to obtain orders for peripherally inserted central catheter line (PICC line, a tube/catheter inserted into a vein for medication administration) care, obtain laboratory tests and daily weights as ordered and did not schedule a follow-up visit with physician. In addition, the facility did not clarify physician orders [REDACTED].#1, #6, #8, #7, #9, #5 and #4). The total census was 108 with 40 residents in certified beds. 1. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 5/21/15, showed the following: -Alert and oriented; -[DIAGNOSES REDACTED]. -Required limited to extensive assistance from staff for activities of daily living (ADLs); -Incontinent of bowel and bladder; Review of the resident's physician's orders [REDACTED]. -An order dated 4/30/15, to apply geri-sleeves to both arms daily; -An order dated 6/16/15, for 1200 cubic centimeters (cc) fluid restriction per day. Review of the resident's progress notes, showed the following: -On 6/16/15 at 10:05 P.M., staff documented the resident's physician was contacted regarding laboratory test results for basic metabolic panel (BMP, blood test that measures glucose level, electrolyte and fluid balance and kidney function). Staff documented the resident's sodium level 129 low (normal range 136-145) and received an order for [REDACTED].>-On 6/19/15 at 5:33 P.M., staff documented the resident's physician made aware of the BMP test result with a sodium level of 131. Staff documented an order was received to continue 1200 cc fluid restriction per day and obtain a BMP on 6/29/15. Review of the resident's intake and output (I&O) record dated 6/1 through 6/26/15, showed the following: -From 6/16/ through 6/26/15, staff left the dated space blank for the daily intake of fluids and documented total daily intake of fluids as zero. Review of the resident's treatment administration record (TAR) dated 6/1 through 6/30/15, showed the following: -An order dated 6/16/15, for 1200 cc fluid restriction per day (scheduled time for day, evening and night shift); -On 6/16/15, staff did not initial the dated space for evening and night shift and did not document the amount of intake for fluids on each shift; -From 6/17 through 6/26/15, staff initialed the dated space for day, evening and night shift and provided no documentation for the amount of intake of fluids for each shift. Review of the resident's Medication Administration Record [REDACTED] -No order for 1200 cc fluid restriction per day; -From 6/16 through 6/26/15, staff did not provide documentation for amount of fluids administered with medications for day, evening and night shift. Observation of the resident during the survey, showed the following: -On 6/24/15 at 1:45 P.M. and 3:00 P.M., the resident sat in the recliner without wearing geri-sleeves on his/her arms exposing multiple, fading purple bruises. The resident had one, full 8 ounce cup of water on the bedside table next to his/her recliner; -On 6/25/15 at 8:30 A.M., the resident sat in his/her wheelchair in the dining room without wearing geri-sleeves on his/her arms. Staff served the resident a regular diet with one large glass of water (280 cc) and one cup of coffee (240 cc). The resident drank all of the coffee and drank a few sips of water; -On 6/25/15 at 5:10 P.M., the resident sat in his/her wheelchair in the dining room without wearing geri-sleeves on his/her arms exposing multiple, fading purple bruises on each arm. Staff served the resident a regular diet with one large glass of water (280 cc). At 5:15 P.M., observation of the resident's room, showed a 240 cc Styrofoam cup of water on the bedside table next to the resident's recliner; -On 6/26/15 at 6:00 A.M., the resident had on a short sleeve shirt without geri-sleeves on his/her arms. Certified Nurse Aide (CNA) I assisted the resident from the bathroom to the bed. In the resident's room a styrofoam cup with approximately 120 cc of water sat on the bedside table. The CNA offered the resident a drink of water and handed the cup of water to the resident. The resident drank a few sips. The CNA said most of the resident's do not have water pitchers in their rooms and each shift provides the resident's with a cup of water. The resident's cup of water was dated 6/25/15 for the night shift; -On 6/26/15 at 11:45 A.M., the resident sat in his/her recliner without wearing geri-sleeves on his/her arms; -On 6/29/15 at 8:00 A.M., the resident sat in his/her wheelchair in the dining room. Staff served the resident a regular diet with one cup of coffee (240 cc). During an interview on 6/26/15 at 12:05 P.M., the Director of Nurses (DON) said charge nurses are responsible for taking off the physician's orders [REDACTED]. She said the nursing staff should notify the dietary department regarding the order for the fluid restriction. She expected the CNAs and charge nurses to enter the resident's fluid intake on the intake and output in the computer system. She expected the charge nurses to look in the computer for the daily total amount of fluids for the resident. She expected the nursing staff to monitor the resident's daily total amount of fluids and expected the 1200 cc fluid restriction per day to be followed as ordered. The DON said a system should be in place to ensure the resident is receiving the 1200 cc fluid restriction per day. She said the blank spaces on the resident's intake and output record meant nursing staff were not monitoring the amount of fluids the resident received per day. During an interview on 6/29/15 at 9:00 A.M., the administrator said the resident's 1200 cc fluid restriction per day is now divided between nursing and dietary to ensure the resident receives the amount of fluids allowed per day for the 1200 cc fluid restriction. The administrator said a system should have been in place to ensure the resident received the 1200 cc fluid restriction per day prior to 6/26/15. The administrator provided the resident's dietary sheet that showed the amount fluids provided by the dietary staff for each meal and verified the amount of fluids were not addressed on the resident's dietary sheet until 6/26/15. 2. Review of Resident #6's admission face sheet, showed an admission date of [DATE] with a readmission on 6/17/15, and [DIAGNOSES REDACTED]. doesn't produce enough [MEDICAL CONDITION] hormone). Review of the resident's current POS, showed an order dated 6/17/15, to obtain weight daily during the day. Review of the weight tracking form, provided by staff, showed staff did not obtain the resident's weight on 6/18/15, 6/19/15, 6/20/15, 6/22/15, 6/23/15, 6/25/15, or 6/26/15. Review of the resident's laboratory results, showed the following: -BMP dated 6/18/15, with a hand written entry that results had been reported to the physician; -BMP dated 6/19/15, with a hand written entry, recheck BMP stat 6/20/15; -Potassium 5.4 (high), normal range 3.5-5.0; -Blood urea nitrogen (bun, what forms when protein breaks down) 38 (high), normal range 10-26; -No lab obtained 6/20/15; -BMP dated 6/21/15 at 5:40 P.M., showing a stat lab was requested two days prior. During an interview on 6/26/15 at 12:20 P.M., the administrator said the stat lab request should have documented on the POS and the lab should have been called to let them know that a stat lab was ordered. She would have expected staff to obtain labs as ordered and to get daily weights as ordered. 3. Review of Resident #8's quarterly MDS dated [DATE], showed the following: -Brief interview of mental status (BIMS, a screening tool used to evaluate mental cognition) score of 3 out of 15; -A BIMS score of 0-7, shows the resident is rarely or never understood; -[DIAGNOSES REDACTED]. -Received a therapeutic diet; -Current weight of 175 pounds. Review of the resident's current POS on 6/24/15, showed an order for [REDACTED]. Review of the resident's dietary progress notes dated on 6/18/15, showed the following: -10.71% weight loss in the last six months; -Special dietary programs include thin liquids and healthshake daily. Review of the resident's care plan updated 3/11/15, showed resident is at risk for weight loss. Review of the resident's MAR indicated [REDACTED]. Observation on 6/24/15, 6/25/15, and 6/26/15 during meal observations, showed the resident was not given a healthshake. During an interview on 6/26/15 at 12:05 P.M., the DON said the dietician meets with the nurse when a healthshake is added to the resident's diet. The dietician can put in the orders for the healthshake. DON expects staff to document when healthshakes are administered. During an interview on 6/29/15 at 8:40 A.M., the administrator said the order for the healthshakes were seen, but the Dietician did not add it to the MAR. 4. Review of Resident #7's POS dated June 2015 on 6/24/15 at 3:00 P.M. and 6/25/15 at 4:00 P.M., showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -An order dated 6/22/15, to administer [MEDICATION NAME] (antibiotic) 2 grams (gm) intravenously (IV, administered into the vein) every eight hours for right knee infection; -An order dated 6/22/15, to change PICC line dressing to the right upper extremity once every seven days and as needed (PRN); -No order for PICC line flushes. Review of the resident's MAR indicated [REDACTED] -An order dated 6/22/15, to administer [MEDICATION NAME] 2 gm IV every eight hours for right knee infection; -No order for PICC line flushes. Review of the resident's TAR dated June 2015, showed no order for PICC line flushes. Observation on 6/25/15 at 6:45 A.M., showed the resident sat in his/her recliner with one bag of [MEDICATION NAME] infusing at 100 cc an hour per IV pump through his/her PICC line. At 7:10 A.M., Nurse E reviewed the resident's MAR indicated [REDACTED]. Nurse E entered the resident's room with one 10 cc prefilled syringe of Sodium Chloride (saline solution used to flush IV tubing) and one 50 unit/5 milliliter (ml) prefilled syringe of [MEDICATION NAME] (anticoagulant). Nurse E turned off the IV pump and disconnected the [MEDICATION NAME] bag and IV tubing from the resident's PICC line. Nurse E cleansed the PICC line port with an alcohol wipe, administered 10 cc of the Sodium Chloride followed with 3 cc of the [MEDICATION NAME] 50 units/5 ml and cleansed the end of the PICC line port with an alcohol wipe. Review of the facility's Intravenous Infusion/Flush Protocol dated 2008 and revision dated March 2010, showed the following: -PICC line flush/maintenance protocol: -Maintenance flush for each lumen (flexible tubing connected to the PICC line) with 5 ml of NS followed with 5 ml of 10 units/ml of [MEDICATION NAME]; -Intermittent flush protocol: -Flush PICC line with 5 ml NS, administer medication, flush PICC line with 5 ml NS and flush PICC line with 5 ml 10 units/ml of [MEDICATION NAME]. During an interview on 6/26/15 at 12:05 P.M., the administrator said the charge nurse should have obtained a physician's orders [REDACTED]. She expected the nursing staff to use the facility's protocol for PICC line flushes. She said the protocol is to flush the PICC line with NS, administer medication, flush the PICC line with NS followed with [MEDICATION NAME] flush (SASH) method. The administrator verified the nursing staff contacted the resident's physician and obtained PICC line flush orders on 6/26/15. She expected all resident's with a PICC line to have physician's orders [REDACTED]. 5. Review of Resident #9's face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the resident's POS dated 6/16/15, showed the following: -Follow up with the resident's physician in one week on 6/23/15; -Did not have an order for [REDACTED]. Observation of the resident on 6/24/15 at 8:20 A.M., showed the resident lay in bed with his/her PICC line attached to an antibiotic. Review of the nurses note's dated 6/25/15 at 11:20 A.M., showed staff flushed the resident's PICC line without difficulty. During an interview on 6/26/15 at 12:20 P.M., the administrator said there should always be orders for a PICC line if the resident has one. She would expect nursing to catch the mistake and to notify the physician. She said any resident with a PICC line should also have an order for [REDACTED]. During an interview on 6/29/15 at 9:00 A.M., the administrator said the resident did not have a follow up appointment. Clerical associates are responsible for taking off the order and setting up appointments. She said social services are responsible for setting up transportation. She said although the resident arrived to the facility on [DATE], no orders were obtained for the PICC line and maintenance until 6/26/15. 6. Review of Resident #5's face sheet, showed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the POS [REDACTED] -Flush [DEVICE] with 60 ml every 4 hours; -Flush [DEVICE] with 250 ml 3 times a day; -Hang no more tube feeding than can be consumed in 4 hours; -Change tube feeding container and syringe daily and as needed; -If resident eats less than 50% of meal give 1 can of [MEDICATION NAME] 1.2 (brand tube feeding) in [DEVICE] for all three meals; -One can of [MEDICATION NAME] 1.2 given at bedtime; -Document strict I&O. Review of I&O documentation dated 6/19/15 through 6/26/16, showed only one entry where staff documented the resident ate more than 50%. Review of nurses note's dated 6/19/15 through 6/26/15, showed only 2 entries about meal consumption: -6/24/15 the resident consumed more than 50% of breakfast and lunch; -6/26/15 the resident consumed more than 50% of breakfast. During an interview on 6/26/15 at 12:30 P.M., the administrator was asked about the two different flush orders for the resident on the POS. The administrator said she would look into it. The administrator also said that if there is an order for [REDACTED]. During an interview on 6/29/15 at 9:00 A.M., the administrator said the resident did mistakenly have two flush orders. She said the physician was made aware and discontinued one of the two orders. The order for 60 ml every four hours was discontinued. The CNA's are responsible for documenting the consumption for meals and the nurses are responsible for overseeing it. She said there was no clear way to determine what meals were eaten, which flushes were given, and which order for tube feedings were given. During an interview on 6/29/15 at 11:55 P.M., the administrator said the multiple orders for the resident's tube feeding were confusing and the order (hang no more tube feeding than can be consumed in 4 hours) is for a continuous feeding that should not be on the resident's POS. 7. Review of Resident #4's quarterly MDS dated [DATE], showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -BIMs score of 5 out of a possible score of 15; -Required extensive assistance from staff for bed mobility, transfers, dressing and hygiene; -Occasionally incontinent of bowel and bladder. Review of the resident's POS dated June 2015, showed the following: -An order dated 5/20/14, to apply elastic support stockings to the lower extremities, on the morning and remove in the evening; -An order dated 9/12/14, to apply [MEDICATION NAME] to the lower extremities, from feet to knees, on in the morning and off at bedtime; -No order to discontinue the [MEDICATION NAME] until 6/26/15. Review of the resident's TAR dated June 2015, showed the following: -An order dated 9/12/14, to apply [MEDICATION NAME] to both lower extremities, from feet to knees, on in the morning and off at bedtime; -From 6/24/15 through 6/26/15, staff initialed the dated space for applying the [MEDICATION NAME] in the morning and removal of the [MEDICATION NAME] at bedtime. Observations of the resident during the survey, showed the following: -On 6/24/15 at 1:55 P.M. and 3:00 P.M., the resident lay in bed without [MEDICATION NAME] worn on his/her both lower extremities. The resident's pant legs were pushed upward and exposed beige colored elastic support stockings on his/her both lower extremities; -On 6/25/15 at 8:40 A.M. and 5:15 P.M., the resident sat in his/her wheelchair without [MEDICATION NAME] to his/her lower extremities. The resident's pant legs were pushed upward and exposed beige colored elastic support stockings on his/her lower extremities; -On 6/26/15 at 7:10 A.M., the resident lay in bed without wearing [MEDICATION NAME] on his/her lower extremities. At this time, a skin assessment was completed with nursing staff present in the resident's room; -On 6/26/15 at 11:45 A.M., the resident sat in his/her wheelchair without wearing [MEDICATION NAME] on his/her lower extremities. The resident's pant legs were pushed upward and exposed beige colored elastic support stockings on his/her lower extremities. During an interview on 6/26/15 at 12:05 P.M., the administrator said [MEDICATION NAME] and elastic support stockings were not the same and expected the charge nurse to have contacted the resident's physician for clarification regarding both orders for the [MEDICATION NAME] and elastic support stockings. She said CNAs are responsible for applying the [MEDICATION NAME] and charge nurses are responsible for making sure they are applied as ordered. She expected the charge nurse to have contacted the resident's physician and obtained an order to discontinue the [MEDICATION NAME].

Based on observation and interview, the facility failed to provide and follow recipes for 3 of 3 residents who received pureed diets. The total census was 108 with 40 residents in certified beds. 1. Observation on 6/25/15 at 7:00 A.M., showed Cook A prepared a sausage puree. Cook A placed 8 sausage links and applesauce into the blender. Cook A blended the puree for approximately two minutes. The pureed sausage contained a mashed potato like consistency. Cook A put the puree mixture into three cups using a 12 oz scoop. Cook A put the date on container and placed the pureed into the food warmer. Cook A did not have a recipe while preparing the pureed sausage. 2. Observation on 6/25/15 at 7:15 A.M., showed Cook A prepared pureed eggs. He/She placed three scoops of scrambled eggs into the blender with a 12 oz scoop. Cook A mixed the eggs in the blender without any added ingredients. Cook A removed the pureed eggs from the blender, and placed the pureed eggs into three containers. The consistency of the eggs were thick. Cook A put the date on the container and placed the container in the food warmer. Cook A did not have a recipe while preparing the pureed eggs. 3. Observation on on 6/25/15 at 3:35 P.M., showed Cook B prepared pureed carrot cake. Cook B placed slices of carrot cake into a blender with milk. He/she did not use measuring utensils or a recipe. Cook B mixed the milk and cake in the blender. Cook B added more unmeasured milk into the mixture and blended it. During an interview on 6/25/15 at 3:55 P.M., the Executive Chef said staff do not follow a recipe. The cooks are all trained to do purees. The puree recipes are approved by the Dietician. During an interiew on 6/26/15 at 7:45 A.M., the Dining Services Manager C said the pureed sausage is a mixture of apple sauce or gravy. The mixture should have a mashed potato like consistency. The eggs are mixed without any added liquid unless it is too thick. He/she would expect the cook to add milk if the eggs are too thick. He/she expects the cooks to have access to a recipe. During an interview on 6/25/15 at 8:00 A.M., the Dietician said the cooks submit a menu twice a year. The Dietician comes up with a puree version for the foods that can be pureed. He/she expects the cooks to follow a recipe for a puree. During an interview on 6/26/15 at 11:00 A.M., the Director of Dining said there are no recipes available for the cooks. The cooks are taught to take a 3 oz protein and use liquid to bring to a mashed potato consistency. The cooks would normally use gravy; however, gravy was not available, so the cooks used apple sauce. He said the cooks will have a recipe to follow for the puree diets in the future. During an interview on 6/26/15 at 12:05 P.M., the Executive Director said there should have been a system in place. It is the Director of Dining's responsibility to make sure there were recipes for the staff to follow.

Based on observation, interview and record review, the facility failed to cover and date food when in the refrigerator and freezer and remove expired food for four of four observations. The total census was 108 with 40 residents in certified beds. 1. Observation of the walk-in refrigerator, freezer, and preparation refrigerator on 6/24/15 at 8:55 A.M., showed the following: -Uncovered metal container of raw salmon without a date; -Uncovered bucket labeled duck fat dated 6/5; -Wrapped pack of sliced moldy cheese dated 5/1; -Uncovered lasagna sauce dated 6/24; -Uncovered manicotti dated 6/24; -Wrapped pack of shredded cheese without a date; -Wrapped pack of sliced cheese without a date. 2. Observation of the walk-in refrigerator, freezer, and preparation refrigerator on 6/25/15 at 6:40 A.M., showed the following: -Ziploc bag of parmesan cheese without a date; -Wrapped pack of sliced moldy cheese dated 5/1; -Wrapped bag of shredded cheese without a date; -Uncovered metal container of salmon without a date; -Uncovered bucket labeled duck fat dated 6/5; -Uncovered container of a brown liquid substance without a date. 3. Observation of the walk-in refrigerator, freezer and preparation refrigerator on 6/25/15 at 3:05 P.M., showed the following: -Uncovered bucket of frozen country fried steak gravy with a large utensil inside the mixture dated 6/26; -Uncovered bucket of frozen mushroom gravy with a large utensil inside the mixture without a date; -Uncovered container of lentil soup dated 6/25; -Uncovered container of chicken stock dated 6/25; -Uncovered chocolate dessert on the food cart without a date; -Uncovered tray of cake with icing without a date; -Uncovered frozen dough on the food cart without a date; -Container of fruit without a date; -Three containers of uncovered vegetables without a date; -Uncovered metal container of salmon without a date. 4. Observation of the walk-in refrigerator, freezer, and preparation refrigerator on 6/26/15 at 6:45 A.M., showed the following: -Wrapped pack of sliced moldy cheese dated 5/1; -Wrapped pack of sliced cheese without a date; -Uncovered bucket labeled duck fat dated 6/5; -Covered bucket of thawed country fried steak gravy with large utensil inside the mixture; -Uncovered metal container of raw salmon with a bag of ice directly on top. Observation on 6/26/15 at 6:45 A.M., showed the Sous Chef sliced the salmon into cubes after he/she removed the salmon from the refrigerator. Review of the sign on the preparation refrigerator on 6/25/15 said, If you open a bag of cheese, put the reminder in a Ziploc bag. Don't forget to label it. 5. During an interview on 6/26/15 at 11:00 A.M., the Director of Dining (DOD) said he would expect staff to throw out food that is not dated or has a date past ten days. He would expect the moldy cheese to be thrown out by staff. He would expect staff to cover the food with lids. The chefs and cooks put food into freezer to cool it down, but for only four hours. He would expect staff to not leave uncovered foods in the freezer with utensils left inside them. He said the facility receives 400 pounds of salmon a month, so the salmon is always cut daily, but expects the salmon to be covered when it is in the refrigerator.

Based on observation, interview, and record review, the facility failed to ensure the kitchen floors, walls, air vents, and equipment remained clean and free of visible dirt and stains for four of four days of observation. The total census was 108 with 40 residents in certified beds. Observation of the kitchen on 6/24/15, 6/25/15, 6/26/15, and 6/29/15 during the survey, showed the following:-Brown and yellow stains on the side of the fryer; -Dried white stains in the left side of the grill; -Dried stains and food crumbs around the perimeter of the kitchen; -Food crumbs underneath the preparation counter and the preparation counter; -Dust and debris behind and underneath the tilt grill, kettle, and the oven; -Brown stains on the wall behind the preparation counter; -White spots on the floor underneath the tilt grill and kettle; -Dust and debris on the air vents above the tilt grill, kettle, and oven; -Dried stains and food crumbs on the inside of all five food warmer carts; -Slippery floor inside of the walk-in freezer; -Dried white stains around the perimeter of the dishwashing room; -Dried grease stains on the outside of the oven. During an interview on 6/25/15 at 11:00 A.M., the Director of Dining (DOD) said the chefs are responsible for pulling the equipment to clean behind them on Fridays and Saturdays. There is also a cleaning crew that cleans the kitchen on Saturdays. The cooks and servers are responsible for cleaning the inside of the food warmer cart. He would have to check with the staff to see how often the cleaning is getting done, and increase it. There is also a cleaning schedule that the staff follows. A company comes into the kitchen every six months to clean the vents above the equipment. He expects the staff to clean the vent between the six month visits. Review of the cleaning schedule dated 6/22/15 to 6/25/15, showed the dishwashing staff are responsible for cleaning the floors and the equipment. During an interview on 6/26/15 at 12:05 P.M., the Administrator would expect the kitchen staff to clean all areas of the kitchen on a daily basis.

Based on interview and record review, the facility failed to follow physician's orders, report a significant lab result to the physician and monitor/track the administration of [MEDICATION NAME] (prevents the formation of blood clots), which resulted in a serious medication error. The facility failed to administer a resident's [MEDICATION NAME] (Resident #2) for four days and on the fifth day, the resident sustained [REDACTED]. The census was 124. 1. Review of Resident #2's face sheet, showed an admission date of [DATE], from an independent living apartment on campus. [DIAGNOSES REDACTED]. lungs), obstructive sleep apnea (the stopping of breathing while asleep) and [MEDICAL CONDITION] ([MEDICAL CONDITION], heart unable to pump enough blood to meet the body's needs). Review of the resident's admitting medication orders, dated 6/25/14 at 1:58 P.M., showed the resident received [MEDICATION NAME] 5 milligrams (mg) daily, as an anticoagulant. There was no [MEDICATION NAME] stop date and no order for PT/INR (PT, [MEDICATION NAME] time; the time it takes the blood to clot. INR-international normalized ratio; a standardized numeric measurement) labs. Review of the handwritten admitting physician's telephone orders, dated 6/25/14 at 5:30 P.M., showed the following: -Admit to the Medicare A Reach Unit; -Obtain physical therapy and occupational therapy evaluations and treatment; -Regular diet; -Resident may use home supply of medication until completed, then order from pharmacy here; -Obtain basic metabolic panel (BMP, a blood test that measures blood sugar level, kidney function, electrolyte and fluid balance), and PT/INR on Monday, 6/30/14, for [DIAGNOSES REDACTED]. -Hold [MEDICATION NAME] and [MEDICATION NAME] if systolic blood pressure is less than 100. Review of the facility's Management of [MEDICATION NAME] Therapy policy, dated 4/01/08, showed when an order was received for [MEDICATION NAME] therapy, the following procedure must be followed: -1) The nurse receiving the order will ask the physician for an order to monitor PT/INR outcomes; -2) The lab order will be entered into the computer lab website by the nurse receiving/transcribing the order; -3) The date of the lab draw will be passed along to future shifts by noting it on the calendar at the nurse's desk or by using other community specific tracking/communication tool; -4) The [MEDICATION NAME] Flow Sheet will be completed, showing the date, INR results, current [MEDICATION NAME] dose, action taken, nurse initials and lab requisition number; -5) The [MEDICATION NAME] Flow Sheets will be kept at the nurse's station; -6) The lab technician will print the requisition and review it with the nurse; -7) PR/INR results will be communicated to the physician's office as soon as they are obtained. Orders related to [MEDICATION NAME] dosing and next scheduled PT/INR are to be obtained. If physician response is not obtained prior to the scheduled dose, the nurse should notify the nurse leader and as necessary, the Medical Director; -8) [MEDICATION NAME] doses will be scheduled to be given at 8:00 P.M., unless the physician orders indicate a different time; -9) Stop dates for [MEDICATION NAME] orders are to equal the date of the next PT/INR and should be noted when transcribing the order on the MAR (medication administration record) or entering in Optimus EMAR (electronic MAR); -10) Type in Optimus EMAR, under Special Instruction, when the next PT/INR is due; -15) Documentation in the medical record is to include communication with the physician, related to [MEDICATION NAME] management, assessment information communicated to physician and monitoring for bleeding precautions. Review of the computer admitting orders print out, dated 6/25/14 at 12:00 A.M., showed the [MEDICATION NAME] order was entered into the computer, by Nurse A, as "[MEDICATION NAME] 5 mg tablet: Give 5 mg by mouth one time per day at 7:00 P.M. for 5 days, for [MEDICAL CONDITION]. Special Instructions: Next PT/INR 6/30/14". Review of the resident's admission nurse's note, dated 6/25/14 at 8:38 P.M., showed the resident arrived at the facility at 2:00 P.M., via a wheelchair and accompanied by two family members. The physician was called to approve the resident's admitting orders. The physician added orders for blood work, PT/INR and BMP, to be done on 6/30/14. Review of the EMARs, dated June 2014, showed the resident's [MEDICATION NAME] was ordered on [DATE] and initialed as administered, on page one of seven, on the following dates: -6/25/14, given by certified medication technician (CMT); -6/26/14, given by Nurse D; -6/27/14, given by Nurse D; -6/28/14, given by CMT E; -6/29/14, given by CMT C; -6/30/14 had an "X" in the box, indicating (according to the EMAR code and user legend on page 7) the medication was "not to be administered". Review of the resident's nurse's note, dated 6/29/14 at 3:53 P.M., showed the resident fed him/herself at lunch without difficulty. Review of the resident's PT/INR lab report, dated 6/30/14 and specimen collection time of 6:30 A.M., showed it was faxed to the facility on [DATE] and printed at 3:56 P.M. The INR result was 1.4. The therapeutic ranges listed on the lab report showed 0.9-1.2 range indicated non-medicated patients and a range from 1.5-2.0 indicated low-intensity range. Handwritten, at the bottom of the page, was a note that showed the lab results were reported to the physician, on 7/4/14 at 4:00 P.M., by Nurse M. Further review of the resident's nurse's notes, dated 6/30/14, showed the following: -4:06 A.M.: Resident alert with confusion and no signs or symptoms of pain or confusion; -1:30 P.M.: Resident talked about what happened to his/her hand (fell on [DATE] and sustained a severe skin tear), is pleasant and is aware of what is going on, is using his/her wheelchair for mobility, which he/she propels; -No note regarding blood work drawn or blood work results received and physician notification. Review of the resident's physician orders, from 6/25/14 to 7/4/14, showed no new physician's orders received for the administration of [MEDICATION NAME] on 6/30/14, 7/1/14, 7/2/14 or 7/3/14. Review of the EMARs, pages one through eight, dated July 2014, showed no [MEDICATION NAME] was administered on 7/1/14, 7/2/14 and 7/3/14. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/14, showed the following: -Moderate cognitive impairment; -Very important for the resident to keep up with the news; -Required assistance of one staff with bed mobility, transfers, dressing and toilet use; -Independent with eating; -Occasionally incontinent of urine; -Continent of bowel. Further review of the resident's nurse's notes, showed the following: -7/3/14 at 4:39 P.M.: One person assist with transfer, alert and oriented to person and place, and right and left hand grasp is equal; -7/4/14 at 6:48 P.M.: Acute unresponsive episode, [MEDICAL CONDITION] with [MEDICAL CONDITION]. Resident returned from physical therapy at 11:05 A.M. and spouse arrived five minutes later. Resident was noted to be alert and verbal and in no acute distress, communicating with spouse per usual. Called to room at 11:15, by spouse, as resident suddenly stopped talking to him/her. Resident found with eyes open, but non-responsive to surroundings. Hands were cold and nail beds were purple. After four to six minutes of non-responsiveness, the resident was able to read the nurse's name tag and identified his/her spouse by name. After another five minutes, the resident was able to provide one word responses to the nurse's and spouse's questions. The right side of the resident's body, both upper and lower extremities, were flaccid (weakness or loss of muscle tone). The resident required two staff to transfer to his/her bed, with no assistance from the resident. Bilateral hand grips tested and showed remarkable weakness on the right side. The resident was unable to lift his right upper or lower side. The physician was notified and ordered a stat (immediately) INR; -7/4/14 at 6:53 P.M.: Stat INR results from 4:00 P.M. reported to the physician. Physician also informed the resident had not received [MEDICATION NAME] since 6/30/14. New orders received to start [MEDICATION NAME] 5 mg daily and give 325 mg of aspirin now. Review of the resident's stat PT/INR lab report, dated 7/4/14 with the blood specimen collection time at 2:46 P.M., showed the INR result was 1.04. The therapeutic ranges listed on the lab report showed 0.9-1.2 range indicated non-medicated patients. Handwritten in, at the bottom of the page, was a note that showed the lab results were reported to the physician, no date or time, and to resume [MEDICATION NAME] 5 mg daily and give 325 mg of aspirin now. Further review of the resident's nurse's notes, showed the following: -7/5/14 at 2:41 A.M.: The resident is disoriented to time, incontinent of urine, total dependence for bed mobility, total dependence for dressing, total dependence for toilet use and personal hygiene, two person assist needed for toilet use. Right upper and lower extremities remain flaccid. -7/5/14 at 4:48 P.M.: Resident encouraged to eat slowly and encouraged, two to three times, to swallow after each bite. Elevated leg rests used on wheelchair. Speech remains clear but resident needs adequate response time, able to follow simple commands and right arm and leg remain flaccid; -7/5/14 at 7:45 P.M.: Resident unable to express self clearly and is incontinent of urine; -7/7/14 at 10:00 P.M.: Resident required encouragement to swallow, two to three times, after each bite. Further review of the EMARs, pages one through eight, dated July 2014, showed on page two, [MEDICATION NAME] 5 mg tablet, give one tablet daily at 5:00 P.M. for [MEDICAL CONDITION], was ordered on [DATE]. The name of the nurse that entered the order was not entered/listed. The medication was initialed as administered at 5:00 P.M. (not scheduled for 8:00 P.M. per facility [MEDICATION NAME] policy) on the following dates: -7/4/14, given by CMT C; -7/5/14, given by Nurse A; -7/6/14, given by Nurse D; -7/7/14, given by CMT F and discontinued on this date by Nurse B, no time. Further review of the EMARs, pages one through eight, dated July 2014, showed, on page two, [MEDICATION NAME] 6 mg tablet, give one tablet daily at 8:00 P.M. for four days, for [MEDICAL CONDITION], was ordered on [DATE]. The name of the nurse that entered the order was not entered/listed. The medication was initialed as administered at 8:00 P.M. on the following dates: -7/7/14, given by CMT F (Resident received 5 mg at 5:00 P.M. and given an additional 6 mg at 8:00 P.M.); -7/8/14, given by CMT G; -7/9/14, given by Nurse H; -7/10/14, given by Nurse D and discontinued on this date by Nurse B. Further review of the resident's physician's orders, from 6/25/14 to 7/19/14, showed no physician's order for the resident to receive [MEDICATION NAME] 11 mg on 7/7/14. Review of the facility's investigation, dated 7/8/14, showed the following corrective measures were instituted: -An immediate audit was conducted to ensure all residents' PT/INR results had been reported to the physician and current [MEDICATION NAME] orders were in place; -A new lab log was initiated to track the test, order date, requisition date, due date, lab drawn date, results received and physician notification. The lab log was to be updated by the charge nurse, reviewed daily by the charge nurse and audited by nurse leadership every morning; -[MEDICATION NAME] flow sheet initiated to ensure that INR results, current [MEDICATION NAME] dose and action are all readily available for daily review by the charge nurse and will be audited by nurse leadership every morning; -An audit was completed by nursing leadership to ensure [MEDICATION NAME] profile orders were in place. Nurse leadership to audit for [MEDICATION NAME] profile orders within 24 hours of admission and weekly; -Management of [MEDICATION NAME] policy was updated. Observation of the resident on 7/16/14, showed the following: -10:50 A.M., resident sat in his/her wheelchair, in open family area, in front of the nursing station. His/her right forearm lay on an elevated foam trough, attached to the wheelchair arm, and did not move. He/she was alert and smiled when spoken to; -1:40 P.M., resident in bed with eyes closed; -4:40 P.M., resident in bed and said "I'm fine". When asked if he/she had eaten lunch, the resident said "yes". When asked what he/she had for lunch, the resident said "Didn't eat yet". When asked how long he/she had been at the facility, the resident said "Since daylight, at night I guess. They woke me up at daylight". All other responses were unintelligible. During an interview on 7/16/14 at 4:30 P.M., the resident's roommate said the resident had a stroke, about 10 days ago. Before the stroke, they spent time together and talked about baseball teams and other things. They watched the baseball games together, on television. Now, the resident needed people to feed him/her. The roommate said, "I don't think (he/she) even knows me anymore". Review of the Director of Nurses' (DON) written statement, dated 7/18/14, showed she notified the resident's spouse, by phone on 7/7/14 at 9:25 A.M., the resident had missed [MEDICATION NAME] doses. The spouse said he/she assumed this had happened, as the resident had been on [MEDICATION NAME] for [AGE] years and had been told the purpose of the [MEDICATION NAME] was to prevent a stroke. During an interview on 7/22/14 at 2:04 P.M., Nurse A said he/she put the [MEDICATION NAME] order in the computer, on 6/25/14, to be administered for only 5 days, because that was the facility policy; you must have a stop date. On 6/30/14, he/she worked the first shift and did not recall the night nurse reporting the resident's blood had been drawn. He/she probably did not document the resident's PT/INR lab draw to the nurses between shift report sheet, because he/she had not been given that information by the night shift nurse. Nurse A said he/she knew the resident well and when he/she first arrived, there was a twinkle in his/her eye, like Santa Clause, and he/she was always happy and smiling. He/she was weak, but still able to help with transfers and was able to move all body parts. He/she could carry on a conversation and would remind him/her when it was time for his/her nebulizer breathing treatment. Following the stroke, the resident could not move the right side of his/her body and could not feed him/herself; the resident was now total care. During an interview on 7/22/14 at 3:13 P.M., the DON said the nurses were taught to stop all [MEDICATION NAME] administration the day before the PT/INR was to be drawn and this was according to facility policy. During an interview on 7/22/14 at 4:18 P.M., Nurse N said he/she was assigned to the resident's hall for the second shift on 6/30/14, but was not the regular nurse on that hall, and was overwhelmed that evening. He/she did not know the resident had a PT/INR drawn that morning. The next week, when informed he/she had not notified the physician of the resident's PT/INR results on 6/30/14, he/she went to look at the nursing report sheet from that day and found it missing. All other report sheets were there. He/she checked the fax machine, between 5:00 P.M. or 5:30 P.M., that day and there were no lab reports. There were three units that receive lab faxes on the same machine. There were three mailboxes, in the same room with the fax machine, that reports could be filed in, when someone from another hall collects another hall's faxes. He/she did not check the box that evening. The resident, prior to the stroke, was coherent and was up walking and talking. He/she was much, much more coherent before the stroke. The stroke could have been prevented; it was a very unfortunate situation. During an interview on 8/5/14 at 9:07 A.M., the DON said the cause of the medication error was due to the second shift nurse not checking the fax machine. The lab was not found and did not get reported to the physician. The resident received a double dose of his/her [MEDICATION NAME] on 7/7/14. Nurse M entered the [MEDICATION NAME] order, on 7/4/14, into the computer and scheduled all the doses for 5:00 P.M., instead of the normal time of 8:00 P.M. When the nurse, on 7/7/14, entered the new [MEDICATION NAME] order into the computer, he/she assumed the 7/7/14 dose had not been yet been given. The nurse should have checked the computer to verify it had not yet been given. As of this date, the CMTs would no longer be giving the [MEDICATION NAME]. The nurses would be administering [MEDICATION NAME]. During an interview on 7/22/14 at 12:31 P.M., the resident's physician said the resident had a full stroke and it occurred because his/her [MEDICATION NAME] was stopped. The resident had been on the [MEDICATION NAME] for a long time. When someone has been taking [MEDICATION NAME] for a long time, and then it is stopped, the blood becomes thicker than normal, making it easier to clot. The physician said she did not give the order to stop the [MEDICATION NAME] in 5 days, the nurse put it in the computer that way, because of the INR order. The resident had been on [MEDICATION NAME] forever, he/she was on it for life and there should have been no stop date. The facility nurse did not report the resident's INR lab results to the physician on 6/30/14. Had the lab results been reported, the physician would have increased the resident's [MEDICATION NAME] to 6 mg daily, as the INR was 1.4, which was not therapeutic. The INR result of 1.04, on 7/4/14, was very non-therapeutic; not on [MEDICATION NAME] at all. The resident's INR should have been around 2.0. The physician said she was not aware of any facility policy that had the nurses stop all [MEDICATION NAME] administration, the day before the PT/INR lab is to be drawn. The physician said the facility's system was at fault. MO 373