Every finding on record at NHC Healthcare, Kennett

Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was kept off the floor for two residents (Residents #5 and #249) and to ensure proper cleaning of the catheter tubing for one resident (Resident #81) out of three sampled residents. The facility census was 98. Review of the facility's policy titled, Skills Checklist: Catheter Care, undated, showed: - While holding the catheter, clean down the catheter tube; - Clean with strokes moving away from the urethra; - Use a clean portion of the washcloth for each stroke. The facility did not provide a policy related to the positioning of urinary catheters. 1. Review of Resident #5's medical record showed: - admitted on [DATE]; - Diagnosis of obstructive and reflux uropathy (a disorder characterized by blockage of the normal flow of contents of the urinary tract). Review of the resident's Physician Order Sheet (POS), dated April 2025, showed: - An order for indwelling catheter care every shift, dated 03/27/24; - An order to change the catheter every 30 days, insert a catheter size 16 French (Fr - size of the urinary catheter) and bulb size 5 milliliters (ml) on the 25th of the month, dated 04/25/25. Observation on 05/02/25 at 1:30 P.M., showed: - The resident lay in bed and the uncovered catheter drainage bag hung on the bed frame; - The catheter drainage bag bottom touched the floor; - One inch of the catheter bag drainage spout touched the floor. 2. Review of Resident #81's medical record showed: - admitted on [DATE]; - Diagnosis of neurogenic bladder (a condition where the nerves that control bladder functions are damaged or dysfunctional, leading to various urinary problems). Review of the resident's POS, dated April 2025, showed: - An order to change the indwelling catheter every 30 days. Insert catheter size 16 Fr and bulb size 5 ml on the 19th of the month, dated 03/23/25; - An order for indwelling catheter care every shift, dated 03/23/25. Observation on 05/01/25 at 11:115 A.M., of the resident's catheter care showed: - Certified Nurse Assistant (CNA) I put on a gown, performed hand hygiene, and put on gloves; - CNA I cleaned the catheter and down one inch of the catheter tubing from the insertion site with a soapy wash cloth; - CNA I rubbed the same area of the tubing multiple times with the same area of the wash cloth going back and forth from and towards the insertion site; - CNA I cleaned three inches down the catheter tubing from the insertion point again with same area of the wet wash cloth; - The catheter tubing had a discolored area and CNA I rubbed the same of area of the tubing multiple times with the same area of the wash cloth going back and forth from and towards the insertion site. During an interview on 05/01/25 at 11:35 A.M., CNA I said you cleanse away from insertion point with a new side of the wash cloth with each wipe. You should cleanse down the tube. 3. Review of Resident #249's medical record showed: - admitted on on 04/25/25 - Diagnosis of obstructive and reflux uropathy. Review of the resident's POS, dated April 2025, showed: - An order to change the indwelling/suprapubic (a urinary catheter inserted directly into the bladder through a small incision in the lower abdomen) catheter every 30 days. Insert catheter size 16 French and bulb size 10 ml once a day on the 24th of every 3rd month, dated 04/26/25; - An order for indwelling catheter/suprapubic catheter care every shift, dated 04/26/25. Observations on 04/30/25 at 9:34 A.M., and 11:40 A.M., showed: - The resident lay in bed with the catheter drainage bag in a privacy cover and lay in the floor under the bed; - The top of the catheter drainage bag was outside the privacy cover and lay on the floor; - Four inches of the catheter tubing lay on the floor. Observation on 04/30/25 at 12:58 P.M., of the resident's bed bath, catheter care, and a transfer showed: - CNA A emptied the catheter drainage bag with the catheter drainage bag placed on the floor without a privacy cover multiple times and the catheter bag drainage spout touched the inside of the urinal when emptied; - CNA A held the catheter drainage bag above the level of the resident's bladder during the transfer and the resident's urine flowed towards the bladder in the catheter tubing. Observation on 05/01/25 at 9:12 A.M., showed: - The resident lay in bed with six inches of the catheter tubing lay on the floor under the bed. Observation on 05/02/25 at 9:25 A.M., showed: - The resident lay in bed; - The catheter drainage bag hung on the bed frame without a privacy cover; - The catheter drainage bag was visible from the hallway. Observation on 05/02/25 at 1:10 P.M., showed: - The resident lay in bed; - The catheter drainage bag hung on the bed frame without a privacy cover; - The catheter drainage bag was visible from the hallway; - A visitor was in the room. During an interview on 05/02/25 at 2:42 P.M., Registered Nurse (RN) C said a catheter should be hung on the bedside if a resident was in bed with a privacy cover, off the floor, and below the bladder. The drainage spout shouldn't touch anything when being emptied. During catheter care, should wipe away from the insertion point and not go up and down the tubing. If it needed to be cleaned in the same area more than once, then a new wash cloth was needed for each swipe. During an interview on 05/02/25 at 2:46 P.M., Licensed Practical Nurse (LPN) D said the catheter should be hung at the bedside, never touch the floor, and below the bladder. Catheter care should be done wiping away from the insertion point and should change wash cloths if need more than one wipe. During an interview on 05/02/25 at 2:51 P.M., CNA E said catheters should never touch the floor, stay below the bladder, and always be in a privacy bag. The drainage spout should never touch anything when emptied. Should cleanse away from the insertion point and not back and forth on the tube because otherwise it cross contaminated it. During an interview on 05/02/25 at 2:52 P.M., LPN H said catheters shouldn't have any kinks, should be lower than the bladder, should be in a privacy cover, and should never touch the floor. He/She would cleanse down six inches from the insertion point and never go back and forth on the tubing during catheter care. During an interview on 05/02/25 at 3:00 P.M., CNA A and CNA B said the catheter shouldn't touch the floor, should stay below the bladder, should cleanse away from the insertion point, and shouldn't be cleaned back and forth. The drainage spout should not touch anything when emptying the bag. During an interview on 05/02/25 at 4:17 P.M., the Director of Nursing (DON) said residents with catheters receive catheter care every shift. Catheter care was done by wiping down from the insertion point, should never go back and forth. The drainage bag should stay below knee level and not touch the floor. The facility bought the non-reflux drainage bags as an extra safety net and the purpose of the privacy bags other than privacy was to ensure the drainage bag wasn't contaminated by touching the floor. The catheter drainage spout shouldn't touch anything but if it did, it became contaminated and should be cleaned. During an interview on 05/02/25 at 4:30 P.M., the Administrator said it was expected that catheter care be done correctly, wiping from the insertion point down, and never back and forth. The drainage bag and tubing should not be in the floor and should be in the privacy bags. The catheter drainage spout shouldn't touch anything when emptying it.

Based on observation, interview, and record review, the facility failed to follow physician's orders for supplemental oxygen therapy for one resident (Resident #247) out of four sampled residents. The facility's census was 98. Review of the facility's policy titled, The Basics of Oxygen, dated 01/12/14, showed: - Nasal cannula (plastic tubing inserted into the nose to deliver additional oxygen) oxygen range from one to six liters. The facility did not provide a policy about following physician orders regarding oxygen. 1. Review of Resident #247's medical record showed: - An admitted [DATE]; - Diagnoses of pneumonia (an infection that inflames the air sacs in one or both lungs), congestive heart failure (CHF - a condition where the heart muscle is unable to pump enough blood to meet the body's needs), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing problems). Review of the resident's Physician's Order Sheet (POS), dated 04/29/25, showed: - An order to check the oxygen saturation (O2 sat - a measure of how much oxygen is in the blood) every shift, dated 04/21/25; - An order for oxygen at 3 liters per minute (L/min) via a by nasal cannula continuous, Every Shift, dated 04/18/25. Review of the resident's Baseline Care Plan, dated 04/18/25, showed: - Resident received oxygen therapy; - Did not address the amount and frequency for the oxygen. Observation of the resident showed: - On 04/29/25 at 12:39 P.M., and 2:50 P.M., on 04/30/25 at 11:45 A.M., and on 05/01/25 at 9:13 A.M., the resident sat in a recliner in his/her room with the oxygen concentrator not in use and the undated oxygen tubing stored in a zip lock bag attached to the oxygen concentrator; - On 05/01/25 at 2:30 P.M., the resident sat slouched down in a recliner in his/her room and eyes closed. Staff Coordinator O verbally aroused the resident and he/she showed confusion upon waking. Staff Coordinator O checked the resident's O2 sat and it was 89% on room air. After one minute, the resident's O2 sat was 91%, was 92% with the resident taking a deep breath, and then dropped to 90%. Staff Coordinator O asked the resident if he/she could put the oxygen on and the resident agreed. Staff Coordinator O turned on the oxygen concentrator on and placed the oxygen on the resident at 1 L/min and the resident's O2 sat remained at 90%; - On 05/01/25 at 3:38 P.M., the resident sat slouched down in a recliner in his/her room, eyes closed, and oxygen on at 1 L/min.; - On 05/02/25 at 9:30 A.M., the resident sat in a recliner in his/her room with the oxygen concentrator on at 1 L/min and the oxygen tubing stored in a zip lock bag attached to the oxygen concentrator. During an interview on 04/29/25 at 2:50 P.M., Resident #247 said sometimes he/she wore the oxygen, but therapy said he/she did not have to do so. During an interview on 05/01/25 at 3:35 P.M., Registered Nurse (RN) J said Resident #247 came to the facility on three liters of oxygen. During an interview on 05/02/25 at 9:35 A.M., Licensed Practical Nurse (LPN) H said Resident #247 came in wearing oxygen and it was more for symptoms of pneumonia, not long-term chronic use. The resident's physician's order showed the order was for three liters of oxygen per minute continuous, so he/she would need to address the order. LPN H said he/she would expect to follow the physicians order and for the resident's oxygen to be on and at three liters per minute. During an interview on 05/02/25 at 4:10 P.M., the Director of Nursing (DON) said oxygen orders should be followed and if the resident required a different liter than the physician order, the physician should be notified. During an interview on 05/02/25 at 4:40 P.M., the Administrator said oxygen orders should be followed as written.

Based on interview and record review, the facility failed to follow one resident's (Resident #27) care plan regarding smoking out of two sampled residents. The facility failed to ensure staff utilized safe transfer techniques for one resident (Resident #87) when staff failed to transfer the resident with the assist of a gait belt (a device used to aid in the safe movement of a person from one place to another) out of two sampled residents. The facility census was 98. The facility did not provide a smoking policy. Review of the facility's policy titled, Gait Belts For Transfer, dated 01/08/08, showed: - Gait belts are provided to assist staff to safely transfer or ambulate residents; - Apply belt around the resident's waist; - To transfer, assist the resident to a standing position by grasping the belt at the waist from underneath. 1. Review of Resident #27's medical record showed: - admitted [DATE]; - Diagnoses of hemiplegia (a condition characterized by paralysis on one side of the body) and seizure disorder. Review of the resident's Care Plan, dated 05/09/24, showed: - Resident smoked; - Instruct about the facility policy on smoking locations; - Wear a flame resistant apron at all times when smoking; - Provide supervision when smoking. Review of the resident's Smoking Assessment, dated 09/05/24, showed: - The resident smoked safely; - The resident required supervision to smoke; - Continue the plan of care; - Did not address the use of a smoking apron. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 02/05/25, showed: - No cognitive impairment; - Dependency for activities of daily living; - Impairment to one side of the lower and upper extremity. Observation on 05/02/25 at 10:00 A.M., of the resident showed: - The resident sat in the smoking area and smoked a cigarette; - The resident did not wear a smoking apron. During an interview on 05/02/25 at 12:01 P.M., the Administrator said she expects the smoking assessment to be done on admission, with a change in status, and annually. During an interview on 05/02/25 at 3:06 P.M., Director of Nursing (DON) said if the resident's care plan showed a resident required a safety apron to smoke, they should be wearing it during a smoke break. He completed the smoking assessment and the MDS Coordinator completed the care plan. During an interview on 05/02/25 at 1:34 P.M., Certified Nursing Assistant (CNA) B said he/she handed the cigarettes and supervised the residents while smoking. There was a list attached to the cigarette container that listed the names of which residents required an apron, but it had been removed for editing about a week ago. During an interview on 05/02/25 at 3:45 P.M., the MDS Coordinator said he/she used a standard smoking plan for the resident assessments and care plans. Resident assessments were used to decide if a smoking apron should be utilized. If a resident's care plan showed they needed a smoking apron, they should be wearing one. Resident #47 should wear an apron while smoking because he/she was care planned for it. The MDS Coordinator normally completed the resident smoking assessments and used them to complete the care plan. 2. Review of Resident #87's medical record showed: - An admitted [DATE]; - Diagnoses of atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls) of native arteries of extremities with intermittent claudication (a painful muscle ache or cramping in the legs, typically experienced during exercise, that is relieved by rest), unspecified extremity, chronic obstructive pulmonary disease COPD - a progressive lung disease characterized by persistent airflow limitation, usually caused by chronic inflammation and damage to the lungs), and chronic kidney disease stage 3 (signifies a moderate decline in kidney function). Review of the resident's admission MDS, dated [DATE], showed: - Mild cognitively impairment; - Impairment to both upper extremities; - Partial to moderate assist with sit to standing, transfers, and activities of daily living (ADLs). Review of the resident's Care Plan, dated 02/12/25, showed: - Functional decline in ADLS and requires partial/moderate to substantial/maximal assist with ADLS. Review of the resident's Nurse's Notes showed: - On 04/22/25 at 10:20 P.M., required assistance of one for transfers but the resident was noncompliant and transferred him/herself; - On 04/30/25 at 6:21 P.M., required partial/moderate assistance with upper body dressing, personal hygiene, toilet transfers, walking 10 feet in his/her room, and shower transfers. Observation on 04/30/25 at 1:54 P.M., of the resident's transfer from the wheelchair to the shower chair showed: - Certified Nursing Assistant (CNA) E did not put a gait belt around the resident's waist; - CNA E locked the wheelchair wheels and the shower chair wheels; - CNA E grabbed the back of the resident's pants at the waist with his/her left hand and put his/her right hand under the resident's left armpit; - CNA E pulled up on the resident to assist him/her to a standing position. The CNA guided the resident as he/she slowly shuffled to the wheelchair; - CNA E continued to hold onto the back of the resident's pants at the waist and under the resident's left armpit as he he/she lowered the resident into the shower chair. During an interview on 05/02/25 at 2:42 P.M., Registered Nurse (RN) C said a resident that required assistance with a transfer should always have a gait belt used. During an interview on 05/02/25 at 2:46 P.M., Licensed Practical Nurse (LPN) D said a gait belt should always be used when transferring a resident that didn't require a mechanical lift. During an interview on 05/02/25 at 2:51 P.M., CNA E said he/she would always use a gait belt with all transfers. During an interview on 05/02/25 at 4:10 P.M., the Director of Nursing (DON) said gait belts should be used for all transfers with residents that require assistance and not mechanical lifts. During an interview on 05/02/25 at 4:40 P.M., the Administrator said she would expect a gait belt to be used on residents that required assistance with transfers.

Based on observation, interview, and record review, the facility failed to ensure the resident's dignity was maintained while performing incontinence care for one resident (Resident #5) out of one sampled resident. The facility census was 98. Review of the facility's policy titled, Patient Rights, revised September 2024, showed: - We provide the resident with privacy; - Privacy is maintained during toileting, bathing, and other activities of personal hygiene, except when assistance is needed for safety and well being. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federal mandated assessment to be completed by the facility, dated 03/31/25, showed: - Dependent for toileting; - Dependent for personal hygiene; - Dependent for showering; - Sometimes understands others; - Makes self understood; - Diagnoses of anemia (a condition where the blood doesn't have enough red blood cells or enough hemoglobin to carry oxygen throughout the body), hypertension (the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood), dementia (a broad term encompassing various neurological conditions that cause a decline in cognitive abilities like memory, thinking, and reasoning), renal insufficiency (refers to the kidneys not functioning properly, meaning they are unable to filter waste products from the blood effectively), and depression (mood disorder characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly affect daily life). Observation on 05/01/25 at 2:30 P.M. showed Certified Nurses Assistant (CNA) E and CNA K performed incontinence care to Resident #5 with window blinds open and able to see outside patio for resident's and guest open. Several people passed by window during care. During an interview on 05/02/25 at 12:13 P.M., CNA E and CNA K said the window blinds should be closed in the resident rooms to avoid resident's bodies from being exposed during care. During an interview on 05/02/25 at 4:20 P.M., the Director of Nursing (DON) said they would expect windows blinds to be closed prior to care for a resident's dignity to be maintained during incontinence care.

Based on observation, interview, and record review, the facility failed to ensure two medication carts were locked while unattended out of a sample of three medication carts. This had the potential to affect all residents. The facility census was 98. Review of the facility policy titled, Medication Storage In The Facility, revised 02/25/25, showed: - Medication and biologicals are stored safely, securely, and properly; - Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1 Observations on 04/29/25 at 11:20 A.M. - 11:56 A.M., of the Hall D medication cart showed: - At 11:20 A.M., the unlocked and unattended medication cart sat against the outside of the nurse's station and faced D Hall. One staff nurse walked past the unlocked cart and one hospice nurse stood on the outside of the nurse's station counter 10 feet from the unlocked cart; - From 11:21 A.M. - 11:38 A.M., two residents and multiple staff walked past the unlocked and unattended medication cart 20 times; - From 11:38 A.M. - 11:44 A.M., the Director of Nursing (DON) walked through the nurse's station and past the unlocked and unattended medication cart five times; - From 11:39 A.M. - 11:44 A.M., nine staff walked past the unlocked and unattended medication cart; - At 11:40 A.M., Registered Nurse (RN) L walked to the unlocked and unattended medication cart, touched the top of the unlocked medication cart, walked inside the nurse's station, and sat down at a computer with his/her back to the unlocked and unattended medication cart; - The D Hall medication cart remained unlocked and unattended from 11:20 A.M.- 11:47 A.M., with multiple staff and two residents walking past it; - At 11:47 A.M., Certified Medication Technician (CMT) M walked up to the unlocked medication cart, sat paper and pens on top of the unlocked medication cart, walked away from the unlocked medication cart and left it unattended, walked to another medication cart on the A Hall side of the nurse's station, retrieved a laptop, returned to the unlocked D Hall medication cart, and moved the unlocked medication cart down the D Hall; - At 11:48 A.M., CMT M left the unlocked and unattended medication cart outside of Room D4 facing D Hall, retrieved the vital sign cart from outside of Room D2, moved the vital sign cart near the unlocked and unattended medication cart outside of Room D4, walked towards Room D2 and talked to Housekeeper P while the medication cart remained unlocked and unattended; - At 11:52 A.M., CMT M stepped into Room D3 and left the unlocked and unattended medication cart between Room D3 and D4 facing D Hall. CMT M returned to the unlocked medication cart, stepped back inside room D3 and left the unlocked medication cart unattended, talked to the resident, returned to the unlocked medication cart, unlocked the narcotic box, and retrieved medications; - At 11:56 A.M., CMT M locked the medication cart and returned to Room D3. 2. Observations on 05/02/25 at 11:02 A.M. - 11:05 A.M., of the A Hall medication cart showed: - At 11:02 A.M., the unlocked and unattended medication cart sat against the wall across from the nurse's station and faced the A Hall; - Licensed Practical Nurse (LPN) D assisted a resident across from the nurse's station; - At 11:05 A.M., Registered Nurse (RN) C walked to the unlocked and unattended medication cart from the dining room, opened the unlocked medication cart, and locked it. During an interview on 05/02/25 at 11:40 A.M., CMT G said every time the medication cart was stepped away from, it should be locked. During an interview on 05/02/25 at 11:44 A.M., LPN F said he/she tried to lock the medication cart when stepping away from it. During an interview on 05/02/25 at 11:47 A.M., RN C said when a person walked away from the medication cart, it should be locked. During an interview on 05/02/25 at 11:50 A.M., LPN D said anytime the medication cart was walked away from, it should be locked. During an interview on 05/02/25 at 4:20 P.M., the DON said medication carts should be locked anytime they were left unattended. During an interview on 05/02/25 at 4:40 P.M., the Administrator said medication carts should be locked anytime they were left unattended.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 83. Review of the facility's policy titled, Safe Food Storage, revised ,d+[DATE], showed: - To equip dietary partners with the knowledge and ability to properly store food items in a safe manner which preserves food quality; - All time/temperature control for safety (TCS), ready-to-eat food prepped in-house and leftover, cooked food items must be labeled with the following information: name of food item and the date by which it should be eaten or discarded; - Always discard in-house prepped food items made with previously cooled/stored food with the discard date of the previously cooked item; - Discard perishable leftovers within 7 days from original date prepped/cooked. Review of the facility's policy titled, Dry Storage, revised 2017, showed: - Dry storage areas will be designated and adequately maintained for storage of packaged or containerized bulk food that is not potentially hazardous, and dry goods such as single-service items; - Products that are not easily identified such as flour, sugar, salt, etc. should be be clearly tabled with the common name of the food when removed from original packages; - Foods that are readily and unmistakably recognized such as dry pasta, dried beans, rice, etc. need not be identified with a label. The facility did not provide a kitchen cleaning policy. Review of the daily cleaning tasks showed: - Sweep and mop floor or designate someone to do this; - Scrub, clean and sanitize three compartment sink; - Clean steamtable and delime. Observations made on [DATE] at 10:59 A.M., [DATE] 02:33 at P.M. and [DATE] at 8:05 A.M. of the right-side walk-in freezer across from the kitchen employee entrance, showed: - Six bags of frozen hoagie buns undated; - A bag of frozen thick sliced toast undated; - A large opened bag of frozen biscuits undated; - A container of frozen chili-like prepared food covered with a clear wrap undated and not labeled; - A large bag of breaded okra undated; - A large bag of tortellini undated; - Two zip-lock bags of frozen cornbread undated; - A large bag of fried-like pieces of an unidentifiable frozen food undated and not labeled; - Two opened bags of breaded patties undated; - A small opened bag of frozen biscuits undated; - An opened bag of frozen cookies undated. Observations made on [DATE] at 11:04 A.M., [DATE] at 2:36 P.M. and [DATE] at 8:13 A.M., of the kitchen, showed: - Three bags of cereal undated in the dry goods area; - A buildup of dirt and debris on the floors under the three compartment sink, a standup shelf containing baking and cooking pans by the ice machine, and the stove; - The three compartment sink with a buildup of a white residue on the front surface areas; - A build up of a white substance, dirt and debris on the floor under the ice machine; - A plastic tumbler (glass) and salt and pepper packets laid on the floor under the ice machine; - A buildup of a white residue on inside lid and outside surface areas of the ice machine; - Five lid covers and surface areas with a buildup of dried food and residue on the steam table. During an interview on [DATE] at 2:29 P.M., Cook G said the floors should be clean and free of dirt and debris. Food should be labeled and dated. Kitchen surfaces should be cleaned and not have a buildup of dried residue. He/she tries to clean as much as possible for the time worked in the kitchen. During an interview on [DATE] at 2:34 P.M., Cook H said the floors should be clean and free of dirt and debris. Food should be labeled, dated and kitchen surfaces should be cleaned and not have a buildup of dried residue. The floors could look better. During an interview on [DATE] at 2:39 P.M., Kitchen Aid I said the floors should be clean and free of dirt and debris, kitchen surfaces should be cleaned and not have a buildup of dried residue. Food should be labeled an dated so kitchen staff will know if its expired or needs to be thrown away. During an interview on [DATE] at 8:08 A.M., the Dietary Manager (DM) said he/she would expect the kitchen floors to be clean, free of dirt and debris and foods to be labeled and dated. Kitchen surfaces should be free of grime and residue buildup. The DM said the ice machine does need to be cleaned and was told by maintenance to get an outside vendor to clean it. During an interview on [DATE] at 8:24 A.M., the Administrator said she would expect the kitchen floors to be clean and free of dirt and debris. She said kitchen surface areas should be cleaned and not have a buildup of a dried residue. All foods should be labeled and dated.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 83. Review of the facility's policy titled, Homelike Environment, revised May 2017, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. - These characteristics include a clean, sanitary and orderly environment. Observations made on 03/12/24 at 2:22 P.M. and 03/13/24 at 11:24 A.M., of the G hall, showed: - Several areas of exposed sheetrock and peeled paint behind a recliner in room [ROOM NUMBER]; - Several scuff-marked areas on the lower part of the walls on the left and right side of the bathroom door in room [ROOM NUMBER]; - Several scuff-marked areas behind the headboard of the bed near the window in room [ROOM NUMBER]. - Several scuff-marked areas with peeled/cracked paint on the wall inside the bathroom near the toilet paper holder in room [ROOM NUMBER]; - A paper towel holder unsecured and coming out of the wall with minimal effort inside the bathroom in room [ROOM NUMBER]; - A large area of cracked and peeled paint on the the wall under the towel holder inside the bathroom in room [ROOM NUMBER]. - Several areas of peeled paint on the outside ceiling area of the exit door. Observations made on 03/12/24 at 2:42 P.M. and 03/13/24 at 3:44 P.M., of the F hall exit door, showed a buildup of cobwebs and peeled paint on the outside ceiling area . Observations made 03/12/24 at 2:49 P.M. and 03/13/24 at 3:50 P.M., of the E hall exit door, showed several areas of peeled paint on the outside ceiling area. Observations made 03/12/24 at 2:54 P.M. and 03/13/24 at 3:57 P.M., of the outside smoker's area, showed a buildup of cobwebs throughout the ceiling area under the awning. Observations made 03/14/24 at 2:30 P.M. and 03/15/24 at 8:30 A.M. showed: - A ceiling vent with a rust like substance in the middle hall near the private dining room; - A linear area with exposed wood the width of the door and a kick plate with dark markings and scrape lines throughout the storage room door across from the private dining room. Observations made 03/14/24 at 10:10 A.M. and 03/15/24 at 8:37 A.M., showed a buildup of dust and debris on a ceiling vent near the nurses' station and 100 hall. Observations made 03/14/24 at 12:30 P.M. and 03/15/24 at 8:39 A.M., of the A hall showed a two foot (ft.) x four ft. ceiling tile with a large and small brown water circle. Observations made 03/14/24 at 12:40 P.M. and 03/15/24 at 8:42 A.M., showed a buildup of dust and debris on two ceiling vents near the nurses' station at the beginning of C and D hall. Review of the maintenance request log dated, 02/07/24 thought 03/13/24, showed no current requests for areas of concern addressed. During an interview on 03/14/24 at 10:22 P.M., Housekeeper A said there is a maintenance request log at the nurse's station to write down any needed repairs or concerns to be addressed by maintenance. He/She has not seen anything recently to write down on the maintenance request log to be addressed. During an interview on 03/14/24 at 10:26 P.M., Housekeeper B said there is a maintenance request log at the nurse's station to write down any needed repairs or concerns to be addressed by maintenance. Sometimes he/she will verbally tell maintenance of things that need to be addressed. He/She has not seen anything recently to write down on the maintenance request log to be addressed. During an interview on 03/14/24 at 10:32 P.M., Housekeeper C said there is a maintenance request log at the nurse's station to write down any needed repairs or concerns to be addressed by maintenance. He/She has not seen anything recently to write down on the maintenance request log to be addressed but has reported concerns in the past. During an interview on 03/15/24 at 9:11 A.M., Housekeeper C said the housekeeping department is responsible for cleaning the ceiling vents and the vents are on the monthly cleaning schedule. During an interview 03/15/24 at 8:02 A.M., Maintenance Assistant D said he/she would expect staff to write down any repairs or concerns that needed to be addressed regarding homelike environment. He/she said the outside ceilings of exit doors is the responsibility of the maintenance department and should not have a buildup of cobwebs or areas of peeled paint. During an interview on 03/15/24 at 8:16 A.M., the Administrator said she would expect staff to write down needed repairs for maintenance to address in a timely manner. She would expect maintenance to address environmental issues outside the building such as cobweb buildup and peeled paint.

Based on interview and record review, the facility failed to provide restorative services for four residents (Residents #1, #13, #19 and #60) out of six sampled residents. The facility census was 83. Review of the facility's policy titled, Nursing Policies, dated 02/2023, showed: - An active program of restorative nursing care will be directed toward assisting each patient to achieve and maintain his or her highest level of self-care and independence. Self-care is encouraged in all patients to the degree possible. Assistive devices may be provided based on assessed needs of the individual patient. - Restorative nursing services are available to all patients. The services are provided by a licensed nurse, a certified nursing assistant, a temporary nurse aide, or other staff who are specifically trained in restorative services. Some centers may elect to have licensed rehabilitation professionals perform repetitive exercises and other maintenance treatments or to supervised aides performing these maintenance services. Services available include: range of instruction to patient on safe and effective transfer techniques, body mechanics, proper bed positioning, assistance with activities of daily living, and bladder and bowel training. The patient plan and/or physician orders determine which services are provided to patients. 1. Review of Residents #1's medical record showed: - admitted [DATE]; - Diagnoses of fracture (partial or complete break in the bone) of other and unspecified parts of lumbar (lower back) spine and pelvis, and Sjogren syndrome (diseases of the musculoskeletal system and connective tissue). Review of resident's Physician order sheet (POS) dated, 01/30/24, showed; - Restorative therapy to ambulate three times per week. Review of Resident #1's significant change Minimum Data Set (MDS) (a federally mandated assessment instrument, completed by facility staff), dated 01/05/24, showed; - Impairment of upper and lower extremities both sides; - Partial/moderate assistance with eating, oral hygiene, upper and lower body dressing, putting on and taking off footwear, personal hygiene, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub shower transfer; - Substantial/maximal assistance with toileting hygiene and shower/bathe self. Review of the resident's physical therapy (PT) documentation, dated 10/23/23, showed: - Received skilled services from 01/02/23 through 01/30/24; - Discharge plan to remain in skilled facility with restorative nursing program. Review of restorative program documentation, dated January 2024 through March 2024, showed: - Restorative therapy to ambulate three times per week; - The last date staff provided restorative was documented as 02/24/24; - No restorative documentation for March 2023. During an interview on 03/12/24 at 10:48 A.M., Resident #1 said he/she should be receiving restorative care routinely, but the facility's restorative nurse aide (RNA) is often pulled to another floor for staffing and hasn't had restorative therapy in a long time. 2. Review of Resident 13's medical record showed: - admitted [DATE]; - Diagnoses of hyperlipidemia (high blood level of cholesterol), hemiplegia (paralysis on one side of the body after a stroke), epilepsy (a disorder of the brain characterized by repeated seizures), anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (common mental disorder that involves a depressed mood or loss of pleasure or interest in activities for long periods of time), and asthma (a condition in which your airways narrow and swell and may produce extra mucus). Review of resident's Physician order sheet (POS) dated, 06/06/23, showed; - Restorative therapy to ambulate 3 times per week. Review of the resident's significant change MDS, dated [DATE], showed; - Impairment on one side; - Independent with eating; - Required supervision/touching assistance with oral hygiene and upper body dressing; - Dependent with lower body dressing, putting on and taking off footwear, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub shower transfer, toileting hygiene and shower/bathe self. Review of the resident's occupational therapy (OT) documentation, dated 03/21/23, showed: - Received skilled services from 03/21/23 through 05/31/23; - Discharge plan to remain in skilled facility with restorative nursing program. Review of the resident's restorative program documentation, dated, January 2024 through March 2024 showed: - Restorative therapy to ambulate three times per week; - Last day of restorative therapy received on 02/13/24. - No restorative documentation for March 2023. 3. Review of Resident #19's medical record showed: - admitted [DATE]; - Diagnoses of unspecified fracture of upper end of left tibia (shin bone), other fracture of upper end of left tibia, other fracture of upper and lower end of left fibula (calf bone), other fracture of upper and lower end of left fibula, other fracture of upper and end of left tibia, unspecified fracture of upper end of left tibia, history of falling, congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs) and long-term use of an anticoagulant (blood thinner). Review of the resident's quarterly MDS, dated [DATE], showed: - Supervision or touching assistance with ability to walk at least 10 feet in a room, corridor or similar space once standing; - Partial/moderate assistance with ability to walk 50 feet and make two turns once standing; - Partial/moderate assistance with ability to walk 150 feet in a corridor or similar space once standing. During an interview on 03/12/24 at 2:21 P.M., the resident said he/she would like to continue restorative services. The resident said he/she was receiving skilled therapy in February, but his/her insurance had ran out. The resident said a girl had been walking him/her for exercise in the hall and dining room, but hasn't seen her or had any exercises in a couple of weeks. During an interview on 03/14/24 at 3:32 P.M., the resident said he/she hasn't had any one come in this week to do exercises with him/her but would like it to continue if he/she could. Review of the resident's physical therapy discharge summary, dated 02/15/24, showed: - Received skilled services from 11/02/23 through 02/13/24; - Therapy recommendations to discharge to restorative for walking program multiple times per week; - Ambulation program with front forward walking (FWW) and gait belt (an assistance safety device than can be used to help a patient sit, stand or walk around, as well as to use to transfer) in hallway four times per week; - Bed mobility, transfers, level surfaces, uneven surfaces with supervision. Review of the resident's restorative program documentation, dated January 2024 through March 2024, showed: - Restorative therapy to ambulate four times per week; - Last day of restorative therapy received on 02/24/24; - No restorative documentation for March 2023. During an interview on 03/13/24 at 3:26 P.M., the Director of Rehab (DOR) said Resident #19 was discharged from skilled services on 02/13/24. A care plan meeting over the phone was done with the resident and the resident's son. It was agreed that the resident would continue therapy recommendations for restorative services. The RNA has been working the floor lately and has not been able to do restorative exercises. The administrator and/or Director of Nursing (DON) reviews and signs off on the residents receiving restorative services. 4. Review of Resident #60's medical record showed: - admitted [DATE]; - Diagnoses of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), bipolar disease (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs), anxiety disorder (a persistent and excessive worry that interferes with daily activities), arthritis (inflammation or swelling of one or more joints), femur (thigh bone) hip fracture, peripheral vascular disease(PVD) (a slow and progressive circulation disorder), renal insufficiency (poor function of the kidneys that may be due to a reduction in bloodflow to the kidneys), gastroesophageal reflux disease (GERD) (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and esophagus (stomach), hypertension (HTN) (high blood pressure), atrial fibrillation (irregular heartbeat), and coronary artery disease (CAD) (plaque buildup in the wall of the arteries that supply blood to the heart). Review of resident's Physician order sheet (POS) dated, 10/07/22, showed; - Restorative therapy to ambulate three times per week. Review of the resident's annual MDS dated [DATE], showed; - Impairment on one side; - Independent with eating; - Set up/clean up assistance with oral hygiene; - Substantial/maximal assistance with upper body dressing; - Dependent with lower body dressing, putting on and taking off footwear, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toileting, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub shower transfer, toileting hygiene and shower/bathe self. Review of the resident's PT and OT documentation, dated 09/19/22, showed: - Received skilled services from 09/20/22 through 10/06/22; - Discharge plan to remain in skilled facility with restorative nursing program. Review of the resident's restorative program documentation, dated January 2024 through March 2024, showed; - Restorative therapy to ambulate three times per week; - Last day of restorative therapy received was on 02/24/24. - No restorative documentation for March 2023. During an interview on 03/14/24 at 4:35 P.M., the Administrator said she would expect residents to receive restorative therapy as physician ordered weekly or recommended. The facility's restorative aide is not here to be interviewed at this time, but he/she has been pulled to other areas of the facility to work due to being short staffed at times. During an interview on 03/19/24 at 9:53 A.M., RNA J said the last date restorative services for any facility resident was given by him/her was on 02/25/24.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for two out of two nurse aides sampled and for Abuse Prevention for one out of two nurse aides sampled. The facility census was 83. 1. Record review of the facility's 2023 in-service records showed: - Certified Nurse Aide (CNA) E with a hire date of 07/13/2021; - CNA E attended a total of eight hours and 45 minutes of in-services; - CNA E did not attend an annual competency in-service on Dementia Care. 2. Record review of the facility's 2023 in-service records showed: - CNA F with a hire date of 10/03/2022; - CNA F attended a total of one hour of in-service; - CNA F did not attend an annual competency in-service on Dementia Care; - CNA F did not attend an annual competency in-service on Abuse Prevention. During an interview on 03/15/2024 at 9:45 A.M. the staffing coordinator said she was responsible for monitoring the in-services for all staff. She said the staff completed face to face in-services as well as the computerized program. During an interview on 03/15/2024 at 11:31 A.M., the Administrator said she was aware of the required nurse aide training and would look into the concern further. The facility did not provide a policy.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident #39) out of three sampled residents. The facility census was 74 . 1. Record review of Resident #39's SNF ABN form showed: - The resident discharged from skilled Medicare services on 6/25/22, and remained in the facility; - The resident received and signed the form on 6/27/22; - The facility failed provide the SNF ABN form to the resident at least two calendar days before the skilled Medicare services ended. During an interview on 8/19/22 at 10:49 A.M., the Administrator said the Social Services Director (SSD) was responsible for the ABN's and he/she has been out for about three months for an illness and it just got missed. The admission coordinator was filling in also. She said it should have been signed prior to 6/25/22. The facility did not provide a policy.

Based on observation, interview, and record review, the facility failed to monitor and keep one resident's (Resident #19) equipment in good, working order. The facility also failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 74. 1. Observations showed: - On 8/16/22 at 9:40 A.M., 8/18/22 at 11:00 A.M., and on 8/19/22 at 10:15 A.M., Resident #19's geri chair (a medical recliner chair designed to allow resident to get out of bed and to be able to sit comfortable in a variety of positions while being fully supported) left arm rest with plastic covering, torn one and one-half inches by three inch area with the outer side of the arm rest torn open with foam exposed; - The resident's geri chair right arm rest with a two inch by three inch torn area of the plastic covering with the outer side opened with exposed foam and the front area opened with exposed metal; - The resident's fall mat lay on the floor with several tattered and torn areas with the foam exposed. During an interview on 8/19/22 at 10:20 A.M., Certified Nurse Aide (CNA) E said when staff sees something torn up or in need of repair, it should be reported to maintenance or there was a maintenance log book staff can write in. CNA E said he/she had not looked at the resident's chair or fall mat today. 2. Observations on 8/16/22 at 10:57 A.M., of B Hall showed: - Room B04 with the wall by window and right side of bed with several areas of exposed sheet rock and no paint; - Room B07 with the right side of wall in bathroom next to the toilet with several areas of exposed sheet rock and no paint; - Room B14 with the wall by window and behind headboard with several areas of exposed sheet rock and no paint; - Room B14 with the wall by door and behind headboard with several areas of exposed sheet rock and no paint. 3. Observation on 8/16/22 at 11:14 A.M., of private dining room located on F Hall showed: - The ceiling area approximately 24 inches long with surface peeling of the cracked seam near the recessed lighting fixture. 4. Observations on 8/19/22 at 10:25 A.M., of the bathroom shared between rooms A12 and A13 showed: - Bathroom doorframe on left side of the toilet and the bathroom wall on the right side of the toiled shared between Rooms A12 and A13 with several areas of chipped paint; - Bathroom ceiling vent shared between Rooms A12 and A13 with dust and debris buildup. Record review of Housekeeping Work Report log, dated 3/22/22 through 8/19/22, showed: - Observations not addressed. Record review of Maintenance Work Report log, dated 8/5/22 through 8/17/22, showed: - Observations not addressed. During an interview on 8/19/22 at 8:13 A.M., Housekeeper A said that if he/she observes something that needs repair, a request was written down on the housekeeping work report log or the maintenance report work log. During an interview on 8/19/22 at 8:13 A.M., CNA B said if he/she observes something that needs repair, a request was written down on the housekeeping work report log or the maintenance report work log. During an interview on 8/19/22 at 8:18 A.M., Licensed Practical Nurse (LPN) C said if he/she observes something that needs repair, a request was written down on the housekeeping work report log or the maintenance report work log. LPN C said the maintenance report log and the housekeeping report log was kept in a designated room located across from the nurse's station for staff to request repairs. During an interview on 8/19/22 at 8:25 A.M., Maintenance Associate D said if anyone has a request for a repair or other concern, it should be written down on the housekeeping work report log or the maintenance work report log to be addressed in a timely manner. During an interview on 8/19/22 at 11:32 A.M., the Administrator said she would expect staff to report and write down any repair needed or concern identified on the maintenance report request log or the housekeeping report request log. The facility did not provide a policy.

Based on observation, interview and record review the facility failed to document, measure, stage and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 82 . 1. Record review of the facility Skin Integrity manual, revised strategies for interventions/risk assessment interventions showed: - Based on the Braden Scale Risk Assessment and individual patient needs- implement appropriate interventions; - Consider each patients individual preferences and psychosocial needs in the development of the patient plan of care; - Physician receives accurate assessment data to assure that orders are appropriate to the staff and condition of the pressure ulcer. Orders are implement, promptly and the physician is kept informed of wound progress and or lack thereof. Record review of the facility undated Wound Policy, directs staff to: - At anytime during a skin assessment,admission body assessment, or any reporting of altered skin integrity of any resident, the nurse's responsibility is to incorporate a treatment plan and or intervention; - The nurse should report the findings to the wound care nurse for evaluation. 2. Record review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 5/12/2021 showed: - admitted to facility on 3/2/17; - Moderately impaired cognitive skills; - No rejection of care; - Requires assist of two staff for bed mobility, dressing, toileting and personal hygiene; - Total dependence upon staff for transfer and bathing; - Incontinent of bowel; - Indwelling catheter (a tube placed into the bladder for urine to drain into a bag); - At risk for pressure ulcer; - No pressure ulcer and or other skin impairments; - Pressure reducing mattress for bed; - No pressure reducing pad to wheelchair. Record review showed: - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 't pump blood as well as it should). Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - No orders for skin care. Record review of the Braden Scale (an instrument used to determine if at risk for skin breakdown and or pressure ulcers based upon score) dated 6/3/2021, showed: - A score of 16 (score of 15-18 indicates at risk for developing pressure ulcer). Record review of Resident #1's care plan dated on 6/1/2021, showed: - No interventions for being at risk for pressure ulcer and or skin breakdown. Record review of the nurses notes dated 7/16/2021 through 8/11/2021, showed: - On 8/9/2021 red area to peri area/buttocks; - No further documentation of skin condition. Record review of the Weekly Skin Assessments showed: - On 7/16/2021, current pressure ulcer risk score 16, wound/open/red area, peri area, no measurements of affected areas or of surrounding tissue. No interventions for pressure reducing device in bed and or chair; - On 7/25/2021, current pressure ulcer risk score 16, wound/open/red area, redness to peri area, right and left buttocks, no measurements of affected areas or of surrounding tissue. No interventions for turning and repositioning in bed and or positioning/repositioning in chair; - On 7/28/2021 current pressure ulcer risk score 16, wound/open/red area, peri area, right and left buttocks, no measurements of affected areas or of surrounding tissue, no interventions of pressure reducing device in bed and or chair, no positioning/repositioning in chair; - On 8/5/2021 current pressure ulcer risk score 16, wound/open/red area, peri area, right and left buttocks, no measurements of affected areas or of surrounding tissue. No interventions of pressure reducing device in bed and or chair; - On 8/10/2021 current pressure ulcer risk score 16, wound/open/red area, red right and left buttocks, no measurements of affected areas or of surrounding tissue. No interventions of pressure reducing device in bed and or chair. No interventions for turning and repositioning in bed and or positioning/repositioning in chair. Observations of Resident #1 on 8/11/2021, showed: - At 9:40 A.M. staff transferred resident with use of Hoyer lift to wheelchair, with no pressure relieving device and or pad in wheelchair; - At 10:45 A.M. Resident #1 sat in wheelchair without a pressure relieving device and or pad; - At 11:20 A.M., accompanied by the Director of Nursing (DON), showed Resident #1 lay in bed, noted on right buttocks a 1.5 centimeter (cm) x 0.5 cm open friction wound, right gluteal fold 1.5 cm x 1.5 cm an open friction wound, and on dorsal side of scrotum a 2 cm x 0.1 cm Stage 2 pressure ulcer. During an interview on 8/11/2021 at 9:45 A.M., Certified Nurse Assistant (CNA) A stated the resident does not have a cushion for his/her wheelchair at this time and is unsure if he/she ever had one. The CNA stated the residents buttocks are red and he/she is unsure if there are any open wounds. During an interview on 8/11/2021 at 10:30 A.M., the DON said Resident #1 does not have a cushion or pressure relieving device in the wheelchair at this time, he/she is not up often in the wheelchair, if he/she does begin to get up more often a cushion would be placed, the resident is not a concern at this time. During an interview on 8/11/2021 at 10:45 A.M., Resident #1 said his/her butt was burning and was unsure if staff had put medication on it although he/she stated he/she reported to the staff his/her butt hurts. The resident denies having a cushion in chair and is not able to say whether or not he/she had ever had one in the past. During an interview on 8/11/2021 at 11:35 A.M., the DON said he was not aware of the resident having any skin issues. The nurses are to report to him weekly or as needed regarding any break in skin for all residents including any macerations, friction wounds and or pressure ulcers. He said the nurses are able to place interventions at any time the need arises for residents and would have expected to see if the resident developed skin concerns a pad placed in the resident wheelchair. The DON said the resident should have had interventions on the care plan due to him/her being identified at risk by the Braden Scale assessment performed by nursing staff. During an interview on 8/11/2021 at 2:05 P.M., Licensed Practical Nurse (LPN) B said he/she had observed the resident's buttocks the day prior, but did not notice any open wounds and/or pressure ulcers. LPN B said the resident may have had a pressure relieving device in the wheelchair at one time but is unsure. He/she said a pressure relieving device should be in the wheelchair due to the resident is unable to ambulate or reposition self appropriately. MO 1

Based on observation, interview, and record review, the facility failed to obtain a physician's order for attendance at an off-site psychiatric day program for one resident (Resident #43) out of 21 sampled residents. The facility's census was 103. Record review of Resident #43's Physician's Order Sheet (POS), dated 11/1/19 - 11/22/19, showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. to perform everyday activities), major [MEDICAL CONDITION] (a mood disorder that interferes with daily life), and anxiety disorder (persistent and excessive worry about activities or events, even ordinary, routine issues); - No order for off-site psychiatric services or attendance at a day program. Record review of the resident's quarterly Minimum Data Set (MDS; a federally mandated assessment to be completed by the facility staff), dated 9/19/19, showed no psychiatric services in place. Observation on 11/19/19 at 9:54 [NAME]M., showed resident to be absent from facility. During an interview on 11/19/19 at 10:00 [NAME]M., Registered Nurse (RN) [NAME] said the resident attends group therapy twice a week offsite. Record review of the social worker note, dated 6/28/19, at 4:48 P.M., showed: - He/she is seen by nurse practitioner for psychiatric services at facility; - He/she also continues to go to a clinic 3 times weekly for group activities, counseling. Record review of the social worker note, dated 8/9/19, at 2:19 P.M., showed he/she continues to go to day counseling therapy 2-3 times per week. Record review of Social Services note, dated 11/20/19, showed Psychiatric Clinic called this morning to let us know they have increased patient's days at the clinic for participation from two days per week to three times weekly. This week he/she will go Monday, Thursday and Friday. Information given to nursing. During an interview on 11/21/19 at 11:58 [NAME]M., the Director of Nursing (DON) said she would expect there to be an order for [REDACTED]. The facility did not provide a policy for obtaining physician orders. A typed document, dated 11/21/19, titled Physician Orders Protocol provided by the facility showed Physician orders are obtained from the physician by the nurse. Orders are entered into the matrix system by the nurse as they are received. We then electronically transfer the orders to Network Pharmacy where they are filled.

Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital for eight residents (Resident #14, #35, #36, #43, #44, #48, #60, and #67) out of 21 sampled residents. The facility's census was 103. 1. Record review of Resident #14's Progress Notes showed: - The resident was transferred to the hospital on [DATE] and readmitted on the same day; - The resident was transferred to the hospital on [DATE] and readmitted on the same day; - The resident was transferred to the hospital on [DATE] and readmitted on the same day; - The resident was transferred to the hospital on [DATE] and readmitted on the same day. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 2. Record review of Resident #35's Progress Notes showed: - The resident was transferred to the hospital on [DATE] and readmitted on [DATE]; - The resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 3. Record review of Resident #36's Progress Notes showed: - The resident was transferred to the hospital on [DATE] and readmitted on [DATE]; - The resident was transferred to the hospital on [DATE] and readmitted on [DATE]; - The resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 4. Record review of Resident #43's Progress Notes showed the resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 5. Record review of Resident #44's Progress Notes showed the resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 6. Record review of Resident #48's Progress Notes showed the resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 7. Record review of Resident #60's Progress Notes showed the resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 8. Record review of resident #67's Progress Notes showed the resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Record review of the resident's medical record did not contain documentation to show the resident was prepped and oriented for transfer out of the facility. 9. During an interview on 11/21/19 at 11:58 [NAME]M., the Director of Nursing (DON) said she would expect documentation that a resident has been prepared and oriented for transfer to the hospital. 10. The facility did not provide a policy for preparation and orientation for transfer.

Based on interview and record review, the facility failed to implement an individualized comprehensive care plan for three residents (Resident #21, #27, and #296) out of 21 sampled residents. The facility's census was 103. 1. Record review of Resident #21's physician's orders [REDACTED]. -- Resident admitted on [DATE]: - [DIAGNOSES REDACTED]. - Order dated 8/26/19 for pain assessment every shift; - Order dated 11/5/18 for [MEDICATION NAME] (pain/fever medication) tablet 500 milligrams (mg), two tablets every six hours as needed for pain and temperature; - Order dated 3/25/19 for [MEDICATION NAME]-[MEDICATION NAME] (pain medication) 10-325 mg, one tablet three times a day as needed. Record review of the resident's quarterly Minimum Data Set (MDS; a federally mandated assessment to be completed by the facility staff), dated 8/13/19, showed the resident received opioid pain medications seven of seven days. Record review of the resident's comprehensive care plan, dated 8/29/19, showed no care plan and interventions for pain. 2. Record review of Resident #27's POS, dated 11/21/19, showed: - Resident was admitted on [DATE]; - [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (formation of a blood clot) and embolism (blocking of an artery); - Order written on 11/4/19 for [MEDICATION NAME] time (PT; lab test to measure how much time it takes for blood to clot) and international normalized ratio (INR; lab test to measure how much time it take the blood to clot-to check the effectiveness of blood clotting medications/treatments), weekly on Mondays, twice a day on Monday, 5:00 [NAME]M. and 5:00 P.M. Record review of the resident's medical record showed: - The resident was discharged on [DATE] return not anticipated; - On 11/18/19 [MEDICATION NAME] (anticoagulant, blood-thinning medication to prevent blood clots) to be held for three days and recheck labs on Thursday. Record review of the resident's comprehensive care plan, dated 11/7/19, showed the facility staff did not develop a current, accurate comprehensive care plan to address the use of the anticoagulant and place interventions for the previous admission on 7/30/19 and current admission on 11/3/19. 3. Record review of Resident #296's POS, dated 11/21/19, showed: - Resident was admitted [DATE]; - [DIAGNOSES REDACTED]. - Order written on 11/14/19 for [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday; - Order written on 11/18/19 clean site to coccyx with wound cleanser, apply [MEDICATION NAME] ag and pink allvyn dressing every 72 hours and as needed. Record review of the resident's comprehensive care plan, dated 11/18/19, showed the facility staff did not develop a comprehensive care plan to address [MEDICAL TREATMENT] and the pressure ulcer or place interventions 4. During an interview on 11/21/19 at 11:58 [NAME]M., the Director of Nursing (DON) said she would expect a resident on [MEDICAL TREATMENT] to have a care plan for [MEDICAL TREATMENT]. A resident with chronic pain should have a care plan for pain. A resident with a pressure ulcer should have a care plan for the care of the pressure ulcer. The DON said if a resident was discharged in (MONTH) with return not anticipated and readmitted in November, the resident should have a new comprehensive care plan initiated. 5. The facility did not provide a policy for care plans. An undated, untitled, typed document provided by the facility showed the facility Care Plan Completion Times to be completed on the 14th day of the admitted or sooner, annually, and quarterly.

Based on record review and interview, the facility staff failed to check, prior to hire, the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect), for two of five sampled staff. The facility census was 114. Record review of the facility's undated policy on checking the Nurse Aide Registry, showed the Nurse Aide Registry should be checked prior to hire date. Review of the facility personnel records showed: - CNA A hired on 12/05/18, the CNA Registry check had no date requested; - Housekeeping Staff (HKS) B hired on 9/20/18, the CNA Registry check had no date requested. During an interview on 1/23/19 at 4:10 P.M., the Licensed Practical Nurse (LPN) C said: - The date on the CNA registry request form for the two staff for some reason did not print; - Sometimes the date is not printed on the request form, but they will start to ensure the date is on the request form.

Based on interview and record review, the facility failed to conduct care plan meetings and include the resident and/or the resident's legal representative for six residents (Resident #4, #12, #19, #74, #99, and #103) out of 24 sampled residents. The facility census was 114. 1. During an interview on 1/22/19 at 11:08 A.M., Resident #4 said he/she had never been invited to a care plan meeting. He/she said no one had ever mentioned one to him/her or his/her spouse. Record review of the resident's care plan, dated 10/30/18, showed: - Signature for the Social Services Director (SSD); - Signature for the Registered Dietitian (RD); - Signature of the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff) Coordinator; - The care plan did not include the resident's or a family member signature. 2. During an interview on 1/22/19 at 3:10 P.M., Resident #12 said he/she did not think he/she had ever been invited or attended a meeting where the resident's care or plan of care had been discussed. Record review of the resident's care plan, dated 11/01/18, showed: - Signatures for the SSD, the Activities Director (AD), and the MDS Coordinator; - The care plan did not include the resident's or a family member's signature. 3. During an interview on 1/22/19 at 10:59 A.M., Resident #19's family representative said he/she did not believe the family had ever had any participation in the resident's care except for hospice. The resident is now on hospice and the family thought hospice to be in charge of the resident's care. Record review of the resident's care plan, dated 11/06/18, showed: - Care plan last updated 12/28/18; - Signatures for the SSD, the RD, the AD, the MDS Coordinator, and the hospice Registered Nurse (RN); - The care plan did not include the resident's or a family member's signature. 4. During an interview on 1/23/19 at 9:20 A.M., Resident #74 said he/she hasn't been invited or attended a care plan meeting. He/she said his/her family would attend a care plan meeting, but as far as he/she knows, they have not been invited to one either. Record review of the resident's care plan, dated 12/27/18, showed: - Signatures of the SSD, the RD, the AD, and the MDS Coordinator; - The care plan did not include the resident's or a family member's signature. 5. During on interview on 1/22/19 at 3:30 P.M., Resident #99 said he/she has not been invited to any meetings by the Director of Nursing (DON) or the SSD to discuss his/her care at the facility. Record review of the resident's care plan, last updated on 1/15/19, showed: - Signatures of the SSD, the RD, the AD, and the MDS Coordinator; - The care plan did not include the resident's or a family member's signature. 6. During an interview on 1/22/19 at 3:00 P.M., Resident #103 said as far as he/she knew he/she had only been invited one time to a care plan meeting and it had been a really long time ago. Record review of the resident's care plan, dated 1/15/19, showed: - Signatures of the SSD, the RD, the AD, and the MDS Coordinator; - The care plan did not include the resident's or a family member's signature. During an interview on 1/23/19 at 1:22 P.M., the SSD said that he/she does not have a form letter or any way of documenting when he/she invites a resident or family member to have a meeting about the resident's care plan. He/she does not hold a care plan meeting with the resident on a quarterly basis, only on an as needed basis, or when the resident or family requests a meeting. During an interview on 1/23/19 at 3:03 P.M., the MDS Coordinator said he/she is not the one who schedules care plan meetings with the resident or family members, that he/she attends the meeting if he/she is asked to be there by the SSD. During an interview on 1/24/19 at 5:08 P.M., the DON said she would expect the residents and/or the resident representatives to be invited to the resident's scheduled care plan meetings. Record review of the facility's Care Plan Meeting policy, undated, showed: - Care plan meetings will be held twice weekly on Tuesdays and Thursdays; - The MDS Coordinator sets the schedule for the comprehensive care plan; - The MDS Coordinator will be responsible to inform the interdisciplinary team when the meeting will be held; - The meeting times should be communicated at least one week in advance; - The Social Worker will be responsible to invite the patient or the patient representative.

Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident (Resident #88) out of a sample of 24. The facility census was 114. 1. Record review of Resident #88's significant change Minimum Data Set (MDS) (a federal mandated assessment to be completed by the facility), dated 12/21/18, showed: - Severely impaired cognitive skills; - Sometimes understands others; - Rarely understood; - [DIAGNOSES REDACTED]. Observation on 1/25/19 at 9:16 A.M., showed: - Certified Nursing Assistant (CNA) D pushed the resident down the hall; - The resident sat in a shower chair (a chair with a commode seat and open sides), with his/her back curved over, head bowed down, arms bent and drawn up to the torso, legs dangling, and no support for the feet; - A thin shower cape (a hooded towel) partially covered the resident, leaving him/her exposed from from the mid-thigh down and no covering on the feet; - The resident's skin and veins could be seen through the thin shower cape; - The resident's arms and legs visually shaking. During an interview on 1/25/19 at 9:25 A.M., CNA D said he/she usually brings Resident #88 to the shower room with a hooded shower cape on because the resident is hard to stand and transfer in the shower room. CNA D said he/she does not always use an additional sheet to make sure the resident is completely covered. CNA D said the shower cape is supposed to cover the residents. During an interview on 1/25/19 at 9:35 A.M., the Director of Nursing, (DON), said residents are transported from their rooms to the shower room with a shower cape on them. If the resident is unable to stand on their own they are transferred to the shower chair, given a shower cape then transported to the shower room in the shower chair. The DON said the shower cape used to cover Resident #88 was too thin and should no be used. Record review of the facility's procedure to transport patients to the shower, undated, showed: - Patients may be transported to the shower room by shower chair; - A shower cape to be used to cover the patient when the patient not clothed.

Based on interview and record review, the facility failed to issue Notice of Medicare Non-Coverage (NOMNC) letters when a resident's Medicare covered services had ended for three residents (Resident #74, #262, and #263) out of three sampled residents. The facility census was 114. 1. Review of Resident #74's medical record showed: - The resident discharged from Medicare A skilled services on 12/13/18 and days remained in the benefit period; - The facility failed to issue a NOMNC letter. 2. Review of Resident #262's medical record showed: - The resident discharged from Medicare A skilled services on 10/31/18 and days remained in the benefit period; - The facility failed to issue a NOMNC letter. 3. Review of Resident #263's medical record showed: - The resident discharged from Medicare A skilled services on 12/12/18 and days remained in the benefit period; - The facility failed to issue a NOMNC letter. During an interview on 1/23/19 at 2:40 P.M., the Social Service Designee (SSD) said he/she doesn't serve the residents with a NOMNC letter, only the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) forms, when discharged from Medicare A skilled services. He/she didn't know the NOMNC letter had to be served to the residents or resident representatives prior to discharge from Medicare A skilled services. During an interview on 1/24/19 at 5:06 P.M., the Administrator said he would expect the correct Medicare A skilled forms to be completed and served to the resident or the resident's representative prior to a resident being discharged from Medicare A skilled services. Record review of the facility's American Association of Nurse Assessment Coordination Beneficiary Notice Guidelines, dated (YEAR), showed: - A NOMNC letter required when the facility determined the beneficiary no longer required daily skilled services and days remained in the benefit period.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Resident #19, #21, and #72) with hospice services (palliative care for the terminally ill with a life expectancy of six months or less) out of three sampled residents. The facility's census was 114. 1. Record review of Resident #19's medical record showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. to perform everyday activities); - admitted to hospice on 10/05/18. Record review of the resident's significant change MDS, dated [DATE], did not show the resident had a life expectancy of six months or less. 2. Record review of Resident #21's medical record showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. - admitted to hospice on 10/26/17. Record review of the resident's annual MDS, dated [DATE], did not show the resident had a life expectancy of six months or less. 3. Record review of Resident #72's medical record showed: - admitted on [DATE]; - [DIAGNOSES REDACTED]. - admitted to hospice on 11/26/18. Record review of the resident's significant change MDS, dated [DATE], did not show the resident had a life expectancy of six months or less. During an interview on 1/24/19 at 4:06 P.M., the MDS Coordinator said he/she doesn't always mark a life expectancy of six months or less for a hospice resident on the MDS due to he/she rarely sees where a doctor has documented it. Also, he/she thought that this section was no longer on the new version of the MDS. During an interview on 1/24/19 at 5:07 P.M., the Director of Nursing (DON) said she would expect the MDS to be completed accurately. She would expect the MDS to show a hospice resident to have a life expectancy of six months or less due to the hospice physician documents this information and it is located in the hospice residents' charts. Record review of the facility's procedure for MDS accuracy, showed the MDS will be filled out by following the Resident Assessment Instruction Manuel per Center for Medicare and Medicaid Services guidelines.