Every finding on record at Ochsner Medical Center Skilled Nursing Facility

Based on interviews and record reviews, the facility failed to ensure residents who received psychotropic medications were adequately monitored for targeted behaviors for 4 (Resident #6, Resident #12, Resident #182, Resident #186) of 5 (Resident #6, Resident #12, Resident #29, Resident #182, Resident #186) sampled residents reviewed for unnecessary medications. Findings: Resident #6 Review of Resident #6's medical record revealed, in part, Resident #6 was admitted to the facility on [DATE] with diagnoses including depression and anxiety disorder. Review of Resident #6's Minimum Data Set with an Assessment Reference Date of 02/19/2025 revealed, in part, Resident #6 received medications for depression and anxiety. Review of Resident #6's March 2025 Physician's orders revealed, in part, orders for: - Bupropion (a medication used to treat depression) tablet 150 milligrams (mg) by mouth daily; and, - Clonazepam (a medication used to treat anxiety) tablet 0.5 mg by mouth twice daily. There was no documented evidence, and the facility was unable to present any documented evidence, Resident #6 was evaluated for targeted behaviors and/or adverse consequences of psychotropic medications. Resident #12 Review of Resident #12's medical record revealed, in part, Resident #12 was admitted to the facility on [DATE] with diagnoses including depression and anxiety disorder. Review of Resident #12's Minimum Data Set with an Assessment Reference Date of 02/18/2025 revealed, in part, Resident #12 received medications for depression and anxiety. Review of Resident #12's March 2025 physician's orders revealed, in part, and order dated 02/14/2025 for fluoxetine (a medication used to treat depression) 20 mg capsule by mouth nightly. Review of Resident #12's care plan with a start date of 02/11/2025 revealed, in part, Resident #12's care plan had a care plan for depression with no approaches related to antidepressant medication therapy and/or monitoring for targeted behaviors and/or adverse consequences of antidepressant medications. There was no documented evidence, and the facility was unable to present any documented evidence, Resident #12 was evaluated for targeted behaviors and/or adverse consequences of psychotropic medications. In an interview on 03/06/2025 at 4:15PM, S6Licensed Practical Nurse (LPN) confirmed Resident #12 was on a psychotropic medication. S6LPN further indicated she did not routinely monitor Resident #12 for targeted behaviors and/or adverse consequences of psychotropic medications. Resident #182 Review of Resident #182's medical record revealed, in part, Resident #182 was admitted to the facility on [DATE] with diagnosis of anxiety disorder. Review of Resident #182's Minimum Data Set with an Assessment Reference Date of 02/26/2025 revealed, in part, Resident #182 received medications for anxiety. Review of Resident #182's March 2025 physician's orders revealed, in part, and order dated 02/19/2025 for clonazepam tablet 0.5 mg by mouth nightly. Review of Resident #182's care plan with a start date of 02/19/2025 revealed, in part, Resident #182's care plan for anxiety had no approaches related to antianxiety medication therapy and/or monitoring targeted behaviors and/or adverse consequences of antianxiety medications. There was no documented evidence, and the facility was unable to present any documented evidence, Resident #182 was evaluated for targeted behaviors and/or adverse consequences of psychotropic medications. In an interview on 03/06/2025 at 4:08PM, S13LPN indicated she was not aware Resident #182 was on any psychotropic medications. Resident #186 Review of Resident #186's medical record revealed, in part, Resident #186 was admitted to the facility on [DATE] with diagnosis of depression. Review of Resident #186's care plan with a start date of 02/27/2025 revealed, in part, Resident #186's depression care plan had no approaches related to antidepressant medication therapy and/or monitoring targeted behaviors and/or adverse consequences of antidepressant medications. Review of Resident #186's March 2025 physician's orders revealed, in part, an order dated 02/27/2025 for escitalopram (a medication used to treat depression)10 mg capsule by mouth daily. There was no documented evidence, and the facility was unable to present any documented evidence, Resident #186 was evaluated for targeted behaviors and/or adverse consequences of psychotropic medications. In an interview on 03/06/2025 at 3:00PM, S3Minimum Data Set Coordinator (MDSC) indicated there was no documented evidence the above mentioned residents were routinely monitored for targeted behaviors of psychotropic medications. In an interview on 03/06/2025 at 3:50PM, S12Pharmacist indicated the above mentioned residents who were prescribed a psychotropic medication should have been monitored every shift for targeted behaviors and/or adverse consequences related to their psychotropic medication use. In an interview on 03/07/2025 at 10:37AM, S2Director of Nursing (DON) indicated the facility could not provide any documented evidence the above mentioned residents were assessed and/or monitored for targeted behaviors and/or adverse consequences of psychotropic medications.

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure three expired bags of 5% dextrose solution were not available for resident use in 1 (Medication Room b) of 2 (Medication Room a, Medication Room b) medication rooms observed; and, 2. Ensure an expired sterile intravenous (IV) catheter was not available for resident use in 1 (Workstation on Wheels [WOW] a) of 3 (WOW a, WOW b, WOW c) WOWs observed. Findings: 1. Review of the facility's Medication Security and Storage policy and procedure dated [DATE] revealed, in part, medications will be stored in a manner consistent with manufacturer recommendations and applicable federal, state, and local laws. Observation on [DATE] at 9:45AM of Medication Room b revealed: - Two 50 milliliter (mL) bags of 5% dextrose injection solution with an expiration date of ,d+[DATE]; and, - One 50 mL bag of 5% dextrose injection solution with an expiration date of ,d+[DATE]. Review of the [NAME] Product Expiration Date Extension document dated [DATE] revealed, in part, the above mentioned 50 mL bags of 5% dextrose injection solution expiration dates were not extended as a result of the intravenous solution shortage. In an interview on [DATE] at 9:50AM, S11Licensed Practical Nurse (LPN) confirmed the above mentioned 50 mL bags of 5% dextrose injection solution located in Medication Room b were expired, and should not have been available for resident use. In an interview on [DATE] at 9:55AM, S1Administrator could offer no further explanation as to why the above mentioned 50 mL bags of 5% dextrose injection solution were expired and available for resident use. 2. Observation on [DATE] at 10:15AM of WOW a revealed a 24 gauge (G) x ,d+[DATE] inch (in.) Introcan sterile safety IV catheter with an expiration date of [DATE]. Review of the Center for Disease Control and Prevention (CDC)'s Guideline for Disinfection and Sterilization in Healthcare facilities dated 2008 and updated in [DATE] revealed, in part, any item that has been sterilized should not be used after the expiration date for that item has been exceeded. In an interview on [DATE] at 10:30AM, S10LPN confirmed the above mentioned IV catheter in WOW a was expired, and available for resident use and should not have been. In an interview on [DATE] at 10:40AM, S2Director of Nursing (DON) confirmed the above mentioned IV catheter was expired and offered no further explanation as to why the IV catheter was in WOW a and available for resident use.

Based on observations, interviews, and record reviews, the facility failed to ensure staff members followed isolation precautions for 3 (S5Registered Nurse [RN], S6Licensed Practical Nurse [LPN], S8Rehabilitation Technician [RT]) of 3 (S5RN, S6LPN, S8RT) staff members observed for adherence to isolation precautions. Findings: Resident #190 Review of the facility's Isolation policy and procedure dated 03/08/2021 revealed, in part, airborne, contact, and droplet precautions required all who entered the room to wear gown, gloves, eye protection (face shield or goggles), and an N-95 respirator. Review of Resident #190's medical record revealed Resident #190 was admitted to the facility on [DATE] with a positive Covid-19 test result from the same date. Review of Resident #190's March 2025 physician's orders revealed, in part, an order dated 03/03/2025 for airborne, contact, and droplet isolation precautions. Observation on 03/05/2025 at 12:13PM revealed Resident #190 had an airborne, contact, and droplet precautions sign on his door indicating an N-95 mask, eye protection (face shield or goggles), gown, and gloves should be put on before entering the room. Further observation revealed no eye protection was available for use in the isolation door caddy. Observation on 03/05/2025 at 12:15PM revealed S5RN entered Resident #190's room without eye protection on. Further observation revealed S5RN was in direct contact with Resident #190 while in Resident #190's room. In an interview on 03/05/2025 at 12:58PM, S5RN confirmed Resident #190 was on airborne, contact, and droplet isolation precautions for Covid-19. S5RN further indicated only an N-95 mask, gown, and gloves were required to be worn while inside an airborne, contact, and droplet isolation precautions room. Observation on 03/06/2025 at 9:05AM revealed S6LPN entered Resident #190's room without eye protection on. Further observation revealed S6LPN was in direct contact with Resident #190 while in Resident #190's room. In an interview on 03/07/2025 at 10:37AM, S2Director of Nursing (DON) confirmed Resident #190 was on airborne, contact, and droplet isolation precautions. S2DON further indicated all personnel should have put on eye protection before entering Resident #190's room in accordance with the facility's policy. In an interview on 03/07/2025 at 11:15AM, S9Infection Control Director confirmed staff members were required to wear eye protection when entering an airborne, contact, and droplet isolation precautions room in accordance with the facility's policy. Resident #182 Review of the facility's Isolation policy and procedure dated 03/08/2021 revealed, in part, protective precautions are used for patients that are immunocompromised. Review of Resident #182's March 2025 physician's orders revealed, in part, an order dated 02/19/2025 for continuous enhanced respiratory precautions due to Resident #182's history of cancer. Observation on 03/07/2025 at 10:00AM revealed, Resident #182 had an Enhanced Respiratory Precautions sign on her door indicating a mask should be put on before entering the room. Observation on 03/07/2025 at 10:07AM revealed S8RT was in Resident #182's room, sitting on the sofa next to Resident #182 without a mask on. In an interview on 03/07/2025 at 10:10AM, S8RT confirmed she was sitting in Resident #182's room without a mask on and should not have been. In an interview on 03/07/2025 at 10:37AM, S2DON confirmed Resident #182 was on Enhanced Respiratory Precautions. S2DON further confirmed anyone who entered Resident #182's room should have put a mask on before entering.

Based on observation, interviews, and record reviews, the facility to ensure each resident received adequate supervision to prevent accidents by failing to ensure a resident assessed as being at high risk for falls and dependent on staff for showering was not left unattended and/or unseen in the shower. This deficient practice resulted in an actual harm on 04/29/2024, when Resident #1's Certified Nursing Assistant (CNA), S7CNA, turned her back and left Resident #1 alone in the shower of the bathroom. Resident #1 sustained a fall with injury in the shower on 04/29/2024 which required Tranforaminal Lumbar Interbody Fusion (TLIF) from Lumbar 3 spine vertebra to Lumbar 5 spine vertebra (spinal bones) repair surgery on 05/01/2024. This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for falls. Findings: Resident #1 was admitted to the skilled nursing facility on 04/05/2024 with a diagnosis, in part, of post-operative Transforaminal Lumbar Interbody Fusion (TLIF) from Lumbar 3 to Lumbar spine 5. Review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date of 04/12/2024 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact. Resident #1 was assessed as dependent on staff for tub/shower transfers; the resident required substantial/maximal assistance during shower/baths. Review of Resident #1's Fall Risk assessment dated [DATE], revealed a score of 10 and identified as being at high risk for falls. Review of Resident #1's Care Plan dated 04/05/2024 revealed, in part, Resident #1's injury risk prevention included to assess the assistance levels required for safety, provide support for activities of daily living, and to determine the need for increased observation. Review of Resident #1's Physical Therapy Note dated 04/19/2024 revealed, in part, Resident #1 presented with limitations in performance of self-care and self-care skills, impaired endurance, impaired functional mobility, unsteady gait, decreased self-awareness, and decreased lower extremity function. Review of Resident #1's Nurse Progress Note dated 04/26/2024 at 11:40 a.m. revealed, in part, Resident #1 was witnessed by staff getting up multiple times without calling for assistance or waiting for help. Further review revealed Resident #1 often reported dizziness when getting up. Review of facility's Incident Occurrence Log dated April 2024 revealed, in part, Resident #1 experienced a fall with severe harm on 04/29/2024. In a phone interview on 05/21/2024 at 9:47 a.m., Resident #1's daughter-in-law indicated Resident #1 told her she (Resident #1) was left alone in the shower. Resident #1's daughter-in-law further indicated S2CNA told Resident #1 she would be back and instructed her to call if she needed anything while in the shower. Resident #1's daughter-in-law further indicated Resident #1 kept pulling the call light cord in Resident #1's bathroom prior to falling, but facility staff did not respond to the repeated calls from the call bell. Resident #1's daughter-in-law indicated S4Orthopedic Surgeon stated after Resident #1's surgery on 05/01/2024, that Resident #1's orthopedic screws in her spine that were placed on 04/02/2024 were now loose, and the only way orthopedic screws can become loose was by an incident, fall, or infection. In a telephone interview on 05/21/2024 at 12:04 p.m., Resident #1's son indicated he received a call from S6Director of Nursing (DON) and was told his mother, Resident #1, was left alone in the bathroom and was trying to get up from the shower bench alone in the bathroom and fell . In a telephone interview on 05/21/2024 at 12:07 p.m., Resident #1 indicated S2Certified Nursing Assistant put her in the shower sitting on the shower bench and then turned the water on. Resident #1 further indicated S2CNA informed her (Resident #1) that she was going down the hall, and would come back and assist her (Resident #1). Resident #1 then indicated S2CNA left the room. Resident #1 further indicated she was waiting for assistance after using the call light for a while, but staff did not respond, so she got up from the shower bench, and then slipped and fell . In an interview on 05/20/2024 at 11:03 a.m., S2CNA indicated, she was present in Resident #1's bathroom when Resident #1 was sitting on the shower bench showering. S2CNA further indicated she turned her back on Resident #1 to get Resident #1's clothes off of the bed, and when she turned back to face Resident #1, Resident #1 was on the floor in the bathroom near the shower. S2CNA further indicated she did not witness the fall. In an interview on 05/20/2024 at 1:22 p.m. the Director of Nursing (DON) stated Resident #1 was sent to an orthopedic appointment on 04/29/2024 after the fall and was admitted to an acute care hospital on 04/29/2024 and had orthopedic surgery on 05/01/2024 for fusion of spine, posterior approach L3 to pelvis revision. She further stated the resident was discharged from the acute care hospital to another skilled nursing facility on 05/08/2024. Review of S3Medical Doctor Progress Note dated 05/01/2024 revealed, in part, Resident #1's principle problem was status post TLIF Lumbar spine 3 to Lumbar spine 5 with [NAME] repair on 04/02/2024 and failure of TLIF Lumbar spine 3 to Lumbar spine 5 with hardware failure likely secondary to a ground level fall. Review of S4Orthopedic Spine Surgeon Post-Operative Progress Note dated 05/01/2024 revealed, in part, Lumbar spine 5 had loose screws and hardware failure. Review of S4Orthopedic Spine Surgeon Follow-Up Progress Note dated 05/02/2024 revealed, in part, Resident #1 was seen 05/02/2024 for a post-operative orthopedic visit for revision of Lumbar spine 3 to pelvis on 05/01/2024. Further review revealed Resident #1 had history of TLIF Lumbar spine 3 to Lumbar spine 5 on 04/22/24, and presented with hardware failure likely secondary to a ground level fall. In an interview on 05/20/2024 at 2:19 p.m., S1Administrator further indicated Resident #1 was a one person assist, and did not feel it was a wrong practice when S2CNA turned her back on Resident #1 while Resident #1 was in the shower. In an interview on 05/21/2024 at 10:30 a.m., S1Administrator indicated her investigation of Resident #1's fall on 04/29/2024 was based solely on facility staff reports. S1Administrator further indicated S2CNA did turn her back on Resident #1, but it was her belief S2CNA was in the room with Resident #1. In a telephone interview on 05/21/2024 at 11:12 a.m., S5Physicians Assistant for S4Orthopedic Spine Surgeon indicated she personally saw Resident #1 in the office after the fall at the facility on 04/29/2024, and agreed with S4Orthopedic Spine Surgeon that a result of loose orthopedic screws can occur from an incident, fall, or infections. S5Physicians Assistant further indicated cultures were taken at the time of surgery on 05/01/2024, which was negative for infection. Review of Resident #1's 05/01/2024 Laboratory Report for Acid Fast Bacilli (AFB) Culture ( a sample of bodily fluid used to diagnose infections caused by acid-fast bacilli bacteria) revealed it was negative, with no acid fast bacilli seen.

Based on record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) was not employed after having a conviction that barred employment in accordance with state law for 1 (S7CNA) of 5 (S7CNA, S8CNA, S9CNA, S10CNA, and S11CNA), unlicensed personnel criminal background checks reviewed. Findings: Review of the Louisiana Revised Statute 40:1203.3 revealed, in part, criminal convictions that bar an employer from hiring a non-licensed person included, in part, the following: Distribution or possession with the intent to distribute controlled dangerous substances as listed in Schedules I through V of the Uniform Controlled Dangerous Substances Act. Statutory references for these convictions are as follows: 40:966 Penalty for distribution or 40:966 Penalty for distribution or possession with intent to distribute narcotic drugs listed in Schedule 1; 40:967 Prohibited acts - Schedule II penalties; 40:968 Prohibited acts - Schedule III penalties; 40:969 Prohibited acts - Schedule IV penalties; 40:970 Prohibited acts - Schedule V penalties; and, 40:971 Prohibited acts - all schedules. Review of S7CNA's criminal background check(s) revealed, in part, the following: 04/10/2004 RS 40:966 Manufacturing/Distribution/Possession of Schedule I (drug with no current accepted medical use and has high potential for abuse) marijuana (chemical compound in cannabis plant that has various psychological and physiological effects on the human body) RS 40:966 1 count. Further review revealed no final disposition of the above, and the provider did not present a final disposition of the above mentioned charge. 01/16/2005 RS 40:1033 Drug Paraphernalia (equipment, product, or material used for the purpose of planting, cultivating, manufacturing, producing, processing, packaging, storing, or concealing a controlled substance); and RS 40:967 Prohibited Acts (unlawful for any person to sell, lend, rent, lease, give, exchange, or otherwise distribute to any person any drug paraphernalia). Schedule II (drugs or chemical with high potential for abuse and potentially leading to severe psychological or physical dependence) 2 counts (convicted). 04/12/2007 RS 40:1033 Prohibited Acts/Drug Paraphernalia 40:1033 Prohibited Acts Schedule II 40:967 2 counts. Further review revealed no final disposition of the above, and the provider did not present a final disposition of the above mentioned charge. 11/18/2009 RS 40:967 Schedule II Drugs Distribution Scheduled II possession 28 to 200 grams of cocaine 2 counts (convicted), Warrant 12/06/2012. Review of S7CNA's criminal background check dated 08/12/2021 and with a completion date of 08/27/2024 revealed, in part: Distribution of Drug - Schedule II felony, guilty 01/04/2013 Sentencing summary: 5 years prison, 3 years suspended. Possession of Cocaine - 28 grams to 200 grams, felony, and guilty 01/04/2013 Sentencing summary: 5 years prison, 3 years suspended and was incarcerated. There was no documented evidence and the facility did not present any documented evidence to dispute the above mentioned findings. In an interview on 05/22/2024 at 10:56 a.m., S12Human Resource Director indicated he/she was aware of the above mentioned findings, that S7CNA was hired on 08/27/2024, and as of 05/22/2024, S7CNA was still employed at the facility. The surveyor requested a copy of S7CNA's criminal background check. The facility allowed the surveyor to review the criminal background check, but refused to provide a copy of S7CNA's criminal background check as requested. In an interview on 05/22/2024 at 1:03 p.m., S13Manager Regulatory and Environment Safety indicated the surveyor cannot keep a copy of S7CNA's background check to protect employees.

49753 Based on record reviews, observations, and interviews, the facility failed to ensure S5Dietary Staff wore personal protective equipment (PPE) when they entered an isolation room for 1 (Resident #34) of 1 (Resident #34) residents reviewed for transmission base precautions. Findings: Review of Resident #34's clinical record revealed was admitted [DATE] and subsequently tested positive on 03/22/2024 for Covid-19, an upper respiratory infection, and transmission based precautions enacted from 03/22/2024 through 04/01/2024. Review of the facility's policy titled, Isolation Policy, dated 03/08/2021revealed, in part, all persons who entered the room of residents on airborne, contact, and droplet isolation were required to wear a gown, gloves, eye protection (face shield and goggles) and N-95 respirator. The isolation policy further revealed a gown, gloves, and respirator must be worn regardless of patient contact. Observation on 03/26/2024 at 11:03 a.m. revealed Resident #34 had signage posted on the door of Room A for airborne, droplet, and contact precautions; along with the appropriate PPE supplies on the door. Observation on 03/26/2024 at 12:15 p.m. revealed S5Dietary Staff entered Resident #34's room, without putting on PPE. In an interview on 03/26/2024 at 12:16 p.m., S5 Dietary Staff indicated she always entered the room of residents on isolation precautions, without putting on any PPE. In an interview on 03/27/2024 at 11:56 a.m., S3Director Infection Control confirmed S5Dietary Staff did not follow the facility's infection control policy.

Based on record reviews, observations, and interviews, the facility failed to ensure portable equipment and surfaces were disinfected after a blood sample was taken from a Random Resident R1 who was on contact isolation. This deficient practice was identified for 1(Random Resident R1) of 1 residents observed during a blood sample collection and had the potential to affect any of the 29 residents documented on the facility's Census list. Findings: Review of the facility's procedure titled Blood Collection by Venipuncture revealed in part, under Dismissing/Leaving the Patient revealed under Step 6: Clean any environmental surfaces or phlebotomy work services. Review of the facility's policy and procedure titled Cleaning Portable Equipment revealed in part, under the purpose was to reduce the opportunity for organisms to spread via inanimate objects such as reusable patient care equipment. Further review revealed this policy outlines the proper cleaning of portable equipment. Further review of the policy revealed in part, all equipment used for multiple patients shall be cleaned and disinfected between each use. Review of Resident R1's record revealed she had was on contact isolation for Escherichia Coli ESBL (Extended Spectrum Beta Lactamase- a bacteria) in her urine. Review of Resident R1's January 2021 physician's orders [REDACTED].>Observation on 01/26/2021 at 1:00pm revealed a metal cart with phlebotomy supplies half way in Resident R1's doorway. Further observation revealed on Resident R1's door was an isolation caddy, filled with supplies and signage of contact precautions taped to the caddy. Further observation revealed S3Phlebotomist came from inside of Resident R1's room to the cart, located in the doorway with her gloved hands. S3Phlebotomist proceeded to remove an alcohol prep from the cart, and Coban tape from the cart and proceeded back into Resident R1's room. S3Phlebotomist then returned to Resident R1's doorway with gloved hands, removed the PDA (Personal Digital Assistant) barcode scanner device from the cart and scanned the blood tube she was holding in her hand. S3Phlebotomist then replaced the PDA barcode scanner device back on top of the cart. S3Phlebotomist went back into Resident R1's room, removed her gown and gloves, exited Resident R1's room, sanitized her hands, and was observed to go down the hallway. In an interview and observation on 01/26/2021 at approximately 1:10pm, S3Phlebotomist was questioned if she cleaned the (PDA) device between residents, and she stated she never touches the device without gloves on and she does not clean the device. Further observation during the interview revealed the (PDA barcode scanner) device had been placed on clean unused blood tubes. When the surveyor questioned S3Phlebotomist about the device laying on the top of the unused blood tubes, she stated I don't use them that often and I see what you mean cross contamination. During the observation and interview, the PDA barcode scanner device was not disinfected and the surfaces where the PDA device was placed were not disinfected. In an interview on 01/26/2021 at approximately 1:15pm, S1Director of Infection Control stated the PDA device should be cleaned if she had touched the (PDA barcode scanner) device with her used gloves. S1Director of Infection Control further stated (PDA) device should be cleaned like any other equipment when it needs to be cleaned. S1Director of Infection Control acknowledged the S3Phlebotomist should have cleaned the (PDA) device. In a telephone interview on 01/27/2021 at 2:10pm, S2Laboratory Director stated they use a PDA device for scanning the armband of the resident to generate test labels and have a mobile printer on the cart that prints the labels they use for the blood tubes. She stated the phlebotomist goes into the resident room, scans the resident's armband and the mobile printer will print the labels they need. S2Laboratory Director stated they can leave the PDA device in the resident's room or they can place it back on the cart. S2Laboratory Director stated after they have drawn the blood, they place the labels on the tubes and they scan the labels on the blood tubes which enters this information into their (LIS) Lab Information System. S2Laboratory Director stated the Lab Information System stamps the collection date and time with the collector's initials. S2Laboratory Director further stated when the phlebotomist was finished they should set down the PDA device, doff their PPE (Personal Protective Equipment), remove their gloves and sanitize their hands. S2Laboratory Director further indicated the facility procedure was to put on gloves and clean any environmental surface and phlebotomy work surface that was used with a quaternary disinfectant, which the phlebotomist has on their carts. When the surveyor asked if the PDA device was included and needed to be cleaned before going to the next resident she stated yes. S2Laboratory Director acknowledged the PDA device and the surfaces should have been cleaned.

Based on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety as evidence by failing to ensure perishable foods were labeled and dated, and perishable foods were not past the expiration date available for use. This failed practice had the potential to affect all residents who reside at the facility and who receive food prepared by the facility's kitchen. The facility census was 24 residents as documented on the facility's Census and Conditions of Resident's form (CMS-672.) Findings: Review of the facility's policy titled Food and Supply Storage revealed in part, under Refrigerator Storage Life: Use manufacturer's expiration date for products before they are opened. If there is no expiration date on the package, add the time listed here to the date of the food is received. Add time in the opened column to the date when the food is prepared or opened. Label when the product is opened. The time listed is added to today's date. Further review under Freezer Storage Life of Food revealed in part, the following: Use manufacturer's expiration date for products but do not exceed one year. If there is no expiration date on the package, add the time listed here to date the food is received. If a case of food is partially used, and the remaining food is exposed to the air (example 20# case of frozen vegetables), re-label when the product is opened to use within 3 months. Observation on 12/3/18 at 10:15am of the facility's refrigerator with S1 Director of Food and Nutrition Services revealed the following: Six bags of coleslaw identified by S1 Director of food services as coleslaw with an expiration date of 11/17/18 and available for use; One opened plastic bag of nine shallots with no date and available for use; One closed plastic bag of twelve shallots with no date and available for use; One plastic bag of seven white onions with no date and available for use; One plastic bag eight purple onions with no date and available for use; One plastic bag of two purple onions with no date available for use; One open cardboard box of one hundred sixty four squash with a delivery date of 11/23/18, no expiration date and available for use; Four plastic bags of rotisserie chicken identified by S1 Director of Food Services as rotisserie chicken with no date and available for use; One plastic container of chicken gravy chicken identified by S1 Director of Food Services as chicken gravy with an expiration date of 11/30/18 available for use; One plastic container of pepperoni's identified by S1 Director of Food Services as pepperoni's with an expiration date of 11/30/18; One plastic container of cornbread base chicken identified by S1 Director of Food Services as cornbread base with an expiration date of 11/21/18 and available for use; One plastic container of pineapple chunks identified by S1 Director of Food Services as pineapple chunks with an expiration date of 11/17/18 and available for use; One plastic container of jalapenos identified by S1 Director of Food Services as jalapenos with no expiration date and available for use; One plastic container of banana pudding identified by S1 Director of Food Services as banana pudding with an expiration date of 12/1/18 and available for use; and One plastic container of spinach and artichoke dip identified by S1 Director of Food Services as spinach and artichoke dip with an expiration date of 11/3/18 and available for use. Observation on 12/3/18 at 10:30am of the facility's freezer with S1 Director of Food and Nutrition Services revealed the following: One plastic bag of cali vegetables identified by S1 Director of Food Services as cali vegetables with no date and available for use; One plastic bag of baked ziti identified by S1 Director of Food Services as baked ziti with no date and available for use; One plastic bag of basil chicken with an expiration date of 11/13 and available for use. No year was documented; One plastic bag of creamed spinach with an expiration date of 11/30 and available for use. No year was documented; One plastic bag of pesto identified by S1 Director of Food Services as pesto with an expiration date of 12/01/18 and available for use; One plastic bag of chicken tenders identified by S1 Director of Food Services as chicken tenders with no date and available for use; One plastic bag of pizza crust identified by S1 Director of Food Services as pizza crust with no date and available for use; and One plastic bag of turkey identified by S1 Director of Food Services as turkey with no date and available for use. In interview on 12/3/2018 at 10:30am, S1 Director of Food and Nutrition Services acknowledged all foods in the refrigerator and freezer should have been labeled and dated. S1 Director of Food and Nutrition Services further stated the executive chef is responsible for checking all foods but he was not here so all staff were responsible for checking the dates of the food. In interview on 12/4/18 at 09:16am, S2 Performance Improvement Coordinator acknowledged foods in the refrigerator and freezer should be dated and labeled to prevent food borne illness.

Based on observation and interview the facility failed to ensure food was stored, prepared, distributed, and/or served under sanitary conditions by failing to keep trays, pans, and cooking utensils clean where clean dishes were stored. This deficient practice had the potential of affecting any of the 21 Stage 2 residents who received meals that were prepared in the facility ' s kitchen. Findings: An observation conducted on 11/3/16@11:00AM during a tour of the facility ' s kitchen revealed a storage area which staff identified the shelf containing pans and cooking utensils as clean and available for use. The surveyor observed three food trays and four metal pans on the shelf which were unclean with dust and dried food residue on both inner and exterior surfaces of the pans. The surveyor also observed one metal pan with a plastic clear lid, with yellow tinting, which did not completely cover the pan. Stains and dust particles were seen on all surfaces of the pan. The surveyor also noted cooking utensils inside the pan with the plastic covering which were dusty and contained particles of food. During the observation, S3, Chef removed a cooking spoon from the unclean metal pan with unsecured lid, and proceeded to scoop tomato sauce onto manicotti noodle meal being prepared for the residents ' lunch meal. An interview was conducted with S3, Chef on 11/3/16 at 11:25AM in which the surveyor identified that S3, Chef had utilized a spoon from a metal pan containing dust and dried food particles. S3, Chef acknowledged the findings, and stated the area needs to be cleaned. The surveyor continued the tour with S2, Dietary Manager in which grease build up with dust and food particles were noted on the stove surface where foods were being cooked. The surveyor, S2, Dietary Manager, and S3, Chef also identified dust and food particles on the cooking equipment and behind appliances in the kitchen. S3, Chef commented the grease needs to be broken up. An interview was conducted with S2, Dietary Manager on 11/3/16@11:30AM in which she acknowledged all findings and stated she would work to get the kitchen cleaned.

Based on record review and interview the facility failed to maintain accurate documentation in accordance with acceptable professional standards and practices that are complete for 3 of 3 resident records reviewed for nutrition from a total of 21 Stage 2 residents. This deficient practice was evidenced by the facility ' s failure to identify discrepancies with documented weights for 3 of 21 Stage 2 residents (#31, #73, and #86). Findings: Record review of documented weights for Resident#31 conducted on 11/3/16 revealed the resident was admitted to the facility on [DATE] with a documented admit weight of 186 pounds. Further review of the records revealed a weight of 202 pounds on 9/10/16, and review of the documented weights revealed a weight of 176 pounds on 9/30/16. This finding reflects a weight loss of 26 pounds over a span of 20 days. Record review of documented weights for Resident #73 conducted on 11/3/16 revealed the resident was admitted to the facility on [DATE] with a documented weight of 282 pounds. Review of a documented weight on 10/03/16 revealed the resident ' s weight was 287 pounds. Review of a weight documented 10/04/16 revealed a finding of 283 pounds. On 10/06/16 the resident ' s weight was documented as 253 pounds. This latest documentation reflects a weight loss of 30 pounds within two days. Record review of documented weights for Resident#86 conducted on 11/3/16 revealed the resident was admitted to the facility on [DATE]. Documentation indicated a weight measurement obtained at 1731 hours of 272 pounds. An additional documentation of a weight measurement obtained at 1842 hours on 9/16/16 revealed a weight of 243 pounds. The documentation reflected a weight loss of 29 pounds within 1.5 hours. Weight documented 10/06/16 revealed a finding of 128 pounds. The documented weight on 10/07/16 was 178 pounds. The documented weight taken on 10/08/16 was 302 pounds. This documentation reflects a weight gain of 134 pounds within a single day. An interview was conducted with S1, Director of Nursing on 11/3/16 @1:30PM in which she stated the patient care technicians are responsible for weighing the residents, and the values may either be inputted into the system by the technician or the nurse. S1, DON stated the facility ' s staff nurses are responsible for validating the accuracy of the information placed in the system. Finally, S1, DON acknowledged the discrepancies, and stated she had no explanation for the documented weight discrepancies.

Based on observations, interviews, and record reviews the facility failed to complete an accurate assessment for 2 residents (#216 and #230) of 3 residents (#216, #230, #91) assessed for pressure ulcers in a total of 20 Stage II Sampled Residents, as evidenced by the facility failed to ensure Resident #216 and Resident #230 ' s Minimum Data Set (MDS) was accurate for the assessment of pressure ulcers. This failed practice had the potential to affect all 32 residents as listed on the facility ' s Resident Census and Condition Form. Findings: Review of Resident #216 ' s medical record revealed Resident #216 returned to the facility from an out-patient procedure on 10/5/15 with diagnosis, in part of, [MEDICAL CONDITION] and Left Arm Fracture. Review of wound assessment dated [DATE] revealed Resident #216 had a Suspected Deep Tissue Injury (SDTI) to the left heel. Observation of Resident #216 on 10/15/15 at 9:00 AM revealed a SDTI to the left heel. Review of Resident #216 ' s 14 Day MDS with Assessment Reference Date (ARD) of 10/12/15 Section M revealed Resident #216 did not currently have a pressure ulcer at a Stage I or higher as of 10/12/15. Review of section M did not address pressure ulcers of any stages. In interview on 10/16/15 at 8:40 AM S2 indicated Resident #216 was identified as having a SDTI to the left heel on 10/5/15. S2 further indicated Resident #216 ' s SDTI was identified before the ARD of 10/12/15 and should have been indicated on the MDS. S2 indicated Resident #216 ' s 14 Day MDS Section M with ARD 10/12/15 was coded incorrectly. Review of medical records revealed Resident #230 was admitted to the facility on [DATE] with a pressure ulcer to left medial back. Review of Resident #230 ' s Wound/Ostomy notes dated 10/7/15 revealed Resident #230 was admitted to the facility with an unstageable, full thickness, yellowish-non granulating wound to left mid back area. Observation on 10/15/15 at 11:31 AM revealed Resident #230's left medial back wound was small, circular in shape, well approximated, pink in color with yellowish fibrous tissue to the wound bed. In interview on 10/15/2015 at 1:17 PM S3/Wound/Ostomy nurse stated Resident #230 ' s pressure ulcer was classified as a stage II ulcer by the admitting nurse but her assessment on 10/7/15 revealed the wound was unstageable. Review of Resident #230 ' s 5 Day MDS with ARD of 10/12/15 Section M revealed Resident #230 was assessed as having a stage II pressure ulcer upon admission. Further review of Resident #230 ' s MDS revealed Resident #230 was not assessed as having an unstageable ulcer as documented on Resident #230 ' s Wound/Ostomy notes dated 10/7/15. Interview on 10/16/2015 11:00 AM S1 indicated the pressure ulcer staging on the 5 Day MDS with ARD 10/12/15 should have reflected the pressure ulcer as unstageable as assessed by the wound/ostomy nurse on 10/7/15.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing by failing to implement the facility's Pressure Ulcer Prevention and Wound Care Management Protocol. This was evidenced by the failing to: 1) Assess the stage and size of the Pressure Ulcer on initial assessment and at least weekly and on discharge in centimeters of length, width, and depth by a Registered Nurse; 2) Photograph areas of Pressure Ulcers and breakdown on admission; 3) Notify the Resident's physician of pressure ulcers; 4) Timely document placement of an air mattress as ordered by the resident's physician. This deficient practice was identified for 1 of 1 Stage 2 residents reviewed for Pressure Ulcers (#52) currently residing in the facility and 3 of 3 (#33,#42 and #85) Stage 2 sampled residents reviewed for Pressure Ulcers per closed record review in a total sample of 17. This deficient practice had the potential to effect any resident admitted to the facility with a pressure sore or any resident residing at the facility who may become at risk for Pressure Ulcers. Review of the facility's Resident and Census and Conditions of Residents form revealed there were 2 residents who had pressure ulcers of the 17 residents residing at the facility. Findings: Review of the facility's policy used for Pressure Ulcer and Treatment per Mosby's Skills revealed, in part, a Stage II wound was described as a partial loss of the skin presenting as a shallow open ulcer with a red pink wound bed, without dead skin and may also present as an intact or open/ruptured serum-filled blister on a heel. Further review under the section titled assessment revealed, in part, a complete thorough assessment upon admit including all skin surfaces to assess skin at least daily and as often as necessary. Assess the location, size on initial assessment and at least weekly and on discharge and use centimeters to document length, with, and depth. Review of the facility's Pressure Ulcer Prevention and Wound Management Protocol revealed, in part, all residents will be assessed for pressure ulcers as documented on admission. The initial assessment will create a baseline for further skin and/or wound care, and minimize and/or prevent any further deterioration of tissue. Review of the protocol revealed if skin breakdown is evident refer to staging guidelines and notify the Medical Director. Further review revealed the facility was to photograph areas of breakdown on admission and place photograph on the progress sheet. The Protocol also revealed how to measure and document the dimensions of the wound. Resident #33 Resident #33's closed electronic records revealed, in part, the resident was admitted on [DATE] and discharged to a nursing facility on 7/25/14. Review of Resident #33's Hospital Problem List revealed, in part, the resident was diagnosed with [REDACTED]. Review of Resident #33's Minimum Data Set ((MDS) dated [DATE] revealed, in part, the resident was assessed as having had a Stage II Pressure Ulcer and was at risk for the development of a pressure ulcer. Review of Resident #33's MDS section bed mobility and transfer revealed it was coded as the resident needed total dependence and two person physical assist for help in these task. Review of Resident #33's Braden scale on 6/12/14 revealed the resident was at risk for a pressure ulcer. Further review revealed he was bedfast and mobility revealed he did not even make slight changes in body or extremity position or movement without assistance. Review of Resident# 33's Electronic Chart revealed, in part, skin section dated 6/10/14 before the resident was admitted to the skilled facility the resident had a Stage II Pressure Ulcer on the Coccyx (Lower Back Area) left lower side. Review of Resident #33's discharge notes dated 7/25/14 revealed a Stage II Pressure Ulcer but an but there was no documentation related to the size of the wound. Review of Resident #33's physician's orders [REDACTED]. In interview on 12/11/2014 at 1:45pm, S5/Performance Improvement Coordinator stated she could see the order for the Air Fluidized bed, but did not know what type of bed it was, and she stated that per the documentation Resident #33 was admitted to the facility with a Stage II pressure ulcer. In interview on 12/12/14 at 10:16 am, S11/Information System Clinical Informatics with S2/DON present stated that this was the first time she saw in the electronic record recorded on 7/15/14 about documentation of the air mattress. In interview on 12/11/14 at 1:35pm, S1/DON stated that there was no documentation of wound size, but he could show pictures of the wound. In interview on 12/11/14 at 1:56pm, S2/Director stated that a wound care nurse resigned in August 2014 and there was no treatment documentation about what she did to the residents pressure ulcers that were in the facility. Review of Resident #33's skin assessment documentation revealed a Stage II Pressure Ulcer and the following: -6/12/14 assessed by a Registered Nurse (RN) revealed no assessment of the size of pressure ulcer. -6/13/14 assessed by a Licensed Practical Nurse (LPN) and pressure ulcer size not assessed. -6/14/14 assessed by a LPN, pressure ulcer size not assessed. -6/15/14 assessed by a LPN, pressure ulcer size not assessed. -6/16/14, assessed by LPN in the morning and the evening, with no assessment of the size of pressure ulcer -6/17/14 assessed by LPN with no assessment of the size of pressure ulcer -6/27/14 (10 days later) assessed by RN as stage 2 healing with no documentation of size of pressure Ulcer. -6/29/14 assessed by a LPN with no assessment of the size of pressure ulcer. -6/30/14 assessed by a LPN with no assessment of the size of pressure ulcer. -7/1/14 assessed by two LPNs with no assessment of the size of pressure ulcer. -7/2/14 assessed by two LPNs with no assessment of the size of the pressure ulcer. -7/3/14 assessed by two LPNs with no assessment of the size of the pressure ulcer. -7/4/14 assessed by two LPNs with no assessment of the size of the pressure ulcer. -7/7/14 assessed by an RN as a Stage II pressure ulcer with no documentation of the size of the wound but healing. -7/9/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/10/14 assessed by LPN with no documentation of the size of the pressure ulcer. -7/11/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/12/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/13/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/14/14 assessed by LPN with no documentation of the size of the pressure ulcer. -7/15/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/16/14 assessed with [REDACTED]. -7/17/14- assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/18/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/19/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/20/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/21/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/22/14 assessed by two LPNs with no documentation of the size of the pressure ulcer -7/23/14 assessed by a LPN with no documentation of the size of the pressure ulcer. -7/24/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/25/14 assessed in the morning and the resident was discharge with no size documented of the pressure ulcer. Review of Resident #33 ' s Progress Notes revealed, in part, the following: - 6/16/14 by a nurse practitioner (NP) revealed severe Protein Malnutrition and Anorexia. - 6/24/14 revealed resolving pressure ulcer right buttock fold size 1cm x 2 cm. - 6/26/14 revealed Pressure Ulcer Stage II right buttocks was present on admit and to continue current wound care. Review of Resident #33's Care Plan revealed, in part, pressure reduction techniques turned/repositioned. There was no documentation on how often to turn the resident. In an interview on 12/11/2014 at 2:16pm, S5/Performance Improvement Coordinator stated that she did not see any documentation of the size of the Stage II Pressure Ulcer per the nursing staff. In interview on 12/12/14 at 9:40am, S2/Unit Director stated the order for Resident #33's air fluidized was for an air mattress that had to be ordered and placed on the resident's bed. She further stated the plan of care was standard to turn a resident every 2 hours for a resident that does not have a pressure ulcer. Review of Resident # 33's electronic chart from the time frame of 7/21/14 through 7/25/14 revealed there was no documentation to reflect the resident was turned at least every 2 hours. In interview on 12/12/14 at 9:25am, S1/DON stated that the Registered Nurses should stage the wound and document the size of the wound at least weekly. He stated that for Resident #33 it was not documented. Resident #52 Resident #52 was admitted on [DATE] for [DIAGNOSES REDACTED]. Review of Resident #52 ' s Physician Order's dated 12/6/14 revealed wound care routine and apply [MEDICATION NAME] to bilateral heel pressure ulcers. Review of Resident's #52's Braden Scale assessment dated [DATE] revealed in part she was at risk for pressure ulcer development and skin breakdown. Review of Resident #52's Nurses Notes dated 12/6/14 signed by S6/LPN revealed in part, the resident was admitted from the Hospital to the Skilled Nursing Facility with a dime size eschar to her left heel and a Stage 2 to sacrum pink and most. Further review revealed no wound measurements were documented for Resident #52 on 12/6/14. Review of Resident #52's Nurses Notes dated 12/7/14 revealed Resident #52 was assessed by S6/LPN with documentation in part, Resident #52 had Stage 2 to her sacrum (lower back). Further review revealed no wound measurements were documented on Resident #52 on 12/6/14 or 12/7/14. Review of Resident #52 ' s Physical Therapy notes dated 12/11/14 revealed Resident #52 needed extensive assistance on bed mobility and transfers. Review of Resident #52's S7/ Nurse Practitioner Notes dated 12/10/14 revealed documentation in part of Resident #52's skin assessment warm and dry, with ulceration. Further review revealed documentation of bilateral heel pressure ulcers and buttock ulceration, but no measurements of the pressure ulcers were documented on Resident #52. Further review revealed no wound measurements were documented on Resident #52 on 12/10/14. Observation during a skin audit on 12/12/14 at 12:10pm of Resident #52 ' s pressure ulcers revealed she had two Stage II Sacral Pressure Ulcers with the following measurements: 1) left buttock 2 cm (length) x 0.5 cm (width) red pink, open and no drainage noted, 2) Coccyx (lower back) 0.5 cm x 0.5 cm wound was open pink and without drainage, 3) Resident #52's left heal was unstageable with measurements at 3 cm x 1 cm with light black skin noted. In interview on 12/12/14 at 12:00 pm S12/ RN Operational Coordinator indicated the Registered Nurses (RN) assesses and stages pressure ulcers on the residents on the unit. In interview on 12/12/14 at 12:55pm S2/ RN Unit Director indicated she did a Quality Assurance Measure on Pressure Ulcers in September 2014 and the RN is responsible for assessing and measuring pressure ulcers on Residents initially, weekly, and on discharge. She further indicated she did not have any RN measurements assessments and or photographs of Resident #52's Pressure Ulcers. Resident #85 Record review of Resident #85 ' s MDS (Minimum Data Set) dated 7/08/14 revealed the resident was coded as having a Stage 1 Pressure Ulcer. Review of the resident's MDS dated [DATE] Section G; functional status,s revealed Resident #85 was a 2-person physical assist with bed mobility. Record review of the resident's Braden Scale assessment tool dated 7/1/14 revealed Resident #85 had a score of 17 which indicated the resident was at a risk of pressure ulcer. Review of Resident #85's care plan dated 7/1/14 revealed she was care planned for pressure ulcer risk and the goal revealed the resident will have intact skin integrity. Interventions listed included: evaluate skin integrity; consider use of skin barrier if skin is intact; and place patient in appropriate pressure redistribution device in bed, chair and wheelchair. Record review of the Resident #85's Nurses Notes revealed an entry date of 7/01/14 which revealed that Resident #85 was admitted with a Sacral Spine Stage 1 pressure ulcer. Further review of the Nurses Notes dated 7/02/14 through 7/04/14 revealed Resident #85 had a Stage 1 pressure ulcer. Record review of Resident #85's Nurses Notes dated 7/07/14 through 7/15/14 revealed Resident #85 was assessed as having a Stage 2 pressure ulcer. Review of Resident #85's Physician order [REDACTED]. Record review of Resident #85 ' s progress notes, entered by S8/NP and dated 7/3/14, 7/8/14, 7/10/14 and 7/15/14 did not reveal documentation of a pressure ulcer in his notes. In interview on 12/12/14 at 11:16 am, S8/NP indicated he did not see a pressure ulcer when he assessed the resident and a pressure ulcer on Resident #85 was never was reported by the nursing staff. Further interview with S8/NP revealed after he reviewed the physician's History & Physical and physician's notes there were no mention of a pressure ulcer. In interview on 12/11/14 at 1:39pm S9/LPN indicated she assessed Resident #85 ' s pressure ulcer on 7/05/14 and the wound was a Stage 1 pressure ulcer and she placed a moisture barrier on the pressure ulcer. Interview on 12/11/14 at 2:00pm S10/RN/OC indicated no orders were written for pressure ulcer care other than turn every 2 hours and there was no documented evidence that care was being done on Resident #85. Record review of Resident #85 ' s Discharge Summary dated 7/17/14 revealed no mention of treatment for [REDACTED]. In interview on 12/12/14 at 09:15am, S 2/RN/Unit Director reported that after reviewing the clinical record of Resident #85, there were no orders for sacral pressure ulcer wound care and the RN was responsible for staging of the pressure ulcer.

Based on observation, record review, and interview the facility failed to implement their Quality Assurance (QA) Plan of Action as developed by the facility in September 2014 to address identified problems with Pressure Ulcer treatment. The facility failed to ensure residents with Pressure Ulcers received the necessary treatment and services to promote healing of pressures sores as written in the facility's QA Action Plan for pressure sores. This was evidenced by the facility failing to implement the facility's Pressure Ulcer Prevention and Wound Care Management Protocol as follows: 1) Failing to implement the Quality Assurance Plan of assessing the stage and size of the Pressure Ulcer on initial assessment and at least weekly by a Registered Nurse (RN); and 2) Failing to photograph areas of Pressure Ulcers and breakdown. This deficient practice was identified for 1 of 1 Stage 2 residents reviewed for Pressure Ulcers (#52) currently residing in the facility and 3 of 3 residents (#33,#42 and #85) Stage 2 sampled residents reviewed for Pressure Ulcers per closed record review in a total sample of 17. This deficient practice had the potential to effect any resident admitted to the facility with pressure sores or any resident residing at the facility who would become at risk for Pressure Ulcers. Review of the facility's Resident and Census and Conditions of Residents form revealed there were 2 residents residing at the facility with pressure ulcers in a total of 17 residents residing at the facility. Findings: In interview on 12/11/14 at 1:56pm, S2/ RN Unit Director indicated a wound care nurse resigned in August 2014 and there was no documentation of what she did to the wounds. In interview on 12/11/14 at 3:25pm, S2 /RN Unit Director stated she developed a Quality Assurance Plan of Action in September 2014 related to pressure ulcers. She further stated her plan was to have the Registered Nurse (RN) assess the stage and size of the pressure ulcer on initial assessment and at least weekly and photograph areas of pressure ulcers and breakdown. She further indicated there was an [MEDICATION NAME][MEDICATION NAME] Therapy Nurse available as needed for wound care. She then indicated she could not produce any documented evidence to reveal what she had done to implement the plan of action or any monitoring of the implementation of the plan. In interview on 12/11/14 at 3:35pm, S12/RN Operations Coordinator stated most Stage II pressure ulcers are related to abrasions. She stated that if a resident has a stage II pressure ulcer she would compare the size to a nickel or a dime and document it. S12/RN Operations Coordinator stated that if a resident came to the facility from the hospital, she would wait to assess what's under the dressing when the date on the dressing revealed to be changed. In interview on 12/12/14 at 10:10am, S10/ RN Operational Coordinator indicated she has been at the facility since August 2014 and has not had any training on pressure ulcers. She further indicated only a Registered Nurse can assess Pressure Ulcers and not the Licensed Practical Nurse. She indicated the nursing staff can only take a picture of the Pressure Ulcer only if it is ordered by the Nurse Practitioner. In an interview on 12/12/14 at 10:20am, S13/LPN stated she had been inserviced last year on Pressure Ulcers on a computer. She further indicated the RN was to measure wounds, but she did not know what RN was to do the skin assessment. In interview on 12/12/14 at 12:55pm with S2/ RN Unit Director indicated she did a Quality Assurance Measure on Pressure Ulcers in September 2014 and the RN is responsible for assessing and measuring pressure ulcers on Residents initially, weekly and on discharge. Resident #33 Resident #33's closed electronic records revealed, in part, the resident was admitted on [DATE] and discharged to a nursing facility on 7/25/14. Review of Resident #33's Hospital Problem List revealed, in part was diagnosed with [REDACTED]. Review of Resident #33's Minimum Data Set ((MDS) dated [DATE] revealed, in part, the resident was assessed as having had a Stage II Pressure Ulcer and was at risk for the development of a pressure ulcer. Review of Resident #33's MDS section for bed mobility and transfer revealed it was coded as the resident needed total dependence and two person physical assist for help in these task. Review of Resident #33's Braden scale on 6/12/14 revealed the resident was at risk for a pressure ulcer. Further review revealed he was bedfast and mobility revealed he did not even make slight changes in body or extremity position or movement without assistance. Review of Resident# 33's Electronic Chart revealed, in part, skin section dated 6/10/14 before the resident was admitted to the skilled facility the resident had a Stage II Pressure Ulcer on the Coccyx (Lower Back Area) left lower side. Review of Resident #33's discharge notes dated 7/25/14 revealed a Stage II Pressure Ulcer but an but there was no documentation related to the size of the wound. Review of Resident #33's doctor order dated June 12, 2014 revealed an order for [REDACTED]. In interview on 12/11/2014 at 1:45pm, S5/Performance Improvement Coordinator stated she could see the order for the Air Fluidized bed, but did not know what type of bed it was, and she stated that per the documentation Resident #33 was admitted to the facility with a Stage II pressure ulcer. In interview on 12/12/14 at 10:16 am, S11/Information System Clinical Informatics with S2/DON present stated was the first time she saw in the electronic record recorded on 7/15/14 about documentation of the air mattress. In interview on 12/11/14 at 1:35pm, S1/DON stated that there was no documentation of wound size, but he could show pictures of the wound. In interview on 12/11/14 at 1:56pm, S2/Director stated that a wound care nurse resigned in August 2014 and there was no treatment documentation about what she did to the residents' pressure ulcers that were in the facility. Review of Resident #33's skin assessment documentation revealed a Stage II Pressure Ulcer and the following: -6/12/14 assessed by a Registered Nurse (RN) revealed no assessment of the size of pressure ulcer. -6/13/14 assessed by a Licensed Practical Nurse (LPN) and pressure ulcer size not assessed. -6/14/14 assessed by a LPN, pressure ulcer size not assessed. -6/15/14 assessed by a LPN, pressure ulcer size not assessed. -6/16/14, assessed by LPN in the morning and the evening, with no assessment of the size of pressure ulcer -6/17/14 assessed by LPN with no assessment of the size of pressure ulcer -6/27/14 (10 days later) assessed by RN as stage 2 healing with no documentation of size of pressure Ulcer. -6/29/14 assessed by a LPN with no assessment of the size of pressure ulcer. -6/30/14 assessed by a LPN with no assessment of the size of pressure ulcer. -7/1/14 assessed by two LPNs with no assessment of the size of pressure ulcer. -7/2/14 assessed by two LPNs with no assessment of the size of the pressure ulcer. -7/3/14 assessed by two LPNs with no assessment of the size of the pressure ulcer. -7/4/14 assessed by two LPNs with no assessment of the size of the pressure ulcer. -7/7/14 assessed by an RN as a Stage II pressure ulcer with no documentation of the size of the wound but healing. -7/9/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/10/14 assessed by LPN with no documentation of the size of the pressure ulcer. -7/11/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/12/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/13/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/14/14 assessed by LPN with no documentation of the size of the pressure ulcer. -7/15/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/16/14 assessed with [REDACTED]. -7/17/14- assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/18/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/19/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/20/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/21/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/22/14 assessed by two LPNs with no documentation of the size of the pressure ulcer -7/23/14 assessed by a LPN with no documentation of the size of the pressure ulcer. -7/24/14 assessed by two LPNs with no documentation of the size of the pressure ulcer. -7/25/14 assessed in the morning and the resident was discharge with no size documented of the pressure ulcer. Review of Resident #33 ' s Progress Notes revealed, in part, the following: - 6/16/14 by a nurse practitioner (NP) revealed severe Protein Malnutrition and Anorexia. - 6/24/14 revealed resolving pressure ulcer right buttock fold size 1cm x 2 cm. - 6/26/14 revealed Pressure Ulcer Stage II right buttocks was present on admit and to continue current wound care. Review of Resident #33's Care Plan revealed, in part, pressure reduction techniques turned/repositioned. There was no documentation on how often to turn the resident. In an interview on 12/11/2014 at 2:16pm, S5/Performance Improvement Coordinator stated that she did not see any documentation of the size of the Stage II Pressure Ulcer per the nursing staff. In interview on 12/12/14 at 9:40am, S2/Unit Director stated the order for Resident #33's air fluidized was for an air mattress that had to be ordered and placed on the resident's bed. She further stated the plan of care was standard to turn a resident every 2 hours for a resident that does not have a pressure ulcer. Review of Resident # 33's electronic chart revealed from the time frame of 7/21/14 through 7/25/14 there was no documentation to reflect the resident was turned at least every 2 hours. In interview on 12/12/14 at 9:25am, S1/DON stated the Registered Nurses should stage the wound and document the size of the wound at least weekly. He stated that for Resident #33 it was not documented. Resident #85 Record review of Resident #85 ' s MDS (Minimum Data Set) dated 7/08/14 revealed the resident was coded as having a Stage 1 Pressure Ulcers. Review of the MDS dated [DATE] Section G; functional status revealed that Resident #85 was a 2-person physical assist with bed mobility. Record review of the Braden Scale assessment tool dated 7/1/14 revealed Resident #85 had a score of 17 which indicated the resident was at a risk of pressure ulcer. Review of Resident #85's care plan dated 7/1/14 revealed she was care planned for pressure ulcer risk and the goal revealed the resident will have intact skin integrity. Interventions listed included: evaluate skin integrity; consider use of skin barrier if skin is intact; and place patient in appropriate pressure redistribution device in bed, chair and wheelchair. Record review of the Resident #85's Nurses Notes revealed an entry date of 7/01/14 which revealed that Resident #85 was admitted with a Sacral Spine Stage 1 pressure ulcer. Further review of the Nurses Notes dated 7/02/14 through 7/04/14 revealed Resident #85 had a Stage 1 pressure ulcer. Record review of Resident #85's Nurses Notes dated 7/07/14 through 7/15/14 revealed Resident #85 was assessed as having a Stage 2 pressure ulcer. Review of Resident #85's Physician order [REDACTED]. Record review of Resident #85 ' s progress notes, entered by S8/NP and dated 7/3/14, 7/8/14, 7/10/14 and 7/15/14 did not reveal documentation of a pressure ulcer in his notes. In interview on 12/12/14 at 11:16 am, S8/NP indicated that he did not see a pressure ulcer when he assessed the resident and a pressure ulcer on Resident #85 was never was reported by the nursing staff. Further interview with S8/NP revealed that after he reviewed the physician's History & Physical and doctor ' s notes there was no mention of a pressure ulcer. In interview on 12/11/14 S9/LPN at 1:39pm indicated she assessed Resident #85 ' s pressure ulcer on 7/05/14 and the wound was a Stage 1 pressure ulcer and she placed a moisture barrier on the pressure ulcer. Interview on 12/11/14 at 2:00pm S10/RN/OC no orders were written for a pressure ulcer care other than turn every 2 hours and no documentation was reviewed that care was being done on Resident #85. Record review of Resident #85 ' s Discharge summary dated 7/17/14 revealed no mention of treatment for [REDACTED]. In interview on 12/12/14 at 09:15am, S 2/RN/Unit Director reported that after reviewing the clinical record of Resident #85, there were no orders for sacral pressure ulcer wound care and the RN was responsible for staging of the pressure ulcer. After the development of the facility's Quality Assurance (QA) Plan of Action in September 2014 to address identified problems with Pressure Ulcer treatment, the following was noted during the Stage 2 review for Pressure Sores for Resident #52: Resident #52 was admitted to the facility on [DATE] with the diagnoses, in part, [MEDICAL CONDITION], Type II Diabetes, Debility Cardiovascular Disease and [MEDICAL CONDITION]. Review of Resident #52 ' s Physician Order's dated 12/6/14 revealed wound care routine and apply [MEDICATION NAME] to bilateral heel pressure ulcers. Review of Resident's #52's Braden Scale assessment dated [DATE] revealed in part she was at risk for pressure ulcer development and skin breakdown. Review of Resident #52's Nurses Notes dated 12/6/14 signed by S6/LPN revealed in part, the resident was admitted from the Hospital to the Skilled Nursing Facility with a dime size eschar to her left heel and a Stage 2 to sacrum pink and most. Further review revealed no wound measurements were documented on Resident #52 on 12/6/14. Review of Resident #52's Nurses Notes dated 12/7/14 revealed Resident #52 was assessed by S6/LPN with documentation in part, Resident #52 had Stage 2 to her sacrum (lower back). Further review revealed no wound measurements were documented on Resident #52 on 12/6/14 or 12/7/14. Review of Resident #52 ' s Physical Therapy notes dated 12/11/14 revealed Resident #52 needed extensive assistance on bed mobility and transfers. Review of Resident #52's S7/ Nurse Practitioner Notes dated 12/10/14 revealed documentation in part of Resident #52's skin assessment warm and dry, with ulceration. Further review revealed documentation of bilateral heel pressure ulcers and buttock ulceration, but no measurements of the pressure ulcers were documented on Resident #52. Further review revealed no wound measurements were documented on Resident #52 on 12/10/14. Observation during a skin audit on 12/12/14 at 12:10pm of Resident #52 ' s pressure ulcers revealed she had two Stage II Sacral Pressure Ulcers that was measured with the following measurements: 1) left buttock 2 cm (length) x 0.5 cm (width) red pink, open and no drainage noted, 2) Coccyx (lower back) 0.5 cm x 0.5 cm wound was open pink and without drainage, 3) Resident #52's left heal was unstageable with measurements at 3 cm x 1 cm with light black skin noted. In interview on 12/12/14 at 12:00 pm S12/ RN Operational Coordinator indicated the Registered Nurses (RN) assesses and stages pressure ulcers on the residents on the unit. In interview on 12/12/14 at 12:55pm S2/ RN Unit Director indicated she did a Quality Assurance Measure on Pressure Ulcers in September 2014 and the RN is responsible for assessing and measuring pressure ulcers on Residents initially, weekly and on discharge. She further indicated she did not have any RN measurements assessments and or photographs of Resident #52's Pressure Ulcers as the facility's QA plan required.

Based on interview and record review the facility failed to provide sufficient nursing staff to provide services in a timely manner for 1 (Resident #5) of 5 sampled residents (Resident #1, #2, #3, #4 and #5) who required extensive assistance for toileting out of a total census of 15 residents coded as occasionally or frequently incontinent on the facility's Resident Census and Conditions of Residents report. This deficient practice had the potential to affect all 15 residents. Findings: Review of the resident's record revealed that Resident #5 was an 86 y/o female who was admitted to the skilled unit status [REDACTED]. Other [DIAGNOSES REDACTED]. Resident #5 was discharged to home on 8/23/13. Review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed that Resident #5 was coded as being total dependent and required one person assist with toilet use. Further notation revealed that the resident was coded as always incontinent. During a telephone interview on 09/06/13 at 2:30 PM, Resident #5's son stated that he had visited Resident #5 on 8/19 or 8/20. Resident #5's son acknowledged that he could not recall the exact date but stated that around 6:00 PM he had pressed the call light for someone to help Resident #5 to use the bedpan. Resident #5's son stated that after about 25-30 minutes, he went to the nursing station to see if he could get someone to help his mother. Resident #5's son stated that he asked a female staff who was sitting behind the nursing station if someone could come to assist his mother and was told that everyone was in a staff meeting. Resident #5 stated he went back to his mother's room and that his mother was very upset and started to hyperventilate. Resident #5's son stated that his mother tends to hyperventilate when she is upset and that he knows how to calm her by telling her to purse lip breathe until she relaxes and starts to breathe normal again. Resident #5's son stated that he was glad he was there because his mother had actually started to turn blue. Resident #5's son stated that he did not go back to the nursing station to ask for help because he had already been told that everyone was in a staff meeting. Resident #5's son stated that it was about 7:30 PM before someone came to the room to check on his mother. During an interview on 9/10/13 at 12:30 PM, S1, Unit Director (UD) stated that the monthly staff meetings are held every 3rd Wednesday from 6:00 PM until 7:00 PM. S1, UD stated the evening and night shift staff attend these meeting. S1, UD stated that the meeting was held on Tuesday, 8/20/13, because she had an event that prevented the normal 3rd Wednesday meeting that month. S1, UD stated that during these staff meetings some staff are assigned to stay on the unit to monitor and care for the residents. S1, UD stated that on 8/20/13 there were four nurses assigned to monitor the unit during the staff meeting from 6:00 PM-7:00 PM. S1, UD stated that S6, RN/Charge, S15, LPN, S16, RN and S17, RN were assigned to remain on the unit during the staff meeting on 8/20/13. S1, UD was asked if she had ever received any complaints from residents that there was no staff on the unit to assist them. S1, UD acknowledged that she had received a complaint from Resident #5's son on 8/21/13. S1, UD stated that Resident #5's son told her that he had gone to the nursing station to ask for assistance for Resident #5 and that there was a female behind the desk who told him that everybody was in a meeting. S1, UD stated that Resident #5's son was able to describe the person who was sitting at the nursing station and she was able to determine from his description that the staff was S14, Patient Care Technician (PCT). S1, UD stated that S14, PCT had clocked in around 6:30 PM for her 7:00 PM to 7:00 AM shift. S1, UD was asked if she had spoken to S14, PCT to find out if she helped the resident or found someone else to help him. S1, UN stated at this time that she had not obtained that information from S14, PCT but that there were nurses on the unit who could have been called to help the resident. S1, UN acknowledged that S14, PCT's response was inappropriate. S1, UD stated that she did not document her discussion with S14, PCT but that she had counseled her regarding the inappropriate response. S1, UD was asked if any one came to help the resident at the time of the request. S1, UD stated that she could not verify at what time someone came to help the resident but that the resident did get help. S1, UD was asked if the help came before or after the staff got out of the meeting since S14, PCT had stated to the resident that everyone was in a staff meeting. S1, UD acknowledged that she did not know the answer to this. S1, UD stated that she would make a telephone call to S14, PCT. S1, UD returned momentarily and stated that she attempted to call S14, PCT but was unable to reach her. During a telephone interview on 09/06/13 at 2:30 PM, Resident #5's son stated that he had been pressing the call light since about 6:00 PM. Resident #5's son stated that after about 25-30 minutes he went to the nursing station and was told that everyone was in a meeting. Resident #5's son stated that staff did come about 7:30 PM

Based on record review and interview the facility failed to (1) provide incontinence care to the resident in a manner that respects her dignity, (2) strive to meet the need of the resident in a timely manner (3) monitor the resident who was totally dependent for toilet use, and (4) strive to minimize feelings of being "upset" to the point of hyperventilation of the resident by not responding to her call for assistance in a timely manner for 1 (Resident #5) of 5 sampled resident (#1, #2, #3, #4, #5) who were noted on the facility's Resident Census and Conditions of Residents report as occasionally or frequently incontinent of bladder. This deficient practice had the potential to affect all 15 residents in the facility. Findings: Review of the resident's record revealed that Resident #5 was an 86 y/o female who was admitted to the skilled unit status [REDACTED]. Other [DIAGNOSES REDACTED]. Resident #5 was discharged to home on 8/23/13. Review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed that Resident #5 was coded as being total dependent and required one person assist with toilet use. Further notation revealed that the resident was coded as always incontinent. During a telephone interview on 09/06/13 at 2:30 PM, Resident #5's son stated that he had visited Resident #5 on 8/19 or 8/20. Resident #5's son acknowledged that he could not recall the exact date but stated that around 6:00 PM he had pressed the call light for someone to help Resident #5 to use the bedpan. Resident #5's son stated that after about 25-30 minutes, he went to the nursing station to see if he could get someone to help his mother. Resident #5's son stated that he asked a female staff who was sitting behind the nursing station if someone could come to assist his mother and was told that everyone was in a staff meeting. Resident #5 stated he went back to his mother's room and that his mother was very upset and started to hyperventilate. Resident #5's son stated that his mother tends to hyperventilate when she is upset and that he knows how to calm her by telling her to purse lip breathe until she relaxes and starts to breathe normal again. Resident #5's son stated that he was glad he was there because his mother had actually started to turn blue. Resident #5's son stated that he did not go back to the nursing station to ask for help because he had already been told that everyone was in a staff meeting. Resident #5's son stated that it was about 7:30 PM before someone came to the room to check on his mother. During an interview on 9/10/13 at 12:30 PM, S1, UD acknowledged that she had received a complaint from Resident #5's son on 8/21/13. S1, UD stated that Resident #5's son told her that he had gone to the nursing station to ask for assistance for Resident #5 and that there was a female behind the desk who told him that everybody was in a meeting. S1, UD stated that Resident #5's son was able to describe the person who was sitting at the nursing station and she was able to determine from his description that the staff was S14, Patient Care Technician (PCT). S1, UD was asked if she had spoken to S14, PCT to find out if she helped the resident or found someone else to help him. S1, UN stated at this time that she had not obtained that information from S14, PCT but that there were nurses on the unit who could have been called to help the resident. S1, UN acknowledged that S14, PCT's response was inappropriate. S1, UD was asked if any one came to help the resident at the time of the request. S1, UD stated that she could not verify at what time someone came to help the resident but that the resident did get help. S1, UD was asked if the help came before or after the staff got out of the meeting since S14, PCT had stated to the resident that everyone was in a staff meeting. S1, UD acknowledged that she did not know the answer to this. S1, UD stated that she would make a telephone call to S14, PCT. S1, UD returned momentarily and stated that she attempted to call S14, PCT but was unable to reach her. During a telephone interview on 09/06/13 at 2:30 PM, Resident #5's son stated that he had been pressing the call light since about 6:00 PM. Resident #5's son stated that after about 25-30 minutes he went to the nursing station and was told that everyone was in a meeting. Resident #5's son stated that staff did come to assist Resident #5 about 7:30 PM.

Based on interviews and record reviews the facility failed to ensure prompt efforts were made to resolve grievances. The facility failed to provide resolution for a grievance related to missing personal items for 1 (resident#1) of 5 samples residents. Findings: A telephone interview was conducted with Resident #1 ' s wife on 9/30/12 at 8:30PM. During the interview Resident #1 ' s wife stated when her husband was moved from the main campus to the SNF (Skilled Nursing Facility) unit the hospital staff packed all her husband clothes and moved him to the SNF unit. She also stated when Resident #1 was transferred back to the main campus she assumed the hospital staff would pack her husband ' s clothes and move them from the SNF unit to the main campus. An interview was conducted with S1, RN on 10/1/12 at 11:20AM. During the interview S1, RN stated during the admit process information is gathered regarding dentures, hearing aids and etc. This information is noted as to whether the patient came in with any of these items. S1, RN further stated it is not their practice to itemize every item the patients has with them. S1, RN stated they use the word belonging to indicate the patient presented with personal items. S1, RN further stated that each item is not itemized on admit or discharge. Review of Resident #1 ' s Admission Assessment revealed in part the following: next to the word belonging the word yes is noted. Also on the admission assessment next to the word dentures the word full is noted. S1, RN was asked to explain what the word full next to dentures means. S1, RN stated the word full next to dentures indicates the client wears full dentures. She further states the word full does not indicate the dentures were present, just that the patient wears dentures. Review of Resident#1 ' s Nurses ' Admission note date 8/9/12 at 15:40 noted in part the following: Patient arrived on the unit via wheelchair, awake and alert, oriented x3 accompanied by ambulance personnel. Patient required assistance for transfer, no distress noted ... No teeth, patient has full dentures at home. A telephone interview was conducted with S3, SW (Social Worker) on 10/1/12 at 12:30PM. During the interview S3, SW stated she first became aware of Resident#1 ' s missing items on 9/6/12 when she was talking to the family about discharge planning. S3, SW stated the resident ' s wife asked how was her husband going to be discharged when he didn ' t have any clothes. S3, SW stated that Resident #1 ' s wife further stated that Resident #1 ' s clothes were still on the SNF unit. S3, SW stated she spent the next 2 or 3 days in communication with the SNF unit trying to get the resident ' s clothes. S3, SW also stated she asked the resident and his wife did they want to talk with someone from Patient Relations (the department responsible for the Grievance Process). S3, SW said the client and his wife declined saying they would rather everything be handled on the unit level if possible. S3, SW stated after three days of emails and phone calls the situation remained unresolved and she was assigned to another area. S3, SW stated this issue was turned over to S4, SW to continue the investigation. Review of an email from S1, RN, Unit Manager to S3, SW dated 9/10/12, 11:29AM revealed that a black bag with resident ' s clothes had been found and that the black bag was being sent by the courier to the main campus. The email also noted in part the following: Our usual procedure is to have the belongings picked up by the family within 24 hours of discharge to Main and if they are not picked up they are sent to security since we cannot be responsible for personal belongings of patients no longer on the unit. A telephone interview was conducted with S4, SW on 10/1/12 at 2:00PM. During the interview, S4, SW stated on 9/12/12 she was in Resident #1 ' s room discussing discharge planning. S4, SW stated she noticed a black bag and commented that the lost items had been found. S4, SW further stated she talked with the client ' s wife on the phone about discharge planning and informed Resident #1 ' s wife that the black bag and the clothes had been found. S4, SW stated she believed the situation to be resolved when she did not hear anything else from the resident or his wife referencing missing clothes. An interview was conducted with S1, RN on 10/1/12 at 2:40PM. During the interview S1, RN stated that Resident #1 ' s wife returned to the SNF unit on the day of her husband ' s discharge or the day after her husband ' s discharge from the acute care hospital looking for the rest of her husband ' s missing items (apparently not all of Resident #1 ' s clothing was in the black bag). S1, RN stated the wife was looking for a pair of sneakers, shirts and pants. S1, RN stated she remembered that there were no sneakers in the bag. S1, RN further stated that she and Resident#1 ' s wife looked through some other clothes that had been left on the unit but Resident #1 ' s clothes were not among those clothes. S1, RN also stated she apologized to Resident #1 ' s wife regarding the missing clothes. S1, RN stated that Resident#1 ' s wife left the unit after the clothes were not found and there was no other action taken by the facility regarding Resident #1 ' s missing items. The facility had no functional system in place, at the unit level, to track grievances (i.e. missing personal items) from initial complaint to resolution. An interview was conducted with S5, RN on 10/1/12 at 2:20PM. During the interview S5, RN acknowledged that a better tracking system (paper trail) referencing grievances needs to be implemented at the unit level.

Based on interview and record review the facility failed to ensure that data for the Minimum Data Set (MDS) was transmitted within 14 days per regulatory requirement. This deficient practice was evident for all residents who had been admitted to the facility since the inception of the MDS 3.0 version which began on 10/25/10 and remains currently in use. MDS data for all residents admitted to the facility between the time periods of 10/25/10 through 12/1/11 had not been transmitted. Findings: An interview was conducted with S2, RN on 11/28/11 at 2:30pm. In the interview S2, RN informed the surveyors that the facility was entering data for MDS and they were utilizing the 2.0 version. S2, RN also stated in the same interview that the facility had acquired a new system for entering MDS data. S2, RN informed the survey team members that the facility planned to begin utilizing the new system on 11/29/11. An interview was conducted with S4, RN MDS nurse on 11/30/11 at 1:00pm, and she stated that she was utilizing the 3.0 version, but had difficulty transmitting the data. S4, RN MDS nurse added that because the facility was receiving compensation for each admit, she did not know that the inability to transmit the data was a problem which needed to be addressed. An interview was conducted with S2, RN on 11/30/11 at 2:00pm. In the interview S2, RN stated that her knowledge of MDS is fragmented, and she was misinformed by another employee. S2, RN corrected her earlier statement by informing the survey team that the facility was not utilizing the 2.0 version of MDS. S2, RN informed the survey team that the data was not being transmitted because of technical issues that she could not explain. DHH administration at State Office was informed of the findings. State Office investigation of the data revealed that the facility had not transmitted any MDS data since the inception of the currently used MDS 3.0 version which began 10/25/10. An interview was conducted with S1, RN, S2, RN, and S3, RN on 12/1/11 at 10:00am. In the interview S1, RN, S2, RN and S3, RN acknowledged the findings of DHH administration at State Office and stated that they understood the problem and had already began devising a plan of corrective action.

Based on record reviews and interviews the facility failed to ensure a comprehensive assessment was conducted on each resident within 14 day after admission for 3 (resident#7,#8,#9) of 6 residents with an admitted greater than 14 days in a total of 10 sampled residents. Findings: Resident#7 A review of resident#7 ' s medical record revealed that the resident was admitted to the facility on [DATE]. The resident ' s comprehensive assessment should have been conducted on 11/15/11. Review of resident#7 ' s MDS (Minimum Data Set) revealed that the comprehensive assessment was conducted on 11/30/11. Resident#8 A review of resident#8 ' s medical record revealed that the resident was admitted to the facility on [DATE]. The resident ' s comprehensive assessment should have been conducted on 11/22/11. Review of resident#8 ' s MDS revealed that the comprehensive assessment was conducted on 12/01/11. Resident#9 A review of resident#9 ' s medical record revealed that the resident was admitted to the facility on [DATE]. The resident ' s comprehensive assessment should have been conducted on 11/27/11. Review of resident#9 ' s MDS revealed that the comprehensive assessment was conducted on 12/01/11. An interview was conducted with S5, MDS nurse on 12/1/11 at 10:30AM. During the interview S5, MDS nurse acknowledged that the comprehensive assessments were not conducted within 14 days after admission.