Every finding on record at Perkins Country Manor

Based on observation, interview, and review of the facility's policies, the facility failed to protect and preserve the dignity of 1 of 16 sampled residents, Resident (R) 13, by standing while assisting the resident with her meal.The findings include:Review of the facility's policy titled, Resident Rights Policy, copyrighted 2026, revealed the resident has the right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation for the resident's need or preferences, except when to do so would endanger the health and safety of the resident or other residents.Review of the facility's policy titled, Meal Supervision and Assistance, updated 08/20/2025, revealed compliance guidelines including the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position. It also instructed staff to provide a relaxing, enjoyable environment during mealtime.Review of R13's Face Sheet revealed the facility admitted the resident on 01/14/2023 with diagnoses to include late-onset Alzheimer's disease, protein malnutrition, metabolic encephalopathy, and multiple co-morbidities.Review of R13's Physician Orders from 01/13/2023 revealed her diet was ordered as a mechanically altered diet with thin liquids.Review of R13's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 02/16/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 1 out of 15, which indicated the resident had severe cognitive impairment. Further review revealed the facility assessed the resident to have swallowing concerns, including pocketing food and residual food, after oral intake. R13 was further assessed as requiring supervision and intermittent, hands-on assistance with her meals.Review of R13's Care Plan, dated 01/13/2023, revealed a focus of a mechanically altered diet with thin liquids, a goal of maintaining a stable weight, and interventions that included monitoring for any signs or symptoms of dysphagia, pocketing, choking, coughing, drooling, holding food in the mouth, several attempts at swallowing, and refusing to eat or appearing concerned during meals. A revision was added on 02/05/2024, which required staff to assist R13 with all meals.Observation of the meal service on 03/16/2026 at 12:22 PM, revealed Certified Nursing Assistant (CNA) 1 was feeding R13 her entire meal from a standing position, while R13 was sitting at the dining room table.During an interview with CNA1 on 03/16/2026 at 3:29 PM, she stated she normally sits beside the resident to assist her, but another resident's walker was in the way, so she stood. She stated she should have moved the walker and sat at eye-level with the resident so she could be seen, and that not doing so could make the residents feel as if the staff did not care about them. During an interview with the Director of Nursing/Infection Preventionist (DON/IP) on 03/18/2026 at 2:46 PM, she stated it was her expectation that staff would feed residents from an eye-level position. This was to provide dignity, and it would allow for better observation of how the residents were tolerating the meal.During an interview with the Administrator on 03/18/2026 at 3:35 PM, she stated her expectation depended on who was in the dining room, as it would look a little different if it were a cue versus a feeding. She added that feeding a resident was normally done one at a time. She expected whoever assisted a resident with a meal would be focusing on the resident and expected the staff to sit beside the resident. The purpose would be to make the residents experience a home-like feeling and to feel they were important.

Based on interview, record review, and facility policy review, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 9 out of 9 residents investigated for transfer and/or discharge, Resident (R) 31, R5, R14, R2, R25, R17, R10, R12, and R15. The findings include: Review of the facility's policy titled, Transfer and Discharge, dated [DATE], revealed the facility was to provide the resident and their representative with a notice of transfer if the resident required emergency transfer to an acute care facility. Further review revealed the notice was to be in a language and manner the resident and their representative could understand. Continued review revealed the notice was to include the specific reason and location for the transfer, effective date of the transfer, as well as an explanation of the right to appeal a transfer with the contact information for the Ombudsman and appropriate state agencies. 1. Review of R31's admission Record revealed the facility admitted the resident on [DATE] with diagnoses including vascular dementia, anxiety, and osteoporosis. Review of R31's Discharge Summary, dated [DATE], revealed the facility transferred R31 to the hospital for increased aggression toward staff, exit seeking, and refusing care. Further review revealed the facility documented Family Member (F) 31 as the resident's caretaker. However, the facility failed to provide evidence they provided F31 with written information related to R31's transfer. In an interview on [DATE] at 1:42 PM, F31 stated she was not notified of R31's transfer to the hospital until after the facility had already transferred her. She further stated she was notified by text message, but never received written information detailing the reason for the transfer in a manner she could understand. F31 also stated she did not receive information regarding her appeal rights related to the transfer. 2. Review of R2's admission Record revealed the facility admitted the resident on [DATE] with current diagnoses, as of [DATE], including hemiplegia (partial paralysis) following cerebral infarction (stroke), neuromuscular dysfunction of the bladder, and infection due to indwelling urinary catheter. Review of R2's Nurse's Note, dated [DATE], revealed the facility transferred the resident to the hospital on that date for blood pressure changes, pallor, and low oxygen saturations. In an interview on [DATE] at 11:21 AM, R2's Power of Attorney (POA) stated she did not receive paperwork from the facility related to his hospitalization, but the facility did notify her over the phone they were sending him to the hospital. In an interview on [DATE] at 4:12 PM, Licensed Practical Nurse (LPN) 1 stated she was the nurse who sent R2 to the hospital after she noted in her assessment R2 had increased tremors, shortly followed by high blood pressure and low blood oxygen saturations. LPN1 further stated she notified the Nurse Practitioner (NP) and the POA by phone, but she did not provide the POA with paperwork that described the location and reasons for the transfer or information on the resident's appeal rights. LPN1 stated it was not part of her process to provide the resident and their representative with paperwork related to their transfer, and she did not know who would be responsible for that. 3. Review of R15's admission Record revealed the facility admitted the resident on [DATE] with current diagnoses, as of [DATE], including spina bifida (malformation of the spine present at birth), neuromuscular dysfunction of the bladder, and urinary tract infection. Review of R15's Transfer Form, dated [DATE], revealed the facility transferred the resident to the hospital for low blood oxygen saturations and low blood pressure. Further review of the record revealed no evidence the resident or the resident's representative received written transfer information. In an interview on [DATE] at 5:32 PM, R15 stated he had been hospitalized recently. He stated he did not recall the reasons for transfer nor did he receive any paperwork related to his hospitalization. 4. Review of R25's admission Record revealed the facility admitted the resident on [DATE] with diagnoses including cirrhosis of the liver and hepatorenal syndrome (injury to kidneys caused by liver failure). Review of R25's Nurse's Note, dated [DATE], revealed the facility transferred the resident to the hospital for increased ascites (abdominal swelling) and significant decline in activities of daily living function. Further review revealed the note stated R25's Family Member (F) 25 was aware of the transfer; however, the facility failed to provide evidence R25 and/or F25 received written information about her transfer to the hospital. In an interview on [DATE] at 2:44 PM, F25 stated he did not receive paperwork describing the reasons for F25's transfer to the hospital. He further stated R25 was discharged home from the hospital with hospice and had since died. 5. Review of R5's admission Record revealed the facility admitted the resident on [DATE] with diagnoses of pneumonia, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of R5's Nurse's Note, dated [DATE] at 2:36 PM, revealed staff observed her to be lethargic and hard to arouse, with blue fingers and a low blood oxygen saturation reading of 69 percent, which was significant for hypoxia (very low oxygen level in the tissue). Further review revealed R5 was transferred to a local hospital emergency room for evaluation, and a family member was called and verbally informed of the situation. However, the facility failed to provide evidence R5 and/or R5's Family Member (F) 5 received written information about her transfer to the hospital. Review of R5's Nurse's Note, dated [DATE], revealed she returned to the facility from the hospital admission. Telephone interview was attempted with F5 on [DATE] at 11:13 AM, and a second attempt was made [DATE] at 8:42 AM. However, on both attempts there was no answer and no voicemail available. 6. Review of R12's Facesheet revealed the facility admitted the resident on [DATE] with diagnoses of depression, anxiety disorder, and dementia. Review of the facility's document Census revealed R12 was sent to the hospital on [DATE] and [DATE]. However, the facility failed to provide evidence R12 and/or R12's responsible party received written information about her transfer to the hospital for both events. Telephone interview was attempted with R12's responsible party on [DATE] at 9:05 AM, [DATE] at 2:58 PM, and [DATE] at 6:39 PM. However, these three attempts were unsuccessful. 7. Review of R14's Facesheet revealed the facility admitted the resident on [DATE] with diagnoses of vascular dementia with behavioral disturbances and schizoaffective disorder. Review of the facility's document Census revealed R14 was sent to the hospital on [DATE]. However, there was no documentation by the facility stating written information was sent to R14's responsible party. Review of R14's Transfer Form, dated [DATE], revealed R14's transfer was unplanned related to intermittent tremors-full body, and the resident's responsible party was notified via telephone. Review of R14's Progress Note, dated [DATE], revealed R14 returned to the facility via emergency medical services (EMS) from the hospital with a diagnosis of seizures. In an interview with R14's responsible party on [DATE] at 4:50 PM, she stated she did not recall getting anything in writing from the facility regarding the reason for R14 being transferred to the hospital. 8. Review of R10's Facesheet revealed the facility admitted the resident on [DATE] with diagnoses of end stage renal disease (ESRD), cerebral infarction, and convulsions. Review of the facility's document Census revealed R10 was sent to the hospital on [DATE] and [DATE]. However, there was no documentation by the facility for either transfer stating written information was sent to R10's responsible party. Review of R10's Progress Note, dated [DATE], revealed R10 was transferred to the hospital from the dialysis clinic because of a clotted dialysis access site. The note also stated the dialysis clinic spoke to R10's family member for notification of the transfer. Review of R10's Transfer Form, dated [DATE], revealed R10 was having an unplanned transfer to the hospital for abdominal pain, and R10's responsible party was notified of the transfer via telephone on [DATE]. Telephone interview with R10's responsible party was attempted on [DATE] at 8:57 AM. However, this attempt was unsuccessful. 9. Review of R17's Facesheet revealed the facility admitted R17 on [DATE] with diagnoses of cerebral infarction, major depressive disorder, and COPD. Review of the facility's document Census revealed R17 was sent to the hospital on [DATE] and [DATE]. However, there was no documentation by the facility for either transfer stating written information was sent to R17's responsible party. Review of R17's Long Term Care Transfer Form, dated [DATE], revealed R17's reason for transfer was medical emergency, and R17's representative gave verbal consent via telephone authorizing the transfer. Review of R17's Progress Note, dated [DATE], revealed R17 was sent to the hospital from a scheduled doctors appointment. Telephone interview was attempted with R17's representative on [DATE] at 12:08 PM. However, this was unsuccessful. A voicemail was left, but a telephone call was not returned. In an interview with the Director of Nursing (DON) on [DATE] at 4:52 PM, she stated the nurse assigned to a resident was the person responsible for calling and notifying a family member of a change in condition and transfer to the hospital. In an interview on [DATE] at 11:48 AM, the Administrator stated the facility identified during the course of the survey that they had been inconsistent in implementing their process to ensure residents and their representatives received required transfer paperwork. She stated they would address the process failures through their quality assurance program.

5. Review of R5's admission Record revealed the facility admitted the resident on [DATE] with diagnoses of pneumonia, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of R5's Nurse's Note, dated [DATE], revealed staff observed her to be lethargic, hard to arouse, with blue fingers and a low blood oxygen saturation reading of 69%, significant for hypoxia, meaning very low oxygen level in the tissues. Further review revealed R5 was transferred to a local hospital emergency room for evaluation, and a family member was called and verbally informed of the situation. Review of R5's Nurse's Note, dated [DATE], revealed she returned to the facility from the hospital admission. Review of R5's Bed Hold Agreement, dated [DATE], revealed the BOM signed to verify she obtained verbal consent to hold the resident's bed. Further review revealed no evidence the form was sent to the resident or the resident's representative. Telephone interview was attempted with R5's representative on [DATE] at 11:13 AM and [DATE] at 8:42 AM. However, on both attempts there was no answer and no voicemail available. 6. Review of R12's Facesheet revealed the facility admitted the resident on [DATE] with diagnoses of depression, anxiety disorder, and dementia. Review of the facility's document Census, revealed R12 was sent to the hospital on [DATE] and [DATE]. However, R12's Bed Hold Agreement was requested for both events but never produced, and there was no documentation by the facility stating these written notices were sent to R12's responsible party. Telephone interview was attempted with R12's responsible party on [DATE] at 9:05 AM, [DATE] at 2:58 PM, and [DATE] at 6:39 PM. However, none of these three attempts were successful. 7. Review of R14's Facesheet revealed the facility admitted the resident on [DATE] with diagnoses of vascular dementia with behavioral disturbances and schizoaffective disorder. Review of the facility's document Census revealed R14 was sent to the hospital on [DATE]. However, no documentation by the facility stating written information was sent to responsible party was in the medical record. Review of R14's Transfer Form, dated [DATE], revealed R14's transfer was unplanned and related to intermittent tremors-full body. Review of R14's Bed Hold Agreement, dated [DATE] and signed by the BOM, stated, Called guardian, she is aware of the 14-day bed hold for Medicaid, wants me to call her if she gets close to the 14 days and she will decide at that point. Review of R14's Progress Note, dated [DATE], revealed R14 returned to the facility via emergency medical services (EMS) from the hospital with a diagnosis of seizures. In an interview with R14's representative on [DATE] at 4:50 PM, she stated she did not recall getting anything in writing from the facility regarding the resident's bed hold. 8. Review of R10's Facesheet revealed the facility admitted the resident on [DATE] with diagnoses of end stage renal disease (ESRD), cerebral infarction, and convulsions. Review of the facility's document Census revealed R10 was sent to the hospital on [DATE] and [DATE]. However, although requested, no documentation by the facility of R10's Bed Hold Agreement for both transfers was ever produced. Review of R10's Progress Note, dated [DATE], revealed R10 was transferred to the hospital from the dialysis clinic because of a clotted access site. Per the note, staff at the dialysis clinic spoke with the son for notification. Review of R10's Transfer Form, dated [DATE], revealed R10 was having an unplanned transfer to the hospital for abdominal pain, and R10's representative was notified of the transfer via telephone on [DATE]. Telephone interview with R10's responsible party was attempted on [DATE] at 8:57 AM. However, this attempt was unsuccessful. 9. Review of R17's Facesheet revealed the facility admitted R17 on [DATE] with diagnoses of cerebral infarction, major depressive disorder, and COPD. Review of the facility's document Census revealed R17 was sent to the hospital on [DATE]. Review of R17's Progress Note, dated [DATE], revealed R17 was sent to the hospital from a scheduled doctor's appointment. Review of R17's Bed Hold Agreement, dated [DATE], revealed the BOM signed to verify she obtained verbal (telephone) consent from R17's representative to hold the resident's bed. Further review revealed no evidence the form was sent to R17 or R17's representative. Telephone interview was attempted with R17's representative on [DATE] at 12:08 PM. However, this was unsuccessful. A voicemail was left, but a telephone call was not returned. In an interview with the Director of Nursing (DON) on [DATE] at 4:52 PM, she stated the nurse assigned to a resident was the person responsible for calling and notifying a family member of a change in condition and transfer to the hospital. She stated bed holds were determined by a resident's payor source, and that was handled through the business office. In an interview on [DATE] at 7:02 PM, the BOM stated her process for obtaining bed hold consents was to call the family or talk about it with the family. She further stated she did not provide written copies or mail a copy of the bed hold policy or agreement to the resident or the representative related to hospitalizations. In an interview on [DATE] at 6:09 PM, the Administrator stated she believed the BOM mailed a copy of the bed hold policy and agreement to the resident's representative, but she was not sure. In further interview on [DATE] at 11:48 AM, the Administrator stated the facility identified the need to fix inconsistencies in their process with transfer paperwork. Based on interview, record review, and facility policy review, the facility failed to provide to the resident and the resident's representative a written notice which specified the duration of the bed hold policy. The deficient practice was identified for 9 out of 9 residents investigated for hospitalizations, Resident (R) 31, R5, R14, R2, R25, R17, R10, R12, and R15. The findings include: Review of the facility's policy titled, Transfer and Discharge, dated [DATE], revealed the facility was to provide the resident and their representative with a notice of the facility's bed hold policy as indicated. 1. Review of R31's admission Record revealed the facility admitted the resident on [DATE] with diagnoses including vascular dementia, anxiety, and osteoporosis. Review of R31's Discharge Summary, dated [DATE], revealed the facility transferred R31 to the hospital for increased aggression toward staff, exit seeking, and refusing care. Further review revealed the facility documented Family Member (F) 31 as the resident's caretaker. Review of R31's Bed Hold Agreement, dated [DATE], revealed the Business Office Manager (BOM) signed to verify she obtained verbal consent from F31 to release the resident's bed. Further review revealed no evidence the form was sent to F31. In an interview on [DATE] at 1:42 PM, F31 stated she was notified by text message of the resident's transfer, but she never received any paperwork detailing her options for holding R31's bed if she so chose. 2. Review of R2's admission Record revealed the facility admitted the resident on [DATE] with current diagnoses, as of [DATE], including hemiplegia (partial paralysis) following cerebral infarction (stroke), neuromuscular dysfunction of the bladder, and infection due to indwelling urinary catheter. Review of R2's Nurse's Note, dated [DATE], revealed the facility transferred the resident to the hospital on that date for blood pressure changes, pallor, and low blood oxygen saturations. Review of R2's Bed Hold Agreement, dated [DATE], revealed the BOM signed to verify she obtained verbal consent from R2's Power of Attorney (POA) to hold the resident's bed. Further review revealed no evidence the form was sent to the POA. In an interview on [DATE] at 11:21 AM, R2's POA stated she did not receive paperwork from the facility related to the facility's bed hold policy, but the facility did notify her over the phone that they were sending him to the hospital and verbally confirmed her wishes related to holding the resident's bed. In an interview on [DATE] at 4:12 PM, Licensed Practical Nurse (LPN) 1 stated she was the nurse who sent R2 to the hospital after she noted in her assessment R2 had increased tremors, shortly followed by high blood pressure and low blood oxygen saturations. LPN1 further stated she notified the Nurse Practitioner (NP) and the POA by phone, but she did not provide the POA with paperwork related to the transfer, including a bed hold notice. 3. Review of R15's admission Record revealed the facility admitted the resident on [DATE] with current diagnoses, as of [DATE], including spina bifida (malformation of the spine present at birth), neuromuscular dysfunction of the bladder, and urinary tract infection. Review of R15's Transfer Form, dated [DATE], revealed the facility transferred the resident to the hospital for low blood oxygen saturations and low blood pressure. Review of R15's Bed Hold Agreement, dated [DATE], revealed the BOM signed to verify she obtained verbal consent to hold the resident's bed. Further review revealed no evidence the form was sent to the resident or the resident's representative. In an interview on [DATE] at 5:32 PM, R15 stated he had been hospitalized recently. He stated he did not recall the reasons for transfer nor did he receive any paperwork related to his hospitalization. 4. Review of R25's admission Record revealed the facility admitted the resident on [DATE] with diagnoses including cirrhosis of the liver and hepatorenal syndrome (injury to kidneys caused by liver failure). Review of R25's Nurse's Note, dated [DATE], revealed the facility transferred the resident to the hospital for increased ascites (abdominal swelling) and significant decline in activities of daily living function. Review of R25's Bed Hold Agreement, dated [DATE], revealed the BOM signed to verify she obtained verbal consent from F25 to release the resident's bed. Further review revealed no evidence the form was sent to the resident or F25. In an interview on [DATE] at 2:44 PM, F25 stated he did not receive paperwork describing the facility's bed hold policy. He further stated he verbally confirmed with the facility that they did not wish to hold the resident's bed space because he already expected R25 to be going home under hospice care following the transfer to the hospital for evaluation. He stated R25 was discharged home from the hospital with hospice and had since died.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Observation on 02/18/2025, revealed the facility was unable to demonstrate the temperature in the medication refrigerator was within acceptable limits after two thermometers were malfunctioning. On 02/19/2025, observation revealed the thermometer read 50 degrees Fahrenheit (F). This had the potential to affect all residents in the facility, with a census of 25. The findings include: Review of the facility's policy titled, Storage of Medication Requiring Refrigeration, dated 12/01/2024, stated, It is the policy of this facility to assure proper and safe storage of medication requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. Further review revealed the policy also stated, The facility will ensure that all medications and biologicals will be stored at proper temperatures and other appropriate environmental controls according to manufacturer's recommendations to preserve their integrity. The policy also revealed that refrigerated meant the medication needed to be maintained at a temperature of between 36 to 46 degrees F as measured by an accurate, functioning thermometer. Per the policy, the medication refrigerator temperature was to be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of person performing the check clearly written. Review of the facility's document Med Area Audit Details, dated 02/17/2025, revealed the facility's pharmacy staff performed an audit on 02/17/2025. Per the document, the medication refrigerator temperature was Satisfactory, with a temperature between 36 to 46 degrees F. Review of the facility's document Refrigerator/Freezer Temperature Log revealed a consistent 40 degrees F temperature was documented for the months of January 2025 and most of February 2025, with 42 degrees F documented for 02/18/2025. Observation on 02/18/2025 at 3:00 PM, revealed Licensed Practical Nurse (LPN) 1 was unable to locate a thermometer in the medication refrigerator. Observation on 02/18/2025 at 3:30 PM, revealed the thermometer was located in the back of the refrigerator, behind all the medications, stuck in a block of ice. Observation on 02/18/2025 at 4:00 PM, revealed the temperature on the refrigerator's thermometer read 20 degrees F, although the medications were not frozen. The medication refrigerator's temperature was rechecked at 4:30 PM, and the thermometer continued to read 20 degrees F. Observation on 02/19/2025 at 1:10 PM, revealed the medication refrigerator's thermometer read 50 degrees F. LPN1 stated a new thermometer was placed yesterday. Further observation revealed a different thermometer (third thermometer) was placed in the medication refrigerator at this time. Observation on 02/19/2025 at 2:29 PM revealed the medication refrigerator's new (third) thermometer temperature read 50 degrees F. During an interview on 02/18/2025 at 3:00 PM with LPN1, she stated night shift staff was responsible for checking medication refrigerator temperatures and documenting them. LPN1 stated she was new to the facility, and this was the first time she had ever accessed the medication refrigerator. LPN1 stated keeping the medications within the correct temperature parameters was important to prevent medications from going bad. During an interview on 02/19/2025 at 3:24 PM with the Pharmacy Account Manager, she stated she audited the medication cart and medication refrigerator quarterly, with the last audit being on 02/17/2025. She stated, for the medication refrigerator during the audit, she . usually has to empty the refrigerator because it's pretty full. She stated she checked the temperature, made sure there was no ice buildup, and checked all medications for expiration dates. She stated the temperature was between 36 to 46 degrees F on Monday, which was a safe range for all medications stored in the medication refrigerator. During an interview on 02/19/2025 at 3:38 PM with the Registered Pharmacist (RPh), he stated 50 degrees F was too warm for the medications to be used, and staff did not know how long it had been 50 degrees F. He stated medications in the medication refrigerator would need to be replaced. He stated 36-46 degrees F was an acceptable range for six weeks once the medication left the pharmacy. During an interview on 02/20/2025 at 11:36 AM with the Director of Nursing (DON), she stated she had already educated staff and made a new temperature log for the medication refrigerator. She stated the facility had already put another medication refrigerator in place. She stated she spoke to a pharmacist, who said all medications in the medication refrigerator would be fine since it was only a couple of hours of an unknown temperature. She stated it was important to store medications in the appropriate temperature so that the medications were effective. During an interview on 02/20/2025 at 2:50 PM with the Administrator, she stated she expected the medication refrigerator temperature to be checked and the logs to be completed per policy. She stated storing medications at the wrong temperature could take away their effectiveness.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and include at a minimum the medication name, prescribed dose, strength, expiration date, resident's name and route of administration. Observation of the treatment cart, on 11/24/19 at 9:40 AM, revealed a blue plastic lidded cup in the top drawer. Continued observation revealed the cup contained an unidentified thick white paste. The lid of the cup was labeled with Resident #2's name and a date of 11/25/19; however failed to identify the medication, strength of medication, prescribing physician or directions for use. The findings include: Review of the facility's Policy, titled Medication Administration General Guidelines 7.1, dated 09/18, revealed medications are prepared only by licensed nursing, medical, pharmacy or other authorized by state regulations to prepare medications. Further review of the facility's policy revealed medications are administered in accordance with written orders of the prescriber. Further review revealed the nurse should place a date opened sticker on the medication. Additional review of the facility's policy revealed the manufacturer or pharmacy label should include the following elements: medication name, medication strength, quantity, accessory information, lot number, and expiration date. Observation of the facility's treatment cart, on 11/24/19 at 9:40 AM, revealed a blue plastic lidded cup in the top drawer. Continued observation revealed a thick white paste inside the cup. Further observation revealed Resident #2's name was written on the lid of the cup with the date of 11/25/19; however, there was no documented evidence what the white paste substance was or directions for use. Interview with Registered Nurse (RN) # 1, on 11/24/19 at 10:05 AM, revealed the white paste was for use on Resident #2. She further stated the cup contained Zinc Ointment, Hydraguard, and [MEDICATION NAME] Ointment and it was used to treat areas on Resident #2's thighs. Continued interview revealed the mixture was not sent from pharmacy, she stated it was mixed together at the facility. Further interview revealed she did not know when or who mixed the medications together and she did not know what amount of each of the medications was mixed in the cup. She further stated the date of the lid was an expiration date. RN#1 stated she trusted the compounded mixture found unlabeled in the treatment cart to contain what the physician ordered, but could not be 100% certain of the mixture. She stated the medication mixture should have been labeled correctly with the resident's name, ordering physician, name of medication, strength, directions for use and the expiration date. Interview with Licensed Practical Nurse (LPN) #1, on 11/24/19 at 10:25 AM, revealed she had called the physician, on 11/24/19 at 10:15 AM, to obtain a clarification on the ingredients and proportions. LPN #1 stated she thought the white paste compound contained thirty (30) grams of Zinc Oxide Ointment (used to treat skin irritation), thirty (30) grams of Hydraguard Ointment (a water resistant barrier cream to protect skin), and thirty (30) grams of [MEDICATION NAME] Cream (an antifungal cream). LPN#1 stated she did not know when the mixture was made or who at the facility had compounded the mixture. Further interview with LPN #1 revealed the mixture should have been labeled correctly with the resident's name, ingredients, expiration date and directions for use. Interview with the Director of Nursing (DON), on 11/24/19 at 11:00 AM, revealed the facility mixed the compound per the physician's orders [REDACTED]. The DON further stated she did not know who had compounded the mixture contained in the treatment cart. The DON discarded the container and contents and stated the medication mixture should have been properly labeled. Further interview revealed a nurse new to the facility would not have known the contents or directions for use of the container. Interview with the Interim Administrator, on 11/26/19 at 3:45 PM, revealed the facility compounded the mixture per physician's orders [REDACTED]. Continued interview revealed the facility received thirty (30) gram tubes of each ingredient to mix for use on the resident's thighs. Per interview, there was a possibility the mixture may not be consistent from mixture to mixture and there was an opportunity for someone to alter the ingredients. Further interview revealed it was her expectation that medications would be labeled per the facility's policy.

Based on interview, record review and review of facility Policies, it was determined the facility failed to provide prompt efforts to resolve grievances for one (1) of thirteen (13) sampled residents (Resident #3) and four (4) Unsampled Residents (Residents B, C, D, and F). A Quality of Life Assessment Group Interview, conducted by the State Agency (SA) Representative with resident representatives of the Resident Counsel on 10/26/17, revealed during multiple Resident Council Meetings residents had expressed concerns related to Resident #10's loud and disruptive behaviors that effected their psychosocial well-being and kept them awake at night. However, the residents revealed the facility had failed to effectively resolve their grievances related to Resident #10's behaviors. This affected Resident #3 and Unsampled Residents B, C, D, and F). The findings include: Review of the facility's Policy titled, Investigate Complaint/Grievance review date of 05/12/17, revealed residents had the right to present a concern or a complaint about his/her care and treatment, staff, other residents, and any other concerns regarding their facility stay free from interference, coercion, restraint, discrimination, or reprisal. Continued review revealed the Social Service Director or his/her designee would coordinate efforts to comply with this policy. Per Policy, all grievances or complaints would be documented on the Grievance and Complaint Report by the person receiving the report. The Policy further revealed the Social Service Director or Designee would begin an investigation into the allegations and complete a report that included the date and time the incident took place; the nature of the grievance and complaint; the name of any witness and their account of the incident/occurrence; the employee's account of the incident/occurrence; follow-up/recommendation for corrective action, resolution, and the date the resolution was reported. Continued review of the Policy, revealed the Social Service Director, or designee would also take immediate action if warranted, to prevent any further potential violation of any resident right while the alleged grievance was being investigated. Per Policy, written grievance decisions would include, but not be limited to the date the grievance was received; a summary statement of the resident's grievance; the steps taken to investigate the grievance; a summary of the pertinent findings or conclusions regarding the resident's concerns; a statement as to whether the grievance was confirmed or not confirmed; any corrective action taken or to be taken by the facility as a result of the grievance; and the date the written decision was issued. The facility Policy further revealed all reports of abuse, harassment or mistreatment must be reported to the facility Administrator immediately and to the state agencies as required. Continued review of the Policy, revealed appropriate corrective action as required under state law would be taken by the facility if an alleged grievance involving a violation of a resident's rights was substantiated by either the facility or government agency. Review of the facility's Policy titled, Resident Council dated June 2007, revealed the purpose of the resident counsel was to provide a forum for residents to have input in the operation of the facility, discussion of concerns, and consensus building communication between residents and facility staff. Per Policy, responsibilities of the group council may include assisting in the development of resident grievance and complaint procedures; assisting in the development of the resident rights and responsibilities; making recommendations for the improvement of resident services provided by the facility; and maintaining minutes of all meetings and submitting a copy to the Administrator for their review. Further review of the Policy, revealed a Resident Council Response Form would be utilized to track issues and their resolution. The facility department related to any issues would be responsible to address the item(s) of concern. Continued review of the Policy, revealed minutes were to include the issues discussed; the Administrator would review the minutes and any responses from the departments within the facility; and the responses would be presented at the next meeting or sooner if indicated. Review of the facility's Kentucky Resident Handbook & Admission Information, revised 11/29/16, revealed the facility should protect and promote the rights of each resident including the right to voice grievances with respect to treatment or care without discrimination or reprisal and the right to prompt efforts by the facility to resolve resident grievances, including grievances regarding the behavior of other residents. Review of the Resident Council Meeting Minutes for the past six (6) months, revealed no documented evidence by the Activities Director, of reported complaints regarding loud and disruptive noises. However, during the Quality of Life Assessment Group Interview, conducted by the SA Representative with residents of the Resident Council on 10/26/17 from 10:00 AM, until 11:30 AM, revealed Residents #3, Unsampled Resident B, Unsampled Resident C, Unsampled Resident D, and Unsampled F complained about the noise level in the facility. During Group Interview, the residents voiced Resident #10 was loud and disruptive and there was an ongoing grievance related to this resident keeping them awake at night. Per Group Interview, Resident #10's room was across the hall from Unsampled Resident B's and Unsampled Resident D's room, and Resident #10 had kept them awake all through the night as many as five (5) nights in one (1) week, when he/she was engaging in behaviors. Resident B stated they would like to see the noise level change related to Resident #10, and all residents agreed, complaining the resident's behavior was disruptive to them. A. Unsampled Resident D was assessed by the facility in a Quarterly Minimum Data Set (MDS) Assessment, dated 09/22/17, as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of (15), indicating the resident was cognitively intact with no confusion. Review of Unsampled Resident D's Social Service Note dated 01/09/17, revealed ear plugs were offered to the resident to help diminish/muffle other resident sounds and hallway sounds. B. Unsampled Resident F was assessed by the facility to have a BIMS score of ten (10) out of fifteen (15), which was an indication the resident was moderately cognitively impaired. Unsampled Resident F complained during the Group Interview of loud noise levels at night related to Resident #10's behaviors. C. Resident #3 was assessed by the facility on a Quarterly MDS Assessment, dated 10/07/17, as having a BIMS score of nine (9) out of fifteen (15), indicating the resident was moderately cognitively impaired. Resident #3 complained during the Group Interview his/her room was close to Resident #10's room and Resident #10 would sometimes keep him/her awake all night. D. Unsampled Resident C was assessed in a Quarterly MDS Assessment, dated 10/19/17, as having a BIMS score of fifteen (15) out of (15), indicating the resident was cognitively intact. During the Group Interview, Unsampled Resident C stated the noise did not bother him/her at night due to poor hearing; however, he/she stated Resident #10 was disruptive during the day when he/she was awake. E. Unsampled Resident B/ Resident Council President, was assessed by the facility in a Quarterly MDS assessment dated [DATE], as having a BIMS score of fifteen (15) out of (15), indicating the resident was cognitively intact with no confusion. Review of Unsampled Resident B's Social Service Progress Notes dated 01/09/16, revealed ear plugs were provided to help decrease/muffle sound from surrounding resident rooms. During the Group Interview, Unsampled Resident B complained Resident #10 was noisy and disruptive and this was discussed at every council meeting for the past nine (9) to ten (10) months. Review of Resident #10's medical record revealed the facility admitted the resident on 08/01/03 and readmitted the resident on 12/08/15, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/21/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of (15), indicating the resident was cognitively intact. Review of the Comprehensive Care Plan initiated 08/23/17, revealed Resident #10 had active alteration in behavior as evidenced by resisting care; verbal outburst; refusing to wear clothes or to use bed linen; speaking to people who were not there; and throwing urinal and smearing feces at times. The goal stated the resident would have fewer episodes of verbal outburst and resisting care as evidenced by behavior occurring less than four (4) times per day by the next review date. There were several interventions which included: anticipate care needs and provide them before the resident becomes overly stressed; explain care to the resident in advance; administer and monitor the effectiveness and side effects of medications as ordered; monitor behavior episodes and attempt to determine underlying cause; intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention; remove from situation and take to another location as needed, re-approach resident later when the resident becomes agitated; and provide opportunities for positive interaction. Interview, on 10/26/17 at 12:02 PM, with the Activities Director, revealed she took the minutes during the Resident Council Meetings. Per interview, the residents used to talk about Resident #10's loud behavior all the time during Resident Council Meetings and she would inform the clinical department of their concerns. Continued interview revealed she had also notified the Director of Nursing (DON) of the Resident Council Concerns related to Resident #10, and the DON told her she would look into it and take care of it. The Activities Director stated she had been employed at the facility for almost two (2) years and Resident #10 had always engaged in these behaviors. Per interview, she had been told by different residents that Resident #10's behavior was keeping them awake at night and residents were always complaining about him/her being loud. Further interview with the Activities Director, revealed she had not been educated to complete a Grievance Report if a resident complained about another resident keeping them awake, and she had not completed the Complaint Grievance Report related to the Resident Council concerns and other residents' concerns related to Resident #10 being loud and keeping them awake. The Activities Director further stated she thought she had put the Resident Council complaints about Resident #10 in her Resident Council Minutes; however, after reading through the past six (6) months of minutes, she revealed there was no mention of the complaint. Continued interview revealed she should have documented the complaint in the Minutes in order for the department heads to be aware of the concern. Interview on 10/27/17 at 7:02 PM, with State Registered Nurse Aide (SRNA) #2, revealed Resident #10 had mood and behavior changes that were unpredictable and engaged in loud and noisy behaviors. Further interview revealed when residents asked Resident #10 to be quiet, his/her behaviors would escalate. Per interview, residents had complained to her they could not fall asleep or they were awakened by Resident #10. The SRNA stated when residents reported these complaints to her, she notified the nurse. The SRNA further stated Resident #10's behaviors sometimes lasted eight (8) to ten (10) hours and she had even seen him/her have behaviors [MEDICATION NAME] for two (2) whole shifts when she had worked a double shift. Continued interview revealed Resident #10's averaged having behaviors every other night. Further interview revealed she had observed residents who had been kept awake all night because of Resident #10's behaviors. Interview, on 10/27/17 at 7:52 PM, with Registered Nurse (RN) #1, revealed Resident #10 yelled so loud, he/she could be heard from the nurse's station at the other end of the hall. Per interview, the resident engaged in the behavior about every third night. The RN stated other residents of the facility were not happy and had trouble sleeping when the resident was yelling and shaking his/her bed. RN #1 further stated she had gone in to check on a resident or to give them medications and they would be awake and would tell her they could not sleep because of Resident #10. Continued interview revealed she had reported these resident complaints to the DON who told her she would look into it. Further interview revealed she had come on shift before and received report that the resident had engaged in behaviors all shift and then he/she would continue behaviors her whole shift which was a total of twenty-four (24) hours. The RN stated she did not recall being trained on the grievance process. Interview, on 10/26/17 at 2:28 PM, with the Social Services Director (SSD), revealed she had just taken back over the grievances this month. Continued interview revealed in the past, clinical staff had let her know residents were complaining of Resident #10 disturbing them. Per interview, the residents' main complaint was Resident #10 yelling and shouting during all hours throughout the night, keeping them from falling asleep. The SSD further stated since she had taken back over the grievances, staff had only reported to her once that residents were complaining of Resident #10 during the Resident Council. Continued interview with the SSD, revealed it concerned her that other residents were being disturbed by Resident #10 because this was their home and they should be able to rest. The SSD further stated staff and residents probably didn't come to her that often with the complaint anymore because they may feel like they are beating a dead horse. The SSD stated the complaint related to Resident #10 being loud and keeping them awake at night had been an ongoing problem at the facility. Review of the Complaint/Grievance Report, dated 10/26/17, completed by the SSD, revealed the Resident Council had concerns of a resident that had disturbing noises that disrupted them, including during sleep. Continued review of the Report, revealed under findings: the resident involved did have negative behaviors at times and ear plugs had previously been provided due to residents' concerns as well as room changes were offered. Further review revealed the resolution was ongoing. Interview, on 10/27/17 at 2:30 PM, with the Director of Nursing (DON), revealed when staff received a complaint, they were to complete a Complaint Grievance Report, and the complaint was assigned to the appropriate department head or administrative staff member to resolve the grievance within seventy-two (72) hours. The DON further stated it was her expectation the Activities Director record and report every time the residents voiced concerns during the Resident Council Meetings in order to make administrative staff aware of the Council concerns. However, continued interview with the DON, revealed she did not complete a Complaint Grievance Report, or document complaints related to Resident #10's behaviors every time it was brought to her attention because it had been an ongoing issue for management for approximately a year. She stated the grievance related to Resident #10 disturbing residents had never been able to be resolved. Further interview revealed although residents complained about Resident #10 being loud and disruptive; she felt there were resident rights on both ends and if the residents who were complaining did not want to move to a different room where it was quieter, maybe they could close their door. Per interview, she was aware residents were offered ear plugs to wear, and some refused to wear them. Interview, on 10/27/17 at 8:34 PM, with the facility's Interim Administrator, revealed it was her expectation staff would report all grievances and follow the facility's process by completing the grievance log. The Administrator stated it was important to keep trying to find solutions and answers. The Administrator further stated it was her expectation the grievance related to Resident #10's behaviors would have been resolved for both Resident #10's quality of life and the other resident's quality of life. Continued interview revealed it was her expectation and the facility's policy that all grievances including resident council concerns were documented and reported to ensure there was follow up and resolution.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure medically-related social services were provided to attain or maintain the highest practical mental and psychosocial well-being of each resident for one (1) of thirteen (13) sampled residents (Resident #10). Although Resident #10 had multiple psychiatric [DIAGNOSES REDACTED]. The findings include: Review of the facility's Policy titled, Psychosocial Services, dated June 2007, revealed it was facility policy to provide psychosocial services to all residents as required. Continued review revealed the onset of symptoms in a residents psychosocial well-being, or any changes would be communicated to the Social Worker, or designee, verbally, or in in writing on the Psych Referral Form. Further review of the Policy, revealed if a resident had not been evaluated for psych services previously, the Social Worker, or designee, would enter the referral into the Psych Referral Tracking Log. Review of the Social Service Director (SSD) Job Description, updated December 2011, revealed the SSD was to identify and provide for each resident's social, emotional, and psychological needs; and was to assist in the planning for his/her discharge. Continued review revealed it was an essential duty and responsibility for the SSD to assist residents and families with social, emotional, and family issues and to work closely with the facility mental health provider to ensure that all resident psychosocial needs were identified, referrals were made, and services were provided. Review of Resident #10's medical record revealed the facility admitted the resident on 08/01/03 and readmitted the resident on 12/08/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/21/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of (15), indicating the resident was cognitively intact. Review of Resident #10's Comprehensive Plan of Care, initiated 08/23/17, revealed the resident had active alteration in behavior as evidenced by resisting care, verbal outbursts, throwing urinal and smearing feces; refusing to wear clothes or to use bed linen; and speaking to people who were not there. The goal revealed the resident would have fewer episodes of verbal outburst and resisting care as evidenced by behavior occurring less than four (4) times per day by the next review date. There were several interventions to include: anticipate care needs and provide them before the resident becomes overly stressed; explain care to the resident in advance; administer and monitor the effectiveness and side effects of medications as ordered; monitor behavior episodes and attempt to determine underlying cause; intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention; remove from situation and take to another location as needed; and re-approach resident later when the resident becomes less agitated. Review of Resident #10's Mood and Behavior Flowsheet, dated September 2017, revealed the resident was assessed by the facility staff to have little interest or pleasure in doing things, feeling down, depressed, or hopeless, and trouble falling or staying asleep, sixteen (16) out of thirty (30) days for the month. Continued review revealed the resident had hallucinations fifteen (15) out of thirty (30) days for the month. Further review of the Mood and Behavior Flowsheet, revealed the resident engaged in verbal behaviors of threatening, cursing, and/or screaming, sixteen (16) out of (30) days for the month. Review of the Nurse's Progress Note, dated 07/11/17 at 1:21 AM, revealed Resident #10 was noted to have verbal behaviors through the night. Continued review revealed the resident was rattling the bedrails; and activated the call light multiple times throughout the night even after receiving Ativan (anti-anxiety medication) as ordered earlier in the evening. Review of the Nurse's Progress Note, dated 07/30/17 at 1:17 PM, revealed Resident #10 had multiple episodes of yelling out, and cursing. Continued review revealed the resident was hallucinating that a non-present person was underneath him/her, and staff was unable to redirect the resident. Per the Notes, routine Haldol (antipsychotic medication) and PRN (as needed) Ativan was given, with no relief. The Note revealed the resident continued to yell and attempt to throw his/her legs out of the bed. Further review of the Note, revealed the Physician was notified and a new order was obtained for Haldol 5 Milligram (MG) Injection intramuscular (IM) every six (6) hours as needed for increased agitation. Review of the Nurse's Progress Note, dated 08/29/17, at 3:04 AM, revealed Resident #10 yelled continuously for staff members during the first part of the shift. Per the Note, the resident shook and rattled bed rails while yelling and calmed down after receiving his/her evening medications. Review of the Social Service Director (SSD) Progress Note, dated 08/29/17 at 11:03 AM, revealed for the week of 08/21/17 through 08/28/17, Resident #10 continued to exhibit behaviors of depression; little interest and pleasure in doing things; trouble falling and staying asleep; hallucinations; delusions; and verbal behaviors of yelling out. Continued review revealed the SSD assessed the resident's current behaviors as no significant change in the resident's baseline. Review of the Nurse's Progress Note dated 09/22/17, at 9:53 PM, revealed the State Registered Nurse Aide (SRNA) reported Resident #10 was threatening to throw himself/herself out of the bed. Per the Note, the nurse entered the resident's room to assess the resident and he/she appeared to be experiencing a hallucination and threatened to throw himself/herself on the floor and continued to shake his/her bedrails. Further review revealed the resident would not make eye contact and continued to stare at the ceiling stating, I need to get on the floor. Review of the Nurse's Progress Note, dated 10/12/17 at 3:52 AM, revealed Resident #10 was refusing care, and emotional support was provided. Per the Note the resident appeared to be in a deep hallucination, and became combative hitting staff. Further review of the Note, revealed PRN Ativan was administered which was not effective; one on one (1:1) redirection was not effective; and PRN Haldol IM was administered. Continued review of the Note, revealed at 5:09 AM, Resident #10 was provided a bed bath to try and redirect the resident from hallucinations; however, the resident continued to chant and shake bed rails. Interview on 10/27/17 at 7:02 PM, with SRNA #2, revealed Resident #10 had mood and behavior changes that were unpredictable. Continued interview revealed the resident engaged in loud and noising behaviors. Further interview revealed when residents asked him to be quiet, his/her behaviors would escalate. The SRNA further stated Resident #10's behaviors sometimes last eight (8) to ten (10) hours and she has even seen him have behaviors for two (2) whole shifts when she had worked a double shift. Continued interview revealed Resident #10's would have behaviors on an average of every other night. Further interview revealed she has observed residents who had been kept awake all night because of the resident's behaviors. Interview, on 10/27/17 at 7:52 PM, with Registered Nurse (RN) #1, revealed Resident #10 yelled so loud, he/she could be heard from the nurse's station at the other end of the hall. Continued interview revealed the resident engaged in the behavior about every third night. Further interview revealed she had reported these resident complaints to the DON who told her she would look into it. RN #1 stated she had come onto shift before and received report that the resident had engaged in behaviors all shift and then the resident would have behaviors her whole shift which was a total of twenty-four (24) hours. Interview on 10/27/17 at 2:30 PM, and at 8:09 PM, with the Director of Nursing (DON), revealed Resident #10 received his/her mental health services from his/her Attending Physician, and was not followed by any type of psychiatric or mental health services. The DON stated the facility considered the resident's behavior as per the Behavior Flow Sheets and Nurse's Notes as the resident's baseline. The DON further stated one to one (1:1) supervision and redirection worked at times when the resident was engaging in behaviors; however, if the resident was in his/her aggressive personality, then those interventions would not work. Continued interview revealed it was her expectation residents of the facility would get the mental health services they needed to ensure their mental health needs were met. Interview, on 10/27/17 at 4:09 PM, with the Social Service Director (SSD), revealed she had been employed at the facility since April 2017. She stated she had identified the facility could not meet Resident #10's needs shortly after she began working as the SSD at the facility. She stated this was because the facility did not have access to a psychiatrist or psychiatric service provider. Continued interview revealed the resident's Attending Physician prescribed the resident's psychotropic medications. When the SSD was asked about the Psych Tracking Log referred to in the facility's policy, she stated she was sure there was a Log; however, she had not seen it. Further interview revealed it was important the resident would have received mental health services for his/her overall quality of life. Interview, on 10/27/17 at 7:15 PM, with the facility's Medical Director, revealed if Resident #10 engaged in behaviors for eight (8) to ten (10) hours, he would consider that normal for the resident. Continued interview revealed he was treating the resident with routine and PRN psychotropic medications and he felt the resident was doing good with the medication regimen he/she was receiving. Per interview, he was unsure of what else could be done to treat the resident other than what the facility staff was already doing. Continued interview revealed he thought the resident was best suited for this facility and the facility could provide care to meet the resident's needs. Continued interview revealed the resident did not see any outside services for his/her mental illnesses; however, he would welcome any outside service's input. Interview, on 10/27/17 at 8:34 PM, with the facility's Interim Administrator, revealed it was her expectation that the facility would have a mental health service which would make consultations at the facility. Further interview revealed if there was no mental health service which did consultation at the facility, Resident #10 should have been sent to a routine clinic to receive mental health care due to ongoing behaviors.

Based on interview and record review, it was determined the facility failed to ensure, prior to admission, that individuals with an intellectual disability, developmental disability, or a related condition, were accurately assessed using the Level 1 Pre-admission Screening Assessment and Resident Review (PASRR) Form; and referred to the State Intellectual Disability Authority for a Level II PASRR to determine if they required Specialized Services for intellectual disability for one (1) of thirteen (13) sampled residents, (Resident 9). The facility admitted Resident #9 on 03/11/17 with [DIAGNOSES REDACTED]. The findings include: review of the resident's medical record revealed [REDACTED]. Continued review of the medical record revealed a Note written on an original Prescription Pad from the resident's Primary Care Physician, dated 03/07/17, which stated the patient had a history of [REDACTED]. The Note further stated the patient could not spell or clock draw; family relays behavior changes, argumentative; and family inclined to place in nursing home. Review of Resident #9's Hospital Discharge Summary, dated 03/11/17, revealed Discharge [DIAGNOSES REDACTED]. Review of Resident #9's Admission PASRR, completed by the Director of Nursing (DON), dated 03/11/17, Section I A [DIAGNOSES REDACTED]. Continued review revealed on page 3, under Section II Mental [MEDICAL CONDITION] and Related Conditions, E was checked No for Persons with related conditions; which means individuals who have a severe, chronic disability that meets all of the following conditions: 1. It is attributable to: a. [MEDICAL CONDITION] or [MEDICAL CONDITION], or b. Any other condition, other than mental illness, found to closely related to mental [MEDICAL CONDITION] because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental [MEDICAL CONDITION], and requires treatments or services similar to those required for these persons. 2. It is manifested before the person reaches age 22. 3. It is likely to continue indefinitely. 4. It results in substantial functional limitations in three (3) or more of the following areas of major life activities: a. Self-care; b. Understanding and the use of language; c. Learning; d. Mobility; e. Self-direction; or f. Capacity for independent living. Further review of Resident #9's Admission PASRR, revealed examples of [DIAGNOSES REDACTED]. Further review revealed No was checked for the question, Does this applicant meet all the conditions in Section E? Additional review revealed on page 3, Section III, if responses to the applicable Section I and/or Section II were answered Yes, do not admit the applicant to the nursing facility. The nursing facility staff shall refer the applicant to the Community Mental Health Center for a Level II PASRR. The Level II PASRR determination shall be completed prior to the nursing facility admitting the applicant. Review of Resident #9's Initial Minimum Data Set (MDS) assessment dated [DATE], Section A 1550 Conditions related to MR/DD (Mental [MEDICAL CONDITION]/ Developmental Disability) Status revealed the [DIAGNOSES REDACTED]. Continued review of the Initial MDS Assessment revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of three (03) out of fifteen (15) indicating the resident was severely cognitively impaired. Continued review of the Initial MDS, Section G Activities of Daily Living (ADL) and Functional Limitations revealed the facility assessed the resident to require extensive assistance of two (2) persons for bed mobility, transfers and toileting; and extensive assistance of one (1) person for person hygiene, bathing and dressing. Review of the Admission physician's orders [REDACTED]. Further review revealed orders for Physical, Social, Self-Care and Work related Activities as tolerated per Care Plan and Psych Evaluation, as indicated. Review of Resident #9's Interim Admission Care Plan, dated 03/11/17, revealed problems which included Self-Care Deficit as evidenced by Weakness, Cognitive Impairment and Visual Impairment. The Goal stated the resident would have reduced risk regarding complications related to decreased mobility and would be appropriately groomed and dressed. The Approaches included: observe need for referral/screen and provide as indicated; provide Activities of Daily Living (ADL) care to ensure daily needs are met; encourage out of room dining and activities daily; invite, encourage, remind and escort to activity programs; and provide restorative programs. Review of Resident #9's Care Plan Conference Summary, dated 03/16/17, revealed the Interdisciplinary Team (IDT) met with the resident's cousin, and discussed the resident's desire to live with family and possibly siblings; however, family member voiced the resident required too much care, and she could not properly take care of the resident after discharge. Continued review revealed the family member would reconsider if the resident could walk and do simple things for self, such as bathe. Review of the IDT Meeting Notes, dated 03/22/17, revealed the IDT met with Resident #9's brother and sister to decide plans for discharge and goals. Per review of the Notes, therapy did not feel that the resident was safe to be at home alone, and process to become a long-term resident would require current Medicare coverage be changed to Medicaid for Nursing Home. Continued review revealed the resident became upset, repeated what was said about staying as a long-term resident, and the resident stated he/she was concerned about his/her dog. Review of Resident #9's IDT Meeting Notes to review Care Plan and Goals, dated 06/21/17, revealed the resident attended activities of choice; liked outings in group settings; had no medication changes; was up and about in room and had no complaints of pain. Further review of the Notes revealed the resident had a history of [REDACTED]. Interview with the Social Services Director (SSD)/Admissions Coordinator on 10/27/17 at 4:10 PM, revealed she had been employed since 03/09/17, and had only been employed two (2) days when Resident #9 was admitted on [DATE]. She stated at that time she was in the training process, and had not been informed about PASRRs. She further stated the Chief Executive Officer (CEO)/ Administrator was training her during that time period, and she assumed the Administrator did the resident's PASRR. Continued interview revealed she found out about PASRRs for the first time when she attended the Dementia Training provided by the State in May 2017. She stated she started doing PASRR Screenings in August 2017, which was around the same time the facility's CEO resigned. Further interview with the Social Services Director (SSD)/Admissions Coordinator, revealed she did not know anything about a PASRR Level II for Resident #9 until the Medicaid Auditor reviewed the chart in September 2017, and told her they might want to do a referral for a Level II because the resident's [DIAGNOSES REDACTED]. She stated she didn't know who she was supposed to call for the referral and neither did the Director of Nursing (DON). She further stated she had an email trail of all the people she had called in an effort to find out where to make the referral, and she provided a copy of all the names and dates of the people she had contacted. Per interview, she finally contacted the Supervisor over the Dementia Training she had attended and got an answer on how, and to whom, to refer residents for PASRR Level II Screenings. She stated she just found out this week, on 10/23/17 at 11:00 AM, how to initiate referrals, and on 10/23/17 at 11:29 AM she received a fax number for future Level II referrals for their county. Interview with the DON, on 10/27/17 at 7:50 PM revealed she had been the DON for five (5) years, and when Resident #9 was admitted on [DATE] the facility did not have a Social Services Director, who would have normally been the person who completed the PASRR Screening Form. Continued interview revealed she had completed PASRRs in the past, and completed Resident #9's the best she could to the best of her knowledge. She further stated the resident was very functional when he/she was admitted , but needed rehabilitation therapy due to a physical decline. Further interview revealed based on the resident's [DIAGNOSES REDACTED]. Further interview revealed it was important to complete the PASRR Level 1 accurately for a resident with a development disability in order for them to be referred for PASRR Level 2 Screening prior to admission. She stated the PASRR Level 1 determined if residents were appropriate for nursing home placement, and/or eligible for Specialized Support Services. Interview with Resident #9's Primary Care Physician, on 10/27/17 at 7:30 PM, revealed he was familiar with the resident who been referred to him from another physician. He stated the resident's family was in need of respite from the resident's care; therefore, on 03/07/17 he wrote the note on his prescription pad as an introduction for the emergency room Physician. He further stated the intention was to try to give the resident a qualifying hospital stay for admission to the facility for rehabilitation for physical decline. Continued interview revealed he expected the PASRR Level 1 Screening Forms to be completed properly, in order for Level 2 Screening referrals to be made, when indicated. Per interview, the resident was comfortable and doing well at the facility. However, he stated if there were Specialized Support Services in which the resident could benefit, the resident deserved to be evaluated for eligibility for these services. Interview with the Interim Administrator/Regional Vice President, on 10/27/17 at 8:30 PM, revealed it was her expectation the PASRR Level 1 Screening would be read thoroughly, completed accurately, and referrals for a Level 2 PASRR would be made prior to admission when the resident met the criteria. Continued interview revealed all residents who qualified should be referred for an evaluation for Specialized Support Services, and they should receive those services if the PASRR Committee determined them to be eligible.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure glucometers (medical device for determining the approximate concentration of glucose in the blood) were kept in safe operating order. Although it was the facility's expectation for the nursing staff to perform a control solution test daily on the glucometers to ensure they were working properly, record review revealed the glucometer had not been checked for the control solution test on 12/01/16, 12/05/16, 12/11/16, 12/13/16, 12/14/16, 12/19/16, 12/23/16, 12/24/16, 12/25/26 and 12/27/16. The findings include: Review of the facility's policy titled, Blood Glucose Monitoring, no date, revealed quality control assessment and calibration shall be completed as recommended. If the monitoring device had not been used in twenty-four (24) hours, the nurse shall perform a quality control assessment prior to use. The facility's policy further revealed when the quality control check was outside of the expected range, the monitoring device shall be cleaned and the test repeated. If the values continue to be out of range, the monitoring device shall be replaced. Continued review revealed the actual performance of the blood glucose monitoring device shall be performed as outlined in the manufacturer's manual. Review of the Medline EvenCare G2, Blood Glucose Monitoring System with Voice Guidance User's Guide, dated 2010 and revised March 2015, revealed the EvenCare G2 Glucose Control Solution helped to validate the performance of the system at low and high range blood glucose readings. The User's Guide further revealed, run the control test to make sure the test strips and the meter were working together properly, to practice testing procedure and after opening a new bottle of EvenCare G2 Blood Glucose Test Strips. Further review of the User's Guide, revealed the purpose of the control solution testing was to made sure the EvenCare G2 Meter and the EvenCare G2 Test Strips were working properly. Review of the facility's Glucometer checks, dated December 2016, revealed no documented evidence the quality control test was completed for the glucometer on 12/01/16, 12/05/16, 12/11/16, 12/13/16, 12/14/16, 12/19/16, 12/23/16, 12/24/16, 12/25/26 and 12/27/16 . Interview on 01/12/17 at 1:25 PM, with Registered Nurse (RN) #1, revealed Glucometer Logs should have been checked daily for accuracy. Interview further revealed there was no way to know if the Glucometer was working properly on the days the nurses missed the Glucometer checks as per the Log. Further interview revealed if the glucometers were not within normal levels for the control solutions, there may be an incorrect reading when testing a resident's fingerstick blood sugar (FSBS). Continued interview revealed if there was an incorrect reading for the FSBS, the nurse could administer the incorrect dosage of insulin which could harm the resident. Interview on 01/12/17 at 1:27 PM, with Licensed Practical Nurse (LPN) #1, revealed she used to work night shift and night shift nurses were responsible for checking Glucometer controls daily. Further interview revealed it was important to check the glucometer controls to ensure the Glucometer gave an accurate reading when testing the resident's FSBS. Interview further revealed, for the days the nurses failed to check the Glucometer Log, there would be no way to know if the Glucometer was reading a resident's FSBS accurately. She stated if the glucometer was not working accurately, this could lead to administering the incorrect dosage of insulin and possibly causing [DIAGNOSES REDACTED] (low blood glucose) or [MEDICAL CONDITION] (high blood glucose) which could be dangerous for the resident. Interview on 01/12/17 at 2:50 PM, with the Director of Nursing (DON), revealed night shift nurses were responsible for checking the glucometers and performing the control solution test nightly. The DON further revealed it was important to check the glucometer to ensure the accuracy of FSBS readings. Further interview revealed if the Glucometer check record was not completed for the dates of 12/01/16, 12/05/16, 12/11/16, 12/13/16, 12/14/16, 12/19/16, 12/23/16, 12/24/16, 12/25/26 and 12/27/16, the glucometer may have given incorrect results which could lead to the nurses giving a wrong dosage of insulin. Interview on 01/12/17 at 4:00 PM, with the Administrator, revealed night shift nurses were responsible for checking the glucometers and performing the control solution test nightly. Further interview revealed if the Glucometer check record was not completed, the glucometer could give an inaccurate reading and insulin would be given based on this inaccurate reading which could be harmful to the resident.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident had the right to exercise his/her rights as a resident of the facility and as a citizen of the United States for one (1) of ten (10) sampled residents (Resident #6). Record review revealed Resident #6 wanted to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community; however, the facility failed to make a referral to the local contact agency. The findings included: Review of the facility's Policy titled, Resident Rights, undated, revealed employees should treat all residents with kindness, respect, and dignity. Continued review of the policy revealed federal and state laws guaranteed certain basic rights to all residents of the facility including the right to participate in decisions and the right to exercise their rights and privileges to the fullest extent possible. The Policy further revealed the facility was to make every effort to assist each resident in exercising his/her rights to assure the resident was always treated with respect, kindness, and dignity. Review of Resident #6's medical record revealed the facility admitted the resident on 03/11/13 and readmitted the resident on 01/24/14, with [DIAGNOSES REDACTED]. Review of Resident #6's Annual Minimum Data Set (MDS) Assessment, dated 11/28/16, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS, specifically Section Q, revealed the Resident #6 participated in his/her Annual MDS Assessment and stated yes when asked the question, Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? However, further review of the MDS, revealed the facility answered no, to the question, Has a referral been made to the local contact agency?. Review of the Comprehensive Care Plan dated 04/11/16, revealed Resident #6 had Advanced Directives on record with a goal of having proper treatment as necessary and to maintain comfort and dignity through life transition. The Care Plan interventions included: maintaining resident dignity and following wishes of the resident and family. Interview, on 01/10/17 at 3:05 PM, with Resident #6, revealed he/she remembered being asked the question about talking to someone about leaving the facility. Continued interview revealed the resident answered yes; however, further interview revealed the resident had never spoken to anyone outside the facility about the possibility of leaving the facility. The State Survey Representative attempted to interview the resident further about the subject; however, the resident stated he/she did not want to talk about it anymore. Interview, on 01/11/17 at 11:05 AM, and 01/12/17 at 4:05 PM, with the MDS Coordinator, revealed she was the staff person who completed Section Q of Resident #6's Annual MDS assessment dated , 11/28/16. Continued interview revealed Resident #6 was assessed to be cognitively intact during the completion of the MDS, meaning the resident was able to make his/her own decisions. The MDS Coordinator stated the resident did have a Power of Attorney (POA) that would take over decision making when the resident could not make his/her own decisions any longer. Further interview with the MDS Coordinator, revealed usually the Social Worker was the discipline who completed section Q of the MDS, but during the time Resident #6's MDS was completed, she was completing that section of the MDS until another social worker was hired. The MDS Coordinator stated she was not that familiar with Section Q, but thought the intent of Section Q was to find out if the resident wanted to go home. Additional interview with the MDS Coordinator, revealed Resident #6 did state he/she wanted to talk to someone regarding returning to the community; however, she spoke with the resident's POA who stated they wanted the resident to remain at the facility. The MDS Coordinator revealed she was unsure if she should have made the referral to the local contact agency since the facility assessed the resident as being cognitively intact. Interview, on 01/11/17 at 11:30 AM, with the Social Service Director, revealed as the facility's Social Worker, he was responsible for completing sections C, D, E, and Q of all residents' MDS's. Continued interview revealed he was not employed by the facility at the time Resident #6's MDS was completed; however, if the resident stated he/she wanted to speak with someone about the possibility of returning to the community during the MDS assessment interview, a referral should have been made to the local Department for Community Based Services (DCBS). Further interview revealed if Resident #6 was assessed as cognitively intact he/she was to be asked this question directly because the resident's POA did not have authority as long as the resident could make his/her own decisions. Continued interview revealed it was important not only for Resident #6 to be asked the question, but it was also important his/her request was honored because it was the resident's right to not only be a part of that decision, but to be the person to spear head it, as it was his/her life. The Social Service Director further stated it was a violation of the resident's rights by allowing the resident's POA to make the decision for a referral not to be made when Resident #6's MDS indicated he/she wanted the referral to be made. Interview, on 01/12/17, at 4:17 PM, with the Director of Nursing (DON), revealed it was her expectation all residents' rights were met. Continued interview revealed a resident who had a BIMS score of fifteen (15) out of fifteen (15) was cognitively intact and although Resident #6 had a designated POA, the POA would not be in effect as long as the resident could make his/her own decisions. The DON stated she was not aware Resident #6 had voiced he/she wanted to return to the community. The DON further stated it was important for resident's rights to be honored to enhance the resident's dignity and quality of life. Interview, on 01/12/17 at 4:30 PM, with the facility Administrator, revealed it was her expectation the facility honored all residents rights. Continued interview revealed it was her expectation a referral would have been made to the local agency, if a resident stated they wanted to return to the community. The Administrator stated it was important resident rights be maintained for residents' dignity and individuality.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure a safe, clean, and homelike environment for eleven (11) of sixteen (16) resident rooms (rooms #1, #2, #3, #5, #6, #9, #10, #11, #13, #15, and #16) and six (6) of eight (8) shared bathrooms for resident rooms #1,#2, #3,#4, #5, #6, #7, #8, #9, #11, #14, and #16. Observations during environmental tour on 01/12/17, revealed the residents' rooms had ceiling tiles with brown stains; damaged wall grout bordering the windows; rusted ceiling tile tracks; brown stains on the window blinds; a build up of dust like particles and dirt in the corners of the rooms; a white and red residue like substance on the walls; and dusty furniture. Further observation during environmental tour on 01/12/17, revealed shared resident bathrooms had a green and black substance on the walls, floors and behind the toilets; toilet paper holders covered in rust; rusted ceiling tile tracks; and an excess of dirt in the floor behind the toilets. The findings include: Review of the facility's Form titled, Bracken Nursing and Rehab Light Housekeeping Routine, undated, revealed housekeeping staff was to complete morning walk through in residents' rooms beginning at 7:10 AM each morning to identify issues that needed immediate action. Continued review revealed housekeeping staff was to begin cleaning resident rooms #1 through #16 at 9:30 AM each day. Further review of the facility Form, revealed beginning at 2:40 PM each day, housekeeping staff was to complete a walk through the facility including resident rooms to identify issues that needed attention prior to clocking out at 3:00 PM. Review of the facility's Resident Handbook, with a revision date of 11/2013, revealed the facility was to strive to provide a safe, clean, comfortable, and homelike environment. Interview, on 01/12/17 at 4:30 PM, with the facility administrator, revealed there was no facility policy regarding maintenance of the facility in maintaining a clean, safe, and homelike environment. Observation, on 01/12/17 during the environmental tour which started at 2:30 PM and ended at 3:05 PM, revealed the following concerns in resident rooms: Resident Room #1 had ceiling tiles with brown stains. Resident Room #2 had ceiling tiles with brown stains. Resident Room #3 had damaged wall grout bordering the window. Resident Room #4 had rusted ceiling tile tracks. Resident Room #5 had brown stains on the blinds of the window, and brown stains on the ceiling tiles. Resident Room #6 had ceiling tiles with brown stains. Resident Room #9 had rusted ceiling tile tracks Resident Room #10 had a build up of dust like particles and dirt in the corners of the rooms and rusted ceiling tile tracks. Resident Room #11 had a white residue like substance build up on the wall and rusted ceiling tile tracks. Resident Room #13 had a white and red residue like substance build up on the wall. Resident Room #15 revealed a white, residue like substance build up on the wall. Resident Room #16 had a build up of dust like particles on furniture in the room. Also, observation, on 01/12/17 during the environmental tour which began at 2:30 PM and ended at 3:05 PM, revealed the following concerns of resident shared bathrooms: Bathroom between resident rooms #1 and #3 had a green and black substance on the wall and floor, behind the toilet. Bathroom between resident rooms #2 and #4 had a toilet paper holder covered in rust. Bathroom between resident rooms #5 and #7 had rusted ceiling tile tracks. Bathroom between resident rooms #6 and #8 had a green and black substance on wall and floor behind the toilet. Bathroom between resident rooms #9 and #11 had a rusted toilet paper holder. Bathroom between resident rooms #14 and #16 had excess dirt in the floor behind the toilet. Interview, on 01/12/17 at 4:30 PM with State Registered Nurse Aide (SRNA) #1, revealed if she identified a maintenance issue, she was to complete a maintenance request form in a binder located at the nurse's station and the maintenance staff person would check the binder daily. Continued interview with SRNA #1, revealed if she discovered something in the facility that needed cleaning, she would notify a housekeeping staff person if they were on duty, but if housekeeping was not on duty, she would clean it herself. Interview, on 01/12/17 at 4:33 PM, with Registered Nurse (RN) #1, revealed it was her expectation if a staff person identified a maintenance issue at the facility, the staff would complete the maintenance form in the binder at the nurse's station so that maintenance staff would be made aware. RN #1 stated if the issue was something that could cause harm, she or the RN on duty would notify maintenance to come in. Continued interview with RN #1, revealed it was her expectation staff would notify housekeeping of any housekeeping concerns unless housekeeping staff was not on duty, then she would expect staff to do the cleaning themselves. Interview, on 01/12/17 at 3:10 PM, with the Housekeeping Supervisor, revealed it was his expectation for housekeeping staff to clean the resident rooms and bathrooms as scheduled and as needed. Continued interview revealed it was important resident's rooms remained clean to maintain a clean homelike environment for the residents. The Housekeeping Supervisor further stated he had just started at the facility in December of 2016 and the housekeeping agency had just started at the facility in November 2016, and he was prioritizing housekeeping duties. Interview, on 01/27/17 at 3:15 PM, with the Maintenance Supervisor revealed facility staff was to complete a maintenance request when they noticed something that needed attention from maintenance. Continued interview revealed he was the only maintenance person on staff at the facility. The Maintenance Supervisor stated he completed rounds once a week through the facility to identify things that needed fixed or repaired. The Maintenance supervisor further stated some of the concerns identified by the State Survey Agency had not been identified by the facility, and some had been identified by the facility and he had not time to correct the concerns yet. Continued interview revealed it was important for the identified concerns to be addressed to ensure a homelike environment for the residents. Interview, on 01/12/17 at 4:17 PM, with the Director of Nursing (DON), revealed it was her expectation residents of the facility would have a clean and homelike environment and she expected all staff to monitor and observe for needed cleaning and repairs. The DON stated she expected SRNAs and Nurses to complete maintenance slips identifying problems found, so they could be addressed with maintenance. The DON further stated if SRNAs or Nurses discovered something that needed to be cleaned, they should notify housekeeping or take care of the concern themselves. Continued interview with the DON, revealed it was important to maintain a safe, clean, environment not only for the safety and appearance of the building, but also so the residents would feel like the facility was more homelike. Interview, on 01/12/17 at 4:30 PM, with the facility Administrator, revealed it was her expectation resident rooms and bathrooms be homelike and comfortable as well as safe and clean for the residents.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure services provided were in accordance with each resident's written Comprehensive Care Plan for one (1) of ten (10) sampled residents (Resident #1). Resident #1's Comprehensive Care Plan revealed interventions to pad the resident's bilateral lower extremities with pillows and keep pillows under the heels and between ankles while in bed for pressure relief related to Pressure Ulcers of the lower extremities. However, observation of Resident #1 on 01/10/17 and 01/11/17, revealed the care plan was not followed as no pillows were in use to pad the resident's lower extremities. The findings include Review of the facility's policy titled, Care Plans Comprehensive, no date, revealed an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. Further review revealed each resident's comprehensive care plan was designed to identify the professional services that were responsible for each element of care. Review of Resident #1's medical record revealed the facility admitted the resident on 01/29/11 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of a four (04) which indicated severe cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as having a worsening pressure ulcer since the prior assessment. Review of the physician's orders [REDACTED]. Further review, revealed a physician's orders [REDACTED]. Review of the Comprehensive Care Plan initiated 10/24/16, revealed the resident was at risk for Pressure Ulcers, and a revision on 01/10/17 revealed the resident had a problem of Pressure Ulcers, including one (1) Unstageable Pressure Ulcer to the left ischial tuberosity, one (1) Stage II Pressure Ulcer to the left shoulder, two (2) Stage II Pressure Ulcers to the left shoulder, one (1) Unstageable Pressure Ulcer to the right lateral foot, two (2) Suspected Deep Tissue Injuries (SDTI's) to the left lateral foot and one (1) Unstageable Pressure Ulcer to the left medial great toe. The goal stated the resident would not develop any new areas of skin breakdown through the next review date of 04/10/17. The approaches included padding bilateral lower extremities with pillows for pressure relief to assist in preventing the development of skin breakdown, and keep pillows under the resident's heels and between the resident's ankles when in bed as an approach to assist in preventing pressure ulcers. Review of the Nurse Aide Care Plan, dated January 2017, revealed Resident #1 had Decubitus on his/her feet, left shoulder and left lower buttocks. Further review revealed an intervention to pad both legs, feet, and ankles with pillows and to place pillows under the resident's heels. Observation on 01/10/17 at 12:16 PM, revealed Resident #1 was lying in bed with eyes closed and no pillows were being used to pad the lower extremities as per the care plan and physician's orders [REDACTED]. Observation on 01/11/17 at 10:00 AM, revealed Resident #1 was lying in bed, and no pillows were in use to pad the lower extremities as per the care plan and physician's orders [REDACTED]. Interview on 01/11/17 at 10:00 AM, with State Registered Nursing Assistant (SRNA) #1, revealed she was assigned to the resident and was aware the facility had assessed Resident #1 to need pillows under his/her feet; however, when Resident #1 was re-positioned to the side the SRNA's used the pillows in the bed to place behind his/her back for positioning. Further interview revealed the SRNA should have obtained another pillow and placed it under his/her feet and between his/her ankles. Interview further revealed SRNA #1 understood the importance of placing the pillows as per the Care Plan to keep the resident from developing pressure pressure ulcers and to keep the pressure ulcers the resident already had from worsening. Continued interview revealed SRNA #1 understood she did not follow the Care Plan or physician's orders [REDACTED]. Interview on 01/11/17 at 11:30 AM, with Licensed Practical Nurse #1, revealed she was assigned to Resident #1 and the resident should have had pillows under his/her feet and between his/her ankles in order to relieve pressure and keep the current pressure ulcers from worsening. Continued interview revealed the interventions for Resident #1 regarding pillow placement was located on the resident's Comprehensive Care Plan and Nurse Aide Care Plan, and therefore the care plan was not followed. Interview on 01/12/17 at 2:50 PM, with the Director of Nursing (DON), revealed staff did not follow Resident #1's Care Plan in regards to pillow placement for pressure reduction. Interview further revealed pressure reduction was important for Resident #1 to prevent skin breakdown on bony prominences and to prevent skin breakdown from worsening. Interview on 01/12/17 at 4:00 PM, with the Administrator, revealed staff did not follow the Comprehensive Care Plan when Resident #1 was observed by the surveyor to have no pillows under his/her heels or between his/her ankles for pressure reduction. Further interview revealed the importance of following Resident #1's Plan of Care was pressure reduction and to prevent current pressure ulcers from getting worse or increasing in size.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident receives necessary treatment and services to promote healing, prevent infection and prevent new pressure sores from developing for one (1) of ten (10) sampled residents (Resident #1). Resident #1 had multiple Pressure Ulcers to the lower extremities including one (1) Unstageable Pressure Ulcer to the right lateral foot, two (2) Suspected Deep Tissue Injuries (SDTI's) to the left lateral foot and one (1) Unstageable Pressure Ulcer to the left medial great toe per record review. Although the resident had physician's orders [REDACTED]. The findings include: Review of the facility's policy titled, Pressure Ulcer Management Resource, date reviewed 06/2015, revealed staff was to obtain and initiate treatment orders and implement a preventive program to prevent additional new areas from developing. Further review revealed staff was to avoid positioning residents directly on a pressure ulcer. Review of Resident #1's clinical record revealed the facility admitted the resident on 01/29/11 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) of four (4) out of fifteen (15) indicating the resident had severe cognitive impairment. Continued review revealed the facility assessed the resident as having a worsening pressure ulcer since the prior assessment. Review of the Comprehensive Care Plan initiated 10/24/16, revealed Resident #1 was at risk for Pressure Ulcers, and a revision on 01/10/17, revealed the resident had a problem of Pressure Ulcers including one (1) Unstageable pressure ulcer to the left ischial tuberosity, one (1) Stage II pressure ulcer to the left shoulder, two (2) Stage II pressure ulcers to the left shoulder, one (1) Unstageable pressure ulcer to the right lateral foot, two (2) SDTI's to the left lateral foot and one (1) Unstageable pressure ulcer to the left medial great toe. The goal revealed the resident would not develop any new areas of skin breakdown through the next review date of 04/10/17. The interventions included padding bilateral lower extremities with pillows for pressure relief to assist in preventing the development of skin breakdown and keep pillows under the resident's heels and between the resident's ankles when in bed as an approach to assist in preventing pressure ulcers. Review of the Nurse Aide Care Plan, dated January 2017 revealed interventions to pad both legs, feet and ankles and under the resident's heels. Review of the physician's orders [REDACTED]. Further review revealed an order to keep pillows under heels and between ankles when in bed with an original order date of 12/08/16. Observations on 01/10/17 at 12:16 PM, 01/10/17 at 2:05 PM, 01/10/17 at 4:00 PM and 01/11/17 at 10:00 AM revealed Resident #1 was lying in bed; however, there were no pillows being used for the lower extremities for pressure relief as per the physician's orders [REDACTED]. Interview on 01/11/17 at 10:00 AM, with State Registered Nursing Assistant (SRNA) #1, who was assigned to Resident #1, revealed she was aware the facility had assessed Resident #1 as needing pillows under his/her feet. However, she stated when Resident #1 was re-positioned the SRNA's used the pillows in the resident's room to place them behind his/her back for positioning. Further interview revealed the SRNA should have obtained another pillow and placed it under the resident's feet and between his/her ankles. Interview further revealed SRNA #1 knew it was important to use the pillows for Resident #1's lower extremities to prevent the resident from developing pressure ulcers and to keep the pressure ulcers the resident already had from worsening. Interview on 01/11/17 at 11:30 AM, with Licensed Practical Nurse (LPN) #1 who was assigned to Resident #1, revealed the resident should have had pillows under his/her feet and between his/her ankles in order to relieve pressure and keep the pressure ulcers from worsening as per the physician's orders [REDACTED]. Observation on 01/11/17 at 2:20 PM, of an attempted skin assessment by Licensed Practical Nurse (LPN) #1, revealed the resident became combative and refused to allow the nurse to perform the skin assessment and dressing changes. Interview with LPN #1, revealed Resident #1 did become combative with dressing changes, and the nurse would sometimes have to change one dressing at a time and wait in between dressings to prevent the resident from becoming so upset. Interview on 01/12/17 at 2:50 PM, with the Director of Nursing (DON), revealed the use of pillows to relieve pressure was important for Resident #1, to prevent skin breakdown on bony prominences and to prevent his/her pressure ulcers from worsening. Further interview revealed staff was aware the use of pillows for pressure reduction information was located on the Comprehensive Care Plan, Nurse Aide Care Plan and the physician's orders [REDACTED]. Interview on 01/12/17 at 4:00 PM, with the Administrator, revealed pressure reduction was important to prevent current pressure ulcers from getting worse or increasing in size and to prevent new pressure ulcers from developing.

Based on observation, interview and review of the facility policies, it was determined the facility failed to store, prepare, and serve food under sanitary conditions. Observation on initial tour of the kitchen, on 02/02/16 at 1:35 PM, revealed the stove top, and drip pan had a build up of burnt on grease and particles of food. In addition, the dry storage area had flour and sugar bins with the lids open, and cans of food with dents on the seams sitting on the shelf accessible for use. The findings include: 1. Review of the facility's policy titled Cleaning Schedule dated 10/2009, revealed, a new cleaning schedule was to be posted weekly or monthly with cleaning assignments assigned to the associate. Once the cleaning assignment was complete, it was initialed and dated by the associate who completed the job. Further review, revealed once initialed and dated by the associate, the dietary manager was to periodically inspect. Observation on initial tour of the kitchen, on 02/02/16 at 1:35 PM, revealed the stove top, and drip pan had a build up of burnt on grease and particles of food. Review of the posted weekly cleaning schedule(s), revealed the equipment/area was listed on the schedule and was assigned out to shifts but not to associate/staff as per policy. Continued review, revealed the stove top/oven/racks was initialed as completed on 12/06/15, 12/13/15, 12/20/15, 12/27/15, 01/03/16, 01/17/16, and 01/31/16; however was not initialed as completed on 01/10/16 and 01/24/16. Interview with the Dietary Manager (DM) on 02/02/16, at 1:58 PM, revealed the stove should be wiped down daily and deep cleaned weekly, and the drip pan should be cleaned weekly with the stove and as needed. She further stated, the stove and drip pan was dirty and should be cleaned. 2. Review of the facility's policy titled Food Storage undated, revealed metal or plastic containers with tight fitting covers must be used for storing flour and sugar. Scoops must be provided for flour, and sugar. Further review, revealed scoops were not to be stored in the food containers, but were to be kept covered in a protected area near the containers. Further observation on initial tour of the dry storage area on 02/02/16 at 1:35 PM, revealed the lid was open on the flour and sugar bin's, and there was about an inch opening between the rim of the container and the lid. Further interview with the Dietary Manager (DM) on 02/02/16, at 1:58 PM, revealed the flour and sugar bin lids should have been snapped shut to ensure they were closed. 3. Review of the facility's policy titled Dented Can Policy undated, revealed dented cans would be stored separately from non dented cans. If a can presented dented upon arrival, the can should be returned to the distributor at that time. Once cans were stored and then a can was observed to be deeply dented, the can(s) would be placed on a separate shelf to be returned to the distributor or discarded. A deep dent was one you could lay your finger into. Deep dents often have sharp points. Further review, revealed, a sharp point dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Further observation of the dry storage area on 02/02/16 at 1:35 PM, revealed one (1) can of Tropical Fruit Salad, one (1) can of Pineapple Tidbits, one (1) can of Apricot Halves and two (2) cans of Therapeutic Nutrition with dents on the seams sitting on the shelf accessible for use. Continued interview with the Dietary Manager (DM) on 02/02/16, at 1:58 PM, revealed the dented cans should not be on the shelf for use, but was to be placed out of the storage area and in the dented can area. Additional interview with the Dietary Manager (DM), on 02/04/16 at 10:00 AM, revealed she reviewed the cleaning schedule weekly to assure the tasks were completed and did a walk through of the kitchen to monitor that tasks were completed. She further stated, the dietary staff was inserviced upon hire, annually, and as needed on infection control/cross contamination in the kitchen, and policy's of the facility relating to the kitchen. Interview with the Administrator on 02/04/16 at 3:40 PM, revealed he expected the dietary staff to follow the policies and procedures of the facility. I expect dented cans to be returned or discarded and bins to be closed tightly to prevent contamination of food items which could result in residents becoming sick. I do expect the dietary staff to keep a clean and safe kitchen at all times.

Based on observation, interview and review of facility's policy, it was determined the facility failed to provide a safe, clean, comfortable and homelike environment. Observation on 02/02/16 and 02/03/16, revealed the bathroom for Rooms #1, #5, #6, #12 and #14 had a brown/black substance on the floor grout surrounding the base of the toilet. Also, observation on 02/03/16, revealed the shower room had a brown substance on the wall under the toilet, a black substance on the wall and a green substance on the toilet flusher. In addition, observation on 02/04/16 at 2:00 PM, revealed Unsampled Resident #A was sitting in a recliner chair with a pillow to his/her back. The pillow was ripped exposing a white cotton material and there was no pillow case on the pillow. The findings include: 1. Review of the facility Plant and Operations Policy and Procedure Manual-Bathroom Cleaning dated January 2005, revealed sanitize commode, tank, bowl, and base, clean walls and damp mop behind the commode. Review of the facility Housekeeping Deep Clean Schedule dated January 2016, revealed each room was scheduled for deep cleaning one (1) time during the month and the remaining days were used for make-up days. Observation on initial tour on 02/02/16 at 1:30 PM, revealed the bathroom for Room #1 had a brown/black substance on the floor grout surrounding the toilet. Observation on 02/03/16 from 09:35 to 09:45 AM on follow-up environmental room tour, revealed in the bathrooms for Rooms #5, #6, #12 and #14, there was a black/brown substance on the floor grout surrounding the toilet. Further environmental tour, on 02/03/16 at 11:10 AM, in the shower room revealed a brown substance on the wall under the toilet, a black substance on the wall and a green substance on the toilet flusher. Interview on 02/04/16 at 11:40 AM, with the Housekeeping Supervisor, revealed the deep cleaning schedule included resident bathrooms. He stated he tried to audit the rooms for cleanliness but did not document the audit results. 2. Observation on 02/04/16 at 2:00 PM, revealed Unsampled Resident #A was sitting in a recliner chair with the pillow to his/her back. The pillow did not have a pillow case and the plastic pillow covering was ripped open exposing a cotton-like substance. Interview on 02/04/16 at 2:15 PM, with Certified Nursing Assistant (CNA) # 1, revealed pillows should be covered with a pillow slip and if a pillow was ripped, it should be thrown away. Interview on 02/04/16 at 2:18 PM, with Registered Nurse (RN) # 1, revealed a torn pillow should be discarded and replaced and any pillow being used should have a pillow case. Interview on 02/04/16 at 3:50 PM, with the Director of Nursing (DON) revealed, pillows should be intact and if not intact should be replaced. the DON further stated, pillows should be covered with a pillow slip when in use. Interview and tour of the facility on 02/04/16 at 11:05 AM to 12:00 PM, with the Administrator, revealed the housekeeper's deep cleaning schedule did include resident bathrooms and showers and if these areas were not kept clean this could be harmful to the residens. Further interview, revealed ripped pillows should not be used, but should be discarded.

Based on observation, and interview, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Observation on 02/02/16 revealed un-bagged and un-labeled urinals in the shared bathroom between room [ROOM NUMBER] and #8, and the shared bathroom between room [ROOM NUMBER] and #12. In addition, observation on 02/03/16, revealed a urinary drainage bag containing a yellowish/brownish substance hanging on a towel rack in the shared bathroom between room [ROOM NUMBER] and #14. The findings include: Observation on initial tour on 02/02/16 at 1:30 PM, revealed un-bagged and un-labeled urinals in the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER], and the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER]. Further observation on follow up environmental tour on 02/03/16 from 9:30 AM to 945 AM, revealed a urinary drainage bag containing a yellowish/brownish substance hanging on a towel rack in the shared bathroom between room [ROOM NUMBER] and #14. Interview on 02/04/16 at 2:26 PM, with CNA #2, revealed urinals should be labeled with resident's name, bagged and hung in the resident's bathroom. Interview on 02/04/16 at 2:50 PM, with Certified Nursing Assistant (CNA) # 1, revealed urinals should be labeled and placed in a plastic bag and hung on the rail in the bathroom. Interview on 02/04/16 at 3:50 PM, with the Director of Nursing (DON), revealed urinals should be stored in a plastic bag and labeled for identification to avoid cross contamination with another resident. Further interview, revealed the urinary drainage bag which was found on the towel rack in a resident bathroom should have been discarded for infection control purposes. Interview with the Administrator, on 02/04/16 at 11:05 AM, revealed urinals should be bagged and labeled when stored and soiled urinary drainage bags should not be stored in resident bathrooms but should be discarded.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure services were provided in accordance with each resident's written Comprehensive Care Plan for (4) of ten (10) sampled residents (Residents #3, #4, #5 and #7). Resident #3's Comprehensive Care Plan stated the resident was at risk for bowel elimination problems with interventions which included monitoring bowel movements (BMs) and administering and monitoring the effectiveness of medications used for bowel elimination. Record review revealed there was no documented evidence Resident #3 had a bowel movement (BM) from 07/09/14 until 07/13/14, four (4) days later. On 07/13/14, Resident #3 was noted to have several loose stools, became ashen and clammy, and was sent to the hospital emergency room (ER) where he/she was diagnosed with [REDACTED]. In addition, there was no documented evidence Residents #4, #5, and #7's Comprehensive Care Plans were implemented related to monitoring BMs. There was no documented evidence these residents experienced experienced BMs for periods ranging from four (4) to five (5) days (Refer to F-309). The findings include: Review of the facility's policy titled, "Care Plans-Comprehensive", revised October 2010, revealed the Comprehensive Care Plan was designed to incorporate identified problem areas and risk factors associated with problem areas. Continued review of the Policy revealed the Comprehensive Care Plan was to aid in preventing or reducing declines in residents' functional status and functional levels; it was to enhance optimal functioning of the resident; and, reflect currently recognized standards of practice for problem areas and conditions. 1. Record review revealed the facility admitted Resident #3 on 04/17/07, with [DIAGNOSES REDACTED]. Review of the 12/10/14, Quarterly Minimum Data Set (MDS) Assessment revealed the facility assessed Resident #3 to have short and long term memory loss. Further review of the MDS revealed the facility assessed Resident #3 to always be incontinent of bowel and bladder, and to require total dependence of two (2) staff for toileting. Review of Resident #3's Comprehensive Care Plan dated 10/17/13, revealed a care plan related to the resident being at risk for a bowel elimination problem related to decreased liquid intake, side effects of medication, decreased mobility and [MEDICAL CONDITION]. Review of the care plan revealed a goal for Resident #3 to have regular BMs as evidenced by soft/formed BMs at least every three (3) days. Further review of the care plan revealed interventions which included administering the bowel regimen as per physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. mg suppository rectally if no BM by evening of day three (3); and an Enema rectally as needed if no BM in the morning (AM) of day four (4), then call the Physician. Review of Resident #3's "Elimination Report" from 06/01/14 to 07/31/14, revealed Resident #3 had a medium soft BM on 07/09/14 which was documented at 12:28 AM. However, further review of the Elimination Report revealed no documented evidence Resident #3 had another BM until 7/13/14, four (4) days later, when documentation revealed the resident had a large loose BM at 12:02 AM. However, there was no documented evidence Resident #3's care plan intervention to administer his/her bowel regimen as per physician's orders [REDACTED].#3 had received MOM on 07/11/14 at 4:35 PM, which was documented as "no effect", but there was no documented evidence the resident received the MOM as ordered in the AM of day three (3) without a BM, 07/12/14. Further review of the MAR revealed no documented evidence the resident received the Bisac-Evac suppository rectally if he/she had no BM by the evening of day three (3), 07/12/14. Review of the Nurse's Notes from 07/11/14 through 07/13/14, revealed no documented evidence an abdominal/bowel assessment was completed by the nurses, even though there was no documented BM for Resident #3 on day three (3), 07/12/14. Review of the Nurse's Notes 07/13/14 revealed the nurses documented: at 2:00 AM Resident #3 had several loose stools that night, and moaned when having the stools; at 2:50 AM, the nurse was called to the room by the Certified Nursing Assistant (CNA) with the resident noted to be clammy, ashen, with vital signs listed; and at 3:00 AM and 3:30 AM the Physician was notified with orders received to transport Resident #3 to the ER, which was done. Further review of the Nurse's Notes revealed no documented evidence the nurse on 07/13/14 performed an abdominal/bowel assessment when Resident #3 was moaning with loose stools. Review of the Hospital Discharge Instructions dated 07/13/14, revealed Resident #3 was diagnosed with [REDACTED]. Further record review revealed Resident #3 was re-admitted to the facility on [DATE] from the ER. Interview, on 01/29/15 at 12:00 PM, with Registered Nurse (RN) #1, revealed she was assigned to Resident #3 for the day shift on 07/11/14 and 07/12/14. She explained, each morning the Charge Nurse printed out a bowel list of residents who had not had a BM on day three (3) and day four (4). Per interview, she was administering medications on 07/11/14 and had given Resident #3 the MOM at 4:35 PM, but there was no documentation of an abdominal/bowel assessment, so she was not sure why she gave the medication since that was just day two (2) of no BM. Continued interview revealed she should have given the MOM on 07/12/14 which would have been day three (3) without a BM, as per the order and care plan. RN #1 stated, she went around each morning and asked the CNA's if the residents on the bowel list had a BM or not, and if the resident had a BM which was not yet documented that morning, she would not give the laxative. She further stated she did not do abdominal assessments before giving prn (as needed) laxatives, but just gave the medications per orders and protocol. Interview, on 01/28/15 at 5:44 PM, with Licensed Practical Nurse (LPN) #2 revealed she was assigned to Resident #3 on 07/12/14 from 7:00 PM through the next morning at 7:00 AM. She stated, according to the physician's orders [REDACTED]. However, she revealed according to the MAR for that date, the medication was not administered as ordered. According to LPN #2, the evening nurses received report and were told which residents they were to follow up on with laxatives. Per interview, she was unsure why she had not administered the [MEDICATION NAME] suppository on the evening of 07/12/14, as per the order and care plan. LPN #2 stated Resident #3 started having loose stools around 12:00 AM on 07/13/14 and had several loose stools after that. Continued interview revealed she did an abdominal assessment but, was not sure if she had checked the rectum digitally for stool. LPN #2 stated she failed to document her abdominal/bowel assessment of Resident #3. Continued interview with LPN #2, revealed Resident #3 became ashen and clammy and she notified the Physician who ordered the resident to be sent to the ER. Interview on with RN #2 01/29/15 at 12:06 PM revealed she was the Charge Nurse on the days she worked. She stated, the facility had a bowel protocol in place where on the morning of the third day of a resident not having a BM, MOM would be administered, and the evening of the third day without a BM a [MEDICATION NAME] suppository would be administered. Continued interview revealed if no BM by the fourth day, a Fleets Enema would be administered and the Physician would be notified. She further stated she printed off a bowel list each morning and gave it to the nurses who were assigned to administer medications. Further interview revealed the nurses were to document the medications given on the MAR and also any results of the laxatives and was to pass the information on in report to the next shift. RN #2 stated she did not always follow up to see if the nurses had administered the prn laxatives and whether the residents had results from the laxative. Continued interview revealed Resident #3 should have had MOM given on 07/12/14 on the day shift and a [MEDICATION NAME] suppository on the evening of 07/12/14; however, there was no documented evidence the medications were given as ordered and as per the care plan intervention. Interview with the Director of Nursing, on 01/30/15 at 5:35 PM, revealed Resident #3 should have been monitored per the care plan including a abdominal/bowel assessment if she/he was not having BM's at least every three (3) days. 2. Review of Resident #4's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6), which was indicative of being cognitively impaired. Continued review of the MDS revealed the facility assessed the resident to require extensive assistance of two (2) staff for toileting and to be frequently incontinent of bowel and bladder. Review of the resident's Physician Orders, dated 01/05/15, revealed Resident #4 was prescribed to have Milk of Magnesia, 30ML by mouth as needed if there was no bowel movement in three (3) days. Staff was instructed to administered the MOM the morning of the third (3rd) day. Continued review revealed the resident was to receive an Enema, one (1) rectally daily, as needed, for constipation after four (4) days of no bowel movement. Review of Resident #4's Comprehensive Plan of Care dated 12/09/13, revealed Resident #4 was at risk for a bowel elimination problem related to decreased mobility, constipation, side effects of medication, and [MEDICAL CONDITION]. The goal stated the resident would have a regular BM pattern as evidenced by soft/formed stool at least every three (3) days. There were several interventions including: monitor bowel movement status, report changes in BM status to the Physician, and administer bowel regimen per physician's orders [REDACTED]. Review of the computerized "Elimination Report" for Resident #4 revealed the resident did not have a BM for four (4) days, from 12/18/14 to 12/21/14. Further review of the resident's chart revealed there was no documented evidence the resident was administered medication to relieve the resident of his/her bowels for the four (4) days he/she had gone without a BM as per the care plan. 3. Review of Resident #5's medical record revealed [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of twelve (12), which was indicative of the resident being cognitively aware. Continued review of the MDS revealed the facility assessed the resident to require extensive assistance of two (2) staff for toileting and to be occasionally incontinent of bladder and was always continent of bowel. Review of Resident #5's physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of Resident #4's Comprehensive Care Plan, dated 12/27/13, revealed a problem that Resident #5 was at risk for a bowel elimination related to decreased mobility and side effects of medication. The goal stated the resident would have a regular BM pattern as evidenced by soft/formed stool at least every three (3) days. There were several interventions including: monitor bowel movement status, report changes in BM status to the Physician, and administer bowel regimen per physician's orders [REDACTED]. Review of the computerized "Elimination Report" for Resident #5 revealed the resident did not have a BM for four (4) days, from 12/04/14 to 12/07/14 and from 12/08/14 through 12/11/14 and 01/13/15 through 01/16/15. Further review of the resident's chart revealed there was no documented evidence the resident was administered medication to relieve the resident of his/her bowels for the four (4) days he/she had gone without a BM as per the care plan. 4. Review of Resident #7's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as being severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident to require extensive assistance of two (2) staff for toileting and to be always incontinent of bowel and bladder. Review of the resident's MAR, dated 01/01/15 to 01/31/15, revealed the resident was prescribed Milk of Magnesia Suspension Magnesium [MEDICATION NAME]. It was to be given to the resident, 30 ML by mouth as needed if the resident did not have a BM in three (3) days. Continued review revealed the resident also had a physician's orders [REDACTED]. Review of the Comprehensive Plan of Care dated 02/28/14, revealed Resident #7 was at risk for a bowel elimination problem related to occasional constipation, decreased mobility, [MEDICAL CONDITION], Alzheimer's, and side effects of medication. The goal stated the resident would have a regular BM pattern as evidenced by soft/formed stool at least every three (3) days. There were several interventions including; monitor bowel movement status, report changes in BM status to physician, and administer bowel regimen per physician's orders [REDACTED]. [REDACTED]. Review of the computerized "Elimination Report" for Resident #7 revealed the resident did not have a BM for four (4) days, from 01/23/15 to 01/27/15. Further review of the resident's chart revealed there was no documented evidence the resident was administered medication to relieve the resident of his/her bowels for the five (5) days he/she had gone without a BM as per the care plan. Interview with the Director of Nursing (DON), on 01/30/14 at approximately 6:45 PM, revealed the Bowel Protocol and care plan was not followed for Residents' #4, #5, and #7, but should have been. Continued interview with the DON, on 01/30/15 at 5:35 PM, revealed her expectation was for each resident to have a BM at least every three (3) days. The DON stated, the current policy was not followed and the policy needed to be revised. Continued interview, revealed each morning the charge nurse printed a bowel list which showed which residents had not had a BM in the past forty-eight (48) hours which was kept at the nurse's station. The DON revealed the facility followed the three (3) day rule and if a resident had no BM by the morning of the third day the protocol should be started. Per interview, the Charge Nurses no longer followed up to see if the PRN (as needed) laxatives were administered because they no longer used Certified Medication Tech's (CMT's), and the medication nurses were to monitor residents' BM's and PRN laxatives for effectiveness. She further stated the care plans should have been followed and the nurses on the medication carts were responsible for ensuring this was done related to the bowel protocol.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure necessary care and services were provided for residents physical well-being for four (4) of ten (10) sampled residents (Resident #3 #4, #5 and #7). The facility failed to follow the bowel protocol for Resident #3 who did not have a bowel movement (BM) for four (4) days, from 07/09/14 until 07/13/14. On 07/13/14, Resident #3 was noted to have several loose stools, became ashen and clammy and was sent to the hospital emergency room (ER) where the resident was diagnosed with [REDACTED]. In addition, the facility failed to provide documented evidence Residents #4, #5, and #7 experienced BM's as per the facility's policy for "Bowel Movement Regimen". These residents experienced three (3) days or greater time periods of no documented BMs; however, there was no documented evidence the facility followed the "Bowel Movement Regimen" policy, regarding administration of bowel medications as ordered by the Physician for residents who had not had regular BMs. The findings include: Review of the facility's policy titled, "Bowel Movement (BM) Regimen", undated, revealed the facility would monitor and track residents on a daily basis to determine the need for dietary and or chemical interventions to treat chronic and/or acute episodes of constipation. Per the Policy, the facility would implement appropriate interventions as identified on the resident's individualized care plan, physician's orders [REDACTED]. The Policy noted the suggested interventions included if no BM for two (2) days the resident would receive additional high fiber drink and/or food supplements such as four (4) ounces of prune juice. Continued review revealed if still no BM the following would be initiated: on day three (3) the resident was to be given prune juice with breakfast and Milk of Magnesia (MOM) thirty (30) milliliters (mls) in the AM (morning) of day three (3); if no BM by the evening of day three (3), the resident was to be given [MEDICATION NAME] suppositories per rectum; if no BM by the AM of day four (4), the resident was to receive a Fleets Enema per rectum. Further review revealed if the resident had no results from the enema, notify the Physician for additional orders. Additional review of the facility's policy titled, "Bowel Movement (BM) Regimen", undated, revealed the Certified Nursing Assistants (CNAs) would record all residents' BM's on the CNA Assignment Sheet or facility specified form. Per the Policy, the 11:00 PM to 7:00 AM CNA would transcribe the BM record to the Tracking Form and give it to the Charge Nurse, who would utilize the BM Tracking Form at the beginning of their shift to identify residents who had not had a BM in more than forty-eight (48) hours. Review revealed the Charge Nurse would implement the appropriate regimen for the resident. According to the Policy, residents identified as needing initiation of the bowel protocol would be placed on the Twenty-Four (24) Hour Report by the Charge Nurse. The Policy revealed any medical interventions would be recorded on the Medication Administration Record (MAR), interventions would be documented and the Charge Nurse would follow up with the MAR to ensure interventions had been documented by the staff member. Further review revealed the Attending Physician/Designee would be notified on all residents who did not have a BM within four (4) days. Additionally, the Policy revealed during the clinical meetings, the Interdisciplinary Team (IDT) would ensure all residents were assessed for constipation and provided needed dietary and hydration interventions, and the residents's Care Plan would be revised with all appropriate interventions. 1. Review of Resident #3's medical record revealed the facility admitted him/her on 04/17/07, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having both short and long term memory loss. Continued review of the MDS revealed the facility assessed the resident to require total dependence of two (2) staff for toileting and to be always incontinent of bowel and bladder. Review of the Comprehensive Care Plan dated 10/17/13, revealed Resident #3 had a care plan for his/her risk for a bowel elimination problem related to decreased mobility, side effects of medication, [MEDICAL CONDITION], and decreased liquid intake. Continued review of the care plan revealed the goal stated Resident #3 would have a regular BM pattern as evidenced by soft/formed stool at least every three (3) days. Review revealed several interventions which included administering the bowel regimen as per physician's orders [REDACTED]. Review of Resident #3's physician's orders [REDACTED]. three (3); and an Enema rectally as needed if no BM in the morning (AM) of day four (4), then call the Physician. Review of the facility's computerized "Elimination Report" for Resident #3 revealed the resident had a medium soft BM on 07/09/14, which was documented at 12:28 AM. Continued review of the "Elimination Report" revealed no documented evidence Resident #3 had another BM until 7/13/14, four (4) days later, when documentation revealed the resident had a large loose BM at 12:02 AM. Review of Resident #3's Medication Administration Record (MAR) dated July 2014, revealed the resident received MOM 30 ml on 07/11/14 which was documented to have "no effect". However, review of the MAR revealed no documented evidence MOM 30 ml was administered on 07/12/14, day three (3) of no documented BM. Continued review revealed no documented evidence Resident #3 received the Bisac-Evac suppository rectally as ordered if no BM by the evening of day three (3), which was 07/12/14. Review of the Nurse's Notes dated 07/13/14 at 2:00 AM revealed Resident #3 had several loose stools that night and had been "moaning" when having the stools. Review of the Nurse's Note on 07/13/14 at 2:50 AM, revealed the nurse was called to the room by the CNA and the resident was noted to be ashen and clammy, with his/her blood pressure 125/97, pulse 89 and respirations 20. Review of the 07/13/14 at 3:00 AM and 3:30 AM, Nurse's Notes revealed the Physician was notified and the resident was transported to the hospital ER. Further review of the Nurse's Notes from 07/11/14 through 07/13/14, revealed no documented evidence an abdominal/bowel assessment was completed, even though according to the "Elimination Report", Resident #3 had no documented BM on day three (3), 7/12/14. In addition, review of the Nurse's Notes revealed no documented evidence an abdominal/bowel assessment was performed on 07/13/14, when Resident #3 was "moaning" with the loose stools. Review of the Hospital Discharge Instructions dated 07/13/14, revealed Resident #3 was diagnosed with [REDACTED]. Interview with Registered Nurse (RN) #1 on 01/29/15 at 12:00 PM, revealed she was assigned to Resident #3 on the day shift on 07/11/14 and 07/12/14. Per interview, the Charge Nurse printed out a bowel list of residents who had not experienced a BM on day three (3) or four (4). She reported giving Resident #3 MOM 30 ml 07/11/14 at 4:35 PM, but was not sure why she gave the medication since that was just day two (2) of no BM. According to RN #1, she should have given Resident #3 MOM on 07/12/14, which would have been day three (3) without a BM. Continued interview revealed she asked the CNA's each morning if the residents on the bowel list had experienced a BM or not, and if the resident had a BM which was not documented yet that morning, she would not give the laxative. Further interview revealed she did not perform abdominal assessments of residents before giving prn (as needed) laxatives, she just gave the medications as per the orders and the protocol. Interview with Licensed Practical Nurse (LPN) #2 on 01/28/15 at 5:44 PM, revealed she was assigned to Resident #3 on 07/12/14 from 7:00 PM to 7:00 AM on 07/13/14. She stated, according to Resident #3's physician's orders [REDACTED]. Per interview, the evening nurses received report and were told which residents they were to follow up on with laxatives. Continued interview revealed she was unsure why she had not administered the [MEDICATION NAME] suppository on the evening of 07/12/13. LPN #2 stated Resident #3 started having loose stools around 12:00 AM on 07/13/14 and had several loose stools. She stated, she did an abdominal assessment including listening for bowel sounds in all four (4) quadrants and checking the resident's abdomen for firmness, but was not sure if she had checked his/her rectum digitally for stool. According to LPN #2, Resident #3 had bowel sounds in all four (4) quadrants of the abdomen, and the abdomen was soft and non-distended. However, she stated she failed to document any of her abdominal/bowel assessment of Resident #3. Further interview revealed Resident #3 became clammy and ashen, so she notified the Physician and sent the resident to the hospital ER. Interview with RN #2 on 01/29/15 at 12:06 PM, revealed she was the Charge Nurse on days she worked, and the facility had a bowel protocol which was for residents to have MOM administered on the morning of the third day without a BM and a [MEDICATION NAME] suppository administered on the evening of the third day without a BM. Per interview, if the resident had no BM by the fourth day per the protocol, a Fleets Enema would be administered and the Physician would be notified. She stated she printed off a bowel list each morning and gave it to the nurses who were assigned to administer medications. Continued interview revealed the nurses were to document the medications given on the MAR, note any results of the laxatives and pass the information on in report to the next shift. RN #2 stated she did not always follow up to see if the nurses had administered the laxatives prn and whether the residents had results. Further interview revealed Resident #3 should have had MOM given on 07/12/14, on the day shift and a [MEDICATION NAME] suppository on the evening of 07/12/14. She stated however, there was no documented evidence the medications were given as ordered. 2. Review of Resident #4's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #4 as having a Brief Interview for Mental Status (BIMS) score of six (6), which was indicative of being severely cognitively impaired. Continued review of the MDS revealed the facility assessed Resident #4 to require extensive assistance of two (2) staff for toileting and to be frequently incontinent of bowel and bladder. Review of the Comprehensive Care Plan, dated 12/09/13, revealed Resident #4 was at risk for a bowel elimination problem related to decreased mobility, constipation, side effects of medication, and [MEDICAL CONDITION]. Per the care plan, the goal stated Resident #4 would have a regular BM pattern as evidenced by soft/formed stool at least every three (3) days. Continued review of the care plan revealed there were several interventions including monitor BM status, report changes in BM status to the Physician, and administer the bowel regimen as per physician's orders [REDACTED]. Review of the computerized "Elimination Report", from 12/01/14 to 01/27/14, revealed Resident #4 had no documented evidence of a BM from 12/18/14 to 12/21/14, a period of three (3) days. Review of the MAR dated, 12/01/14 to 12/31/14, revealed Resident #4 was prescribed MOM 30 mls by mouth as needed if the resident did not have a BM in three (3) days, and an order for [REDACTED]. However, further review of the MAR revealed no documented evidence Resident #4 was given the MOM or Bisac-Evac suppository as per physician's orders [REDACTED]. 3. Review of Resident #5's medical record revealed [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated , 01/06/15, revealed the facility assessed the resident as having a BIMS score of twelve (12), which was indicative of being moderately cognitively impaired. Continued review of the MDS revealed the facility assessed Resident #5 to require extensive assistance of two (2) staff for toileting and to be occasionally incontinent of bladder and was always continent of bowel. Review of the Comprehensive Care Plan dated 12/27/13, revealed the facility care planned Resident #5 to be at risk for a bowel elimination problem related to decreased mobility and side effects of medication. Per the care plan, the goal stated Resident #5 would have a regular BM pattern as evidenced by soft/formed stool at least every three (3) days. Further review of the care plan revealed several interventions which included monitoring his/her bowel movement status, reporting changes in BM status to the Physician, and administering the bowel regimen as per physician's orders [REDACTED]. Review of the computerized "Elimination Report", from 12/01/14 to 01/27/14, revealed Resident #5 had no documented evidence of a BM: from 12/04/14 through 12/07/14, a three (3) day period; from 12/08/14 through 12/11/14, a three (3) day period; and from 01/13/15 through 01/16/15, a three (3) day period. Review of the MARs dated 12/01/14 to 12/31/14 and 01/01/15 through 01/31/15, revealed Resident #5 was prescribed MOM 30 ml by mouth as needed if no BM in three (3) days, and Bisac-Evac 10 mg suppository rectally every three (3) days as needed for no BM by the evening of day three (3). However, further review of the MAR revealed no documented evidence the MOM or Bisac-Evac suppository were administered as per the physician's orders [REDACTED]. 4. Review of Resident #7's medical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #7 as being severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident to require extensive assistance of two (2) staff for toileting and to be always incontinent of bowel and bladder. Review of Resident #7's Comprehensive Care Plan dated 02/28/14, revealed the facility care planned the resident to be at risk for a bowel elimination problem related to occasional constipation, decreased mobility, [DIAGNOSES REDACTED]. Per the care plan, the goal stated Resident #7 would have a regular BM pattern as evidenced by soft/formed stool at least every three (3) days. Further review of the care plan revealed interventions which included administering the bowel regimen as per physician's orders [REDACTED]. Review of the computerized "Elimination Report", from 12/01/14 to 01/27/14, revealed Resident #7 had no documented evidence of a BM from 01/23/15 through 01/27/15, a four day period. Review of Resident #7's MAR dated 01/01/15 through 01/31/15, revealed Resident #7 was prescribed MOM 30 ml by mouth as needed if no BM in three (3) days, and Bisac-Evac 10 mg suppository rectally every three (3) days as needed for no BM by the evening of day three (3). However, further review of the MAR revealed no documented evidence the MOM or Bisac-Evac suppository were administered as per the physician's orders [REDACTED]. Interview on 01/30/15 at 5:35 PM and at 6:45 PM, with the Director of Nursing (DON) revealed it was her expectation each resident have a BM at least every three (3) days. She revealed the care plan and the physician's orders [REDACTED].#3. In addition, the DON explained Resident #3 should have been monitored including a abdominal/bowel assessment if she/he was not having BM's at least every three (3) days. Per interview, the Bowel Protocol was not followed for Residents #4, #5, and #7, but should have been. The DON stated the current policy needed to be revised, but had not been followed. Continued interview revealed since the facility utilized computerized documentation by the CNA's the BM Tracking Form indicated in the Bowel Regimen policy was no longer in use. She revealed the Charge Nurse printed a bowel list each morning which showed residents who had not had a BM in the past forty-eight (48) hours. According to the DON, the bowel list was kept at the nurse's station on a clip board, and a copy was given to the medication nurses. The DON stated the nurses did not utilize the 24 Hour Report as indicated in the Bowel Regimen policy anymore related to the bowel protocol. She revealed a three (3) day rule was followed where if a resident had no BM the morning of the third day, the protocol should be started. Further interview revealed the Charge Nurses no longer followed up as indicated in the Bowel Regimen policy to see if the prn laxatives were administered. She stated this was because the facility no longer used Certified Medication Techs (CMT's) and only had medication nurses now on the medication carts.

Based on observation,interview and review of the facility's policy, it was determined the facility failed to have a system in place to provide a safe, functional, sanitary, and a comfortable environment for residents, staff and the public as evidenced by observations revealed The findings include: Review of the facility's policy titled, "Plant Operations Policy and Procedure Manual Maintenance/Maintenance Service", dated January 2005, revealed it was the policy for maintenance service to be provided to all areas of the building, grounds and equipment. The Policy revealed the maintenance department was responsible for maintaining the buildings grounds and equipment in a safe and operable manner at all times. Additionally, the Policy revealed maintenance was responsible for maintaining the building in good repair and free from hazards and for providing routinely scheduled maintenance service to all areas of the facility. Review of the facility's policy titled, "Plant Operations Policy and Procedure Manual Maintenance/Work Orders", dated January 2005, revealed in order to establish a priority of maintenance service, work orders were to be filled out and forwarded to the Maintenance Director. Per the Policy, it was the responsibility of the Department Directors or any staff member to identify needed repairs, fill out and forward work orders for the repairs to the Maintenance Director. Continued review of the Policy revealed a supply of work orders would be maintained at each nurse's station. The Policy noted any work order requests completed would be placed in the appropriate file basket at the nurse's station, and the work orders would be picked up daily. Observation during the facility tour, 01/28/15 at 9:15 AM, revealed: a brown substance was located on the tiles of the ceiling in the dining room; a handrail located close to the entrance door had a hanging splinter; dust and clutter were present throughout the laundry room; with food and staff's personal items in the "folding" area of the residents' laundry. Additionally, observation revealed cracked tile in the residents' shower room and a missing piece of the shower covering which exposed the plastic and wire pieces when the shower was turned on. Interview with Housekeeper #1, on 01/28/15 at 9:25 PM, revealed the housekeepers did not formally have a cleaning schedule and cleaned whatever needed to be cleaned as necessary. She reported she thought maintenance would clean the dust observed on the walls, outlets, and pipes of the laundry room. Per interview, she had not filled out a work order for items that needed to be repaired and/or cleaned. Continued interview revealed she was still learning her role as a housekeeper and she had been without a Housekeeping Supervisor to provide guidance. Further interview revealed staff should not have stored food or personal items in the "folding" area of the laundry room. Interview with the Plant Operations Director (POD), on 01/28/15 at 11:45 AM, revealed the brown substance from the ceiling tile in the dining room appeared to from water leakage somewhere. The POD revealed the handrail should have been sanded down to prevent residents or visitors from getting a splinter. Per interview, he assisted the facility once a week, until the facility could hire a full time maintenance person. He revealed he made a walk through of the facility once a week and would check into any repairs or maintenance requested. The POD stated he was not aware of the dust/rust observed in the laundry room, the cracked tile in the shower room and the missing shower protector on the shower and all of the other maintenance concerns observed by the Surveyor. Additionally, he added if staff noticed areas where the facility should be repaired, they should have filled out a work order so he would have been aware of the maintenance concerns. Interview with the Administrator, on 01/30/15 at 9:00 AM, revealed the process for informing maintenance of work requests was for staff to fill out a maintenance request log. Continued interview revealed the POD would make a list of items which needed to be repaired, and the POD would take care of them. The Administrator added, "there were not a lot of maintenance requests" at the facility. He stated the POD was responsible for logging the items needing to be repaired to ensure the repairs were done. Per interview, the POD came to the facility on ce a week and the Regional POD would come once a week also to make any repairs. The Administrator revealed he would call contractors for larger jobs and would repair smaller jobs himself. According to the Administrator, staff should make a request for maintenance once they noticed items within the building needing to be repaired. Further interview with the Administrator revealed he did not believe there was a cleaning schedule for the laundry, and dusting in the laundry room would be part of the POD's routine maintenance. The Administrator reported it would be his expectation for staff not to leave personal items or food in the "folding area" of the laundry room. He stated staff had lockers to store their items in and break rooms in which they could eat. The Administrator stated this was important to prevent cross contamination.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for three (3) of ten (10) sampled residents (Resident #2, #3 and #6). Resident #3's Comprehensive Care Plan was not revised after the resident was diagnosed and treated for [REDACTED]. Resident #2's Care Plan was not revised when the resident's scoop mattress was removed from the bed. Resident #6's Care Plan was not revised to include changes in the dose of his/her [MEDICATION NAME] [MEDICATION]), and for the laboratory (lab) monitoring of the [MEDICATION NAME] levels. The findings include: Review of the facility's policy titled, "Care Plans-Comprehensive", revised October 2010, revealed care plans were revised as information about the resident and the resident's condition changed. Review of the Policy revealed the care planning/interdisciplinary team was responsible for the review and revising of care plans when there was a significant change in a resident's condition, and when the desired outcome was not met. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 04/17/07, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 as having both short and long term memory loss, as requiring total dependence of two (2) staff for toileting, and as always incontinent of bowel and bladder. Review of the Comprehensive Care Plan dated 10/17/13, revealed a care plan for the resident's risk for bowel elimination problems related to decreased mobility, side effects of medication, [MEDICAL CONDITION], and decreased liquid intake. Continued review of the care plan revealed the goal stated Resident #3 would have a regular bowel movement (BM) pattern as evidenced by soft/formed stool at least every three (3) days. Further review revealed several interventions which included: monitor BM status; report changes in BM status to Physician; and administer bowel regimen as per physician's orders [REDACTED]. Review of the Nurse's Note dated 07/13/14 at 2:00 AM, revealed Resident #3 had several loose stools that night and was moaning when having the stools. Review of the Nurse's Note entry on 07/13/14 at 2:50 AM, revealed the nurse was called to the room by the Certified Nursing Assistant (CNA). Per the Note Resident #3 was noted to be ashen and clammy, with a blood pressure of 125/97, pulse of 89 and respirations of 20. Review of the Nurse's Notes on 07/13/14 at 3:00 AM and 3:30 AM, revealed the Physician was notified and Resident #3 was transported to the hospital ER where he/she was diagnosed with [REDACTED]. Review of the Hospital Discharge Instructions dated 07/13/14, revealed Resident #3 was diagnosed with [REDACTED]. However, additional review of Resident #3's Comprehensive Care Plan, dated 10/17/13, revealed no documented evidence the care plan was revised in regards to Resident #3's [DIAGNOSES REDACTED]. Although the Care Plan had an area to check if a resident had a history of [REDACTED].#3 had a history of [REDACTED]. Interview, on 01/29/15 at 5:20 PM, with MDS Coordinator #1, revealed she revised care plans with any new physician's orders [REDACTED]. However, she stated she always reviewed the chart during the MDS Assessment timeframes and should have caught the diagnoses, including Fecal Impaction to add to Resident #3's Care Plan when she completed the 12/10/14 MDS. Interview, on 01/30/15 at 5:35 PM, with the Director of Nursing (DON) revealed the MDS Nurses revised residents' Comprehensive Care Plans. Per interview, the MDS Nurses got the information for the care plan updates in the morning meetings held Monday through Friday. She stated the Interdisciplinary Team talked about who had went to the ER the following day, and the MDS Nurses were to follow through with updating the care plans as needed. She stated Resident #3's care plan should have been revised to indicate the resident had a history of [REDACTED]. 2. Review of Resident #2's medical record revealed the facility admitted him/her on 05/21/13, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #2 as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) out of fifteen (15), indicating he/she was cognitively intact. Further review of the MDS revealed the facility assessed Resident #2 as having no falls. Review of Resident #2's Comprehensive Care Plan dated 02/24/14, revealed the facility had care planned the resident for the potential for falls related injury due to weakness, cognitive concerns, hearing loss, visual changes, inability to transfer without a mechanical lift. Continued review of the falls care plan revealed the goal stated Resident #2 would not sustain a fall related injury. Further review of the falls care plan revealed several interventions listed which included: total assist with transfers with a mechanical lift; bed in lowest position; and a scoop mattress. Review of the physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) dated January 2015 revealed a treatment procedure for a scoop mattress to the bed as a fall prevention. Continued review of the January 2015 TAR revealed nurses had initialed from 01/01/15 through 01/27/15, the scoop mattress as a fall prevention, indicating the scoop mattress was in place to the resident's bed. However, observation of Resident #2 on 01/27/15 at 4:05 PM, revealed the resident was lying on his/her back on the bed with the two (2) upper half siderails raised, and eyes closed with no scoop mattress observed on the bed. Observation of Resident #2 on 01/28/15 at 9:00 AM, revealed the resident was in the bed tilted to the left with the two (2) upper half siderails raised and eyes closed, and no scoop mattress observed. Observation of Resident #2 on 01/29/15 at 2:10 PM with CNA #1, revealed there was no scoop mattress on the resident's bed. CNA #1 stated she was assigned to Resident #2, and she referred to her Nurse Aide Care Plan for interventions the resident needed. She reviewed her Nurse Aide Care Plan and stated there was no intervention for Resident #2 to have a scoop mattress on his/her bed. Interview with Registered Nurse (RN) #2 on 01/29/15 at 2:15 PM, revealed she was the Charge Nurse assigned to Resident #2 and she signed the residents' treatments on the TAR. RN #2 checked Resident #2's bed during the interview, and stated she thought the mattress was a scoop mattress because the edges of the mattress were firm. Interview and observation of Resident #2's bed with the Assistant Director of Nursing (ADON) on 01/29/15 at 2:40 PM, revealed Resident #2 did not have a scoop mattress on his/her bed. She stated Resident #2 no longer had the scoop mattress because he/she did not try to get up out of the bed anymore, and the scoop mattress did not fit the resident's long bed frame. She stated Resident #2 had not had the scoop mattress for a long time and the order for the scoop mattress needed to be discontinued. Per interview, Resident #2's care plan needed to be revised as Resident #2 no longer needed the scoop mattress. Interview with MDS Nurse #1 on 01/29/15 at 5:20 PM, revealed she revised residents' care plans. Per interview, if Resident #2 had the scoop mattress removed from his/her bed, she should have been notified so she could revise the resident's care plan. MDS Nurse #1 stated the nurse assigned to the resident at the time the mattress was removed could also have revised the care plan. Interview with the DON on 01/30/15 at 5:35 PM, revealed Resident #2's scoop mattress was too short for the bed and the facility had ordered a new mattress. She stated the scoop mattress was an intervention the staff had placed after a fall; however, the resident no longer attempted to get out of bed. Per interview, the Physician should have been notified for an order change and the nurse assigned to the resident when the scoop mattress was removed should have updated his/her care plan. Continued interview revealed the nurses were fairly new right now and were growing, and she had to guide the nurses as it was a work in progress. 3. Record review revealed the facility admitted Resident #6 on 11/08/14, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated ????, revealed the assessed Resident #6 as having a [DIAGNOSES REDACTED].#6's Comprehensive Care Plan, dated, revealed the facility care planned the resident for the [DIAGNOSES REDACTED].?????. Review of Resident #6's Admission physician's orders [REDACTED]. Review of the Telephone physician's orders [REDACTED].#3 received an order to increase Resident #6's [MEDICATION NAME] medication to 400 mg by mouth in the AM (morning) and 200 mg by mouth at bedtime, and to obtain a laboratory (lab) level for the [MEDICATION NAME] on 11/21/14. However, further review of Resident #6's care plan revealed no documented evidence it was updated and revised to include the the increase in the resident's [MEDICATION NAME], the lab order for the [MEDICATION NAME] level and for further lab monitoring of his/her [MEDICATION NAME] levels. Interview, on 01/29/15 at 5:40 PM, with RN #3 revealed she did remember there was something to do with Resident #6's [MEDICATION NAME] levels in November 2014. Per interview, she thought Resident #6's levels were low. RN #3 stated she did not know why she didn't update Resident #6' s care plan with the orders she received. Interview, on 01/29/15 at 5:50 PM and 01/30/15 at 5:30 PM, with the Director of Nursing (DON) revealed "somehow" the lab order had been missed and was not available for review in the "management meeting" held each morning where all new orders were reviewed. Per interview, Resident #6's care plan should have been updated and revised regarding the order to increase the [MEDICATION NAME], and for monitoring the [MEDICATION NAME] Levels and the potential [MEDICATION NAME] interaction with alcohol.