Every finding on record at Pine Meadows Health Care

Based on facility policy review, observation, and interview, the facility failed to ensure residents were treated with dignity and respect when staff failed to provide personal care to 1 of 1 (Resident #1) sampled residents reviewed for Activities of Daily Living (ADL) care. The findings include: 1. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 10/26/2023, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.All staff members are involved in providing care to residents to promote and maintain resident dignity and resident rights.During interactions with residents, staff must report, document and act upon information regarding resident preferences.Groom.residents according to resident preference. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Diabetes, Heart Failure, Dysphagia, and Tracheostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Resident #1 was dependent on staff to perform personal hygiene. Observations in the Resident's room on 7/6/2026 at 8:52 AM,10:14 AM, and 3:04 PM, revealed Resident #1 had visible facial hair to her chin. Observation in the dining room on 7/6/2026 at 11:38 AM, revealed Resident #1 had visible facial hair to her chin while she was up in her geri-chair (mobile reclining armchair) in the dining room. During an observation and interview in the Resident's room on 7/7/2026 at 7:55 AM, revealed Resident #1 was sitting up in a geri-chair with facial hair on her chin. The resident was asked if staff had offered to shave or remove the facial hair on her chin. Resident #1 stated, It embarrasses me and I have asked staff to shave it, but they say they don't have any razors. Observation in the dining room on 7/7/2026 at 9:55 AM, revealed Resident #1 had visible facial hair on her chin while up in the dining room. Observation at the front entrance of the facility on 7/7/2026 at 12:00 PM, revealed Resident #1 had visible facial hair on her chin while she was sitting in her geri-chair at the facility's front entrance. During an interview on 7/7/2026 at 1:14 PM, the Director of Nursing (DON) was asked where personal care tasks such as shaving are documented. The DON stated, I don't think we have a place other than the task in [named electronic medical record] and it just states if the resident was a bed bath or shower. The DON was asked regarding the resident's facial hair. The DON stated, The resident had facial hair when she was first admitted to the facility. The DON was asked should personal care be provided to remove the facial hair. The DON stated, I think she has refused for us to shave her in the past and she needs to be care planned for refusals if that is her preference. During an interview on 7/8/2026 at 8:36 AM, the DON was asked if a resident has unwanted facial hair should staff assist with shaving it. The DON stated, Yes. The DON was asked should the resident be care planned for refusal of care. The DON stated, Yes, she should be if she refuses care.

Based on facility policy review, medical record review, and interview, the facility failed to include the Resident and/or Resident Representative in the care plan conference for 2 of 20 (Resident #11 and Resident #64) sampled residents reviewed for care plan conferences. The findings include: 1. Review of the facility policy titled, Care Plan-Interdisciplinary Team, dated 9/28/2017, revealed .The resident, the resident's family and/or the residents legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. The care Plan will be printed and reviewed for accuracy prior to Care Conference. The care plan will be read aloud to the resident, family and IDT team. A written summary or copy of the baseline care plan will be given to the resident and/or representative.Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family . 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Cerebrovascular Disease, Aphasia, and Hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11's Brief Interview for Mental Status (BIMS) assessment was unable to be completed, due to the Resident is rarely to never understood and noted as moderately impaired. Review of the Care Plan Conference Summary dated 12/19/2025, 3/19/2026, and 6/19/2026, revealed Resident #11 and/or Resident Representative (RR) did not attend the care plan conferences. During an interview on 7/6/2026 at 12:42 PM, Resident #11's RR was asked if she participated in Residents #11's care plan meetings. The RR stated, No, I do not. No one has ever told me about care plan meetings since my father has been there. The RR was asked if at any time had she received an invite verbally or by mail for care plan meetings. The RR stated, No, I have not. The facility was unable to provide documentation that Resident #11 and/or their RR had been invited to attend the annual Care Plan Conference dated 12/19/2025, the quarterly Care Plan Conference dated 3/20/2026, and the quarterly Care Plan Conference dated 6/19/2026. 3. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Major Depressive Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #64 scored a 15 on the BIMS assessment, which indicated that he was cognitively intact. Review of the Care Plan Conference Summary dated 11/11/2025, 2/11/2026 and 5/11/2026 revealed Resident #64 and/or their RR did not attend the care plan conferences. The facility was unable to provide documentation that Resident #64 and/or their RR had been invited to attend the quarterly Care Plan Conference dated 11/11/2025, the annual Care Plan Conference dated 2/11/2026, and the quarterly Care Plan Conference dated 5/11/2026. During an interview on 7/7/2026 at 10:47 AM, the Social Services Director (SSD) and the Social Services Assistant (SSA) were asked if they were responsible for invites to care plan meetings for residents and families. The SSD stated, Yes, we are .We do send out letters to the families also. The SSD was asked if she kept a record of the letters that were sent to families. The SSD stated, No we do not. The SSA was asked if she documented when the families were invited by phone calls. The SSA replied, No, I don't. The SSD was asked if the residents are documented as cognitively intact, do you invite the resident to the care plan meeting. The SSD stated, Yes, we go invite them verbally. The SSD was asked if it was documented when the resident was verbally invited. The SSD and SSA replied, No, ma'am. During an interview on 7/8/2026 at 11:30 AM, the Director of Nursing (DON) was asked who should be invited to care plan meetings. The DON replied, All department heads, families and residents (if the resident request). We try to involve the family if the resident approves it.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure wound assessments were completed accurately for 1 of 2 (Resident #95) sampled residents reviewed for pressure ulcers/wounds. The findings include: 1. Review of the facility policy titled, Pressure Injury Prevention Guidelines, dated 3/20/2024, revealed .To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence–based interventions for residents who are assessed at risk or who have a pressure injury present.Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment.staging, wound characteristics. Review of the facility policy titled, Wound Treatment Management, dated 10/26/2023, revealed .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence- based treatments in accordance with current standards of practice and physician orders.Characteristics of the wound.Pressure injury stage.The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications. 2. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE], with diagnoses including Protein-Calorie Malnutrition, Fracture of the Right Femur, Dementia, and Pressure Ulcer. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #95 was rarely/never understood and had short and long-term memory problems, and his cognitive skills were severely impaired. Resident #95 was dependent on staff for all care and had 1 Stage 4 pressure ulcer. Review of the Physician Orders dated 6/30/2026, revealed .Wound Care: Cleanse unstageable [unable to see the wound bed due to slough, or dead tissue] pressure ulcer to left hip with DWC [dermal wound cleanser]. Apply skin prep to peri wound [skin and tissue surrounding a wound], lightly pack undermining [tissue destruction creating a deep pocket or shelf] and tunneling area with aquacel ag [silver] rope [an antimicrobial ribbon dressing designed to pack deep or tunneling wounds], cover with hydralock [a sterile, super absorbent wound dressing designed for moderate to heavy oozing of fluid] and dry dressing everyday. Review of the Skin and Wound Evaluation., form dated 11/6/2025, revealed .Pressure.Unstageable.Slough [a moist yellow or white stringy substance in a wound bed made of dead cells, fibrin (a tough, insoluble protein formed by the body to support wound healing), and bacteria] and/or eschar [dead tissue on the skin].Front Left Trochanter [boney area at the top of the hip bone].New.Length 4.6 cm [centimeter].Width 5.0 cm.Depth Not Applicable. Review of the .Skin Issues, forms revealed: a. 5/4/2026 unstageable, 3.6 x 3.83 x 0, (L (length) x W (width) x D (depth) cm) undermining length (cm) 1 Tunnel length (cm) 1.5 b. 5/11/2026 unstageable, 2.66 x 3.74 x 0, undermining length (cm) 3 Tunnel length (cm) 2.5 c. 5/18/2026 unstageable, 2.48 x 3.56 x 0, undermining length (cm) 2.5 Tunneling No d. 5/25/2026 unstageable, 2.65 x 3.35 x 0, undermining length (cm) 3.5 e. 6/1/2026 unstageable, 2.63 x 3.76 x 0, undermining length (cm) 2.5 f. 6/8/2026 unstageable, 2.32 x 3.9 x 0, undermining length (cm) 2.5 g. 6/15/2026 unstageable, 2.19 x 3.11 x 0, undermining length (cm) 2 h. 6/22/2026 unstageable, 2.4 x 3.39 x 0, undermining length (cm) 1 i. 6/30/2026 unstageable, 2.11 x 3.34 x 0, undermining length (cm) 2 j. 7/6/2026 unstageable, 2.24 x 3.49 x 0, undermining length (cm) 2 During a wound treatment observation in Resident #95's room on 7/7/2026 at 9:05 AM, with Licensed Practical Nurse (LPN) B, revealed Resident #95's wound on the Left Trochanter was clean, wound edges approximated (edges slightly turned outward), no eschar, necrosis or odor present, no obstruction to wound, observed wound being packed with aquacel ag. Resident #95's wound presents as a Stage 3. During an interview on 7/7/2026 at 2:05 PM, the Director of Nursing (DON) was asked what Resident #95's wound stage was when it first started. The DON stated, It was an unstageable wound with slough, in house acquired. The DON was asked if this wound is now stageable. The DON stated, Yes. The DON was asked why this wound is now stageable. The DON stated, Because the slough is gone, they should have staged it once the slough was gone. The DON was shown the wound pictures in the medical record and acknowledged the wound was incorrectly staged and was not an unstageable pressure ulcer as documented on the .Skin Issues forms for May 2026, June 2026 and July 2026. The DON looked at the wound pictures in the medical record and stated, It should have been staged.because you can see the wound bed and there is no slough anymore. The DON was asked why she thought this wound was staged wrong. The DON stated, She [wound nurse] was thinking she couldn't backstage or downstage. The DON was asked what stage the wound is. The DON stated, It's a Stage 3.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 1 staff (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) during medication administration through a percutaneous endoscopic gastrostomy (PEG) tube (tube inserted directly into the stomach to provide nutrition or medications) for 1 of 1 (Resident #86) sampled resident reviewed for PEG medication administration. The findings include: 1. Review of the facility policy titled, Medication Administration, dated 1/17/2023, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Review of the facility policy titled, Enhanced Barrier Precautions (EBP), dated 3/26/2024, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .enhanced barrier precautions will be obtained for residents with any of the following .Indwelling medical devices .feeding tubes .High-contact resident care activities to consider include .Device care or use .feeding tubes . 2. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Vascular Dementia, Atrial Fibrillation, and Anorexia. Review of the (Named facility) Order Listing Report, dated July 8, 2026, revealed orders for the following: a. methIMAzole [an antithyroid drug] 10 MG [milligram] give 2 tablets by PEG-Tube one time a day b. Lexapro [ an antidepressant] 20 MG give 1 tablet by PEG-Tube one time a day c. flush PEG-Tube with 50 ML (milliliters) water] every shift. d. Enhanced Barrier Precautions for PEG. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #86 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Resident #86 had a peg tube. Observation during medication administration outside of Resident #86's room on 7/8/2026 at 7:48 AM, revealed LPN A gathered supplies and prepared the medications Escitalopram 20 mg and Methimazole 10 mg for administration via PEG. LPN A crushed the medication, knocked and entered Resident #86's room. LPN A performed hand hygiene, put on clean gloves, checked gastric residual (the amount of undigested food, liquid, or material that can be aspirated from the stomach through a feeding tube), administered the medication, and flushed the tube with 50 ML of water. LPN A removed her gloves, performed hand hygiene, and exited the room. LPN A failed to wear a gown when accessing Resident #86's peg tube. During an interview on 7/8/2026 at 8:00 AM, LPN A was asked if Resident #86 had an order for enhanced barrier precautions. LPN A stated, Yes. LPN A was asked what the proper PPE for enhanced barrier precautions was. LPN A stated, Gown and gloves. LPN A was asked if proper PPE was worn during medication administration via Resident #86's PEG tube. LPN A stated, I wore gloves but not a gown. LPN A was asked if she wore the proper PPE for med administration with a Peg tube. LPN A stated, No. During an interview on 7/8/2026 at 9:42 AM, The Director of Nursing (DON) was asked what PPE should be worn with enhanced barrier precautions. The DON stated, Gloves and gown. The DON was asked what residents should be in enhanced barrier precautions. The DON stated, Anyone who has an opening in the skin such as wound, tracheostomy [opening in the neck to facilitate breathing], peg, or IV [Intravenous catheter used for administering fluids or medications]. The DON was asked should staff wear a gown and gloves during medication administration using a PEG. The DON stated, Yes. The DON was asked if there is an order for enhanced barrier precautions should staff follow orders. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect during dining when 2 of 28 staff members (Certified Nursing Assistant (CNA) #1 and Activities Assistant) stood to assist residents (Resident #65 and #37) with their meal. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 1/1/2021, revealed .the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life . Observation in the A Hall on 4/7/2021 at 1:01 PM, revealed CNA #1 was standing over Resident #65 to assist with the meal. Observation in the A Hall on 4/7/2021 at 1:02 PM, revealed the Activities Assistant was standing over Resident #37 to assist with the meal. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .staff should sit down to assist residents with meals .should not stand .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure abuse policies were implemented and followed when facility staff to report allegations of abuse to the Administrator immediately for 1 of 5 sampled residents (Resident #85) reviewed for alleged abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 7/28/2020, documented .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: Immediately . Review of the medical record, revealed Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set Assessment (MDS) dated [DATE], revealed Resident #85 scored a 00 on the Brief Interview of Mental Status (BIMS), which indicated severely impaired cognition. Review of the Nurses' Progress Note dated 6/7/2021, revealed an allegation of resident to resident contact on 6/6/2021. Resident #85 was sitting at the desk with his head down and the other resident came by and hit him on the back. Observation in the resident's room on 6/7/2021 at 9:39 AM, revealed Resident #85 alert with confusion. He would answer questions by nodding his head. During an interview on 6/7/2021 at 5:04 PM, the Administrator stated, .we have another resident to resident abuse to report .the Assistant Director of Nursing (ADON) was reviewing the resident's medical record [Resident #13] and found a note that she had slapped a resident on the shoulder yesterday [6/6/2021] when she was leaving the Dining Room . During an interview on 6/10/2021 at 5:39 PM, the Administrator confirmed she should have been notified immediately about the incident of the alleged abuse that occurred on 6/6/2021 and that she was not aware of the incident until 6/7/2021 at approximately 4:00 PM.

Based on review of the Geriatric Medication Handbook, policy review, medical record review, observation, and interview, the facility failed to ensure a resident was free from a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #2) failed to administer insulin within the proper time frame related to meals for Resident #61. The failure to provide a substantial meal or snack within 15 minutes of insulin administration resulted in a significant medication error. The findings include: Review of the Geriatric Medication Handbook, eleventh edition, page 41 revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Rapid-Acting Insulin Analog .ONSET .15 min [minutes] .5-[to]10 minutes .before meals . Review of the facility policy titled, Medication-Insulin, revised 10/30/2020, revealed .to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on resident's condition .insulin administration will be coordinated with meal times . Review of medical record, revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders dated 7/8/2019 revealed, Novolog Insulin inject 9 units for blood glucose reading of 221-290 before meals. Observations in the resident's room on 6/8/2021 at 12:14 PM, revealed LPN #2 administered 9 units of Novolog insulin subcutaneously to Resident #61. Observations in the Dining Room on 6/8/2021 at 12:53 PM, revealed Resident #61 took their first bite of food, this was 39 minutes after Resident #61 received the insulin. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .should provide a meal or snack within 15-30 minutes of administering insulin .

Based on policy review, observation, and interview, 1 of 28 staff members (Certified Nursing Assistant (CNA) #2) failed to distribute and serve food in a sanitary manner during dining when the staff touched food with their bare hands. The findings include: Review of the facility's policy titled, .Hand hygiene ., revised 5/7/2021, revealed .all staff will perform proper hygiene procedures to prevent the spread of infection to other personnel, residents and visitors .all staff working in all locations within the facility with the exception of food prep [preparation]areas .employees may not contact exposed, ready-to-eat foods with their bare hands and shall use suitable .gloves are not a substitute for hand washing or hand hygiene .if your tasks requires direct contact with ready-to-eat food, wash your hands and exposed portions .prior to donning gloves and before touching food .wash hands immediately after removing gloves . Observations in the resident's room on 6/7/2021 at 12:45 PM, revealed CNA #2 picked up a hot dog with her bare hands and served it to Resident #259. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .staff should not touch residents food with their bare hands .

Based on policy review, observation, and interview, the facility failed to ensure appropriate infection control measures were followed during medication administration when 2 of 4 nurses (Licensed Practical Nurse (LPN) #1 and 2) touched medication with their bare hands and failed to rinse a disposable piston syringe after medication administration through a Percutaneous Endoscopic Gastrostomy (PEG) (a tube placed in the stomach for nutrition). The findings include: Review of the facility's policy titled, Flushing a Feeding Tube, revised 3/10/2021, revealed .Upon completion of the administration, remove plunger from barrel and wash all reusable equipment with warm water. Dry the equipment thoroughly, store in a bag or container for next use . Observation on 6/8/2021 at 7:53 AM, LPN #1 touched Resident #6's [MEDICATION(S)] capsule with bare her hands. Observation in front of the resident's room on 6/8/2021 beginning at 8:40 AM, revealed LPN #2 touched Resident #63's [MEDICATION(S)] capsule with her bare hands. Observations in the resident's room on 6/8/2021 at 8:54 AM, revealed LPN #2 completed PEG medication administration using a piston syringe for Resident #63. The piston syringe was placed in a plastic bag at the bedside. LPN #2 did not rinse the piston syringe with water after use. During an interview on 6/10/2021 at 5:12 PM, the Director of Nursing (DON) stated, .nurses should not touch medications with their bare hands .piston syringe should be rinsed with warm water after use .

Based on review of the Center for Disease Control (CDC) and Prevention guidelines, facility policy review, observation, and interview, the facility failed to prevent the risk of transmission of COVID-19 (Coronavirus) for 3 of 26 sampled residents (Resident #1, #3, and #6) in isolation, which had the potential to result in transmission of [MEDICAL CONDITION] to these 6 residents. The findings include: Review of the CDC guidelines titled, .Preparing for COVID-19 in Nursing Homes, updated June 25, 2020, showed that, given the congregate nature and resident population served (for example, older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens, and a strong infection control program is critical to protect both residents and healthcare personnel. Review of the CDC guidelines titled, .Responding to Coronavirus (COVID-19) in Nursing Homes, updated April 30, 2020, showed that a resident with new-onset suspected or confirmed COVID-19 should be isolated and cared for using all recommended COVID-19 PPE. The resident should be placed in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, revised 7/12/2020, documented, .In addition to Standard Precautions, implement Airborne Precautions for anyone who is documented or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small particles of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance) .Examples of infections requiring Airborne Precautions include .[MEDICAL CONDITION] (COVID-19) .Resident Placement .If .isolation is necessary, place the individual in a private room (a room with no one else in it) . 1. Review of the medical record, showed Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had been asymptomatic for signs and symptoms of COVID-19. Review of the medical record, showed Resident #2 had [DIAGNOSES REDACTED]. Review of the facility's Respiratory Surveillance Line List and nursing progress notes showed Resident #2 developed symptoms of cough, congestion, and low oxygen saturation on 7/17/2020. Review of the facility's .Midnight Census report, showed the facility had 4 semi-private rooms that were unoccupied on 7/17/2020. The rooms that were unoccupied were Rooms 213, 214, 215, and 216. Review of the final report of the COVID-19 laboratory test for Resident #2, collected on 7/20/2020, showed the COVID-19 virus was not detected. Review of the final report of the COVID-19 laboratory test for Resident #2, collected on 7/27/2020, showed a positive result for COVID-19. This report was received on 7/29/2020, and Resident #2 was moved to a private isolation room on the COVID Unit on 7/30/2020. Observation in the residents' room on 7/28/2020 at 9:50 AM, showed Resident #1 and #2 resided together in the room. The facility failed to follow CDC guidelines for isolating a symptomatic resident in a single isolation room. During a phone interview conducted on 8/3/2020 at 10:47 AM, the Director of Nursing (DON) confirmed Resident #1 and #2 were left in the room together despite Resident #1 being asymptomatic and Resident #2 being symptomatic. 2. Review of the medical record, showed Resident #3 had [DIAGNOSES REDACTED]. Resident #3 had been asymptomatic for signs and symptoms of COVID-19. Review of the medical record, showed Resident #4 had [DIAGNOSES REDACTED]. Review of the facility's Respiratory Surveillance Line List and nursing progress notes showed Resident #4 developed symptoms of diarrhea on 7/28/2020. Review of the facility's .Midnight Census report, showed the facility had 7 semi-private rooms that were unoccupied on 7/28/2020. The rooms that were unoccupied were Rooms 110, 213, 214, 311, 312, 313, and 314. Observation in the residents' room on 7/28/2020 at 9:52 AM, showed Resident #3 and 4 resided together in the room. The facility failed to follow CDC guidelines for isolating a symptomatic resident in a single isolation room. Review of the final report of the COVID-19 laboratory test for Resident #4, collected on 7/27/2020, documented a positive result for COVID-19. This report was received on 7/29/2020, and Resident #4 was moved to an isolation room on the Covid Unit on 7/30/2020. Review of the final report of the COVID-19 laboratory test for Resident #3, collected on 7/27/2020, documented a positive result for COVID-19. This report was received on 7/29/2020, and Resident #3 was moved to an isolation room on the Covid Unit on 7/30/2020. During a phone interview conducted on 8/3/2020 at 10:48 AM, the Director of Nursing (DON) confirmed Resident #3 and #4 were left in the room together despite Resident #3 being asymptomatic and Resident #4 being symptomatic. 3. Review of the medical record, showed Resident #5 had [DIAGNOSES REDACTED]. Review of the facility's Respiratory Surveillance Line List and nursing progress notes showed Resident #6 developed symptoms of fever and cough on 7/23/2020. Review of the medical record, showed Resident #6 had [DIAGNOSES REDACTED]. Review of the facility's Respiratory Surveillance Line List and nursing progress notes showed Resident #6 developed symptoms of fever and cough on 7/25/2020. The facility did not remove Resident #6 from the room when Resident #5 developed symptoms on 7/23/2020. Review of the facility's .Midnight Census report, showed the facility had 5 semi-private rooms that were unoccupied on 7/23/2020. The rooms that were unoccupied were Rooms 213, 214, 311, 312, and 314. Review of the final report of the COVID-19 laboratory test for Resident #5, collected on 7/23/2020, documented a positive result for COVID-19. This report was received on 7/28/2020, and Resident #6 was moved to an isolation room on the Covid Unit on 7/29/2020. Observation in the residents' room on 7/28/2020 at 9:53 AM, showed Resident #5 and #6 resided together in the room. The facility failed to follow CDC guidelines for isolating a symptomatic resident in a single isolation room. During a phone interview conducted on 8/3/2020 at 10:49 AM, the Director of Nursing (DON) confirmed the facility preferred an asymptomatic resident not be left in the room with a symptomatic resident. The DON was asked if leaving an asymptomatic resident in the room with a symptomatic resident was good infection control practice. The DON stated, Probably not. During a phone interview conducted on 8/3/2020 at 5:04 PM, the Medical Director confirmed that when a resident becomes symptomatic they should be removed from the asymptomatic roommate.

Based on policy review, observation, and interview, the facility failed follow infection control procedures to prevent the potential spread of infection when 1 of 20 (Certified Nursing Assistant (CNA) #1) staff members failed to perform appropriate hand hygiene and placed a dirty plate lid cover on a clean meal cart. The findings include: The facility's Handwashing/Hand Hygiene policy dated 2/18 documented, .Employees must wash their hands .Before and after direct contact with residents . Observations in Resident #96's room on 4/8/19 at 12:20 PM, revealed CNA #1 touched the bottom of Resident #96's sock, performed tray set up, then removed a piece of cornbread out of the wrapper with her bare hands and placed it on the resident's plate without performing hand hygiene. CNA#1 left the room and placed Resident #96's plate cover lid on the food cart with meal trays. that had not been served. Interview with the Director of Nursing (DON) on 4/11/19 at 10:18 AM, in the DON office, the DON was asked if staff should touch the bottom of a resident's sock, perform meal tray set up, take a piece of cornbread out of a wrapper with her bare hands, and place it on the resident's plate. The DON stated, No . The DON was asked should a plate cover lid be taken out of a resident's room and be placed on the food tray cart with meal trays that have not been served. The DON stated, No.

Based on medical record review and interview, the facility failed to ensure the accuracy on the Minimum Data Set (MDS) assessment for medications, diagnoses, skin, and restraints for 4 of 12 (Resident #39, 42, 49, and 103) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #39 received antidepressants for 7 days during the 7 day look back period. The quarterly MDS dated [DATE] did not document a [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. During an interview with the Resident Assessment Instrument (RAI) Director on 5/17/17 at 3:05 PM, in the MDS office, the Regional RAI Director was asked if the MDS was coded for depression. The Regional RAI Director stated, .Depression, not coded . The Regional RAI was asked if a [DIAGNOSES REDACTED]. The Regional RAI stated, Yes. 2. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] documented the resident did not have a pressure ulcer or other skin problem and did not receive any skin or ulcer treatments, except a pressure reduction mattress, over the 7 day look back period. The ADMISSION EVALUATION DATA sheet dated 3/6/17 documented Resident #42 was admitted with skin tears to his Left forearm and a pressure sore to his coccyx. The Skin Care notes dated 3/13/17 documented a wound to the sacral/coccyx area. The Treatment Administration Record (TAR) dated 3/7/17 through 3/31/17 documented Resident #42 received a moisturizer to periarea, treatment to a skin tear to the Right forearm, and treatment to a coccyx wound during the 7 day assessment period. The 5 day MDS assessment dated [DATE] documented Resident #42 received injections on 3 of 7 days, insulin on 0 of 7 days, hypnotics on 0 of 7 days, and antidepressants, anticoagulants, and antibiotics on 7 of 7 days. The Medication Administration Record [REDACTED]. Resident #42 did not receive antidepressants, anticoagulants or antibiotics this look back period. 3. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Function In Sitting Test dated 4/10/17, completed by the therapy department, documented Resident #49 was evaluated for positioning in a Broda/scoot chair due to excessive leaning forward with her face down on the (lap) tray. The test indicated Resident #49 was unable to relax and could not safely complete functional testing due to the excessive amount of leaning forward. A second trial in the scoot chair was attempted on 4/12/17 to reassess the appropriateness of wheelchair seating. The resident was again noted to be leaning forward and reaching for the floor. Resident #49 was unable to follow commands to complete the functional assessment. The most recent quarterly MDS assessment dated [DATE] documented Resident #49 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS- used to capture cognitive functioning), which indicated the resident had severe cognitive impairment. According to the assessment, Resident #49 needed extensive assistance with all activities of daily living (ADLs). The MDS, Section P - Restraints, which looked back 7-days before the assessment reference date, indicated that a restraint was not used for Resident #49. Section P of the MDS documented .physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's body. The May 2017 physician's orders [REDACTED].apply lap tray for positioning due to leaning forward and safety when up in wheelchair . Observations on 5/16/17 at 12:52 PM in the dining room revealed Resident #49 was seated in a wheelchair, which had a tilted back axel and included a plastic lap tray, attached to both arm rests. The lap tray was also belted, with a clasp, behind the resident's wheelchair. Due to the resident's limited functional ability and cognitive level, she was unable to remove the tray without unlocking the clasp in the back of the wheelchair. The position of the clasp was in the middle of the wheelchair backrest. It was not physically possible for the resident to turn around in her chair and unlock the belt. During an interview with LPN #3, who coordinated the MDS, on 5/16/17 at 5:00 PM in the MDS office said the lap tray was a restraint but the Interdisciplinary Team (IDT) recommended it not be coded as a restraint because it was used as an enabler. The IDT consisted of nursing, the Director of Nursing (DON), therapy department and other facility departments. She confirmed the resident did have the lap tray in place during the look-back period. LPN #3 said since the resident could not remove the tray herself then it was a restraint. She said the staff used the lap tray as an enabler to help with positioning and to prevent falls. During an interview with the DON on 5/17/17 at 3:38 PM, in C hall nurses station, the DON stated she did not feel the facility needed to code Resident #49's belted lap tray as a restraint. The DON stated the lap tray did not restrict the resident's movement. After reviewing the MDS manual definition for restraints, the DON agreed the lap tray was adjacent to the resident's body and that she could not remove the lap tray herself. The DON said the belted lap tray was used as an enabler to prevent Resident #49 from leaning completely forward and possibly falling out of her wheelchair. 4. Medical Record Review revealed Resident #103 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A MAR indicated [REDACTED]. The MDS dated [DATE] documented Resident #103 received no Insulin injections during the 7 day look back period. This quarterly review assessment did not accurately reflect Resident #103's insulin use during the 7 day look back period. During an interview with the Regional Resident Assessment Instrument (RAI) Director on 5/16/17 at 4:31 PM, in the MDS office, The Regional RAI Director was asked if resident was on insulin and was insulin coded on the 7 day look back period. The Regional RAI Director stated .We don't have any injections coded . The Regional RAI Director was asked is this an incorrect MDS. The Regional RAI Director stated .Yes, I will modify it now .

Based on policy review, review of the GERIATRIC MEDICATION HANDBOOK ELEVENTH EDITION, observation and interview the facility failed to ensure 2 of 4 (Licensed Practical Nurses (LPN) #4 and 5) nurses administered medications accurately with a medication error rate of less than 5 percent (%). A total of 3 medication errors were observed out of 29 opportunities, resulting in a medication error rate of 10XXX % The findings included: 1. The facilities Administering Medications through a Metered Dose Inhaler policy documented, .Allow at least one (1) minute between inhalation of the same medication 2. The GERIATRIC MEDICATION HANDBOOK ELEVENTH EDITION documented, .Inhaled Medications .if another puff of the same or different medications required, wait 1-2 minutes . 3. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physicians' orders dated May 2017 documented, [MEDICATION NAME] 100 MG (milligram) .1 TABLET PER (by) TUBE EVERY MORNING AT 630 AM Review of the Medication Administration Record [REDACTED]. Observations in Resident #25's room on 5/16/17 at 9:13 AM, revealed Licensed Practical Nurse (LPN) #4 administered Spirolactone 100 mg, resulting in medication error #1. Interview with Licensed Practical Nurse (LPN) #4 on 5/16/17 at 12:54 PM, at the A/B nurses station, LPN #4 was shown a list of meds that were given during the medication pass including [MEDICATION NAME] 100 mg and confirmed those were the meds she had given Resident #25. LPN #4 was shown a copy of the May MAR indicated [REDACTED]. LPN #4 stated, I didn't even realize . LPN #4 was asked if she administered the [MEDICATION NAME]. LPN #4 stated, Yes I gave it . 4. Medical record review revealed Resident #56 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physicians orders dated May 2017 documented, .ASPIRIN EC ([MEDICATION NAME] coated) 81 MG .1 TABLET ORALLY DAILY AT NOON . Observations in Resident #56's room, on 5/17/17 at 8:29 AM, revealed LPN #5 administered Aspirin EC 81 mg tablet, resulting in medication error #2. Review of the MAR indicated [REDACTED]. Interview with LPN #5 on 5/17/17 at 10:43 AM at the C/D nurses station, LPN #5 was asked what time the Aspirin should have been given. LPN #5 stated, It was due at 12:00 . LPN #5 confirmed that she had signed the MAR indicated [REDACTED]. 5. Medical Record review revealed Resident #149 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physicians orders dated May 2017 documented .[MEDICATION NAME] .100 MCG (micrograms) INHALER .INHALE 2 PUFFS BY MOUTH TWICE DAILY . Observations in Resident #149's room on 5/17/17 at 8:52 AM, LPN #5 administered [MEDICATION NAME] 2 consecutive puffs without waiting 1 minute between puffs, resulting in medication error #3. Interview with the Director of Nursing (DON) on 5/17/2017 at 11:15 AM, in the DON office, the DON was asked how long you should wait between puffs of a [MEDICATION NAME] inhaler. The DON stated, 1 minute.

Based on observation, interview, and record review the facility failed to provide palatable food to 16 of 16 (Resident #20, #77, #78, #95, #114, #18, #21, #127, #51, #17, #64, #41, #117, #87, #88 and #55) residents who received pureed food. The findings included: Observations in the kitchen on 5/16/17 at 8:57 AM, revealed Dietary Cook #1 prepared the pureed squash by combining 19 - 4 ounces (oz.) servings of cooked squash with 5- 4 oz. servings of thickener. Dietary Cook #1 did not refer to a recipe or thickener guidelines while preparing the pureed squash. Neither Dietary Cook #1 nor other kitchen staff tasted the pureed food once it was prepared. Observations on 5/16/17 at 12:30 PM, revealed a test tray was tasted by the surveyor, along with the District Dietary Manager. The pureed squash tasted of thickener. The District Dietary Manager stated the squash tasted too much like thickener and did not taste good. The Instant Food Thickener Mixing Chart that was provided by the District Dietary Manager, documented that for pureed vegetables, a serving size of 4 oz of the vegetables should be used. According to the chart, ¾ to 1½ teaspoons of thickener should be added to each of the previously mentioned servings. During the previously mentioned observations, Dietary Cook #1 used 76 oz. of squash and 20 oz. of thickener (120 teaspoons). Seventy-six oz. of squash, produced 19 - 4 ounce servings of squash. According to the Instant Food Thickener Mixing Chart, for 76 oz. of squash, the facility should have used 28.5 teaspoons of thickener. This calculation was based on using the maximum amount of thickener per serving, which was 1½ teaspoons. This indicated Dietary Cook #1 used 91.5 more teaspoons of the thickener than needed for the pureed squash. A list of residents who received pureed diets was provided by the Dietary Manager. Interview with the Registered Dietician on 5/16/17 at 4:23 PM, the Registered Dietician stated the kitchen staff should always refer to the thickener guidelines when preparing pureed food items. Interview with the District Dietary Manager on 5/17/17 at 9:34 AM, the District Dietary Manager calculated the amount of thickener used for the pureed squash and found that it was excessive. He stated the cook should have referred to the thickener guidelines and someone on the kitchen staff, preferably the cook, should have tasted all the food items.

Based on policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented and monitored appropriate plans of action to correct issues. The findings included: 1. The QAA Committee failed to ensure dignity related to a Resident's name on the back of their wheelchair. The deficient practice of F 241 is a repeat deficient practice for failure to treat resident's with dignity and respect. The facility was cited F 241 on the recertification survey on 3/22/16. 2. The QAA Committee failed to ensure that each resident had a care plan related to wounds. The deficient practice of F 279 is a repeat deficient practice for failure to ensure all wounds are care planned. The facility was cited F 279 on the recertification survey on 9/2013. 3. The QAA Committee failed to ensure the resident's care plan was followed related to insulin administration and [MEDICATION NAME] care. The deficient practice of F 282 is a repeat deficient practice for failure to follow a resident's care plan. The facility was cited F 282 on the recertification survey on 9/2013. 4. The QAA Committee failed to ensure effective infection control practices related to hand hygiene during medication administration and a ripped gerichair. The deficient practice of F441 is a repeat deficiency for failure to ensure effective infection control practices. The facility was cited at F441 on the recertification survey on 3/22/16. 5. The QAA Committee failed to identify quality deficiencies, develop, implement, and monitor action plans. The deficient practice of F 520 is a repeat deficient practice for failure to identify, develop, implement, and monitor identified issues. The facility was cited F 520 on the recertification survey on 10/2013. Interview with the Administrator on 5/18/17 at 5:00 PM, in the Administrator office, the Administrator confirmed the repeat deficient practices and stated inservices with staff are ongoing, The Administrator stated the facility was in the process of hiring a new Minimum Data Set (MDS) Coordinator and that monitoring for medication administration and for adherence to dignity standards was on going.

Based on medical record review and interview, the facility failed to notify the physician of significant changes in a resident's status for 1 of 20 (Resident #87) sampled residents of the 32 residents included in the stage 2 review. The findings included: Closed medical record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #87 was cognitively intact, required extensive assistance with activities of daily living, and had no functional limitations in range of motion. Confidential QA (Quality Assurance) document - allegation of neglect (Resident #87) (undated) documented, .She stated that around 5:45-6:00 A.M. she made her round on the resident and noted he was not speaking as he had been earlier and was staring. She immediately got the night nurse to check him. They both went into the room and the resident was cold to touch. His blood pressure was 90/50 and he started responding by nodding his head when they asked him questions . Written statement by Registered Nurse (RN) #1 (undated) documented, .At approximately 545 AM, the CNA (Certified Nursing Assistant) call me to his room. She stated he was not talking to her. We checked his vitals. I noted his skin was cool so I replaced his blanket and sheet . Written statement by CNA #3 (undated) documented, .On Thursday Feb (February) 2nd 2017 .When I went in to check on (Resident #87) around 5:45am-6:00am he was lying like he was sleeping with his eyes open and he was cold to the touch. He would not answer me. I called for the nurse. She came right away to check on him. The nurse tried to take (Resident #87)'s O2 (oxygen) but his fingertips were very cold. The nurse told me to take his BP (blood pressure) and it was 90/50. The nurse and I kept talking to (Resident #87) to try to get a response. (Resident #87) did not talk but he nodded his head in response to the nurse and I . Interview with the Director of Nursing (DON) on 5/16/17 at 1:10 PM, in the Break Room, the DON was asked if the physician was notified when the resident became unresponsive in the night. The DON stated, .Not to my knowledge .there was not any documentation of that incident . The DON was asked if there should have been documentation describing the earlier incident with the resident. The DON stated, .oh yes, there should have been . The DON was asked if the family was notified. The DON stated, Not to my knowledge. The DON was asked if she expected her staff to notify the physician when there is a change in status. The DON stated, Yes, the nurse should have notified the doctor. Telephone interview with (Named Physician) on 5/17/17 at 11:47 AM, (Named Physician) was asked if he was familiar with Resident #87. (Named Physician) stated, .I see a lot of residents .I will look at the medical records on my computer . (Named Physician) was asked if the facility notified him of Resident #87's non-responsive episode at 6:00 AM on 2/3/17. (Named Physician) stated, .they will notify me .I don't remember if they did, I get a lot of phone calls . (Named Physician) was asked if he expected for the facility to notify him when a resident becomes non-responsive. (Named Physician) stated, .well sure .I would send them to the emergency room unless maybe they were a DNR (Do not Resuscitate) .

Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 1 (Resident #49) sampled residents was free from restraints of the 1 resident reviewed with a restraint. This failure placed Resident #49 at risk for physical decline and potential harm. The findings included: 1. The Use of Restraints policy documented, .an evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom. Restraints with locking devices shall not be used . 2. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Pre-Restraining Evaluation dated 7/17/14 revealed a lap tray to Resident #49's wheelchair was recommended. The Informed Consent for Use of Restraints, for Resident #49, dated 7/17/14 documented, .I have been informed that an evaluation has been done by the appropriate healthcare professionals to determine the appropriateness of use of restraints and participation in the restraint reduction program . was left blank. The consent also documented, .I understand that I have the right to refuse the use of restraints or can revoke this consent at any time . was left blank, however, the consent was signed by the resident's responsible party. Review of the resident's Physical Restraint Elimination Review dated from 3/9/17 to 3/27/17 revealed on 3/27/14 the staff put a self-releasing alarm lap buddy on Resident #49's wheelchair. The next review dated 4/8/14 the lap buddy was discontinued. On 7/22/14 the self-releasing lap belt was discontinued and a lap tray was ordered. The most recent Physical Restraint Elimination Review, dated 3/9/17, indicated Resident #49 was .not diagnosed as being restrained at this time. The lap tray serves as an enabler . A quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #49 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had severe cognitive impairment, needed extensive assistance with all activities of daily living (ADLs) and a restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's body) was not used for Resident #49. The care dated 7/18/14 and revised on 4/27/17 documented, .Focus .potential for complications related to use of lap tray .Interventions .apply lap tray to w/c (wheelchair) when up due to res (resident) leaning abnormal posture and h/x (history of) attempts to stand without assist .check resident and release device every 2 hours and PRN (as needed) for toileting needs, positioning, and exercise. Remove at meals as res tolerates .ensure MD (physician) order for device and consent for use is current and updated as needed .evaluate need and effectiveness of lap tray quarterly and as needed . The physician's orders [REDACTED].apply lap tray for positioning due to leaning forward and safety when up in wheelchair . 3. Observations during initial tour of the facility on 5/15/16 at 9:35 AM, in C hall between room C19 and the storage room, Resident #49 was observed in a wheelchair with a plastic tray attached to both armrests and positioned across her lap. The tray was tilted upward slightly and was belted behind the resident's chair with a clasp. Observations of Resident #49 in the wheelchair restrained by the belted lap tray on 5/16/17 at 12:52 PM in the dining room, on 5/16/17 at 4:10 PM in her room, on 5/17/17 at 7:41 AM in the hallway, and on 5/17/17 at 1:46 PM in her room. Observations of Resident #49 on 5/17/17 at 1:58 PM, in Resident #49's room, the Director of Nursing (DON) asked Resident #49 repeatedly to remove the lap tray. The DON placed the resident's hands on the tray and asked her to push it off. Resident #49 was unable to comply with the request. The DON stated, .at this time that the resident's current level of dementia and decreased strength would not allow her to remove the belted lap tray . During an interview with Licensed Practical Nurse (LPN) #1 on 5/16/17 at 3:33 PM, at C hall nurses station, LPN #1 was asked about the belted lap tray and what was the purpose for its use. LPN #1 stated, .the belted lap tray on Resident #49's wheelchair was used for positioning. LPN #1 also stated, . (she) had suggested to the Interdisciplinary Team (IDT) that a geri (geriatric)-chair for the resident be tried, but it had not been attempted and (she) had not seen the resident try and remove the tray in 3 or 4 months . During an Interview with LPN #3 (MDS Nurse) on 5/16/17 at 5:00 PM, in the MDS office, LPN #3 was asked about the belted lap tray. LPN #3 stated, .(I) thought the belted lap tray was a restraint . During an Interview with the Therapy Coordinator, on 5/17/17 at 8:39 AM, in the therapy room, the Therapy Coordinator was asked about the lap tray. The Therapy Coordinator stated, .(Resident #49) used the chair for several years .recently attempted a scoop chair but it was unsuccessful for the resident, due to her leaning forward . The Therapy Coordinator stated, .utilizing the tray without the clasped belt had never been tried .(named Resident #49) had a decline in her mobility and cognition .she could no longer stand or ambulate on her own . During an Interview with the Director of Nursing (DON) on 5/17/17 at 3:38 PM, in the DON's office, the DON was asked what medical symptom required the lap tray. The DON stated, .I guess the medical symptom would be Alzheimer's . The DON agreed the documentation regarding the lap tray, for Resident #49, did not reflect this. The DON stated, . the restraint consent form should be filled out completely. After reading the facility's policy on restraints, the DON stated, .the term locking device left some questions, I am unsure if the belt clasp was technically a lock .(Named Resident #49) was unable to remove the lap tray and that was in contradiction to their policy. The DON stated, .did not think a restraint should be coded on the resident's MDS because they were using the lap tray as an enabler. When asked what the belted lap tray enabled the resident to do, the DON stated, sit upright . When asked if the resident did in fact sit upright with the lap tray, the DON stated, She does not, but it keeps her from leaning all the way forward . The DON confirmed, they had not attempted to use the lap tray without the belt or to utilize a geri-chair.

Based on policy review, medical record review, observation and interview, the facility failed to promote dignity and respect for residents by labeling a gerichair with a residents name for 1 of 32 (Resident #7) sampled residents included in the stage 2 review. The findings included: Review of the facility's Resident Rights Protocol for All Nursing Procedures policy revealed, .To provide general guidelines for resident rights .Resident dignity and respect . The medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Observations in Resident #7's room on 5/15/17 at 10:35 AM, and 5/17/17 at 9:09 AM revealed Resident #7's gerichair was labeled with his name, written in ink on top of chair. Interview with the Director of Nursing (DON) on 5/17/17 at 9:09 AM, in Resident #7's room, the DON was asked if it is acceptable for resident's name to be on a gerichair for anyone to see and if this would be a dignity issue. The DON stated, .his name should not be on his chair .

Based on medical record review and interview the facility failed to develop a comprehensive care plan for pressure ulcers for 1 of 12 (Resident #42 ) sampled residents reviewed of the 32 residents included in the Stage 2 review. The findings included: Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/21/17 documented, Risk for alteration in skin integrity .treat dry skin with a moisturizer as needed . No wounds or wound treatments were care planned. The Skin Care notes dated 3/13/17, 3/21/17 and 3/28/17 documented a wound to the coccyx area. Review of a physician telephone order dated 3/7/17 documented, Cleanse wd (wound) to coccyx c (with) ns (normal saline) apply Santyl skin oint (ointment) to necrotic tissue et (and) cover c moist saline gauze et borderfoam daily til necrotic tissue resolved. The Treatment Administration Record (TAR) for March 2017 documented treatments were performed as ordered to a coccyx wound. Interview with the Regional RAI (Resident Assessment Instrument) Director, on 5/17/17 at 10:17 AM, in the Care Plan office, the Regional RAI Director was asked if the pressure ulcer and treatments should have been care planned. The Regional RAI Director stated, There should be a care plan in place and no, I do not see one.

Based on policy review, medical record review, observation and interview, the facility failed to revise the resident care plan for pressure ulcers and medications for 3 of 12 (Resident #39, 132, and 143) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: 1. The facility's Care Plans - Comprehensive policy documented, .5. Care plans are revised as changes in the resident's condition dictate 2. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #39 received antidepressants for 7 days during the 7 day look back period. Resident #39 did not have a care plan related to administration of antidepressant medication. During an interview with the Resident Assessment Instrument (RAI) Director on 5/17/17 at 3:05 PM, in the MDS office, the Regional RAI Director was asked if the resident should have a care plan related to antidepressant medications. The RAI Director stated, I do not see one . 3. Medical record review revealed Resident #132 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Evaluation Data Sheet dated 4/7/17 revealed Resident #132 returned to the facility with a Stage 2 red open area to coccyx. Review of the 14 day Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #132 was admitted with Pressure Ulcer of Stage 1 or greater, an unhealed pressure ulcer, and 1 Stage 2 Pressure Ulcer with granulation tissue on admission. The Wound History Screen Report dated 04/11/2017 documented, Location Name .Sacrum/Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted (with) .Length/Width/Depth .3.8/2.7/0.2 cm (centimeters) .Thickness/Stage .II (2) .Type of Wound .Pressure .General Comments and Observations .The report revealed resident was a hospital return with the wound noted to site. Review of the care plan dated 7/29/16 with revision on 7/29/16 documented, resident has a reddened area to the buttocks .resident has an area to her left interior aspect of heel . The Wound History Screen Report dated 4/17/17 documented, Location Name Sacrum / Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted .Length/Width/Depth .2.0/4.3/0.10 cm .Thickness/Stage .II (2) .Type of Wound .Pressure .General Comments and Observations .Treatment continues to wound as ordered . The Wound History Screen Report dated 4/24/17 documented, Location Name .Sacrum/Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted (with) .Length/Width/Depth .3.8/2.7/03 cm .Thickness/Stage .II (2) .Type of Wound: Pressure .General Comments and Observations .Wound site has mild amount of Slough to wound bed with treatment changed to adjust to wound needs . The Wound History Screen Report dated 5/1/17 documented, Location Name .Sacrum/Coccyx .This wound is .Open .Date First Observed .04/07/2017 .Acquired: admitted .Length/Width/Depth: 3.8/2.7/UTD (unable to determine) cm .Thickness/Stage .III (3) .Type of Wound .Pressure .General Comments and Observations .Use of Santyl effective in removing slough tissue . The facility's wound report documented, .Wound Type: Pressure Report dated 5/14/17 documented Resident #132 had a .Stage III (3) .admitted with on 4/7/17 to her Sacrum/Coccyx .Type .Pressure .Length 4.2 x Width 2.5 x UTD . Observations on 5/17/17 at 11:11 AM, in Resident #132's room revealed, Certified Nursing Assistant (CNA) #5, Treatment Nurse #1, and CNA #6 knocked and entered Resident #132's room, asked for permission to remove dressing to coccyx and sacrum area and assess the wound. CNA #5, #6 and Treatment Nurse #1 entered the bathroom washed their hands and donned gloves. The head of the bed was lowered and Resident #132 turned towards the window on her right side exposing a dressing to Resident #132's Sacrum and Coccyx. The dressing was taken off exposing a wound to the Sacrum/Coccyx appearing to be a Stage III (3) with a moderate amount of serous drainage noted with a slightly yellow wound bed and pink approximated edges with no odor detected. During an interview with the Regional RAI (Resident Assessment Instrument) on 5/17/17 at 10:35 AM, in the MDS/Care Plan Office, the Regional RAI was asked should the care plan for Resident #132 have been updated upon her return hospital return to facility on 4/7 /17 to reflect the Stage 2 Pressure Ulcer that was hospital acquired. The Regional RAI stated, Yes it should have. The Regional RAI was then asked should the care plan have been updated when the pressure ulcer worsened to a Stage III (3) on 5/1/17. The Regional RAI stated, Yes they should have updated it. The care plan was not revised to reflect the Stage II Pressure Ulcer that Resident #132 was admitted with or the worsening of the same to a Stage III Pressure Ulcer. 4. Medical record revealed Resident #143 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The wound history screen report dated 2/21/17 documented, .Location .Left medial knee .Wound .Open .First Observed .2/16/17 .L 2.0x W x 1.0 x D 0.1 cm .Wound .Pressure .Stage II . The Wound History Screen report dated 5/12/17 documented Resident 143 had a stage unstageable to her Left medial knee The facility failed to revise the care plan to reflect the pressure ulcer status change from a stage II to unstageable. The wound history screen report dated 2/21/17 documented, .Location . Right medial knee .Wound .Open .First Observed 2/20/17 .L) 2.0 x (W) 1.0 x (D) 0.1 (cm) .Wound .Pressure .Stage II . The Wound History Screen report dated 5/16/17 documented Resident #143 had a stage unstageable to her Right medial knee. The facility failed to revise the care plan to reflect the pressure ulcer status change from a stage II to unstageable. The wound history screen report dated 3/20/17 documented, .Location .Rt proximal hip .Wound .Open .First Observed 3/16/17 .L 2.0 x W 1.8 x D 0.3 cm .Wound .Pressure . The wound history screen report dated 4/11/17 documented, .Location .Left hip .Wound .Open .First Observed 3/30/17 .L 1.0 x W 1.7 x D UTD cm . Wound .Pressure. The wound history screen report dated 12/15/16 documented, .Location .Sacral .Wound .Open .First Observed 12/14/17 .L 3.5 x W x 1.5 x 0.1 cm .Wound .Pressure .Stage III . The Wound History Screen report dated 5/16/17 documented Resident #143 had a stage IV (4). The facility failed to revise the care plan to reflect the pressure ulcer status change from a stage III to stage IV. The care plan dated 12/15/16 for Resident #143 revealed the care plan did not reflect Resident # 143 additional pressure ulcers to Left medial knee, Right medial knee, Right proximal hip and Left hip. During an interview with the Treatment Nurse #1 on 5/17/17 at 2:32 PM, at the nurses' station A/B, the Treatment Nurse was asked if she was responsible for revising the care plan for pressure ulcers. The Treatment Nurse stated, Yes. The Treatment Nurse was asked if the care plan should be revised to address all of Resident #143's pressure ulcers and should it be updated to reflect the current stage of the pressure ulcers. The Treatment Nurse stated, Yes.