Every finding on record at Presbyterian Home Of South Carolina-Columbia

Based on review of facility policy, observation, and interview, the facility failed to ensure proper storage of food items in 1 of 1 main kitchens. Findings include: Review of the facility policy titled Food Storage (Dry, Refrigerated, and Frozen) dated 2020, documented, 1a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded . c. Discard food that has passed the expiration date . During an observation on 06/03/25 at approximately 10:09 AM, of the main kitchen, with Certified Dietary Manager (CDM), the following was observed in the freezer: An opened bag of lobster was wrapped in cellophane and unlabeled, and an opened bag of gluten multigrain sandwich bread was labeled and dated 11/17/24. During an interview on 06/03/25 at approximately 10:09 AM, the CDM revealed that the Executive Chef oversees ensuring all food that is received in the kitchen is stored, labeled and discarded. The CDM further stated it is the duty of all staff to make sure all food items are rotated, labeled and discarded. During an interview on 06/03/25 at approximately 10:48 AM, the Executive Chef revealed that it is facility policy that all opened food items must be labeled with both an open date and an end (discard) date. He further stated that labeling and rotation are checked daily, and any expired or unlabeled items must be discarded immediately. During an interview on 06/03/25 at approximately 10:51 AM, the Lead [NAME] explained that she supports the Executive Chef in ensuring all food items are properly labeled, stored, and discarded in accordance with facility policy. She emphasized that all expired food items must be discarded immediately, with no exceptions. During a follow-up interview on 06/05/25 at 8:22 AM, the CDM confirmed the facility policy requires all food to be labeled with receive, open, and discard dates, and that expired/unlabeled items must be discarded immediately.

Based on review of facility policy, observation and interview, the facility failed to ensure expired biological's and medications were removed from storage and not stored with other medications and biological in use, for 1 of 1 treatment cart and in 1 of 2 medication carts. Findings include: Review of the facility policy titled Storage of Medications states, It is the policy of this facility to store all drugs and biological's in a safe, secure, and orderly manner. The Policy Interpretation and Implementation states, 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed. During an observation on [DATE] at 8:45 AM, revealed 3 packets of Lubricating Jelly, manufactured by [NAME] with Lot #CLTBB05-01, was expired on [DATE]. Licensed Practical Nurse (LPN)1 confirmed the expiration date and removed the packets of Lubricating Jelly from the treatment cart. During an observation on [DATE] at 8:25 AM, of Medication Cart 1 revealed a bottle of Prostat AWC, the bottle with Lot #2400690 was expired on [DATE]. Additionally, the bottle was stuck to the bottom of the storage bin and difficult to pick up due to dried spillage in the bottom of the drawer and on the sides of the bottle. The expired medication was confirmed by Registered Nurse (RN)1 and removed from storage in the medication cart and discarded in the trash bin.

Based on review of the facility policy, manufacturer's recommendation, observation, and interview, the facility failed to ensure Resident (R)68 was free from a significant medication error. Specifically, Registered Nurse (RN)2 failed to correctly prime an insulin kwik pen prior to administering the insulin, for 1 of 1 residents observed receiving insulin via an insulin pen. Findings include: Review of the facility policy titled Insulin Pen implemented on 04/15/25, states as the policy, It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Policy Explanation and Compliance Guidelines: . 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir . 11. Procedure: g. Attach pen needle: i. Remove the pen cap from the insulin pen. ii. Wipe the rubber seal with an alcohol pad. iii. Screw the pen needle onto the insulin pen. iv. Twist open and remove outer cover from the pen needle. h. Prime the insulin pen: i. Dial 2 units (or other amount if indicated depending on medication) by turning the dose selector clockwise. ii. Push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Review of the manufacturer's recommendations for administering Insulin using an Insulin Pen revealed, How to Use . 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or a cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it onto the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the dose window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least one drop of insulin appears. This will prime the needle and remove any air from the needle. Repeat this step if needed until a drop appears. 12. Dial the number of units ordered. During an observation on 06/04/25 at 12:02 PM, of insulin administration went as follows: R68 required 2 units of insulin related to a blood glucose level of 218, RN2 retrieved the insulin pen from the medication cart and wiped off the hub. She then applied a covered needle. Then holding the insulin pen horizontal she dialed up the 2 units for priming the pen, leaving the cover on the needle, she pushed the injection button. RN2 did not indicate that she saw the insulin escape the needle as the cap was still over the needle. She then dialed up the 2 units for the blood glucose level of 218 and proceeded to R68's room to administer the insulin. During an interview on 06/04/25 at 12:15 PM, RN2 confirmed that she had held the insulin pen horizontal and stated that was how she was taught in nursing school to prime the insulin pens. She indicated that she was not in-serviced by the facility or checked off at time of hire on priming insulin pens.

Based on review of the Resident Assessment Instrument (RAI) manual, report review, and interviews, the facility failed to ensure an Omnibus Budget Reconciliation Act (OBRA) assessment was transmitted timely for 3 of 5 residents (Resident (R)267, R268 and R269). Findings Include: Review of the RAI 3.0 manual section 5.2, dated 10/19, revealed Timeliness Criteria indicated .Transmitting Data: Submission files are transmitted to the Quality Improvement and Enhancement System (QIES) Assessment Submission and Processing (ASAP) system using the CMS wide area network. Providers must transmit all sections of the MDS 3.0 .Transmission requirements apply to all MDS 3.0 records used to meet both federal . requirements . Assessment Transmission .All other MDS assessments must be submitted within 14 days of the MDS Completion Date . Review of an MDS 3.0 NH Final Validation Report revealed that Minimum Data Set (MDS) submissions for R267, R268 and R269 were submitted more than 14 days after the completion date. During an interview on 05/09/24 at 12:22 PM with the MDS coordinator, she stated that she was responsible for transmitting the MDS and takes responsibility for not submitting the data in a timely manner. During an interview on 05/09/24 at 12:57 PM with the Director of Nursing (DON), she stated that it is her expectations that the MDS coordinator follow regulatory guidelines concerning submission of MDS data.

Based on interview, record review, and facility policy the facility failed to provide an appropriate clinical rationale for indication of use for Resident (R)5's antipsychotic medication. 1 of 5 reviewed for antipsychotic medications. Findings include: Review of the facility's policy titled, Facility Pharmacy Services and Procedures Manual Psychotic Medication Use last revised 10/24/22, revealed Psychotropic drugs include but are not limited to anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental process and behavior. Procedures include: psychotropic medication is prescribed for a diagnosed condition and noted being used for convenience or discipline. Facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications. Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for efficacy; risks; benefits; and harm or adverse consequences. Antipsychotic medications used to treat behaviors or psychological conditions of dementia must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. R5 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's Disease, major depressive disorder (recurrent) with psychotic symptoms, and dementia with behaviors. According to the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R5 had no behaviors during the assessment period and receives antipsychotic medications on a routine basis. Review of the Manufacturer Warning for the medication, Risperidone, revealed Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERDAL(R) is not approved for use in patients with dementia-related psychosis. Record review on 05/08/24 at 01:26 PM of R5's Medication Administration Record (MAR) for March 2024 revealed Risperidone 0.5 MG (milligrams) for dementia with behavioral disturbance with an order dated of 03/28/24 was administered as ordered 03/29/24-03/31/24. Record review on 05/08/24 at 01:34 PM of R5's MAR for March 2024 revealed Risperidone oral tablet 0.5 MG for dementia with an order date of 03/21/24 and discharge date of [DATE] was administered 03/22/24-03/28/24. Record review on 05/08/24 at 01:41 PM of R5's MAR for March 2024 revealed Risperidone Oral Tablet 0.5 MG for dementia - give one tablet by mouth in the evening for dementia with an order date of 03/21/24 and discharge date of [DATE] revealed the medication was administered 03/22/24 - 03/27/24. Record review on 05/08/24 at 01:45 PM of R5's MAR for March 2024 revealed Risperidone 0.5 MG with an order date of 03/28/24. The medication was administered 03/28/24 - 03/31/24. Record review on 05/08/24 at 01:49 PM of R5's MAR for March 2024 revealed R5 had no behaviors when assessed from 03/21/24 - 03/31/24. Record review on 05/08/24 at 01:55 PM of R5's April MAR revealed an order for Risperidone 0.5 MG with a start date of 03/28/24 for dementia with behavioral disturbances. R5 received this medication each day in April (04/01/24 - 04/30/24.) R5 also had an order to receive Risperidone 0.5 mg at bedtime. The April MAR revealed it was received each day in the month of April. Record review on 05/08/24 at 02:01 PM of R5's May 2024 MAR revealed an order for Risperidone 0.5 MG, give one tablet by mouth one time a day for dementia with behavioral disturbance with a start date of 03/28/24. R5 received this medication 05/01/24 - 05/08/24. Record review on 05/08/24 at 02:05 PM of R5's May 2024 MAR revealed an order for Risperidone 0.5 MG, give at bedtime with a start date of 03/28/24. R5 received this medication 05/01/24 - 05/07/24. Review on 05/09/24 at 09:34 AM of a Consultation Pharmacy Report dated 03/22/24 revealed R5's medical record listed a potentially inappropriate supporting diagnosis or indication for the following: Risperdal (2 orders) please change diagnosis to F02.818 Dementia in other disease classified elsewhere, unspecified severity with other behavioral disturbance. Recommendation: please clarify the appropriate supporting diagnosis and document accordingly. Director of Nursing Comments: none A phone interview on 05/09/24 at 9:50 AM with the Physician Assistant (PA) revealed that the resident was prescribed Risperdal while in a memory care unit prior to being admitted to this facility related to her major depressive disorder, that is recurrent with psychotic features. During the resident's most recent hospital stay, she was having psychotic features, and they increased her dosage. When the resident was admitted to the facility, her psychiatric hospital discharge summary included an order for Risperidone 0.5 MG taken daily by mouth. The PA further stated that when the Pharmacist reviewed the resident's medication on 03/22/24, they flagged the order for Risperdal due to having an inappropriate diagnosis of dementia with behavioral disturbances, which should have been updated to major depressive disorder with psychotic symptoms. Due to the resident being admitted with this medication and being on this medication since December (when they started to review resident medications), the resident is not due to for a gradual dose reduction (GDR) at this time. A phone interview on 05/09/24 at 12:37 PM with the Consultant Pharmacist revealed that they flagged the resident medication because there was no diagnosis attached to this medication, which is why they added dementia with behaviors as diagnosis because that was on the resident's face sheet and hospital summary. The Consultant Pharmacist further stated that they were unaware that dementia with behaviors is not an appropriate diagnosis for this medication. Further interview revealed that the Consultant Pharmacist did not have a clinical rationale for the resident being on this medication.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure all training of employees was completed after an allegation of staff to resident abuse was reported and investigated. Resident (R)5 alleged that Certified Nursing Assistant (CNA)3 had physically abused him/her. The facility investigated the allegation, contacted law enforcement, and provided mandatory training to staff related to the abuse allegation. Review of facility training records revealed CNA3 had not attended the training and had worked at least 21 shifts without having attended the mandatory in-service training on abuse. Findings include: Review of the facility's policy Abuse Prevention Program, with revision date 11/28/17 revealed, Preface - It is the policy of the community to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property from all residents, staff, families, visitors and volunteers. When the incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident. All staff must cooperate during the investigation to assure the resident is fully protected. The community must develop and implement written policies and procedures that include training as required. Update training for orientation, annual, agency staff, as needed. Review of R5's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included unspecified Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis of Right Dominant Side and Adjustment Disorder with Mixed Disturbance of Emotions Conduct. Review of Physician Order's last updated 1/24/23 revealed the resident did not have medications and/or behavioral therapy ordered to address the diagnosis of mixed disturbance of emotions. R5's annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's cognitive status was intact with a Brief Interview for Mental Status (BIMS) score of 14. The resident exhibited physical behaviors directed toward others one (1) to three (3) days of the assessment period which put the resident at risk for physical illness or injury, significantly interfered with resident's care, put others at risk for significant risk of physical injury and intruded on the privacy of others. The assessment also documented the resident exhibited wandering behaviors daily which intruded on the privacy of others. The Care Area Assessment (CAA) for behavioral symptoms indicated the resident made poor decisions based on interactions with other residents and staff. The resident wandered, would strike out at others, occasionally refused care from staff, and had placed self in unsafe areas unassisted. Review of R5's Care Plan with revision date 1/31/23 revealed the resident had the potential to be physically aggressive related to a history of striking others and exhibited poor impulse control. The goal of the Care Plan was for the resident to demonstrate effective coping skills and the resident would not harm self or others through the next review date. Interventions listed on the Care Plan included the resident's triggers for physical aggression were unusually unpleasant remarks from other residents and/or occasionally staff or reason(s) was unknown. The resident's behaviors are de-escalated by redirection by staff. Analyzed times of day, places, circumstances, triggers and what de-escalated behavior and document. Provide physical and verbal cues to alleviate anxiety and give positive feed-back. Monitor daily and document observed behavior and attempted interventions on behavior log. Monitor and document any signs or symptoms of the resident when he/she posed a danger to self or others. When the resident became agitated, staff were to intervene before the agitation escalated. Guided the resident away from the source of distress and engaged calmly in conversation. If the resident's response was aggressive, staff were to walk calmly away and re-approach later. Review of a Health Progress Note dated 2/6/23 at 8:22 PM documented the resident made an allegation of abuse. The administrator was notified. An interview with CNA3 on 4/18/23 at 9:50 a.m. revealed he/she was assigned to provide care to R5 on 2/6/23 on the second shift. The CNA said he/she was getting the resident ready for bed and the resident spat on the gown that had been placed beside the resident. He/she said the resident just kept spitting on the gown and toward the CNA, so he/she put on the brief, pulled the blanket over the resident and went to get the nurse. He/she said a hospital type gown was left at the bottom of the bed and the resident was told someone would be back to put the gown on him/her. The CNA said when he/she reported to the Licensed Practical Nurse (LPN) the LPN immediately went into the resident's room, and Resident # 5 reported that he/she had been beaten up by the CNA. CNA3 said he/she did not hit the resident and had never been accused of abuse before. He/she said the facility put him/her on suspension during the investigation. The CNA stated he/she had abuse training in the past, at least once a year, but had not received any recent training from the facility. A telephone interview on 4/19/23 at 7:20 p.m. with LPN5 revealed he/she was working on second shift on 2/6/23 and was assigned to provide care to R5. He/she said CNA3 came out of R5's room and informed him/her that the resident was spitting all over the place and the CNA could not get a night gown on the resident. The LPN said when he/she entered the resident's room the resident was attempting to put on hospital gown, and that he/she assisted the resident with putting on the gown. The LPN said the resident immediately said the staff that had just left the room had beaten him/her up all over. He/she said the resident was asked to describe how he/she was beaten up and the resident kept saying that he/she was beaten all over. The LPN said he/she examined the resident and there was no redness or discoloration of the resident's skin, and the resident did not appear to be upset. The LPN said he/she left the resident's room and immediately called the administrator and informed him/her of the allegation of abuse. CNA3 sat at the nurse's station until the administrator came to begin the investigation. Review of the facility's investigation dated 2/11/23 revealed there was no evidence CNA3 had physically abused R5 on 2/6/23. Assessment of the resident revealed no evidence of physical abuse and interviews with staff indicated no suspected abuse occurred. Review of the Education In-service training provided to staff on 2/9/23 revealed 44 staff had attended the training on Dementia which included preventing and responding to abuse, however, CNA3's name was not on the list of staff that had attended the training. An interview with the Administrator on 4/19/23 at 1:20 p.m. revealed the facility's investigation did not substantiate R5 had been physically abused by CNA3. He/she stated R5 did not want to be in the facility and had been discharged . He/she said during the investigation the resident indicated he/she wanted the police called and the police came out and took a report from the resident. The Administrator said that anytime there is an allegation of abuse in the facility, it is facility policy that there was a facility wide training for reeducation on the facility's abuse policies and procedures and that it was mandatory for all staff to attend. He/she said CNA3 should have attended the mandatory training on abuse, but there was no evidence the CNA had received the training. The Administrator said it was the former Director of Nursing's (DON's) responsibility to ensure all staff had attended mandatory training on the facility's abuse policy after allegation of abuse occurred on 2/6/23. Review of the PRN (as needed) schedule for CNA3 provided by the Administrator revealed CNA3 worked providing direct care to residents six (6) shifts in February 2023, 13 shifts March 2023, two (2) shifts April 2023. The CNA worked providing direct resident care for at least 21 shifts without attending the facility's mandatory training on Dementia which included preventing and responding to abuse.

Based on review of the facility policy, interview and record review, the facility failed to report the resident - resident altercation between Residents (R)2 and 3 in a timely manner. The alleged altercation occurred on 09/09/22 at approximately 10:42 PM but was not reported until 10/07/22. Findings include: Review of facility abuse policy revealed that If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. R2 was admitted to the facility on [DATE] with diagnoses including - but not limited to - heart disease, chronic obstructive pulmonary disease, vascular dementia with behavioral disturbances, and anxiety. R3 was admitted to the facility on [DATE] with diagnoses including - but not limited to - dementia, anxiety, restlessness and agitation, and repeated falls. Review of facility reportable for the 09/09/22 incident between R2 and R3 revealed the 24-hour report was submitted to on 10/07/22 and the 5-day report was submitted on 10/12/22. Interview with Administrator on 12/07/22 revealed the previous Director of Nursing (DON) was fired due to the delayed reporting of this resident - resident incident.

Based on review of the facility policy, record review, and interviews, the facility failed to thoroughly investigate two resident - resident altercations. On 09/09/22, Residents (R)2 and R3 had an altercation that was not thoroughly investigated. Similarly, on 10/21/22, R4 and R5 were involved in an altercation that was not thoroughly investigated. For both incidents, there were no witness statements taken, and interview attempts with the residents involved were not documented. Findings include: Review of facility's undated policy titled, Abuse revealed, the investigation will include Residents' statements. If residents are unable to give statements, the facility will complete an evaluation of the resident's behavior, affect, and response to interaction and document findings. The investigation must also include involved staff and witness statements of events. R2 was admitted to the facility on [DATE] with diagnoses including,but not limited to; heart disease, chronic obstructive pulmonary disease (COPD), vascular dementia with behavioral disturbances, and anxiety. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia, anxiety, restlessness and agitation, and repeated falls. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, COPD, muscle wasting, and diabetes mellitus type 2. R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia, behavioral disturbances, psychotic disturbances, and anxiety. Review of an 09/09/22 Incident Report for R3 on 12/07/22 revealed that R3 was slapped by R2. The incident report was written by Licensed Practical Nurse (LPN)1. Review of an 09/09/22 progress note for R2 on 12/07/22 revealed a resident hit R3 in the face multiple times. The progress note was written by LPN2. Review of an 09/09/22 progress note for R3 on 12/07/22 revealed R3 had been slapped in the face by R2. Both residents were immediately separated. The progress note was written by LPN1. Review of an 09/09/22 Incident Report for R2 on 12/07/22 revealed R2 and another resident slapped each other in the face. The progress note was written by Registered Nurse (RN)1. Review of the facility investigation of the 09/09/22 incident between R2 and R3 on 12/07/22 revealed there were no witness statements attached to the facility investigation. Multiple unsuccessful attempts were made to reach LPN1, LPN2, and RN1 to clarify the details of the incident as written in their notes. Interview with Administrator on 12/07/22 at approximately 12:00 PM revealed a delayed reporting for the incident between R2 and R3. As a result of the delayed reporting, the previous Director of Nursing was terminated. The facility had no timely investigation, and no witness statements or documentation of interview attempts with the involved residents. Review of a 10/21/22 progress note for R4 on 12/07/22 revealed the resident had an outburst and began yelling at another resident. Review of the facility 5-day report of the 10/21/22 incident between R3 and R4 on 12/07/22 revealed a Certified Nursing Aide (CNA) reported a resident kicked another resident in the day room. Both R3 and R4 were attached to the reportable, but it was unclear who was the perpetrator, victim, and witness was. There were no witness statements taken, and there was no documentation of interview attempts with the residents involved. Interview with the Current Director of Nursing on 12/07/22 at approximately 11:21 AM revealed that there was no paper record of what the primary witness (identified as CNA1) observed. Interview attempt with CNA1 on 12/07/22 at approximately 11:27 PM revealed she did not witness the incident. She identified the primary witness as CNA2. Multiple unsuccessful attempts were made to reach CNA2 by phone.

Based on record review and interviews, the facility failed to address resident preferences in regards to bathing for two of three residents reviewed for Choices. Resident (R) 70 and R16 were not offered the opportunity to choose their bathing preferences or bathing schedules. The findings included: The facility admitted R70 on 1/24/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with R70, on 2/7/2022 at 2:54 PM, R70 was asked if she received a bath or a shower as often as she liked. R70 stated she preferred a shower but had not had one since admission. R70 stated she had been getting a sponge bath and no one had asked her if she would like a shower. During an interview with the Director of Nursing (DON), on 2/8/2022 at 1:48 PM, the DON stated prior to 2/8/2022 no one had asked the resident about her bathing preferences and a bathing schedule had not been set up for R70. The DON stated the resident's preferences had since been addressed and a shower schedule was created for the resident. The DON stated the nurse aides will give any resident a shower if they ask for one, but had no documentation the resident had received, or been offered a shower. The DON stated it's on me to ensure all residents have a shower schedule based on their preferences. During an interview with R70, on 2/10/2022 at 9:41 AM, R70 stated staff had addressed her bathing preferences with her and a shower schedule had been set up on 2/8/2022. R70 stated she still had not received a shower. R70 stated she was a retired nurse and had been giving herself a sponge bath daily since admission to the facility. R70 was asked if she received any assistance with this and she stated she was able to do so with out assistance. During an interview with the DON, on 2/10/2022 at 10:10 AM, the DON stated a bath or shower schedule is to be set up for all residents by the day of or day after admission to the facility. The DON stated this was not done for R70 and R16. The DON stated this is done by her or the Assistant Director of Nursing (ADON). The DON stated the facility did not currently have a ADON. The DON stated she has since confirmed all residents have a bathing schedule based on their preference. The DON stated there was no policy addressing resident bathing preference or bathing schedules. She stated she had added this to her admission checklist, though. Record review of the resident's care plan, on 2/7/2022 at 3:33 PM revealed the resident's bathing preference for a bath or shower, or frequency of such was not indicated on the care plan. The facility admitted R16 on 1/10/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with R16, on 2/7/2022 at 2:03 PM, R16 stated she had been in the facility for four weeks and had only received two showers. She stated she was not offered those showers but was given the showers when she asked for them. R16 stated she had not been asked about her bathing preferences. She also stated no one had talked to her about a shower schedule or how often she would like a shower. During an interview with the Director of Nursing (DON), on 2/8/2022 at 1:48 PM, the DON confirmed R16 did not have a shower schedule set up for her prior to 2/8/2022. The DON stated R16's preferences had been addressed and a shower schedule was created. In addition, the DON stated R16 would receive a shower today (See above DON interviews). During an interview with R16, on 2/10/2022, she stated she had received a shower since the last interview. She stated a staff person had come to talk with her about her bathing preferences on 2/8/2022, offered her a shower and set up a shower schedule for her. R16 recalled a week or so after admission to the facility she had asked one of the staff when she was going to get a shower. R16 stated the staff person told her they weren't sure when and would check the schedule. R16 stated no one ever followed up with her about this. R16 stated she had been washing herself up at the sink without staff assistance due to the lack of showers. Record review of the resident's care plan, on 2/9/2022 at 3:01 PM, revealed Shower with bed bath on alternate days scheduled as requested.

Based on observation, interviews, and review of facility policy the facility failed to remove expired items from active storage in 1 of 1 treatment carts. 19, expired, iodine swabs were observed in the treatment cart. The findings include: On [DATE] at 10:10 AM, observation of the treatment cart, on the Medicare certified unit, revealed 20, individually packaged, [NAME] Providone - Iodine USP Swab Sticks. 19 of the 20 Swab Sticks had an expiration date of [DATE]. During an interview with the Director of Nursing (DON), on [DATE] at 10:15 AM, the DON confirmed the 19 Swab Sticks were expired on [DATE]. The DON stated it was the responsibility of the nurses and pharmacist to ensure the treatment cart was free of expired items. The DON also stated the pharmacist had been in the facility yesterday checking storage areas for any expired items, but must not have checked the treatment cart. Review of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals revealed: 4. Facility should ensure that medications and biologicals that: (1) have an expired dated on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

Based on observation, staff interview, and the facility policies titled, Food Storage and Handling of Ice-Machine and Ice-Machine Scoops and Scoop Holders review, the facility failed to ensure food items were properly dated, labeled and stored. In addition, the facility also failed to maintain cookware properly cleaned, dried and stored, kitchen floor clean and free from grease, ice-machine free from buildup and scoops properly stored for one of one kitchen observed. Findings: During the initial observation of the kitchen on 10/13/20 at 10:43 AM and in the presence of the Certified Dietary Manager (CDM) the following was noticed: In a reach-in freezer- Observation showed (3) three large pies without expiration dates, with one pie being soft to the touch with its cover crushed into the pie. In the same reach-in freezer, a large chunk of meat wrapped in clear plastic wrap without a label or date, and small amount of cookie dough in a Ziploc bag without date or label. There were (2) two individual pies placed on the floor under one of the storage shelves of the walk-in freezer. In the area where clean dishware are stored, there were over 20 wet nesting pans, some greasy to the touch and some with food particles on them. The ice-machine door had brown buildup inside and two small ice-scoops were lying flat on the surface of a second smaller ice-maker. The floor behind and under both ice-machines had accumulation of old trash and brown substance buildup. The overall appearance and cleanliness of the kitchen was unsatisfactory; the floor, throughout the entire kitchen, was noted to be wet in both the morning and afternoon visits to the kitchen for the 3 days of the survey, in some areas the floor was slippery due excessive grease, food debris on the floor as well, dried pasta spread on the counter top of the prep area and the aprons worn by several of the kitchen staff, including the cook, appeared extremely soiled. In an interview with the CDM on 10/15/20 at approximately 11:15 AM (s/he) acknowledged the above findings. Review of the facility policy titled Food Storage states all products are labeled and dated with receiving date. Shelving should be no closer than 6 inches to the floor to permit cleaning underneath. Keep storage areas neat and remove safety hazards such as empty boxes and spilled liquids. Review of the facility policy tittle Handling of Ice Machine and Ice Machine Scoops and Scoops Holders stated the interior of ice dispensers shall be cleaned and preventive maintenance will be performed and documented on a monthly basis. The ice machine scoop is stored outside of the ice machine in a scoop holder with a lid. The scoop holder must be designed to drain properly or modified as needed.

Based on observation, record review and staff interview, the facility failed to ensure Resident #8 received respiratory care consistent with professional standards of practice, the comprehensive care person-centered care plan and physician's orders [REDACTED]. Findings: The facility admitted Resident #8 on 6/30/20 with [DIAGNOSES REDACTED]. During an observation on 10/13/20 at 4:04 PM, Resident #8 was observed in (his/her) wheelchair in (his/her) room. (His/her) oxygen concentrator was set at 3.5 liter per minutes. The oxygen concentrator bottle was empty and dated 10/4/20. The oxygen concentrator tubing was also dated 10/4/20. physician's orders [REDACTED]. Change oxygen tubing, water bottle and clean filter weekly. Care plan reviewed on 10/15/20 at approximately 8:45 AM indicated that Resident #8 has oxygen therapy related to ineffective gas exchange. Oxygen set at 2 liter per minutes. During a second observation on 10/15/20 at 9:19 AM, Resident #8's oxygen remained set incorrectly with his/her tubing also dated 10/4/20. In an interview with Licensed Practical Nurse (LPN) #1, (s/he) confirmed the Doctor's order for Oxygen at 2 liters per minute, water bottle and tubing to be changed weekly. S/he also confirmed that Resident #8's oxygen was set at 3.5 liters per minute, the water bottle was empty and that both the water bottle and the oxygen tubing were dated 10/4/20.

Based on record review, interview, and review of facility policy, the facility failed to ensure resident rights were respected related to choices for 1 of 3 residents reviewed for alleged abuse (Resident #1). The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility submitted a 2 hour report to the Bureau of Certification on 11/1/2019 at 7:45 AM alleging a Certified Nursing Assistant (CNA) had physically abused Resident #1. The description of the incident on the 2 hour report included CNA was seen lifting the resident out of bed by her arms. Investigation to follow. Review of the witness statements revealed the resident was refusing to get out of bed when CNA #1 entered the room and assisted the resident up by the arms after the resident refused to get out of bed for another staff member. Review of Resident #1's care plan dated 10/17/2019 showed a focus area of resistance to care. Interventions in place were to allow the resident the opportunity to choose times of care and to participate in decision making of care. Review of the Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 4, which indicated the resident was cognitively impaired. During an interview with the Director of Nursing on 12/23/2019, s/he confirmed it was the facility's policy to allow a resident to refuse care and that the CNA should have walked away, rather than insist the resident get out of bed, although it was believed to be for a good cause. Review of the facility's policy on 12/23/2019 at 1:15 PM showed a policy titled, Resident Bill of Rights, which stated, As a resident of this facility, YOU have or your legal guardian has, the right to participate in any changes to your care and treatment .

Based on observation, record review, and interview, the facility failed to ensure that all components of the call light system were operational on 1 of 1 certified unit observed. The findings included: Observation of the call light in room [ROOM NUMBER] on 5/7/18 at approximately 11:15 AM revealed the light did not illuminate in the hallway when the call light at the bedside was activated. The call light also did not illuminate in the hallway when the call light in the bathroom was activated. The call system did not activate an audible system at the Nurses Station. During an interview, Resident #58 in room [ROOM NUMBER] stated that it took a long time for staff to answer the call light. In addition, he/she stated that he/she asked staff to check the call light the previous week and stated that he/she was informed the call light had been fixed. However, he/she stated that he/she did not think that the call light worked. On 5/7/18 at approximately 11:25 AM, the surveyor asked Certified Nurses Aide (CNA) #1 to help check the resident's call light. At that time, CNA #1 verified that the light did not illuminate in the hallway when the call light was activated. CNA #1 stated that the CNAs carried pagers that buzzed when the residents pushed the call light. When the surveyor asked to see his/her pager, CNA #1 stated that he/she did not have a pager. CNA #1 stated that there was not one available this morning. At that time, CNA #1` proceeded to the Nurses Station and retrieved a pager from a bin on the desktop. CNA #1 stated that he/she would report the malfunctioning call light to the Maintenance Director. On 5/7/18 at approximately 11:30 AM, CNA #2 entered the room next door to room [ROOM NUMBER] while the surveyor was checking the call light in that room. When the surveyor asked CNA #2 if he/she had a pager, CNA #2 stated that he/she did not know anything about the pagers and stated that he/she usually did not work on that unit. On 5/7/18 at approximately 12:00 PM, the surveyor informed the Administrator that the call light in room [ROOM NUMBER] did not illuminate in the hallway. The surveyor requested the Maintenance Log at that time. Review of the Maintenance Log revealed that the call light bulb was replaced on 5/1/18. On 5/8/18 at approximately 2:00 PM, CNA #3 helped the surveyor check the call light in room [ROOM NUMBER]. The light illuminated in the hallway at that time. When the surveyor asked CNA #3 if he/she had a pager in his/her pocket, CNA #3 stated, No. When asked why he/she did not have a pager, CNA #3 stated that he/she thought they were lost. The Maintenance Director informed the surveyor that work had been done on wiring for the call light in room [ROOM NUMBER]. The surveyor requested a schedule indicating when resident call lights were checked. On 5/8/18 at approximately 4:15 PM, the Administrator provided a schedule entitled HealthCare log Sheet - QUARTERLY which was used to document when call lights were checked. Review of the log revealed call lights were checked at random on a quarterly basis. Further review of the log indicated that 1 room out of the certified rooms 115-128 was randomly checked every 3 months. The Log indicated that since 11/1/17, only 3 call lights in rooms 115-128 rooms had been checked. No further documentation was provided to indicate that the call lights were checked in all resident rooms during that timeframe. On 5/9/18 at approximately 9:00 AM, the Maintenance Director verified this information.

Based on observation, record review and interview the facility failed to ensure accuracy of Minimum Data Set assessment for Resident #1 with regard to Limited Range of Motion x 4 assessments for 1 of 1 resident reviewed for Range of Motion. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Multiple observations through the days of the survey noted Resident #1's left hand in a fixed fisted position. During an interview with the MDS Coordinator, on 05/08/18 at 1:30 p.m., s/he indicated the resident does have a contracture and this information is recorded on the census and condition and the resident's care plan. However, the MDS coordinator noted the contracture was not coded on the assessments, in section, G. 0400, dated 05/15/17, 08/15/17, 11/15/17 and 02/08/18. On 11/11/16 the order to wear a Left static, wrist, hand, digit orthotic splint daily was enacted and was recently discontinued on 05/01/18.

Based on review of facility records, the facility failed to show evidence of complete staff postings to include hours worked and number of staff per shift, for 3 of 3 months reviewed. The findings included: Review of the provided postings for the dates of 02/08/18 through 05/08/18 revealed the facility had not documented hours worked for 87 of 90 days of Staffing Level postings reviewed. Further review revealed the number Certified Nursing Assistants and Licensed Practical Nurse and/or Registered Nurse was not documented per shift for 26 of 90 days of Staffing Level postings reviewed. This information was reviewed and confirmed as being incomplete by the facility's Administrator on 05/08/18.

Based on observation, interview, and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 2 kitchens reviewed and has the potential to affect 16 of 16 residents with ordered diets as evidenced by failing to do the following: Disposing of expired food items, cleaning pans and scoops. The findings included: On 3-6-17 at approximately 2:42 PM, an initial tour of the Main and Health Care kitchens with the Executive Chef revealed: Main kitchen area: 1.) (9) Full pans and (7) Half pans were stacked wet 2.) Scoops were lying in the flour and sugar bins with ingredients on the handles 3.) (13) 8 ounce Imperial Dairy Drink Nectar Consistency with a use by date of 1/19/17 4.) (32) 8 ounce Imperial Dairy Drink with a use by date of 2/17/17 Main kitchen walk-in refrigerator: 1.) (36) Green peppers in a bin on the storage rack were discolored and had a black and white fuzzy substance growing on them The Health Care kitchen: Dry Storage cabinet above counter: 1.) (1) 7 and ¼ ounce can of tomato soup low sodium with an expiration date 11/29/16 2.) (2) 7 and ¼ ounce cans of tomato soup low sodium with an expiration date 3/3/17 3.) (1) 7 and ¼ ounce can of mushroom soup with an expiration date of 12/8/16 Following the initial tour observations of the Main and Health Care kitchens the Executive Chef verified the above 8 findings. Review of the facility policy Food and Supply Storage, states under procedure bullet #1, Most products contain an expiration date. The words sell by, best -by, enjoy-by, or use-by, should proceed the date. The sell-by, date is the last date that the food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell by, best -by, or enjoy-by date should be discarded. Also, the policy Storage of Pots, Dishes, Flatware, Utensils states under bullet #1, Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 1 sampled resident reviewed for nutrition and 1 of 1 sampled resident reviewed for hospice. The facility failed to intervene when Resident #19 had no bowel movement for 5 days. The facility failed to monitor pain and coordinate care with hospice for Resident #27. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review of hospice social services notes revealed no evidence of documentation that hospice was invited to the facility care plan meeting for Resident #27. Social service notes revealed one entry dated 02/22/2017 that indicated the hospice staff did not attend that care plan meeting because the facility failed to notify hospice. During an interview on 03/08/2017 at 3:20 PM, Registered Nurse (RN) #1 verified that hospice did not attend Resident #27's care plan meeting. RN #1 stated that the facility does not require hospice to attend the care plan meetings or to review or sign the residents care plan. RN #1 verified that there was no evidence of documentation that hospice reviewed the residents care plan or that the facility reviewed the residents hospice care plan. Review of the resident's Medication Administration Record (MAR) revealed an order for [REDACTED]. with at protocol to Monitor pain and follow up in 60 minutes. Review of the MAR and clinical notes revealed that when the resident reported pain on the following dates: 1/3/17, 1/4/17, 1/6/17, 1/8/17, 1/12/117, 1/13/17, 1/14/17, 1/18/17, 1/22/17, 1/24/17, 1/26/17, 1/27/17, 1/30/17, 1/31/17, 2/3/17, 2/5/17, 2/6/17, 2/8/17, 2/11/17, 2/14/17, 2/15/17, 2/17/17, 2/20/17, 2/21/17, 2/24/17, 2/25/17, 3/2/17, 3/5/17, 3/6/17, and 3/7/17, there was no evidence of documentation for follow up in 60 minutes when the resident did and did not receive pain medication. During an interview on 03/08/2017 at 4:40 PM, LPN #2 stated that after s/he documents pain (numeric) on the MAR there is no additional place on the MAR for documentation of follow up in 60 minutes when pain medication is not administered and no place for documentation of non-pharmacological interventions. LPN #2 stated that s/he does not document pain follow up when pain medication is not administered or non-pharmacological interventions in the clinical notes. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 03/07/17 at 3:21 pm revealed that on 03/02/17 Resident #19 was given Milk of Magnesia (MOM) due to no bowel movements for 6 days. Further review of the bowel movement monitoring documentation revealed that Resident #19 did not have a bowel movement on 02/25-28/17 and 03/01/17, 5 consecutive days. Review of the Care Plan revealed that Resident #19 had an issue with the potential for constipation. The goal for Resident #19 was to have regular bowel movements (BM) at least every 3 days through next review. The interventions included: monitoring of bowel patterns and administration of medication or treatments for constipation. Review of the facility's Bowel/Constipation - Clinical Protocol revealed if no BM in last 3 days residents should be given 30 cc (cubic centimeters) of Milk of Magnesia along with additional measures as indicated. In an interview on 03/09/17 at 10:12 am the Director of Nursing (DON) stated that s/he runs a report each day to track resident bowel movements. The DON did not know why treatment was not provided prior to 03/02/17.

Based on observation, record review, and interview, the facility failed to administer medication resulting in significant medication errors for 1 of 2 residents reviewed for blood pressure (BP) medication administration. Resident #77 did not receive physician ordered BP medications. The findings included: The facility admitted Resident #77 with [DIAGNOSES REDACTED]. On 3/7/17 at approximately 9:45 AM, during observation of Resident #77's medication administration on Unit 2, Licensed Practical Nurse (LPN) #1 was observed to take the residents blood pressure (BP) which read 111/53. LPN #1 then administered Resident #77's medication without physician ordered Metroprolol 100 milligram (mg.) and [MEDICATION NAME] 40 mg. LPN #1 stated to Resident #77, Your blood pressure is low so you won't be receiving your heart medication. LPN then disposed of the [MEDICATION NAME] and Metroprolol into the medication cart disposal. LPN #1 then addressed the facility Nurse Practitioner in the hall regarding another medication Resident #77 requested. LPN #1 did not mention Resident #77's low BP or the withholding of their medication. LPN #1 then recorded in the Medication Administration Record [REDACTED]Below Normal Parameters. LPN #1 was asked where the physicians order states to hold the resident medication for a BP of 111/53. LPN #1 stated, It is facility policy and standard order protocol to not give residents medication for a systolic BP below 120. LPN #1 was then asked if s/he was going to contact the physician. LPN #1 stated, Maybe I need to. On 3/7/17 at approximately 10:15 AM, during an interview with the Director of Nursing (DON), Resident 77's physician's orders [REDACTED]. The DON was asked for the resident standard order protocol and the facility policy for the administration of BP medications. The DON stated that BP medication orders are resident specific and there was not a standard order protocol for Resident #77. The DON verified Resident #77 did not have an order to hold medication for a low BP and indicated the LPN should have contacted the physician regarding the holding of BP medications.

Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that medication was stored at proper temperatures in accordance with manufacture specifications in 1 of 1 medication storage room reviewed. Tuberculin Purified Protein Derivative, (Mantoux) (PPD) (Tubersol), insulin, and Flor-Lorazapam were stored at a temperature below manufacture specifications. The findings included: On 3/7/17 at 1:55 PM, an observation of the Unit 2 medication storage room refrigerator with Licensed Practical Nurse (LPN) #1 revealed an internal temperature thermometer that read 32 degrees of Fahrenheit and the contents of the refrigerator were: 1.) (1) Unopened Levemir Flex insulin pen, Lot #FZF0477 2.) (1) Unopened vial of Novolog mix 70/30, 100 unit, Lot # FZF0470 3.) (1) Unopened Novolog FlexPen, Lot # FZF0531 4.) (1) Unopened vial Humolog, 100 units, Lot #C 3A 5.) (1) Unopened vial Novolin R, 100 units, Lot #FZF0075 6.) (1) Unopened vial Novolin R, 100 unit, Lot #FZF0546 7.) (1) Vial Novolin R, 100 unit, Lot #FZF0219 8.) (2) Vials Tubersol PPD, 10 tests, Lot #C5035AA (1) unopened 9.) (31) Unopened doses of Flor-Lorazapam 2 mg./ml. Lot # 018 Following the observation LPN #1 verified the internal temperature thermometer of the refrigerator read 32 degrees of Fahrenheit and the contents of the refrigerator. On 3/7/17 at 2:00 PM, a review of the Refrigerator Temperature Log posted on the refrigerator door with LPN #1 revealed a recording of 33 degrees of Fahrenheit on March 6, 2017. Also, the log had instructions stating, Refrigerator must be kept between: 33-40 degrees. Following the observation of the log, LPN#1 verified the temperature recording of 33 degrees of Fahrenheit on March 6, 2017. LPN #1 then stated s/he did not know the correct temperature for the storage of medications PPD, insulin or Flor-Ativan. After review of the box manufacture instructions for Novolin R and Tubersol PPD with LPN #1, s/he indicated that the internal temperature of the refrigerator should be above 36 degrees of Fahrenheit. Review of the facility policy Storage of Medications state under number (9.) Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Refrigerator temperatures should reflect the manufacturer recommendations. Review of the manufacture recommendations for Novolin R insulin state under How should I store Novolin R?, Unopened Novolin R, Unopened Novolin R should be kept in the refrigerator between 36 to 46 degrees of Fahrenheit (2 to 8 degrees of Celsius). Review of the manufacture recommendations for Tuberculin Purified Protein Derivative, (Mantoux) (PPD) (Tubersol) states under section Storage, Store at 2 degrees to 8 degrees of Celsius (35 to 46 degrees of Fahrenheit). Do not freeze. Discard product if exposed to freezing.

Based on record reviews and interview, the facility failed to review and revise the Comprehensive Plan of Care to reflect changes in resident's status for 3 of 9 Comprehensive Care Plans reviewed. The facility failed to update the care plan for Resident #17 related to falls. Resident #59's care plan was not updated related to weight loss. Resident #60's care plan was not updated related to falls and pressure ulcers. The findings included: Based on record review and interviews, the facility failed to update the care plan for Resident #60 who was at "mild risk" for and developed a pressure ulcer on the left ankle. The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Review of the 8-6-14 Admission Minimum Data Set (MDS) Assessment on 9-3-14 at 8:35 PM revealed that the resident required extensive assistance with bed mobility and had no pressure ulcers. Review of the Braden Scale completed on 8-1-14 with the Admission Nursing Assessment revealed that Resident #60 was at "mild risk" for pressure ulcer development. On 9-3-14 at 12:25 PM, review of 8-12-14 Nursing Progress Notes revealed that staff noted "Resident left ankle is red but blanchable with scab noted to center of reddened area." The Nursing-Weekly Skin Assessment noted an area on the left outer ankle measuring "3 cm (centimeters) (I(ength)) x 2 cm (w(idth))". A physician's orders [REDACTED]." Review of the 8-27-14 (most current) Weekly Skin Assessment revealed that the resident had a "2 cm x 2 cm scab over area (diagram indicated left outer ankle) with surrounding skin red but blanchable." Record review on 9-3-14 at 12:52 PM revealed that the facility developed a Care Plan upon admission for the "...risk for skin breakdown related to impaired mobility, muscle weakness... and requires extensive assist with ADL's (activities of daily living) including bed mobility. Resident is also at risk for skin tears related to fragile skin." Interventions included to "Assist resident with turning and repositioning " and "Dietician to evaluate as needed." The Plan had not been updated to reflect the development of the left ankle pressure ulcer noted by the facility on 8-12-14 with individualized interventions implemented to promote healing and provide ongoing assessment to evaluate the effectiveness of the interventions by qualified personnel. During an interview on 9-3-14 at 4:15 PM, the Acting Director of Nursing (DON) reviewed the Care Plan and verified that it had not been updated to reflect the development of an actual skin breakdown and that the MDS Coordinator was responsible for updating the Care Plan. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of Resident #17's medical record on 9/3/2014 at approximately 10:15 AM revealed a fall on 7/26/2014, 8/3/2014, and 8/12/2014. Review of Resident #17's Comprehensive Plan of Care on 9/3/2014 at approximately 10:20 AM revealed a care plan last updated on 5/7/2014. There was no evidence the plan of care was reviewed to determine the appropriateness to prevent additional falls or that additional interventions were put in place after each fall to prevent or reduce further falls. An interview on 9/4/2014 at approximately 9:55 AM with Registered Nurse (RN) #1 Minimum Data Set/Care Plan Coordinator confirmed that the Comprehensive Plan of Care had not been reviewed or updated for falls. The facility admitted Resident #59 to the facility with [DIAGNOSES REDACTED]. Review of Resident #59's medical record on 9/3/2014 at approximately 4:53 PM revealed a 15 pound weight loss since admission. The record also revealed labs which indicated a low [MEDICATION NAME] level of 2.87 and a low Protein level of 4.9. An admission weight on 7/15/2014 was recorded as 125 pounds. On 7/24/2014 his/her weight was 119 pounds, and on 8/27/2014 his/her weight was 110 pounds. On 9/3/2014 the weight was recorded as 109 pounds totaling a 15 pound weight loss in less than 2 months. Review of Resident #59's Comprehensive Plan of Care on 9/3/2014 at approximately 4:53 PM documented the resident was receiving a regular diet. However, the current physician's orders [REDACTED]. An interview on 9/4/2014 at approximately 10:15 AM with the Registered Dietician, he/she stated that he/she had not updated the care plan with the correct diet and verified that no additional interventions had been implemented to prevent or reduce further weight loss.

Based on record review, review of the facility's policy entitled "Skin Care Management Policy & Procedure (2013)" and interviews, the facility failed to ensure that interventions were provided to prevent further skin breakdown and promote healing for 1 of 3 sampled residents reviewed for pressure ulcers. No dietary or direct care interventions were implemented for Resident #60 who developed a pressure ulcer after admission. In addition, services were not provided by qualified staff for 3 of 3 sampled residents reviewed for pressure ulcers. Weekly wound assessments (to include staging) were not completed by a Registered Nurse (RN) for Residents #13, #40, and #60. The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Review of the 8-6-14 Admission Minimum Data Set (MDS) Assessment on 9-3-14 at 8:35 PM revealed that the resident required extensive assistance with bed mobility and had no pressure ulcers. Review of the Braden Scale completed on 8-1-14 with the Admission Nursing Assessment revealed that Resident #60 was at "mild risk" for pressure ulcer development. On 9-3-14 at 12:25 PM, review of 8-12-14 Nursing Progress Notes revealed that staff noted "Resident left ankle is red but blanchable with scab noted to center of reddened area." The Nursing-Weekly Skin Assessment noted an area on the left outer ankle measuring "3 cm (centimeters) (I) x 2 cm (w)". A physician's orders [REDACTED]." Review of the 8-27-14 (most current) Weekly Skin Assessment revealed that the resident had a "2 cm x 2 cm scab over area (diagram indicated left outer ankle) with surrounding skin red but blanchable." There was no evidence in the record of ongoing routine assessment/staging of the wound by a Registered Nurse or of a dietary assessment/evaluation to determine the nutritional needs of the resident with the pressure ulcer. There was no evidence of resident education related to the importance of keeping weight off the area of skin breakdown. Record review on 9-3-14 at 12:52 PM revealed that the facility developed a Care Plan upon admission for the "...risk for skin breakdown related to impaired mobility, muscle weakness... and requires extensive assist with ADL's (activities of daily living) including bed mobility. Resident is also at risk for skin tears related to fragile skin." Interventions included to "Assist resident with turning and repositioning " and "Dietician to evaluate as needed." The Plan had not been updated to reflect the development of the left ankle pressure ulcer noted by the facility on 8-12-14 with individualized interventions implemented to promote healing and provide ongoing assessment to evaluate the effectiveness of the interventions by qualified personnel. Multiple observations (on 9-2-14 at 12:50 PM, 2:15PM, 2:40PM, 3:05PM, and 4:15PM, and on 9-3-14 at 10:15AM, 12PM, 1:45PM, and 3PM) revealed the resident laying in bed on her/his left side without any measures in place to promote healing and prevent worsening of the existing skin breakdown on the left outer ankle. There was no evidence of an ongoing repositioning program or efforts to provide support surfaces or off-loading of pressure to the left ankle to provide pressure reduction and/or reduce friction and shearing. During an interview on 9-4-14 at 10;06 am, Certified Nursing Assistant (CNA) #2 stated that s/he did not assist Resident #60 with turning and positioning. Review of the electronic (CNA) Care Plan with the CNA revealed extensive assist was required with bed mobility. When asked if s/he was aware that the resident had a pressure ulcer on the ankle, the CNA stated s/he was "pretty sure she (he) came over with it." Further review of the CNA Care Plan revealed no reference to use of pressure relief devices on the Plan, CNA #2 stated,"The nurses take care of that." During an interview on 9-3-14 at 2 PM, the Acting Director of Nursing (DON) reviewed the wound care book and stated there was nothing in it for this resident. S/he reviewed the electronic record and confirmed that Resident #60 had no pressure ulcers noted upon admission and should have had weekly assessments after that date in the wound care book. At 4:15 PM, the Acting DON verified that the facility should have complete wound assessments including staging by a RN and a daily assessment of the site, "even if just dressing dry and intact". S/he also reviewed the Care Plan and verified that it had not been updated to reflect the development of an actual skin breakdown. During an interview on 9-4-14 at 10 AM, the Registered Dietician stated s/he had not conducted an assessment of the nutritional needs of Resident #60 related to the pressure ulcer because s/he was unaware the resident had one. Review of the facility's policy entitled "Skin Care Management Policy & Procedure (2013)" under "Interventions" revealed the following: "4... all residents identified with skin impairment will be evaluated by a Registered Dietitian for nutritional status in a timely manner... 8. Based on the resident assessment and clinical condition care plan interventions may include: redistribution of pressure (i.e. repositioning, heels off bed),... providing appropriate...support surfaces, maintaining or improving nutrition and hydration status... 9. Skin status and preventive interventions are documented daily and should include an evaluation of the ulcer if no dressing is present, an evaluation of the status of the dressing (i.e. intact), status of area around ulcer, signs and symptoms of infection..., and whether pain is present... 10. Wounds are... documented on the Weekly Wound Assessment Worksheet or in the software tracking system..." No mention was made of the qualifications of the licensed nurse assessor. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of Resident's #40's medical record on 09-03-14 at approximately 10:00 AM revealed physician's orders [REDACTED]." Review of Resident #40's Weekly Skin Assessments revealed documentation of twelve Weekly Skin Assessments were not available: May 07, May 14, May 21, May 28, June 4, June 11, June 18, June 25, July 02, July 09, July 16, and July 23, 2014. Further review of the Weekly Skin Assessments revealed the following inconsistencies: 07-30-14: Stage III Pressure Wound of the right calf without measurements, 08-06-14: Stage III Pressure Wound of the right calf noted, Stage II Pressure Wounds of the second digits of the right and left foot without measurements, 08-13-14: no documentation of Pressure Wounds present, 08-20-14 and 08-27-14: measurements unavailable. Review of the Weekly Wound Records revealed documentation from May 07, 2014 to August 29, 2014 was not available. Review of the Weekly Wound Record dated 09-02-14 revealed Resident #40 had four Pressure Wounds present. Review on 09-04-14 at approximately 11:00 AM of the facility policy titled, "Skin Care Management Policy and Procedure", revealed the following in the section Policy #3: "Weekly head to toe assessments or body audits will be conducted on all residents and documented on the form designated for this purpose." Further review of the "Skin Care Management Policy and Procedure", revealed in the section Policy: #4: "Weekly assessment and measurement of wounds will be performed and documented on the medical record." During an interview on 09-04-14 at approximately 11:00 AM with the Director of Nursing (DON), he/she stated, "All of the Weekly Body Audit documentation and the Weekly Skin Assessment documentation is not available. Our policy has not been followed." The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review of Resident #13's medical record on 9/4/2014 at approximately 10:53 AM revealed a nurse's note dated 6/3/2014 at 5:14 PM stating measurements for both pressure ulcers on Resident #13's left great toe and left second toe measured 0.5 centimeters long by 0.5 centimeters wide. Another nurse's note dated 6/18/2014 at 5:52 PM revealed measurements for the left great toe as 0.5 centimeters long by 0.4 centimeters wide. The left second toe measured 0.4 centimeters long by 0.4 centimeters wide. No documentation was located in Resident #13's medical record that a Registered Nurse had staged the pressure ulcers. Review of Resident #13's Comprehensive Plan of Care on 9/4/2014 at approximately 11:00 AM revealed the pressure ulcers were a Stage II on 6/6/2014. Review of Resident #13's Minimum Data Set ((MDS) dated [DATE] under Section M for Skin Conditions, M0300, B. is coded for 1 stage II pressure ulcer. The MDS dated [DATE] under Section M for Skin Conditions, B. is coded for 2 Stage II pressure ulcers. During an interview on 9/4/2014 at approximately 1:46 PM with the acting Director of Nursing, he/she stated, "there is no documentation in the medical record as to whom had staged the pressure ulcers."