Every finding on record at Pruitthealth - Spring Valley

Based on staff interview and record review, the facility failed to notify the family/health agent of a significant change related to weight loss for one of 21 sampled Residents (R) (R155). Findings Include: Review of R155's Vital Results revealed his weight on 4/6/2023 was 204.6 lbs. (pounds) and on 4/18/2023 was 193 lbs. which indicated he had lost 11 pounds (5.67 percent) within a two-week period. Review of the facility's Situation, Background, Assessment and Recommendation (SBAR) form indicated that the family/health agent should be notified if the resident experienced a change in condition. Review of R155's medical records revealed there was no evidence that the family/health agent had been notified or that a SBAR form had been completed related to his significant weight loss. Interview conducted on 1/6/2024 at 10:30 am with the Director of Health Services (DHS) confirmed R155 had a significant weight loss within two-weeks of admission to the facility. The DHS was unable to explain why staff did not notify the family/health agent of the resident's weight loss. She acknowledged that staff should have notified the family. A policy was requested from the facility during survey on 1/6/2024 at 12:40 pm related to change in condition but was not provided to the surveyor prior to exit. Cross Reference F641and F692

Based on staff interview, record review, and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to ensure two of 21 Residents (R) (R155 and R31) were accurately assessed on the Minimum Data Set (MDS) assessments related to significant weight loss. Findings Include: A review of the facility policy, MDS Assessment Accuracy, dated 12/6/2022, Policy Statement revealed, It is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessments would be scheduled to accurately account for the acuity and complexity of the patient/resident . 1. Review of R155's Vital Results revealed a documented weight loss between 4/6/2023 and 4/18/2023 of 11 pounds (lbs.) (5.67 percent). Review of R155's MDS Discharge assessment dated [DATE], revealed Section K-Swallowing/Nutritional Status, indicated a height of 62inches and weight of 193 lbs., with no reported weight loss of 5% (percent) in the past three months or 10% in the last six months. 2. Review of R31's Vital Results revealed a documented weight loss between 7/4/2023 and 10/5/2023 of 15.2 lbs. (7.86%). Review of R31's MDS Quarterly assessment dated [DATE], revealed Section K-Swallowing/Nutritional Status, indicated a height of 65inches and weight of 182 lbs., with no reported weight loss of 5% in the past three months or 10% in the last six months. Interview with the MDS Coordinator on 1/6/2024 at 9:19 am confirmed that R31 had a 7.86 weight loss in three months based on the resident's weight of 193.4 lbs. on 7/4/2023 and 178.2 lbs. on 10/5/2023. The MDS Coordinator stated the MDS assessment was not coded correctly. The MDS Coordinator confirmed that R155 had a 5.67 % weight loss as evidenced by the documented weight of 204.6 lbs. on 4/6/2023 to 193 lbs. on 4/18/2023. The MDS Coordinator stated the previous MDS Coordinator did not code the MDS assessment correctly. Cross Reference F580 and F692

Based on observations, staff interviews, record review, and review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to develop a care plan related to surgical wounds for one of 21 sampled Residents (R) (R155). In addition, the facility failed to implement a care plan for one of 21 sampled residents (R52) related to the use of a sit to stand lift. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 7/27/2023, the Policy Statement revealed, It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) . Under the section titled, Admission Comprehensive Plan of Care revealed 2. A comprehensive person-centered care plan will be developed by the interdisciplinary team for each patient/resident within seven days after completion of the comprehensive assessment 4 .The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners 1. Review of R155's Minimum Data Set (MDS) Admission Assessment, dated 4/10/2023, revealed Section M: Skin Conditions indicated that R155 had a surgical wound on admission. Review of R155's care plan revealed there was no care plan for a surgical wound related to a hip fracture or a surgical wound to the abdomen related to a bladder biopsy. Interview on 1/6/2024 at 9:24 am with the MDS Coordinator revealed that R155 was admitted with a surgical wound related to a right hip fracture and a small surgical wound to the abdomen related to a bladder biopsy. The MDS Coordinator acknowledged there was no care plan developed that addressed the wounds. The MDS Coordinator stated the care plan should have included a surgical wound care plan, but it was overlooked. Interview on 1/6/2024 at 10:30 am with the Director of Health Services (DHS) confirmed R155 should have had a care plan developed for his surgical wounds. 2. Review of R52's Admission Minimum Data Set (MDS) dated [DATE] revealed, Section C: Cognitive Patterns-a Brief Interview for Mental Status (BIMS) Score of 14 which indicated he had intact cognition; Section GG: Functional Abilities and Goals-indicated the resident was dependent for chair/chair to bed transfer. Review of R52's care plan revealed a care plan for Activities of Daily Living (ADL) Functional Status/Rehabilitation Potential dated 11/21/2023 with an Approach of Transfer Status: Sit to stand. Review of In-service Education Summary Record Form dated 10/31/2023 revealed an In-service provided by the Assistant Director of Health Services (ADHS) that stated: All residents mode of transfer must match their care plans. Please notify the primary nurse or myself of any changes. For example, someone who could stand, and pivot and they no longer can. This person may benefit from a stand lift or Hoyer. Please notify primary nurses and ADHS so that we can implement the right method/mode of transfer according to the residents needs and update resident's care plan to match what resident can actually do. Observation on 1/5/2024 at 9:10 am revealed Certified Nursing Assistant (CNA) AA entered room [ROOM NUMBER] alone with a Hoyer lift. Observation on 1/5/2024 at 9:15 am revealed CNA AA exited room [ROOM NUMBER] and came down the hall to get another sling for the Hoyer lift. Observation and interview on 1/5/2024 at 9:35 am revealed upon CNA AA exit of room [ROOM NUMBER], R52 was observed up in a wheelchair at this time. An interview was conducted with CNA AA and she revealed that she had used the Hoyer lift to get R52 out of bed. Record review and Interview on 1/6/2024 at 11:05 am with CNA BB and CNA AA revealed CNA BB stated the residents care plan would tell them what type of lift a resident was assessed for and this would determine which lift to use. During this time CNA AA reviewed R52's Point of Care (POC) and it stated she required the use of a sit to stand lift. Interview on 1/6/2024 at 11:15 am with the Director of Health Services (DHS) revealed an assessment/observation was done for the sit to stand lift for R52 and was care planned. She stated unless the resident fluctuates in ability to use the sit to stand she would not need a Hoyer lift. DHS stated, she did not know why CNA AA used a Hoyer lift when R52 was care planned for a sit to stand. DHS stated if the resident was currently requiring a Hoyer lift then an assessment should have been done to determine if she was fluctuating and at times needed a Hoyer lift. She stated this information should have been care planned. DHS confirmed the resident did not have a care plan for the use of a Hoyer lift and had not been assessed for the use of a Hoyer lift. Cross Reference F689 38991

Based on observations, resident and staff interviews, and record review the facility failed to provide Activities of Daily Living (ADL) related to incontinent care in a timely manner for one of 21 sampled Residents (R) (R16). This failure has the potential to affect the resident's comfort and increase the risk of infection. Findings include: Review of R16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C: Cognitive Patterns- a Brief Interview for Mental Status (BIMS) score of 13 indicated his cognition was intact; Section GG: Functional Abilities and Goals-indicated the resident's range of motion was impaired bilaterally, and he was dependent on staff for toileting. Section H: Bladder and Bowel-indicated a urinary catheter was in place, and he was always incontinent of bowel. Review of R16's care plan dated 1/24/2024 revealed he was at risk for skin breakdown related to weakness and mobility with an Approach that included but not limited to providing incontinence care. Observation on 1/5/2024 at 9:11 am revealed the call light for room [ROOM NUMBER] was on and Licensed Practical Nurse (LPN) CC entered the room at 9:12 am. R16 stated to LPN CC he had a bowel movement and asked to be changed. LPN CC turned the light off and told R16 she would try to get him and would be back. She walked back to her medication cart and did not inform anyone of R16's request to be changed. Observation on 1/5/2024 at 9:17 am revealed LPN CC remained standing at the medication cart. Staff were observed in the hall during this time. LPN CC did not inform anyone of R16's request to be changed. Observation on 1/5/2024 at 9:19 am revealed LPN CC entered room [ROOM NUMBER] with medications in hand. At 9:21 am, LPN CC exited room [ROOM NUMBER] and went back to the medication cart and had not addressed R16's request to be changed. Observation on 1/5/2024 at 9:29 am revealed LPN CC entered room [ROOM NUMBER] with medications in hand to administer to another resident in the room with R16. At 9:31 am, LPN CC exited room [ROOM NUMBER] and did not address R16's request to be changed. LPN CC then went back to the medication cart and began preparing for another medication pass. Observation on 1/5/2024 at 9:39 am revealed LPN CC remained standing at the medication cart. During this time WCN EE was observed speaking with LPN CC. She did not inform WCN EE of R16's request to be changed. Observation on 1/5/2024 at 9:42 am revealed Certified Nursing Assistant (CNA) AA walk pass LPN CC who did not inform CNA AA that R16 in room [ROOM NUMBER] had a bowel movement and had requested to be changed. Interview on 1/5/2024 at 9:44 am with the WCN EE confirmed LPN CC did not inform her that R16 had requested to be changed. WCN EE stated R16 informed her that he had a bowel movement and needed to be changed. She stated she was going to get CNA FF to assist with getting him changed. Observation on 1/5/2024 at 9:47 am revealed CNA FF and WCN EE in room [ROOM NUMBER] to provide incontinent care on R16. At this time 36 minutes had passed since R16's initial request to be changed due to having a bowel movement. Interview on 1/6/2024 at 8:35 am with LPN CC revealed that when R16 told her he had a bowel movement and requested to be changed that she went into room [ROOM NUMBER] where CNA FF was and told her that R16 had a bowel movement and was requesting to be changed. She stated the CNAs would get to the residents as soon as they could. She acknowledged 36 minutes was too long for a resident to wait to be changed. LPN CC stated the CNAs were doing the best that they could. Interview on 1/6/2024 at 8:50 am with the Director of Health Services (DHS) revealed it was her expectations that a resident should not have to wait no longer than 5 to 10 minutes to be changed and stated she herself would not want to be left sitting in a bowel movement for a long period of time. She stated if the CNAs were busy she expects the nurse to provide incontinent care to the resident. She stated 36 minutes was too long for a resident to wait to be changed. Interview on 1/6/2024 at 3:50 pm with R16 revealed he had been left soiled for long periods of time on many occasions. He stated it was worse at night when there was only one CNA on the hall but stated what he could not understand why it happened on the day shift when there were plenty of staff during the day to assist with resident's needs. He stated it makes him feel bad and added that it was not enjoyable having to sit through meals with a bowel movement in his brief and that there have been times when this has happened.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Procedure: Transferring a Resident Using a Mechanical Lift, the facility failed to ensure that the appropriate method of transfer and the appropriate number of staff assist was utilized for one of 21 sampled Residents (R) (R52). Findings include: Review of the facility's policy titled, Procedure: Transferring a Resident Using a Mechanical Lift dated 2019 revealed under 'Considerations' the mechanical lift is a two-person device. One care giver should never use it alone. Review of the Admission Minimum Data Set (MDS) dated [DATE] for R52 revealed, Section C: Cognitive Patterns-a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognition; Section GG: Functional Abilities and Goals-indicated the resident was dependent for chair/chair to bed transfer Review of the care plan for R52 revealed a care plan for Activities of Daily Living (ADL) Functional Status/Rehabilitation Potential dated 11/21/2023 with an Approach of Transfer Status: Sit to stand. Review of the Observation Detail List Report for R52 dated 11/21/2023 revealed for Transfer Activity, a Mechanical lift used but did not specifically mention the type of lift R52 required. Observation on 1/5/2024 at 9:10 am revealed Certified Nursing Assistant (CNA) AA entered room [ROOM NUMBER] alone with a Hoyer lift. Observation on 1/5/2024 at 9:15 am revealed CNA AA exited room [ROOM NUMBER] and came down the hall to get another sling for the Hoyer lift. Upon CNA AA re-entering room [ROOM NUMBER] there was no one else observed in the room to assist CNA AA with using the Hoyer lift. Observation and interview on 1/5/2024 at 9:35 am revealed upon CNA AA exit of room [ROOM NUMBER], R52 was observed up in a wheelchair. During this time an interview was conducted with CNA AA and she revealed that she used the Hoyer for lifting R52 out of bed by herself. She stated that she knew everyone was busy and would sometime use the lift by herself. She stated that R52 was a two person assist when using a Hoyer lift and understood it was a safety risk when she used a lift with a resident by herself. Review of records and Interview on 1/6/2024 at 11:05 am with CNA BB and CNA AA revealed CNA BB stated the residents care plan would tell them what type of lift a resident was assessed for and this would determine which lift to use. During this time CNA AA reviewed R52's Point of Care (POC) which stated she required the use of a sit to stand lift. Interview on 1/6/2024 at 11:15 am with the Director of Health Services (DHS) revealed an assessment/observation was completed for R52 and that she required the use of a sit to stand lift. She stated the resident may be fluctuating in her mobility needs and may require the use of a Hoyer, but she had not been informed of that and stated R52 would need a new assessment/observation done to determine if she was fluctuating and in need of a Hoyer lift at times. Interview on 1/6/2024 at 12:20 pm with the DHS revealed she was unsure what 'Total Mechanical Lift must be used' means related to if it means a sit to stand or a Hoyer lift but stated the staff knew they were supposed to use a sit to stand lift with R52 and added that it was on the POC for R52. She stated she reviewed the facility policy on lifts, and she did not see where it stated a lift required two people but stated staff have been told to ensure two people are present when a lift was used for safety purposes. Interview on 1/6/2024 at 4:05 pm with R52 revealed she got up often with a lift with only one staff member assisting her. She stated she was not aware it should be two people getting her up. Cross Reference F656

Based on record review, staff interviews, and review of the facility's policy titled, Weight Monitoring Program, the facility failed to provide nutritional care and services for one of 21 sampled Residents (R) (R155) with a significant weight loss. Findings Included: Review of the facility's policy titled, Weight Monitoring Program, dated 6/2/2023 revealed under the section titled, Procedure: Patients/residents will be placed on the Weight Monitoring Program unless the weight loss is anticipated and/or planned. 2. New admissions will be weighed weekly times four weeks and/or until the weight was stable. Under section titled, Significant Weight Changes revealed, 1. A significant weight change is defined as 5% weight loss or gain in one month, 7.5% weight loss or gain in three months, and 10% weight loss or gain in six months. Review of R155's medical records revealed a significant weight loss of 5.67% (11 pounds) in 14 days from 4/6/2023 to 4/18/2023. During an interview with the Director of Health Services (DHS) on 1/6/2024 at 10:30 am, she stated that any resident with weight loss was added to the Patient at Risk (PAR) list and discussed during all PAR meetings. The DHS stated that when a weight loss occurs, the Medical Director (MD), Registered Dietician (RD), and families are notified, and the resident would be placed on a supplement immediately. The RD would then follow the patient to determine the resident's nutritional needs. The DHS stated R155 was not placed on the PAR and should have been. The DHS could not explain why the resident's weight loss was not reported or why the staff did not notify the family of the weight change. During an interview with the RD on 1/6/2024 at 11:00 am, she explained that R155 was on a NAS (sodium-restricted) diet on admission and had come from the hospital. The RD stated that the resident would often retain fluids while in the hospital, so she expected the resident would lose some weight due to fluid retention. She stated during the time R155's assessment was completed on 4/12/2023, she concluded the weight loss was within normal limits based on his clinical history, and he was well above his ideal weight. The RD added the facility would either email or call her with information related to a resident if there was a concern about weight gain or loss. She stated the facility never contacted her regarding R155's weight loss or change in his appetite. Cross Reference F641and F580

Based on observations, interviews, and policy review, the facility failed to maintain an effective Infection Control Program to prevent the spread of infections by not ensuring staff wore appropriate personal protective equipment (PPE) when sorting soiled laundry; clean lift slings and mop heads were hung to air dry in the dirty area of the laundry area; air flow was impeded from the dirty to the clean laundry areas. The census was 51. Findings include: Review of the policy titled Infection Control - Linen and Laundry, revised 4/2/20 revealed the policy of all [name] Healthcare Centers to implement and adhere to this policy to mitigate or decrease infections caused by sources of microbial contamination through collection, handling, sorting, transportation, processing, and storage of laundry. Definitions . -Personal protective equipment (PPE) are barriers, (e.g., gloves, gowns, and masks), designed to protect mucous membranes, skin, and clothing from coming in contact with potentially infectious microorganisms. -Standard Precautions are the basic level of infection prevention practices that are used to prevent transmission of diseases to health care personnel and patients that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. . Personnel . 2. Soiled laundry will be handled as contaminated, and all partners will practice standard precautions when handling or exposed to soiled laundry. Standard precautions involve wearing the appropriate PPE when handling or exposed to soiled laundry. 3. Personal protective equipment (e.g., gown, gloves, and mask) will be readily available for use and must be worn, as indicated, to protect employees from exposures. 5. Laundry Process a. Soiled laundry i. The soiled laundry area is to be clearly separate from the clean laundry area. ii. The two sides are separated with no airflow to the clean side. Ventilation air should flow from the clean to the dirty area. iii. All soiled laundry is contained in leak resistant bags which are transported inside carts from the resident care area to the inside of the laundry facility. iv. Personal protective equipment is readily available and must be worn by those working with soiled laundry. b. Clean laundry i. Following the wash cycle, laundry is machine dried . ii. Do not leave damp laundry in machines overnight. iii. Laundry is sorted, ironed, folded, and placed on clean laundry exchange carts iv. Laundry dropped on the floor or soiled in any way is rewashed. v. At the end of the workday, all unprocessed, clean laundry is covered. vi. Clean laundry is covered and transported inside the facility to designated areas . Observation on 10/20/22 at 12:57 p.m. during tour of the laundry revealed a ceiling fan on high speed over the washer area and a ceiling fan over the dryer area on low speed with an open arch way between the washer area and dryer/clean sorting and folding area. Housekeeper (HK) CC and HK DD confirmed there was no barrier in the arch area to impede air flow. Observation of lift slings and mop heads hanging in the washing machine area were confirmed by HK CC as being clean and hanging to air dry. Interview on 10/20/22 12:57 p.m., HK CC and HK DD revealed dirty laundry is sorted in a small anteroom that has a door that was open into the washing machine area. When asked what staff wore when sorting dirty laundry, both HK CC and HK DD stated they wear gloves and pointed to boxes of vinyl gloves on the opposite side of the laundry room, next to the washing machines, from the sorting area. Hanging close to the washing machines, was a brown apron with a neck loop and waist tie, and a face shield. HK CC and HK DD stated they wear the apron and face shield when the building is red or when there is a lot of COVID. They were asked who did the training with them on when to wear the apron and face shield, HK DD stated, Our supervisor. Interview on 10/20/22 at 1:14 p.m., the Housekeeping Director (HKD) stated, when sorting linen, all under pads are sorted by their self, colored resident clothes are together, sort out sheets and blankets together, napkins and bibs are together, are all sorted in the small area [anteroom]. She stated staff should wear a face shield, gloves, and an apron to sort dirty laundry. The HKD confirmed there was not a barrier for air flow between the dirty washing machine area and the clean dryer folding/sorting area. Interview on 10/20/22 at 5:00 p.m., the Administrator stated he felt like the laundry room was two separate rooms, with dirty laundry in on the wash side and out on the dryer side, despite being open, and no barrier to impede the air flow. On 10/20/22 at 5:15 p.m., two surveyors measured the open archway area in the laundry room which was 57.5 inches wide x 80 inches high. During a follow-up interview on 10/20/22 at 5:40 p.m., HKD confirmed the clean 14 lift slings, and 20 mop heads were hanging to dry in the washing machine (dirty) area.

Based on interview, record review and review of Pre-Admission Screening and Resident Review (PASARR) website, the facility failed to ensure one of four residents (R) (R#1) admitted with a mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The sample size is 31. Findings include: Review of the PASARR website (https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review showed: .Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities: 1. Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID) 2. Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings) 3. Provide all applicants the services they need in those settings . The PASARR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASARR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. Review of the clinical record for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's PASARR Level I completed by the discharging hospital, signed by the hospital representative, dated 3/9/21, with an approved status. On 10/19/22 at 3:22 p.m., the Social Services Director (SSD) explained the approved status meant R#1 could be admitted to the nursing home. Further review of the PASARR Level I did not show the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/20/22 at 3:46 p.m. with the SSD regarding the [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/20/22 at 5:05 p.m., with the Administrator, stated he knows now it is an issue and will take care of it. The Administrator stated the facility did not have a PASARR policy.

Based on observations, interviews, record review, and policy review, the facility failed to attempt other alternatives prior to utilizing side rails; and failed to assess the medical need for use of side rails for three of four residents (R) reviewed with side rails (R#5, R#13, and R#24). The sample size was 31. Findings include: Review of policy titled Bed Rails revised 2/1/18, revealed the policy of [name] should be free from the use of bed rails .Prior to installing or using the bedrails on a patient's bed, the patient should be assessed by the admitting nursing and/or inter-disciplinary team (IDT) to determine whether the use of bed rails would constitute an enabler or a restraint for the patient. All factors of the patient's functional ability should be taken into consideration when making this determination. Review of a document provided during the admission process titled CONSENT FOR THE USE OF BED RAILS, revealed, The risk and alternatives to using bedrails, have been clearly explained to me with the education provided . 1. Review of the clinical record revealed R#5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated resident was cognitively intact. This assessment indicated the resident required extensive assistance of two staff members for bed mobility and transfers. Observation of R#5 on 10/17/22 at 3:45 p.m. revealed R#5 was in bed with the side rails up on both sides of the bed. Review of R#5's CONSENT FOR THE USE OF BED RAILS, dated 6/29/22 revealed that the resident's representative electronically signed the document on 6/29/22. Review of a document provided by the facility titled, General Order dated 6/29/22, indicated, Order Description 1/4 siderails for turning and repositioning dated 6/29/22. Review of document titled Observation Detail List Report: Restraint Adaptive Equipment Use, dated 6/30/22 at 1:05 a.m., indicated, Is restraint in use? No; Is adaptive equipment in use? No; no other assessments indicated, and nothing is marked to indicate a medical need for bed rails. Interview on 10/20/22 at 2:40 p.m., R#5's representative stated, the facility did not go over anything about bedrails. Review of R#5's care plan, dated last care conference 9/22/22 indicated R#5 has a mobility problem, but bedrails are not mentioned. Interview on 10/20/22 at 10:40 a.m., R#5 wrote on her note pad, I am not sure what those things are for while pointing to the siderails. 2. Review of the clinical record for R#13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#13's admission MDS dated [DATE] revealed a BIMS score of six, which indicates severe cognitive impairment. This assessment indicated the resident required extensive assistance of two staff members for bed mobility and transfers. Review of R#13's CONSENT FOR THE USE OF BED RAILS, dated 8/12/22 revealed that the resident's representative electronically signed the document on 8/12/22. Review of a document provided by the facility titled General Order dated 8/12/22, indicated, Order Description 1/4 siderails for turning and repositioning dated 8/12/22. Review of document titled Observation Detail List Report: Restraint Adaptive Equipment Use, dated 8/12/22 at 6:59 p.m., indicated, Is restraint in use? No; Is adaptive equipment in use? No, all other questions marked Not Applicable, except Narcotics, marked positive, nothing was marked to indicate a medical need for bed rails. Interview on 10/20/22 at 5:30 p.m., R#13's representative stated, the facility did go over the risk of siderails, but I don't remember them suggesting any other choices or alternatives. Review of R#13's care plan, dated last care conference 8/16/22 indicated R#13 had several care areas planned but bedrails were not included on the care plan. 3. Review of the clinical record for R#24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#24's admission MDS dated [DATE] revealed a BIMS score of 99, which indicates the resident was cognitively impaired. This assessment indicated the resident required extensive assistance of two staff members for bed mobility and transfers. Review of R#24's CONSENT FOR THE USE OF BED RAILS, dated 8/31/22 revealed that the resident's representative electronically signed the document on 8/31/22. Review of document provided by the facility titled General Order dated 9/5/22, indicated, Order Description 1/4 siderails for turning and repositioning dated 9/5/22. Review of document titled Observation Detail List Report: Restraint Adaptive Equipment Use dated 9/1/22 at 3:20 a.m., indicated, Is restraint in use? No; Is adaptive equipment in use? No, all other questions marked Not Applicable, except Cognitive loss dementia, marked positive, nothing is marked to indicate a medical need for bed rails. Review of R#24's care plan, dated last care conference 9/7/22 indicated R#24 had several care areas planned but bedrails were not included on the care plan. Observation on 10/20/22 at 6:00 p.m. revealed R#24 was slid down in bed asleep with her head resting at the bottom of the bed rail. The side rails on both sides of the bed were in the up position. Interview on 10/20/22 at 9:40 a.m. with the Director of Nursing (DON), when asked about alternatives attempted prior to the use of bed rails, the DON replied, As far as I know we don't do any alternatives. Interview on 10/20/22 at 10:00 a.m. with the Social Service Director (SSD), when asked about the consent for bed rails signed during admission, as part of the admission packet, the SSD stated, the consent is always signed at admission, and I review it as part of the admission process. Interview on 10/20/22 at 4:00 p.m. Licensed Practical Nurse (LPN) AA, stated the Observation Detail List Report: Restraint Adaptive Equipment Use, is the assessment form used to assess the need for bed rails. She indicated that the form should be marked 'yes' on one of the questions of Is a restraint in use or Is adaptive equipment in use.

Based on interview and document review, the facility failed to ensure training was provided to educate staff direct care staff in dementia management for one Certified Nursing Assistant (CNA) of five sampled personnel records. Findings include: Review of the personnel record for CNA BB revealed hire date was 2/17/22. There was no documentation that CNA BB received dementia and/or behavioral health education/training prior to working with the residents at the facility. Interview on 10/20/22 at 5:50 p.m., the Administrator confirmed CNA BB had not received any dementia management training. The Administrator stated the Social Service Director (SSD) or the Administrator provides dementia training during the employee's orientation to the facility.

Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of residents personal care equipment in two (2) resident rooms (rooms [ROOM NUMBERS]) on one (1) of two (2) halls. The facility census was 46 residents. Findings include: Review of untitled and undated document located in facility Activities of Daily Living (ADL) book, revealed a statement: Please label these items in your patient rooms and if you take a new item out of the supply closet, label it before you place it in the room. Denture Cups, tooth brushes, tooth paste, bed pans, bath pans, urinals. Remember that bed pans and wash basins are to be stored in the bottom of the night stand. Bar soap is not to be used. If a resident has their own soap, it should be kept in a travel container and labeled. Observation on 6/17/19 at 11:18 a.m. revealed in room [ROOM NUMBER] bathroom, unlabeled denture cup with dentures sitting on sink counter; unlabeled bedpan and two unlabeled bath basins in bathroom shared by four female residents. Observation on 6/17/19 at 11:52 a.m. revealed in room [ROOM NUMBER] bathroom, three bars of hand soap un-bagged and unlabeled sitting on sink ledge. Observation on 6/18/19 at 2:19 p.m. revealed in room [ROOM NUMBER], un-labeled denture cup with dentures remains sitting on counter in bathroom; unlabeled bedpan and bath basins remain in bathroom shared by four female residents. Observation on 6/18/19 at 2:20 p.m. revealed in room [ROOM NUMBER], three bars of hand soap, un-bagged and unlabeled sitting on sink ledge. Observation on 6/20/19 at 8:58 a.m. revealed in room [ROOM NUMBER], three bars of hand soap remain un-bagged and unlabeled sitting on sink ledge. Interview on 6/20/19 at 9:13 a.m. with Certified Nursing Assistant (CNA) HH stated that bedpans and bath basins should be labeled with residents name and/or room number, and stored in the bathroom in a plastic bag. She stated that if items were not labeled, then she would throw them in the trash and get a new one and put residents name and room number on it. Interview on 6/20/19 at 9:36 a.m. with Director of Nursing (DON) stated that residents personal care equipment (bedpans and bath basins) should be bagged and labeled and kept in bathroom. For residents toothbrushes, toothpaste and dentures, she stated they should be kept in residents bed side table. She further stated that she is not sure where the three bars of soap came from, because they use body wash for bathing and each sink has soap dispensers on the wall. During walking rounds, at this time, the DON verified concerns identified during the survey. Interview on 6/20/19 at 10:37 a.m. with Administrator, stated that it is her expectation that residents personal care equipment be bagged and tagged. She further stated staff should throw out and start with a new bath basin or bed pan, if they have some that are not labeled.

Based on observation, record review, policy review and interviews, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two (2) residents (R) #16 and #24 out of three (3) residents who were reviewed after being discharged from Medicare Part A Services and remained in the facility. The sample size was 25. Findings include: Review of the facility policy titled Advance Beneficiary Notices (ABNs) revised 7/19/2016 revealed the purpose of an Advanced Beneficiary Notice (ABN) is to inform the patient/resident that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay for the item or service under different circumstances. This allows the patient/resident to make an informed decision about whether or not to receive the item or service for which he/she may have to pay out of pocket or through other insurance. Procedure 1. If physician orders services for treatment of [REDACTED]. The facility will discuss the options related to non-covered services with the patient/resident and will answer any inquiries from the patient/resident. The patient/resident will receive instruction and guidance of options with each Advance Beneficiary Notice issued. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that R#16 and R#24 remained in the facility after skilled services ended. 1. Review of records for R#16 indicated that services were initiated on 3/11/19 and discharged from Medicare Part A services on 5/3/19 and remained in the facility. Review of her Beneficiary Notices revealed that only the Notice of Medicare Non-Coverage form (NOMNC)(Form CMS- ) was provided, which was signed by the resident on 5/3/19. There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#16 providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. Review of records for R#24 indicated that services were initiated on 1/25/19 and discharged from Medicare Part A services on 3/22/19 and remained in the facility. Review of her Beneficiary Notices revealed that only the Notice of Medicare Non-Coverage form (NOMNC)(Form CMS- ) was provided, which was signed by the resident on 3/22/19. There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#24 providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. Interview on 6/18/19 at 9:50 a.m. with Administrator, stated that she checked in the discharge notebook for the Advanced Beneficiary Notices (ABN), and the only ones she was able to find are the CMS- NONMC. She was not able to find the CMS- form for the two residents that remained in the facility, after discharged from Medicare Part A services. She further stated that the Social Services Director is out on medical leave and is unreachable by phone. Interview on 6/20/19 at 7:45 a.m. with Interim Social Services Director GG stated that residents who remain in the Skilled Nursing Facility (SNF) after discharging from Medicare Part A services, are to be given both the CMS and the CMS . She stated that the residents have the right to appeal the discharge from services, and if they desire to continue receiving skilled services.

Based on observations, staff interviews, and review of policy titled Labeling, Dating, and Storage the facility failed to label, date, and store open food items in one of two reach in refrigerators. The sample size was 44 residents. In addition, the facility failed to sanitize the food processor equipment after pureeing tatar tots and chicken tenders for s sample size of four residents. Findings include: Review of facility policy titled Labeling, Dating, and Storage revealed that food and/or beverage items in the kitchen were to be properly labeled with the name of the item, and a use by date. Foods were to be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. Items that require refrigeration and/or require refrigeration once they have been opened will be labeled with a use by date based on the USDA Quick Reference Shelf Life List. The initial our of the kitchen was conducted on 4/24/18 at 10:03 a.m. Observation of a reach in freezer revealed that inside the freezer were: Four unidentifiable cylindrical food items in an unsealed plastic bag. The plastic bag was without a product description and did not have an open or use by date on the bag. 16 French toast sticks in an unsealed plastic bag without an open or use by date on the bag. Observation of the inside of the three-door refrigerator, following observation of the freezer, revealed: A box with two (12 count) unopened packets of hard boiled eggs. Also, inside box was six loose hard-boiled eggs that were unwrapped and resting directly on the cardboard on the bottom of the box, without an open or use by date. Sliced oven roasted turkey breast sandwich meat, opened and rewrapped in plastic wrap without an open or use by date. A five-pound bag of shredded cheddar cheese opened and approximately two-thirds full without an open date. An opened gallon container 3/4 empty containing Buttermilk Ranch Dressing without an open date or use by date. Pasteurized shell eggs used, stored on the floor of the cooler. During an interview with the Dietary Manager at on 4/24/18 at 10:07 a.m., he confirmed and verified that all the opened, unlabeled, and undated food items. He stated that the facility policy was for staff to date food items when they were opened and food items were supposed to be labeled with the name of food, and the use by date. He stated the four cylindrical items in the reach-in freezer were manicotti pasta rolls. An interview and observation on 04/25/18 at 4:08 p.m., with the cook revealed the cook was observed using the food processor to prepare food for four residents receiving a puree diet. She placed tater tots, four-ounce (oz.) servings for four residents into the food processor. She added a soup mixture into the tater tots to help with food consistency. The cook used the three compartment sink to wash the lid, bowl, and blade from the food processor. She stated that compartment one contained soap and water. Compartment two contained water to rinse dishes. Compartment three contained water and a sanitizing solution. Next, she pureed eight two oz chicken tenders and added the soup mixture to the chicken tenders. She was observed using the three compartment sink to wash the chicken mixture from the food processor. The food processor lid stayed in the sanitize mixture for 30 seconds. The bowl was in the sanitizer solution for ten seconds. The blade was dipped into the sanitizer solution and then quickly pulled out. The Cook was asked to check the concentration of the sanitizer in the three-compartment sink. The reading was 100 ppm. She stated that the concentration should be 200ppm. She rechecked the sanitizer solution. The reading was still 100ppm. She stated that she had filled the sink around 4:00 p.m., but that she had not checked the sanitizer level. At 4:20 p.m., the Dietary Manager (DM) was observed/interviewed checking the sanitizer solution in the three-compartment sink, and the reading was 100ppm. He stated that the pump to the sanitizer had been broken and that they had been manually adding sanitizer to the sink. The DM stated that a work order had been placed for EcoLab to fix the pump. An (MONTH) (YEAR) log above the three-compartment sink area showed that staff had been checking sanitizer solution three times/day with readings at 200 ppm. A poster above the three-compartment sink labeled Pot & Pan Washing & Sanitizer read that the chemical concentration for the sink should be 200 ppm. Review of the policy titled Pot/Pan Washing and Sanitizing revealed an effective date of 9/01/01, reviewed date of 8/03/17, and a revised date of 4/11/16. The policy procedure stated that Quaternary concentration was to read 200-300 ppm. Items needed to be immersed for 60 seconds in the Quaternary. Water temperature and sanitizer level should be tested and recorded during each set-up of the three-compartment sink.

Based on observations, record review and staff interviews, the facility failed to follow Activities of Daily Living (ADL) care plan approaches related to nail care for two residents (R) (#6 and #31). The sample was 21 residents. Cross Refer to F677 Findings include: 1. Record review for R#6 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] that assessed the resident for total assistance by staff for ADL Care including personal hygiene. The Care Area Assessment (CAA) did not trigger ADL Function to be care planned. Review of a Quarterly MDS dated [DATE] assessed that the resident required total assistance by staff for ADL care including personal hygiene. Review of the care plan for R#6 with an onset date of 8/23/17 and updated on 2/9/18 identified the resident has self-care deficit for ADLS related to Basal Ganglia hemorrhagic [MEDICAL CONDITIONS] with hematoma requiring craniotomy and obstructive [DIAGNOSES REDACTED] with ventriculoperitoneal (VP) shunt placement, decreased responsiveness, comatose state and need for total assist with all care, and limited range of motion (ROM) to all extremities. A care plan Approach included, but limited to; Nail care/Shampoo as needed. Observations on 4/24/18 at 1:37 p.m., 4/25/18 at 8:55 a.m. and 2:54 p.m., 4/26/18 at 1:05 p.m., 4/27/18 at 10:20 a.m. and 4/27/18 at 10:35 a.m. with the Assistant Director of Nursing (ADON) revealed R#6 had very long, un-trimmed fingernails on both hands. Interview on 4/27/18 at 10:48 a.m. with Certified Nursing Assistant (CNA) EE, who was assigned care of R#6 revealed that she worked this week on Monday, Tuesday and Thursday. She further stated that she washed the R#6's hands on Monday and Tuesday but did not notice the resident's fingernails were long and stated she does not usually trim residents' fingernails. 2. Record review for R#31 revealed a Significant Change MDS assessment dated [DATE] which assessed that the resident required extensive assistance with ADLs, including personal hygiene. The Care Area Assessment (CAA) triggered ADL Function with the decision to be care planned. A Quarterly assessment dated ,[DATE] 18 assessed that the resident required extensive assistance with ADLs including personal hygiene. Review of the care plan for R#31 with an onset date of 6/4/15 and updated 4/16/18 identified the resident presents with self-care deficits related to decreased cognitive and physical status, left above the knee amputation (AKA), need for staff assist with ADL care. A care plan Approach included, but not limited to; Nail care/shampoo as needed. Observations on 4/25/18 at 8:39 a.m., 12:25 p.m. and 2:57 p.m., 4/26/18 at 1:10 p.m., 4/27/18 at 10:23 a.m., 4/27/18 at 10:33 a.m. then on 4/27/18 at 10:33 a.m. with the ADON revealed the resident's fingernails on both hands were very long and untrimmed. Interview on 4/27/18 at 10:30 a.m. with CNA FF, who was in care of R#31, revealed the CNAs are responsible for washing hands, cleaning and trimming a resident's fingernails. CNA FF further stated she worked yesterday and today but did not provide nail care for R#31. Interview on 4/27/18 at 10:33 a.m. with the ADON revealed the facility did not have a specific policy related to nail care but the CNAs are responsible for monitoring the residents' fingernails for cleaning and trimming, unless the resident is a diabetic. The ADON stated the nurses are responsible for trimming a resident's nails if the resident is a diabetic.

Based on record review and staff interview, the facility failed to involve the interdisciplinary team (IDT), resident and responsible party (RP) in developing a discharge plan for one resident (R) (R #50). The sample size was 21 residents. Findings include: Review of R #50's clinical record revealed that he was admitted to the facility on [DATE] after a hospital stay from 12/29/17 to 1/10/18 for [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of R #50's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). Review of a Baseline Care Plan (undated) revealed a problem statement for discharge planning, with interventions to involve the patient/resident, representative and IDT in the discharge planning process; identify anticipated needs post discharge; and to provide education to resident, family and caregiver as needed. Review of the Patient/Resident Initial Goals of Care and Patient/Resident Representative sections of the care plan were blank. Further review of this baseline care plan revealed that the section for Post Admission Care Conference/Initial Care Plan Meeting Date was blank, as was the line for Baseline Care Plan and Admission Physician order [REDACTED]. Review of a discharge planning comprehensive care plan dated 1/30/18 revealed that R #50 and his RP (responsible party) planned on him discharging home when stronger and more independent. Further review of this care plan revealed the following approaches: A baseline care plan would be initiated upon admission within 24 hours by the admitting nurse, in conjunction with other IDT, patient/resident, and/or patient representative. Copy of baseline care plan will be provided to patient/resident and the representative during post admission care conference/initial care plan meetings addressing resident's goals and treatment preferences. Involve patient/patient representative and caregiver in the discharge process. Review of a Discharge Planning Form dated 1/31/18 revealed that R #50 indicated that he would be going home on 2/3/18, and wished to use a certain home health service. Further review of all entries on the Discharge Planning Form revealed that the Social Services Director (SSD) was the only one that made any notes related to discharge planning, with no indication of IDT team involvement. Review of a Post Discharge Plan of Care Form revealed that R #50's date of discharge was 2/3/18, with the RP signing that he understood the contents of the form that included use of [MEDICAL CONDITION] (continuous positive airway pressure), diet, and primary physician's address and phone number. Further review of this discharge form revealed no indication of a referral to the home health agency, including the agency's name and phone number. On 4/27/18 at 2:10 p.m., the Director of Nursing (DON) verified that there was no evidence that a discharge care plan meeting was held with the resident or responsible party, as the attendance would have been documented on the Baseline Care Plan form. During interview with the SSD on 4/27/18 at 3:05 p.m., she stated that a discharge planning meeting was usually held with the resident, responsible party and IDT team about three days after admission. She stated during further interview that she recalled that R #50 said he wanted to go home with home health, but that a formal meeting with the IDT team had not been held with him. Review of the facility's Discharge Planning policy with a revised date of 10/5/17 revealed the following: Discharge planning will begin with each patient/resident and patient/resident's representative upon admission, the process is coordinated by the Social Service/Senior Care Partner/Nurse Navigator or designee. The patient/resident, patient/resident representative and Interdisciplinary Team (IDT) are involved in the planning process. The post-discharge plan of care is developed with the participation of the patient/resident and/or the patient/resident's representative with the patient/resident's consent. The discharge plan will be monitored and revised as necessary throughout the patient/resident stay. Discharge and care plan goals will be established with the IDT, patient/resident and patient/resident representative at the time of admission based on the patient/resident discharge goals and treatment preferences in conjunction with needs as identified by the IDT.

Based on record review and staff interview, the facility failed to provide evidence that reconciliation of all pre- and post-discharge medications and treatments was done for one resident (R) (R #50). The sample size was 21 residents. Findings include: Review of R #50's clinical record revealed that he was admitted to the facility on [DATE] after a hospital stay from 12/29/17 to 1/10/18 for [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of a Physician's Interim Orders dated 2/3/18 noted to discharge R #50 to home with meds. Review of R #50's Post Discharge Plan of Care Form dated 2/3/18 revealed that the Nursing/Devices and Treatments and Nursing Special Instructions sections noted the resident used [MEDICAL CONDITION] (continuous positive airway pressure), and he had a pacemaker. Review of the My Medication List section of this Post Discharge Plan of Care revealed a handwritten notation to see med list. During interview with the Director of Nursing (DON) on 4/27/18 at 2:10 p.m., she stated that she could not find the medication list given to R #50 on discharge, and could not print one as the resident had been discharged out of their computerized system. She stated during further interview that she called the home health agency, and they faxed her a list of medications R #50 was discharged home on. Review of R #50's facility physician's orders [REDACTED]. [REDACTED]. Further review revealed that ProAir (a [MEDICATION NAME][MEDICATION NAME]) 2 puffs four times a day as needed for wheezing; [MEDICATION NAME] 50 mcg (micrograms) 1 spray in each nostril daily as needed for allergy symptoms; and [MEDICATION NAME] 3 mg (milligrams) at bedtime as needed for sleep were all ordered PRN (as needed) on the facility's physician's orders [REDACTED]. This was verified during interview with the DON on 4/27/18 at 3:32 p.m. The DON further verified that R #50 had an order for [REDACTED].

Based on observations, record review and staff interviews, the facility failed to ensure that staff provided nail care for two residents (R) (#6 and #31). R#6 was totally dependent of staff for personal hygiene and R#31 required extensive staff assistance for personal hygiene. The sample was 21 residents. Findings include: 1. R#6 was admitted with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted and assessed that R#6 required total assistance with all Activities of Daily Living (ADL) including personal hygiene. Observation on 4/24/18 at 1:37 p.m. revealed R#6 in bed with noted right sided craniotomy and non-responsiveness to verbal stimuli. Further observation revealed the resident was wearing bilateral arm/hand splints for contractures. The resident fingernails on both hands were noted to be very long and un-trimmed. Observation on 4/25/18 at 8:55 a.m. revealed R#6 in bed with bilateral arm/hand splints in place. The resident's fingernails remained very long and un-trimmed Observation on 4/25/18 at 2:54 p.m. revealed R#6 with bilateral arm/hand splints in place. The resident's fingernails remained very long and untrimmed. Observation on 4/26/18 at 1:05 p.m. revealed R#6 with bilateral arm/hand splints in place. The resident's fingernails remained very long and un-trimmed. Observation on 4/27/18 at 10:20 a.m. revealed R#6 with bilateral arm/hand splints in place. The resident's fingernails remained very long and un-trimmed. Observation on 4/27/18 at 10:35 a.m. with the Assistant Director of Nursing (ADON) confirmed R#6's fingernails nails were very long and in need of trimming. The ADON stated yes, his fingernails definitely need to be trimmed. Interview on 4/27/18 at 10:48 a.m. with Certified Nursing Assistant (CNA) EE, who was assigned care of R#6 revealed the CNAs are responsible for cleaning and trimming a resident's fingernails unless the resident is a diabetic. She stated is a resident has diabetes, the Director of Nursing (DON) or a Registered Nurse (RN) will trim the resident's fingernails. CNA EE stated she worked this week on Monday, Tuesday and Thursday. She further stated that she washed the R#6's hands on Monday and Tuesday but did not notice the resident's fingernails were long. CNA EE stated she did not know if the resident was a diabetic or not and does not usually trim residents' fingernails. CNA EE stated she reports to nursing when a resident's fingernails are long. 2. R#31 was admitted to facility with [DIAGNOSES REDACTED]. R#31 did not have a [DIAGNOSES REDACTED]. R#6 had BIMS summary score of nine, indicating moderate cognitive impairment. No behaviors or rejection of care was assessed and the resident required extensive assistance with all ADLs, including personal hygiene. A Quarterly assessment dated ,[DATE] 18 documented a BIMS summary score of six, indicating severe cognitive impairment. No behaviors or rejection of care was assessed and the resident required extensive assistance with ADLs including personal hygiene. Observation on 4/25/18 at 8:39 a.m. revealed R#31 in his bed. The resident's fingernails on both hands were noted to be long and un-trimmed. The resident was pleasant but confused and unable to be interviewed. Observation on 4/25/18 at 12:35 p.m. revealed R#31 in his bed eating his lunch with the assistance of staff. The resident's fingernails remained long and un-trimmed. Observation on 4/25/18 at 2:57 p.m. revealed R#31 in his bed sleeping. The resident's fingernails remained long and un-trimmed. Observation on 4/26/18 at 1:10 p.m. R#31 in his bed sleeping. The resident's fingernails remain long and untrimmed. Observation on 4/27/18 at 10:23 a.m. revealed R#31 asleep in his bed. The resident's fingernails remained long and untrimmed. Interview on 4/27/18 at 10:30 a.m. with CNA FF, who was assigned care of R#31, revealed the CNAs are responsible for washing hands, cleaning and trimming a resident's fingernails. CNA FF confirmed that the resident's fingernails were long and needed to be trimmed. CNA FF stated she would clean and trim the resident's fingernails. CNA FF further stated she worked yesterday and today but did not provide nail care. Observation on 4/27/18 at 10:33 a.m. with the ADON revealed CNA FF cleaning under the resident's fingernails with an orange stick. The ADON confirmed that R#31's fingernails were long and needed to be trimmed. The ADON stated the facility did not have a specific policy related to nail care but the CNAs are responsible for monitoring the residents' fingernails for cleaning and trimming, unless the resident is a diabetic. The ADON stated the nurses are responsible for trimming a resident's nails if the resident is a diabetic.

Based on record review, review of the policy titled Monitoring of Anxiolytics and staff interviews, the facility failed to ensure that the Consultant Pharmacist made recommendations to the attending physician related to documentation of a clinical rationale and intended duration of therapy for two residents (R) (R#3 and R#41) that received PRN (as needed) [MEDICATION NAME] (an antianxiety medication) beyond 14 days. The sample was 21 residents. Cross Refer to F758 Findings include: Review of the facility policy titled Monitoring of Anxiolytics effective 6/1/1998 and revised on 11/27/17 documented: #5- PRN anxiolytic medications should not be given past a 14 day period unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and he/she indicates the duration for the PRN order. #6- Monitoring the effectiveness of the anxiolytic medication will include a monthly chart review by the pharmacist and a monthly drug regimen review by the responsible physician. Non-pharmacologic behavior modification activities and their effects, as well as the effect of pharmacologic behavioral modifiers are addressed in nursing notes in the patient's/resident's chart as they occur and in patient/resident care planning records. These records are reviewed by the physician and the pharmacist in the process of assessing the patient/resident's response to therapy. 1. R#3 was readmitted to the facility with [DIAGNOSES REDACTED]. Record review for R#3 revealed physician orders on 1/15/18 for [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg (milligrams) every eight hours (q8) as needed for anxiety. On 3/16/18 the physician wrote an order to change [MEDICATION NAME] 0.5 mg every six hours (q6) as needed for anxiety. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 4/4 18 the physician wrote and order to change [MEDICATION NAME] to 1.0 MG every eight hours (q8) at 6:00 a.m., 2:00 p.m., 10:00 p.m. and every six hours (q6) as needed (PRN) for anxiety. Review of the Mediation Administration Record (MAR) for (MONTH) (YEAR) documented that PRN [MEDICATION NAME] 1.0 mg was administered once on 4/4/18. Review of the Consultant Pharmacist Communication to Physician form dated 2/1/18 revealed the Consultant Pharmacist DD made a recommendation for a gradual dose reduction attempt for [MEDICATION NAME] (an antidepressant medication) 100 mg every day (QD). The recommendation did not address the use of PRN [MEDICATION NAME] beyond 14 days or the need for a clinical rationale for the use of PRN [MEDICATION NAME] beyond 14 days. Further review of R#3's clinical record revealed no evidence of prior or additional pharmacy recommendations. Review of the Consultant Pharmacist Drug Regimen Review sign-in form revealed the Consultant Pharmacist DD's signature on 1/5/18, 2/1/18, 3/6/18, and 4/5/18. Interview with the Director of Nursing (DON) on 4/26/18 at 2:20 p.m. revealed the Consultant Pharmacist monitors the PRN [MEDICAL CONDITION] medication orders when she comes monthly and stated the one for R#3 must have been overlooked. Interview on 4/27/18 at 1:00 p.m. with the Consulting Pharmacist DD revealed she had been working on the PRN anxiolytics and antipsychotic MEDICATION ORDERS FOR [REDACTED]. She had begun sending recommendations requesting a duration and clinical rationale for PRN anxiolytics but she did not want to hit the physicians all at once. Continued interveiw revealed that the Consulting Pharmacist DD covers seven facilities and thought she had covered all the PRNs orders at this facility. She further stated she has no good explanation why she did not send a recommendation to the physician about the PRN [MEDICATION NAME] for R#3. The Consulting Pharmacist further stated she checked her computer and she did not see a recommendation to the physician related to PRN [MEDICATION NAME] for R#3. She further stated that PRN Antipsychotics have an automatic 14 day stop date but not the Anxiolytics. 2. Review of R #41's Physicians Orders revealed an order for [REDACTED]. Review of R#41's Medication Administration Record [REDACTED]. Record review revealed documentation by the Consultant Pharmacist of monthly Drug Regimen Reviews (DRR) revealed that the Consultant Pharmacist Communication to the Physician dated 12/01/17 stated that the resident was receiving [MEDICATION NAME] 0.5 mg every 12 hours and [MEDICATION NAME] one mg every four hours PRN for severe anxiety. The Consultant Pharmacist was unable to locate information in the residents' chart that contraindicated an attempt at dose reduction. The Pharmacist suggested a trial reduction of the PRN [MEDICATION NAME] order. On 12/13/17, the physician wrote to continue the PRN [MEDICATION NAME] order. Observations of R #41 on 4/25/18 at 11:05 a.m., 4/26/18 at 9:16 a.m. and 12:19 p.m. and 4/27/17 at 9:45 a.m. revealed that R #41 was alert with no behaviors observed. During an interview with the Director of Nursing on 04/26/18 at 03:22 p.m., she stated that she was aware of the change in the guidelines for PRN anxiolytics medications. She stated that these medications should not be given greater than 14 days. The Director of Nursing also stated that the facility was working with the Physicians and nursing staff to make sure that they document why a resident is receiving this type of medication as well as the duration of the medication.

Based on observations, record review, review of the policy titled Monitoring of Anxiolytics, resident, family and staff interviews, the facility failed to ensure one resident's (R) (#3) medication regimen was free from unnecessary medications and failed to document a clinical rationale and intended duration of therapy for two residents (R#3 and R#41) that received PRN (as needed) [MEDICATION NAME] (an antianxiety medication) beyond 14 days. The sample was 21 residents. Findings include: Review of the facility policy titled Monitoring of Anxiolytics effective 6/1/1998 and revised on 11/27/17 documented: Patients/residents receive anxiolytic medications only when medically necessary. Every effort is made for patients/residents who use anxiolytics to receive the intended benefit of the medications and to minimize the unwanted effects of the anxiolytic medications. #5- PRN anxiolytic medications should not be given past a 14 day period unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and he/she indicates the duration for the PRN order. 1. R#3 was readmitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. R#3 was assessed with [REDACTED]. The resident was not assessed for having behaviors or rejection of care. R#3 received an antidepressant medication all seven days of the look back period. The Care Area Assessment (CAA) triggered [MEDICAL CONDITION] Drug Use with the decision to be care planned. Review of the care plan for R#3 with an onset date of 1/24/18, identified the resident has the potential for side effects and/or adverse reactions related to the use of antidepressant, antianxiety medication. She has [DIAGNOSES REDACTED]. A care plan Approach included: Observe for significant side effects or adverse reaction: Common-Sedation, Drowsiness, Dry mouth, Blurred vision, [MEDICAL CONDITIONS] Muscle tremor, Agitation, H/A skin rash, photosensitivity. On 4/4/18 increase [MEDICATION NAME] and add antipsychotic r/t [MEDICAL CONDITION] Depression. Record review for R#3 revealed the following medication orders [REDACTED] a. On 4/4/18- Change [MEDICATION NAME] ([MEDICATION NAME]) (an antianxiety medication) to 1.0 mg (milligrams) by mouth every eight hours (q8) at 6:00 a.m., 2:00 p.m., 10:00 p.m. and every six hours (q6) as needed (PRN) for anxiety. Review of the Mediation Administration Record (MAR) for (MONTH) (YEAR) documented that [MEDICATION NAME] 1.0 mg was administered as prescribed from 4/4/18 through 4/26/18 every eight hours. [MEDICATION NAME] 1.0 mg PRN was administered once on 4/4/18 for anxiety. Prior orders for [MEDICATION NAME] were as follows: On 3/16/18- [MEDICATION NAME] 0.5 mg q6 as needed for anxiety. On 1/15/18- [MEDICATION NAME] 0.5 mg q8 as needed for anxiety. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) MARs revealed R#3 received [MEDICATION NAME] 0.5 mg PRN 16 times from 3/2/18 to 4/4/18 for anxiety. b. On 4/4/18- [MEDICATION NAME] (an antipsychotic medication) 25 mg by mouth twice a day (BID) at 9:00 a.m. and 5:00 p.m. c. On 4/4/18- [MEDICATION NAME] (an antianxiety medication) 10 mg by mouth BID (twice daily) at 9:00 a.m. and 5:00 p.m. Prior order for [MEDICATION NAME] was 5 mg BID. d. On 4/4/18- Change [MEDICATION NAME] (a pain medication) 7.5/325 mg to q6 and q4 PRN for pain. Prior orders for [MEDICATION NAME] was 7.5/325 mg q8 hours and q4 PRN for pain. e. On 3/30/18- Trazadone (an antidepressant medication) 100 mg by mouth every bedtime (qHS) f. On 3/26/18- [MEDICATION NAME] (an antidepressant medication) 20 mg by mouth qHS During the resident screening process conducted on 4/24/18 at 10:03 a.m. an interview was attempted with R#3. Despite a BIMS summary score of 15, the resident was drowsy, could not keep her eyes open or stay engaged in conversation and appeared to have some confusion. Interview on 4/24/18 at 3:07 p.m. with the family of R#3 in the resident's room revealed the resident has been drowsy and confused more than her usual. The family stated at one time for a couple weeks, R#3 was yelling constantly and she wouldn't stop and the facility did not know what to do. The facility would call her to come sit with R#3. The family stated R#3 began to holler mostly after she fell in (MONTH) (YEAR) and sustained a [MEDICAL CONDITION] and was having pain. The family stated they started R#3 on [MEDICATION NAME] and pain medication on a scheduled basis. The family stated that one time R#3 was so drowsy she could hardly eat, and the nurses told her it would take a few days to level out. The family stated she had requested an order for [REDACTED].#3 at the time of the family interview revealed the resident sitting in her wheel chair. R#3 would engage in the conversation with noted heavy eyelids. R#3'eyes would shut and she had difficulty finishing a sentence without having to arouse the resident and repeating a question over and over. Observation on 4/25/18 at 8:30 a.m. revealed R#3 sitting at side of bed with her head hanging down and her eyes closed. The resident's bed was in a lowered position with a fall mat at bedside. Observation on 4/25/18 at 8:52 a.m. revealed R#3 sitting on the side of her bed. R#3 could engage in conversation but she was drowsy with slow speech. R#3 stated she had been sick and threw up on the floor. There was no evidence of vomit on the floor. R#3 was somewhat confused and did not appear to feel well. At 10:25 a.m. R#3 was in her bed asleep. At 11:30 a.m. R#3 was again noted sitting at the side of her bed with her head hanging down. At 2:52 p.m. R#3 was in her bed under the covers. The resident was awake and appeared pale in color, tired and her eyelids were red. During an interview with R#3 at the time of the observation, she stated that last night she felt sick as a dog. Stated she feels a little bit better but is staying in bed today. R#3 stated she hurt all over; her head, her hip and her legs hurt all night. Observation on 4/26/18 at 10:19 a.m. revealed R#3 in her bed. The resident was awake and stated that she was feeling better. The resident's eyes were drooping but denied feeling tired. Observation on 4/26/18 at 1:00 p.m. revealed R#3 in her room, sitting in her wheel chair eating her lunch. The resident was awake and alert, her color was improved and she appeared to feel better. During an interview with R#3 at the time of the observation, she stated she walked a long way in Physical therapy today and she was very proud of that. R#3 stated she was feeling better. Interview on 4/26/18 at 1:50 p.m. with the Licensed Practical Nurse (LPN) AA, who was in care of R#3 had behaviors of hollering out at times and complaints of pain. She stated R#3 would get out of bed without assistance and in (MONTH) (YEAR), R#3 had a fall resulting in a [MEDICAL CONDITION] by getting out of her bed by herself. LPN AA stated there was several weeks where the resident's yelling out and hollering had gotten so bad, they would have to put her in geri chair and sit her at the nurse's station. She further stated it was very disruptive to the other residents. LPN AA stated a lot of it was related to pain after her [MEDICAL CONDITION] and she was started scheduled pain medication, scheduled [MEDICATION NAME] and PRN [MEDICATION NAME] as needed in (MONTH) (YEAR). LPN AA stated the residents had not been yelling out lately and this behavior had improved. LPN AA stated that just in the past few days she has noticed the resident was not necessarily over sedated but very mellow and she was wondering herself if the increase in [MEDICATION NAME] might be too much. LPN AA stated she had not documented drowsiness in the MAR for possible side effects but she planned on talking to the doctor about it after she had made more observations. LPN AA stated R#3 did not feel good yesterday so she just wasn't sure. She stated R#3 was not usually like that. Interview on 4/26/18 at 2:20 p.m. with the Director of Nursing (DON) revealed R#3 has good days and bad days. She stated the resident's mood fluctuates often and she has been a delicate balancing act as far as antianxiety and pain medications have gone. The DON further stated they met with Physician BB in Performance Improvement (PI) committee about the regulations related to PRN [MEDICAL CONDITION] medications limited to 14 days. She further stated the nurses have been educated when they receive a PRN [MEDICAL CONDITION] medication that there needs to be a stop date of 14 days and she guessed they just have forgotten. Interview on 4/26/18 at 3:10 p.m. with Physician BB revealed he understands that Medicare does not want residents restrained with medication but in the real world that is not the case. He stated he tries to keep the residents as calm and happy as he can without over medicating them. He stated he was not aware of the 14-day limit on PRN [MEDICAL CONDITION] medications or that he had to document a clinical rationale and duration for orders beyond 14 days. Physician BB further stated he relies on the pharmacy to put a stop date on the medications. Observation on 4/27/18 at 9:15 a.m. revealed R#3 in the mall area in her wheel chair. The resident was very alert, oriented and her color was good. The resident was in good spirits and was smiling. R#3 stated she felt much better and had walked from her bed to the bathroom last night. R#3 stated she knows she is supposed to ask for help and a second time she thought about getting up by herself, she decided No, I'm going to call for help. Interview 04/27/18 at 12:04 p.m. with the LPN CC, who was in care of R#3, revealed the physician decreased the resident's scheduled [MEDICATION NAME] last night from 1.0 mg three times a day to 0.5 mg three times a day. She stated the night shift nurse did not report any behaviors by R#3 and she had not seen any behaviors herself today. LPN CC stated the night shift nurse often reports R#3 does not always sleep well at night, has her nights and days mixed up and they have to put her in a geri-chair and bring her to the nurse's station. LPN CC stated R#3 sort of got slammed with several medications at once. 2. Review of R #41's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Physicians Orders revealed an order dated 11/28/17, for [MEDICATION NAME] ([MEDICATION NAME]) 0.5 milligrams (mg) one tablet by mouth twice daily. Another order on the chart dated 11/03/17 was for [MEDICATION NAME] one mg tablet by mouth every four hours as needed for severe anxiety. Review of her quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she received an antianxiety all seven days of the assessment period. Review of her care plans included one general psycho-social care plan with approaches to observe and monitor resident behavior and mood. Another one was related observing and monitoring for side-effects of antianxiety and antidepressant medications. Record review revealed documentation by the Consultant Pharmacist of monthly Drug Regimen Reviews (DRR) for the resident. Review of the Consultant Pharmacist Communication to the Physician dated 12/01/17 specified that the resident was receiving [MEDICATION NAME] 0.5 mg every 12 hours and [MEDICATION NAME] one mg every four hours PRN for severe anxiety. The Consultant Pharmacist was unable to locate information in the residents' chart that contraindicated an attempt at dose reduction. The Pharmacist suggested a trial reduction of the PRN [MEDICATION NAME] order. On 12/13/17, the physician wrote to continue the PRN [MEDICATION NAME] order. Review of the Behavioral Monitoring Chart for R # 41 located on the Medication Record revealed no documented behaviors during the months of (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). Observations of R #41 on 4/25/18 at 11:05 a.m., 4/26/18 at 9:16 a.m. and 12:19 p.m. and 4/27/17 at 9:45 a.m. revealed that R #41 was alert with no behaviors observed. An interview with R #41 on 4/27/18 at 9:45 a.m. revealed the resident to be sitting in her wheelchair at a table in the Hall area working on putting together a 2000 piece puzzle. She was alert, calm, and smiling as she talked with staff and other residents.

Based on observation, record review, and staff interview, the facility failed to wash dishes in a location that was not exposed to possible contamination from dust; failed to store individual resident water pitchers and lids in a sanitary manner; and failed to ensure that one of one resident refrigerators was kept clean with all items inside labeled and dated. There were 51 residents that consumed an oral diet. Findings include: 1. During initial tour of the kitchen on 5/8/17 beginning at 9:50 a.m., and on 5/9/17 at 12:56 p.m., a thick coating of dust was noted on the grate covering the exhaust fan in the dish machine room. Further observation revealed that the racks of items just washed were pulled out of the the dish machine and were stored directly under this fan until either moved to a different location or until another rack of washed items were pulled out of the dish machine. During interview on 5/10/17 at 1:29 p.m., the Dietary Manager (DM) verified the thick coating of dust on the grate covering the exhaust fan, and that the cleaned dishes pulled out of the dish machine were located directly under this. She stated during further interview that this fan was on frequently as the room often got hot. During interview with the Maintenance Director on 5/10/17 at 1:41 p.m., he verified the dust on the exhaust fan, and stated that he had last pulled the grate off and cleaned it about two months ago, but that he had no documentation of this. During interview with the DM on 5/11/17 at 9:07 a.m., she stated that maintenance took down and cleaned the grate over the exhaust fan. Observation of the exhaust fan on 5/11/17 at 10:50 a.m. revealed that the grate covering the fan was clean and appeared like new. During interview with the DM at this time, she stated that maintenance was going to add it to their list of things to clean monthly. 2. During observation in the Pantry on 5/9/17 at 4:45 p.m., a heavy ice buildup was noted in the freezer section of the resident refrigerator. Further observation revealed that in the freezer was a plastic bag containing ten 3-ounce cups of vanilla ice cream, that appeared to have thawed at one time and then refrozen. A light yellowish substance, possibly melted ice cream, was observed covering the layer of ice in the freezer, and was also observed on the middle shelf and on the floor of the refrigerator, and was sticky. Also observed inside the freezer compartment was a carton of milk, that was so solidly frozen to the ice buildup that the carton could not be dislodged. Observation in the refrigerator section revealed one 16.9-ounce bottle of water, that was half full, but had no name or date when opened on it. Further observations in the Pantry at this time revealed that there were 2-1/4 racks full of insulated water pitchers with lids on the counter close to the handwashing sink, making them subject to splatter when someone washed their hands. In addition, there were four more pitchers and three lids that appeared to be clean directly on the counter between the racks of pitchers and the sink . Further observation revealed that there was one plastic drinking glass with a lid and straw in it, approximately 1/3 full of a light brown liquid with the appearance of tea in it, as well as one plastic drinking glass with a lid and straw with a yellowish liquid on the bottom of the glass, with the appearance of orange juice on the counter between the rack of pitchers and the sink. The straw of the glass with the yellowish liquid was touching one of the pitchers that was on the countertop. During interview with the interim Administrator on 5/9/17 at 4:56 p.m., she stated that the water pitchers on the countertop by the handwashing sink in the Pantry were dirty, and the staff knew this, and that the other pitchers on the racks were clean, and she removed the pitchers she said were dirty and the two dirty plastic glasses. During interview with the DM at this time, she verified the contents and appearance of the refrigerator/freezer, and stated that it was defrosted about three weeks ago. The DM further stated that she was responsible for checking the contents of the refrigerator/freezer, and stated that housekeeping cleaned out the refrigerator when it was dirty. During observation on 5/10/17 at 11:13 a.m., a rack of clean water pitchers and a rack of clean lids were noted to be stacked on top of the ice machine in the Pantry and away from possible contamination from the handwashing sink. Further observation revealed that the refrigerator had been emptied and cleaned, and the freezer defrosted. During interview with the DM on 5/10/17 at 1:29 p.m., she stated that she looked at the refrigerator/freezer in the Pantry on Friday (5/5/17), and that there was not much of an ice buildup at that time. She further stated that a log was not kept of how often the unit was cleaned and defrosted. During interview with Certified Nursing Assistant (CNA) AA on 5/11/17 at 1:06 p.m., she stated that if she needed to get a pitcher for ice water, that she got it out of the Pantry. She further stated that all of the pitchers in the Pantry should be clean. Review of the facility's Patients/Resident's Personal Food policy revealed: To attempt to cooperate with the patient/resident and their family regarding personal food items brought into the healthcare center for patient/resident consumption that will maintain a clean, healthy environment and prevent foodborne illnesses. Food refrigerated must be labeled and dated and will be discarded after 24 hours. Nursing personnel will be responsible for the disposal of outdated foods maintained in the patient/resident's room and those stored in the nursing unit refrigerators.

Based upon observation, record review and staff interviews the facility failed to provide services in accordance with Professional Standards of Care to ensure that X-ray procedures were done in a timely manner, that the physician was notified of abnormal X-ray results a timely manner, that an appointment for the Orthopedic consult was made in a timely manner and the Physical Therapy services were provided in accordance with orders. This failure resulted in actual harm of an immediate and serious threat to the resident health and safety for one (1) resident "B" of twenty (20) sampled residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of 3/09/2011 until 5/27/2011, on which date, the facility implemented an acceptable allegation of immediate jeopardy removal. Although the Immediate Jeopardy was removed, the noncompliance continues at a lesser scope and severity of "D" in order to ensure licensed staff will provide care and services in accordance with professional standards of care. Findings include: Resident "B" had a history of [REDACTED]. The resident was ambulatory with assistance with mobility in a wheelchair. Record review of 3/9/11 revealed the resident fell /slipped from the bed during a transfer at 6:35 a.m. and was lowered to the floor by a private sitter "BB". The Licensed Practical Nurse (LPN) assessed the resident after being assisted by staff back to bed and found the resident's right leg to be turned inward. The resident's attending physician was notified at this time and ordered a right hip X-ray. The facility supplied a cover letter from the private mobile X-ray company on 5/24/11 at 4:15 p.m. revealing the order had been called in at 7:30 a.m. although the X-ray technician did not arrive at the facility until 5:05 p.m. The abnormal X-ray results of a dislocated right hip were faxed and called to the facility at 6:00 p.m. There is no documentation that the nursing staff had attempted to contact the X-ray company to see when they would be arriving, or that the resident's physician was notified until the next day of the abnormal X-ray results or the delay in getting the X-ray done. On 3/10/2011 the physician ordered an Orthopedic consult. The facility supplied a fax cover sheet on 5/27/11 at 8:30 a.m. revealing that a fax had been sent to the Orthopedic office on 3/10/11 at 3:56 p.m. requesting a consult regarding the resident's right hip. There was no further documentation of contact with the Orthopedic office until 3/14/11 at 11:00 a.m. revealing the resident's X-ray films were emailed to the Orthopedic Surgeon's secretary to have the Surgeon's Physician Assistant review the films and advise on weight bearing status and physical therapy. On the same day at 5:00 p.m. an entry in the Nurses Notes reveals the Surgeon's office called stating the resident should be non-weight bearing and no physical therapy. Following a closed reduction on 3/16/11, the resident was re-admitted to the facility on [DATE] with discharge/admission orders [REDACTED]. Record review of the Activities of Daily Living (ADL) form revealed the resident remained on bed rest until 3/21/11 at 11:00 a.m. when physical therapy transferred resident "B" to a wheelchair for an evaluation. Upon returning the resident to bed from the wheelchair at 3:00 p.m. the resident's right leg was noted to be shortened and rotated inward. An X-ray revealed the resident had dislocated the right hip again and was admitted to the hospital for nine (9) days. An interview with the Therapy Manager "DD" on 5/25/11 at 2:00 p.m. revealed that she has a standing order to evaluate and treat resident's from the Medical Director and does not need an order to evaluate. She was unable to locate a written doctors order for physical therapy on 3/21/11. On 5/26/11 at 10:15 a.m. the nursing consultant supplied a signed, but not dated, physician order [REDACTED]." or to get orders to begin PT. Review of the Georgia Practical Nurses Practice Act Scope of Practice Section 2.3.2 Standards related to Licensed Practical Nurse revealed: Section J. Implements appropriate aspects of client care in a timely manner Section K.Communicates relevant and timely client information with other health team members including client status and progress and significant changes in client condition The facility's acceptable plan of removal included: 1. Licensed personnel assessed all residents for risk for falls and developed interventions for those identified as at risk for falls. A standardized Fall Risk Assessment tool to be used. Completion on 5/26/11 2. Director of Health Services/Consultant (DHS) provided inservice of all licensed staff, content included, identifying change in condition and the timely notification of physician of changes, abnormal labs, X-ray results, falls or any occurrence requiring interventions. Completion date 5/26/11 3. Development of policy related to actions to take if the resident's physician is not available. All licensed staff inserviced on new policy. Completion date 5/26/11 4. Development of policy regarding timeliness of making consultation appointments. Inservice of all professional staff. Completion date 5/26/11 5. Improve communication between facility staff by use of 24 hour reporting manual, to be monitored daily by DHS. Inservice of all licensed staff, completion date 5/26/11. 6. A new process to include the new policies will be included in new employee orientation. Completion date 5/27/11. 7. New policies regarding Physician notification and Appointments were revised and staff inserviced on changes. Completion date 5/27/11. Cross Refer to F309

Based on record review, staff and family interview the facility failed to ensure that care and services to promote the highest well being was not provided by not notifying the attending physician in a timely manner of an abnormal X-ray finding and not following the doctor's order in a timely manner related to making an Orthopedic consult appointment. This failure resulted in actual harm of an immediate and serious threat to the resident health and safety for one (1) resident "B" of twenty (20) sampled residents. This noncompliance with the requirements at F309-Care and Services for Highest Well Being was determined to constitute Substandard Quality of Care and it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of 3/09/2011 until 5/27/2011, when the facility submitted an acceptable plan of removal for the immediacy of the jeopardy situation. Findings include: Resident "B" had a history of [REDACTED]. The resident was ambulatory with assistance and mobile with a wheelchair. Record Review revealed that on 3/09/11 at 6:35 a.m. the resident was being assisted by a private sitter to the wheelchair, became weak and was assisted to the floor. The staff was summoned to help put the resident back to bed at this time. The Licensed Practical Nurse (LPN) assessment of the resident at that time revealing the resident complaint of right hip pain and the right leg was turned (rotated) inward. The physician ordered a right hip X-ray. The X-ray revealed a right hip superior lateral dislocation of the acetabular and femoral prosthetic device with severe osteopenia and no obvious acute displaced fracture fragment. On 5/25/11 at 4:15 p.m. the Administrator supplied a document faxed from the X-ray provider, dated 5/24/11 at 3:43 p.m., that the order was placed on 3/09/11 at 7:30 a.m. with the X-ray tech arriving in the facility at 5:05 p.m. and the X-ray report was faxed to facility at 6:00 p.m. on 3/09/11. The fax cover sheet also indicated that the facility was notified by telephone of the X-ray results. Record review of the Nurses Notes revealed a response from the physician on 3/10/11 ordering an Orthopedic Consult. The Orthopedic physician was contacted on 3/14/11 (6 days after the X-ray) at 11:00 a.m. Nurses Notes documented that the X-ray films were emailed to the Orthopedic physician's office and included the Physician's Assistant (PA) would review the films and call regarding weight bearing status and orders for physical therapy. A Nurses Note on the same day at 5:00 p.m. revealed the Orthopedic office called stating the resident should be non-weight bearing and was to have no physical therapy. Record review of the Nurses Notes on 3/16/11 at 6:50 p.m. revealed the resident was admitted to the hospital following the Orthopedist consultation. A nurses note on 3/17/11 at 1:45 p.m. documented the resident was readmitted to the facility after a closed reduction to the right hip. Admission physician orders [REDACTED]. An interview on 5/25/11 at 4:30 p.m. with the Therapy Manager "DD" reveal the resident began receiving physical therapy on 3/21/11. She stated the resident was in pain during the physical therapy (PT) evaluation. An interview with the Therapy Manager "DD" and the DON on 5/25/11 confirmed the Orthopedic surgeon's discharge orders on 3/17/11 were not clear as to the resident's level of activity and doesn't know why the Orthopedic Surgeon wasn't contacted before proceeding with PT evaluation. Therapy Manager "DD" stated a physician order [REDACTED]. Both were unable to produce a written order at this time for the PT evaluation on 3/21/11. The Therapy Manager "DD" says that PT uses their best clinical judgement and felt it was safe to get the resident up for an evaluation. Review of the facility's Occurrence Policy supplied by the facility on 5/25/11 at 3:45 p.m. did not address notifying the physician, assessment after an occurrence or delay in X-ray service. Review of standing orders and facility policy for PT evaluation supplied by Therapy Manager "DD" at the same time revealed a verbal or written order from the physician was required before doing an evaluation. Interview with Director of Nursing (DON) at 2:15 p.m. on 5/24/11 revealed she was unable to explain why it took over ten (10) hours to get the X-ray or to get the order from the physician for an Orthopedic consult. She agreed there was no documentation of contacting the physician when the results were called and faxed to the facility that the resident had a dislocated right hip. She assumed the results were faxed to the MD's office after business hours. An interview on 5/26/11 at 10:22 p.m. with the resident's physician, revealed faxes sent to the office after hours would not be addressed until the next day. The oncall physician was available after hours and should have been called to clarify orders. Review of the physician progress notes [REDACTED]. On 5/05/11 Physical Therapy wanted to get the resident up but the resident's right hip was extremely likely to dislocate. The resident was to remain bed bound until a hip brace was procured. Resident was extremely likely to suffer another hip sublucation without this brace. The facility's acceptable plan of removal included: 1. Licensed personnel assessed all residents for risk for falls and developed interventions for those identified as at risk for falls. A standardized Fall Risk Assessment tool to be used. Completion on 5/26/11 2. Director of Health Services/Consultant (DHS) provided inservice of all licensed staff, content included, identifying change in condition and the timely notification of physician of changes, abnormal labs, X-ray results, falls or any occurrence requiring interventions. Completion date 5/26/11 3. Development of policy related to actions to take if the resident's physician is not available. All licensed staff inserviced on new policy. Completion date 5/26/11 4. Development of policy regarding timeliness of making consultation appointments. Inservice of all professional staff. Completion date 5/26/11 5. Improve communication between facility staff by use of 24 hour reporting manual, to be monitored daily by DHS. Inservice of all licensed staff, completion date 5/26/11. 6. A new process to include the new policies will be included in new employee orientation. Completion date 5/27/11. 7. New policies regarding Physician notification and Appointments were revised and staff inserviced on changes. Completion date 5/27/11.

Based on observation, record review and staff interviews the facility failed to be administered in a manner that ensured efficient and effective use of facility resources. The failure to have procedure and/or policies for the delivery of care and services in accordance with professional standards of care, ensure prompt notification of abnormal X-ray results and that care was provided in accordance with physician orders [REDACTED]. Although the Immediate Jeopardy was removed, the noncompliance continues at a lesser scope and severity of "D" in order to ensure ongoing compliance with the plan of removal. Findings include: Administrative staff failed to ensure facility staff provided care in accordance with professional standards of care. The professional staff seek clarification of orders prior to initiating care. Cross refer to F281 Administrative staff failed to ensure policy and procedures were in place and/or followed regarding notification of changes in condition, providing prompt specialized consultation appointment, ensure that care is provided in accordance with physician orders. Cross refer to F309 Administrative staff failed to ensure prompt notification of abnormal X-ray results. Cross refer to F511 The facility's acceptable plan of removal included: 1. Licensed personnel assessed all residents for risk for falls and developed interventions for those identified as at risk for falls. A standardized Fall Risk Assessment tool to be used. Completion on 5/26/11 2. Director of Health Services/Consultant (DHS) provided inservice of all licensed staff, content included, identifying change in condition and the timely notification of physician of changes, abnormal labs, X-ray results, falls or any occurrence requiring interventions. Completion date 5/26/11 3. Development of policy related to actions to take if the resident's physician is not available. All licensed staff inserviced on new policy. Completion date 5/26/11 4. Development of policy regarding timelessness of making consultation appointments. Inservice of all professional staff. Completion date 5/26/11 5. Improve communication between facility staff by use of 24 hour reporting manual, to be monitored daily by DHS. Inservice of all licensed staff, completion date 5/26/11. 6. A new process to include the new policies will be included in new employee orientation. Completion date 5/27/11. 7. New policies regarding Physician notification and Appointments were revised and staff inserviced on changes. Completion date 5/27/11.

Based on record review and staff interview the facility failed to ensure that the physician was notified promptly of an abnormal X-ray findings which resulted in a delay of services to one (1) resident ("B") with a dislocated hip from a sample of twenty (20) residents. It was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of 3/09/2011 until 5/27/2011, when the facility submitted an acceptable plan of correction. Although the immediate jeopardy was removed, noncompliance continues at a lesser scope and severity of "D". Findings include: Record review of nurses notes dated 3/9/11 revealed the resident fell /slipped from the bed during a transfer at 6:35 a.m. to the wheelchair and was lowered to the floor by a private sitter. The Licensed Practical Nurse (LPN) assessed the resident after being assisted by staff back to bed and found the resident's right leg to be turned inward. The resident's attending physician was notified at this time and ordered a right hip X-ray. The facility supplied a cover letter from the private mobile X-ray Company on 5/24/11 at 4:15 p.m. revealing the ordered had been called in at 7:30 a.m. although the X-ray technician did not arrive at the facility until 5:05 p.m. The abnormal X-ray results of a dislocated right hip were faxed and called to the facility at 6:00 p.m. There is no documentation that the nursing staff notified the resident's physician until the next day of the abnormal X-ray results. An interview on 5/26/11 at 10:22 a.m. with resident's physician revealed that his office would have been closed at 6:00 p.m., therefore, if results were faxed to his office he wouldn't have known until the next day. There was an oncall physician and the facility should have called the results to the oncall physician. cross to F309 The facility's acceptable plan of removal included: 1. Licensed personnel assessed all residents for risk for falls and developed interventions for those identified as at risk for falls. A standardized Fall Risk Assessment tool to be used. Completion on 5/26/11 2. Director of Health Services/Consultant (DHS) provided inservice of all licensed staff, content included, identifying change in condition and the timely notification of physician of changes, abnormal labs, X-ray results, falls or any occurrence requiring interventions. Completion date 5/26/11 3. Development of policy related to actions to take if the resident's physician is not available. All licensed staff inserviced on new policy. Completion date 5/26/11 4. Development of policy regarding timelessness of making consultation appointments. Inservice of all professional staff. Completion date 5/26/11 5. Improve communication between facility staff by use of 24 hour reporting manual, to be monitored daily by DHS. Inservice of all licensed staff, completion date 5/26/11. 6. A new process to include the new policies will be included in new employee orientation. Completion date 5/27/11. 7. New policies regarding Physician notification and Appointments were revised and staff inserviced on changes. Completion date 5/27/11.

Based on observation, record review and staff interview the facility failed to have an effective Quality Assurance Process that identified the facility's failure to ensure appropriate treatment for one (1) resident, "B" of twenty (20) sampled residents and failed to effectively communicate to all staff issues identified by the committee for improvement. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of 3/09/2011 and continued until 5/27/2011 when the facility submitted an acceptable plan of correction. Although the immediate jeopardy was removed, noncompliance continues at a lesser scope and severity of "D" to ensure compliance with interventions are followed. Findings include: The Administrator was interviewed on 5/27/2011 at 10:25 a.m. and provided information about the facility's Quality Assurance Program. The Administrator stated the committee met monthly and the Medical Director attended every three (3) months. In addition to the Medical Director, committee membership included the Administrator, the Director of Nursing (DON) and all Department Heads. The agenda for each month included a discussion of old business and assessment of progress for any current improvement plan. The Administrator further stated approaches to action plans are changed as necessary. Administrator stated they are currently working on physician notification, change of condition, falls, alarm battery checks and the Occurrence Reduction Program. However, the process failed to prevent a delay in treatment for resident "B" who sustained a right hip dislocation following a fall on 3/09/2011. Licensed Practical Nurse (LPN) "AA" was interviewed on 5/27/2011 at 11:00 a.m. and stated she did not know what issues were currently in the quality assurance process now, or during the previous 6 months. The facility's acceptable plan of removal included: 1. Licensed personnel assessed all residents for risk for falls and developed interventions for those identified as at risk for falls. A standardized Fall Risk Assessment tool to be used. Completion on 5/26/11 2. Director of Health Services/Consultant (DHS) provided inservice of all licensed staff, content included, identifying change in condition and the timely notification of physician of changes, abnormal labs, X-ray results, falls or any occurrence requiring interventions. Completion date 5/26/11 3. Development of policy related to actions to take if the resident's physician is not available. All licensed staff inserviced on new policy. Completion date 5/26/11 4. Development of policy regarding timelessness of making consultation appointments. Inservice of all professional staff. Completion date 5/26/11 5. Improve communication between facility staff by use of 24 hour reporting manual, to be monitored daily by DHS. Inservice of all licensed staff, completion date 5/26/11. 6. A new process to include the new policies will be included in new employee orientation. Completion date 5/27/11. 7. New policies regarding Physician notification and Appointments were revised and staff inserviced on changes. Completion date 5/27/11. Cross refer to F309 and F511

Based on observation, record review and staff interview, it was determined that the facility failed to ensure that residents did not develop pressure ulcers and failed to provide the necessary treatment and services to promote healing and prevent new ulcers from forming for one (1) resident ("B") from a sample of twenty (20) residents. This resulted in actual harm to resident "B". Findings include: 1. Resident "B" was admitted to the facility on [DATE] after repair of a fractured right hip. The resident was ambulatory with assistance and mobile with a wheelchair until contracting the flu on 3/03/11. The resident was able to turn independently while in the bed. On 3/09/11 at 6:35 a.m. the resident was being assisted to transfer to the wheelchair by private sitter "BB" and fell /slipped and was assisted to the floor by "BB" resulting in a dislocated right hip. The resident has been bed bound since 3/09/11. Resident "B" was assessed by the Licensed Practical Nurse "AA", the Treatment Nurse, on 3/11/11 as having a "denuded" area on the sacrum but was not staged. The area measured 2centimeter (cm) x 2 cm x zero (0) cm. The resident had an order dated 3/10/11 to clean sacrum with normal saline and apply a [MEDICATION NAME] dressing to the area and change every five (5) days and prn (as needed) then monitor daily. Record Review of the Treatment Administration Record (TAR) revealed the dressing was applied on 3/10/11 and changed on 3/15/11. There were no additional skin notes prior to admission to the hospital on [DATE]. An interview with treatment nurse, LPN "AA" on 5/24/11 at 2:15 p.m. revealed the resident did not have an open area prior to the hospitalization on [DATE]. Record review of the Orthopedic surgeon's hospital admission notes dated 3/16/11 revealed the resident had a Stage III or IV pressure sore to the sacrum measuring four (4) cms in diameter and ordered a Wound Nurse Consult. The hospital wound nurse assessed the pressure ulcer on 3/16/11 at 8:30 p.m. with findings of a 10 cm X 7 cm unstagable pressure sore with heavy black eschar and a [MEDICATION NAME] which was rolled up at the edges and soaked with urine. During observation of pressure treatment on 5/25/11 at 10:00 a.m., LPN "AA" cleaned the top of the resident's overbed table with hand sanitizer then covered the table with a plastic bag. LPN "AA" put a small amount of hand sanitizer in a medicine cup which was used during the treatment to clean her hands between changing her gloves. When the [DEVICE] dressing was removed a strong foul odor was noted. The wound was noted to be a large and deep ulcer with eschar noted on the left side of the wound edge and inside the wound on the right side, a small area of wound edge was raw and breaking down. The wound was not measured at this time. LPN "AA" cleaned the Inside of wound with a gauze soaked with normal saline. An interview with Director of Nursing (DON) on 5/25/11 at 1:55 p.m. revealed that it appears the resident had a more involved sacral wound before admission to hospital on [DATE]. Review of the facility's policy and procedure for Staging of Pressure Ulcers, revealed that a Stage II is described as a partial thickness loss of skin involving the epidermis and/or dermis. The definition of denuded from the Merriam-Webster dictionary is: to strip all covering or surface layers. Review of the facility's policy and procedure for Documentation of Skin and Wound Care revealed that wound assessments are to be done weekly and documented on the Skin Integrity form with additional narrative added on the Skin Notes. Skin Integrity notes were not begun for this resident until 3/17/11.