Every finding on record at Signature Healthcare of Glasgow Rehab & Wellness C

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The failure had the potential to affect all residents who consumed meals from the kitchen.The findings include:Review of the facility's policy titled, Dietary Services, revised 02/15/2024, revealed the facility was to utilize best practices guidelines in matters pertaining to dietary and nutrition. Further review revealed the facility was to work with the dietary department, Registered Dietician, Physician, and the contracted dietary provider in determining the best practices and each resident's individual needs. Review of the facility's policy titled, Food Storage; Cold Foods, revised 04/2018, revealed all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, were to be appropriately stored in accordance with the guidelines of the Food and Drug Administration (FDA) Food Code. Per review, freezer temperatures were to be maintained at a temperature of 0 degrees Fahrenheit (F) or below and an accurate thermometer was to be kept in each refrigerator and freezer. Additionally, policy review further revealed all foods were to be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy titled, Food Storage; Dry Goods, revised 09/2017, revealed all dry goods were to be appropriately stored in accordance with the FDA Food Code. Further review revealed all packaged and canned food items were to be kept clean, dry, and properly sealed. 1). Observation of the kitchen's walk-in refrigerator, on 07/07/2026 at 4:20 PM, revealed a large sheet pan of cheesecake, with a sheet of aluminum foil lying loosely over top of it, that was not sealed around the pan to prevent the food from potential contamination. Continued observation revealed a large zip lock bag of sliced bologna with an expiration date of 07/06/2026 noted on the bag; however, remained on the shelf for service to residents. In interview with the Dietary Manager (DM), on 07/07/2026 at 4:30 PM, she stated the cheesecake was for the next day's meal service, and she was not aware it needed to be completely covered. She further stated the bologna should have been discarded by the expiration date of 07/06/2026.2). Observation of the walk-in freezer, on 07/07/2026 at 4:35 PM, revealed no thermometer available for checking the temperature. Further observation of the walk-in freezer revealed biscuits in their original packaging (box); however, the inner wrapping was uncovered exposing the biscuits to air contaminants. 3). Observation of the dry storage pantry, on 07/07/2026 at 4:45 PM, revealed a large clear plastic container labeled as corn flake cereal with an expiration date of 07/02/2026. Continued observation of the dry storage pantry revealed a large clear plastic container of round Cheerio type cereal that was unlabeled and undated. Further observation revealed three large bins unsealed, labeled as sugar, flour, and brown sugar, with the lids lying loosely on top of the containers. In addition, observation revealed a dented 50 ounce (oz) can of cream of mushroom soup, and a dented 112 oz can of tomato ketchup stored in active rotation for meal service to residents. In interview with the DM, on 07/09/2026 at 5:32 PM, she stated her expectation for dietary staff was for them to ensure all food items stored were labeled, dated, and covered properly when stored in the refrigerator, freezers, and dry storage pantry. She said all expired food items were to be discarded, and all dented or damaged cans should have been removed from active rotation, so those items were not served to residents. The DM further stated her expectations, included all dietary staff to follow the dietary policies to ensure food safety procedures were being followed.During an interview with the Administrator, on 07/09/2026 at 6:00 PM, she stated the dietary department service was provided by an outsourced contract company, which had their own policies and procedures. She stated her expectation however, was for the dietary staff to follow those policies and procedures to ensure safe food service for the residents in the facility.

Based on observation, interview, and review of facility policy, the facility failed to ensure the protection of private personal information for for 1 of 1 residents, sampled during medication administration, out of the total sample of 13 residents, (Resident (R)37). Registered Nurse (RN) 2 walked away from the medication cart leaving the computer screen, with R37's information on it, opened and unattended.The findings include:Review of the facility policy titled, Medication Administration, revised 06/24/2024, revealed staff were to provide for (residents') privacy as appropriate during medication administration.Review of the facility policy titled, Electronic Medical Records, revised 01/31/2025, revealed the facility was to make reasonable efforts to limit the use or disclosure of (residents') protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure.Review of the facility policy titled, Notice of Privacy Practices, revised 08/20/2025, revealed the facility was required by law to maintain the privacy and security of a resident's protected health information. In addition, policy review revealed the facility must follow the duties and privacy practices described in the notice and give the resident a copy of it. Observation of Registered Nurse (RN) 2, during medication administration on 07/08/2026 at 9:50 AM, revealed the RN walked away from the medication cart, leaving the computer screen open and unattended with Resident (R)37 information on it.During an interview with RN 2 on 07/08/2026 at 10:00 AM, she stated that she had minimized the screen and thought that was sufficient enough. She stated she thought that none of the information could be seen on the screen. She further stated normally she covered the screen or closed her computer prior to walking away from it.During an interview with the Director of Nursing (DON) on 07/09/2026 at 5:53 PM, she stated her expectations were for nursing staff to follow the facility's policies, and the federal Health Information Portability and Accountability Act (HIPAA) guidelines. During an interview with the Administrator on 07/09/2026 at 6:11 PM, she stated she expected staff to follow the regulations in regard to protecting residents' private medical information. The Administrator further stated she did not have a response regarding any potential negative outcomes that might come from leaving a computer screen open.

Based on observation, interview, and review of facility policy, the facility failed to ensure medications and medication-related products were stored in accordance with professional standards for 1 of 3 medication carts inspected during the State Survey Agency (SSA) survey, which had the potential to affect residents receiving medications from that cart.The findings include: Review of the facility policy titled, Medication Administration, revised 06/24/2024, revealed staff were to check the expiration dates on packages or containers. Further policy review revealed staff checking the expirations dates was performed to ensure no expired medications were administered to a resident.Review of the facility policy titled, Medication Storage, Storage of Medication, dated 01/2025, revealed medications and biologicals were to be stored properly, following the manufacturer's or provider pharmacy's recommendations, to keep the integrity and support safe, effective drug administration. Continued review of the policy revealed outdated, contaminated, discontinued or deteriorated medications were to be immediately removed from stock and disposed of according to procedures for medication disposal. Further policy review revealed medication storage conditions were to be monitored on a regular basis as a random quality assurance (QA) check.Observation of a medication storage cart, located on the 200 Hall, on 07/08/2026 at 9:45 AM, revealed one expired 30 fluid (fl.) ounce (oz.) cherry flavored bottle of liquid protein medical food product with an expiration date of 06/11/2026. Continued observation revealed three containers of germicidal bleach wipes with the following expiration dates: 05/10/2026; 06/04/2025 and 06/24/2026. Review of the manufacturer's website information at www.cloroxpro.com, for the Clorox germicidal wipes, revealed the wipes had a shelf life of 12 months.During an interview with Registered Nurse (RN) 2 on 07/08/2026 at 9:47 AM, she stated there was no actual schedule for checking the medication carts for expired products/medications; however, checked for those, from time to time. She said the nightshift nurse told her she had just checked the medication carts last night and they were good, so she (RN 2) did not think to check for expired things behind the nightshift nurse. RN 2 reported the nightshift nurse must not have looked at the expired items' dates. She further stated a potential negative outcome of using expired products was they might not work as well or be ineffective. During an interview with the Director of Nursing (DON) on 07/09/2026 at 5:53 PM, she stated her expectations for the medication carts was for them to be kept locked, clean, and checked for expired medications and supplies routinely. She said she recently started as the facility's DON about six weeks ago and was unsure if the facility had a process already in place for checking the carts. The DON further stated however, expired items should not have been left on the medication cart. She additionally said any negative outcomes would be hypothetical as it depended on what was expired. During an interview with the facility's Administrator on 07/09/2026 at 6:11 PM, she stated she would defer to the facility's policies and regulations guiding that aspect of resident care. The Administrator further stated she did not have a response regarding any potential negative outcomes (that might occur regarding the expired items identified on the medication cart).

Based on interviews and document reviews, it was determined the facility failed to ensure there was a qualified food and nutrition director with appropriate competencies and skills sets to carry out food and nutrition services The facility failed to ensure the Director for Food and Nutrition Services was a Certified Dietary Manager (CDM), a Certified Food Service Manager, had a national certification for food service management, or had an associates or higher degree in food service management. This could affect all residents who receive meals from the kitchen. Facility census of sixty-one (61) residents. Findings included: Review of the job description for Dining Services Director, revised 09/2017, revealed, A facility that employs a qualified dietitian less than full time should require a full time Director of Dining Services who is a certified dietary manager or a certified food service manager or has similar national certification for food service management and safety from a national certifying body; or had an associates or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and in states that had established standards for food service managers or dietary managers, should meet state requirements for food service managers or dietary managers. Review of the Dietary Manager's (DM) personnel record revealed completion of in-services (dated 08/03/2021) for personal protective equipment (PPE); hand washing; cleaning and sanitizing; cross contamination; garbage and trash disposal; glove usage; grease fire procedures; knife, slicer, and cutting board use; plate presentation; pots and ware washing; receiving and storage of food; service line procedure; texture modification; time and temperature control; and labeling and dating. A ServSafe (food safety course) certification was completed on 12/13/2019. The CDM certification program had been not been completed, but had been started with a portion of module one (1) completed. Interview with the Registered Dietitian (RD), on 09/23/2021 at 9:00 AM, revealed she was in the facility every week, not to exceed eight (8) hours. She stated she completed resident assessments, portions of the Minimum Data Set (MDS) assessment, followed up on weights and skin concerns, and visited with residents for needed assessments. The RD further stated the current DM was not a Certified Dietary Manager (CDM). She stated the current DM obtained resident preferences and was the nutrition representative for the Nutrition At Risk (NAR) meetings. Interview with the Dietary Manager (DM), on 09/23/2021 at 9:47 AM, revealed he had been the DM for about two and a half (2.5) to three (3) months. He stated it was supposed to have been a more permanent position, but he was transferring to another facility. He further stated he had completed some of the first module for the CDM program, but an extension had to be filed. He stated it had been tough with COVID-19. Interview with the Nursing Home Administrator (NHA), on 09/24/2021 at 10:30 AM, revealed the DM had been in the current position since July 2021. She further stated she was aware of the DM education/training requirement, but was not aware of the DM's past work experience or his progress in the CDM course.

Based on observations, interviews, and facility policy review, it was determined the facility failed to label and date one (1) vial of [MEDICATION(S)] and failed to dispose of a medication after the dispose-of date in one (1) of two (2) medication rooms (Grace Hall). The facility also failed to dispose of a liquid protein supplement sixty (60) days after opening on one (1) of five (5) medication carts (Oak Lawn 1). Findings included: Review of the facility's policy titled, Medication Administration General Guideline, reviewed 09/2018, indicated, expiration dates should be checked on packages/containers and no expired medications should be given to a resident. The nurse should place a date opened sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. Observation on 09/24/2021 at 9:31 AM, of the medication refrigerator in the Grace Hall Medication Room, revealed an opened and undated multi-use vial of [MEDICATION(S)] (PPD) Diluted [MEDICATION(S)]. Further observation revealed a liquid medication mixture for wound care for Resident #14. The bottle of medication had a label that indicated, DO NOT USE AFTER 08/29/2021. Observation on 09/24/2021 at 8:40 AM, of the Oak Lawn 1 medication cart, revealed a container of a liquid protein supplement with an open date of 06/21/2021 on top of the cart. Further observation of the label of the protein supplement indicated the supplement should be discarded 60 days after opening. Certified Medication Aide (CMT) #2 verified at that time the liquid protein supplement was outdated and should have been taken out of the medication cart. CMT #2 stated he/she was unsure why the protein supplement remained on the cart. Interview with Licensed Practical Nurse (LPN) #1, on 09/24/2021 at 9:40 AM, revealed the PPD had no opened date, and the liquid wound care medication was past the expiration date. LPN #1 stated the person that opened the vial of PPD was responsible for writing the open date on the vial. She further added she was unsure how the liquid medication would be disposed. LPN #1 stated she was not sure who was responsible to ensure the medication refrigerator did not contain discontinued, unlabeled, or outdated medications. Interview with the Assistant Director of Nursing (ADON), on 09/24/2021 at 10:30 AM, revealed typically the night nurses were responsible for taking discontinued medications out of the carts and out of the medication rooms. The ADON added that any nurse or CMT that opened a vial or bottle of a medication were responsible for dating when opened and removing the medication when outdated or discontinued. She further stated that she and the DON reviewed medication carts and medication rooms weekly to make sure all medications were labeled and ensured discontinued medications had been removed or discarded. The ADON stated that leaving the medications on the cart after expiration and not dating the medications was an oversight of the nurses, the CMTs, and the supervisory staff. Interview with the Director of Nursing (DON), on 09/24/2021 at 9:30 AM, revealed the nurse or CMT on the hall that opened a medication was responsible for placing an opened date on the medication. The nurses or CMT on the hall were also responsible for removing any discontinued, outdated, or unlabeled medications. The DON added the nurse managers for the halls checked the medication carts and the medication rooms one (1) to two (2) times per week to make sure all medications were dated when opened and/or removed when discontinued. She was unsure why the PPD had not been dated or the wound medication and the liquid protein supplement remained on the cart when expired.

Based on observations, interviews, and facility policy review, it was determined the facility failed to provide a privacy cover for a urinary catheter drainage bag for one (1) of three (3) sampled residents (Resident #59) reviewed for dignity. Findings included: Review of the facility's policy, titled, Catheter Care Procedure, revised 05/23/2020, revealed, drainage bags should be routinely checked to ensure drainage bag is covered with a privacy cover unless resident requested otherwise. Record review revealed the facility admitted Resident #59 on 09/18/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record revealed no Minimum Data Set (MDS) assessment had been completed yet for the resident. Review of Resident #59's Comprehensive Care Plan, dated 09/20/2021, revealed Resident #59 had an indwelling catheter and staff were to provide catheter care as ordered. Observation on 09/21/2021 at 9:43 AM, revealed Resident #59 lying in bed, with a catheter drainage bag hanging on the right side of the bed. The catheter bag was not covered with a privacy bag. Further observation revealed urine was visible in the bag upon entering the resident's room. Observation on 09/22/2021 at 12:53 PM, revealed Resident #59 lying in bed, with a catheter drainage bag hanging on the right side of the bed. The catheter bag was not covered with a privacy bag. Further observation revealed urine was visible in the bag upon entering the resident's room. Observation on 09/23/2021 at 10:50 AM, revealed Resident #59 lying in bed, with a catheter drainage bag hanging on the right side of the bed. The catheter bag was not covered with a privacy bag. Further observation revealed urine was visible in the bag upon entering the resident's room. Observation, on 09/24/2021 at 8:35 AM, revealed Resident #59 lying in bed, with a catheter drainage bag hanging on the right side of the bed. The catheter bag was not covered with a privacy bag. Further observation revealed urine was visible in the bag upon entering the resident's room. Interview with Certified Nurse Aide (CNA) #2, on 09/24/2021 at 10:20 AM, revealed CNA staff were responsible for ensuring catheters were always in a privacy bag because it was part of catheter care provided. Interview with Certified Nurse Aide (CNA) #1, on 09/24/2021 at 10:40 AM, revealed CNA staff were responsible for a resident's catheter care by ensuring the catheter bag was always in a privacy bag. Interview with the Director of Nursing, on 09/24/2021 at 10:46 AM, revealed that a resident's catheter bag should always be in a privacy bag. The DON stated if staff moved Resident #59 out of the bed into a wheelchair, the staff possibly forgot to put the catheter bag back inside the privacy bag.

Based on observations, record reviews, interviews, and facility policy review, it was determined the facility failed to ensure adequate nutrition status for the healing of pressure injuries for one (1) of three (3) sampled residents (Resident #46). The facility failed to ensure ordered fortified foods were provided and according to the resident's preference, ensure adequate assistance at meals, ensure reassessment of supplement effectiveness, and ensure finger foods were provided. Findings included: Review of the facility's policy titled, Medical Nutrition Therapy: Assessment and Care Planning, revised 09/2017, revealed, The Registered Dietitian Nutritionist (RDN) or other clinically qualified nutrition professional would be responsible for ensuring follow-up and appropriate documentation of recommended changes in the plan of care. Review of the facility's policy titled, Assistance with Meals, reviewed 06/27/2018, revealed, The facility staff would serve residents meals and help residents who required assistance with eating. Review of the facility's policy titled, Resident Food Preferences, reviewed 07/11/2018, revealed, The Dietitian would visit residents periodically to determine if revisions were needed regarding food preferences. The nursing staff would inform the kitchen about resident requests. The Food Services Department would offer a limited number of food substitutes for individuals who do not want to eat the primary meal. Record review revealed the facility admitted Resident #46 on 01/06/2021 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/31/2021, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), which indicated intact cognition. Further review of the assessment revealed the resident required one-person physical limited assistance with eating. The assessment revealed the resident was identified as having weight loss and was not on a physician-prescribed weight loss regimen. Further review of the assessment revealed the resident was identified as having six (6) stage one (1) pressure ulcers, two (2) stage two (2) pressure ulcers (one (1) out of the two (2) pressure ulcers was present on admission), three (3) stage three (3) pressure ulcers (one (1) out of the three (3) pressure ulcers was present on admission), and one (1) stage four (4) pressure ulcer, present on admission. Review of the Comprehensive Care Plan, last revised 08/27/2021, revealed the resident had actual nutrition and/or hydration risk related to significant weight loss, multiple pressure ulcers (PU), weakness, and vitamin/mineral deficiencies. Interventions included finger foods when possible, supplement, vitamins and minerals as ordered, and provide diet as ordered. Observation and interview with Resident #46, on 09/22/2021 at 12:45 PM revealed the resident was in bed with a meal on the bedside table. Resident #46 stated the staff member told the resident she was coming back to help assist with the meal. The resident stated the meal had been sitting there for about half an hour and the food was cold. The resident stated staff never came back for meal assistance. The resident stated the facility did not provide preferences. The resident stated, they give what they want to. The lunch meal consisted of a glass of tea or juice, two (2) containers of sherbet, mashed potatoes, broccoli, a slice of bread, and a carton of milk. There was no ice cream, finger foods, or fortified milk observed on the tray. The resident further stated they were provided a supplement but did not like it and preferred a different flavor of vanilla instead of chocolate. The resident stated that not getting fed by staff was the problem, as the resident could not feed themselves and needed assistance to eat. Observation of the resident revealer he/she was leaning to the right side with their head on a pillow and was unable to fully move his/her upper extremities. Observation and interview on 09/22/2021 at 12:45 PM, revealed an unidentified staff member came into the room to assist Resident #46's roommate. Further observation revealed Resident #46 asked the staff where the certified nurse aide (CNA) was who was supposed to help him/her and the staff member stated the CNA had went on break. The staff member left the room to get another staff member to help reposition this resident. The resident attempted to pick up the melted sherbet but was unable to. The staff came back to assist the resident, and they asked the resident about breakfast. The resident stated they did not like the breakfast food, so they did not eat it. The resident stated they did not like the eggs, sausage, and biscuit the resident received most days. The resident asked them if they could warm the food up. The resident was observed to have offered the carton of milk to the roommate. At 1:07 PM, the staff proceeded to feed the resident his/her lunch meal. Review of Resident #46's meal intakes, dated 09/22/2021, revealed the resident had consumed 1-25% of his/her breakfast and 51-75% of his/her lunch. A review of the computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Start date of 01/06/2021: Multivitamin with [MEDICATION(S)] once a day. - Start date of 01/06/2021: [MEDICATION(S)] 220 milligram (mg) once a day. - Start date of 01/19/2021 and discontinued 08/16/2021: Pro-Stat advanced wound care (AWC) 30 milliliter (ml) twice a day. - Start date of 05/09/2021: Vitamin C 500 mg, once a day. - Start date of 07/14/2021 and discontinued 09/14/2021: Juven ([MEDICATION(S)]-[MEDICATION(S)]-calcium powder). - Start date of 07/16/2021: Diet order - Regular with thin fluids, finger foods when possible. Kennedy (specialized spill proof cup) cup for thin liquids. Fortified milk with meals. Ice cream with all meals. Magic cup - HS (night) snack. - Start date of 09/08/2021: [MEDICATION(S)] ([MEDICATION(S)]) 15 mg once a day. - Start date of 09/16/2021: Med plus 200 milliliter (ml/cc) or five (5) times a day. A record review revealed fluctuations between Med Plus and sugar free (SF) Med Plus since admission. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note, dated 09/08/2021, revealed the resident felt okay but was having complaints of not having enough help with eating. Further review revealed he resident did not like the food there and it was hard to eat what you don't like. Review of the Progress Note further revealed a new order for [MEDICATION(S)] fifteen (15) mg at night (HS) for increased hunger and depression. Continued review of the note indicated the resident's life was declining fast related to not eating enough protein and the body could not heal. The resident was aware of this, and stated they would try to eat more as long as staff provided all meals with feedings. Review of the Nurse Practitioner (NP) notes of service, dated 08/12/2021, revealed the resident's assessment and plan for protein calorie malnutrition. The NP documented she discussed ways with the resident to increase the resident's calorie intake as well as protein intake to promote wound healing. The NP discussed the patient's dietary likes and dislikes. The resident's food preferences were passed along to the dietary department and there was a request for the dietary manager to review further with the resident. The NP documented the resident was a moderate risk and would follow up to monitor. Review of the registered dietitian's (RD) quarterly assessment, dated 08/13/2021, revealed the resident's weight was 156 pounds. Usual food intakes were noted as 25-50%. The interventions included: 200 ml sugar free (SF) Med Pass five (5) times/day, Juven twice a day (BID), and 30 ml Pro-Stat BID. The nutrition care summary revealed the resident was receiving multiple nutrition interventions to help meet estimated nutrition needs for weight maintenance and wound healing. The resident had many pressure ulcers in various stages, significant weight loss since admission but was relatively stable over the last 90 days. The resident's intakes were fair, the resident accepted Med Pass supplement, but did not accept Juven. The note indicated that intake of Med Pass alone could have met the resident's estimated nutrition needs for weight maintenance. The RD recommend discontinuing Pro-Stat due to the resident refusing it. The goals included no significant weight changes and improved skin condition. Review of the NP note of service, dated 08/31/2021, revealed the resident was a moderate risk resident who was monitored for multiple chronic conditions including stage four (4) pressure ulcer. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Weight was noted at 145 pounds. The assessment and plan revealed the resident had a significant weight drop over the past week. The NP would have dietary re-evaluate the patient preferences and encourage supplementation of the resident's oral intake with Med Plus. The goals of care included that the NP discussed with the resident the overall goal of tissue and wound healing and the importance of proper nutrition to assist in the continued healing of the resident's large stage four (4) pressure wound. There was no mention of the resident's additional pressure areas. Interview with Med Tech (MT) #1, on 09/22/2021 at 2:03 PM revealed the resident took the Med Plus supplement sometimes. MT #1 stated the flavor of the supplement was vanilla, but they sometimes had butter pecan. She was unaware if other supplements had been attempted for this resident. She stated the resident ate a lot of snack foods and liked sweets. Interview with MT #2, on 09/23/2021 at 7:43 AM, revealed the resident refused the Med Plus supplement. MT #2 stated the resident reported it was too thick and did not like the taste. No other supplements had been attempted with the resident. She stated Ensure or Boost supplements were usually provided by the families. She had not seen any carton nutritional shakes in a while. She stated the resident ate well if they fed the resident. The resident loved pinto beans and would eat that every day. She stated the resident enjoyed candy and chips brought in from the family. Observation of the resident on 09/23/2021 at 7:54 AM, revealed the resident received a carton of whole milk with the breakfast meal. Further observation revealed there was no fortified milk on the tray. The Director of Nurses (DON) was observed to feed the resident 12 minutes after meal was delivered. The resident had received an egg omelet, a piece of sausage, and a piece of toast. The DON was interviewed following the observation and reported the resident consumed a Magic Cup (high calorie frozen ice cream equivalent) and a honey bun at breakfast. The DON said the resident did not like milk. Observation of the resident, on 09/23/2021 at 12:15 PM, revealed the resident received a glass of milk but did not drink it. Further observation revealed the resident was not provided with any finger foods and he/she had consumed some of the meat, potatoes, and peas provided. The resident stated he/she only drinks milk with cereal. Interview with Cook #2, on 09/23/2021 at 8:51 AM, revealed they prepared fortified foods which included oats with brown sugar, milk with dry powder, mashed potatoes with extra butter, and cream soup with powdered milk. Interview with the Registered Dietitian (RD) on 09/23/2021 at 9:00 AM, revealed her work duties included completing resident assessments, MDS assessments, following up on weights and skin, and monthly kitchen sanitation audits. She stated they had fortified foods, carton nutritional shakes, nutrition treats, Med Plus supplement, Pro-Stat, and Juven to help with weight gain. The Dietary Manager (DM) usually obtained resident food preferences. She stated they had a standard menu and always had a list of foods available. She stated when a resident had a food dislike, they placed it into the system so that the food item would not show up on the tray card. Interview with the RD, on 09/23/2021 at 9:37 AM, revealed the facility had a Nutrition at Risk (NAR) meeting, but she was not involved in the meeting. She stated the staff would notify her if there was something she needed to know. She said the DM was the nutrition representation at the meeting. Interview with the DM, on 09/23/2021 at 9:54 AM, revealed he completed resident food preferences on admission and upon any resident complaints. He stated he participated in the NAR meeting and they reviewed weight losses during the meeting and added any new interventions needed. The DM further stated potential interventions included appetite stimulants, fortified foods, double portions, and supplements. He stated they had not had to add any additional supplements at meals or snack times for any residents. Interview with the RD, on 09/23/2021 at 9:54 AM, revealed she monitored meal percentages for the Med Pass supplements. She stated she considered the meal percentage equivalent to the percentage of fortified food consumed. Additional interview with the RD, on 09/23/2021 at 11:51 AM, revealed Resident #46 did not eat much. She stated she had not spoken to the resident directly. The resident was on palliative care, and she had charted multiple times. She further stated the resident was on fortified foods and ice cream at meals and usually consumed about 50 percent. She stated she was unsure why the resident was not eating much and thought it could have been related to contractures and positioning concerns. She stated the resident's pressure areas were related to lack of mobility and poor intakes. The resident was on fortified milk because the resident tended to drink better than eat and wasn't aware the resident disliked milk. Interview with the RD, on 09/23/2021 at 12:42 PM, revealed the only supplements the resident had tried was Med Plus, Pro-Stat, Juven, and ice cream. She stated she did not see any other supplements attempted. The resident was ordered for finger foods at meals. Additional interview with the RD, on 09/23/2021 at 1:07 PM, revealed she obtained preferences from the resident on this day. She stated the resident would be willing to try fortified oatmeal and potatoes. She stated they would continue the nutritional treat and ice cream. She stated they would add sandwiches of choice and some chocolate carton nutrition shakes. Interview with the DM, on 09/23/2021 at 12:49 PM, revealed he last reviewed the resident's preferences at the beginning of August 2021. He stated the resident was getting bacon and wanted sausage. He stated he was not aware the resident was receiving a carton of milk instead of fortified milk and was not aware the resident disliked milk. Interview with the Director of Nursing (DON), on 09/23/2021 at 3:18 PM, revealed the resident's nutrition had declined, and the resident refused to be repositioned. She stated the resident did not eat how the resident needed to eat and the resident had declined a tube feeding. She stated the Certified Nurse Aides (CNAs) on the floor would have told the nurse any preferences, and the nurse would notify the DM. She stated the DM should update preferences quarterly and as needed. Interview with the Nurse Practitioner(NP), on 09/23/2021 at 3:31 PM, revealed the resident was non-compliant with pressure relief. She stated the resident was non-complaint with diet and ate a lot of junk food. The NP further stated the goal was to maintain current wound status and prevent infection. Interview with the Nursing Home Administrator (NHA), on 09/24/2021 at 10:30 AM, revealed the resident refused meals and wanted snacks. She further stated that nurses were communicating with the RD about the resident's consumption.

Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure oxygen therapy was administered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of the facility's policy titled, Respiratory, revised 10/23/2020, revealed the policy did not contain anything specific related to oxygen use. 1. Record review revealed the facility admitted Resident #60 on 09/16/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No Minimum Data Set (MDS) had been completed yet for the resident. Review of Resident #60's Comprehensive Care Plan, initiated 09/17/2021, revealed the resident did not have a care plan related to oxygen therapy. Review of the Admission Physician Orders, dated September 2021, revealed there was no current order for oxygen. Observations on 09/21/2021 at 10:38 AM and on 09/23/2021 at 3:56 PM, revealed the resident was wearing a nasal cannula for oxygen administration at two (2) liters per minute. Interview with the Director of Nursing, on 09/24/2021 at 10:46 AM, revealed she was not sure if Resident #60 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #60 was a new admission, and when the resident arrived at the facility the resident was on oxygen on the stretcher. Further interview with the DON on 09/24/2021 at 11:30 AM, revealed the resident should be on two liters of oxygen and she had just updated the resident's care plan and physicians orders to reflect the usage. 2. Record review revealed the facility readmitted Resident #32 on 04/02/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was fourteen (14), indicating the resident was cognitively intact. Further review of the MDS assessment revealed Resident #32 required oxygen therapy. Review of Resident #32's Comprehensive Care Plan, updated 09/21/2021, revealed the resident was at risk for respiratory complications related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A further review revealed interventions included oxygen to be administered as ordered. Review of Resident #32's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of Resident #32, on 09/21/2021 at 10:44 AM and 09/22/2021 at 9:47 AM, revealed the resident was wearing a nasal cannula for oxygen administration at four (4) liters per minute. Interview with the Director of Nursing (DON), on 09/24/2021 at 10:46 AM, revealed nursing staff should have been checking the resident's oxygen concentration setting every shift and every time they checked the resident's oxygen saturation. The DON further stated she was not sure why Resident #32's oxygen settings were not at the correct liters on 09/21/2021 and 09/22/2021. 3. Record review revealed the facility readmitted Resident #15 on 07/10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS assessment revealed Resident #32 required oxygen therapy. Review of Resident #15's Comprehensive Care Plan, updated 08/26/2021, revealed the resident was at risk for respiratory complications related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A continued review revealed interventions included oxygen to be administered as ordered. Review of Resident #15's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of Resident #15, on 09/21/2021 at 11:12 AM and 09/22/2021 at 12:56 PM, revealed the resident was wearing a nasal cannula for oxygen administration at four (4) liters per minute. Interview with the Director of Nursing (DON), on 09/24/2021 at 10:46 AM, revealed nursing staff should have been checking the resident's oxygen concentration setting every shift and every time they checked the resident's oxygen saturation. The DON further stated she was not sure why Resident #15's oxygen settings were not at the correct liters on 09/21/2021 and 09/22/2021.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure an effective infection control program was implemented related to the wearing gown on active COVID unit in facility. The findings include: Review of facility policy titled, Reuseable Gowns and/or Coverall Process, dated 04/09/2020 revealed on a dedicated COVID Unit a stakeholder (staff) would don a gown provided to them at the beginning of their shift and it would be worn during their entire shift along with other PPE appropriate for caring for the COVID positive resident per CDC guidelines. Review of facility policy titled, COVID-19 Guidelines, dated 06/29/2020, revealed the facility was closely monitoring CDC updates, and would continue to follow CDC guidelines and recommendations. Review of CDC guidelines for healthcare personnel dated 06/03/2020, revealed when caring for a patient with suspected or confirmed COVID-19, PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. Preferred PPE was listed as face shield or goggles, one pair of clean non-sterile gloves, isolation gown, N95 or higher respirator when respirators were not available, and use the best available alternative, like a facemask, Observation on 10/29/2020 at approximately 1:56 PM, during tour with Director of Nursing (DON), revealed while looking into the COVID UNIT of the facility, the Advanced Practice Registered Nurse (APRN) was observed on the hall wearing pink scrubs with no gown on while speaking with three (3) staff that were fully gowned. The DON stated several times she was just seeing a pink blob, and could not tell if a gown was worn by ARNP. Interview with Advanced Practical Registered Nurse (APRN), on 10/29/2020 at 2:02 PM, revealed she was not wearing a gown while on the COVID UNIT. She stated she removed her gown when she went into a office on the unit to do charting and had come out to speak with the nurses. She stated if she would have come out more than two (2) feet from office she would have put her gown on. She revealed she was providing care to several residents on the COVID Unit that were very sick that day. Interview with Director of Nursing (DON), on 10/29/2020 at 3:30 PM, revealed the APRN did not have a gown on in the COVID UNIT but she had come out of the office where she had been charting, and there was no patients on the hallway. The DON stated the APRN did not need to put a gown on because she was standing away from other staff on the hall. Interview with Administrator (who is also a licensed nurse), on 10/29/2020 at 2:25 PM, revealed gowns do not need to be worn in a break room or in offices but hallways were considered patient areas.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide the guardian of one (1) of one (1) resident with written notice of discharge as soon as practivable and failed to send a copy of the notice to the Ombudsman (Resident #1). The findings include: Review of the facility policy titled, Transfer/Discharge Notice, not dated, revealed before a transfer or discharge occurs, the facility will notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility will send a copy of the transfer or discharge notice to a representative of the Office of the State Long-Term Ombudsman. Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #1's cogntion as severely impaired with a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was not interviewable. Further review of the record revealed Resident #1 was transferred to a Behavioral Unit on 06/05/18 for increased behaviors of verbal and physical aggression and he/she had hit another resident in the eye, causing injury, at the behavioral unit again on 08/01/18 for cognitive treatment and was transferred to the hospital on [DATE] for evaluation and treatment for [REDACTED]. Review of Discharge/Transfer Form for (MONTH) (YEAR) revealed Resident #1 was transferred to the hospital on [DATE] for medical reasons, date of notice to resident guardian was 08/04/18, and date faxed to Ombudsman 09/04/18. Interview with Resident #1's Guardian, on 09/04/18 at 8:48 AM revealed he was never given a written notice of discharge on 08/04/18 and still had not received any written notification. Interview with Social Services Director (SSD) on 09/05/18 at 12:19 PM revealed Resident #1 was transferred to the hospital due to behaviors for evaluation. The SSD stated she sends a log of discharges to the Ombudsman once a month and the Ombudsman was notified on 09/04/18. The SSD revealed Resident #1's Guardian was notified by phone and the nurse fills out a notice of transfer form, places it on the chart, and if family is present will give them a copy of transfer; if not it will be mailed the next day or as soon as possible. Interview with the Director of Nursing (DON) on 09/05/18 at 12:45 PM revealed if a resident is Medicare status, the resident is automatically considered discharged . She stated the hospital was to clear Resident #1 medically and transfer to Psychiatric Uunit at Medical Center but the resident was not cleared medically to be transferred to the Psychiatric Unit. She revealed the nursing staff had been educated and they now have a form to be filled out, and a system in place where the Business Office Manager will call the family/guardian to explain to them and make sure the family/guardian understands if a resident is being discharged . Interview with the Administrator on 09/05/18 at 12:38 PM revealed Resident #1 never received medical clearance for Psychiatric services and since he/she did not, he felt it was not appropriate to admit Resident #1 back to the facility. He stated the guardian was not given written notice of discharge nor was the Ombudsman notified at the time of discharge. He revealed he did not remember the date the decision was made for discharge but the guardian was told verbally by nurse of transfer. He further stated the facility should have sent the written notice to guardian and Ombudsman, and it was an oversight on their part.

Based on interview, record review, review of room reservation form, and resident admission agreement, it was determined the facility failed to provide the guardian of one (1) of one (1) sampled resident with a second written notice of bed hold and the opportunity to privately pay for the bed hold. The findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident had been transferred to a Behavioral Unit on 06/05/18 for increased behaviors of verbal and physical aggression and had hit another resident in the eye, causing injury. In addition, the resident had been in the hospital Behavioral Unit on 08/01/18 for cognitive treatment. Further review revealed the resident was transferred to hospital again on 08/04/18 for evaluation and treatment for [REDACTED]. Review of a Resident Room Reservation Form, signed by Resident #1's guardian on 07/30/15 revealed the option box was checked stating, I am Medicaid and am aware that Medicaid will pay for my room hold up to fourteen (14) nights per calendar year. Should my absence from the facility exceed fourteen (14) allowable covered nights, I may choose to pay the current daily rate to continue to reserve the room or I can release the room. Should I release my room I understand I can be readmitted to the facility upon first available room. Review of an Admission Agreement form under Bed Hold Agreements, signed by Resident #1's guardian on admission revealed if the resident is not covered by Medicaid or other payer source and if the resident requires temporary hospitalization or otherwise leaves the facility for a temporary period, the resident agrees to pay the facility at the prevailing daily rate in order to retain the resident's room. If the resident is a Medicaid beneficiary, the facility will reserve the bed in accordance with applicable law. Review of Discharge/Transfer Form for (MONTH) (YEAR) revealed Resident #1 was transferred to the hospital on [DATE] due to aggressive behavior. Interview with the Director of Nursing (DON) on 09/05/18 at 12:45 PM revealed if a resident is Medicare, as Resident #1 was, the facility does not need to hold bed and the resident is automatically discharged . She stated she did not know if the guardian was offered bed hold if he/she privately paid for it. Interview with Director of Nursing ( DON) and the Administrator on 09/05/18 at 2:30 PM revealed Resident #1 was given notice of bed hold, transfer/discharge policy on admission. However, the DON and Administrator stated they were unable to find where the facility had given the guardian a second copy of bed hold and transfer/discharge notice prior to transfer, and he/she was not offered a chance to hold the bed if he/she paid for it.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the physician of a lack of availability of routine pain medication which could of required an alteration in treatment for one of three (3) sampled residents (Resident #1). Resident #1 ran out of [MEDICATION NAME]/[MEDICATION NAME] (narcotic pain medication) 5-325 milligrams (mg) on 08/04/18; however, the licensed nurses failed to notify the physician when two (2) or more consecutive doses of narcotic pain medication was not available for administration. The findings include: Review of facility policy titled, Medication Administration General Guidelines, dated (MONTH) (YEAR), revealed medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the prescriber. Documentation: The individual who administers the medication dose, records the administration on the resident's MAR's immediately following the medication being given. If the medication is refused, withheld, or given at other than the scheduled time the space provided is initialed and circled; and an explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two (2) consecutive doses of a vital medication are withheld or refused then the physician is notified. The MAR/TAR is initialed by the person administering the medication. Record review revealed the facility admitted Resident #1 on 04/26/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/28/18 revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review revealed the resident's pain was assessed as six on a pain scale of zero to ten (0-10) with ten (10) being the worse occasionally; and, to have taken an opioid the last seven (7) days. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Further review of the EZMAR revealed Resident #1 did not receive the medication on 08/05/18-08/07/18 at 3:00 PM, on 08/06/18 at 9:00 AM, and on 08/05/18 at 9:00 PM. In addition, review of facility Controlled Drug Record for Resident #1's [MEDICATION NAME] 5-325 revealed the narcotic pain medication was not signed out from 08/04/18 at 9:00 PM until a tablet was signed out on 08/08/18 at 9:00 AM (ten {10} consecutive missed doses). However, review of the Nursing Notes revealed there was no documented evidence the Physician was notified the medication was not available for administration until 08/07/18 at 9:50 AM and 2:14 PM. Interview with Resident #1 on 08/13/18 at 5:00 PM revealed the facility had run out of the [MEDICATION NAME]. The resident stated he/she had to take Tylenol every six (6) hours, and it only helped a little bit. Interview with Licensed Practical Nurse (LPN) #2 08/14/18 at 5:10 PM revealed Resident #1 ran out of the [MEDICATION NAME] 5/325 and did not have a script. She stated the resident was administered Tylenol because that is what the physician had ordered the last time the resident was out of medication. LPN #2 revealed she could not remember if she had called the physician (LPN #2 worked 08/05/18 and 08/06/18). LPN #2 stated Resident #1 should not have been without the medication for three (3) days because of his/her diagnosis. Interview on 08/15/18 at 3:00 PM with Physician#1/Medical Director revealed Resident #1 did not receive his/her [MEDICATION NAME] 5/325 for three (3) days. He stated it does happen occasionally and the facility and pharmacy should inform the physician by Friday at 4:30 PM if a resident is going to be out of medication. Interview with Director of Nursing (DON) on 08/14/18 at 3:30 PM revealed she and the Physician should have been notified Resident #1 was without his/her medication.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure pain management was provided to residents who require such services for one (1) of three (3) sampled residents (Resident #1). Resident #1 had Physician order [REDACTED]. Resident #1 did not receive his/her medication from 08/04/18 at 9:00 PM until 08/08/18 at 9:00 AM (ten {10} missed doses). Resident #1 stated he/she received Tylenol but it was not as effective, The findings include: Review of facility policy titled, Medication Administration General Guidelines, dated (MONTH) (YEAR), revealed medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the prescriber. Documentation: The individual who administers the medication dose, records the administration on the resident's MAR's immediately following the medication being given. If the medication is refused, withheld, or given at other than the scheduled time the space provided is initialed and circled. and an explanatory note is entered on the reverse side of the record provided for PRN documentation. If two (2) consecutive doses of a vital medication are withheld or refused then the physician is notified. The MAR/TAR is initialed by the person administering the medication. Record review revealed the facility admitted Resident #1 on 04/26/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/28/18 revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) indicating the resident was interviewable. Further review revealed the resident's pain was assessed as six (6) on a pain scale of zero to ten (0-10) with ten (10) being the worse; and to have taken an opioid the last seven (7) days. Review of 07/30/18 Comprehensive Care Plan for at risk for Pain related to Hypertension, [MEDICAL CONDITIONS], Anxiety, MS, [MEDICAL CONDITION], History of Left Hip Surgery, Chronic Pai[DIAGNOSES REDACTED] and History of Stroke with approach to -administer Medications as ordered. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Diagnosis (Dx) [MEDICAL CONDITION] (MS), with frequency of 9:00 AM/3:00 PM/9:00 PM. Review of the (MONTH) (YEAR) Easy Medication Administration Record [REDACTED]. Further review revealed 99 indicated medication not given, see nurses notes. Review of the Nurses Notes, dated 08/05/18-08/06/18 revealed no documented evidence of why the medication was not administered per EZMAR. Review of the facility Controlled Drug Record for Resident #1's [MEDICATION NAME] 5-325 mg revealed the medication was not signed out from 08/04/18 at 9:00 PM until a tablet was signed out on 08/08/18 at 9:00 AM (ten {10} missed doses). Review of Progress Notes Report dated 08/07/18 at 9:50 AM and 2:14 PM revealed LPN #1 called Physician#1/Medical Director about Resident #1 being out of [MEDICATION NAME] 5-325. Review of Pharmacy Manifest Slip dated 08/08/18 revealed Resident #1 received (60) sixty tablets of [MEDICATION NAME] 5-325. Interview with Licensed Practical Nurse (LPN) #1, on 08/14/18 at 5:39 PM revealed she had called the physician and pharmacy on 08/07/18 to send the medication and the script for Resident #1's [MEDICATION NAME] 5/325 three (3) times a day. Interview with Resident #1 on 08/13/18 at 5:00 PM revealed the facility had run out of the his/her pain medication. Resident #1 stated he/she had to take Tylenol every six (6) hours, and it only helped a little bit. Interview with Resident #1's Guardian, on 08/15/18 at 10:28 AM revealed Resident #1 had spoken with him/her and told her his/her pain medication had not been filled. The Guardian stated Resident #1 had a broken back and [MEDICAL CONDITION] and has been in pain lately. Interview with LPN #2 (worked on 08/05/18 and 08/06/18) on 08/14/18 at 5:10 PM, revealed Resident #1 was to have [MEDICATION NAME] 5/325 three (3) times a day, but did not have a script. LPN #2 stated staff administered Tylenol because that is what the physician had ordered the last time the resident was out of medication. LPN #2 stated the Physician was aware of the resident's medication being out but she did not know if she called the Physician or not. She revealed Resident #1 should not have been without the medication for three (3) days because of his/her diagnosis. LPN #2 did not answer question when asked about the discrepancy in the narcotic count sheet when compared with the MAR's being filled in. Interview with Pharmacist #1 on 08/20/18 at 1:55 PM revealed they had received notification on the 08/04/18 that the facility needed the [MEDICATION NAME] 5/325 mg for Resident #1, and faxed the facility on 08/04/18 that a script was needed but did not have a confirmation that the facility received the fax. The Pharmacist stated the facility had called the pharmacy back on 08/07/18 requesting the refill and reported they still did not have the medication. Pharmacist #1 stated it was a phone request on 08/07/18, and the pharmacy had faxed the physician on 08/07/18 of need for a script and had received the script at 12:30 PM on 08/07/18. Pharmacist #1 stated the pharmacy does request that facilities order the medication before the resident runs out of the medication. Interview with Physician#1/Medical Director on 08/15/18 at 3:00 PM revealed Resident #1 did miss his/her [MEDICATION NAME] 5/325 mg. and it does happen occasionally and the facility and pharmacy should inform the physician by Friday at 4:30 PM if a resident is going to be out of medication. Physician #1/Medical Director revealed the resident should not have been out of the medication for three (3) days and the facility should have notified her before the resident's medication was no longer available. Interview with the Director of Nursing (DON) on 08/14/18 at 3:30 PM and 5:01 PM revealed she and the physician should have been notified Resident #1 was without his/her medication and the MAR's should match the Narcotic sheets for (MONTH) (YEAR). Additionally, the DON stated she expected the physician orders [REDACTED]. Interview on 08/15/18 at 6:30 PM with Administrator revealed he expected pain medication to be available for residents.

Based on interview and review of the facility policy, it was determined the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the residents on the weekends. The findings include: Review of the facility policy titled Resident Mail, revised 02/15/18, revealed it is the intent of this policy that the Quality of Life Director/Designee is responsible for the distribution of all resident mail. Further review of the policy revealed delivery of resident mail will be coordinated by the Quality of Life Director/Designee and Resident mail will be delivered within twenty-four (24) hours of delivery to the facility. Interview with Resident Council members during a Resident Council meeting, on 04/17/18 at 2:04 PM, revealed the facility was not delivering mail to the residents on the weekends. Interview with the Activity Director, on 04/18/18 at 3:22 PM, revealed there were two (2)Activity Assistants who worked the weekend and were responsible to deliver the mail to the residents on the weekend. She stated she was not sure when the issue with not delivering mail to the residents started, but she would address the issue. She stated she was aware of the policy for delivering mail to the residents on the weekends, and expected facility staff to follow the facility policies. Interview with the Administrator, on 04/18/18 at 2:42 PM, revealed he was aware that mail was not delivered to the residents on the weekends and would fix the issue. He stated he knew there were systems problems and mail had not been delivered timely. He further stated he would ensure the Activities Department delivered the residents' mail.

Based on observation, interview, and review of the facility policies, it was determined the facility failed to store, prepare, distribute and serve food under sanitary conditions. Review of the facility Census and Condition, dated 04/17/18, revealed fifty-six (56) of fifty-seven (57) residents received their meals from the kitchen. Observation, on 04/17/18, revealed a build-up of debris on the can opener cutting edge, a build-up of thick black colored debris on the inside of the door and inside surface for oven #2, uncovered bowls full of cereal stacked on top of each other, and remnants of food particles, paper and cardboard scattered across the walk in freezer floor. The findings include: Review of the facility policy titled Trayline Setup and Service, revised 03/19/18, revealed if a tray is going to the floor or dining room, all items must be covered on the tray unless the tray is transported in an enclosed cart. Review of the facility policy titled Can Opener, updated 9/2011, revealed the can opener should be cleaned after each meal and more frequently if needed. Review of the facility policy titled Oven - Convection, Gas, revised 02/01/12, revealed staff should immediately sanitize the oven with any spills, spillovers and burned food deposits. If further stated to wipe the oven's exterior and interior daily, and it also stated to spray sides, interior and oven doors weekly with oven cleaner. Review of the facility policy titled Food Storage, revised 08/09/17, revealed food should be covered, labeled and dated. Observation of the kitchen, on 04/17/18 at 6:13 AM, revealed twenty-two (22) uncovered cereal bowls full of cereal sitting on top of other bowls full of cereal, with nothing covering them and the bottom of the bowls were sitting on top of the cereal in the other bowls. Observation of the walk-in freezer, on 04/17/18 at 6:17 AM, revealed remnants of food particles, paper, and cardboard, scattered across the walk-in freezer floor. Observation of the oven, on 04/17/18 at 6:23 AM, revealed the stove back splash had a black and brown build-up of material caked on it and the right side oven #2 was very dirty with a build-up of black material caked on the inside of the oven door, as well as inside the oven. Observation, on 04/17/18 at 6:29 AM, revealed the can opener was dirty with build-up visible on the cutting edge of the can opener. Observation of the breakfast tray line, on 04/17/18 at 7:24 AM, revealed there were five (5) trays of bacon, sausage, eggs, gravy and biscuits for facility home-style dining, which were left open to air sitting on an open cart while staff fixed the other residents' regular trays. These home-style dining trays sat on the food cart uncovered for approximately ten (10) minutes, and then the open food cart with the uncovered trays of food was transported to the dining room with the trays still uncovered during transport. Interview with Cook #1, on 04/17/18 at 6:25 AM, revealed she expected the stove to be clean, the can opener to be cleaned after each use and prior to using it, and the walk-in freezer floor to be clean and not have trash all over it. She also stated they should not be storing cereal bowls full of cereal on top of other cereal bowls full of cereal, with nothing covering each bowl of cereal. Interview with Dietary Aide #1, on 04/17/18 at 6:35 AM, revealed she was the one who set the cereal bowls stacked on top of each other and uncovered. She stated she had been doing that for awhile and had never thought about it until now, that it was inappropriate and unacceptable to have the cereal bowls full of cereal, uncovered and sitting on each other with nothing in between them. Interview with the Dietary Manager, on 04/17/18 at 7:45 AM, revealed she thought it was inappropriate to send food out uncovered to the dining room and she had concerns with the way they send out the homestyle dining breakfast trays uncovered; however, the previous Administrator was fine with it. She stated she was not fine with it and food should be covered after the food was set up to go out of the kitchen. She stated she expected the kitchen to be clean, the stove and ovens to be clean and it was not acceptable for build-up to be on the stove back splash and in the oven. She also stated there should not be trash on the floor in the walk-in freezer and she expected the floors to be clean. She stated the can opener should be cleaned by each shift and as often as needed if the cutting edge was dirty or getting build-up on it. She stated the staff setting up bowls of cereal uncovered and the other bowls of cereal sitting directly on the other cereal in bowls was unacceptable and inappropriate. Interview with the facility's Registered Dietician, on 04/17/18 at 10:02 AM, revealed food must be covered and she expected it to be covered when it was dished up and it had to be covered until it was served. She stated she expected the can openers to be cleaned after being soiled and to be cleaned prior to being used, if it was visibly soiled. She stated the stove and oven should be cleaned regularly. She stated it was not acceptable to put bowls or dishes to be placed in food, such as cereal bowls on top of cereal in other bowls. She also stated she expected the walk-in freezer to be cleaned and the floors to be cleaned.

Based on observation, interview, and review of the facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of fifteen (15) sampled residents (Residents #22, #27, and #49). The findings include: Review of the facility policy entitled Policies and Practices-Infection Control, revised 07/2014, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and practices are to prevent, detect, investigate, and control infections in the facility, and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Review of the facility policy entitled Dressings, Dry/Clean, revised 09/2013, revealed the steps in procedures included clean the bedside stand, establish a clean field, place clean equipment on the clean field. Arrange supplies so to be easily accessible, tape bag on the bedside table or use a waste basket below the clean field, position the resident and adjust the clothing to provide access to the affected area. Wash/dry hands thoroughly, put on clean gloves, remove the dressing, discard the glove and dressing, wash and dry hands thoroughly, open dressings should be labeled with date/time/initials, placed on the clean field, open other products with clean technique, wash/dry hands thoroughly, put on clean gloves, clean the wound, dry the wound, apply dressing, remove gloves, and wash and dry hands thoroughly. Review of the facility policy Perineal Care Male/Female Competency, revised 11/21/2017, revealed to gather supplies and equipment, knock and obtain permission to enter the room, explain the procedure, provide privacy (pull curtain and/or close blinds), assemble equipment and supplies and place on the bedside stand -- arrange to be easily accessible, if using wash cloths have a wash basin, perform hand hygiene, don gloves, and obtain a wipe or apply the cleansing agent to a washcloth, and maintain standard precautions for the prevention of cross-contamination and spread of infection during the procedure. Separate labia with one (1) hand and wash with the other using gentle downward [MEDICAL CONDITION] from the front to the back of the perineum, avoid areas around the anus, obtain a different wet wash cloth and rinse thoroughly from front to back. Pat dry with a bath towel. Clean/rinse and dry the anal area, remove gloves and wash/dry hands if using cream/ointment - staff must don gloves prior to application. Perform hand hygiene before leaving the room. 1. Observation during Resident #22's incontinent care, on 04/17/18 at 2:20 PM, revealed Certified Nurse Aide (CNA) #1 and CNA #2 were wearing gloves upon entrance to the room and equipment was already set up to provide incontinent care. CNA #2 removed trash bags from her pocket, opened the bags and placed the open bag on the floor with gloves on. She proceeded to clean the sides of the resident's groin area, then with the middle of the washcloth, she cleaned the front peri-area and did not change gloves. CNA #1 and CNA #2 turned the resident over and provided incontinent care to his/her buttocks. The CNAs placed a clean brief on the resident using the same gloves. CNA #1 and CNA #2 then pulled Resident #22's clothes up and handed the resident a bible and tissues, and then placed a blanket over Resident #22. CNA #2 and CNA #1 took the pair of gloves off which were worn throughout the provision of incontinent care. Interview with CNA #1, on 04/17/18 at 2:45 PM, revealed she did not change gloves during provision of incontinent care for Resident #22. She stated if her gloves were soiled, then she should have changed them. Additionally, CNA #1 stated staff should not touch other things in the room before providing care, because of spreading germs and infection control. Interview with CNA #2, on 04/17/18 at 2:50 PM, revealed she should have changed gloves prior to putting a clean brief and pants on the resident. CNA #2 stated she should have changed gloves during provision of peri-care for Resident #22, and before handing the resident a bible, tissues, and pulling up his/her blanket. 2. Further observation of CNA #1 and CNA #2, on 04/17/18 at 2:34 PM, revealed, after completion of incontinent care for Resident #22, they washed their hands and put on gloves. CNA #2 touched the privacy curtain, moved Resident #27's (roommate of Resident #22) wheelchair and did not change her gloves. CNA #1 removed his/her brief and wet clothes, cleaned the side of the resident's groin, and cleaned the front peri-area. CNA #2 obtained a clean brief, which was laying on the resident's chest, with neither CNA#1 or CNA #2 changing gloves. CNA #1 and CNA #2 then placed the clean brief on Resident #27 after CNA #1 had cleaned Resident #27's buttocks. CNA #2 emptied the basin and dried it out with the same gloves. CNA #1 took her gloves off and emptied the trash can. Interview with CNA #1, on 04/17/18 at 2:45 PM, revealed to change gloves when going from front to back during incontinent care, and if soiled, change gloves. She also stated she should have changed gloves after moving Resident #27's wheelchair, and should have the supplies ready before putting gloves on. CNA #1 revealed staff should not touch other things in the room prior to providing incontinent care because of spreading germs and infection control. Interview with CNA #2, on 04/17/18 at 2:50 PM, revealed she should have changed gloves before putting a clean brief on the resident and pulling his/her pants up, and also, when going from front to back during incontinent care. She stated she should have changed gloves after moving Resident #27's wheelchair, and after touching the privacy curtain. CNA #2 stated she should have changed gloves because she was touching different areas of the resident as well as different objects, and due to the risk of spreading germs. Interview with Licensed Practical Nurse (LPN) #2, on 04/19/18 at 9:38 AM, revealed staff should don gloves before starting care, after cleaning and rinsing the resident, and then change gloves to dry the resident. Staff should not use one (1) pair of gloves to provide incontinent care. She added do not touch anything with gloves before or during provision of incontinent care because of cross contamination. Interview with LPN #1, on 04/19/18 at 10:00 AM, revealed staff should have everything set up in the resident's area, washed his or her hands, gloved, and should not go in/out of the room to get anything due to cross contamination. LPN #1 stated the process was to wash, glove, setup, provide care, then if gloves were ripped or soiled, change gloves. After completion, wash hands, change gloves, and if applying a barrier cream, apply it with clean gloves. Additionally, LPN #1 stated before putting on a clean brief, staff should change gloves. LPN #1 stated staff do not use one (1) pair of gloves from start to finish during peri/incontinent care because of introducing bacteria, and do not touch anything with dirty gloves because of risk of contamination. There should be no linen on the floor, and staff should have everything set up before gloving. 3. Observation of Resident #27's wound care completed by Registered Nurse (RN) #1, on 04/18/18 at 11:15 AM, revealed the nurse sanitized her hands and donned gloves which she pulled from her pocket, prior to wound care. After gloving, RN #1 revealed a black mark around a cyst on Resident #27's right upper back. RN #1 pulled gloves from her pocket three (3) times during wound care. At one point, she left the room to get an alcohol pad to help remove the dressing from the wound on his/her back. RN #1 provided wound care after removing the dressing from the resident's wound. Observation of an old dressing was covered with serosanguineous drainage, scant amount. RN #1 changed gloves and pulled gloves from her pocket to use each time. Interview with RN #1, on 04/18/18 at 11:15 AM, revealed she should get gloves from a box, not her pocket. She stated she kept permanent markers, hand sanitizer, keys, and pens in her pockets. RN #1 stated the gloves needed to be clean, because it was a clean dressing change, and could cause infection or contamination if not clean. 4. Record review revealed the facility admitted Resident #49 on 03/29/18 with [DIAGNOSES REDACTED]. Record review revealed he/she had an unstageable pressure ulcer to the right heel and a Stage two (2) pressure ulcer to the coccyx. Review of measurements of the resident's wounds upon admission to the facility, on 03/29/18, revealed a two (2.0) centimeter (cm) x three (3.0) cm wound to the right heel, unstageable; and a Stage two (2) wound to the sacral area measuring 1.5 cm x 4.0 cm. Observation of measurements, on 04/17/18, revealed the right heel wound measured 3.0 cm x 4.0 cm x 0 cm, unstageable; a Stage 2 wound to the coccyx measuring 0.4 cm x 1.0 cm x 0 cm, and a second Stage 2 wound to the coccyx area measuring 3.0 cm x 3.0 cm x 0.2 cm. Observation of wound care, on 04/18/18 at 10:58 AM, completed by the Assistant Director of Nursing (ADON), revealed he took gloves from his scrubs pocket and removed an old dressing from the resident's foot, washed his hands, took gloves from his scrubs pocket a second time, and cleaned the resident's right foot heel wound. He cleaned his/her right first toe with wound cleanser and dried the area, removed his gloves and washed his hands. The ADON then took his gloves from his scrubs pocket a third time. He cleansed the resident's right heel with wound cleanser, and applied Santyl to the right toe and heel, applied [MEDICATION NAME] to the right heel and an abdominal pad and wrapped the area with Kling. The ADON removed his gloves, washed his hands and took gloves from his scrubs pocket a fourth time and removed an old dressing from the resident's sacrum. He then washed his hands, took gloves from his scrub pocket a fifth time and cleaned the resident's sacral wound with wound cleanser. Observation during the last dressing change, the ADON needed more gloves and a CNA got him a box of gloves. The ADON washed his hands and got gloves from the box, put the gloves on and put a dressing on the resident's sacral wound. Interview with the ADON, on 04/17/18 at 3:30 PM, revealed Resident #49 had a pressure sore on his/her sacrum upon admission. He stated some call it sacrum, some call it coccyx; however, there was one (1) ulcer on his/her coccyx when he/she came in which turned into two (2) ulcers in the same area. Further interview with the ADON, on 04/19/18 at 12:02 PM, revealed he realized now it was inappropriate to take gloves from his scrub pocket during wound treatment, and it could be an infection control issue, as other things may be in his pocket such as keys, change, etc. Interview with the Staff Development Coordinator (SDC), on 04/19/18 at 3:20 PM, revealed it was inappropriate to use gloves from his or her pocket during wound care because the body was considered dirty. When providing peri-care/incontinent care, use wipes, change gloves before putting a clean brief on a resident, and staff were not to touch anything with dirty gloves. Interview with the Director of Nursing (DON), on 04/19/18 at 3:35 PM, revealed staff should not have gloves in their pockets for wound care, and if gloves were soiled, then staff should change their gloves. She expected staff not to touch wheelchairs, bibles, or tissues with gloves, and they should change gloves after cleaning a resident's peri-area. The DON further stated she expected gloves to be changed before a clean brief was put on a resident, as all of these issues were infection control issues.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Minimum Data Set (MDS), it was determined the facility failed to ensure each resident was accurately assessed to reflect his/her status for one (1) of fifteen (15) sampled residents (Resident #45). The findings include: Review of the RAI MDS 3.0 Manual revealed steps for assessment of weight: upon admission, weigh the resident and record results. For subsequent assessments, check the medical record and enter the weight taken within thirty (30) days of the Assessment Reference Date (ARD) of the assessment. Record review revealed the facility admitted Resident #45 on 12/01/17 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 12/08/17, revealed the facility assessed Resident #45's weight at 157 pounds (lbs). Review of the Quarterly MDS Assessment, dated 03/06/18, revealed the facility assessed Resident #45's weight at 168 lbs. Review of Resident #45's weight report, dated 01/01/18 through 04/19/18, revealed, on 03/18/18, the resident weighed 167.2 lbs. Review of the Quarterly MDS Assessment, dated 03/19/18, revealed the facility assessed Resident #45's weight at 247 lbs. Interview with the MDS Coordinator Registered Nurse (RN) #10, on 04/19/18 at 8:50 AM, revealed there was no way the resident's weight was at 247 lbs. She reviewed the resident's last weight completed on 03/18/18, which was 167.2 lbs. She stated the Dietary Manager filled out Section K on the MDS; however, she would do an MDS modification, which included the resident's weight. She stated she expected the resident's information to be recorded accurately. Interview with Dietary Manager #4, on 04/19/18 at 9:25 AM, revealed she was responsible for completing Section K of the MDS, which included the resident's weight. She retrieved the information from the resident's weight record report which the Nurses completed, and stated the resident's weight was 167.2 lbs on 03/18/18. She stated she was unaware idea why the weight was listed on the MDS as 247 lbs.

Based on interview, record review, and review of facility guidelines, it was determined the facility failed to ensure Comprehensive Care Plan interventions reflected actions to meet the objectives toward achieving the residents' goals for one (1) of fifteen (15) sampled residents (Resident #40), related to a J-tube. The findings include: Review of facility guidelines on Comprehensive Care Plans, not dated, revealed the residents' Comprehensive Care Plan interventions are implemented after consideration of the resident's problem areas and causes. Interventions address the underlying source of the problem area. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the residents' goals. Record review revealed the facility admitted Resident #40 on 01/26/18 with [DIAGNOSES REDACTED]. Resident #40 was discharged on [DATE] for hospitalization , and returned to the facility with a re-admission date of [DATE]. Review of the Minimum Data Set (MDS) Assessment, dated 03/22/18, revealed the facility assessed the resident to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of five (5), which indicated he/she was non-interviewable. Review of Resident #40's Care Plan, dated 03/06/18, revealed no interventions were in place to reflect pausing, or turning off the feeding pump when the head of the bed was flat. Interview with Licensed Practical Nurse (LPN) #1, on 04/20/18 at 10:30 AM, revealed she expected the Care Plan to be updated to include pausing the resident's feeding with the head of the bed flat. Interview with the Staff Development Coordinator, Registered Nurse (RN #2), on 04/20/18 at 10:36 AM, revealed the Care Plan should be updated to include pausing the feeding pump during long periods of time with the head of the bed flat. Interview with the Director of Nursing (DON), on 04/20/18 10:00 AM, revealed she expected the Care Plan to be updated to include the feeding pump being placed on hold, paused, or turned off during care which required extended periods with the head of the bed lowered. She stated the Nurse/Interdisciplinary Team was responsible for the review and updating of care plans.

Based on observation, interview, and record review, it was determined the facility failed to follow the implementation of delivering a gastric tube feeding for one (1) of fifteen (15) sampled residents (Resident #40). The findings include: Interview with the Director of Nursing (DON), on 04/20/18 at 9:45 AM, revealed the facility did not have a Standard of Practice regarding a [MEDICATION NAME]-tube feeding/Gastric-tube feeding (J-tube/[DEVICE]). Record review revealed the facility admitted Resident #40 on 01/26/18 with [DIAGNOSES REDACTED]. Resident #40 was discharged on [DATE] for hospitalization , and returned to the facility with a re-admission date of [DATE]. Observation of Resident #40, on 04/18/18 at 2:30 PM, revealed he/she was laying flat in the bed with a tube feeding flowing. Interview with Registered Nurse (RN) #6, at 2:35 PM, revealed if the tube feeding was on due to the feeding pump covered with a pillow case for dignity, and unable to view the pump. RN #6 stated he/she was not sure, moved the pillow case which revealed the feeding pump was running at 25 ml/hour, and paused the pump. Interview with RN #6, on 04/18/18 at 3:05 PM, revealed the head of the bed appeared to be flat and the feeding pump should have been paused whenever the head of the bed was flat. Interview with Registered Dietician #3, on 04/19/18 at 11:32 AM, revealed it was less likely for a resident to aspirate with a J-tube than a [DEVICE]; however, she expected the feeding pump to be turned off during care of the resident. Interview with the DON, on 04/18/18 at 4:10 PM, revealed her expectations were that the feeding pump should be placed on hold, paused, or turned off during care which required extended periods with the head of the bed lowered.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure each resident received care and services for the provision of [MEDICAL TREATMENT] and/or peritoneal [MEDICAL TREATMENT] consistent with professional standards of practice including the ongoing assessment of the resident's [MEDICAL TREATMENT] vascular access monitoring for one (1) resident of fifteen (15) sampled residents (Resident #49). The findings include: Review of the facility Policy, [MEDICAL TREATMENT] Vascular Access Monitoring, undated, revealed the following definitions: Vascular Access-(Arteriovenous fistula, shunt/graft, and tunneled double-lumen catheter) a connection made between an artery and a vein to provide good blood flow for [MEDICAL TREATMENT]. Bruit: the constant buzz heard like a swishing or whoosh via a stethoscope placed on the access. Thrill: a steady vibration or buzz felt in the length of the access. Review of the policy revealed auscultation/palpation of the AV access (bruit and thrill) will be performed upon return from the [MEDICAL TREATMENT] Center and each day. Record Review revealed the facility admitted Resident #49 on 03/29/18 with [DIAGNOSES REDACTED]. Observation of Resident #49, on 04/18/18 at 11:17 AM, revealed a temporary [MEDICAL TREATMENT] shunt access device to the right chest, [MEDICATION NAME] area. Review of an Admission Minimum Data Set (MDS), dated [DATE], revealed he/she had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was not interviewable. Review of a Comprehensive Care Plan, initiated on 04/06/18, revealed the resident had a potential for complications related to [MEDICAL TREATMENT] (process to cleanse the blood of toxic chemicals or drugs in residents whom one (1) or both kidneys are defective or absent). Interventions included checking the permacath ([MEDICAL TREATMENT] Access site) for signs/symptoms of infection, pain, or bleeding daily and as needed, and to protect the permacath site in the right chest from injury. Review of the Treatment Administration Records (TARs), dated (MONTH) (YEAR) and (MONTH) (YEAR), revealed no evidence the [MEDICAL TREATMENT] Access site was monitored, and was not on the TAR until 04/18/18. Interview with Licensed Practical Nurse (LPN) #3, on 04/20/18 at 10:55 AM, revealed staff should be checking the [MEDICAL TREATMENT] port site for signs/symptoms (s/s) of infection, thrill, and bruit. Interview with the Assistant Director of Nursing (ADON), on 04/20/18 at 11:15 AM, revealed he added checking of the [MEDICAL TREATMENT] port site on the TAR on 04/18/18, as he wanted to be sure staff were checking the port site. He stated staff should be checking the port site for s/s of infection, thrill, and bruit, and making sure it was in place. He stated it should have been on the TAR prior to 04/18/18. Interview with the Director of Nursing (DON), on 04/20/18 at 11:18 AM, revealed she expected staff to check the [MEDICAL TREATMENT] port site every shift for s/s of infection and placement.

Based on interview, record review and facility policy review, it was determined the facility failed to promote care for residents in a manner and in an environment that maintains/enhances resident's dignity and respect in full recognition of his/her individuality, and refrain from practices demeaning to two (2) of six (6) sampled residents (Resident #6 and Resident #7). The facility failed to empty Resident #7's [MEDICAL CONDITION] bag in a timely manner resulting in the [MEDICAL CONDITION] bag bursting open and spilling feces on the resident. Resident #7 stated it was so humiliating and dirty. In addition, the facility failed to toilet Resident #6 in a timely manner to prevent incontinent episodes. Resident #6 stated the incidents made him/her feel dirty, ashamed and humiliated. The findings include: Review of the policy titled, Resident Rights, not dated, revealed employees shall treat all residents with kindness, respect, and dignity. Residents are entitled to exercise their rights and privileges to the fullest extent possible. The facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. 1. Record review revealed the facility admitted Resident #6 on 10/21/15 with [DIAGNOSES REDACTED]. Further review revealed Resident #6 also has a Left [MEDICAL CONDITION] which was performed in July 2016. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/23/17, revealed the facility assessed Resident #6's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was continent of bowel and occasionally incontinent of bladder. Interview with Resident #6, on 02/07/26 at 3:30 PM, revealed he/she had to pee on myself multiple times due to staff not answering call lights on time. The resident stated it mostly happens on night shift between the hours of 2:00 AM and 5:00 AM. The resident revealed it takes forty-five (45) minutes to over an hour for the call light to be answered at night. The resident stated he/she would not be incontinent if call lights were answered in a timely manner and he/she has called the nurses station by cell phone to reach the nurse and tell her he/she needs to go to the restroom. Resident #6 stated it makes him/her feel dirty, ashamed and humiliated when it happens which is at least five (5) times a week. Interviews on 02/08/17 with Certified Nurse Aide (CNA) #1 at 6:05 AM and CNA #2 at 6:15 AM revealed there has only been two (2) CNA's on night shift this past week and it is impossible to care for sixty (60) residents, especially when there are multiple residents that require the assistance of two (2) staff. They stated it was impossible to answer the call light in a timely manner and residents may have to wait over an hour to get help. Interview with Licensed Practical Nurse (LPN) #1, on 02/08/17 at 5:00 AM, revealed Resident #6 often calls her from the room from his/her cell phone to let her know that he/she needs to urinate. She stated the call light above the door on Resident #6's room cannot be seen from the hallway as the hall has a double doorway that obstructs the view of the light and unless staff go through the double doors, the light cannot be seen. She stated there is no audible call system that can be heard by staff so Resident #6 often has incontinent accidents. 2. Record review revealed the facility admitted Resident #7 on 08/15/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/9/16 revealed the facility assessed Resident #7's cognition as intact with a BIMS score of fifteen (15 ) which indicated the resident was interviewable. Interview with Resident #7 on 02/07/17 at 2:15 PM revealed it takes a long time for staff to answer call lights especially between the hours of 2:00 AM and 4:00 AM. The resident stated, I can't get anyone to answer the call light. The resident stated it makes him/her feel anxious and the anxiety causes me to have chest pain. He/she further revealed his/her [MEDICAL CONDITION] bag burst open two (2) days ago and stool went all over him/her because staff had not answered his/her call light. The resident stated, I had stool all over me and it was so humiliating and dirty. He/she further stated it has happened before. Interview with Certified Nurse Aide (CNA) #1, on 02/08/17 at 6:05 AM, revealed she worked nights and could not get to Resident #7 before his/her [MEDICAL CONDITION] burst open. CNA #1 stated Resident #7 had his/her call light on and she was unable to get to the resident before it burst. She revealed she cleaned the resident up after the feces had spilled out and over the resident. She stated she can empty the [MEDICAL CONDITION] but could not change the bag. She stated the resident said his/her light had been on for a while and she couldn't get to him/her. Interview with Licensed Practical Nurse (LPN) #1, on 02/08/17 at 5:30 AM, revealed Resident #7 has had the [MEDICAL CONDITION] bag burst open recently but she was not sure of the date. She stated if the [MEDICAL CONDITION] bag is not emptied on time then the stool pushes the bag causing the wafer and bag to separate and potentially spilling feces onto the resident and bed. She revealed it had happened a few times because staff were not able to respond in time to change it and the incidents had happened in the last two (2) weeks. She stated the resident becomes very upset because the stool spills out on him/her. She becomes very anxious and his/her blood pressure increased. She stated licensed staff would stop and help the CNAs but even with helping them they could not answer all the lights timely. Interview with the Administrator and Director of Nursing (DON), on 02/08/17 at 3:30 PM, revealed they expected call lights would be answered in a timely manner and would not want residents to be incontinent if it could be prevented and everyone has the right to be kept as clean and dry as possible. They also revealed they expected all staff to respect residents' rights and ensure dignity as much as possible.

Based on interview, record review, and facility policy and procedure review, it was determined the facility failed to follow the plan of care for two (2) of six (6) sampled residents (Resident #6 and #7). Resident #6 was care planned to encourage the resident to ask for assistance as soon as he/she has the urge to urinate and/or defecate; however, the staff failed to answer the resident's call light timely so the resident could be toileted to prevent the resident from being incontinent and feeling dirty, humiliated and embarrassed. Resident #7 was care planned to change [MEDICAL CONDITION] bag and wafer as indicated; however, the facility staff failed to change the resident's [MEDICAL CONDITION] bag timely to prevent the [MEDICAL CONDITION] bag from bursting off the stoma and feces to pour on to the resident. This caused the resident to feel dirty and humiliated. The findings include: Review of facility policy titled, Care Plans-Comprehensive, policy statement revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The Guideline #1 states the Nurse/Interdisciplinary Team develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan will be developed with participation from the resident, resident's family and/or responsible party as indicated. Record review revealed the facility admitted Resident #6 on 10/21/15 with [DIAGNOSES REDACTED]. Resident #6 also has a Left [MEDICAL CONDITION] which was performed in 7/2016. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/23/17, revealed the facility assessed Resident #6's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #6's Comprehensive Care Plan for risk for total loss of bladder and bowel control related to muscle weakness, history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION], dated 04/29/15, revealed an intervention to encourage the resident to ask for assistance as soon as he/she has the urge to urinate and/or defecate. However, interview with Resident #6, on 02/07/16 at 3:30 PM, revealed he/she has had to pee on myself multiple times due to staff not answering the call lights on time. Resident #6 stated it happens mostly on night shift between the hours of 2:00 AM and 5:00 AM because it takes as long as forty-five (45) minutes to over an hour for the call light to be answered. The resident further revealed he/she has called the nurses station by cell phone to reach the nurse and tell her he/she needs to go to the restroom. The resident stated it happens at least five (5) times in a week and makes him/her feel like no one cares and I am dirty and embarrassed. Interviews on 02/08/17 with Certified Nurse Aide (CNA) #1 at 6:05 AM, and CNA #2 at 6:15 AM, revealed Resident #6 uses his/her call light when he/she needs to be toileted. They stated the resident is continent as long as staff can answer the call light timely to toilet the resident. They stated staff cannot answer call lights in a timely manner due to there being only two (2) CNAs and revealed residents may have to wait over an hour to get help. Interview with Licensed Practical Nurse (LPN) #1, on 02/08/17 at 5:00 AM, revealed Resident #6 is normally continent and often calls her from the room from his/her cell phone to let her know that he/she needs to urinate. She stated the call light above the door on Resident #6's room cannot be seen from the hallway as the hall has a double doorway that obstructs the view of the light and unless staff go through the double doors, the light cannot be seen. She stated there is no audible call system that can be heard by staff so Resident #6 often has incontinent accidents. 2. Record review revealed the facility admitted Resident #7 on 08/15/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/09/16, revealed the facility assessed Resident #7's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Risk for complications related to [MEDICAL CONDITION] and [MEDICAL CONDITION], dated 08/30/16, revealed a goal to not have complications of ostomies without appropriate nursing interventions through next review date, and an intervention to change the [MEDICAL CONDITION] bag and wafer as indicated. However, interview with Resident #7, on 02/07/17 at 2:15 PM, revealed he/she stated, My [MEDICAL CONDITION] bag burst open two (2) days ago and I had stool all over me and it has happened before. He/she stated it was so humiliating and dirty. The resident stated the bag was not emptied in time before it burst open. The resident stated it happens on night shift and has happened a few times. He/she stated each time he/she had pushed the call light and no one had answered before the [MEDICAL CONDITION] bag burst open. Interview with CNA #1, on 02/08/17 at 6:05 AM, revealed she worked nights and could not get to Resident #7 before his/her [MEDICAL CONDITION] burst open. CNA #1 stated Resident #7 had his/her call light on and she was unable to get to the resident before it burst. She revealed she cleaned the resident up after the feces had spilled out and over the resident. She stated she can empty the [MEDICAL CONDITION] but could not change the bag. She stated the resident said his/her light had been on for a while and she couldn't get to him/her. Interview with LPN #1, on 02/08/17 at 5:30 AM, revealed Resident #7 has had the [MEDICAL CONDITION] bag burst open recently but she was not sure of the date. She revealed it had happened a few times because staff were not able to respond in time to change it and the incidents had happened in the last two (2) weeks. She stated the resident becomes very upset because the stool spills out on him/her and becomes very anxious and his/her blood pressure has increased. She stated licensed staff would stop and help the CNAs but even with helping them they could not answer all the lights. Interview with the Administrator and Director of Nursing (DON), on 02/08/17 at 3:30 PM, revealed they expected all staff to follow care plans as written.

Based on interview, record review and review of Lippincott's Nursing Procedures, fifth edition; it was determined the facility failed to provide appropriate treatment and services to ensure residents' abilities in toileting do not diminish for one (1) of six (6) sampled residents (Resident #6), Resident #6 was assessed as continent of bowel and occasionally incontinent of bladder and required the assistance of staff for toileting: however, staff failed to toilet the resident in a timely manner which caused the resident to have incontinent episodes. Resident #6 stated it made him/her feel dirty, ashamed and humiliated when it happens which is at least five (5) times a week The findings include: Review of the facility's Lippincott's Nursing Procedures Fifth Edition regarding Bedpan and Urinal Management, using a commode, Incontinence Management, and Correcting Urinary Incontinence with bladder retraining revealed incontinence is not a disease nor a part of normal aging. Incontinence may be caused by restricted mobility. Bedpan and urinal should be offered frequently-before meals, visiting hours, during morning and evening care, and at the time of any treatments or procedures. Using a commode is an alternative to a bedpan. The bedpan allows the patient to assume his/her normal elimination posture which aids in defecation. Record review revealed the facility admitted Resident #6 on 10/21/15 with [DIAGNOSES REDACTED]. Further review revealed Resident #6 also has a Left [MEDICAL CONDITION] which was performed in July 2016. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/23/17, revealed the facility assessed Resident #6's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment, revealed the resident was continent of bowel and occasionally incontinent of bladder. Review of the Comprehensive Care Plan for at risk for skin compromises, dated 04/29/15, revealed an intervention to toilet per schedule and an intervention, dated 01/31/17, to utilize bedside commode at night. Review of Resident #6's Nurse Aide Care Plan, dated 05/30/14, revealed an update, dated 06/03/14, to toilet upon rising and at bedtime, and an update, dated 01/31/17, to use bedside commode at night, no bedpans. Interview with Resident #6, on 02/07/16 at 3:30 PM, revealed he/she had to pee on myself multiple times due to staff not answering call lights on time. The resident stated it mostly happens on night shift between the hours of 2:00 AM and 5:00 AM. The resident revealed it takes forty-five (45) minutes to over an hour for the call light to be answered at night. The resident stated he/she would not be incontinent if call lights were answered in a timely manner and he/she has called the nurses station by cell phone to reach the nurse and tell her he/she needs to go to the restroom. Resident #6 further stated it makes him/her feel dirty, ashamed and humiliated when it happens which is at least five (5) times a week. Interview with Certified Nurse Aide (CNA) #1, on 02/08/17 at 6:05 AM, revealed she works short on nights most nights. CNA #1 stated there was only two (2) CNA's and two (2) licensed staff this past week and it is impossible to care for sixty (60) residents timely especially when there are multiple residents that require two (2) assist. She revealed staff cannot answer call lights in a timely manner and revealed residents may have to wait over an hour to get help. She revealed Resident #6 was continent if the resident received help to the bathroom or a bed pan in time. Interview with CNA #2, on 02/08/17 at 6:15 AM, revealed she was called in today at 3:30 AM to help with residents. CNA #2 stated it is impossible to get around to everyone for turning, changing, toileting and getting out of bed when there is only two (2) CNA's. She stated Resident #6's was normally continent but when it takes too long to answer the call light due to not enough staff the resident is incontinent. Interview with Licensed Practical Nurse (LPN) #1, on 02/08/17 at 5:00 AM, revealed Resident #6 is normally continent and often calls her from the room from his/her cell phone to let her know that she needs to urinate. She stated the call light above the door on Resident #6's room cannot be seen from the hallway as the hall has a double doorway that obstructs the view of the light and unless staff go through the double doors, the light cannot be seen. She stated there is no audible call system that can be heard by staff so Resident #6 often has incontinent accidents. was resident normally continent Interview with Administrator and Director of Nursing, on 02/08/17 at 3:30 PM, revealed they expected call lights would be answered in a timely manner so residents would be as continent as possible.

Based on interview and record review, it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #7) received care that was consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences related to [MEDICAL CONDITION]/[MEDICATION NAME] care. Resident #7 required his/her [MEDICAL CONDITION] bag to be changed; however, staff failed to change the [MEDICAL CONDITION] bag timely which resulted in the [MEDICAL CONDITION] bag becoming full and bursting off of the stoma with feces spilling over the resident and his/her bed on several occasions. Resident #7 stated he/she felt dirty and humiliated each time it happened. The findings include: Interview with the Administrator, on 02/07/17 at 2:30 PM revealed the facility did not have a policy to address [MEDICATION NAME]/[MEDICAL CONDITION] care but later produced a [MEDICAL CONDITION] check sheet for care that did not address how often the care should be done. Record review revealed the facility admitted Resident #7 on 08/15/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/09/16, revealed the facility assessed Resident #7's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Risk for complications related to [MEDICAL CONDITION] and [MEDICAL CONDITION], dated 08/30/16, revealed a goal to not have complications of ostomies without appropriate nursing interventions through next review date, and an intervention to change [MEDICAL CONDITION] bag and wafer as indicated. In addition, an intervention was added that Resident #7 prefers for the [MEDICAL CONDITION] bag to be changed instead of emptying when BM noted. Interview with Resident #7, on 02/07/17 at 2:15 PM, revealed he/she stated I can't get anyone to answer the call light. He/she further stated his/her [MEDICAL CONDITION] bag burst open two (2) days ago and stool went all over him/her because staff had not answered his/her call light. The resident stated, I had stool all over me and it was so humiliating and dirty. He/she further stated this has happened before and each time he/she had pressed the call light. Interview with Certified Nurse Aide (CNA) #1, on 02/08/17 at 6:05 AM, revealed she worked nights and could not get to Resident #7 before his/her [MEDICAL CONDITION] burst open. CNA #1 stated Resident #7 had his/her call light on and she was unable to get to the resident before it burst. She revealed she cleaned the resident up after the feces had spilled out and over the resident. She stated she can empty the [MEDICAL CONDITION] but could not change the bag. She stated the resident said his/her light had been on for a while and she couldn't get to him/her. Interview with Licensed Practical Nurse (LPN) #1, on 02/08/17 at 5:30 AM, revealed Resident #7 has had the [MEDICAL CONDITION] bag burst open recently but she was not sure of the date. She stated if the [MEDICAL CONDITION] bag is not emptied on time then the stool pushes the bag causing the wafer and bag to separate and potentially spilling feces onto the resident and bed. She revealed it had happened a few times because staff were not able to respond in time to change it and the incidents had happened in the last two (2) weeks. She stated the resident becomes very upset because the stool spills out on him/her. She becomes very anxious and his/her blood pressure increased. She stated licensed staff would stop and help the CNAs but even with helping them they could not answer all the lights. Interview with the Administrator, on 02/07/17 at 2:30 PM, revealed she was unaware of Resident #7's [MEDICAL CONDITION] bag bursting open but expected staff to change the [MEDICAL CONDITION] bag prior to the [MEDICAL CONDITION] becoming so full and to follow the Comprehensive Care Plan on changing the bag and emptying the bag as needed. She also revealed to ensure the resident's bag did not come off or burst, she expects all nursing staff who cares for resident to make every effort to ensure bag does not burst open. She also stated that accidents happen.

Based on interview, record review and review of the facility KRONOS Time Keeping System, it was determined the facility failed to ensure sufficient staff and related services to maintain the highest practicable physical, mental and psychosocial well-being of three (3) of nine (9) sampled residents (Resident #2, #6, and #7). The facility's failure to have sufficient staff caused Resident #2 to not be able to get up in the morning when he/she preferred; Resident #6 to have incontinent episodes due to not toileting timely which caused him/her to feel humiliated, dirty and ashamed and possibly contributed to his/her skin breakdown; and, caused Resident #7's [MEDICAL CONDITION] bag to burst open on several occasions due to not being emptied timely causing him/her to feel humiliated and dirty. Refer to F241, F282, F310, F314 and F328. The findings include: Interview with the Administrator, on 02/08/17 at 6:50 AM, revealed the staffing matrix she wanted for night shift was four to five Certified Nurse Aides (CNA) with two (2) licensed staff (Registered Nurse {RN} or Licensed Practical Nurse {LPN}. She stated she did not use an acuity based staffing program although one was available. Review of the KRONOS Time Keeping System used for this facility from 01/26/17 to 02/08/17 revealed CNA staffing for the hours from 11:00 PM to 7:00 AM were as follows: two (2) CNAs with one in orientation on 01/28/17, 01/29/17, 02/01/17, 02/06/17, and 02/07/17; three (3) CNAs on 01/26/17, 01/27/17, 01/31/17, 02/03/17, and 02/05/17; three (3) CNAs with one (1) on orientation on 02/02/17; four CNA (4) with one CNA entering at 3:30 AM on 02/08/17; two CNAs with one (1) on orientation and one (1) entering at 3:00 AM on 01/30/17, and, five (5) CNAs and one (1) coming in at 4:00 AM on 02/04/17. Further review revealed there were two (2) licensed staff scheduled each night. Interview with the Administrator, on 02/08/17 at 11:00 AM, revealed the Director of Nursing and other staff came in to help on short staffed nights; however, review of the KRONOS Report for 01/27/17 through 02/08/17 revealed there was no documented evidence the DON worked any shifts at night. 1. Record review revealed the facility admitted Resident #2 on 03/04/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/03/16, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was a two (2) person assist for transfers. Interview with Resident #2, on 02/06/17 at 1:00 PM, revealed he/she was wheelchair bound with bilateral amputations and had to have assistance to move from bed to chair and back. He/she stated at around 5:00 AM to 6:00 AM, he/she wants to get out of bed and when he/she uses his/her call light, it sometimes takes a long time for someone to answer and can take till 7:00 AM when the next shift comes in to get out of bed. He/she stated he/she should be able to get out of the bed when he/she wants to. 2. Record review revealed the facility admitted Resident #6 on 10/21/15 with [DIAGNOSES REDACTED]. Resident #6 also has a Left [MEDICAL CONDITION] which was performed in 7/2016. Review of the Quarterly MDS assessment, dated 01/23/17, revealed the facility assessed Resident #6's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review revealed the resident was continent of bowel and occasionally incontinent of bladder. Interview with Resident #6, on 02/07/26 at 3:30 PM, revealed he/she had to pee on myself multiple times due to staff not answering call lights on time. Resident #6 stated it happens mostly happens on night shift between the hours of 2:00 AM and 5:00 AM and takes as long as 45 minutes to over an hour for the call light to be answered. The resident further revealed he/she would not be incontinent if call lights were answered in a timely manner and he/she has called the nurses station by cell phone to reach the nurse and tell her he/she needs to go to the restroom. Resident #6 stated it makes him/her feel dirty, ashamed and humiliated when it happens which is at least five (5) times in a week. 3. Record review revealed the facility admitted Resident #7 on 08/15/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/09/16, revealed the facility assessed Resident #7's cognition as intact with a BIMS score of 15 which indicated the resident was interviewable. Interview with Resident #7, on 02/07/17 at 2:15 PM, revealed it takes a long time to answer call lights especially between the hours of 2:00 AM and 4:00 AM. Resident #7 stated, I can't get anyone to answer the call light. He/she revealed it makes him/her feel anxious and the anxiety causes him/her to have chest pain. Resident #7 revealed his/her [MEDICAL CONDITION] bag burst open two (2) days ago and he/she had stool all over him/her. He/she stated it was so humiliating and he/she felt dirty. The resident revealed this has happened before. Interviews on 02/08/17 with Certified Nurse Aide (CNA) #1 at 6:05 AM and CNA #2 at 6:15 AM revealed there has only been two (2) CNA's on night shift this past week and it is impossible to care for sixty (60) residents, especially when there are multiple residents that require the assistance of two (2) staff. They stated it was impossible to answer the call light in a timely manner and residents may have to wait over an hour to get help. Interview with Licensed Practical Nurse (LPN) #1, on 02/08/17 at 5:00 AM revealed when there is less staff residents dont get the care they should. She further stated its happened a lot lately because of a staffing shortage. Interview with the Administrator and Director of Nursing (DON), on 02/08/17 at 3:30 PM, revealed they expected to have appropriate staffing to meet all the needs of the residents.

Based on interview, record review and review of the facility KRONOS Time Keeping System, it was determined the facility failed to ensure sufficient staff and related services to maintain the highest practicable physical, mental and psychosocial well-being of three (3) of nine (9) sampled residents (Resident #2, #6, and #7). The facility's failure to have sufficient staff caused Resident #2 to not be able to get up in the morning when he/she preferred; Resident #6 to have incontinent episodes due to not toileting timely which caused him/her to feel humiliated, dirty and ashamed and possibly contributed to his/her skin breakdown; and, caused Resident #7's [MEDICAL CONDITION] bag to burst open on several occasions due to not being emptied timely causing him/her to feel humiliated and dirty. Refer to F241, F282, F310, F314, F328, F353. The findings include: Interview with the Administrator, on 02/08/17 at 6:50 AM, revealed the staffing matrix she wanted for night shift was four to five Certified Nurse Aides (CNA) with two (2) licensed staff (Registered Nurse {RN} or Licensed Practical Nurse {LPN}. She stated she did not use an acuity based staffing program although one was available. Review of the KRONOS Time Keeping System used for this facility from 01/26/17 to 02/08/17 revealed CNA staffing for the hours from 11:00 PM to 7:00 AM were as follows: two (2) CNAs with one in orientation on 01/28/17, 01/29/17, 02/01/17, 02/06/17, and 02/07/17; three (3) CNAs on 01/26/17, 01/27/17, 01/31/17, 02/03/17, and 02/05/17; three (3) CNAs with one (1) on orientation on 02/02/17; four CNA (4) with one CNA entering at 3:30 AM on 02/08/17; two CNAs with one (1) on orientation and one (1) entering at 3:00 AM on 01/30/17, and, five (5) CNAs and one (1) coming in at 4:00 AM on 02/04/17. Further review revealed there were two (2) licensed staff scheduled each night. Interview with the Administrator, on 02/08/17 at 11:00 AM, revealed the Director of Nursing and other staff came in to help on short staffed nights; however, review of the KRONOS Report for 01/27/17 through 02/08/17 revealed there was no documented evidence the DON worked any shifts at night. 1. Record review revealed the facility admitted Resident #2 on 03/04/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/03/16, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was a two (2) person assist for transfers. Interview with Resident #2, on 02/06/17 at 1:00 PM, revealed he/she was wheelchair bound with bilateral amputations and had to have assistance to move from bed to chair and back. The resident stated at around 5:00 AM to 6:00 AM, he/she wants to get out of bed and when he uses his/her call light, it sometimes takes a long time for someone to answer and can take till 7:00 AM when next shift comes in to get out of bed. He/she stated he/she should be able to get out of the bed when he/she wants to. 2. Record review revealed the facility admitted Resident #6 on 10/21/15 with [DIAGNOSES REDACTED]. Resident #6 also has a Left [MEDICAL CONDITION] which was performed in 7/2016. Review of the Quarterly MDS assessment, dated 01/23/17, revealed the facility assessed Resident #6's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review revealed the resident was continent of bowel and occasionally incontinent of bladder. Interview with Resident #6, on 02/07/16 at 3:30 PM, revealed he/she had to pee on myself multiple times due to staff not answering call lights on time. Resident #6 stated it happens mostly happens on night shift between the hours of 2:00 AM and 5:00 AM and takes as long as 45 minutes to over an hour for the call light to be answered. The resident further revealed he/she would not be incontinent if call lights were answered in a timely manner and he/she has called the nurses station by cell phone to reach the nurse and tell her he/she needs to go to the restroom. Resident #6 stated it makes him/her feel dirty, ashamed and humiliated when it happens which is at least five (5) times in a week. 3. Record review revealed the facility admitted Resident #7 on 08/15/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/09/16, revealed the facility assessed Resident #7's cognition as intact with a BIMS score of 15 which indicated the resident was interviewable. Interview with Resident #7, on 02/07/17 at 2:15 PM, revealed it takes a long time to answer call lights especially between the hours of 2:00 AM and 4:00 AM. Resident #7 stated, I can't get anyone to answer the call light. The resident revealed it makes him/her feel anxious and the anxiety causes him/her to have chest pain. Resident #7 revealed his/her [MEDICAL CONDITION] bag burst open two (2) days ago and he/she had stool all over him/her. Resident #7 stated it was so humiliating and he/she felt dirty. The resident revealed this has happened before. Interviews on 02/08/17 with Certified Nurse Aide (CNA) #1 at 6:05 AM and CNA #2 at 6:15 AM revealed there has only been two (2) CNA's on night shift this past week and it is impossible to care for sixty (60) residents, especially when there are multiple residents that require the assistance of two (2) staff. They stated it was impossible to answer the call light in a timely manner and residents may have to wait over an hour to get help. Interview with Licensed Practical Nurse (LPN) #1, on 02/08/17 at 5:00 AM revealed when there is less staff residents don't get the care they should. She further stated its happened a lot lately because of a staffing shortage. Interview with the Administrator and Director of Nursing (DON), on 02/08/17 at 3:30 PM, revealed they expected to have appropriate staffing to meet all the needs of the residents.