Every finding on record at Vicksburg Convalescent Center

Based on observation, resident and staff interviews, record review and facility policy review the facility failed to remove facial hair on a female resident who required assistance with Activities of Daily Living (ADLs) for one (1) of 78 residents observed on initial tour. Resident #44. Findings Include: Record review of the facility policy titled, Resident Hygiene revised 06/2022 revealed .Standard It is the practice of this facility to assist residents with bathing/showering to maintain proper hygiene and help prevent skin infections. Bathing includes washing the entire body, in addition, resident's fingernails and toenails will be trimmed when needed, facial hair shaved when needed and hair washed as needed Staff Responsibilities .7. Staff providing assistance will provide nail care (unless medically contraindicated), shampoo, and shave each resident on every bath/shower day . On 4/30/24 at 9:39 AM, an observation of Resident #44 lying in her bed revealed six (6) to eight (8) scattered facial hairs approximately three (3) inches long on her chin and some facial hair above her upper lip that was approximately one-half to one inch long. On 4/30/24 at 9:42 AM, an interview with Resident #44 revealed that no one had removed the hair from her face, and she would like the hair to be gone. She stated, That would be wonderful if someone would. On 4/30/24 at 4:55 PM, an observation revealed scattered facial hair to Resident #44's chin and upper lip. On 4/30/24 at 5:00 PM, an interview with Licensed Practical Nurse (LPN) #1, confirmed that Resident #44 had long facial hair to her chin and hair above her top lip. She stated, I can see it plainly. LPN #1 revealed the Certified Nursing Assistants (CNAs) were supposed to look at the residents while they gave them their baths and take care of facial hair if it was needed during that time. On 5/01/24 at 9:00 AM, an interview with CNA #1 revealed that Resident #44 was assigned to her yesterday, 4/30/2024, and she gave her a bath but did not shave her facial hair. She revealed that it was a hectic day, and she was focused on getting Resident #44 cleaned up and didn't look at or notice the facial hair. CNA #1 revealed that trimming facial hair was part of their job. She stated this was supposed to be done when they were doing resident baths and she failed to do this. CNA #1 confirmed she should have taken care of this. On 5/01/24 at 10:39 AM, an interview with LPN #2 revealed Resident #44 was confused and may not always know what was asked of her. She revealed that Resident #44 had worsening confusion and needed help with her bathing and personal hygiene. LPN #2 revealed that Resident #44 was not able to shave herself or pluck her own facial hairs. Record review of Resident #44's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Osteoarthritis of Knee, Muscle Weakness, Unsteadiness on Feet and Unspecified Lack of Coordination. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/02/2024 revealed under Section C, a Brief Interview for Mental Status (BIMS) Score of 11 which indicated that she had moderate cognitive deficits.

Based on facility policy review, resident interview, staff interviews, and record reviews, the facility failed to provide adequate Activities of Daily Living (ADL) personal care, to a resident, as evidenced by dentures not being properly stored for 1 of 5 residents for Activities of Daily Living (ADL) personal. Resident #1 Findings include: Review of facility policy titled, Resident Hygiene . Denture Care, dated 08/2021, revealed, Denture Care . Standard . It is the standard of this facility that every resident who has dentures will receive denture care at least twice daily and as needed or requested. Each resident will be encouraged to complete his or her own denture care, as he or she is able. A telephone interview on 6/22/22 at 10:11 AM, with the Resident #1's Resident Representative (RR), revealed she still had the concerns about Resident #1's unclean dentures, and about the dentures not being stored properly in the denture cup. The RR revealed Resident #1's top denture plate could be removed from her mouth, but her bottom denture plate was a calculus bridge, and could not be removed, but could be brushed while her mouth. The RR revealed she had submitted information, to the Social Worker, via text message, on Sunday, January 30, 2022, and sent another text message, on March 12, 2022, and asked for an update from the first text. The RR noted she could only visit the nursing facility on Saturdays and Sundays and sent a text message, to the Social Worker, because there was no office staff available to talk with on the weekends. The RR revealed she had not gotten a return text or verbal response from the Social Worker. An observation and interview with Resident #1, on 6/22/22 at 10:25 AM, along with the Certified Nurse Aide (CNA) #1, revealed Resident #1's top denture plate was stored in a dry denture cup, that was in the top drawer of Resident #1's chest, next to her bed. The denture cup was observed to have a ring of black residue around the top, inside area, and black residue in the bottom of the denture cup, underneath where the top denture plate sat. CNA #1 confirmed the top denture plate was stored in a dry denture cup that had a ring of black residue around the top, inside area, and had black residue in the bottom of the denture cup, underneath where the top denture plate sat. CNA #1 revealed the top denture plate should have been placed in a clean, covered, denture cup, with water and a denture cleansing tablet, to soak until Resident #1 was ready for them to be put back in her mouth. CNA #1 revealed that the CNAs are responsible for the ADL's task of denture care and had been in-serviced on denture care. An observation and interview on 6/22/22 at 10:50 AM, with the Staff Development Nurse, confirmed Resident #1's top denture plate was in a dry denture cup, with no water or a cleansing tablet, that the denture cup had a ring of black residue around the inside at the top, and the top denture plate rested on the bottom of the denture cup that was covered in the black residue. The Staff Development Nurse revealed the CNAs had been in-serviced on denture care and the CNAs should not have placed the top denture plate in a dirty denture cup. She also revealed the top denture plate was supposed to have been in a clean, covered in the denture covered with water and a cleansing tablet. The Staff Development Nurse revealed that Resident #1 did not receive adequate ADL care for the top denture plate. An observation and interview on 6/22/22 at 11:00 AM with the Assistant Director of Nursing (ADON), confirmed that Resident #1's top denture plate was in a dry denture cup, with no water or a cleansing tablet, that the denture cup had a ring of black residue around the inside at the top, and the top denture plate rested on the bottom of the denture cup that was covered in the black residue. The ADON confirmed that the CNAs were responsible for the ADL task of denture care, but nurses can assist the residents with denture care. The ADON revealed that Resident #1's top denture plate should have been placed in a clean denture cup, by the CNAs, with water, and a denture cleaning tablet, to soak and cleanse. The denture plate should remain in the denture cup until Resident #1 wanted it placed back in her mouth. The ADON confirmed that the resident did not receive proper ADL care for her top denture plate. An observation and interview on 6/22/22 at 12:00 PM, with the Social Worker, confirmed she had text messages from the Resident #1's RR, dated 1/30/22 and 3/12/22. The SA did visually observe the messages on the Social Worker's cell phone. The text message from 1/30/22 noted, Also, her teeth hasn't been brushed . Her top denture is sitting in water and looks awful. Has a film in it. The observation also revealed that the text message sent to the Social Work, from the RR, on 3/12/22 read, I know you won't get this until Monday, but Mom's dentures still haven't been cleaned. The Social Worker revealed she had not followed up with Resident #1 to confirm that she was not receiving adequate ADL denture care. An interview on 6/22/22 at 04:04 PM with the Registered Nurse (RN) Charge Nurse, revealed the CNAs are primarily responsible for the ADL task of denture care, which included placing the cleaned dentures in a denture cup with water and a denture cleansing tablet. An interview on 6/22/22 at 04:17 PM with CNA #2 revealed the CNAs are responsible for the ADL denture care task and have been in-serviced to put the dentures in a denture cup with water and a cleansing tablet to soak. An interview on 6/22/22 at 04:20 PM with CNA #3 revealed that CNAs are the ones to do the denture care and it was an ADL task and the dentures must be put in a denture cup with water and a cleaning tablet. An interview on 6/22/22 at 04:25 PM CNA # 4 revealed the CNAs are the ones to do ADL denture and mouth care. CNA #4 revealed dentures are to be put in a clean denture cup, with water and a cleaning tablet to soak. Record review of the Efferdent Denture Tablets directions revealed, . Can be used in a dental bath . Dental appliance may be soaked safely in EFFERDENT Cleanser Solution overnight . Recommended for use on full or partial dentures. Record review of a signed letter, date 6/22/22, from the Social Worker, on the nursing facility's letterhead, disclosing the information from the text message, that the Social Worker received from the RR on 1/30/22 revealed, I received a text message from (Resident's Daughter's named removed) Responsible Party on January 30, 2022 at 1:23pm . Also her teeth hasn't been brushed . Her top denture is sitting in the water and looks awful. Has a film in it. Record review of the ADL Care Plan, for resident, revealed, (Resident #1) has an ADL Self Care Performance Deficit r/t left side [CONDITION(S)], bilateral hand contractures, weakness. Record review of the in-service titled, Importance of Daily Oral Care for the Elderly . The Smile Proud Mississippi Project, dated 5/12/22, for CNAs and nurses, revealed, Training Topics . Performing daily resident oral health assessments . Developing individual resident oral health care plans . Using assistive oral care devices and improving direct-care staff perceptions of working with residents' mouths. Record review of the in-service titled, Oral Care, Denture Care, ADL Care and Documentation, dated 2/1/22, revealed, Important Points Covered . 1. Oral Care . 2. Denture Care . 3. ADL Care .Procedure for oral care, proper cleaning and storing of dentures. Record review of Section G . Functional Status, of the MDS Quarterly Assessment, dated 5/10/22, revealed, J. Personal Hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, and hands . 1. Self-Performance . 4 . Total dependence - full staff performance every time during entire 7-day period. Record review of Section C . Cognitive Patterns, of the Minimum Data Set (MDS) Quarterly Assessment, dated May 10, 2022, revealed resident has a BIMS Score of 7, indicating the resident has severely impaired cognition.

Based on facility policy review, staff interviews and record review the facility failed to resolve grievances for a resident, as evidenced by there being no grievance forms completed for investigation/resolution of reported grievances for 1 of 3 residents assessed for unresolved grievances. Resident #1 Findings include: Review of the facility policy titled, Grievance/Concern/Comments, revealed, Standard . Residents and their family members may voice grievances to the facility or other agency/entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The facility will make prompt efforts to resolve grievances . 3. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay . g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official issues a written decision on the grievance to the resident or representative at the conclusion of the investigation, which should conclude within 14 days. A telephone interview on 6/22/22 at 10:11 AM, with Resident #1's Responsible Party (RP) daughter, revealed she still had the concerns about resident's unclean dentures, about the dentures not being stored properly in the denture cup, about the refrigerator not being returned to resident or replaced, and still had concerns about resident not getting a bath. The RP revealed she had submitted this information, via text, as a complaint, to the Social Worker, on Sunday, January 30, 2022, and had sent another message on March 12, 2022, asking for an update from the first text. The RP noted she could only visit the nursing facility on Saturdays and Sundays, and sent a text to the Social Worker, because there was no office staff available to talk with on the weekends. The RP revealed she had not gotten a text or verbal response from the Social Worker regarding any of her complaints. An observation and interview on 6/22/22 at 12:00 PM, with the Social Worker, confirmed she had text messages from the RP dated 1/30/22 and 3/12/22. The message from 1/30/22 read, Hey I just went to see mom, her refrigerator isn't in her room, and no one can find it. Also, her teeth hasn't been brushed and looks like she hasn't had a bath. Her top denture is sitting in water and looks awful. Has a film in it. The observation also revealed that the text message sent to the Social Work, from the RP, on 3/12/22 read, I know you won't get this until Monday, but Mom's dentures still haven't been cleaned her skin is still very dry and her refrigerator is still not in her room. The Social Worker revealed she did write a grievance for Resident #1's missing refrigerator, when she returned to work on the Monday, 2/1/22, but did not resolve that grievance. The Social Worker revealed she did not write a grievance for the RP's complaints about the dentures and about Resident #1 looking like she had not had a bath. The Social Worker confirmed she did not resolve any of the grievances, for Resident #1, that were mentioned in the RP's text messages from 1/30/22 and 3/12/22. An observation and interview on 6/22/22 at 12:15 PM, with the Assistant Director of Nursing (ADON), confirmed a text message was sent to the Social Worker, by the RP, on 1/30/22, that read, Hey I just went to see mom, her refrigerator isn't in her room, and no one can find it. Also, her teeth hasn't been brushed and looks like she hasn't had a bath. Her top denture is sitting in water and looks awful. Has a film in it. The ADON also confirm the Social Worker received a text from the RP on 3/12/22 that read, I know you won't get this until Monday, but Mom's dentures still haven't been cleaned her skin is still very dry and her refrigerator is still not in her room. The ADON confirmed that there was only a grievance form done for resident's missing refrigerator, that was unresolved. She also confirmed there was not a grievance form completed for the RP's complaints regarding resident's denture care and for Resident #1 looking like she had not had a bath. The ADON confirmed there should have been a grievance form completed for all of the complaints from the RP on Monday, 2/1/22, and confirmed that all of the grievances were unresolved. Record review of a signed letter, date 6/22/22, from the Social Worker of the nursing facility's letterhead, disclosing the information from the text messages that the Social Worker received from the RP on 1/30/22 and 3/12/22, revealed, I received a text message from (Family member's name removed) Responsible Party on January 30, 2022 A 1:23pm . Hey I just went to see mom, her refrigerator isn't in her room and no one can find it. Also her teeth hasn't been brushed and looks like she hasn't had a bath. Her top denture is sitting in the water and looks awful. Has a film in it . 3/12/22 @ 1:48pm (I never read this message) . I know you won't get this until Monday but Mom's dentures still haven't been cleaned her skin is still very dry and her refrigerator is still not in her room. Record review of the Grievance Log revealed a grievance form titled, Grievance/Concern/Comment Report, dated 2/1/22, for Resident's missing refrigerator. The grievance form revealed, . Grievance/Concern/Comment . Missing Frig . Resident's Name: (Resident's name removed) . Person Reporting: (Family member's name removed) . Relationship: Daughter . Investigation findings: Spoke w/(maintenance worker name removed) no one has seen a frig . actions taken to resolve and respond to concern: voiced this to (Family member's name removed). The record review did not reveal grievance forms for the RRs complaints regarding Resident #1's denture care and her looking like she had not had a bath. Resident #1's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date of 5/10/22 revealed a Brief Interview for Mental Status score of 7 which indicates severe mental impairment.

Based on observation, staff interview, and facility policy review, the facility failed to discard out of date foods, provide proper sanitation during food handling, and properly clean cooking utensils as evidenced by expired food items in the refrigerator, prepping foods with contaminated gloves and the presence cookware with heavy grease buildup for two (2) of two (2) kitchen tours. Findings include: Review of the facility's Food Storage Labeling policy, revised ,[DATE], revealed the facility will ensure the safety and quality of food by following good storage labeling procedures. Procedure 3b. revealed foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by-date or expiration date. Review of the facility's Dining Service Operational Standards for Purchasing, Cooking, and Storage policy, revised ,[DATE], revealed the facility stores, prepares, distributes, and serves food under sanitary conditions to prevent the spread of food borne illness and reduce those practices that result in food contamination and comprised food safety. Procedure 6d. revealed to wash hands before handling food, after handling raw food, and after any interruption that may contaminate hands. Review of the facility's Manual Warewashing policy, revised ,[DATE], revealed dining service pots and pans that cannot fit in a dish machine are cleaned and sanitized in the three-compartment sink. Procedure #2 revealed to rinse, scrape, and soak all items before washing. Procedure #3 revealed to use a brush, cloth, or nylon scrub pad to loosen remaining soil. An observation, of the kitchen on [DATE] at 11:20 AM, and a revisit on [DATE] at 11:15 AM, revealed the following out of date foods in the walk in refrigerator: One (1) five (5) pound opened Ricotta cheese container with a pinkish -orange film over the top of the cheese, expiration date ,[DATE] ; two (2) five (5) pound containers of Ricotta cheese with an expiration date of [DATE]; one third of a quart of buttermilk, expiration date [DATE]; one (1) five (5) pound container of cottage cheese, expired on [DATE] ; and two (2) five (5) pound containers of Pimento cheese, expired on [DATE]. An interview, on [DATE] at 11:15 AM, with the Dietary Manager (DM), revealed it is everyone's responsibility to check dates, but ultimately it was her responsibility because she is the manager. The DM stated they need to be checking food expiration dates closer every day. She stated this could cause people to get sick. An observation, on [DATE] at 11:45 AM, with the Dietary Manager (DM) during the tray line prep, revealed the Dietary Aide (DA) prepping parsley in a large bowl that was to be placed on the lunch trays. The parsley was being stemmed. The DA stemmed several pieces of parsley with gloves on then moved to another table and picked up the tray cards and a box of plastic wrap taking them back to prep table and started prepping the parsley again. He then assisted with the tray line by placing the parsley and tray cards on the plates and picking up the plate covers. The dietary aide did not change gloves and wash his hands at any time during this process. An interview, on [DATE] at 11:50 AM, with the dietary aide (DA),. confirmed his gloves were not clean when he touched the parsley. He stated this could cause illness or infection. An interview, on [DATE] at 11:55 AM, with the DM, revealed the DA should have changed his gloves and washed his hands before touching the parsley. The DM confirmed the DA's gloves were contaminated by touching the plastic wrap and the tray cards .She stated the only thing the DA should have been doing was putting the parsley on the trays. The DM stated she felt he was just nervous. An observation, on [DATE] at 12:05 PM, revealed a large skillet sitting on the stove with an approximate two (2) inch ring of dark brownish black build-up around the inside of the top of the skillet and the outer sides and bottom were thickly coated with a rough black build-up. The observation also revealed five (5) large and two (2) small baking pans coated on the outside and bottom with a dark brownish build-up. An interview, on [DATE] with the DM, revealed the skillet and the pans should be scrubbed to remove the burned-on grease. The DM stated it is possible that some of the black buildup on the skillet could come off in the food. She also stated the build up on the skillet and pans could cause a fire during cooking.

Based on observation, record review, staff interview and facility policy review the facility failed to provide catheter care in a manner to prevent the possibility for a Urinary Tract Infection [MEDICAL CONDITION] for one (1) of four (4) residents reviewed with catheters, Resident #41. Findings include: Review of the facility's statement on letterhead, dated 12/11/19, revealed, The Perineal Care standard dated (MONTH) 2014 is the Policy and Procedure for Perineal Care. Review of the Perineal Care Standard, revised (MONTH) 2014, revealed: Perineal Care, for a female resident: a. Using washcloth/personal wipes, clean in a downward motion (front to back) and from center to thighs (center to side to side). b. Separate labia with non-dominant hand to expose urethral and vaginal openings; and wash area downward from front to back using clean surface of washcloth for each swipe. Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three (3) inches. On 12/11/19 at 11:00 AM, an observation revealed Resident #41's catheter care was provided by Certified Nursing Assistant (CNA) #1. CNA #1 wiped back to front along the left labia major, back to front along the right labia major and back to front between the labia minor with each step of the cleaning process to include cleansing, rinsing and drying. CNA #1 grasped the Foley Catheter at the connection to the drainage bag tubing, instead of at the catheter insertion site at the meatus and wiped downward from the direction of the catheter insertion site three (3) times to include cleansing, rinsing, and drying the Foley Catheter tubing. On 12/11/19 at 11:10 AM, an interview with CNA #1 revealed she was taught to wipe back to front on females during catheter care. CNA #1 stated the catheter should be held by the connector to the drainage tubing to prevent the catheter from being pulled out during care. An interview with Registered Nurse (RN) #3/Staff Education Nurse, on 12/11/19, at 12:00 PM, revealed RN #3 stated females should be wiped from front to back during catheter care and the catheter should be secured at the meatus to prevent pulling it out with the bulb inflated, which could cause stretching of the urethra and increased risk of infection. Review of the Perineal Care: Performance Checklist Female revealed,CNA #1 had completed a performance check off with an Acceptable grade conducted by RN #3 on 5/7/19. The performance evaluation included female catheter care per agency policy. Review of the Medication Review Report, dated 12/11/19, revealed Resident #41 had an indwelling catheter, for wound/shin protection due to a stage 3 sacral wound, with a start date of 10/23/19. Review of the Admission Record for Resident #41 revealed the resident was admitted by the facility, on 10/22/19, with a primary [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 10/29/10, revealed a Brief Interview for Mental Status Score of 99, and the Cognitive Skills for Daily Decision Making was coded a 3, which indicated severe cognitive impairment, never or rarely made decisions. The MDS also revealed Resident #41 was coded for the presence of an indwelling catheter ( which included a suprapubic catheter and/or nephrostomy tube) .

Based on record review, facility policy review and staff interviews, the facility failed to develop a Care Plan for catheter care for one (1) of four (4) residents with catheters, Resident #41. Findings include: Review of the facility's Comprehensive Care Plan policy, dated 03/2019, revealed:, Standard: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 6. The comprehensive care plan will describe at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. 9. The comprehensive care plan will include measurable objectives and timeframes to meet the needs identified in the resident's comprehensive assessment. the objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of Resident #41's care plan revealed the Focus: Resident #41 has an indwelling catheter (cath) related to (r/t) stage 3 sacral wound. Resident has a stage 4 (wound) to the left elbow. Date initiated: 10/23/19. The Desired Outcome was Resident #41 will remain free from catheter-related trauma through review dated of 01/30/2020. Further review of the Interventions/Tasks revealed there was no intervention/tasks to provide catheter care. The Interventions/Tasks only spoke to the presence of the 16 fr (french) indwelling Foley catheter with a 10 cc (cubic centimeter) bulb, keep the catheter bag and tubing below the bladder level and away from the entrance room door, monitor and document intake and output, monitor for pain/discomfort due to the catheter, monitor/record/report signs and symptoms (s/s) for Urinary Tract Infection [MEDICAL CONDITION] to the MD (Medical Doctor), and observe for s/s of discomfort on urination and frequency. On 12/11/19, at 11:00 AM, an observation during Resident #41's catheter care provided by Certified Nursing Assistant (CNA) #1 revealed CNA #1 wiped back to front along the left labia major, back to front along the right labia major and back to front between the labia minor with each step of the cleaning process to include cleansing, rinsing and drying. CNA #1 grasped the Foley Catheter at the connection to the drainage bag tubing, instead of at the catheter insertion site at the meatus, and wiped downward from the catheter insertion site three (3) times to include cleansing, rinsing, and drying the Foley Catheter tubing. On 12/11/19 at 11:10 AM, in an interview with CNA #1, CNA #1 stated she was taught to wipe back to front on females during catheter care. CNA #1 stated the catheter should be held by the connector to the drainage tubing to prevent the catheter from being pulled out during care. Record review of the Medication Review Report dated 12/11/19, revealed Resident #41 had an order for [REDACTED]. On 12/11/19 at 4:00 PM, an interview with the Assistant Director of Nursing (ADON), revealed Registered Nurse (RN) #1 was responsible for care plans, so the ADON could not speak to care plans. On 12/11/19 at 4:07 PM, an interview with Registered Nurse #1, (RN) confirmed there was no catheter care intervention for cleaning Resident #41's Foley catheter included on the care plan and the catheter care should be care planned. Review of the Admission Record for Resident #41 revealed the resident was admitted by the facility, on 10/22/19, with a primary [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 10/29/10, revealed a Brief Interview for Mental Status Score of 99, and the Cognitive Skills for Daily Decision Making was coded a 3, which indicated severe cognitive impairment, never or rarely made decisions. The MDS also revealed Resident #41 was coded for the presence of an indwelling catheter (which included a suprapubic catheter and/or nephrostomy tube) .

Based on observation, record review, staff interview and facility policy review, the facility failed to post staffing in an easily accessible area for residents and visitors for one (1) of two (2) observations. Findings include: Review of the facility's Facility Staff Posting Information policy, dated 10/2019, revealed the facility will post the nurse staffing total number at the beginning of each shift. The information posted will be clear, readable and in a readily accessible area to residents and visitors. On 12/12/19 at 11:32 AM an observation and review of the staff posting revealed the staffing information was located on the ledge of the 1st floor nursing station, on a clip board and was upside down. On 12/12/19 at 11:59 AM, an interview with the Assistant Director of Nursing (ADON) confirmed the staff posting was located at the nursing station, on the ledge, upside down. The ADON revealed the facility did not have it posted on the wall because this was the resident's home and she felt it would not be home like to have the staff posting on the wall. The ADON revealed visitors would not likely walk up and turn over a clip board looking for staffing information. An interview, on 12/12/19 at 12:15 PM, with the Administrator confirmed the placement of the staff posting was not easily accessible to visitors and residents, and she would move it immediately.

Based on record review, staff interview and facility policy review, the facility failed to develop a comprehensive care plan to address Behaviors for one (1) of 14 records reviewed; Resident #3. Findings include: Review of the facility's Care Plan Policy policy, dated 04/8/2011, revealed it is the policy of the facility to provide a care plan for each resident that is current, up-to-date and reflects the individual needs for each resident. A review of the Centers of Medicare and Medicaid Services (CMS) RAI 3.0 Manual, dated 10/15, revealed under Section 2.7 The Care Area Assessment (CAA) Process and Care Plan Completion, the assessment information is used to develop, review and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. The MDS information and the CAA process provide foundation upon which the care plan is formulated. Resident #3 A review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/04/16, revealed Section E0200 (Behavioral Symptoms) was coded due to Resident #3 exhibiting other behavior symptoms not directed toward others one (1) to three (3) days during the seven (7) day look back period. Section V0200 Care Area Assessment (CAA) Summary revealed Behavioral Symptoms triggered and a care plan would be developed. A review of the CAA Worksheet revealed documentation of Resident #3 having a problem of hollering out. A review of the comprehensive care plan for Resident #3 revealed there was not a care plan developed to address Behaviors. An interview on 01/05/17 at 3:40 PM, with the Director of Nursing (DON) revealed Resident #3 hollers out but that's just part of her Dementia. Interview on 01/05/17 at 3:52 PM, with Social Services (SS) #1 revealed she completed Section E of the admission assessment for Resident #3. SS revealed Resident #3 had behaviors of hollering out. Upon reviewing Resident #3's care plan on SS #1's computer, SS #1 stated It's not there, referring to the behavior care plan. SS #1 further revealed it is her responsibility and nursing to make sure care plan is completed related to behaviors. Interview on 01/05/17 at 4:30 PM, with Registered Nurse (RN) #1, revealed that upon reviewing the hard copy of the care plan and looking on the computer, there was not a care plan for Behaviors for Resident #3. RN #1 further revealed that she was going to create one. A review of the Face Sheet revealed the facility admitted Resident #3 on 10/31/16, with [DIAGNOSES REDACTED]. A review of the admission MDS assessment with an ARD of 11/04/16, revealed Resident #3, per staff assessment, had severe cognitive impairment.

Based on observation, and staff interview, the facility failed to prevent the potential spread of infection as evidenced by failing to change soiled gloves prior to touching clean surfaces for Resident #3, and using gloves pulled from pocket to complete incontinent care for Resident #6. Findings include: The facility did not provide an Infection Control Policy related to incontinent care. Resident #6 Observation on 02/04/2016 at 4:45 PM with Certified Nurse Assistant (CNA) #2 revealed CNA #2 removing gloves from pocket to complete incontinent care on Resident #6. During an interview, on 02/04/2016 at 4:45 PM, CNA #2 stated after incontinent care gloves are not to be used from their pockets due to bacteria. Interview with the Registered Nurse/Staff Development Nurse, on 02/04/2016 at 5:05 PM, revealed staff had been educated on not using gloves from their pockets because of bacteria. Interview on 02/04/2016 at 4:55 PM with Director of Nursing confirmed staff had received education about not using gloves from their pockets. Review of the facility's Face Sheet revealed the facility admitted Resident #6 on 10/12/2009 with [DIAGNOSES REDACTED]. Review of the Resident #6's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2016, revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating Resident #6 has severe cognitive impairment. Resident #3 On 2/4/16 at 1:20 PM, an observation revealed Certified Nursing Assistant (CNA) #1 touched the resident and his clothing, handrails of his bed, and the privacy curtain with contaminated gloves, following incontinent care for Resident #3. During an interview on 2/4/16 at 1:30 PM, CNA #1 confirmed she had contaminated Resident #3 and his environment, including handrails and privacy curtain by failing to remove contaminated gloves she wore during incontinent care. CNA #1 explained she received frequent in-services on infection control measures during incontinent care; the last being about two (2) weeks prior. CNA #1 further stated her failure to remove her gloves was due to nervousness and she just forgot, but definitely knows better. On 2/4/16 at 3:35 PM, an interview with the Staff Educator concluded incontinent care had been a major focus area of this facility. She explained she does hands on training with repeat demonstrations on all CNA staff and provided documentation reflecting CNA #1 received this training in January of this year. CNA #1's signature was present on documentation. Review of the facility's face sheet revealed, the facility admitted Resident #3 on 6/6/1994 with [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS,) with an Assessment Reference Date (ARD) of January 5, 2016, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 2. This indicates Resident #3 had severely impaired cognition.

Based on record review, staff interview, and facility policy review, the facility failed to develop a Urinary Tract Infection [MEDICAL CONDITION] Care Plan for Resident #10, for one (1) of 10 Care Plans reviewed. Findings include: Review of the facility policy entitled, Care Plan Policy (no date) revealed, Policy: It is the policy of (Name of Facility) to provide a care plan for each resident that is current, up-to-date, and reflects the individual needs for each resident. Procedure: The care plan will be updated as needed by the MDS (Minimum Data Set) nurse and/or floor nurse in a timely manner. Review of Resident #10's physician's orders revealed an order dated 5/15/15 to transfer the resident to the emergency room (ER) for evaluation and treatment R/T (related to) altered mental status, confusion, and feeling weak. Review of the hospital Discharge Summary dated 5/26/15 revealed Resident #10 was admitted to the hospital on [DATE] for the treatment of [REDACTED]. Review of Resident #10's Care Plan revealed there was no problem to address the UTI, nor recurrent UTIs. Interview, on 06/18/15 at 11:00 AM, with Registered Nurse (RN) #1 verified there was not a Care Plan for the UTI, or recurrent UTIs for Resident #10. RN #1 stated she did not know why the Care Plan was not completed. Review of the Admission Record revealed the facility admitted Resident #10 on 05/06/14 with diagnoses, which included [MEDICAL CONDITION].

Based on record review, staff interview, and facility policy review, the facility failed to include a Urinary Tract Infection [MEDICAL CONDITION] on two (2) of Resident #10's Minimum Data Sets (MDS), for two (2) of 21 MDS's reviewed. Findings include: Review of the facility policy entitled, MDS Completion Policy (no date) revealed, It is the policy of (Name of Facility) to ensure timely and thorough documentation for MDS purposes by all team members of the Interdisciplinary team. Review of Resident #10's Progress Notes revealed the following entries: 1) 05/15/15 at 10:50 PM, Resident confused and noted to have an acute change in mental status. 2) 05/16/15 at 3:30 AM, was admitted to hosp. (hospital) with Dx (Diagnosis) UTI. Review of the hospital History and Physical for Resident #10, dated 05/16/15, revealed Resident #10 was admitted to the hospital for altered mental status, and [DIAGNOSES REDACTED]. Review of Resident #10's significant change in status MDS with an Assessment Reference Date (ARD) of 06/02/15, and 14 Day MDS with an ARD of 6/7/15 revealed the Active [DIAGNOSES REDACTED]. Interview, on 06/18/15 at 9:25 AM, with Registered Nurse (RN) #1 verified the UTI was not coded on the 06/02/15, and 06/07/15 MDS, even though Resident #10 had symptoms, a [DIAGNOSES REDACTED]. RN #1 stated she did not know why the UTI was not coded on the MDS. Review of the Admission Record revealed the facility admitted Resident #10 on 05/06/14, with diagnoses, which included [MEDICAL CONDITIONS].

Based on interview, record review, and facility policy review, the facility failed to obtain laboratory (lab) results in a timely manner for one (1) of 18 residents reviewed for lab results (Resident #6). Findings include: A review of the facility's no name policy revealed: It was the facility policy to obtain routine labs at anytime during the month unless otherwise specified by MD. Lab would be obtained by a contract phlebotomist, and if unable to obtain, the facility staff would obtain. The record review revealed a physician's orders [REDACTED]. Record review revealed, as of 1/7/15, no results for these lab test were obtained and there was no evidence the lab was drawn. Further record review revealed there was no evidence the physician's orders [REDACTED]. A staff interview on 1/7/15 at 3:30 PM with Registered Nurse #1 (RN #1), revealed the contracted lab service did not come for the holidays so the facility staff contacted the physician and got an order to draw the lab yesterday (1/6/15). RN #1 confirmed if the facility had a physician's orders [REDACTED]. The facility admitted Resident #6 on 10/21/13 with [DIAGNOSES REDACTED].

Based on observation, staff and resident interview, and facility policy review, the facility failed to ensure the resident received eighty square feet of useable space for resident area. This was for one (1) of four (4) residents observed in four resident ward room, Resident #12. Findings include: Review of the facility's policy entitled, "Resident Rights and Dignity Management", revised 09/2014, revealed, "5. Each resident will be provided with adequate personal space in their room to promote health and well-being. Semi-private and multi person bedrooms will be monitored to ensure personal space is maintained." Observation of Resident #12's room on 01/07/15 at 9:15 AM with Licensed Practical Nurse (LPN #1), revealed Resident #12's room was shared with three other residents', who's privacy curtains were positioned vertically/horizontally across room, and allowed for adequate resident space with in them. Resident #12's room was positioned horizontally against the wall, with the television mounted securely above the bed. The privacy curtains pulled around Resident #12's bed were pulled open so LPN #1 could move Resident #12's bed from the wall while reaching to the right of the residents bed. During interview and observation with Resident #12 on 01/08/15 at 11:30 AM, Resident #12 confirmed, "Sometimes when they turn me over it is a little small." Resident #12 had a bedside table next to the bed rail, and the privacy curtain was flush against bedside table. Resident #12's wheelchair was outside of curtain, as there was no room for it inside curtain. Resident #12 confirmed he needed assistance with being transferred from bed to chair, and staff had to open the curtain to have room for this transfer; thereby exposing the resident during transfer. Observation with the Administrator and the Director of Nursing (DON) on 1/08/15 at 11:45 AM, revealed the resident space (from privacy curtain to wall) was forty-five square (45) feet. (The sink area/vanity which was at the front entrance to the room was shared by all residents for useable space as well.) The Administrator spoke with Resident #12, who confirmed he did not wish to move and was "okay" with the space. The Administrator stated room layout had "always been this way," and Resident #12 had left the facility and returned requesting the same room. The Administrator and the DON confirmed the space was "a little small," Resident #12's wheelchair was unable to be stored in his area, and he would also be unable to sit in wheelchair with curtains closed. The Administrator confirmed she had not been made aware by staff of having to open curtains to transfer the resident or how little space was provided to resident. Observation and interview with Administrator and the Director of Nursing on 01/09/15 at 3:30 PM, revealed the privacy curtain previously stretched horizontally for Resident #12's area had been moved to a connecting track, affording more space for Resident #12. The Administrator confirmed when the new privacy curtains were re-hung the tracks were not placed as they were previously which resulted in lack of space for Resident #12. During an observation and interview on 01/09/15 at 9:30 AM, with the Maintenance Director and the Maintenance Assistant, Resident #12's space between privacy curtains were measured 8 feet by 9.4 feet (equaling 75.2 feet) inside privacy curtains. (The sink/vanity area outside of curtain was also useable space for residents.) However, another resident's area which was vertically placed by Resident #12, required the resident's television to be placed inside Resident #12's space, requiring the curtains to remain open. The Maintenance Director confirmed and stated, "I'm going to have to get him a small TV and mount it on the wall so that the curtain can close." The facility admitted Resident #12 on 08/22/14 with [DIAGNOSES REDACTED]. A review of Resident #12's Minimum Data Set (MDS) with and Annual Reference Date (ARD) of 11/17/14, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognitive status. This MDS confirmed Resident #12 required assistance with transfers and required the use of a wheelchair for ambulation.

Based on observation, record review, staff interview, the facility failed to ensure that one (1) of 11 residents received the therapeutic diet ordered by the physician from September 10, 2014 until February 26, 2014 (Resident #6). Findings include: Review of the facility's policy entitled "Dietary Tray Cards", dated January 15, 2012, revealed "each resident shall have a diet card. 4. Resident's diet exactly as ordered by the physician. " Resident #6 Record review revealed Resident #6 was admitted by the facility on 3/11/13 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date of 12/9/14, revealed a Brief Interview for Mental Status score of 6, which indicated that Resident #6's cognitive status was severely impaired. Record review of the Medication Review Report, dated January 30, 2014, revealed an order, dated 9/10/13, for a NAS (No Added Salt) diet - Mechanical Soft Texture, Regular liquids consistency, No Raw Vegetables, Fruits, Fried Foods, Cornbread. Review of the Order Listing Report, dated February 25, 2014, revealed Resident #6's diet order, dated 9/10/13, for NAS (No Added Salt) diet - Mechanical Soft Texture, Regular liquids consistency, No Raw Vegetables, Fruits, Fried Foods, Cornbread. An observation of the supper meal on 2/25/14 at 5:00 PM revealed Resident #6 was served a turkey sandwich with lettuce and tomato on the sandwich. The turkey sandwich had been cut in quarters. An observation of the lunch meal on 2/26/14 at 12:15 PM revealed Resident #6 was served a turkey burger with lettuce and tomato, French fries and fried corn nuggets. The turkey burger had been cut in quarters. An interview with the Assistant Director of Nursing (ADON) on 2/26/14 at 5:15 PM revealed the ADON was informed of the observation of raw vegetables and fruits being served to Resident #6 during the supper meal of 2/25/14; and, and raw vegetables, raw fruit and fried foods being served to Resident #6 during the lunch meal of 2/26/14. An interview on 2/27/14 at 9:15 AM with the Administrator confirmed Resident #6 had received her meals incorrectly. The facility did not ensure that Resident #6 received the diet ordered on [DATE] from September 10, 2013 through February 26, 2014.

Based on observation, record review, staff interview and policy review, the facility failed to store and distribute food under sanitary conditions as evidenced by improper food temperatures on the tray line and improper storage of food items for three (3) of four (4) dietary tours. Findings include: Observation on 4/15/13 at 11:00 a.m. of the kitchen revealed there were an accumulation of debris on shelves and the lids of the flour, meal and sugar bends in the dry storage area. One (1) male staff with facial hair was observed working in the dietary area without a hair restraint and the walls in the walk-in cooler were stained. There was a build-up of ice in the ice cream freezer. Observation on 4/16/13 at 11:15 a.m. revealed Dietary Staff #3 took the temperature of food items on the tray line. The temperature of the pureed diet foods (ham, spinach and potatoes) were less than 140 degrees on the line. Dietary Staff #3 did not initiate the removal of the items from the line but spoke on starting the line and the time. The low temperature items were not removed until the Dietary Supervisor #2 came over and proceeded to ask what was wrong. Dietary Staff #3 informed the Dietary Supervisor #2 of the low food temperatures and Dietary Supervisor #2 explained to Dietary Staff #3 that the items would need to be removed and reheated to the appropriate temperature before the tray line could be started. Dietary Staff #3 was also observed to wipe the digital thermometer used to take the tray line temperatures with a napkin between uses. Interview and observation on 4/17/13 at 2:50 p.m. of the dietary area revealed the ice cream freezer with two (2) bags of frozen chicken stored on top of the ice cream. Dietary Supervisor #2 stated, "I don't know who put that in there." Interview on 4/18/13 at 10:00 a.m. with the Dietary Manager and Dietary Supervisor regarding the concerns with the initial tour and the tray line temperatures and the lack of staff follow through when the pureed food temperatures were observed to be below 140 degrees. Review of the facility's "Dietary Services" policy, noted, "... U. Steam tables: 1. Must be able to maintain hot foods at temperatures of 140 degrees or above. 2. Must not contaminate food through splashing or condensation..."

Based on observation, staff interview, record review and policy review, the facility failed to provide an effective pest control program as evidenced by observation of a live roach in Room 104, and a live roach crawling on the second floor hallway for one (1) of four (4) days of survey. Findings include: Observation during the initial tour on 4/15/13 from 11:27 a.m. until 1:05 p.m. revealed one (1) live roach was observed on a box by the window in Room 104. One (1) live roach was observed in the hallway on second floor across from Room 204. The roach on second floor was observed by the Director of Nursing who attempted to step on the roach. Interview on 4/16/13 at 11:35 p.m. with the Director of Nursing revealed that (name of pest company) had come to spray for bugs that day. Review of facility's unnamed policy, reviewed 1/1/13, noted, "Policy: It is (name of facility) policy to maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is free of insects and rodents. 2. Pest control services will be provided by an approved vendor and a contract will be initiated for these services ...." Review of facility's contract with (name of contractor), dated 11/1/12, noted that services for pest elimination "... shall be performed Monthly or as needed based on the nature of any recurring pest problem ...Exhibit A ... Sighting logs are placed at every nursing station ..." Interview on 4/17/13 at 11:50 a.m. with the Assistant Director of Nursing regarding the pest log for the second floor nursing station, revealed, "We don't have one here." Interview on 4/17/13 at 12:05 p.m. with the Director of Nursing (DON) to determine how facility notified Pest Control Company regarding the pests observed, stated, "We notify the administrator, and she adds it to a log. The DON immediately went to the Administrator's office and requested the log. Interview, at this time, with the Administrator revealed the Administrator stated, "We almost never see anything." The DON provided a log with two (2) entries dated 8/20/12 and 4/15/13. No other entries were noted. Observation on 4/17/13 at 2:50 p.m. on the first floor nurses station revealed a notebook was on wall labeled, "(Name of company) Pest Control Sightings Log." All the log sheets inside the logbook were all blank.

Based on observation, record review, staff interview and policy review, the facility failed to ensure each resident's dignity was respected during meals by not offering glasses with milk cartons and supplements; not encouraging the removal of trays during meal serving; failing to offer alternatives to clothing protectors for three (3) of four (4) meals observed; and not knocking on door prior to entering the room of one (1) of 15 residents reviewed (Resident #16). Findings include: Observation on 4/15/13 at 11:00 a.m. during initial tour of the main dining room revealed residents were served meals with no glasses for milk cartons, and clothing protectors were placed on resident's clothing. Observation on 4/16/13 at 12:15 p.m. of the main dining during the lunch meal revealed clothing protectors were observed on all residents and residents were served milk in cartons with no glasses on four (4) of the six (6) tables used by residents without glasses provided. Observation on 4/16/13 at 5:08 p.m. of the supper meal in the main dining room revealed residents at five (5) tables were served milk cartons and supplements without glasses and clothing protectors were observed on all residents. Observation on 4/17/13 at 11:55 a.m. of the lunch meal in main dining area and in the second floor dining room revealed residents were served milk cartons without glasses; bibs were noted to be offered to resident without an alternative. Serving trays were observed on the tables with plates left inside food containers and lids were stacked on the center of the tables. Interview on 4/18/13 at 10:00 a.m. with the Dietary Manager and Dietary Supervisor acknowledged understanding when the need for residents to have options of clothing protectors; glasses offered with milk cartons and supplements and plates and containers with trays left on the table. Interview on 4/18/13 at 11:40 a.m. with the Administrator revealed there was an attempt to make changes from institutional dining offered for residents in September 2012 but the resident council saw no need to change. Review of the Resident Council minutes for September 2012 revealed the Dietary Manager offered to place plates on tables and off trays. There were no other documented attempts to provide more normalized dining for residents. Resident #16 Record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Minimum Data Set, date 2/27/13, revealed a Brief Interview for Mental Status score of 15, which indicated Resident #16 was cognitively intact. Observation on 4/16/13 at 4:00 p.m. revealed Resident #16 received his 1630 (4:00 p.m.) Finger Stick Blood Sugar (FSBS) per Licensed Practical Nurse (LPN) #2. The door to Resident #16's room was open, and Resident #16 was seated on his bed. LPN #2 entered Resident #16's room without knocking. LPN #2 completed the FSBS for Resident #16, left the room and returned to the medication cart which was located in the hallway in front of room [ROOM NUMBER]. LPN #2 was observed to enter room [ROOM NUMBER] without knocking on the door. The resident in the B Bed was observed lying in the bed at this time. LPN #2 entered the room to obtain a paper towel, and then returned to the medication cart. Interview, at this time, with LPN #2 revealed she should have knocked on the resident's doors before entering the room. Interview on 4/18/13 at 7:15 p.m. with the Director of Nursing confirmed knowledge of staff not knocking on resident's doors before entering resident's rooms. Review of the facility's "Resident Rights to Privacy and Dignity" policy, noted, "It is the policy of (name of facility) to provide the highest level of privacy and dignity to our residents. Entering Resident's Room: Always knock (you are entering their home); Address resident by name (Mr. and Mrs. (NAME REDACTED) name of their choice if properly documented/care planned); Introduce self; Explain procedure; Wash hands (Wash hands between each resident); Provide Privacy (Pull curtains/close doors/blinds for any treatment). Review of the facility's "Resident Rights to Privacy and Dignity Policy", updated 5/19/12, noted, "... 18. Dining Room: May offer bib ..." This policy did not address offering alternatives to bibs and providing glasses for beverages and removing plates from trays.

Based on observation and staff interview, the facility failed to maintain a sanitary, orderly, and comfortable interior for two (2) of four (4) days of observation as evidenced by a frayed light string, dirty ice machine and a broken sink in four (4) of 46 resident rooms and in one (1) common area. Findings include: Observation on the initial tour of the facility on 4/15/13 with the Director of Nursing at 11:30 a.m. revealed: Room 202 - There was a frayed string for the light over the sink. Room 206 - There were scuff marks on the bottom of the doors in the bathroom and the sink was spotted and dingy. Room 209A and B - There were stains on the wall to the right of the sink in the room. The bathroom floor grout was dirty. Room 210A - There was a loose sink fixture in the room. Interview, at this time, with the Director of Nursing confirmed these findings. Observation on 4/17/2013 at 3:20 p.m. revealed there was an accumulation of dirt and dust on and around the ice machine in the hallway near the dietary department.

Based on observation and staff interview, the facility failed to ensure a clean, comfortable, and homelike environment for two (2) of four (4) days of observation as evidenced by odors in six (6) of 46 resident rooms and stains on the seat one (1) of four (4) chairs in the front lobby area. Findings include: Observation during the initial tour on 4/15/13 from 11:27 a.m. until 12:11 p.m. revealed pungent smelling odors in Rooms #222, #223, #224, #225, #226 and #227. Interview on 4/15/13 at 12:11 p.m. with Licensed Practical Nurse #3 confirmed the findings of odors in the resident's rooms. Observation on 4/17/13 at 3:20 p.m. revealed there were stains on one (1) solid green colored fabric chair located at the front door entrance.

Based on observation, record review, staff interview and policy review, the facility failed to ensure residents privacy by failing to provide a medical assessment in a private area for one (1) of four (4) Unsampled residents (Unsampled A). Findings include: Record review revealed Unsampled Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 6, which indicated that Unsampled Resident A's cognitive status was severely impaired. This MDS coded that Unsampled Resident A had an absence of speech and limited ability to make concrete requests. Observation on 4/17/13 at 3:30 p.m. revealed Unsampled A was seated in the hallway near the nurse's desk and a female in a white laboratory jacket was observed checking her chest area and asking Unsampled Resident A questions. Facility staff was observed at the nurse's desk; however, no staff intervention was made to encourage the person wearing the white laboratory jacket to perform the assessment of Unsampled Resident A in a private area. Interview on 4/17/13 at 3:44 p.m. with the Assistant Director of Nursing revealed the person in the white laboratory was Nurse Practitioner #1. Interview on 4/17/13 at 3:44 p.m. with the Assistant Director of Nursing revealed she saw what happened with the Nurse Practitioner and was going to talk with her about the observation. Interview on 4/18/13 at 9:10 a.m. with Assistant Director of Nursing (ADON) regarding the incident with the Nurse Practitioner and Unsampled Resident A revealed the visit was made and a progress note was documented on the visit. The ADON stated, "She's (Nurse Practitioner) is new and has only made two (2) visits. She doesn't work for us she works for the medical doctor." Interview on 4/18/13 at 9:37 a.m. with the Director of Nursing (DON) revealed resident had given the Nurse Practitioner (NP) the "OK" to check her out in the lobby. The DON stated, "I asked (name of Unsampled Resident A) if the NP asked if she could check her out and she said yes. Well she nodded yes. The NP said she asked (name of Unsampled Resident A) "Do you want/or is it ok to check her in the lobby." Interview on 4/18/13 at 10:15 a.m. with the Nurse Practitioner regarding the observation with Unsampled Resident A stated, "She's (Unsampled Resident A) usually in the hallway and doesn't like to go to her room. I'm very careful not to expose them to much. Most of the residents will go to their room. But it's their choice or their right to refuse to." Interview on 4/18/13 at 11:25 a.m. with Unsampled Resident A regarding Nurse Practitioner asking her about providing care in the hallway revealed Unsampled Resident A moved her head but gave no direct yes or no responses with her head. It was difficult to understand her gestures. Review of the facility's "Compliance Program & Code of Business Conduct Acknowledgement" policy, signed 4/12/12 by Nurse Practitioner #1, noted, "The compliance Program and Code of Business Conduct have been adopted by (name of facility) to provide standards by which employees, physicians and allied health professionals are to conduct themselves in order to protect and promote the organization and to enhance the organization's ability to achieve its mission ...Conform to applicable professional standards, to exercise sound judgment in the exercise of duties ...Treat all residents with respect and dignity, promote and provide the highest quality of life possible for each resident..."