Every finding on record at Warm Springs Medical Center Nursing Home

Based on observations, staff interviews, and review of the facility's policies titled, Warewashing and Manual Warewashing (3-Compartment Sink), dietary staff failed to prevent wet-nesting in stored steam table pans to avoid the potential for bacterial growth. The facility census was 76 and all residents were receiving an oral diet.Findings include:Review of the facility's policy titled Warewashing revealed at bullet point number 4, all dishware will be air dried and properly stored.Review of the facility's policy titled Manual Warewashing (3-Compartment Sink) revealed at bullet point number 2, all serviceware and cookware will be air dried prior to storage.Observation on 05/15/2026 at 9:15 AM of the pot and pan rack revealed several stacks of steam table pans. A stack with four small square steam table pans were pulled apart and the inside of the top pan was wet with large drops of water. Due to the inside of the top pan being wet, the water coated the bottom of the following pan. Another stack with five small square steam tables were pulled apart and the pan second from the top, the inside was wet with large drops of water.During an interview on 05/15/2026 at 9:15 AM the Dietary Manager (DM) confirmed that the pans identified were stored wet inside. The DM stated that dietary staff were to allow pans to completely air dry before stacking and storing.Observation on 05/15/2026 at 9:20 AM, Dietary [NAME] DD was wiping the identified wet steam table pan dry with a white linen towel.During an interview on 05/15/2026 at 9:20 AM, Dietary [NAME] DD revealed she was told by the DM that the pans needed to be dried so she was drying them with a towel.During an interview on 05/15/2026 at 9:20 AM, the DM confirmed she told Dietary [NAME] DD that the pans needed to be dry and assumed that [NAME] DD would re-wash and air dry the pans. The DM revealed that dietary staff were not to use a towel to dry any dish items and that all dishes should be air dried.

Based on observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to follow physician's orders for oxygen (O2) for one of 18 residents (R) (R18) with physician's orders for O2. This deficient practice had the potential to place R18 at risk of respiratory complications. Findings include: Review of the facility's policy titled Oxygen Administration, dated 7/22/2024, revealed the Policy section stated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The Policy Explanation and Compliance Guidelines section included, Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Review of R18's electronic medical record (EMR) revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and hypoxemia. Review of R18's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented the resident received O2. Review of R18's care plan revealed a Problem last reviewed 11/13/2024 of Resident has hypoxia and shortness of breath related to respiratory disease history of COVID-19, pneumonia, COPD, and CHF. The Approaches included administering O2 at 2 liters per minute (LPM) via nasal cannula (NC). Review of R18's Physician's Orders revealed an order dated 3/17/2025 for O2 at 2 liters per minute via a NC, continuous. Observations on 3/25/2025 at 9:36 am, 3/26/2025 at 10:36 am, and 3/27/2025 at 9:11 am revealed R18 lying in bed receiving O2 via an NC. Observations of the O2 concentrator revealed the flow rate was set at 1.25 LPM at all observations. Review of R18's medication administration record (MARS) revealed documentation that the O2 was administered as ordered. In a concurrent observation and interview on 3/27/2025 at 9:11 am, Licensed Practical Nurse (LPN) BB verified that R18's O2 flow rate setting was a little over 1 LPM. LPN BB confirmed R18's O2 order was for 2 LPM and adjusted the flow rate. In an interview on 3/27/2025 at 4:03 pm, the Director of Nursing (DON) stated that nurses manage the O2 settings and document once a shift that the settings were checked.

Based on observations, staff interviews, and a review of the facility policy titled, Safe Food Handling, the facility failed to ensure one of three reach-in freezers were clean and free from debris; failed to ensure inside the ice machine was clean and free from residue. The facility failed to ensure dietary staff washed hands and changed gloves in the dish room to prevent cross contamination. The facility census was 76 with 74 residents receiving an oral diet. Findings include: 1. Observation on 11/3/2023 at 8:45 am of the three door freezer in the dry storage area revealed on the bottom left side was dirt and food debris consisting of two lima beans and a French fry. During an interview on 11/3/2023 at 8:45 am the Director of Dining Services (DDS) confirmed that the bottom of the three door freezer had dirt and food debris. The DDS stated that she was waiting for a part for the shelf in the freezer and then she was going to take all items out of the freezer, clean and reassemble. The DDS revealed that cleaning the freezers is on the cleaning schedule and confirmed that dietary staff had not been cleaning the bottom of the freezer. Observation on 11/3/2023 at 9:05 am of the ice machine revealed that there was a black substance on the left and right side edges of the metal ice slide. The black substance on the left was in a shape of the straight line that was about one inch in length. The black substance on the right side was the size and shape of a dime. The black substances were touched with a white paper napkin and the substances were able to be removed. Continued observation revealed the ice scoop was located in a bin; the bin was attached to the wall near the ice machine. The ice scoop was clean however the bottom of the ice scoop bin was dirty with a brown and black type substance. During an interview on 11/3/2023 at 9:05 am the DDS confirmed that the ice slide had black substance on the left and right side that was removed by a white paper napkin. The DDS also confirmed that the bottom of the ice scoop bin was dirty with debris. The DDS revealed that the ice scoop is washed regularly but was not sure how often or the last time the ice scoop bin had been cleaned. The DDS revealed that cleaning the ice machine is dietary responsible and should be completed weekly and confirmed that it had not been clean. During an interview on 11/5/2023 at 10:30 am with the DDS revealed that she does not have any cleaning sheets from the past DDS since she recently took the position. The DDS stated that dietary staff are expected to clean as part of their positions. 2. Review of the facility policy titled Safe Food Handling revealed when to wash your hands - 2. Whenever you go between food items or between clean and dirty items. Observation on 11/4/2023 at 12:00 pm of dietary aide FF revealed he was assigned to the dish room and was wearing blue colored plastic gloves. Continued observation revealed he was using a plumbing plunger to unclog the sink in the dish room. He then began to scrub two steam table pans and placed them inside the dish machine. Dietary aide FF was observed placing the clean steam table pans on the drying rack that was located on the other side of the kitchen. The dietary aide did not remove or wash his hands after using the plumber and scrubbing pans before touching the clean pans. During an interview on 11/4/2023 at 12:25 pm with dietary aide FF revealed that he changes his plastic gloves three or four times during his shift when working in the dish room. The dietary aide stated that no one had discussed with him that he needed to change gloves and wash hands going between dirty and clean dishes. During an interview on 11/5/2023 at 10:10 am the DDS revealed that dietary staff are required to change gloves and wash hands going from the dirty side of the dish machine to the clean side and touching clean dishes.

Based on record review, staff interviews, and review of the policy titled Abuse Program Policy and Procedures, the facility failed to ensure pre-employment screening, specifically reference checks, were conducted prior to employment for 10 of 33 employees. The census was 76 residents. Findings include: Review of the undated policy titled Abuse Program Policy and Procedures, the policy included to maintain an environment free of abuse and neglect. The Procedure section stated: Line numbered 1. All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of residents. Line numbered 2. Screening of potential employees will include requesting information from previous and/or current employers. Observation of employee files on 11/3/2023 at 4:30 pm with the Director of Human Resources, in her office, revealed there were no reference checks performed for ten employees reviewed. The reviewed files included the Administrator, Director of Nursing, Dietary Manager, Infection Preventionist, Social Services Director, Licensed Practical Nurse (LPN) AA, LPN BB, LPN CC, Certified Nursing Assistant (CNA) DD, and CNA DD. Interview on 11/3/2023 at 4:50 pm with The Director of Human Resources revealed the facility did not conduct reference checks as part of the new hire process. She stated she had worked as the Director of Human Resources for one year and she was unsure why the refence checks were not conducted. Interview on 11/4/2023 at 9:00 am with the Administrator revealed he had been the Administrator for six weeks. He stated he was unaware the facility did not conduct pre-employment reference checks on applicants. He stated he thought pre-employment reference checks would be a good idea, but most new hires were known by staff prior to employment. Telephone interview on 11/4/2023 at 9:05 am with the Director of Human Resources, in the Administrator's office and with the Administrator present, revealed reference checks were not conducted due to due to a history of no response from previous employers. She stated background checks were conducted and verified the background checks would only provide information of reported events. Interview on 11/4/2023 at 9:10 am with the Administrator revealed his expectation was for the Director of Human Resources to follow the facility policy for conducting reference checks and stated he was unaware of the facility policy for pre-employment background checks. He stated a reason for conducting pre-employment reference checks was to protect residents from abuse and neglect.

Based on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, for seven days a week for 13 days (6/1/2023, 6/5/2023, 6/7/2023, 6/9/2023, 6/15/2023, 6/19/2023, 6/21/2023, 6/25/2023, 6/26/2023, 6/27/2023, 10/3/2023, 10/17/2023, and 10/27/2023). The census was 76. Findings include: Review of the PBJ Staffing Data Report for FY Quarter 3 2023 revealed no RN hours for 6/7/2023, 6/9/2023, 6/13/2023, 6/19/2023, 6/23/2023, 6/26/2023, 6/27/2023, 6/28/2023, and 6/30/2023. Review of the Facility Two-Week Staffing Grid for 10/17/2023 through 10/30/2023 revealed no RN hours on 10/17/2023 and 10/27/2023. Review of facility documentation and interview with Human Resources (HR) GG on 11/5/2023 at 1:00 pm confirmed the following dates in June 2023 and October 2023 with no RN hours: 6/1/023, 6/5/2023, 6/7/2023, 6/9/2023, 6/15/2023, 6/19/2023, 6/21/2023, 6/25/2023, 6/26/2023, 6/27/2023, 10/3/2023, 10/17/2023, and 10/27/2023. Interview with the Director of Nursing (DON) on 11/5/2023 at 2:01 pm revealed she came to work here in August 2023, and someone quit back in June 2023 when they did not have enough RN coverage. She stated that she has one RN that works three days per week, one RN that works two days per week, and a weekend RN. Two RNs were scheduled to work at the same time in October 2023 which was why they had several days without RN coverage. They recently moved the one RN to another schedule and hired an agency RN to also provide RN coverage. She acknowledged the days that did not have RN coverage.

Based on record review, staff interviews, and review of the policy titled Advanced Beneficiary Notice (ABN), the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS-10055) to two residents (R) (R47 and R36) from a sample of three residents who were discharged from Medicare Part A services and remained in the facility in the last six months. The census was 76 residents. Findings include: Review of the facility policy titled Advanced Beneficiary Notice (ABN) with an effective date 11/18/2016 revealed the policy stated the facility was to comply with the rules established by the Centers for Medicare and Medicaid Services (CMS) to inform Medicare patients about services that may not be covered. The ABN is a notification given to Medicare patients to convey that Medicare is not likely to provide coverage in a specific case. The ABN must be delivered to affected patients before providing the items or services that are the subject of the notice. Under the section titled Three Events Prompting Issuance of ABN line numbered 3. Termination - If services are being terminated and the beneficiary wants to continue receiving care that is no longer considered medically reasonable and necessary, you must issue an ABN prior to furnishing non-covered care. 1. R36 was discharged from Medicare Part A services on 9/15/2023 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS-10123). There was no evidence that the facility had issued an SNFABN (Form CMS-10055) to R#36 or her responsible party, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. R47 was discharged from Medicare Part A services on 6/27/2023 and remained in the facility. However, the only notice provided to the resident was the NOMNC (Form CMS-10123). There was no evidence that the facility had issued the SNFABN (Form CMS-10055) to R47 or her responsible party, providing the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. There were only three residents discharged from Medicare Part A in the last six months. A telephone interview on 11/4/2023 at 10:45 am with the SSD in the Administrator's office and with the Administrator present, revealed she had worked as the SSD for about two months. She stated she was unaware of what the SNF ABN Form CMS-10055 was. She further stated she had not received education on the SNF ABN Form CMS 10055. She stated she provided a NOMNC to all residents that discharge from Medicare Part A but did not provide an SNFABN form. She verified R47 and R36 had discharged from therapy, remained in the facility, and the facility did not provide R47 and R36 or the responsible party with a SNFABN. A telephone interview on 11/4/2023 at 11:05 am with the Chief Financial Officer (CFO) for the facility, in the Administrator's office and with the Administrator present, revealed the facility did not typically provide the SNFABN form. She stated she was unaware of the CMS guidelines for the issuance of SNF ABN form. Interview on 11/4/2023 at 1:15 pm with the CFO, in the Conference Room, revealed the facility did not provide SNFABN notices to any resident when their Medicare Part A was exhausted. She stated it was her understanding the NOMNC was all that was required to be provided. Interview on 11/4/2023 at 2:37 pm with the Administrator revealed his expectations were for beneficiary notices to be provided according to CMS guidelines. He stated he was unaware the beneficiary notices were not being provided according to CMS guidelines.

Based on interviews and record review, the facility failed to follow up on grievances related to Certified Nursing Assistants (CNA) not treating the residents with dignity and respect for three residents (R) (A, B, and C) of 33 sampled residents. Findings include: 1. Interview with R A on 11/3/2023 at 10:34 am revealed Certified Nursing Assistant (CNA) HH and CNA JJ are always talking on their phones when providing care to the residents. She stated that they do not pay attention to what the resident needs because they are distracted while on the phone. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R A with a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact, and had no documented behaviors. 2. Interview on 11/3/2023 at 10:23 am with R B revealed that CNAs do not treat the resident with dignity and respect, specifically CNA HH and CNA II. They are always on the phone when providing care. She stated she complains and lets staff know in resident council meetings, but she has noticed a worsening rudeness after complaining. She feels they know she complained and are acting differently. She stated she received no follow-up from the facility related to her complaint. The Quarterly MDS assessment dated [DATE] documented R B with a BIMS score of 15 and had no documented behaviors. 3. Interview on 11/4/2023 at 2:45 pm with R C revealed that during the resident council meeting in October 2023, it was mentioned that CNAs are always on their phones while providing care. She stated staff said they would handle the concern. Resident C stated the CNAs are always on their phone when they provide care. Resident C stated she will often think they are talking to her but later realize they are talking to someone on the phone though an earpiece. The Quarterly MDS assessment dated [DATE] documented R C with a BIMS score of 15 and had no documented behaviors. Review of the Grievance Log for October 2023 revealed no grievances. Review of the Resident Council Minutes from October 2023 revealed no indication that a complaint was voiced related to staff being on the phone. Interview with the Administrator on 11/5/2023 at 12:00 pm revealed he took over during the last resident council meeting for maybe the last five minutes of the meeting. He stated someone did mention that CNA staff are always on their cell phones while caring for the residents. He stated he gave a verbal response to the CNA but did not know who the CNA was. He stated that he did not take any additional corrective action. He stated he walks the halls, instructing them to take earbuds out immediately. Review of the Education In-service dated 8/29/2023 revealed CNA education was provided related to no cell phone use being allowed except on your break. CNA HH and CNA JJ were not listed as receiving the education. Review of the facility policy titled Resident and Family Grievances revised 7/9/2020 revealed it is the policy of this facility to support each resident's and family members right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/ grievance.

Based on observation, interview, and record review, the facility failed to complete wound assessments weekly for one resident (R) (51) of three residents reviewed for pressure ulcers. Findings include: Review of the undated facility policy titled Wound Treatment Management revealed the effectiveness of treatments will be monitored through ongoing assessments of the wound. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed R51 was unable to complete the Brief Interview of Mental Status (BIMS) Assessment and had two Stage 3 pressure ulcers and one Stage 4 pressure ulcer present on admission. Review of Wound Documentation in the Electronic Medical Record revealed the following wounds: 1. Sacrum, Date identified - 4/27/2023. Most Recent Documentation dated 11/3/2023 - 4.3 centimeters (cm) X 5.7 cm. Previous Documentation dated 8/28/2023 - 3.1 cm X 4.7 cm. 2. Right Ankle, Date identified - 4/27/2023. Most Recent Documentation dated 11/3/2023 - 3 cm X 0.8 cm. Previous Documentation dated 8/28/2023 - 0.5 cm X 0.3 cm. 3. Left Ankle, Date identified - 4/27/2023. Most Recent Documentation dated 11/3/2023 - 2.1 cm X 2 cm. Previous Documentation dated 8/28/2023 - 0.6 cm X 0.4 cm. Additional wound documentation provided by the wound nurse via the (name) Skin and Wound App included: 1. Pressure ulcer, stage 4 - sacrum - 8/24/2023, 9/20/2023, 9/27/2023, 10/6/2023, and 11/2/2023. 2. Pressure ulcer, stage 3 - right lateral malleolus: 8/17/2023, 8/24/2023, 9/1/2023, 9/8/2023, 9/21/2023, 10/4/2023, and 11/1/2023. 3. Pressure ulcer, stage 3 - left lateral malleolus: 8/24/2023, 9/1/2023, 9/21/2023, 10/4/2023, and 11/1/2023. Interview with the Treatment Nurse, Licensed Practical Nurse (LPN) KK on 11/4/2023 at 4:55 pm revealed that what she provided was all she had completed for wound assessments for R51. She acknowledged that wound assessments are supposed to be completed weekly. Observation on 11/5/2023 at 2:20 pm revealed R51 wound treatment was provided as ordered by the Physician. There were no concerns with infection control or status of the wound. Review of the clinical record revealed R51 was placed on Hospice Services on 8/21/2023.

Based on observations and staff interview, the facility failed to have medical equipment plugged into a wall outlet and not an electrical power strip in one of 42 resident rooms. Findings include: Observations on 11/3/2023 at 9:45 am, 11/4/2023 at 12:45 pm, and 11/5/2023 at 12:50 pm of resident room [ROOM NUMBER] revealed that the oxygen concentrator was plugged into a power strip and was not the wall outlet. The power strip was lying on the floor near the head of the resident bed. Interview on 11/5/2023 at 12:50 pm the Director of Nursing (DON) confirmed that resident in room [ROOM NUMBER] oxygen concentrator was plugged into a power strip and should not be. The DON revealed that once an order is written for a resident to receive oxygen treatment the nurse will obtain an oxygen concentrator from storage, place in resident room and plug in wall outlet for usage. The DON stated that nursing staff should know not to plug any medical equipment into a power strip and expects nursing staff to plug directly into wall outlet. A policy regarding Medial Equipment/Oxygen Concentrator was requested, no policy was provided.

Based on observations, staff interviews, medical record review, and policy review, the facility failed to serve a proper renal diet for one resident (R28) of three residents ordered to receive a renal diet. The facility also failed to have the registered dietitian document weight loss for one resident (R68) from a sample of 33. Findings include: 1. Review of the policy titled Therapeutic Diets revealed that a therapeutic diet is defined as a diet ordered by a physician or delegated registered dietitian or licensed dietitian as part of the treatment for a disease or clinical condition. Procedures included: Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. Resident 28 has a diagnosis of end stage renal disease and is dependent on dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C the Brief Interview for Mental Status (BIMS) was coded as 15, which indicates intact cognition. Review of the physician orders revealed R28 was ordered a renal diet. Observation and interview on 11/4/2023 at 5:15 pm with R28 revealed that his dinner meal was served and consisted of a fish sandwich, mixed vegetables, potato wedges, apple crisp, and ice tea. R28 confirmed that he received potato wedges on his dinner tray and stated that he will likely eat all the potato wedges provided. Photo of R28 dinner meal was taken with his consent. Review of R28 meal tray ticket revealed that he was to receive a renal diet of breaded fish on bun, buttered noodles, country vegetable blend, maple apple crisp, milk, and tea. During an interview on 11/4/2023 at 5:30 pm the Director of Dining Services (DDS) confirmed that R28 is ordered to receive a renal diet. The DDS confirmed that the photo of R28 dinner meal, R28 was served potato wedges. The DDS revealed that the renal diet should have been served buttered noodles instead of potato wedges. The DDS stated that dietary staff did not follow the meal tray ticket and she expects dietary staff to serve the correct food items for renal restrictions, this was an oversight by dietary. 2. Resident 68 is a [AGE] year old long term care resident that was admitted to the facility on [DATE] due to cerebral infarction affecting right dominant side. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C that the Brief Interview for Mental Status could be assessed due to poor cognition. The MDS Section K revealed that the resident had weight loss and was not on a physician prescribed weight loss regimen. Review of the medical record revealed R28 weights for the past six months were as follow: 11/2/2023 - 134.3 pounds 10/3/2023 - 139.4 pounds 9/5/2023 - 141.4 pounds 8/3/2023 - 147.5 pounds 7/5/2023 - 150.1 pounds 6/4/2023 - 149.1 pounds Weight loss calculations revealed 9.9% in six months, 5% weight loss in three months, and 3.7% in one month. Review of the medical record revealed that nursing had been documenting R68 weight loss in the progress notes. The last nursing progress note that discussed R68 weight loss was dated 9/20/2023 and stated: resident has been added to PAR (performance assessment review) due to increased weight loss. 4.1% in 30 days. Diet recently downgraded to mechanical soft due to resident having trouble eating meats. Review of the medical record revealed no nutrition assessment or nutrition documentation from the registered dietitian. Interview on 11/5/2023 at 1:45 pm with the Director of Nursing (DON) revealed that nursing staff are aware that R68 has been losing weight and the weight loss has been discussed during PAR meetings. The DON revealed that the registered dietitian attends the PAR meetings via phone. Continued interview revealed that the DON confirmed that no dietitian assessment or dietitian notes were found in R68 electronic medical records. The facility started electronic charting in May 2023. Further interview with the DON revealed that she contacted the registered dietitian to assist with finding dietitian assessment/notes. The dietitian stated to the DON that she last documented on R68 on 9/21/2023, the DON was not able to find dietitian note and dietitian was not able to provide note. A policy for nutrition assessment was requested and was not provided.

Based on observation, interview, and review of facility policy, the facility failed to ensure that a lunch meal remained hot upon delivery to residents. This had the potential to affect 18 residents on the hall. Findings include: Interviews with residents, including R A on 4/19/22 at 9:30 a.m., revealed that the food is always cold. Sometimes, the food is served in a Styrofoam box which makes it even colder. Observation on 4/20/22 at 12:30 p.m. revealed the Dietary Manager and Dietary Aide brought a closed meal cart to the floor. The cart remained on the floor for six minutes before a staff member began to pass trays to the residents. The last tray was distributed 28 minutes from the start time. Staff were observed to stay in resident's rooms for prolonged amounts of time before delivering the remainder of the meal trays. A test tray was sampled by the surveyor on 4/20/22 at 12:58 p.m. after trays had been passed to all 18 residents on that hall. The food was no longer hot, and the temperature of the food items (sweet potatoes, roast beef tips and green beans) was 64 degrees. During an interview on 4/20/22 at 2:05 p.m., the Administrator stated the dietary manager was expected to review any complaints of cold food voiced by the residents and respond appropriately. Review of facility policy titled Menus with copyright date of 2020 revealed it was the intent of the facility to provide meals based on a menu following established national guidelines. Further review revealed that menu items will be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections.

Based on record review, review of the facility's policy titled Pneumococcal Vaccines, and staff interviews, the facility failed to have an effective immunization program in place to ensure residents were offered pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for residents over the age of 65. This failure affected one of five sampled residents (R) (#1) reviewed for immunizations. Findings include: Review of the facility's policy titled, Pneumococcal Vaccines revised 03/2018 revealed, It is our policy to offer our residents, staff and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.1.) Each resident will be assessed for pneumococcal immunizations upon admission.any additional efforts to obtain vaccine information should be documented, including efforts to determine the date of vaccination or the type of vaccine received. Review of the CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, revealed, There are 2 types of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) and Pneumococcal [MEDICATION NAME] vaccine (PPSV23 or [MEDICATION NAME]®). CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain medical conditions or who smoke.CDC recommends you: Give 1 dose of PCV13 and 1 dose of PPSV23.For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccines:.HIV infection, [MEDICAL CONDITION], or nephroti[DIAGNOSES REDACTED], Alcoholism, Chronic [MEDICAL CONDITION], Chronic liver disease, [MEDICAL CONDITION], including [MEDICAL CONDITIONS], and Diabetes mellitus. CDC recommends you: Give 1 dose of PPSV23.CDC recommends pneumococcal vaccination for all adults [AGE] years or older.All adults [AGE] years or older should receive 1 dose of PPSV23. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html Review of R#1's undated Face Sheet, (a document with demographic and limited diagnostic information) located in the resident's hard copy medical record, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Face Sheet revealed R#1 was [AGE] years old at the time of the survey. Review of R#1's physician's orders [REDACTED]. Continued paper chart review revealed an informed consent for the pneumococcal vaccine and the influenza vaccine were offered and accepted by R#1's representative/daughter on 4/4/17 when R#1 was transferred from the medical center into long term care. The paper chart documented a historical first dose of Prevnar 13 prior to admission but did not include a record of the second dose of the pneumococcal vaccine (PPSV23) as recommended by the CDC. An interview with the Director of Nursing (DON) on 2/24/21 at 10:39 a.m., revealed the facility has not changed to electronic medical records, so the paper charts are the entire medical record. The DON stated the hospital, and the nursing home shared an Infection Preventionist and she should have all of the vaccination records and would provide for review. An interview with the Infection Preventionist (IP) on 2/24/21 at 1:15 p.m. revealed there were no additional vaccination records for R#1. The IP confirmed there was no record the facility offered R#1 the second pneumococcal vaccine per CDC recommendations. The IP stated it was .important the residents get all the protection they can, especially with COVID around.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that open items in the dry storage and cooler were labeled and dated. The deficient practice had the potential to affect 68 of 72 residents receiving an oral diet. Findings include: Initial observation of the facility kitchen on 2/3/2020 at 11:00 a.m. with the Food Service Manager (FSM) revealed 30 containers of assorted spices in the dry storage area and two opened containers of milk in the cooler without labels to indicate the dates they were opened and when they should be discarded. During an interview with the FSM on 2/03/2020 at 11:21 a.m., she stated she has only been employed at this facility for two weeks and has not completed her assessment of the kitchen and processes. She discarded the undated items immediately. Review of the undated facility policy titled Food Storage revealed: 15. Leftover food is store is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Guidelines for Storage: Date your products with use by dates. The food category Spices, Herbs, Condiments, and [MEDICATION NAME] documented spices should be used from six months to two years. The food category Dairy Products documented milk should be used from 8 to 20 days.

Based on record review, review of the facility policy titled [MEDICAL TREATMENT] Residents, and staff interviews, the facility failed to ensure that post-[MEDICAL TREATMENT] assessments were completed for one resident (R) (#28) reviewed of three residents receiving [MEDICAL TREATMENT]. Findings include: Record review revealed R#28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Admission Physician Orders dated 6/12/19 revealed an order for [REDACTED].>Review of the [MEDICAL TREATMENT] Communication Book revealed missing [MEDICAL TREATMENT] Communication Forms (DCF) for 15 scheduled [MEDICAL TREATMENT] days: 6/29/19, 7/23/19, 8/3/19, 8/8/19, 8/17/19, 8/22/19, 8/27/19, 8/31/19, 9/3/19, 9/5/19, 9/7/19, 9/10/19, 9/12/19, 9/14/19, and 9/21/19. Review of the DCF revealed the document to include pre-[MEDICAL TREATMENT] information such as date/time, name, date of birth (DOB), room number, medications given before [MEDICAL TREATMENT], meal/snack sent, shunt location/status, vital signs (VS), additional information, and the nurse's signature. The DCF further documents the [MEDICAL TREATMENT] Center Information including pre- and post-[MEDICAL TREATMENT] weights, start and end times of treatment, fluid removed, new physician orders, vital signs, and the nurse's signature. The DCF finally documents the Post-[MEDICAL TREATMENT] Information including date/time, shunt location/status, bruit/thrill present, bleeding present, general condition of the resident, vital signs, and the nurse's signature. Review of the Nurses Notes and Medication Administration Record [REDACTED]. During an interview with the Registered Nurse (RN) Supervisor on 2/06/2020 at 10:25 a.m., she stated she has been working at this facility less than two weeks and did not know what the post-[MEDICAL TREATMENT] nursing responsibilities were. During an interview with the interim Director of Nursing (DON) on 2/06/2020 at 10:30 a.m., she stated the post-[MEDICAL TREATMENT] nursing responsibilities included review of the [MEDICAL TREATMENT] data, checking VS and the [MEDICAL TREATMENT] port/site for bleeding, infection, and bandage. She stated the assessment should be documented on the DCF Post [MEDICAL TREATMENT] Information section or the daily Nursing Notes. She stated she would, and staff should, send the [MEDICAL TREATMENT] Communication Book to the [MEDICAL TREATMENT] center with the resident. She stated if the resident does not return with the DCF or the book, the nurse should contact the center to obtain the information and proceed with the assessment. During an interview with the Quality Assurance (QA)/Educational Nurse on 2/06/2020 at 10:30 a.m., she stated the post-[MEDICAL TREATMENT] nursing responsibilities include VS, checking for thrill/bruit, bleeding, and bandage. She stated the resident should take the [MEDICAL TREATMENT] Communication Book with them to the center with pre-[MEDICAL TREATMENT] data from the facility and return with the book complete with [MEDICAL TREATMENT] Center Information. She further stated the receiving nurse should fill in the post-[MEDICAL TREATMENT] information upon the resident's return. She stated there have been no inservices regarding post-[MEDICAL TREATMENT] assessment or care. Review of the undated policy titled [MEDICAL TREATMENT] Residents revealed the resident has a contract with the [MEDICAL TREATMENT] clinic that includes transportation to and from the [MEDICAL TREATMENT] center, checking the [MEDICAL TREATMENT] site for swelling and redness, drainage and bleeding, and to notify the physician if any if these occur.

Based on observation and staff interview, the facility failed to ensure that it was maintained in a safe, clean and comfortable environment for two rooms on the long hall upstairs and 4 rooms downstairs on two of five halls, two resident bathrooms, and in the main dining room. These areas contained a leak in roof in dining room, loose boards, staining to toilet base, odor in bathroom, broken or missing ceiling tiles, holes in walls, and missing paint from walls. There were also dust and dirt build on the wheelchairs for Residents ((R) #34, #36, #59, and #63). The sample size was 42. Findings include: Observation on 8/10/18 at 10:52 a.m. in room [ROOM NUMBER] there is missing paint from the wall near bed B, there is a half inch gap between the wall and the floor near the air conditioner, in the shared bathroom there is missing paint to the over toilet seat, and there is rusting on the call box. Observation on 8/10/18 at 11:30 a.m. in main dining rooms there were buckled tiles with a trash can under it due to a leak. Observation on 8/10/18 at 12:13 p.m. in room [ROOM NUMBER] there is a strong urine smell in the shared bathroom, spackled but not painted wall near bathroom and window, and a loose board on counter by sink. Observation on 8/10/18 at 12:19 p.m. in shared bathroom for room [ROOM NUMBER] and 62 there is staining around toilet. Observation on 8/11/18 at 10:55 a.m. at the conclusion of the resident council meeting dirt and buildup noted on the undercarriage of wheelchairs for R #36, R#59, R#63, and white buildup on wheels and dirt and dust buildup to undercarriage to wheelchair for R#34. Interview on 8/12/18 at 12:38 p.m. with Environmental Aide JJ who reported that Certified Nursing Assistants (CNA) are responsible for cleaning wheelchairs. Interview on 8/12/18 at 12:45 p.m. with CNA II who reported that night shift CNAs are responsible for cleaning resident's wheelchairs. Observations with the Director of Nursing (DON) on 8/12/18 from 12:45 p.m. until 12:55 p.m. revealed the following: 1. R#34 observed sitting in wheelchair with gray buildup of dust, dirt, and hair on the under carriage of the wheelchair. Resident's wheelchair also noted to have a cracked armrest on the right side. 2. R#59was observed sitting in dining area in wheelchair that had buildup of dust and dirt on the undercarriage and wheels of the wheelchair. 3. R#63 wheelchair was observed to have dust and build up on wheels and undercarriage. 4. R#36 wheelchair was observed to have dust and build up on the wheels and undercarriage. Interview on 8/12/18 at 12:55 p.m. with the DON who acknowledged that resident's wheelchairs were dirty but reported that she was not sure of who was responsible for assuring wheelchairs are cleaned. An environmental tour with Maintenance Worker and Housekeeping Supervisor began on 8/12/18 at 1:08 p.m. and revealed the following In room [ROOM NUMBER] at 1:16 p.m. Maintenance reported that he was not aware of the wall and floor being separated by the air conditioner. Housekeeping supervisor confirmed staining around toilet and reported that there is a deep cleaning schedule and rooms get cleaned once a month. He also reported that the Floor tech also addresses the bathroom floor whenever the room floor is stripped. In room [ROOM NUMBER] at 1:26 p.m. Housekeeping supervisor confirmed the strong urine smell in the shared bathroom and reported that for rooms with strong urine odors housekeeping staff are to clean the area more than once per day. Maintenance reported that he had not been made aware of the loose board on the counter. Maintenance reported that the leak in the dining room is a new leak as of last Wednesday and Thursday. He reported that he has not contacted anyone yet related to the leak due to contacts in his phone being lost. He explained that there was a hard rain on last Wednesday and he is unsure if the roof will still leak during milder showers. He reported that he was looking to contact someone on Monday morning in regards to the leak in the dining room. Maintenance reported that in room [ROOM NUMBER] the scrubbing on wall at Bed B is due to the letting up and down of bed and the bed being too close to the wall. In room [ROOM NUMBER] there was missing stripping under the air conditioner and there was a hole in the ceiling tile for the light in the shared bathroom for room [ROOM NUMBER] and 17. Maintenance reported that the tile potentially was wet from a leak upstairs and he did not get a chance to fix it because he was pulled to another project. In room [ROOM NUMBER] there is a hole in the wall (3/4 inch high and 3 inches long) under the napkin dispenser there. Maintenance reported that he was not sure how the hole got into the wall but he had not been made aware of it. In room [ROOM NUMBER] there is spackle on walls but not walls are not painted. It was reported that one of the floor techs work every other weekend and he assists with painting areas and he just had not got to this room yet. Interview with Maintenance on 8/12/18 at 1:52 p.m. who reported that Administrator provides a punch report. He explained that this report is composed after the Administrator does rounds and identifies areas that need attention whether it be with housekeeping or Maintenance. The last report was received on 8/10/18 per Maintenance. Interview on 8/12/18 at 2:07 p.m. with the DON reported that it is the responsibility of the supervisors and DON to assure that wheelchairs are cleaned. DON confirmed that she has not been checking for the cleanliness of resident wheelchairs. DON then provided a copy of the wheelchair cleaning schedule and the Angel rounds book but there was no rounding for (MONTH) and August. DON reported that she is unsure that there is a policy regarding rounding but she was informed by staff that Angel rounding is done. Observation on 08/10/18 at 9:04 a.m. of the bathroom shared by rooms [ROOM NUMBERS] was observed to have three large ceiling tiles with large brown stains covering 90% of the tiles and that two of the three tiles were bulging out and downward. In the corner was a bucket. Further observation, at this time of room [ROOM NUMBER] revealed that the wall beside the B bed revealed that there was a hole approximately the size of a fifty-cent piece on the wall to the right of the B bed. Further observation revealed a brown night stand between the A and B bed that had three drawers that had a large gap between the third and second drawer and between the third drawer and the bottom of the nightstand. Observation of the bathroom for room [ROOM NUMBER] on 08/10/18 at 9:09 a.m. revealed that there was a hole approximately 1.5 feet (ft) long by approximately 8 inches wide to the left side of the light in the ceiling, one board approximately 4 ft x 2 ft wide was leaned against the wall. Observation of room [ROOM NUMBER] on 8/10/18 at 9:20 a.m. revealed that the wall under the paper towel holder had a hole /scrape that was approximately six inches long. The wall on the left side at the bottom just above the coping is scraped. The wall behind the A bed is scraped approximately 2.5 ft. The dresser in the left corner is scuffed. Further observation revealed that the wallpaper at the foot of the B Bed has a bubbled area and is stained. Around the sink is five tabs that are brown rust colored. Observation of the bathroom for room [ROOM NUMBER] revealed that the tiles around the wall in the bathroom on the right-hand side are buckled loose from the wall and heavy dirt goes around the base of the wall around the bathroom. Observation on 8/10/18 at 3:11 p.m. of room [ROOM NUMBER] revealed that the wall beside the A bed was scarred and stained along the entire length of the bed.

Based on observation, record review and staff interview, the facility failed to ensure that two items (turkey cutlets with gravy and egg noodles) were held on the steam table at 135 degrees Fahrenheit (F) or above. There were 63 residents that received an oral diet. Findings include: On 8/11/18 at 11:25 a.m., Cook DD was observed plating food from the steam table for lunch, and stated during interview that one cart of lunch trays had already been delivered to residents eating in the dining room. Cook DD was observed to check steam table temps with the facility's calibrated thermometer at this time, and the turkey cutlets with gravy was noted to be 133 degrees F and the pureed egg noodles were noted to be 120 degrees F. Cook DD removed the items from the steam table and placed them on the stove to reheat, and stated during interview that she had checked the temperature of all foods on the steam table prior to serving, and they were all fine. Review of the Time/Temp Food Preparation Log dated 8/11/18 at 11:20 a.m. revealed that no temperatures had been recorded for the alternate items which included the turkey cutlets with gravy and the pureed egg noodles were documented as 150 degrees F. During an interview with the Dietary Manager (DM) on 8/12/18 at 7:30 a.m., she stated that no pureed items were on the first cart that went out and two resident trays were prepared for the second cart before the steam table temps were taken for the surveyor. Further interview with the DM on 8/12/18 at 9:15 a.m. revealed that five residents received the alternate tray before the steam table temps were taken for the surveyor. She stated that she expects the cook to check the temps of all the food items on the steam table including the alternate items and to document them on the food temp preparation log. She stated that they normally do it and that she must have forgot to write it down on 8/11/18. In-service sign in sheet dated 7/15/18 and 1/15/18 revealed education provided to dietary staff related to food temps and hot food temps. Cook DD signature noted on each in-service. In-service Education document dated 7/12/18 revealed education provided to cook DD related to infection control as follows: 8. Holding of Foods. All potential hazardous foods must be stored below 40 degrees F or above 140 degrees F. All foods on the steam table should be held at around 160 degrees to ensure the hot foods remain above 140 degrees F up to when the resident begins to eat his or her meal. Undated Policy titled Food Temperatures revealed that foods will be maintained at proper temperatures to ensure food safety. 4. The temperature will be taken and recorded for all items at all meals. Record temperatures on extended menus. 6. The following range of temperatures is recommended for food at point of tray assembly. a. broth, soup, hot beverages: 180-190 degrees F b. meat, portioned for service: 160 degrees F c. casserole dishes, creamed items, creamed soups: 160 degrees F d. potatoes and vegetables: 160 degrees F Undated document titled Proper Temperatures for Meal Preparation and Service indicated the holding temperature (minimum acceptable) for all hot food items to be 140 degrees F.

Based on interview, observations and record review, the facility failed to ensure resident's dignity was maintained by pulling residents backwards in Geri-chairs and/or wheelchairs for three residents (R) (#16, #9, and #51) out of 42 sampled residents. Findings include: 1. Observation on 8/10/18 at 1:48 p.m. revealed Certified Nursing Assistant (CNA) CC pulled R#16 backwards in a Geri-chair from the dining room down the hallway and into the resident's room. 2. Observation on 8/11/18 at 10:27 a.m. revealed CNA CC pulled resident #9 backwards in a Geri-chair out of the elevator on the lower level and down the hall into the resident's room. Review of the CNA In-service book for (YEAR) revealed no education provided related to resident rights or dignity. Review of the Nursing Assistant Continuing Education Record for (YEAR) revealed the last education provided to CNA CC related to resident rights was 1/24/17. During an interview with the Director of Nursing (DON) on 8/12/18 at 10:23 a.m., she stated that she expects staff to always push residents in a forward position in the wheelchairs or Geri- chairs and to never drag the residents backwards. Review of the undated policy titled Resident's Rights revealed Quality of Life - the facility must care for you in a manner that enhances your quality of life. Dignity - the facility will treat you with dignity and respect in full recognition of your individuality. 3. Observation on 8/11/18 at 10:37 a.m. revealed that the Activity Director pulled R#51's wheelchair backwards from behind approximately five feet in the dining/activity room without first warning the resident that she was going to do so. Further observation revealed that R#51 turned her head around to see who was pulling her wheelchair backwards. Continued observation revealed that R#51 was able to self-propel her wheelchair with her feet.

Based on record review and staff interviews, the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#37 and R#42)). The sample size was 42 residents. Findings include: 1. Review of medical record for R#37 revealed a POLST with a choice to allow natural death/DNR that was signed by one Physician on 8/24/17 and a resident's daughter, who was not the residents Health Care agent, but there was no concurring Physician's signature. Further review of the Medical Record for R#37 revealed that there was not a Health Care Agent for R#37. 2. Review of medical record for R#42 revealed a POLST with a choice to allow natural death/DNR that was signed by one Physician on 12/6/17 and resident's daughter, who was the General Power of Attorney, on 12/5/17 but there was no concurring Physician's signature. Interview on 8/11/18 at 1:55 p.m. with Acting Social Services Director (SSD) who reported that the former Social Services Director was responsible for completing the POLST for R# 42. She then reported that R#42 had a power of attorney (POA). However, after reading the document she acknowledged that it was for general power of attorney and not for healthcare. Acting SSD reported that she was told that if the family has power of attorney one physician signature would be needed. She further reported that she would then send the POLST form to the physician to get signed. SSD reported that she was not aware that two physician signatures would be needed if the person signing was not the health care agent. Interview on 8/11/18 at 2:44 p.m. with the Director of Nursing (DON) who reported that Social services are to complete advance directives on admission. However, she was not sure of how often this is audited and checked. Review of POLST and POA for R# 42 and DON revealed that two physician signatures were needed for the POLST. Interview on 8/12/18 at 11:54 a.m. with the DON who reported that as of yesterday that the Medical Director was contacted, and all residents have been made FULL code until a complete audit can be done to assure that all information is accurate. She explained that all POLSTs and DNR stickers have been removed from the medical records and all care plans now show full code. DON reported that the facility realized they did not have appropriate signatures or documentation on the forms and will be reviewing the Advance Directives policy in the future. Interview on 8/12/18 at 2:09 p.m. with the DON who clarified that not all residents were made full code but only those residents who were found to not have the proper signatures on the POLST.

Based on observation, record review, and staff interview, the facility failed to implement the care plans related to monitoring and recording effectiveness of pain medications administered; for the pharmacy consultant to review medications and consider a [MEDICAL CONDITION] dosage reduction at least quarterly; and to document behaviors for one resident (R) (R#20) who was receiving antipsychotic, antianxiety, mood stabilizer, and two antidepressant medications. In addition, the facility failed to implement the care plan related to physical therapy (PT) and occupational therapy (OT) for strengthening and to follow PT/OT recommendations for one resident (R#64). In addition, the facility failed to develop any comprehensive care plans within the required timeframe for one resident (R#38). The sample size was 42 residents. Findings include: 1. Review of R#20's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#20's physician's orders [REDACTED]. Review of R#20's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had daily verbal behaviors, and received an antipsychotic, antianxiety, and antidepressant medication all seven days of the assessment period, and received an opioid three days during this period. Review of R#20's [MEDICAL CONDITION] Drug Use care plan with a start date of 9/4/17 revealed approaches to observe her for adverse side effects, and to observe, document and report behaviors. Further review of this care plan revealed an approach for pharmacy consultant to review medications and consider a dosage reduction at least quarterly. Review of R#20's care plan for chronic pain due to right knee pain developed on 9/5/17 revealed interventions to administer medications as ordered, monitor and record effectiveness, evaluate the effectiveness of pain management interventions, and monitor and record any complaints of pain with location, frequency, effect on function, intensity, alleviating and aggravating factors. Observation on 8/11/18 at 8:39 a.m. and 10:40 a.m., and 8/12/18 at 9:43 a.m. revealed that R#20 was in a wheelchair, alert, with no signs of pain and no behaviors noted. Review of R#20's Medication Records (MAR) revealed that there was no evidence of ongoing monitoring for behaviors and for the presence of side effects from use of the antipsychotic and other [MEDICAL CONDITION] medications, to be able to determine the effectiveness of the medications. Further review of R#20's MARs revealed nurse's initials to indicate that she received the [MEDICATION NAME]/APAP 17 times in June, 15 times in July, and 13 times in (MONTH) (through 8/12/18). Further review of the back of the MARs, as well as review of the Nurse's Notes, revealed no documentation of the time the pain medication was given, nor the reason for the administration and effectiveness of the medication except for three times in August. During interview with the Director of Nursing (DON) on 8/12/18 at 10:32 a.m., she verified that there was no evidence that behavior monitoring was being done for R#20. She further verified that the indication for the frequent PRN use of the [MEDICATION NAME]/APAP, as well as the effectiveness after administration of this medication, was not documented for the past three months, except for three times in August. She verified during continued interview that there was no evidence that a gradual dose reduction (GDR) recommendation had made by the consultant pharmacist for the two antidepressants that R#20 had been on since admission on 8/22/17. Cross-refer to F 756, F 757, and F 758. 2. Record review of medical record for R#64 revealed that the 7/21/18 Minimum Data Set (MDS) quarterly assessment Section O, Specialized Services, indicated restorative services for splint devices, Passive Range of Motion (PROM) and Active Range of Motion (AROM) being received six times during the review period. However, walking was not indicated during this review period. Further review of the medical record revealed a care plan for Activities of Daily Living (ADL) functional and rehabilitation potential with an intervention of physical therapy (PT) and occupational (OT) for strengthening and follow PT/OT recommendations. Review of the functional program assessment dated [DATE] indicated the following plan: (1) sit to stand x 5 reps x 2 sets, (2) Stand pivot transfer bed to and from wheelchair x 2 reps/rounds, (3) walking with support from longest hallway handrail provide walking to move feet apart, moderate assistance, wheelchair should stay close. It was also noted to refer to the Therapist if there were significant functional changes. Review of the Nursing Restorative Care Program documentation from (MONTH) (YEAR) indicated R#64 was walked twice. There was no indication that R#64 was walked in June, July, or (MONTH) nor were there any documentation to suggest that this task was refused by resident. Interview on 8/11/18 at 1:26 p.m. with Certified Nursing Assistant (CNA) II who reported that R#64 is supposed to be walked when he gets up and he is to walk for less than 100 feet because he tends to lean. It was further reported that two staff must assist with gait belt when assisting resident with walking. Interview on 8/11/18 at 1:43 p.m. with the Director of Nursing (DON) who acknowledged that she has not seen resident being walked. Upon review of the documentation for (MONTH) DON reported that as activity takes place staff should initial. Review of restorative form for (MONTH) revealed no signatures for ambulation. There was also no documentation to support that resident refused. It was reported that currently there is no restorative nurse and the facility has been without a restorative nurse since May. DON agreed to provide documentation for the May, June, and (MONTH) restorative care program but reported that there will be no weekly notes due to there not being a nurse. Interview on 8/11/18 at 2:25 p.m. with the DON who provided further documentation of services for R#64. DON reported that the restorative staff had stopped walking resident due to him requiring two people to safely walk him and they did not have the staff for that. It was further reported that therapy was not informed of the change or that staff had stopped walking R#64. DON acknowledged that the care plan was not being followed related to following the therapy recommendations of notifying therapy of the change in R#64 walking status. 3. Review of R #38's clinical record revealed that she was admitted on [DATE] with diagnoses's including severe debility, failure to thrive and diabetes mellitus (DM). Review of R #38's Admission Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment); needed supervision and/or set-up help for locomotion and dressing; Review of the Care Area Assessment (CAA) for this MDS revealed that Activity of Daily Living (ADL) Functional/Rehabilitation Potential, Falls and Nutritional Status triggered as areas of concern, with the decision made to care plan for them. Review of R#38's Admission Baseline Care Plan dated 6/13/18 revealed the resident was admitted for skilled services due to weakness and disease management, diabetes, pain, weight loss and nutrition. Further review of her baseline care plan revealed that an ADL problem had been developed which included needing assistance with grooming, hygiene, and bathing. Her admission goal is for therapy to evaluate and treat for short term care. Review of a Registered Dietician's Nutrition Assessment Note dated 6/27/18 revealed that R #38's current weight was below Ideal Body Weight (IBW). Further review of this dietary note revealed the current diet is not formulary and it will be clarified to No Concentrated Sweets related to her un controlled diabetes mellitus. Record Review of the undated Warm Springs Medical Center Nursing Home Care Area Assessment and Care Plan Completion form revealed Care Plan Completion After completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessments, the interdisciplinary team (IDT) then proceeds to evaluate the information gained through both the assessment processes in order to identify problems causes, contributing factors and risk related to the problems. The care plan completion date must be either later than or the same date as the CAA completion date, but no later than 7 calendar days after the CAA completion date. The MDS completion date must be earlier than or the same day as the care plan completion date. Review of R #38's Admission MDS was dated 6/19/18. Observation on 8/10/18 at 9:12 a.m. revealed R#38 was lying in bed with her eyes closed, she gave no response to the surveyor knocking on her door. Interview on 8/11/18 at 11:40 a.m. with the Director of Nursing (DON) confirmed R#38 does not have a comprehensive care plan. She further revealed that the MDS Coordinator quit in (MONTH) (YEAR) and the DON has been doing the care plans herself. Interview on 8/12/18 at 9:41 a.m. with the MDS Licensed Practical Nurse (LPN) revealed a comprehensive care plan for R#38 was created on 8/11/18.

Based on record review and staff interviews the facility failed to revise the care plan to address the resident's actual weight loss for one resident (R) (R#11). The sample size was 42 residents. Findings include: Record review revealed that Resident # 11 was admitted to the facility with the following Diagnoses: [REDACTED].>Admission Minimum Data Set ((MDS) dated [DATE] revealed Section G Functional Status: Eating: that the resident was independent, and that support was needed only for set up. Section I revealed that the resident was coded for Nutrition: malnutrition - at risk for. Section V revealed that development of a care plan for nutrition did not trigger. Review of the resident's care plans revealed the following care plans and approaches: Problem: Nutritional Status: Risk for impaired skin integrity such as skin tears, r/t (related to) fragile skin. She has poor safety awareness due to dementia. Goal - target date: 8/31/18 - Resident's skin will remain intact through the next review date. Approaches documented include: Turn as need and reposition Diet as ordered Encourage fluids. Fluids within easy reach. Encourage the resident to avoid uninterrupted sitting. Encourage her to reposition every two hours. Provide night time snack Use pressure relieving mattress for her head Dehydration/Fluid Maintenance Started 5/22/18 Resident at risk for dehydration r/t (related to) UTI in the past. She has cognitive impairment she may not assess her own fluids and she may not drink fluids served with meds and meals related to her dementia Goal date of 8/31/18 Resident will maintain moist mucous membranes and good skin turgor and she will not exhibit signs of dehydration through the next review date. Assess for dehydration Assess for risk factors for dehydration Encourage fluids. Fluids within reach Report abnormal labs indicative of dehydration Approach: Weigh resident per policy and MD/Family notified of any unplanned significant weight loss. Record review revealed the following weights for R#11: 5/11/18 - 136 pounds 6/8/18 - 133 pounds 2.21% weight loss in one month 7/6/18 - 126 pounds 5% weight loss in one month 8/8/18 - 119 pounds 12.5% weight loss in three months and 5% in one month The resident experienced a 5% weight loss between (MONTH) 8, (YEAR) and (MONTH) 6, (YEAR) and an additional 5% weight loss between (MONTH) 6, (YEAR) and (MONTH) 8, (YEAR). The resident had a total weight loss of 12.5% in three months. Further review of the care plans revealed that the care plans had not been updated with the resident's actual weight loss and that interventions to address the residents actual weight loss had not been implemented. Telephone interview with the Administrator and MDS Coordinator on 8/14/18 at 3:46 p.m. revealed that historically the MDS Coordinator has been responsible for updating and revising care plans; however, the facility lost their MDS Coordinator the first week of (MONTH) and the Director of Nursing has been filling in until the new MDS Coordinator was hired. Further interview revealed that the care plan for R#11 should have been updated to reflect her actual weight loss but was not. A post survey telephone interview on 8/21/18 at 10:57 a.m. with the Director of Nursing (DON) revealed that printing the weight reports became her responsibility when the former MDS Coordinator resigned unexpectedaly in (MONTH) (YEAR). She was not aware of the resident's weight loss until (MONTH) 1, (YEAR) and had not updated the care plan to reflect the residents weight loss. Cross refer to F692