Every finding on record at Washington Co Extended Care Facility

Based on observations, staff interviews, and a review of the facility's policy titled Production, Purchasing and Storage, the facility failed to label, store, prepare, and discard food in a manner that protected the nutritional quality and safety of meals. These deficient practices had the potential to place 56 residents (R) who received nutrition services at risk for consuming meals with compromised nutritional value or increased risk for foodborne illness.Findings include:Review of the facility's policy titled Production, Purchasing, Storage, revised on 01/17, documented under Procedures: Most products contained an expiration date. The words sell by, best by, enjoy by, or use by should have preceded the date. The sell by date was the last date that food could be sold or consumed; products were not to be sold in retail areas or placed on patient trays/resident plates past the date on the product. Foods past the use by, sell by, best by, or enjoy by date were to be discarded. Unused portions and open packages were to be covered, labeled, and dated. The [NAME] orange label, MedVantage label, or Ecolab Prep N Print label were to be used; all sections on the label were to be completed. Products were good through the close of business on the date noted on the label.Observation and interview on 02/25/2026 at 8:52 AM with the Certified Dietary Manager (CDM) revealed and confirmed the following concerns:Refrigerator One contained:A plastic container of pickles with an expiration date of 02/18/2026.A silver metal pan of hamburgers with an expiration date of 02/20/2026.A silver metal pan of grilled chicken with an expiration date of 02/22/2026.A silver metal pan of sausage gravy with an expiration date of 02/22/2026.Three plastic containers of ranch dressing dated 02/17/2026 without expiration labels.Refrigerator Two contained:A clear plastic bag of sliced meat dated 02/23/2026 without an expiration date.Freezer One contained:A boxed sponge cake opened on 02/22/2026 without an expiration date.Two cases of low fat vanilla yogurt dated 02/17/2026 without expiration dates.One open, improperly sealed bag of kernel corn; two bags of okra; one bag of shoestring fries; one bag of chicken; and one bag of mushrooms-all unlabeled and lacking open and expiration dates.An open bag of breaded okra with no open or end date.Dry Pantry One contained:A plastic container of bananas with brown spots.A plastic container of red onions that were uncovered and unlabeled.A plastic container of yellow onions that were uncovered and unlabeled.Dry Pantry Two contained:Several cans of vegetables with expired expiration dates.Bread cart outside Pantry One contained:Several loaves of whole wheat bread with expired dates.At the conclusion of the observation and interview, the CDM confirmed all identified concerns and stated that staff needed additional training on labeling, dating, and discarding expired items.Interview on 02/26/2026 at 1:21 PM with the Administrator acknowledged that she rarely entered the kitchen to monitor operations. She stated that it was difficult to correct staff. She further stated that her expectation was for staff to discard old food and any expired items.

Based on observations and staff interview, the facility failed to ensure pureed foods were prepared according to standardized recipes and professional food service standards for residents (R) requiring texture modified diets. This deficient practice had the potential to affect 11 residents receiving pureed diets. Findings include:Interview on 02/25/2026 at 4:45 PM with the Certified Dietary Manager (CDM) confirmed that the facility did not have a written policy guiding how nutritional value was ensured and monitored. The CDM stated that the facility had to ensure that food maintained its nutritive value, was properly prepared, and was palatable and appropriately served.Observation and interview on 02/25/2026 at 2:32 PM with the CDM and Dietary Aide (DA) II revealed that pureed meals were prepared the day prior to service, then covered and dated. The first observation involved the preparation of pureed chicken. During the observation, the DA combined diced chicken (unmeasured), mashed potato flakes (unmeasured), and water (unmeasured). No standardized measurements were used. The second observation involved the preparation of pureed green peas and carrots. During this preparation, mashed potato flakes and water were added to the peas and carrots without measuring. The DA confirmed that she did not use a recipe when preparing pureed meals. The CDM advised the DA that a recipe should be used. The CDM revealed that her expectation was for staff to follow standardized recipes; however, she acknowledged that staff did not always follow this practice. The DA stated that she had done this job for many years and did not feel the need to measure ingredients, as she believed she could achieve the proper consistency based on experience. The CDM further advised that mashed potato flakes were used as a thickening agent instead of commercial thickener because the facility stocked thickener in small individual packets rather than in a large container. She stated that opening multiple small packets to achieve the desired consistency was time consuming.Interview on 02/26/2026 at 1:21 PM with the Administrator revealed that her expectation was for kitchen staff to order the necessary items to ensure residents received proper nutrition and that shortcuts were not to be made in meal preparation. She stated that staff were expected to use standardized recipes when preparing meals and should not estimate or guess whether residents were receiving appropriate nutritional content. The Administrator advised that all kitchen staff required immediate education regarding proper meal preparation practices.

Based on staff interviews and record review, the facility failed to ensure a criminal background check was completed for one of 13 staff members reviewed. This deficient practice had the potential to place residents (R) residing in the facility at risk of abuse, neglect, and exploitation from staff. The facility census was 58 residents. Findings include:Record review on 02/25/2026 at 3:00 PM of the state and federal fingerprint based background checks (GCHEXS) list provided by the facility revealed one Certified Medical Assistant (CMA)/Certified Nursing Assistant (CNA), JJ, was not listed as completed by the facility.Interview on 02/25/2026 at 3:30 PM with the Administrator confirmed and explained that CMA/CNA JJ was removed from the schedule until her GCHEXS was completed with a satisfactory background.Interview on 02/26/2026 at 9:15 AM with the Human Resources (HR) Director and Assistant HR Director revealed one CMA/CNA had not completed a background check since 2023. The CMA/CNA JJ was a rehire, and it was described as an oversight.

Based on observations, staff interviews, record review and review of the facility's policy titled Standard Precautions, the facility failed to practice infection control protocol by placing a tablet in the bare hand during medication administration for one of four sampled residents (R) R32 and used gloves from the pocket of staff uniform for one of one resident R35 sampled for blood sugar monitoring . This deficient practice had the potential to cause infection to the residents.Findings include: 1.Review of the facility's policy titled Standard Precautions, undated, documented PURPOSE: to provide a safe environment for patients and personnel in order to reduce the risk of nosocomial infections, to prevent the transmission of community -acquired infections.Review of the facility's paper-based medical records revealed R32 was admitted to the facility on [DATE] with diagnosis included but not limited to benign prostatic hyperplasia. R32 was diagnosed on [DATE] with Urinary Tract Infection (UTI).Review of the Comprehensive Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) of 99 which indicated R32 had severely impaired cognition, Section I (Active Diagnosis) R32 had benign prostatic hyperplasia.Review of care plan dated 11/25/2025 documented R32 is at risk for Urinary Tract Infection related to BPH with UTIs and history of outlet obstruction. UTI will be resolved within 10 days of occurring-and monitor for adverse side effects. Diagnostic tests as ordered, report abnormal findings to Medical Director (MD) with follow up as indicated Monitor vital signs, report abnormalities to MD with follow up as indicated. Observe urine for sediment, cloudiness, odor, blood and report abnormalities to MD with follow up as indicated. Encourage fluids. Report any complaints of pain with urinating, Flank pain, or changes in mentation with follow as ordered.Review of the Physician's Orders dated 02/17/2026 documented included but not limited to Urinalysis culture and sensitivity, Bactrim 800/160 milligram (mg) per oral (PO) every 12 hours x 14 days.Observation and interview on 02/25/2026 at 9:45 AM during medication administration, Registered Nurse (RN) BB placed one Bactrim tablet in her bare right palm then placed it in medication cup to administer it to the resident. RN BB confirmed she placed the tablet in her bare hand then placed it in medication cup. She stated she should not have placed it in her bare hand because her hand was dirty and it could cause cross-contamination. She stated the residents would get sick if she placed medications in her bare hands and then gave them.Interview on 02/25/2026 at 1:35 PM with Registered Nurse (RN) DD revealed she stated pills should not be placed in the bare hands before administering them to the residents because that was not sanitary and the residents could get infections.Interview on 02/25/2026 at 1:41 PM with the Director of Nursing (DON) revealed she stated her expectations were for tablets never to be placed in staff's bare hands because hands are not clean and it was an infection control issue. She stated if the tablets were given to residents after they were placed in the staff's bare hands, the residents could get infection.2. Review of the facility's policy titled Standard Precautions, undated, documented PURPOSE: to provide a safe environment for patients and personnel in order to reduce the risk of nosocomial infections, to prevent the transmission of community - acquired infections.Review of the facility's paper-based medical records revealed R35 was admitted to the facility on [DATE] with diagnosis included but not limited to diabetes mellitus.Review of the Comprehensive Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) of 99 which indicated R35 had severely impaired cognition, Section I (Active Diagnosis) R35 had diabetes mellitus.Review of care plan dated 04/10/2025 documented included but not limited to R35 has the potential for (hyperglycemic or hypoglycemic) episodes secondary to diabetes She uses insulin. R35's fasting blood sugar will be within 100-200 range by next review. R35 will have relief of hypo/hyperglycemic episodes within 30 minutes of interventions. Monitor blood sugar levels per medical doctor (MD) order, notify MD of abnormal findings as indicated.Review of the Physician's Orders dated 06/2/2025 documented included but not limited to finger stick blood sugar (FSBS) Three times Daily [Time: 6:00 AM, 11:00 AM, 17:00 PM] notify if blood sugar (BS) is less than 50 or greater than 450.Observation and interview on 02/25/2026 at 10:37 AM during blood sugar monitoring revealed Licensed Practical Nurse (LPN) CC removed gloves from her pocket and used it to check R35's blood glucose. She confirmed that she removed gloves from her right uniform pocket and used them to check R35's blood glucose. LPN CC further stated that her right pocket contained keys, pulse oximeter and marker, and they were not clean items. She stated the gloves would get contaminated in her pocket and from the items in her pocket and when the gloves were used on R35, she would get infection. Interview on 02/25/2026 at 1:35 PM with Registered Nurse (RN) DD revealed she stated gloves were not to be placed in pockets of staff clothing because it was unsanitary and it was infection control issue. She stated that things were in pockets which were not clean and if gloves were in their pockets the gloves would get contaminated and cause infection to the residents.Interview on 02/25/2026 at 1:41 PM with DON revealed she stated her expectations were for gloves not to be in the pockets of staff and used on the residents. She stated there were other things in the pockets, and the gloves would get contaminated. The DON further stated that keeping gloves in pockets was an unsatisfactory practice and when the gloves were used on the residents, the residents would get sick.

Based on observations, staff interviews, and review of the facility's policy titled, Storage of Drugs and Biologicals, the facility failed to ensure two of three medication carts were locked and secured when unattended by the nurse, and one of one medication storage room did not have medications with no expiration date. The deficient practices had the potential to allow unauthorized staff, residents, and visitors access to medications, and place residents at risk of receiving expired medications. The facility census was 57. Findings include: Review of the facility's undated policy titled, Storage of Drugs and Biologicals, revealed the Policy Statement of It is the policy of this facility that all drugs and biologicals be properly stored. The Procedure section included . 3. All drugs and biologicals are stored in locked compartments, and only authorized personnel have access to the keys. On 12/7/2024 at 8:18 am, three medication carts were observed. The Middle Hall Medication Cart was observed unlocked, unattended and out of the visual sight of a nurse. During an interview on 12/7/2024 at 8:18 am, Licensed Practical Nurse (LPN) AA stated she had counted the cart at shift change and that no one used it after she counted. She stated the nurses usually lock it when not in use and she did not know why it was unlocked. She stated that she thought that she had locked it. During observation on 12/7/2024 at 12:45 pm, Medication Cart Two was unlocked and unattended. At 12:46 pm, LPN BB returned to the cart and confirmed the cart was unlocked. She stated the medication cart should be locked when the cart was unattended. During an interview and observation on 12/8/2024 at 9:30 am of the medication room with the Assistant Director of Nursing (ADON), observation revealed two containers of Calmoseptine ointment without an expiration date on the containers. The absence of the expiration dates was verified by the nurse, and she removed the medications from the room. During an interview on 12/9/2024 at 12:34 pm, the Education Coordinator stated she has in-services all the time with the nurses about securing medications and stated the last in-service was on 6/4/2024. During an interview on 12/9/2024 at 1:38 pm, the Assistant Director of Nursing (ADON) confirmed that LPN AA had signed as having received the education on 6/4/2024. During an interview on 12/9/2024 at 2:15 pm, the Administrator and the Director of Nursing (DON) both stated the nursing staff had received in-services on the medication carts and how to secure them. 37739

Based on observations, staff interviews, and a review the facility's policy titled, Food and Supply Storage and Food Handling Guidelines - HACCP the facility failed to label and date opened food items in the freezer, refrigerator, and dry storage area. The facility also failed to properly thaw fish filets to prevent bacteria growth. The facility census was 57 with 52 residents consuming an oral diet. Findings include: 1. A review of the policy titled Food and Supply Storage revealed cover, label, and date unused portions and opened packages. Completed all sections on an orange label. Observation on 9/8/2023 at 9:03 a.m. of the 3 door reach-in freezer located in front of the steam table revealed an open two pound bag of frozen corn and a two pound bag of frozen pea & carrots that had been opened with no date. Continued observation revealed a clear plastic bag containing breaded okra that had been opened with no date. Interview on 9/8/2023 at 9:03 a.m. the Director of Dietary (DD) confirmed that the frozen corn, peas & carrots, and breaded okra had all been opened and placed in freezer with no open date. The DD stated that staff are to date any opened food item. Observation on 9/8/2023 at 9:10 a.m. of the dry storage area revealed a ten pound bag of spiral noodles and a ten pound bag of elbow macaroni that had been opened with no open date. Interview on 9/8/2023 at 9:10 a.m. the DD confirmed that the spiral noodles and elbow macaroni bags had been opened with no open date. The DD stated that she expects staff to date any opened food item. Observation on 9/8/2023 at 9:12 a.m. of the food storage rack located in front of the walk-in refrigerator revealed an open bag of grits within a resealable clear plastic bag with no open date. The food rack also had a half gallon container of zesty orange sauce, half gallon container of stir fry sauce, and a gallon container of Red Hot, hot sauce all had been opened with no open date. Interview on 9/8/2023 at 9:12 a.m. the DD confirmed that the grits, zesty orange sauce, stir fry sauce and hot sauce containers were all opened and stored with no open date. The DD stated she expects staff to date any open food item. Observation on 9/8/2023 at 9:18 a.m. of the 3 door reach-in refrigerator revealed a five pound bag of shredded cheddar cheese that was open with no open date. Interview on 9/8/2023 at 9:18 a.m. the DD confirmed that the bag of shredded cheddar cheese had been opened and had no open date. The DD stated that staff should have dated after opening. Observation on 9/10/2023 at 8:23 a.m. of the 3 door reach-in freezer located in front of the steam table revealed an open two pound bag of peas & carrots with no open date. Interview on 9/10/2023 at 8:23 a.m. the DD confirmed that the bag of peas & carrots had been opened with no date. The DD stated that staff should have dated before placing in freezer. Observation on 9/10/2023 at 8:29 a.m. of the dry storage area revealed an open ten pound bag of elbow macaroni with no open date. Interview on 9/10/2023 at 8:29 a.m. the DD confirmed that the bag of elbow macaroni had been opened with no open date and staff should have dated after opening. Observation on 9/10/2023 at 8:34 a.m. of the walk-in freezer revealed a frozen clear plastic bag containing a light tan food item sitting on the shelf. The bag had no label or date. Interview on 9/10/2023 at 8:34 a.m. the DD she revealed that the frozen food item was diced chicken and confirmed that the bag had no label or date. The DD stated that staff should have labeled and dated the item after opening. 2. A review of the policy titled Food Handling Guidelines - HACCP revealed Thaw frozen meat/poultry/seafood, under running water: submerged under portable running water at a temperature of 70F or below with sufficient velocity to agitate and float off loose food particles into the overflow. Delicate items such as fish filets should never be thawed in water. Observation on 9/8/2023 at 9:25 a.m. of the sink in the food prep area revealed a rectangle plastic bin with fish filets and the plastic bin also had a stainless steel bowl on one side of the bin that also contained fish filets. Continued observation revealed a small/slow trickle of water coming from the faucet and over part of the fish filets in the stainless steel bowl. The fish filets in the plastic bin were completely submerged in water but the fish filets in the bowl where not completely covered with water. Interview on 9/8/2023 at 9:25 a.m. the DD confirmed that was fish filets were being thawed for lunch meal. The DD confirmed that not all of the fish filets in the bowl were submerged in water. The DD stated that usually the cook will completely submerge frozen food items in running water to thaw.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Care Plan-Comprehensive the facility failed to follow the care plan related to providing oxygen as ordered for one of 22 Residents (R) (R26) reviewed for oxygen administration.The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings Include: A review of facility policy titled Care Plan-Comprehensive, updated 5/1/2023 revealed the following: It is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Record review of Electronic Medical Record (EMR) for R26 revealed diagnoses of chronic obstructive pulmonary disease (COPD), emphysema, chronic atrial fibrillation, and seasonal allergic rhinitis. Record review of care plan dated 8/9/2023 revealed R26 receiving oxygen (O2) therapy related to COPD with interventions, but not limited to: Administer oxygen per medical doctor (MD) order. Observation and Interview on 9/8/2023 at 10:05 a.m. revealed R26 receiving O2 therapy via simple face mask from the wall unit. The observation also revealed the O2 setting was set at seven (7) L/min. Observation on 9/8/2023 at 1:05 p.m. revealed R26 receiving O2 therapy via simple face mask from the wall unit set at 7 L/min. Interview and observation on 9/8/2023 at 1:06 p.m. with Licensed Practical Nurse (LPN) AA of R26 in room [ROOM NUMBER] confirmed the wall unit was set at 7 L/min. LPN AA also confirmed that the physician order documented the oxygen was to be set at 8 L/min. LPN AA reported she was his primary nurse and responsible for checking his oxygen settings and administration. Interview on 9/9/2023 at 2:49 p.m. with the Director of Nursing (DON) it was revealed nurses are primarily responsible for making sure orders are carried out per the Physician's orders. DON reported that nurses are expected to follow the Physician's orders and the care plan. Interview on 9/9/2023 at 2:50 p.m. with the Minimum Data Set (MDS) Coordinator reported she was responsible for ensuring residents had care plans. She confirmed R26 had a care plan to administer oxygen as ordered. She reported her expectations of staff to follow care plans as directed.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Oxygen Administration and Set Up, the facility failed to ensure that the physician's order for oxygen administration was followed for one 22 Residents (R) (R26) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings Include: A review of facility policy titled Oxygen Administration and Set Up , revised date 2/9/2023 under the Policy statement revealed: Confirm physician order for oxygen; and Adjust the flowmeter to the prescribed amount. Record review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed: Sections C - Cognitive Patterns: Brief Interview of Mental Status (BIMS) of 15 Section J - Health Conditions: Shortness of Breath (SOB) on exertion, sitting at rest and when lying flat. Section O - Special Treatments, Procedures, and Programs: he received oxygen therapy while a resident. Review of Physician Orders dated 9/1/2023-9/30/2023 revealed physician orders for oxygen (O2): may use simple face mask at 31% at eight (8) L/min (liters per minute) (will deliver three (3) L/min) on days and PM (afternoon) Shift one (1), Shift 2 (two) for COPD. Observation and Interview on 9/8/2023 at 10:05 a.m. revealed R26 receiving O2 therapy via simple face mask from the wall unit. The observation also revealed the O2 setting was set at seven (7) L/min. R26 reported he did not feel like he was getting enough oxygen. He reported his O2 setting should be set at 8 L/min. He reported he did not make any adjustments to his O2 settings and that the nurses make all the adjustments. Observation on 9/8/2023 at 1:05 p.m. revealed R26 receiving O2 therapy via simple face mask from the wall unit set at 7 L/min. Interview and observation on 9/8/2023 at 1:06 p.m. with Licensed Practical Nurse (LPN) AA of R26 in room [ROOM NUMBER] confirmed the wall unit was set at 7 L/min. LPN AA also confirmed that the physician order documented the oxygen was to be set at 8 L/min. LPN AA reported she was his primary nurse and responsible for checking his oxygen settings and administration. She reported R26 could not have changed it himself because he was unable to ambulate without assistance. Interview on 9/9/2023 at 10:06 a.m. with the Director of Nursing (DON) revealed that her expectations of nurses to administer oxygen as ordered by the Physician. The DON confirmed that the oxygen setting for R26 was ordered at 8 L/min.

Based on record review, interviews, and review of the facility policy titled Medication Monitoring Medication Management, the facility failed to ensure a fourteen day stop date for an ordered psychotropic medication for one of six residents (R) (R12) reviewed for the use of unnecessary medications. Findings include: A review of the policy titled Medication Monitoring Medication Management, dated 1/2023 stated that in certain situations, psychotropic medications may be prescribed on a as needed (PRN) basis, such as while the dose is adjusted, to address acute or intermittent symptoms, or in an emergency. A table explaining additional limitations for PRN psychotropic (other than antipsychotic medications), and PRN antipsychotic medications stated PRN orders for psychotropic medications, excluding antipsychotics have a time limitation of 14 days. The table further stated the order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. The required actions stated the attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. Record review on 9/8/2023 revealed physicians orders dated: 8/4/2022 Ativan (a medication used to treat anxiety, seizures, agitation, panic attacks, restlessness) 2mg (milligram) per ml (milliliter) solution injection 1mg (0.5ml) give every 20 minutes if resident is seizing and notify the Medical Doctor (MD)/Nurse Practitioner (NP) after first dose, as needed for symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus; 5/10/2023 Ativan 2mg one tablet every eight hours as needed for seizures, arm pulling, and/or anxiety. There was not a 14-day stop date on the orders. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Sections C documented a Brief Interview for Mental Status (BIMS) of 15, indication intact cognition; Section I documented a diagnosis of seizure disorder; Section N documented received an antianxiety seven of seven days. Record review of the care plan revealed a problem area of resident is at risk for side effects from psychotropic medication use. Receives antianxiety medications for seizures. The goal was that resident will not have any adverse side effects from medication through next review. Interventions included reporting side effects that interfere with functioning to the MD and the Pharmacist to review drug regimen monthly and prn. Record review of the Medication Administration Record (MAR) dated June 2023, July 2023, August 2023, September 2023 revealed in June 2023 Ativan 2mg oral table was administered six times during the month for arm pulling and seizure activity; in July Ativan 2mg/1ml (0.5ml) injection was administered two times for arm pulling and Ativan 2mg oral tablet was administered nine times during the month for arm pulling and seizure activity: in August 2023 Ativan 2mg oral tablet was administered twelve times during the month for arm pulling and seizure activity; in September Ativan 2mg oral tablet was administered seven times for arm pulling. A review of the Consulting Pharmacist Gradual Dose Reduction (GDR) documents dated 7/25/2023, 4/25/2023,1/28/2023, 10/24/2023 documented: The resident is currently on PRN Ativan. Please evaluate current diagnosis, behaviors, and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents' medical record and indicate the duration for the prn order. The provider documented to continue due to seizure disorder and continue indefinitely secondary to refractory seizure disorder. Interview on 9/9/2023 at 12:30 p.m. with Licensed Practical Nurse (LPN) BB revealed she followed physician orders for medications and was unaware of a requirement for end dates for any medications. Interview on 9/10/2023 at 11:00 a.m. with the Director of Nursing (DON) revealed she was aware of the pharmacist recommendations on the GDRs for the prn Ativan oral and injectable orders for R#12. She stated she thought since the provider provided a clinical rationale of a diagnosis of seizure disorder and a duration of indefinitely, the order was within regulatory requirement. She stated she would discuss with the provider the need to provide a stop date.

Based on observations, interviews, record review, and review of facility policy titled Foley Catheter Care, the facility failed to ensure two of three residents (R) (R#44 and R#148) was provided with a dignity bag for indwelling catheter. Findings include: 1. Record review for R#44 revealed resident was admitted to facility on 12/11/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented R#44 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. The resident had an indwelling urinary catheter. Observation on 4/23/22 at 8:45 p.m. R#44 noted to have catheter bag to bedside drainage with tea colored urine noted in the bag, there was no dignity bag noted. Foley catheter was facing the door. Second observation of R#44 on 4/24/22 at 8:00 a.m. revealed catheter was facing door with no dignity bag. Interview on 4/24/22 at 8:15 a.m. with R#44 revealed that there was a dignity bag that was on his catheter bag at one time but was unaware of where it was at time of interview. Further interview revealed that staff completes catheter care daily while conducting ADL (activities of daily living) care and he has not had any issues with infections recently. 2. Record review for R#148 revealed resident was admitted to facility on 4/21/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#148 was a new admission to facility and did not have any indication of catheter use noted on baseline care plan. Observation on 4/23/22 at 11:15 a.m. and 4/24/22 at 9:00 a.m. revealed R#148 had a urinary catheter without a dignity bag. The resident's catheter was visible from the hall. On 4/24/22 at 9:15 a.m. interview with Certified Nursing Assistant (CNA) DD revealed that there are three residents in the facility that have urinary catheters. Residents with a catheter are supposed to have a dignity bag to cover their catheter bag when they are in bed and when they are up in the chair. Continued interview confirmed that R#44 and R#148 did not have a dignity bag in their room for use and that the catheter should have been covered and not in view from the door of residents' room. The dignity bags are stored in the supply room and if they are not available the charge nurse would be notified, and she would retrieve a bag for them. Continued interview revealed that there were no dignity bags available for staff use in the facility. On 4/24/22 at 9:25 a.m. interview with Licensed Practical Nurse (LPN) FF revealed that residents are supposed to have a dignity bag on their bed or chair. Further interview confirmed that R#44 and R#148 did not have a dignity bag in place. When a dignity bag is needed for a resident, they are usually retrieved from the supply room and if there are not any available, then someone would call to the hospital which is attached to facility and retrieve them from there. On 4/24/22 at 11:53 a.m. interview with Director of Nursing (DON) revealed that residents should have a dignity bag to cover their catheter while out of their rooms. It is the responsibility of the CNA and charge nurse to ensure that the bags are covered. The catheter dignity bags are kept in the supply room with the regular supplies and if they are not available the materials management staff member would be notified so that the storage room could be stocked. Continued interview revealed the expectation is that all residents that have a catheter should have a dignity bag available for use. On 4/24/22 at 12:00 p.m. interview with Registered Nurse (RN) BB revealed that materials management from the hospital is responsible for ensuring that all supplies used by facility staff are available for use. If there are items that are needed that are not usually used like the dignity bag, then the hospital materials manager is notified so that those supplies can be stocked and available for staff use. Review of undated facility policy titled Foley Catheter Care revealed that catheter dignity bag should be available and used properly.

Based on observation, interview and review of facility policy titled Nebulizer Treatments, Jet, the facility failed to properly store respiratory equipment in three resident rooms (334, 336, and 339) and failed to maintain and utilize respiratory equipment in a sanitary manner during medication administration for three residents (R) (R#45, R#28, and R#22). There were 17 residents that received respiratory treatments. Findings include: 1. Observation on 4/23/22 during initial tour from 8:16 a.m. to 8:42 a.m. revealed in room [ROOM NUMBER] bed A, continuous positive airway pressure ([CONDITION(S)]) mask sitting on bedside table, not bagged; in room [ROOM NUMBER] bed B revealed a jet nebulizer mask sitting in the nightstand, un-bagged. Observation on 4/23/22 at 10:33 a.m. revealed in room [ROOM NUMBER] bed B, one oxygen mask at bedside not bagged. Observation on 4/24/22 at 8:57 a.m. revealed in room [ROOM NUMBER] bed B, oxygen face mask hanging on flower meter on the wall, unbagged. Observation on 4/24/22 at 9:55 a.m. revealed in room [ROOM NUMBER] bed A, [CONDITION(S)] mask remains sitting on bedside table, unbagged. Observation on 4/24/22 at 1:10 p.m. revealed in room [ROOM NUMBER] bed B jet nebulizer remains sitting on nightstand, unbagged. 2. On 4/24/22 at 08:16 a.m. during medication administration observation, Registered Nurse (RN) HH placed [MEDICATION(S)]/ [MEDICATION(S)] 0.5 mg/3 mg/3 ml (1 vial) in nebulizer and placed nebulizer on R#45's face. RN HH did not wash, sanitize, or apply gloves during this process. RN HH washed her hands prior to leaving the room. RN HH did not wash or sanitize her hands or apply gloves prior to administering nebulizer treatment. At 08:26 a.m. RN HH returned to R#45's room. RN HH not wash or sanitize her hands or apply gloves prior to removing nebulizer. RN HH did not rinse, separate, or allow the nebulizer to air dry after nebulizer treatment. On 4/24/22 at 8:44 a.m. during medication administration observation, RN HH assessed lung sounds and checked pulse saturation for R#28, as she prepared to administer scheduled nebulizer treatment. RN HH placed medication in nebulizer and instructed R#28 to remove oxygen face mask. Face mask was placed on R#28's bed and left on the bed through the duration of the nebulizer treatment. RN HH applied the nebulizer. RN HH was not wearing gloves, nor did she practice hand hygiene prior to administering nebulizer treatment. At 09:01 RN HH returned to R#28's room, removed the nebulizer and placed the nebulizer in the bag. RN HH did not rinse, separate, or allow the nebulizer to air dry after nebulizer treatment. RN HH picked oxygen face mask off the bed and handed it to R#28 to reapply. RN HH washed and dried hands prior to leaving the room. On 4/24/22 at 9:43 a.m. during medication administration observation, RN HH entered R#22's room to administer scheduled nebulizer treatment. RN HH placed medication in nebulizer and applied the nebulizer onto R#22's face. RN HH did not wash, sanitize, or apply gloves during this process. RN HH washed her hands prior to leaving the room. At 09:56 a.m. RN HH removed nebulizer from R#22's face and placed the nebulizer in a bag. RN HH did not wash, sanitize her hands or apply gloves prior to removing nebulizer. RN HH did not rinse, separate, or allow the nebulizer to air dry after treatment Interview on 4/24/22 at 12:41 p.m. with Licensed Practical Nurse (LPN) FF revealed that has been educated on respiratory care. She furthered stated the training was conducted on site at the facility face to face by the Director of Nursing (DON). LPN FF was able to cite and demonstrate respiratory care involving oxygen, oxygen tubing and nebulizer treatment. No issues were identified. During an interview on 4/24/22 at 1:26 p.m., the DON stated it is her expectation that nurses practice good hand hygiene and wear gloves during respiratory care for residents. She stated that nurses are aware that they are required to wear gloves when handling respiratory supplies. DON stated that the respiratory therapist from the hospital were doing the facility's respiratory care but that changed and now the nurses at the facility are responsible for respiratory care for the residents. She stated that the nurses were educated on respiratory care. DON stated that she is not sure if RN HH had completed respiratory training. The undated facility policy titled Nebulizer Treatments, Jet documented to wash or sanitize hands, apply gloves . remove treatment and turn oxygen compressor off, rinsed the nebulizer equipment and let air dry. When dry store in a plastic bag. Wash hands.

Based on record review, interviews and review of the facility policy titled Comprehensive Care Plan, the facility failed to invite three residents (R) (R#8, R#14 and R#47) or their representatives, to participate in quarterly care plan meetings. The sample size was 16. Findings include: Review of the undated facility policy titled Comprehensive Care Plan, revealed the facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must facilitate the inclusion of the resident and/or resident representative. An explanation shall be documented in the resident's medical record if the participation of the resident and his/her representative is determined not practicable for the development of the resident's care plan. 1. A review of the clinical record for R#8 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 99, which indicated cognition could not be determined. Review of a Care Plan Conference Sheet revealed that the last meeting recorded was held on 2/1/22. There was no evidence that resident or her representative was invited to attend the quarterly care plan conference. Further review revealed that members of the Interdisciplinary Team (IDT) in attendance were MDS Nurse, Activity Director, Certified Nursing Assistant (CNA) and Registered Dietician. There is no evidence that the full IDT attended this quarterly care plan conference. 2. A review of the clinical record for R#14 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Significant Change MDS dated [DATE], revealed a BIMS was coded as 13, which indicated no cognitive impairment. Review of Care Plan Conference Sheets revealed that meetings were held on 4/12/22 and 2/15/22. The family was invited, but did not attend, the meeting held on 4/12/22, but there is no evidence that resident was invited to attend. There was no evidence that the resident or his representative was invited to attend the quarterly care plan conference held on 2/15/22. Further review revealed that members of the IDT in attendance were MDS Nurse, Activity Director, Social Services Director (SSD) and Registered Dietician. There is no evidence that the full IDT attended this quarterly care plan conference. During an interview on 4/23/22 at 12:20 p.m., R#14 stated he was not invited to the care plan meeting. 3. A review of the clinical record for R#47 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly MDS dated [DATE], revealed a BIMS was coded as 99, which indicated cognition could not be determined. Review of Care Plan Conference Sheets revealed that meetings were held on 10/19/21 and 4/5/22. There was no evidence that resident or her representative was invited to attend either of the quarterly care plan conferences. Further review revealed that members of the IDT in attendance were MDS Nurse, Activity Director, CNA, SSD and Registered Dietician. There is no evidence that the full IDT attended this quarterly care plan conference. Interview on 4/24/22 at 10:13 a.m. with MDS Coordinator revealed that she mails a notice to the family/responsible party inviting them to the upcoming care plan conference meetings. She stated on the day of the care plan conference meetings, the SSD or the Activities Director go around and verbally invite residents to the care plan meetings. She further stated that she does not keep a copy of the letter sent to family or any documentation about verbal invites in the resident's medical record pertaining to care conference meetings. During further interview, she stated that if the family attendance section of the care plan conference sheet was not marked as invited or attended, it does not mean they were not invited. She stated the family attendance section being left blank means she forgot to mark the box that they were invited.

Based on record review and staff interviews, the facility failed to obtain a concurring Physician's signature for a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #148 of 16 sampled residents. Findings include: 1. Review of medical record for R#32 revealed resident was admitted to facility on 9/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review Medical Data Set (MDS) quarterly assessment completed 3/9/22 section C (Cognitive Patterns) revealed Brief Interview for Mental Status (BIMS) score was 5 indicating resident was cognitively impaired. A POLST with a choice to allow natural death/DNR that was signed by one Physician on 9/20/21 and resident's son, that was not the residents Power of Attorney, on 9/20/21 there was no concurring Physician's signature. Further review of the Medical Record for R#32 also revealed that there was not a Health Care Agent for resident on file at facility. 2. Review of the clinical record for R #148 revealed resident was admitted to facility on 4/21/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication of resident current code status noted in medical records for review. Review of document titled Guidance for completing POLST form revealed under additional guidance for health care professionals Section III. When a POLST form is signed by an authorized person (other than the health care agent) and attending Physician, I. If section A indicates allow natural death -Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined by Georgia Code 31-39-2 (4). A concurring physician signature is required per Georgia code 31-39-4 (c). Interview with Social Services Director (SSD) on 4/24/22 at 2:40 p.m. revealed that when a resident is admitted to the facility, Advanced Directives are discussed at that time with the resident and the family member. If the resident is cognitive, they are given the POLST form to complete which is then signed by the resident, physician, and the social services director. If the resident is not cognitive and unable to speak for themselves the residents responsible party is given the POLST document, and they will sign for them. Continued interview revealed that staff member was not aware that at any time there should be a concurring physician signature for residents that are not cognitive and who do not have a health care agent or court appointed guardian. Further interview did confirm that R#32 should have had a second physicians' signature on the POLST document due to residents' cognitive status and lack of legal guardianship. During the interview it was also disclosed that R#148 was a full code and there was no indication of residents' status noted in medical records. On 4/24/22 at 3:32 p.m., interview with Director of Nursing (DON) revealed that residents code status is completed upon admission to facility and once it is established it is placed on a sticker in the front of the residents' chart, or the staff can refer to the residents POLST information. Continued interview also revealed that R#148 was admitted to the facility as with a full code status though full code was not documented in medical record. Further interview also revealed the expectation was that every resident would have a documented code status on their chart for staff review. On 4/24/22 at 3:58 p.m., interview with Administrator revealed that she was unaware that residents who did not have a legal guardian document did not have a concurring physicians' signature on their POLST documentation for their preferred code status.

Based on record review, staff interview, and review of facility policy titled Baseline Care Plan, the facility failed to implement care plan for one of four residents (R) (R#148). Specifically, the facility failed to indicate resident had a catheter present within 48 hours of admission. Findings include: Record review for R#148 revealed resident was admitted to facility on 4/21/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#148 was a new admission to facility and did not have any indication of catheter use noted on baseline care plan. Review of facility policy revealed under Policy: A baseline care plan shall be developed and implemented for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. On 4/24/22 at 11:53 a.m. interview with Director of Nursing (DON) confirmed that R#148 did not have any indication of catheter use on the 48-hour baseline care plan. Further interview also revealed that catheter should have been indicated on care plan after it was inserted within the 48-hour period by the nurse that completed the procedure. Continued interview also revealed that any changes in a resident's condition can be indicated on the care plan by any nurse at the time change occurs.

Based on observation, record review, and staff interview, the facility failed to follow the care plan related to catheter care for one resident (R) (R#44) and related to nail care for one resident #8 of 16 sampled residents. Findings include: Record review for R#44 revealed resident was admitted to facility on 12/11/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented R#44 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. The resident had an indwelling urinary catheter. Review of care plan date 10/18/21 revealed R#44 is at risk for complications related to use of suprapubic catheter. Interventions included to keep drainage bag of Foley always covered and below level of bladder. During observations on 4/23/22 at 8:45 p.m. and 4/24/22 at 8:00 a.m., R#44 was noted to have catheter bag to bedside drainage facing the door with no dignity bag. On 4/24/22 at 11:53 a.m. interview with Director of Nursing (DON) revealed that residents should have a dignity bag to cover their catheter while out of their rooms. Staff are expected to follow the plan of care for the residents. Cross refer to F550. 2. Review of the clinical record for R#8 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 99, which indicated cognition could not be determined. The resident required one-person total assist with personal hygiene and bathing. Review of the care plan revised 2/1/22 revealed resident needs total assistance with two-person support for bathing related to right side [CONDITION(S)] and cognitive deficit. Interventions to care include provide total assistance with bathing, showers 3x's per week, bed bath on non-shower days and as needed, safety precautions at all times when bathing. Observations on 4/23/22 at 9:45 a.m. and 3:51 p.m. and 4/24/22 at 1:34 p.m. revealed fingernails on both hands have dark brown substance underneath the fingernails. Interview on 4/24/22 at 2:45 p.m. with Certified Nursing Assistant (CNA) AA revealed that she finds out what is the residents need from the care plan. She stated that she does nail care as needed but stated the shower team is supposed to clean and trim the nails on the days resident gets showers. Interview on 4/24/22 at 2:53 p.m. with the DON revealed that she expects staff to provide care per the care plan. Cross refer to F677.

Based on observation, record review, staff interviews, and policy review titled A.M. Care, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent residents (R) (R#8) related to nail care. The sample size was 16. Findings include: Review of the undated facility policy titled A.M. Care revealed the purpose is to provide the patient cleanliness, comfort, and social contact; to give the assigned staff member an opportunity for an ongoing assessment of the patient. Procedure number 4. F. Arms and hands: Soak hands and nails; clean as needed. A review of the clinical record for R#8 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 99, which indicated cognition could not be determined. Review of April 2022 Physicians Orders revealed an order dated 10/25/21 to clean and trim fingernails twice a month. Observations on 4/23/22 at 9:45 a.m. and 3:51 p.m. and 4/24/22 at 1:34 p.m. revealed fingernails on both hands have dark brown substance underneath the fingernails. Interview on 4/24/22 at 2:45 p.m. with Certified Nursing Assistant (CNA) AA revealed that showers are given three times per week, and bed baths are given the other days as needed. She stated that she does nail care as needed but stated the shower team is supposed to clean and trim the nails on the days resident gets showers. She stated that she did not notice that R#8 nails were dirty. Interview on 4/24/22 at 2:53 p.m. with the Director of Nursing (DON) revealed that she expects staff to provide care per the ADL care plan. She stated that nail care should be done on bath days and as needed if they are long or dirty. She confirmed R#8 fingernails had dark brown substance on both hands.

Based on staff interview, review of the resident fund account bank statements, and the policy Surety Bond the facility failed to have in force a surety bond to cover the amount of funds in the resident fund account. There were 28 residents in the facility with funds accounts managed by the facility. Findings included: Review of an undated policy titled, Surety Bond revealed: It is the policy of this facility to purchase a surety bond, or provide self-insurance to assure the security of all personal funds of residents deposited with the facility. Review of the bank statements for the resident fund account managed by the facility revealed the following statement balances: May (YEAR) the starting balance of $17,221.25 and the ending balance of $23,346.49. June (YEAR) the starting balance of $23,346.49 and the ending balance of $20,191.14. July (YEAR) the starting balance of $20,191.14 and the ending balance of $22,447.63. August (YEAR) the starting balance of $22,447.63 and the ending balance of $22,224.63. September (YEAR) the starting balance of $22,224.63 and the ending balance of $20,977.64. October (YEAR) the starting balance of $20,977.64 and the ending balance of $32,065.93. Review of the State of Georgia, Department of Community Health, Long Term Care Facility Residents' Fund Bond dated 9/17/14 revealed a surety bond in the amount of $20,000.00. An interview was conducted on 12/4/18 at 9:45 a.m. with the Administrator regarding the ending bank balances exceeding the Surety Bond coverage of $20,000.00 for the six-month reviewed by the surveyor. Administrator revealed she was not aware of the resident's funds account balance exceeded the $20,000.00 Surety Bond. The Administrator stated she would review the statements with the Social Service Director. An interview was conducted on 12/4/18 at 2:00 p.m. with the Administrator who confirmed that the balance of the resident fund exceeded the current Surety Bond amount and would need to be increased.

Based on interview, observation, review of the facility policy titled Production, Purchasing, Storage and review of Dry Storage Life of Foods the facility failed to discard expired items, and failed to label and date items upon delivery. This included storage and refrigeration areas in the kitchen and emergency food supply. The facility census was 58 residents. Findings include: During a brief kitchen tour with Registered Dietitian on [DATE] at 10:50 a.m. the following was identified: 1. In reach in cooler #5 there were whipped toppings in bags that did not have an in date or expiration date. 2. There were five, 4-ounce (oz.) chocolate pudding containers with a use by date of [DATE]. 3. There were 17, 4 oz. containers of vanilla pudding with a use by date of [DATE]. 4. There was 1 case of chocolate pudding with a use by date of [DATE]. It is noted that the case had an in date of [DATE]. 5. In the #4 milk and dessert cooler there was one gallon of 2% reduced fat milk with a best buy date of [DATE]. Observation of the dry storage area with Registered Dietitian on [DATE] at 11:20 a.m. revealed: 1. There were two large containers containing flour and sugar but there were no in dates or expiration dates. 2. There were five, 6.56lb cans with an in date of [DATE] with and expiration date of [DATE]. 3.There were two loaves of sandwich wheat bread with an expiration date of [DATE], (YEAR). Observation of the emergency food supply with Registered Dietitian on [DATE] at 11:40 a.m. revealed: 1. There was one can of chicken noodle soup that had an expiration date of [DATE] in the emergency food supply. 2. There were seven, #10 cans of sliced peaches that had an in date of [DATE] in the emergency food supply. 3. In the storage area there were five, 128 fluid oz containers of sweet relish, two, 1 gallon containers of Kraft Mayo, three, 1 gallon containers of Thousand Island dressing, and two, 1 gallon containers of Ranch dressing that did not have an in date or an expiration date. Interview on [DATE] at 10:50 a.m. with the Registered Dietitian who reported that the whipped topping items have to be used within three days of being opened. However, the Registered Dietitian acknowledged that the items were not dated and did not have an expiration date. Interview on [DATE] at 11:20 a.m. with the Registered Dietitian who reported that the stock person empties the sugar and flour containers whenever a new case arrives. She further reported that the last case was delivered about two weeks ago but confirmed that the containers did not have dates. The Registered Dietitian reported that the stock person should be checking expiration dates upon delivery and is to notify supervisor if there are issues so that the vendor can be contacted for a credit or replacement. It was further reported that deliveries are completed twice a week and the staff should utilize first in first out when stocking. Interview on [DATE] 2:05 p.m. with the Registered Dietitian who reported that sugar and flour are used frequently and are used before six months. It was further reported that she has spoken with her stock person related to putting dates on items that do not have expiration date. It is reported that the whipped topping mix is used frequently and is ordered weekly. The Registered Dietitian reported that emergency food items are checked and rotated periodically but did not have a specific time frame for checking. It was reported that the Certified Dietary Manager is responsible for reviewing of food items to assure they have not expired. Review of the Dry Storage Life of Foods guide dated (MONTH) (YEAR) revealed that unopened canned products without a manufacturer's expiration/best by date should be used within one year. It also reported that the expiration date on bread package should be followed. Lastly, mayo and salad dressings should be used within six months when not opened. POLICY Section: Production, Purchasing, Storage Subject: Receiving Procedures: Director/Authorized Designee Rotate items: first in, first out. Subject: Food Supply storage procedures Dry storage Date and rotate items; first in, first out (FIFO). Remove from storage any items for which the expiration date has expired. Return product from credit if possible. Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid. Hang scoop. (Scoops are not stored in bins.) Frozen Storage Date and rotate items; first in, first out (FIFO).

Based on record review and staff interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment since 7/25/18 for one resident (R) (R#1). The sample size was 23 residents. Findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, dated (MONTH) (YEAR) revealed: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. During interview with the MDS Coordinator on 12/5/18 at 10:37 a.m., she verified that the last MDS assessment completed for R#1 was a Quarterly MDS with an Assessment Reference Date (ARD) of 7/25/18. She stated during continued interview that R#1 was due for another Quarterly MDS on 10/17/17, but it was not done, and she did not know why. The MDS Coordinator further stated that there was nothing that prompted her when an MDS was past due, so that she was not aware of it.

Based on observation and staff interviews the facility failed to have an up to date staffing posting on 12/3/18 and to maintain the posted daily nurse staffing data for a minimum of 18 months. The facility census 58. Findings include: Observation on 12/3/18 at 10:30 a.m. upon entering the facility the staffing posting revealed date 12/1/18. The information posted included the census; shift, category of staffing, Registered Nurse (RN), Licensed Practical Nurse (LPN) and Certified Nurse Assistant (CNA); the number of staff, planned hours, and the actual hours. An interview was conducted on 12/4/18 at 8:45 a.m. with the Administrator regarding the staffing posting revealed that staff posting should be completed the first thing in the morning by 8:30 a.m. - 8:45 a.m. The Administrator revealed that the Director of Nursing (DON) is responsible for training, overseeing the staffing posting, and keeping 18 months of staffing posting. An interview was conducted on 12/4/18 at 9:00 a.m. with the DON regarding the staffing posting revealed that the staff posting should be posted as early as possible and should be up by 8:30 a.m. Any correction on the posting is completed by the ward clerk and keep for 18 months. A policy and review of the 18 months was requested. An interview was conducted on 12/4/18 at 12:30 p.m. with the DON revealed that the facility did not have a policy on staffing posting. An interview was conducted on 12/5/18 at 12:55 p.m. with Ward Clerk AA who is responsible for the daily schedule (assignment) and posting the daily nursing staffing. Ward Clerk AA confirmed that the staff posting for 12/3/18 and was not posted when survey team entered the building. She revealed that she was not aware the staffing posting had to be up at a certain time. The surveyor requested the daily posted staffing sheets that the facility currently has kept however Ward Clerk AA revealed she does not have 18 months of the staffing sheets. Ward Clerk AA revealed she was not aware that she was required to keep 18 months of the staffing posting. Review of the POS [REDACTED]. Staffing posting were not completed on a daily basis. An interview was conducted on 12/6/18 at 9:05 a.m. with Ward Clerk AA regarding the staffing sheets that were provided to the surveyor. Ward Clerk AA confirmed that the sheets provided were the only staffing sheets she could provide. Ward Clerk AA Confirmed for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) staffing posting was not completed on a daily consistent basis.

Based on observations, record review, and staff interviews, the facility failed to address signs of pain and provide pain management during the provision of wound care for two (2) residents ( "A" and #64) from a sample of thirty one (31) residents. This failure resulted in actual harm for resident "A" and resident #64 that was not immediate jeopardy. Findings include: 1. Review of the medical record for resident #64 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of photographic wound documentation dated 4/20/11 revealed that the largest pressure ulcer, on the sacrum, measured 9.5 centimeters (cm) by 13.5 cm x 1.4 cm. Interview with Licensed Practical Nurse (LPN) "AA", on 6/20/11 at 3:36pm confirmed resident #64 had three (3) Stage four (4) pressure ulcers, to the sacral area and right and left hip. Observation of Physical Therapy Assistant (PTA) "KK" on 6/22/11 at 1:15pm, during provision of wound care, revealed that LPN "AA" entered the room as the dressing change started and indicated that the resident had been medicated for pain at 1:05 pm, ten (10) minutes before the dressing change began. During wound care to the right hip and sacral wounds, the resident winced, grimaced, and jumped. PTA "KK" indicated that the resident's right hip wound is always tender. PTA "KK" did not stop the wound care to assess the resident's pain but continued to perform the wound care. Physical Therapy/Occupational Therapy Aide (PT Aide) "MM", assisting with the wound care, held the resident's right hand because he was trying to stop the wound care. Interview with PT Aide "MM" on 6/23/11 at 9:39am revealed that she usually assists PTA "KK" with wound care and that the resident usually shows facial expressions of pain, especially with dressing change on the right hip. Review of the physician's orders [REDACTED]. Interview with LPN "AA" on 6/22/11 at 3:20pm revealed that she tries to medicate the resident before the dressing change if she knows when physical therapy is going to do the procedure. Interview with LPN "LL" on 6/23/11 at 9:03 am revealed that PTA "KK" has never communicated pain issues related to the resident's wound care to her. Further interview revealed that pain medicine is not routinely given before wound care. 2. Review of the clinical record for resident "A" revealed that the resident had returned to the facility on [DATE] after having same day surgery for [REDACTED]. Review of physician orders [REDACTED]. Observation on 06/22/11 at 11:20 a.m. of wound care provided for resident "A" by PTA "KK" revealed that after setting up supplies, the PTA asked the resident if he was hurting or in pain. The resident indicated that he was hurting. Continued observation revealed that LPN "AA" was notified and gave resident "A" [MEDICATION NAME] ES 1 tablet (crushed) per [DEVICE] at 11:30 a.m.. PTA "KK" began wound care at 11:35 a.m. The resident continued to complain of discomfort during and after wound care but was never asked about the pain or discomfort. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Although resident "A" had been assessed with [REDACTED]. Interview on 06/22/11 at 1:45 p.m. with LPN "AA" revealed that physical therapy does not always let the facility staff know when they are going to do wound care so that pain medication can be given as ordered. Continued interview revealed that wound care was scheduled at 10:15 a.m., but Physical Therapy was running late and the nurse was not notified to give pain medication until the PTA was in the resident's room. Interview on 06/23/11 at 1:15 p.m. with PTA "KK" revealed if Physical Therapy provides wound care to the resident, pain medication is given 30 minutes before care is provided. A schedule of wound care is given to nursing staff on Mondays. Continued interview revealed that sacral ulcer care on resident "A" is scheduled on Mondays, Wednesdays, and Fridays.