Every finding on record at Webster Health Services Nursing Facilty

Based on staff interview and record review, the facility failed to accurately complete section I (active diagnoses) and O (special treatments and programs) of the Minimum Data Set (MDS) for four (4) of 14 sampled residents. Resident #6, #7, #29, and #34 Findings include: Review of facility letterhead revealed, (Proper name of facility) Long Term Care follows the RAI (Resident Assessment Instrument) Regulatory Requirements. This was signed by the Administrator and dated 8/20/25. Resident #6 Record review of Resident #6's Order dated 6/26/25 revealed, Admit to Hospice. Record review of the MDS Section O - Special Treatments, Procedures, and Programs with Assessment Reference Date (ARD) of 6/30/25 did not indicate hospice service was received by Resident #6. During an interview on 8/19/25 at 3:20 PM, the Director of Nursing (DON) revealed the MDS assessment's purpose was to reflect each resident's health status at the time of the assessment. Resident #6 was admitted to hospice service on 6/26/25 and the MDS assessment dated [DATE] did not indicate the resident received hospice services. She confirmed her expectation was for the assessment to be completed correctly, and the facility failed to submit an accurate assessment on 6/30/25 for a resident who received hospice services. Record review of Resident #6's Demographics form revealed an admission date of 3/17/25. Record review of Resident #6's Hospital Problems revealed a diagnosis of Alzheimer's Disease. Record review of Resident #6's MDS Section C - Cognitive Patterns dated 6/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severe cognitive impairment. Resident #7 Record review of the Quarterly MDS with an ARD of 6/9/25 revealed under section I (active diagnoses), Resident #7 was coded for having a diagnosis of bipolar disorder. Record review of the “Hospital Problem List” revealed Resident #7 did not have a diagnosis of bipolar disorder. An interview with the Director of Nursing on 8/19/25 at 3:20 PM revealed Resident #7’s MDS was coded in error and confirmed the resident did not have a bipolar diagnosis. She revealed her expectations were for the MDS to be checked for accuracy before the assessment was closed and submitted. Record review of the Demographics” revealed the facility admitted Resident #7 on 4/1/20 with medical diagnoses that included History of Cerebrovascular Accident and Left Sided Hemiparesis. Record review of the Quarterly MDS with an ARD of 6/9/25 revealed under section C, a BIMS summary score of 15, indicating Resident #7 was cognitively intact. Resident #29 Record review of the Quarterly Minimum Data Set (MDS) with an ARD of 5/20/25 revealed under section I (active diagnoses), Resident #29 was marked for having a diagnosis of bipolar disorder. Record review of the “Hospital Problem List” revealed Resident #29 did not have a diagnosis of bipolar disorder. An interview with the Director of Nursing on 8/19/25 at 3:23 PM revealed Resident #29’s MDS was coded in error and confirmed the resident did not have a bipolar diagnosis. Review of the “Demographics” revealed the facility admitted Resident #29 on 9/2/24 with medical diagnoses that included Closed Fracture of First Lumbar Vertebra with Routine Healing. Review of the Quarterly MDS with an ARD of 5/20/25 revealed under section C, a BIMS summary score of 13, indicating Resident #29 was cognitively intact. Resident #34 Record review of Order dated 6/24/24 for Resident #34 revealed, Resident on hospice. Record review of Resident #34's MDS Section O - Special Treatments, Procedures, and Programs dated 5/26/25 did not indicate the resident received hospice services. During an interview on 8/19/25 at 3:21 PM, the DON revealed the MDS assessment reflected the health status of each resident and should be entered accurately. She stated Resident #34 was admitted to hospice on 6/19/24. She confirmed her expectation was for the assessment to be completed correctly and the facility failed to submit the 5/26/25 assessment accurately for a resident who received hospice services. Record review of Resident #34's Demographics record revealed an admission date of 7/5/21. Record review of Resident #34's Hospital Problems list revealed diagnoses of Congestive Heart Failure and Advanced Dementia. Record review of Resident #6's MDS Section C Cognitive Patterns with ARD of 5/26/25 revealed a BIMS score of 2 which indicated the resident had severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident receiving enteral feeding received appropriate care for one (1) of two (2) residents with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Resident #20Findings Include:Review of the facility policy titled Enteral Feeding: Gastrostomy, PEG, Jejunostomy, unrevised, revealed under Policy: It is the policy of ‘Proper name of the facility' that residents unable or unwilling to ingest oral nutrients should be properly provided nutrition and care.During an observation of a medication pass on 8/20/2025 at 12:10 PM with Licensed Practical Nurse (LPN) #1, she checked placement of Resident #20's feeding tube and withdrew three and one-half (3 1/2) 60 ml (milliliter) syringes of beige-colored gastric residual. She placed the contents into a non-measurable white Styrofoam cup, administered the resident's medication, and discarded the gastric residual by flushing it down the toilet.An interview with LPN #1 on 8/20/25 at 12:32 PM revealed Resident #20 had 150 cc's (cubic centimeters) of gastric residual and confirmed she did not return the residual contents back to the resident. LPN #1 revealed that Resident #20 received a bolus feeding at 10 AM and acknowledged that failing to return the stomach contents resulted in a lost feeding, which could lead to fluid and nutrient imbalance and possible weight loss.An interview with the Director of Nursing on 8/20/25 at 12:44 PM confirmed Resident #20's gastric residual should have been returned. She acknowledged that failure to do so could result in weight loss or electrolyte imbalance and stated this was a standard of nursing practice.Record review of the Demographics revealed the facility admitted Resident #20 on 8/2/24 with medical diagnoses that included Cerebral Infarction due to Unspecified Occlusion, Dysphagia, and Encounter for Attention to Gastrostomy.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #20 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices during blood glucose monitoring by not using a barrier and by cleaning the multiuse glucometer with an agent that was not effective against bloodborne pathogens for three (3) of eight (8) resident care opportunities observed. Resident # 8, Resident #22, and Resident #36Findings Include: Review of the facility policy titled “Care of Equipment: Cleaning, Disinfecting, and Storage,” revised 1/10/24, revealed under “Cleaning and Disinfecting: Any equipment/devices entering the room or treatment area should be cleaned and disinfected between patient use with the approved disinfectant and according to the manufacturer’s instructions for use (IFU), regardless of whether or not the equipment is visibly soiled. (e.g., glucometer) . During an observation on 8/19/2025 at 3:56 PM with Certified Nurse Aide (CNA) #1, she entered Resident #22’s room and placed the glucometer on the bedside table without a barrier. After completing the blood glucose reading, she exited the room and briefly wiped the end of the glucometer (at the strip insertion site) with an alcohol prep. CNA #1 then entered Resident #36’s room, placed the glucometer on the bedside table without a barrier while prepping the resident’s finger, and after completing the blood glucose reading, briefly swiped the end of the glucometer with an alcohol pad. Lastly, CNA #1 entered Resident #8’s room and placed the glucometer on the bedside table without a barrier. After obtaining the glucose reading, she again briefly swiped the glucometer with an alcohol wipe. Further observation revealed a bottle of Clorox Disinfecting Wipes available for use on the rolling cart, which was never used. An interview with CNA #1 on 8/19/25 at 4:16 PM confirmed she did not use a barrier during blood glucose monitoring. She acknowledged the purpose of using a barrier was to prevent cross contamination. She stated she used an alcohol wipe to clean the glucometer and reported that administration told her it was acceptable. CNA #1 explained she had Clorox wipes available but used them only after finishing all glucose checks to disinfect the machine. She admitted that not using a barrier and not cleaning the glucometer with the appropriate disinfecting agent between residents could cause the spread of infection. An interview with the Director of Nursing on 8/19/25 at 4:27 PM revealed the multiuse glucometer should be cleaned with the available Clorox wipes. She stated CNA #1 had been trained on using and properly disinfecting the machine. The Director of Nursing also confirmed that a barrier should be used to prevent cross contamination and the spread of infection. Record review of the “Demographics” revealed the facility admitted Resident #8 on 4/28/22 with a medical diagnosis that included Type 2 Diabetes Mellitus. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/23/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #8 was cognitively intact. Record review of the “Demographics” revealed the facility admitted Resident #22 on 11/1/21 with a medical diagnosis that included Type 2 Diabetes Mellitus with Stage 4 Chronic Kidney Disease. Record review of the MDS with an ARD of 7/2/25 revealed under section C, a BIMS summary score of 99, indicating Resident #22 could not complete the interview. Record review of the “Demographics” revealed the facility admitted Resident #36 on 11/18/24 with a medical diagnosis that included Type 2 Diabetes Mellitus Without Complications. Record review of the MDS with an ARD of 8/4/25 revealed under section C, a BIMS summary score of 6, indicating Resident #36 was severely cognitively impaired.

Based on observation, staff interview, record review, and facility policy review the facility failed to ensure the safety of a resident when bilateral side rails were applied to the middle of a residents' bed without assessing the resident for alternative safety methods, risk for entrapment, and failed to obtain informed consent prior to installation of bedrails for one (1) of three (3) residents reviewed. Resident #6. Findings include: A review of the facility policy titled, Side Rails, revised June 14, 2023, revealed Rationale: To provide guidelines for safe and effective use of bed rails in the patient care environment . An observation of Resident #6's room on 1/23/24 at 10:30 AM, revealed side rails in the up position bilaterally on each side of the bed. An observation of measurements taken of Resident #6's bed and side rails by the maintenance staff on 1/24/24 at 2:00 PM, revealed the bed mattress length measurement was 79 inches long. The length of the open space from the headboard to the top of the rail and bottom of the rail to the foot board measured 26 inches long respectively, and the side rails bilaterally measured 26 1/2 inches long. The bed rails were bilaterally in the middle of the bed. An observation on 1/24/24 at 9:00 AM, revealed bilateral side rails up in the middle of Resident #6's bed, with a padding noted to top of the first bar of the side rail, with the two bars below observed to have no padding, and the two lateral bars on the side rails had no padding. Resident is observed sticking her arms into the side rails. A record review of the Skin Tear Report dated 10/9/23 for Resident #6 revealed, bleeding from right leg, three (3) skin tears noted two (2) cm (centimeters) x 0.5 cm, (1) one cm x (1) one cm moon shaped, and 0.2 cm x 0.2 cm. Blood was noted on the right side bed rail, orders to clean skin tears with normal saline (NS), pat dry, apply steri-strips, cover with telfa, wrap with gauze dressing. A record review of Skin Tear Report for Resident #6 dated 1/08/24, revealed CNA (Certified Nurse Assistant) reported when she entered room, resident had legs over the side of the head of the bed (HOB), blood was noted on the sheets, skin tear noted behind left knee .Resident has issues with skin tears due to fragile skin related to leukemia and trying to get out of the bed. A record review of the Skin Tear Report dated 1/23/24 for Resident #6, revealed CNA reported while getting resident dressed for bed she was hitting at staff and hit the bed rail, skin tear occurred, triangle in shape, two (2) cm on each side .skin tear to arm .they gently tried to remove her arm from side rail . An interview with Licensed Practical Nurse (LPN) #1 on 1/24/24 at 10:00 AM, she revealed she cares for Resident #6 often and revealed she often attempts to get out of the bed, resists care at times, and has hit her arms and legs on the side rails causing skin tears because she is so small, and her skin is thin and fragile. LPN #1 confirmed Resident #6 obtained a skin tear on 1/23/24 when she began hitting at staff and hit her right arm on the side rail causing a skin tear. An interview with CNA #2 on 1/24/24 at 10:20 AM, reported that Resident #6 is very active and always moving around. She confirmed she has observed Resident #6 with her legs and feet over the side rails and sometimes her hands and arms have been in between the the side rail bars. An interview with CNA #1 on 1/24/24 at 10:30 AM, revealed she has not cared for Resident #6 when she actually obtained a skin tear, but she has reported to multiple staff that the resident attempts to get out of bed throwing her arms and legs over the side rails. She has also had her arms between the bars on the side rails which she was able to easily remove without injuring the resident. An interview with the Director of Nursing (DON) on 1/24/24 at 11:00 AM, revealed she was unable to find any side rail assessments for safety, risk of entrapment, any alternative methods attempted prior to use of the side rails, or a consent for use of the side rails for Resident #6. She confirmed Resident# 6 has had multiple skin tears related to hitting her arms on the side rails. She confirmed after review of the Skin Tear Reports the reports dated 10/9/23 skin tears times three to right lower leg, 1/08/24 skin tear behind left knee, and 1/23/24 skin tear to right forearm were from Resident #6 hitting/bumping her extremities on the side rails. The DON then revealed the resident does have padding to the side rail to help prevent skin tears but confirmed the resident was still at risk for receiving skin tears because the entire side rail was not padded and confirmed the resident was at risk for entrapment in getting her arms and legs caught between the the rails and could possibly come over the rails and fall. Record review of the resident information form revealed the facility admitted Resident # 6 on 9/18/2023 with diagnoses including Unspecified Dementia, Unspecified severity without behavior/psych/mood, and Anxiety. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 12/25/23, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated that she was severely cognitively impaired. Section K revealed Resident #6 was 61 inches in height and weighed 98 pounds.

Based on observation, staff interview, and facility policy review, the facility failed to preserve the privacy of resident information during medication pass for two (2) of five (5) residents observed during medication pass. Resident #14 and Resident #31. Findings include: Review of the facility's policy titled, Resident Rights: Privacy and Confidentiality, review date of (MONTH) 8, 2019, revealed the rational was to provide guidelines to help preserve and protect a resident's confidentiality and privacy. It was the policy of Long Term Care that resident's confidentiality and privacy should be protected. The policy procedure revealed residents have the right to confidentiality for his/her personal and clinical records. Resident #14 An observation, on 1/14/2020 at 8:55 AM, during the medication pass observation revealed Licensed Practical Nurse (LPN) #3 left the computer screen up and open with pertinent resident information on Resident #14 visible while she was in the resident's room administering medications. During the remainder of the medication pass, the screen was tilted downward when the nurse was away from the cart, but resident information was not protected. Depending on the degree the screen was tilted down, the information remained on the screen or the screen blacked out and resident information readily reappeared when the screen was lifted. An interview, on 1/16/2020 at 11:48 AM, with LPN #3, confirmed she did not close the computer screen while she was in Resident #14's room. LPN #3 confirmed that anyone could have seen the resident's information. She stated she usually pushes the screen down to hide it but she did not think about the possibility of anyone being able to raise the screen and see the information. LPN #3 stated she guessed they needed to figure out how they could log off or sign out when giving medications. An interview, on 1/16/2020 at 12:00 PM, with the Administrator (ADM) confirmed the resident's information was not protected and data could have been viewed by people who should not be seeing it. The ADM stated this was a HIPAA (Health Insurance Portability and Accountability Act) issue. Resident #31 An observation, on 01/14/2020 at 8:27 AM, during the medication pass observation for Resident #31, revealed LPN #2 closed the computer screen approximately 50% and did not activate the privacy screen. Resident #31's pertinent and confidential information was visible while LPN #2 was away from the medication cart.

Based on observation, staff interview, and facility policy review, the facility failed to maintain a medication error rate of less than five percent (5%) as evidenced by failure to flush between the administration of six (6) medications via Resident #31's Percutaneous Endoscopic Gastrostomy (PEG) tube, for one of two (1 of 2) medication administration observations. There was 40 medication administration opportunities observed. The med error rate was 15 %. Findings include: Review of the facility's policy titled, Medication Administration: Gastrostomy PEG Tube, dated (MONTH) 2011, revealed: Gastro/PEG tube should be flushed with ten millimeters (ml) of water after each separate administration of medication. On 1/14/2020 at 8:27 AM, an observation revealed Licensed Practical Nurse (LPN) #2 failed to flush Resident #31's PEG tube between each medication administered via the PEG tube. LPN #2 administered six (6) medications via Resident #31's PEG tube. LPN #2 administered [MEDICATION NAME] 0.25 milligrams (mg), [MEDICATION NAME] 125 mg per 5 milliliters (ml), Ranidtidine 15 ml/ml give 10 ml, Benezepril 20 mg, Amolodipine 5 mg, and [MEDICATION NAME] 25 mg. The observation revealed each medication was mixed with water and given individually, but the PEG tube was not flushed with water between each medication. During an interview, on 1/14/2020 at 8:35 AM, LPN #2 stated she was aware of the policy to flush the PEG tube between each medication during medication administration. LPN #2 stated she was nervous and forgot to flush the PEG tube between each medication. LPN #2 stated she should have flushed the PEG tube with ten milliliters of water between each medication given to prevent complications.

Based on observation and staff and resident interview, the facility failed to store respiratory equipment in a manner to prevent the possibility of infection and/or contamination for two (2) of four (4) residents reviewed for respiratory treatments. Resident #27 and Resident #33. Findings include: Resident #27 On 01/13/2020 at 2:07 PM, an observation revealed Resident #27's nebulizer mask was hanging on the oxygen flow meter and not stored in a bag. Follow-up observations, on 01/14/2020 at 3:11 PM and 1/15/2020 at 10:40 AM, revealed Resident #27's oxygen cannula was hanging over the bedside table and the nebulizer mask was hanging on the oxygen flow meter. Neither were stored in bags. On 01/15/2020 at 4:40 PM, an observation with the Director of Nursing (DON), revealed Resident #27 had her oxygen in use, but her nebulizer mask was hanging on the flow meter. On 01/15/2020 at 4:42 PM, an interview with the DON revealed the staff administering the treatments are responsible for storing the oxygen cannulas and masks. She stated they should be sealed in a plastic bag when not in use. The DON stated this could be a concern due to infection control issues and could be a concern for tripping and falls. Resident #33 During an observation and interview, on 01/13/2020 at 12:05 PM, Resident #33 stated she had been receiving respiratory treatments for Pneumonia several days ago. An observation at this time revealed Resident #33's nebulizer and tubing was hanging from the oxygen flowmeter in Resident #33's room. The tubing and nebulizer were not in a bag. An observation, on 01/14/2020 2:30 PM, revealed Resident #33's nebulizer and tubing continued to hang from the oxygen flowmeter without being in bag. An observation, on 01/15/20 at 2:58 PM, revealed Resident #33's nebulizer and tubing continued to hang from the flowmeter without being stored in bag.

Based on family interview, staff interview and record review, the facility failed to provide the resident or resident's Representative Person (RP) written notification of the bed hold policy upon transfer to an acute care facility for two (2) of two (2) residents reviewed for bed hold. Resident #19 and Resident #20. Findings include: Review of the facility's policy titled, Bed Hold for hospitalized or Therapeutic Leave Residents, with a review date of (MONTH) 18, 2019, revealed all residents and their representatives are informed of guidelines related to Bed-hold notices. The facility policy revealed the family, surrogate, or representative are provided with written notification on admission and at the time of transfer. In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or representative are provided with written notification within 24 hours of the discharge. Resident #19 On 01/13/2020 at 12:30 PM, an interview with Resident #20's daughter revealed the resident had been sick with pneumonia and had been in the hospital. The daughter stated Resident #19 had been short of breath and was sent to the hospital for more care. Review of Resident #19's medical record revealed the resident was admitted to the hospital on [DATE] and was discharged on [DATE]. Chest x-ray and labs were done which confirmed Resident #19 was admitted for inpatient treatment. Resident #19 returned to the facility after discharge from the hospital. An interview with the Director of Nursing (DON), on 01/15/2020 at 3:35 PM, revealed the DON stated Resident #19 had an upper respiratory type cold prior to the hospital admission. The DON stated Licensed Practical Nurse (LPN) #1 had worked with Resident #19 during that time. An interview with LPN #1, on 01/15/2020 at 3:37 PM, revealed LPN #1 stated the resident had some slight upper respiratory symptoms the morning of the hospital admission, but was doing well and even participated in activities and ate lunch in the dining room. LPN #1 stated Resident #19 started feeling worse and coughing and was evaluated by the Nurse Practitioner (NP). A Chest x-ray and labs were ordered and the NP transferred Resident #19 to the inpatient area of the hospital for treatment. An interview, on 01/15/2020 at 3:40 PM, revealed LPN #1 stated Resident #19 returned to the facility after discharge from the hospital and is recovering. LPN #1 stated she is still weak, but has improvement in her alertness and appetite is noted. An interview with Registered Nurse (RN) #1, on 01/15/2020 at 4:30 PM, revealed the facility failed to have a bed hold and notification of transfer signed by the resident's family. RN #1 stated the family was present at the time of the transfer, but no paperwork was signed. RN #1 stated this should be the responsibility of the nurse on duty at the time of transfer and she should follow up to be sure it is done. RN #1 stated she plans to work on this and make staff aware. Resident #20 An interview, on 01/13/2020 at 3:20 PM, with Resident #20 revealed she had been the in the hospital due to dizziness. Review of Resident #20's medical record revealed Resident #20 was sent to the hospital on [DATE]. An interview, on 01/15/2020 at 10:00 AM, with the Administrator (ADM), confirmed a bed hold form was not done on Resident #20 at the time of her transfer to acute care. She stated the Responsible Party was present at the time of the transfer. An interview, on 1/16/2020 at 8:15 AM, with the ADM, revealed they have a bed hold form that they go over with the resident/responsible party on admission and in care plan meetings. The ADM stated the families were notified by phone when a resident was sent to the hospital. She stated getting the bed hold form signed just fell though the cracks, because they were not considering residents going to the emergency room or acute care a transfer, because they (the nursing home and the hospital) were in the same building. The ADM stated it was an oversite. An interview, on 01/16/2020 at 8:20 AM, with Licensed Practical Nurse (LPN) #1, revealed she was aware of bed hold forms, but they had just forgot to do them.

Based on family interview, staff interview and record review, the facility failed to provide the resident or the resident's Representative Person (RP) written notification of a transfer or discharge to an acute care facility for two (2) of two (2) residents reviewed for transfer/discharge. Resident #19 and Resident #20. Findings include: Resident #19 During an interview, on 01/13/2020 at 12:30 PM, Resident #19's daughter stated the resident had been sick and had been in the hospital. Review of Resident #19's medical record the resident was admitted to the hospital on [DATE]. An interview, with Registered Nurse (RN) #1 on 01/15/2020 at 4:30 PM, revealed the facility failed to have a notification of transfer signed by the family. RN #1 said the resident's family was present at the time of transfer, but no paperwork was signed. RN #1 stated this should be the responsibility of the nurse on duty at the time of transfer. RN #1 stated she should have followed up to be sure it was done. Resident #20 An interview, on 01/13/2020 at 3:20 PM, with Resident #20 revealed she had been in the hospital due to dizziness. Review of Resident #20's medical record revealed the resident was transferred to the hospital on [DATE]. On 01/15/2020 at 9:18 AM, an interview with the Director of Nursing (DON) revealed the family was notified by phone or verbally of transfers, but was not aware of the regulation concerning a transfer form. On 01/15/2020 at 10:00 AM, an interview with the Administrator (ADM) revealed a transfer form was not done for Resident #20 at the time of her transfer to acute care. The ADM stated she was not aware this was a requirement. She stated they did send the transfer information to the Ombudsman. The ADM stated she accepted responsibility because she should have known about it. On 01/16/2020 at 09:24 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed that she was not aware that transfer forms were supposed to be done.

Based on observation, record review, staff interview, and facility policy review, the facility failed to maintain accurate physician orders [REDACTED].#2. Findings include: Review of the facility's policy entitled Medical Orders revised 07/13, revealed if there are questions regarding medical orders, it is the Health Care Professional's (HCP) responsibility to verify the individual practitioner regarding the order(s). Orders for medication should include the route of the medication. Review of the facility's policy entitled Medication Administration revised 12/13, revealed if any element that compromises a complete medication error is missing or unclear, the nurse should contact the physician for order clarification. Resident #2 An observation and interview on 11/01/17 at 10:50 AM, with the Director of Nursing (DON), revealed Resident #2 sitting in a recliner and non-verbal. The DON revealed Resident #2 has a Percutaneous Endocscopic Gastrostomy (PEG) tube and receives bolus feedings. The DON further revealed Resident #2 does not receive anything by mouth. In an observation on 11/02/17 at 8:41 AM, during medication pass, Licensed Practical Nurse (LPN) #1 administered seven (7) medications via PEG tube, which included [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME] and Alprazalam, and one (1) [MEDICATION NAME] medication. A record review of Resident #2's active physician orders [REDACTED]. Only two (2) of the 12 medications ordered for Resident #2 indicated to be given per PEG, which included [MEDICATION NAME] and [MEDICATION NAME]. The other 11 medications indicated an oral route (PO) of administration. Interview on 11/02/17 at 12:05 PM, with the DON, revealed upon review of Resident #2's physician orders, that the medical record for medication route was incorrect for medications that should be given per PEG. The DON revealed it was important that the orders are correct because somebody could give the resident medications by mouth when they should be given per PEG tube. The DON stated, I'm going to correct that right now. An interview on 11/02/17 at 2:25 PM, with LPN #2, revealed she administered Resident #2s medications through her PEG tube. Upon review of Resident #2's physician orders, LPN #1 revealed the orders showed medications to be given by mouth and agreed the orders were incorrect in the medical record. A review of the Face Sheet revealed the facility admitted Resident #2 on 09/14/16, with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), assessment with an Assessment Reference Date (ARD) of 08/28/17, revealed staff assessed Resident #2 with severe cognitive impairment.

Based on observation, record review, staff interview, and facility policy review, the facility failed to administer medications in a manner to prevent cross contamination for one (1) of three (3) residents observed during medication pass; Resident #2. Findings include: Resident #2 A review of the facility's policy entitled, Management of Environment and Preventing Spread of Infection, reads: Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. A review of the facility's policy entitled, Medication Administration, last revised 2013, revealed: Tablets/capsules should be placed in medication cup with package/wrapper intact. When crushing medications, they should be crushed individually and labeled. Observation on 11/02/17 at 8:41 AM, revealed Licensed Practical Nurse (LPN) #1 crushed and prepared Resident #2's medications, then she placed the plastic medication cups on top of the medication cart which had not been sanitized and had no barrier. LPN #1 stacked the plastic medication cups on one another. When LPN #1 entered Resident #2's room she placed the medication cups on this resident's bedside table, which had no barrier and had not been sanitized. After LPN #1 performed the gastric tube dressing change, this nurse placed the soiled linen and trash bags on Resident #2's floor. In an interview on 11/02/17 at 10:35 AM, LPN #1 stated she sat the medication cups inside one another and that caused contamination. This nurse also stated, she did not use a barrier, which caused contamination. LPN #1 also stated that she placed the soiled linen and trash bags on Resident #2's floor, which was contamination as well. A review of the Face Sheet revealed the facility admitted Resident #2 on 09/14/16, with [DIAGNOSES REDACTED]. A review of Resident #2's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/17, revealed a Brief Interview for Mental Status (BIMS) score of 99 and staff assessed Resident #2 with severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure expired medications were removed/discarded for two of two (2 of 2) medication carts, and one of one (1 of 1) Medication Rooms checked for expired medications. Findings include: Review of the facility's policy titled, Storage and Expiration Dating of Drugs and Biologicals, Syringes and Needles, with an effective date of 12/01/07, revealed the facility should destroy or return all outdated/expired drugs or biologicals according to the Pharmacy guidelines. Review of the facility's policy titled, House Stock Medications, with an effective date of 12/01/07, revealed the facility will ensure floor stock medications are kept in the original manufacturer's container with a visible expiration date. Observation of the Medication Room on 02/02/17 at 11:10 AM, with the Director of Nursing (DON), revealed two (2) medication carts in the room. Medication cart for Rooms #217 to #234, revealed 22 vials of Albuterol Sulfate Inhalation Solution 0.083%, two and five tenths milligrams/three milliliters (2.5 mg/3 ml) in the original container with an expiration date of 01/17, and labeled for Un-sampled Resident A. Further observations revealed eight (8) vials of Albuterol Sulfate Inhalation Solution 0.083%, 2.5 mg/3 ml in the original container with an expiration date of 01/17, and labeled for Resident #9. There was an Epi-pen three tenths (0.3) mg automatic injection/two (2) pack with an expiration date of 01/17 labeled for Un-sampled Resident B. The medication cart for Rooms #200 to #216 revealed Aspirin Enteric Coated (EC) Regular Strength 325mg (5) grains (gr) each with 47 tablets in the original container, with an expiration date of 12/16. There were nine (9) packs of Triple Antibiotic Ointment in the original box, with an expiration date of 11/16 in one of the floor stock cabinets in the Medication Room. Staff interview with the DON on 02/02/17 at 11:40 AM, confirmed the presence of the expired medications in the medication carts and floor stock. She revealed the nurses do not have a schedule to designate when they are to check the medication room, and medication carts for expiration dates. She said there is a pharmacist consultant that comes to the facility every month, however she does not check for expiration dates each time she comes. The DON said she would expect the nurses to check the floor stock and medication carts for expiration dates by the end of each month. Staff interview with Certified Licensed Practical Nurse (LPN) #1 on 02/02/17 at 2:45 PM, confirmed she had not checked her medication cart for the presence of any expired medications. She said she started working on the medication cart for Rooms #200 to #216 on this same date. Staff interview with Certified Licensed Practical Nurse (LPN) #2 on 02/02/17 at 2:50 PM, confirmed she did not check her medication cart for the presence of any expired medications. She said she started working on the medication cart for Rooms #217 to #234 on this same date. Staff interview with Pharmacist #1 on 02/02/17 at 11:30 AM, revealed she is responsible for checking expiration dates on 25% of the medications in the medication carts, and from the supply stock every three (3) months. The pharmacist said she last checked for expiration dates during her 12/16 visit to the facility.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a clean and sanitary environment for the food preparation area and cooking equipment for two (2) of two (2) dietary tours. This deficient practice has the potential to affect all residents. Findings include: Review of the facility's policy titled, Drains, with an issued date of 02/14, and a reviewed date of 02/17, revealed drains will be cleaned and maintained by maintenance monthly, and as needed. The dietary staff will complete a work order to submit to maintenance to report issues. Review of the facility's policy titled, Area and Equipment Cleaning and Maintenance, with a issued date of 5/10, and a reviewed date of 02/17, revealed daily (as needed) and weekly clean all areas and equipment in the department. Complete duties as assigned. Complete a maintenance work order for equipment which requires special cleaning. Review of the facility's, Master Cleaning Schedule, with a revision date of 01/16/17, revealed walls behind areas are to be cleaned weekly. Observation of the dietary department during the initial tour on 1/31/17 at 10:20 AM, revealed a build-up of dirt in a corner leading from the kitchen into the dishwashing area, which measured 13 inches in length by the eight x eight (8x8) inch floor tiles. There was a grate on the top of a drain leading from the walk-in refrigerator and freezer with a brownish dirt build-up. There was a thick amount of a reddish brown colored debris and dust on the pipes underneath the two compartment sink and food preparation areas. Two pipes were approximately 14 inches long, and one was approximately 72 inches long. The wall underneath the two compartment sink and food preparation areas had a build-up of black and brown colored residue and dust. The drain on the floor under the two compartment sinks revealed a black and gray colored build-up, trash, and a thick amount of dust on the grate. There was trash and debris behind and under the convection oven, the double stacked oven, the kettle steamer, the steamer, and the two deep fryers. An interview on 01/31/17 at 10:20 AM, revealed the Dietary Manager (DM) confirmed the facility failed to clean the corner of the floor, the wall and pipes under the two compartment sink/preparation area, under and behind the drain to the floor under the two compartment sinks, the trash and thick amount of dust on the drain grates, and that there was trash and debris behind and under the convection oven, the double stacked oven, the kettle steamer, the steamer, and the two deep fryers. Observation of the dietary department on 02/01/17 at 10:50 AM, revealed a thick, black colored build-up on three (3) nine (9x9) inch baking pans, ten (10) 18x26 inch baking pans, and one (1) 13x17 inch baking pan. There was standing water in the ice machine drain under the ice machine with a brownish red colored build-up on the grate and inner areas of the drain. Staff interview with the Dietary Manager (DM) on 02/01/17 at 11:53 AM, revealed the facility failed to clean the baking pans. The DM said she was aware of the thick, black colored build-up on the baking pans. The DM said the dietary department needed new baking pans. The DM stated they have a carbonizer, but it has not worked. She confirmed there was standing water in the ice machine drain under the ice machine, and the floor drains needed to be cleaned by maintenance. Staff interview with the Registered Dietician (RD) on 02/01/17 at 11:50 AM, revealed the facility failed to clean the baking pans, and the baking pans could be cleaned by placing them in the dishwasher. An interview on 2/2/17 at 9:35 AM, with the Administrator revealed housekeeping does the floors, they put down water and suck it up with the industrial cleaning machine. Housekeeping was also responsible for cleaning the baseboards and vents. The Administrator stated maintenance could pull out the equipment from the wall so the dietary staff could clean the floors and under the equipment. The Administrator stated the water pipes should be cleaned, and that there would not be any build up if they were washed daily.

Based on record review, policy review, and staff, resident, and family interviews, the facility failed to resolve group concerns about food to the resident's satisfaction as evidenced by eight of eight (8 of 8) alert and oriented residents attended the group meeting on 03/07/16 and voiced ongoing complaints about food including preferences, taste, appearance and choices; the complaint had not been resolved to the resident's satisfaction at the time of the survey. Findings include: A review of the facility's policy entitled, Complaint/Grievance Policy and Procedure, reviewed 12/13, documented as follows: Any employee presented with a patient complaint/grievance should attempt to resolve the issue immediately. If unable to resolve the issue the complaint becomes a grievance and should be documented in the occurrence data base and communicated through the chain of command. During the group meeting on 03/07/16 at 1:30 PM, eight of eight (8 of 8) alert and oriented residents complained about the food. The residents said the concerns had been worse in the past three months. Complaints included: half heated foods, no flavor, taste like the food was poured right out of a can, poor appearance, small portions, not enough for seconds, the food alternate list is mostly quick items, no alternate menu for meats or vegetables. The residents stated they had been asking for more choices for vegetables. Two residents stated they prefer dark meat chicken but are never given an alternate for breast (white meat) when chicken is served. The residents stated they had complained about noodles being served with no sauce and the noodles served at lunch (on 03/07/16) were plain, no sauce, no taste and cold. A review of the Resident Council Meeting Minutes on the following dates revealed: 06/29/15: Do not like the butter noodles, would lik (like) sauce. 07/27/15: Would like some chicken livers or dark meat. 09/04/15: Dark meat chicken, legs, thighs, would like something other than breast. 10/05/15: Please review likes/dislikes of every patient, they are getting things they do not like or eat. 02/29/16: Food complaints, not any better but not worse. A review of emails communicated to the Director Food and Nutrition Services revealed: 01/20/16: From the Director of Nurses: I want to bring a few complaints to your attention: Soup is being sent to the dining room but no bowls or crackers are sent. Requested drinks are not consistently being sent. When sandwiches (Hoagies) are served, condiments are rarely sent. Food has been sent cold, food is too salty. 02/01/16: From The Associate Administrator: The residents are saying the food is cold when they get it. 02/15/16: From The Associate Administrator: I came over to the LTC (Long Term Care) around 4:30 PM; I was given multiple complaints and I told them I would share them with you: sausage in the mornings is not browned on both sides, need to have less starch and more real vegetables with meals (said peas, butterbeans, fried okra), They like the meal but it was not hot enough. There were not any sandwiches served with the meals except for the two extra that I went and got. Two people did not like the entrée. Several said it was great, just cold. During a confidential interview on 03/06/16 at 5:20 PM, a family member said there had been complaints about food choices, more often since December 2015. The family member said previously there were alternate choices for meats and vegetables at mealtime, but now residents had no choice except to order from a food alternate list which was mainly soup and sandwiches. During an interview on 03/07/16 at 3:40 PM, Licensed Practical Nurse (LPN) #4 said residents complained about no seasoning, no taste, and no alternates on the serving line. LPN #4 stated the residents complained today (03/07/16) about the noodles, saying they were poured into a colander and no sauce. LPN #4 stated previously the residents had a choice of different meat and vegetables, but now there was not a choice. LPN #4 said there was a list of alternates, but not what the residents want. During an interview on 03/07/16 at 5:20 PM, the Medical Director of the facility said he had been receiving complaints about the food all the time. The Medical Director stated the meal today (03/07/16) was awful. He said the noodles tasted like cut up straws, tasteless with no seasoning. During an interview on 03/08/16 at 8:00 AM, Certified Nursing Assistant (CNA) #2 said residents had been complaining about food more often in the past three months. CNA #2 said residents complained about the menus, seasoning, and there was no alternate when serving meals, especially vegetables. During an interview on 03/08/16 at 12:50 PM, the Director of Food Nutritional Services stated she didn't plan for an alternate meat or an alternate vegetable. The Director said she first met with residents in October and November 2015, and the concerns were preferences. She said the complaints in January 2016, were the same complaints of preferences. The Director said she had been told to go to a food alternate list like hamburgers, sandwiches, chef salads, egg rolls. The Director affirmed an alternate menu for meat or vegetables was not served at mealtime. During an interview on 03/09/16 at 6:55 PM, the Director of Nursing (DON) stated residents had been complaining about food, including preferences, taste and appearance. The DON said serving foods that residents enjoy makes them feel loved and important. The DON acknowledged residents have the right for their grievances to be resolved. During an interview on 03/08/16 at 1:30 PM, Resident #8 said foods are tasteless. The resident said she would like more variety of vegetables including peas, butterbeans, okra and homemade soups. Resident #7 said, we have complained; they listen but don't hear. The facility readmitted Resident #8 on 07/11/15, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) identified the resident with a BIMS (Brief Interview for Mental Status) Score of 11, which indicated moderate cognitive impairment. The resident required setup help only for eating. During an interview with on 03/09/16 at 9:30 AM, Resident #5 said vegetables taste like they have been poured out of a can, never seasoned. The resident stated she has asked for dark meat chicken instead of breast, but there is never an alternate meat or vegetable during mealtime. The facility readmitted Resident #5 on 10/11/15, with [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date (ARD) of 12/14/15, identified the resident with a BIMS Score of 15, cognitively intact. The resident required setup help only for eating.

Based on observation, record review, and staff interview, the facility failed to complete a Significant Change (SC) Minimum Data Set (MDS) as required for Resident #1 and Resident #2. The resident's status had changed in two or more areas on the MDS, and the facility failed to complete a significant change within 14 days after identifying the changes for two (2) of nine (9) sampled residents reviewed for MDS Assessments. Findings include: Resident #1 A review of Resident #1's annual MDS assessment, with an Assessment Reference Date (ARD) of 07/27/15, identified the following sections, and resident status: Section C - Cognitive Status: BIMS (Brief Interview for Mental Status) Score of 15 (Independent Decision Making). Section D - Mood: Score 0 (zero) or no mood concerns. Section G - Functional Status: Independent with bed mobility and transfer. Section H - Bladder and Bowel; Always continent. Section K - Swallowing/Nutritional Status; Weight (in pounds) 185 (pounds). A review of Resident #1's quarterly MDS assessment, with an ARD of 01/11/16, identified the following sections and resident status: Section C - Cognitive Status: BIMS Score of 14 (Independent Decision Making). Section D - Mood: Score two (2). Section G - Functional Status: Supervision, oversight, encouragement or cueing with bed mobility and transfer. Section H - Bladder and Bowel: Occasionally incontinent of bowel. Section I - Active Diagnoses: [REDACTED]. Section K - Swallowing/Nutritional: Weight 165 (pounds). A review of a hospital discharge summary dated 12/21/15, documented, Biopsies of mass revealed [MEDICAL CONDITION]. A review of Departmental Notes revealed the following documentation: 01/10/16 and electronically signed by the MDS Coordinator, Cognitive interview: BIM score of 12. 02/17/16: Resident continues to be very weak with c/o (complaints) LLE (left lower extremity) weakness in addition to generalized unspecific ill feeling. Appetite remains poor. During an observation of incontinent care on 03/06/16 at 4:45 PM, Resident #1 was observed to be incontinent of bowel and bladder. An interview at this time with CNA (Certified Nursing Assistant) #1 revealed Resident #1 has been weaker and not able to transfer by himself since he was recently in the hospital. During an interview on 03/08/16 at 10:30 AM, the MDS Coordinator affirmed a Significant Change MDS should have been completed on 01/11/16, for Resident #1 instead of a Quarterly MDS. The MDS Coordinator said the resident had changes related to weight loss, ADLs (Activities of Daily Living), Cognitive Status, Mood, and a new [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS, with an ARD of 01/11/16, identified the resident with a BIMS Score of 14, although notes identified a score of 12. The resident required limited assistance with most ADLs except eating, which required setup help only. Resident #2 Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/15, revealed Resident #2 had reentered the facility from an acute care hospital on [DATE]. The MDS Section C - Cognitive Patterns, revealed Resident #2 was able to answer and recall some questions, answers and had a final score of four (4) on the Brief Interview for Mental Status (BIMS). A score of four (4) indicated severe cognitive impairment. The MDS Section G - Functional Status, revealed Resident #2 required extensive assistance of one person in bed mobility, transfers, walking in the bedroom, dressing and bathing. Section G also assessed that Resident #2 was independent with eating after set-up help, and required limited assistance with toileting, and hygiene. MDS Section H - Bladder and Bowel revealed Resident #2 was occasionally incontinent of bowel and bladder. MDS Section M - Skin Conditions, revealed Resident #2 did not have any pressure ulcers during the assessment dates, and had no pressure ulcers on the prior assessment. Review of the Quarterly MDS with an ARD of 2/25/16, revealed Resident #2 reentered the facility from an acute care hospital on [DATE]. The MDS Section C - Cognitive Patterns, revealed a BIMS score of ninety-nine (99) indicating Resident #2 had no recall and could not answer any questions during the assessment. Section G - Functional Status, revealed a decline in multiple areas: Resident #2 was assessed to be totally dependent on staff for bed mobility, dressing, toileting, hygiene, bathing, eating and was not walking in the bedroom. MDS Section H - Bladder and Bowel revealed Resident #2 was always incontinent of bowel, and now had a urinary catheter. MDS Section M - Skin Conditions, revealed Resident #2 had developed a Stage three (3) or four (4) pressure ulcer which measured length - 4.0 centimeters (cm), width - 5.0 cm and depth - 1.0 cm. This decline in multiple areas was not coded as a Significant Change in status by the MDS Coordinator Registered Nurse (RN) but was submitted as a Quarterly assessment. In an interview on 3/9/16 at 5:50 PM, the MDS Coordinator acknowledged the areas of decline for Resident #2 after sustaining a fractured leg. The MDS Coordinator said a Significant Change in status should be initiated when there are two (2) - three (3) areas of decline, and the Care Area Assessments (CAA's) and Care Area Triggers (CATs) alert staff that there has been a change in resident status. When asked why a Significant Change assessment was not completed on Resident #2, the MDS Coordinator said she just missed it. An observation on 3/7/16 at 11:44 AM revealed Resident #2 was totally fed by staff. An observation of wound care on 3/7/16 at 3:15 PM revealed a Stage 3 pressure ulcer to the sacrum, bowel incontinent episode, and an indwelling urinary catheter. An observation on 3/9/16 at 11:20 AM, revealed Resident #2 was manually lifted from the bed by four (4) staff members into a gerichair. Review of the facility's Face Sheet revealed the facility admitted Resident #2 on 7/31/13. Resident #2's [DIAGNOSES REDACTED].

Based on record review, policy review, and staff interview, the facility failed to provide evidence of destruction of control drugs for accountability or specifically the date and method of destruction for one (1) of two (2) groups of drugs destroyed in the facility. Findings include: A review of the information provided by the facility on 03/07/16, entitled, Disposal of Controlled Substances revealed: An institution may make on-premises destruction of controlled substances provided: C. The destruction is recorded showing: The name of the drug which was administered and the amount of the drug which was destroyed; The time and the date of the destruction; The name of the patient; The room number of the patient; The name of the person administering the drug; The signature of the person (pharmacist or nurse) making the destruction; The signature of a second person who witnessed the destruction. A review of the Pharmacy Consultant Agreement provided by the facility revealed: Assist Facility in the accounting, destruction and reconciliation of unused controlled substances as prescribed by law, rule or regulation. During an interview on 03/09/16 at 1:10 PM, the Director of Nursing (DON) was asked to provide evidence of destruction of controlled drugs in the facility for the previous three months. The DON provided copies of logs/forms which documented spaces for information including resident's names, resident's number, Rx (prescription) number, Drug, D/C (discontinued) Date, Quantity Destroyed, Method, Signature Nurse, Other Licensed Staff and Date. A review of the logs revealed 61 medications were listed on the forms. The form was observed to have incomplete information, including the date of destruction and method of destruction. A review of the Controlled Substances Proof of Use accountability sheets revealed no identification when the drugs were destroyed, or the method used for destruction. During the interview on 03/09/16 at 1:10 PM, the Director of Nursing (DON) stated the drugs were destroyed by the DON and another nurse as a witness. The DON affirmed the logs/forms did not identify the date of destruction, or method of destruction. The DON said the date and method should have been documented for accountability of controlled drugs. During a telephone interview on 03/09/16 at 4:55 PM, the Pharmacy Consultant acknowledged she checked monthly to make sure discontinued controlled drugs were not stockpiling, but does not oversee the actual drug destruction, or review logs of drug destruction. The Pharmacy Consultant affirmed that information should be complete, including date and method of destruction for accountability.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain accessible and accurate medical records regarding wound assessments, measurements, status, and treatments for Residents #4 and #9 for two (2) of nine (9) residents reviewed for accuracy of medical records. Findings include: Review of the facility's policy titled, Documentation: Patient Care, (revised 08/2012), revealed a rationale to provide guidelines for proper patient care services documentation. Entries to the medical records should be electronically entered into the electronic medical record or legibly written. The medical record should include documentation of patient assessment/reassessment, patient's [DIAGNOSES REDACTED]. Review of the facility's policy titled, Skin and Wound Care, (revised 11/2002), revealed a rationale to outline Nursing responsibilities in the identification of skin anomalies and the provision of basic wound care. The policy revealed nurses would perform Braden Pressure Ulcer Risk Assessments on every patient upon admission and every Wednesday. Resident #4 Review of the Nursing Progress Note dated 2/7/16 at 10:00 AM, revealed a wound assessment of Resident #4's sacrum by Registered Nurse (RN #1). The note described a pink area to the sacrum that measured 0.2 x 0.2 (measurement type not identified) and was cleansed with normal saline, [MEDICATION NAME] medicated gauze type dressing applied and covered with a foam type dressing. The next Nursing Progress Note addressing Resident #4's sacral wound was dated 2/20/16 at 1:50 PM, and signed by RN #1. The note described the wound as closed, and healing, continue to apply dressings and treat until healed. The facility could not provide documentation of the wound being assessed or measured between 2/7/16 - 2/20/16. An observation of wound care on Resident #4's sacral area by Licensed Nurse (LPN) #2 was conducted on 3/8/16 at 12:30 PM. LPN #2 measured the area's length as 1.8 cm X width 1.5 X 0.1 depth. RN #1 and the Director of Nurses (DON) were present for the wound assessment. An interview conducted with RN #1 and the DON on 3/8/16 at 12:40 PM revealed the DON said the wound to the sacral area was a Stage two (2) pressure ulcer. RN #1 said the wound had gotten worse since the last time she observed it on 2/20/16. RN #1 said on 2/20/16 the sacral area was pink and had no broken skin. RN #1 said nursing staff had not reported any skin changes since she observed the wound on 2/20/16. Review of the facility's Face Sheet revealed the facility admitted Resident #4 on 12/05/08. Resident #4's [DIAGNOSES REDACTED]. Review of Resident #4's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/1/16, revealed Resident #4 had long and short term memory problems, and severely impaired cognitive skills for decision making. The MDS assessed Resident #4 as being totally dependent on staff for bathing, hygiene, bed mobility, and toileting and was totally incontinent of bowel and bladder. Resident #9 Review of a Physician's Telephone Order, dated 1/10/16, revealed an order to apply triple antibiotic ointment to Resident #9's buttock abrasion until healed. The telephone order was signed by RN #1. Review of a Physician's Telephone Order, dated 1/11/16, revealed an order to cleanse Resident #9's buttock with normal saline (NS), apply ointment (no type documented) and use (name of dressing) until healed. The telephone order was signed by RN #1. Review of the Nursing Progress Notes revealed on 2/7/16 - An assessment of Resident #9's buttocks was done by RN #1. RN #1 described the area as slightly red with no open areas. RN #1's note read the area was cleaned with normal saline, (name of ointment) applied and the area was covered with a (name of dressing) foam type dressing. There was no measurement of the size or stage of the area in the nurse's note. Review of the Nursing Progress Notes revealed on 2/20/16 - RN #1's noted care was given to buttocks and the area was slightly red but no open areas or abrasion was observed. The note read antibiotic ointment was applied and covered with (name of dressing) foam type dressing per order. There was no measurement of the size or stage of the area in the nurse's note. Review of Resident #9's Wound Healing Progress Report dated 2/15-3/8/16, revealed, No matching records found. Review of Resident #9's Skin Inspection Report dated 2/15-3/8/16, revealed, No matching records found. An observation of wound care to Resident #9's sacral and buttocks area by Licensed Practical Nurse (LPN) #1 on 3/7/16 at 2:10 PM, revealed LPN #1 cleansed the sacral and inner buttock area with normal saline, applied triple antibiotic ointment to the sacrum, covered the area with a foam dressing and applied moisture barrier ointment to the area surrounding the sacrum. LPN #1 described the area as superficial broken skin and excoriation. LPN #1 said she had been providing wound care to the area for about a month. An observation of the wound measurement by LPN #2 on 3/8/16 at 12:50 PM, revealed the reddened (excoriated) area to be length - 9.0 centimeters (cm), width - 6.5 cm and zero (0) depth. The Director of Nursing (DON) and RN #1 were present during the observation and measuring of the wound. In an interview with RN #1 on 3/8/16 at 10:10 AM, revealed she stated skin areas to be measured were pressure ulcers, abrasions, open areas, and maceration. When asked if there were any LPN notes or skin audits on Resident #9, RN #1 said there was no LPN documentation in the electronic medical record system which included Wound Healing Progress Report and the Skin Inspection Report. RN #1 said the most recent assessment and documentation was 2/20/16, when she observed redness to the buttocks but no broken skin. When asked how she determined if the skin areas were getting better or worse, RN #1 said you would see a change in size, color, odor, or change in appearance. RN #1 said the area had not been measured before 3/8/16, and the nursing staff should notify her of any changes to the wound status. Review of the facility's Face Sheet revealed, the facility readmitted Resident #9 on 11/25/13. Resident #9's [DIAGNOSES REDACTED]. The most recent quarterly MDS with an ARD of 1/4/16, revealed a Brief Interview for Mental Status (BIMS) score of three (3) which indicated severe cognitive impairment. The MDS assessed Resident #9 as requiring extensive assistance with bed mobility, toileting, hygiene and dressing and always incontinent of bowel and bladder.

Based on observation, record review, interview and policy review the facility failed to complete a Significant Change MDS (Minimum Data Set) after the facility identified a change in Resident #5's assessment. This affected Resident #5, one (1) of nine (9) sampled residents reviewed for change of status in completing an assessment for the MDS. Findings include: A review of information provided by the facility entitled "Assessments for the RAI (Resident Assessment Instrument,)" page 2-20 documented as follows: "The Significant Change in Status Assessment is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either improvement or decline. It can be performed at any time after the completion of an Admission Assessment." The facility admitted Resident #5 to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date (ARD) of 03/13/14, identified Resident with a BIMS (Brief Interview for Mental Status) Score of 12. The resident had a Mood Score of 1 (one). The Functional Status of the MDS identified that Resident #5 was totally dependent on staff for Activities of Daily Living (ADLs) except eating which required set up help only. The resident's weight was identified as 127 pounds. The resident was identified with a pressure wound. A review of the "Nutrition Assessment," dated 05/04/14, documented as follows: "Current weight 142.4 lbs (pounds). Excess fluid retention and increase in PO (by mouth) intake are likely both causes for weight gain. She is noted to be less active, contributing to the [MEDICAL CONDITION] in her legs." A Quarterly MDS, with an ARD of 06/02/14, identified that the resident's BIMS Score had changed to 9 (nine). The MDS identified that the resident's mood score had changed from 1 (one) to 8 (eight). The Functional Status of the MDS identified that the resident required total dependence on staff for all ADLs including eating and the resident's weight had changed to 138 pounds. During an interview on 06/13/14 at 11:30 AM with RN (Registered Nurse) #1, responsible for MDS Assessments, she said a Significant Change MDS should be completed when there are 2 or more changes in a resident's condition. The RN said the resident had declined in mobility, requiring 2 persons for transfer and required more assistance with eating. The RN also acknowledged the changes in Cognitive Status and Mood Score. During an interview on 06/13/14 at 1:40 PM, RN #1 said she used the RAI (Resident Assessment Instrument) Manual as a guide for completing the MDS. She acknowledged that a Significant Change should have been completed on Resident #5 instead of a Quarterly Assessment on 06/02/14. She said the MDS tells the staff how to develop a plan of care for the resident and a Significant Change would have had a Care Area Trigger Worksheet.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide quarterly assessments, updates and implement and follow care plans for seven (7) of nine (9) residents reviewed (Residents #1, #2, #3, #4, #5, #8, and 10). Findings include: Resident #1 Record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 13, which indicated Resident #1 was cognitively intact. Record review and observation on 08/15/13 at 4:00 p.m. revealed that Resident #1's care plan had a goal and target date through 08/11/13 and reflected that care plan was not current with dates it reflected. Interview with Director of Nursing (DON) on 08/16/13 at 10:30 a.m. confirmed that care plan has not been updated to reflect current dates. Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated 4//13, revealed a Brief Interview for Mental Status score of 5, which indicated Resident #2's cognitive status was severely impaired. Record review and observation of Resident #2's care plan on 08/15/13 revealed Resident #2 has a goal and target date through 05/20/13 and reflected that care plan was not current with dates it reflected. Interview with Director of Nursing (DON) on 08/16/13 at 10:30 a.m. confirmed that the care plan had not been updated to reflect current dates. Resident #3 Record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/13 and a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #3 was cognitively intact. Review of Resident #3's Care Plan revealed a Goal and Target date for each problem of 7/08/13, and that the Plan of Care had not been reviewed since 4/16/13 when it was signed by Social Services staff #1. Resident #4 Record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/13 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #4 was cognitively intact. Review of Resident #4's care plan revealed a Goal and Target date for each problem of 7/08/13, and the care plan had not been reviewed since 4/16/13 when signed by staff. Resident #5 Record review revealed Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/07/13, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated Resident #5's cognitive status was severely impaired. Review of Resident #5's care plan revealed a Goal and Target date for each problem of 6/10/13, and the care plan had not been reviewed since 3/19/13 when signed Social Services staff #1 with the statement, "telephone with (Resident Responsible Party) addressed concerns with (Director of Nursing)." Resident #8 Record review revealed Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #8 was cognitively intact. Record review and observation on 08/16/13 at 3:30 p.m. revealed a care plan with no goal and target dates. Interview with Director of Nursing (DON) on 08/16/13 at 10:30 a.m. confirmed that care plan did not have goal and target dates present. Resident #10 Record review revealed Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/13, revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated that Resident #10 was not able to participate in assessment. Review of Resident #10's care plan revealed a Goal and Target date for each problem of 7/22/13, and the care Plan had not been reviewed or signed by any staff member. Interview with Director of Nursing (DON) on 08/16/13 at 10:30 a.m. confirmed that care plan did not have goal and target dates present. Review of the facility's policy entitled "Resident Care Plans", dated 07/24/01 noted, "It shall include measurable objectives and timetables to meet all residents needs identified in the comprehensive assessment. Each resident's plan of care shall be reviewed and revised by an interdisciplinary team after each comprehensive assessment is conducted, including the Resident Assessment Protocols and Utilization Guidelines, will be the criteria used to conduct resident assessments and plans of care."

Based on observation, staff interview, record review and facility policy review, the facility failed to maintain resident's dignity by not providing weekly nail care and hygiene care for three (3) of nine (9) residents reviewed (Residents #1, #8 and #9). Findings include: Resident #1 Record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status on 05/20/13 revealed a score of 13, which indicated Resident #1 was cognitively intact. An observation on 08/15/13 at 2:00 p.m. revealed Resident #1 had long discolored fingernails with brown and yellow colored debris under nail beds. In an interview on 8/15/13 at 2:00 p.m. revealed Resident #1 stated, "My daughter cleans my nails sometimes," but, confirmed the staff does not provide nail care on a weekly basis. Resident #1 stated, "No" when asked if staff trims, cleans, and files nails. An observation and interview on 08/16/13 at 3:55 p.m. with the Director of Nursing (DON) confirmed lack of nail care through observation at Resident #1's bedside. The DON confirmed that nurses are to do diabetic nail care weekly. Record review revealed the care plan with a problem onset dated 05/21/13, noted, "Unable to independently perform basic self care due to [MEDICAL CONDITION]: Will have optimal hygiene and appearance: Diabetic nail care to be provided weekly and prn (as needed)." Resident #8 Record review revealed Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated Resident #8 was cognitively intact. An observation on 08/16/13 at 3:00 p.m. revealed Resident #8 had long thick yellow discolored toenails with debris observed under nail bed of toenails. In an interview on 8/16/13 at 3:00 p.m. Resident #8 stated, "Yeah I've told them I needed them clipped but nobody ever does it. I clip my fingernails and take care of them but I can't reach my toenails, and they need it bad." Resident #8 also talked about how she would like to go to the shower instead of a bed bath every day. Resident is paying to get hair washed weekly in beauty shop and had rather just let staff wash it in the shower but she only receives a bed bath. In an interview on 8/16/13 at 4:00 p.m. the Director of Nursing (DON) confirmed the lack of nail care through observation at Resident #8's bedside. The DON confirmed that nurses are to perform nail care weekly. DON also confirms that Resident #8 is receiving a bed bath everyday instead of shower or whirlpool bath as care plan states. Review of Resident #8's care plan, dated 6/17/13, noted, "Unable to perform basic self care independently due to generalized weakness with [MEDICAL CONDITION]: Maintain optimum appearance and hygiene. Resident will be clean and odor free: Shower and whirlpool twice weekly with bedside bath on other days." Resident #9 Record review revealed Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/13, revealed a Brief Interview for Mental Status score of 08, which indicated Resident #9's cognitive status was moderately impaired. Observation of Resident #9 on 8/16/13 at 5:25 p.m. revealed Resident #9 was seated in a wheelchair while in room. Resident #9's toenails were observed to be long, uncut with sharp points. In an interview on 8/16/13 at 5:25 p.m. revealed Resident #9 stated, "They need to be cut. It's been over three months," in response to the question regarding his uncut toenails. Resident #9 stated, "This little one is so sharp it could cut you." Review of Resident #9's care plan with a problem onset of 4/30/13, noted, "Needs Asst (assistance) of 1 person with ADL's (activities of daily living). " Interventions included, "Nail care weekly, May go for manicure weekly if desired." Review of the facility's policy entitled, "Resident Rights: Dignity and Respect", dated 07/12, noted, "To provide the kind of care to our residents that should maintain and enhance their dignity, individuality, and quality of life." Review of the facility's policy entitled, "Nail, Care Of", dated 08/13, noted, "It is the policy of (name of facility) that nails should be properly cared for. Fingernails: Cleaning can be performed by any member of the nursing staff. Clipping can only be performed by the RN (Registered Nurse)." Review of the facility's policy entitled, "Resident Rights: Dignity and Respect", dated 07/12, noted, "To provide the kind of care to our residents that should maintain and enhance their dignity, individuality, and quality of life."