Every finding on record at Wilson Rehabilitation and Nursing Center

Based on record reviews, and staff, Medical Director, Psychiatric Nurse Practitioner, Pharmacy Consultant, and Guardian interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications or treatment alternatives for 4 of 4 residents reviewed for unnecessary medications (Resident #1, Resident #2, Resident #62, and Resident #46). The findings included: a. Resident #1 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, dementia with behavioral disturbance, anxiety and depression. A physician's order dated 4/30/25 written by the Medical Director revealed an active order for quetiapine fumarate (antipsychotic medication) 12.5 milligrams (mg) to be administered at bedtime related to depression and Parkinson's disease. Review of Resident #1's electronic medical record (EMR) revealed no documented evidence that the resident or the RR were informed in advance of the risks, benefits, and treatment alternatives associated with the use of quetiapine fumarate. Further review of the EMR identified a psychotropic medication consent form dated 9/11/24 signed upon admission by Resident #1's RR that only provided general permission to treat with psychotropic medications and did not include documentation of the specific risks, benefits, or alternative forms of treatment related to quetiapine fumarate therapy. Resident #1's care plan dated 11/25/25 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits, and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions. Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. Resident #1 was coded for an antipsychotic medication. Review of Resident #1's May 2026 Medication Administration Record (MAR) documented the quetiapine fumarate 3 mg was initialed as administered per the physician order. An interview was conducted with Resident #1's RR on 5/20/26 at 12:45 PM who stated she was not notified by the facility of the risks, benefits and treatment alternatives associated with the use of quetiapine fumarate. She reported it was prescribed by Resident #1's neurologist. b. Resident #2 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies, dementia with psychotic disturbance, depression and Parkinson's disease. A physician's order dated 2/10/26 revealed an active order for pimavanserin tartrate (antipsychotic medication) 34 milligrams (mg) to be administered daily related to dementia associated with Parkinson's disease. Review of Resident #2's electronic medical record (EMR) revealed no documented evidence that the resident or the RR were informed in advance of the risks, benefits, and treatment alternatives associated with the use of pimavanserin tartrate. Further review of the EMR identified a psychotropic medication consent form dated 9/11/24 signed upon admission by Resident #2's RR that only provided general permission to treat with psychotropic medications and did not include documentation of the specific risks, benefits, or alternative forms of treatment related to pimavanserin tartrate therapy. Resident #2's care plan dated 2/11/26 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions. Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Resident #2 was coded for antipsychotic medication. Review of Resident #2's May 2026 Medication Administration record (MAR) documented the pimavanserin tartrate 34 mg was administered per the physician order. Attempts to interview Resident #2 were not successful. Attempts to contact Resident #2's resident representative were not successful. c. Resident #62 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety and depression. A physician's order dated 8/26/25 revealed an active order for aripiprazole (an antipsychotic medication) 5 milligrams (mg) to be administered daily related to unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #62's electronic medical record (EMR) revealed no documented evidence that the resident representative was informed in advance of the risks, benefits, and treatment alternatives associated with the use of aripiprazole. Further review of the EMR identified the psychotropic medication consent form dated 7/28/25 signed upon admission by Resident #62's RR that only provided general permission to treat with psychotropic medications and did not include documentation of the specific risks, benefits, or alternative forms of treatment related to aripiprazole therapy. Resident #62's care plan dated 9/2/25 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions. Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #6 was coded for antipsychotic medication. Review of Resident #6's May 2026 Medication Administration record (MAR) documented the aripiprazole 5 mg was administered per the physician order. Attempts to contact Resident #6's resident representative were not successful. d. Resident #46 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, schizoaffective disorder, and bipolar disorder with severe psychotic features. A physician's order dated 1/17/25 revealed an active order for risperidone (antipsychotic medication) 3 milligrams (mg) to be administered twice a day related to bipolar disorder with psychotic features. Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. Resident #46 was coded for an antipsychotic medication. Resident #46's care plan dated 3/24/26 identified the use of psychotropic medications and included interventions for education regarding the risks, benefits, and side effects of psychotropic medications, as well as monitoring and documenting for behaviors and adverse reactions. Review of Resident #46's May 2026 Medication Administration Record (MAR) documented the risperidone 3 mg was initialed as administered per the physician order. Review of Resident #46's electronic medical record (EMR) revealed no documented evidence that the resident's Guardian was informed in advance of the risks, benefits, and treatment alternatives associated with the use of risperidone. Further review identified the psychotropic medication consent form dated 10/28/22 signed upon admission on ly provided general permission to treat with psychotropic medications and did not include documentation of the specific risks, benefits, or alternative forms of treatment related to risperidone therapy. During an interview on 5/19/26 at 2:05 pm, the Director of Nursing (DON) stated the only consent form for psychotropic medications was included in the admission packet and signed upon admission to the facility. The DON further stated she was under the impression the Psychiatric Providers were responsible for explaining the risks and benefits of psychotropic medications to the residents and/or the Guardian. The Administrator was interviewed on 5/19/26 at 2:05 pm and stated the psychotropic medication consent form was included in the admission packet and signed upon admission to the facility. The Administrator further stated she was also under the impression the Psychiatric Providers were responsible for explaining the risks and benefits of psychotropic medications to the residents and/or the Guardian. During a telephone interview conducted on 5/20/26 at 3:37 p.m., Resident #46's Guardian stated she was aware Resident #46 was receiving an antipsychotic medication. However, the Guardian reported she had not signed an informed consent form for the antipsychotic medication prior to 5/20/26. The Guardian stated the facility contacted her on 5/20/26 and requested that she sign an informed consent form for Resident #46's antipsychotic medication at that time. During a phone interview on 5/20/26 at 2:00 p.m., the Psychiatric Nurse Practitioner stated that during facility visits, she reviewed the risks and benefits of psychotropic medications in addition to nonpharmacological treatments with residents and documented in her progress notes. The Psychiatric Nurse Practitioner further stated it was the responsibility of the nursing staff to obtain signed consent forms from the resident and/or resident representative. During an interview on 5/20/26 at 2:14 pm, the Medical Director stated that when residents were admitted already receiving psychotropic medications, an informed consent form was not completed and the risks, benefits, and treatment alternatives were not explained. The Medical Director stated these discussions occurred only when psychotropic medications were initiated at the facility. The Medical Director further stated he was unaware of who was responsible for obtaining signed informed consent for psychotropic medications.

Based on record review and staff interviews, the facility failed to accurately code the physician's documented clinical contraindication of a gradual dose reduction (GDR) of psychotropic medications for 2 of 25 residents reviewed for MDS assessment accuracy (Resident #1 and Resident #62).The findings included:a. Resident #1 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, dementia with behavioral disturbance, anxiety and depression.A physician's order dated 4/30/25 revealed an active order for quetiapine fumarate (antipsychotic medication) 12.5 milligrams (mg) to be administered at bedtime related to depression and Parkinson's disease. A review of the psychiatric provider note dated 6/9/25 revealed an attempted dosage reduction to the psychotropic regimen was likely to impair the resident's function and exacerbate underlying psychiatric conditions. The quarterly MDS dated [DATE] for Resident #2 indicated a GDR had not been documented by the physician as clinically contraindicated.b. Resident #62 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety and depression.A physician's order dated 8/26/25 revealed an active order for aripiprazole (an antipsychotic medication) 5 milligrams (mg) to be administered daily related to unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the psychiatric provider note dated 12/4/25 revealed an attempted dosage reduction to the psychotropic regimen was likely to impair the resident's function and exacerbate underlying psychiatric conditionsThe quarterly MDS dated [DATE] for Resident #62 indicated a GDR had not been documented by the physician as clinically contraindicated.An interview was conducted with MDS Nurse #1 and MDS Nurse #2 on 5/19/26 at 3:26 AM who stated the physician documented GDR as clinically contraindicated was marked no which was an error and should have been marked yes. They indicated MDS Nurse #2 coded the assessments and she misunderstood the question. An interview with Administrator was held on 5/20/26 at 3:30 PM. She stated her expectation was for MDS assessments to be accurate.

Based on observations and staff interviews, the facility failed to place cautionary no smoking signage on the primary entrance to the facility indicating it was a non-smoking facility for 1 of 1 primary entrance to the facility.Findings included:The facility's policy No Smoking Policy dated 12/31/22 and last revised 1/1/26 stated, Smoking or vaping by employees, contractors, visitors, or residents is strictly prohibited within the facility, in any company owned vehicle and on the grounds of the facility. The policy further stated that No Smoking signs are clearly posted to notify visitors and others of the policy.Observations on 5/18/26 at 2:15 PM, 5/19/26 at 8:00 AM, and 5/19/26 at 4:00 PM revealed there was not a No Smoking sign on the primary entrance of the facility.An observation on 5/19/26 at 4:43 PM revealed a No Smoking sign on the oxygen storage room.An interview was conducted with the facility Administrator on 5/19/26 at 4:46 PM and she stated she was unaware that a No Smoking sign was required at the main entrance of the facility. She confirmed it was a non-smoking facility, and she was aware of the facility policy.

Based on record review, observations and staff interviews, the facility failed to discard an expired Novolog insulin flex pen from 1 of 4 medication carts observed. (300-hall medication cart) Findings included: A review of the Resident #33's Medication Administration Records (MAR) for [DATE] and [DATE] revealed she received Novolog Insulin flex pen for sliding scale coverage of blood sugars readings. She received one dose of Novolog Insulin on [DATE] and received twenty-two doses of Novolog Insulin in January: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. An observation of the 300-hall medication cart was conducted on [DATE] at 11:23 a.m. in the presence of Medication Aide #1 who was assigned to the 300-hall medication cart. Resident #33's Novolog Insulin flex pen (100 units per milliliter) label was observed with [DATE] written as the date opened and the expiration date written as [DATE]. The label indicated the medication was to be discarded twenty days after opening. In an interview with Medication Aide #1 on [DATE] at 11:23 a.m., she stated the Infection Preventionist was responsible for checking the 300-hall medication cart, and nurses administered insulin to her residents. She said Resident #33 received Novolog Insulin as needed for elevated blood sugars and read the expiration date as [DATE] on the Novolog Insulin flex pen. On [DATE] at 11:27 a.m. the Director of Nursing (DON) observed Resident #33's Novolog Insulin flex pen from the 300-hall medication cart. She stated she could not tell if the open date was written as [DATE] or [DATE], and the expiration date written looked like [DATE]. Medication Aide #1 re-examined the Novolog flex pen and stated the open date written on the label looked like [DATE], and the expiration date written looked like [DATE]. She said she did not think Resident #33 had received Novolog Insulin on [DATE]. The DON disposed of Resident #33's Novolog Insulin Flex pen in a sharp container. In an interview with the DON on [DATE] at 11:32 a.m., she said the pharmacy checked the medication carts monthly, the Infection Preventionist (IP) checked the medication carts weekly, and the nursing staff checked the medication carts each shift and before administering medications to residents for expirations. She further stated the IP was to check the medication carts and medication rooms daily during the survey that week. An interview with the Infection Preventionist (IP) on [DATE] at 2:51 p.m., she stated she was responsible for checking the medications carts and medication rooms monthly, and she had checked the 300-hall medication cart on [DATE] and did not recall Resident #33's Novolog Insulin flex pen on the 300-hall medication cart. She disclosed medication carts and medication rooms should be checked weekly, and she had not been checking the medication carts and medication rooms weekly. She said she checked the medication rooms on Monday ([DATE]) and had not checked the medication carts that week as directed by the DON. On [DATE] at 3:00 p.m. in an interview with Nurse #1, she stated she administered Resident #33 her Novolog Insulin per sliding scale on [DATE] and could not recall using the Novolog Insulin flex pen dated with an expiration date of [DATE] and checking the expiration date on the label of the Novolog Insulin. She stated when a new insulin vials or flex pens were opened, the date opened and the expiration date which was ,d+[DATE] days after opening depending on the type of insulin was written on the label. She further stated the expirations date on insulin should be checked before administering insulin to Resident #33. A written statement dated [DATE] from Nurse #1 to the Director of Nursing revealed Nurse #1 wrote she could not specifically remember checking Resident #33's Novolog Insulin expiration date on [DATE] and she always checked the expiration dates. When she was done with the Novolog Insulin pen, she returned the Novolog Insulin pen to Medication Aide #1 who disposed of the Novolog Insulin Flex pen in the sharp container because it was empty. Therefore, the Novolog Insulin flex pen found on the 300-hall medication cart on [DATE] expired could not have been the Novolog Insulin flex pen used on [DATE]. A written statement not dated from Medication Aide #1 to the Director of Nursing revealed Nurse #1 returned Resident #33's Novolog Insulin flex pen to Medication Aide #1 on [DATE]. There was no more insulin in Resident #33's Novolog Insulin flex pen, and Medication Aide #1 discarded the Novolog Insulin flex pen into a sharp container on [DATE]. Medication Aide #1 wrote the Novolog Insulin flex pen found on 300-medication cart on [DATE] was not the one used for Resident #33 on the evening of [DATE]. On [DATE] at 10:03 a.m. in a phone interview with Pharmacist #1, she stated she randomly checked the contents of one medication cart and one medication room for expirations monthly. The last pharmacy medication cart check was performed on [DATE], and she checked the 100-hall medication cart. On [DATE] at 9:53 a.m. in a phone interview with Pharmacist #2, she disclosed pharmacy records showed Resident #33 was dispensed a Novolog Insulin Flex Pen 100 units per milliliter on [DATE] and [DATE] to the facility. She stated the Novolog Insulin flex pen expired after 28 days of removing from the refrigerator and opened.

Based on resident interview, staff interviews and record review the facility failed to report an allegation of abuse to the State Agency within two hours of becoming aware of the allegation for 1 of 2 allegations of abuse reviewed (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had intact cognition. She had verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) daily. She required extensive to dependent care with activities of daily living. She received antipsychotic medication daily during the assessment look back period. Record review revealed the facility became aware of an allegation of abuse on 10/25/22 at 8:23 PM. Resident #1 alleged Nurse Aide #1 had squeezed her hand. An Initial Allegation Report for resident abuse was faxed to the State Agency at [PHONE NUMBER] on 10/26/22 at 4:54 PM. Local law enforcement was notified of a reasonable suspicion of a crime on 10/26/22 at 3:55 PM, Report #22- 9. Nurse Aide #1 was suspended from employment on 10/26/22 pending the outcome of the investigation. During an interview with Resident #1 on 10/26/22 at 2:30 PM she stated a Nurse Aide the previous evening had squeezed her hand while providing care. She reported the Nursing Supervisor had made a report the evening before but no one from the facility had been in to talk to her about the incident. She stated she had been preparing to call the State to report she had been abused. During an interview with the Second Shift Nursing Supervisor on 10/26/22 at 2:49 PM she stated she was in the resident's room when Nurse Aide #1 touched the resident's hand. Nurse Aide #2 was also present. She reported Nurse Aide #1 reached to remove the resident's oxygen nasal cannula to enable them to change the resident's shirt when Resident #1 grabbed Nurse Aide #1's left hand. Nurse Aide #1 put her right hand on the resident's hand to free herself. Resident #1 began swinging her fists at Nurse Aide #1. She reported she instructed Nurse Aide #1 to step out of the room. She recalled Nurse Aide #1 never said a word during the interaction with the resident. She stated the resident started screaming, that girl squeezed my hand. Herself and Nurse Aide #2 finished getting the resident ready for bed. She assessed the resident's hand and found no marks or redness on her hand. The Second Shift Nursing Supervisor commented she instructed both Nurse Aides to write a statement along with herself. She called the Director of Nursing and the Administrator. The Second Shift Nursing Supervisor stated the Administrator instructed her to get written statements. She placed the statements under the Director of Nursing's office door. In an interview with the facility Administrator on 10/26/22 at 3:02 PM she stated she had instructed the Second Shift Nursing Supervisor to have staff write statements and to update progress notes. She reported Resident #1 was known for making false statements and threatening to have staff fired or to call the State. She thought the issue was resolved as a concern and had not filed an initial report of alleged abuse to the State within two hours of the allegation.

Based on record review, staff interview, and physician interview the facility failed to acknowledge, clarify or implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #3 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the most recent annual Minimum Data Set assessment dated [DATE] coded Resident #3 as having moderately impaired cognition, always incontinent of bladder, and frequently incontinent of bowel. The documentation on the same assessment revealed Resident #3 received anticoagulants (blood thinner) for 7 days of the assessment period. Documentation on the care plan dated as last reviewed on 5/17/2022 had a focus area for Resident #3's use of the anticoagulant [MEDICATION(S)] due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the interventions was to monitor/document/report as needed any adverse reactions from the anticoagulant therapy such as blood tinged or red blood in urine, black tarry stools, or bright red blood in stools. Additional documentation on the same care plan for Resident #3 had a focus area for the potential for pain relative to gastroenteritis, [CONDITION(S)], and hemorrhoids. One of the interventions was to observe for bleeding with hemorrhoids and notify the physician. Resident #3 had a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A part of the same physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Documentation in the nursing notes for 4/30/2022 at 7:12 AM revealed the physician for Resident #3 (MD #1) was contacted and informed Resident #3 was having rectal bleeding. The nursing note documentation revealed MD #1 informed the nurse that if the bleeding persisted to contact him. Documentation in the nursing notes for 5/10/2022 at 2:30 PM revealed MD #1 visited Resident #3 due to rectal bleeding and gave physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record and the paper medical record revealed a hand-written progress note from a gastrointestinal consult for Resident #3 dated 5/19/2022. The hand-written progress note was reviewed with the day nursing unit supervisor to confirm what the gastrointestinal consult note stated. An interview was conducted with the day nursing unit supervisor on 6/2/2022 at 12:25 PM. The 5/19/2022 gastrointestinal consult progress note for Resident #3 was reviewed and read with the unit supervisor. The unit supervisor acknowledged the gastrointestinal consult progress note was difficult to read but agreed the note had orders for a complete blood count (CBC) weekly, an unknown medication to be administered as 25 milligrams twice a day, requested for a reconsideration of the use of the medication [MEDICATION(S)] if persistent bleeding continued, the bleeding source was likely hemorrhoids, and to follow up in a month. The unit supervisor stated she was new to the position of day unit supervisor and she was not familiar with Resident #3, but she would obtain more information. An additional interview was conducted with the day nursing unit supervisor on 6/2/2022 at 1:02 PM. The unit supervisor stated that as far as she could tell the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The unit supervisor acknowledged there was no indication clarification of the orders was sought from the gastrointestinal consulting physician or the facility physician (MD #1) for Resident #3 and the orders were not transcribed or followed. The unit supervisor stated a medication aide was working on the hallway for which Resident #3 resided and therefore another nurse from another hall would have had to address the orders when Resident #3 came back from the consult. An interview was conducted with the Director of Nursing (DON) on 6/2/2022 at 1:19 PM. The DON stated it was her impression that the gastrointestinal consult progress note dated 5/19/2022 for Resident #3 was scanned into the electronic medical record and the then filed in the paper chart without having the orders clarified or implemented. The DON stated she would have to make sure the medical records were addressed by the nursing staff and the physician before they were scanned into the medical record and filed in the chart. An interview was conducted with the Medical Director/Physician (MD #1) for Resident #3 on 6/2/2022 at 1:41 PM. MD #1 stated he came to the facility every Tuesday and reviewed laboratory reports or anything that had been flagged for him to review in the paper charts of the residents in the facility. MD #1 stated it was his policy to initial the reports or consults he has reviewed or to write new orders showing he had addressed the concern. MD #1 further stated he expected the nursing staff to call him for clarification if new orders came from a consulting physician. MD #1 stated he could not say for sure if he had received a phone call from the nursing staff or had seen the gastrointestinal consult progress note for Resident #3 but that he usually did initial on the note if he had seen it. During the interview MD #1 found and reviewed the gastrointestinal consult for Resident #3 in the electronic medical record. MD #1 revealed he would have had to consider the risks versus the benefits of discontinuing the medication [MEDICATION(S)] for Resident #3. He further revealed Resident #3 was probably already on a hemorrhoid cream after he identified the medication Hydrocortisone as the ordered medication on the consult form that was previously unidentifiable by the day nursing unit supervisor. MD #1 indicated he tried to avoid unnecessary orders. MD #1 also stated he did not think a weekly CBC for Resident #3 was necessarily needed. The medical records staff member was interviewed on 6/2/2022 at 3:21 PM. The medical record staff member revealed she obtained the gastrointestinal consult progress note for Resident #3 out of a box the nursing staff put documentation to be scanned and filed after physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record staff person acknowledged the initials of MD #1 were not on the consult progress note. The medical records staff member revealed that often the nursing staff put items to be scanned in her box that have not yet been addressed and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical records staff member stated she often took it upon herself to check behind the nurses and let them know they needed to put orders into the electronic records prior to her scanning the documentation.

Based on staff interviews, the facility failed to designate a qualified Infection Control Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Control and Prevention program. This failure occurred during the COVID-19 pandemic. Findings Included: An interview with the Director of Nursing (DON) on 06/02/2022 at 10:58 am revealed she was the acting IP for the facility since taking the DON position on April 7, 2022. The DON stated she had not been trained in a specialized infection control program or training as required to be the Infection Control Preventionist. An interview with the Administrator on 06/02/2022 at 11:34 am revealed he was aware that the IP position was vacant, and the Director of Nursing had not received specialized training as required for the IP and stated there was no one at the facility that had the specialized training for the infection control program. He continued by stating the facility was recruiting for the position of IP since it became vacant in February 2022. An interview with the Medical Director on 06/02/2022 at 1:57 pm revealed he knew about the Infection Preventionist vacancy at the facility. He stated it was his understanding that the DON and the Administrator would split the duties of the IP until the position was filled. He continued by stating he was not aware the acting DON was not trained to fill in as the infection preventionist.

Based on observations, family interview, resident interview and staff interviews, the facility imposed a restricted visitation schedule that limited indoor visitations of family and friends for 1 of 1 resident sampled for visitation. (Resident # 19). This facility practice had the potential to affect all residents. Findings included: Resident #19 was admitted to the facility on [DATE], and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/28/2021 at 12:51 p.m. in an interview with family member #1 for Resident #19, he stated visitations were limited to Monday through Friday from 10:00a.m. to 6:00p.m., and there were no visitations on the weekend. He stated he lived out of town, and the reason he was able to visit Resident #19 that day was because he happen to be off work. On 6/30/2021 during an interview with Nurse #3, she stated visitation consisted of two visitors at a time from 10:00 a.m. to 6:00 p.m. Monday through Friday. She stated there was no visitation on the weekends due to less staff in the facility to monitor the visitations. On 7/1/2021 at 10:49 a.m. in an interview with the Director of Nursing, she stated there was no time limits on the resident visitations, and residents and family members were aware visitations occurred on Monday through Friday from 10:00 a.m to 6:00 p.m. She further stated the restricted visitation hours were due to accountability for screening and safety reasons like when children were left unattended outside the facility. She stated the facility did not have a screener at the door at all times, and visitors were unable to conduct the COVID-19 screening themselves. She further stated the facility door was locked at 6:00 p.m. and visitations were not allowed except for compassionate care visits or scheduled off hour visits. On 7/1/2021 at 1:29 p.m. during an interview with alert and oriented Resident #1, she stated her family members were visiting a little, but a lot of people did not visit because they were working during the set visitation hours 10:00a.m. to 6:00p.m. on Monday to Friday. On 7/1/2021 at 1:39 p.m. during an interview, the administrator stated visitations were restricted to 10:00 a.m. to 6:00 p.m. Monday through Friday. He further stated the facility misinterpreted the use of time frames in the Centers of Medicare and Medicaid Services guidance for visitations.

Based on record review and staff interviews, the facility failed to notify the state mental health authority of a significant change in status for a resident diagnosed with [CONDITION(S)] and [CONDITION(S)] for 1 of 1 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Resident #57) Findings Included: Resident #57 was admitted on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day/admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact and rejected care. The MDS revealed Resident #57 was diagnosed with an anxiety disorder, depression, [CONDITION(S)], and [CONDITION(S)] and received antipsychotic and antidepressant medications. No information was recorded indicating Resident #57 was considered for a State Level II PASARR. The MDS further revealed an unplanned discharge on 5/19/2021. A review of the psychiatric physician notes dated 5/19/2021 revealed Resident #57 reported she was a failure and would be better off dead and documented Resident #57 was experiencing auditory and visual hallucinations, feelings of hopelessness and worthlessness, depression, [CONDITION(S)], energy deficit, no appetite and passive [CONDITION(S)]. The psychiatric notes listed depression, severe anxiety, post traumatic stress disorder ([CONDITION(S)]) and borderline [CONDITION(S)] as diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57 refused to sign a verbal contract and reported to the psychiatric physician if she came up with a suicide plan, she would carry it out and not alert the nursing staff. The psychiatric progress notes further revealed the Director of Nursing and the nursing staff were alerted Resident #57 was experiencing passive [CONDITION(S)] and was placed on suicidal ideation precautions prior to sending to an inpatient psychiatry facility for safety and stabilization. Nursing documentation dated 5/19/2021 revealed Resident #57 ' s did not want to live and felt comfortable with dying when visited by the psychiatric physician. Resident #57 was placed on suicidal precautions prior to sending to the hospital for an evaluation. When the responsible party was notified, she revealed Resident #57 was seen one to two times a week by psychiatric therapy. On 5/19/2021, Resident #57 was discharged to the hospital for an evaluation. On 6/1/2021, Resident #57 was readmitted to the facility. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/9/2021, the physician ordered [MEDICATION(S)] 0.25mg at bedtime daily for anxiety and on 6/23/2021, [MEDICATION(S)] 25mg daily for [CONDITION(S)]. The 5-day re-admission MDS dated [DATE] revealed Resident #57 remained cognitively intact and rejected care. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57's care plan dated 6/11/2021 revealed she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included administering medications as ordered, monitoring and documenting side effects and effectiveness of medications, behavioral health consults as needed, encouraging her to express her feelings and monitoring, documenting and reporting to physician as needed any risk of harm to self or others. The care plan further revealed a focus for impaired cognitive function and impaired thought processes related to [CONDITION(S)] and depression, use of antidepressant and antipsychotic medications and hypnotic therapy initiated on 6/11/2021. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/29/2021 at 10:33 a.m., no PASARR Level I or II determination letter was found in the medical record. On 6/29/2021 at 2:13 p.m. in an interview with the Social Services Coordinator, she stated she did not have a PASARR Level II determination letter for Resident #57. She stated with the COVID-19 PASARR waiver PASARRs were due if the resident was in the facility longer than thirty days. She stated she had not submitted information on Resident #57 yet and anticipated her receiving a PASARR Level II due to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #57 was assessed by a psychiatric physician on 5/19/2021 for a mental episode that sent the resident to the hospital but was unaware of Resident #57 experiencing any mental issues since readmission on 6/1/2021. She stated she was using the thirty days in the facility as a guide as when to submit Resident #57's PASARR information to the state mental health authority. On 6/30/2021 at 12:13 p.m. in an interview with MDS Nurse #1, she stated she generates a report on the electronic medical record that showed if Resident #57 had a PASARR Level II and stated Resident #57 was not on the list. She stated she needed a current PASARR to complete the MDS assessment and stated with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #57 should have a PASARR Level II. On 7/1/2021 at 8:45 a.m. in an follow up interview with the Social Services Coordinator, she stated when submitting PASARR forms she did not know if a resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if Resident #57 had remained in the facility the whole time, it would had triggered her to reprioritized submission of her PASARR and would not have waited the thirty days. On 7/1/2021 at 10:25 a.m. with the Director of Nursing, she stated psychiatric and significant changes in residents were discussed in the morning meetings, and an acute episode would trigger reprioritizing a resident to the top of the list to summit PASARR forms. She stated Resident #57 received a psychiatric consult due to appearing depressed and was not working with therapy. She stated Resident #57 was sent to the hospital and was out of the facility for more than a week before returning to the facility. She stated submission of PASARR forms to the mental health authority needed to be individualized completing first the residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/1/2021 at 1:39 p.m. in an interview with the Administrator, he stated Resident #57 having [CONDITION(S)] and receiving treatment outside the facility was considered a significant change in her mental health and required notification to the state agency mental health authority.

Based on record review, resident interview and staff interviews, the facility failed to conduct an interdisciplinary care plan meeting with a newly admitted resident (Resident #57) for 1 of 1 resident reviewed for care plans. Findings included: Resident #57 was admitted to the facility on [DATE] and was discharged on [DATE]. She was readmitted on [DATE] and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact. On 6/28/2021 at 3:50 p.m. in an interview with Resident #57, she denied having a care plan meeting with any of the staff at the facility since admission. A review of Resident #57's medical record revealed no documentation of an interdisciplinary care plan meeting since admission. On 6/29/2021 at 3:27 p.m. in an interview with the Social Services Coordinator, she stated care plan meetings were held within the first week after a resident was admitted . She stated the care plan calendar showed a resident with the same first name of Resident #57 but a different last name was scheduled for a care plan meeting on May 21, 2021 and June 23, 2021 and stated it must be Resident #57 because there was no other resident with the other last name in the facility. She stated the MDS Nurse #1 had placed the care plan meeting signature sheet in medical records to be scanned into the electronic medical record. On 6/30/2021 at 9:30 a.m. in an interview with the Medical Records Specialist, she stated care plan meeting signature sheets waiting to be scanned into the electronic medical record were in alphabetical order located in a box. She stated she did not have a care plan meeting signature sheet for Resident #57. On 6/30/2021 at 12:07 p.m. in an interview with the MDS Nurse #1, she stated care plan meetings were conducted in the resident ' s room, and the social services coordinator, MDS nurse, therapy, dietary and nursing attended the care plan meetings. She stated the admission ' s coordinator or the social services coordinator scheduled the care plan meetings, and the MDS Nurse #1 was responsible for completing the care plan meeting signature sheet and placing it in a box in medical records to be scanned into the electronic medical record. She was unable to recall any specifics about a care plan meeting with Resident #57. On 7/1/2021 at 08:45 a.m. in a follow up interview with the social services coordinator, she stated she was unable to recall attending a care plan meeting with other team members in Resident #57's room. On 7/1/2021 at 10:25 a.m. in an interview with the Director of Nursing, she stated during the morning meetings scheduled interdisciplinary care plan meetings for that day were discussed. She stated she could not recall attending a care plan meeting for Resident #57 and stated she did not attend all care plan meetings. On 7/1/2021 at 1:39p.m. in an interview with the Administrator, he stated interdisciplinary care plan meetings with the resident or resident representative were to be held within seven days of admission.

Based on observations and staff interviews, the facility failed to trained Nurse #1 to follow Centers for Disease Control and Prevention (CDC) recommendations for use of Personal Protective Equipment (PPE) when performing the COVID-19 nasopharyngeal swab test. This occurred during a COVID-19 pandemic. Findings included: Documentation on the Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Guidance For Collecting, Handling, and Testing Clinical Specimen for COVID-19 dated 2/26/21, stated healthcare providers collecting specimens or working within six feet of patients suspected to be infected with [CONDITION(S)]-CoV-2 were to maintain proper infection control and use recommended PPE which included an N95 or higher lever respirator (or facemask is respirator not available), eye protection, gloves and a gown. On 6/28/2021 at 2:15 p.m., Nurse #1 was observed not wearing eye protection, a gown and a N-95 mask when performing a COVID-19 nasopharyngeal swab test for COVID-19 testing purposes. She was observed wearing a surgical face mask and gloves within six feet of distance swabbing the right and left nostril of a staff member, the Rehabilitation Director. On 7/1/2021 at 8:10 a.m. in an interview with Nurse #1, she stated she had not been trained at the facility on how to conduct COVID-19 testing. She stated she had watched other staff members perform the COVID-19 nasopharyngeal swab test wearing only the surgical mask and gloves and was following what she had observed when staff members were tested for COVID-19. On 7/1/2021 at 10:49 a.m. in an interview with the Director of Nursing (DON), she stated several nurses were trained to perform COVID-19 testing by the clinical lead nurse prior to her medical leave. The DON stated there was no documentation of the COVID-19 testing training. The DON further stated a surgical mask and gloves were required when performing the COVID-19 test since there were no positive COVID-19 cases in the facility.

Based on record review, observation and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of special treatments for 1 of 16 sampled residents reviewed for MDS accuracy. (Resident #57) Findings included: Resident #57 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note further revealed Resident #57 used a Continuous Positive Airway Pressure (C-PAP), a mechanical device that sends a steady flow of oxygen into the nose and mouth while one sleeps, for obstructive sleep apnea prior to hospitalization , and a Bilevel Positive Airway Pressure (Bi-Pap), a non-invasive ventilator that pushes air into the lungs to improve oxygen levels and decreased [MEDICATION(S)] in the blood, was used to treat pleural effusion while Resident #57 was in the hospital. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .) The care plan dated 5/17/2021 documented Resident #57 rejected care and revealed she did not like to wear the Trilogy device due feeling like she was suffocating. Interventions included assisting her with placement of the Trilogy mask and reminding her of the importance of wear the trilogy mask and the adverse outcomes if the Trilogy mask was not worn. Resident #57 was also care planned for chronic respiratory failure with [CONDITION(S)], and interventions included the use of a Trilogy device with 2 liters of oxygen at bedtime and removing in the morning. It also could be used as needed for shortness of breath. Nursing documentation revealed Resident #57 used a Trilogy device at night, and a representative from the Trilogy company explained to Resident #57 how the Trilogy device worked in a phone conversation on 5/17/2021. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact and rejected care. The MDS further documented Resident #57 received oxygen and an invasive mechanical ventilator as special treatments. A Social Services note dated 6/7/2021 revealed a trilogy machine was at the bedside and applied at night. The Social Services note further revealed Resident #57 stated she felt like she was suffocating when wearing the Trilogy device, and the nursing staff were increasing the time she wore the Trilogy device at night to help her get more comfortable using the Trilogy device. A review of the facility assessment revealed respiratory treatments included no residents used ventilators or required [CONDITION(S)] care, and ten residents used a Bi-Pap or C-Pap device. A review of the Resident Matrix dated 6/28/2021 revealed Resident #57 used a ventilator. Resident #57 on 6/28/2021 at 3:47p.m. was observed sitting up in a wheelchair with no [CONDITION(S)] or the use of an invasive mechanical ventilator. She answered interview questions verbally with no respiratory difficulty observed. On 6/29/2021 at 3:05 p.m. in an interview with the MDS Nurse #1 and MDS Nurse #2, MDS Nurse #1 stated the Trilogy machine was not a Bi-Pap or C-Pap device but a more mechanical device that forced air in the lungs and pulled air out of the lungs. She further stated the Trilogy ventilator device was not an invasive device. MDS Nurse #2 stated the Trilogy device was an external device and often referred to as a Bi-Pap. She stated Resident #57 was unable to support her own ventilations and used the mechanical device to fill the lungs with air. She further stated the facility did not accept residents on invasive mechanical ventilators, and the use of a Bi-Pap and C-Pap devices should not be coded as an invasive mechanical ventilator. On 7/1/2021 at 7:35 a.m. in an interview with Nurse #2, she stated the Trilogy device was like a Bi-Pap, and the nursing staff applied the Trilogy device at night and removed in the morning for Resident #57. She further stated Resident #57 was more cooperative in wearing the Trilogy device when asleep. On 7/1/2021 at 10:25 a.m. in an interview with the Director of Nursing, she stated the use of the trilogy machine was not an invasive procedure. She stated the respiratory services department at the hospital educated the nursing staff on the Trilogy device as part of their competency training last month. On 7/1/2021 at 1:39 p.m. in an interview with the Administrator, he stated the MDS assessment needed to be completed accurately. He further stated the facility did not accept residents with invasive ventilators.

Based on observation and staff interviews, the facility failed to follow Centers for Disease Control and Prevention (CDC) recommendations for use of Personal Protective Equipment (PPE) for collecting COVID-19 nasopharyngeal specimens for Point of Care testing when Nurse #1 was observed conducting the COVID-19 nasopharyngeal test within six feet of 1 of 1 staff member (Rehabilitation Director). The facility also failed to have a policy for collecting COVID-19 nasopharyngeal specimens for Point of Care testing. This occurred during a COVID-19 pandemic. Findings included: Documentation on the Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Guidance For Collecting, Handling, and Testing Clinical Specimen for COVID-19 dated 2/26/21, stated healthcare providers collecting specimens or working within six feet of patients suspected to be infected with [CONDITION(S)]-CoV-2 were to maintain proper infection control and use recommended PPE which included an N95 or higher lever respirator (or facemask is respirator not available), eye protection, gloves and a gown. The CDC visual guidance titled, Nasopharyngeal Specimen Collection Steps, recommended PPE was worn when collecting specimens. PPE included gloves, a gown, eye protection (face shield or goggles) and an N-95 or higher-level respirator (or surgical mask if a respirator is not available). On 6/28/2021 at 2:15 p.m., Nurse #1 was observed not wearing eye protection, a gown and a N-95 mask when performing a COVID-19 nasopharyngeal swab test for COVID-19 testing purposes. She was observed wearing a surgical face mask and gloves within six feet of distance swabbing the right and left nostril of the staff member. She was observed placing the COVID-19 swab into the COVID-19 testing device and transporting the testing device to the collection area. On 7/1/2021 at 8:10 a.m. in an interview with Nurse #1, she stated she was verbally trained while working at the hospital to conduct COVID-19 testing, and the PPE requirements included gown, gloves and a N-95 mask when performing COVID-19 testing. She stated she was not trained at the facility on how to conduct COVID-19 testing. She stated she had watched other staff members perform the COVID-19 testing wearing only the surgical mask and gloves and was following what she had observed when staff members were tested for COVID-19. On 7/1/2021 at 10:49 a.m. in an interview with the Director of Nursing (DON), she stated several nurses were trained to perform COVID-19 testing by the clinical lead nurse prior to her medical leave. The DON stated there was no documentation of the COVID-19 testing training. The DON further stated if there were positive COVID-19 cases in the facility, PPE requirements of the staff performing the COVID-19 testing included a N-95 mask but was not required, gloves, gown and goggles. She stated when there were no positive COVID-19 cases in the facility, a surgical mask and gloves was required when performing COVID-19 testing. The DON stated she completed the Statewide Program for Infection Control and Epidemiology (SPICE) training in December 2020, and the facility did not have a policy on performing COVID-19 testing that listed the PPE requirements. On 7/1/2021 at 1:39 p.m. in an interview with the Administrator, he stated PPE requirements for staff conducting COVID-19 testing included gown, gloves, goggles and N-95 mask.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 6 of 18 resident assessment reviewed (Resident #17 and Resident #26 for use of an anticoagulant, Resident #57 for discharge destination, Resident # 10 for urinary catheter, and Resident #51 and Resident #30 for functional status). The finding included: 1. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #17's quarterly Minimum Data Set ((MDS) dated [DATE] revealed section N at N0410 item E was coded as Resident #17 received an anticoagulant for all 7 days of the look back period. A review of the Medication Administration Record [REDACTED]. During an interview with MDS nurse #2 and MDS nurse #1 on 3/8/19 at 12:45 pm MSA nurse #2 reviewed the Anticoagulation List and stated [MEDICATION NAME] was not on the list. MDS Nurse #2 then reviewed the RAI (Resident Assessment Instrument) manual under section instructions for N0410 which stated do not include [MEDICATION NAME]. MDS Nurse #1 stated she thought the medication was an anticoagulant so she had coded the N0410 item E incorrectly. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated it was her expectation MDS assessments are coded completely and accurately. 2. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #26 revealed section N at N0410 item E was coded as the resident received an anticoagulant for all 7 days of the lookback period. A review of the Medication Administration Record [REDACTED]. During an interview with MDS nurse #2 and MDS #1 on 3/8/19 at 12:45 pm MDS nurse #2 reviewed the Anticoagulation List and stated [MEDICATION NAME] was not on the list. MDS Nurse #2 then reviewed the RAI (Resident Assessment Instrument manual under section instructions for N0410 which stated do not include [MEDICATION NAME]. MDS Nurse #1 stated she thought the medication was an anticoagulant so she had coded it incorrectly. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated it was her expectation MDS assessments are coded completely and accurately. 3. Resident # 10 was admitted to the facility 7/1/17 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) revealed section H item A was coded that Resident #10 had an indwelling catheter. This MDS also coded item H0300 as frequently incontinent. During an interview with MDS nurse #1 on 3/8/19 at 11:52 am she stated if a resident had a catheter then the bladder continence would not be coded and instead it should be coded a 9 as not rated resident had a catheter. She stated it was a coding error. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated it was her expectation MDS assessments are coded completely and accurately. 4. Resident #57 was admitted to the facility 1/15/19 with [DIAGNOSES REDACTED]. A review of the discharge Minimum Data Set ((MDS) dated [DATE] revealed section A at item F was coded as 10. Discharge assessment - return not anticipated. Also in Section A at A2100 the discharge status was coded as item 03 acute hospital. A review of the nursing notes revealed Resident #57 was discharged home. A record review revealed a Discharge Summary form which indicated Resident #57 was discharged on [DATE] as a planned discharge to home. The form was signed by the physician. During an interview with MDS nurse #1 on 3/8/19 at 2:45 PM she stated the MDS coding for discharge destination was not coded correctly. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated it was her expectation MDS assessments are coded completely and accurately. 5. Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #51's annual minimum data set (MDS) assessment dated [DATE] revealed Resident #51 was not assessed in Section G, question G0100E for locomotion on the unit, Section G, question G0100F for locomotion off the unit and Section G, question G0120 for bathing. During an interview on 3/8/18 at 11:52 AM with MDS Nurse #1 she stated Resident #51 should have been assessed for locomotion on and off the unit and bathing. She indicated these areas were not coded by staff and she was unaware questions G0100E, G0100F, and G0120 were answered as not assessed. During an interview with the Administrator on 3/8/19 at 5:15 PM who indicated it is her expectation MDS assessments are coded completely and accurately. 6. Resident # 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's annual minimum data set (MDS) assessment dated [DATE] revealed Resident #30 was not assessed in Section G, question G0100C for walking in her room, Section G, question G0100D for walking in the corridor, Section G, question G0100E for locomotion on the unit, Section G, question G100F for locomotion off the unit, and Section G, question G100I for toilet use. Review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was not assessed in Section G, question G100I for toilet use. During an interview on 3/8/19 at 11:52 AM with MDS Nurse #1 she stated Resident #30 should have been assessed for walking in her room and the corridor, locomotion on and off the unit and toilet use. She said these areas were not coded by staff and she was unaware questions G100C, G100D, G100E, G100F, and G100I were answered as not assessed on Resident #30's MDS assessment dated [DATE]. She stated she was unaware question 100I was coded as not assessed on Resident #30's MDS assessment dated [DATE]. During an interview with the Administrator on 3/8/19 at 5:15 PM who indicated it is her expectation MDS assessments are coded completely and accurately.

Based on observation, record review and staff interviews the facility failed to keep the collection bag of an indwelling catheter covered for 1 of 1 residents (Resident # 10) reviewed for catheter care. The findings included: Resident #10 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #10 was severely cognitively impaired, had an indwelling urinary catheter and was frequently incontinent of bowel. She required extensive to total assistance for activities of daily living. A review of Resident #10's care plan revised on 1/11/19 revealed she had an indwelling catheter due to unspecified hydro [DIAGNOSES REDACTED], urine retention and chronic [MEDICATION NAME]. The interventions included position catheter bag (with privacy bag) and tubing below the level of the bladder and away from the entrance room door. During an observation from the doorway of Resident #10's room on 3/5/19 at 11:58 am the urine collection bag was visible hanging on the side of the bed. The black privacy bag was observed hanging on the bed rail approximately 1 foot away from the collection bag. During an interview on 3/5/29 at 12:09 pm with NA #3 stated she was unsure why the collection bag the collection was not covered with the privacy bag. She stated the collection bag should be inside the privacy bag. NA #3 stated the nursing assistants were responsible for putting the collection bag inside the privacy bag. During an interview on 3/5/19 at 1:45 PM Nurse #3 stated the urine collection bag should have been inside the privacy bag. Nurse #3 stated the nursing staff were responsible to ensure the catheter bag was covered. On 3/8/19 at 10:00 am during an interview the Administrator stated she expected the catheter bag to always be covered.

Based on record review and staff interview the facility failed to provide Physician documentation of criteria for facility-initiated discharge necessary for the resident's welfare, and documentation the facility could not meet the needs of the resident for 1 of 3 residents (Resident #56). Resident #56 was admitted to the facility 12/14/18 with [DIAGNOSES REDACTED]. Review of Resident #56's minimum data set assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired and had displayed wandering behaviors 1 to 3 days of the previous 7 days. He required limited assistance with walking in room and locomotion on unit. He required supervision with locomotion off unit. Review of Resident #56's physician's orders [REDACTED]. Review of Resident #56's care plan revealed the resident was care planned as an elopement risk which was initiated on 1/8/19. The interventions included a sign with Resident #56's name on it was placed by his door to make it easier for Resident #56 find his room, monitor for fatigue and weight loss, provide assistance with locating room when needed, and wander guard placed with nurses to check placement every shift and function daily. Review of a nurse's note dated 2/10/19 revealed Resident #56 was found outside the facility. Review of a Social Services Coordinator's note dated 2/11/19 revealed Resident #56's family was contacted about transfer to a skilled nursing facility with a secure unit. Review of a Social Services Coordinator's note dated 2/12/19 indicated Resident #56 was discharged from the facility by family for transport to a skilled nursing facility with a secure unit. Review of Resident #56's physician orders [REDACTED].#56 was transferred to another facility on 2/12/19. Review of Resident #56's medical record revealed no documentation by the Physician of specific resident needs the facility could not meet, facility efforts to meet those needs, and specific services the receiving facility would provide to meet the needs of the resident. An interview was conducted on 3/8/19 at 2:37 PM with the Social Services Coordinator who stated there was no documentation from the physician which indicated Resident #56's specific needs the facility could not meet, facility efforts to meet those needs, and specific services the facility would provide to meet the needs of the resident. An interview was conducted with the Administrator on 3/8/19 at 5:15 PM who indicated she did not know the reason the doctor did not document Resident #56's specific needs the facility could not meet, the facility efforts to meet those needs and specific services the receiving facility would provide to meet the needs of the resident. Attempts to interview the physician were unsuccessful.

Based on record review and staff interviews the facility failed to ensure a resident dependent on transfers by lift was transferred by a lift which resulted in an assisted fall without injury for 1 of 2 residents reviewed for accidents (Resident #156). Findings included: Resident #156 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the most current Minimum Data Set Assessment (MDS), dated [DATE], revealed resident #156 was assessed as cognitively moderately impaired and required total assistance from two persons for transfers. The MDS revealed the resident used a wheelchair but was dependent on staff for all efforts of mobility. Review of the care plan for Resident #156, dated 2/19/2019, documented Resident #156 had a deficit in performing Activities of Daily Living (ADLs) and not ambulatory. The care plan for risk of falls, dated 2/19/2019, noted to follow facility fall protocol and physical therapy (PT) to evaluate and treat as ordered or as necessary (prn). Updated care plan for ADLs, dated 2/25/2019, revealed transfers required total assistance from two staff members and the staff to use the mechanical lift. Risk for falls care plan updated on 3/1/2019 revealed a fall occurred on 2/28/2019, with no injury, due to poor balance and core strength. The plan of care noted to continue interventions on the at-risk plan, to determine and address causative factors of the fall, and (PT) consult for strength and mobility, and to make sure all transfers were with mechanical lift and two staff members. Record review of nursing notes, dated 2/20/2019-2/28/2019, revealed resident #156 transferred out of bed to the wheelchair using a mechanical lift daily seven times. On 2/28/2019 at 11:20 am, nurse's notes documented a description as patient weak and lowered to floor during transfer. The use of a mechanical lift was confirmed during the interview process. The intervention documented on 2/28/2019 at 11:20am was assessed, no injury, mechanical lift up to bed by three staff members. Nurses notes from 3/1/19-3/4/19 revealed Resident #156 transferred out of bed using the mechanical lift. Review of the physical therapy initial assessment dated [DATE] revealed resident #156 required maximum assistance to maintain balance and transfers bed/chair and sit-stand. The initial assessment also revealed the resident's inability to walk and use of a mechanical lift. Review of the Kardex, used by nursing staff to communicate important information on patients, dated 2/19/2019, revealed Resident #156 was not ambulatory at this time and needing total assistance from two staff to use mechanical lift for transfers out and into bed/chair. Transfer section dated a fall for 2/28/19 and noted make sure all transfers are with mechanical lift and two staff members. Review of a nurse aide care documentation report dated 2/19/19-2/28/19 noted Resident #156 required total assistance with 2 persons physical assistance in transferring for the 7 am-3 pm shift. No transfers were documented for the 3 pm-11 pm or 11 pm-7 am shift. On 3/5/2019 at 8:40am during an interview conducted with Resident #156, the resident stated while staff were getting her up to the side of the bed, there was a blanket on the floor, and she just sat down. Resident #156 further stated she thought there was one person helping her but was not sure. Resident #156 denied injury from the fall. Resident #156 further stated staff informed her to call if she needed to get up and to go to the bathroom, one person comes to help me in the wheelchair. On 3/5/2019 at 12:15 pm Nurse #4 stated during an interview she was present the day the resident fell on [DATE]. She said that physical therapy had gotten the resident up in the wheelchair. The resident wanted to go back to bed and when the NA#4 stood the resident up, resident was weak and was lowered to the floor. Nurse #4 stated resident #156 had been using a mechanical lift for transfers. Nurse #4 stated NA #4 was pulled to the hall to work that day and the Resident #156 had told the NA #4 that she could help NA#4. On 3/5/19 at 3:46 pm during an interview with the Physical Therapy aide (PTA)#1, PTA #1 stated it was protocol if a resident was maximum assistance (2 persons) or total assistance, a mechanical lift was automatically used for transfers and each resident had their own lift pad that was left in the room. On 3/6/19 at 10:08 am an interview with NA #4, care provider during the transfer on 2/28/19, was conducted. NA#4 stated (MONTH) 2019 as her hired date with orientation and training [MEDICATION NAME] two weeks that included demonstration of the lift. NA #4 stated that during the training she was assigned the Rehabilitation hall once. NA#4 further stated she wasn't familiar with Resident #156, but one day Resident #156 yelled out as she walked by. When NA#4 went into Resident #156's room, Resident #156 wanted to go back to bed. NA#4 admitted to seeing a lift pad in the wheelchair underneath the resident but when the NA#4 asked Resident #156 if she could transfer or had to use the lift, Resident #156 told the NA#4 both. NA #4 stated after standing Resident #156, the resident became weak, couldn't move, and as Resident #156 was starting to sit down, NA#4 eased her to the floor. NA#4 stated she went next door to get physical therapy (PT) to help her and Nurse#4 was notified. NA#4 further stated the PT informed her to always use a lift when a lift pad was in the wheelchair. During the interview, NA#4 stated the needs of each resident was shared among staff through room to room conversations with other shift, word of mouth, checking Kardex and asking the nurse. NA#4 stated max assistance was total assistance and required two persons and if resident's care changes during the day, therapy or the nurse would inform the nurse aides. On 3/6/19 at 11:30 am during an interview with the Rehabilitation Director PT #1 stated after evaluations of the residents, PT #1 plan of care was entered into the computerized system and the nurse aides could see on the Kardex. PT #1 stated a two-person extensive assistance for a resident would indicate the use of a lift. PT#1 further stated changes in care of the resident were communicated to the nurse, nurse aides, and during Leadership Morning Meetings and the Rehabilitation MDS Coordinator updated the care plan. PT#1 stated he was familiar with Resident #156 and recalled NA#4 going next door while he was working with another resident requesting his help. PT #1 stated Resident #156 was on the floor and complained of a little back pain. PT#1 further stated the nurse was notified, came into the Resident's room, and using the lift, the three of them assisted resident #156 back into the bed. PT#1 stated NA#4 was new to the hall and informed NA#4 if you see a lift pad, to use the lift. On 3/6/19 at 11:50 am during an interview with Nurse #4, Nurse #4 stated on 2/28/19 Resident #156 was on the floor when she entered the room and complained of back pain. Nurse #4 stated Resident #156 was assessed, the Resident's physician and the Resident's family were notified. Nurse#4 stated nurse aides gathered information on resident's care needs from room to room reports with the previous shift and the nurse in charge of the unit. Nurse #4 stated when changes in resident care occur, changes are verbally communicated to the nurse aide. On 3/6/19 at 4:40 pm an interview was conducted with the MDS Rehabilitation Coordinator who evaluated Resident #156's functional abilities. MDS Rehabilitation Coordinator stated Resident #156 was a lift for transfers. She stated on 3/1/2019 the fall of Resident #156 was discussed at the Leadership Morning Meeting and Resident #156's care plan and Kardex were updated after the meeting.

Based on record review and staff interviews the facility failed to provide written notice of discharge to the resident or the resident's representative for a facility-initiated discharge for 5 of 5 residents reviewed for a facility-initiated discharge (Resident #56, # 53, # 24, #28, and #54 ). The findings included: 1. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's minimum data set assessment dated [DATE]/19 revealed the resident was assessed as moderately cognitively impaired and had display wandering behaviors 1 to 3 days of the previous 7 days. He required limited assistance with walking in the room and locomotion on the unit. He required supervision with locomotion off the unit. Review of Resident #56's orders revealed on 1/8/19 the resident was ordered to have a wander alarm in place and for the functionality to be checked on third shift daily. Review of a nurse's note dated 2/10/19 revealed Resident #56 was found outside the facility. Review of a Social Service Coordinator's note dated 2/11/19 revealed Resident #56's resident representative was contacted by phone regarding transfer to a skilled nursing facility with a secure unit. The note indicated the resident representative had no issue with the transfer. Review of a Social Services Coordinator's note dated 2/12/19 revealed Resident #56 was discharged from the facility with family members for transport to a skilled nursing facility with a secure unit. A review of the medical record revealed no written notice of discharge was provided to the resident representative for the resident's transfer to a skilled facility with a secure unit on 2/12/19. During an interview on 3/7/19 at 2:40 pm the Social Services Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's transfer to a skilled facility with a secure unit on 2/12/19. The Social Services Coordinator stated the resident representative was verbally informed of the transfer and agreed with the transfer. During an interview on 3/7/19 at 2:43 pm with the Business Office Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's transfer to a skilled facility with a secure unit on 2/12/19. She added she would create a form to send. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated she was not aware of the requirement to provide written notification to the resident or responsible party for facility-initiated discharges necessary for the resident's welfare. 2. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurse's note dated 1/24/19 revealed Resident #53 was sent to the hospital for evaluation for shortness of breath. A review of the medical record revealed no written notice of discharge was provided to the resident representative for the resident's hospital transfer on 1/24/19. Review of a nurse's note dated 1/30/19 revealed Resident #53 was readmitted to the facility from the hospital on [DATE]. During an interview on 3/7/19 at 2:31 pm with Nurse #4 she stated when a resident was sent to the hospital the paperwork sent included the face sheet, the physician's orders [REDACTED]. Nurse #4 said no other paperwork was sent when a resident was sent to the hospital. No written notice of discharge was provided so the written notice of discharge was not provided by Nurse #4. During an interview on 3/7/19 at 2:40 pm the Social Services Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's hospital transfer on 1/24/19. During an interview on 3/7/19 at 2:43 pm with the Business Office Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's hospital transfer on 1/24/19. She added she would create a form to send. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated she was not aware of the requirement to provide written notification to the resident or the responsible party for emergent hospital transfers. 3. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurse's note dated 9/11/18 revealed Resident #24 was sent to the hospital for evaluation after being found nonresponsive. A review of the medical record revealed no written notice of discharge was provided to the resident representative for the resident's hospital transfer on 9/11/18. Review of a nurse's note dated 9/19/18 revealed Resident #24 was readmitted to the facility from the hospital on [DATE]. During an interview on 3/7/19 at 2:31 pm with Nurse #4 she stated when a resident was sent to the hospital the paperwork sent included the face sheet, the physician's orders [REDACTED]. Nurse #4 said no other paperwork was sent when a resident was sent to the hospital. No written notice of discharge was provided so the written notice of discharge was not provided by Nurse #4. During an interview on 3/7/19 at 2:40 pm the Social Services Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's hospital transfer on 9/11/18. During an interview on 3/7/19 at 2:43 pm with the Business Office Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's hospital transfer on 9/11/18. She added she would create a form to send. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated she was not aware of the requirement to provide written notification to the resident or the responsible party for emergent hospital transfers. 4. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's progress note dated 12/17/18 revealed Resident #28 was sent to the hospital due to altered mental status and confusion on 12/6/18. A review of the medical record revealed no written notice of discharge was provided to the resident representative for the resident's hospital transfer on 12/6/18. Review of a physician's progress note dated 12/17/18 revealed Resident #24 was readmitted to the facility from the hospital on [DATE]. During an interview on 3/7/19 at 2:31 pm with Nurse #4 she stated when a resident was sent to the hospital the paperwork sent included the face sheet, the physician's orders [REDACTED]. Nurse #4 said no other paperwork was sent when a resident was sent to the hospital. No written notice of discharge was provided so the written notice of discharge was not provided by Nurse #4. During an interview on 3/7/19 at 2:40 pm the Social Services Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's hospital transfer on 12/6/18. During an interview on 3/7/19 at 2:43 pm with the Business Office Coordinator stated she did not send written notice of discharge to the resident or the resident's representative for the resident's hospital transfer on 12/6/18. She added she would create a form to send. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated she was not aware of the requirement to provide written notification to the resident or responsible party for emergent hospital transfers. 5. Resident #54 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #54's Minimum (MDS) data set [DATE] revealed she was moderately cognitively impaired. She required extensive assistance with most of her activities of daily living. A review of the nursing notes dated 12/18/19 revealed Resident #54 was sent to the hospital for possible urinary tract infection and abdominal pain. A record review revealed Resident #54 was readmitted to the facility 12/21/18. During an interview on 3/7/19 at 2:31 pm with Nurse #4 she stated when a resident was sent to the hospital the paperwork sent included the face sheet, the physician's orders [REDACTED]. Nurse #4 said no other paperwork was sent when a resident was sent to the hospital. No written notice of discharge was provided so the written notice of discharge was not provided by Nurse #4. During an interview on 3/7/19 at 2:40 pm the Social Services Coordinator stated she did not provide written information to the resident or the resident's responsible party about the discharge to the hospital. During an interview on 3/7/19 at 2:43 pm with the Business Office Coordinator she stated she did not provide any written information to the resident or the family for emergent hospital transfers. She added she would create a form to send. During an interview with the Administrator on 3/8/19 at 5:15 PM she indicated she was not aware of the requirement to provide written notification to the resident or the responsible party for emergent hospital transfers.

Based on record review and staff, family and resident interviews, the facility failed to provide showers or baths for 2 of 8 dependent residents (Resident #3, and Resident #4), and failed to provide incontinence care when requested for 1 of 1 residents (Resident #4). Findings included: 1. Resident #3 was originally admitted [DATE] and re-admitted [DATE]. Review of a Quarterly MDS dated [DATE] revealed Resident #3 had no cognitive impairment and had not rejected care. All ADLs, except eating and personal hygiene, required extensive assistance. Resident #3 bathed independently and was not steady to transition from a seated to standing position without assistance, and had not walked during the look back period. The resident had limb impairments of both lower extremities. Active [DIAGNOSES REDACTED]. Review of a care plan last updated 8/2/18 read, in part, (Resident #3) has an ADL Self Care Performance Deficit r/t (history of) [MEDICAL CONDITIONS], chronic pai[DIAGNOSES REDACTED], progressive lumbar spinal stenosis, [MEDICAL CONDITION] dz (disease). Resident will complete adls with supervision/assistance as needed. Bathing: Ensure that my feet and legs are washed as I can no longer reach them. I also need help to make sure my groin and buttocks are cleaned thoroughly. This is no longer easy for me to do. I would like to have a shower every Tuesday with baths at other times. Review of ADL completion flowsheets dated 9/1/18 through 9/30/18 revealed bathing was to be completed every shift on the 7:00 AM to 3:00 PM shift, and was not completed Tuesday 9/11/18, 9/14/18, Tuesday 9/18/18, Tuesday 9/25/18, and 9/28/18. An interview was conducted on 10/1/18 at 12:10PM with Resident #3. She stated there were not enough staff members to meet her needs, and has missed showers because there were not enough staff to help her. She stated the facility was well aware of her concerns as she had told the staff there was not enough staff to provide care. An interview was conducted on 10/1/18 at 2:30 PM with a Nursing Assistant (NA #1). She stated she typically had 10 residents to care for, but today had 12. She had been employed here for over 1 year and stated staffing had always been short. She also stated when there was not enough staff resident showers were not given, and sometimes residents did not received baths. She also stated if there were no initials in a box on the ADL completion flowsheets it meant a bath or shower was not given on that day. An interview was conducted on 10/2/18 at 8:54 AM with Nurse #1. He stated he has been employed since (MONTH) (YEAR) and staffing was challenging every shift, every day. He stated the greatest challenge was with NAs, and they typically worked short which led to missed showers or baths for residents. An interview was conducted on 10/1/18 at 10:45 AM with the Interim Director of Nursing (IDON). She stated there was a staffing shortage in the facility, and the facility was in the hiring process for NAs. She also stated residents miss showers when the facility was short staffed and this had been brought up multiple times in Resident Council meetings, by multiple residents. She stated her expectation was for residents to receive baths or showers on their scheduled day and as needed. 2. Resident #4 was admitted to the facility 3/9/16 and re-admitted [DATE]. An Annual MDS dated [DATE] revealed it was very important to Resident #4 for her to choose between a tub bath, shower, or bed bath and to participate in group activities or do her favorite activities. A Quarterly MDS dated [DATE] revealed Resident #4 was cognitively intact and had no behaviors or rejection of care. All ADLs, except eating, required extensive assistance, and bathing required physical assistance, and she was frequently incontinent of bowel and bladder. Resident #4 was not steady for ambulation without physical assistance and had 1 lower limb impairment. Active [DIAGNOSES REDACTED]. A care plan last updated 8/2/18 read, (Resident #4) has an ADL Self Care Performance Deficit r/t Lt (left) AKA (above knee amputation), pain, impaired mobility, weakness, deconditioning. ADL needs will be met daily w/ (with) staff assistance. Bathing: provide total assistance with bathing activity, bed bath or shower, her preference. Review of ADL completion flowsheets dated 9/1/18 through 9/30/18 revealed bathing was to be completed every shift on the 7:00 AM to 3:00 PM shift, and was not completed 9/7/18, and 9/21/18. An interview was conducted with Resident #4 on 10/1/18 at 2:00 PM. She stated she had activated her call light 20 minutes prior and knew this by the clock observed on the wall. She stated she was incontinent and needed to be changed because she did not like sitting in a wet brief. She felt there was not enough staff, especially on 2nd shift (3:00 PM to 11:00 PM) and she had to sometimes wait an hour for her call light to be answered. She stated she had spoken to the facility at least 5 times about this, but nothing ever changed. She stated the NAs don't help each other and they are very hard to find. An interview was conducted on 10/1/18 at 2:30 PM with a Nursing Assistant (NA #1). She stated she typically had 10 residents to care for, but today had 12. She had been employed here for over 1 year and stated staffing had always been short. She also stated when there was not enough staff resident showers were not given, and sometimes residents did not received baths. She also stated if there were no initials in a box on the ADL completion flowsheets it meant a bath or shower was not given on that day. She stated incontinent rounds were completed every 2 hours or as needed (PRN), and whenever a resident requested care. An interview was conducted on 10/2/18 at 8:54 AM with Nurse #1. He stated he has been employed since (MONTH) (YEAR) and staffing was challenging every shift, every day. He stated the greatest challenge was with NAs, and they typically worked short which led to missed showers or baths for residents. An interview was conducted on 10/1/18 at 10:45 AM with the Interim Director of Nursing (IDON). She stated there was a staffing shortage in the facility, and the facility was in the hiring process for NAs. She also stated residents miss showers when the facility was short staffed and this had been brought up multiple times in Resident Council meetings, by multiple residents. She stated her expectation was for residents to receive baths or showers on their scheduled day and as needed. She also stated it was her expectation for incontinent care to be completed whenever a resident requested it, and residents were to receive the assistance they needed to meet their care needs.

Based on record review and interviews with staff, residents and family members, the facility failed to provide sufficient staff to provide showers or baths to 2 of 8 sampled residents (Resident #'s 3, and 4) and failed to provide incontinence care when it was requested for 1 of 1 resident (Resident #4). Findings included: The facility had insufficient staff to complete baths or showers or to provide incontinence care when requested. Cross refer to citation F561: Based on record review and staff, family and resident interviews, the facility failed to provide showers for 2 of 8 dependent residents (Resident #3, and Resident #4), and failed to provide incontinence care when requested for 1 of 1 residents (Resident #4). A review of the daily scheduling sheets for 9/1/18 through 9/30/18 revealed a consistent pattern of insufficient licensed and unlicensed personnel on all shifts. (7:00AM-3:00PM; 3:00PM-11:00PM; and 11:00PM-7:00AM). An interview was conducted with Nurse #3 on 10/1/18 at 12:01 PM. She stated, There are not enough nurses or NAs (Nursing Assistants). For example, today there were 7 NAs scheduled and only 3 showed up. They pulled the Restorative Aid and a Medication Aid to help staff. I've seen an agency nurse here once, but when I ask why the facility doesn't use agency staff they tell me the hospital shoots it down and they can't. The residents miss showers when we're short. An interview was conducted on 10/1/18 at 12:30 PM with Nurse #4. She stated there was not enough staff. She stated there are 4 nursing openings and 4-5 openings for NAs. Today, there were 7 NAs scheduled, but only 4 showed up and they pulled the restorative aid and medication aid to do resident care. There were typically 6-7 NAs for the facility and residents had not received showers when the NAs were short. An interview was conducted on 10/1/18 at 2:21 PM with Nurse #2. She stated there were not enough staff to meet the resident needs. She stated there is 1 NA for 20 residents today, and she was trying to pass medications, give baths, and get residents fed and other activities of daily living completed to try to help the NA. She stated, It's a lot. I've only been here 3 weeks and there isn't enough help. I worked 3:00PM-11:00PM last night to cover a shortage. I had the 300 Hall by myself from 3:00PM-7:00PM and then the 300 Hall and half the 200 Hall, about 32 residents, from 7:00PM to 11:00PM. There wasn't a unit secretary on rehabilitation aid either to help answer the phone, set up appointments, or anything. An interview was conducted on 10/1/18 at 2:30 PM with NA #1. She stated she typically had 10 residents to care for, but today had 12. She had been employed here for over 1 year and stated it had always been this way. When there was not enough staff resident showers were not given, and sometimes residents did not received baths. An interview was conducted on 10/2/18 at 8:54 AM with Nurse #1. He stated he works 7:00 PM to 7:00 AM and had been employed since (MONTH) (YEAR). He stated staffing was challenging and there was overtime available for every shift, every day. He stated the greatest challenge was with NAs, and they typically worked short which led to residents missed showers or baths, especially on the 7:00PM to 11:00PM portion of his shift. He stated it had been like this since he was hired. He was not aware of agency nurses or NAs being utilized. An interview was conducted with the Interim Director of Nursing (IDON) on 10/1/18 at 10:45 AM. She stated there was a staffing shortage in the facility, but they were in the hiring process currently. New hires must go through the hospital orientation/on boarding process and that took 3 weeks. Then, the new hires arrived at the facility for training. This was for both licensed and unlicensed staff. She also stated they had been approved to use an agency, but there was only 1 agency nurse and she only worked approximately 1 weekend per month. There was overtime available every shift, every day, and residents missed showers when the facility was short staffed. This had been brought up multiple times by multiple residents, and the Quality Improvement (QI) Nurse was currently doing a QI project related to insufficient staffing. An interview was conducted with the QI Nurse on 10/2/18 at 11:50 AM. She stated, My staffing project is focused on hiring right now. We send a requisition to the main hospital and when they approve it, it goes on the internet. I'm not aware if it appears anywhere else (newspapers, social media) that we are looking for help. The Administrator and 2 nursing supervisors are currently holding interviews to try to speed the process up. After the interview, human resources at the main hospital gets our recommendation and they finish screening the applicant and then make an offer. Hospital orientation is held once monthly so it could be 5-6 weeks before we see a new hire from the time we interview. All new hires must go through hospital orientation. We are also utilizing asking staff to work over their scheduled time, and we have overtime available just about every day. We're also offering surge money which is incentive money above their base pay. Me and the 2 other nursing supervisors are on-call every weekend on a rotating basis and we each get called in every weekend we are on call. An interview was conducted with Medication Aid #1 on 10/2/18 at 1:45 PM. She stated incontinent checks were done every 2 hours and as needed. She stated there were not enough staff because of call outs or staff arrived late without any consequences, so staff just did whatever they wanted. She stated she was pulled from administering medication 3-4 out of 5 days because of staffing issues. She stated, We try to get showers done, but if we're short, showers aren't happening. But incontinence care always, always gets done. An interview was conducted with NA #3 on 10/2/18 at 2:10 PM. She stated she typically worked 11:00PM-7:00AM, but she was typically asked to work 7:00 PM through 7:00 AM since the facility was short staffed. An interview was conducted with the Administrator on 10/2/18 at 2:50 PM. He stated he believed there was sufficient staff most days, but not 100% (percent) of the time to meet all resident care needs. He also stated the facility was trying to hire more NAs by using the hospital web site and offering higher per diems and a higher rate of pay for the area as an incentive. He stated from interview to being on the floor usually took between 6-10 weeks. Retention strategies included longer orientation, and more interaction with new hires at the 30, 60, and 90 day period so they felt supported and comfortable. He also stated his expectation for showers was for a resident to get a shower or bath when they were due or when they were requested.

Based on observation, record review and staff interview the facility failed to identify and assess a resident at risk for pressure ulcers for 1 of 3 (Resident #53) sampled residents who developed unstageable pressure ulcers to bilateral heels. The facility also failed to ensure staff carried out physician orders [REDACTED].#30) of 4 resident's reviewed for nutrition. Findings include: 1. Resident #53 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #53's admission Minimum Data Set ((MDS) dated [DATE] indicated that Resident #53 had severe cognitive impairment, was at risk for the development of pressure ulcers, had 1 arterial or venous ulcer and was totally dependent on one person for bed mobility. A review of the Skin Care Policy Revised November 2011 stated that, "Residents without pressure ulcers will be monitored daily by Certified Nursing Assistant during personal care for skin problems and assessed by the nurse for skin problems as needed." A review of the Care Plan dated 3/5/12 indicated that Resident #53 was at risk for impaired skin integrity related to impaired bed mobility. Interventions included pressure reduction devices for the bed and chair, turning and repositioning every two hours and observing skin integrity daily during care. On 3/23/12 an intervention for heel lift boots bilaterally was begun. A review of the Physician's Telephone Orders dated 3/22/12 showed an order for [REDACTED]. A review of the Nurses Notes dated 3/23/12 at 8:50 AM indicated," L (left) heel has 1cm (centimeter) x (by) 1 cm eschar area R (right) heel entire heel has eschar present. Both are dry and intact. [MEDICATION NAME] used per order. Sacral area healed. See new order. Heel lift boots on pt (patient) at this time." A review of the Wound Documentation sheet dated 3/26/12 showed that Resident #53 developed unstageable (full thickness tissue loss with the ulcer covered with slough or eschar) bilateral heel ulcers in the facility on 3/23/12. The left heel ulcer measured 3x1.5 cm. The right heel measured 5.5x5.5 cm. Both heels had 100% eschar and there was no drainage to either wound. A review of the Wound Documentation sheet dated 4/2/12 showed the left heel ulcer measurement as 3x1.5 cm and the right heel ulcer measurement as 5x5.2 cm. A review of the Wound Documentation sheet dated 4/9/12 showed the left heel ulcer measurement as 3x1.8cm and the right heel ulcer measurement to be 3.5x5cm. In an observation on 4/10/12 at 8:30 AM, Resident #53 was sitting up in bed finishing breakfast. Resident #53's bare feet were resting on the bed. There were no heel boots in place and the feet were not elevated. In an interview on 4/12/12 at 8:20 AM with the Director of Nursing, she indicated that the facility did not formally monitor resident's skin. A Licensed Nurse Weekly Skin Assessment sheet had just been initiated by the facility on 4/10/12. The new policy read in part, "8. Weekly Skin Assessments will be conducted on all residents who have a significant potential for alteration in skin integrity as identified by a Braden scale score of 18 or less. 11. Braden scale will be completed on all admissions and for significant change as deemed by MDS 3.0." In an interview on 4/12/12 at 8:25 AM with Nursing Assistant (NA) #3, she stated that resident's skin was monitored during care. She indicated that the aides do not document any findings but would let the nurse know if they found anything on the resident's skin. In an interview on 4/12/12 at 8:45 AM with Nurse #3, she stated that the facility had just recently started to utilize the Braden scale (a scale used to determine the risk level of pressure ulcer development for a resident). She was unable to find a Braden scale for Resident #53 and stated that Resident #53 must have been admitted prior to the initiation of the scale. She indicated that the Norton scale (similar to the Braden scale) was not in use at the facility. Nurse #3 stated that Resident #53 would have been considered at high risk for the development of pressure ulcers on admission to the facility. She indicated that Resident #53 should have had her skin monitored weekly (by a licensed nurse). Nurse #3 indicated that the facility had re-written its policy and was waiting for final approval. In an interview on 4/12/12 at 11:45 AM with NA #2, she indicated that residents are turned and repositioned every 2 hours and as needed. She stated that resident's heels are checked during care. In an interview on 4/12/12 at 11:55 AM with NA #4, she indicated that heel protectors should be removed by the NA's so they could look at the resident's feet. She stated that on admission Resident #53 was dependent on staff for turning and repositioning. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a dietary assessment on Resident #30, dated 06/14/11, recommended [MEDICATION NAME] 1 package twice daily to aid in wound healing. A written physician's orders [REDACTED]. Review of Resident #30's monthly Physician order [REDACTED]. Review of Resident #30's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #30's MAR's from July 2011 to March 2012 did not have an order for [REDACTED]. Review of Resident #30's wound care notes and treatment record indicated her wounds were healed on 08/08/11. In an interview with the Registered Dietician (RD) on 04/11/12 at 3:15 PM, she said she would recommend a resident to be put on [MEDICATION NAME] supplements to aid in wound healing if a residents [MEDICATION NAME] level was low and their oral intake was poor. The RD said she had made the recommendation on Resident #30 in her note dated 06/14/11 for a [MEDICATION NAME] supplement to be given twice a day. The RD said she did not make any further recommendation as she noted 08/16/11 Resident #30's wounds were healed and her [MEDICATION NAME] level was within normal range. In an interview with Nurse Supervisor #1 on 04/12/12 at 8:40 AM, she reviewed Resident #30's clinical record and said she did not see a physician's orders [REDACTED]. Nurse Supervisor #1 reviewed Resident #30's MAR's and said it looked as though the order for the [MEDICATION NAME] supplement had not been carried over to the July 2011's MAR. Nurse Supervisor #1 said since Resident #30's wounds were healed she would contact the physician for a clarification order. During an interview with the Director of Nurses (DON) on 04/12/12 at 10:25 AM, she said all supplements were reviewed in the weekly meetings. The DON said the night nurses had been responsible for checking the monthly physician order [REDACTED]. The DON said it was her expectation that the [MEDICATION NAME] supplement would either still be given or a discontinued physician's orders [REDACTED].