Every finding on record at Windsor Point Continuing Care

Based on observations, record review, and interviews with staff and resident representative, the facility failed to provide personal privacy when a resident's door to the room was left open during incontinent care allowing the resident to be visible from the hallway for 1 of 2 residents (Resident #16) reviewed for privacy. A reasonable person has an expectation of privacy during care and would have experienced feelings such as embarrassment. The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, glaucoma, and age-related physical debility. Resident #16's Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment, was always incontinent of bowel and bladder, and was totally dependent on staff for toilet hygiene. Observation on 11/25/24 at 10:38 a.m. revealed Resident #16's room was close to the nurses' station at the beginning of the hallway. A continuous observation on 11/27/24 from 5:01 a.m. through 5:06 a.m. revealed Resident #16's room door was open approximately 12 inches and Nursing Assistant (NA) #8 was in the room. Resident #16 resided in a room without a roommate. NA #8 was putting a brief onto the resident, who slept in the bed by the door, and the resident's legs and the brief were in view. If the brief was not being put on the resident, her private areas would have been in view. NA #8 had not pulled a privacy curtain. NA #9 walked down the hall, stopped by Resident #16's room, spoke to NA #8, then grabbed the trash bag outside of the room. In an interview on 11/27/24 at 5:06 a.m., NA #8 said that she must have left the door open when she had to get the nurse to change the resident's dressing. She said she should have shut it for privacy when she finished providing care. In an interview on 11/27/24 at 9:15 a.m., Resident #16's representative said she was a very private person who kept to herself. In an interview on 11/27/24 at 11:12 a.m., the Director of Nursing (DON) said NA #8 should have closed the door and pulled the curtain to provide privacy during care.

Based on record review and staff interviews, the facility failed to develop comprehensive care plans for the care areas of use of anticoagulant medication {medications that prevent or treat blood clots in the heart and blood vessels} (Resident #22), the use of antipsychotic medications {a class of drugs used to treat symptoms of psychosis, such as hallucinations, delusions, and disordered thinking} (Resident #14), and for the care area of respiratory care (Resident #5) for 3 of 14 residents whose comprehensive care plan were reviewed. Findings included: 1. Resident #22 was admitted to the facility on [DATE]. Her diagnoses included heart failure (a condition where the heart is unable to pump enough oxygen-rich blood to the body) atrial fibrillation (a heart condition that causes an irregular and often fast heartbeat), and deep vein thrombosis or DVT (a condition that occurs when a blood clot forms in a vein deep within the body, usually in the lower extremities). Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was coded for anticoagulant use (a substance or medication that prevents or treats blood clots in the heart and blood vessels). Review of Resident #22's medication administration record (MAR) dated August 2024 revealed she was receiving an anticoagulant medication. Review of Resident #22's care plan dated 9/9/24 and revised on 9/24/24 revealed she did not have a care plan for anticoagulants. An interview was conducted on 11/27/24 at 12:25 PM with MDS Nurse #1. She stated she was an interim MDS nurse and was responsible for care plans. She stated this resident should have been care planned for anticoagulants. She was unable to offer a reason why Resident #22 did not have a care plan for anticoagulants. An interview was conducted on 11/27/24 at 12:33 PM with the Director of Nursing (DON). She stated she expected Resident #22 would have an anticoagulant care plan. 41387 2. Resident #14 was admitted to the facility on [DATE] with diagnoses including dementia. Physician orders dated 9/3/2024 included Quetiapine Fumarate (an antipsychotic medication) half of a 25 milligram tablet twice a day for dementia with agitation. The quarterly Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #14 was severely cognitively impaired and was receiving antipsychotics on a routine basis. Resident #14's care plan last reviewed 9/25/2024 did not include a focus for the use of antipsychotic medications. A review of Resident #14's Medication Administration Record from 9/3/2024 to 11/26/2024 recorded Resident #14 received Quetiapine Fumarate half of a 25 milligram tablet twice a day. In a phone interview with the MDS Nurse #1 on 11/27/2024 at 12:14 pm, she explained she worked part-time on weekends and she had been working as the MDS nurse since the last full time MDS Nurse left the facility in September 2024. She stated as the MDS Nurse, she was responsible for developing the initial care plan and updating residents' care plan quarterly. She stated Resident #14's Quetiapine Fumarate medication was an antipsychotic and Resident #14 was scheduled to receive daily. She stated Resident #14's care plan should have included the use of antipsychotics. She explained with her only working weekends, she had been trying to keep care plans up-to-date and did not know why Resident #14's care plan did not include a focus for the use of antipsychotics. In an interview with the Director of Nursing on 11/27/2024 at 11:17 am, she stated residents' care plans were updated quarterly by the MDS nurse. She explained Resident #14 was receiving Quetiapine Fumarate, an antipsychotic, and should have been care planned for the use of antipsychotics. In an interview with the Administrator on 11/27/2024 at 3:28 pm, she explained the MDS Nurse, who worked part-time, had access to Resident #14's electronic medical records to gather information to care plan for the use of antipsychotic medications when ordered. She stated Resident #14 should have been care planned for the use of antipsychotics. 50234 3. Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia and respiratory failure. Resident #5's physician's orders revealed an order dated 9/4/24 for oxygen supplementation as needed for shortness of breath, hypoxia, and comfort at 2 liters per minute (Lpm) by nasal canula as needed to maintain oxygen saturation levels above 90%. Resident #5's Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment, had shortness of breath or trouble breathing with exertion, while sitting at rest, and while lying flat. The MDS indicated she used oxygen therapy and received hospice services. Resident #5's care plan last reviewed 10/22/2024 did not include a focus for the use of oxygen. Observation on 11/25/24 at 10:06 a.m. revealed Resident #5 asleep in low bed. She had a nasal cannula on and oxygen was running from her concentrator at 2 Lpm. Observation on 11/26/24 at 11:40 a.m. revealed Resident #5 in bed. She had removed her nasal cannula, but the oxygen concentrator was running at 2 Lpm. In a phone interview with the MDS Nurse #1 on 11/27/2024 at 12:14 pm, she explained she worked part-time on weekends and she had been working as the MDS nurse since the last full time MDS Nurse left the facility in September 2024. She stated as the MDS Nurse, she was responsible for developing the initial care plan and updating residents' care plan quarterly. She stated if Resident #8 was using oxygen, there should be a focused care plan for the use and care of her oxygen. In an interview with the Director of Nursing on 11/27/2024 at 11:50 am, she stated Resident #8 should have had a care plan for the use of oxygen. In an interview with the Administrator on 11/27/2024 at 3:10 pm, she said Resident #8 had a care plan for the use of oxygen and provided a copy of the hospice agency's care plan for pulmonary/dyspnea (shortness of breath), which included instructing the patient and patient caregiver in safe oxygen use. The care plan provided did not include interventions and goals for oxygen usage.

Based on observations, interviews with staff, and record review, the facility failed to ensure an oxygen filter was clean of dust and debris for 1 of 2 residents (Resident #5) reviewed for oxygen use. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia and respiratory failure. Resident #5's physician's orders revealed an order dated 9/4/24 for oxygen supplementation as needed for shortness of breath, hypoxia, and comfort at 2 liters per minute (Lpm) by nasal canula as needed to maintain oxygen saturation levels above 90%. Resident #5's Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment, had shortness of breath or trouble breathing with exertion, while sitting at rest, and while lying flat. The MDS indicated she used oxygen therapy. Observation on 11/25/24 at 10:06 a.m. revealed Resident #5 asleep in low bed. She had a nasal cannula on and oxygen was running from her concentrator at 2 Lpm. The external air filter had a buildup of dust-like gray and white particles. Observation on 11/26/24 at 11:40 a.m. revealed Resident #5 in bed. She had removed her nasal cannula, but the oxygen concentrator was running at 2 Lpm. The external air filter had a build-up of dust-like gray and white particles. In an interview on 11/26/24 at 11:42 a.m., Nurse #10 said that the night shift nurse was normally supposed to change and clean the oxygen filters. When Nurse #10 saw the filter, she said it was extremely dirty and took the filter off to clean it. In an interview on 11/27/24 at 5:15 a.m., the nurse on the night shift, Nurse #11 said she never thought about checking and cleaning the filter when she changed the oxygen tubing. In an interview on 11/27/24 at 11:12 a.m., the Director of Nursing (DON) said the nurses should be monitoring and cleaning the oxygen concentrator filters when they were dirty.

Based on record review and staff interviews, the facility failed to ensure 2 of 5 staff reviewed who were assigned nurse aide tasks met the minimum qualifications for working as a nurse aide when Staff #1 and Staff #2 were performing nurse aide tasks without having completed a training and competency evaluation program, or a competency evaluation program approved by the State and were not in a state approved training and competency evaluation program. The findings included: The North Carolina (NC) Department of Health and Human Services (DHHS) Health Care Personnel Education and Credentialing Section's website indicated under the section of Nurse Aide I, last updated 1/24/24, that in accordance with federal law, a facility may employ a nurse aide (NA) for a period of up to 4 months under the following conditions: -During the 4-month grace period, an individual must be deemed competent to provide nursing or nursing-related services by a Registered Nurse and work toward meeting the training and testing requirements by participating in a state-approved Nurse Aide I training and competency evaluation program or a state-approved competency evaluation program. The website clarified that the individual must be actively participating in a state-approved Nurse Aide I training and competency evaluation program during the 4-month grace period. It further indicated the NC Nurse Aide I Registry was a registry of all people who met the state and federal training and testing requirements to perform Nurse Aide I tasks. a. Review of the facility records revealed Staff #1 was hired on 10/23/24. Review of Staff #1's human resource file revealed there was no evidence she had completed a state approved NA training and competency evaluation program, or a competency evaluation program approved by the State. Review of the nursing schedule dated 11/25/24 through 11/29/24 revealed Staff #1 was scheduled to work 8-hour shifts and was assigned NA tasks on 11/25/24, 11/26/24, 11/27/24, and 11/28/24. During an interview on 11/26/24 at 2:19 PM Staff #1 stated she moved to the United States (US) from another country. She further stated while in that other country, she worked as a certified NA. She stated she planned to apply to take the CNA certification test here as a challenge, as North Carolina (NC) did not recognize her certification from her country of origin. She verified she had not completed a state-approved nurse aide training and competency evaluation program or competency evaluation program and that she was not participating in a state approved training and competency evaluation program. b. Review of the facility records revealed Staff #2 was hired on 9/16/24. Review of Staff #2's human resource file revealed there was no evidence she had completed a state approved NA training and competency evaluation program, or a competency evaluation program approved by the State. Review of the nursing schedule dated 11/25/24 through 11/29/24 revealed Staff #2 was scheduled to work 8-hour shifts and was assigned NA tasks on 11/25/24, 11/26/24, 11/27/24, and 11/28/24. During an interview on 11/26/24 at 3:25 PM with Staff #2 he stated he moved to the US from another country. He stated he worked in a hospital in his country of origin as a caregiver, providing direct patient care. He further stated he is registered to begin a CNA certification program in December 2024. He verified he had not completed a state-approved nurse aide training and competency evaluation program or competency evaluation program and that he was not participating in a state approved training and competency evaluation program. An initial interview was conducted on 11/26/24 at 12:03 PM with the Business Administrator, who was also in charge of Human Resources. She stated she thought nurse aides could work if they were in competency skills training at the facility. In a subsequent interview on 11/26/24 at 3:33 PM she explained her role in the hiring process. This included checking the nurse aide registry for certification and placing the information in a folder. The Director of Nursing (DON) retrieves the folder and was responsible for following up on certification status. An interview was conducted with the Director of Nursing (DON) on 11/26/24 at 3:44 PM. She indicated if a potential NA hire did not have a CNA certification, she talked to them about enrolling in CNA school. She stated she was aware Staff #1 and Staff #2 were not certified as CNAs, however she was aware Staff #1 planned to take a challenge exam and Staff #2 was registered to begin a CNA certification program in December 2024. During an interview on 11/27/24 at 12:43 PM with the Administrator she stated if an NA did not have certification, the facility informed them they needed to register for a class within the 4-month period from date of hire. She further stated if they did not complete the class or get their certification within 4 months the employee was let go. She indicated she was unaware the regulation required an NA who had not completed a state-approved training and competency evaluation program and/or competency evaluation program to be actively participating in a state-approved Nurse Aide I training and competency evaluation program or a state-approved competency evaluation program.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of Gradual Dose Reduction (Residents #16 and #13) and Restraints (Resident #8) for 3 of 12 residents reviewed. Findings included: 1. Resident #13 was admitted on [DATE] with diagnoses including dementia and major depressive disorder. A psychiatric Nurse Practitioner progress note dated 10/03/24 recorded Resident #13 was to continue taking quetiapine (an antipsychotic medication used to treat mental health conditions) 25 milligrams (mg) and apriprazole 2.5 mg. Her medications were reviewed for possible Gradual Dose Reduction (GDR- to reduce the dose or discontinue the medication) of psychotropics (includes several classifications of medications used to treat mental illness), and it was noted a GDR was not recommended at that time. Review of Resident #13's October 2024 Medication Administration Record revealed she had received quetiapine and aripiprazole daily. Resident #13's significant change MDS assessment dated [DATE] indicated she had received antipsychotic medication routinely and a GDR had not been documented by a physician as clinically contraindicated. The date when a GDR review was completed and not recommended was blank. In an interview on 11/27/24 12:30 PM, MDS Nurse #1 said the information provided by the psychiatric Nurse Practitioner should have been used in the MDS and it was an error to not indicate a GDR review was done and to leave the date it was done blank. 2. Resident #16 was admitted on [DATE] with diagnoses including dementia and bipolar disorder. A psychiatric Nurse Practitioner progress note dated 10/22/24 recorded Resident #16 was to continue taking apriprazole (an antipsychotic medication used to treat mental health conditions) 5 milligrams (mg) in the morning and 2 mg at bedtime. Her medications were reviewed for possible Gradual Dose Reduction (GDR to reduce the dose or discontinue the medication) of psychotropics (includes several classifications of medications used to treat mental illness), and it was noted a GDR was not recommended at that time. Review of Resident #16's October 2024 Medication Administration Record revealed she had received aripiprazole twice daily. Resident #16's quarterly MDS assessment dated [DATE] indicated she had received antipsychotic medication routinely and a GDR had not been documented by a physician as clinically contraindicated. The date when a GDR review was completed and not recommended was blank. In an interview on 11/27/24 12:30 PM, MDS Nurse #1 said the information provided by the psychiatric Nurse Practitioner should have been used in the MDS and it was an error to not indicate a GDR review was done and to leave the date it was done blank. 3. Resident # 8 was admitted to the facility on [DATE] with diagnoses including depression and heart failure. Resident #8's annual Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact, had no behaviors, and needed assistance with bed mobility and transfers. The MDS also documented that Resident #8 had bed rails used as a physical restraint daily during the observation period. Review of Resident #8's physician's orders from 7/1/24-11/27/24 did not reveal an order for bed rails as a restraint. Review of Resident #8's progress notes from 7/1/24-11/27/24 did not reveal notes that he had any behaviors or any indications of a need for a restraint. The notes did not document that a restraint was used. In an interview on 11/27/24 12:30 PM, MDS Nurse #1 said Resident #8 did not use bed rails as a restraint and the MDS was coded in error. She said Resident #8 used his bed rails for mobility and assistance for bed mobility and transfers. In an interview on 11/27/24 at 8:50 AM, the Director of Nurses (DON) said Resident #8 did not use his bed rails as a restraint and the MDS was coded incorrectly.

Based on a review of the facility arbitration agreement and staff interview, the facility failed to allow residents/resident representatives the right to choose whether or not to enter into a binding arbitration agreement when they required a binding arbitration agreement to be signed as a condition of admission to the facility and as a requirement to continue to receive care. This agreement was provided in the admission packet and was required to be signed during the admission process and it remained in effect throughout a residents stay at any level of care within the continuing care community. This affected all facility residents. The findings included: A review of the facility's admission packet titled, Resident Agreement Continuing Care Contract 2023/2024 was conducted on 10/23/2023. The arbitration agreement read in part, In the event either party wishes to seek the enforcement of any remedy or bring any claim arising from or otherwise related to this Agreement of to the [Facility], the parties shall submit the matter to binding arbitration . During the entrance conference on 10/23/2023 at 10:21 AM, the Administrator stated the facility did not have binding arbitration agreements. A follow up interview with the Administrator was completed on 10/23/2023 at 1:45 PM. The Administrator stated the arbitration agreement in the admission packet did not apply to the residents on the healthcare side of the facility in certified nursing home beds within continuing care community. She further stated that the residents on the healthcare side signed a new contract, and it did not contain an arbitration agreement. An interview was conducted with the Executive Director on 10/23/2023 at 1:55 PM. The Executive Director stated everyone signed the arbitration agreement when they signed up to live at the continuing care community. She further stated that either she or the Marketing Specialist were responsible for getting the contracts signed prior to admission. The Executive Director explained that the facility had been using the same arbitration agreement for [AGE] years. The Executive Director indicated the Marketing Specialist was unavailable at this time. A follow-up interview was conducted with the Executive Director on 10/24/2023 at 09:48 AM. The Executive Director stated she wanted to clarify that the residents were still bound by the arbitration contract when they were in the healthcare unit in certified nursing home beds. She indicated the Marketing Specialist was still unavailable. An interview was conducted with the Administrator on 10/26/2023 at 1:31 PM. The Administrator stated that she had not realized that the arbitration agreement applied to the residents on the healthcare unit. She further stated she had not been aware they were out of compliance with the regulation.

Based on record review of the facility arbitration agreement and staff interviews, the facility failed to provide an arbitration agreement that provided for 1) a selection of a neutral arbitrator agreed upon by both parties and 2) the selection of a venue that was convenient to both parties. This agreement was provided in the admission packet and was required to be signed during the admission process and it remained in effect throughout a residents stay at any level of care within the continuing care community. This affected all facility residents. Findings included: A review of the facility's admission packet titled, Resident Agreement Continuing Care Contract 2023/2024 was conducted on 10/23/2023. The arbitration agreement read in part, In the event either party wishes to seek remedy or bring any claim arising from or otherwise related to this Agreement or to [Facility], the parties shall submit the matter to binding arbitration . It further read in part, Should arbitration between the parties become necessary or ensue, the parties agree that Wake County, North Carolina is a convenient forum and the only forum selection . The agreement listed, Without waiving the arbitration provisions of this agreement, the parties agree that, should litigation between the parties for any reason becomes necessary or ensues, state courts located in Wake County, North Carolina and the federal courts for the Eastern District of North Carolina are convenient forums and are the only forums in which a claim arising from or related to [Facility] may be filed, or litigated, and both parties submit to the jurisdiction of these courts and waive their right to commence or maintain litigation in any other forum. During the entrance conference on 10/23/2023 at 10:21 AM, the Administrator stated the facility did not have binding arbitration agreements. A follow up interview with the Administrator was completed on 10/23/2023 at 1:45 PM. The Administrator stated the arbitration agreement in the admission packet did not apply to the residents on the healthcare side of the facility in certified nursing home beds within the continuing care community. She further stated that the residents on the healthcare side signed a new contract, and it did not contain an arbitration agreement. An interview was conducted with the Executive Director on 10/23/2023 at 1:55 PM. The Executive Director stated everyone signed the arbitration agreement when they signed up to live at the continuing care community. She further stated that either she or the Marketing Specialist were responsible for getting the contracts signed prior to admission. The Executive Director explained that the facility had been using the same arbitration agreement for [AGE] years and was unaware that the regulation required the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that was convenient to both parties. She indicated the Marketing Specialist was unavailable at this time. A follow-up interview was conducted with the Executive Director on 10/24/2023 at 09:48 AM. The Executive Director stated she wanted to clarify that the residents were still bound by the arbitration contract when they were in the healthcare unit in certified nursing home beds. She indicated the Marketing Specialist was still unavailable. An interview was conducted with the Administrator on 10/26/2023 at 1:31 PM. The Administrator stated that she had not realized that the arbitration agreement applied to the residents on the healthcare unit. She further stated she had not been aware they were out of compliance with the regulation as their agreement did not provide for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that was convenient to both parties.

Based on record review and staff interviews the facility failed to electronically submit complete and accurate Registered Nurses hours based on payroll data to the Centers for Medicare and Medicaid (CMS) for the third quarter of 2023. Findings included: The payroll-based journal staffing report triggered for no Registered Nurses hours on four or more days. A review of the staffing sheets did not include Registered Nurses who were in the building 16 out of 92 days reviewed. A review of the payroll for those days revealed that there were Registered Nurses in the building for 8 consecutive hours on those days. An interview with the Director of Nursing on 10/26/23 at 10:40 AM revealed that she used to input the information into the payroll-based journal but that she no longer did the Administrator now completed that task, she was unable to state as to when the Administrator started inputting the data. She further revealed that she had used the staffing sheets to input the data. An interview with the Administrator on 10/26/23 at 11:25 AM indicated that she now puts in the data for the payroll-based journal, and she used the staffing sheets to ensure accuracy. She further indicated that there would be a continuous check to ensure that the Registered Nurses hours were accurately included in the payroll-based journal.

Based on record reviews and staff interviews the facility failed to follow a resident's care plan for transfers for 1 out of 22 residents reviewed (Resident #19). Findings included: Resident # 19 was admitted into the facility on [DATE] with diagnoses that included Alzheimer's dementia. A review of Resident #19's most recent comprehensive care plan dated 9/20/23 stated that she was a 1 person assist with transfers via mechanical lift. Resident #19's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired and was totally dependent on one staff member for transfers. On 10/25/23 at 9:28 AM an interview with Nursing Assistant #3, who was caring for Resident #19 that day, revealed that she transferred Resident #19 using a stand pivot transfer. When asked if she knew that it was care planned for a mechanical lift, she stated yes but that Resident #19 did not like the mechanical lift and Resident # 19 was able to stand long enough to complete a stand-pivot transfer. An interview with Nursing Assistant #4 conducted on 10/25/23 at 9:35 AM indicated that she used a stand pivot transfer when transferring Resident #19 from the bed to chair or chair to bed. When she was asked if she knew what the plan of care stated regarding transfers, she stated yes but that Resident #19 did not like the mechanical lift, and she was easy to transfer using the stand pivot method. An interview with the Director of Nursing on 10/25/23 at 10:10 AM revealed that she thought the plan of care stated that Resident #19could be either a stand-pivot or mechanical lift transfer and that staff should follow the plan of care. She further revealed that while two staff were the preference during a transfer with a mechanical lift one staff member was acceptable. An interview with the Administrator on 10/26/23 at 10:30 AM indicated that staff should always follow the plan of care in all areas of patient care including transfers

Based on record review, staff and family interviews the facility failed to provide a written summary of the baseline care plan to the resident or family in 2 out of 2 residents (Resident # 21 and Resident #7). Findings included: 1a. Resident #21 was admitted into the facility on [DATE] with diagnoses including: dementia and anxiety. A review of Resident 21's admission Minimum Data Set (MDS) dated [DATE] revealed she had severe cognitive impairment. An interview conducted on 10/25/23 at 11:25 AM with her Family Member indicated the Family Member had not received a copy or a summary of the base line care plan, she was informed of and did attend the comprehensive care plan meeting. 1b. Resident #7 was admitted into the facility on [DATE]. A review of Resident #7's admission MDS dated [DATE] revealed he was cognitively intact. An interview conducted with Resident #7 on 10/25/23 at 10:45 AM indicated he went to the comprehensive care plan meeting but he had not received a copy or summary of his baseline care plan. He further explained the baseline care plan had not been reviewed with him either. A telephone interview with the MDS Coordinator conducted on 10/25/23 at 1:52 PM revealed the MDS Coordinator verbally goes over the resident's baseline care plan with the resident and/or family but she does not provide a summary or a copy of the baseline care plan. An interview with the Director of Nursing conducted on 10/25/23 at 2:15 PM revealed she thought the MDS Coordinator went over the baseline care plan verbally with the resident and/or family and was not aware that a copy or summary of the baseline care plan was to be provided to the family and/or resident. An interview with the Administrator was conducted on 10/26/23 at 11:30 AM and revealed she was aware that the MDS Coordinator went over the baseline care plan verbally with the resident and/or their family. She further revealed in the future a copy or summary would be given either in person, email or mailed to the resident or family.

Based on observations, staff interviews and record review, the facility failed to implement their policy for COVID-19 vaccinations and to meet the requirement for staff vaccinations when Nursing Assistant (NA) #1 and NA #2 worked without being fully vaccinated and without an exemption. This was for 2 of 7 staff members reviewed for COVID-19 vaccinations. The facility was in outbreak status from 6/11/22 to 7/9/22 and had 4 resident infections from 6/11/22 through 6/20/22 (Residents #14, #16, #22 and #4) with one of those residents experiencing a hospitalization (Resident #16). Immediate Jeopardy began 6/16/2022 when Resident #16 tested positive for COVID-19, was admitted to the hospital for pneumonia related to COVID-19, and was the third resident to test positive for COVID-19 since 6/11/2022. Immediate Jeopardy was removed on 7/15/2022 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place are effective and to complete employee in-service training. Findings included: The facility's COVID-19 testing documentation revealed there were four resident infections from 6/11/22 through 6/20/22 (Residents #14, #16, #22 and #4) with 1 of those residents experiencing a hospitalization (Resident #16). a. Resident #22 tested positive for COVID-19 on 6/11/2022 and remained in the facility. b. Resident #16 tested positive for COVID-19 on 6/16/2022 and was admitted to the hospital on 6/16/2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Resident #16 improved and returned to the facility on [DATE]. c. Resident #14 tested positive for COVID-19 on 6/16/2022 and remained in the facility. d. Resident #4 tested positive for COVID-19 on 6/19/2022 and remained in the facility. A review of records revealed the facility began an outbreak on 6/11/2022 and remained in outbreak until 7/9/2022. 1. The facility COVID-19 Vaccination Policy, undated, stated employees were required to be fully vaccinated (2 weeks or more since they completed a primary vaccination series for COVID-19 was defined as the administration of a single dose vaccine, or the administration of all required doses of a multi-dose vaccine) against COVID-19. The National Healthcare Safety Network (NHSN) data for the week ending 6/5/22 revealed the facility's recent percentage of staff who were fully vaccinated was 93.1 %. The COVID-19 staff vaccination matrix was provided by the facility Administrator on 6/27/22 and included all facility staff. Nursing Assistant (NA) #1 and NA #2 were each checked as a temporary delay per Center for Disease Control/new hire. a. The timecard sheets for NA #1 revealed the hire date was 5/9/22 and she had worked a regular work week (five days out of seven) every week since then. The daily staffing schedules for the week of 6/27/22 revealed NA #1 was scheduled as a Certified Nursing Assistant with specific assignments each day. NA #1 was observed on 6/27/2022 at 10:30 AM assisting Resident #15 with a bath. On 6/29/22 NA #1 was observed entering residents' rooms and carrying out breakfast trays at 8:30 AM and lunch trays at 12:40 PM. In an interview with NA #1 on 7/5/22, NA #1 stated she received her second dose of a multi-dose COVID-19 vaccine on 7/1/22. The Administrator stated in an interview on 6/29/22 at 2:30 PM, NA #1 received her first dose of a COVID-19 multi-dose vaccine on 5/24/22 and had not received her second dose of the vaccine yet. The Administrator stated NA #1 could have received her second dose as early as 6/23/2022. In a follow up interview on 7/5/22 at 3:45 PM, the Administrator stated NA #1 had received her second dose of a multi-dose COVID-19 vaccine on 7/1/22. The Administrator stated she realized she had filled out the vaccine matrix wrong and understood NA #1 should not have come to work with residents without being fully vaccinated. The Administrator stated she was responsible for vaccination of staff and ensuring staff were fully vaccinated prior to working. b. NA #2's timecard sheet revealed the date of hire was 6/15/22 and NA #2 had worked 6/15/22 through 6/22/22 and returned to work 7/1/22. In an interview on 7/5/22 at 1:43 PM, NA #2 stated she had gotten sick the week of 6/26/22 and had gone to her physician on 7/1/22 and the physician told her to wait at least one week before getting her second dose of the multi-dose COVID-19 vaccine due to an upper respiratory infection. She tested negative for COVID-19. NA #2 stated she had worked giving care to residents and had an assignment since she was hired on 6/15/22. The Administrator stated in an interview on 6/29/22 at 2:30 PM, NA #2 had received her first dose of a multi-dose COVID-19 vaccine on 5/27/22 and had not received her second dose of the vaccine yet. In an interview on 7/5/22 at 3:45 PM, the facility Administrator stated she realized she had filled out the vaccine matrix wrong and understood NA #2 should not have been hired without being fully vaccinated. The facility Administrator was notified of the Immediate Jeopardy on 7/13/22 at 2:24 PM. The facility provided an acceptable credible allegation on 7/15/22. The credible allegation: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance: Resident #22 tested positive for COVID-19 on 6/11/2022. Resident #14 tested positive for COVID-19 on 6/16/2022. Resident #16 tested positive for COVID-19 on 6/16/2022 and was admitted to the hospital on 06/16/2022. Resident #16 returned to facility on 6/21/2022 and has continued to improve. Hospital treatment included oxygen and [MEDICATION(S)] for inflammation and [MEDICATION(S)] on 6/18/2022 which is an antiviral often used in COVID-19 treatment. Resident #4 tested positive for COVID-19 on 6/19/2022. Nursing Assistant #1 was hired on 5/9/2022. NA #1 worked on 5/9/2022-5/12/2022, 5/14/2022-5/16/2022, 5/18/2022-5/20, 2022, 5/23/2022, 5/24/2022, 5/26/2022, 5/27/2022, 5/30/202-6/1/2022, 6/3/2022, 6/4/2022, 6/9/2022, 6/10/2022, 6/12/2022-6/14/2022, 6/16/2022, 6/18/2022, 6/19/2022, 6/21/2022,6/24/2022, 6/27-6/30/2022, 7/4/2022-7/7/2022, 7/9/2022, 7/13/2022. NA #1 received the first dose of a multi-dose COVID 19 vaccinations on 5/24/2022 and the second dose on 7/1/2022. NA #1 presented a religious exemption on 5/22/2022 and did not disclose a reason for being vaccinated 2 days later. NA #1 last worked on 7/13/2022. NA #1 has been removed from the facility's schedule until 7/15/2022. The facility policy states that all staff are required to be fully vaccinated by their first day of work or submit a negative test result dated no more than seven days prior to their first day of work, with subsequent weekly testing until the next vaccination clinic is held at the facility. Administrator ensured that NA #1 was tested upon hire and weekly. The policy created by the Administrator was not aligned with the regulation. The Administrator was responsible for ensuring the regulation was followed and that the facility policy aligned with the regulation. NA #2 was hired on 6/15/2022. NA #2 worked on 6/15/2022-6/17/2022, 6/20/2022, 6/21/2022, 7/1/2022, 7/11/2022 and 7/13/2022. NA #2 received the first dose of a multi-dose COVID-19 vaccination on 5/27/2002 and the second dose on 7/9/2022. NA #2 had a medical exemption for 7/1/2022-7/8/2022. NA #2 was eligible to receive a 2nd dose on 06/17/2022. NA #2 was out of the state 06/22/2022-6/30/2022. The medical exemption was written on 07-01-2022 by her physician related to an illness and NA #2 was advised to wait a week before getting her second vaccination. Administrator ensured that NA #2 was tested upon hire and weekly. NA #2 has been removed from the facility schedule until 7/23/2022. NA #2 last worked 07/13/2022. All residents are at risk as a result of the deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility has met the 100% staff vaccination rate requirement as of 7/14/2022. An audit was conducted by the Minimum Data Set Nurse and the Medical Records Clerk on 7/13/2022. The current vaccination policy will be revised by the Administrator on 7/14/2022 in accordance with the regulation and staff will be educated accordingly by the Director of Nursing and the Administrator beginning 7/14/2022. The education will be completed by 7/14/2022. All hiring managers will be educated by the Administrator on ensuring potential new hires are fully vaccinated as of 7/13/2022 prior to being scheduled to work. Alleged date of IJ removal 7/15/2022. On 7/15/22 it was confirmed there were no positive COVID-19 residents in the facility. Dates of previous residents' COVID 19 positive tests were confirmed. Hospital records of Resident #16 were reviewed, and treatment was confirmed. A review of staffing confirmed NA #1 and NA #2 were not scheduled to work until after 7/15/2022 (NA #1) and 7/23/2022 (NA #2). A review of COVID-19 vaccine cards for NA #1 and NA #2 revealed both NAs were fully vaccinated. A review of the facility policy for COVID-19 vaccination stated all staff were required to be fully vaccinated by their first day of work (2 weeks or more since they completed a primary vaccination series for COVID-19 is defined as the administration of a single dose vaccine, or the administration of all required doses of a multi-dose vaccine) against COVID-19. The facility was at 100% vaccination rate. The audit conducted by the Minimum Data Set Nurse and the Medical Records Clerk was a verbal audit and after interviewing the Medical Records Clerk, it was noted to be complete. The facility's immediate jeopardy removal date was validated as 7/15/2022.

Based on observation and staff interviews the facility failed to ensure that food items that had been opened were securely closed, labeled, and dated. The facility also failed to maintain equipment used to prepare, store, and serve food in a sanitary condition. This was evidenced by carts and equipment that had a heavy accumulation of grease and dark matter, items that were stained, and an item with areas that were rusted through the metal surface. This was evident in 2 of 2 kitchen observations. Findings included: An observation of the facility kitchen on 6/27/2022 at 10:03 AM revealed the following: 1. In the reach-in refrigerator, there were two small clear plastic bags of shredded yellow cheese that were opened and not labeled and dated. Both bags were also open and exposed to the air in the refrigerator. An observation of the facility kitchen on 6/29/2022 at 9:50 AM revealed the following: 2. a. On an open storage rack in the kitchen, 14 metal sheet pans were observed to have heavy accumulation of thick, black grease around all four sides of each of the sheet pans. b. Four plastic rolling bins in the kitchen that contained sugar, rice, flour, and seafood breader were observed. Each of the bins was observed to have food product in them and none of them are dated. Each of the bins were labeled. c. Three drains in the floor under 3 sinks that were labeled meat, poultry, vegetable were observed. Each of the three drains were open and were stained with dark brown matter. d. One drain in the floor under a worktable that holds juice equipment was observed. This drain did not have a line draining into it and was not being used. The drain was stained with dark brown matter and there was an empty plastic coffee mug in the drain. e. One can opener that was mounted on a metal worktable was observed to have a heavy accumulation of food on the blade of the can opener. f. A white plastic scoop that was used in the ice machine was observed to be heavily soiled. There were marks of dark black matter on the inside of the scoop. g. A large open metal cart that had the capacity to hold 10 sheet pans was observed positioned next to the stove area. The metal cart was observed to be soiled with a heavy accumulation of grease and dark matter. There were two areas on the lower ledge of the cart that were completely rusted through the metal surface. The dietary manager reported the cart is used to hold desserts, drinks, and cookies that were prepared for the residents and was currently being used in the kitchen to hold food and beverages for the residents. h. A large grey/black service cart that was made of heavy plastic was observed to have a divided area near the handle on the cart. The inside portion of the divided areas was observed to have a heavy accumulation of dark grey matter. i. A smaller grey/black service cart that was made of heavy plastic was observed also. This cart was also observed to have a divided area near the handle of the cart. The divided areas were stained with dark grey matter. j. One square rolling platform that held the racks for the dish machine and currently in use in the dish machine operation was observed to have some dark brown matter accumulated on the inside base of the rack. An interview with the dietary manager was conducted on 6/29/2022 beginning at 9:50 AM. She stated that all food items that have been opened should be labeled and dated. She also reported the large sheet pans probably need to be replaced because of the heavy accumulation of grease and dirt. She reported the sheet pans are used several times daily in preparation for resident meals and should be washed completely between each use. The dietary manager reported the open metal cart that can hold 10 large sheet pans was used to hold desserts, drinks, and cookies that were prepared for the residents and was currently being used in the kitchen to hold food and beverages for the residents. The dietary manager stated she was unaware when the food product was placed in each of the 4 bins and stated she was unaware the bins should be dated. The dietary manager stated the drains that were observed in the floor need to be cleaned to remove the stains. She also stated the can opener and the scoop used in the ice machine need to be cleaned. The dietary manager stated the large, open metal cart that was used to hold the food and beverage for residents will probably need to be replaced because the rusted areas cannot be repaired. And she reported the divided areas on both grey/black carts need to be cleaned. The dietary manager also stated the rolling platform in the dish machine area needs to be thoroughly cleaned. The dietary manager confirmed that these items, except for 1 floor drain, were currently being used in the daily preparation of food and beverages for the residents. She reported that each of these items were on the dietary routine cleaning schedule but was unable to specify when these items were most recently cleaned. A staff interview with the administrator on 6/30/2022 at 10:25 AM revealed that all opened food items in the kitchen should be stored, labeled, and dated according to regulations and all equipment should be maintained in a sanitary condition.

Based on observation and staff interview, the facility failed to maintain the area surrounding the cardboard dumpster free from trash and debris. This was evident in 1 of 1 observation of the dumpster area. The findings included: An observation of the cardboard dumpster area on 6/29/2022 at 09:50 AM revealed there was one dumpster on a concrete pad and the doors and lid to the cardboard dumpster were closed. Behind the cardboard dumpster were four large plastic cooking oil containers that were each enclosed in cardboard boxes. Each of the oil containers had the capacity to hold 35 lbs. of cooking oil. And each of the cardboard boxes that contained the jug-like containers were observed to be a dark blackish, brown color and were shriveled, wrinkled, saturated with oil and appeared to be in the process of decomposition and showed signs of rotting and decay. Interview with the dietary manager on 6/29/2022 at 09:50 AM revealed that she was unaware how long the oil containers in cardboard boxes had been in the area near the dumpster. She reported the cooking oil containers had come from the dietary department and had been delivered to the facility in the cardboard boxes. She reported someone from the dietary department probably put the containers in the dumpster area because each of the four containers was surrounded by cardboard. The dietary manager reported she did not know when the area was last cleaned, and she thought all departments worked together to keep the area surrounding the dumpster clean. Interview with the facility administrator on 6/30/2022 at 2:25 PM revealed that all departments in the facility work together to keep the dumpster area clean.

Based on record review and staff interviews the facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments for a resident (Resident #6) and failed to transmit an assessment for a resident (Resident #12). This was for 2 of 3 residents reviewed for Resident Assessment. The findings included: 1. Resident #6 was discharged from the facility on 2/16/22. Record review revealed no discharge MDS was completed for Resident #6. An interview was conducted with the MDS Nurse on 7/1/22 at 10:52 AM. She stated a discharge MDS should have been completed and transmitted for Resident #6. The nurse stated she began working at the facility on 4/16/22. She stated she was unaware the assessment had not been completed. During an interview with the Administrator on 7/1/22 at 3:14 PM she stated the former MDS Nurse left the facility in January. She reported the former MDS Nurse assisted on a part-time basis until a new MDS Nurse was hired in April. She stated completion of the Resident #6's discharge assessment must have been overlooked. 2. Resident #12 was discharged from the facility on 2/16/22. A discharge MDS dated [DATE] was completed but not transmitted for Resident #12. An interview was conducted with the MDS Nurse on 7/1/22 at 10:52 AM. She stated a discharge MDS was completed but not transmitted for Resident #12. The MDS Nurse stated the assessment should have been transmitted. She reported she transmitted assessments weekly. The nurse stated she began working at the facility on 4/16/22. She stated she was unaware the assessment had not been transmitted. During an interview with the Administrator on 7/1/22 at 3:14 PM she stated the former MDS Nurse left the facility in January. She reported the former MDS Nurse assisted on a part-time basis until a new MDS Nurse was hired in April. She stated transmission of the assessment must have been overlooked.

Based on record review and staff interviews, the facility failed to complete an annual resident comprehensive assessment for 1 of 9 residents assessments reviewed. (Resident #174) Findings Included: Resident #174 was admitted to the facility on [DATE]. Four consecutive quarterly assessments were completed on Resident #174 with the most recent quarterly assessment dated [DATE]. The last annual comprehensive assessment was dated 3/1/2020. On 3/16/2021 at 2:16pm in an interview with the Minimum Data Set Coordinator, she stated the quarterly assessment dated [DATE] should had been an annual comprehensive assessment. When asked if there was a reason the quarterly assessment was completed instead of the annual comprehensive assessment, she was unable to provide a reason and stated, I missed it. On 3/16/2021 at 2:59pm in an interview with the Administrator, she stated there was a regulated schedule for the facility to follow when conducting assessments on residents. She stated the quarterly assessment dated [DATE] should had been an annual comprehensive assessment.

Based on staff interviews and observations, the facility failed to protect residents from COVID-19 when they did not restrict visitors and follow guidance issued by the Centers for Medicare and Medicaid Services (CMS). This failure occurred during a COVID-19 pandemic. Findings included: The Center for Medicare and Medicaid Services issued a memorandum on Guidance for Infection Control and Prevention of Coronavirus Disease 2019 on March 13, 2020 (Reference QSO-20-14-NH). The memorandum stated facilities should restrict visitation of all visitors and non-essential heath care personnel except for certain [MEDICATION NAME] care situations, such as an end-of-life situation. A tour of the skilled nursing side of the facility was conducted on 6/17/20 at 11:00 AM. A wall was observed which consisted of dry wall on the lower portion of the wall, plexiglass in the center of the wall and plastic reaching to the ceiling. The wall was sectioned off by wood beams to create a 3-section sitting area. A table and chair were placed at 2 of the sections. Chairs had been placed on the other side of the wall. Baby monitors were placed on both sides which were used for communication between visitor and resident. An interview was conducted with the Director of Nursing on 6/17/20 at 11:30 AM, and she stated staff could take a resident to the constructed wall, place the resident facing the visitor, and they are instructed on how to use the baby monitor. An interview was conducted with the owner of the facility on 6/17/19 at 12:43, and she stated she had the wall erected for the main purpose of facilitating visitations. She also stated she had it built late April early May and it had been used in the last week for visitation. An interview was conducted with the administrator on 6/19/20 at 10:00 AM, and she stated the owner wanted the wall up, and it was used for visitation.

Based on record review and staff interviews, the facility failed to include a nursing assistant in care plan meetings for 14 of 14 residents (Resident #8, Resident #41, Resident #42, Resident #27, Resident #20, Resident #24, Resident #28, Resident #38, Resident #15, Resident 25, Resident #37, Resident 36, Resident #7, Resident #46). Findings included: 1. Review of Resident #8 medical record indicated she was admitted in the skilled facility on 05/18/2017. Her [DIAGNOSES REDACTED]. Review of the resident's interdisciplinary care plan conference dated 08/30/2017 indicated there was no nursing assistant present for the conference. 2. Review of Resident #41's medical record indicated he was admitted in the skilled facility on 03/22/2017. His [DIAGNOSES REDACTED]. Review of the resident's quarterly interdisciplinary care plan conference dated 07/01/2017 indicated there was no nursing assistant present for the conference. 3. Review of Resident #42's medical record indicated he was readmitted in the skilled facility on 06/20/2017 with [DIAGNOSES REDACTED]. Review of the resident's interdisciplinary care plan conference dated 07/02/2017 indicated there was no nursing assistant present for the conference. 4. Review of the Resident #27's medical record indicated he was admitted in the skilled facility on 07/28/2017 following a hospitalization for pneumonia. Review of the resident's interdisciplinary care plan conference dated 08/16/2017 indicated there was no nursing assistant present for the conference. 5. Review of Resident #20 medical record indicated he was admitted in the skilled facility on 04/05/2017. His [DIAGNOSES REDACTED]. Review of the resident's interdisciplinary care plan conference dated 04/15/2017 indicated there was no nursing assistant present for the conference. 6. A review of medical records revealed Resident #24 was admitted [DATE] with [DIAGNOSES REDACTED]. A review of the resident's medical record revealed [REDACTED].#24 on 6/5/2017. There was no nursing assistant present at the meeting. 7. A review of medical records revealed Resident #28 was admitted [DATE] with [DIAGNOSES REDACTED]. A care plan meeting was held on 4/10/2017 for Resident #28 and was attended by the Director of Nursing, Social Worker, Activities Director and Dietary Manager. No Nursing Assistant was present. 8. Record review indicated Resident #38 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the interdisciplinary Care Plan meeting dated 8/23/2017 revealed a Nursing Assistant was not present for the meeting. 9. Record review indicated Resident #15 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the interdisciplinary Care Plan meeting dated 7/10/2017 revealed a Nursing Assistant was not present for the meeting. 10. Record review indicated Resident #25 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the interdisciplinary Care Plan meeting dated 9/16/2017 revealed a Nursing Assistant was not present for the meeting. 11. Record review indicated Resident #37 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the interdisciplinary Care Plan meeting dated 9/27/2017 revealed a Nursing Assistant was not present for the meeting. 12. Record review indicated Resident #36 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the interdisciplinary Care Plan meeting dated 6/12/2017 revealed a Nursing Assistant was not present for the meeting. 13. Record review indicated Resident #7 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the interdisciplinary Care Plan meeting dated 5/31/2017 revealed a Nursing Assistant was not present for the meeting. 14. Record review indicated Resident #46 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the interdisciplinary Care Plan meeting dated 8/13/2017 revealed a Nursing Assistant was not present for the meeting. In an interview with the Director of Nursing (DON) on 09/14/2017 at 2:55 PM, she stated the Social Worker (SW) and the Minimum Data Set (MDS) Coordinator were responsible for scheduling care plan conferences. The DON also stated she heard of new changes regarding the meetings, but they were not implemented yet in the facility. In an interview with the facility SW on 09/14/2017 at 3:00 PM, the SW stated it was part of her responsibility to coordinate and schedule care plan meetings. The SW also stated she was aware of the new changes, but they had not made the changes yet. In an interview with the MDS Nurse on 09/14/2017 at 3:05 PM, he stated he was partially responsible for implementing the new changes which required a nursing assistant to participate in care plan meetings, but this had not been implemented yet in the facility.

Based on observations, record review and staff interviews, the facility failed to comprehensively assess side rails for 5 of 23 residents reviewed (Residents #15, #38, #36, #24 and #28), and failed to comprehensively assess 1 of 23 residents reviewed for contractures/range of motion (Resident #24). Findings included: Side Rails- 1-Record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive assistance of 1 person with all activities of daily living (ADLs). The MDS indicated the resident did not have restraints or side rails. An observation of Resident #15 on 9/12/2017 at 9:20 AM revealed the resident was lying in bed with half side rails raised on each side of the bed. Observations were made of Resident #15 on 9/12/ at 2:50 PM, 9/13/2017 at 10:29 AM and 9/13/2017 at 2:10 PM. The resident was in bed during each observation, and side rails were in the same position as the first observation on 9/12/2017 at 9:20 AM. An interview was conducted with the MDS Nurse on 9/13/2017 at 10:45 AM. The MDS nurse stated the basis for the information used for the restraint section of the MDS assessments came from the state level several years ago. The MDS nurse indicated if the side rails were half, quarter, or grab bars, they were not coded as restraints. The MDS nurse indicated even if the rails were used for a safety intervention for falls, any rails half-length or less were not considered restraints, and did not need to be coded on the MDS. An interview was conducted with the Director of Nursing (DON) on 9/13/2017 at 2:15PM. The DON stated the facility did not code any rails as restraints because they thought only full rails were considered restraints. The DON reported the facility did use the half rails for safety to help prevent the residents from falling out of bed. The DON stated the expectation was all residents were accurately assessed and the MDS assessments contained correct information. 2-Record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive MDS dated [DATE] indicated the resident was severely cognitively impaired and required extensive to total assist of 1 person with all ADLs. The MDS indicated the resident had no restraints or side rails. An observation of Resident #38 was made on 9/11/2017 at 2:45PM. The resident was observed in bed with half side rails raised on each side of the bed. The resident was sleeping during the observation. On 9/13/2017 at 1:40PM an observation was made of the resident. The resident was in bed and the half side rails were raised on each side of the bed. An interview was conducted with the MDS Nurse on 9/13/2017 at 10:45 AM. The MDS nurse stated the basis for the information used for the restraint section of the MDS assessments came from the state level several years ago. The MDS nurse indicated if the side rails were half, quarter, or grab bars, they were not coded as restraints. The MDS nurse indicated even if the rails were used for a safety intervention for falls, any rails half-length or less were not considered restraints, and did not need to be coded on the MDS. An interview was conducted with the Director of Nursing (DON) on 9/13/2017 at 2:15PM. The DON stated the facility did not code any rails as restraints because they thought only full rails were considered restraints. The DON reported the facility did use the half rails for safety to help prevent the residents from falling out of bed. The DON stated the expectation was all residents were accurately assessed and the MDS assessments contained correct information. 3-Record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed the resident was rarely/never understood and required extensive to total assist of 1 to 2 people with all ADL's. The MDS indicated the resident did not have side rails or restraints. An observation was conducted on 9/11/2017 at 3:31PM and revealed the resident to be resting in bed. There were half side rails on each side of the bed, and both rails were raised. An observation was conducted of the resident on 9/12/2017 at 11:42AM and revealed the resident resting in bed. The side rails were raised. An interview was conducted with the MDS Nurse on 9/13/2017 at 10:45 AM. The MDS nurse stated the basis for the information used for the restraint section of the MDS assessments came from someone at the state level several years ago. The MDS nurse indicated if the side rails were half, quarter, or grab bars, they were not coded as restraints. The MDS nurse indicated even if the rails were used for a safety intervention for falls, any rails half-length or less were not considered restraints, and did not need to be coded on the MDS. An interview was conducted with the Director of Nursing (DON) on 9/13/2017 at 2:15PM. The DON stated the facility did not code any rails as restraints because they thought only full rails were considered restraints. The DON reported the facility did use the half rails for safety to help prevent the residents from falling out of bed. The DON stated the expectation was all residents were accurately assessed and the MDS assessments contained correct information. 4. A review of medical records revealed Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #24 to be severely impaired for cognition and needed extensive to total assistance for all Activities of Daily Living (ADLs) with the physical assistance of one to two persons. The MDS noted no restraints present. A review of the Weekly Nursing Summary from May 2 through September 12, 2017 noted the assessment for restraints to be upper half rails, when in bed, for safety. On 9/13/2017 at 2:15 PM, the Director of Nursing stated her expectation was all assessments would be complete and accurate. 5. A review of medical records revealed Resident #28 was admitted [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #28 to be severely impaired for cognition and needed total assistance for all Activities of Daily Living (ADLs), with the physical assistance of one person. The MDS noted no restraints were used. On 9/13/2017 at 2:15 PM, the Director of Nursing stated her expectation was all assessments would be complete and accurate. Contractures: 1.A review of medical records revealed Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #24 to be severely impaired for cognition and needed extensive to total assistance for all Activities of Daily Living (ADLs) with the physical assistance of one to two persons. The MDS noted no impairment for functional range of motion in the upper or lower extremities. The care plan dated 5/30/2017 noted a focus of potential for further contractures with a notation the family denied therapy services for contractures, this notation was undated. The goal was to maintain skin integrity. The intervention was therapy to assess for contracture management. A review of the Weekly Nursing Assessments from 5/2/2017 through 9/12/2017 revealed no contractures in each weekly summary. On 9/14/2017 at 11:02 AM, in an interview, Nurse #1 walked into the room where Resident #24 was sitting in a chair. Nurse #1 stated Resident #24 did not have contractures, but would have contractures if nothing was done about her hands. Nurse #1 stated Resident #24 had only had this hand problem for about two weeks. A review of the therapy services screening form revealed Resident #24 had bilateral hand contractures and due to behaviors was not a candidate for therapy at that time. The form was dated 4/12/2017. On 9/14/2017 at 2:30 PM, the Administrator stated the expectation was that assessments would be accurate and comprehensive.

Based on observations, record review and staff and family interviews, the facility failed to identify the use of loose side rails as an accident hazard for 5 of 23 residents reviewed for accidents which resulted in the risk for entrapment (Residents #15, #38, #36, #24 and #28). Findings included: 1-Record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive assistance of 1 person with all activities of daily living (ADLs). The MDS indicated the resident did not have functional limitations in upper or lower extremities. An observation of Resident #15 on 9/12/2017 at 9:20 AM revealed the resident was lying in bed with half side rails raised on each side of the bed. The bed was observed with a concaved mattress with the sides of the mattress raised approximately 2 inches above the concave. There was a 3.5 to 4 inch gap observed between the side rails and the mattress. The side rails were loose on both sides of the bed. The resident was awake and moved her arms from the side of her body and rested them on her abdominal area during the observation. Observations were made of Resident #15 on 9/12/ at 2:50 PM, 9/13/2017 at 10:29 AM and 9/13/2017 at 2:10 PM. The resident was in bed during each observation, and the mattress and side rails were in the same position as the first observation on 9/12/2017 at 9:20 AM. An interview was conducted with the Director of Nursing (DON) on 9/13/2017 at 2:15PM. The DON stated she was unaware of any possible side rail hazards in the facility. The DON accompanied this surveyor to Resident #15's room and observed the resident in bed with the side rails raised. The DON observed the rails to be loose and observed the 3 to 4 inch space between the rails and the mattress. The DON indicated the space was a possible safety hazard. The DON stated the expectation was for all side rails to fit securely with no space between the rails and the mattress. 2-Record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive MDS dated [DATE] indicated the resident was severely cognitively impaired and required extensive to total assist of 1 person with all ADLs. The MDS indicated the resident had no impairment to upper or lower extremities. An observation of Resident #38 was made on 9/11/2017 at 2:45PM. The resident was observed in bed with half side rails raised on each side of the bed. Both of the side rails were loose and there was a 3 to 4 inch space between the mattress and the rail on the right side. No space was observed between the mattress and the rail on the left side. The resident was sleeping during the observation. On 9/12/2017 at 11:22AM an interview was conducted with the resident's family member. The family member was in the resident's room sitting with the resident. The resident was in a wheelchair. The family member reported the side rails on the resident's bed would loosen and the staff would tighten them. The family member reported the resident never sustained an injury due to the loose rails. The family member stated he never noticed a space between the rails and the mattress. An observation was made on 9/12/2017 at 4:10PM of Resident #38 lying in bed. The side rails were up on both sides and were loose. There was a 3 to 4 inch space between the right side rail and the mattress. On 9/13/2017 at 1:40PM an interview was conducted with the resident's family member. The family member was in the resident's room sitting with the resident. The resident was in bed. The family member reported the side rails on the resident's bed were often loose and the staff would tighten them. The family member reported the resident never sustained an injury due to the loose rails. The family member stated he never noticed a space between the rails and the mattress. An interview was conducted with the Director of Nursing (DON) on 9/13/2017 at 2:15PM. The DON stated she was unaware of any possible side rail hazards in the facility. The DON accompanied this surveyor to Resident #38's room and observed the resident in bed with the side rails raised. The DON observed the rails to be loose and observed the 3 to 4 inch space between the right rail and the mattress. The DON indicated the space was a possible safety hazard. The DON stated the expectation was for all side rails to fit securely with no space between the rails and the mattress. 3-Record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed the resident was rarely/never understood and required extensive to total assist of 1 to 2 people with all ADL's. An observation was conducted on 9/11/2017 at 3:31PM and revealed the resident to be resting in bed. There were half side rails on each side of the bed. Both rails were loose and there was a 3 to 4 inch space between the left rail and the mattress. An observation was conducted of the resident on 9/12/2017 at 11:42AM and revealed the resident to be resting in bed. The side rails were in the same condition as the day before. An interview was conducted with the Director of Nursing (DON) on 9/13/2017 at 2:15PM. The DON stated she was unaware of any possible side rail hazards in the facility. The DON stated the expectation was for all side rails to fit securely with no space between the rails and the mattress. 4. A review of medical records revealed Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #24 to be severely impaired for cognition and needed extensive to total assistance for all Activities of Daily Living (ADLs) with the physical assistance of one to two persons. The MDS noted no restraints present. On 9/12/2017 at 2:30 PM, Resident # 24 was observed lying in bed with side rails raised. There was a gap of three and one fourth inches between the side rail and the mattress. The side rail was loose and did not fit the bed. A review of the Weekly Nursing Summary from May 2 through September 12, 2017 noted the assessment for restraints to be upper half rails, when in bed, for safety. On 9/13/2017 at 2:15 PM, the Director of Nursing stated her expectation was all side rails would fit the beds appropriately with no space between the mattress and the rail. 5. A review of medical records revealed Resident #28 was admitted [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #28 to be severely impaired for cognition and needed total assistance for all Activities of Daily Living (ADLs), with the physical assistance of one person. The MDS noted no restraints were used. On 9/12/2017 at 11:44 AM Resident #28 was observed in bed with the half side rail raised. The side rail was very loose. The MDS nurse came into the room and tightened the rail with a knob located on the side of the bed rail. On 9/13/2017 at 2:15 PM, the Director of Nursing stated her expectation was all side rails would fit the beds appropriately with no space between the mattress and the rail.

Based on observations, record review and staff interviews, the facility failed to maintain dignity for 5 of 6 residents who needed assistance with feeding by standing over the residents while feeding them. (Residents #12, #18, #22, #24, #38). Findings included: 1. Review of the medical record of Resident #24 indicated she was admitted into the facility on [DATE]. Records also indicated the resident had a current [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident had severe cognitive impairment and required extensive assistance of one person for eating. During an observation on 10/18/2016 at 10:10 AM, Resident #24 was observed seated in a wheelchair in the hallway directly in front of the nursing station. At 10:15 AM, Nursing Assistant (NA) #1 was observed spoon feeding the resident a snack from a container. During the entire feeding which lasted 4 minutes, the NA stood directly over the resident. During the feeding, the NA was chatting with other staff members and not engaged with the resident. During an observation on 10/19/2016 from 10:15 AM to 10:22 AM, Resident #24 was observed seated in a wheelchair in the resident lounge directly across from the nursing station. At 10:15 AM, NA #2 was observed spoon feeding the resident a snack while standing directly over the resident. During the feeding, the NA was chatting with other staff members and not engaged with the resident. 2. Review of the medical record of Resident #22 indicated the resident was admitted into the facility on [DATE]. Records also indicated the resident had a current [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident had severe cognitive impairment and required extensive assistance of one person for eating. During an observation on 10/18/2016 at 10:10 AM, Resident #22 was observed seated in a reclining chair in the lounge directly across from the nursing station. At 10:15 AM, the facility Director of Nursing (DON) was observed spoon feeding the resident a snack while standing directly in front of the resident. During an observation on 10/19/2016, Resident #22 was observed seated in a reclining chair in the lounge directly across from the nursing station. At 10:30 AM, NA #2 was observed feeding the resident a nourishment/snack. The NA stood directly in front of and over the resident during the feeding. During the feeding, the NA was chatting with other staff members and not engaged with the resident. 3. Review of the medical record of Resident #12 indicated the resident was admitted into the facility on [DATE]. Records also indicated the resident had a current [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident had severe cognitive impairment and required extensive assistance of one person for eating. During an observation on 10/18/2016 at 10:30 AM, Resident #12 was observed seated in a wheelchair in the hallway directly across from the nursing station. At 10:30 AM, the facility DON was observed spoon feeding the resident a snack. During the feeding, the DON stood directly over the resident. During an observation on 10/19/2016 at 10:30 AM, Resident #12 was observed seated in a wheelchair in the hallway directly across from the nursing station. At 10:38 AM, the facility DON was observed spoon feeding the resident a snack. During the feeding, the DON stood directly over the resident. 4. Review of the medical record of Resident #18 indicated the resident was admitted into the facility on [DATE]. Records also indicated the resident had a current [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident had severe cognitive impairment and required extensive assistance of one person for eating. During an observation on 10/19/2016, Resident #18 was observed seated in a reclining chair in the lounge directly across from the nursing station. At 10:35 AM, NA #2 stood over Resident #18 in the lounge and spoon fed the resident a snack standing directly in front of and over the resident's chair. 5. Review of the medical record of Resident #38 indicated the resident was admitted into the facility on [DATE]. Records also indicated the resident had a current [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident had severe cognitive impairment and required extensive assistance of one person for eating. During an observation on 10/18/2016, Resident #38 was observed seated in a reclining chair in the lounge directly across from the nursing station. At 10:20 AM, NA #2 stood over Resident #38 in the lounge and spoon fed the resident a snack standing directly in front of and over the resident's chair. During an interview with NA #1 on 10/20/2016 at 11:55M, the NA stated she received training on feeding residents when hired. The NA also stated she should be at eye level when feeding a resident. The NA also stated it might intimidate a resident if you stand over them while feeding them. The NA further stated she should have sat beside the resident's chair when feeding them the snack. During an interview with NA #2 on 10/20/2016 at 12:02 PM, the NA stated she received training on feeding residents when hired. The NA also stated she should be at eye level when feeding a resident. The NA further stated she should have sat beside the resident's chair when feeding them the snack. The facility Director of Nursing (DON) was interviewed on 10/20/2016 at 12:08 PM and stated all staff should sit or be at eye level and engaged with the resident during feeding. The DON further stated the facility focused on being seated beside a resident while feeding them in the dining room during meals and not on feeding them in other places in the facility. The DON also stated feeding the residents while standing over them and not engaging with them was not dignified.

Based on record review and staff interviews, the facility failed to use a mechanical lift during a transfer which resulted in an injury for 1 of 4 (Resident #11) sampled residents reviewed for accidents. Findings include: Resident #11 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #11's admission Minimum Data Set ((MDS) dated [DATE] indicated that Resident #11 was totally dependent on staff for transfers. Resident #11 was severely impaired in cognition. Review of the Resident Care Guide (a form which dictates the type of specialized care each resident needs) dated 10/24/12 showed a mechanical lift under additional information for Resident #11. Review of the Admission Nursing assessment dated [DATE] showed a non-weight bearing status for Resident #11. Review of the Weekly Nursing Summaries dated 10/31/12, 11/2/12, and 11/7/12 indicated that Resident #11 needed to be transferred using a specialized mechanical lift and not physically lifted by the staff. Review of the Nurses Notes dated 11/3/12 at 5:30 PM showed Nursing Assistant (NA) #1 had approached Nurse #1 to report that Resident #11 had received a large skin tear to the right leg during a transfer from the bed to a wheelchair. Bright red blood was noted dripping onto the floor and pressure was applied to the wound by Nurse #1. Emergency Medical Services (EMS) was called. Review of the Nurses Notes dated 11/3/12 at 5:40 PM indicated the arrival of EMS and the removal of pressure from the wound. On assessment a 3 inch by 3 inch "V" shaped laceration (cut) was noted to Resident #11's right calf by Nurse #1. The wound was bandaged and Resident #11 was transported by EMS to the Emergency Department (ED). Review of the Nurses Notes dated 11/3/12 at 7:45 PM showed that Nurse #1 received information from the ED staff that Resident #11 had received stitches (10) to the right calf to close the wound. Review of the Nurses Notes dated 11/3/12 at 9:30 PM showed Resident #11 was returned to the facility. Review of the Nurses Notes dated 11/3/12 at 10:00 PM indicated that NA #1 had not used a mechanical lift to transfer Resident #11 as required but had transferred Resident #11 by herself from the bed to a wheelchair. According to the note, NA #1 did not use the mechanical lift because there was no mechanical lift sign over Resident #11's bed. In an interview on 11/28/12 at 2:26 PM NA #2 stated that Resident #11 had needed a mechanical lift for transfer since admission on 10/24/12. She indicated there was a card (Resident Care Guide) in the Activities of Daily Living (ADL) book to show what assistance each resident needed. NA #2 stated she had been at the facility when Resident #11 had been admitted and had been informed at that time that a mechanical lift would be needed for transfers. In an interview on 11/29/12 at 9:27 AM Nurse #1 stated that Resident #11 was non-weight bearing and needed a mechanical lift for transfers. Nurse #1 indicated that this was NA #1's first time working with Resident #11. Nurse #1 stated that the transfer information was available hanging in the resident's closet, on the Resident Care Guide and also in the assignment book. She indicated that NA #1 should have looked for the information in the areas provided or asked the nurse prior to providing care to Resident #11 if she was not familiar with the resident. In an interview on 11/29/12 at 11:22 AM NA #3 stated she would look in the closet and on the Resident Care Guide to see if a resident needed one or two people to assist with transfers or needed a mechanical lift for transfers. She indicated the Resident Care Guide should be checked by the aide at the beginning of the shift to see if any changes to care had been made. NA #3 indicated that Resident #11 had needed a mechanical lift for transfers since admission. In an interview on 11/29/12 at 11:42 AM NA #4 indicated she would look in the assignment book which was kept at the nursing station or on the Resident Care Guide to see if special equipment was needed for transfers. She stated Resident #11 had been a mechanical lift transfer since admission. In an interview on 11/29/12 at 1:18 PM the Rehabilitation Manager stated Resident #11 had been a mechanical lift transfer since admission. He indicated Resident #11 was weak and could not bear weight on her legs. In an interview on 11/29/12 at 1:49 PM Nurse #2 indicated that Resident #11's stitches had been removed. The wound was still being bandaged and monitored by the nursing staff. In an interview on 11/29/12 at 2:10 PM the Director of Nursing (DON) stated it was her expectation that aides check the Resident Care Guide, look in the assignment book at the list of residents requiring mechanical lifts, or to ask the nurse for direction prior to transferring a resident. Multiple attempts over three days were made to contact NA #1. She was unavailable for interview.

Based on observations, staff interviews and record review, the facility failed to maintain the dignity of 1 of 3 sampled residents whose personal hygiene was observed. Findings include: 1. Resident # 18 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident # 18's care plan, dated 03/25/11, identified an inability to perform activities of daily living independently related to cognitive loss. The goal to have her needs met and to keep Resident # 18 clean, neat and well groomed daily would be achieved by routine nail care, morning and evening care and routine oral care. The approaches included to anticipate the resident's needs for activity of daily living assistance. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident # 18 was severely cognitively impaired. She was identified as totally dependent on staff for toilet use and personal hygiene. Rejection of care was not exhibited during the assessment period. Resident # 18 was coded as always incontinent of bowel and bladder. An observation was made of Nurse # 3 during medication pass at 3:45 PM on 10/18/11. Nurse # 3 entered Resident # 18's room. The nurse stated the resident had been playing in her brief again. Black matter was noted on 4 fingers of the resident's right hand. Nurse # 3 was observed giving the resident her medications and a liquid supplement. As the nurse was giving the medication which was mixed in pudding, she commented she had stool in her mouth. Nurse #3 continued to place the straw into her mouth and encouraged her to drink the chocolate supplement. Once she had given both the medication and the supplement she exited the room. Nurse # 3 did not offer mouth care before offering the supplement or completing medication pass. The nurse then exited the room and reported to the Nursing Assistant (NA) that Resident # 18 had "been down south again". The NA commented it was not any fun if it was not down south, went in another resident's room, stayed approximately 5 minutes and then went down the hall to another resident's room and shut the door. Resident # 18 remained soiled. The nurse stated the NA had to complete care on the resident he was assisting and then he would take care of Resident # 18. The nurse continued her medication pass. Resident # 18 remained soiled. An observation was made on 10/18/11 at 4:15 PM of Nursing Assistant (NA) # 2 providing incontinent care to Resident # 18. The NA cleaned the resident's perineum from front to back. The folded sheet used in moving the resident was on the bed. Brown stains were seen on the left side of the turn sheet and pencil eraser sized brown balls were seen on the right side of the turn sheet. NA # 2 identified the stains and balls as feces. Resident # 18's hand was laying in the brown smear on the left. Brown stains were seen under Resident # 18's fingernails and around the nail beds. The NA did not clean the resident's nails, nor did he provide oral care. The resident was dressed and placed in her wheelchair and taken to the lounge area. An interview was held with NA # 2 on 10/18/11 at 4:29 PM. NA # 2 stated he did not provide oral care and had cleaned Resident # 18's nails the best he could. The NA stated Nurse # 3 had informed him Resident # 18 had feces around her mouth. He added that was why he wiped her face. NA # 2 stated he did not provide oral care or clean under the resident's nails because Resident # 18 had no orange sticks or oral swabs in her room. He added these items were available in the facility. NA # 2 stated he could have gotten someone to retrieve those items in order to provide nail care and oral care for Resident # 18, but, he was not thinking. Nurse # 3 was interviewed at 5:00 PM on 10/18//. The nurse stated Resident # 18 had a habit of putting her hands in her brief and playing in her feces adding that Resident # 18 also put the feces in her mouth. Nurse # 3 stated that was what Resident # 18 had done that afternoon. She stated interventions provided by the facility included a consultant psychiatric assessment. Nurse # 3 stated she had seen what looked like feces on Resident # 18's chin but thought it was chocolate supplement. The nurse added when she touched the spot on Resident # 18's chin, the area was dried and did not move, so she figured it was feces. The nurse stated she continued to give the resident medications and the supplement. Nurse # 3 stated she reported the incident to NA # 2 adding that he should have moved quicker in cleaning Resident # 18. The nurse added that since Resident # 18 smeared feces on her face and her chest, the NA should have washed the resident's hands and provided oral care. The nurse could offer no explanation as to why she did not offer to assist the resident with personal care, but after discussion stated she should have cleaned the resident. The Director of Nursing (DON) was interviewed at 5:10 PM on 10/18/11. Her expectations for this situation included the nurse stopping medication pass and assisting the resident by washing her hands and providing oral care prior to giving medication and supplements. The DON stated she expected the NA to provide oral care and clean the resident's nails to remove the feces. The DON added she thought the entire incident was disgusting. An observation was made of Resident # 18's hands at 5:34 PM on 10/18/11. Resident # 18 was sitting in the resident lounge. The resident's left hand had spots of brown matter with brown matter observed under the nails and around the nail beds. The right hand had brown specks of matter with brown matter under the nail and around the nail bed. The DON stated the nails should have been cleaned and oral care provided.

Based on staff interview and record review the facility failed to develop a care plan to address the care area trigger of Nutritional Status for 1 of 6 sampled residents (Resident #45) reviewed for nutrition concerns and failed to care plan behaviors for 1 of 4 sampled residents (Resident # 18) that exhibited behaviors. Findings include: 1. Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's documented [DIAGNOSES REDACTED]. The resident's Monthly/Weekly Weight Record documented she weighed 106.8 pounds on 01/03/11, 104.8 pounds in February 2011, and 100 pounds on 03/03/11. A 03/24/11 physician's orders [REDACTED]. The resident's April 2011 through October 2011 Medication Administration Records (MARs) documented the FYI (for your information), "Add ice cream to lunch and supper tray." The Care Area Assessment (CAA) Summary generated by Resident #45's 09/30/11 Significant Change Minimum Data Set (MDS) documented the care area Nutritional Status triggered, and was to be addressed in the resident's care plan. The resident's Nutritional Status CAA documented, "Resident is at risk for weight loss. Complicating factors include impaired cognition, refusal of care, bilateral hand ROM (range of motion), sleep pattern disturbance, confusion, possible sedative effects of [MEDICATION NAME], [MEDICAL CONDITION] fib (fibrillation), dementia, disorientation, and multiple medical comorbidities. Will care plan with resident receiving assistance for eating, weights as ordered, labs as ordered, PO intake (intake by mouth) monitored and MD (doctor of medicine) notification for decreased intake, Hospice services as ordered, dietary evaluation and recommendations, supplements as ordered with snacks offered on hydration rounds, diet mechanical soft with chopped meats." Review of Resident #45's care plan revealed the resident being at risk for weight loss was not identified as a problem with interventions developed to address the problem. At 11:07 AM on 10/19/11 the Director of Nursing (DON) stated, after reviewing Resident #45's Significant Change MDS assessment, the resident's care plan was supposed to address the resident being at risk for weight loss. She reported the care plan did not address this problem, but she could not explain why the MDS Nurse had not followed through since the Nutritional Status care area triggered, and it was documented on the CAA Summary that the care area would be addressed in the resident's care plan. At 11:34 AM on 10/19/11 the MDS Nurse stated she just started work in the facility this week, but after reviewing Resident #45's 09/30/11 Significant Change MDS and current care plan, she reported the care plan did not address the resident being at risk for weight loss like it should have. She explained all care areas which triggered, and were documented as being addressed in the care plan on the CAA Summary, should be identified as problems in the care plan with interventions developed to address the problems. 2. Resident # 18 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident # 18 was severely cognitively impaired. She was identified as requiring extensive assistance with bed mobility and total dependence on staff for toilet use and personal hygiene. Rejection of care was not exhibited during the assessment period. Resident # 18 was coded as always incontinent of bowel and bladder. Resident # 18 was coded as having behaviors that did not affect others, including smearing of feces on a daily basis. Resident # 18's care plan, with an onset date of 07/29/11, did not identify any behaviors for Resident # 18. The care plan did identify Resident # 18 was incontinent of bowel. The plan did not identify any behavioral issues associated with bowel incontinence. Resident # 18's care plan also identified she had difficulty making decisions and the inability to complete activities of daily living independently. There were no entries that addressed behavioral issues associated with these identified problems. The Nursing Weekly Summary, dated 09/30/11, indicated the resident had repetitive health complaints and repetitively calling out for help. On 09/30/11, a physician's orders [REDACTED]. There was no care plan developed for the medication or the behaviors associated with receiving the medication. The September 2011 Documentation of Behavior Sheet, indicated behaviors on an almost daily basis on the 7 to 3 and 3 to 11 shift. The care plan for Resident # 18 did not identify behaviors. The Physician's progress note, dated 10/06/11, indicated the physician issued an order for [REDACTED]. On 10/14/11, an order was received to increase the [MEDICATION NAME] to 1 milligrams at bedtime and 0.5 milligrams every morning. There was no problem identifying behaviors added to Resident # 18's care plan. An observation was made of Nurse # 3 during medication pass at 3:45 PM on 10/18/11. Nurse # 3 entered Resident # 18's room. The nurse stated the resident had been playing in her brief again. Black matter was noted on 4 fingers of the resident's right hand. After the nurse had given the supplement and medications, she turned and stated the resident had feces in her mouth. The nurse then exited the room and reported to the Nursing Assistant (NA) that Resident # 18 had "been down south again". Nurse # 3 was interviewed at 5:00 PM on 10/18//. The nurse stated Resident # 18 had a habit of putting her hands in her brief and playing in her feces adding that Resident # 18 also put the feces in her mouth. Nurse # 3 stated that was what Resident # 18 had done that afternoon. She stated interventions provided by the facility included a consultant psychiatric assessment. The Director of Nursing (DON) was interviewed at 5:10 PM on 10/18/11. Her expectations for this situation included the nurse stopping medication pass and assisting the resident by washing her hands and providing oral care prior to giving medication and supplements. The DON stated she expected the NA to provide oral care and clean the resident's nails to remove the feces. The DON added she thought the entire incident was disgusting. Nurse # 4 was interviewed on 10/20/11 at 10:12 AM. The nurse reported Resident # 18 required extensive/total assistance for activities of daily living. Nurse # 4 stated Resident # 18's behaviors included playing in her brief/feces. An interview was held with NA # 5 on 10/20/11 at 10:32 AM. The NA reported Resident # 18 played in her brief and smeared feces. A telephone interview was held with the MDS Coordinator on 10/26/11 at 3:05 PM. She stated she was new to the facility and not aware of all resident behaviors. The MDS Coordinator stated behaviors and psychoactive medications should be addressed on a resident's care plan. She added if a resident played with feces, that surely should be added to that individual resident's care plan. .

Based on observations, staff interviews and record review, the facility failed to provide proper personal hygiene for 2 of 3 sampled residents (Resident # 18 and Resident # 46 ) whose care was observed. Findings include: 1. Resident # 18 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident # 18's care plan, dated 03/25/11, identified an inability to perform activities of daily living independently related to cogntive loss. The goal to have her needs met and to keep Resident # 18 clean, neat and well groomed daily would be acheived by routine nail care, morning and evening care and routine oral care. The approaches included to anticipate the resident's needs for activity of daily living assistance. The Annual Minimum Data Set (MDS), dated [DATE], indicated Resident # 18 was severely cognitively impaired. She was identified as requiring extensive assistance with bed mobility and total dependence on staff for toilet use and personal hygiene. Rejection of care was not exhibited during the assessment period. Resident # 18 was coded as always incontinent of bowel and bladder. An observation was made of Nurse # 3 during medication pass at 3:45 PM on 10/18/11. Nurse # 3 entered Resident # 18's room. The nurse stated the resident had been playing in her brief again. Black matter was noted on 4 fingers of the resident's right hand. Nurse # 3 was observed giving the resident her medications and a liquid supplement. After the nurse had given the supplement and medications, she turned and stated the resident had feces in her mouth. Nurse # 3 did not offer mouth care before offering the supplement or completing medication pass. The nurse then exited the room and reported to the Nursing Assistant (NA) that Resident # 18 had "been down south again". The NA commented it was not any fun if it was not down south, went in another resident's room, stayed approximately 5 minutes and then went down the hall to another resident's room and shut the door. Resident # 18 remained soiled. The nurse stated the NA had to complete care on the resident he was assisting and then he would take care of Resident # 18. The nurse continued her medication pass. Resident # 18 remained soiled. An observation was made on 10/18/11 at 4:15 PM of Nursing Assistant (NA) # 2 providing incontinent care to Resident # 18. The NA cleaned the resident's perineum from front to back. The folded sheet used in moving the resident was on the bed. Brown stains were seen on the left side of the turn sheet and pencil eraser sized brown balls were seen on the right side of the turn sheet. NA # 2 identified the stains and balls as feces. Resident # 18's hand was laying in the brown smear on the left. Brown stains were seen under Resident # 18's fingernails and around the nail beds. The NA did not clean the resident's nails, nor did he provide oral care. The resident was dressed and placed in her wheelchair and taken to the lounge area. An interview was held with NA # 2 on 10/18/11 at 4:29 PM. NA # 2 stated he did not provide oral care and had cleaned Resident # 18's nails the best he could. The NA stated Nurse # 3 had informed him Resident # 18 had feces around her mouth. He added that was why he wiped her face. NA # 2 stated he did not provide oral care or clean under the resident's nails because Resident # 18 had no orange sticks or oral swabs in her room. He added these items were available in the facility. NA # 2 stated he could have gotten someone to retrieve those items in order to provide nail care and oral care for Resident # 18, but, he was not thinking. Nurse # 3 was interviewed at 5:00 PM on 10/18//. The nurse stated Resident # 18 had a habit of putting her hands in her brief and playing in her feces adding that Resident # 18 also put the feces in her mouth. Nurse # 3 stated that was what Resident # 18 had done that afternoon. She stated interventions provided by the facility included a consultant psychiatric assessment. Nurse # 3 stated she had seen what looked like feces on Resident # 18's chin but thought it was chocolate supplement. The nurse added when she touched the spot on Resident # 18's chin, the area was dried and did not move, so she figured it was feces. The nurse stated she continued to give the resident medications and the supplement. Nurse # 3 stated she reported the incident to NA # 2 adding that he should have moved quicker in cleaning Resident # 18. The nurse added that since Resident # 18 smeared feces on her face and her chest, the NA should have washed the resident's hands and provided oral care. The nurse could offer no explanation as to why she did not offer to assist the resident with personal care, but after discussion stated she should have cleaned the resident. The Director of Nursing (DON) was interviewed at 5:10 PM on 10/18/11. Her expectations for this situation included the nurse stopping medication pass and assisting the resident by washing her hands and providing oral care prior to giving medication and supplements. The DON stated she expected the NA to provide oral care and clean the resident's nails to remove the feces. The DON added she thought the entire incident was disgusting. An observation was made of Resident # 18's hands at 5:34 PM on 10/18/11. Resident # 18 was sitting in the resident lounge. The resident's left hand had spots of brown matter with brown matter observed under the nails and around the nail beds. The right hand had brown specks of matter with brown matter under the nail and around the nail bed. The DON stated the nails should have been cleaned and oral care provided. 2. Resident #46 was re-admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. According to the most recent Quarterly MDS (Minimum Data Set) assessment of 08/21/11, Resident #46 required total assistance with toilet use, bathing and hygiene. There were no behaviors noted. Resident #46 was observed on 10/18/11 at 8:30 AM in her wheelchair out in the front of the facility. She was noted to have long white chin hairs and light brownish hair on her upper lip. Resident #46 was observed again on 10/18/11 at 4:00 PM with long white chin hairs as well as light brownish hair on her upper lip. Resident #46 was observed being pushed in her wheelchair by staff on 10/19/11 at 10:55 AM. She remained unshaven. During an interview with Nurse #5 on 10/20/11 at 10:00 AM, she stated Resident #46 was usually cooperative with care. She added that female residents were usually shaved on an as needed basis. Resident #46 was observed being pushed by staff in her wheelchair on 10/20/11 at 11:30 AM. She had long white chin hairs and light brownish hair on her upper lip. During an interview with Nurse Aide#4 (NA#4) on 10/20/11 at 1:30 PM, she stated residents were scheduled for showers every other day and partial bed baths on the other week days. She commented that resident's hair was washed on shower days. NA#4 also commented that men were shaved daily and females were shaved as needed. When questioned about Resident #46, she reported she had not noticed any facial hair. She stated she was not aware of any females in the facility who were being shaved on a regular basis. During an interview with the Director of Nurses (DON) on 10/20/11 at 1:45 PM, she stated her expectation was for female residents to be well groomed. She stated she expected direct care staff to shave the ladies on an as needed basis during morning care. On 10/20/11 at 3:00 PM, Resident #46 was noted in the activity room reading a magazine. She remained unshaven.