Every finding on record at Aviata at Green Cove Springs

Based on facility record review, staff interview, and a review of facility policy and procedure, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are especially at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. This had the potential to affect all residents residing in the facility. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. The findings include: From 02/10/25 through 02/13/25 a review of the facility's infection control and water management program was conducted. The facility water management program binder was provided for review, and it contained a copy of the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, A Practical Guide to Implementing Industry Standards. U.S. Department of Health and Human Services Centers for Disease Control and Prevention, dated 06/24/21. (Copy obtained) Further review of the water management program binder revealed that the program had no documentation indicating that the facility had conducted an annual review of the water management program. The program did not include control measures to include points in the system where critical limits could be monitored, and where control could be applied, such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. It did not specify testing protocols and acceptable ranges for control measures, and documented results of testing of pH levels of disinfectant in the water. There were no confirmatory procedures, including verification steps to show that the program was being followed as written, or validation to show that the program was effective. A review of the facility's policy titled Water Management Program (effective 08/01/17) revealed: The facility will provide a source of domestic water supply, as safe as possible, to residents, staff and visitors. The center will strive to eliminate the source of, or distribution of, unacceptable levels of preventable contamination (including but not limited to Legionella, cryptosporidium, arsenic) within the water and HVAC systems. Section D stated, Establish water safety control limits (ex. Temperature and disinfectant levels) and where control limits should be applied. Develop responses and ways to intervene when measurements are outside the established limits. (Photographic evidence obtained) Further review of the water management policy revealed in Attachment C water management information that included where the main water supply came into the building, location of water systems components, and a check list to check water supply components, which was left blank. (Photographic evidence obtained) During an interview with the Director of Maintenance on 02/13/25 at 11:22 AM, she confirmed that she had received no training on the water management program. She confirmed water testing for pathogens had not been done since she was hired in August 2024. She stated she had no testing kit for the disinfectant levels in the water. There had not been any testing other than what was completed by an outside provider in September 2024. When asked about control limits, the Director of Maintenance stated she was not aware of any control limits. She stated there were no water safety team members as stated in the water management policy, and she did not use the CDC (Centers for Disease Control and Prevention) toolkit guide included in the water management binder. When asked, she stated there was no water flow diagram that she was aware of, but she did regularly flush the hot water heaters and tested water temperatures in resident rooms with the range being between 105-110 degrees. The main hot/cold valves were used to either increase or decrease the temperature to get it within acceptable limits. Monthly cleaning/checks were performed on all ice machines. Proof of testing was requested on 02/13/25 at 11:30 AM. Proof of testing was requested again at 12:30 PM on 02/13/25. No proof of testing was provided prior to the survey exit.

Based on kitchen food service observations, staff interviews, record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to clean the juice dispenser hose attachment connected to the thickened water bag in box and the 100% apple blend juice (regular consistency) on the juice machine. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A follow-up tour of the kitchen was conducted on 02/12/25 at 11:21 AM. During the tour, the juice dispenser attachment connected to the thickened water bag in box and the 100% apple blend juice (regular consistency) was observed with brownish-orange substances around the hose attachment area connected to thickened water bag and the 100% apple blend juice (regular consistency). Two juice dispenser hoses that were hanging from the juice rack below the bag in boxes, were observed with dusty substances and a greasy buildup on the external parts of the hoses. On 2/13/25 at 3:14 PM, the same observations were made again of the juice dispenser attachment connected to the thickened water bag in box and the 100% apple blend juice (regular consistency) as well as the two juice dispenser hoses hanging below the bag in boxes. (Photographic evidence obtained) An interview was conducted on 02/12/25 at 11:56 AM with Dietary Aide D. When asked who was responsible for cleaning the juice machine hoses, she replied, The Kitchen Manager cleans the machine weekly. An interview was conducted on 02/12/25 at 2:26 PM with Kitchen Manager E. She stated the Dietary Aide removed, soaked, cleaned, sanitized and reattached the nozzles back to the bag in box once cleaned. On 02/13/25 at 3:12 PM, Kitchen Manager E reported that the two hoses hanging from the juice rack below the bag in boxes were not utilized. A review of the facility's policy and procedure titled Equipment (Revised: 9/2017), revealed: All food service equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food equipment will be clean and free of debris. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observations, interviews, record review, and a review of facility policies and procedures, the facility failed to ensure that one (Resident #84) of four residents reviewed for accident hazards, from a total survey sample of 36 residents, had an environment as free of accident hazards as possible. Hydrogen peroxide, isopropyl alcohol, and disinfectant spray were found on Resident #84's chest of drawers. The findings include: On 02/10/25 at 12:32 PM, Resident #84's room was observed. An aerosol can of disinfectant spray, a bottle of hydrogen peroxide (mild antiseptic), and isopropyl alcohol were observed sitting on top of the resident's chest of drawers adjacent to his bed. (Photographic evidence obtained) On 02/10/25 at 2:56 PM, Resident #84's room was observed. An aerosol can of disinfectant spray, a bottle of hydrogen peroxide (mild antiseptic), and isopropyl alcohol were observed sitting on top of the resident's chest of drawers adjacent to his bed. (Photographic evidence obtained) A review of the resident's medical record revealed he was admitted to the facility on [DATE] with diagnoses including adjustment disorder, anxiety, and major depressive disorder. No assessment for self-administration of medication was found in the record. No indication of the physician having approved self-administration of medication was found in the record. On 02/12/25 at 12:02 PM, a review of the resident's progress notes from December 13, 2024 through February 12, 2025, revealed that the resident was followed by psychotherapy for depressed mood and insomnia. A review of the resident's active Care Plan revealed the following Focus Area: [Resident #84] has Behaviors - Is known to refuse certain medications, is known to refuse ADL (activities of daily living) care at times, and is known to refuse catheter to promote wound healing. He is known to request to be double briefed. He has been educated on risks associated with double briefing and continues to insist he be double briefed related to personal choice. (Created 8/19/2024, revised 12/4/2024) Further review of the Care Plan revealed no Focus Areas for storing aerosol disinfectant sprays, isopropyl alcohol, or hydrogen peroxide unsecured at the resident's bedside. On 02/12/25 at 1:15 PM, an interview was conducted with Licensed Practical Nurse (LPN) A who was assigned to the resident. He was asked if residents were permitted to keep medication/antiseptics of any kind in their rooms. He stated, It depends on their status and whether the doctor approved it. Also, the facility has to determine the cognitive status of the resident and Speech Therapy has to approve them for their swallowing reflex. He was asked what the facility process was if medications/antiseptics were found in the resident's room that had not been approved. He stated, We tell the resident we must remove it and that they are not allowed to have medication in the room because another resident might take it and overdose, and we notify the doctor. He was asked if the facility permitted residents to use/keep aerosol disinfectant sprays/isopropyl alcohol in their rooms. He replied, No. He was accompanied to Resident #84's room to observe the items located on the resident's chest of drawers. He was asked why the resident had disinfectant spray, hydrogen peroxide, and isopropyl alcohol located on his chest of drawers. (Photographic evidence obtained). LPN A did not offer an explanation. On 02/12/25 at 1:26 PM, an interview was conducted with Certified Nursing Assistant (CNA) B who was assigned to the resident. She reported that she was familiar with Resident #84. She was asked if the facility permitted residents to keep medications/antiseptics in their rooms. She stated, Definitely not. She was asked if the facility permitted residents to keep disinfectant sprays and/or isopropyl alcohol in their rooms. She stated, Yes, I'm not going to say that they are allowed, but he usually keeps it in the drawer. On 02/13/25 at 2:54 PM, an interview was conducted with the Maintenance Director who was asked if the facility permitted residents to have, use or keep any type of aerosol sprays in their rooms. She stated, No, they are not allowed to have any. She was asked for the documentation explaining the facility's policy pertaining to the use or possession of aerosol sprays in resident rooms. No policy was provided prior to the survey exit. A review of the facility's policy and procedure titled Administering Medications (Revised April 2019), revealed: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with the prescriber's orders, including any required time frame. 27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the facility's policy and procedure titled Medication Storage (Undated), revealed: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the resident and is in accordance with Florida Department of Health guidelines. A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. A review of the Hazardous Material Storage and Handling/MSDS(Material Safety Data Sheet) (S-270) (Effective 11/30/14), revealed: Hazardous materials shall be stored and handled in a manner that shall minimize the risk of injury or property damage. 2. The facility shall maintain Material Safety Data Sheets (MSDS) for all materials used or stored. Each department shall maintain those sheets appropriate to their operation. Executive Director shall house a complete set accessible to all personnel.

Based on observations, resident and staff interviews, a review of resident records, and the facility's policy and procedure titled G-Tube Care, the facility failed to 1) Follow treatment ordered by the physician for G-tube (G-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and fluids) dressing changes, 2) Arrange G-tube removal in a timely manner, and 3) Prevent complications of the G-tube, specifically, recurrent stoma infections for one (Resident #80) of three residents reviewed with G-Tubes, from a total of 36 residents in the sample. The findings include: A review of Resident #80's medical record found he was admitted to the facility on [DATE] with a planned discharge to an acute-care hospital on 07/13/22 and a readmission on 07/17/22. His diagnoses included type 2 diabetes mellitus, major depressive disorder, gastrostomy status (status post-surgical procedure creating an opening in the stomach for the introduction of food through a feeding tube, G-tube), and moderate protein-calorie malnutrition. On 03/26/23 at 2:00 PM, Resident #80 was observed in his room sitting on his bed. When asked whether he was satisfied with his care, Resident #80 pointed to his feeding tube site (abdomen) and stated, This tube had to be removed a long time ago, but the hospital of Veteran's Administration (VA) needs more information in order to proceed. The dressing around the G-tube was soiled with serosanguineous (contains both blood and blood serum) drainage. The date on the dressing was 3/24/23. (Photographic evidence obtained) Resident #80 stated his G-tube dressing was not changed last night, 3/25/23. On 03/27/23 at 3:30 PM, Resident #80 was observed in the Activities area. He stated, I have been waiting for you the whole day. Please follow me to my room; I want to show you something. Upon entering the resident's room, he lifted his shirt to expose an intact dressing covering the G-tube site. The dressing was dated 3/27/23. The resident stated the dressing was changed this morning. As of 3/27/23, the dressing had not been changed since 3/24/23. On 3/29/23 at 9:40 AM, Resident #80 was observed in his room sitting on his bed. His G-tube site dressing was observed with a scant amount of blood and was dated 3/27/23. He stated the dressing was not changed last night, 03/28/23. A review of the Significant Change Minimum Data Set (MDS) assessment, dated 1/26/23, revealed that Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating that he was cognitively intact. He required supervision with bed mobility and transfers, limited assistance with dressing and toileting, and was noted as independent walking in his room and for eating. The MDS indicated that Resident #80 had gained weight, was using a feeding tube and had 25% or less fluid intake by tube feeding. The Care Plan, dated 7/18/22 and revised on 2/6/23, revealed that Resident #80 had a G-tube related to a history of dysphagia (trouble swallowing). The goal was that the resident would remain free from side effects or complications related to the tube feeding through the next review date, on 5/7/23. Interventions included: Gastroenterologist consult as ordered (initiated 11/11/22). Provide local care to the G-tube site as ordered, monitor for signs and symptoms of infection (initiated 7/18/22). Isolation precautions (initiated 3/28/23). Registered dietitian to evaluate quarterly and as needed, making recommendations for changes to the tube feeding as indicated (initiated 7/18/22). ST (Speech Therapy) evaluation and treatment as ordered (initiated 7/18/22). Swallow test as ordered (initiated 11/11/22). A review of the resident's physician's orders revealed: 3/27/23 - Isolation type - Enhanced MRSA/Stoma (MRSA - Methicillin-resistant Staphylococcus Aureus, bacterial infection that is resistant to many of the antibiotics used to treat an ordinary staph infection). 2/9/23 - Enteral stoma (an artificial opening made into a hollow organ) care Q shift (every shift). 2/9/23 - Cleanse gastric stoma site once daily with NS (normal saline). Apply sterile drain sponge to site every night shift. 1/6/23 - Order cultures from stoma site d/t (due to) discharge bloody/smelly site. Order to start mupirocin (antibiotic) topical cream 2%. Apply cream TID (three times daily) for 10 days for skin infection. 11/28/22 - Consult GI (gastroenterologist) to evaluate and reassess the changing or removal of PEG (percutaneous endoscopic gastrostomy) feeding tube due to skin redness/odor around the stoma. 9/27/22 - Consistent Carbohydrate (CCD) diet, regular texture, regular/thin liquid consistency. A review of the Registered Dietitian's progress note dated 10/4/22 revealed: Spoke with Speech Language Pathologist (SLP) and she reported the resident has been eating >1 week since the tube feed TF was decreased and switched to nocturnal. Given resident's consistent PO (oral) intake and ability to meet hydration needs via PO, recommend discontinue TF (feeding tube) entirely. Will monitor and if change in clinical status, will reassess need for supplemental nutrition support. A review of the Meal Percentage intake forms for March 2023 revealed that Resident #80 was eating 76-100% of his meals. A review of Resident #80's weight history revealed that he had gained 17.8% from 12/29/22 to 3/6/23. A review of the February and March 2023 electronic Medication Administration Record (eMAR) found that the gastric stoma site was scheduled to be cleaned and the dressing changed daily, on every night shift, however, on 2/21/23, 3/26, 3/29, 3/30 and 3/31/23, the signature box used to indicate completion of the task for cleansing the stoma site and changing the dressing was not signed off by the nurse indicating that the care had been provided. Further review of the March 2023 MAR revealed that signature boxes indicating stoma care had been provided every shift, were not signed off by the nurse to verify that care was provided on 2/10/23 or 2/13/23 during the night shift. Stoma care was not signed off by nursing as having been provided on both the day and night shifts on 2/21/23; on the day shift on 3/12, 3/30, or 3/31/23; on the evening shift on 3/24, 3/29, 3/30 or 3/31/23, or on the night shift on 3/26, 3/29, 3/30, or 3/31/23. On 3/25/23 and 3/28/23, both signature boxes had nurses' initials in them, indicating stoma care was done and a dressing applied, but observations on 3/26/2023 and 03/29/2023, revealed that dates on the dressing were 3/24/23 and 3/27/23 respectively. A review of an infection progress note dated 1/19/23, revealed that Resident #80 was on contact precautions due to MRSA in his g-tube stoma at that time. A review of the laboratory reports revealed a history of infection at the G-tube stoma site: On 2/01/23 - Aerobic culture wound: Light growth Yeast. On 1/10/23 - Aerobic stoma culture: Light growth Proteus Mirabilis, heavy growth MRSA. On 12/03/22 - Aerobic culture wound: Moderate growth Proteus Mirabilis (a bacterial infection), light growth MRSA. On 11/04/22 - Aerobic culture wound: Heavy growth Escherichia Coli, ESBL (Extended Spectrum Beta-Lactamase - a bacterial infection that is resistant to antibiotics). Heavy growth Klebsiella Pneumoniae (a bacterial infection), and heavy growth MRSA. A review of the March 2023 Treatment Administration Record (TAR) revealed the following: Consult GI as soon as possible to remove the PEG tube. Patient may go to outpatient GI hospital for PEG tube removal [every shift for] no longer in need/frequent/recurrent infection. Start date: 2/1/23. Discontinuation Date: 3/10/23. Nursing signatures were documented on each shift from 3/1/23 through the day shift on 3/10/23. Refer to the 11/28/22 physician's order above for a GI consult to change or remove the G-tube due to skin redness/odor around the stoma. A review of the ARNP's (Advanced Registered Nurse Practitioner) progress note from 03/03/23, revealed that the resident had an appointment on 03/07/23 with the VA for a G-tube consult for removal. As of 3/29/23, the resident's G-tube remained in place. A nursing progress note dated 2/13/23 revealed, Contact isolation has been discontinued as discussed with provider. Resident's stoma has been re-cultured which revealed yeast present at stoma, not MRSA. Education provided to staff and resident regarding his new status of Enhanced Barrier due to his history and current G-tube that hasn't been discontinued by GI yet. Will continue to follow care. A review of Licensed Practical Nurse (LPN) L's 2/17/23 progress note revealed, This writer placed a call to [Provider name] regarding follow up for g-tube. Resident needs referral from insurance, have been making multiple calls with no response back. Spoke with billing at GI who will help with referral process to get follow up, will keep in contact once referral is obtained. Nursing and Doctor will be made aware. On 03/29/23 at 9:50 AM, Resident #80's sister was interviewed. She shared how frustrating the situation had been for her and her brother. He was supposed to have it done. (referring to removal of the G-tube) She stated they (she and her brother) had an appointment at [hospital name], she could not remember the date, for the G-tube removal. Her brother had been prepared for the procedure at the hospital, and they were told that he had a $300.00 co-pay, which she was prepared to pay. She said she was not sure why her brother was not accepted for the procedure. On 03/29/23 at 10:02 AM, an interview was conducted with LPN K. She was familiar with Resident #80. She stated the resident had a telehealth appointment with his gastroenterologist, and they were waiting for authorization in order to remove his G-tube. She said the VA was delaying the process. On 03/29/23 at 10:05 AM, an interview was conducted with LPN I. She was assigned to Resident #80 this shift. She stated the resident did not use his feeding tube; he had been eating and drinking with no problems. The problem was with the VA and the resident's insurance. On 03/29/23 at 1:42 PM, an interview was conducted with the Wound Care Nurse. She stated the night shift nurses were responsible for dressing changes for Resident #80. She confirmed that stoma care had not been provided and the dressing had not been changed if the signature boxes on the MAR were empty. She was aware that Resident #80 had been experiencing recurrent MRSA and Proteus Mirabilis infections of his stoma site, and the tube had been ordered to be changed or removed a long time ago per his doctor's order dated 11/28/22. She was not sure why Resident #80 had been unable to get to the doctor for gastric tube removal since that time. On 3/29/23 at 2:40 PM, the Director of Nursing (DON) was interviewed with the Clinical Supervisor present. She was advised that Resident #80's G-tube site care/cleaning and dressing changes were being signed off by nursing as having been done, when the care had not been completed. She had no explanation and acknowledged the findings. She was made aware that Resident #80 had a physician's order (11/28/22) and recommendations (10/4/22) from the Registered Dietitian for G-tube removal, however, as of 3/29/23, the resident still had the G-tube. On 3/30/23 at 12:47 PM, a telephone interview was conducted with the Registered Dietitian. She stated, I have spoken to the Speech Therapist, and she confirmed that [Resident #80] is able to eat and swallow with no problems. She stated the resident was not eating through the tube, and his weight has been stable. She confirmed the presence of the tube was a risk for infection and said she had recommended the discontinuation of the G-tube back in October (2022). On 3/30/23 at 1:24 PM, a telephone interview was conducted with the facility's Medical Director. He stated he would like to see a calorie count for Resident #80 from the Registered Dietitian. The Medical Director was informed that Resident #80 had been gaining weight and eating/drinking with no concerns noted. Additionally, there had been recurrent infections at the G-tube stoma site. He then said, Okay, I will place the order to discontinue the G-tube. A review of the facility's policy and procedure titled G-Tube/J-Tube Care revealed: Clinical Nurses shall provide routine care to Gastrostomy and Jejunostomy tubes in order to maintain patency of the tube and good skin integrity. If the site appears to be locally infected, notify the physician.

Based on observations and interviews with staff, the facility failed to dispose of garbage and refuse properly and in a manner to prevent invitation, harboring and feeding of pests which can carry infectious diseases. This had the potential to affect all 103 residents residing in the facility at the time of the survey by risking exposure to vermin and disease. The findings include: An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 03/27/23 at 9:37 AM. The tour concluded with the inspection of the three garbage dumpsters which were situated on the southwest side of the facility. The chain link cage that enclosed the dumpsters was ajar and one of the dumpsters had one of two lids open. The area surrounding the dumpsters was littered with copious amounts of trash including food containers, used gloves, cardboard and other trash. The wooden privacy fence behind the dumpsters had a panel that had fallen into the wooded area and the waste extended into the woods. An interview with the CDM at this time found all departments use and were responsible for maintaining the cleanliness of the dumpster area. She confirmed the presence of trash and debris, agreeing it appeared it had been accumulating over time, and not just over the weekend. (Photographic evidence obtained) On 03/27/23 at 10:48 AM, the CDM came into the conference room and requested that the dumpster area be observed again. She had it cleaned up. She was assured it would be observed again by the end of the survey. On 3/28/23 at 03:35 PM, she reported again she had the area cleaned up. On 03/29/23 at 9:40 AM, the CDM asked if the dumpster area had been inspected again since she had it cleaned. She also reported she had in-serviced her staff on maintaining the area. The CDM was reminded all departments needed to be re-trained, not just her dietary staff. She acknowledged the reminder. A final inspection of the dumpsters was conducted on 03/30/23 at 9:56 AM. The fallen wooden fence panel had been erected, but there was still trash, food containers and medical waste strewn about behind the dumpsters and in the wooded area. The middle dumpster had bags of waste protruding from the cracks between the container doors. (Photographic evidence obtained) In an interview with the Director of Clinical Services (DCS) on 03/30/23 at 11:30 AM, she was asked who was responsible for maintaining the cleanliness of the dumpster area. She said the maintenance department was, and she called the Maintenance Manager to her office. He arrived in the DCS's office and when asked the same question, he said housekeeping was responsible for the maintenance of the dumpsters and surrounding areas. The DCS called the Housekeeping Supervisor to her office, and he was asked if he was responsible for cleaning around the dumpsters. He replied his department does some of the cleaning. They were all shown the before and after photographs and confirmed the area's still unacceptable condition. The DCS agreed that even after the clean-up it was insufficient to keep vermin out. The DCS then telephoned the facility Administrator to clarify who was responsible for the cleaning the area. He stated the Maintenance department was responsible. .

Based on interviews and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours on February, 27, 2023. Nurse staffing in nursing homes has a substantial impact on the quality of care and outcomes that residents experience. Failure to staff a registered nurse for at least 8 hours a day could result in a negative impact on resident care. The findings include: A review of the Payroll Based Journal Staffing Data Report for the period covering July 1, 2022 through September 30, 2022, rvealed that the facility's submitted weekend staffing data was excessively low. A review of the facility's staffing calculations from February 5, 2023 through March 25, 2023, revealed there was no RN on duty at all on February 27, 2023, a Monday. (Copies obtained). An interview was conducted with the Director of Nursing on 3/29/23 at 1:40 PM. She stated the facility only employed two registered nurses currently, herself and the Minimum Data Set (MDS) Coordinator. The facility relied on Staffing Agencies for RNs. She confirmed that at times, she had to work a resident care assignment and administer medications. She stated in the last month, she had to work a resident care assignment twice. On March 5, 2023, she had to help with medication administration because the assigned nurse had to leave at 3:00 AM. On March 7, 2023, she had to come to take a resident care assignment because an agency nurse did not show up for work. She added that normally the unit managers and the supervisors were expected to be on call, but they had all resigned. In an interview with the Administrator on 3/29/23 at 2:00 PM, he confirmed that there was no RN assigned to work on 2/27/23.

Based on observations, resident and staff interviews, a review of resident records, and the facility's policy and procedure for Care of Nails, the facility failed to provide appropriate grooming, personal hygiene and oral care to three (Residents #88, #94 and #20) of six residents reviewed for activities of daily living (ADLs), from a total of 36 residents in the sample. The findings include: 1. An observation of Resident #88 was made on 3/27/23 at 11:03 AM. He was in his bed and his feet were protruding from under the bedding. His toenails were long, jagged and thickened. The nails on both great toes were approximately an inch long and at least one of the nails on his smaller toes was beginning to curl under. Resident #88 confirmed his nails needed care. He said he was supposed to be on the list for the podiatrist. An observation on 3/28/23 at 9:41 AM, found Resident #88 in bed with his feet protruding from under the blanket. His toenails were in the same condition as the previous day's observation. He still did not know if the podiatrist would be seeing him but stated he would like to be seen. (Photographic evidence obtained with verbal consent at this time) Certified Nursing Assistant (CNA) F was interviewed on 3/28/23 at 10:24 AM. She stated Resident #88 could perform a lot of his ADLs with set up and some help. She provided no nail care to residents. Restorative provided all nail care unless the resident was diabetic, then the nurse did it. In an interview with Licensed Practical Nurse (LPN) I on 3/28/23 at 1:53 PM, she stated the podiatrist came to the facility on ce a week. The residents had to be put on the list. There was a purple folder on the west wing that contained that list. When the podiatrist came in he went to the list, then he placed a star next to the residents' names when he saw them. LPN I stated she was not sure if Resident #88 was on the list. Resident #88 was interviewed on 3/29/23 at 10:18 AM. He was in bed with his toenails in the same condition as they had been on 3/27 and 3/28/23. He said he still didn't know if he would be seeing a podiatrist. They were supposed to put him on the list. The Social Services Director (SSD) was interviewed on 3/29/23 at 2:30 PM. She stated residents were not necessarily signed up for podiatry visits unless the resident or family requested it or if nursing staff identified a need. The staff put the resident's name in the purple folder and the podiatrist saw them if their name was on the list. That was their system/process. On 3/30/23 at 10:15 AM, the SSD was asked for any podiatry visits for Resident #88, since a brief review of his record at this time found none. She stated she would contact the podiatrist and have them sent over. A review of the podiatrist's folder found Resident #88's name was not on the list and the enclosed list was blank. Resident #88 was interviewed on 3/30/23 at 10:20 AM. He said he told the nurses to put him on the list for podiatry. He hoped to be seen soon because he was supposed to start working with therapy on standing up and he couldn't put his [NAME] on with his toenails like this. CNA A was interviewed on 3/30/23 at 10:21 AM. She stated CNAs were supposed to care for the residents' nails. The doctor had to do the toenails, but he never does. She stopped reporting the need to nursing because nothing gets done. When told of the condition of Resident #88's toenails, CNA A said, It doesn't matter if it is reported, the podiatrist never sees the patients on this hall. She said she had only seen him here maybe once. CNA A said the nurse was supposed to notify the podiatrist when a resident needed services, but didn't, so she didn't report the need anymore. The Director of Clinical Services (DCS) was interviewed on 3/30/23 at 11:19 AM. She stated care staff, the resident or the family were to report the residents' need for podiatry care. Staff were supposed to write the resident's name in the book. She was shown the photograph of Resident #88's toenails and agreed they were in need of podiatry care. She picked up her telephone, called another staff member to request Resident #88 be seen explaining Resident #88's nails look horrible. The DCS had no explanation for why Resident #88 was told he would be put on the list but was not. She said, There is no way you can see that (his toenails) and not say something. A record review for Resident #88 found he was admitted to the facility on [DATE]. He had diagnoses including diabetes mellitus and morbid obesity. He had a quarterly Minimum Data Set (MDS) assessment dated [DATE], that noted a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, reflecting that he was cognitively intact and independent with daily decision making. He required extensive assistance with personal hygiene. Resident #88 had a physician's order dated 8/9/22 for podiatry as needed. (Photographic copy obtained) A second search of the records found no podiatry visits. On 3/30/23 at 4:03 PM, Resident #88's podiatry notes were received from his office. A review found there was only one documented visit on 2/21/22. The report was illegible. There were no subsequent visits documented. 2. Resident #94 was observed in the east wing day room on 3/27/23 at 11:50 AM. He was sitting at a table working on a word search puzzle. Both of his hands were observed with a dark brown substance resembling feces underneath his fingernails. The nails appeared to be stained dark yellow/orange in color and coated with the matter, as were his fingers on both hands. Resident #94 had no explanation for what was on his hands and under his nails. On 3/27/23 at 12:00 PM, Resident #94 was observed in the same room feeding himself lunch. His nails and hands were in the same condition and it did not appear as though he had been assisted to clean them before eating. On 3/28/23 at 9:28 AM, Resident # 94 was again observed in the east wing day room drinking some orange colored juice. His fingernails were still impacted with the dark brown substance underneath, but the substance on his fingers was now mostly removed. Resident #94 stated he did not know if staff provided his nail care and would not answer when asked what was under his nails. Resident #94 stated he received bed baths but not showers. With his verbal consent his hands and nails were photographed. (Photographic evidence obtained) A record review for Resident #94 found he was admitted to the facility on [DATE] and was his own responsible party. He had an Admission MDS assessment dated [DATE], which assessed him with modified independence for daily decision making. No refusal of care was noted. Resident #94 required extensive assistance with toilet use and hygiene and was always incontinent of bowel and bladder. Diagnoses included aphasia (loss of ability to understand or express speech), cerebrovascular accident (CVA or stroke) and hemiparesis/hemiplegia (weakness or the inability to move one side of his body). Resident #94 was care planned on 12/30/22, and reviewed on 1/2/23 and 3/20/23, for his activities of daily living (ADL) self-care performance deficit related to hemiplegia, status-post (following) stroke, muscle weakness, difficulty walking, reduced mobility, lack coordination and multiple medical comorbidities. The goal was to improve his current level of function through the next review date. Interventions included, but were not limited to: Bathing/showering: check nail length and trim and clean on bath day and as necessary. Report changes to nurse. Toileting- requires extensive assistance by staff. (Photographic evidence obtained) A review of nursing progress notes found Resident #94 refused nail care on 2/8/23 and 2/22/23. There were no nail care refusals documented after 2/22/23. CNA F was interviewed on 3/28/23 at 10:26 AM. She stated she was assigned to Resident #94 and he required moderate assistance with ADLs. He was incontinent of bowel and bladder. She provides no nail care to residents; restorative aides provided all nail care unless the resident was diabetic. CNA F said she brought a bin of soapy water for residents to wash their hands, usually once a day in the morning, and sometimes twice during the shift. CNA H was interviewed on 3/28/23 at 12:52 PM. She stated nail care was provided by the CNAs including clipping and using the orange stick to clean underneath, unless the resident was diabetic. She stated it should be done daily in her opinion. Some residents play in their feces including Resident #94, who also sometimes refused showers. An observation of Resident #94 was conducted on 3/28/23 at 1:50 PM. He was in the day room, and his hands and nails were now very clean and free of all previously observed matter. He confirmed the staff had cleaned them. He was not sure who the staff member was who did it. The east wing Unit Manager was interviewed on 3/28/23 at 1:53 PM. She was asked if she knew who provided nail care to Resident #94. She speculated that perhaps his CNA did. When told his assigned CNA reported only restorative aides provided nail care, Licensed Practical Nurse (LPN) I, who was standing nearby, laughed and looked surprised. She corrected, saying, CNAs do provide the nail care, including cutting and cleaning the resident's nails unless they're diabetic. Activities also does spa days, where they cut, clean and even paint nails. The spa days are on the activities calendar. The activities calendar for March 2023 was reviewed and reflected the Nail Spa was on the calendar for March 4, 7, 13, 24, 26, 18, 20, 21, 26 and 28th. (Photographic copy obtained) CNA A was interviewed on 3/30/23 at 10:21 AM. She confirmed she was the staff member who cleaned Resident # 94's nails on Tuesday afternoon (3/28/23). When asked what was on his hands and under his nails, she replied, Poop. He digs in his diaper. When asked how his nails were in that condition and hadn't been addressed, she shrugged and said it was because no one cleaned them for him. When told Resident #94 was observed eating with his soiled hands earlier that day, she shrugged her shoulders and did not respond. CNA A said the CNAs were expected to care for their assigned residents' nails and hands, but no one did it. Nobody cares. An interview was conducted with the Director of Clinical Services (DCS) on 3/30/23 at 11:30 AM. When advised and shown the picture of Resident #94's nails, she agreed the nails and fingers were soiled and caked with what appeared to be feces. The DCS had no explanation for why staff did not address the condition of his hands or assist him to clean his hands before feeding himself. The facility policy titled Care of Nails, policy # N-1173, effective 11/30/14 and revised 9/1/17, read: Procedure: Perform hand hygiene; explain procedure and bring the following equipment to the resident's bedside: Basin, optional, towel, [NAME] board, orange stick, nail clippers. Place towel beneath area to be treated. May soak hands in basin half full of warm water if needed. Trim fingernails, clean nails . (Photographic copy obtained) 42442 3. A review of the clinical record revealed that Resident #20 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia/hemiparesis, dysphagia, protein calorie malnutrition, and anemia in chronic kidney disease. A review of the physician's orders, dated 10/28/22, revealed orders for: Oral care qshift (every shift), Enteral (tube) feeding every 4 hours, 170 cc H20 (100 cubic centimeters of water), FEES (fiberoptic endoscopic evaluation of swallowing) to assess swallow function (10/14/22). Resident receives SLP (speech language pathologist) services effective as 2/14/23, 5x/week (five times a week) for 2 weeks. Goals with focus on swallowing, apply drain sponge on G- tube area. Check residual every shift and notify MD of greater than 100cc. Jevity 1.5 type of feeding 70ml/hr x 20hrs (70 milliliters per hour for 20 hours), off at 6:00 a.m. and on at 10:00 a.m. A review of a dietary note dated 3/13/23, revealed Jevity 1.5 goal rate at 70ml/hr x20hrs off at 6:00 a.m. and on at 10:00 a.m. A review of the care plan dated 1/17/22, indicated that the resident had an ADL self-care performance deficit related to impaired mobility and multiple medical comorbidities. Resident has own teeth and requires oral inspection every shift with mouth care as ordered. Resident requires total assistance by staff with personal hygiene. A 2/25/23 progress note read, Resident does not cooperate with the care. He is known to refuse medication and treatments, shower/bed bath, mouth care. Has been known to refuse to be hospitalized related to dementia, anxiety disorder, major depressive disorder, acute and chronic respiratory failure, hypoxia and hypercapnia. A Community Life progress note, dated 3/16/23, revealed, Spent 15 minutes with resident. Activities assisted with mouth care and washing of hands and face. Resident seemed to enjoy the the visit. A review of the quarterly MDS assessment, dated 1/25/23, revealed a BIMS score of 10 out of a possible 15 points, indicating moderate cognitive impairment. The resident required extensive assistance of two staff members for bed mobility and toilet use. The resident was totally dependent for toileting and personal hygiene. A review of a dietary progress note, dated 3/13/23, revealed a body mass index (BMI) of 22, weight stable. Resident to continue to be NPO (nothing by mouth) with 200 cc water flushes. During a telephone interview with the RD on 3/30/23 at 12:54 PM, she stated assessments were conducted upon admission, re-admission and as needed based on communication with the nursing department or weight loss. When asked about Resident #20, she stated she saw the resident frequently because he received his nutrition via a feeding tube. He was on 70 ml of Jevity 1.5 (enteral nutritional product) and 200 ml water flushes. She added that if she changed anything, she put the new orders in the electronic medical record and the nurses had to acknowledge the changes. She added that she also verbally notified the physician and the nurse of any changes. On 3/30/23 at 2:41 PM, the Director of Clinical Services (DCS) reviewed the RD's progress notes and the physician's order. She stated if the RD changed the orders, she should put the new orders in the electronic medical record. She further stated the current order was added by the RD. On 3/27/23 at 11:58 AM, the resident stated oral care had not been provided yet today. On 3/28/23 at 10:29 AM, the resident was observed lying in bed with tube feeding running at 70ml/hr. A whitish substance was observed on the resident's mouth. Resident # 20 confirmed that oral care had not been provided. On 3/28/23 at 3:09 PM, the resident stated oral care had still not been provided today. On 3/29/23 at 12:20 PM, CNA A stated she had been employed by the facility for two years. She stated she had always worked on the long-term care side of the facility (East Wing) and was familiar with all the long-term care residents. If there was a new resident, she would obtain the information regarding their functional ability from the nurse or a resident interview. When asked about the care for Resident #20, she stated the resident refused care at times. She added that if a resident refused care, the nurse was notified and it should be documented in the electronic medical record. She confirmed that she had not performed oral care for the resident. The nurse did not ask. When asked if the nurses were expected to provide oral care, she replied no and added that if the nurses saw that it needed to be done, they should inform the CNAs. She added that most of the time this resident refused care because the water was always cold. When asked about staffing, she stated she was assigned 25-27 residents most of the time, and it was difficult to meet the residents' needs. When asked about the residents' meals, she stated they were always complaining about the food and the dietary department did nothing about it. She added that residents did not consistently receive snacks and when dietary did bring the residents snacks there were never enough of them for the residents, so the staff did not pass them out. They waited until a resident came to the nurses' station and asked for a snack. On 3/29/23 at 1:48 PM, Resident #20 was observed uncovering himself. He stated he had called for the CNA to change him, they came in and turned the call light off and said they'd be back. Resident #20 was asked to push the light again. At this time, he stated again that the staff did not provide him with oral care. A review of the CNA Task List for March 2023 revealed that there was no documentation of Resident #20's refusal of care. (Copies obtained) On 3/29/23 at 2:52 PM, a staff member was observed going into Resident #20's room to provide care. During a 3/29/23 interview with LPN B at 2:40 PM, she stated Resident #20 received 170 cc water flushes every 4 hours. She added that his feeding tube clogged up easily. When asked about oral care for the resident, she stated the nurses were expected to ensure it was done but the CNAs were responsible for doing it. When asked what happened when the resident refused care, she stated the CNAs were supposed to notify the nurse. She denied anyone having notified her that Resident #20 refused care. On 3/30/23 at 10:41 AM, the Clinical Supervisor confirmed that oral care was not performed for this resident. She reviewed the orders and stated the orders were not entered the appropriately because they did not appear in the TAR (treatment administration record) or the CNA task list.

Based on observations, resident and staff interviews, and a review of resident records, the facility failed to review and revise the plan of care to reflect the discontinuation of a gastrostomy tube (G-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and fluids) after the resident resumed food and medications by mouth for one (Resident #46) of three residents reviewed for g-tubes from a total of 36 residents in the sample. The findings include: An interview was conducted with Resident #46 on 03/29/23 at 10:10 AM. He was speaking very loudly and threatened that he was about to rip his g-tube out. Resident #46 lifted his shirt to show the insertion site and the tube. He reported he was eating by mouth and insisted the tube was supposed to have been removed. A record review for Resident #46 found he was admitted to the facility on [DATE]. He had a 5-day Minimum Data Set (MDS) assessment with an assessment reference date of 2/8/23, that noted he had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating that he was cognitively intact and able to make daily decisions. He was coded as being totally dependent for eating. His primary medical conditions included stroke, dysphagia (difficulty swallowing) following cerebral infarction (stroke), non-Alzheimer's dementia, malnutrition (protein, calorie), and adult failure to thrive. Resident #47 had one surgery involving the gasgtrointestinal tract prior to admission. He was assessed with no swallowing difficulty and no weight loss, and had a feeding tube. Resident #46 was care planned on 2/15/23 for requiring tube feedings related to dysphagia following cerebral infarction. The goal was to remain free of signs/symptoms or complications related to tube feedings through the next review date. Interventions include, but were not limited to, head of bed elevated 45 degrees during and thirty minutes after tube feeding; check for placement and gastric contents/residual volume as ordered; provide local care to g-tube site as ordered and monitor for signs of infection; Registered Dietician (RD) to evaluate quartery and as needed . and make recommendations for changes to tube feeding as needed. Resident #46 had a physician's order for nothing by mouth (NPO) which was started on 1/28/23 but discontinued 2/19/23, as was an order for medications through his PEG (pericutaneous endoscopic gastrostomy) tube. He also had an active diet change order for a regular diet, dysphagia advanced texture and nectar thickened fluids and an order that he receive 1:1 supervision with all meals. Both orders were written 2/19/23. (Photographic copy obtained) Resident #46 also had the following physician's orders: Jevity (a liquid food for administration via g-tube) 1.5 calories, 320 cc (cubic centimeters) via g-tube every 6 hours per bolus. (Started 1/31/2023 and discontinued 3/7/2023). GI (gastrointestinal) consultation to evaluate and remove PEG tube due to no longer being in use (3/14/23). Zyprexa (medication used to treat psychosis) 5 milligrams (mg), give 1 tablet via DH-Tube (Dobhoff tube, a type of nasogastric tube inserted into the nostril and down the esophagus into the stomach) at bedtime for paranoia (started 1/29/23 ). Depakene Oral Solution (used for seizure disorders) 250 mg/milliliters, give 5 ml via DH tube two times day for stroke as ordered (started 3/1/2023 with no end date). Tramadol (pain medication) oral tab 50 mg: Give 0.5 mg by mouth every 8 hours as needed for pain (start 3/10/2023). (Photographic copy obtained) Nursing progress notes revealed that on 3/7/23, nursing staff spoke with the Registered Dietitian (RD) regarding Resident #46's declining/refusing gastric feedings. The resident was consuming 100% plus of all meals daily. The RD instructed the resident/staff that he should consume food by small teaspoons and consume foods slowly. Gastric feedings were discontinued. An interview was conducted with the RD on 3/30/23 at 1:13 PM. She explained that Resident #46 recently had his g-tube placed for altered mental status and stroke. The g-tube was to remain in place until speech therapy could see him and upgrade his diet, which was done as of 2/19/23. Resident #46 was now eating by mouth. The APRN (Advanced Practice Registered Nurse) was interviewed on 3/30/23 at 2:07 PM. She confirmed that she wrote an order for the g-tube to be removed, since Resident #46's diet was upgraded, and the tube could come out. She stated the resident was taking all food and medications by mouth. When told his physician's orders and MARs reflected three different routes of administration for medications (by mouth, through a DH tube and through the g-tube), she said, No, that should be removed. His is taking everything by mouth. She had no explanation why there were orders for medication through a DH-Tube and confirmed he did not have one. An unidentified nurse behind the desk overheard the conversation and confirmed when an order for medications via g-tube was discontinued, all accompanying orders should be revised as well to reflect the resident's status.

Based on observations, staff and resident interviews, a review of resident records and the resident handbook, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, by failing to implement its own policy on the storage of resident food items brought in by family and other visitors to ensure safe and sanitary storage and consumption for two (Residents #18 and #88) of two residents observed storing and eating unrefrigerated perishable foods in their rooms, from a total of 36 residents in the sample. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The findings include: During lunch observation in the Activities room on 03/27/23 at 12:47 PM, Resident #18 was observed eating a salad. A bottle of store-brand ranch salad dressing was on the table next to him. It was opened, partially used and at room temperature. The label on the bottle listed perishable ingredients including egg yolk, buttermilk, milk and warned: Contains Milk and Eggs. Instructions were to Refrigerate after opening. Photographic evidence was obtained. Resident #18 stated it was his dressing and he kept it in a drawer in his room. He gets a salad every day at lunch. Certified Nursing Assistant (CNA) H was interviewed on 03/28/23 at 12:52 PM. She confirmed some residents kept food in their rooms like canned foods, crackers, and other non-perishable foods, which was okay. There were no residents with refrigerators in their rooms, but some would keep milk and other perishable items in their rooms even though staff ask them not to. CNA H stated she would remove any unsafe items and offer to store perishable food in the activity room refrigerator. Staff would label the food with the resident's name before storing it there. Resident #18 was observed again in the activities room on 03/28/23 at 12:54 PM, his same bottle of salad dressing on the table. There was now only about an inch of dressing left in the bottom of the bottle. His salad arrived with 4 small single-serve packets of ranch dressing. (Photographic evidence obtained) Resident #18 put the dressing on his salad. The surveyor stepped away, then returned to the table moments later to see his salad swimming in dressing. Resident #18 explained he went through about a bottle of his ranch dressing a week. Licensed Practical Nurse (LPN) I was interviewed on 03/28/23 at 2:03 PM. She stated residents could keep non-perishable foods in their rooms, but perishable foods were kept in the nourishment room refrigerators. The food was dated, labeled with the resident's name, and must be discarded in three days if perishable or brought from home. Salad dressings and condiments were disposed of on or by the expiration date on the bottle. On 03/28/23 at 2:30 PM, Resident #18 showed this writer where he kept his food. He opened the bottom drawer of the nightstand in his room explaining his sister brought in most of his food. There was a large bottle of unopened ranch salad dressing in the drawer. (Photographic evidence obtained) Resident #18 explained that he finished his other bottle of dressing at lunch today. When asked about refrigeration, Resident #18 insisted the dressing was safe in the drawer. Staff had offered to put it in the refrigerator, but he never gave them an answer. Further inspection of the resident's room found there was no refrigerator. On 03/29/23 at 10:05 AM, during an interview with the Director of Clinical Services (DCS) in her office, an unopened bottle of store brand-ranch salad dressing was observed sitting on the side table. It was the same size and brand observed in Resident #18's drawer but was not labeled with a name. During a visit to Resident #88's room on 03/29/23 at 10:18 AM, a wax bag containing chicken wings was observed on his overbed table. There were crumbs surrounding the bag. Resident #88 explained his brother brought the chicken in last night and he ate it this morning. He was asked if the chicken had been refrigerated overnight and he said no. When advised the chicken should have been refrigerated after four hours at room temperature, Resident #88 insisted he does this all the time at home. When asked if staff offered to put the chicken in the refrigerator overnight, at first, he said the staff didn't see it. Then Resident #88 said the certified nursing assistant (CNA) gave him a baggie (small trash can liner) to put the chicken in and offered a basin to put the wrapped wings in because we don't want any roaches in here. He declined use of the basin and put the chicken in the baggie overnight. Resident #18 was observed on 03/29/23 at 12:51 PM at lunch. He had a salad (mostly eaten) and approximately 10 used packs of the single-serving ranch dressing on the table next to him. There was no bottled dressing on the table. When asked where his salad dressing was, he said staff took it from him because (this writer) told them it needed to be in the refrigerator. Resident #18 confirmed nobody brought it to him to use at lunch today. The DCS was interviewed on 03/29/23 at 12:59 PM and asked if the bottle of dressing, which was still on the table in her office, was Resident #18's. She confirmed it was and stated it had been removed from his room. She said Resident #18 was told he could use the individual packets of dressing the facility provides and have as many as he likes, since he prefers a lot of dressing. The DCS pointed out the removed dressing was still unopened. When asked why Resident #88 was not provided with his preferred dressing at lunch, given the bottle was unopened and safe for him to eat, she did not provide a reason. The DCS said staff was going to put his name on it and put it in the refrigerator. CNA A was interviewed on 03/30/23 at 10:21 AM. She was asked about residents storing food in their rooms. CNA A said most of the residents on the east wing did that, but there was only one small dorm-sized refrigerator on the unit for perishable food storage. When asked what staff did if residents brought in perishable foods and there was no room in the refrigerator, she said, Nothing. They just leave it in the room. When told Resident #88's chicken sat at room temperature overnight, she said, That happens all the time, with other residents too. When asked what she did when that happened, she replied, Nothing, that she would just leave the food in the room unless it was milk, which she would throw away. CNA A said they needed more refrigerator space. When asked if residents ever suffered from stomach upset as a result of eating unsafely stored food, she said yes. CNA A again insisted more cold storage was needed, since a lot of the residents ordered food in from stores and had more food than the current cold storage room could accommodate. She confirmed there were no personal refrigerators in resident rooms. In an interview with the DCS on 03/30/23 at 11:30 AM, she confirmed that all perishable food should be refrigerated. When told of the observation of Resident #88's chicken in addition to the observations of Resident #18's salads, she stated the foods should have been refrigerated. The DCS was advised one employee reported they just left the food in the room if there was no refrigerator space. She had no explanation for why that was occurring when there was a refrigerator on each unit. She was advised the refrigerator was only dorm-sized and acknowledged that many residents ordered food out. The DCS acknowledged there was insufficient space for accommodating all resident's perishable foods. She agreed a full-sized refrigerator was needed and that staff should be storing resident foods safely. The Admissions Coordinator (AC) stated in an interview on 03/30/23 at 12:53 PM, that on admission, he verbally advised new residents of the policy for bringing in food from outside sources. The residents also received a handbook. All perishable foods must be refrigerated. The AC provided the resident handbook which stated on page 9 that food provided by family that required refrigeration would be stored in a refrigerator designated for such items. All items must be in a sealed, disposable container marked with the resident's name, the type of food and the date brought in. (Photographic evidence obtained) The facility's Policy #031 Food: Safe Handling for Foods from Visitors stated, Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. Procedures stated: 1. staff will request visitors bringing in food . notify a staff member of nursing or the activities departments. 2. Responsible staff will determine if the food item is for immediate consumption or stored for later use . . 4. When food items are intended for later consumption, the responsible staff will: Ensure the food is stored separately . from facility food. Label foods with resident name and current date. Determine if food items are shelf stable and whether they can be stored in the resident's room or under refrigeration . (Photographic evidence obtained)

Based on observations and interviews with residents and staff, the facility failed to provide sufficient storage to accommodate personal belongings for one (Resident #756) of two residents reviewed for accommodation of needs from a total of 36 residents in the sample. The findings include: An observation of Resident #756's room was made on 03/27/23 at 10:55 AM. She occupied the bed on the window-side of the double-occupancy room. Personal belongings were stored on the floor along the baseboards on all three sides of the room on Resident #756's side. Belongings included two insulated drinking cups, four bags of personal belongings, a small plastic bin containing hygiene supplies, an electric keyboard with items piled on top, a large cardboard box with approximately two feet of clothing piled on top, and a suitcase with boxes and clothing resting on it. Almost every linear foot of the baseboard around her side of the room was lined with personal belongings. She had a small dresser, nightstand and a wardrobe but there was still enough space for additional storage bins or a second dresser. (Photographic evidence obtained) During an interview with Resident #756 on 03/27/23 at 1:08 PM, she complained she did not have a place to lock up her belongings or money. Resident #756's room was observed in the same condition on 03/28/23 at 9:50 AM. Personal items, the suitcase, bags and boxes were still on the floor. (Photographic evidence obtained) Another interview was conducted with Resident #756 on 03/28/23 at 1:22 PM. She was asked about her numerous personal belongings. Resident #756 stated she wished she had somewhere to store her items off the floor. Licensed Practical Nurse (LPN) I was interviewed on 03/28/23 at 1:53 PM. She stated some residents came in with more items than there was storage. In those instances, they sometimes asked family to come pick up items or they asked Social Services to store them. On 03/30/23 at 11:30 AM, an interview was conducted with the Maintenance Manager (MM). He was asked about Resident #756's belongings and was shown the photographic evidence. He and the Director of Clinical Services (DCS), who was in the room, acknowledged the floor all the way around the resident's side of the room was being used for storage. The DCS reported Resident #756 hoarded items and would retrieve her belongings from storage. She did, however, admit there were plastic stacking bins in storage that could be used to get the resident's belongings off the floor. The DCS directed the MM to look for them. She did not know why staff did not report the condition of Resident #756's room and her need for additional storage. .

Based on observation, record review, interviews with staff, and a review of the facility's policy and procedure for Medication Management for Psychotropic Medications, the facility failed to ensure behavior monitoring was conducted for one (Resident #83) of five residents reviewed for unnecessary medication use, from a total of 36 residents in the sample. The findings include: On 3/28/23 at 12:30 p.m., Resident #83 was observed eating lunch in the day room. She had bruising noted under both her left and right eyes. She reported she fell and hit something, but she was not sure what that was. The resident had some confusion and was unable to remain focused during the interview. A record review was conducted for Resident #83, which noted an admitted [DATE] with a readmission on 2/22/23. Her diagnoses included schizo-affective disorder with a physician's order for Haldol (antipsychotic medication) 10 mg (milligrams) BID (twice daily), ordered on 3/6/23. There was also a 2/23/23 order for Lorazepam (benzodiazepine sometimes used for agitation), 1 mg every 8 hours as needed for aggression, and Trazodone (antidepressant) 150 mg at bedtime, ordered on 2/22/23. A review of the resident's March 2023 Medication Administration Record (MAR), revealed that no behavior monitoring was documented. A review of the March 2023 Treatment Administration Record (TAR) and progress notes, revealed two progress notes concerning behaviors. An interview was conducted with Licensed Practical Nurse (LPN) D on 3/28/23 at 1:29 PM. She stated behaviors were documented on the resident's MAR, TAR or Progress Notes. Behaviors would also be documented in the nursing notes. LPN D reviewed the MAR, TAR and Progress Notes, and reported that only two incidents of behaviors were documented on the same day this month. An interview was conducted with the Director of Nursing (DON) on 3/28/23 at 1:56 PM. She was asked where behaviors would be found in the electronic medical record, and she replied that behaviors would be charted in progress notes or in the electronic MAR. She confirmed that Resident #83 had no behavior monitoring in place after reviewing the electronic record. The DON reported finding a note on 3/6/23 indicating no behaviors, but later the same day at 12:13 PM, cursing and yelling at the nurses' station. She confirmed that the charting was inconsistent, and reported side effects of medications would be in the nursing notes and the provider would be notified. The DON stated the nurses were responsible for documentation of behavioral monitoring and it was not done. An interview was conducted with LPN D on 3/30/23 at 10:34 AM. She stated Resident #84 did have behaviors such as yelling out, getting up constantly out of her wheelchair, requiring constant redirection, and she was combative and verbally abusive toward staff. A review of the facility's policy and procedure for Medication Management for Psychotropic Medications (revision date of 3/23/18), revealed under Procedure #4: Monitor behavior and side effects every shift utilizing the Behavior Monitoring Flow Record. .

Based on observation, record review, interviews with staff, and a review of the facility's policy and procedure for Medication Management for Psychotropic Medications, the facility failed to ensure psychotropic medications ordered as needed included a stop date for one (Resident #83) of five residents reviewed for unnecessary medication use, from a total of 36 residents in the sample. Resident #83 was receiving Lorazepam (benzodiazepine sometimes used for agitation) as needed for aggression with no stop date noted or rationale for continuing the medication beyond 14 days. The findings include: On 3/28/23 at 12:30 PM, Resident #83 was observed eating lunch in the day room. She had bruising noted under both her left and right eyes. She reported she fell and hit something, but she was not sure what that was. The resident had some confusion and was unable to remain focused during the interview. A record review was conducted for Resident #83, which noted an admitted [DATE] with a readmission on 2/22/23. Her diagnoses included schizo-affective disorder with a 2/23/23 physician's order for Lorazepam (benzodiazepine sometimes used for agitation) 1 mg (milligram) every 8 hours as needed for aggression. Further review of the medical record revealed no stop date for the as needed medication, or documentation of a rationale for its continuation. A review of the March 2023 Medication Administration Record (MAR) revealed that the resident received Lorazepam on 3/6/23 and 3/22/23. An interview was conducted with Licensed Practical Nurse (LPN) D on 3/28/23 at 1:29 PM. She reviewed the MAR and confirmed that Lorazepam 1 mg is ordered as needed and did not have a stop date. An interview was conducted with the Director of Nursing (DON) on 3/28/23 at 1:56 PM. She reviewed the resident's order for Lorazepam 1 mg as needed and confirmed that there was no stop date when there should have been. She stated she would alert her psychiatric Advanced Registered Nurse Practitioner (ARNP) and request a stop date. The facility's policy and procedure for Medication Management for Psychotropic Medications (revision date of 3/23/18) was reviewed. Stated under Procedure #7: Whenever needed (prn), physician's orders for psychotropic medications are limited to 14 days, unless the physician believes it is appropriate to extend beyond 14 days and documents the rationale in the medical record.

Based on observations, staff and resident interviews, a review of resident records and the resident handbook, the facility failed to ensure that food received and/or prepared by resident families, friends and/or other outside sources was handled safely once it was brought into the facility for two (Residents #18 and #88) of two residents observed storing and eating unrefrigerated perishable foods in their rooms, from a total of 36 residents in the sample. The findings include: During lunch observation in the Activities room on 03/27/23 at 12:47 PM, Resident #18 was observed eating a salad. A bottle of store-brand ranch salad dressing was on the table next to him. It was opened, partially used and at room temperature. The label on the bottle listed perishable ingredients including egg yolk, buttermilk, milk and warned: Contains Milk and Eggs. Instructions were to Refrigerate after opening. Photographic evidence was obtained. Resident #18 stated it was his dressing and he kept it in a drawer in his room. He gets a salad every day at lunch. Certified Nursing Assistant (CNA) H was interviewed on 03/28/23 at 12:52 PM. She confirmed some residents kept food in their rooms like canned foods, crackers, and other non-perishable foods, which was okay. There were no residents with refrigerators in their rooms, but some would keep milk and other perishable items in their rooms even though staff ask them not to. CNA H stated she would remove any unsafe items and offer to store perishable food in the activity room refrigerator. Staff would label the food with the resident's name before storing it there. Resident #18 was observed again in the activities room on 03/28/23 at 12:54 PM, his same bottle of salad dressing on the table. There was now only about an inch of dressing left in the bottom of the bottle. His salad arrived with 4 small single-serve packets of ranch dressing. (Photographic evidence obtained) Resident #18 put the dressing on his salad. The surveyor stepped away, then returned to the table moments later to see his salad swimming in dressing. Resident #18 explained he went through about a bottle of his ranch dressing a week. Licensed Practical Nurse (LPN) I was interviewed on 03/28/23 at 2:03 PM. She stated residents could keep non-perishable foods in their rooms, but perishable foods were kept in the nourishment room refrigerators. The food was dated, labeled with the resident's name, and must be discarded in three days if perishable or brought from home. Salad dressings and condiments were disposed of on or by the expiration date on the bottle. On 03/28/23 at 2:30 PM, Resident #18 showed this writer where he kept his food. He opened the bottom drawer of the nightstand in his room explaining his sister brought in most of his food. There was a large bottle of unopened ranch salad dressing in the drawer. (Photographic evidence obtained) Resident #18 explained that he finished his other bottle of dressing at lunch today. When asked about refrigeration, Resident #18 insisted the dressing was safe in the drawer. Staff had offered to put it in the refrigerator, but he never gave them an answer. Further inspection of the resident's room found there was no refrigerator. On 03/29/23 at 10:05 AM, during an interview with the Director of Clinical Services (DCS) in her office, an unopened bottle of store brand-ranch salad dressing was observed sitting on the side table. It was the same size and brand observed in Resident #18's drawer but was not labeled with a name. During a visit to Resident #88's room on 03/29/23 at 10:18 AM, a wax bag containing chicken wings was observed on his overbed table. There were crumbs surrounding the bag. Resident #88 explained his brother brought the chicken in last night and he ate it this morning. He was asked if the chicken had been refrigerated overnight and he said no. When advised the chicken should have been refrigerated after four hours at room temperature, Resident #88 insisted he does this all the time at home. When asked if staff offered to put the chicken in the refrigerator overnight, at first, he said the staff didn't see it. Then Resident #88 said the certified nursing assistant (CNA) gave him a baggie (small trash can liner) to put the chicken in and offered a basin to put the wrapped wings in because we don't want any roaches in here. He declined use of the basin and put the chicken in the baggie overnight. Resident #18 was observed on 03/29/23 at 12:51 PM at lunch. He had a salad (mostly eaten) and approximately 10 used packs of the single-serving ranch dressing on the table next to him. There was no bottled dressing on the table. When asked where his salad dressing was, he said staff took it from him because (this writer) told them it needed to be in the refrigerator. Resident #18 confirmed nobody brought it to him to use at lunch today. The DCS was interviewed on 03/29/23 at 12:59 PM and asked if the bottle of dressing, which was still on the table in her office, was Resident #18's. She confirmed it was and stated it had been removed from his room. She said Resident #18 was told he could use the individual packets of dressing the facility provides and have as many as he likes, since he prefers a lot of dressing. The DCS pointed out the removed dressing was still unopened. When asked why Resident #88 was not provided with his preferred dressing at lunch, given the bottle was unopened and safe for him to eat, she did not provide a reason. The DCS said staff was going to put his name on it and put it in the refrigerator. CNA A was interviewed on 03/30/23 at 10:21 AM. She was asked about residents storing food in their rooms. CNA A said most of the residents on the east wing did that, but there was only one small dorm-sized refrigerator on the unit for perishable food storage. When asked what staff did if residents brought in perishable foods and there was no room in the refrigerator, she said, Nothing. They just leave it in the room. When told Resident #88's chicken sat at room temperature overnight, she said, That happens all the time, with other residents too. When asked what she did when that happened, she replied, Nothing, that she would just leave the food in the room unless it was milk, which she would throw away. CNA A said they needed more refrigerator space. When asked if residents ever suffered from stomach upset as a result of eating unsafely stored food, she said yes. CNA A again insisted more cold storage was needed, since a lot of the residents ordered food in from stores and had more food than the current cold storage room could accommodate. She confirmed there were no personal refrigerators in resident rooms. In an interview with the DCS on 03/30/23 at 11:30 AM, she confirmed that all perishable food should be refrigerated. When told of the observation of Resident #88's chicken in addition to the observations of Resident #18's salads, she stated the foods should have been refrigerated. The DCS was advised one employee reported they just left the food in the room if there was no refrigerator space. She had no explanation for why that was occurring when there was a refrigerator on each unit. She was advised the refrigerator was only dorm-sized and acknowledged that many residents ordered food out. The DCS acknowledged there was insufficient space for accommodating all resident's perishable foods. She agreed a full-sized refrigerator was needed and that staff should be storing resident foods safely. The Admissions Coordinator (AC) stated in an interview on 03/30/23 at 12:53 PM, that on admission, he verbally advised new residents of the policy for bringing in food from outside sources. The residents also received a handbook. All perishable foods must be refrigerated. The AC provided the resident handbook which stated on page 9 that food provided by family that required refrigeration would be stored in a refrigerator designated for such items. All items must be in a sealed, disposable container marked with the resident's name, the type of food and the date brought in. (Photographic evidence obtained) The facility's Policy #031 Food: Safe Handling for Foods from Visitors stated, Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. Procedures stated: 1. staff will request visitors bringing in food . notify a staff member of nursing or the activities departments. 2. Responsible staff will determine if the food item is for immediate consumption or stored for later use . . 4. When food items are intended for later consumption, the responsible staff will: Ensure the food is stored separately . from facility food. Label foods with resident name and current date. Determine if food items are shelf stable and whether they can be stored in the resident's room or under refrigeration . (Photographic evidence obtained)

Based on observation, a review of resident records, and interviews with staff, the facility failed to ensure resident clinical records were accurately documented and reflective of the care provided for one (Resident #46) of three residents reviewed with gastrostomy tubes (g-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and liquids), out of 25 residents whose clinical records were reviewed, from a total of 36 residents in the sample. The findings include: An interview was conducted with Resident #46 on 03/29/23 at 10:10 AM. He was speaking very loudly and threatened that he was about to rip his g-tube out. Resident #46 lifted his shirt to show the insertion site and the tube. He reported he was eating by mouth and insisted the tube was supposed to have been removed. A record review for Resident #46 found he was admitted to the facility on [DATE]. He had a 5-day Minimum Data Set (MDS) assessment with an assessment reference date of 2/8/23, that noted he had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating that he was cognitively intact and able to make daily decisions. He was coded as being totally dependent for eating. His primary medical conditions included stroke, dysphagia (difficulty swallowing) following cerebral infarction (stroke), non-Alzheimer's dementia, malnutrition (protein, calorie), and adult failure to thrive. Resident #47 had one surgery involving the gastrointestinal tract prior to admission. He was assessed with no swallowing difficulty and no weight loss and had a feeding tube. Resident #46 was care planned on 2/15/23 for requiring tube feedings related to dysphagia following cerebral infarction. The goal was to remain free of signs/symptoms or complications related to tube feedings through the next review date. Interventions include, but were not limited to, head of bed elevated 45 degrees during and thirty minutes after tube feeding; check for placement and gastric contents/residual volume as ordered; provide local care to g-tube site as ordered and monitor for signs of infection; Registered Dietician (RD) to evaluate quarterly and as needed . and make recommendations for changes to tube feeding as needed. (Photographic evidence obtained) Resident #46 had a physician's order for nothing by mouth (NPO) which was started on 1/28/23 but discontinued 2/19/23, as was an order for medications through his PEG (pericutaneous endoscopic gastrostomy) tube. He also had an active diet change order for a regular diet, dysphagia advanced texture and nectar thickened fluids and an order that he receive 1:1 supervision with all meals. Both orders were written 2/19/23. (Photographic copy obtained) On 3/14/23, a GI (gastrointestinal) consultation was ordered to evaluate and remove the PEG tube due to it no longer being in use. (Photographic evidence obtained) Review of additional current physician's orders found three conflicting routes of administration for his medications, including by mouth, through the (now discontinued g-tube) and through a DH tube (Dobhoff tube, a type of nasogastric tube inserted into the nostril and down the esophagus into the stomach) which the resident did not have. Orders included: Jevity (a liquid food for administration via g-tube) 1.5 calories, 320 cc (cubic centimeters) via g-tube every 6 hours per bolus. (Start 1/31/2023, discontinued 3/7/2023) Zyprexa (medication used to treat psychosis) 5 milligrams (mg), give 1 tablet via DH-Tube at bedtime for paranoia (started 1/29/23). Depakene Oral Solution (used for seizure disorder) 250 mg/milliliters give 5 ml via DH-Tube two times day for stroke as ordered (started 3/1/2023). Tramadol HCL (hydrochloride) oral tab 50 mg, give 0.5 mg by mouth every 8 hours as needed for pain (start 3/10/2023). A review of the medication administration record (MAR) found nurses were signing off that they were giving medications through all three administration routes even though the g-tube was not in use and the resident never had a DH-Tube. (Photographic evidence obtained) An interview was conducted with the Registered Dietician (RD) on 03/30/23 at 1:13 PM, who confirmed the resident still had the g-tube but was eating by mouth now. The APRN (Advanced Practice Registered Nurse) was interviewed on 03/30/23 at 2:07 PM. She confirmed that Resident #46's G-tube could come out, as he was taking all food and medications by mouth. When told his physician's orders included three different routes of administration for medications, including by mouth, by DH-Tube and g-tube, she said, No, that should be removed. She confirmed Resident #46 did not have a DH-Tube and had no explanation why there were ever orders written for medication via that route.

Based on record review, staff interviews, and facility policy and procedure review, the facility failed to implement their abuse investigation and reporting policy related to an injury of unknown origin and failed to file a federal report within the required timeframe to the State Survey Agency for one (Resident #1) of three sampled residents reviewed for abuse. The findings include: A review of the clinical record for Resident #1 revealed she was admitted to the facility on [DATE] and discharged on [DATE]. Her medical diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, atrial-fibrillation, personal history of other malignant neoplasm of bronchus and lung, acute stress reaction and hypertension. A review of the initial nursing weekly skin integrity review assessment form dated 11/01/2022 at 14:59 hours revealed Resident #1 was cognitively impaired. All her skin surfaces were intact, and she had no bruising on her hands. The assessment was conducted by Employee K, Licensed Practical Nurse (LPN). (Copy obtained) A review of the nursing weekly skin integrity review assessment form dated 11/03/2022 at 13:32 hours revealed Resident #1 had two bruises noted on her right hand. The first site measured 2.5 x 3.0 centimeters (cm) sized light purple area to anterior hand at medial wrist. The second site measured 3.5 x 4.0 cm light purple area to anterior hand distal 4th and 5th fingers. The assessment was conducted by Employee K. (Copy obtained) A review of the Agency for Health Care Administration Nursing/Social Work Assessment 3008 form dated 10/14/2022 revealed the Skin Condition section read: 1. Intact. (Copy obtained) A review of the Baseline Care Plan and Summary for Resident #1 dated 11/01/2022 revealed the resident was care planned for Focus: Falls/Safety/Elopement. Goal: The resident will remain free of injury. Intervention: Maintain a safe environment. Focus: Altered Skin Integrity/Potential For. Goal: Prevent any skin breakdown or injury. Intervention: Report any skin breakdown to charge nurse. (Copy obtained) During an interview on 02/16/2023 at 12:20 pm with the Administrator, he stated he did not receive an allegation of abuse regarding Resident #1. He remembers her son complaining about the bathroom and they cleaned the bathroom immediately but that is all he recalls. He left the interview to go research the case. During an interview with the Director of Nursing (DON) on 02/16/2023 at 12:27 pm, she stated, she did not receive a complaint of an allegation of abuse by Resident #1 nor her family. She said, I would have remembered that. Her son had complaints about multiple other things, but he did not allege abuse. I would have immediately investigated it. During a second interview with the DON on 02/16/2023 at 2:09 pm, she confirmed that she had reviewed Resident #1's chart. The initial weekly skin assessment documented that the resident's skin was clear. She remembers telling Employee K to conduct another assessment because she was hearing that Resident #1's son was complaining about the cleanliness of the room. She wanted to make sure the resident was doing well, and he would not have any complaints about her care. It was not reported back to her about the bruises. The nurse, Employee K, who is the unit manager now, had just started working at this facility when the resident was admitted on [DATE]. Employee K told the DON that she conducted the assessment and that the resident was fine. Employee K told the DON today, when questioned that she remembered that the bruising was faint on 11/03/2022 and that she did not think it rose to the level of abuse. The DON stated, she does not remember ever being told about the bruises. She confirmed that Employee K should have reported the bruising as an injury of unknown origin so it could be investigated. She went back through Resident #1's clinical record and tried to tie the bruising to something else but could not. She did not fall or have any injection or intravenous therapy that may have caused the bruising. She was on an anticoagulant that would have exacerbated the bruising. She confirmed that the facility policy is to report injuries of unknown origin to the DON, and she initiates an investigation immediately. She confirmed that did not happen due to no one reporting it. During an interview with Employee K on 02/16/2023 at 2:36 pm, she stated she has worked at this facility since 10/31/2022. She remembers the bruises being dark purple. She does not remember the resident telling her what happened. Resident #1 had dementia and was confused. She confirmed, she should have reported it right away as an injury of unknown origin. She normally would not have done a second skin assessment so soon except the resident's son had multiple complaints and concerns but none about her skin. She conducted the second skin assessment and noted the bruising. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation N-1265 (last revised on 11/16/2022) read: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property against any resident. 7. Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse, or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property, to a resident is obliged to report such information immediately, but no later than 2 hours after the allegation is made. (Copy obtained)

Based on observations, interviews, and record review, the facility failed to provide assistance with showers for one (Resident #16) of three residents reviewed for activities of daily living (ADLs), from a total of 34 residents in the sample. The findings include: A review of Resident #16's medical record revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment, dated 6/2/2021, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. The assessment did not identify any resident behaviors or rejection of care. The resident was documented as totally dependent for bathing and required extensive assistance with personal hygiene. On 8/19/2021 at 10:45 AM, an interview was conducted with Resident #16. He was lying in his bed. His hair was greasy and matted. He explained that he hadn't received a shower in over a month. He stated he wasn't aware of his shower schedule and that any time he asked for a shower, the staff told him they were too busy. A review of the resident's comprehensive care plans revealed a focus area for ADL self-care performance deficit. Interventions identified the resident as being totally dependent on one staff member to provide a bath/shower as necessary. Another intervention directed staff to provide bathing and showering per resident requested schedule and routine. (Photographic Evidence Obtained) A review of the care flow records for Resident #16 revealed no documented showers between 7/20/2021 and 8/17/2021. (Photographic Evidence Obtained) On 8/19/2021 at 10:55 AM, an interview was conducted with Certified Nursing Assistant (CNA) D. She confirmed that she was assigned to Resident #16, but that she was employed by an agency and was not familiar with his care. She was asked how she obtained information unique to each resident in order to provide needed care. She explained that the agency staff had access to the kiosk. She was asked to locate the shower schedule for Resident #16 but she was unable to do that. On 8/19/2021 at 11:01 AM, an interview was conducted with Licensed Practical Nurse (LPN) B. She confirmed that she was assigned to Resident #16. She was asked whether Resident #16 required assistance with showers and whether he received them regularly. The nurse stated, I don't think he refuses them. I don't know. I've never seen him get one, though. When asked how she ensured her assigned residents received showers, the nurse stated, Well, we are supposed to look at the CNAs' documentation. The nurse was asked to review Resident #16's care flow records. She confirmed that no showers had been documented for the most recent 30 days. .

Based on observations, interviews, and record review, the facility failed to respond appropriately to a resident's change in condition for one (Resident #37) of one resident reviewed from a total of 34 residents in the sample. The findings include: On 08/18/21 at 11:40 AM, an observation of medication administration for Resident #37 was conducted with Licensed Practical Nurse (LPN) C. Upon entering the room, the resident stated, I don't feel good at all. The nurse asked the resident what was wrong. The resident replied, I feel like I might have a fever. The nurse stated, Ok. We will check your temperature. The nurse then completed the resident's blood glucose monitoring and exited the room to prepare the resident's insulin coverage. On 08/18/21 at 11:52 AM, LPN C entered Resident #37's room with the resident's insulin coverage. As she was preparing to inject the insulin, the resident stated, I don't think I've ever felt this bad. The nurse did not respond. She injected the insulin into the resident's left arm, discarded the syringe, and washed her hands. As the nurse was exiting the room, the resident stated, You forgot to take my temperature. The nurse did not respond to the resident. On 08/18/21 at 2:05 PM, Resident #37 was observed sitting in the day room. The resident was asked whether the staff had checked her temperature. She stated, No. They never did get around to it. On 08/18/21 at 2:10 PM, an interview was conducted with LPN C. She was asked whether she had checked Resident #37's temperature or provided any other assessment related to her reported change in condition. The nurse stated, Oh. I haven't checked it yet. The nurse then directed the CNA to obtain the resident's temperature. The CNA checked the resident's temperature with a temporal thermometer. The CNA reported the result was 98.0. The nurse acknowledged that she had not assessed the resident any further, nor had she contacted the resident's physician or representative. On 08/19/21 at 11:20 AM, an interview was conducted with Resident #37. She was asked how she was feeling. She stated, I feel about the same. Not too good. When asked what the facility's response had been, she stated, Well, they took my temperature and that was about it. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's policy titled, Notification of Change in Condition was reviewed. The policy was revised on 12/16/2020. The policy directed the nurse to complete an evaluation of the resident and document the evaluation in the medical record. It also directed the nurse to contact the resident's physician. .

Based on observations, interviews and record reviews, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Residents #21 & #81) of three residents reviewed for pressure ulcers, from a total of 34 sampled residents. The findings include: 1. A review of Resident #21's medical record revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21 required extensive assistance from one person for bed mobility, transfers, dressing and toileting. The most recent quarterly Minimal Data Set (MDS) assessment, dated 6/8/2021, revealed that Resident #21 had multiple stage 4 pressure ulcers and was receiving wound care. A review of an 11/6/2020 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/23/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An 8/17/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Calcium alginate was to be applied and covered with a dry dressing every Monday, Wednesday, and Friday. A review of the Wound Physicians Group notes revealed that on 8/2/2021, the physician identified an unstageable deep tissue injury (DTI) of the right posterior upper thigh with orders to apply a [MEDICATION(S)] dressing three times per week for 30 days. A review of the Wound Physicians Group note dated 8/16/2021, revealed that Resident #21's visit was rescheduled. A review of the Care Plan dated 6/10/2021, revealed a focus area for pressure injuries with interventions that included administering treatments as ordered and to monitor for effectiveness. A review of Resident #21's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR/TAR had no entry for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication that this treatment was being completed by nursing. A review of the facility's policy and procedure for Pressure Injury Records, document WC-130 (revision date 4/1/2017) revealed, To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. One site will be recorded per page. On 8/18/2021 at 10:19 AM, an interview was conducted with the Director of Nursing (DON). When asked who performed resident wound care, she stated the facility used a wound treatment nurse, but when the wound treatment nurse was not available, the assigned nurse was responsible for providing and documenting the treatments. On 8/18/2021 at 11:18 AM, an interview was conducted with the Corporate Nurse Consultant (CNC). The CNC confirmed that the required documentation of Resident #21's pressure injury had not been completed since June of 2021. On 8/18/2021 at 2:34 PM, Licensed Practical Nurse (LPN) A was observed performing wound care for Resident #21. The DTI of the right posterior thigh was not treated with a [MEDICATION(S)] dressing. LPN A used calcium alginate on the wound site. On 8/19/2021 at 5:33 PM, an interview was conducted with the DON regarding the process of transcribing the Wound Physicians Group orders. The DON stated the wound treeatment nurse was to download the Wound Physicians Group notes, review them and transcribe any new orders. She further stated at this time the wound treatment nurse did not have access to download the Wound Physicians Group notes. The DON stated the notes and orders had not been downloaded, so the orders were not being transcribed. 2. A review of Resident #81's medical record revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A five-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 points, indicating severe cognitive impairment. The assessment indicated the resident required extensive assistance of two or more persons for bed mobility. She had an indwelling urinary catheter and was incontinent of bowel. The resident had a stage 4 pressure injury. A review of the resident's comprehensive care plans revealed a focus area for Activities of Daily Living (ADL)/Self-Care Deficit. The intervention for bed mobility indicated the resident required the extensive assistance of 1-2 staff to turn and reposition in bed as necessary. A second focus area was identified for the resident's sacral pressure injury. Interventions included assist to turn and reposition and pressure reducing devices as ordered. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read, Alternate from side-lying to supine (on her back) every 2 hours. Ensure pt (patient) is not in side-lying (position) during meals. On 8/16/2021 at 10:15 AM, Resident # 81 was observed lying in bed on her back. No positioning pillows or devices were in place. On 8/16/2021 at 11:24 AM, Resident # 81 was observed lying in bed on herb back. No positioning pillows or devices were in place. On 8/16/2021 at 1:30 PM, Resident # 81 was observed lying in bed on her back. No positioning pillows or devices were in place. On 8/18/2021 at 10:13 AM, Resident # 81 was observed lying in bed on her back with the head of the bed elevated to above 35 degrees. No positioning pillows or devices were in place. On 8/18/2021 at 2:06 PM, Resident # 81 was observed lying in bed on her back. She was repeatedly yelling out, Grandma, help me. A purple positioning wedge was observed sitting on the floor between the resident's dresser and armoire. On 8/18/2021 at 4:48 PM, Resident # 81 was observed lying in bed on her back. Her eyes were closed. A purple positioning wedge was positioned under the resident's knees. Her heels were touching the mattress. On 8/19/2021 at 10:46 AM, an interview was conducted with Certified Nursing Assistant E. She confirmed that she was caring for Resident #81. She explained that the resident had a big wound on her bottom. When asked about pressure injury interventions, she stated, We turn her every two hours. She stated the resident was turned when she came in at 7:00 AM and she had just placed the resident on her back. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read, Alternate from side-lying to supine (on her back) every 2 hours. Ensure pt (patient) is not in side-lying (position) during meals. On 8/18/2021 at 3:42 PM, an interview was conducted with the Director of Nursing (DON). She was asked what her expectation was for turning and repositioning a resident with a pressure injury. She stated, They should be turned and repositioned frequently and as needed. She further explained that the facility did not have a specific time frame for turning and repositioning. When asked whether a resident with a stage four pressure injury would need to be turned and repositioned at least every two hours, she replied yes. .

Based on observations, interviews, and record review, the facility failed to provide effective pain management by 1) Failing to administer pain medication prior to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: A review of Resident # 81's the medical record revealed an admitted [DATE]. Her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A five-day Minimum Data Set (MDS) assessment, dated 7/29/2021, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 points, indicating severe cognitive impairment. The assessment indicated the resident required extensive assistance of two or more persons for bed mobility, and that she had an unhealed Stage 4 pressure injury. A review of the resident's comprehensive care plans revealed a focus area for a pressure injury to her sacrum. An intervention on the care plan read, Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Continued review of the care plans revealed a focus area for the potential for pain. Interventions included, Administer [MEDICATION(S)] as per orders. Give 1/2 hour before treatments. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. (Photographic Evidence Obtained) A review of the resident's physican's orders revealed an order dated 4/8/2021 for acetaminophen 650 milligrams every four hours as needed for pain. (Photographic Evidence Obtained) A review of the resident's medication administration records (MARs) for August 2021, revealed no documented administration of the acetaminophen. (Photographic Evidence Obtained) On 08/19/2021 at 12:45 PM, an observation was made of wound care provided to Resident #81. The wound care was provided by the Unit Manager (UM). Upon entering the room, the resident was positioned on her back. Certified Nursing Assistant E assisted the resident to turn on her left side. An adhesive island dressing was observed on the resident's sacrum. As the UM began removing the adhesive dressing from the resident's skin, the resident furrowed her brow and repeatedly stated, Grandma, help me. The behaviors continued as the UM continued removing the dressing. Once the adhesive dressing was removed from resident's skin, the UM sprayed a wound cleanser onto gauze sponges and began to clean the stage IV pressure injury with the gauze sponges. As the sponges made contact with the wound edges and wound bed, the resident again furrowed her brow and threw her right leg over the side of the bed. She then began repeatedly kicking the bed frame with the heel of her right foot while repeatedly stating, Ouch, ouch, ouch. The UM finished cleaning the wound and then began packing the wound with calcium alginate. As he was placing the calcium alginate in the wound, the resident began to kick the bed frame with the heel of her right foot repeatedly until the UM finished. The wound was then covered and the resident was positioned on her back. On 8/19/2021 at 2:01 PM, an interview was conducted with the Director of Nursing (DON) regarding her expectations for the management of pain in residents with pressure injuries. She stated, My goal is to keep them pain free. She explained that she would expect staff to offer pain medication prior to wound care or treatments. Concerns regarding Resident #81's pain were discussed with the DON during the interview. On 8/19/2021 at approximately 6:00 PM, the DON provided a copy of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She also provided a copy of a nursing progress note regarding communication to the pain management physician and the new order for pain medication. However, the order and the progress note referenced a different resident and were not written for Resident #81. (Photographic Evidence Obtained) The facility's pain management policy titled, Pain Management Guideline was reviewed. The policy was revised on 8/28/2017. The policy indicated it's purpose was to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The process directed staff to evaluate pain using either the resident's self report of pain or by using the resident's non-verbal clinical indicators. .

Based on interview and record review, the facility failed to ensure that the resident's medical record included documentation that indicated, at a minimum, the following: That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal for two (Residents #94 and #12) of five residents reviewed from a total of 34 residents in the sample. The findings include: A review of Resident #94's medical record revealed that the resident signed a consent form to receive the influenza immunization on 12/7/2020. No documentation was found in the medical record to support evidence of administration of the immunization. A review of Resident #12's medical record revealed that the resident signed a consent form to receive the pneumococcal immunization on 9/28/2020. No documentation was found in the medical record to support evidence of administration of the immunization. On 8/19/2021 at 4:13 PM, an interview was conducted with the Director of Nursing (DON). She confirmed that she was unable to find evidence verifying that the immunizations were administered to these two residents.

Based on the findings of this survey and the review of the facility records, the facility had not developed and implemented an effective quality assessment and assurance program (QAA) to monitor and improve the services provided. The deficient practices identified actual harm for 8 (#2, #10, #23, #41, #53, #66, #144 and #159) of 36 sampled residents, and Substandard Quality of Care relative to the Activities Department for all of the 113 residents who resided in the facility. The findings include: 1. An interview with the administrator and the risk manager on 4/29/11 at 4:30 PM confirmed that none of the identified concerns including catheters, infections, laboratory values, following physician orders, providing medications as ordered, and not treating infections effectively had been identified through their QAA team. The administrator stated she was unsure why the QAA team had not identified these concerns. When interviewed about their processes for identifying potential concerns to bring to the QAA meeting, either through clinical record audits, reviewing resident grievances to ensure timely and acceptable resolutions, monitoring the Medication Administration Records (MAR) for missing medications, or reviewing resident specific infections and interventions, the administrator stated they do not use any of these resources to identify potential issues for QAA team. 2. An interview with the risk manager (RM) on 5/17/11 at 1:30 PM revealed that she was a member of the QAA committee. The RM stated that "as problems come up with guardian angel rounds, we QA the problem, most of the physician orders [REDACTED]." The RM stated that a lot of issues revealed by the AHCA survey 2011 would be used to "get stuff done" in the QAA committee. The RM revealed the Guardian Angel program was created through the QAA process. The angels have personal questions that they ask the residents and the reports are submitted to the administrator every Friday. The report is submitted each week and is addressed the next week by QAA. The RM stated that procurement of laboratory specimen results were not discussed in QAA committee. There was a question revealed on the Angel rounds questionaire about whether activities meet the residents' needs. Per the RM, the guardian angels were held accountable for information and a lot of grievances come from angel rounds such as lost clothing and clutter, and the questionaire asks about resident pain. For residents who don't communicate verbally, the RM stated that family members and certified nursing assistants were consulted. The Guardian Angel reports go to QAA, and if it's something that was trending, it was addressed by QAA. The angel rounds that are in use now were revamped in December 2010. The Angel Rounds findings were tracked and trended, but it was performed by the administrator who was out on leave during the extended survey. The RM stated that Activities were QA'd, but the action plan was "real vague". The RM also stated that the only thing she addressed in QAA since she had been working at the facility was related to the pharmacy about missing medication and she only spoke to the person that audited the medication carts. The RM stated that the goals for QAA were high at 100% compliance for the things that were addressed by the committee. 3. Based on observations, review of clinical records, minutes from the Residents' Council meetings, the scheduled activities, and interviews with residents, a family member, and facility staff, the facility failed to provide an effective Activities Program for 7 (Residents #23, #159, #145, #41, #31, #53, and #10) of 36 sampled residents which resulted in social isolation and loss of control of important aspects of their home environment. They also failed to provide an effective Activities program for the other 107 residents, who resided in the facility. The failure to schedule and plan activities effectively resulted in substandard quality of care for the residents. In addition, the residents were unable to participate in the planning of the scheduled activities, they were uninformed when significant changes were made to the daily schedule, they were not assisted to the planned activities timely, they were not given notice before the activities began, and they were not encouraged to attend or participate in the daily activities. See F248 for additional information regarding Residents #23, #159, #145, #41, #31, #53 and #10 as well as the Activities Program. 4. Based on observations, resident and staff interviews, review of the minutes from the Resident Council meetings, and review of the scheduled activities; the facility failed to act upon the residents' concerns about the Activities Program and they failed to provide enough space for all of the residents to attend activities of their choice. The facility's failure to address and act upon the concerns of the residents affected the residents' quality of life resulting in social isolation, feelings of boredom, and loss of control of important aspects of the residents home environment; therefore, substandard quality of care exists at this facility. See F244 for additional information regarding Resident #10 and the potential effect on all residents. 5. Based on observations, interviews, and clinical record review the facility failed to ensure that 2 (#159 and #2) of the 3 sampled residents with urinary catheters received the necessary care and services resulting actual harm as evident by the pain and suffering experienced by Resident #159. The facility failed to identify, assess and manage Resident #159's [MEDICAL CONDITION] and urinary tract infections. The facility failed to report to the physician ongoing signs and symptoms of urinary tract infections such as pain, fever, cloudy and discolored urine, clogged urinary catheters, and failed to follow through on laboratory tests as ordered. The facility failed to identify, assess and manage Resident #2's ongoing urinary tract infections by failing to notify the residents physician of signs and symptoms of urinary tract infections and complete laboratory tests as ordered. See F315 for additional information regarding Residents #159 and #2. 6. Based on resident observations, resident and staff interviews, clinical record review and policy review, the facility failed to ensure that the physicians for 2 (#159 and #2) of 3 sampled residents with indwelling urinary catheters were notified of laboratory findings. This failure resulted in ongoing pain and suffering related to ongoing urinary tract infections, causing actual harm for Residents #159 and #2. See F505 for additional information regarding Residents #159 and #2. 7. Based on resident observations, resident and staff interviews, clinical record review and policy review, the facility failed to file the laboratory reports for 2 residents (#159 and #2) of the 3 sampled residents with indwelling urinary catheters. This failure resulted in actual harm for Residents #159 and #2 related to ongoing pain and suffering caused by ongoing urinary tract infections. See F507 for additional information regarding Residents #159 and #2. 8. Based on family interview, staff interview and clinical record review the facility failed to notify the physician and family members of changes in condition and treatment of [REDACTED]. This failure resulted in ongoing pain and suffering related to ongoing urinary tract infections, causing actual harm for Residents #159 and #2. See F157 for additional information regarding the facility's failure to notify Resident #159 and #2's physicians and families, and the actual harm related to this deficient practice. 9. Based on resident and staff interviews and review of the Grievance Log, the facility failed to resolve 2 grievances filed by Resident #53, 1 of 36 sampled residents. The facilities failure to resolve Resident #53's grievances caused the resident to suffer from ongoing pain and feelings of loss of self-determination related to her home environment by the facility imposing the care of an undesirable personal care attendant. See F166 for additional information regarding the facility's failure to resolve Resident #53's grievances and the actual harm related to this deficient practice. 10. Based on observations, interviews with residents and staff, and review of the clinical records, the facility failed to respect resident preferences and choices for 4 (#23, #53, #66, and #41) of 36 sampled residents. The facility failed to consider the quality of life, and failed to create an environment of trust and honoring preferences. The failure resulted in actual mental and physical harm due to the resident's loss of control over important aspects of their environment, social isolation, pain and suffering. See F242 for additional information regarding the facility's failure to respect Resident #23, #53, #66 and #41's choices and preferences and the actual harm related to this deficient practice. 11. Based on observation, interview and clinical record review the facility failed to meet professional standards quality of care for 4 (#159, #2, #53, and #144) 36 sampled residents. The facility failed to notify the physician of changes in the resident's condition, and obtaining laboratory tests as ordered for Resident's #159 and #2. Failure to meet professional standard's of care resulted in pain, suffering and on-going urinary tract infections for Resident #159 and on-going urinary tract infections for Resident #2. The facility failed to meet professional standards of care for Resident #53 and #144 by failing to notify Resident #53's physician of their unrelieved pain and to notify Resident #144's physician of unavailable medications prescribed to relieve pain. Failure to notify Resident #53's and #144's physician resulted in on-going pain and suffering related to chronic pain. See F281 for additional information regarding the facility's failure to provide services that meet professional standards for Residents #159, #2, #53 and #144 and the actual harm related to this deficient practice. 12. Based on observation, resident and staff interviews, and review of the clinical records, the facility failed to manage chronic pain for 2 (#53 and #144) of 36 sampled residents. The facility has caused harm to Resident #53 and #144 by failing to notify Resident #53's physician of their unrelieved pain and to notify Resident #144's physician of unavailable medications prescribed to relieve pain. Failure to notify Resident #53's and #144's physician resulted in ongoing pain and suffering related to chronic pain. See F309 for additional information regarding the facility's failure to provide provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #53 and #144 and the actual harm related to this deficient practice. 13. Based on clinical record review and interview with the unit manager, the facility failed to provide medications as prescribed for 5 (#66, #53, #144, #133 and #98) of 36 sampled residents. See F425 for additional information regarding Residents #66, #53, #144, #133, and #98. .

Based on family interview, staff interview and clinical record review the facility failed to notify the physician and family members of changes in condition and treatment of [REDACTED]. This failure resulted in pain and suffering related to ongoing urinary tract infections, causing actual harm for Residents #159 and #2. The findings include: 1. A review of the clinical record revealed that Resident #159 was admitted to the facility in February 2011 with multiple [DIAGNOSES REDACTED]. A review of the nursing Admission Data Collection sheet dated 02/03/11 revealed that Resident #159 was alert and oriented to person and place, but was unable to speak. A review of the Care Plan for Resident #159 dated 04/20/11 revealed the resident was at risk for infection related to having an indwelling catheter for [MEDICAL CONDITION]. An observation on 04/29/11 at 8:15 AM revealed Resident #159 lying on her back in bed. The resident was awake and tracking with her eyes, but was not able to speak. An observation of the the indwelling urinary catheter tubing revealed the resident's urine was dark yellow. A review of the clinical record nursing progress notes revealed that Resident #159 did not produce any urine on 02/09/11. The physician was notified and ordered a urine analysis and a culture and sensitivity via catheterization. The clinical record revealed there was 250 milliliters (ml) of urine output with the straight catheter procedure. On 02/18/11 the nursing notes revealed Resident #159 did not have any urine output. The nurse did not indicate the physician was notified, but she referred to the 02/09/11 physician order [REDACTED]. On 02/21/11 Resident #159 did not have any urine output. The nurse did not notify the physician, but referred to the 02/09/11 order and catheterized Resident #159 with a 16 french,10 ml catheter. The nurse documented that there was 400 ml urine return with the catheterization on 02/21/11. On 03/05/11 at 2:45 PM the nursing notes revealed Resident #159's indwelling catheter was clogged and not draining . The nurse documented that she was unsuccessful with flushing of the catheter and the catheter was replaced. There was no indication the physician was notified of the clogged catheter. On 03/09/11 at 11:15 AM the nursing notes revealed that Resident #159 was "writhing and grimacing and unable to verbalize pain." The note indicated there was no urine in the catheter bag. The note indicated the nurse attempted to flush the catheter with no results. The note indicated that the catheter was removed and the resident urinated dark yellow urine prior to the new catheter being placed. There was no indication the physician was notified of Resident #159's pain, clogged catheter and dark yellow urine. On 03/24/11 the nursing notes revealed Resident #159's indwelling catheter came out with the balloon intact. A new catheter was inserted with a larger 30 ml balloon. There was no indication the physician was notified. On 03/28/11 the nursing notes revealed Resident #159's catheter came out and was re-inserted. There was no indication the physician was notified. On 04/06/11 the nursing notes revealed Resident #159's catheter came out, there was no urine noted and the catheter was re-inserted. The physician was not notified. The nursing notes revealed on 04/13/11 at 2:00 AM Resident #159 was diaphoretic and had a temperature of 100.5. At 3:00 AM the resident's temperature was 100.1, pulse was 100 and her respirations were 18. At 3:15 AM the resident's temperature was 99.8, pulse 80 and respirations were 18. That afternoon at 3:25 PM Resident #159's catheter was clogged the nurse attempted to flush the catheter without success. The catheter was replaced and drained yellow urine. There was no indication the physician was notified of the resident's status on 4/13/11. Review of the physician orders [REDACTED]. The nursing notes dated 04/16/11 revealed the nurse at 11:00 PM entered a note indicating the note was for the 6:00 AM shift and stated, "resident had hematuria (blood in her urine) when collected original prescription - kept as 3-11 had very little urine available to collect; ended-up keeping in case lab needed. Collected a 2nd specimen at 5:00 AM as hematuria all but cleared; 2nd specimen for ua (urine analysis)." The 4/16/11 nurses note did not indicate the physician had been contacted about the blood in the resident's urine or the minimal amount of urine output from the resident. On 04/20/11 the nursing notes revealed Resident #159's catheter was changed by the nurse. Per the 04/20/11 nursing note there was a copious amount of rust colored urine with white thick drainage noted from the catheter site. There was no indication the physician was notified of the resident's status. On 04/29/11 at 11:00 AM the nursing notes revealed that Resident #159 was in distress throughout the night. The nurse documented that the resident had 75 ml of dark red/brown urine output. The physician was not notified of Resident #159's distress throughout the night and the status of the resident's urine. A review of the clinical record did not indicate the facility was aware of the results of the urine analysis and culture and sensitivity that was ordered by the physician on 04/15/11. An interview with Resident #159's physician on 04/29/11 at 11:17 AM revealed that she had not treated the resident for a urinary tract infection because there were no urine culture results to support antibiotic therapy. A family interview on 04/25/11 at 2:05 PM revealed that when visiting Resident #159 a few weeks ago the resident pointed to her feet so that the family member would look at them. The resident's family discovered the resident had bandages on both heels. The resident's daughter stated that the facility had not notified her about this change in condition or the change in her treatment. Resident #159's family member indicated that she was very upset she had not been notified. A review of the nurses progress notes revealed that new wounds were identified on both of Resident #159's feet on 04/16/11. There was no documentation in the progress notes to indicate that the family of Resident #159 was notified of the new wounds to the resident's feet. An interview with the facility wound care nurse on 04/29/11 at 1:05 PM revealed that she had not notified Resident #159's family regarding the the blisters to the resident's feet and new treatment initiated on 04/16/11. 2. An interview with the Resident #2 on 05/17/11 at 8:48 AM revealed that the resident [MEDICAL CONDITION] of her labia that was aggravated by contact with urine and that was the reason for the urinary catheter. The resident stated that the catheter kept her vaginal area dry so that she could heal from her recent surgery. The resident stated that she has had an ongoing infection since the catheter was inserted. A review of the clinical record revealed a care plan dated 11/18/10 indicating the resident had an indwelling catheter due to [MEDICAL CONDITION]. An observation of Resident #2's urinary catheter tubing on 05/17/11 at 8:55 AM revealed cloudy urine with white sediment. An interview with the nurse and observation on 5/17/11 at 9:00 AM of the urine in the catheter bag revealed that there was a lot of sediment in the resident's urine. The nurse stated that she would notify the physician of the cloudy urine. A clinical record review revealed that Resident #2 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the clinical record revealed physician orders [REDACTED]. The laboratory report revealed the urine was collected on 3/30/11 and on 3/31/11 the laboratory reported that the urine specimen was contaminated and suggested recollection of the urine. There was no evidence the urine was recollected. On 3/31/11 the physician ordered another urine culture and sensitivity 5 days from the date of the order (4/05/11). However, there was no evidence in the clinical record the urine culture and sensitivity was repeated on the 4/05/11. On 4/12/11 the clinical record revealed an order for [REDACTED]. On 05/03/11 the clinical record revealed an order for [REDACTED]. However, the clinical record did not reveal evidence that the urine was recollected. An interview with the resident's nurse on 05/17/11 at 10:41 AM revealed that there were no laboratory results pending for Resident #2. The nurse stated , "Anybody that worked that hall should have caught it." An interview with the Director of Nursing (DON) on 05/17/11 at 10:48 AM revealed that there were problems with the laboratory reporting that specimens were contaminated. The DON acknowledged that any of the nurses for Resident #2 could have collected the second specimen. An interview with the infection control nurse on 05/17/11 at 11:50 AM revealed that the laboratory notified the facility of the specimen contaminated with 3 or more organisms on 03/30/11 and the nurse's staff collected a second specimen on 04/13/11. The infection control nurse stated that she did not know why it took so long to get the second/repeat specimen. .

Based on resident and staff interviews and review of the Grievance Log, the facility failed to resolve 2 grievances filed by Resident #53, 1 of 36 sampled residents. The facility's failure to resolve Resident #53's grievances caused the resident to suffer from ongoing pain and loss of self-determination related to her home environment by the facility imposing the care of an undesirable personal care attendant. The findings include: 1. An interview with Resident #53 on 4/26/11 at 9:00 AM, on 4/27/11 at 9:00 AM, and on 4/28/11 at 2:30 PM revealed the resident was in constant pain. The resident stated her left shoulder rotator cuff hurt too much to propel her wheelchair, her back hurt due to her mattress and not being able to reposition independently, and her bottom hurt when sitting up too long during the day. This resident stated she had filed a formal grievance with the facility and had shared the pain with staff, but remained in constant pain on a daily basis. A review of the grievances filed since 2/5/10, when the facility admitted this resident, revealed a grievance was filed on 11/11/10 relative to "pain with no relief." The resolution stated on the grievance was to have the physician change the pain medications to alleviate the resident's constant pain. A review of the clinical record and the medication administration records from 11/11/10 through 4/29/11 revealed the resident's pain medication had not been changed. There was no documentation in the resident's clinical record that the facility had contacted the physician relative to this resident's chronic unrelieved pain. An interview with the risk manager on 4/19/11 at 8:00 AM confirmed Resident #53's pain medications had not been changed since the grievance was filed in November 2010. In addition, no documentation could be located in the clinical record that revealed the facility acted upon the grievance by contacting the resident's physician to address the chronic pain. 2. An interview with Resident #53 on 4/26/11 at 9:00 AM revealed the resident was unhappy with one of the certified nursing assistants (CNAs) that the facility had assigned to the resident. The resident revealed that she had requested that this particular CNA not be assigned to her again and had filed a formal grievance relative to that concern. A review of the grievances filed since March 2010 confirmed that Resident #53 had filed a grievance on 9/28/10 relative to care and services. The resident stated in the grievance that the CNA did not perform bath functions effectively and requested that the facility not assign the CNA to her in the future. A review of the resolution for the care and services grievance filed by Resident #53 revealed that the facility's resolution to the concern was to in-service the CNA, not to re-assign her. An interview with the resident on 4/28/11 at 3:30 PM revealed that the CNA continued to work as the care provider, even though a request for re-assignment had been made. A review of the staffing schedule for 4/1/11 through 4/29/11 confirmed the CNA had been assigned to this resident on 4/20/11 and on 4/21/11. An interview with the Risk Manager on 4/28/11 at 3:00 PM revealed the facility had mandated that each CNA complete some additional in-service education relative to the care and services provided to their residents, but the CNA had not been re-assigned, as requested in the grievance filed by Resident #53. .

Based on observations, interviews with residents and staff, and review of the clinical records, the facility failed to respect resident preferences and choices for 4 (#23, #53, #66, and #41) of 36 sampled residents. The facility failed to consider the quality of life, and failed to create an environment of trust and honoring preferences. The failure resulted in actual mental and physical harm due to the resident's loss of control over important aspects of their environment, social isolation, pain and suffering. The findings include: 1. A review of the clinical record for Resident #23 revealed she was re-admitted to the facility on [DATE] and was assessed as having difficulties with speech and making her needs known. An observation of Resident #23 on 4/25/11 at 1:55 PM revealed she was lying in bed attempting to communicate her needs and wants. An attempt to interview the resident was made, but she was very hard to understand and she became more and more frustrated by not being able to express her needs. Resident #23 did not want the staff to assist and the interview ended. An observation of Resident #23 again on 4/25/11 at 2:15 PM revealed she was unable to express her desires effectively. The resident continued to try to communicate orally for approximately 10 minutes, to no avail. On 4/26/11 at 2:30 PM an interview with the nurse on the West unit revealed Resident #23 had a communication device to help her express her needs and wants; however, it could not be located. She stated this resident relocated to another room approximately three months ago and the communication device had not been seen since. An interview with Resident #23's family member on 4/26/11 at 3:00 PM confirmed that she enjoyed many activities, but did not attend most of them because staff could not understand her spoken word and tended to ignore her. Consequently, she remained in her room and in bed, most every day. An observation of Resident #23 on 4/27/11 at 1:45 PM revealed she was lying in bed while a birthday party was going on in the dining room. When interviewed about why she was not attending the party, she became very frustrated and tried to express her feelings and desires. It was difficult to understand her and she began to get frustrated and speak more loudly. A review of the clinical record and the psychology progress note dated 4/4/11 revealed Resident #23 was "frustrated due to social isolation". The resident told the psychologist that people had difficulty understanding her so they "avoid seeing her " and that made her angry. A review of the clinical record and the Activity Care Plan revised on 4/21/11 revealed that Resident #23's current interests were animals/pets, arts and crafts, listening to any kind of music, outdoors/walking and sitting, spiritual and religious activity, talking and conversing, and watching TV and movies. 2. A review of the clinical record for Resident #53 revealed the facility admitted her on 2/5/10 with [DIAGNOSES REDACTED]. An interview with Resident #53 on 4/26/11 at 9:00 AM, on 4/27/11 at 9:00 AM, and on 4/28/11 at 2:30 PM revealed she was in constant pain due to her left shoulder rotator cuff. She stated her left shoulder rotator cuff hurt too much for her to propel a wheelchair forward, so she had to remain in her room. She stated she had a power chair at her son's home and had on many occasions requested to have the power chair brought to the facility. In addition, she stated she was afraid that she was losing muscle tone in her upper body and was becoming isolated. She requested again that her son be allowed to bring her power chair from home, so she could get out or her room on a daily basis. A review of the clinical record and the occupational therapist's notes dated 2/1/11 confirmed Resident #53 had worked with therapy to increase mobility and strength in her upper extremities. The therapist documented the resident was complaining of increasing pain when propelling a wheelchair so she would investigate the use of a power chair. An interview with the occupational therapist on 4/26/11 at 3:25 PM confirmed she had worked with Resident #53 in therapy and had investigated the potential for a power chair with the facility's risk manager. She stated that Resident #53 was cognitively aware, alert and was able to control a power chair. She believed the power chair had to be assessed by the risk manager for safety precautions before the resident's son could leave the chair with the resident. An interview with the medical director on 4/29/11 at 11:50 AM revealed Resident #53 was alert and oriented to time, place, and person. A review of the clinical record revealed no documentation could be located from the risk manager or the social services director relative to Resident #53's power chair. An interview with the risk manager at 3:30 PM on 4/26/11 confirmed she was aware that Resident #53 had requested to use her power chair since her admission in 2010. However, the chair needed to be assessed for safety and she had yet to evaluate the chair. She stated the occupational therapist had brought this matter to her attention over a year prior, but she had failed to follow up and arrange the assessment with the resident's family. An interview with the social services director and the resident at 3:45 PM on 4/26/11 revealed the resident had a power chair at her son's home, but the facility would not allow her to bring it into the facility. The social services director stated she would take care of the situation immediately. An interview with Resident #53 on 4/26/11 at 9:00 AM revealed she was unhappy with a female Certified Nursing Assistant (CNA) that was assigned to her room. She stated that the CNA did not perform her bath effectively. Resident #53 also requested not to have a male CNA. A review of the Resident Information Sheet, revealed that Resident #53 requested a female CNA only. Resident #53 stated during an interview on 4/28/11 at 3:00 PM that she filed a formal grievance on 9/28/10 with the facility about a particular female CNA and requested to have her re-assigned to a different room. However, she stated, the female CNA continued to be assigned to her. In addition, male CNA's were also assigned to her. She stated on Easter Sunday a male CNA was assigned to her, so she refused care. A review of the grievances revealed the resident had filed a grievance about the female CNA on 9/28/10 and requested a different CNA in the future. A review of the CNA April 2011 schedule revealed the female CNA, named by the resident in her grievance, was assigned to her on 4/20/11 and on 4/21/11. In addition, a male CNA was assigned to work with her on 4/9/11, 4/17/11, and on 4/24/11 (Easter Sunday). 4. A review of the clinical record for Resident #66 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was unable to get in or out of bed independently and she relied on staff for her activities of daily living. An interview with Resident #66 on 4/26/11 at 10:39 AM revealed she had just finished breakfast and was upset for three reasons. She could not find her dentures, she could not access her nightstand drawer, and her bed was broken. Consequently, she ate without her dentures, had nowhere to store her belongings, and she had to be elevated at a 90 degree angle while sleeping because the crank shaft on her bed was broken. An interview with the CNA at 2:30 PM on 4/26/11 revealed she did not know the resident had dentures. She did not know where they might be located and she did not have a key to the locked nightstand drawer. An observation of Resident #66 on three separate occasions during meal times on 4/25/11, 4/27/11, and on 4/29/11 revealed she had eaten her meals without her dentures in place. An observation of Resident #66 on 4/27/11 at 8:30 AM revealed she was attempting to eat her breakfast without her dentures in place. An observation of the resident's plate revealed she had ground up the sausage links with her hands, and placed the pieces on her tray. She stated she was unable to chew the links without her dentures in place. An observation of Resident #66 on 4/27/11 at 10:00 AM revealed staff had located her dentures in a dresser drawer that was located across the room, but not within her reach. An interview with a nurse on 4/26/11 at 2:45 PM confirmed that she was assigned to Resident #66 for over a year, and since that time, the nightstand drawer had been locked. An interview with the maintenance director on 4/26/11 at 10:30 AM confirmed the resident's nightstand drawer was locked and he had a key. He stated he would open the drawer for her immediately. When interviewed about why the drawer was locked and unavailable to this resident for almost a year, he was unsure. When interviewed about her broken bed, the maintenance director stated that her bed had a broken crankshaft and had been broken for approximately two weeks. He stated the evening staff did not have the appropriate tool to lower the head of her bed, so she had to sleep in an elevated position. He stated he needed to replace the bed because the crank bolt was irreplaceable. 4. Observations between 4/25/11 and 4/29/11 revealed that Resident #41 had not left her room or her bed on those days. An interview with Resident #41 on 4/29/11 at 10:05 AM revealed she had not been able to attend activities for a significant period because she did not have a wheelchair available. According to the resident, the aides did not like to get her because she was large and required extra effort and extra aides to help. Because the aides did not get her up, Resident #41 was assumed to not want to get out of bed. According to Resident #41, because she was not getting out of bed, the wheelchair the facility had "rented" for her use was returned to Jacksonville, Florida and was no longer available. Because there was no wheelchair to transport the resident, Resident #41 had not asked to go to activities. In addition, Resident #41 revealed that since the activity calendar was posted on the outside of the bathroom door, it was inaccessible and she did not know what was going on in the facility. An interview with a CNA on 4/29/11 at 10:15 AM revealed that the resident had had a wheelchair stored in the therapy department at one time, but was not positive, and would check on it. An interview with the rehabilitation director and maintenance director on 4/29/11 at 10:19 AM revealed that the resident still had a wheelchair, but it was stored in a shed at the back of the facility. According to the maintenance director, the storage shed was locked and not accessible to staff and residents after hours. According to the maintenance director and the rehabilitation director, Resident #41 was known to not get out of bed and the wheelchair took up significant room, and was moved outside the facility. The interview revealed that staff members knew the resident believed the wheelchair had been rented and returned to Jacksonville, Florida. An interview with the CNA on 4/29/11 at 10:25 AM confirmed that Resident #41 believed the wheelchair had been returned to Jacksonville, Florida and was not available for use. Per the CNA, Resident #41 was surprised when she was informed the wheelchair was being returned to her room. The CNA confirmed Resident #41 would enjoy bingo, as she had a sibling living in the facility that also regularly attended bingo. An interview with Resident #41 on 4/29/11 at 1:25 PM revealed the resident was surprised that her wheelchair was available and had not been returned to Jacksonville, Florida. Resident #41 stated that she was told by staff that she did not have a wheelchair, so there was no point in asking to get out of bed for any activities. According to Resident #41, she would start getting out of bed more and was glad to know she now had the choice. .

Based on observations, resident and staff interviews, and review of clinical records and facility provided documentation, the facility failed to respect resident preferences and choices for 1 ( #53) of 12 sampled residents. The facility failed to consider quality of life, and failed to create an environment of trust and of honoring preferences. The failure resulted in social isolation due to the resident's loss of control over important aspects of her environment. The findings include: An interview with Resident #53 at 10:15 AM on 6/24/11 revealed she was unable to self-propel a manual wheelchair due to pain in her shoulders. She stated she owned a motorized wheelchair but staff would not allow her to bring it to the facility. Consequently, she felt isolated in her environment. A review of the clinical record revealed Resident #53 was unable to self-propel a manual wheelchair due to constant pain in her left shoulder rotator cuff. A review of the clinical record and the Occupational Therapist's (OT) notes dated 2/1/11 confirmed Resident #53 had worked with therapy to increase mobility and strength in her upper extremities. The therapist documented the resident was complaining of increasing pain when propelling a wheelchair so she would investigate the use of a power chair. An interview with the DON and Resident #53 on 6/24/11 at 10:20 AM revealed that the OT had evaluated her for safe use of her power wheelchair on 5/23/11. She stated she had passed the test and was granted permission to use her power chair on 5/23/11. She stated she was so happy to be able to enjoy her environment and go outside for fresh air. However, after only 3 days, the OT removed Resident #53's chair from the facility and she again felt isolated in her environment. She stated she was unsure why OT removed her motorized wheelchair from the facility but she felt it was unfair and unwarranted. A review of the facility provided documentation, the "Resident /Family Education Record" dated 5/22/11, confirmed the resident was educated on how to use an electric scooter in the facility and she was able to demonstrate safe use. A review of the facility provided documentation, the "Electric Wheelchair/Motorized Cart Evaluation/assessment dated [DATE] confirmed that Resident #53 passed the safety test. She demonstrated safety in turning the chair on and off, driving it inside and outside of the facility, accelerating and reverse modes, regulating speed, steering through the facility's halls, making left and right turns, completing a 360 degree turn, turning at intersections, parking, going through doorways, and she passed the obstacle course. However, she was unable to transfer independently, so she required assistance from staff for transfer in and out of the motorized wheelchair. The OT documented that Resident #53 would be able to safely operate a motorized cart or wheelchair on the premises. An interview with the Speech Therapist on 6/24/11 at 11:00 AM confirmed that she had evaluated Resident #53 for her cognitive abilities to safely operate a motorized wheelchair. She stated the resident passed with "flying colors". The Speech Therapist stated the resident is very intelligent, alert and oriented to person, place and time. However, Resident #53 did have some difficulties with her vision. Interview with the Social Services Director on 6/24/11 at 11:30 AM confirmed the resident had some vision problems. She could see out of her right eye but only shadows from her left eye. Review of the clinical record revealed this resident had not seen an ophthalmologist for her vision problems. The Social Services Director stated that Resident #53 had not seen an eye doctor and she would make the appointment immediately. An interview with the OT on 6/24/11 via telephone at 11:10 AM, revealed she had evaluated the resident for safe use of her motorized wheelchair and she passed the test on 5/23/11. However, on 5/26/11 the OT removed the motorized chair from the premises because the resident did not demonstrate safety while backing up. OT documented that the resident hit a garbage can and ran over a Certified Nursing Assistant's (CNA) foot. An interview with Resident #53 on 6/24/11 at 10:30 AM revealed she had accidentally hit the small garbage can that was located next to the wall in her room. She stated the garbage can was usually located on the opposite side of the room and she did not know that staff had placed it behind her motorized wheelchair. Consequently, when she backed up, she hit the garbage can accidentally. In addition, she stated she had no recollection of running over anyone's foot. An interview with the DON and the CNA via telephone on 6/24/11 at 2:20 PM revealed that when the CNA attempted to transfer the resident out of her motorized wheelchair on 5/26/11, the resident accidentally hit the power button with her arm and the chair propelled forward hitting her foot. She stated she did not sustain any injury and she did not fill out an incident report. She stated the resident apologized and they went on with the transfer. The CNA stated that she was unaware that the resident's motorized wheelchair had been removed from the facility due to this accident. The OT removed the motorized wheelchair and subsequently confined Resident #53 to her room without discussing the accident with the interdisciplinary team. No documentation could be located that the OT discussed this matter with the DON or the Administrator. An interview with the DON and the Administrator on 6/24/11 at 3:30 PM confirmed that the facility had failed to ensure that Resident #53 was given to right to make choices regarding significant aspects of her life. .

Based on observation, interview and clinical record review the facility failed to meet professional standards quality of care for 4 (#159, #2, #53, and #144) of 36 sampled residents. The facility failed to notify the physician of changes in the resident's condition, and obtaining laboratory tests as ordered for Residents #159 and #2. Failure to meet professional standards of care resulted in pain, suffering and ongoing urinary tract infections for Resident #159 and ongoing urinary tract infections for Resident #2. The facility failed to meet professional standards of care for Resident #53 and #144 by failing to notify Resident #53's physician of their unrelieved pain and to notify Resident #144's physician of unavailable medications prescribed to relieve pain. Failure to notify Resident #53's and #144's physician resulted in ongoing pain and suffering related to chronic pain. Chapter 464 Nurse Practice Act, Florida Statutes, Rules of the Board of Nursing, 3 (a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. The supervision and teaching of other personnel in the theory and performance. The findings include: 1. A review of the clinical record revealed that Resident #159 was admitted to the facility in February 2011 with multiple [DIAGNOSES REDACTED]. A review of the nursing Admission Data Collection sheet dated 02/03/11 revealed that Resident #159 was alert and oriented to person and place, but was unable to speak. A review of the care plan for Resident #159 dated 04/20/11 revealed the resident was at risk for infection related to having an indwelling catheter for [MEDICAL CONDITION]. An observation on 04/29/11 at 8:15 AM revealed Resident #159 lying on her back in bed. The resident was awake and tracking with her eyes, but was not able to speak. An observation of the the indwelling urinary catheter tubing revealed the resident's urine was dark yellow. A review of the clinical record nursing progress notes revealed that Resident #159 did not produce any urine on 02/09/11. The physician was notified and ordered a urine analysis and a culture and sensitivity via catheterization. The clinical record revealed there was 250 milliliters (ml) of urine output with the straight catheter procedure. On 02/18/11 the nursing notes revealed Resident #159 did not have any urine output. The nurse did not indicate the physician was notified, but she referred to the 02/09/11 physician order [REDACTED]. On 02/21/11 Resident #159 did not have any urine output. The nurse did not notify the physician, but referred to the 02/09/11 order and catheterized Resident #159 with a 16 french,10 ml catheter. The nurse documented that there was 400 ml urine return with the catheterization on 02/21/11. On 03/05/11 at 2:45 PM the nursing notes revealed Resident #159's indwelling catheter was clogged and not draining. The nurse documented that she was unsuccessful with flushing of the catheter and the catheter was replaced. There was no indication the physician was notified of the clogged catheter. 03/09/11 at 11:15 AM the nursing notes revealed that Resident #159 was "writhing and grimacing and unable to verbalize pain." The note indicated there was no urine in the catheter bag. The note indicated the nurse attempted to flush the catheter with no results. The note indicated that the catheter was removed and the resident urinated dark yellow urine prior to the new catheter being placed. There was no indication the physician was notified of Resident #159's pain, clogged catheter and dark yellow urine. On 03/24/11 the nursing notes revealed Resident #159's indwelling catheter came out with the balloon intact. A new catheter was inserted with a larger 30 ml balloon. There was no indication the physician was notified. On 03/28/11 the nursing notes revealed Resident #159's catheter came out and was re-inserted. There was no indication the physician was notified. On 04/06/11 the nursing notes revealed Resident #159's catheter came out, there was no urine noted and the catheter was re-inserted. The physician was not notified. The nursing notes revealed on 04/13/2011 at 2:00 AM Resident #159 was diaphoretic and had a temperature of 100.5. At 3:00 AM the resident's temperature was 100.1, pulse was 100 and her respirations were 18. At 3:15 AM the resident's temperature was 99.8, pulse 80 and respirations were 18. That afternoon at 3:25 PM Resident #159's catheter was clogged the nurse attempted to flush the catheter without success. The catheter was replaced and drained yellow urine. There was no indication the physician was notified of the resident's status on 4/13/11. Review of the physician orders [REDACTED]. The nursing notes dated 04/16/11 revealed the nurse at 11:00 PM entered a note indicating the note was for the 6:00 AM shift and stated, "resident had hematuria (blood in her urine) when collected original prescription - kept as 3-11 had very little urine available to collect; ended-up keeping in case lab needed. Collected a 2nd specimen at 5:00 AM as hematuria all but cleared; 2nd specimen for ua (urine analysis). " The 4/16/11 nurses note did not indicate the physician had been contacted about the blood in the resident's urine or the minimal amount of urine output from the resident. On 04/20/11 the nursing notes revealed Resident #159's catheter was changed by the nurse. Per the 04/20/11 nursing note there was a copious amount of rust colored urine with white thick drainage noted from the catheter site. There was no indication the physician was notified of the resident's status. On 04/29/11 at 11:00 AM the nursing notes revealed that Resident #159 was in distress throughout the night. The nurse documented that the resident had 75 ml of dark red/brown urine output. The physician was not notified of Resident #159's distress throughout the night and the status of the resident's urine. A review of the clinical record did not indicate the facility was aware of the results of the urine analysis and culture and sensitivity that was ordered by the physician on 04/15/11. An interview with Resident #159's physician on 04/29/11 at 11:17 AM revealed that she had not treated the resident for a urinary tract infection because there were no urine culture results to support antibiotic therapy. The physician stated that she had not ordered a consult for a urologist because she thought that Resident #159 was admitted into the facility with a catheter, but that a urology consult was an option for Resident #159. An interview with the West Wing unit manager (UM) on 04/29/11 at 11:30 AM revealed that there was no evidence of the urine culture and sensitivity report on the clinical record for Resident #159. The West Wing UM accessed the laboratory report on the computer and printed the report. The urine culture final report dated 04/17/11 for Resident #159 documented that the specimen was contaminated with 3 or more organisms and suggested recollection. A review of the Urine Culture Final Report dated 05/04/2011 for the specimen collected on 4/29/11 at 12:30 PM revealed that the urine was positive for Proteus Mirabilis, and [MEDICATION NAME] faecalis. An observation of the urinary catheter care on 04/29/11 at 1:18 PM with the CNA (Certified Nursing Assistant) for Resident #159 revealed that there was no anchor to hold the catheter in place on the resident's thigh in order to prevent pulling or tension on the catheter. An interview with the CNA at that time revealed that the facility had not used an anchor for Resident #159's Foley catheter tubing currently or in the past. An interview with the medication nurse for Resident #159 on 04/29/11 at 1:18 PM revealed that there was no catheter anchor on Resident #159, but she would put one on now. 2. An interview with Resident #2 on 05/17/11 at 8:48 AM revealed that the resident [MEDICAL CONDITION] of her labia that was aggravated by contact with urine and that was the reason for the urinary catheter. The resident stated that the catheter kept her vaginal area dry so that she could heal from her recent surgery. The resident stated that she had an infection since the catheter was inserted. A review of the clinical record revealed a care plan dated 11/18/10 indicating the resident had an indwelling catheter due to [MEDICAL CONDITION]. An observation of Resident #2 ' s urinary catheter tubing on 05/17/11 at 8:55 AM revealed cloudy urine with white sediment. An interview with the nurse and observation on 5/17/11 at 9:00 AM of the urine in the catheter bag revealed that there was a lot of sediment in the resident's urine. The nurse stated that she would notify the physician of the cloudy urine. A clinical record review revealed that Resident #2 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the clinical record revealed physician orders [REDACTED]. The laboratory report revealed the urine was collected on 3/30/11 and on 3/31/11 the laboratory reported that the urine specimen was contaminated and suggested recollection of the urine. There was no evidence the urine was recollected. On 3/31/11 the physician ordered another urine culture and sensitivity 5 days from the date of the order (4/05/11). However, there was no evidence in the clinical record the urine culture and sensitivity was repeated on 4/05/11. On 4/12/11 the clinical record revealed an order for [REDACTED]. On 05/03/11 the clinical record revealed an order for [REDACTED]. However, the clinical record did not reveal evidence that the urine had been recollected. An interview with the nurse for the resident on 05/17/11 at 10:41 AM revealed that there were no laboratory results pending for Resident #2. The nurse stated, "Anybody that worked that hall should have caught it." An interview with the Director of Nursing (DON) on 05/17/11 at 10:48 AM revealed that there were problems with the laboratory reporting that specimens were contaminated. The DON acknowledged that any of the nurses for Resident #2 could have collected the second specimen. An interview with the infection control nurse on 05/17/11 at 11:50 AM revealed that the laboratory notified the facility of the specimen contaminated with 3 or more organisms on 03/30/11 and the nurse's staff collected a second specimen on 04/13/11. The infection control nurse stated that she did not know why it took so long to get the second/repeat specimen. 3. A review of the clinical record for Resident #53 revealed the facility admitted her on 2/5/10 with [DIAGNOSES REDACTED]. An interview with Resident #53 on 4/26/11 at 9:00 AM, on 4/27/11 at 9:00 AM, and on 4/28/11 at 2:30 PM revealed she was in constant pain. She stated her left shoulder rotator cuff hurt too much for her to propel a wheelchair, her back hurt due to her mattress and not being able to reposition herself independently, and her bottom hurt when she sat up too long in a wheelchair during the day. She stated she had filed a formal grievance with the facility and had shared her pain with staff, but remained in constant pain on a daily basis. A review of the grievances filed since 2/5/10, when the facility admitted this resident, revealed she had filed a grievance on 11/11/10 relative to "pain with no relief." The resolution to the grievance was to have the physician change her pain medications to alleviate the resident's constant pain. A review of the clinical record and the monthly "Clinical Reviews" revealed that each month since December 2010 the resident had complained of pain. Her pain was rated on a scale from 1-10 and on 12/13/10 her pain was documented between 5 and 6. In January 2011 her pain was a 4, in February her pain was assessed to be a 3, and on 4/5/11 her pain was assessed to be a 4. A review of the clinical record and the Medication Administration Records (MARs) from 11/11/10 through 4/29/11 revealed the resident's pain medication had not been changed and no documentation could be located that the facility had contacted the physician relative to this resident's chronic unrelieved pain. Per the April 2010 MAR, the resident was to receive pain medication four times each day. The physician ordered 600 mgs (milligrams) of [MEDICATION NAME] twice each day at 9:00 AM and again at 5:00 PM for the [DIAGNOSES REDACTED]. However, per the resident and clinical record review, she remained in pain. A review of the nursing notes dated 1/25/11 through 4/28/11 revealed no evidence the nurses had contacted Resident #53's physician relative to her chronic and constant pain. An interview with the risk manager on 4/19/11 at 8:00 AM confirmed Resident #53's pain medications had not been changed since November 2010. In addition, documentation could not be located in the clinical record that revealed the facility had attempted to help the resident with her chronic pain. No documentation could be located that the facility had contacted the physician about her current medications and no documentation could be located that they tried other methods of pain control. 4. An interview on 04/26/11 at 10:53 AM revealed that Resident #144's pain was not relieved by the current pain regimen. A clinical record review revealed that Resident #144 was admitted to the facility in January 2011 with [DIAGNOSES REDACTED].#144 revealed that the resident had back pain and pain in the lower extremities that was chronic. A clinical record review also revealed a plan for Resident #144 dated 02/21/11 for the potential decline in health status related to weakness and pain. The nurse documented that the pain was exacerbated by movement and relieved by medication. A review of the nurse's progress notes dated 04/24/11 revealed that Resident #144 complained of his pain medication being ineffective. The nurse documented that she notified Resident #144's physician on 04/24/11 of the resident's complaint and the physician requested a call back on 04/25/11 between 8:00 AM and 8:30 AM for further orders. Further review of the clinical record revealed no indication of a phone call to the physician on 04/25/11 related to the ineffective pain control in the nurses progress notes. There were no nursing progress notes in the clinical record after 04/24/11 until Resident #144 was transferred to the emergency roiagnom on [DATE] with possible pneumonia. The last physician progress notes [REDACTED]. An interview was conducted with the East Wing unit manager on 04/28/11 at 12:05 PM regarding the call to the physician on 04/24/11 about Resident #144's pain medication and the lack of documentation of a follow-up call on 4/25/11 as requested by the physician. The unit manager stated that the physician had been cautious with pain medications. The unit manager stated that usually on Monday mornings she handled this kind of stuff. She was not aware of Resident #144's pain concerns. She stated that she was working on the communication process on the East Wing. An interview was conducted with the Director of Nursing (DON) on 04/28/11 at 2:03 PM regarding the follow-up call to Resident #144's physician. The DON stated that the call was made by the nurse and recorded on the 24 Hour report. The DON stated that the physician was called and a prescription was sent directly to the pharmacy. A clinical record review revealed no indication of new orders sent to the facility for Resident #144. The DON acknowledged that there was no nurses documentation of the conversation in the clinical record and there were no new orders for pain medication for Resident #144. An interview with the physician on 04/29/11 at 11:17 AM revealed that she was not notified by the facility that Resident #144's pain medication regimen was ineffective. The physician stated she was contacted to approve more [MEDICATION NAME] for the resident. Per the physician she did not have a fax machine in her home, so she asked the facility to call her the next morning at her office and she would fax the order for [MEDICATION NAME] to the pharmacy. An interview on 04/29/11 at 12:15 PM with the medication nurse that cared for Resident #144 on the morning of 04/25/11 revealed that she called the doctor to request additional [MEDICATION NAME]. Per the medication nurse the reason she called the doctor was because the resident was low on medication. The medication nurse stated she was unaware that Resident #144's pain medication regimen was ineffective. .

Based on observation, resident and staff interviews, and review of the clinical records, the facility failed to manage chronic pain for 2 (#53 and #144) of 36 sampled residents. The facility caused harm to Residents #53 and #144 by failing to notify Resident #53's physician of their unrelieved pain and to notify Resident #144's physician of unavailable medications prescribed to relieve pain. Failure to notify Resident #53's and #144's physician resulted in ongoing pain and suffering related to chronic pain. The findings include: 1. A review of the clinical record for Resident #53 revealed the facility admitted her on 2/5/10 with [DIAGNOSES REDACTED]. An interview with Resident #53 on 4/26/11 at 9:00 AM, on 4/27/11 at 9:00 AM, and on 4/28/11 at 2:30 PM revealed she was in constant pain. She stated her left shoulder rotator cuff hurt too much for her to propel a wheelchair, her back hurt due to her mattress and not being able to reposition herself independently, and her bottom hurt when she sat up too long in a wheelchair during the day. She stated she had filed a formal grievance with the facility and had shared her pain with staff, but remained in constant pain on a daily basis. A review of the grievances filed since 2/5/10, when the facility admitted this resident, revealed she had filed a grievance on 11/11/10 relative to "pain with no relief." The resolution to the grievance was to have the physician change her pain medications to alleviate the resident's constant pain. A review of the clinical record and the monthly "Clinical Reviews" revealed that each month since December 2010 the resident had complained of pain. Her pain was rated on a scale from 1-10 and on 12/13/10 her pain was documented between 5 and 6. In January 2011 her pain was a 4, in February her pain was assessed to be a 3, and on 4/5/11 her pain was assessed to be a 4. A review of the clinical record and the Medication Administration Records (MARs) from 11/11/10 through 4/29/11 revealed the resident's pain medication had not been changed and no documentation could be located that the facility had contacted the physician relative to this resident's chronic unrelieved pain. Per the April 2010 MAR, the resident was to receive pain medication four times each day. The physician ordered 600 mgs (milligrams) of [MEDICATION NAME] twice each day at 9:00 AM and again at 5:00 PM for the [DIAGNOSES REDACTED]. However, per the resident and clinical record review, she remained in pain. A review of the nursing notes dated 1/25/11 through 4/28/11 revealed no evidence the nurses had contacted Resident #53's physician relative to her chronic and constant pain. An interview with the risk manager on 4/19/11 at 8:00 AM confirmed Resident #53's pain medications had not been changed since November 2010. In addition, documentation could not be located in the clinical record that revealed the facility had attempted to help the resident with her chronic pain. No documentation could be located that the facility had contacted the physician about her current medications and no documentation could be located that they tried other methods of pain control. 2. An interview on 04/26/11 at 10:53 AM revealed that Resident #144's pain was not relieved by the current pain regimen. A clinical record review revealed that Resident #144 was admitted into the facility in January 2011 with [DIAGNOSES REDACTED].#144 revealed that the resident had back pain and pain in the lower extremities that was chronic. A clinical record review also revealed a plan for Resident #144 dated 02/21/11 for the potential decline in health status related to weakness and pain. The nurse documented that the pain was exacerbated by movement and relieved by medication. A review of the nurse's progress notes dated 04/24/11 revealed that Resident #144 complained of his pain medication being ineffective. The nurse documented that she notified Resident #144's physician on 04/24/11 of the resident's complaint and the physician requested a call back on 04/25/11 between 8:00 AM and 8:30 AM for further orders. Further review of the clinical record revealed no indication of a phone call to the physician on 04/25/11 related to the ineffective pain control in the nurses progress notes. There were no nurses progress notes in the clinical record after 04/24/11 until Resident #144 was transferred to the emergency roiagnom on [DATE] with possible pneumonia. The last physician progress notes [REDACTED]. An interview was conducted with the East Wing unit manager on 04/28/11 at 12:05 PM regarding the call to the physician on 04/24/11 about Resident #144's pain medication and the lack of documentation of a follow-up call on 4/25/11 as requested by the physician. The unit manager stated that the physician had been cautious with pain medications. The unit manager stated that usually on Monday mornings she handled this kind of stuff. She was not aware of Resident #144's pain concerns. She stated that she was working on the communication process on the East Wing. An interview was conducted with the Director of Nursing (DON) on 04/28/11 at 2:03 PM regarding the follow-up call to Resident #144's physician. The DON stated that the call was made by the nurse and recorded on the 24 Hour report. The DON stated that the physician was called and a prescription was sent directly to the pharmacy. A clinical record review revealed no indication of new orders sent to the facility for Resident #144. The DON acknowledged that there was no nurses documentation of the conversation in the clinical record and there were no new orders for pain medication for Resident #144. An interview with the physician on 04/29/11 at 11:17 AM revealed that she was not notified by the facility that Resident #144's pain medication regimen was ineffective. The physician stated she was contacted to approve more [MEDICATION NAME] for the resident. Per the physician she did not have a fax machine in her home so she asked the facility to call her the next morning at her office and she would fax the order for [MEDICATION NAME] to the pharmacy. An interview on 04/29/11 at 12:15 PM with the medication nurse that cared for Resident #144 on the morning of 04/25/11 revealed that she called the doctor to request additional [MEDICATION NAME]. Per the medication nurse the reason she called the doctor was because the resident was low on medication. The medication nurse stated she was unaware that Resident #144's pain medication regimen was ineffective. .

Based on observation, interviews, and clinical record review the facility failed to ensure that 2 (#159 and #2) of the 3 sampled residents with urinary catheters received the necessary care and services resulting actual harm as evident by the pain and suffering experienced by Resident #159. The facility failed to identify, assess and manage Resident #159's [MEDICAL CONDITION] and urinary tract infections. The facility failed to report to the physician ongoing signs and symptoms of urinary tract infections such as pain, fever, cloudy and discolored urine, clogged urinary catheters, and failed to follow through on laboratory tests as ordered. The facility failed to identify, assess and manage Resident #2's ongoing urinary tract infections by failing to notify the residents physician of signs and symptoms of urinary tract infections and complete laboratory tests as ordered. The findings include: 1. A review of the clinical record revealed that Resident #159 was admitted to the facility in February 2011 with multiple [DIAGNOSES REDACTED]. A review of the nursing Admission Data Collection sheet dated 02/03/11 revealed that Resident #159 was alert and oriented to person and place, but was unable to speak. A review of the Care Plan for Resident #159 dated 04/20/11 revealed the resident was at risk for infection related to having an indwelling catheter for [MEDICAL CONDITION]. An observation on 04/29/11 at 8:15 AM revealed Resident #159 lying on her back in bed. The resident was awake and tracking with her eyes, but was not able to speak. An observation of the indwelling urinary catheter tubing revealed the resident's urine was dark yellow. A review of the clinical record nursing progress notes revealed that Resident #159 did not produce any urine on 02/09/11. The physician was notified and ordered a urine analysis and a culture and sensitivity via catheterization. The clinical record revealed there was 250 milliliters (ml) of urine output with the straight catheter procedure. On 02/18/11 the nursing notes revealed Resident #159 did not have any urine output. The nurse did not indicate the physician was notified, but she referred to the 02/09/11 physician order [REDACTED]. On 02/21/11 Resident #159 did not have any urine output. The nurse did not notify the physician, but referred to the 02/09/11 order and catheterized Resident #159 with a 16 french,10 ml catheter. The nurse documented that there was 400 ml urine return with the catheterization on 02/21/11. On 03/05/11 at 2:45 PM the nursing notes revealed Resident #159's indwelling catheter was clogged and not draining. The nurse documented that she was unsuccessful with flushing of the catheter and the catheter was replaced. There was no indication the physician was notified of the clogged catheter. On 03/09/11 at 11:15 AM the nursing notes revealed that Resident #159 was "writhing and grimacing and unable to verbalize pain." The note indicated there was no urine in the catheter bag. The note indicated the nurse attempted to flush the catheter with no results. The note indicated that the catheter was removed and the resident urinated dark yellow urine prior to the new catheter being placed. There was no indication the physician was notified of Resident #159's pain, clogged catheter and dark yellow urine. On 03/24/2011 the nursing notes revealed Resident #159's indwelling catheter came out with the balloon intact. A new catheter was inserted with a larger 30 ml balloon. There was no indication in the clinical record the physician was notified. On 03/28/2011 the nursing notes revealed Resident #159's catheter came out and was re-inserted. There was no indication the physician was notified. On 04/06/2011 the nursing notes revealed Resident #159's catheter came out, there was no urine noted and the catheter was re-inserted. There was no indication the physician was notified. The nursing notes revealed on 04/13/2011 at 2:00 AM Resident #159 was diaphoretic and had a temperature of 100.5. At 3:00 AM the resident's temperature was 100.1, pulse was 100 and her respirations were 18. At 3:15 AM the resident's temperature was 99.8, pulse 80 and respirations were 18. That afternoon at 3:25 PM Resident #159's catheter was clogged the nurse at tempted to flush the catheter without success. The catheter was replaced and drained yellow urine. There was no indication the physician was notified of the resident's status on 4/13/11. A review of the physician orders [REDACTED]. The nursing notes dated 04/16/11 revealed the nurse at 11:00 PM entered a note indicating the note was for the 6:00 AM shift and stated, "resident had hematuria (blood in her urine) when collected original prescription - kept as 3-11 had very little urine available to collect; ended-up keeping in case lab needed. Collected a 2nd specimen at 5:00 AM as hematuria all but cleared; 2nd specimen for ua (urine analysis)." The 4/16/11 nurses note did not indicate the physician had been contacted about the blood in the resident's urine or the minimal amount of urine output from the resident. On 04/20/11 the nursing notes revealed Resident #159's catheter was changed by the nurse. Per the 04/20/11 nursing note there was a copious amount of rust colored urine with white thick drainage noted from the catheter site. There was no indication the physician was notified of the resident's status. On 04/29/11 at 11:00 AM the nursing notes revealed that Resident #159 was in distress throughout the night. The nurse documented that the resident had 75 ml of dark red/brown urine output. The physician was not notified of Resident #159's distress throughout the night and the status of the resident's urine. A review of the clinical record did not indicate the facility had obtained the results of the urine analysis, culture and sensitivity that was ordered by the physician on 04/15/11. An interview with Resident #159's physician on 04/29/11 at 11:17 AM revealed that she had not treated the resident for a urinary tract infection because there were no urine culture results to support antibiotic therapy. An interview with the West Wing unit manager (UM) on 04/29/11 at 11:30 AM revealed that there was no evidence of the urine culture and sensitivity report on the clinical record for Resident #159. The West Wing UM accessed the laboratory report on the computer and printed the report. The urine culture final report dated 04/17/11 for Resident #159 documented that the specimen was contaminated with 3 or more organisms and suggested recollection. A review of the Urine Culture Final Report dated 05/04/11 for the specimen collected on 4/29/11 at 12:30 PM revealed that the urine was positive for Proteus Mirabilis, and [MEDICATION NAME] faecalis. An observation of the urinary catheter care on 04/29/11 at 1:18 PM with the CNA (Certified Nursing Assistant) for Resident #159 revealed that there was no anchor to hold the catheter in place on the resident's thigh in order to prevent pulling or tension on the catheter. An interview with the CNA at that time revealed that the facility had not used an anchor for Resident #159's urinary catheter tubing currently or in the past. An interview with the medication nurse for Resident #159 on 04/29/11 at 1:18 PM revealed that there was no catheter anchor on Resident #159, but she would put one on now. 2. An interview with Resident #2 on 05/17/11 at 8:48 AM revealed that the resident [MEDICAL CONDITION] of her labia that was aggravated by contact with urine and that was the reason for the urinary catheter. The resident stated that the catheter kept her vaginal area dry so that she could heal from her recent surgery. The resident stated that she has had an infection since the catheter was inserted. A review of the clinical record revealed a care plan dated 11/18/10 indicating the resident had an indwelling catheter due to [MEDICAL CONDITION]. An observation of Resident #2's urinary catheter tubing on 05/17/11 at 8:55 AM revealed cloudy urine with white sediment. An interview with the nurse and observation on 5/17/11 at 9:00 AM of the urine in the catheter bag revealed that there was a lot of sediment in the resident's urine. The nurse stated that she would notify the physician of the cloudy urine. A clinical record review revealed that Resident #2 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the clinical record revealed physician orders [REDACTED]. The laboratory report revealed the urine was collected on 3/30/11 and on 3/31/11 the laboratory reported that the urine specimen was contaminated and suggested recollection of the urine. There was no evidence the urine was recollected. On 3/31/11 the physician ordered another urine culture and sensitivity 5 days from the date of the order (4/05/11). However, there was no evidence in the clinical record the urine culture and sensitivity was repeated on 4/05/11. On 4/12/11 the clinical record revealed an order for [REDACTED]. On 05/03/11 the clinical record revealed an order for [REDACTED]. However, the clinical record did not reveal evidence that the urine had been recollected. An interview with the nurse for the resident on 05/17/11 at 10:41 AM revealed that there were no laboratory results pending for Resident #2. The nurse stated, "anybody that worked that hall should have caught it." An interview with the Director of Nursing (DON) on 05/17/11 at 10:48 AM revealed that there were problems with the laboratory reporting that specimens were contaminated. The DON acknowledged that any of the nurses for Resident #2 could have collected the second specimen. An interview with the infection control nurse on 05/17/11 at 11:50 AM revealed that the laboratory notified the facility of the specimen contaminated with 3 or more organisms on 03/30/11 and the nurse's staff collected a second specimen on 04/13/11. The infection control nurse stated that she did not know why it took so long to get the second/repeat specimen. .

Based on resident observation, resident and staff interviews, clinical record review and policy review, the facility failed to ensure that the physicians for 2 (#159 and #2) of 3 sampled residents with indwelling urinary catheters were notified of laboratory findings. This failure resulted in ongoing pain and suffering related to continuing urinary tract infections, causing actual harm for Residents #159 and #2. The findings include: 1. An observation on 04/29/11 at 8:15 AM revealed Resident #159 lying on her back in bed. The urine observed in the resident's indwelling urinary catheter tubing was dark yellow. A review of the clinical record revealed that Resident #159 was admitted to the facility in February 2011. The nursing notes revealed that Resident #159 did not void any urine on 02/09/11. The physician was notified and ordered a urine analysis and a culture and sensitivity via catheterization. The clinical record revealed there was 250 milliliters (mls) of urine output obtained with the straight catheter procedure. Continued review of the clinical record revealed the nurse documented on 02/18/11, that Resident #159 did not have any urine output. The physician was not notified. The nurse referred to the 02/09/11 physician order [REDACTED]. The nurses notes revealed on 02/21/11, Resident #159 did not have any urine output. The nurse did not notify the physician, but referred to the 02/09/11 order and catheterized Resident #159 with a 16 French 10 ml urinary catheter. There was 400 ml urine return with the catheterization on 02/21/11. On 03/05/11 at 2:45 PM the nurses notes revealed the resident's indwelling urinary catheter was clogged and not draining. The nurse documented that she was unsuccessful with flushing the catheter. The physician was not notified of the clogged catheter, and the catheter was replaced by nurse. On 03/09/11 at 11:15 AM, the clinical record nurse's progress notes revealed that Resident #159 was writhing and grimacing and unable to verbalize pain. There was no urine in the catheter bag. The note indicated the nurse attempted to flush the catheter with no results and a new catheter was inserted and there was dark yellow urine. The physician was not notified of Resident #159's pain and difficulty with the catheter. The nurses notes revealed on 03/24/11, Resident #159's indwelling catheter came out with the balloon intact. A new catheter was inserted with a larger 30 ml balloon. The nurses notes revealed on 03/28/11, Resident #159's catheter came out and was re-inserted. On 04/06/11 the nurses notes revealed Resident #159's catheter came out, there was no urine noted and the catheter was re-inserted. The physician was not notified. On 04/13/2011 at 2:00 AM the nurses notes revealed Resident #159 had a low grade temperature of 100.5. At 3:00 AM, the resident's temperature was 100.1, and at 3:15 AM the temperature was noted to be 99.8. On 04/13/11 at 3:25 PM the nurses notes revealed Resident #159's catheter was clogged and the nurse attempted to flush the catheter without success. The catheter was replaced and drained yellow urine. There was no indication the physician was notified. A review of the physician orders [REDACTED]. On 04/16/11 the nurses notes revealed the urine sample was obtained, the resident had blood in her urine, and a urine specimen was sent to the laboratory for analysis. A review of the laboratory results of the urine analysis, culture and sensitivity that was ordered by the physician on 04/15/11 revealed the specimen was contaminated and the laboratory recommended recollection. On 04/20/11 the nurses notes revealed that Resident #159's catheter was changed by the nurse. Per the nurse there was a copious amount of rust colored urine and white thick drainage noted from the catheter site. There was no indication the physician was notified. On 04/29/11 at 11:00 AM the nurse documented that Resident #159 was in distress throughout the night. The resident had 75 ml of dark red/brown urine output. There was no indication the physician was notified of Resident #159's distress throughout the night or the low dark red/brown urine output. An interview with Resident #159's physician on 04/29/11 at 11:17 AM revealed that the physician had not treated the resident for a urinary tract infection because there were no urine culture results to support antibiotic therapy. An interview with the West Wing unit manager on 04/29/11 at 11:30 AM revealed that there was no evidence of the urine had been recollected for the culture and sensitivity for Resident #159. The West Wing unit manager accessed the laboratory report on the computer and printed the report in question. The urine culture final report dated 04/17/11 for Resident #159 documented that the specimen was contaminated with 3 or more organisms and suggested recollection. The unit manager requested a urine culture and sensitivity for Resident #159 on 04/29/11. Review of the Urine Culture Final Report dated 05/04/11 for the specimen collected 04/29/11 at 12:30 PM revealed that 2 organisms were cultured from the urine. 1. Proteus Mirabilis 2. [MEDICATION NAME] faecalis Resident #159 was treated with antibiotics for 10 days. 2. An interview with Resident #2 on 05/17/11 at 8:48 AM revealed that the resident [MEDICAL CONDITION] of her labia that was aggravated by urine contact when she had on incontinent briefs. The resident stated that the catheter kept the vaginal area dry so that she could heal from the recent surgery. The resident stated that there has been urinary tract infections since the catheter was inserted. An observation of the tubing and bedside drainage bag for Resident #2 on 05/17/11 at 8:55 AM revealed white cloudy urine in the tubing. An interview with the medication nurse for this resident and observation of the urine in the catheter bag on 05/17/11 at 9:00 AM revealed that there was a lot sediment in the urine. The nurse stated that Resident #2 drank copious amounts of liquids daily. The nurse stated that she would notify the physician of the cloudy urine. A clinical record review revealed that Resident #2 was admitted into the facility in May 2007 and readmitted into the facility in October 2010. Resident #2 had [DIAGNOSES REDACTED]. A review of the nurse's progress notes, physician orders [REDACTED].#2. The staff also failed to notify the physician of laboratory results for Resident #2 in a timely manner. A review of the physician orders [REDACTED]. This specimen was collected on 03/30/11, but according to the laboratory report dated 03/30/11, the specimen was contaminated with 3 or more organisms and the laboratory suggested recollection of the urine. On 3/31/11 the physician ordered a 10 day course of antibiotics for Resident #2 and to repeat the urine culture in 5 days. There was no evidence that the physician order [REDACTED].#2. The physician ordered a urine culture and sensitivity again for Resident #2 on 04/12/11. The specimen was collected on 04/13/11 and the laboratory reported to the facility on [DATE] that there were four organisms isolated from the specimen. 1. [DIAGNOSES REDACTED] 2. [MEDICATION NAME] Faecalis 3. [MEDICAL CONDITION] (MRSA) 50,000 cfu/ml 4. Pseudomonas aeruginosa An interview with the infection control nurse on 05/17/11 at 11:50 AM revealed that the laboratory sent a report of the urine culture specimen contaminated with 3 or more organisms on 03/30/11 for Resident #2 and felt the laboratory should have reported the type of organisms isolated. The nurse's staff collected a second specimen for Resident #2 on 04/13/11. The infection control nurse stated that she did not know why it took so long to get the second/repeat specimen. A review of the physician orders [REDACTED]. The laboratory suggested recollection of the specimen. An interview with the medication nurse for Resident #2 on 05/17/11 at 10:41 AM revealed that there were no laboratory results pending for a urine culture and sensitivity for the resident. The nurse stated that any nurse that worked that hall should have caught the missing laboratory test. An interview with the Director of Nurses (DON) on 05/17/11 at 10:48 AM revealed that there were problems with the laboratory reporting that specimens were contaminated. The DON acknowledged that any of the medication nurses for Resident #2 could have collected the second specimen. The infection control nurse called the laboratory on 05/17/11 at 12 noon and learned that the lab did not run additional tests on the laboratory specimen for the urine culture and sensitivity done on 05/04/11 for Resident #2. A review of the facility Nursing Procedure Manual for Urine Specimen Indwelling Catheter that was dated march 2004 and revised October 2005 revealed that the 18th step was for the nurse to notify the physician of laboratory results. .

Based on resident observation, resident and staff interviews, clinical record review and policy review, the facility failed to file the laboratory reports for 2 residents (#159 and #2) of the 3 sampled residents with indwelling urinary catheters. This failure resulted in actual harm for Residents #159 and #2 related to ongoing pain and suffering caused by continuing urinary tract infections. The findings include: 1. An observation on 04/29/11 at 8:15 AM revealed Resident #159 lying on their back in bed. The indwelling urinary catheter drainage bag was covered with a privacy bag, but the urine observed in the catheter tubing was dark yellow. A review of the physician orders [REDACTED]. A review of the laboratory results of the urine analysis, culture and sensitivity that was ordered by the physician on 04/15/11 revealed no results in the clinical record for the culture and sensitivity. An interview with Resident #159's physician on 04/29/11 at 11:17 AM revealed that the physician had not treated the resident for a urinary tract infection because there were no urine culture results to support antibiotic therapy. An interview with the West Wing unit manager on 04/29/11 at 11:30 AM revealed that there was no evidence of the urine culture and sensitivity report on the clinical record for Resident #159. 2. An interview with Resident #2 on 05/17/11 at 8:48 AM revealed that the resident [MEDICAL CONDITION] of the labia that was aggravated by urine contact when in an incontinent brief. The resident stated that the catheter kept the vaginal area dry so that she could heal from her recent surgery. The resident stated that there has been urinary tract infections since the catheter was inserted. An observation of the tubing and bedside drainage bag for Resident #2 on 05/17/11 at 8:55 AM revealed cloudy urine with white sediment in the tubing. Interview and observation of the urine in the catheter bag with the medication nurse for this resident on 05/17/11 at 9:00 AM revealed that there was a lot of sediment in the urine. Review of the physician orders [REDACTED]. This specimen was collected on 03/30/11, but according to the laboratory report dated 03/30/11, the specimen was contaminated with 3 or more organisms and the laboratory suggested re-collection. The physician's orders [REDACTED].#2 and to repeat a urine culture in 5 days (04/06/11). There was no evidence that the physician order [REDACTED].#2. A review of the physician orders [REDACTED]. The laboratory suggested recollection of the specimen, however there was not evidence in the clinical record a specimen was recollected. An interview with the medication nurse for Resident #2 on 05/17/11 at 10:41 AM revealed that there were no laboratory results pending for a urine C&S for the resident. .