Every finding on record at Ballinger Healthcare and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 resident (Resident #1) reviewed for accidents, hazards, supervision. CNA A and CNA B improperly transferred Resident #1 by hooking their arms under hers. The failure could place residents who required assistance during transfers at risk for injuries. The findings included:Review of Resident #1's admission Record, dated 4/14/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of the left hip, stroke, dementia with agitation, and osteoporosis. Review of Resident #1's Quarterly MDS Assessment, dated 3/20/26, revealed:She had a BIMS of 1 of 15 (indicating severe cognitive impairment) and showed signs of delirium including inattention and disorganized thinking.She rejected care 1 to 3 days of the previous 7.She was dependent on staff for chair to bed transfers. Review of Resident #1's Care Plan Report, revised 4/8/24, revealed:Focus: Resident had an ADL Self Care Performance Deficit. Resident was mostly substantial to totally dependent [on staff for] ADLS except when eating.Goal: Resident will improve current level of function in (transfers) through the review date.Interventions included: Bed Mobility: require two staff for assistance. Observation on 4/14/26 at 4:35 p.m. revealed CNA A and CNA B assisted Resident #1 to sit at the edge of the bed. CNA B placed the gait belt on Resident #1. CNA A hooked her arms under Resident #1's arms and grabbed her by the seat of her pants. CNA B hooked her arms under Resident #1's and grabbed the back of the gait belt. The CNAs counted to three and completed a pivot transfer with Resident #1. Interview and observation on 4/14/26 at 4:39 p.m. the DOR stated the expectation for a two-person gait belt transfer was to place the gait blet on the resident and have the resident between the two staff. The DOR said staff were to have both hands on the gait belt and help the resident stand up and control where the resident went. The DOR stated he did not like the staff hooking their arms under the resident's arms because it placed a strain on the upper shoulders. The DOR said potential outcomes for this were to stretch the shoulders, skin tears, and bruises. The DOR stated it could hurt the resident including broken bones on the fragile residents. The DOR admitted he worked with Resident #1; he described her as impulsive since she had a stroke two years ago, she had cognitive problems and had sundowners (loss of cognitive ability at the end of the day) very quickly, and fragile since she lost a lot of weight. The DOR stated Resident #1 was able bear weight, stand, transfer, and walk 10 - 15 feet if encouraged but her balance was not good. He said his part of training the staff was usually on a one-on-one basis when the facility identified issues. During the interview, CNA A walked in and returned a gait belt labeled 'therapy'. CNA A said she did not need it and usually transferred a resident by the seat of their pants. The DOR stated transferring a resident by the seat of their pants was not a safe practice because it could cause friction, skin tears, and get very uncomfortable in a hurry. Interview on 4/14/26 at 5:17 p.m. the Administrator was informed of the observation and stated that staff hooking their arms under a resident's arms was not appropriate. Interview on 4/17/26 at 1:17 p.m. CNA B stated she thought the transfer went really well because Resident #1 did not fight them. Initially CNA B denied hooking her arms under Resident #1's arms but admitted she did and said it was not the correct way to transfer a resident. CNA B said she did not know why she hooked her arms under Resident #1's arms. CNA B said sometimes the management staff would check how the aides did care during Champion Rounds, but she did not know if all staff got checked off since CNA A was as-needed. Review of in-service Training in Transfers, Bed mobility, repositioning and pain, dated 3/16/26 revealed:Two-Person Sit Pivot transfer - this is a variation of the sit pivot transfer. Use this transfer when the patient requires the aid of two people. The second person aiding in the transfer will help from behind. The patient will place both feet on the floor, lean forward and scoot. The second person will boost the patient's hip and guide the transfer.The following lifting and transfer procedure is toCNA B attended the Inservice, CNA A did not. Review of the computer transcript of staff completed in-services for the 3 months prior (1/2026 thru 4/13/26)to investigation revealed CNA A took the computer class on fall prevention on 2/24/26. Review of the facility's policy and procedure on Moving a Resident Bed to chair/Chair to bed, undated, revealed:Purpose: the purpose of this procedure are to allow the residents to be out of his or her bed as much as possible and to provide for safe transferring of the resident.Steps in the procedure:Note: this procedure may require two (2) persons.Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable.If the patient requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.

Based on interview and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed had a full time or interim DON from 12/27/2025 through present (02/19/2026). This failure could place all residents at risk of not receiving necessary care and services. Findings included: During an interview on 02/19/2026 at 2:55 PM, the Administrator said the previous DON's last day at the facility was 12/27/2025. The Administrator said the interim DON was the RNC whom would oversee the facility and was readily available by phone as needed. The Administrator acknowledged stated the RNC did not qualify to be the interim DON due to the RNC not being in the facility 8 hours a day. The Administrator said they had interviewed some possible candidates for the DON position. The Administrator said he did not believe the residents had had had any negative outcomes due to no current DON. as He said the RNC had been overseeing the facility plus and they had nursing staff available. Interview on 02/19/2026 at 3:00 PM, the Administrator said they the facility did not have a policy for DON requirements and went based on the state regulations for guidance.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #2 and #36) of 4 residents observed for oxygen management. The facility failed to ensure Resident #2 and Resident #36 had an oxygen signs posted outside their room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and at risk of harm and exposure to a fire hazard if staff and visitors are not aware of oxygen present.Findings included: Record review of Resident #2's admission record dated 02/19/2026, revealed she was admitted to the facility on [DATE] with diagnoses of dementia and heart failure. The admission record indicated She was [AGE] years old. Record review of the current care plan for Resident #2, last reviewed/revised: dated 09/10/2025, revealed in part indicated: The resident has Oxygen Therapy related to SOB due to CHF. Provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. Record review of Resident #2's MDS assessment dated [DATE], revealed in part: Section O - Special Treatments, Procedures, and Programs. Respiratory Treatments - Oxygen therapy. Record review of Resident #2's order summary report dated 02/18/2026, revealed in part: Oxygen LPM: 2-5 liters via nasal cannula as needed for Shortness of Breath. Start date: 09/01/2025. Observation on 02/18/2026 at 10:28 AM, Resident #2 was observed in bed resting and was observed with oxygen on via nasal cannula on which was connected to the concentrator at . The concentrator was on and set at 2 liters per minute. There was no oxygen sign seen outside of the room. Record review of Resident #36's admission record dated 02/19/2026, revealed she was admitted to the facility on [DATE], with a diagnosis of chronic respiratory failure with hypoxia (low blood oxygen). The admission record indicated She was [AGE] years old. Record review of the current care plan for Resident #36, last reviewed/revised: dated 01/19/2026, revealed in part: The resident has Oxygen Therapy related to Chronic Respiratory Failure. Monitor for signs/symptoms of respiratory distress and report to MD PRN: Record review of Resident #36's MDS assessment dated [DATE] revealed in part: Section O - Special Treatments, Procedures, and Programs. Respiratory Treatments - Oxygen therapy. Record review of Resident #36's order summary report dated 02/18/2026 revealed in part: Oxygen LPM: 2 Via: nasal cannula every shift. Start date: 01/19/2026. Observation on 02/18/2026 at 10:22 AM, Resident #36 was in bed resting and had their oxygen on. She was observed with her nasal cannula on which was connected to the oxygen concentrator at 2 liters per minute. The concentrator was on and set at 2 liters per minute. There was no oxygen sign seen outside of the room. During an interview on 02/19/2025 at 2:34 PM, the ADON said it was expected for the resident rooms to have an oxygen signs posted outside the room to indicate there was oxygen being used in that room. The ADON said a possible negative outcome would be that someone could light a cigarette in that room, and also an electronic devices could lead to a fire. During an interview on 02/19/2026 at 2:52 PM, with the Administrator, he said it was expected for an oxygen signs in use to be posted outside the resident's residents rooms where oxygen was being used. The Administrator said this was expected for safety reasons such as no smoking allowed in that room. Record review of the facility policy titled 2.0 Nasal Cannula dated June 1, 2006, revealed in part: Oxygen therapy via nasal cannula is administered as ordered by a physician. Explain safety rules. Post No smoking - Oxygen in use sign on the patient's door if appropriate.

Based on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 3 (Rooms 5, 18 and 21) of 30 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being. Findings included: During an observation on 02/17/2026 at 2:35 PM, resident rooms 5, 18 and 21 on halls A and B revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately 12 inches from the wall. Both A and B beds had a side curtain each but they each had a gap of 18 inches and 30 inches and were unable to allow for beds to have total visual privacy. Interview on 02/19/2026 at 3:02 PM, the Administrator said if the resident room did not have a full visual privacy curtain, then it would not provide privacy when a resident requested it. The Administrator said they were already in the process of correcting the curtains. Interview on 02/19/2026 at 3:04 PM the Administrator said they did not have a policy regarding privacy curtains.

Based on observation, interview and record review, the facility failed to ensure services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #27) of one resident observed for g-tube feedings.The facility failed to ensure the ADON administered medication and water to Resident #27 via her gastrostomy tube (g-tube) by following facility policy.The Facility failed to ensure the ADON performed hand hygiene and changed gloves while administering medication via g-tube.The facility failed to ensure the ADON cleaned the plunger after it came off established clean field area before using it again.These failures could place residents at risk for fluid overload, weight loss, aspiration pneumonia, abdominal discomfort, and risk for spread of infection.Findings included:Review of Resident #27 face sheet dated 02/19/26 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of gastronomy status (indicates that an individual has a surgically placed gastronomy tube (g-tube) providing direct access to the stomach for nutrition, hydration or medication), cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues affecting daily functioning and quality of life), intellectual disability, convulsion (a sudden, involuntary contractions of muscle causing uncontrollable shaking, which can affect part or all of the body), and dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities).Record review of Resident # 27's quarterly MDS dated [DATE], reflected a BIMS score 03 which indicated cognition was severely impaired. The MDS indicated that Resident #27 required total dependent on two or more staff for bed mobility, transfers, locomotion, eating, toilet use, and personal hygiene. The MDS indicated she was always incontinent with bowel and bladder.Review of Resident # 27's care plan dated 12/16/25, reflected the resident had a surgical site to abdomen related to peg-tube placement. The goal was for the surgical site to remain free from signs and symptoms of infection with treatment as ordered over the next 90 days.Review of Resident #27's Physician's Orders dated 2/01/26 through 02/28/26, reflected the following orders: Enteral feed order related to dysphagia. Start continuous enteral feeding. Formula: brand name 1.4. Rate: 45ml/hr. x 20 hours. Free water at 25ml/hr x20 hours. Start at 7:00a.m and end next day at 3: 00p.mObservations of medication administration via g-tube on Resident #27 on 02/18/26 at 11:47a.m., the ADON was observed putting on gloves without performing hand hygiene before starting care During the medication pass for Resident #27, The ADON separated the medications into different cups and crushed them. The ADON attached 60 cc of g-tube syringe. She checked for placement and instilled 60cc water before administering the medication. She was using over 30 cc of water for each medication administered which could cause fluid overload. This was against the facility's policy as reflected on the enteral tube medication administration policy. Resident #27 started coughing which caused the medication to spill out of the syringe and spattered around the resident. The ADON tried to contain the spatter by using the plunger to cover the syringe. She placed the plunger on the unclean part of the bedside table away from the established clean field. The ADON did not clean the plunger before using it to stop the splatter. Additionally, her gloves were visible soiled with spattered medications. She did not wash hands, change gloves or perform hand hygiene. Meanwhile, the ADON did not completely dissolve the medication for Dilantin oral chewable 50 mg and omeprazole magnesium. There was a great quantity of these medications left on the cups. The ADON threw these medications in the trash can. Consequently, Resident#27 did not get all her medications as ordered.Record review of Resident #27's Physician Orders dated 02/01/26 through 02/28/26 reflected the following:Omeprazole Magnesium Oral Packet 40 mg. Give 1 tablet via p-tube two times a day.Dilantin Oral Tablet Chewable 50 MG. Give three tablets via peg-tube once a day.Famotidine Oral Tablet 20 MG. Give tablet via peg-tube two times a daySucralfate Oral Suspension 1 GM/10ML-10 ml via peg-tube four times a dayMetoclopramide Oral Solution 5 MG/5M. Give 10 ml via peg -tube four times a dayAcetaminophen Oral 15 ml. Give 15 ml via peg tube three times a dayFerrous Sulfate oral solution. Give 7.5 ml via g-tube one time a dayMiralax oral Powder 17 gm/scoop-Give I scoop via g-tube once a dayMultivitamins with minerals. Give 15 ml via g-tube one time a day.In an interview with the ADON on 02/19/26 at 3:36p.m., she stated she had been employed by the facility for about three weeks. She stated she received infection control training during her orientation. The ADON stated cross contamination was not washing hands or changing gloves. She stated she should have washed her hands and changed gloves while providing care. She said she was nervous. The ADON explained she was not aware she used excess water while administering medication to Resident #27 via g-tube. The ADON stated she did not receive training from the facility regarding medication administration via g-tube.During an interview with RNC on 02/19/26 at 4:12p.m, he stated he was aware of the concerns raised about infection control and medication administration via g-tube. He stated the staff was expected to wash hands before and after providing care to residents. RNC said staff were supposed to follow the facility procedure in medication administration through g-tube including checking placement and ensuring all medication was given to the resident. The RNC stated he could not locate training/in-services on g-tube medication administration by the facility. He stated that the staff receive annual training on infection control with checks with return demonstrations.Record review of the facility infection control policy updated 03/2024 reflected the following: Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty. When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). Before and after performing any invasive procedure (e.g., fingerstick blood sampling). Before and after entering isolation precaution settings. Before and after eating or handling food (hand washing with soap and water). Before and after assisting a resident with meals. Before and after assisting a resident with personal care (e.g., oral care, bathing).Record review of the facility enteral tube medication administration policy undated reflected the following:Policy:Safely and accurately administer oral medications through an enteral tube.MedicationFeeding (50cc) syringe75-100 ml water 4) Clamp5. Stethoscope6. Drinking cupProcedure:1. Wash hands2. Identify resident before administering medicatione Check arm band or photograph ask resident to state their name or check with other staff members ifnecessary.Explain procedure and purpose of medication to resident. Residents have the right to be informed of all medications he/she receives. Provide privacyIf the resident is in bed, elevate the head of bed to 30-45-degreeangle.deletedVerify tube placement Unclamp tube and use either of the following procedures:(C) Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscopefor gurgling sounds(C) Aspirate stomach contents with syringe Never administer medications through a [NAME]-[NAME] tube. Use a Dubhoff or Kangaroo tube.e Re-clamp tube to maintain a closed system. Check that the breathing tube is not clamped.Read medication label three times before administering, checking with MAR. If the label is incorrect, the nurse is responsible for applying a direction change sticker to the medicationlabel. Empty capsule contents into 10 to 15 ml of water or other appropriate liquid. Administer each medication separately, flushing tube with 5-15 ml of water after each dose. Medications are never added directly to the feeding solution.

Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 12 residents (Resident #2) reviewed, in that: The facility failed to ensure Resident #2's eTAR for the month of January 2026 were completed by the nursing staff and not left blank. This failure could place residents at risk of not receiving proper care and having their personal needs met.The findings included: Record review of Resident #2's admission record dated 02/19/2026, revealed she was admitted on [DATE] with diagnoses of dementia and heart failure. The admission record indicated she was [AGE] years old. Record review of care plan for Resident #2dated 09/10/2025, revealed The resident has Oxygen Therapy related to SOB due to CHF. Provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. Record review of Resident #2's MDS assessment dated [DATE], revealed Section O - Special Treatments, Procedures, and Programs. Respiratory Treatments - Oxygen therapy. Record review of Resident #2's eTAR for the month of January 2026 revealed Oxygen LPM: 2-5 liters via nasal cannula as needed for Shortness of Breath. The document did not indicate documentation for oxygen, pulse and rate, and time completed. During an interview on 02/19/2026 at 2:36 PM, the ADON said nurses should have documented Resident #2's oxygen status on the eTAR and not just on the vital signs section. The ADON said if e nurses did not document on the residents' eTAR they would not know if the resident was using the oxygen more regularly or if the resident needed it more than just as needed. During an Interview on 02/19/2026 at 3:12 PM, the Administrator said it was expected for nursing staff to document the residents' treatments on their corresponding eTAR. The Administrator said the documentation was located on the resident's electronic chart under vital signs but not on the eTAR. The Administrator said if the treatment was not documented, then they would not be able to determine if the treatment was done. Record review of the facility's undated policy titled Documentation revealed in part: Documentation is the recording of all information both objective and subjective in the clinical record of an individual and or soft resident file. Goal - the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #9) of 3 residents reviewed for infection control. The facility failed to ensure LVN A used recommended PPE for Resident #9 who was on EBP precautions when changing her urinary catheter. This failure could place residents at risk of cross contamination and the spread of infection. Finding included: Record review of Resident #9's admission record dated 02/17/2026, indicated she was admitted [DATE], diagnosis included uninhibited neuropathic bladder (Usually due to damage to the brain from a stroke or brain tumor. This can cause reduced sensation of bladder fullness, low-capacity bladder, and urinary incontinence. The admission record indicated she was [AGE] years old. Record review of Resident #9's care plan dated 01/28/2026, revealed Resident is on enhanced barrierprecautions related to the presence of colostomy and foley catheter. There will not be any transmission of infection from or to the resident. Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, catheter care, or other high-contact activity. Date Initiated: 01/11/2026 Record review of Resident #9's MDS assessment dated [DATE] indicated Section H - Bladder and Bowel. Check all that apply: Indwelling catheter. Record review of Resident #9's order summary report dated 02/17/2026, indicated Foley Catheter: 18 French (size of catheter) with 10 bulb - change for occlusion, leaking, closed system was compromised as needed. Start date 01/28/2026. During an observation on 02/17/2026 at 10:55 AM, LVN A changing Resident #9's urinary catheter. LVN A entered the resident's room and washed her hands and then put on a pair of clean gloves. LVN A then proceeded to remove Resident #9's urinary catheter. LVN A used gloves but did not wear a gown during the resident care. There was a 3-drawer plastic dresser in the room that contained gloves and gowns observed. There was a posting posted outside Resident #9's room, the posting indicated Multi drug-Resistant Organism (MDROs) are a threat to our residents. Enhanced Barrier Precautions (EBP) steps, perform hand hygiene, wear gown, wear gloves, dispose of gown and gloves in room. Use EBP during high-contact care activities for residents with: Indwelling medical devices e.g. urinary catheter. During an interview on 02/19/2026 at 1:58 AM, LVN A said she was supposed to use a gown when she changed Resident #9's urinary catheter. The LVN said that she had a lot going on that day and was distracted so she forgot to put a gown on. LVN A said she had been trained on when and how to use EBP. LVN A said not wearing a gown could lead to an infection or cross contamination. During an interview on 02/19/2025 at 2:24 PM, the ADON said the expectation was for nursing staff to use PPE when assisting Resident #9 with her urinary catheter. The ADON said LVN A should have known to use PPE . The ADON said if nurses did not wear PPE as indicated then they could spread infections to and from that resident. During an interview on 02/19/2026 at 3:05 PM, the Administrator said it was expected for nursing staff to use EBP when care was provided to a resident that was on EBP precautions. The Administrator said that if the correct EBP was not worn it could lead to cross contamination. Record review of the facility undated policy titled Enhanced Barrier Precautions revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device example include urinary catheters.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure chicken was thawed under running water or in the refrigerator. 2. The facility failed to ensure staff appropriately cleaned and sanitized the thermometer prior testing food temperatures. 3. The facility failed to ensure sick staff wore an appropriate face mask. 4. The facility failed to ensure staff wore effective hair restraints. 5. The facility failed to ensure food was stored in a manner that was not opened to the air. These failures could place residents at risk for food borne illness and cross contamination. Findings include: Observation and interview on 11/19/24 at 9:53 a.m. revealed: A bag of chicken thawing on the counter of the industrial sink, it was not in running water. There was a bag of chicken thawing in running water immediately next to it. Upon moving the thawing bag of chicken, a puddle of pink chicken juices the size of the bag (5 gallons) was observed. [NAME] B stated she took the bag of chicken out at 6 a.m. that morning and left it by the sink. [NAME] B was observed wearing a face mask on. The face mask covered her mouth but not her nose. [NAME] B started coughing she covered her mouth with her arm, [NAME] B stated she did not know what was wrong. [NAME] B was actively prepping food. Observation of the freezer during initial tour revealed a box of chicken with a bag of exposed chicken. Observation of the dry storage during initial tour area revealed a 50-pound bag of dry milk on the floor. Observation and interview on 11/21/24 at 11:08 a.m. revealed some spices on the spice shelf that were open to the air. The DM said they were used the night before and were not closed or wiped off because the other cooks were not paying attention. The DM stated they should be wiped and covered after food preparation. [NAME] C's hair net slid up and left half her hair hanging out, approximately an inch and a half of hair out of net. Observation on 11/21/24 at 11:20 a.m. revealed the DM gave [NAME] C a paper towel with the instructions that if there were large particles of food on the thermometer to wipe off the food prior to cleaning off the thermometer with the alcohol pad [NAME] C had on the counter in front of her. [NAME] C cleaned the thermometer with the paper towel between eight separate dishes. In an interview on 11/21/24 at 11:25 a.m., [NAME] C stated she used the paper towel because she was really a nurse and the DM gave it to her but she normally uses an alcohol wipe. [NAME] C stated the paper towel did not adequately clean the thermometer and it caused cross contamination between dishes. The DM who was also present stated we all make mistakes. Observation at 12:45 p.m. an unidentified dietary staff came in through the dirty dish area with no hair net on while the lunch serving task was still being completed. The staff was holding a hair net and did not put it on until she reached the other side of the kitchen. In an interview on 11/21/24 at 4:07 p.m., the DM stated she did not feel the kitchen did not go well this year because there were a lot of mistakes. The DM stated the mistakes included the raw chicken on the counter and temperature thing with the paper towel. The DM stated she did not think [NAME] B was really sick on 12/19/24 because there was no coughing on 11/20/24 or 11/21/24. The DM stated she was in the process of putting the dry milk up when the State Surveyors came into the kitchen which was why it was on the floor. The DM said she had it on the rack of cans and got it down so she could pour it into the appropriate container. The DM stated the consequence to the thawing chicken improperly was the growth of bacteria and it would do the same thing with the thermometer and the cross contamination. The DM stated she did not say anything to [NAME] C at the time because she did not want [NAME] C to feel like she was being scolded. The DM said hair restraints were supposed to be put on immediately upon entering the kitchen and they weren't supposed to take it off until they left the kitchen. The DM said if the hair net was half on it was not effective because there was hair hanging out and it could fall into the food. In an interview on 11/21/24 at 4:26 p.m the Administrator was informed of all of the kitchen findings. He stated he had no rebuttal to the findings. Record review of the facility's policy and procedure dated 2012, on Thawing Foods revealed: All foods will be thawed in a safe and sanitary manner. Procedure: Foods may be thawed in the following manner: under potable running water of a temperature of 70 degrees or below, with sufficient velocity to agitate and float off loose food particles into the overflow, in a sealed package. All raw meats will be thawed separately from each other, and separately from any other foods. Record review of the facility's, undated, policy and procedure on Dry Storage and Supplies, revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: Storerooms are to be well lighted, ventilated, and temperature controlled. b. All food and supplies are to be store six (6) inches above the floor on surfaces which facilitate thorough cleaning. Record review of the facility's policy and procedure dated 2012, on Infection Control, revealed: We will ensure that all employees practice infection control in the Dietary Service Department, and maintain sanitary food preparation. All dietary service employees will follow Infection Control Policies as established and approved by the Infection Control committee. Procedure. b. Clean hair is required. It is to be totally covered with an effective hair restraint. Food preparation: A, Frozen items are thawed in refrigeration or under cold running water in a draining sink.

30057 Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #2 and #5) reviewed for infection control. 1. RN A failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #5. 2. RN A failed to wash her hands or use hand sanitizer between glove changes during medication administration and PEG tube dressing change for Resident #2. These failures could place resident's risk for cross contamination and the spread of infection. Finding include: 1. Record review of Resident #2's admission record, dated 11/20/2024, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included gastrostomy status (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) and cerebral palsy ( A disorder that affect a person's ability to move, maintain balance, and posture). Record review of Resident #2's Order Summary Report dated 11/20/2024, indicated in part: Sucralfate Oral Suspension 1 GM/10ML (Sucralfate) Give 10 ml via PEG-Tube four times a day for ulcer of esophagus. Enteral Feed Order one time a day Cleanse peg tube site with normal saline and gauze, pat dry, apply barrier ointment around stoma, cover with T drain sponge. Order date 08/22/2024. Record review of Resident #2's quarterly MDS, dated [DATE], indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Nutritional Approaches Check all of the following nutritional approaches that apply - Feeding tube. Record review of Resident #2's care plan dated 08/23/24 indicated in part: Focus: The resident requires tube feeding related to difficulty swallowing. GOAL: The resident will remain free of side effects or complications related to tube feeding through the review date. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than 80 ml aspirate. Clean insertion site daily as ordered, monitoring for symptoms of infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to doctor if symptoms arise. During an observation on 11/20/24 at 08:55 AM, RN A administered Resident #2's medications via PEG tube and also changed her PEG tube site dressing. RN A prepared the resident's medication on her treatment cart then entered the resident's room. Without first sanitizing or washing her hands she put on a pair of gloves and proceeded to administer the medication via Resident #2's PEG tube. RN A removed her gloves and went to the supply room to obtain a towel and also obtained a dressing from her treatment cart. RN A returned to Resident #2's room and put on a pair of clean gloves without first washing or sanitizing her hands. RN A then removed the old PEG tube dressing, cleaned the PEG site area and while still wearing the same gloves applied the new dressing to the resident. RN A then removed her gloves and stated she was done and proceeded to move to her next assignment without washing or sanitizing her hands. During an interview on 11/20/24 at 11:05 AM, RN A said during Resident #2's medication administration she had not sanitized or washed her hands in between glove changes because she stayed in the same room and provided care for the same resident care. RN A was made aware of the times she went back to the medication cart and the supply closet to obtain items and when she put on clean gloves again, she was not noted to have washed or sanitized her hands. RN A said she was sorry she had not washed or sanitized her hands when she changed her gloves. RN A said if she did not sanitize or wash her hands she could possibly spread germs or infections. During an interview on 11/21/24 at 03:24 PM, the DON said it was expected for nursing staff to wash or sanitize their hands before putting gloves on and after taking them off. The DON said RN A should have sanitized or washed her hands during Resident #2's patient care. The DON said if staff did not wash or sanitize their hands, that could lead to the spread of infections. The DON said she monitored the staff by conducting rounds and in-services regarding hand washing and glove use. During an interview on 11/21/24 at 04:18 PM, the Administrator said it was expected for nursing staff to wash or sanitize their hands before putting gloves on and after taking them off. The Administrator said it could lead to infections if the staff did not wash or sanitize their hands. The Administrator said the failure probably occurred because the nurse got nervous due to the state surveyor observing them. 2. Record review of Resident #5's Admission Record, dated 11/21/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included local infections of the skin and subcutaneous tissue (under the skin); debility (weakness); and dementia (A disorder in which a person can lose the ability to think, remember, and reason to the point that it interferes with their daily life). Record review of Resident #5's Quarterly MDS Assessment, dated 10/25/24, revealed: She had long and short-term memory impairment with severely impaired decision-making abilities. At the time of the assessment, there were no skin tears identified. Record review of Resident #5's care plan, revised on 11/11/24, revealed Resident #5 had the potential for impaired skin integrity related to incontinence, impaired mobility, dementia, and fragile skin with decreased safety awareness. The identified goal was the resident would maintain or develop clean, intact skin by the review date. The identified interventions included: follow facility protocols for treatment of injury. Record review of Resident #5's Order Summary, dated 11/21/24, revealed orders: Start date 11/12/24: Skin tear to right calf, cleanse with wound cleanser apply steri-strips. Cover with soft dressing daily. May leave open to air if no drainage present. Record review of Resident #5's Weekly Skin Assessment, dated 11/18/24, revealed: Resident has a healing skin tear to right calf. During an observation on 11/19/24 at 2:23 PM revealed Resident #5 was in bed asleep on a low bed. Resident #5 had a fall mat in place and there were wound care supplies (gloves, gauze, tape, tape) on the fall mat with no barrier in place. During an observation on 11/19/24 at 2:29 PM revealed RN A brought in a linen (porous) towel and placed it on the fall mat. RN A placed the wound care supplies from the fall mat onto the towel. Without any hand-hygiene practices, RN A donned gloves. RN A hooked her left arm under Resident #5's knee and pulled off the dirty dressing. RN A took off the right glove, but not the left. Resident #5 had an approximately 2-inch skin tear to the back of her right shin held together with steri-strips. With no hand hygiene, RN A placed another glove on her right hand and cleaned Resident #5's skin tear. RN A removed the right glove only. With no hand hygiene, RN A donned the right glove, patted Resident #5's skin tear dry. RN A took off her right glove. With no hand hygiene, RN A donned a glove to her right hand and applied antiseptic wound cleanser with an applicator. RN A took off her right glove. Without hand hygiene RN A place a non-adherent dressing on a dressing retention tape and placed on Resident #5's skin tear. RN A then gathered the piled of used gloves/dirty wound care supplies and the towel. RN A threw the gloves/dirty wound care supplies in the trash of the treatment cart, put the towel in the dirty linen barrel and then sanitized her hands with alcohol gel. During an interview on 11/20/24 at 10:46 AM, RN A stated she remembered she removed the old dressing, put it in the glove and took off the glove. RN A said she donned a new glove, cleaned the wound with normal saline, held the wet gauze in the glove and took the glove off. RN A said she put on a new glove, dried the wound, held the gauze and took off the old glove. The RN stated she put on a new glove and applied the antiseptic gel, broke the applicator and took off the glove while holding the applicator. RN A stated then she put the non-stick pad on the tape and applied it. RN A said she threw out the pile of used gloves, put the towel in the dirty linen and sanitized her hands with alcohol gel RN A said she set the wound care supplies up outside the room, so nothing came into the room. RN A said she put the towel on the ground and then placed the wound care supplies on the towel. RN A said the towel was a porous surface so there was not an effective barrier. RN A stated all the supplies were not touching the towel so they were still clean. The State Surveyor reminded her the wound care supplies were on the floor and RN A stated she forgot that part of it and said none of the supplies touched the fall mat before being placed on the towel. RN A said with the supplies laid out on the floor it was not a clean technique. RN A stated she did not remember when she did hand-hygiene prior to doing wound care but she usually did before she entered a room but added she probably did not do it when she left for the towel. RN A said there was no alcohol based hand rub (ABHR) in the room for her to use in between glove changes. RN A thought for a second and then pulled a bottle of ABHR out of her pocket. RN A said she never did hand hygiene between glove changes on the same residents because she was told changing gloves was enough. RN A stated on 11/20/24 when she did wound care Resident #5 was on her side and it was much easier to do. During an interview on 11/20/24 at 1:06 PM, the DON and the Regional RN Consultant stated the expectation was hands were washed prior to starting and gel between dirty to clean. The DON stated the facility expected a non-porous barrier like wax paper or incontinent pad with the plastic backing. The Regional RN stated the corporation's expectation was for the staff to perform hand hygiene, gather their supplies on a tray or wax paper or use a clean bed side table. The Regional RN stated nothing should go into the room unless it could be cleaned, like scissors. The Regional RN said the nurse should put the dry gauze, wet gauze, any medications, date and initial the dressing, put any medication in a cup and get the applicators, gloves, and a bottle of hand sanitizer. The Regional RN stated the staff should bring in a separate trash bag for the dirty supplies. The Regional RN said the corporation expectation was for the staff to apply gloves, take off the dirty dressing, dispose of the dressing, take off gloves, clean hands, don new gloves, clean the wound, pat dry, apply any medications, take off the gloves, gel, don new gloves apply a clean dressing, take off the gloves, sanitize hands, and then get rid of the dirty supplies and clean the resident's area. During an interview on 11/20/24 at 1:35 PM, the Administrator was informed of the 11/19/24 wound care observation. When informed of the supplies on the floor, the Administrator said, you're kidding me? The Administrator stated they saw the issue with infection control. Interview on 11/20/24 at 1:42 PM, the DON stated there were no recent in-services on wound care or infection control. Record review of the facility's policy titled Infection Control Plan, dated 2019, indicated in part: Infection control - the facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Infection control program - the facility will establish an infection control program under which it - investigates controls and prevents infections in the facility . The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Implement hand hygiene (Hand washing) practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination. Record review of the facility's policy titled Fundamentals of infection control precautions, dated 3/2023, indicated in part: .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care, before and after changing a dressing, upon and after coming in contact with a resident's intact skin, after handling soiled or used dressings, after removing gloves.Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use and hands can become contaminated during removal of gloves, failure to change gloves between resident contacts is an infection control hazard.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 treatment carts (Hall 4 cart) reviewed for medication storage. The facility failed to ensure the nurses' treatment cart was not left unlocked and unsupervised for 10 minutes on hall 4. This failure could place residents at risk of loss, diversion or accidental ingestion of medications. The findings include: During an observation on 11/20/24 at 09:10 AM till 09:20 AM revealed RN A left the nurse's treatment cart unlocked and unattended for approximately 10 minutes while she entered a resident's room to attend to them. The cart contained several ointments, nail clippers, dressings and several other normal saline bottles. The cart was facing the hall. During an interview on 11/20/24 at 11:05 AM, RN A said she was not aware she left the treatment cart unlocked. RN A said she always was very good about locking her cart when walking away from it, but she had just plain missed it today. RN A said if the cart was left unlocked then someone could get into the cart and into the supplies used for wound care and medication administration. During an interview on 11/21/24 at 03:30 PM the DON said it was expected for nursing staff to lock their medication carts when not using them. The DON said the nurse had probably forgotten to lock the cart when she went back into the resident's room to perform the resident care. The DON said if the cart were left opened then other unauthorized people or residents could have access of the cart. During an interview on 11/21/24 at 04:22 PM, the Administrator said it was expected for nursing staff to lock their medication carts when not using them. The Administrator said if the cart was left unattended and unlocked it could lead to drug diversions and other people having access to the items in the cart. The Administrator said the failure probably occurred because the staff had gotten nervous due to being observed by the state surveyor. Record review of the facility's policy titled Medication Carts, dated 2003, indicated: The carts are to be locked when not in use or under the direct supervision of the designated nurse. Record review of the facility's policy titled Medication Administration Procedures, dated 2003, indicated : After the medication administration process is completed, the medication cart must be completely locked or otherwise secured.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one medication cart (carts A and C) of four medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure treatment cart A was locked when unattended. The facility failed to ensure medication cart C was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on 09/20/2023 from 8:30 AM to 09:00 AM, revealed treatment cart A and medication cart C were found unlocked and unattended in front of the nurses station with no staff in sight. The Surveyor waited by the carts until the ADON came around the corner, from the dining room and stated that she had only walked away for a little bit. The ADON stated that she knew that she shouldn't have left the cart unattended while unlocked. During an observation and interview on 09/20/2023 from 10:30 AM to 10:40 AM, revealed medication cart C was found unlocked and unattended in front of the nurses station. RN D was on the other side of desk, on the computer, not paying attention as the Surveyor opened the drawers to the medication cart. The Regional Compliance Nurse and the DON were called over to observe. The Regional Compliance Nurse stated that the nurse was in-serviced about unlocked carts 09/19/23 and should know better. The DON stated that she would in-service all staff immediately regarding locking medication carts and how it can lead to possible harm or drug diversions. During an observation and interview on 09/21/2023 from 11:30 AM to 11:37 AM, revealed medication cart C was found unlocked and unattended in front of the nurses station, no staff in sight. RN D came by and stated it was her cart. RN D stated that it is dangerous to leave carts unlocked when unattended. Anybody could get in the cart which contained over-the-counter medications, zofran, anti-anxiety medications, and blood pressure medications. RN D stated that there were residents who wander around the facility and could hurt themselves by ingesting thee medications. RN D stated that she knew better than to leave the carts unlocked when unattended and that the DON just did an in-service with her yesterday. Review of the facility's policy, titled Medication Carts, dated 2003, reflected (in part): Policy Interpretation and Implementation: 1. Medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse. 3. Carts not in use are to be stored in a designated area not blocking egress in the building.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 of 11 employee files (AD G, LVN C, LPN D, DON) reviewed for abuse and neglect, in that The facility did not complete employee misconduct registry (EMR) nurse aide registries (NAR) checks upon hire date or annually for (AD G, LVN C, LPN D, DON). These deficient practices could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Review of the facility's Abuse Prevention Program Policy, updated January 2019, revealed To Prohibit and prevent abuse, neglect, exploitation, misappropriation of a resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. 2. Screening, each center will follow any and all state specific requirements: 2. Appropriate licensing board or registry checks 4. Criminal Background check pursuant to company policy or state law 5. OIG exclusion background check The center will not retain any team member with a history of abuse or neglect if that information is known to the center. The center must not employ or otherwise engage individuals who have had a disciplinary action taken against a professional license by a state licensure body or had a finding entered into the state NA Registry concerning or as a result of abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Record review of the staff roster, dated 07/19/22, revealed AD G's hire date was on 07/31/17. Record review of AD G's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of AD G's EMR/NAR, dated 07/19/22, revealed no results found. 2. Record review of the staff roster, dated 07/19/22, revealed LVN C's hire date was on 2/24/17. Record review of LVN C's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of LVN C's EMR/NAR, dated 07/20/22, revealed no results found. 3. Record review of the staff roster, dated 07/19/22, revealed LPN D's, hire date was on 07/1/15. Record review of LPN D's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of LPN D's EMR/NAR, dated 07/19/22, revealed no results found. 4. Record review of the staff roster, dated 07/19/22, revealed the DON's hire date was on 02/14/03. Record review of the DON's employee file revealed no evidence of an EMR/NAR check within the last year. Record review of the DON's EMR/NAR, dated 11/17/21, revealed no results found. During an interview on 07/20/22 at 4:55 p.m., BOM H confirmed she had done the EMR/NAR searches for listed staff, AD G, LVN C, LPN D, DON prior to 07/19/22, which was after the state surveyor's initial inquiry for those specific staff members. BOM H stated she was unaware of the EMR/NAR. She stated she came from home health and she did not have to run EMR/NAR checks. BOM H stated she had no clue what the EMR/NAR was until it was asked for during the survey. BOM H stated she was unaware the EMR/NAR had to be done upon hire and yearly thereafter. BOM H stated the facility went months without having a BOM, and she was never trained on the EMR/NAR, employed since 6/28/21 as the BOM. Bom H stated the Regional HR performs all the criminal check and license checks which I had observed for the license staff. BOM H stated she was already working on a spread sheet to keep track of hire dates and EMR/NARs that would need to be done after the surveyor asked her for the EMR/NAR. BOM H stated the risk of not running an EMR/NAR check could put the residents at risk due to an employee being hired that could hurt the resident; they would not know if they were unemployable. During an interview on 07/21/22 at 2:46 p.m., the Administrator stated he thought the EMR/NAR checks had already been completed for all staff and was unaware the checks were not previously done for AD G, LVN C, LPN D, DON. The Administrator stated BOM H, and Regional HR was responsible for making sure the checks were done for all staff. The Administrator stated he should know that, but he didn't.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 (Resident #19) residents reviewed for indwelling catheters. The facility failed to ensure Resident #19's indwelling catheter was secured to prevent pulling or tugging. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Record review of Resident #19's admission record dated 07/21/2022, indicated he was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was [AGE] years of age. Record review of Resident #19's MDS dated [DATE] indicated in part: Brief Interview Mental Status was a 15 indicating the resident was cognitively intact. His urinary incontinence was not rated and the resident had a catheter. Record review of Resident #19's care plan dated 03/18/2022 indicated in part: Focus: At risk for complications related to Indwelling Urinary Catheter. Goal: The resident would have no complications from use of his indwelling catheter such as pain, infection, obstruction. Interventions: Check catheter tubing for proper drainage and positioning. Record review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date 11/15/2021. During an observation and an interview on 07/21/22 at 09:55 AM revealed Resident #19 was in his bed, awake and alert. The resident's urinary catheter tubing was noted to be unsecured to his leg. The resident said the staff would at times secure it and at other times they would not. Resident #19 said he had a condition which caused him to have several bouts of loose stools and sometimes the catheter strap would get soiled, and the staff would remove it and not replace it. The resident said sometimes when he did not have it secured it would tug on his urethra and make it sore but not always. The resident said he would prefer for it to be secured if possible . During an interview on 07/21/22 at 02:12 PM CNA A said she had just placed a urinary catheter leg strap on Resident # 19's leg. She said she was not aware the resident did not have one and he was supposed to have one to prevent the catheter tubing from tugging. CNA A said if she noticed the resident did not have a leg strap, she would notify the nurse to get a strap for the resident . During an interview on 07/21/22 at 02:28 PM LVN B said it was all of the nursing staff's responsibility to make sure the residents that required a leg strap had one to prevent tugging of their urethras. LVN B said they would see that Resident #19 had a leg strap to secure his catheter. During an interview on 07/21/22 at 03:30 PM the DON said residents that required a leg strap to secure their catheter tubing were supposed to have one. The DON said if the residents did not have the leg strap it could lead to the catheter being dislodged. The DON said Resident #19 did not have a leg strap because it probably got soiled and the aides forgot to apply a clean one. The DON said it was the CNAs responsibility to report to the nurse if the resident was missing the strap and the nurse was supposed to check it every shift. During an interview on 07/21/22 at 03:36 PM the Administrator was made aware of the observation of Resident #19 without a catheter leg strap. The Administrator said it was the nursing staff's responsibility to make sure the residents had their catheters secured if they required one. The Administrator said it just got missed and they would see that the residents had one if they allowed them to place it on them as some would refuse to wear one or they would take it off. Record review of the facility's undated document titled urinary elimination provided by the DON indicated in part: Secure indwelling catheter with catheter strap or other securement device. Leave enough slack to allow leg movement. Attach securement device at tubing just above catheter bifurcation. Securing catheter reduces risk if urethral erosion, CAUTI (Catheter-Associated Urinary Tract Infections) or accidental catheter removal.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards of practice for 5 of 5 residents who were reviewed for respiratory care. The facility failed to: a) Keep resident's oxygen nasal cannula changed and protected from outside contamination when not use. b) Change out oxygen humidifiers weekly per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] c) Keep other respiratory equipment protected from outside contamination when not in use. SVN mask and [CONDITION(S)] masks were left out open to air. This deficient practice could place who had orders to receive respiratory therapy respiratory infections. Findings included: Observation on 5/18/21 during initial tour between 9:40 a.m. and 2:14 p.m. showed: room [ROOM NUMBER] [CONDITION(S)] machine mask not bagged, left open to air. room [ROOM NUMBER] B oxygen nasal cannula coiled neatly and hung on the oxygen machine. Review of Resident #9's Admission Record dated 5/20/21 documented he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #9's Order Summary Report dated 5/20/21 documented change oxygen tubing and water weekly on Sundays. Resident #9's oxygen cannula was not in use, and not bagged. The humidifier was dated 4/12. Resident #9 stated the last time he used the oxygen was a few days ago. The Resident had an SVN unit in his room that was unbagged and open to air. Observation on 5/19/21 at 9:59 AM of revealed his oxygen humidifier bottle had not been changed, the nasal cannula was still draped over the concentrator open to air, and the SVN mask was still laying out open to air. room [ROOM NUMBER] Oxygen was bagged , but not dated. The resident also had an SVN machine and the face mask was left on the dresser open to air and not dated. Interview on 05/20/21 at 9:37 AM with the DON, Administrator, and Corporate Nurse, the DON stated his expectation for concentrators was they being in the room with the tubing dated and bagged . He stated all tubing and humidifiers should be dated and changed weekly each Sunday. He stated he and the other nurses monitored to ensure it was done. They were informed they were not bagged, and some were not dated. They were informed Resident #9's was dated 4/19. The DON left to verify. At 10:36 AM the DON returned and stated the bottle of water did not expire and the tubing was dated. He did not mention the bagging of the nasal cannula. Surveyor requested the policy and any in-services held in the last three months regarding respiratory equipment. No in-services or policy about respiratory equipment was provided.

Based on observation, interview, and record review the facility failed to provide full visual privacy for 4 of 30 resident-use rooms (Rooms 37, 16, 53 or 57) reviewed for visual privacy. Resident rooms that were dually occupied did not have privacy curtains. room [ROOM NUMBER] did not have a door on the bathroom. This failure could place the residents at risk for loss of dignity and lower their quality of life. The findings included: Observation on 5/18/21 during initial tour between 9:40 a.m. and 2:14 p.m. revealed: room [ROOM NUMBER] had no privacy curtains at all in between beds and the public enterance. The resident stated the room had not had curtains since the resident became a resident. Observation and interview on 5/18/21 at 11:40 AM of room [ROOM NUMBER] showed the bathroom doorway did not have a door. It had a tension rod with a shower curtain hanging from it. The resident stated she did not know why she did not have a door on her bathroom. She shrugged and stated, just a curtain. Interview during the Resident Council Meeting on 5/19/21 at 1:51 p.m. the Residents stated she did not have a curtain in her room. She stated it bothered her sometimes because she had to go into bathroom to get changed and the staff did not always knock on the door. The resident stated she would like a curtain because she could get changed in privacy. The resident stated it made her feel bad. Another resident stated there was not a curtain in her room and she would like one because she knew eventually, she would get a roommate. Observation on 5/20/21 at 9:20 a.m. revealed: room [ROOM NUMBER] had no center curtain between the A-bed and the B-bed. room [ROOM NUMBER]'s had the long curtain that went across the foot of the residents' bed was missing. Interview on 5/20/21 at 9:37 AM the DON, Administrator and Corporate Consultant stated the expectation for the curtain was if nothing going on they be pushed back and if things were happening with other resident and roommate was in the room the expectation was the curtain be pulled for privacy. The DON stated monitoring was done during NA proficiency audit. The DON said that the charge nurses were to be monitoring on going to ensure the curtains were pulled for privacy. The Administrator stated there better not be any curtains missing. She stated they had gone over the requirement for curtains with the Housekeeping Department that if they took it down to be cleaned, they had to put one back up. She stated she did not know why the Housekeeping department missed it, or the CNAs or the nursing department. She stated the facility went over this in February. The Corporate Consultant asked if there were enough curtains and the DON stated there had been a stash in a spare room and they had done a room audit on every room. At that time the Corporate Consultant stated she could not find anything in the corporate policies that specifically addressed full visual privacy. Review of the facility's Nurse Aide Proficiency Audit, undated, documented Is complete privacy maintained: door closed, privacy and window curtains down, resident is covered during care. Review of the facility's policy on Resident Rights revised 6/2014 documented: it is the policy of the corporation that all residents have a right to a dignified existence, self-determination and communication with an access to people and services inside and outside the facility.

Based on observation and interview the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 7 (residents who were in their rooms during observation) of 37 residents reviewed for call lights: Residents call lights were on the floor, behind furniture, or coiled on the wall unit, out of reach while residents were in their room. This deficient practice could affect residents who need assistance with activities of daily living of not having needs met. Findings Include: Observations held during initial tour on 5/18/21 between 9:40 a.m. and 2:14 p.m. showed: room [ROOM NUMBER] B had possessions piled on top of her call light leaving it unable to be reached. The resident was in the attached bathroom and was unavailable for interview. Observation and interview with Resident #11 on 5/18/21 at 11:40 a.m. had both call lights coiled up neatly and hung from the call light unit. Resident #11 was present in the room and stated she never used the call light because it was out of reach. She stated she did not know why it was out of reach. room [ROOM NUMBER]'s call light was on the floor behind the night stand. Observation on 5/20/21 at 9:20 AM showed: room [ROOM NUMBER]'s call light was on the floor behind nightstand. room [ROOM NUMBER]'s call light was on the floor. During the Resident Council Meeting on 5/19/21 at 1:51 p.m. a resident stated they thought the staff would leave the call light out of reach on purpose or leave their call light coiled on the wall. Another resident stated if they needed help their roommate would have to push the button for them. A third resident stated the staff would sometimes chew you out for not asking for help but the resident could not because it was out of reach. Interview on 5/20/21 at 9:37 AM the DON, Administrator and Corporate Consultant stated the expectation for call lights were them to be answered as quickly as possible. They acknowledged the resident was unable to use the call light if it was hanging on the wall unit out of reach. The DON said that was not satisfactory. He stated there were multiple people able to check if the call lights were in reach. The DON stated, anyone can give a call light, it doesn't require a license. Surveyor requested the facility's policy and procedure on call lights and the Corporate Consultant stated there was policy regarding call lights (There was no record to review).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 staff sampled for infection control. The facility Administrator failed to ensure all staff wore face masks at all times. These failures placed residents at risk of exposure to COVID-19, which could result in illness, hospitalization , or death. Findings include: In an observation on 12/22/2020 at 1:00 PM, Dietary staff A entered the kitchen area through the back door of the facility without a face mask on with another employee present in the kitchen. In an observation on 12/22/2020 at 1:35 PM, Laundry staff B was in the laundry area and opened the door to the laundry area from the inside, and did not have a face mask on while she talked to other staff closer than 6 feet apart. During an interview on 12/22/2020 at 1:00 pm, Dietary cook A stated she did not wear a face mask at all times in the kitchen. The only time she wore a face mask was when a resident or another staff came to the closed kitchen door, and then stated if they do, I would put it (the mask) on to go talk to them, then take it back off. I'm a smoker, and it's hard to breathe with it on while I am cooking. She stated she had received training by the facility to wear a face mask at all times. She stated she was not medically exempt from wearing a face mask. During an interview on 12/22/2020 at 1:35 PM, Laundry staff B was inside the laundry room, opened the door, and did not have a mask on. She stated she had been eating lunch and had forgotten to put it on before she answered and opened the laundry room door. She then turned around, put the face mask on. She stated she had received training by the facility to wear a face mask at all times. During an interview with the Administrator on 12/22/2020 at 1:55 PM, she stated her expectation was for all staff in the facility to wear a face mask at all times, and all staff had been trained and in-serviced to wear a mask at all times to prevent the spread of COVID-19. She stated she was not aware Dietary cook A and Laundry worker B did not have face masks on. She stated these 2 employees did not have medical exemptions related to a face mask on file. During an interview on 12/22/2020 at 1:56 PM, the DON stated it was her expectation that all staff wear a face mask at all times, any other PPE required, and stated all staff have been in-serviced to wear a mask at all times to prevent the spread of COVID-19. In a review of documents, on 12/22/2020 at 3:30 PM, the Administrator produced an in-service training, dated 06/16/2020, titled, Wearing of Masks. The document revealed the signatures of Dietary staff A and Laundry staff B had attended and signed the signature sheet. The Administrator provided a facility policy, dated 11/6/2020, titled COVID-19 Education, Prevention and Response Guide. It stated (in part): team member should wear a face mask at all times; in compliance with current PPE requirements.

Based on observation, interview and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and complications associated with and indwelling catheter for 4 (Resident #1, Resident #2, Resident #3 and Resident #4) of 4 residents reviewed for catheters. The facility failed to provide appropriate treatment and indwelling catheter services consistent with professional standards of practice, for Resident #1 resulting in an emergency situation [MEDICAL CONDITION], physical harm, pain, and mental anguish and emotional distress for Resident #1. An Immediate Jeopardy (IJ) situation was identified on 6/18/20. While the IJ was lowered on 6/21/20, the facility remained out of compliance at a severity level of actual harm a scope of pattern, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This failure resulted in life threating situation resulting in physical and emotional harm for one resident with the potential for harm for the rest of the facility residents. Findings: Record review of Resident #1 face sheet dated 6/17/20 revealed a [AGE] year old male admitted on [DATE] with a most recent admission date of [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #1 electronic orders accessed on 6/12/20 revealed there were no orders to address his indwelling catheter, his [MEDICAL CONDITION], or pressure ulcers to his scrotum or penis. Resident #1 did have orders to Clean wounds to coccyx and ischium area with wound cleaner apply wet to dry dressing secure with abdominal pads and secure with tape every day one time a day for wound care with a start date of 4/11/2020 with no end date. Record review of skilled nursing facility/nursing home admissions orders for Resident #1 accessed on 6/16/20 revealed he was marked has not having a Foley catheter. The admission orders [REDACTED]. Record review of Resident #1 electronic care plan accessed on 6/12/20 revealed the following: Focus - Resident #1 has Indwelling Foley Catheter: [MEDICAL CONDITION] bladder. Chronic UTI's, Goal - He will show no signs and symptoms of urinary infection through review date. He will be/remain free from catheter-related trauma through review date., Interventions - Check tubing for kinks with routine care., Monitor for signs and symptoms of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter., Monitor/record/report to MD for signs and symptoms of a UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Initiated date of 8/16/19 and revised date of 6/12/20. Record review of Resident #1 most recent quarterly Minimum Data Set (MDS) after reentry from acute hospital on [DATE] revealed he had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 out of score of 15 which indicated an intact cognition. Resident #1 was totally dependent for activities of daily living (ADL) expect for eating where he required extensive assistance. Record review of Resident #1 admission MDS on 8/9/19 revealed Resident #1 had an indwelling catheter on admission. Record review of Resident #1 electronic progress notes accessed on 6/12/20 revealed the last time his foley catheter was addressed was 5/19/20 and it only addressed his catheter bag was in place. Record review of Resident #1 health notes dated 6/8/20 through 6/9/20 for his first 24 hours in a surrounding area hospital revealed the following: Clinical note from hospital Registered Nurse (RN) Resident #1 presented with a foley catheter that was malfunctioning and had to replaced with 2 liters output once old foley was replaced, patient developed acute kidney injury, [MEDICAL CONDITION] was pale and dusky in appearance, and possible concerns of neglect. Further review of hospital records revealed Resident #1 was [MEDICATION NAME] with an altered mental status, in acute [MEDICAL CONDITION], had a distended bladder with hydro[DIAGNOSES REDACTED] bilaterally, it was suspect the foley was obstructed and not in the correct position causing increased volume with backflow acute kidney failure and [MEDICAL CONDITION], mental status changes could be from uremic [MEDICAL CONDITION] and the patient is critically ill and survival is highly unlikely but not impossible. In an interview on 6/12/20 at 1:20 pm Certified Nurse Aide (CNA) A stated they empty bags once a shift and they do not record output. CNA A stated they used to record catheter output, but their kiosk changed, and it does not give them a place to document catheter output. In an interview on 6/15/20 at 10:47 am with License Vocational Nurse (LVN) A stated she cared for Resident #1 on the 5th, 6th, and 7th. LVN A stated on 5/7/20 the aides reported his cath was leaking but that LVN E took care of it. LVN A stated she has worked at the facility since 2/2020 and she has never changed the catheter tubing for Resident #1 but to get direction on his catheter needs she would access the orders, observe what appliances he already has in place, and call the physician to get orders if non-was available. In an interview on 6/15/20 at 12:15 pm the DON stated he could not find any orders related to Resident #1 indwelling catheter. The DON stated he cannot find orders for Resident #2 type and size of strait catheter used to self-catheterize. The DON stated he cannot find any order that addressed catheter care for Resident #3. The DON stated he cannot find orders addressing Resident #4 suprapubic catheter type or size or suprapubic catheter care. The DON stated they do not have an admissions nurse and it is up the nurse who is receiving a new/returning resident to ensure the accuracy of orders. The DON stated he can't say for certain if catheter changes had been done for Resident #1. The DON stated he has not done any training with nursing staff concerning changing, assessing, and monitoring of catheters, and he has not received any training in this area since becoming the DON in January of 2020. In an interview on 6/16/20 at 10:40 am Family B stated Resident #1 reported vomiting on 6/7/20 (Note: there was no notes addressing vomiting) and was requesting to see his doctor. Family B was present when Resident #1 was admitted to the hospital and she was shocked to see Resident #1's condition. Family B stated when Resident #1 was non-responsive and had a swollen hard abdomen. Family B stated when the foley catheter from the nursing home was removed Resident #1 had release of urine from his penis and it was a strong foul odor and a large amount filled with sediment, once the urine stopped flowing on its own they replaced the catheter and Resident #1 filled a bag of urine. Family B stated since Resident #1 admission to the hospital he has been able to come of life support. Family B stated Resident #1 has not been able to sleep and reports he is having nightmares of needing help and no one is coming to his aide. Resident #1 does not like his room door shut if he is alone in the room and this is a new behavior for him. Family B states Resident #1 is now having [MEDICAL CONDITION] and he has no previous history of [MEDICAL CONDITION] activity, and Resident #1 bladder is still not emptying correctly. In an interview on 6/16/20 at 1:59 pm LVA A stated she did not know of any vomiting for Resident #1. LVN A stated Resident #1 usually has [PHONE NUMBER] milliliter urine output for her shift but she never emptied his catheter bag on the 5th, 6th, and 7th on June 2020. In an interview on 6/16/20 at 2:10 pm Certified Medication Aide (CMA) A stated that CMA's do not deal with catheters or assess urine output. CMA A was certain aides empty catheter bags. CMA A stated she knew Resident #1 had vomiting some time during the week but was unsure when. CMA A stated Resident #1 told her he would throw up chunks about 10 hours after he ate. CMA A stated she did not report this to anyone and she told Resident #1 he needs to let a nurse or his doctor know. CMA A was unsure if Resident #1 report his illness to anyone else. In an interview of 6/16/20 at 3:07 pm the DON stated a CNA or a nurse can empty a catheter bag and they do not document output unless there is an order, and they have no guidelines on when to report findings for catheters or catheter output to the DON or doctor. In an interview on 6/16/20 at 7:50 pm Family A stated that before COVID-19 the facility had been taking good care of Resident #1 and she is not sure what has happened because she has not been able to see Resident #1. Family A stated her and Resident #1 spoke the night of 6/7/20 he sounded fine but told her he had been throwing up undigested food for the last couple of days and Family A though the facility had called his doctor for him. Family A stated the next time she heard anything was around 3 pm on 6/8/20 when she was told they called 911 for Resident #1. Family A was at the hospital when Resident #1 arrived and when she saw him she thought he was going to die. Family A stated Resident #1 looked dirty, his skin was grayish colored, his abdomen was hard and swollen, and he was not breathing right. Family A stated she overheard an emergency medical team member tell the nurse he had been having a change in mental status all day. Family A stated when they removed the urinary catheter urine just started to flow out and it smelled awful and it just kept coming. Family A stated when the flow stopped they replaced the catheter and he quickly filled another bag of urine. Family A stated his catheter bag from the facility was empty when he arrived at the hospital. Family A stated Resident #1 is now having nightmares of people not being able to help him and is scared to sleep and does not want his door shut. Family A stated Resident #1 is now having [MEDICAL CONDITION] that started when he was in the intensive care unit (ICU). Family A stated from what she understands this is all related to his catheter not functioning properly, Resident #1 is still very ill, and a full recovery is unknown. Family A was very emotional and crying during our phone conversation. In an interview on 6/17/20 at 10:15 am CMA B stated she worked with Resident #1 on the day before and the morning he got ill. CMA B stated the day before 6/8/20 he was ok and had no reports of vomiting. CMA B stated on the morning of 6/8/20 she went to his room to pass medication around 8:40 am and she had to touch him to get him to wake up, but he took his pills telling her he was sleeping. CMA B though noting of it because it was not unusual for Resident #1 to sleep late. CMA B stated around lunch she went to give him pills and he would not wake up and was cold to the touch at his arms, he moved his head but gave no verbal response. CMA B stated she informed LVN C of her findings at 1:00 pm and LVN C stated she would check on him. CMA B left for the day around 1:08 pm. CMA B stated for resident concerns they are to fill out a yellow Interact from and give it to the nurse and she acknowledged she did not complete this form on 6/8/20 for Resident #1. In an interview on 6/17/20 at 10:39 am LVN C stated CMA B had to give medication to Resident #1 on 6/8/20 at 11:00 am and she reported to her that he will not wake up enough to take medications. LVN C stated she checked on him about 5-10 minutes later and Resident #1 shook his and said he was just sleeping which was not unusual for him. LVN C states he had 250-300 milliliters of urine amber in color and cloudy in his catheter bag. LVN C told Resident #1 she was going to lunch and would check on him after her lunch. LVN C stated she took approximately a 35-minute lunch and when she returned to Resident #1 he was unresponsive, and she called emergency services. LVN C stated she had no report of vomiting over the weekend when she received report the morning of 6/8/20, but she had heard LVN E had repositioned Resident #1 catheter and that he had low output over the weekend. LVN C stated she had not emptied or replaced the catheter bag for Resident #1 that day. LVN C stated a CNA can empty catheter bags. LVN C stated she is unaware of any parameters of reporting for catheters or catheter output. LVN C stated she has not had any training from the facility on catheters. In an interview on 6/17/20 at 12:45 pm CNA C stated Resident #1 refused breakfast and lunch on 6/8/20 but it was not all that unusual for him to skip those meals as he is up more at night, but when he did not request his snuff by lunch she went to check on him and he did not look right. CNA C stated she told LVN C and LVN C told her that CMA B could not get him awake for medications. CNA C stated she went on lunch break around 2 pm and was back by 3 pm and Resident #1 was gone by then. CNA C stated she did not empty his catheter bag that day and assumed CNA D emptied his bag and she had seen only a little bit of urine in his bag that day. (Note, even though she did not empty Resident #1 catheter bag she noted on ADL care log she did). In an interview on 6/17/20 at 1:46 pm CNA A stated on 6/7/20 Resident #1 got a shower and they noticed he was a little distended in the abdomen and they got LVN E to adjust Resident #1 catheter tubing because he was having leakage. CNA A stated after LVN E adjusted his tubing there was urine flow and it looked normal for him. CNA A stated LVN A did wound care and Resident #1 wanted in his recliner. He ate some cheese sticks and crackers and a little later he vomited mucus. CNA A stated Resident #1 had at least 900 milliliters urine output on her shift. In an interview on 6/17/20 at 3:05 pm LVN E stated on the night of 6/7/20 she deflated and repositioned the catheter tubing for Resident #1 because the CNAs reported it was leaking. LVN E stated when she was done Resident #1 had no more leaking and urine return was seen in the catheter bag. LVN E did not check his orders before adjusting the catheter tubing stating she removed 10 milliliters from the bulb and returned 10 milliliters to the bulb, and she did not check to see when the last time his catheter had been changed. LVN E stated Resident #1 had output of urine after adjusting the tubing but did not know how much. LVN E stated Resident #1 has a history of blockages but that day it was just yellow urine. In an interview on 6/17/20 at 3:26 pm Dr. A stated Resident #1 catheter was to be changed monthly and as needed if clogged. Dr. A stated a urine output of less than 400 milliliters a day would be a concern. Dr. A stated if a blockage was to present the symptoms you would likely see would be mental status changes, nausea and vomiting, fever, chills, and complaints of back pain. Dr. A stated a decrease in output for Resident #1 was never reported to him, nor was the vomiting, all the facility told him was he was unresponsive. In an interview on 6/17/20 at 3:45 pm the DON stated if there was no order for a foley catheter change in a resident's chart and a nurse felt like it needed to be changed she would need to contact the doctor to get an order. The DON stated he does not have a set schedule of assessment for residents with catheters but he expects his nurses to know the residents well enough to know when there is a change in a resident. The DON stated if a resident was to report vomiting to an CMA or CNA he expects them to let the charge nurse for that side know. In an interview on 6/18/20 at 9:15 am the DON stated he could not find any orders even from Resident #1 admission that addressed his indwelling catheter or [MEDICAL CONDITION]. In an interview on 6/19/20 at 1:05 pm Dr. B the hospitalist stated when Resident #1 left their hospital in March of 2020 he left with a normal bladder. Dr. B stated when he returned to their hospital on [DATE] his foley catheter was jammed into the prostate causing obstruction and improper drainage of his foley catheter, which lead to infection; that lead [MEDICAL CONDITION]; which also resulted in a rupture of his bladder causing him to develop a diverticulum next to the bladder that is larger than his bladder; leaving his bladder distorted beyond use and possibly to an extent of not being saved. Dr. B stated if the bladder cannot be saved the providers are at a loss as how to treat him given his large pressure wounds and already having a [MEDICAL CONDITION] every treatment option for Resident #1 carries a huge risk or just may not be possible. Record review of the https://www.cdc.gov/dengue/training/cme/ccm/page .html Centers for Disease Control and Prevention CDC website accessed on 6/23/20 revealed normal urine output for an average adult is 0.5 to 1.5 cubic centimeters(cc)/kilogram(kg)/hour. Given this formula Resident #1 would have a normal output of 28.44cc to 85.32cc per hour giving him an average output of 56.88cc per hour. Resident #1 average output for a 24-hour period should be 1,365.12cc a day. Record review of hospital records from admission on 6/8/20 revealed Resident #1 had spontaneous drainage of urine when the nursing home catheter was removed and when his catheter was replaced he drained 1 liter of urine into a catheter bag. It is documented he drained 2 liters of urine. (Note 2 liters is equal to 2000cc and Resident #1 average urine output for a 24-hour period is 1,365.12cc a day. The hospital drained two days' worth of urine from Resident #1). Record review of Resident #2 face sheet revealed a [AGE] year old female admitted on [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #2 electronic orders accessed on 6/15/20 revealed an order stating Resident #2 may self-cath but no orders addressing the size or type catheter needed for Resident #2 to self-cath. Record review of Resident #2 electronic care plan accessed on 6/16/20 revealed the following: Focus - I am at risk for Urinary Tract Infection, related to self-cath/Intermittent with 14french non-latex catheter due to: Neuromuscular Dysfunctional bladder. With [DIAGNOSES REDACTED]. Interventions - Encourage fluids unless contraindicated., Observe and report signs and symptoms of UTI: changes in color, odor or consistency or urine, dysuria, frequency, fever, pain. Initiated on 2/13/20 with a revision date of 6/16/20 prior to revision on 6/16/20 this care plan did not address the size and type of catheter Resident one utilized to self-cath. Record review of Resident #2 most recent quarterly Minimum Data Set (MDS) revealed Resident #2 could clearly make herself understood with the ability to understand others. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated a intact cognition. Resident #2 had no history of rejecting evaluation or care for the quarter and only needed supervision for ADLs. The MDS also indicated Resident #2 had a for intermittent catheterization. Record review of Resident #3 face sheet dated 6/17/20 revealed a [AGE] year old male admitted on [DATE] with a most recent admission date of [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #3 electronic orders accessed on 6/12/20 revealed an order for [REDACTED]. Record review of Resident #3 electronic care plan accessed on 6/12/20 revealed the following: Focus - I use an indwelling foley catheter related to neuromuscular dysfunction of bladder. I have a history of [MEDICAL CONDITION] and frequent UTI's. (18fr5cc ribbed balloon Carson Model Coude Tip), Goal - I will not experience any unidentified complications related to catheter use thru next review date, Interventions - Change catheter tubing/bag per protocol/orders., Irrigate foley cath with Acetic acid solution to decrease UTI's as per order., Observe catheter tubing for kinks or twists in tubing., Observe for acute behavioral changes that may indicate UTI., Position catheter tubing below level of bladder., Provide catheter care every shift., Refer to urologist for evaluation as needed., Secure tubing to thigh to prevent pulling. Record review of Resident #3 most recent quarterly Minimum Data Set (MDS) revealed had unclear speech but could usually make himself understood and had the ability to understand others. Resident #3 had a Brief Interview for Mental Status (BIMS) of score of 12 out of 15 which indicated a moderately impaired cognition. Resident #3 did not have any rejection of evaluation or care for the quarter. Resident #3 needed extensive assistance with all ADLs except for eating which required limited assistance. Resident #3 also required an indwelling catheter. Record review of Resident #3 electronic progress notes and Medication Administration Record [REDACTED]. Record review of Resident #4 face sheet dated 6/17/20 revealed a [AGE] year old female admitted on [DATE] with a most recent admission date of [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #4 electronic orders accessed on 6/12/20 revealed Resident #4 had no current orders addressing her suprapubic catheter placed 2/26/20 or her percutaneous endoscopic gastrostomy (PEG) tube, date of placement is uncertain given chart review. There was orders to address her PEG tube feedings. Record review of Resident #4 electronic care plan accessed on 6/12/20 revealed no care planning for her suprapubic catheter but there was care planning for an indwelling catheter initiated on 3/26/19 but not revised to reflect her suprapubic catheter. Resident #4 did have her PEG tube addressed in her care plan with the following: Focus - Dependent on tube feeding due to: Dysphagia. I am at risk for weight loss and malnutrition. I can have pleasure feedings as requested. I am aware of the choking and aspiration risks. I request to use a pacifier because I believe it strengthens the muscles for swallowing and keeps my mouth from being dry. I have 1 can of Jevita 1 time daily along with my tube feeding., Goal - Maintain nutritional status and body weight., No S/S of aspiration., Will be free from GI Discomfort related to Tube Feeding., Will be free from S/S of complications due to presence of feeding tube., Will be free from S/SX of dehydration.; Interventions - Check tube placement every feeding., Elevate HOB at least 30-45 degrees during and for 30-60 minutes after feeding., Enteral formula and feedings as ordered., Hold feeding if residual is above 50 ml., Monitor lab data as available., Monitor vitals and breathe sounds for S/S of aspiration., Monthly weights., Observe and report skin irritation at the tube site., Observe for S/SX of intolerance to TF: gastic residuals, abdominal distention, vomiting, loose stools, nausea, nasal pain, fever, dehydration., Refer to RD for assessment as needed., Water flushes as ordered. Initiated on 3/27/20 and revised on 4/17/20. Record review of Resident #4 most recent quarterly Minimum Data Set (MDS) revealed she had unclear speech, could sometimes make herself understood, and could understand others. Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated an intact cognition. Resident #4 had rejected evaluation or care for 1 to 3 days in the last quarter and was totally dependent for all ADLS. Resident #4 utilized an indwelling catheter The DON could not provide any policies related to indwelling or suprapubic catheters relating to care, assessment, and monitoring, but was able to provide a Performance Checklist for Skills addressing all them with a date of 2018: Care and Removal of an Indwelling Catheter . 3. Assessed need for catheter care a. Observed urinary output and urine characteristics . 4. Assessed need for catheter removal: a. Reviewed patient's medical, noted length of time catheter was in place . c. Assessed urine color, clarity, odor, and amount; noted any urethral discharge, irritation, or trauma . 9. Checked drainage tubing and bag routinely for proper securement and positioning . Recording and Reporting 1. Recorded time for catheter care and appearance of urine, described condition of meatus and catheter. 2. Recorded and reported time of catheter removal; amount of water removed from balloon; condition of urethral meatus and catheter; and time, amount, and characteristic of first voided urine. Suprapubic Catheter Care, Assessment . 2. Assessed urine in drainage bag for amount, clarity, color, odor, and sediment . Evaluation . 3. Observed catheter insertion site for [DIAGNOSES REDACTED], [MEDICAL CONDITION], discharge, and tenderness; checked dressing at least every 8 hours . Recording and Reporting 1. Recorded and reported character of urine, type of dressing, and patient's comfort level. 2. Recorded urine output on Input and Output (I&0) flow sheet properly. Record review of CDC GUIDELINE FOR PREVENTION OF CATHETERASSOCIATED URINARY TRACT INFECTIONS dated 2009 electronically accessed on 6/19/20 revealed the following: . II. Proper Techniques for Urinary Catheter Insertion . B. Ensure that only properly trained persons who know correct technique of aseptic catheter insertion and maintenance are given this responsibility . III. Proper Techniques for Urinary Catheter Maintenance . B. Maintain unobstructed urine flow . E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . G. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate . Management of Obstruction Q. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. Record review of U.S. National Library of Medicine Medline Plus electronically accessed on 6/19/20 revealed the following: Indwelling catheter care . Cleaning the Catheter, follow these steps two times a day to keep your catheter clean and free of germs that can cause infection: Wash your hands well with soap and water. Be sure to clean between your fingers and under your nails. Change the warm water in your container if you are using a container and not a sink. Wet the second washcloth with warm water and soap it up. Gently hold the catheter and begin washing the end near your vagina or penis. Move slowly down the catheter (away from your body) to clean it. NEVER clean from the bottom of the catheter toward your body. Gently dry the tubing with the second clean towel . When to Call the Doctor . A urinary tract infection is the most common problem for people with an indwelling urinary catheter. Call your health care provider if you have signs of an infection, such as: Pain around your sides or lower back. Urine smells bad, or it is cloudy or a different color. Fever or chills. A burning sensation or pain in your bladder or pelvis. Discharge or drainage from around the catheter where it is inserted into your body. You do not feel like yourself. Feeling tired, achy, and have a hard time focusing. Also call your provider if: Your urine bag is filling up quickly, and you have an increase in urine. Urine is leaking around the catheter. You notice blood in your urine. Your catheter seems blocked and not draining. You notice grit or stones in your urine. You have pain near the catheter. You have any concerns about your catheter.; Suprapubic catheter care . Caring for Your Skin Near your Catheter . Check the catheter site a few times a day. Check for redness, pain, swelling, or pus. Wash the area around your catheter every day with mild soap and water. Gently pat it dry . Changing Your Catheter, you will need to change the catheter about every 4 to 6 weeks. Always wash your hands with soap and water before changing it . When to Call the Doctor . You are having trouble changing your catheter or emptying your bag. Your bag is filling up quickly, and you have an increase in urine. You are leaking urine. You notice blood in your urine a few days after you leave the hospital. You are bleeding at the insertion site after you change your catheter, and it does not stop within 24 hours. Your catheter seems blocked. You notice grit or stones in your urine. Your supplies do not seem to be working (balloon is not inflating or other problems). You notice a smell or change in color in your urine, or your urine is cloudy. You have signs of infection (a burning sensation when you urinate, fever, or chills).; High potassium level ([MEDICAL CONDITION]) . Causes, Potassium is needed for cells to function properly. You get potassium through food. The kidneys remove excess potassium through the urine to keep a proper balance of this mineral in the body. If your kidneys are not working well, they may not be able to remove the proper amount of potassium. As a result, potassium can build up in the blood . When to Contact a Medical Professional Call your provider right away if you have vomiting, palpitations, weakness, or difficulty breathing . The Administrator and DON was notified on 6/18/20 at 3:25 pm and Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the Administrator and signed at 3:25 pm. The facility's Plan of Removal was accepted on 6/20/20 at 3:07 pm and revealed the following: Immediate interventions: 1 identified male resident with indwelling urinary catheter, pressure ulcers, and [MEDICAL CONDITION] remains hospitalized Conducted assessments on current identified residents: o 1 male resident with an indwelling urinary catheter and no indication of signs or symptoms related catheter-associated urinary tract infections (CAUTIs) were observed o 1 female resident with a suprapubic catheter and no indication of signs or symptoms related catheter-associated urinary tract infections (CAUTIs) were observed o 1 female resident requiring straight catheter and no indication of signs or symptoms of urinary tract infections (UTIs) or trauma to urinary meatus was observed o 1 female reside(TRUNCATED)

Based on observation, interview and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan regarding appropriate treatment and services to prevent urinary tract infections and complications associated with indwelling catheters for 4 (Resident #1, Resident #2, Resident #3 and Resident #4) of 4 residents reviewed for catheters. The facility failed to provide appropriate treatment and indwelling catheter services consistent with professional standards of practice, for Resident #1 resulting in an emergency situation [MEDICAL CONDITION], physical harm, pain, and mental anguish and emotional distress for Resident #1. An Immediate Jeopardy (IJ) situation was identified on 6/18/20. While the IJ was lowered on 6/21/20, the facility remained out of compliance at a severity level of actual harm a scope of pattern, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This failure resulted in life threating situation resulting in physical and emotional harm for one resident with the potential for harm for the rest of the facility residents. Findings: Record review of Resident #1 face sheet dated 6/17/20 revealed a [AGE] year old male admitted on [DATE] with a most recent admission date of [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #1 electronic orders accessed on 6/12/20 revealed there were no orders to address his indwelling catheter, his [MEDICAL CONDITION], or pressure ulcers to his scrotum or penis. Resident #1 did have orders to Clean wounds to coccyx and ischium area with wound cleaner apply wet to dry dressing secure with abdominal pads and secure with tape every day one time a day for wound care with a start date of 4/11/2020 with no end date. Record review of skilled nursing facility/nursing home admissions orders for Resident #1 accessed on 6/16/20 revealed he was marked has not having a Foley catheter. The admission orders [REDACTED]. Record review of Resident #1 electronic care plan accessed on 6/12/20 revealed the following: Focus - Resident #1 has Indwelling Foley Catheter: [MEDICAL CONDITION] bladder. Chronic UTI's, Goal - He will show no signs and symptoms of urinary infection through review date. He will be/remain free from catheter-related trauma through review date., Interventions - Check tubing for kinks with routine care., Monitor for signs and symptoms of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter., Monitor/record/report to MD for signs and symptoms of a UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Initiated date of 8/16/19 and revised date of 6/12/20. Record review of Resident #1 most recent quarterly Minimum Data Set (MDS) after reentry from acute hospital on [DATE] revealed he had the ability to express ideas and wants and was able to understand others clearly. Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 out of score of 15 which indicated an intact cognition. Resident #1 was totally dependent for activities of daily living (ADL) expect for eating where he required extensive assistance. Record review of Resident #1 admission MDS on 8/9/19 revealed Resident #1 had an indwelling catheter on admission. Record review of Resident #1 electronic progress notes accessed on 6/12/20 revealed the last time his foley catheter was addressed was 5/19/20 and it only addressed his catheter bag was in place. Record review of Resident #1 health notes dated 6/8/20 through 6/9/20 for his first 24 hours in a surrounding area hospital revealed the following: Clinical note from hospital Registered Nurse (RN) Resident #1 presented with a foley catheter that was malfunctioning and had to replaced with 2 liters output once old foley was replaced, patient developed acute kidney injury, [MEDICAL CONDITION] was pale and dusky in appearance, and possible concerns of neglect. Further review of hospital records revealed Resident #1 was [MEDICATION NAME] with an altered mental status, in acute [MEDICAL CONDITION], had a distended bladder with hydro[DIAGNOSES REDACTED] bilaterally, it was suspect the foley was obstructed and not in the correct position causing increased volume with backflow acute kidney failure and [MEDICAL CONDITION], mental status changes could be from uremic [MEDICAL CONDITION] and the patient is critically ill and survival is highly unlikely but not impossible. In an interview on 6/12/20 at 1:20 pm Certified Nurse Aide (CNA) A stated they empty bags once a shift and they do not record output. CNA A stated they used to record catheter output, but their kiosk changed, and it does not give them a place to document catheter output. In an interview on 6/15/20 at 10:47 am with License Vocational Nurse (LVN) A stated she cared for Resident #1 on the 5th, 6th, and 7th. LVN A stated on 5/7/20 the aides reported his cath was leaking but that LVN E took care of it. LVN A stated she has worked at the facility since 2/2020 and she has never changed the catheter tubing for Resident #1 but to get direction on his catheter needs she would access the orders, observe what appliances he already has in place, and call the physician to get orders if non-was available. In an interview on 6/15/20 at 12:15 pm the DON stated he could not find any orders related to Resident #1 indwelling catheter. The DON stated he cannot find orders for Resident #2 type and size of strait catheter used to self-catheterize. The DON stated he cannot find any order that addressed catheter care for Resident #3. The DON stated he cannot find orders addressing Resident #4 suprapubic catheter type or size or suprapubic catheter care. The DON stated they do not have an admissions nurse and it is up the nurse who is receiving a new/returning resident to ensure the accuracy of orders. The DON stated he can't say for certain if catheter changes had been done for Resident #1. The DON stated he has not done any training with nursing staff concerning changing, assessing, and monitoring of catheters, and he has not received any training in this area since becoming the DON in January of 2020. In an interview on 6/16/20 at 10:40 am Family B stated Resident #1 reported vomiting on 6/7/20 (Note: there was no notes addressing vomiting) and was requesting to see his doctor. Family B was present when Resident #1 was admitted to the hospital and she was shocked to see Resident #1's condition. Family B stated when Resident #1 was non-responsive and had a swollen hard abdomen. Family B stated when the foley catheter from the nursing home was removed Resident #1 had release of urine from his penis and it was a strong foul odor and a large amount filled with sediment, once the urine stopped flowing on its own they replaced the catheter and Resident #1 filled a bag of urine. Family B stated since Resident #1 admission to the hospital he has been able to come of life support. Family B stated Resident #1 has not been able to sleep and reports he is having nightmares of needing help and no one is coming to his aide. Resident #1 does not like his room door shut if he is alone in the room and this is a new behavior for him. Family B states Resident #1 is now having [MEDICAL CONDITION] and he has no previous history of [MEDICAL CONDITION] activity, and Resident #1 bladder is still not emptying correctly. In an interview on 6/16/20 at 1:59 pm LVA A stated she did not know of any vomiting for Resident #1. LVN A stated Resident #1 usually has [PHONE NUMBER] milliliter urine output for her shift but she never emptied his catheter bag on the 5th, 6th, and 7th on June 2020. In an interview on 6/16/20 at 2:10 pm Certified Medication Aide (CMA) A stated that CMA's do not deal with catheters or assess urine output. CMA A was certain aides empty catheter bags. CMA A stated she knew Resident #1 had vomiting some time during the week but was unsure when. CMA A stated Resident #1 told her he would throw up chunks about 10 hours after he ate. CMA A stated she did not report this to anyone and she told Resident #1 he needs to let a nurse or his doctor know. CMA A was unsure if Resident #1 report his illness to anyone else. In an interview of 6/16/20 at 3:07 pm the DON stated a CNA or a nurse can empty a catheter bag and they do not document output unless there is an order, and they have no guidelines on when to report findings for catheters or catheter output to the DON or doctor. In an interview on 6/16/20 at 7:50 pm Family A stated that before COVID-19 the facility had been taking good care of Resident #1 and she is not sure what has happened because she has not been able to see Resident #1. Family A stated her and Resident #1 spoke the night of 6/7/20 he sounded fine but told her he had been throwing up undigested food for the last couple of days and Family A though the facility had called his doctor for him. Family A stated the next time she heard anything was around 3 pm on 6/8/20 when she was told they called 911 for Resident #1. Family A was at the hospital when Resident #1 arrived and when she saw him she thought he was going to die. Family A stated Resident #1 looked dirty, his skin was grayish colored, his abdomen was hard and swollen, and he was not breathing right. Family A stated she overheard an emergency medical team member tell the nurse he had been having a change in mental status all day. Family A stated when they removed the urinary catheter urine just started to flow out and it smelled awful and it just kept coming. Family A stated when the flow stopped they replaced the catheter and he quickly filled another bag of urine. Family A stated his catheter bag from the facility was empty when he arrived at the hospital. Family A stated Resident #1 is now having nightmares of people not being able to help him and is scared to sleep and does not want his door shut. Family A stated Resident #1 is now having [MEDICAL CONDITION] that started when he was in the intensive care unit (ICU). Family A stated from what she understands this is all related to his catheter not functioning properly, Resident #1 is still very ill, and a full recovery is unknown. Family A was very emotional and crying during our phone conversation. In an interview on 6/17/20 at 10:15 am CMA B stated she worked with Resident #1 on the day before and the morning he got ill. CMA B stated the day before 6/8/20 he was ok and had no reports of vomiting. CMA B stated on the morning of 6/8/20 she went to his room to pass medication around 8:40 am and she had to touch him to get him to wake up, but he took his pills telling her he was sleeping. CMA B though noting of it because it was not unusual for Resident #1 to sleep late. CMA B stated around lunch she went to give him pills and he would not wake up and was cold to the touch at his arms, he moved his head but gave no verbal response. CMA B stated she informed LVN C of her findings at 1:00 pm and LVN C stated she would check on him. CMA B left for the day around 1:08 pm. CMA B stated for resident concerns they are to fill out a yellow Interact from and give it to the nurse and she acknowledged she did not complete this form on 6/8/20 for Resident #1. In an interview on 6/17/20 at 10:39 am LVN C stated CMA B had to give medication to Resident #1 on 6/8/20 at 11:00 am and she reported to her that he will not wake up enough to take medications. LVN C stated she checked on him about 5-10 minutes later and Resident #1 shook his and said he was just sleeping which was not unusual for him. LVN C states he had 250-300 milliliters of urine amber in color and cloudy in his catheter bag. LVN C told Resident #1 she was going to lunch and would check on him after her lunch. LVN C stated she took approximately a 35-minute lunch and when she returned to Resident #1 he was unresponsive, and she called emergency services. LVN C stated she had no report of vomiting over the weekend when she received report the morning of 6/8/20, but she had heard LVN E had repositioned Resident #1 catheter and that he had low output over the weekend. LVN C stated she had not emptied or replaced the catheter bag for Resident #1 that day. LVN C stated a CNA can empty catheter bags. LVN C stated she is unaware of any parameters of reporting for catheters or catheter output. LVN C stated she has not had any training from the facility on catheters. In an interview on 6/17/20 at 12:45 pm CNA C stated Resident #1 refused breakfast and lunch on 6/8/20 but it was not all that unusual for him to skip those meals as he is up more at night, but when he did not request his snuff by lunch she went to check on him and he did not look right. CNA C stated she told LVN C and LVN C told her that CMA B could not get him awake for medications. CNA C stated she went on lunch break around 2 pm and was back by 3 pm and Resident #1 was gone by then. CNA C stated she did not empty his catheter bag that day and assumed CNA D emptied his bag and she had seen only a little bit of urine in his bag that day. (Note, even though she did not empty Resident #1 catheter bag she noted on ADL care log she did). In an interview on 6/17/20 at 1:46 pm CNA A stated on 6/7/20 Resident #1 got a shower and they noticed he was a little distended in the abdomen and they got LVN E to adjust Resident #1 catheter tubing because he was having leakage. CNA A stated after LVN E adjusted his tubing there was urine flow and it looked normal for him. CNA A stated LVN A did wound care and Resident #1 wanted in his recliner. He ate some cheese sticks and crackers and a little later he vomited mucus. CNA A stated Resident #1 had at least 900 milliliters urine output on her shift. In an interview on 6/17/20 at 3:05 pm LVN E stated on the night of 6/7/20 she deflated and repositioned the catheter tubing for Resident #1 because the CNAs reported it was leaking. LVN E stated when she was done Resident #1 had no more leaking and urine return was seen in the catheter bag. LVN E did not check his orders before adjusting the catheter tubing stating she removed 10 milliliters from the bulb and returned 10 milliliters to the bulb, and she did not check to see when the last time his catheter had been changed. LVN E stated Resident #1 had output of urine after adjusting the tubing but did not know how much. LVN E stated Resident #1 has a history of blockages but that day it was just yellow urine. In an interview on 6/17/20 at 3:26 pm Dr. A stated Resident #1 catheter was to be changed monthly and as needed if clogged. Dr. A stated a urine output of less than 400 milliliters a day would be a concern. Dr. A stated if a blockage was to present the symptoms you would likely see would be mental status changes, nausea and vomiting, fever, chills, and complaints of back pain. Dr. A stated a decrease in output for Resident #1 was never reported to him, nor was the vomiting, all the facility told him was he was unresponsive. In an interview on 6/17/20 at 3:45 pm the DON stated if there was no order for a foley catheter change in a resident's chart and a nurse felt like it needed to be changed she would need to contact the doctor to get an order. The DON stated he does not have a set schedule of assessment for residents with catheters but he expects his nurses to know the residents well enough to know when there is a change in a resident. The DON stated if a resident was to report vomiting to an CMA or CNA he expects them to let the charge nurse for that side know. In an interview on 6/18/20 at 9:15 am the DON stated he could not find any orders even from Resident #1 admission that addressed his indwelling catheter or [MEDICAL CONDITION]. In an interview on 6/19/20 at 1:05 pm Dr. B the hospitalist stated when Resident #1 left their hospital in March of 2020 he left with a normal bladder. Dr. B stated when he returned to their hospital on [DATE] his foley catheter was jammed into the prostate causing obstruction and improper drainage of his foley catheter, which lead to infection; that lead [MEDICAL CONDITION]; which also resulted in a rupture of his bladder causing him to develop a diverticulum next to the bladder that is larger than his bladder; leaving his bladder distorted beyond use and possibly to an extent of not being saved. Dr. B stated if the bladder cannot be saved the providers are at a loss as how to treat him given his large pressure wounds and already having a [MEDICAL CONDITION] every treatment option for Resident #1 carries a huge risk or just may not be possible. Record review of the https://www.cdc.gov/dengue/training/cme/ccm/page .html Centers for Disease Control and Prevention CDC website accessed on 6/23/20 revealed normal urine output for an average adult is 0.5 to 1.5 cubic centimeters(cc)/kilogram(kg)/hour. Given this formula Resident #1 would have a normal output of 28.44cc to 85.32cc per hour giving him an average output of 56.88cc per hour. Resident #1 average output for a 24-hour period should be 1,365.12cc a day. Record review of hospital records from admission on 6/8/20 revealed Resident #1 had spontaneous drainage of urine when the nursing home catheter was removed and when his catheter was replaced he drained 1 liter of urine into a catheter bag. It is documented he drained 2 liters of urine. (Note 2 liters is equal to 2000cc and Resident #1 average urine output for a 24-hour period is 1,365.12cc a day. The hospital drained two days' worth of urine from Resident #1). Record review of Resident #2 face sheet revealed a [AGE] year old female admitted on [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #2 electronic orders accessed on 6/15/20 revealed an order stating Resident #2 may self-cath but no orders addressing the size or type catheter needed for Resident #2 to self-cath. Record review of Resident #2 electronic care plan accessed on 6/16/20 revealed the following: Focus - I am at risk for Urinary Tract Infection, related to self-cath/Intermittent with 14french non-latex catheter due to: Neuromuscular Dysfunctional bladder. With [DIAGNOSES REDACTED]. Interventions - Encourage fluids unless contraindicated., Observe and report signs and symptoms of UTI: changes in color, odor or consistency or urine, dysuria, frequency, fever, pain. Initiated on 2/13/20 with a revision date of 6/16/20 prior to revision on 6/16/20 this care plan did not address the size and type of catheter Resident one utilized to self-cath. Record review of Resident #2 most recent quarterly Minimum Data Set (MDS) revealed Resident #2 could clearly make herself understood with the ability to understand others. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated a intact cognition. Resident #2 had no history of rejecting evaluation or care for the quarter and only needed supervision for ADLs. The MDS also indicated Resident #2 had a for intermittent catheterization. Record review of Resident #3 face sheet dated 6/17/20 revealed a [AGE] year old male admitted on [DATE] with a most recent admission date of [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #3 electronic orders accessed on 6/12/20 revealed an order for [REDACTED]. Record review of Resident #3 electronic care plan accessed on 6/12/20 revealed the following: Focus - I use an indwelling foley catheter related to neuromuscular dysfunction of bladder. I have a history of [MEDICAL CONDITION] and frequent UTI's. (18fr5cc ribbed balloon Carson Model Coude Tip), Goal - I will not experience any unidentified complications related to catheter use thru next review date, Interventions - Change catheter tubing/bag per protocol/orders., Irrigate foley cath with Acetic acid solution to decrease UTI's as per order., Observe catheter tubing for kinks or twists in tubing., Observe for acute behavioral changes that may indicate UTI., Position catheter tubing below level of bladder., Provide catheter care every shift., Refer to urologist for evaluation as needed., Secure tubing to thigh to prevent pulling. Record review of Resident #3 most recent quarterly Minimum Data Set (MDS) revealed had unclear speech but could usually make himself understood and had the ability to understand others. Resident #3 had a Brief Interview for Mental Status (BIMS) of score of 12 out of 15 which indicated a moderately impaired cognition. Resident #3 did not have any rejection of evaluation or care for the quarter. Resident #3 needed extensive assistance with all ADLs except for eating which required limited assistance. Resident #3 also required an indwelling catheter. Record review of Resident #3 electronic progress notes and Medication Administration Record [REDACTED]. Record review of Resident #4 face sheet dated 6/17/20 revealed a [AGE] year old female admitted on [DATE] with a most recent admission date of [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #4 electronic orders accessed on 6/12/20 revealed Resident #4 had no current orders addressing her suprapubic catheter placed 2/26/20 or her percutaneous endoscopic gastrostomy (PEG) tube, date of placement is uncertain given chart review. There was orders to address her PEG tube feedings. Record review of Resident #4 electronic care plan accessed on 6/12/20 revealed no care planning for her suprapubic catheter but there was care planning for an indwelling catheter initiated on 3/26/19 but not revised to reflect her suprapubic catheter. Resident #4 did have her PEG tube addressed in her care plan with the following: Focus - Dependent on tube feeding due to: Dysphagia. I am at risk for weight loss and malnutrition. I can have pleasure feedings as requested. I am aware of the choking and aspiration risks. I request to use a pacifier because I believe it strengthens the muscles for swallowing and keeps my mouth from being dry. I have 1 can of Jevita 1 time daily along with my tube feeding., Goal - Maintain nutritional status and body weight., No S/S of aspiration., Will be free from GI Discomfort related to Tube Feeding., Will be free from S/S of complications due to presence of feeding tube., Will be free from S/SX of dehydration.; Interventions - Check tube placement every feeding., Elevate HOB at least 30-45 degrees during and for 30-60 minutes after feeding., Enteral formula and feedings as ordered., Hold feeding if residual is above 50 ml., Monitor lab data as available., Monitor vitals and breathe sounds for S/S of aspiration., Monthly weights., Observe and report skin irritation at the tube site., Observe for S/SX of intolerance to TF: gastic residuals, abdominal distention, vomiting, loose stools, nausea, nasal pain, fever, dehydration., Refer to RD for assessment as needed., Water flushes as ordered. Initiated on 3/27/20 and revised on 4/17/20. Record review of Resident #4 most recent quarterly Minimum Data Set (MDS) revealed she had unclear speech, could sometimes make herself understood, and could understand others. Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated an intact cognition. Resident #4 had rejected evaluation or care for 1 to 3 days in the last quarter and was totally dependent for all ADLS. Resident #4 utilized an indwelling catheter The DON could not provide any policies related to indwelling or suprapubic catheters relating to care, assessment, and monitoring, but was able to provide a Performance Checklist for Skills addressing all them with a date of 2018: Care and Removal of an Indwelling Catheter . 3. Assessed need for catheter care a. Observed urinary output and urine characteristics . 4. Assessed need for catheter removal: a. Reviewed patient's medical, noted length of time catheter was in place . c. Assessed urine color, clarity, odor, and amount; noted any urethral discharge, irritation, or trauma . 9. Checked drainage tubing and bag routinely for proper securement and positioning . Recording and Reporting 1. Recorded time for catheter care and appearance of urine, described condition of meatus and catheter. 2. Recorded and reported time of catheter removal; amount of water removed from balloon; condition of urethral meatus and catheter; and time, amount, and characteristic of first voided urine. Suprapubic Catheter Care, Assessment . 2. Assessed urine in drainage bag for amount, clarity, color, odor, and sediment . Evaluation . 3. Observed catheter insertion site for [DIAGNOSES REDACTED], [MEDICAL CONDITION], discharge, and tenderness; checked dressing at least every 8 hours . Recording and Reporting 1. Recorded and reported character of urine, type of dressing, and patient's comfort level. 2. Recorded urine output on Input and Output (I&0) flow sheet properly. Record review of CDC GUIDELINE FOR PREVENTION OF CATHETERASSOCIATED URINARY TRACT INFECTIONS dated 2009 electronically accessed on 6/19/20 revealed the following: . II. Proper Techniques for Urinary Catheter Insertion . B. Ensure that only properly trained persons who know correct technique of aseptic catheter insertion and maintenance are given this responsibility . III. Proper Techniques for Urinary Catheter Maintenance . B. Maintain unobstructed urine flow . E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . G. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate . Management of Obstruction Q. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. Record review of U.S. National Library of Medicine Medline Plus electronically accessed on 6/19/20 revealed the following: Indwelling catheter care . Cleaning the Catheter, follow these steps two times a day to keep your catheter clean and free of germs that can cause infection: Wash your hands well with soap and water. Be sure to clean between your fingers and under your nails. Change the warm water in your container if you are using a container and not a sink. Wet the second washcloth with warm water and soap it up. Gently hold the catheter and begin washing the end near your vagina or penis. Move slowly down the catheter (away from your body) to clean it. NEVER clean from the bottom of the catheter toward your body. Gently dry the tubing with the second clean towel . When to Call the Doctor . A urinary tract infection is the most common problem for people with an indwelling urinary catheter. Call your health care provider if you have signs of an infection, such as: Pain around your sides or lower back. Urine smells bad, or it is cloudy or a different color. Fever or chills. A burning sensation or pain in your bladder or pelvis. Discharge or drainage from around the catheter where it is inserted into your body. You do not feel like yourself. Feeling tired, achy, and have a hard time focusing. Also call your provider if: Your urine bag is filling up quickly, and you have an increase in urine. Urine is leaking around the catheter. You notice blood in your urine. Your catheter seems blocked and not draining. You notice grit or stones in your urine. You have pain near the catheter. You have any concerns about your catheter.; Suprapubic catheter care . Caring for Your Skin Near your Catheter . Check the catheter site a few times a day. Check for redness, pain, swelling, or pus. Wash the area around your catheter every day with mild soap and water. Gently pat it dry . Changing Your Catheter, you will need to change the catheter about every 4 to 6 weeks. Always wash your hands with soap and water before changing it . When to Call the Doctor . You are having trouble changing your catheter or emptying your bag. Your bag is filling up quickly, and you have an increase in urine. You are leaking urine. You notice blood in your urine a few days after you leave the hospital. You are bleeding at the insertion site after you change your catheter, and it does not stop within 24 hours. Your catheter seems blocked. You notice grit or stones in your urine. Your supplies do not seem to be working (balloon is not inflating or other problems). You notice a smell or change in color in your urine, or your urine is cloudy. You have signs of infection (a burning sensation when you urinate, fever, or chills).; High potassium level ([MEDICAL CONDITION]) . Causes, Potassium is needed for cells to function properly. You get potassium through food. The kidneys remove excess potassium through the urine to keep a proper balance of this mineral in the body. If your kidneys are not working well, they may not be able to remove the proper amount of potassium. As a result, potassium can build up in the blood . When to Contact a Medical Professional Call your provider right away if you have vomiting, palpitations, weakness, or difficulty breathing . The Administrator and DON was notified on 6/18/20 at 3:25 pm and Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the Administrator and signed at 3:25 pm. The facility's Plan of Removal was accepted on 6/20/20 at 3:07 pm and revealed the following: Immediate interventions: 1 identified male resident with indwelling urinary catheter, pressure ulcers, and [MEDICAL CONDITION] remains hospitalized Conducted assessments on current identified residents: o 1 male resident with an indwelling urinary catheter and no indication of signs or symptoms related catheter-associated urinary tract infections (CAUTIs) were observed o 1 female resident with a suprapubic catheter and no indication of signs or symptoms related catheter-associated urinary tract infections (CAUTIs) were observed o 1 female resident requiring straight catheter and no indication of signs or symp(TRUNCATED)

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection. The facility failed to: a) ensure 1 of 2 ice machines were maintained in a clean and sanitary manner; and b) ensure 1 of 1 LVN (LVN A) provided wound care following current standards of practice and facility policy for 1 of 1 resident (Resident #20) reviewed for wound care. These deficient practices could place residents at risk for the development and/or spread of infection and a decline in physical health Findings included: 1. Ice machine In an confidential interview with an anonymous resident on 01/27/20 at 12:20 PM the resident stated they had seen residents opening the ice machine on Hall B and getting ice out with their hands. They also said they had seen residents opening the ice chest used to pass ice to residents being opened by residents and those residents taking ice from the ice chest with their hands. The resident felt these actions were very unsanitary and could spread germs. During an observation on 01/27/2020 at 11:40 AM the ice machine located on B Hall in an unobstructed entrance way to the nutrition room had white caked material on the lip of the inside of the ice machine where the ice machine door would open and close, gaining access to ice. The ice machine door had a lock which was unlocked during the 4 days of the survey. Observed ice chest being filled on 01/28/2020 at 11:30 AM from the ice machine located on B Hall which had white caked material surrounding inside lip of the ice machine. During an interview on 01/29/2020 at 2:45 PM, Maintenance Director who is also the house keeping supervisor said the white material caked around the door should be cleaned and is unacceptable. She said the door should have been locked to keep residents from reaching in with their hands and contaminating the ice with unclean hands. She said the ice machine provides ice for most of the facility residents. The ice machine in the kitchen provides ice for meal service. During an interview on 01/29/2020 at 3:15 PM the Maintenance Director said they actually do not have anyone cleaning the ice machine. She said they descale the machine monthly but they will add it to a cleaning schedule from now on. She said she just cleaned the ice machine. 2. Resident #20 Review of resident #20's Admission Record, dated 01/29/20, indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #20's MDS assessment dated [DATE] indicated she had a BIMS score of 9 meaning she had moderate cognitive impairment. She had disorganized thinking. She had no recent behavioral symptoms. She required extensive assistance with ADLs. She was not ambulatory and used a wheelchair for mobility. She was frequently incontinent of urine and was continent of bowel. She received scheduled pain medication. She had no pressure ulcers. She received Hospice care. Review of Resident #20's Care Plan, revised 01/20/20, indicated she had a pressure ulcer on her left heel. Interventions included weekly skin assessment, float heels, provide pressure reducing/relieving mattress and treatments as ordered. Observation of wound care on 01/27/20 at 3:00 PM for Resident #20's left heel pressure ulcer by LVN A included the following: LVN A donned gloves, without washing or disinfecting his hands and entered Resident #20's room. She was sitting in her wheelchair. LVN A removed Resident #20's shoe and the dressing from the left heel. LVN A began pulling dead skin from the wound borders with his gloved fingers. Resident #20 began to complain of pain and he went into the hall and got nail clippers from the treatment cart. He changed gloves but did not wash his hands. He did not disinfect the nail clippers. He returned to Resident #20 and clipped more dead skin from the wound. The resident again complained of pain and also a burning sensation. LVN A returned to the treatment cart, removed his gloves and began gathering wound care supplies. He did not wash or disinfect his hands. He did not set up a clean field on top of the treatment cart. He laid dressing supplies on top of the cart. He went to the front desk and returned with scissors. He uses the scissors to cut the dressing to size, without first disenfecting the scissors. The ADON came into the resident's room to look at the wound. While the ADON was assisting the resident onto the bed, LVN A stood at the treatment cart scratching his head/hair with his gloved hand above the treatment cart with the wound care supplies on top. LVN A changed his gloves, and again did not wash or disinfect his hands. He gathered the wound care supplies and placed them on a table beside the resident's bed without cleaning the surface or placing a clean barrier on top of the table. The ADON held the resident's leg up while LVN A cleaned the wound with wound cleanser and 4x4 gauzes. LVN A tossed the used 4x4s on the end of the resident's bed, instead of in a plastic trash bag. He applied the ordered dressing. He gathered the trash, including the 4x4s laying on the resident's bed, and discarded it in the trash can attached to the treatment cart. He removed his gloves, and again, did not wash or disinfect his hands. He returned the treatment cart to the nurses station. In an interview on 01/27/19 at 3:20 PM the ADON said she was appalled at the way LVN A had performed the wound care. She said the DNS had just recently done competency checks of dressing changes with all the nurses. When asked if LVN A should have been pulling dead skin from the wound she said absolutely not. He should not be doing any [MEDICATION NAME] of wounds. She confirmed her observations of LVN A's lack on handwashing, not making a clean surface for the dressing materials, and tossing the used 4x4s onto the residents bed. LVN A was not available for an interview as the DNS suspended him immediately after learning of the ADON's observations of Resident #20's wound care. On 01/27/20 at 4:30 PM the DNS said the ADON reported her observations of LVN A doing wound care on Resident #20, and LVN A was immediately suspended and would likely be terminated. The DNS confirmed she had done competency checks with the nurses on dressing changes. She said LVN A required some prompting on some of the steps. Review of obervation form, Clean Dressing Change, dated 12/21/19, indicated LVN A was observed by the DNS. The DNS noted he required cueing for step #2, gathering equipment, which included paper towel or towel for a clean field. He also required cueing for step #10, washing hands and putting on second pair of gloves. 01/29/20 10:55 AM DNS said the facility does not have a policy/procedure for clean dressing changes, but uses the Clean Dressing Change check-off list. The DNS acknowledged it was outside LVN As scope of practice to debride a wound, and his technique was incorrect.

Based on observation, interview, and record reviews the facility failed to serve food in accordance with professional standards for food safety for 2 or 4 residents (Resident #34 and #48) reviewed for accidents and supervision, and failed to ensure that food was stored and distributed under sanitary condition in the facility's only kitchen. The Facility failed to: A. The facility failed to provide appropriate supervision to prevent Resident #34 from having a second-degree burn from hot soup. B. The facility failed to provide appropriate supervision to prevent Resident #48 from having a first-degree burn from hot coffee. C. - ensure that tea bags were covered and dated. - ensure that outdated food was discarded in a timely manner. - ensure food was dated to show when opened and sealed. This failure placed residents, who receive their food from the kitchen, at risk for injury or illnesses from dirt, pest or other food borne contamination. Findings include: A. Resident #34 Record review of Resident # 34's Face Sheet, dated [DATE], revealed he was a [AGE] year old male admitted to the facility on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #34's quarterly MDS (Minimum Data Set) 3.0, dated [DATE], revealed he scored a 12 of 15 on the BIMS (Brief Interview for Mental Status) indicating he was moderately cognitively impaired. He needed limited assistance with eating, and one-person physical assist. The MDS indicated he did not have impairment on his upper extremity or lower extremity. Record review of Resident #34's Care Plan, reviewed and revised from [DATE]-[DATE], revealed he is at risk for pressure ulcers. [DATE] burn to bilateral thighs while eating soup. I am noncompliant and refuse the apron at times. The care plan indicated to treat [MEDICAL CONDITION] per orders and notify MD (Medical Doctor) if necessary. Encourage and assist Resident #34 with smoking apron while eating meal/soup to prevent any [MEDICAL CONDITION] eating. His care plan indicated he needed 1-person limited assistant with meals at times. Record review of Resident #34's Resident Incident Report, dated [DATE] at 6:00 p.m., revealed he had a 2nd degree burn that occurred in the dining room. It was unwitnessed. Resident #34 stated he was turning his bowl of soup in his hands, at the table, and it spilled on his thighs, causing a burn. The Incident Report revealed inside of his left thigh [MEDICAL CONDITION] and popped. 3cm X 4 cm each. One blister on outer left thigh 1 cm X 2 cm, that has popped. 1 blister on inside right thigh 1 cm X 1cm that has not popped at this time. They notified physician for treatment of [REDACTED]. Physician and Responsible Party were notified. The treatment occurred in-house. According to WedMD, retrieved on [DATE], Second-[MEDICAL CONDITION](partial thickness burns) affect the epidermis and the dermis (lower layer of skin). They cause pain, redness, swelling, and blistering. (https://www.webmd.com/pain-management/guide/pain-caused-by-burns) Observation and interview on [DATE] at 1:34 p.m. revealed Resident #34 was moving himself down the hallway into his room. He was missing the three middle fingers on his left hand. He said he lost them in a grinder in a feed mill when he was 18. He said his whole left side is an issue. He said the burn is still hurting at times. When asking about the incident with the soup, he said it happened a couple months ago. Resident #34 said he did not feel like the soup was too hot. He said he does not like it to get cold, so he was too anxious and spilled it on himself. He said that it was an accident. He said that it burned the flesh. He said they have been treating it, and that it is now healing. He said he has not had an issue with the soup since. He said it was hot but felt like he just ate it too soon. He said that the staff helped to take care of it. I asked him if it was right away that they addressed, but he did not exactly remember the exact details. He said his thigh was directly underneath, and the soup hit them. He said the right side was healed. Observation on [DATE] at 11:40 a.m. revealed Resident #34 was wearing a smoking protector at lunch in the dining room. He did not have a staff member at that time assisting him with his meals. Record review of Resident #34's Departmental Notes, dated [DATE] at 5:26 p.m., signed by the DON revealed the following: Writer called to shower room this am, as resident had noticeable blisters on inner thighs. Resident stated he spilled his soup, chicken noodle soup, on himself at dinner [DATE]. Resident stated he did not want to tell anyone, as he is just, an old farmer, and did not want to bother anyone. Resident denies pain. Medical Director A was notified, order received for [MEDICATION NAME], cleanse area daily and PRN with (normal) saline, and apply [MEDICATION NAME], cover with [MEDICATION NAME], non-stick pad and tubifast over [MEDICATION NAME]. Resident tolerated treatment well this am and has voiced no concerns this shift. RP (responsible party) aware of incident. No other concerns noted at this time. Record review of Resident #34's Wound Assessment Report, dated [DATE], revealed there was a burn on his left lateral thigh in the front. The length was 2 cm, width 1 cm, and depth .5 cm. There was no drainage or infection. The blisters were broken. Record review of the Resident #34's Hot Liquid Safety Evaluation, dated [DATE], signed by the DON revealed this assessment identifies if the resident is at risk for injury while handling and drinking hot liquids. Place a check mark if the following apply the resident being assessed. The box was marked by has a cognitive impairment that impacts the resident's perception and awareness to hot liquids and safety measures including but not limited to: altered comprehension and/or memory impairment. The box was also marked by fingers for altered range of motion or contracture of joint which causes difficult in handling a regular cup or glass. A clothing protector was marked for an interim measure that was put in place to enhance safety. Record review of Resident #34's Departmental Notes, dated [DATE] at 4:13 p.m., signed by the DON revealed the following: Telemedicine rounds with Medical Director A, burn evaluated, order received to observe area daily for drainage, infection, and cover with nonstick gauze to keep from sticking to clothes. Resident aware of new orders . Record review of Resident #34's Wound Assessment Report, dated [DATE], revealed there was a burn on his left inner thigh in the front. It had improved. The blister was broken. The length was 8 cm, width 3 cm, and depth .5 cm. There was no drainage or infection. There was also a wound on the left lateral thigh in front. The wound was unchanged. There was no drainage or infection. The length was 5 cm, width 1 cm, and depth .5 cm. Record review of Resident #34's Departmental Notes, dated [DATE] at 9:54 p.m. revealed the following: residents burn area to legs are healing well, A & D ointment applied to this area after scabs were removed, no signs of infection noted, resident denies any pain at the burn sites. Record review of Resident #34's Departmental Notes, dated [DATE] 2:02 p.m. revealed the following: Resident approached writer expressing area on leg was causing discomfort at times. Medical Director notified, order received for [MEDICATION NAME] 200mg three times a day . Record review of Resident #34's Investigation Template: Quality Assurance Document, dated [DATE], revealed that there was a red area/blister on bilateral thigh. The center response included temperature log for soup, hot liquid assessments completed, smoking apron provided/offered to resident at meal times. Investigation Summary revealed resident spilled soup on lap. Resident eats soup for dinner frequently. Resident did not report, and injury was discovered during shower/skin checks. Record review of Resident #34's Immediate Quality Assurance Review, dated [DATE], revealed any food being heated in the microwave will be checked for temperature after heating to assure (ensure) at accurate temp .temps will be documented on the microwave use log and will be monitored by staff including the dietary manager. Record review of the Stovetop/Microwave Temp for Extra Soups, dated [DATE]-[DATE], revealed they were taking the temperature of the soups and they were 165 degrees Fahrenheit or below. In an interview on [DATE] at 3:30 p.m. and [DATE] at 9:41 a.m. the DON said they had done an in-house investigation on the incident with Resident #34. She said that they had taken temperatures of the soup and offered for him to have a smoking protector on during meals. She said he refused the smoking protector. She said that they had not reported the incident with the soup. In an interview on [DATE] at [DATE] at 10:07 a.m. the Administrator said that the incident with Resident #34 and the soup was not suspicious or abuse/neglect, so they did not report it. They initially said it was witnessed in the dining room. They then said he was able to tell them what happened. In an interview on [DATE] at 12:01 p.m. and 12:11 p.m. the Dietary Manager said she had been working at the facility for four years. She said that the chicken noodle soup that Resident #34 received on [DATE] was extra and was not temped. She believes that it was between 135- and 140-degrees Fahrenheit. She said they microwave it for 1 minute and 30 seconds. She said if the soup is the main course they will take the temperature of the soup. She said the baked potato soup was the main course, and they put it as the starch on the temperature log. On the temperature log on [DATE] it was 198 degrees Fahrenheit, but she did an in-service with them that it should not be above 165 degrees F. She said Cook A was the one that was working when the soup incident occurred. She said they started temping the additional soups requested after the incident with Resident #34. She said we stopped taking temperatures of the additional soups requested on [DATE], as they were just told by Administration to do it for 30 days. She said that she went over 30 days. She said Resident #34 gets the alternate soup (two bowls of chicken noodle soup) every night for supper. She said three other residents request alternate soups. She said they had not had any issues with any other residents getting burned from the soup. In an interview on [DATE] at 1:38 p.m. Cook A said she had worked at the facility almost four years. She said that she did not take a temperature of Resident #34's soup that day, and that they were not taking temperatures of the additional soups requested. She said that she usually puts them in the microwave for a minute and half. She said that they are now taking temperatures of the soup. She said the temperature should be ,[DATE] degrees Fahrenheit. She said she does not take temperatures of the coffee, but that the line aides do that. She said she did not know about the coffee temperatures. B. Resident #48 Review of Resident #48 undated Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the admitting [DIAGNOSES REDACTED]. Resident #48 BIMS score of 11 indicates she moderately cognitively impaired but able to make her needs know. Review of Resident #48's quarterly MDS dated [DATE] revealed Resident #48 was independent and required her meals to be set up. Review of Resident #48's undated Care Plan revealed has hand tremors . Goal and target is to be able to assist with ADLs. Approaches reveal, assist Resident #48 as needed. Record review of nurses notes dated [DATE] at 10:21 AM, revealed Late entry- [DATE] Resident (Resident #48) spilled coffee on her lap. Has redness to bilateral inner thighs and one blister about half size of dime at the time. Physician notified and told to monitor and put ice on it if resident is okay'd it. Record review of nurse's notes dated [DATE] at 10: 23 AM revealed, assessed inner thighs from burn resident got yesterday from spilled coffee. According to Burnfoundation.org, retrieved on [DATE] revealed the following: Hot Water Causes Third [MEDICAL CONDITION]. .in 1 second at 156º .in 2 seconds at 149º .in 5 seconds at 140º .in 15 seconds at 133º. Hot [MEDICAL CONDITION] 100% preventable Hot water is a major cause of burn injury. As with other scald burns, young children and older adults are most at risk. During an observation on [DATE] at 1:45 PM the coffee pot temperatures were 163 degrees F., in the coffee dispenser and was 154 degrees F. located by the kitchen. In an interview on [DATE] at 2:10 PM with Resident #48 she said she was sitting in the dining room and reached across the table and the sleeve on her coat knocked over the coffee and landed in her lap and burned her. She said the nursing staff were there when it happened but could not remember who they were. In an interview on [DATE] at 12:08 with the Dietary Manager she said she had not temped the coffee until the incident with Resident #48 and just recently (first of the month) told it was not necessary to temp the coffee anymore. In an interview on [DATE] at 10:24 a.m. Dietary Consultant A said she had been working at the facility for ,[DATE].5 years. She said that there is not a maximum temperature for soup or coffee. She said she did not know what their policy is on coffee. She said the soup should be 135 degrees Fahrenheit or greater. She said she would be expecting them to take temperatures of the soup and the coffee. She said that if food is reheated; it should be reheated to 165 degrees Fahrenheit, stirred, and held for two minutes. She did not have a concern about the soup being reheated in the microwave. She said this should be the same for every reheated food item to avoid foodborne illness. She said that she did not know if it should be immediately served to the residents. She said that she is aware that there is no regulation for the temperature of the coffee. She said that she was not aware of any incidents with the soup or coffee or people being burned. She said that she does look at the temperature logs. She said that she does do in-services regularly, and she said she may have done one on food temperatures within the last couple of months. She said if people have been burned by the coffee or soup, she said that the facility should have a policy for the coffee. She said the coffee temperature should be between ,[DATE] to [MEDICAL CONDITION] lids available or residents do not get the coffee themselves. She said that this facility does not have a policy for ideal temperatures coffee or soup or taking temperatures of the coffee. She said if there is an incident, that the nursing staff would be following their protocol, and monitoring the residents. She said as far as temperatures it is individualized for each resident. In an interview on [DATE] at 10:50 a.m., 11:30 a.m., and 11:53 a.m. when asked why the Dietary Manager had stopped taking the temperatures of the soup, the Administrator said the plan was for the Dietary Manager to continue taking the temperatures of the coffee and soup. She said she did not know why the Dietary Manager stopped taking temperatures of the alternative soup, and she did not know why they had stopped taking temperatures on the coffee. The Administrator said she was unaware that they were not taking temperatures of the alternate soups before the incident on [DATE] (the soup coming out of the microwave) until a few minutes ago. She said that they were taking temperatures of soup if it was the main meal on the steam table. The Administrator said that they do not have a policy on the coffee. She said she looked at the manual and it comes out at 185 degrees Fahrenheit of the coffee maker, and then it is served according to the residents' palatability. In an interview on [DATE] at 2:54 p.m. the DON said she was called to the shower room on [DATE] to assess Resident #34. She said at first it was just redness and the blisters, and she said once the blisters on his legs popped it got worse. She said the healing process has been a long process, but it is healing. She said his right side has been healed out. She said that he is farmer and he did not want to bother anyone about the incident. Record review of the facility policy titled Food Holding Temperatures on Food Service Line, effective date [DATE], revealed that it is the policy to maintain food-holding temperatures on food service line to meet quality standards and federal, state and local sanitary codes. All foods will be served at appropriate temperatures to ensure resident/patient acceptance while reducing the risk of foodborne illness. Food holding temperatures are recommended temperatures, above the minimum of 135 degrees Fahrenheit. Temperature logs will be kept on file per state regulations, and the temperature sheets will be reviewed by the Dietary Manager. Record Review of the Texas Food Establishment Rules, dated (MONTH) (YEAR), revealed 228.73 Reheating for Hot Holding. Time/Temperature Controlled for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius (165 degrees Fahrenheit) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. C. During an observation of the kitchen on [DATE] at 1:15 pm the following concerns were identified: Cole slaw in refrigerator that had turned brown with a date [DATE]. Observation of 5-gallon container with gallon sized tea bags lined with plastic bag uncovered without date. Undated 5-gallon container of elbow macaroni. Grits in gallon size plastic bag unsealed and undated. Interview and observations [DATE] at 1:20 pm with Dietary manager, looked at the Cole slaw and said the 2 bags needed to be thrown away, one bag was brown and the other was brown and frozen. The Cook came and took them out and threw them away. Tea bags were not covered or dated, and the grits were open without a date. Dietary Manager said she would make sure dietary staff date and cover food, also discard all food not dated or covered. Interview on [DATE] at 10:20 am with Dietary Manger said she expects her employees to cover and date the tea bags, remove old food from refrigerator, and date and seal all foods in storage room, she said she would do an in-service with her staff to make sure they were dating, covering and removing outdated food. Interview on [DATE] at 10:35 am with Assistant cook, she said that tea bags should have been covered and dated in storage room. Interview on [DATE] at 10:45 am with Cook she said she checks the refrigerator for expired or not dated food every day. Tea bags have not been covered but should be. Facility Policy: Dated - (MONTH) 1, (YEAR) - Policy No. FSM-IV-007 - Revealed the following: It is the policy of this center to store, prepare and serve food that is stored in accordance with federal, state, and local sanitary codes. - Foods will be labeled as to content and dated. - Stock will be rotated on a first in first out (FIFO) basis. Refrigerated Storage Monitor perishables (fresh vegetables, fruits, shell eggs, and cheeses) to avoid freezing. Recommend these items be stored in a refrigerator held at 30 degrees F or stored closest to door in a walk-in refrigerator.

Based on observations, interviews, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents (Resident ID #1) reviewed for medications. The facility failed to monitor Resident ID #1 who, on 11/6/17 had been started on the medication [MEDICATION NAME] which had a side effect of drowsiness. On 11/11/17 the resident was drowsy during breakfast, she was wheeled into the day room by a nurse aide where she sat for 45 minutes. The resident fell asleep and fell forward out of her wheelchair onto the tile floor resulting in a deep laceration injury to her scalp, a lower wound to her arm, and a fractured C1, C2, and C-4 of her neck. An Immediate Jeopardy (IJ) was identified on 11/17/17. While the IJ was removed on 11/18/17, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. This failure could place 30 residents at risk for complications from unnecessary medications. The findings included. Review of Resident ID #1's face sheet dated 11/15/17 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. Review of Resident ID #1's current MDS dated [DATE] revealed the resident had long-term and short-term memory problems. The resident had moderately impaired-decisions with supervision required. The resident was a two person physical assist for bed mobility, and was totally dependent on staff for locomotion. Range of motion indicated that the resident had impairment on one side which could affect her balance. Review of Resident ID #1's current care plans dated 8/16/17 revealed she required staff assistance for ADLs. She had left sided [MEDICAL CONDITION] and weakness due to a prior [MEDICAL CONDITION]. She required extensive assistance for dressing grooming and bathing. The resident was at risk for falls related to impaired mobility from her left sided [MEDICAL CONDITION]. One of the interventions included observing the resident for changes in her condition that might warrant increased supervision/assistance and notification of the physician. Further review of Resident ID #1's care plan revealed she had [DIAGNOSES REDACTED]. The care plan documented that she may exhibit signs of disorganized thinking, rambling, incoherent speech, and hallucinations. One of the interventions included reporting any changes of level of consciousness to the doctor. Interview with the Hospice Nurse on 11/15/17 at 3 PM revealed she received a text from Resident ID #1's daughter to see if they could get something to help with Resident ID #1's leg jerking. The hospice nurse stated she called the physician for an order. The Hospice nurse stated she had not seen any spasms. The Hospice Nurse did state that the ADON did call her to clarify the order for the [MEDICATION NAME] on 11/6/17. Review of the Hospice Notes located in the binder at the nurses station had no indication of an assessment on 11/6/17 and no mention of the resident being placed on a new medication. The next hospice note was dated 11/8/17 and there was still no mention of the [MEDICATION NAME] or that an assessment had been done related to giving the medication. Review of the Resident ID #1's telephone order dated 11/6/17 at 12 PM it was revealed the resident was prescribed a new medication, [MEDICATION NAME] 10 mgs, one tablet PO BID (by mouth twice a day). The telephone order did not document a [DIAGNOSES REDACTED]. According to WebMD.com (accessed on 11/17/17), [MEDICATION NAME] is a muscle relaxant used to treat muscle spasms caused by [MEDICAL CONDITION] or spinal cord injuries to help relax the muscles. The drug may cause dizziness or drowsiness and it states do not perform any activity that requires alertness unless you can perform the activity safely. [MEDICATION NAME] has not significantly benefited patients with [MEDICAL CONDITION] and the patient may have a poor tolerance of the drug. Interview with Resident ID #1's physician on 11/17/17 at 11:00 AM revealed he had gotten a call from Resident ID #1's hospice nurse stating that the resident's daughter had requested something for the resident's muscle spasms to her legs. He stated he ordered [MEDICATION NAME] to alleviate the symptoms and could see since the medication is a muscle relaxer that it could have sedated the resident. The physician went on to say that he felt there was some miscommunication between the hospice and nursing facility with the medication and they would work on that. Interview with Charge Nurse E on 11/14/15 at 3 PM revealed she was the nurse that received an order from the hospice nurse on 11/6/17 for a new order for [MEDICATION NAME] twice a day. Charge Nurse #5 stated she questioned the order because she did not know why they would start that medication. Charge Nurse #5 stated she consulted with the ADON about it. The ADON picked up the phone and called hospice to ask why the medication was ordered and the nurse stated that the daughter requested something to be done about her mother having muscle spasms to her legs. Charge Nurse #5 stated they had not noticed muscle spasms to the legs. Review of Resident ID #1's nurses' notes from 11/6/17 until 11/11/17 indicated only one entry in the notes that a nurse had monitored or mentioned the resident was on the medication. There was no initial entry on 11/6/17 that the medication had been started. The entry dated 11/9/17 at 8:18 AM that stated the following: resident has new order for [MEDICATION NAME] 10 mg BID. The resident was tolerating well with no adverse reactions or unwanted side effects noted Resident has rested better with no complaints of pain or discomfort, will continue to monitor. Review of the MAR indicated [REDACTED]. There was no documentation that staff were monitoring the effects of the medication. Interview with the ADON on 11/17/17 at 2:40 PM revealed that the nurses should have been documenting at least every shift for 72 hours when a new medication is ordered for a resident. Review of the 24 hour report log on 11/15/17 at 3:00 PM revealed documentation the medication on 11/6/17, and no other entries were noted on the 24 hour report about the medication or the effects of the medication on Resident ID #1 Interview with the Pharmacy Consultant on 11/17/17 at 9:00 AM revealed that the resident needed to be assessed closely by staff due to the medication [MEDICATION NAME] being a Central Nervous System Suppressant. Interview with Nurse Aide C on 11/15/17 at 1 PM revealed she was the nurse aide that fed Resident ID #1 in the dining room on 11/11/17 prior to Resident ID #1's fall. Nurse Aide #3 stated that the resident's routine is to come to the dining room for meal assistance due to her left side paralysis. Nurse Aide #3 stated that she was very sleepy and groggy that morning but she did manage to feed the resident her meal. Nurse Aide #3 stated Resident ID #1 got help from Nurse Aide #4 to pull Resident ID #1 up in the wheelchair before she pushed her out of the dining room and placed her in the day room across from the nurses station. Nurse Aide #3 stated Resident ID #1 was very sleepy and not herself that morning but she was not assigned Resident ID #1's hall that day so placed her in the day room for the assigned nurse aide to take her back to her room. Nurse Aide #3 stated that normally Resident ID #1 would yell and ask to go back to her room because she did not like sitting in the dayroom after meals. The surveyor asked Nurse Aide #3 if she reported Resident ID #1 being groggy and sleepy to the charge nurse and she stated she did not report it. Nurse Aide #3 stated she placed her in the day room around 8:30 AM and the resident fell around 9:15AM (45 minutes later). Interview with Nurse Aide D on 11/15/17 at 2:00 PM revealed she was feeding residents in the dining room the morning on 11/11/17 and Nurse Aide #3 had asked her to help pull Resident ID #1 up in her wheelchair. Nurse Aide #4 stated I told Nurse Aide #3 that Resident ID #1 appeared sleepy and she was not talking and drinking her coffee like she normally did. Nurse Aide #4 stated she thought Nurse Aide #3 was going to report it to the Charge Nurse. Interview with Nurse Aide G on 11/17/17 at 12 PM revealed he was the nurse aide assigned to Resident ID #1 the day of her fall on 11/11/17. He stated he did get Resident ID #1 dressed that morning and down to the dining room around 7 AM. He stated she did appear more confused that morning and also confused the week before. Nurse Aide #7 stated that morning he was assigned to pass out hall trays so did not see Resident ID #1 in the dining room for meal service. He stated after breakfast he did notice Resident ID #1 in the day room as he passed in the hallway but she was not yelling out as she normally did. He stated the next thing he knew she had fallen in the floor. He stated he had not reported the change in Resident ID #1 to the charge nurse prior to her fall. Interview with Charge Nurse E on 11/15/17 at 3:10 PM revealed the morning of Resident ID #1's fall, she was sitting at the nurses station charting at 9:15 AM when she held a loud thud. She stated she looked up and saw Resident ID #1 in the dayroom face down on the floor where she had fallen out of her wheelchair. Charge Nurse #5 stated she ran to the resident and realized she was unconscious and was bleeding from the head. She stated other staff came to help as they gently log rolled the resident to control the bleeding by applying pressure to the wound. She stated the resident had a large wound to the left side of the forehead and a wound to the arm. She stated 911 was called and the resident was transferred to the hospital. Charge Nurse #5 stated no one had reported to her that the resident had been sleepy that morning. Interview with Charge Nurse F on 11/15/17 at 1:45 PM revealed the morning of Resident ID #1's fall, he was sitting at the nurses station charting at 9:15 AM when he held a loud noise and realized Resident ID #1 had fallen to the floor in the day room. He stated he called 911. Charge Nurse #6 stated Resident ID #1 had been sitting in the day room facing the TV with her back turned. She was very quiet for a lengthy time period without a word spoken and he stated that was not like Resident ID #1 because she would always yell to go back to her room. He stated that maybe if she had been facing the nurse's station they would have been able to tell that she was sleeping. Interview with Resident ID #1's husband on on 11/15/17 at 11 AM revealed that he ate all his meals in his room and that the staff would take Resident ID #1 to the dining room for all meals to assist her in eating. He stated she was unable to feed herself. He stated that the last three mornings prior to her fall she had slept all night which was unusual for her. He also stated that she appeared sleepier throughout the last few days more than usual. Interview with the ADON on 11/17/17 at 2:40 PM revealed she was the nurse that gave Resident ID #1 her [MEDICATION NAME] the morning of 11/11/17, prior to breakfast. The ADON stated she felt the resident was more quiet than usual and made the comment to the other staff about the resident not being herself. The ADON also stated the resident had been on the new medication [MEDICATION NAME] for almost a week. The ADON stated that hospice had gotten the order per the resident's daughters request for muscle spasms to the legs. The ADON stated she had not noticed any spasms to the legs. The ADON stated that any new medication should have been monitored by the nurses each shift for 72 hours. The ADON stated that the facility did have a procedure for a resident receiving a new medication. The ADON stated that the medication should be monitored for 72 hours at least every shift and placed on the 72 hour log book. Review of the 72 hour log book at that time revealed the medication had not been added to the log. Interview with the DON on 11/18/17 at 11:42 AM revealed that the facility did not have a procedure for starting a resident on a new medication. An Immediate Jeopardy (IJ) was identified on 11/17/17 at 3 PM, the Administrator, Medical Director and Director of Nursing were informed. The facility's plan of removal of immediate Jeopardy was accepted on 11/18/17 at 1:05 PM and included the following: The resident was placed in a reclining high back wheelchair (11/17/17) MD assessed and adjusted medications (11/17/17) Therapy evaluated the resident for positioning (11/17/17) The resident will be in close supervision after meals with close supervision in her high back chair 11/11/17 Activities will evaluate and discuss with family her favorite past time activities (11/17/17) Resident will be put back to bed after meals for rest periods (11/17/17) The center will assess residents that are at risk for falls according to the MDS (11/17/17) Residents identified for high risk were assessed for fall risk (11/17/17) Care plans and care guides were updated to reflect current plan of care. Resident placed on 24 hour report 72 hour report for medication changes for 72 hours and charted on (11/17/17) Folder with individualized residents, new orders, lab orders, etc. Nursing assessment and charting every shift (11/17/17) Team members were educated on STOP and WATCH regarding identifying any safety issues (11/17/17) DNS or designee will validate weekly times 60 days that residents identified as a fall risk have the appropriate interventions in place and care guides and care plans are updated to reflect current plan of care (initiated on 11/17/17) Administrator will review findings and present to QAPI for follow up as appropriate. ( initiated on 11/17/17) Observation of Resident ID #1 on 11/18/17 revealed she was seated in a high back wheelchair and placed back to bed after the meal service. Review of Resident ID #1's current physician orders [REDACTED]. Interviews with some facility staff on 11/18/17 revealed staff had been in serviced on changes of condition and supervision of residents. On 11/18/17 at 1:10 PM the administrator was informed that the IJ was removed. The facility remained out of compliance at a severity level of actual harm that is not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. According to the census in condition (672) dated 11/14/17 there were 30 residents who were taking medications for pain management.

Based on observations, interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 5 residents (Resident ID #1) reviewed for accidents. The facility failed to supervise Resident ID #1 who was at risk for falls and had been started on a new medication with sedating effects. On 11/11/17 the resident was drowsy during breakfast, she was wheeled into the day room by a nurse aide where she sat for 45 minutes. The resident fell asleep and fell forward out of her wheelchair onto the tile floor resulting in a deep laceration injury to her scalp, a lower wound to her arm, and a fractured C1, C2, and C-4 of her neck. The resident had previously suffered a stroke leaving her left side paralyzed. She also recently had been started on the medication Baclofen which had a side effect of drowsiness. An Immediate Jeopardy (IJ) was identified on 11/17/17. While the IJ was removed on 11/18/17, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. This failure could place 35 residents, if left sleeping sitting up unsupervised in their wheelchairs, at risk for falls and injuries. The findings included. Review of Resident ID #1's face sheet dated 11/15/17 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. Review of Resident ID #1's current MDS dated [DATE] revealed the resident had long-term and short-term memory problems. The resident had moderately impaired-decisions with supervision required. The resident was a two person physical assist for bed mobility, and was totally dependent on staff for locomotion. Range of motion indicated that the resident had impairment on one side which could affect her balance. Review of Resident ID #1's current care plans dated 8/16/17 revealed she required staff assistance for ADLs. She had left sided hemipalegia and weakness due to a prior CVA. She required extensive assistance for dressing grooming and bathing. The resident was at risk for falls related to impaired mobility from her left sided hemiparesis. One of the interventions included observing the resident for changes in her condition that might warrant increased supervision/assistance and notification of the physician. Further review of resident ID #1's care plan revealed she had a [DIAGNOSES REDACTED]. The care plan documented that she may exhibit signs of disorganized thinking, rambling, incoherent speech, and hallucinations. One of the interventions included reporting any changes of level of consciousness to the doctor. Review of the facility's grievance log dated 9/28/17 revealed the resident's daughter voiced a grievance that the resident was left up in the wheelchair for over 4 hours. The grievance stated that the staff came in the room and turned the call light off and did not return. The resolution to the grievance dated 9/28/17 revealed the director of nursing in serviced the staff on the importance of providing care at the time the call light is turned on, not turning it off and not going back in a timely manner. Interview with Resident ID #1's daughter on 11/14/17 at 12:25 PM revealed that she had talked to the administrator and director of nursing multiple times about taking her mother back to the room after each meal service. The daughter stated that her father (also a resident) was in the room waiting for her mother to return after meals. She did not like her sitting up in the day room after meals due to her left side paralysis. The daughter stated she worried that since the stroke her mother would lose her balance and fall. The daughter felt this accident could have been prevented if the facility had not left her up unsupervised in the day room. Interview with Resident ID #1's husband on on 11/15/17 at 11 AM revealed that he ate all his meals in his room and that the staff would take Resident ID #1 to the dining room for all meals to assist her in eating. He stated she was unable to feed herself. He stated that the last three mornings prior to her fall she had slept all night which was unusual for her. He also stated that she appeared more sleepy throughout the last few days more than usual. He stated it was routine for the staff to leave her in the day room after each meal for a short period of time before bringing her back to her room. He stated if the staff ever forgot to bring her back and it was after 9 AM, he will go down to ask staff to bring her back to the room. Review of Resident ID #1's nurse' note on 11/11/2017, revealed that the resident fell out of her wheelchair in the day room at 9:15 AM and lost consciousness for up to one minute. The facility stabilized the head and spine until EMS arrived. The resident landed on her left side and had a wound to the forehead and left forearm. Further review of the nurse's notes revealed the next entry was on 11/11/17 at 1:03 PM, it was documented that the resident had been transferred to another hospital. Review of the CT cervical spine report dated 11/11/17 at 1:52 PM revealed the resident suffered a fracture to the C1 right anterior spine, C3 was a mildly displaced fracture, C4 involving a left transverse fracture. Review of the hospital photographs on 11/14/17 at 11:30 AM revealed the resident had a open starburst wound to the left side of the forehead where the skull was visible at the base of the wound. The left mid forearm had a skin tear that was approximately 3X3 Centimeters. Review of the Resident ID #1's telephone order dated 11/6/17 at 12 PM (5 days prior to her falling) it was revealed the resident was put on a new medication, Baclofen 10 mgs, one tablet PO BID (by mouth twice a day). The telephone order did not have a [DIAGNOSES REDACTED]. According to WebMD. Com (accessed on 11/17/17), Baclofen is a muscle relaxant used to treat muscle spasms caused by multiple sclerosis or spinal cord injuries to help relax the muscles. The drug may cause dizziness or drowsiness and it states do not perform any activity that requires alertness unless you can perform the activity safely. Baclofen has not significantly benefited patients with strokes and the patient may have a poor tolerance of the drug. Review of Resident ID #1's nurses notes from 11/6/17 until her fall on 11/11/17 indicated only one entry in the notes that a nurse had monitored or mentioned the resident was on the medication. There was no initial entry on 11/6/17 that the medication had even started. Review of the November MAR indicated the medication was given for 5 days (11/6-11/11) BID without monitoring the effects of the medication. Review of the 24 hour report log on 11/15/17 at 3:00 PM revealed the medication was documented on 11/6/17 for starting the medication and no other entries were noted on the 24 hour report about the medication or the affects of the medication on Resident ID #1. Review of Resident ID #1's nurse note had one entry out of the five days she was taking the medication. The entry was dated 11/9/17 at 8:18 AM that stated the following: resident has new order for Baclofen 10 mg BID. The resident was tolerating well with no adverse reactions or unwanted side effects noted. Resident has rested better with no complaints of pain or discomfort, will continue to monitor. Interview with Nurse Aide C on 11/15/17 at 1 PM revealed she was the nurse aide that fed Resident ID #1 in the dining room on 11/11/17 prior to Resident ID #1's fall. Nurse Aide #3 stated that the resident's routine is to come to the dining room for meal assistance due to her left side paralysis. Nurse Aide C stated that Resident ID #1 was very sleepy and groggy that morning but she did manage to feed the resident her meal. Nurse Aide C stated she got help from Nurse Aide D to pull Resident ID #1 up in the wheelchair before she pushed her out of the dining room and placed her in the day room across from the nurses station. Nurse Aide C stated Resident ID #1 was very sleepy and not herself that morning but she was not assigned Resident ID #1's hall that day so placed her in the day room for the assigned nurse aide to take her back to her room. Nurse Aide C stated that normally Resident ID #1 would yell and ask to go back to her room because she did not like sitting in the dayroom after meals. The surveyor asked Nurse Aide C if she reported Resident ID #1 being groggy and sleepy to the charge nurse and she stated she did not report it. Nurse Aide C stated she placed her in the day room around 8:30 AM and the resident fell around 9:15AM (45 minutes later). Interview with Nurse Aide D on 11/15/17 at 2:00 PM revealed she was feeding residents in the dining room the morning on 11/11/17 and Nurse Aide C had asked her to help pull Resident ID #1 up in her wheelchair. Nurse Aide D stated she told Nurse Aide C that Resident ID #1 appeared sleepy and she was not talking and drinking her coffee like she normally did. Nurse Aide D stated she thought Nurse Aide C was going to report it to the Charge Nurse. Interview with Nurse Aide G on 11/17/17 at 12 PM revealed he was the nurse aide assigned to Resident ID #1 the day of her fall on 11/11/17. He stated he did get Resident ID #1 dressed that morning and down to the dining room around 7 AM. He stated she did appear more confused that morning and also confused the week before. Nurse Aide G stated that morning he was assigned to pass out hall trays so did not see Resident ID #1 in the dining room for meal service. He stated after breakfast he did notice Resident ID #1 in the day room as he passed in the hallway but she was not yelling out as she normally did. He stated the next thing he knew she had fallen. He stated he had not reported the change in Resident ID #1 to the charge nurse prior to her fall. Interview with Charge Nurse E on 11/15/17 at 3:10 PM revealed the morning of Resident ID #1's fall, she was sitting at the nurses station charting at 9:15 AM when she held a loud thud. She stated she looked up and saw Resident ID #1 in the dayroom face down on the floor where she had fallen out of her wheelchair. Charge Nurse #5 stated she ran to the resident and realized she was unconscious and was bleeding from the head. She stated other staff came to help as they gently log rolled the resident to control the bleeding by applying pressure to the wound. She stated the resident had a large wound to the left side of the forehead and a wound to the arm. She stated 911 was called and the resident was transferred to the hospital. Charge Nurse #5 stated no one had reported to her that the resident had been sleepy that morning. Further interview with Charge Nurse E on 11/15/17 at 3:10 PM revealed she was the nurse that received an order from the hospice nurse on 11/6/17 for a new order from Baclofen twice a day. Charge Nurse #5 stated she questioned the order because she did not know why they would start that medication. Charge Nurse #5 stated she consulted with the ADON about it. The ADON picked up the phone and called hospice to ask why the medication was ordered and the nurse stated that the daughter requested something to be done about her mother having muscle spasms to her legs. Charge Nurse #5 stated they had not noticed muscle spasms to the legs. Interview with the Hospice Nurse on 11/15/17 at 3 PM revealed she received a text from Resident ID #1's daughter to see if they could get something to help with Resident ID #1's leg jerking. The hospice nurse stated she called the physician for an order. The Hospice nurse stated she had not seen any spasms. The Hospice Nurse did state that the ADON did call her to clarify the order for the Baclofen on 11/6/17. Review of the Hospice Notes located in the binder at the nurses station had no indication of an assessment on 11/6/17 and no mention of the resident being placed on a new medication. The next hospice note was dated 11/8/17 and there was still no mention of the Baclofen or that an assessment had been done related to giving the medication. Interview with Charge Nurse F on 11/15/17 at 1:45 PM revealed the morning of Resident ID #1's fall, he was sitting at the nurses station charting at 9:15 AM when he heard a loud noise and realized Resident ID #1 had fallen to the floor in the day room. He stated he called 911. Charge Nurse F stated Resident ID #1 had been sitting in the day room facing the TV with her back to the nurses station. She was very quiet for a lengthly time period without a word spoken and he stated that was not like Resident ID #1 because she would always yell to go back to her room. He stated that maybe if she had been facing the nurse's station they would have been able to tell that she was sleeping. Interview with the ADON on 11/17/17 at 2:40 PM revealed she was the nurse that gave Resident ID #1 her Baclofen the morning of 11/11/17, prior to breakfast. The ADON stated she felt the resident was more quiet than usual and made the comment to the other staff about the resident not being herself. Further interview with the ADON at that time revealed the resident had been on the new medication Baclofen for almost a week. The ADON stated that hospice had gotten the order per the resident's daughters request for muscle spasms to the legs. The ADON stated she had not noticed any spasms to the legs. The ADON stated that any new medication should have been monitored by the nurses each shift for 72 hours. The ADON stated that the facility did have a procedure for a resident receiving a new medication. The ADON stated that the medication should be monitored for 72 hours at least every shift and placed on the 72 hour log book. Review of the 72 hour log book at that time revealed the medication had not been added to the log. Interview with the DON on 11/18/17 at 11:42 AM revealed that the facility did not have a procedure for starting a resident on a new medication. Interview with Resident ID #1's physician on 11/17/17 at 11:00 AM revealed he had gotten a call from Resident ID #1's hospice nurse stating that the resident's daughter had requested something for the resident's muscle spasms to her legs. He stated he ordered Baclofen to alleviate the symptoms and could see since the medication is a muscle relaxer that it could have sedated the resident. The physician went on to say that he felt there was some miscommunication between the hospice and nursing facility with the medication and they would work on that. An Immediate Jeopardy (IJ) was identified on 11/17/17 at 3 PM, the Administrator, Medical Director and Director of Nursing were informed. The facility's plan of removal of immediate Jeopardy was accepted on 11/18/17 at 1:05 PM and included the following: The resident was placed in a reclining high back wheelchair (11/17/17) MD assessed and adjusted medications (11/17/17) Therapy evaluated the resident for positioning (11/17/17) The resident will be in close supervision after meals with close supervision in her high back chair 11/11/17 Activities will evaluate and discuss with family her favorite past time activities (11/17/17) Resident will be put back to bed after meals for rest periods (11/17/17) The center will assess residents that are at risk for falls according to the MDS (11/17/17) Residents identified for high risk were assessed for fall risk (11/17/17) Care plans and care guides were updated to reflect current plan of care. Resident placed on 24 hour report 72 hour report for medication changes for 72 hours and charted on (11/17/17) Folder with individualized residents, new orders, lab orders, etc. Nursing assessment and charting every shift (11/17/17) Team members were educated on STOP and WATCH regarding identifying any safety issues (11/17/17) DNS or designee will validate weekly times 60 days that residents identified as a fall risk have the appropriate interventions in place and care guides and care plans are updated to reflect current plan of care (initiated on 11/17/17) Administrator will review findings and present to QAPI for follow up as appropriate. ( initiated on 11/17/17) Observation of Resident ID #1 on 11/18/17 revealed she was seated in a high back wheelchair and placed back to bed after the meal service. Review of Resident ID #1's current physician orders [REDACTED]. Interviews with some facility staff on 11/18/17 revealed staff had been in serviced on changes of condition and supervision of residents. On 11/18/17 at 1:10 PM the administrator was informed that the IJ was removed. The facility remained out of compliance at a severity level of actual harm that is not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. According to the census in condition (672) dated 11/14/17 there were 35 residents who required wheelchairs for mobility.

Based on observation, interview, and record review it was determined the facility failed to provide 1 resident (Resident #3) of 9 residents reviewed for adequate supervision and assistance to prevent falls which resulted in serious injury. Resident #3 had history of 8 falls from 1/31/11 through 7/31/11. On 7/14/11 the facility failed to provide Resident #3 the required extensive physical assistance to prevent the resident from falling and sustaining fractures of the pelvis (the bone structure connecting the spine to the thigh bones) and sacrum (large, triangular bone at the base of the spine). On 8/10/11 the survey team notified the administrator an Immediate Jeopardy (IJ) was identified related to Resident #3's falls. While the IJ was removed on 8/12/11, the facility remained out of compliance at a pattern of actual harm due to the facility requiring time to monitor their Plan of Removal for effectiveness This failure created a risk of serious falls with injuries for 11 residents who were identified as having a recent history of falls. Findings include: Review of Resident #3's admission record revealed she was admitted to the facility on [DATE]. She was [AGE] years old at the time of this survey. Review of the resident's consolidated physician orders [REDACTED]. In osteoporosis the bone mineral density is reduced, bone microarchitecture deteriorates, and the amount and variety of proteins in bone is altered resulting in bone fragility and increased susceptability to fracture). Review of Resident #3's current quarterly MDS dated [DATE] revealed she had significant cognitive impairment. She needed limited to extensive physical help with most activities of daily living. The resident required extensive physical assistance for transfers and walking in her room, and limited physical assistance for walking in halls and on the unit. Review of Resident #3's care plan dated 2/10/11 revealed: -- a requirement of assistance from 1 to 2 staff members for activities of daily living, including dressing and toileting, due to the resident's [DIAGNOSES REDACTED]. -- the problem of poor safety awareness and falls. The interventions included the requirement of assistance of 1 staff member for all ambulation, and the requirement for staff to remind the resident to ask for assistance for all ambulation. Although forms entitled Acute Plan of Care were added to the resident's care plan after falls occureed on 2/21/11 and 3/14/11, these included no new interventions related to supervision documented before the resident fell and suffered a fractured pelvis on 7/14/11. These Acute Plans of Care interventions included the requirement for staff to anticipate the resident's needs and to provide prompt assistance, however there were no interventions directed at the late evening hours (such as toileting the resident) at the time the resident had repeated falls in her room. Review of an undated facility policy entitled Reminders for Coding ADL Sheets revealed: -- limited assistance meant staff provided some hands-on assist but not weight-bearing assistance. -- extensive assistance meant staff were required to provide some weight-bearing assistance. Review of Resident #3's Fall Risk Assessments dated 1/30/11 and 5/4/11 revealed the resident was at high risk for falls. The assessments documented the resident was disoriented at all times, and had balance problems when standing and walking. Review of the facility Incident Logs for January 2011 through July 2011 revealed the resident had unobserved falls on: 1. 1/31/11 at 11:00 p.m. 2. 2/5/11 11:30 p.m. 3. 2/21/11 11:45 a.m. (According to the nursing notes dated 2/21/11, this fall occurred at 11:45 p.m.) 4. 3/14/11 at 10:00 a.m. 5. 3/14/11 at 10:55 p.m. 6. 7/14/11 at 2:30 p.m. Resident #3 had a fall in her room (however according to the nurses notes, this fall occurred at 11:45 p.m. This fall resulted in a fracture injury of the pelvis. 7. 7/25/11 at 1:08 p.m. Resident #3 fell in her room. The resident was taken to a local hospital emergency room due to complaints of pain. According to the nursing notes dated 7/25/11, this fall occurred at 5:45 p.m. According to the resident's hospital history and physical report from 7/26/11, scacral fractures were identified after this fall, but is was not stated with certainty these fractures resulted from this fall or from the fall of 7/14/11. 8. 7/31/11 at 8:45 p.m. Resident #3 was again found on the floor in her room. Review of Resident #3's nursing notes revealed: --on 1/30/11 at 11:15 a.m. the resident was admitted to the facility. The nurse documented the resident had a walker and a cane for ambulation. The nurse also documented the resident told her she had "dribbles" (urinary incontinence). -- on 1/31/11 at 11:00 p.m. the resident was found on the floor beside her bed. The nurse documented the resident said she slid to the floor as she was trying to get up. The nurse documented she told the resident to call staff for assistance when she needed to get up. -- on 2/5/11 at 10:30 p.m. the staff found the resident on the floor in her room. The nurse documented the resident told staff she was trying to get into bed when she slipped. At 1:00 a.m. the nurse documented the staff found the resident out of bed in her room. The nurse documented the resident was unsure of what she was doing at the time. The nurse documented she placed an alarm on the residents bed. -- on 2/7/11 at 9:00 p.m. the nurse documented a bed alarm was in place, however the resident had been asking the staff to show her how to turn off the alarm. -- on 2/17/11 at 2:00 p.m. the nurse documented Resident #3's bed alarm was discontinued but did not document the reason the alarm was discontinued. -- on 2/21/11 at 11:45 p.m. the resident was found on the floor beside her bed. The resident said she was trying to sit on the bed but slid onto the floor, landing on her buttocks. -- on 3/14/11 at 10:00 a.m. the nurse documented a housekeeper found the resident sitting on the floor in her room. The nurse documented the resident's gait was unsteady, and due to the resident's dementia staff frequently reminded the resident to call for assistance when she wanted to ambulate. -- on 3/14/11 at 10:55 p.m. the nurse documented the resident was found on the floor in her room. The nurse documented the resident had unsteady gait and had dementia. The nurse documented she put an alarm on the resident's bed. -- on 3/15/11 at 11:00 a.m. the nurse documented the resident had poor memory due to dementia. At 11:00 p.m. the nurse documented the resident had unsteady gait, and did not use a walker as needed. The nurse again documented the resident has dementia. -- on 3/16/11 at 2:00 p.m. the nurse documented staff observed resident turning off the bed alarm. -- on 3/17/11 at 11:00 a.m. the nurse documented the resident had been unplugging the bed alarm. -- on 6/18/11 at 3:00 a.m. the resident was up with her walker. The nurse documented the resident had unplugged the bed alarm and put it in her dresser drawer. -- on 6/19/11 and 6/20/11 the nurse documented the resident did not have a bed alarm during the day, but was put on the bed at night because the resident continued to get out of bed at night without assistance. -- on 7/14/11 at 11:45 p.m. the staff found the resident on the floor in her room. At that time the resident complained of right groin pain. The nurse documented the resident was assisted back to bed. The next morning at 10:15 a.m. the nurse documented the resident continued to complain of pain, so an x-ray was ordered. The nurse documented the x-ray was obtained on 7/15/11 at 11:00 a.m. In an untimed nursing note dated 7/15/11 the nurse documented the resident had at that time only acetaminophen for pain, which was not effective. At 4:30 p.m. the nurse documented she received a physician order [REDACTED]. At 7:00 p.m. that same day the nurse documented she reported to the physician the x-ray report showed a pelvis fracture. -- on 7/25/11 at 5:45 p.m. staff found the resident sitting on the floor in her room. The nurse documented the resident complained of back pain, and was subsequently sent to the local hospital emergency room by ambulance. -- on 7/31/11 at 8:45 p.m. the nurse documented she responded to the resident's bed alarm and found the resident lying on the fall mat on the floor. Accoring to the resident's care plan, the fall mat was initiated on 8/1/11, however was apparently in use on 7/31/11. Review of an undated Provider Investigation Report revealed on 7/14/11 at 11:00 p.m. staff found Resident #3 on the floor in front of the bathroom in her room. According to this report, staff stated on 7/14/11 as they were passing out ice to residents, they came to Resident #3's room. According to the report, staff said the resident's room door was closed at that time, and on entering they found the resident on the floor. According to this report, the resident told staff she was coming out of the bathroom when she fell . According to a staff statement, the resident's bed alarm was not on at that time. According to the report, staff said the resident's bed alarm was disconnected and in the resident's chair. According to staff statements included in the report, as the resident lay on the floor she was complaining of pain and barely able to move her legs, so staff used a mechanical lift to pick up the resident and place her in bed. Observation on 8/9/11 at 11:00 a.m. revealed Resident #3 was up in a geri-chair (a type of recliner with castors). The resident was awake and alert, and able to answer questions in an articulate manner but was not well oriented with her situation. She said, for example, she fell when working around the facility, but did not recall any details of her fall. In an interview on 8/9/11 at 2:15 p.m. CNA 'A' said she knew Resident #3 well. She said the resident had frequently ambulated in the facility with a walker without staff assistance. In an interview on 8/9/11 at 2:45 p.m. the ADON said Resident #3's gait was very unsteady. The ADON said many times she had seen Resident #3 ambulating in the facility with a walker without staff assistance. She said when she saw Resident #3 up unassisted, she did not go to the resident to provide assistance, and she did not direct other staff to help the resident as required in the care plan. In an interview on 8/10/11 at 8:42 a.m. the administrator reviewed Resident #3's care plan dated 2/10/11 which required staff assistance for all ambulation. The administrator said she did not expect staff to be physically present when Resident #3 was ambulating but she did expect staff to ensure the resident was using her walker and had non-slip socks on. In interviews on 8/10/11 at 11:40 a.m. and at 1:30 p.m. LVN 'A' reviewed Resident #3's care plan and said a bed alarm was initiated on 2/5/11 after the resident fell that day. She said on 2/10/11 floor strips were initiated in the resident's room to decrease the risk of falls. She said the bed alarm was discontinued on 2/17/11, but she could not find any documentation to explain why the alarm was discontinued. She said when the bed alarm was discontinued there were no new interventions initiated to provide the resident the necessary supervision to prevent falls. She said sometime in March 2011 the bed alarm was re-ordered, but in June 2011 the bed alarm was ordered for night use only. She said there was no documentation of any other intervention related to staff supervision or assistance of the resident when the resident was up walking. Review of Resident #3's orthopedic surgery consultation dated 7/26/11 revealed the resident had a displaced pubic fracture which resulted from a fall in the nursing home about 2 weeks earlier (7/14/11). According to this report, the resident subsequently had slid off a bed (on 7/25/11) which resulted in increased pain. According to this report, imaging confirmed the resident had sacral fractures in addition to the pubic fracture. The physician wrote the resident would not be able to stand for several weeks due to the pain related to the fractures. The administrator was notified on 8/10/11 at 2:45 p.m. that an Immediate Jeopardy had been identified because the facility allowed Resident #3 to transfer herself and ambulate without the required physical assistance from staff. Even though staff knew Resident #3 had an unsteady gait, was a high risk for falls, experienced multiple falls in the facility, and had an increased risk of bone fracture due to her [DIAGNOSES REDACTED]. Furthermore, the facility provided a bed alarm only at night even though the resident had fallen 4 times during the day and evening. Plan to Lift Immediate Jeopardy: On 8/12/11 the facility submitted an acceptable plan to lift immediate jeopardy. According to this plan, all residents were assessed for fall risk. The facility identified 39 residents as having a high risk for falls. On 8/10/11 the facility initiated in-service training of staff regarding resident care plan intervention requirements related to high fall risk residents. New staff communication tools were developed for use of the CNAs, and a plan was put in place to monitor staff supervision of residents. Verification of the Plan to Lift Immediate Jeopardy: On 8/12/11 the survey team interviewed direct care staff from each shift and verified those nurses attended the above inservice and were able to explain the information provided in the inservice. While the Immediate Jeopardy was removed on 8/12/11, the facility remained out of compliance at a pattern of actual harm due to the facility requiring time to monitor their Plan of Removal for effectiveness. According to the facility's CMS Form 802 provided on 8/8/11 there were 11 residents who had a recent history of falls.