Every finding on record at Brandenburg Nursing and Rehabilitation Center

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The deficient practice had the potential to affect 57 of the facility's 57 residents who consumed food from the kitchen. Observation revealed food being served to residents on ,d+[DATE] was not within the acceptable temperature (temp) ranges for hot and cold foods. Additionally, observation of the kitchen revealed food stored open and exposed to air in a refrigerator and freezer. The findings include: 1. Review of the facility policy titled, Food: Preparation, revised ,d+[DATE], revealed the Dining Service Director/Cooks were responsible for food preparation techniques which minimized the amount of time that food items were exposed to temperatures greater than 41 degrees Fahrenheit ( F) and/or less than 135 F, or per state regulation. Continued review revealed when hot ground food dropped into the danger zone (below 135 F), the mechanically altered food must be reheated to 165 F for 15 seconds if held for hot service. Further review revealed all foods would be held at appropriate temperatures, greater than 135 F (or as state regulations required) for hot holding, and less than 41 F for cold food holding. Observation of the kitchen on [DATE] at 11:30 AM, revealed temperature (temp) checks for fruit cocktail cups located on the counter in individual servings were at 48 F, cole slaw at 50 F, and cold mixed vegetables at 49.1 F which were all above the required 41 F or below for the acceptable range. Further observation revealed the mechanical ground beef on the steam table was temped at 129 F which was below the required 135 F acceptable hot food temperature range. In interview with the District Dietary Manager on [DATE] at 11:45 AM, she stated cold foods should be held at a temperature of 41 F or below and food items on the steam table should be maintained at 135 F, or higher. In interview with [NAME] 1 on [DATE] at 10:30 AM, she stated she was aware food was to be held at an acceptable temperature; however, did not remember the actual acceptable temperature for cold foods. She said she guessed it was below 40 F, and steam table foods were to be held at 140 F and above. The [NAME] reported there was a list posted in the kitchen that showed the correct temperatures and said if she did not know what the correct temperatures were she asked the manager. She further stated she completed the food temperature checks and had logged them on a list. [NAME] 1 additionally said if foods were not held at safe temperatures residents could have sicknesses, including Listeria (a foodborne, bacterial infection). In interview with the Dietary Manager (DM) on [DATE] at 10:45 AM, he stated he was the manager in training. He stated he was aware of the safe temperatures required for cold foods to be held at 41 F or lower and hot foods to be held on the steam table at 135 F or above. The DM further stated foods held at unsafe temperatures could grow pathogens and cause the residents to get sick, and he would throw away any foods not temped in an acceptable range. 2. Review of the facility policy titled, Food Storage: Cold foods, revised ,d+[DATE], revealed all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated were to be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation of the kitchen on [DATE] at 9:30 AM, revealed stored in refrigerator 2 was an opened package of cream cheese that was not covered, and a package of precooked bacon in the original container; with both food items exposed to air contaminants. Further observation revealed in freezer 2 there was a large amount of dinner rolls in the original container which was not covered exposing the rolls to air. In continued interview with [NAME] 1 on [DATE] at 10:30 AM, she stated all stored food items should be wrapped or covered to prevent potential contamination. She stated unsealed food items could develop mold or become dried out. The [NAME] reported all staff were required to follow the facility's policy and procedure to prevent potential hazards from occurring. She further stated she would not want to serve residents unsafe, stale or freezer-burnt foods. In continued interview on [DATE] at 10:45 AM, the DM stated all opened food items stored in the refrigerator or freezers were to be covered or wrapped to prevent contamination. He said all food items stored in refrigerator or freezers should be stored with an opened date and an expiration date to ensure they were following food safety guidelines. The DM reported all staff were responsible to check stored food items and ensure it was covered. He stated no food items stored should be expired. He stated he would throw away anything found in storage in the refrigerator or freezer that was not wrapped or covered. The DM further stated the residents were older and more susceptible and vulnerable and could have their health affected if the facility did not follow food safety guidelines. During continued interview on [DATE] at 11:00 AM, the District Dietary Manager (DM) stated the cooks took temperatures of the food served to residents daily. She stated foods not held at the correct temperature range could cause sickness in the residents. The District DM reported all staff were in-serviced monthly, were responsible for food safety in the facility, and were to ensure stored food items were sealed or covered to prevent potential contamination. She said she did not want to food served to residents that was not flavorful or was unsafe for them. The District DM further stated staff were informed they were cooking in the residents' kitchen was their home and the facility was to provide the residents a quality, homelike environment. She further stated moving forward the goal would be to ensure staff were educated on food safety guidelines and to continue with the monthly in-services. In interview on [DATE] at 2:50 PM, the Administrator stated her expectations were for all dietary staff to follow the facility's policies and state guidelines for food safety. She further stated the facility's policies and state guidelines included appropriate food storage and ensuring accurate temperature ranges for both hot and cold food items.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide residents a safe, clean, comfortable, and homelike environment in twelve (12) of twenty-nine (29) resident rooms, room [ROOM NUMBER], 103, 105, 107, 108, 109, 111, 112, 121, 126, 128, and 132. Observations revealed scratched walls and doors, a missing toilet tank lid, loud bathroom fans, broken vanities, holes in walls, un-painted patched areas, a door that stuck upon opening, and water stains on ceilings. The findings include: Review of the facility's policy, Quality of Life - Homelike Environment, dated (MONTH) 2008, revealed residents were provided with a safe, clean, comfortable, and homelike environment and staff and management would maximize, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting to include, cleanliness, inviting colors and decor, and comfortable noise levels. 1. Observation of the restroom in Resident room [ROOM NUMBER], on 08/01/18 at 4:36 PM, revealed the toilet did not have a tank cover, which exposed the inside of the water tank. The toilet made a constant running water sound. Interview with Resident #19, on 08/02/18 at 10:39 AM, revealed he/she resided in room [ROOM NUMBER] and it bothered him/her when the toilet constantly ran water because it seemed to be such a waste of water. The resident also stated the toilet tank lid had been gone for several weeks and the water in the tank looked black, and had an odor. The resident stated he/she always had a tank cover in place in his/her own home, prior to moving into the facility. Interview with Certified Nursing Assistant (CNA) #2, on 08/02/18 at 10:49 AM, revealed the toilet tank cover had been missing for the last two (2) days. She stated she had not reported the issue to the Maintenance Department because she assumed they were aware and working on it. Interview with the Maintenance Director, on 08/02/18 at 10:42 AM, revealed he was not aware of the missing toilet tank lid. He stated staff should have informed him of the issue. Interview with Licensed Practical Nurse (LPN) #5, on 08/02/18 at 3:43 PM, revealed it was not very homelike for a resident's toilet tank not to have a cover. 2. Observation of the B Hallway, on 08/01/18 at 2:40 PM, revealed the door entry ways for Resident Rooms 103, 105, 107, 109, 111, and 112, had scraped, scuffed doors and areas of gouged wood at the door casings. In addition, many of the doorways had peeling or missing paint that revealed the previous color (bright green), including the wall in the hallway between Resident rooms [ROOM NUMBERS] at the mid-point above the handrail. Observation, on 08/02/18 at 11:20 AM, in Resident room [ROOM NUMBER] revealed some missing vinyl baseboard between the sink and the bathroom door that exposed an area of the wall with gouged wallboard, scrapes, and missing paint. Interview, on 08/02/18 at 3:20 PM, with CNA #5 revealed she noticed some vinyl baseboard separating from the walls in resident rooms, and had noticed the chipped paint on walls and resident room doorways. She stated the appearance of the walls and doors did not provide a clean, comfortable, or homelike appearance, and if her own home were in disrepair in similar ways, she would want the repairs completed quickly. Interview, on 08/02/18 at 3:40 PM, with LPN #5 revealed damaged walls, doorways, and ceilings did not provide a clean comfortable appearance for the residents who lived at the facility. He stated the facility should seem as homelike as possible. He stated when he identified areas of living space that needed repair, he notified the Maintenance Director, and usually did so by calling the Maintenance Director. However, LPN #5 stated after making reports of needed repairs, there were times when it seemed like a long wait before the repairs were completed. Interview, on 08/02/18 at 4:05 PM, with the Maintenance Director revealed he learned of needed building repairs in several ways. Some staff left notes for him and some staff telephoned him to report a needed repair. However, he stated he preferred staff use the computer system to report building issues and needed repairs because the system permitted logging and tracking of needed and completed repair projects. He stated if staff reported an issue via the computer system, the system would transmit a text message to his cellular phone, and he was notified quicker of issues in the building. He stated he had provided training to staff on use of the computer notification system. 3. Observation of Resident room [ROOM NUMBER], on 08/01/18 at 3:15 PM, revealed the base of the vanity was missing and the hand sanitizer dispenser was lying on the counter. The curtain rod and brackets were missing from over the window, and there were two (2) un-patched holes. Observation of Resident room [ROOM NUMBER], on 08/01/18 at 3:17 PM, revealed a golf ball sized hole in the wall near the heater unit. There were scattered, white patched areas on the wall under the air conditioner, over the window, and adjacent to the paper towel dispenser. Observation, on 08/01/18 at 3:19 PM, of Resident room [ROOM NUMBER] revealed the bottom edge of the door to the room was separated and splintered, and the wall near the heater had cracked and chipped paint. Interview with CNA #1, on 08/02/18 at 11:35 AM, revealed she filled out a stop and watch form or called maintenance when she identified any maintenance issues. She stated she never noticed the hole in the wall of room [ROOM NUMBER] or the missing vanity base in room [ROOM NUMBER]. According to the CNA, all staff knew about the unpainted wall patches. She stated the facility was the residents' home and rooms should be maintained in good repair. Interview with CNA #5, on 08/02/18 at 3:19 PM, revealed she notified the nurse or called the Maintenance Director for any maintenance issues. She stated she noticed some of the resident rooms were in disrepair, including holes and caulked areas on the walls. She revealed she had not noticed any maintenance issues with the vanity cabinets. According to the CNA, residents should have a homelike environment. Interview with LPN #3, on 08/02/18 at 9:30 AM, revealed she notified the Maintenance Director in passing regarding any maintenance issues. She stated she had not noticed the hole in the wall in room [ROOM NUMBER] or the splintered door in room [ROOM NUMBER]. The LPN revealed both were potential safety issues and stated a resident could sustain a skin tear from the door. She further revealed it was important to ensure resident rooms were homelike. Interview with the Director of Maintenance, on 08/02/18 at 4:07 PM, revealed he toured resident rooms weekly, had identified needed repairs, and stated the facility had a long-range plan for painting and updating. The Maintenance Director revealed it was important to complete repairs timely to ensure a clean, comfortable, and homelike environment for the residents. 4. Observation, on 08/01/18 at 11:00 AM, revealed Resident room [ROOM NUMBER]'s bathroom fan contained cobwebs and when turned on, gave off a dim light and produced an audible loud rumble. The ceiling in the restroom had brown stains and a hand sanitizer dispenser had fallen off the wall and was sitting on the back of the toilet tank. Interview with Resident #16, on 08/02/18 at 1:17 PM, revealed he/she resided in room [ROOM NUMBER] and did not use the bathroom fan light because it was too loud, as it rumbled and rattled. Continued observation, on 08/01/18 at 11:00 AM, revealed Resident room [ROOM NUMBER] had a vanity cabinet that held the sink and was broken away from the wall and the cabinet base was broken. Further observation revealed Resident room [ROOM NUMBER]'s bathroom door opened approximately one quarter of the way and then caught on the floor, which required extra effort to open the door completely, and there were brown stains on the ceiling. Interview with Resident #27 and #43, on 08/02/18 at 10:46 AM, revealed they resided in room [ROOM NUMBER] and Resident #27 stated the bathroom door was hard to pull and when he/she pulled the door, it scraped on the floor making a loud noise. Resident #43 stated the door to the restroom dragged and he/she had to go to the shower room to use the toilet because it was too hard to get his/her wheelchair into the bathroom. The resident stated he/she had to notify staff when he/she needed to go to the bathroom in the shower room because the shower room had a code lock. Resident #43 stated he/she would rather use the bathroom in his/her room because he/she could not use the toilet in the shower room if staff was giving another resident a shower. Resident #43 revealed the door had been sticking like that since he/she began residing in that room. Interview with CNA #3, on 08/02/18 at 11:30 AM, revealed she knew Resident #43 and #27's bathroom door stuck upon opening, which made it hard for the residents to open and Resident #43 had difficulty getting his/her wheelchair into the bathroom. She further revealed room [ROOM NUMBER] had a slant to the floor related to past foundation issues and the loose vanity cabinet caused trouble with using the drawers and the drawers closing correctly. Interview with CNA #5, on 08/02/18 at 3:14 PM, revealed a broken vanity sink could affect the resident's safety and with the cabinet being broken, she would be concerned with cuts to the residents or skin tears. She stated she was familiar with the bathroom fans being loud and stated she had called and reported to maintenance the water damage on the ceilings of rooms and restrooms because it created an unsafe environment for residents. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed he did not feel like the facility created a homelike environment for the residents. He stated broken bathroom fans should be reported to the maintenance department because they were not supposed to rattle and create noise pollution, and it indicated the fan was not working properly. LPN #5 further revealed he had noticed and reported water damage on the ceilings in the past because it did not create a homelike environment. LPN #5 stated he was aware some of the resident room doors caught on the floor making them difficult to open and it was not homelike because it was difficult for a resident in a wheelchair to get through. Interview with the Director of Maintenance, on 08/02/18 at 4:09 PM, revealed if staff found issues related to building maintenance, they were supposed to input the issue into the computer system and rate the importance as either low, medium, high, or critical. He stated some staff utilized the system and some did not. He further stated the facility recently had foundation issues, which led to the vanity coming loose from the wall in Resident room [ROOM NUMBER]. He also stated the sprinkler system was set off, which led to several water spots and leaks in the ceilings. He further stated he was aware of doors getting stuck on the floor while opening but it was not something he audited frequently, he relied on staff to report issues of that nature. Interview with the Director of Nursing, on 08/02/18 at 4:39 PM, revealed she had noticed the environment had several issues that needed addressed but her primary focus had been on improving nursing care. She stated she thought the building needed to be renovated because it was outdated and if the issues were repaired, it would create a more attractive environment for residents. Interview with the Administrator, on 08/02/18 at 4:57 PM, revealed the physical environment of the facility required attention. She stated she desired to have it repaired but safety issues in the building took precedence and were being addressed at that time. She stated based on the different environmental factors that required repair, she was concerned for resident safety.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were securely stored in three (3) of six (6) medication carts and within the medication refrigerator in the A Hall medication room. Observations revealed medication carts were unlocked and unattended on the A and B Halls. In addition, the key to the medication refrigerator lock was stored on a hook inside the medication room. The findings include: Review of the facility's policy, Controlled Medication Storage, dated (MONTH) (YEAR), revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. The medication nurse on duty would maintain possession of the key to controlled medication storage areas and the Director of Nursing (DON) would keep back-up keys to all medication storage areas, including those for controlled medications. The policy further revealed the access system (key, security codes) used to lock controlled medications could not be the same access system used to obtain the non-scheduled medications. In addition, controlled medications requiring refrigeration would be stored within a locked, permanently affixed box within the refrigerator. Review of the facility's policy, Storage of Medication, dated (MONTH) (YEAR), revealed in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) were allowed access to medication carts. Medications rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. The policy revealed medication storage conditions would be monitored on a regular basis, as a random quality assurance (QA) check, and recommendations made for corrective action as problems were identified. 1. Observation, on 07/31/18 at 9:20 AM, revealed an unlocked medication cart located outside room [ROOM NUMBER] on the B Hallway. At 9:23 AM, three (3) staff walked past the unlocked cart. Interview with Licensed Practical Nurse (LPN) #2, on 07/31/18 at 9:23 AM, revealed she forgot to lock the medication cart when she walked away to assist a resident. The LPN revealed it was important to ensure the medication cart remained locked at all times to prevent an accidental poisoning or theft of medication. Observation, on 08/02/18 at 9:19 AM, revealed an unlocked medication cart located at the A Hall nurses' station. The third drawer of the cart was slightly ajar. Observation, on 08/02/18 at 10:36 AM, revealed an unlocked medication cart across from the B Hall nurses' station with no staff members in sight. Residents were ambulating in the area near the cart with no staff supervision. At 11:27 AM, the medication care remained unlocked and Resident #21 walked past the unlocked cart. Interview with LPN #4, on 08/02/18 at 11:27 AM, revealed she forgot to lock the medication cart when she walked away to attend to a resident. The LPN revealed there was a risk a resident could access medications in the cart and potentially overdose or die. Interview with the Unit Manager (UM), on 08/02/18 at 9:50 AM, revealed medication carts should be locked at all times to prevent unauthorized access and ensure the safety of residents. The UM revealed she monitored medication carts daily when she walked the hallways and had not identified any concerns regarding unlocked carts. Interview with the DON, on 08/02/18 at 4:39 PM, revealed she had not identified any concerns related to unlocked medication carts. Interview with the Administrator, on 08/02/18 at 5:07 PM, revealed she had not identified any systemic issues related to unlocked medication carts. She revealed it was important to ensure medication carts were secure because residents could potentially access and swallow the medications. 2. Observation, on 08/01/18 at 9:04 AM, of the A Hall medication room refrigerator revealed the door to the refrigerator was locked; however, the key to the lock was hanging from a hook on the wall. There was an unlocked metal box chained to the inside the refrigerator, which contained one (1) bottle of oral [MEDICATION NAME] 2 milligram/milliliter. Further observation of the A Hall medication refrigerator, on 08/01/18 at 2:55 PM, revealed it contained three (3) 12-count jars of [MEDICATION NAME] suppositories, forty-seven (47) [MEDICATION NAME] suppositories, eleven (11) Acephan suppositories, eight (8) vials of insulin, one (1) vial of [MEDICATION NAME], six (6) vials of [MEDICATION NAME], six (6) vials of [MEDICATION NAME], thirteen (13) vials of [MEDICATION NAME], and one (1) vial of [MEDICATION NAME]. In addition, there was an emergency pharmacy box sealed with a zip tag, which contained six (6) vials of insulin and two (2) [MEDICATION NAME] suppositories. Observation, on 08/01/18 at 4:46 PM, revealed LPN #5 entered the A Hall medication room accompanied by a male staff member. Interview with the LPN revealed she administered a [MEDICATION NAME] (TB) skin test to the staff member, which was okay because the staff member was not left alone. Interview with the UM, on 08/01/18 at 3:05 PM, revealed the medication room refrigerator would not be considered secured because the key was accessible. The UM stated it was important to maintain secured storage of medications to prevent access and potential diversion. She further revealed she had not noticed the missing lock on the metal box inside the refrigerator. Further interview with the UM, on 08/02/18 at 9:50 AM, revealed it was probably not okay to administer TB skin tests in the medication room and stated she was not familiar with the facility's policy for storage of the medication room keys. Interview with the DON, on 08/02/18 at 4:39 PM, revealed she was not aware the key to the medication refrigerator was stored inside the medication room. She stated she did not know how many sets of keys there were for the medication carts/rooms and revealed there was no system in place to track keys in the facility. The DON revealed controlled medications should be double-locked and all medications should be stored in a secured area to prevent potential diversion. Interview with the Administrator, on 08/02/18 at 5:07 PM, revealed she had not identified any concerns related to unlocked medication carts or secured storage of medications. The Administrator stated there was the potential for diversion of medication if someone gained access to the refrigerator key stored in the medication room.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for two (2) of fourteen (14) sampled residents, Resident #1 and #20. Residents #1 and #20 had a care plan in place for falls; however, the care plan approaches were not followed to ensure a safe environment. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated (MONTH) (YEAR), revealed it was the practice of the facility to implement a comprehensive person-centered care plan to attain the highest practicable physical well-being. Observation of Resident #1, on 08/01/18 at 8:59 AM, revealed the resident standing by his/her closet with the door ajar and the resident stated he/she had been searching in the closet for a pair of pajama bottoms. When the closet door was opened further, the cord from the television that was mounted wall hung down over the closet door, and when the resident attempted to reach up and grab the cord and place it atop of the closet doorframe, the resident leaned into the wall and struck a wall clock with his/her upper right arm/shoulder. The wall clock fell and the glass face on the clock shattered into pieces on the floor. The resident attempted to lean down to pick up the glass pieces but a Certified Nursing Assistant (CNA) entered the room and stopped the resident. The facility admitted Resident #1 on 03/27/18, with current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) and determined the resident interviewable. Review of Resident #1's Care Plan revealed the resident was at risk for injury related to falls with an intervention to ensure a safe environment. Interview with Resident #1, on 08/02/18, at 9:45 AM revealed he/she was upset over the facility owned clock being knocked off the wall yesterday by him/her. The resident stated it was usual for the television cord to hang down over the closet door and prevent the door from opening, but he/she had learned to work around it. He/she stated staff saw the cord hanging down, but he/she reckoned it had become a usual thing. The resident stated the cord could cause an accident because he/she was unsteady on his/her feet at times. Interview with Resident #20, Resident #1's roommate, on 08/02/18 at 10:00 AM, revealed the television cord hung down all the time and both he/she and Resident #1 had to put the cord back up on the doorframe in order to open the closet door. Resident #20 stated it could cause an accident. Review of Resident #20's clinical record revealed the facility admitted the resident on 03/21/18, with current [DIAGNOSES REDACTED]. Review of Resident #20's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to be interviewable with a BIMS score of fourteen (14) out of fifteen (15). Continued review of the MDS revealed the resident had a lower extremity impairment on one side. Review of an Incident Report, dated 07/10/18, revealed Resident #20 had recently sustained a fall in the bathroom. Review of the Fall Risk Data Set, dated 07/11/18, revealed Resident #20 had a fall risk score of six (6) on 07/11/18; however it stated regardless of the score, any resident with previous falls should be considered high risk until fall free for six (6) months. Review of Resident #20's care plan revealed the resident was at risk for injury related to falls with an intervention to ensure a safe environment. Interview with the Maintenance Director, on 08/01/18 at 9:15 AM and 08/02/18 at 10:15 AM, revealed television cords were threaded along top of the closet doorframe and secured with tape, which was not a good system, as apparently the tape came down. He stated options to secure the television cords another way was limited due to the concrete walls. He revealed a fallen cord could cause an accident. Interview with Licensed Practical Nurse (LPN) #6, on 08/02/18 at 11:20 AM, revealed residents should not be lifting the television cord over the top of their closet doorframe in order to open their closet because it could cause them to fall. Interview with CNA #6, on 08/02/18 at 11:25 AM, revealed there were times the television cords hung down over closet doors, which was a fall risk. She stated certain department heads did rounds daily to check the safety of the rooms. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed loose cords could be hazardous because residents could fall if they attempted to fix the cords themselves. He stated the care plan provided staff with goals to provide care to each resident and it was important for staff to follow each resident's care plan. Interview with the Director of Nursing, on 08/02/18 at 4:39 PM, revealed care plans should reflect a safe environment. Interview with the Administrator, on 08/02/18 at 5:08 PM, revealed loose cords provided a potentially unsafe environment.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the resident environment remained as free from accidents and hazards as possible for two (2) of fourteen (14) sampled residents, Resident #1 and #20. The resident's room had a television cord that hung down in front of the closet door, which obstructed the use of their closet door. In addition, three (3) radiator heaters located in common areas contained no end covers leaving exposed sharp metal edges, and there were chipped, rough exposed areas on the wood bases that affixed handrails to the walls on the B Hallway. The findings include: Review of the facility's policy, Incident and Accident Process, dated (MONTH) (YEAR), revealed the purpose of the Incident and Accident process was to ensure the facility environment was as free from accident hazards over which the facility had control, and each resident received adequate supervision to prevent avoidable accidents. 1. Observation of Resident #1, on 08/01/18 at 8:59 AM, revealed the resident standing by his/her closet and the resident stated he/she had been searching in the closet for a pair of pajama bottoms; the closet door was ajar approximately eight (8) inches. When the closet door was opened further, the television cord from the mounted wall television hung down over the closet door and when the resident attempted to reach up, grab the cord, and place it atop of the closet doorframe, the resident leaned into the wall and struck a wall clock with his/her upper right arm/shoulder. The wall clock fell to the floor and the glass face on the clock shattered into pieces. The resident attempted to lean down to pick up the glass pieces but a Certified Nursing Assistant (CNA) entered the room and stopped the resident. Interview with Resident #1, on 08/02/18, at 9:45 AM, revealed he/she was upset the clock was knocked off the wall yesterday and wanted to pay for it. The resident stated it was usual for the television cord to hang down over the closet door, which prevented the door from opening, but he/she had learned to work around it. He/she stated staff knew the cord hung down, but he/she reckoned it was a usual thing. The resident stated the cord could cause an accident because he/she was unsteady on his/her feet at times. Interview with Resident #20, Resident #1's roommate, on 08/02/18 at 10:00 AM, revealed the television cord hung down all the time and both he/she and Resident #1 had to lift the cord and put it on top the doorframe in order to open the closet door. Resident #20 stated it could cause an accident. Interview with the Maintenance Director, on 08/01/18 at 9:15 AM, revealed television cords were taped into an electrical outlet, threaded along the top of the closet doorframe, and then secured with tape. He stated the tape had apparently come down in Resident #1's room, as it was not a good system. Continued interview, on 08/02/18 at 10:15 AM, revealed options to secure the television cords another way was limited due to the concrete walls. He stated a fallen cord could cause an accident. Interview with Licensed Practical Nurse (LPN) #6, on 08/02/18 at 11:20 AM, revealed residents should not be lifting the television cord to put it on top of their closet doorframe because the residents could fall. Interview with CNA #6, on 08/02/18 at 11:25 AM, revealed there were times the television cords hung down over the closet doors, which was a huge fall risk. She stated certain department heads did rounds daily to check the safety of the rooms. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed loose cords could be hazardous, as residents could fall if they attempted to fix the cord. Interview with the Administrator, on 08/02/18 at 5:08 PM, revealed loose cords provided a potentially unsafe environment. 2. Observation of the B Hallway, on 08/02/18 at 11:25 AM, revealed the wood handrail base, nearest the B Hallway shower room, had exposed wood on the corners of the handrail base, which was rough to touch. The handrail base across the hallway from the shower room had a section of wood that was peeled back (separated from the wood base) and rough to touch. Interview, on 08/02/18 at 11:30 AM, with CNA #3 revealed rough exposed wood on the base that supported the handrails could cause a resident to get a splinter or a cut in his/her skin because elderly residents had fragile and dry skin. She stated with age, a resident's skin might become thinner and therefore not as durable, so staff must protect residents from any type of skin injury. Interview, on 08/02/18 at 11:55 AM, with LPN #4 revealed rough damaged areas of wood along the wood base handrail was a concern because residents with thinning or fragile skin could obtain an injury such as a skin tear, which could become infected. Interview, on 08/02/18 at 1:30 PM, with the Unit Manager revealed administrative staff was assigned areas of the building to monitor on a routine basis and they should report any areas of the building in disrepair and potentially hazardous to residents. The UM stated residents who scraped or rubbed against rough areas of wood near the handrails could obtain a cut or a splinter. She stated older residents had fragile skin and a tear to their skin could potentially become infected. 3. Observation, on 08/01/18 at 11:00 AM, revealed two (2) radiator heaters near the B Hall exit vestibule near the kitchen, had no end caps, which exposed sharp metal edges that were at shin level. In addition, observation in the dining room revealed (1) one radiator heater near the front entry door with no end caps, which exposed sharp metal edges at shin level. Interview with CNA #4, on 08/02/18, revealed she did not know if the radiator ends were supposed to be capped off or not. She stated the metal edges contained sharp edges and she was concerned if there were a fall it could cause a skin tear. Interview with CNA #5, on 08/02/18 at 3:14 PM, revealed the exposed metal edges on the side of the radiators could be sharp and cause a skin tear or a resident's clothing could catch on the metal and cause a fall. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed he believed the radiators with no caps were a safety concern because the edges were sharp and something could get caught on the sharp metal edges. Interview with the Director of Maintenance, on 08/02/18 at 4:09 PM, revealed he did not know where the original caps for the radiators were located. He stated he believed the edges were sharp. Interview, on 08/02/15 at 5:15 PM, with the Administrator revealed the Quality Assurance Committee had not identified trends in accidents or with unsafe conditions in the residents' environment.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure handrails were securely fastened to the wall in one (1) of two (2) hallways, the B Hallway. The findings include: Review of the facility's policy, Maintenance Service, revised (MONTH) 2009, revealed maintenance service would be provided to all areas of the building, grounds, and equipment. The Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Observation, on 08/01/18 at 1:30 PM, revealed the handrail in the B Hallway, between resident rooms [ROOM NUMBERS], was attached to a wooden board that had separated from the wall, about eighteen (18) inches in length, and therefore the handrail was no longer firmly attached to the wall. Observation, on 08/02/18 at 11:55 AM, revealed the handrail between resident rooms 108-110 remained loose and not secured to the wall and unstable for use. Interview, on 08/02/18 at 11:30 AM, with Certified Nursing Assistant (CNA) #3 revealed she normally worked on the B Hallway and a number of residents depended on the handrails to move through the hallway. She stated if residents depended on the handrail, especially when trying to walk down the hall while holding onto the rail, then the unstable handrail could potentially hurt the residents, as they could fall. CNA #3 stated the resident in room [ROOM NUMBER], near the loose section of the handrail, used a wheelchair and often grabbed onto the rail for use to self-propel for mobility. Interview, on 08/02/18 at 3:20 PM, with CNA #5 revealed some residents relied on the handrail for support while walking or moving about the hallway, and a loose handrail could potentially cause them to lose their balance and fall. Interview, on 08/02/18 at 11:55 AM, with Licensed Practical Nurse (LPN) #4 revealed she had not noticed the handrail was loose, but it was of concern to her because it could potentially cause a resident to become unstable on his/her feet and fall. Interview, on 08/02/18 at 1:30 PM, with the Unit Manager (UM) revealed a loose, unstable handrail was concerning because residents attempting to ambulate while holding onto a loose handrail could potentially lose their balance and fall. She stated all handrails should be in good repair to ensure residents' safety. The UM stated the facility had a monitoring process in place where administrative staff was assigned to a number of resident rooms, and they should inspect those rooms and the shower rooms for any hazards or necessary repairs. If repairs were needed, staff should notify the appropriate staff person who could assess the situation and make the necessary repair(s). She stated she would phone the Maintenance Director or the housekeeping staff and she was not aware of any other method to transmit the need for repairs or cleaning. Interview, on 08/02/18 at 4:05 PM, with the Maintenance Director revealed he was not aware of the loose handrail in the B Hallway until it was reported to him today. He stated he learned of needed building repairs in several ways. Some staff left notes for him and some staff telephoned him to report a needed repair. However, he stated he preferred staff use the computer system to report building issues and needed repairs because the system permitted logging and tracking of needed and completed repair projects. He stated if staff reported an issue via the computer system, the system would transmit a text message to his cellular phone, and he was notified quicker of issues in the building. He stated he had provided training to staff on use of the computer notification system. Interview, on 08/02/18 at 4:40 PM, with the Director of Nursing (DON) revealed if a hallway handrail was detached from the wall; it would be unsafe for residents to use for mobility assistance. She state a loose handrail could contribute to a resident's fall. Interview, on 08/02/18 at 5:15 PM, with the Administrator revealed the Quality Assurance Committee had not identified any trends associated with areas in the building that made the environment unsafe for residents. She stated she always wanted ensure a resident's mobility through the facility's hallways was safe and as risk free as possible.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop care plans for two (2) of fourteen (14) sampled residents, Resident #3 and #7. The facility failed to develop care plans regarding isolation and contact precautions for Resident #3 and wound care for Resident #7. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated November 2016, revealed the facility developed and implemented a comprehensive, person centered care plan for each resident. The comprehensive care plan would include services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan would be reviewed and revised by the interdisciplinary team after a significant change of condition. 1. Review of the clinical record for Resident #3 revealed the facility readmitted the resident on 02/13/17, with [DIAGNOSES REDACTED]. Review of Resident #3's laboratory reports revealed the resident tested positive for [MEDICAL CONDITIONS] (infection) on 04/02/17, 05/09/17, and 05/28/17. Review of Resident #3's Care Plan, initiated 02/15/17 and revised 05/18/17, revealed no interventions listed related to [MEDICAL CONDITION] infection. Observation of Resident #3's room, on 05/31/17 at 8:30 AM, 9:43 AM, 10:15 AM, 12:04 PM, and 1:40 PM, as well as on 06/01/17 at 8:40 AM, revealed a stop sign across the door with a contact precautions sign hanging beside the entry of the door. An [MEDICATION NAME] hung on the front of the door containing gloves, gowns, and garbage bags. A biohazard garbage can was inside the room. Interview with Certified Nursing Assistant (CNA) #2, on 06/01/17 at 8:43 AM, revealed Resident #3 was under contact and isolation precautions. Interview with Licensed Practical Nurse (LPN) #3, on 06/01/17 at 9:50 AM, revealed Resident #3 had [MEDICAL CONDITION] and was under contact and isolation precautions. She further stated Resident #3 should have a care plan for isolation and contact precautions. LPN #3 further stated the MDS Coordinator usually updated the care plans. Interview with the MDS Coordinator, on 06/01/17 at 10:35 AM, revealed the Interdisciplinary Team (IDT) was responsible for updating resident care plans and the updates were made quarterly or within two (2) weeks of a significant change in condition. The MDS Coordinator reviewed Resident #3's Care Plan and stated interventions related to isolation and contact precautions for [MEDICAL CONDITION] were not on the care plan; however, those precautions should be listed on the plan. Interview with the Assistant Director of Nursing, on 06/02/17 at 9:45 AM, revealed the facility should have developed a care plan for Resident #3's [MEDICAL CONDITION] diagnosis. Interview with the Administrator, on 06/02/17 at 12:50 PM, revealed care plans were not properly developed. She stated her expectation was for staff to develop care plans appropriately and as soon as possible to reflect the care the residents in the facility required. 2. Review of Resident #7's clinical record revealed the facility readmitted the resident on 12/08/16, after hospitalization for exacerbation of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Continued review of Resident #7's clinical record revealed the resident fell from the wheelchair onto the floor and sustained a large gash to the left side of the forehead on 05/29/17. Observation of Resident #7, on 05/31/17 at 8:15 AM, revealed the resident sitting in a wheelchair with a large purple bruise to the left forehead at the hairline. Several steri-strips were over the bruised area. Review of Resident #7's Care Plan, revised 05/30/17, revealed no care plan to address the head injury to the forehead. Interview with the MDS Coordinator, on 06/02/17 at 9:45 AM, revealed Resident #7's plan of care was reviewed following the IDT meeting on 05/30/17, for the resident's fall; however, a plan of care was not developed to address the wound to the head. The MDS Coordinator stated there should have been a care plan developed to monitor the wound, but it was overlooked. Interview with the Director of Nursing (DON), on 06/02/17 at 12:00 PM, revealed staff should have developed a care plan for Resident #7's head wound. The DON was not aware nursing had not developed a care plan for the resident's wound until surveyor intervention.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to notify the physician of a fall with injury for one (1) of fourteen (14) sampled residents, Resident #7. The findings include: Review of the facility's policy, Fall Assessment/Intervention Process, revised January 2011, revealed when a resident sustained [REDACTED]. Review of Resident #7's clinical record revealed the facility readmitted the resident on 12/08/16, after hospitalization for an exacerbation of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Observation of Resident #7, on 05/31/17 at 8:15 AM, revealed the resident sitting in a wheelchair and had a large purple bruise to the left forehead at the hairline. Several steri-strips were over the bruised area. Continued review of Resident #7's clinical record revealed a Situation Background Assessment Recommendation (SBAR) of a fall on 05/29/17. The documentation revealed the resident fell from his/her wheelchair onto the floor and sustained a large gash to the left side of the forehead. The SBAR documentation revealed the facility transferred the resident to the emergency room (ER) for treatment without physician notification. Review of a Nurse's Note, dated 05/29/17 at 10:29 AM, revealed Resident #7 had fallen and staff notified the Emergency Medical Services (EMS) and family. The resident returned to the facility on [DATE] at 3:05 PM. The record revealed staff did not notify the physician of the resident's fall or ER visit. Interview with Licensed Practical Nurse (LPN) #1, via telephone, on 06/02/17 at 11:20 AM, revealed Resident #7 fell out of the wheelchair trying to pick up food off the floor. When LPN #1 entered the room, the alarm was sounding and the resident was on the floor. She stated the resident was assessed and vital signs obtained. LPN #1 stated the Director of Nursing (DON) was also present. The LPN revealed she did not notify the physician of the resident's fall and assumed the DON had called the physician. Interview with the Director of Sales/Marketing, on 06/02/17 at 11:10 AM, revealed she heard an alarm sound, entered the Resident #7's room, and saw the resident on the floor. After staff placed the resident into bed, she stated staff left to make copies of information needed to transfer the resident to the ER and had no knowledge of who staff notified regarding the resident's fall. Interview with the DON, on 06/02/17 at 12:00 PM, revealed she was in the office at the time of Resident #7's fall on 05/29/17. The DON stated she heard an alarm sounding, went to the resident's room, and saw the resident on the floor. The DON stated LPN #1 had called the physician about the resident's fall and obtained an order to transfer the resident to the ER. However, when the DON learned that LPN #1 had not notified the physician, she stated it was the responsibility of the nurse assigned to the resident to notify the physician. The DON stated she was unaware Resident #7's physician had not been notified of the fall. Interview with Resident #7's Physician, via telephone, on 06/02/17 at 1:00 PM, revealed staff had not notified him of the resident's fall and he learned of the fall on 06/02/17. He stated he wanted staff to inform him of any changes/incidents with his residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care and services for one (1) of fourteen (14) sampled residents, Resident #5. The facility failed to provide physician ordered snacks for Resident #5 along with providing a spill proof (Kennedy) cup for all liquids. The findings include: Review of the facility's policy, Between Meal Nourishment/Snacks, undated, revealed between meal nourishments were available as clinically needed and by resident request. The purpose was to honor resident preferences and meet nutrition therapy needs. Nourishments were a supplement to a regular meal intake and were not meant to replace regularly scheduled meals. Effort should be made to monitor nourishment consumption relevant to meal intake. A list of individualized nourishments would be maintained in the Dining Services Department. Individualized nourishments would be sent to the nursing unit at appropriate times between meals and were to be covered and labeled with the resident's name, room number, and date. Nursing staff would deliver the nourishments to the residents and notify the Dining Services Director if a labeled nourishment, provided for a specific resident, was consistently refused or not tolerated so an alternate plan could be developed. Review of the clinical record for Resident #5 revealed the facility readmitted the resident on 10/21/16, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #5 needed extensive assistance of one (1) person for eating and had limited range of motion on the right side. Review of a Medical Nutritional Therapy Recommendations log, dated 04/14/17, revealed Resident #5 was to have a 10:00 AM snack to increase weight. Review of the log dated 05/09/17, revealed a 2:00 PM snack was recommended to increase the resident's weight. Review of Resident #5's Physician order [REDACTED].#5 to have a snack at 10:00 AM, 2:00 PM, and an order dated 06/01/17, for a bedtime snack. In addition, an order dated 03/21/17, revealed the resident was to use a Kennedy cup for all liquids. Review of Resident #5's Meal and Snack Intake log, dated 05/05/17 to 05/31/17, revealed no documentation related to 10:00 AM and 2:00 PM snacks. Review of Resident #5's Daily Care Guide, not dated, revealed he/she was to receive a bedtime snack; however, the guide did not indicate a snack was to be given at 10:00 AM and 2:00 PM. It further revealed the resident was to use a Kennedy cup for all fluids. Observation of Resident #5, on 05/31/17 at 10:00 AM, revealed the resident sitting in a wheelchair in his/her room with a hand brace on the right hand. A water pitcher was at bedside and there was no snack present. Observation at 2:35 PM, revealed staff gave the resident cranberry juice in a Styrofoam cup but did not offer a snack. Interview with Certified Nursing Assistant (CNA) #3, on 06/01/17 at 2:04 PM, revealed she had not given Resident #5 any snacks on 05/31/17. She revealed she was not aware that she was supposed to give the resident a snack. CNA #3 revealed it should be on the care guide; however, it was not on the CNA care guide. Observation of Resident #5, on 06/02/17 at 10:05 AM, revealed the resident sitting in a wheelchair in his/her room. At 10:20 AM, a CNA asked Resident #5 if he/she wanted cranberry juice or water from the hydration cart but did not offer a snack. Observation at 11:30 AM, revealed Cook #2 brought Resident #5 a peanut butter sandwich. Interview with Cook #2, on 06/02/17 at 11:32 AM, revealed she had forgotten to put Resident #5's sandwich on the hydration cart and brought it to the unit herself to give to the resident. Review of the facility's meal times revealed the facility served lunch to the hall where Resident #5 resided daily at 11:15 AM. Interview with CNA #2, on 06/02/17 at 10:20 AM, revealed staff did not pass snacks until the evening. Interview with CNA #4, on 06/02/17 at 10:30 AM, revealed she did not pass any snacks on day shift and had not given Resident #5 any snacks. Interview with the Dietary Manager, on 06/01/17 at 10:15 AM, revealed the kitchen had a snack list and placed snacks on the hydration cart for the CNAs to pass. Continue interview at 1:00 PM, revealed if a resident was supposed to use a Kennedy cup with fluids, then the cup should be used when passing fluids from the hydration cart. Interview with the Registered Dietician (RD), on 06/02/17 at 10:05 AM, revealed she had recommended for Resident #5 to receive sandwiches at 10:00 AM and 2:00 PM, to aid in gaining weight. Interview further revealed the RD did not know how much of the snacks the resident had eaten because there was no tracking of the intake for the 10:00 AM and 2:00 PM snacks. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), on 06/02/17 at 12:30 PM, revealed the hydration cart came from the kitchen and it should already have hydration and snacks on it. They revealed the CNA assigned to the hydration cart passed the fluids and snacks. The DON and ADON stated the CNA should have documented the intake into the kiosk (computer system). However, after she reviewed the intake form in the kiosk, the DON revealed there was no documentation that Resident #5 had received snacks at 10:00 AM and 2:00 PM. The DON further revealed Resident #5 should have a Kennedy cup for his/her fluids. The DON stated it would be easier for Resident #5 to use a Kennedy cup and it would make him/her more independent. Interview with the Administrator, on 06/02/17 at 1:45 PM, revealed Resident #5 had a physician order [REDACTED].#5 had the potential for weight loss.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure meals were prepared in a sanitary manner as evidenced by improper hand washing and cross contamination of foods. The findings include: Review of the facility's policy, Safe Food Handling, not dated, revealed illness-causing bacteria could survive in many places around the kitchen, including hands, utensils and cutting boards. Unless staff washed hands, utensils, and surfaces the right way, bacteria could spread to the food and residents. Hands were washed when entering the kitchen before touching any food or equipment, when going between food items or between clean and dirty items, and after touching the face or hair. Observation of the kitchen, on 05/31/17 at 11:30 AM, during lunch preparation, revealed Cook #1 used tongs to put spaghetti on the residents' plates. She touched the edge of the steam table and her clothing with her gloved hand and without changing gloves and washing her hand, she picked up dry parsley with the same gloved hand and sprinkled it on the top of the spaghetti. She picked up garlic bread with the same gloved hand and placed it on the plates. Interview with the Dietary Manager (DM), on 06/01/17 at 9:30 AM, revealed Cook #1 received three (3) to five (5) days of training regarding food handling and most of the training was done with the help of an experienced cook. The DM stated cross-contamination of foods could make residents sick. Interview with the Dietician, on 06/01/17 at 9:45 AM, revealed staff had to be vigilant regarding cross contamination of foods that could result in the transfer of gastrointestinal infections, resulting in sickness and possible weight loss for the residents. Interview with the District Dietary Manager, on 06/02/17 at 12:50 PM, revealed Cook #1 should have used tongs to pick up the garlic bread and a shaker or spoon to transfer the dried parsley to the residents' lunch plates. Interview with Cook #2, on 06/02/17 at 1:00 PM, revealed staff should not touch food and should use tongs to pick up food because germs could make a resident sick. Interview with Cook #1, on 06/02/17 at 1:11 PM, revealed she has been trained by many kitchen staff not to touch food with dirty gloves. She stated she should have used tongs to pick up the food because germs could make the residents ill. Continued interview with the DM, on 06/02/17 at 2:00 PM, revealed she tried to observe the techniques of the staff every day. The Dietary Manager also stated that managerial staff should do the training on infection control rather than experienced staff. Interview with the Administrator, on 06/02/17 at 8:45 AM, revealed the Regional Consultant should train on food handling and infection control rather than other experienced kitchen staff.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff utilized Personal Protective Equipment (PPE) when entering a Contact Isolation resident room for one (1) of fifteen (15) sampled residents, Resident #12. Certified Nursing Assistant (CNA) #1 and #3 entered a Contact Isolation room for Clostridium Difficile (C-Diff) without donning PPE. The findings include: Interview with the Director of Nursing (DON), on 04/17/16 at 8:45 AM, revealed the facility used the Center for Disease Control and Prevention (CDC) guidelines as the policy for infection control. Review of the CDC guidelines, titled Healthcare Infection Control Practices Advisory Committee, updated 11/25/09, revealed the facility prevented the transmission of Clostridium Difficile (C-Diff) by applying Contact Precautions for the duration of the illness and using consistent hand hygiene. Facility staff caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Staff should wear PPE including gloves and an isolation gown upon room entry and discarding the PPE gloves and gown prior to exiting the patient room that contained pathogens including[DIAGNOSES REDACTED]. Observation, on 04/05/16 at 8:40 AM, revealed CNA #1 entered Resident #12's room without first putting on an isolation gown. The door to the resident's room contained a hanging blue plastic bag that contained see-through pockets. The isolation bag held boxes of gloves and resident equipment, including a stethoscope and thermometer. The isolation bag did not contain any isolation gowns. CNA #1 knocked on the resident's door, then placed gloves on his hands and entered the room. Observation, on 04/06/16 at 7:45 AM, revealed CNA #3 entered Resident #12's room carrying towels in her ungloved hands. The CNA knocked and entered the resident's room. She did not put gloves or a gown on prior to entering the room. The CNA was in the room for approximately five (5) seconds and then walked out of the room. Review of the clinical record revealed the facility admitted Resident #12 on 03/22/16 with [DIAGNOSES REDACTED]. Review of Resident #12's Initial Minimum Data Set (MDS) assessment, completed on 03/22/16, revealed the facility assessed the resident as requiring extensive one (1) person assistance with transfers, ambulation, dressing, and hygiene needs. The facility conducted a Brief Interview for Mental Status (BIMS) exam during the assessment and assessed the resident with a score of fourteen (14) out of fifteen (15) and determined the resident was interviewable. Interview with CNA #1, on 04/05/16 at 4:00 PM, revealed the CNA entered Resident #12's room to provide morning care without putting on a gown. CNA #1 stated at the time he entered the room he was unsure why the facility had placed the resident on Contact Isolation. He further stated the bag on the resident's door did not contain isolation gowns at the time he entered the room to provide morning care. CNA #1 stated he knew that isolation required the use of a gown, but was unsure where to obtain the gowns for the isolation room. CNA #1 stated he could have asked the nurse where to obtain the isolation gowns, but did not talk to the nurse until after he completed morning care with the resident. He also discovered the reason for the Contact Isolation during that conversation with the nurse. Interview with CNA #3, on 04/06/16 at 3:00 PM, revealed she entered Resident #12's room to hand the resident towels without putting on gloves. The CNA was aware the facility placed Resident #12 on Contact precautions due to a[DIAGNOSES REDACTED] infection. The CNA stated staff used a gown and gloves when entering the room to provide care or anytime the staff may encounter any surfaces in the resident's room. According to CNA #3 the staff was allowed to enter the room wearing only gloves when simply handing an item to the resident. CNA #3 entered the resident's room to hand towels to the resident; however, did not first put on gloves. The CNA stated she should have put the gloves on, but did not because she was in a rush at that time. Interview with Registered Nurse (RN) #1, on 04/07/16 at 9:45 AM, revealed the facility placed Resident #12 in Contact Isolation to prevent the spread of[DIAGNOSES REDACTED]. She stated nursing staff put on a gown and gloves prior to entering the resident room and removed the PPE articles prior to leaving the room. Staff also washed their hands with soap and water. According to RN #1 staff wore this PPE anytime they went into the room to provide care or anytime they encountered any of the resident's belongings or surfaces in the resident's room. RN #1 stated the facility permitted staff to enter the room wearing only gloves if they were handing an item to the resident. RN #1 further stated the facility permitted all nursing staff to obtain additional PPE items from Central Supply. The facility trained all the staff on how to obtain PPE items from Central Supply and on the use of PPE in a Contact Isolation room. Interview with the DON, on 04/07/16 at 8:45 AM, revealed the facility trained staff to use PPE when entering a resident room where the resident was in isolation. The DON further stated she instructed nursing staff they must wear gloves and a gown to enter a Contact Isolation room. However, the DON stated she told nursing staff they may enter the room with only gloves if the staff member entered the room only to hand an item to the resident. According to the DON the isolation bags on the doors to resident rooms where the resident was in Contact Isolation contained gloves, gowns, and resident personal equipment. Central Supply made rounds on a regular basis to ensure the bags contained all the necessary equipment. The DON also stated the facility instructed all of the nursing staff to obtain PPE items as needed from the central supply room and the nurse on the hall had keys to central supply.

Based on observation, interview, record review and policy review, it was determined the facility failed to ensure residents were free from misappropriation of property through missing narcotics for five (5) of six (6) sampled residents (Residents #1, #2, #3, #4 and #5), of the twenty-six (26) residents the Director of Nurses identified as receiving narcotic medications. The facility failed to ensure Narcotic Count Sheets and Narcotic Cards accounted for. The findings include: Review of the Abuse and Neglect Policy, not dated, revealed Misappropriation of Resident Property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings without the resident's consent. Review of the Disposal/Destruction of Expired or Discontinued Medications, revised [DATE], revealed the facility would dispose of discontinued medications after a resident had been discharged in a timely fashion, or no more than ninety (90) days of the date the medication was discontinued. Controlled substances could not be returned to the Pharmacy. The facility would destroy controlled substances in the presence of a Registered Nurse and a licensed professional in accordance with facility's policy. Destruction of controlled medications would be documented on the controlled medication count sheet and signed by the Registered Nurse and the witnessing licensed professional who would record the quantity destroyed; the date of destruction; and, the signature of the Registered Nurse and Pharmacist. 1. Review of Resident #4's closed record, revealed the facility admitted the resident on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #4's Physician Orders, dated [DATE], revealed, Resident #4 was ordered [MEDICATION NAME]-[MEDICATION NAME] (APAP) ,[DATE] mg one (1) tablet by mouth every eight (8) hours as needed for pain. On [DATE], the [MEDICATION NAME]-APAP was changed to ,[DATE] mg one (1) tablet every four (4) hours as needed for pain. Review of the Controls Shipped Log, dated [DATE] through [DATE], revealed the pharmacy shipped one (1) [MEDICATION NAME]-APAP ,[DATE] mg narcotic card with ten (10) tablets and one (1)[MEDICATION NAME]-APAP ,[DATE] mg narcotic card with thirty (30) tablets on [DATE]. The pharmacy also shipped an order of [MEDICATION NAME] ,[DATE] mg thirty (30) tablets on [DATE]. Review of Resident #4's Narcotic Count Sheets, dated [DATE] through [DATE], revealed the facility received [MEDICATION NAME] ,[DATE] then changed the order to two (2) tablets for a total of ,[DATE] mg. Review of the Medication Administration Record [REDACTED]. Review of Resident #4's narcotic count sheets, revealed the two (2) [MEDICATION NAME]-APAP ,[DATE] mg cards containing thirty (30) tablets each and delivered on [DATE] and [DATE], could not be accounted for. 2. Review of Resident #5's closed record, revealed the facility admitted the resident on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Physician Orders, dated [DATE], revealed an order for [REDACTED]. Review of the Controls Shipped Log, dated [DATE] through [DATE], revealed the pharmacy shipped one (1) [MEDICATION NAME]-APAP ,[DATE] mg narcotic card containing thirty (30) tablets on [DATE], [DATE] and [DATE], which equaled three (3) narcotic cards with a total of ninety (90) tablets. Review of Resident #5's MAR, dated [DATE] through [DATE], revealed Resident #5 received [MEDICATION NAME]-APAP ,[DATE] mg as needed for pain. Resident #5 received his/her pain medications while living in the facility. Review of Resident #5's narcotic count sheets, revealed the [MEDICATION NAME]-APAP ,[DATE] mg thirty (30) tablets delivered on [DATE], [DATE] and [DATE], could not be accounted for. Interview with Licensed Practical Nurse (LPN) #3 (who worked third shift), on [DATE] at 12:14 PM, revealed on the morning of [DATE] while conducting narcotic counts with LPN #1, she recognized there were three (3) 8 x 8 narcotic cards of medications for Resident #4 and Resident #5 located in the double locked narcotic box of the front B-Hall medication cart. LPN #3 stated when she came in for her shift the night of [DATE], LPN #4 passed her the medication cart keys and informed her to count the narcotics by herself because LPN #4 was too busy to complete the shift to shift narcotic count. LPN #3 stated she did not catch the discrepancy when she counted the narcotic cards by herself. LPN #3 stated during medication pass, the evening of [DATE] at 11:00 PM, she discovered Resident #4 and #5 narcotic cards were missing while giving another resident a pain medication. Both Residents #4 and #5 had been discharged home by this time. LPN #3 stated she then called the Director of Nursing (DON) to initiate an investigation. LPN #3 stated misappropriation of resident property was abuse. Interview with LPN #1, on [DATE] at 1:39 PM, revealed she could remember working the weekend of [DATE]. LPN #1 stated LPN #3 normally worked night shift and would give her report when she came in to work during the morning shift. LPN #1 stated she never completed the narcotic count by herself. LPN #1 stated she had never taken any narcotics. LPN #1 stated she did not remember seeing three (3) 8 x 8 narcotic cards in the narcotic box. LPN #1 stated misappropriation of resident property was abuse and she would report that information right away to the DON. Interview with LPN #4, on [DATE] at 2:30 PM, revealed she worked the weekend of [DATE] and remembered she did not complete the narcotic count with LPN #3. LPN #4 stated she trusted LPN #3 and would pass her the narcotic keys to count by herself. LPN #4 stated she knew she was not suppose to count narcotics by herself because she could be held responsible when medications were missing. LPN #4 stated she had never taken narcotic medications from the narcotic box. Interview with the DON, on [DATE] at 10:11 AM, revealed LPN #3 had called him the morning of [DATE] around midnight. The DON stated, on [DATE] at 5:00 AM, he called LPN #3 back to ensure she had completed a statement regarding the allegation. The DON stated he had reported the allegation of abuse to his Administrator on the morning of [DATE]. The DON stated he and the Regional Nurse Consultant began interviewing the three (3) nurses (LPN #1, #3 and #4) who worked the weekend of [DATE] and completed a drug test on LPN #1 because she was already in the facility and called the other two nurses into the building to complete their drug tests. The DON stated the Regional Nurse Consultant then began completing audits of the narcotic cards and narcotic count sheets. The DON stated on Tuesday [DATE] they had identified diversion of medications had occurred and reported to all the required agencies. Interview with the Regional Nurse Consultant, on [DATE] at 12:51 PM, revealed she became aware of the allegation of abuse on Monday morning of [DATE]. The Regional Nurse Consultant stated she and the DON had begun to look at narcotic medications that had come up missing as to whether they had been destroyed already or if there was a narcotic control sheet laying around waiting to be filed in Medical Records. The Drug tests that were completed on LPN #1 and #4 had come back negative, but LPN #3's drug test was positive in which she was able to give the facility a list of her medications that she had been prescribed. Both LPN #3 and #4 had obtained disciplinary actions for not completing narcotic counts as directed. The Regional Nurse Consultant stated LPN #4 confessed to not completing the narcotic count with LPN #3. The Regional Nurse Consultant stated she called the Pharmacy and requested a print out of the narcotic medications that had been delivered in the last sixty (60) days. Interview with the Consulting Pharmacist, on [DATE] at 12:23 PM, revealed he came to the facility on [DATE] and conducted an audit. The Consulting Pharmacist stated he first verified the narcotic count sheets and then went through the MARS to identify if there was an order and or subsequent package in the narcotic box. The Consultant Pharmacist did not detect any discrepancies in the documentation of the narcotic count sheets or the number of dosages. The audit revealed the narcotic count sheets that were not located were for a resident who was already discharged or were for residents who had a change in the dosage of the narcotic medications. 3. Review of the active record for Resident #1, revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Physician Orders, dated [DATE], revealed an order for [REDACTED]. On [DATE], the Physician discontinued the [MEDICATION NAME]/APAP ,[DATE] mg and ordered [MEDICATION NAME]-APAP ,[DATE] mg one (1) tablet by mouth every four (4) hours as needed for pain. Review of the Controls Shipped Log, dated [DATE] through [DATE], revealed the pharmacy shipped one (1) [MEDICATION NAME] ,[DATE] mg narcotic card with thirty (30) tablets on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The pharmacy also shipped [MEDICATION NAME]-APAP ,[DATE] mg narcotic card with thirty (30) tablets on [DATE], [DATE], [DATE] and [DATE]. Review of Resident #1's MAR, dated [DATE] through [DATE], revealed administered [MEDICATION NAME] ,[DATE] mg for twenty-seven (27) of the thirty-one (31) days of his/her admission. Review of Resident #1's MAR, dated [DATE] through [DATE], revealed the facility administered [MEDICATION NAME] ,[DATE] mg fourteen (14) of the thirty-one (31) days of his/her admission and received [MEDICATION NAME] ,[DATE] mg six (6) of the thirty-one (31) days of his/her admission. Review of the Narcotic Count Sheets revealed [MEDICATION NAME] ,[DATE] mg, containing thirty (30) tablets was delivered [DATE] and [MEDICATION NAME]-APAP ,[DATE] mg, containing thirty (30) tablets was delivered [DATE], the facility could not account for either of the three narcotic cards. Interview with Resident #1, on [DATE] at 11:00 AM, revealed he had no concerns with his/her pain medications. Resident #1 stated he/she always read the labels on the pills to identify that he/she received the right medications. Resident #1 stated no one had ever taken anything or physically harmed him/her in any way. 4. Review of the active record for Resident #2 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Physician Orders, dated [DATE], revealed an order for [REDACTED]. Review of Resident #2's Physician orders [REDACTED]. Review of the Controls Shipped Log, dated [DATE] through [DATE], revealed the pharmacy shipped [MEDICATION NAME] 15 mg IR containing thirty (30) tablets on [DATE], [DATE] and [DATE]. Review of Resident #2's MARs, dated [DATE] through [DATE], revealed the facility administered [MEDICATION NAME] 7XXX,[DATE] mg at night for thirty (30) of the thirty (30) days for the month of September. Review also revealed the facility administered [MEDICATION NAME] 7XXX,[DATE] mg as needed eleven (11) of the thirty (30) days for the month of September. Review of Resident #2's MAR's, dated [DATE] through [DATE], revealed the facility administered [MEDICATION NAME] 7XXX,[DATE] mg at night for thirteen (13) of the thirty (30) days for the October due to the fact the [MEDICATION NAME] 7XXX,[DATE] mg had been discontinued on [DATE]. Review of Resident #2's [MEDICATION NAME] IR (immediate release) 7.5 mg revealed the facility administered the [MEDICATION NAME] IR seven (7) of the fifteen (15) days it was ordered during the month of October. Review of the Narcotic Count Sheets for Resident #2, revealed the facility could not account for the [MEDICATION NAME] 15 mg IR thirty (30) tablets delivered [DATE]. Interview with Resident #2, on [DATE] at 12:58 PM, revealed Resident #2 had no concerns with receiving his/her pain medications. Resident #2 stated no one had every physically or verbally harmed him/her in any way. 5. Review of the active record for Resident #3, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's Physician Orders, dated [DATE], revealed the facility administered [MEDICATION NAME] 7XXX,[DATE] mg one (1) tablet by mouth every six (6) hours as needed for pain. Review of the Controls Shipped Log, dated [DATE] through [DATE], revealed the pharmacy shipped [MEDICATION NAME] 7XXX,[DATE] mg card containing thirty (30) tablets on [DATE], [DATE] and [DATE]. Review of Resident #3's MAR's, dated [DATE] through [DATE], revealed the facility administered [MEDICATION NAME] 7XXX,[DATE] mg for eight (8) of the thirteen (13) days it was ordered in the month of September. Review of the Narcotic Count Sheets for Resident #3, revealed [MEDICATION NAME] 7XXX,[DATE] mg thirty (30) tablets were delivered [DATE] and the facility could not account for the medications. Interview with Resident #3, on [DATE] at 1:23 PM, revealed he/she had received his/her pain medications. He/she stated no there were no concerns with pain medications. Interview with LPN #2, on [DATE] at 11:19 AM, revealed the narcotic cards and narcotic sheets stayed double locked in the narcotic box of the medication cart. The DON and Assistant Director of Nursing (ADON) would retrieve the narcotic cards and narcotic count sheets. The nurses were responsible to notify the DON or ADON when it was time to remove a narcotic card and count sheet from the narcotic box. The nurses did not have to sign off when the narcotic was removed from the narcotic box. LPN #2 stated if there was a change with a residents medications she would just have to assume the DON or ADON had removed the narcotic card from the narcotic box if she did not see the narcotic card the next day. Interview with LPN #4, on [DATE] at 2:30 PM, revealed if a resident was discharged , the narcotics were given to the DON and the DON would destroy the narcotic medications. The nurses did not destroy the medications. Interview with the ADON, on [DATE] at 3:08 PM, revealed she destroyed medications with the DON. The ADON stated when she and the DON would destroy narcotic medications they would only document on the narcotic count sheets. The narcotic count sheet would then be turned into medical records for filing. The ADON stated the nurses would inform her when it was time to destroy medications. However, the ADON stated she destroyed medications weekly. Interview with the DON, [DATE] at 11:50 AM, revealed when a resident was discharged , the nurses would alert him and the ADON when a medications needed to be destroyed. He would then document the doses transferred for disposal, record the quantity, dated and sign with two signatures. The DON stated he would then turn the narcotic count sheets into medical records for filing. The DON stated it had only been him and ADON who destroyed medications. Interview with the Consulting Pharmacist, on [DATE] at 12:23 PM, revealed the DON should be able to see how many narcotic count sheets were printed and present, because there was a number at the top of the narcotic count sheet which indicated the number of sheets dispensed to the facility. The Consulting Pharmacist stated he had found if the narcotic medications stayed in one secured located it reduced the opportunity for someone to tamper with the narcotic medications, this process was at the facility's discretion. Interview with the Regional Nurse Consultant, on [DATE] at 5:07 PM, revealed misappropriation was abuse. The Regional Nurse Consultant stated the facility would be charged for all medications that could not be accounted for. Interview with the Regional Nurse Consultant, on [DATE] at 12:20 PM, revealed she and the Consultant Pharmacist completed narcotic count sheet audits on [DATE]. The Consultant Pharmacist completed the discharged residents audits and she completed the current resident audits. Review of the audit, dated [DATE], revealed nine (9) active resident narcotic count sheets could not be accounted for and nine (9) discharged residents narcotic count sheets could not be accounted for. Through all of the audits of the MAR's all eighteen (18) residents received their medications. Review of the Facility's charge list, in which the facility had to pay out of pocket for medications because they were either ordered too soon or were not present, revealed the facility was not charged for any narcotic medications since [DATE] to [DATE]. Observation of the Medication Pass, on [DATE] at 9:00 AM, revealed no medication errors were identified, narcotic count sheets were documented appropriately and no evidence of tampering with medications of four (4) of four (4) medication carts. Further interview with the DON, on [DATE] at 4:44 PM, revealed when the pharmacy delivered narcotic medications, the nurse must first sign for the narcotic medications, place the narcotic sheet into the narcotic book and place the narcotic medication into the narcotic box of the medication cart. The DON stated there was no system in place which helped him to identify how many narcotic count sheets were delivered to ensure all narcotic sheets were accounted for before the destruction of narcotics. The DON stated the narcotic sheets for Residents #1, #2, #3, #4 and #5 were unaccounted for. The DON stated the narcotic sheets could have been misplaced or misfiled. The DON stated the narcotic count sheets were placed into the residents record once completed. Further interview with the DON, on [DATE] at 10:11 AM, revealed he was not aware there was a way for him to see how many narcotic cards were delivered and as far as he was aware there was no page number on the narcotic count sheet such as one (1) of two (2). The DON stated misappropriation of medications was abuse and needed to be reported immediately.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident had adequate supervision and assistive devices to prevent accidents for one (1) of four (4) residents, (Resident #1). A staff member transferred Resident #1 using the Hoyer lift when it was meant to be a two (2) person assist. Subsequently Resident #1 sustained an injury to the face and the cause could not be determined. The findings include: Review of the Fall Assessment/Intervention Process Policy, revised 09/13, revealed the facility must ensure that the resident environment remains as free from accident hazards as possible and each resident receive adequate supervision and assistance devices to prevent accidents. Review of the Safe Patient Handling and Movement Policy, revised 10/31/13, revealed Mechanical Lifting Devices: all patient transfers with mechanical lifts will be done with a minimum of two (2) persons or as specified in the patient's plan of care. Based on the resident's ability to assist or self perform, this requirement may be adjusted to reflect one person or independent use of certain lifts such as the Sit to Stand type lift. Review of Resident #1's clinical record revealed the facility admitted the resident on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment, dated 12/30/13, revealed Resident #1 had no BIM score assigned which meant Resident #1 was not interviewable. Observation of Resident #1, on 03/10/14 at 2:58 PM, revealed Resident #1 had a green and yellow bruise at the base of his/her right eye and cheek bone. Observation of Resident #1, on 03/10/14 at 3:46 PM, revealed Resident #1 coming out of his/her room in a wheelchair. Two (2) staff members were observed exiting Resident #1's room and a Hoyer lift was observed to be in Resident #1's room as the staff members were exiting. Review of Resident #1's Nurses Notes, written by Registered Nurse (RN) #2, dated 02/22/14 at 12:26 PM, revealed Certified Nursing Assistant (CNA) #4 reported a knot above Resident #1's right eye. The knot had a pin point bruise in the center and appeared to look like a cyst or edema. RN #2 documented that after breakfast she and another nurse looked at Resident #1's eye to obtain a second opinion. Upon entering the room Resident #1's eye had a hematoma (blood outside the blood vessels, usually in liquid form within the tissue) noted and bruising on the corner of the eye. Further review of the nursing notes revealed that the staff currently in the building denied any knowledge of an incident that caused an injury. The RN then notified the family, Director of Nursing (DON) and the Medical Doctor's office. Statements were taken from the staff and nursing was to continue monitoring for any changes. Interview with CNA #4, on 03/11/14 at 1:41 PM, revealed Resident #1 was in bed when she transferred him/her to the wheelchair and she did not recall the bar of the Hoyer lift hitting Resident #1 in the head or the resident's head hitting the bar. CNA #4 stated she was not really looking at Resident #1's face when placing the strap on the Hoyer bar, but she did notice the pin point mark on Resident #1's face during the transfer. CNA #4 stated at 7:15 AM, she showed the resident to RN #2, who thought the knot was a cyst. Interview with RN #2, on 03/11/14 at 11:26 AM, revealed it was normally first shift's responsibility to get Resident #1 up for breakfast in the morning, which was approximately 7:15 AM. At 7:15 AM, CNA #4 informed her that Resident #1 had a pin point mark on his/her eye. RN #2 stated that at first the mark looked like a cyst and she sent Resident #1 to breakfast. But later around 9:30 AM to 10:00 AM, she and another nurse went to Resident #1's room to help RN #2 distinguish if the mark was a cyst or not and found that the wound looked swollen and bruised. RN #2 stated she attempted to put ice on it, but Resident #1 would not allow that to occur. RN #2 stated the wound appeared to have just happened because the wound had gotten bigger. RN #2 stated she then called the MD, DON and family and was informed by the DON to interview staff. RN #2 stated she interviewed CNA #4 and she had denied anything had happened with the resident. Through interviews with other CNA's, RN #2 had learned that CNA #4 was not as forth coming in how she had utilized the Hoyer lift. RN #2 stated she then interviewed CNA #4 again and learned CNA #4 got Resident #1 up by herself with the Hoyer lift. CNA #4 was then asked to write a statement. Interview with the CNA #4, on 03/11/14 at 1:41 PM, revealed she informed RN #2 that when she was getting Resident #1 up with the Hoyer lift that CNA #2 had walked into the room and did not offer to help with the transfer. CNA #4 stated CNA #2 was giving a shower and the other option was to ask the aid on the other hall, but CNA #4 was in a hurry. CNA #4 stated she did not always transfer a resident without help. Interview with CNA #2, on 03/10/14 at 2:04 PM, revealed she was not made aware of the bruise to Resident #1's face until RN #2 had showed her. CNA #2 stated the nurses had asked her what had happened to Resident #1's eye, because CNA #4 had informed them that she had helped her transfer Resident #1 with the Hoyer lift. CNA #2 stated she told the nurse that she did not transfer the resident and never walked into the room while Resident #1 was being transferred. CNA #2 stated that CNA #4 had walked up to her at that time and she informed CNA #4 that she did not watch her transfer Resident #1. CNA #2 stated the whole situation made her feel uncomfortable. CNA #2 stated that when she used the Hoyer lift that she was to have two people, just in case something was to happen. CNA #2 stated she could ask staff to help when she needed the help. Interview with the Restorative Aid, on 03/11/14 at 1:17 PM, revealed she remembered RN #2 talking with her. RN #2 asked if she had seen a bruise on the residents's face and if CNA #4 was assisted with the Hoyer transfer that morning and she responsed with a "no". The Restorative Aid stated lifts were usually a two (2) person assist, because someone needed to monitor the resident and someone needed to monitor the lift. The Restorative Aid stated it was very easy to hit someone with the bar of the lift, because the bar was loose and there was no way to lock the bar. Further interview with RN #2, on 03/11/14 at 11:26 AM, revealed she then interviewed CNA #4 again and learned CNA #4 got Resident #1 up by herself with the Hoyer lift. CNA #4 was then asked to write a statement. Interview with CNA #4, on 03/11/14 at 1:41 PM, revealed she had written a statement in which she informed the Administrator that she had gotten Resident #1 up in the Hoyer lift all by herself. CNA #4 stated she did not ask anyone to help her with the transfer because CNA #2 was giving a shower and the other option was the aid on the next hall and CNA #4 was in a hurry. CNA #4 stated she did not always get residents up without assistance. CNA #4 stated she did not hear Resident #1 cry out in pain. CNA #4 stated if she had caused an accident she would have informed someone. Review of the written statement made by CNA #4, dated 02/26/14, revealed on Saturday, 02/22/14 around 7:00 AM, she was getting Resident #1 up using a Hoyer lift. While doing this CNA #4 stated she had no one to help assist with the transfer due to both CNA's being busy. CNA #4 stated she new this was not acceptable and very dangerous, but she was sure Resident #1 did not acquire any injuries during the transfer. Interview with RN #1, on 03/10/14 at 2:32 PM, revealed he saw Resident #1 face to face between the hours of 5:30 AM and 6:00 AM, while he provided him/her with medications and did not see any bruising on Resident #1's face. RN #1 stated no CNA came up to him to inform him of any bruising that morning. Interview with the Director of Nursing (DON), on 03/11/14 at 2:07 PM, revealed RN #2 had called her to inform her about Resident #1's face. RN #2 informed her that CNA #4 had communicated that Resident #1 had a bruise to his/her eye and then RN #2 looked at it again and it had gotten bigger. RN #2 stated that the place on the residents eye was a small place, but then it grew as if the wound had just happened. RN #2 informed the DON that CNA #4 had utilized the Hoyer lift by herself and she informed RN #2 to call the Administrator. The DON stated that she expected the CNA's to use two (2) staff members when using the Hoyer lift for safety. The DON stated it was possible that the hook, which was the part that swung, could have hit the resident in the face, but there was no witnesses to this event. Interview with Administrator, on 03/11/14 at 2:59 PM, revealed RN #2 had notified her of the incident that Saturday (02/22/14). The Administrator stated that she spoke with CNA #4 and asked that the nurses interview everyone who was currently working and get statements from everyone. The Administrator stated that she was back and forth all day with the RN #2, CNA #2 and CNA #4. The Administrator stated she did not find out that CNA #4 transferred the resident by herself until Monday (02/24/14). The Administrator stated CNA #4 did not come to work that Sunday, Monday or Tuesday, but when she came back to work the Administrator counseled her about the lift situation and at that time CNA #4 confessed to transferring Resident #1 by herself. The Administrator stated she expected staff to use two (2) people when using the Hoyer lift to prevent injuries.

Based on observation, interview, record review and policy review, it was determined the facility failed to ensure staff followed the care plan for one (1) of four (4) sampled residents, (Resident #1) The staff failed to utilize two (2) person assist with the transfer of Resident #1 in a Hoyer lift as careplanned. The findings include: Review of the Resident Comprehensive Care Plan Guidelines, dated 09/08, revealed the resident comprehensive care plan should be viewed as an interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility. Review of Resident #1's clinical record revealed the facility admitted the resident on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment, dated 12/30/13, revealed Resident #1 had no BIM score recorded which meant Resident #1 was not interviewable. Observation of Resident #1, on 03/10/14 at 2:58 PM, revealed Resident #1 had a green and yellow bruise at the base of his/her right eye and cheek bone. Review of Resident #1's Nurses Notes, written by Registered Nurse (RN) #2, dated 02/22/14 at 12:26 PM, revealed Certified Nursing Assistant (CNA) #4 reported a knot above Resident #1's right eye. The knot had a pin point bruise in the center and appeared to look like a cyst or [MEDICAL CONDITION]. RN #2 documented that after breakfast, she and another nurse looked at Resident #1's eye to obtain a second opinion. Upon entering the room Resident #1's eye had a hematoma (blood outside the blood vessels, usually in liquid form within the tissue) noted and bruising on the corner of the eye. Further review of the nursing notes revealed that the staff currently in the building denied any knowledge of an incident that would have caused injury. Interview with RN #2, on 03/11/14 at 11:26 AM, revealed at approximately 7:15 AM on 02/22/14, CNA #4 informed her that Resident #1 had a pin point mark on his/her eye. RN #2 stated at first the mark looked like a cyst, but later looked swollen and bruised. RN #2 stated she attempted to put ice on it, but Resident #1 would not allow that to occur. RN #2 stated the wound appeared to have just happened because the wound had gotten bigger. RN #2 stated she interviewed CNA #4 and the aid had denied anything had happened with the resident. Through interviews with other CNA's RN #2 had learned that CNA #4 was not as forth coming in how she had utilized the Hoyer lift. RN #2 stated she then interviewed CNA #4 again and learned CNA #4 got Resident #1 up by herself with the Hoyer lift. CNA #4 was then asked to write a statement. Interview with CNA #4, on 03/11/14 at 1:41 PM, revealed on 02/22/14 at 7:15 AM, she saw a knot on Resident #1's head and showed the resident to the nurse, RN #2, who thought the knot was a cyst. CNA #4 stated she had written a statement in which she informed the Administrator that she had gotten Resident #1 up in the Hoyer lift all by herself. CNA #4 stated she did not ask anyone to help her with the transfer, because CNA #2 was giving a shower and the other option was the aid on the next hall and she was in a hurry. CNA #4 stated she did not always get residents up without assistance. CNA #4 stated Resident #1 was in bed when she transferred him/her to the wheelchair and she did not recall the bar of the Hoyer lift hitting Resident #1 in the head or the resident's head hitting the bar. CNA #4 stated she was not really looking at Resident #1's face when placing the strap on the Hoyer bar, but as she did notice the pin point mark on Resident #1's face during the transfer. CNA #4 stated as soon as she saw the mark, she immediately took Resident #1 to the nurse to inform her of the mark. CNA #4 stated she did not hear Resident #1 cry out in pain. CNA #4 stated if she had caused an accident she would have informed someone. Review of the written statement made by CNA #4, dated 02/26/14, revealed on Saturday around 7:00 AM, she was getting Resident #1 up using a Hoyer lift. While doing this CNA #4 stated she had no one to help assist with the transfer due to both CNA's being busy. CNA #4 stated she knew this was not acceptable and very dangerous, but she was sure Resident #1 did not acquire any injuries during the transfer. Review of Resident #1's Activity of Daily Living (ADL) Care plan for the month of February, revealed Resident #1 was to be transferred with a level of support of two (2) or more person physical assist. Review of Resident #1's Falls Nursing Care plan, onset 01/05/14, revealed the approach with transfers was a two (2) person physical assist. Interview with CNA #4, on 03/11/14 at 1:41 PM, revealed she knew Resident #1 was a two (2) person assist with the Hoyer lift and that she was expected to follow the plan of care for each resident. She stated when there are two people assisting with the lift, one person was to help with the sling and one person was to monitor the Hoyer lift. Interview with RN #2, on 03/11/14 at 11:26 AM, revealed nursing staff was expected to follow the plan of care for each resident to ensure each resident's safety. Interview with the Assistant Minimum Data Set (MDS) Coordinator, on 03/11/14 at 2:36 PM, revealed that as an assistant she ensured everything was transferred over to the hard copy of the care plan and the CNA care plans were updated in the Accu nurse computer system. The Assistant MDS stated she would expect the CNA and nursing staff to follow the care plan. Interview with the Director of Nursing (DON), on 03/11/14 at 2:07 PM, revealed the nursing staff and the MDS Coordinator could initiate and update the care plans. The DON stated the CNA care plans had to be manually put into the Accu Nurse System. The DON further stated there should have been two (2) staff members when using the Hoyer lift, because of safety and she thought the hook part of the Hoyer lift had the potential to hit the resident, but there was no witness. Thus it could not be determined that the Hoyer lift was the cause of the injury to Resident #1's face.

Based on interview, record review and policy review, it was determined the facility failed to ensure pharmaceutical services were provided for the dispensing of as needed (PRN) pain medications for one (1) of four (4) sampled residents (Resident #1). The facility failed to ensure the pharmacy refilled orders and sent them to the facility timely to avoid interruption of medication availability. Resident #1 had to wait eight (8) hours for pain medication to be administered; he/she displayed grimacing and moaning with movement. Resident #1 stated to his/her family the pain was getting rough. Hospice accepted the resident on 12/31/13 and the resident expired on 01/02/14. The findings include: Review of the facility's policy regarding Providing Pharmacy Products and Services, revised 01/01/13, revealed the staff should remind the prescriber (MD) that a delay in medication therapy can be prevented by using a medication that is included in the facility's emergency medication supply as permitted by State regulations. If a medication was considered essential and could not be substituted or delayed, contact the emergency number provided by Pharmacy. Review of the facility's policy regarding New Orders for Schedule II Controlled Substances, revised 01/01/13, revealed new orders for Scheduled II controlled substances require a complete written prescription prior to dispensing, unless there is an emergency situation. Facility staff may fax Schedule II prescriptions for long term care residents and terminally ill residents. The prescriber should provide pharmacy with verbal authorization for Schedule II controlled substances in cases of emergency as determined by: immediate administration of the Schedule II controlled substance is necessary for proper treatment of [REDACTED]. If the controlled substance is needed before the pharmacy can make arrangements for timely delivery, the facility must fax a request to remove a controlled substance from the emergency drug supply to the pharmacy. Review of the clinical record revealed the facility admitted Resident #1 on 12/12/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Physician Orders, revealed the physician ordered Oxycodone 5 (a controlled narcotic) mg one (1) tab by mouth every four (4) hours as needed for pain, quantity of sixty (60) to be dispensed. Interview with LPN #3, on 02/04/14 at 4:34 PM, revealed she looked at the resident and took his/her vital signs. The resident was moaning and his/her oxygen saturations were 86% to 88%. She stated she could see the resident was not "fine" as she was told in report. Interview with Resident #1's family member, on 02/03/14 at 10:45 AM, revealed the resident whispered into the family member's ear that the "pain was getting rough". Review of the Refill Reorder Form, dated 12/28/13, revealed Resident #1's Oxycodone 5 mg medication was re-ordered for the remaining thirty (30) tabs on that date. Interview with Registered Nurse (RN) #1, on 02/04/14 at 4:17 PM, revealed the night shift mostly completed the medication audits. RN #1 stated he normally determined when a narcotic needed to be re-ordered by the fact the medication card comes in a pack of thirty (30). RN #1 stated when the medication got below the half way mark he would then re-order the narcotic medication. RN #1 stated he would then pull the sticker and place it in on a refill page and fax the information to the pharmacy. Review of Resident #1's Medication Administration Record, [REDACTED]. Interview with Resident #1's family member, on 02/03/14 at 10:45 AM, revealed Resident #1 had Stage IV Lung Cancer with metastasis to the Femur and his/her pain was getting worse. On the 12/30/13, Resident #1 was given his/her last pain medication at 8:00 AM. The family asked the nurse for pain medication around 12:00 PM and the nurse stated there was no more pain medication left and they would have to order the medication. The family member stated at 7:00 PM they asked the nurse again where the medication was and the nurse stated they had a prescription, but no medication. The nurse informed the family that the prescription had to be faxed to the pharmacy and that was when another nurse informed the family they could go to their pharmacy and get the medication filled faster. Interview with Licensed Practical Nurse (LPN) #1, on 02/05/14 at 10:44 AM, revealed their pharmacy was in Cincinnati, and there was a branch in Louisville they used. She further stated the facility contracts through pharmacies in three (3) surrounding towns that were forty-five (45) minutes in each direction. She stated it takes pharmacy about two (2) hours if they need something STAT. Interview with LPN #2, on 02/04/14 at 3:54 PM, revealed normally when a drug ran low she would pull the sticker and place the sticker on a medication refill sheet which would then be faxed to pharmacy. LPN #2 stated that once a medication sticker was pulled from the card, the pharmacy would usually deliver the medication that night. LPN #2 could not remember if the sticker was already pulled when she gave the last dose. Interview with the facility's Consulting Pharmacist, on 02/05/13 at 2:24 PM, revealed the Oxycodone 5 mg was a schedule II drug and there was a quantity of thirty (30) tabs that could be refilled. The Consulting Pharmacist stated the pharmacy had received a re-order on 12/28/13. The re-order defaulted and alerted the technician. The technician should have checked the alert, but instead, checked it off as seen and did not refill the medication. The Consulting Pharmacist stated he did not know why the pharmacy did not refill the medication. However, the prescription was no longer active in the computer and the prescription looked like it had been discontinued. Basically the Technician checked it off, instead of refilling the drug. During further interview with the Consulting Pharmacist he stated the way the EDK box worked was the facility was required to fax the prescription to the pharmacy and then call the pharmacy to get access to the controlled stock. The pharmacy would give them a control number that they have to put on paper to sign out the drug. They have to have permission to verify there was an active prescription and the pharmacy gave the approval if the drug was in the EDK box. Interview with the family's pharmacy revealed the prescription was brought in at 7:00 PM and filled by 7:27 PM. Interview with the MD, on 02/05/14 at 9:45 AM, revealed she remembered there were two prescriptions written. The first one she was told that they did not have a route and she was told to re-write the second prescription. She then got a call that the resident was in horrific pain and she called and talked with the family's pharmacy. The family member brought the medication back to the facility to ensure the resident got it quickly. There were several hours in delay. The delay in the system was the pharmacy. She further stated the facility did not call her prior to the medication running out and that they had given the last dose. She stated she knew they did not do well with Resident #1. She stated she knew when the medication had to be switched from pill to liquid it was hard to obtain. The MD further stated she did not want this to happen again, so she went to the pharmacy herself and obtained medication for another resident who was also dying. Interview with the Administrator, on 02/05/14 at 4:40 PM, revealed it sounded like the facility had a break down with the pharmacy process in getting the pain medication needed for Resident #1. The Administrator further stated the turn around time for stat medications orders is four (4) to six (6) hours and they needed to talk to pharmacy about it.

Based on observation, interview, record review and review of the facility's Care Plan and Pain Management policy, it was determined the facility failed to assure staff developed an initial care plan when the assessment triggered for such for one (1) of four (4) sampled residents, (Resident #1). The facility staff failed to develop an initial plan of care, prior to the completion of the first comprehensive assessment, to address Resident #1's Stage [MEDICAL CONDITION] with Metastasis to the Femur, the resident's potential and actual pain, assessments of that pain, and evaluation of any pain medication and its effectiveness. Resident #1 experienced untreated pain for eight (8) hours, grimacing and moaning with movement and expressing to the family the pain was getting rough which resulted in actual harm. (Refer to F309 and F425.) The findings include: The facility did not provide a policy regarding the development of the initial care plan. Review of the facility's Care Plan Policy Statement, not dated, revealed an individual's comprehensive care plan included measurable objectives and timetables for each resident. Any licensed nurse and or interdisciplinary team member could update the care plan to reflect changes. The care plan identifies the highest level of functioning the resident may be expected to attain based on assessments. The care plan is to incorporate risk factors, strengths, and expressed wishes regarding care and treatment goals. Review of the facility's policy regarding Pain Management Process, dated [DATE], revealed all residents have the right to be free of pain. Upon admission, the Pain Assessment form is used to collect data of the current presence of pain, type of pain scale to utilize, predisposing causes of the pain, location and etiology of the pain, quality, intensity and duration of the pain, accompanying symptoms associated with the pain, current management, pharmacological and non-pharmacological treatments, history of resolved and unresolved pain and the resident's pain management goal. The resident's care plan would be generated from the data collected from the pain assessment and updated upon any changes made to the resident's pain management regime or resident goals. The physician and family will be notified when pain levels are outside normal levels for each individual resident. The Situation, Background, Assessment, Recommendation (SBAR) form and other Interact II tools can be used to direct appropriate assessment, intervention and documentation related to the pain. Documentation of pain intensity will be recorded along with interventions for pain reduction using appropriate facility forms and no less than the Pain Assessment, Pain Flow Sheet, SBAR for notification and 24 hr Report for any pending re-evaluations or pending interventions. Post intensity evaluation would be assessed and documented in a timely manner. Upon follow-up, if the interventions were effective, process should be repeated until resident indicates adequate relief. When PRN pain meds are given regularly or frequently, the nurse must call the physician to obtain an updated order to meet the current pain needs of the resident. If the physician does not change the medication orders and the nurse believes the resident is at risk for continued pain, the Nursing Supervisor must be notified immediately. Residents who have received PRN pain medication more than twice in the last week or having a pain scale greater than seven (7) will be reviewed weekly by the Pain Management Committee. This will comply with the Inter-Disciplinary Team (IDT) approach to pain management for each individual resident. When tracking of pain management is done weekly the care plan must be kept up to date. All care plan changes must be current in order to provide the latest information to caregivers. Pain scale assessments should be documented. Review of the clinical record for Resident #1 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician orders, revealed the physician ordered [MEDICATION NAME] (narcotic pain medication) 5 mg (milligram) one (1) tab by mouth every four (4) hours as needed for pain. Review of Resident #1's Admission Assessment, dated [DATE], revealed Resident #1 was not on a routine pain management program, but did receive as needed (PRN) medication and also received non-medication interventions for pain. However, the assessment did not specify the interventions. The Admission assessment stated if any of the preceding questions were answered with a yes response, proceed to and complete the Comprehensive Pain Assessment and Pain Care Plan. Interview with the MDS Coordinator, on [DATE] at 1:40 PM, revealed all the care plans developed for Resident #1 were provided for review. Review of the Initial Care Plans, provided by the facility and confirmed as complete by the Minimum Data Set (MDS) Coordinator, revealed no pain care plan was initiated prior to [DATE]. Resident #1 began Hospice services on [DATE] and expired on [DATE]. Interview with Resident #1's family member, on [DATE] at 10:45 AM, revealed Resident #1 had Stage IV [MEDICAL CONDITION] and his/her pain was getting worse. The family member stated they had to ask for the pain medication because the medication was ordered as needed. Review of the PRN (as needed) Flow Sheet, identified by the facility as the only one they had, was blank. Review of the 24 Hour Report, under unusual behaviors listed Resident #1's condition as "... no change". Review of the controlled substance record for [DATE] revealed the resident received [MEDICATION NAME] twice on ,[DATE]; three times on ,[DATE]; twice on ,[DATE] and ,[DATE]; three times on ,[DATE] and ,[DATE]; five times on ,[DATE]; twice on ,[DATE] and ,[DATE]; and, once on the other days. Review of Resident #1's Medication Administration Record (MAR), revealed Resident #1 received the last available dose of [MEDICATION NAME] 5 mg, on [DATE] at 8:00 AM. Further review of the MAR for Resident #1 during the month of [DATE], revealed an order for [REDACTED]. The MAR was blank indicating no medication was provided to the resident although the medication was available for use. Further interview with the family member, on [DATE] at 10:45 AM, revealed the resident could have had additional pain medication at 12:00 PM and 4:00 PM. At 1:00 PM, the family stated they asked the nurse for pain medication, and again at 7:00 PM they asked the nurse about the medication. The nurse informed the family that the prescription had to be faxed to the pharmacy, and that was when another nurse informed the family, they could go to their Pharmacy to get the medication filled faster. Review of the MAR revealed Resident #1 received his/her next dose of pain medication at 8:30 PM after the family came back from the pharmacy. Interview with the family's pharmacy, on [DATE] at 2:45 PM, revealed the prescription was brought in at 7:00 PM and filled by 7:27 PM. Review of the care plans, revealed a pain care plan was initiated on [DATE], two days after the resident had to wait eight (8) hours for pain medication. The care plan stated Resident #1 was at risk for alteration in comfort. The pain care plan revealed the approaches were to utilize the pain assessment, identify the location and rate of pain prior to and after any interventions. The staff was to attempt to document the effectiveness of non-pharmacological interventions as appropriate, and report unrelieved or unacceptable levels of pain to the Medical Doctor (MD) as needed. Review of Resident #1's PRN (as needed) Flow sheet for [MEDICATION NAME] and Other Medication, not dated, revealed the form was blank. On the form it outlined the problem, pre-treatment pain intensity, non-medication interventions, medications given, post treatment time, results of the treatment and post treatment intensity. Review of the PRN Flow sheet for [MEDICATION NAME] and Other Medication, not dated, revealed no documentation that the thirty (30) doses of [MEDICATION NAME] 5 mg had been given. Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 11:16 AM, revealed she did not know why she did not document in the Nursing Notes the care that was provided to Resident #1. LPN #3 stated she usually documented in the Nurses Notes and she was responsible to provide the care required by Resident #1. LPN #3 stated she was taught she could document in the Nurses Notes about pain medication provided or document on the PRN flow Sheet. However, she had completed neither. Review of Resident #1's Nurses Notes, dated [DATE], revealed no documentation of any interventions utilized between the hours of 12:00 PM and 8:30 PM, while Resident #1 was waiting for pain medications to arrive and experiencing pain. Interview with Licensed Practical Nurse (LPN) #6, on [DATE] at 1:45 PM, revealed when there was a new admission the nursing staff was responsible to complete a nursing assessment, pain assessment and initiate a pain care plan if the resident triggered for pain. This plan would inform the nurses what was needed for the resident's care. LPN #6 stated nurses were able to initiate care plans and revise care plans. Interview with the MDS Coordinator, on [DATE] at 3:03 PM, revealed based on the care plan the resident's PRN Flow sheet for [MEDICATION NAME] should have been filled out by the nursing staff. The MDS Coordinator stated when she completed her assessments she looked at the MAR and the Nurses Notes. She did not look at the PRN Flow sheet because the form was not appropriately filled out. The MDS Coordinator stated she had not informed anyone about the form not being completed. The MDS Coordinator stated any nursing staff could update or initiate a care plan. Interview with the Director of Nursing (DON), on [DATE] at 3:13 PM, revealed she expected the nursing staff to document on the PRN Flow Sheet for [MEDICATION NAME]. The DON stated through review of the Nurses Notes the nurses were not documenting the effectiveness of the medication, pain levels or other interventions. The DON stated if the nurses utilized the PRN flow sheet they would be following the care plan. The DON stated nurses could initiate and revise care plans.

Based on observation, interview, record review and policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) was free from pain. The facility failed to administer pain medication to Resident #1 when requested, failed to ensure the medication had been reordered timely, failed to notify the Medical Doctor of available medications in the Emergency Drug Kit (EDK) box that could have been utilized until the pain medication was delivered, resulting in Resident #1 experiencing continued pain for eight (8) hours from Stage IV [MEDICAL CONDITION] with Metastasis to the Femur. Hospice accepted the resident on [DATE] and the resident expired [DATE]. (Refer to F425) The findings include: Review of the facility's policy regarding Pain Management Process, dated [DATE], revealed all residents have the right to be free of pain. Upon admission, the Pain Assessment form is to collect data of the current presence of pain, type of pain scale to utilize, predisposing causes of the pain, location and etiology of the pain, quality, intensity and duration of the pain, accompanying symptoms associated with the pain, current management, pharmacological and non-pharmacological treatments, history of resolved and unresolved pain and the resident's pain management goal. The resident's care plan will be generated from the data collected from the pain assessment and updated upon any changes made to the resident's pain regime or resident goals. The physician and family will be notified when pain levels are outside normal levels for each individual resident. The SBAR and other Interact II tools can be used to direct appropriate assessment, intervention and documentation related to the pain. Documentation of pain intensity will be recorded along with interventions for pain reduction using appropriate facility forms and no less than the Pain assessment, Pain flow sheet, SBAR for notification and 24 hour report for any pending re-evaluations or pending interventions. Post intensity evaluation would be assessed and documented in a timely manner. Upon follow-up, if the interventions were effective, the process should be repeated until resident indicates adequate relief. When PRN pain meds are given regularly or frequently, the nurse must call the physician to obtain an updated order to meet the current pain needs of the resident. If the physician does not change the medication orders and the nurse believes the resident is at risk for continued pain, the Nursing Supervisor must be notified immediately. Residents who have received PRN pain medication more than twice in the last week or having a pain scale greater than seven (7) will be reviewed weekly by the Pain Management Committee. This will comply with the IDT approach to pain management for each individual resident. When tracking of pain management is done weekly the care plan must be kept up to date. All care plan changes must be current in order to provide the latest information to caregivers. Pain scale assessments should be documented. Review of the facility's policy regarding New Orders for Schedule II Controlled Substances, revised [DATE], if the controlled substance is needed before the pharmacy can make arrangements for a timely delivery, the facility must fax a request to remove a controlled substance from the emergency drug supply to the pharmacy. Interview with LPN #6, on [DATE] at 1:45 PM, revealed when there was a new admission the nursing staff was responsible to complete a nursing assessment, pain assessment and initiate a pain care plan if the resident triggered for pain. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission assessment, dated [DATE], revealed Resident #1 was not on a routine pain management program, but did receive as needed (PRN) medication and also received non-medication interventions for pain. However, this assessment did not describe the interventions to be used. The Admission assessment stated if any of the preceding questions were answered with a "yes" response (as noted above the resident received a PRN pain medication) then proceed to and complete the Comprehensive Pain Assessment and Pain Care Plan. Review of the Comprehensive Pain Assessment, dated [DATE], revealed it was an admission assessment and Resident #1 was free of pain. The assessment also stated Resident #1 denied any history of pain. Review of Resident #1's initial Care Plan, revealed there was no initial pain care plan provided. Review of Resident #1's Physician Orders, dated [DATE], revealed the physician ordered [MEDICATION NAME] (a controlled narcotic) 5 mg one (1) tab by mouth every four (4) hours as needed for pain. Interview with Resident #1's family member, on [DATE] at 10:45 AM, revealed Resident #1 had Stage IV [MEDICAL CONDITION] with metastasis to the Femur and his/her pain was getting worse. The family member stated they had to ask for pain medication because the medication was ordered as needed. Review of Resident #1's Medication Administration Record, [REDACTED]. However, the resident had an order for [REDACTED]. Further interview with Resident #1's family member, on [DATE] at 10:45 AM, revealed the resident whispered into the family member's ear that the "pain was getting rough", at 1:00 PM they asked the nurse for additional pain medication and the nurse stated there was no pain medication left and they would have to order the medication. The family member stated the resident was yelling out in pain, and at 7:00 PM they asked the nurse again about the medication. The nurse stated they had a prescription, but no drug. The nurse informed the family that the prescription had to be faxed to Indianapolis and that was when another nurse told the family they could go to their pharmacy to get the medication filled faster. Interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 8:47 AM, revealed when the resident was repositioned he/she would grimace, the resident was very stiff and movement hurt him/her. Interview with CNA #3, on [DATE] at 11:05 AM, revealed every time she went into the room she would ask if the resident needed to be repositioned. When they moved the resident he/she would twitch his/her arms and torso. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 3:54 PM, revealed she could not remember much, but did remember giving the last dose of pain medication to Resident #1. LPN #2 stated that looking at the MAR for [DATE], she could see how Resident #1 did not receive pain medication consistently every four hours. LPN #2 stated normally when a drug ran low she would pull the sticker and place the sticker on a medication refill sheet which would then be faxed to the pharmacy. LPN #2 stated that once a medication sticker was pulled from the card, the pharmacy would usually deliver the medication that night. LPN #2 could not remember if the sticker was already pulled when she gave the last dose. LPN #2 stated she did not remember Resident #1 grimacing, crying or appearing restless. Review of a Refill Reorder Form, dated [DATE], revealed Resident #1's [MEDICATION NAME] 5 mg had been reordered to be filled on that date. Interview with LPN #3, on [DATE] at 4:34 PM, revealed when she came on her shift at 2:00 PM on [DATE], while doing her narcotic count with LPN #2, LPN #2 stated she gave Resident #1 his/her last pain medication. Resident #1's family approached the nurse and was concerned about Resident #1's pain medication because the resident had not received it yet. LPN #2 stated she took Resident #1's vitals and he/she was moaning. She stated Resident #1's oxygenation was between 86% and 88%. LPN #2 stated in report she was told Resident #1 was fine, but she could see Resident #1 was not fine based on the oxygen level and blood pressure. LPN #2 stated to LPN #3 that LPN #1 had completed a Situation, Background, Assessment, Recommendation (SBAR) form for her about Resident #1's oxygen levels, but not his/her pain. Continued interview with LPN #2, on [DATE] at 10:07 AM revealed she did not remember the family coming to her and LPN #3 during the narcotic count to inform them of Resident #1's pain. LPN #2 stated she did not remember completing a SBAR on Resident #1's oxygen saturation though it was in her hand writing; however, it was not signed. Review of the Interact SBAR, no date provided, revealed Resident #1's blood pressure was ,[DATE] and oxygen saturation of 89%. Continued interview with LPN #3, on [DATE], revealed she then called the Doctor who said she would have to look up what she could order for Resident #1 because the resident was having difficulty swallowing. LPN #3 stated she was a new nurse as of [DATE] and LPN #6 helped her with ordering the pain medication. LPN #3 stated Medical Records then went to retrieve the first prescription from the Doctor's office. Interview with LPN #6, on [DATE] at 1:45 PM, revealed LPN #3 came to her around 3:00 PM or 4:00 PM to ask for assistance with Resident #1's medication. Interview with Medical Records, on [DATE] at 9:08 AM, revealed she remembered obtaining a prescription from the Doctor's office. Medical Records stated she remembered it was after dinner when she was asked to go pick up the prescription. Further interview with LPN #3, on [DATE] at 4:34 PM, revealed the pharmacy called about two (2) hours later (5:00 PM) and stated the Doctor did not state the route in which the medication was to be given. Interview with the Doctor, on [DATE] at 9:45 AM, revealed she remembered there were two (2) prescriptions that were written. The first prescription had to be rewritten because there was no route identified. Further interview with LPN #3, on [DATE], revealed she then asked LPN #6 about the Emergency Drug Kit (EDK) box, but LPN #6 stated they needed a hard script to get into the box. LPN #2 stated she was not sure if this was right or wrong and she was not familiar with the process. Interview with LPN #6, on [DATE] at 1:45 PM, revealed she was the veteran nurse in the situation and did not know why she did not suggest the EDK box. LPN #6 stated she did not inform the Director of Nursing because she thought she could handle the situation. LPN #6 stated when the second prescription came in most of the Administrative staff was gone for the evening. Interview with the Doctor, on [DATE] at 10:39 AM, revealed she remembered there was a problem with the prescription, her assistant then took the second prescription to the facility by 6:00 PM because her office was closing. Further interview with LPN #6, on [DATE] at 1:45 PM, revealed the Doctor's office closed at 6:00 PM, so the Doctor's assistant came to the facility with the new prescription. LPN #6 stated she took the prescription and called the pharmacy and told them she was going to fax it to them. In the mean time the family member came to her crying and saying when would they give Resident #1 his/her medication. LPN #6 stated then a family member came up and stated, "give me the damn prescription and I will get it filled myself". So the facility staff gave the family member the prescription and the nurse called the facility's pharmacy and told them to forget the order, that the family was taking the prescription to another pharmacy. LPN #6 stated the family's pharmacy called and stated they could not fill the second prescription so LPN #6 then called the Doctor back. LPN #6 stated the Doctor asked the family's pharmacy what they had and wrote a prescription for that medication. Resident #1 was having a difficult time swallowing, eating and refusing to have anything placed into his/her mouth; Mophine Sulfate was ordered to help with swallowing. Interview with LPN #3, on [DATE] at 11:16 AM, revealed she did not know why she did not document in the Nursing Notes the care that was provided to Resident #1. LPN #3 stated she usually documented in the Nurses Notes and she was responsible to provide the care required. LPN #3 stated she was taught she could document in the Nurses Notes about pain medication provided or document on the PRN flow sheet. Interview with the MD, on [DATE] at 9:45 AM, revealed she got a call that the resident was in horrific pain and she called and talked with the family's pharmacy. The family member brought the medication back to the facility to ensure the resident got it quickly. There were several hours in delay. The delay in the system was the pharmacy. She further stated the facility did not call her prior to the medication running out and the last dose given. She stated she knows they did not do well with Resident #1. The MD further stated she did not want this to happen again, so she went to the pharmacy herself and obtained medication for another resident who was also dying. Interview with the Director of Nursing (DON), on [DATE] at 3:13 PM, revealed there were no other PRN flowsheets for Resident #1 only the one provided for review. However, this form was blank and only contained the last name of the resident. She further stated she worked the Monday of [DATE] and did not remember any of the nursing staff coming to her to inform her they were having problems with obtaining a pain medication. The DON stated she did not hear of any complaints from family members as well. The DON stated she had written a note to herself on [DATE] wanting to know what happened in regards to Resident #1's medication. The DON stated she informed the nurses if they were having problems with obtaining pain medication they needed to request a hard script so that they could obtain medication from the EDK box, while waiting for pharmacy to bring in pain medications. Review of the medication in the EDK box, revealed five (5) medications which included four (4) were by mouth, one (1) was a patch and one (1) was an injection. The EDK box contained six (6) each of [MEDICATION NAME]/Apap ,[DATE]g tab, [MEDICATION NAME] 25 mcg/hr patch, and [MEDICATION NAME] 10 mg/ml injection. However, none had been removed to administer to Resident #1. Further interview with the DON, on [DATE] at 3:13 PM, revealed she would expect the nursing staff to look and see what type of drugs were available in the EDK box. The DON stated when a nurse administered a pain medication they were expected to document the pain levels and effectiveness. The DON stated the nurses should document the non-pharmacological interventions and also document correspondence with the pharmacist. If the nurses were having some problems she would also expect them to document on the 24 Hour Report, nurse to nurse, shift to shift report. The DON stated depending on the type [MEDICAL CONDITION], it could be painful. She stated she felt the process failed because of the lack of communication with nursing. The DON stated it was not the family's responsibility to obtain pain medication for the resident. Review of the 24 Hour Report revealed no documentation about Resident #1's pain medication not being available nor the pain experienced by the resident. Interview with the Administrator, on [DATE] at 4:40 PM, revealed when she left for the evening of [DATE]th, she over heard the family talking to the nurse. The Administrator stated she heard the nurse inform the family, the doctor was sending another prescription so they could get a stat order. She further stated the nursing staff did not tell her how long the resident had been without pain medication. The Administrator stated a resident should not go without pain medication for eight (8) hours and they should have made an effort to ensure the resident was free of pain. In addition, the Administrator stated she would expect the nursing staff to inform her or the DON if they were having problems and it was her impression the nursing staff had it under control. The Administrator further stated she would expect the nursing staff to try to obtain medications from the EDK box. She stated the breakdown was that the nurses did not provide Resident #1 with pain medication that was needed, nor inform the DON to ensure the resident received his/her pain medication.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to follow proper infection control practices during catheter care and perineal care for four (4) of fifteen (15) residents (Residents #4, #8, #10, and #11). The facility failed to ensure proper hand hygiene and glove changes, during indwelling catheter care for Residents #4, #10, and #11. In addition, facility staff failed to demonstrate the correct technique during perineal care for Resident #8. The findings include: Review of the Lippincott's Textbook for Nursing Assistants, copyright 2005, regarding "Providing Catheter Care-Procedure 20-6" (used by the facility as the policy), revealed ...a. If the person is a woman: Using the other hand, separate the labia. Place your wash-cloth-covered hand at the top of the vulva and stroke downward to the anus ... Repeat, using a different part of the washcloth each time, until the area is clean. Rinse and dry the vulva and perineum thoroughly. The facility did not have a policy specific to when hands should be washed before and after specific procedures, or when gloves should be changed. 1. Review of the medical record for Resident #4, revealed the facility admitted the resident on 08/17/12, with [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment, dated 07/12/13, revealed the resident had an indwelling catheter with [DIAGNOSES REDACTED]. During observation of indwelling catheter care for Resident #4, on 01/14/14 at 9:10 AM, revealed CNA #2 put on her gloves and positioned the resident in a standing position while the resident held the grab bar in the resident's bathroom. CNA #2 positioned herself behind the resident in a standing position, using a cleansing cloth to clean bowel movement by reaching under the resident's perineum from the catheter tubing, and wiped back to the rectal area. The CNA then cleaned the bowel movement (BM) by folding the wash cloth and again wiped front to back twice. However, the CNA then took the cleaning cloth and reached underneath the resident's perineum and cleaned the tubing blind-sided straight down the catheter tubing from inside to out. The CNA failed to visualize the area of the labia or cleanse the labia according to the procedure, nor did she change her gloves after cleaning the BM before going back to the labia, or front area. Interview with the CNA #2, on 01/14/14 at 9:20 AM, revealed she should cleanse front to back, and thought that's what she did. However, the CNA stated she should have washed her hands, but she did not think about it. The CNA revealed she did not think she should have changed her gloves. Interview with LPN #3, on 01/16/14 at 10:15 AM, revealed Resident #4 had a catheter since admission to the facility, and stated there had been a multiple past history of Urinary Tract Infections. 2. Review of the medical record for Resident #11 revealed the facility admitted the Resident on 07/24/12, with [DIAGNOSES REDACTED]. Interview with Resident #11, on 01/16/14 at 8:10 AM, revealed he/she had been a resident there for a year, however stated the facility had to insert an indwelling catheter last week for Urinary Retention and stated the catheter drained 1000 cc of urine at first, then 2500 cc after a short period of time. The resident had a bariatric bed in place, and stated he/she did not like to get up. Review of the current care plan for Resident #11, dated 06/12/13, revealed a problem with alteration in bowel and bladder related to decreased mobility, weakness, occasional incontinence, and history of diarrhea with interventions to rule out Urinary Tract Infection with changes in continence. Review of the current physician's orders revealed Foley catheter and perineal care to be completed every shift. Observation of indwelling catheter care for Resident #11, on 01/16/14 at 10:00 AM, after permission obtained from the resident, revealed CNA #2 to put on her gloves, without washing her hands, and cleansed the left side of the perineum using cleansing cloths, then proceded to the right side, cleaning downward. The CNA was observed to picked up the catheter and cleaned the tubing inside to out. The CNA emptied the catheter, with 450 cc'c output, then removed her gloves and cleaned the door knob to the bathroom with the cleansing cloth. The CNA then picked up the dirty trash bag with her dirty hands and carried the dirty bag up the hallway without gloves. There was no hand washing observed before or after the procedure. Interview with CNA #2, on 01/16/14 at 10:10 AM, revealed she should wash her hands before and after each procedure, and realized she did not do it. She stated she usually takes the dirty trash bags to the utility room with her bare hands before washing them. Interview with LPN #3, on 01/16/14 at 10:15 AM, revealed the CNA's were responsible for completing the Perineal area and indwelling catheter care; then they are responsible for documenting in the Accu- Nurse System four (4) times per day and the nurses monitor 3-4 times per day for percentages. The LPN revealed the CNA's have to have 100% by the end of the day. Further interview with the LPN revealed the nurse's do orientation check offs and the CNA's have three (3) days training with another aide. She further stated the CNA's need to be re-educated on the proper technique. The LPN revealed that although CNA #2 had received her Silver Chair Training in October 2013, she would need to be re-educated. In addition, the LPN revealed that Resident #11 recently received an indwelling catheter for Urinary Retention, and stated the resident is non-compliant with most care, and is Diabetic, which makes him/her prone to Urinary Tract Infections. 3. Review of the facility Infection Control Course, dated from 07/01/12 through 01/15/14, revealed staff should wash their hands before and after an invasive procedure and when ever gloves were soiled. Review of the medical record for Resident #10, revealed the facility admitted Resident #10 on 07/01/12, with a [DIAGNOSES REDACTED]. Observation of Catheter Care for Resident #10, on 01/16/14 at 9:18 AM, revealed Certified Nursing Assistant (CNA) # 1, washed her hands, donned gloves and cleaned Resident #10's peri area from front to back. CNA #1 then with the same gloves placed clean linen under Resident #10's coccyx. CNA #1 then asked Resident #10 to grab his/her hand to pull the resident onto his/her side to ensure the linen was not bunched under Resident #10's coccyx (with the same gloves that provided peri care). CNA #1 then drained Resident #10's catheter bag, removed gloves and washed her hands. Interview with CNA #1, on 01/16/14 at 9:35 AM, revealed she was not aware she should remove her gloves. CNA #1 stated that she was sure she had received training on when to remove gloves and wash hands, but could not remember when the last training occurred. CNA #1 stated she should have removed her gloves to prevent the spread of infection. Interview with Licensed Practical Nurse (LPN) #1, on 01/16/14 at 10:16 AM, revealed she had observed peri care at times and found that some of the staff were not changing their gloves at appropriate times, especially when going from dirty to clean. LPN #1 stated that when she observed this she would educate the CNA on the spot. LPN #1 stated this does not happen often. LPN #1 stated she had not notice an increase in urinary bladder infections. 4. Review of the medical record for Resident #8 revealed the facility admitted the resident on 03/13/13 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] and a Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as incontinent of bowel and bladder and required moderate assist of one (1) for incontinent care. There was no indication in the medical record the resident had been treated for [REDACTED]. Observation on 01/15/14 at 9:10 AM revealed, Certified Nursing Assistant (CNA) #3 was providing peri care for Resident #8. The CNA wiped from the vaginal area up toward the pubic area three (3) times. Licensed Practical Nurse (LPN) #3 was assisting and had observed peri care provided by the CNA. Interview with CNA #3 and LPN #3 on 01/16/14 at 10:25 AM revealed the CNA did not realize she had cleaned the resident from back to front and stated it should have been from front to back. She stated the potential complications from using improper technique during peri care was for Urinary Track infections. Interview with LPN #3 at the same time revealed she realized the CNA had done it incorrectly and waited until the surveyor left the room before asking the CNA about not using incorrect technique. CNA #3 stated she did not know when the last time she had been trained on peri care. LPN #3 stated they do most of their training on a computer program now, but will do on the spot in services if necessary. She stated she did not remember if they had an on the spot training on peri care recently. Interview with the Administrator, on 01/16/14 at 3:00 PM, revealed the Nurses should be monitoring all CNA's to ensure all catheter care and perineal care is completed correctly according to their training. The Administrator revealed with the size of the home, there was no Staff Development Coordinator in the facility now. However, the Administrator stated the new Assistant Director of Nursing would be taking some of those responsibilities, and would be monitoring the in-services. Interview with the Director of Nursing (DON), on 01/16/14 at 4:15 PM, revealed she monitors staff providing care and reminds nurses to watch Perineal Care and Catheter Care. The DON also revealed they use an in-service program called Silver Chair, which teaches indwelling catheter care and perineal care. The DON also stated both she and the Assistant Director of Nursing should be monitoring the staff ongoing; however, revealed she had only been in the position a few months. Further interview with the DON, on 01/16/14 at 4:15 PM, revealed the facility did not complete skills competencies for staff, and no longer had a Staff Development Coordinator; she stated the Silver Chair Training on the computer had replaced this. However, the DON stated that spontaneous in-services can be done. Interview with the ADON, on 01/16/14 at 5:00 PM, revealed the facility used the Lippincott Manual for all procedures, and stated the Nursing Assistants wore headsets, which give them Care Plan interventions, such as indwelling Catheter Care and Perineal Care.

Based on observation, interview, record review and Water Temperature Instructions, it was determined the facility failed to ensure water temperatures were maintained at an acceptable range. During Environment Tour, water temperatures were observed to spike up to 117 degrees. Twelve (12) of fifty-five (55) residents could have been affected due to mobility and the ability to get to the water independently. The findings include: Review of the Test Water Temperatures instruction, no date given, revealed to ensure patient room water temperatures were between 105 degrees and 115 degrees Fahrenheit (F) (or as specified by state requirements) test temperatures in shower areas and check resident rooms at the end of each wing on a rotating basis. Note any discrepancies, adjust water heater settings as required and retest as necessary. Interview with the Maintenance Director, on 01/15/14 at 9:22 AM, revealed water temperatures should be between 100 to 110 degrees F. Observations made during the facility Environment Tour, on the A hall, on 01/15/14 at 9:22 AM, revealed Room 122 water temperature spiked to 115 F and then dropped to 110 F in ten (10) seconds. Room 125 water temperature spiked to 114 F and then dropped to 105 F in thirty (30) seconds. Room 133 water temperature spiked to 113 F and held. The shower room water temperature, on A hall, spiked to 113 F and dropped to 109 F in thirty (30) seconds. Observation made during Environment Tour, on B hall, on 01/15/14 at 9:44 AM, revealed Room 103 water temperature spiked to 117 F and then dropped to 110 F in one (1) minute. Room 108 water temperature spiked to 111 F and held. Interview with the Maintenance Director, on 01/15/14 at 9:44 AM, revealed he was taught to check one room on each hall daily. The Maintenance Director stated he was taught to always let the water spike and then drop to obtain a true reading of the water temperature. The Maintenance Director stated if water temperatures reached 120 F and dropped slowly it could possibly scald a resident. Further interview with the Maintenance Director, on 01/15/14 at 3:06 PM, revealed if a temperature was documented high, he would then go check the mixing valve. The Maintenance Director stated that after the Environment Tour, he noticed the water heater temperature was on 117 F. The Maintenance Director then adjusted the valve and stated the highest the water temperatures ever spiked for him was 111 F. The Maintenance Director stated he noticed a flaw in his method of checking the water temperatures and should check front rooms, back rooms and shower rooms on each hall daily. The Maintenance Director stated the boiler was closer to the front of the halls. The Maintenance Director stated the old process of checking water temperatures was not an accurate account of water temperatures in the building because the water heater was closer to the front rooms of the halls. Record Reviews of the water temperature logs for the months of November, December and January revealed water temperatures were within normal limits. Record review of the water temperature logs, also revealed one (1) room on each hall was monitored daily. Interview with the Administrator, on 01/16/14 at 4:15 PM, revealed she was not aware the Maintenance Director was checking one (1) room on each hall daily. The Administrator stated water temperatures should be held between 100 F to 110 F. The Administrator stated water temperatures should not go above 110 F to prevent burns. The Administrator stated there had not been any incidents or injuries due to water temperatures being elevated.

Based on observation, interview, record review and policy review, it was determined the facility failed to develop a comprehensive care plan for two (2) of fifteen (15) sampled residents. Residents #10 and #11 had Foley catheters that were not reflected in the Residents' care plans. The findings include: Review of the Care Plan Policy, dated 09/08, revealed the residents comprehensive care plan should be viewed as an Interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility. Efforts should always be directed towards developing care guidelines for Medical [DIAGNOSES REDACTED]. 1. Review of the medical record for Resident #10, revealed the facility admitted the resident on 07/01/12, with a [DIAGNOSES REDACTED]. Review of Resident #10's, Minimum Data Set (MDS) Quarterly Assessment, dated 10/16/13, revealed the facility documented Resident #10 was incontinent, no catheter. Review of Resident #10's Comprehensive Care Plan, dated 02/04/13, revealed the resident had an alteration in elimination related to extensive assist with two (2) person physical assist and bilateral above the knee amputations. There was no documentation the resident had an indwelling catheter on the care plan. Observation of Resident #10, on 01/15/14 at 3:58 PM and 01/16/14 at 8:50 AM, revealed Resident #10 had a indwelling catheter bag attached to the bed frame in a dignity bag. Interview with MDS Coordinator, on 01/15/14 at 5:20 PM, revealed she completed and updated care plans when assessments were completed. The MDS Coordinator stated the nursing staff were responsible to initiate the care plan when a resident was newly admitted with a catheter. The MDS Coordinator stated Resident #10 was admitted with an indwelling catheter in December of 2013. Interview with the Assistant Director of Nursing (ADON), on 01/16/14 at 5:35 PM, revealed nurses could initiate the care plan when a resident was newly admitted . The ADON stated if there was no care plan than the nursing staff would not be aware of the plan of care for the residents. 2. Review of the medical record for Resident #11, revealed the facility admitted the resident on 07/24/12, with [DIAGNOSES REDACTED]. Interview with Resident #11, on 01/16/14 at 8:10 AM, revealed he/she had been a resident there for a year; however, the facility had to insert an indwelling catheter last week for [MEDICAL CONDITION]. Review of the current care plan for Resident #11, dated 06/12/13, revealed goals for alteration in bowel and bladder related to decreased mobility, weakness, occasional incontinence, and history of diarrhea with interventions to rule out Urinary Tract Infection with changes in continence. Review of the current physician's orders [REDACTED]. Observation of indwelling catheter care for Resident #11, on 01/16/14 at 10:00 AM, revealed CNA #2 put on her gloves, without washing her hands, and cleansed the left side of the perineum using cleansing cloths, then proceeded to the right side, cleaning downward. The CNA was observed to picked up the catheter and clean the tubing inside to out. The CNA emptied the catheter, with 450 cc's output, then removed her gloves. The CNA then picked up the dirty trash bag with her dirty hands and carried the dirty bag up the hallway without gloves. There was no hand washing observed before or after the procedure. Interview with CNA #2, on 01/16/14 at 10:10 AM, revealed she follows the instructions from the head set she wears which has a care plan for each resident, and catheter care was noted for Resident #11. Interview with LPN #3, on 01/16/14 at 10:15 AM, revealed the nurse's are required to make changes on the care plan as they receive physician's orders [REDACTED]. Interview with the Administrator, on 01/16/14 at 3:00 PM, revealed the Nurses should be monitoring all CNA's to ensure all catheter care and perineal care is completed correctly according to their training. In addition, the Administrator revealed nurses, and the Assessment Coordinator should be monitoring for care plan changes needed.