Every finding on record at Carol Woods

Based on staff interview and record review the facility failed to submit accurate payroll data, regarding 24-hour licenses nurse coverage, for 9 of 9 days reviewed (10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, 12/31/23) of the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the 1st quarter in fiscal year 2024. Findings included: The CMS submission report, PBJ Final File Validation Report for Fiscal Year 2024 (October 1 to December 31) showed the facility failed to have Licensed Nursing Coverage, 24 hours out of 24 hours for the days of 10/14/23, 10/28/23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, and 12/31/23. Posted Nurse Staffing, nurse schedules, and the nursing staff's timecards for 10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, and 12/31/23 were reviewed and revealed there was 24-hour licensed nursing coverage for the 1st quarter of Fiscal Year 2024. During an interview with the Administrator on 6/6/24 at 11:35am she revealed that there was 24-hour licensed nursing staff working on 10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, and 12/31/23 but that the office must have not submitted the information incorrectly.

Based on record review and resident and staff interviews the facility failed to follow their policy on pneumococcal vaccine and offer up to date pneumonia vaccines to 5 of 5 residents reviewed for immunization status (Resident #3, Resident #8, Resident #9, Resident #12, and Resident #123). The findings included: The facility's policy on pneumococcal vaccine last reviewed in July 2023 stated, the administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendation at the time of the vaccination. a. Resident #3 was admitted to the facility on [DATE]. Her diagnoses included rheumatic heart disease, hypertension and atrial fibrillation. Review of Resident #3's immunization record revealed she received PPSV23 on 10/16/14 and PCV13 on 2/1/16. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact, and her pneumococcal immunization was up to date. Review of Resident #3's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of the 20-valent pneumococcal conjugate vaccine (PCV20). During an interview on 6/5/24 at 10:30 am, Resident #3 stated she did not know about pneumonia vaccine. She could not remember if a staff member talked to her about it. b. Resident #8 was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease, cholecystitis and hypertension. Review of Resident #8's immunization record revealed she received PPSV23 on 4/15/10 and a PCV13 on 10/4/16. Review of the quarterly MDS dated [DATE] revealed that Resident #8 was cognitively intact, and her pneumococcal immunization was up to date. Review of Resident #8's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. During an interview on 6/5/24 at 10:40 am, Resident denied being offered a pneumonia shot and denied receiving one. c. Resident #9 was admitted to the facility on [DATE]. His diagnoses included chronic kidney disease, heart attack and stroke. Review of Resident #9's immunization record revealed he received PPSV23 on 1/1/94 and a PCV13 on 4/22/16. Review of the comprehensive MDS dated [DATE] revealed that Resident #9 was cognitively intact, and his pneumococcal immunization was up to date. Review of Resident #12's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. Resident #9 was not available for interview. d. Resident #12 was admitted to the facility on [DATE]. His diagnoses included diabetes mellitus, hypertension and vascular dementia. Review of Resident #12's immunization record revealed he received PPSV23 on 7/13/10 and a PCV13 on 2/26/16. Review of the quarterly MDS dated [DATE] revealed that Resident #12 was severely cognitively impaired, and his pneumococcal immunization was up to date. Review of Resident #12's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. The resident's representative was not available for interview by telephone during the survey. e. Resident #123 was admitted to the facility on [DATE]. His diagnoses included hypertension, atherosclerotic heart disease and vascular dementia. Review of Resident #123's immunization record revealed he received PPSV23 on 7/7/10 and a PCV13 on 4/3/15. Review of the quarterly MDS dated [DATE] revealed that Resident #123 was cognitively intact, and his pneumococcal immunization was up to date. Review of Resident #123's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. Resident #123 preferred not to be interviewed during the survey. During an interview on 6/5/23 at 3:50 pm, his representative stated she did not get any information on the update pneumonia vaccine for the resident. During an interview on 6/5/24 at 2:24 pm, the Infection Preventionist stated she thought the residents did not need any more pneumococcal vaccines after they received the PPSV23. She stated she would check the current guidelines. During a follow up interview on 6/6/24 at 8:46 am, the Infection Preventionist stated she would discuss the current guidelines for the pneumococcal vaccine with the Medical Director. During an interview on 6/6/24 at 10:03 am, the Director of Nursing stated she expected staff to follow the facility's policy, current guidelines and immunization best practices for the residents.

Based on observations and staff interviews, the facility failed to discard expired food items, and label and date food available for resident use in 1 of 1 walk-in cooler and 1 of 4 reach-in coolers in the main kitchen, in 1 of 1 walk-in cooler and in 2 of 3 reach-in coolers in building 4 kitchen, and in 2 of 4 nourishment room refrigerators ([NAME] and blue bird pods' refrigerators) in the 3rd floor of building 4 where the nursing home residents resided. These practices had the potential to affect food and beverages served to the residents. Findings included: a. An initial tour of the kitchen on [DATE] at 11:05 am was made with the Dining Services Director, Master Chef and building 4 Kitchen Manager. An initial observation of the walk-in cooler on [DATE] at 11:10 am revealed an opened bag of large flour tortillas dated [DATE], a large tray of mushrooms labeled Discard [DATE], a half block of white cheese wrapped in plastic dated [DATE], an opened jar of blue cheese dressing without any date, an opened jar labeled with a marker salad dressing [DATE] discard [DATE], an opened jar of cheese vinaigrette dressing labeled [DATE]. b. An initial observation of the reach-in cooler in the main kitchen on [DATE] at 11:15 am revealed a medium tray labeled egg salad with a sticker date showing [DATE] and discard [DATE], and olives in a large tray with a sticker date of [DATE] and discard [DATE]. The Dining Services Director stated they were mislabeled but should have been discarded after 7 days. The Master Chef stated the items in the main kitchen were used in preparation of food for residents in all buildings. c. An initial observation of the building 4 kitchen where the nursing home residents resided on [DATE] at 11:45 am revealed the walk-in cooler had an open carton of fat free milk dated [DATE], reach-in cooler #1 had a small tray of shredded cheese without any date, reach-in cooler #2 had a small tray of lettuce without any date and an opened bag of turkey slices dated [DATE]. d. An initial observation of the nourishment refrigerators on [DATE] at 2:30 pm revealed an opened lemonade bottle without a date in the [NAME] pod's refrigerator. The blue bird pod's refrigerator had 6 small cups of cottage cheese dated [DATE] with a marker and a small, opened bag of loaf bread dated [DATE]. During an interview on [DATE] at 1:51 pm, the Dining Services Director stated the Master, and the Sous Chefs were responsible for checking labels and expiration dates in the main kitchen twice daily. He stated one of them was off during the initial tour and the checks were not done yet. He stated there were a lot of new staff that needed to be trained in food storage. He stated the Kitchen Manager was responsible for checking food items in building 4 and she was new. The nourishment refrigerators were also checked by the Kitchen Manager and her staff. He stated they should be checked twice daily. During an interview on [DATE] at 3:24 pm, the Administrator stated she was aware of unlabeled and misdated food items found in the kitchen. She stated they will work on correcting the problem. During a follow up interview on [DATE] at 9:59 am, the Administrator stated she expected staff to follow their policy on labeling and storing food items.

Based on record review and staff interviews, the facility failed to review and revise the care plan in the area of falls for Resident # 2. This was for 1 of 9 residents reviewed for care plans. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction and unsteadiness of feet. Resident #2's active care plan dated 10/24/23 revealed a focus that read resident was at risk for falls related to weakness and fall history. The care plan was initiated on 1/5/22. The active care plan has had no other updates or revisions since 10/24/23. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #2 was cognitively impaired and no falls since admission. A review of the nurse's progress note dated 4/2/24 and authored by Nurse #1, revealed Resident # 2 had attempted to go to the bathroom without calling for staff assistance and fell in her room. The progress note further revealed staff implemented more frequent checks on Resident #2 due to the possibility of her forgetting to call for staff assistance again. An interview was conducted on 06/05/24 at 12:07 PM with MDS Nurse #1. She indicated that Resident #2's falls care plan had not been reviewed or revised since 10/24/23 due to an oversight and the care plan should have been updated to reflect the fall that occurred in the facility. An interview was conducted on 6/5/24 at 12:39 PM with the Director of Nursing. She revealed that she does not know why Resident #2's falls care plan had not been reviewed or revised since 10/24/23 but the care plan should have been reviewed and revised to reflect the fall in the facility and that each care plan should be reviewed and or revised every 92 days and as needed.

Based on record review and staff interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) database (Resident #1) and failed to electronically transmit to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, a 5 day assessment within 14 days of the completion date (Resident #16) for 2 of 9 residents reviewed for resident assessment. Findings Included: a.Resident #1 was admitted on [DATE]. The discharge MDS assessment dated [DATE] was signed as completed on 3/8/24. The facility's electronic medical record indicated the assessment had been transmitted and accepted to the CMS database. Review of the CMS database on 6/5/24 did not indicate this assessment had been accepted. An interview was conducted on 6/6/24 at 10:22 AM with MDS Nurse #1. She indicated that she completed the assessment but was not sure why this was not transmitted and accepted correctly but she had been behind from being off the month of January 2024. An interview was conducted on 6/5/24 at 1:57 PM with the Director of Nursing. She indicated that she is not sure why the MDS Nurse #1 did not confirm that the assessment had been transmitted and accepted and that all assessments should be completed and submitted within the required timeframes. b.Resident #16 was admitted on [DATE]. A review of Resident #16 5-day assessment with an Assessment Reference Date (ARD) of 1/18/24 was signed as completed on 2/1/24. The assessment was submitted to the QIES ASAP system on 3/13/24. An interview was conducted on 6/5/24 at 1:57 PM with the Director of Nursing. She indicated that she is not sure why the MDS Nurse #1 did not confirm that the assessment had been transmitted and that all assessments should be completed and submitted within the required timeframes. An interview was conducted on 6/6/24 at 10:22 AM with MDS Nurse #1. She indicated that she completed the assessment, but it was rejected and had to be resubmitted. She further revealed that she did not know why this was done late but that and that she had been behind from being off the month of January 2024.

Based on staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 10/7/21 in order to achieve and sustain compliance. This was for recited deficiency on a recertification survey on 2/9/23. The deficiency was in the area of Medicaid/Medicare Coverage/Liability Notice. The continued failure during one federal survey of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: F582 - Based on record review and staff interviews, the facility failed to provide the Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage Letter (NOMNC, CMS-10123 form) for 1 of 3 sampled residents reviewed for beneficiary protection notification review (Resident # 73). During the previous recertification survey on 10/7/21, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) letter for discharge from Medicare Part A services for 2 of 3 residents reviewed for beneficiary protection notification review. An interview with the Administrator was conducted on 2/09/23 at 2:54 PM. The Administrator stated the Quality Assurance (QA) committee does 1) identifies areas of concern, 2) does a root cause analysis, 3) develops a plan, audits, and monitors that plan and 4) discusses the outcome. System change and addition task would put in place as needed to resolve the issue. The Administrator further stated that for the last citation the performance improvement plan was in place. The old plan would be revisited and analyzed to see where the failures, and where the breakdown happened. The root cause would be revisited and new interventions, monitoring tools would be put in place. Audit / education would be completed as needed. The new process will be put in place as a plan of correction to ensure compliance. The team would continuously monitor until the deficient area concerns have been resolved. The Administrator indicated that all citations were discussed in the QAA meeting including any repeat citation.

Based on record review and staff interviews, the facility failed to provide the Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage Letter (NOMNC, CMS-10123 form) for 1 of 3 sampled residents reviewed for beneficiary protection notification review (Resident # 73). Findings included: Resident # 73 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to thrombosis of left vertebral artery; Type 2 diabetes mellitus with hyperglycemia, and muscle weakness and abnormalities of gait. The resident was discharged on [DATE]. A review of the Skilled Nursing Beneficiary Protection Notification Review form revealed Resident #73's Medicare Part A services started on 8/10/22 and the last covered day was 10/31/22. The form further revealed that the facility initiated the discharge from Medicare Part A services when benefit days were not yet exhausted. The discharge was planned between the care team and the resident. The medical record review further revealed that the NOMNC letter which explained the Medicare A coverage for skilled services was not issued to the Resident #47 or the resident's representative. During an interview on 2/9/23 at 10.08 AM, the Accounting manager stated the resident's benefits had not been exhausted and the resident was not provided the NOMNC form as it was an oversight due to staff issue. The accounting manager further stated she was not in the office that week and the staff responsible just quit the organization and hence it was not completed. On 2/8/23 at 2:39 PM an interview was conducted with the Administrator and Director of Nursing (DON). The DON stated the resident prior to her discharge went home on a Leave of Absence (LOA). The DON further stated upon return to the facility the resident had initiated the discharge process. Care team and therapy agreed the resident had met her goals and safe discharge process was put in place. The Administrator stated it was more resident initiated discharge versus benefit exhaustion or reduction in the resident's services. The Administrator stated as the resident initiated the discharge, the NOMNC was not provided to the resident. It was overlooked by staff.

Based on observations, staff interviews, and record review the facility failed to maintain clean kitchen equipment on 3 of 3 days observed and staff failed to cover all hair while working in the kitchen for 4 of 14 staff observed. Findings included: 1. During observation of the kitchen on 10/04/21 at 12:43 PM the following items were observed: a. The grill had hard black food debris on the top and in between the grates, food debris on sides and top of grill, the two drip pans located under the grill grates with food/grease debris, and a white rag with areas of dark brown substance in the right drip pan. b. The fryer was observed with debris on the outer surface, dark oil with sediment in the oil, and a dark liquid substance on the floor around the right front leg of the fryer. c. The steam kettle was observed with a white hard substance on the exterior of the steam kettle. d. The salad #2 refrigerator observed with a thick, tan dried substance on the door handle and grease with dust on the bottom front vent area that was sticky to the touch. During observation of the kitchen on 10/06/21 at 11:30 AM the following items were observed: a. The grill had hard black food debris on the top and in between the grates. The two drip pans under the grill grates had food/grease debris, and a white rag with areas of dark brown substance in the right drip pan. b. The fryer was observed with food debris on outer surface, dark oil with sediment in the oil, and a dark liquid substance on the floor around the right front leg of the fryer. c. The steam kettle was observed with white hard substance on the exterior of the steam kettle. d. The salad #2 refrigerator observed with a thick, tan dried substance on the door handle and grease with dust on the bottom front vent area that was sticky to the touch. During observation of the kitchen on 10/07/21 at 10:33 AM the following items were observed: a. The grill with hard black debris on top and in between the grates. The two drip pans under the grill grates with food/grease debris, and a white rag with areas of dark brown substance in the right drip pan. b. The steam kettle was observed with orange/brown hard substance on the exterior of the steam kettle. c. The salad #2 refrigerator observed with a thick, tan dried substance on the door handle and grease with dust on the bottom front vent area that was sticky to the touch. During an interview on 10/06/21 at 11:45 AM the Dietary Cook Manager revealed that the grill and fryer were fully broken down and cleaned weekly. He stated that the grill and fryer should be wiped down after use and the drip pans under the grill were cleaned after use. The Dietary Cook Manager reported that staff were assigned to clean areas of the kitchen which included the grill, fryer, and refrigerators and were required to sign on the check list when completed. He was unable to provide the current cleaning check list with assignments. During an interview on 10/07/21 at 10:33 AM the Dietary Cook Manager presented a weekly cleaning list for staff cleaning assignments for kitchen appliances and surfaces daily and weekly. He stated the assignment list for the current week was not available and he did not have the previous weeks assignments to confirm the cleaning was completed. He reported the white rag should not have been in the drip tray. The Dietary Cook Manager stated that ultimately, he was responsible to confirm the cleaning was completed. During an interview on 10/07/21 at 10:44 AM Dietary Support Staff #3 revealed that he was not familiar with the weekly cleaning list for staff cleaning assignments. He stated he was not aware that he would be assigned to clean refrigerators or other areas of the kitchen. During an interview on 10/07/21 at 10:48 AM the Cook revealed that he was not familiar with the weekly cleaning list for staff cleaning assignments. He stated he was responsible for the grill and he stated he cleaned the grill twice a week. Record review of the Cleaning Procedure for Main Dining Room: Back-of-House checklist dated 10/07/21 revealed that the assigned staff was to clean any noticeable debris from the exterior of the refrigerator daily and scrub interior and exterior of the steam kettle daily. The grill and fryer were broken down, oil drained from fryer, and scrub interior and exterior of the grill and fryer. The checklist was to be initialed after task was completed. 2. During kitchen observation on 10/06/21 at 11:30 AM the Dietary Support Staff Supervisor was observed in the kitchen at the food preparation and cooking area with long, loose hair, her hair was in a ponytail down to middle of her back, hair was not restrained. An immediate interview revealed that she was not told that she was required to wear a hair net to cover her hair when she entered or was in the kitchen area. During a kitchen observation on 10/07/21 at 10:39 AM Dietary Support Staff #1 was observed entering the kitchen with his hair, not restrained. A continuous observation revealed that he walked past the food preparation/cooking area while food was being prepared and entered the break room. He exited the break room and entered the food storage room; his hair was not restrained. He exited the food storage room and entered the second food storage room; his hair was not restrained. He was observed exiting the second food storage room and exited the kitchen, his hair was not restrained. He obtained a hair net from the wall mounted file holder outside the kitchen entrance door and placed over his hair and returned to the kitchen at 10:42 AM. An immediate interview revealed he was aware a hair net or a hat was required in the kitchen, but he just started his workday and did not put one on when he arrived. An observation on 10/07/21 at 10:40 AM Dietary Support Staff #2 walked through the kitchen to the food preparation/cooking area while food was being prepared her long hair with braids, gathered in a loose ponytail down to the lower back, not restrained. An immediate interview revealed she was aware a hair net was required but did not have it on. She was not able to state why she did not have a hair net in place over her braids. She exited the kitchen at 10:42 AM, hair not restrained. An observation on 10/07/21 at 10:45 AM Dietary Support Staff #4 entered the kitchen with a tray cart and walked past the food preparation/cooking area while food was being prepared, with her hair touching her shoulders, not restrained. An immediate interview revealed she was aware a hair net was required to keep her hair covered while in the kitchen. She stated she was returning the items to the kitchen and would get one. During an interview on 10/06/21 at 11:35 AM the Dietary Cook Manager revealed that hair nets or hats were required to be worn in the kitchen to keep hair contained. He stated the hair nets were outside each entrance to the kitchen. He was unable to say why staff entered the kitchen without the hair net on. During an interview on 10/07/21 at 11:30 AM the Administrator revealed that the Dietary Manager (DM) was on vacation and the Dietary Cook Manager oversaw the kitchen in the absence of the DM. She stated she was not familiar with the kitchen cleaning schedule but would attempt to obtain the cleaning guideline.

Based on record review and staff interviews the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) letter for discharge from Medicare Part A services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #171 and #172). Findings included: 1. Resident #171 was admitted to facility for skilled services 08/24/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #171 was discharged from the facility on 09/24/21. A review of the medical record revealed that Resident #171 was not issued a CMS Notice of Medicare Non-Coverage (NOMNC) letter which explained that Medicare A coverage for skilled services would end on 09/12/21. During an interview on 10/06/21 at 03:10 PM the Business Office Manager (BOM) revealed that Resident #171 had agreed to the facility-initiated discharge and had waived the right to appeal the discharge. The BOM stated that the NOMNC was not issued to Resident #171 and she was not aware of the NOMNC form prior to today. 2. Resident #172 was admitted to the facility for skilled services on 08/10/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #172 was discharged from the facility on 09/15/21. A review of the medical record revealed that Resident #172 and/or Resident #172 ' s Responsible Party (RP) was not issued a CMS Notice of Medicare Non-Coverage (NOMNC) letter which explained that Medicare A coverage for skilled services would end on 09/12/21. During an interview on 10/06/21 at 03:10 PM the BOM revealed that Resident #172 ' s RP agreed with the facility-initiated discharge and waived the right to appeal. The BOM stated that the NOMNC was not issued to Resident #172 or Resident #172 ' s RP and that she was not aware of the NOMNC form prior to today. During an interview on 10/07/21 at 11:30 AM the Administrator revealed that the facility and the BOM were not aware of the NOMNC form that was required to be issued for Resident #171 and #172.

Based on observation, staff interview, record review and nurse practitioner interview the facility failed to remove to an indwelling catheter as instructed by the nurse practitioner for 1 of 1 Resident (Resident #74) reviewed for a catheter. The findings included: Resident #74 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was moderately cognitively impaired, was totally dependent on staff for toileting and had an indwelling catheter. Review of Nurse Practitioner clinical admission note dated 8/23/2019 stated a drug regimen review was competed upon admission and stated changes were made from the hospital discharge summary that included (#5) that stated to leave the indwelling catheter in place until resident had a bowl movement (BM). The note continued with will reassess on Monday, 8/26/2019. Review of Resident #74's Bowel movement record, revealed the resident had a Bowel Movement on 8/24/2019 and two Bowel Movements on 8/26/2019. Observation of Resident#74 on 08/26/19 at 3:01 PM revealed the resident had a urinary catheter bag at bedside that was draining, clear light-yellow liquid. Interview on 8/27/2019 at 8:25am with the Nurse Practitioner revealed that she attended Nursing report on 8/23/2019 during shift change and communicated to the staff that Resident #74's indwelling catheter was left in place on admission due to the Resident not having a BM while hospitalized . She also stated that Resident #74's urinary catheter should have been removed after the Resident's first BM on 8/24/2019 as written in the Admission Clinical Note and following physician notification communicating the removal. Interview with Nurse #3 on 8/28/2019 at 9:40 am revealed she did not see the Nurse Practitioner's instructions dated 8/23/2019 regarding the information to leave the catheter in place until Resident had a bowel movement, therefore did not notify the Nurse Practitioner nor the on-call Provider regarding Resident #74's BM on 8/24/2019. Interview with Director of Nursing (DON) and 8/26/2019 at 4:10 PM revealed Nurse Practitioner instructions should have been followed. The DON continued that removal of the catheter was most likely missed because it was not transcribed to a physician order [REDACTED]. Had the note been transcribed to an order the nurse would have seen it and the catheter would have been removed following the resident's BM and physician notification.

Based on observation, record review and staff interview the facility failed to update a care plan 1 of 2 Residents (Resident #18) reviewed for a catheter. The findings included: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required extensive assistance for toileting and had an indwelling catheter. The MDS further revealed Resident #18 was cognitively intact. Review of nursing note dated 7/18/19 revealed Resident #18's indwelling catheter was removed on 7/18/19. A review of Resident #18 care plan revealed that the resident was care planned for indwelling catheter. The interventions included perform catheter care, measure urinary output, assess urine color, odor, and amount. An observation of Resident #18 on 8/26/19 at 11:34 am revealed two urinals at his bedside. The Resident was further observed not to have had an indwelling catheter. Interview with Resident #18 on 8/27/19 at 3:09 pm revealed his catheter was removed a few days after arriving to the facility. An interview was conducted with MDS Coordinator in conjunction with record review on 8/28/19 at 2:34 pm. The MDS coordinator stated that she was aware of the catheter being discontinued but did not know how to take information out of the computer. Interview with the MDS Coordinator on 8/28/19 at 2:34pm revealed she was aware Resident #18's catheter was discontinued but did not know how to remove the information from the computerized care plan. An interview was conducted with the Director of Nursing (DON) on 08/28/19 at 2:54 pm, she stated that she had spoken with the MDS Coordinator about the care plan being updated and that the indwelling catheter had been removed. The DON stated that the MDS Coordinator told her she was afraid to remove the care plan due to her fear that the care plan would disappear and there would be no evidence that the catheter was ever on the care plan. An interview was conducted with the Administrator on 08/28/19 at 04:37 pm. He revealed that the care plan should have been revised.

Based on observations, record review, and staff interviews the facility failed to implement a care plan for 1 of 2 residents reviewed for hearing (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE]. Resident #17 [DIAGNOSES REDACTED]. A review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 had moderate cognitive impairment and required extensive assistance of staff members for most activities of daily living. The MDS further revealed that Resident #17 had adequate hearing with hearing aid. The care plan was reviewed and further revealed that no plan had been established for hearing deficits or hearing aid use. An observation of Resident #17 was made on 08/27/19 at 8:50 AM, and bilateral hearing aids were being placed by Nurse #1. On 08/27/19 at 3:03 PM an interview was conducted with Nurse #1 and she reported that Resident #17 wore hearing aids regularly. An interview was conducted on 08/28/19 at 9:54 AM with MDS Coordinator #1. After review of the MDS, the MDS coordinator stated Resident #17 had not been care planned for hearing deficits and it had been missed. An interview with the Director of Nursing (DON) on 08/28/19 at 4:19 PM revealed that the care plan should have been initiated. An interview with the Administrator on 08/28/19 at 4:39 PM revealed that the resident should have been care planned for hearing deficits.

Based on record reviews, staff interviews, and ombudsman interview, the facility failed to provide written notification to the resident, or resident's representative and the ombudsman when the residents were discharged to the hospital and/or home. This was evidence for 2 of 4 resident reviewed for discharged (Resident #25, and Resident #26). Findings included: 1. Resident #25 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) dated (MONTH) 13, (YEAR), the assessment assess Resident #25 to be cognitively intact. Record review of the departmental notes reviews resident was discharged home on (MONTH) 31, (YEAR). No written notice of discharged was documented to have provided to the Ombudsman. During an interview with the Ombudsman by phone on (MONTH) 26, (YEAR) at 9:00 am revealed that she had not received any written documentation from this facility when residents are discharged . During an interview with Social Worker on (MONTH) 30, (YEAR) at 1:15pm review they did not complete written notification to the resident or resident's representation or the facility ombudsman when a resident was discharged to the hospital or home. During an interview with the Director of Nurses (DON) and the Administrator on (MONTH) 31, (YEAR) at 4:30pm revealed DON indicated she would need to read more on this regulation, however their expectation that Social Workers would have complete written notification to the resident and the Ombudsman about this resident being discharge, per regulation. 2. Resident #26 was admitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. Review of her admission Minimum Data Set (MDS) dated (MONTH) 15, (YEAR) revealed that she has some short and long term memory problems. A review of the departmental notes review dated (MONTH) 4, (YEAR) indicated that the Medical Doctor (MD) made a referral to an area hospice and the family toured the facility. The hospice is ready to accept her as early as tomorrow. A review of clinical note report dated (MONTH) 5, (YEAR) Social Worker (SW) indicated resident continues to experience a functional decline. Per family request and MD assessment, MD made a referral to Hospice. Resident was accepted into Hospice. Resident was discharged on (MONTH) 5, (YEAR). No written notice of discharged was documented to have provided to the Ombudsman. During an interview with the Ombudsman by phone on (MONTH) 26, (YEAR) at 9:00 am revealed that she had not received any written documentation from this facility when residents are discharged . During an interview with Social Worker #2 on (MONTH) 31, (YEAR) at 9:00 am, SW#2 indicated she had no knowledge of completed a written statement to the family and/or ombudsman. SW#2 indicated that the family were the one who requested to discharge the resident. SW #2 was unsure of this information. SW #2 indicated she need to talk to her boss about this. During an interview with the Director of Nurses (DON) and the Administrator on (MONTH) 31, (YEAR) at 4:30pm revealed DON indicated she would need to read more on this regulation, however their expectation that Social Workers would have complete written notification to the resident's representative and the Ombudsman about this resident being discharge, per regulation.

Based on observation, record review and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain procedures and monitor the interventions that the committee put into place in (MONTH) (YEAR). This was for a recited deficiency, which was originally cited in (MONTH) (YEAR) on a recertification survey. This deficiency was in the area of Minimum Data Set (MDS) accuracy. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance (QAA) Program. Findings included: This tag is cross referenced to: F 641 Based on observations, record review, and staff interviews, the facility failed to accurately code the MDS (Minimum Data Set) for 3 out of 5 residents (Resident #15, Resident #20, and Resident #5) reviewed for unnecessary medications and 1 out of 3 residents (Resident #11) reviewed for nutritional status. This tag was originally cited in (MONTH) (YEAR) during the recertification survey when the facility failed to accurately code the Minimum Data Set (MDS) to include the active [DIAGNOSES REDACTED].#9) reviewed for unnecessary medication. The facility also failed to accurately code a resident's behavior of wandering and refusal of care on 2 different MDS for 1 of 3 resident's reviewed for accidents (Resident # 26). Interview with Director of Nurses and Administrator on 10/31/2018 at 5:00 pm indicated their expectation for addressing repeat tags that with the new season staff (MDS Nurse) and other season staff who are aware of the regulation, once the process and monitor of this problem begin we will ensure sustainable improvement will come.

Based on observations, record review, and staff interviews, the facility failed to accurately code the MDS (Minimum Data Set) for 3 out of 5 residents (Resident #15, Resident #20, and Resident #5) reviewed for unnecessary medications and 1 out of 3 residents (Resident #11) reviewed for nutritional status. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #15's medical record revealed a physician's orders [REDACTED]. A review of Resident #15's most recent MDS dated [DATE] was coded as a quarterly assessment. Active [DIAGNOSES REDACTED]. [MEDICAL CONDITION] was not noted as an active [DIAGNOSES REDACTED]. An interview was conducted on 10/31/18 at 3:00pm with the MDS coordinator. She reported it is her responsibility to accurately code all MDS assessments. She reported because [MEDICATION NAME] was ordered for [MEDICAL CONDITION] for Resident #15, she should have coded the [DIAGNOSES REDACTED]. An interview was conducted on 10/31/18 at 5:30pm with the DON (Director of Nursing) and the Administrator. They report the MDS coordinator was responsible for correctly coding the MDS assessments. The DON reported it was her expectation that all MDS assessments were coded accurately. 2. Resident #20 was admitted to the facility in (MONTH) (YEAR) with a [DIAGNOSES REDACTED]. A review of Resident #20's medical record revealed a physician's note dated 6/18/18 that stated the resident had a [DIAGNOSES REDACTED]. A review of the pharmacist's consult regarding Resident #20's medications dated 9/13/18 revealed the resident was on [MEDICATION NAME] 0.5mg three times a day for anxiety. A review of Resident #20's most current MDS dated [DATE] and coded a quarterly assessment revealed active [DIAGNOSES REDACTED]. In the MDS Medication section, it was revealed Resident #20 had taken an antianxiety medication for 7 out of 7 days during the look back period. Anxiety was not noted as an active [DIAGNOSES REDACTED]. An interview was conducted with the MDS coordinator on 10/31/18 at 3:00pm. She reported it was her responsibility to correctly code all MDS assessments. She reported Resident #20's quarterly MDS should have been coded with a [DIAGNOSES REDACTED]. An interview was conducted with the DON (Director of Nursing) on 10/31/18 at 5:30pm. She reported it was the responsibility of the MDS coordinator to assure all MDS assessments were coded adequately. She reported it was her expectation that all MDS assessments were coded with the correct diagnoses. 3. Resident #5 was admitted to the facility 8/12/17 with [DIAGNOSES REDACTED]. A review of Resident #5's most current MDS dated [DATE] was coded as an annual assessment. Active [DIAGNOSES REDACTED]. Under the medication section of Resident #5's MDS it was revealed the resident had taken a diuretic 7 out of 7 days. A review of Resident #5's MAR (Medication Administration Record) revealed for the MDS look back period dated 8/12/18, the resident took [MEDICATION NAME] 20mg 4 out of 7 days - 8/11, 8/9, 8/7, and 8/5. The order for the [MEDICATION NAME] read 20mg every other day for [MEDICAL CONDITIONS]. An interview with the MDS coordinator was conducted on 10/31/18 at 3:00pm. She reported it was her responsibility to accurately code all MDS assessments. She reported the Medication section of Resident #5's annual assessment should have been coded for diuretics 4 out of 7 days in the look back period. An interview was conducted on 10/31/18 at 5:30pm with the DON (Director of Nursing) and the Administrator. They report the MDS coordinator was responsible for correctly coding the MDS assessments. The DON reported it was her expectation that all MDS assessments were coded accurately. 4. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #11's monthly weight record revealed the resident weighed 119.7 lbs. (pounds) on 6/1/18; 112.4 lbs. on 6/25/18, 107.1 lbs. on 8/27/18, and 102.8 lbs. on 10/10/18. There was no recorded weight for (MONTH) (YEAR). A review of Resident #11's medical record revealed a dietician's note dated 8/27/18. The note documented Resident #11's weight on 8/27/18 as 107.1lbs. A review of Resident #11's most recent MDS was coded as a quarterly assessment and was dated 9/1/18. Active [DIAGNOSES REDACTED]. Under the Nutrition section of Resident #11's MDS, it was revealed the resident had no weight loss of 5% in past month or 10% in past 6 months. Resident #11's weight was coded as 118 lbs in past 30 days. An interview was conducted with the facility's registered dietician on10/31/18 at 11:53am. She reported it is the dietician's responsibility to complete the Nutrition section of the MDS assessments. She reported she does not know where the weight of 118 came from on Resident #11's quarterly MDS assessment dated [DATE]. She reported the weight was entered incorrectly. An interview was conducted on 10/31/18 at 5:30pm with the DON. She reported it was the responsibility of the dietician to accurately complete the nutrition section of all MDS assessments. She reported it was her expectation that all MDS assessments were completed accurately.

Based on record reviews and staff interviews the facility failed to develop a care plan for 2 of 4 residents reviewed for discharged (Resident #25 and Resident #26) and 1 of 5 residents reviewed for unnecessary medications (Resident #15). Finding included: 1. Resident #25 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment assess Resident #25 to be cognitively intact. A review of Section Q of the MDS dated [DATE] was reviewed and question Q0400 discharge plan was answered 0-No. A care plan dated 6/10/2018-Present was reviewed and revealed no documentation for Resident #25 for discharge plan. A review of a Social Work Note dated Monday, (MONTH) 30, (YEAR) indicated Resident has been advanced to weight-bearing with walker by Medical Doctor (MD), she would like to d/c (discharge) home on Tuesday. Will need to discharge order. Do not anticipate other needs at this time. Resident has strong family and social support. She is extremely resourceful. Daughter will make sure there are groceries in the home. Resident will continues with outpt. PT. During an interview with Social Worker #1 (SW) on (MONTH) 31, (YEAR) at 1:15pm revealed that she was the SW for Resident #25, Resident #25 was placed here because of a fractural ankle and SW indicated that she would only be here from 4 to 6 week and would return back to the [NAME] Community. SW #1 also indicated that she was unaware that she needed to have a care plan for discharge for Resident #25. SW indicated she only have discharge plan for Residents who had issues with discharge plans. During an interview with the Minimum Date Set (MDS) Nurse on (MONTH) 31, (YEAR) at 4:00pm revealed a care plan for Resident #25 had not been completed, MDS Nurse indicated that the Social Worker would be responsible for care planning this section. MDS Nurse stated that her expectation for discharge planning on the care plan would be done by the Social Worker. During an interview with the Director of Nurses (DON) and the Administrator on (MONTH) 31, (YEAR) at 4:30pm revealed DON indicated she would need to read more on this regulation, however their expectation that Social Workers would have care plan discharge for each residents in the Nursing Home section per regulation. 2. Resident #26 was admitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. Review of her admission Minimum Data Set (MDS) dated (MONTH) 15, (YEAR) revealed that she has some short and long term memory problems. A care plan dated 8/7/2018-Present was reviewed and revealed no documentation for Resident #26 for discharge plan. A review of the departmental notes review dated (MONTH) 4, (YEAR) indicated that the Medical Doctor (MD) made a referral to an area hospice and the family toured the facility. The hospice is ready to accept her as early as tomorrow. A review of clinical note report dated (MONTH) 5, (YEAR) Social Worker (SW) indicated resident continues to experience a functional decline. Per family request and MD assessment, MD made a referral to Hospice. Resident was accepted into Hospice. Resident was discharged on (MONTH) 5, (YEAR). During an interview with Social Worker #1 on (MONTH) 31, (YEAR) at 11:00 am, SW#1 indicated she had no care plan discharge because we knew she was short term. SW#1 indicated that the family were the one who requested to discharge the resident on (MONTH) 5, (YEAR). SW also indicated she did not care plan because she knew coming in that this Resident #26 would be short stay. During an interview with the Minimum Date Set (MDS) Nurse on (MONTH) 31, (YEAR) at 4:00 pm revealed a care plan for Resident #25 had not been completed, MDS Nurse indicated that the Social Worker would be responsible for care planning this section. MDS Nurse stated that her expectation for discharge planning on the care plan would be done by the social Worker. During an interview with the Director of Nurses (DON) and the Administrator on (MONTH) 31, (YEAR) at 4:30pm revealed DON indicated she would need to read more on this regulation, however their expectation that Social Workers would have care plan discharge for each residents in the Nursing Home section per regulation. 3. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #15's medical record revealed a physician's orders [REDACTED]. A review of Resident #15's most recent care plan dated 8/12/18 revealed the resident was care planned for depression with only intervention was to monitor effectiveness of antidepressant medications, anticoagulant therapy, and diuretic therapy. There was no care plan for Resident #15's [MEDICAL CONDITION]. A review of Resident #15's most recent MDS (Minimum Data Set) dated 9/14/18 was coded as a quarterly assessment. Active [DIAGNOSES REDACTED]. An interview was conducted with NA #1 on 10/30/18 at 12:30pm. She reported she got report from previous shift with what needs each resident had. She reported when Resident #15 seemed depressed, she went in the room and talked with her or offered to let her watch old movies on her phone. She reported these actions seemed to help the resident. She reported she wasn't sure what time the resident went to bed, but she liked to sleep until 11:00am. An interview was conducted on 10/31/18 at 3:00pm with the MDS coordinator. She reported it was her responsibility to update and develop the residents' care plans. She reported because [MEDICATION NAME] was ordered for [MEDICAL CONDITION] for Resident #15, she should have care planned [MEDICAL CONDITION]. She also reported Resident #15's care plan for depression should have been individualized with non-pharmacological interventions. An interview was conducted with the DON (Director of Nursing) on 10/31/18 at 3:30pm. She reported it was the MDS coordinator's responsibility for developing and updating care plans. She reported it was her expectation that every care plan was individualized for each resident. She reported it was her expectation that any [DIAGNOSES REDACTED].

Based on record review and staff interviews, the facility failed to revise a comprehensive care plan on 1 out of 3 residents (Resident #11) reviewed for nutrition. Findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #11's monthly weight record revealed the resident weighed 119.7 lbs. (pounds) on 6/1/18; 112.4 lbs. on 6/25/18, 107.1 lbs. on 8/27/18, and 102.8 lbs. on 10/10/18. There was no recorded weight for (MONTH) (YEAR). A review of Resident #11's medical record revealed a dietician's note dated 8/27/18. The note documented Resident #11's weight on 8/27/18 as 107.1 lbs. (pounds). A review of Resident #11's most recent MDS was coded as a quarterly assessment and was dated 9/1/18. Active [DIAGNOSES REDACTED]. Under the Nutrition section of Resident #11's MDS, it was revealed the resident had no weight loss of 5% in past month or 10% in past 6 months. Resident #11's weight was coded as 118 lbs. in past 30 days. A review of the most current care plan for Resident #11 dated 9/1/18 revealed no care plan for weight loss. An interview was conducted with the facility's registered dietician on10/31/18 at 11:53am. She reported it is the dietician's responsibility to complete the Nutrition section of the MDS assessments. She reported she does not know where the weight of 118 came from on Resident #11's quarterly MDS assessment dated [DATE]. She reported the weight was entered incorrectly. She reported the resident's care plan should have been revised to address the weight loss. An interview was conducted on 10/31/18 at 5:30pm with the DON. She reported it was the responsibility of the dietician to accurately complete the nutrition section of all MDS assessments and update care plans accordingly. She reported it was her expectation that all care plans were updated as each resident's condition changes and each care plan be individualized.

Based on record reviews and staff interviews, the facility failed to implement an effective discharge plan for 1 of 4 residents reviewed for discharge planning (Resident #25). Finding included: Resident #25 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment assess Resident #25 to be cognitively intact. A review of Section Q of the MDS dated [DATE] was reviewed and question Q0400 discharge plan was answered 0-No. A care plan dated 6/10/2018-Present was reviewed and revealed no documentation for Resident #25 for discharge plan. A review of a Social Work Note dated Monday, (MONTH) 30, (YEAR) indicated Resident has been advanced to weight-bearing with walker by Medical Doctor (MD), she would like to d/c (discharge) home on Tuesday. Will need to discharge order. Do not anticipate other needs at this time. Resident has strong family and social support. She is extremely resourceful. Daughter will make sure there are groceries in the home. Resident will continues with outpt. PT. During an interview with Social Worker #1 (SW) on (MONTH) 31, (YEAR) at 1:15pm revealed that she was the SW for Resident #25, Resident #25 was placed here because of a fractural ankle and SW indicated that she would only be here from 4 to 6 week and would return back to the [NAME] Community. SW #1 also indicated that she was unaware that she needed to have a discharge plan for Resident #25. SW indicated she only have discharge plan for Residents who had issues with discharge plans. During an interview with the Director of Nurses (DON) and the Administrator on (MONTH) 31, (YEAR) at 4:30pm revealed DON indicated she would need to read more on this regulation, however their expectation that Social Workers would have discharge plan for each residents in the Nursing Home section per regulation.

Based on record reviews and staff interviews, the facility failed to complete Care Area Assessment Summaries which included underlying causes, risk factors, and factors to be considered in developing individualized care plan interventions for 1 of 1 residents (Resident #24) reviewed for indwelling catheter use. Findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive MDS (minimum Data Set) was dated 10/23/17 and coded as an admission assessment. The assessment had documentation of resident's cognition being moderately impaired. His [MEDICAL CONDITION] system was coded as having an indwelling catheter as well as having occasional episodes of bladder incontinence. Review of the CAA (Care Area Assessment) revealed the assessment worksheet was incomplete and the narrative in the Analysis section did not include how the information was gathered, the underlying causes, risk factors or any necessary referrals that may have been needed regarding the use of an indwelling catheter. The only documentation on the Care Area Assessment worksheet read: Resident with chronic indwelling urinary catheter, will care plan this CAA. The MDS nurse was not available for interview. During an interview with the DON (Director of Nursing) on 11/16/17 at 9:25am, she stated she was not sure why the Care Area Assessment Worksheet was incomplete. She stated that the Quality Improvement Committee had identified some areas of concern with the MDS assessment and they had a consultant come and review the MDS. They had been trying to educate staff on correct documentation but it was going to take a while.

Based on record reviews, interviews with resident and staff, the facility failed to answer resident's call bell who needing assistance to maintain dignity for 1 of 1 resident (Resident #38) who was reviewed for dignity. Findings included: Resident # 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Date Set ((MDS) dated [DATE] revealed that Resident # 38 was cognitively intact. Resident # 38 need extensive assistance with one person assist. However for transfer resident #38 needs two person physical assist for transfer. During an interview with Resident #38 on 11/14/2017 at 10 AM, Resident #38 indicated that during the night shift she had to wait for 30 minutes or long for staff to assist her to her bathroom. Resident # 38 indicated that because she wait so long she urinates on herself and that was not a great feeling. Resident # 38 also revealed that when you're my age 15 minutes is a long time to wait to use the bathroom. During an interview with Nurse # 1 on 11/16/2017 at 11 AM indicated that sometimes Resident # 38 had to wait for staff to help her to the bathroom but Resident #38 never complain to her about. Nurse #1 indicated Resident #38 may had waited just a little over 20 minutes but not much longer. During an interview with the Director of Nursing (DON) and Administrator on 11/17/2017 2 PM revealed their expectation of staff answering call bell within a few minutes (10 to 15 minutes) that staff needs to provide care for residents. No residents needs to be waiting over 20 to 30 minutes for care.