Every finding on record at Clinton County Care and Rehabilitation Center

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and serve food in a sanitary manner and in accordance with professional standards for food service safety. This failure had the potential to affect all residents of the facility who consumed food prepared in the kitchen. The findings include: Review of the facility's [NAME] Report, last updated [DATE], revealed 45 of 47 residents received their food from the kitchen. 1. Review of the facility's Chemicals policy, revised ,d+[DATE], revealed the purpose of the policy was to ensure all chemicals would be properly stored. Per the policy, all chemicals would be in a separate/secured area. 2. Review of the facility's Equipment policy, revised ,d+[DATE], revealed the purpose of the policy was to ensure that all food service equipment would be clean, sanitary, and in proper working order and areas would be maintained in a clean and sanitary condition. Per the policy, all equipment would be routinely cleaned and maintained in accordance with manufacturer's guidelines and training material. All staff members would be properly trained in the cleaning and maintenance of all equipment. All food contact equipment would be cleaned and sanitized after every use and all non-foods contact equipment would be clean and free of debris. The Dining Services Director would ensure that the physical plant would be maintained in a clean and sanitary manner. Review of the facility's attachment #1 Morning Daily Tasks to be completed revealed the opening dietary staff was to ensure equipment such as the microwave and can opener be cleaned, and the sink was cleaned and drained. Further morning dietary duties included to remove outdated/unmarked products from the refrigerators. In addition, the morning daily tasks included to wipe down the outside of stove, to include backsplash, top shelf, front of oven doors and knobs, remove stove burners and scrub and run through dishwasher. However, the cleaning schedule did not include that the stove grease trap and/or oven were scheduled to be cleaned. Review of the facility's attachment #2 Evening Daily Tasks to be completed revealed the closing dietary staff was to ensure equipment such as the stove to include the backsplash, top shelf, front of oven doors and knobs were wiped down and the stove trays were to be cleaned with no foil. Further dietary evening duties included to remove outdated/unmarked products from the refrigerators and to pull out counters/steam table/milk cooler to ensure to sweep and mop underneath. However, the cleaning schedule did not include that the stove grease trap and/or oven were scheduled to be cleaned. a. Observation during the initial kitchen tour, on [DATE] at 7:10 PM, revealed the sanitation handwashing area to store a one gallon can of paint, one paint dish, one used paint brush and a screwdriver all stacked and stationed underneath the sanitation prep sink area. Further, the flooring surrounding the sanitation area was dirty/soiled/sticky and in need of cleaning. During interview on [DATE] at 7:14 PM, with Dietary Aide (DA)1, she stated normal procedure for the storage of chemicals such as the gallon of paint and supplies should be stored downstairs; however, she had been painting a section in the kitchen approximately two weeks ago and just forgot to store it properly in the maintenance department. DA1 informed it should not be stored in the kitchen especially surrounding the handwashing station due to sanitation purposes. During interview on [DATE] at 8:00 PM, with the Dietary Manager (DM), she stated any type of chemicals including paint should not be stored in the kitchen and/or cooking area due to the potential of a fire and safety concerns. b. Continued observation on [DATE] at 7:40 PM, during initial tour, revealed the milk cooler to have a one (1) inch deep freezer-burnt build-up of solid ice particles circling the back and sides of the inside cooler, as well as a used, uncapped dirty writing pen and dirt/food particles on the floor of the cooler. c. Further observation on [DATE] at 7:55 PM, during initial tour, revealed the heavy equipment such as the stove to have dried food substance and particles with scattered debris in the grease trap. Additional observation of the appearance inside the stove revealed a build-up of a gritty-greased, blackened substance that covered the entire bottom shelf. During an interview on [DATE] at 8:00 PM, with the DM, she stated all the heavy equipment was to be cleaned throughout the day on both shifts and after each use. However, the DM was not able to convey a past cleaning schedule for the heavy equipment such as the inside of the stove and milk cooler. The DM stated that due to their appearance, the DM felt it had not been cleaned per the facility's cleaning schedule. During an interview on [DATE] at 11:45 AM, during tray-line service with [NAME] 2, she stated it was important to sanitize the kitchen area, as well as all the cooking equipment to prevent residents and staff from getting sick and to prevent cross contamination. Cook2 also stated she was not sure the last time the oven had been cleaned. 2. Review of the facility's Food Storage: Cold Foods policy, revised ,d+[DATE], revealed all food items would be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation during the initial tour of the kitchen conducted on [DATE] at 7:26 PM revealed foods were stored open and unsealed, unlabeled, undated and/or past their expiration date. Observations included: a. Refrigerator 1 contained 11 chicken patties with an open date of [DATE] and a used by date of [DATE]. b. Refrigerator 1 contained two large bags of mozzarella cheese with an open date of [DATE]: however, no discard date. Also, one bag of American cheese with an open date of [DATE] and used by date of [DATE]. c. Refrigerator 2 contained a box of sixteen opened eggs, one cracked with yolk spilling out on the container. d. Refrigerator 3 contained a large bag of cut onion slices with an open date of [DATE]; however, no discard date. e. Dried storage revealed one bag of 12 hotdog buns expired on [DATE]. During an interview on [DATE] at 7:40 PM with Cook1, she stated she threw out leftovers after three days and seven days for newly opened; however, she thought the leftovers were kept longer but was unable to say for sure. When asked why it was important to discard leftovers in a timely manner and per labeling, she stated to prevent people from getting sick. During an interview on [DATE] at 8:00 PM with the DM (who toured with the survey team), revealed each kitchen staff member was responsible for cleaning the kitchen areas of which included the handwashing station, prep stations, surfaces, and floors between equipment, under the equipment and around the equipment in their work area every day after each meal. Continued interview revealed the refrigerators were to be checked one to two times daily per the dietary staff; however, she was unsure of the policy for how long the food items were held after being opened and/or how long it could be kept before disposal. Per the DM, there was a daily cleaning schedule for all staff; however, she indicated the need to start a closer tracking system to monitor the equipment to ensure staff were cleaning the cooking equipment after each meal service, checking to ensure food was being labeled, dated, rotated/discarded, and implementing proper food storage of the refrigerators and freezers. She further stated that she relied on all dietary staff to ensure the kitchen was clean, sanitary and a safe environment. During an interview on [DATE] at 2:00 PM with the Administrator, she stated she expected the kitchen staff to follow facility policies and procedures, as well as the federal and state regulations, pertaining to the kitchen area. In addition, she stated it would be her expectations for the Dietary Manager and kitchen staff to monitor and date all food to ensure accuracy and to discard the outdates for the safety and well-being of the residents.

Based on observation, interview, and a review of the facility policy Coronavirus (COVID-19) - Screening of Visitors and review of the facility policy and manufactures recommendations for sanitization of blood glucose monitors, it was determined the facility failed to have an effective infection control system to prevent the spread of infection by not consistently and adequately screening visitors at one (1) of one (1) designated visitor entrance to the facility and failing to sanitize blood glucose monitors in accordance with manufactures recommendations for three (3) of twenty-three (23) sampled residents. The findings include: 1. A review of the facility infection control policy titled Coronavirus (COVID-19) - Screening of Visitors with a revision date of 03/11/2021, revealed visitors would be screened for signs and symptoms for COVID-19, and visitors would be provided a copy of rules which a visitor would review and sign. Further review of the policy revealed visitors would wear appropriate Personal Protective Equipment (PPE) and use appropriate face covering or mask at all times for all persons. Further review of the policy revealed any provider, consultant, or vendor visiting the facility was subject to these requirements. There was no evidence the policy addressed what specific PPE was required for visiting other than mask. Observation of the screening process upon entry to the facility on [DATE] at 10:23 AM, revealed four (4) state surveyors and one (1) federal surveyor entered the building to conduct a survey and alert facility staff of the reason for the visit. Facility staff did not ensure adequate screening of the surveyors or advise the surveyors on any PPE requirements. A surveyor asked the Administrator upon entrance of the current status of the building regarding COVID-19 and was informed there was no residents/staff with COVID and no resident on precautions. The Administrator was also asked what kind of mask was required and the Administrator stated the facility preferred to have visitors wear a surgical mask. Surveyors were not instructed to wear any eye protection during the screening process and were escorted to an office area to begin the survey. A tour of the building was conducted on all residents by the surveyors on 12/20/2021 and at approximately 2:30 PM, a surveyor asked a staff member if eye protection was required. The staff member told the surveyor staff were required to wear eye protection and a mask. Observation of two (2) visitors, who were visiting a resident in the facility on 12/20/2021 at 3:15 PM, revealed the visitors were wearing a mask but was not wearing eye protection. Interviews with Visitors #2 and #3 on 12/20/2021 at 3:02 PM revealed they were screened at the kiosk by staff, given a mask to wear, and escorted to the resident's room but were not offered eye protection or told they would need eye protection. Observations in the front lobby of the facility on 12/22/2021 at 2:08 PM revealed two (2) ambulance employees entered the facility to transport a resident to a medical appointment. Facility staff failed to screen the ambulance employees into the building and the ambulance employees were not wearing eye protection. Interview with State Registered Nurse Aide (SRNA) #3 on 12/22/2021 at 2:00 PM revealed the SRNA was required to wear a mask and eye protection while working in the facility. According to the SRNA, she was not aware if visitors were to wear eye protection and was uncertain about the screening of the ambulance personnel. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 2:35 PM, revealed the LPN was working and greeted the surveyors when they entered the building. The LPN stated she was also on the phone arranging transportation for a resident. Further interview revealed she should have directed someone to screen the surveyors into the building. The LPN stated the surveyors should have been instructed on PPE and eye protection. Per the LPN, she did not instruct the surveyors on PPE and eye protection but should have. Interview with Registered Nurse (RN) #1 on 12/22/2021 at 2:56 PM revealed she was not aware that visitors had to wear goggles when visiting residents in the facility. The RN stated she was also not aware of the process or requirements for screening ambulance personnel. Interview with the Director of Nursing/Infection Preventionist (DON) on 12/22/21 at 3:20 PM revealed visitors were screened into the facility by whoever was available. Per the DON, the facility used to have a hospitality aide assigned to do the screening but now any available staff would screen individuals entering the facility. According to the DON, staff was wearing masks and eye protection because of the county positivity rate. The DON stated she monitored the screening process but was not aware staff were not consistently screening visitors or were confused about what PPE was required. The DON stated ambulance staff should be screened unless it was an emergency and then they could enter without screening. Interview with the Administrator on 12/22/2021 at 4:24 PM revealed the Administrator was not aware of the concerns with the screening process and should have ensured the surveyors were correctly screened when they entered the building to clear up any confusion regarding the required PPE. According to the Administrator, it was facility policy to wear masks and eye protection if the facility was in the orange or red zone of positivity. Per the Administrator, the facility was currently in the orange zone. The Administrator stated she had not discussed any screening protocols with the ambulance service or set any guidance other than what was in the screening policy which required all visitors to be screened. The Administrator stated she was not aware the policy did not clearly define the required PPE based on the current infection rates. 2. Review of the policy Glucometer Cleaning and Disinfecting policy, dated 11/04/2019, revealed appropriate cleaning and disinfecting steps were needed to prevent the spread of bloodborne pathogens. Further review revealed to clean the Blood Glucose Monitor (BGM), gloves were recommended and to use a dampened soapy cloth or 70-80% isopropyl alcohol to remove visible dirt, body fluids, and blood. Continued review revealed to disinfect the BGM, staff was to use an environmental protection agency (EPA) registered disinfectant or germicidal wipe and follow product label instructions to disinfect and allow to air dry. Review of the facility product label, Microdot Bleach Wipes, (currently used by the facility to disinfect the BGM) revealed it was a combination cleaning/disinfecting product. Continued review revealed staff was to wear gloves and ensure the surface to be disinfected had a solution contact time of thirty (30) seconds. Additionally, the surface was to air dry. Review of the Manufacturers Guidelines website (www.assureus.com/general.html) for the type of BGM the facility used revealed the BGM was tested using four (4) different disinfecting wipes, one of which was the Super Sani-cloth Germicidal Disposable Cloth. Continued review of the website documentation revealed a facility could use a commercially available EPS-registered disinfectant wipe with the recommendation to create supporting documentation as to why the facility chose that product. Interviews with Licensed practical nurse (LPN) #3 on 12/20/2021 at 12:14 PM, LPN #4 on 12/21/2021, at 11:02 AM, and RN #1 on 12/22/2021 at 8:42 AM revealed they previously used Super Sani-cloth to clean/disinfect the BGM but had not had that product for several months. All stated they currently used the Micodot Bleach wipes to clean/disinfect the BGM and were trained on how to disinfect the monitor using this wipe. Observations during Medication Pass on 12/20/2021 and 12/21/2021 with (LPN) #3 revealed she failed to use a thirty (30) second contact time when cleaning the BGM with the Microdot Bleach wipe for Resident #22 on 12/21/2021, at 11:40 AM, Resident #38 on 12/21/2021 at 11:00 AM and Resident #96 12/21/2021 at 12:10 PM . On all three (3) occasions, LPN #3 allowed approximately ten (10) to fifteen (15) second contact time instead of thirty (30) seconds when disinfecting the BGM between uses. Interview with LPN #3 on 12/22/2021, at 11:05 AM, revealed she was aware there was a thirty (30) second kill time when using the disinfectant wipes. Continued interview revealed she thought she had used the required time. Additionally, LPN #3 stated they had recently had a Skills Fair, in which Glucometer disinfection was part of the education. Interview with the Director of Nursing (DON), on 12/22/2021, at 2:43 PM, revealed she was responsible for staff training at this time. Additionally, she stated the facility had not used the Super Sani-cloths in about three (3) months. Further interview revealed it was her belief that the decision to switch to the current product was a corporate decision and the product was appropriate to use on BGM and other points of care equipment. The DON stated LPN #3 failed to clean the BGM per facility policy/product guidance. Continued interview revealed the facility had presented a Skills Fair mid-December and BGM and covered the disinfection of the BGM. The DON stated the facility was not currently monitoring the disinfection of the BGM. Interview with the Administrator on 12/22/2021 at 5:24 PM revealed it was her belief that the Microdot Bleach Wipes the facility was used to disinfect the BGM and other point of care equipment was applicable to use related to the BGM Manufacturers Recommendations was to use an EPA registered product and the current product was EPA registered.

Based on observation, interview and record review it was determined the facility failed to ensure resident privacy during care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide visual privacy for Resident #32 during wound care and a skin assessment on 12/21/2021. Residents #22, #38, and #96 were not provided privacy during blood glucose monitoring and insulin injections on 12/20/2021. The findings include: A review of the facility policy for privacy titled Resident Rights with a revised date of 08/16/2018, revealed all residents had the right to be treated with respect and dignity and the rights would be promoted by the facility. Further review of the policy revealed when providing care and services the stakeholders would respect the resident's individuality by providing the resident a dignified existence and that privacy and confidentiality were a basic right to all residents of the facility. 1. A review of the medical record for Resident #32 revealed the facility admitted the resident on 10/13/2021 with Intellectual Disabilities, Cerebral Infarction, [CONDITION(S)], and [CONDITION(S)] of the right side. A review of the Admission Minimum Data Set (MDS) assessment completed for Resident #32 dated 10/20/2021 revealed the resident was severely impaired for cognition and communication. Attempts to interview Resident #32 revealed the resident was nonverbal and not interviewable. Observation of a skin assessment and wound care for Resident #32 conducted on 12/21/2021 at 3:06 PM by Licensed Practical Nurse (LPN) #4 and the Director of Nursing (DON) revealed the LPN and the DON failed to close the blinds and pull the resident's privacy curtain to provide visual privacy prior to providing wound care to the resident's left ear and left foot. In addition, a head-to-toe skin assessment was conducted exposing the resident's skin which included the abdomen, back, buttocks, and groin area. Additional observation revealed the resident was in view of the facility's main entrance area of the front porch and of the facility parking lot via the resident's window. Interview with LPN #4 on 12/21/2021 at 3:22 PM revealed she was supposed to provide privacy by pulling the privacy curtain and closing blinds prior to providing care. The LPN stated she did not realize she did not pull Resident #32's privacy curtain or pull the blinds prior to providing care. Interview with the DON on 12/21/2021 at 3:25 PM revealed she thought the LPN had moved the curtain back during the assessment and treatment but had not realized Resident #32 was still in view of the front porch via the window. Further interview revealed she should have noticed the resident was not being provided privacy and ensured privacy by closing the curtain or the blinds. 2. Observation of finger stick blood sugar (FSBS) monitoring for Resident #22 on 12/20/2021 at 11:40 AM, Resident #38 on 12/20/2021 at 11:00 AM, and Resident #96 12/20/2021 at 12:10 PM by Licensed Practical Nurse (LPN) #3 revealed the LPN did not provide full visual privacy for the three (3) aforementioned residents by pulling the curtains and/or shutting the door or closing the window blinds prior to providing care. Additional observations revealed LPN #3 also administered an Insulin injection to Resident #22 on 12/20/2021 at 11:40 AM and did not provide full visual privacy for Resident #22 during Insulin administration in which his/her upper left arm was exposed. Continued observations revealed Resident #38's upper left abdominal quadrant was left exposed during insulin administration on 12/20/2021 at 11:55 AM by LPN #3. Interview with LPN #3 on 12/20/2021 at 12:17 PM revealed she was aware she had not provided privacy during the FSBS testing and subsequent insulin administration but should have provided privacy. Additionally, she stated that Resident Rights education had been presented during Skills Fair in mid-December. Interviews with Sampled Residents #38 and Resident #96 (spouses) (both with a brief interview for mental status (BIMS) scores of (12), which indicated they were cognitively intact) on 12/21/2021 at 8:45 AM revealed it did not bother them if nurses did not provide visual privacy while doing the FSBS and insulin injections. Interview with the DON on 12/22/2021 at 4:05 PM revealed it was her expectation for staff to provide full visual privacy for every resident, even if they were the only person in the room. She would expect the curtain/door shut if in Bed one (1) or curtain/blinds/door closed if in Bed two (2). She continued by stating it was the resident's right to have privacy afforded to them. Interview with the Administrator on 12/22/2021 at 4:24 PM, revealed staff were monitored for providing privacy to residents during procedures such as FSBS/Insulin injections and peri/catheter care by clinical/privacy audits. The Administrator stated if staff provided any sort of care, the curtain/door should be shut, no matter which bed the resident occupied.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-three (23) sampled residents (Resident #34) was treated with respect and dignity. Observation on 12/20/2021 revealed Resident #34's catheter bag was not covered or blocked from view. The findings include: Review of the facility's policy titled Resident Rights dated 08/16/2018 revealed all residents have the right to be treated with respect and dignity. These rights would be promoted and protected by the facility. All residents would be treated in a manner and in an environment that promoted maintenance or enhancement of qualify of life. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the assessment revealed the resident had an indwelling catheter. Review of Resident #34's care plan dated 08/23/2021 revealed the facility had identified the residen t's nephrostomy catheters which were to divert urine due to [CONDITION(S)]. However, the plan did not address the drainage bag or privacy concerns. Observation of Resident #34 on 12/20/2021 at 10:05 AM revealed the resident was sitting in bed with two (2) nephrostomy urine bags laying on the bed. The nephrostomy drainage catheter bags were uncovered, and the resident's bed was visible from the hallway as the privacy curtain was not pulled. Observation of Resident #34 on 12/20/2021 at 1:29 PM, revealed the resident was sitting on the side of his/her bed, with two (2) nephrostomy drainage bags laying on the bed uncovered and visible from the hallway. The privacy curtain was not pulled. Interview with Resident #34, on 12/21/2021 at 8:25 AM, revealed he/she liked to carry his/her urine bags or lay them close to him/her. The resident stated he/she usually did not like bed covers over the urine bags and usually just left the bags laying on the bed. Resident #34 stated staff had not mentioned or offered to place covers over the urine bags. Interview with State Registered Nurse Aide (SRNA) #3, on 12/22/2021 at 1:06 PM, revealed Resident #34 would not wear a leg strap for the catheter bag. She stated Resident #34 had dignity bags, but he/she would remove the dignity bags when placed around the catheter drainage bags. The SRNA stated she knew they should try to cover the bags with the quilt if the resident would not wear the dignity bags. However, she stated she had not offered Resident #34 a privacy bag. The SRNA also stated she should pull the privacy curtain in the resident's room to provide privacy and dignity. Interview with SRNA #4, on 12/22/2021 at 1:17 PM, revealed Resident #34 did not want the dignity bag to cover the catheter drainage bags. He stated sometimes Resident #34 would let him pull the curtain but at times the resident wanted the curtain open to watch people. The SRNA stated he was aware he should pull the privacy curtain in residents' rooms to provide dignity and knew Resident #34's catheter drainage bags should be covered/in dignity bags. However, the SRNA stated he had not offered the dignity bags to the resident or applied them to the drainage bags. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 1:35 PM, revealed Resident #34 preferred to keep the urine drainage bags beside of him/her. She stated staff had not reported Resident #34 refusing to cover them up or refusing dignity bags and was unaware that he/she would not wear the leg straps. She stated she does not know if dignity bags have been offered and stated she had not offered a dignity bag to Resident #34 but knows she should have offered the dignity bags. Interview with Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed she was unaware until this week that Resident #34 was refusing to wear catheter leg straps to secure the catheter to the resident's leg. The DON stated before today, Resident #34's care plan had not included interventions for the use of dignity bags nor had the care plan addressed the resident's refusal to use the dignity bags. Per the DON, the resident's care plan should have included the use of dignity bags and privacy. Interview with Administrator, on 12/22/2021 at 4:24 PM, revealed the facility monitored the residents' care and audits staff providing resident privacy and catheter care. The Administrator stated she expected staff to pull privacy curtains. She stated if Resident #34 does not want to wear the catheter leg straps to secure the catheter then he/she can choose not to wear them, but it should be care planned.

Based on interview and record review, it was determined the facility failed to conduct an admission comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one (1) of twenty-three (23) sampled residents (Resident #95). A review of Resident #95's medical record revealed the resident was admitted on [DATE]; however, an admission MDS assessment for Resident #95 was not completed within fourteen (14) days of admission as required. Further, the admission MDS assessment was not completed as of 12/22/2021. the findings include: Interview with the Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed the facility did not have a policy for completing the Minimum Data Set (MDS) assessments; however, the facility followed the Resident Assessment Instrument (RAI) process to complete the assessments. A review of the Long-Term Care Facility Resident Assessment Instrument version 3.0 User's Manual revealed the admission assessment was a comprehensive assessment for a resident that the facility must complete within fourteen (14) days of admission. Review of Resident #95's medical record revealed the facility admitted the resident on 10/28/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record revealed an admission assessment had not been completed for Resident #95. Interview with the Minimum Data Set (MDS) Nurse on 12/22/2021 at 10:05 AM, revealed she had been off work due to sickness and had not completed the resident's MDS assessment. Per the interview, she stated she was working on completing the assessment, on 12/22/2021. Interview with the Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed she was not aware Resident #95's MDS was late and was not completed. According to the DON, the MDS nurse was off sick, and a corporate nurse was helping while she was off work. Further interview with the DON revealed that due to the MDS nurse being off work, the facility became behind on assessments and a performance improvement plan was developed to complete assessments on current residents; however, the facility did not consider new resident admission assessments in the plan. The DON stated she was unaware Resident 95's admission assessment had not been completed. Interview with the Administrator, on 12/22/2021 at 4:24 PM, revealed she was aware of the late Minimum Data Set (MDS) assessments and incomplete assessments when the MDS nurse was off sick. The Administrator stated the facility had a corporate MDS nurse to assist with the residents' assessments that were late, but the facility did not develop a plan to ensure newly admitted residents were assessed, to prevent further late assessments. Per the Administrator, the facility had not considered discontinuing new admissions until the facility was able to complete the residents' MDS assessments, as required.

Based on observation, interview, record review, and facility policy, it was determined the facility failed to revise the plan of care for one (1) of twenty-three (23) sampled residents (Resident #34). Staff interviews revealed Resident #34 often refused the leg straps to secure his/her catheter and dignity bags to cover the catheter drainage bags; however, the facility failed to revise the resident's plan of care to address the refusal of care. The findings include: Review of the facility's policy titled Comprehensive Care Plans last reviewed on 04/14/2021, revealed the care plan would include how the facility would assist the resident to meet their needs, goals and preferences. Person-centered care means the facility focused on the resident as the center of control and supported each resident in making his or her own choices. Care plans were ongoing and revised as information about the resident and the resident's condition changed. The resident had the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals were made, appropriate documentation would be entered into the resident's medical record. In the case of a resident's refusal or declination of care or treatment being declined, the risk the declination posed to the resident, and the efforts made by the Interdisciplinary Team (IDT) to educate the resident and representative as appropriate. The attempts to find alternative means to address the identified need/risk would be documented in the care plan. Review of the facility's policy titled Refusal of Care, Treatment, or to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the facility would document the resident's refusal in the medical record and inform the resident's physician. In consultation with the resident's physician, the facility care plan team would assess the resident ' s needs and if possible and available, offer the resident alternative treatments while continuing to provide the resident other services outlined in the care plan. 1. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Further review of the assessment revealed the resident had an indwelling catheter. Continued review of the Minimum Data Set (MDS) revealed the resident was not assessed to reject care (Section E). Review of Resident #34's care plan dated 08/23/2021 revealed the facility had identified the resident's double nephrostomy catheters which was to divert urine due to [CONDITION(S)]. However, the plan did not address the refusal of care related to securing the catheter and the catheter dignity bags. Observations of Resident #34 on 12/20/2021 at 1:29 PM, revealed the resident was sitting on the side of his/her bed, with two (2) nephrostomy drainage bags laying on the bed uncovered and visible from the hallway. The catheter tubing was not secured. Interview with Resident #34, on 12/21/21 at 8:25 AM, revealed he/she liked to carry his/her urine bags or lay them close to him/her. The resident stated he/she usually did not like bed covers over the urine bags and usually just left the bags laying on the bed. The resident stated he/she has told staff he/she does not want to cover them up. Interview with State Registered Nurse Aide (SRNA) #3, on 12/22/2021 at 1:06 PM, revealed Resident #34 had dignity bags, but he/she would remove the dignity bags when placed around the catheter drainage bags. The SRNA stated Resident #34 would not wear a leg strap for the catheter bag. Interview with SRNA #4, on 12/22/2021 at 2:17 PM, revealed Resident #34 did not want the dignity bag to cover the catheter drainage bags. However, the SRNA stated he had not offered the dignity bags to the resident or applied them to the drainage bags. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 1:35 PM, revealed staff had not reported Resident #34 refusals to utilize his/her dignity bags. Per the LPN, she was unaware Resident #34 would not wear the leg straps to secure the catheter tubing. The LPN stated if a resident refused care she would talk to the resident and explain care, chart the refusal, and notify her supervisor for care plan changes. Interview with Director of Nursing(DON), on 12/22/2021 at 4:05 PM, revealed if a resident refused care then a Situation, Background, Assessment, Recommendation (SBAR) was completed, the care plan was revised and a behavioral meeting was held. She stated she was unaware until this week that Resident #34 refused to wear his/her catheter leg straps to secure the catheter to the resident's leg. The DON stated prior to today, Resident #34's care plan was not updated related to the catheter bags nor did the care plan address the resident's refusal to use his/her dignity bags. Per the DON, the resident's care plan should have been updated as per policy. Interview with Administrator, on 12/22/2021 at 4:24 PM, revealed that if Resident #34 did not want to wear his/her catheter leg straps to secure the catheter, then he/she could choose not to wear them. Continued interview with the Administrator revealed the resident's refusals should have been care planned. She further stated the potential outcome could be Resident #34 could hurt himself/herself.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure catheter tubing was secured for one (1) of twenty-three (23) sampled residents (Resident #34). Resident #34's catheter was not properly secured. The findings include: Review of the facility's policy titled, Catheterization last reviewed on 11/03/2020 revealed to hang the collection bag on the bed frame and to not hang it from the siderails and avoid letting it touch the floor. Per the policy, staff were to tape the catheter or apply a Velcro leg strap and never leave the room until the catheter was secured. Further review revealed the mechanical irritation caused by catheter movement could cause urethral and meatal tearing, accidental removal and serious complications. For the female resident, secure the catheter to the upper thigh. Continued review revealed the catheter in the male was secured to either the upper thigh (with a leg strap) or the abdomen (with tape). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the assessment revealed the resident had an indwelling catheter. Review of Resident #34's care plan dated 08/23/2021 revealed the resident had double nephrostomy catheters to divert urine related to [CONDITION(S)]. The care plan goals included treatment as ordered, keep a closed system as much as possible, manipulate tubing as little as possible during care, position bag below level of bladder and provide nephrostomy care every shift. However, the care plan did not address securing the catheter. Observations of Resident #34 on 12/20/2021 at 10:05 AM, revealed the resident was sitting in bed with two (2) nephrostomy urine bags laying on the bed. The nephrostomy catheter tubing was not secured. Interview with Resident #34, on 12/21/21 at 8:25 AM, revealed he/she liked to carry his/her urine bags or lay them close to him/her. The resident stated he/she usually leaves the bags laying on the bed. Interview with State Registered Nurse Aide (SRNA) #3, on 12/22/2021 at 1:06 PM, revealed Resident #34 would not wear a leg strap for the catheter bag. Interview with Licensed Practical Nurse (LPN) #2, on 12/22/2021 at 1:35 PM, revealed she was unaware that Resident #34 would not wear the leg straps. Interview with Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed if a resident refused care then a Situation, Background, Assessment, Recommendation (SBAR) was completed, the care plan was revised and a behavioral meeting was held. The DON stated she was unaware until this week that Resident #34 was not wearing catheter leg straps to secure the catheter to the resident's leg. Interview with Administrator, on 12/22/2021 at 4:24 PM, revealed that if Resident #34 does not want to wear the catheter leg straps to secure the catheter then he/she can choose not to wear them, but it should be care planned. She stated the potential outcome could be that Resident #34 could hurt himself/herself.

Based on observation, interview, and a review of the facility policy for storage of medication, it was determined the facility failed to ensure drugs/medications in one (1) of three (3) medication carts were locked when unattended by staff. Observation of the A hall medication cart on 12/22/2021 revealed the medication cart was left unlocked and unattended. The findings include: A review of the facility policy for storage of medication titled Medication Storage dated 2007, revealed medications were to be stored properly to maintain integrity and shall be accessible only to personnel authorized to administer medications. Further review of the policy revealed medication carts should remain locked when not in use or attended by persons with authorized access. Observation on 12/22/2021 at 1:55 PM revealed a medication cart was unlocked and unattended with no visible staff nearby. Approximately ten (10) seconds later, a nurse came out of a resident's room and approached the medication cart. Interview with Licensed Practical Nurse (LPN) #3, on 12/22/2021 at 1:57 PM, revealed the LPN did not lock the medication cart when she stepped away from the cart for a few seconds to go into a nearby resident's room. The LPN stated she should have locked the medication cart and not left the cart unlocked/unattended. Interview with the Director of Nursing (DON), on 12/22/2021 at 4:05 PM, revealed it was facility policy to lock the medication carts when the carts were left unattended to prevent someone from tampering with the medications and ensure the integrity of the residents' medications. According to the DON, she monitored medication administration by making daily rounds and had identified no concerns with nurses locking the medication carts. Interview with the Administrator, on 12/22/2021 at 4:24 PM, revealed it was facility policy for medication carts to be locked when unattended. The Administrator stated she would expect the cart to be locked when unattended. Per the Administrator, she made daily rounds to monitor the medication carts and had not identified any concerns with medication carts being left unlocked and/or unattended.

Based on observation, interview, and facility policy review, it was determined the facility failed to develop and follow practices on handling, storing, and processing laundry in a manner to prevent cross-contamination for all residents in the facility. Observation of the facility's laundry processing on 01/25/18 revealed dirty laundry was observed to be taken past the clean laundry area. The laundry room only had one entrance door which was also the exit door. Therefore, all dirty laundry would have to be moved across the clean laundry area to get to the dirty laundry area. The findings include: Review of the facility policy titled Handling Clean Linen, 01/01/2000, revealed the policy did not address cross-contamination of clean linen with dirty linen. Observation of the facility's laundry processing on 01/25/18 at 10:18 AM revealed dirty laundry was observed to be taken past clean laundry to the dirty laundry area. The laundry area was observed to have only one (1) entrance door which was also the exit door and all dirty laundry would have to be moved through the clean laundry area to get to the dirty laundry area. Further observation revealed residents' personal clothing was hung on a rack that had a cover; however, the cover was not closed. Also, there were two (2) blankets, a quilt, and towels observed uncovered in this area. Laundry Worker #1 was observed to not be wearing personal protective equipment and had just filled the washer with dirty laundry. Clean towels and sheets were observed folded and uncovered in the laundry washing area on a table. In addition, wet blankets were observed to be on the floor beside washer #1 and washer #2. Interview conducted with Laundry Worker #1 on 01/25/18 at 10:30 AM revealed dirty laundry was transferred past the clean laundry area and had been occurring for quite some time. Interview with the Laundry Supervisor on 01/25/18 at 10:35 AM revealed the facility had done laundry this way for many years. Interview with the Infection Control Nurse (ICN) on 01/25/18 at 10:55 AM revealed the ICN was responsible to monitor the infection control program at the facility, and she conducted walking rounds to monitor staff compliance with established infection control procedures. The ICN also conducted periodic in-services related to infection control practices. The ICN reported she did not monitor the facility's laundry practices to see if the current practice was in compliance with established infection control policy and procedures. The ICN reported she had not identified any problems or concerns for cross-contamination with laundry practices. Interview with the Administrator on 01/25/18 at 11:30AM revealed she made walking rounds to monitor for infection control practices in the facility. The Administrator also reported she periodically conducted interviews with the residents to see if the residents had any concerns regarding a clean environment. The Administrator reported when she had concerns she directed Laundry personnel or Housekeeping to correct the problem. The Administrator reported she had not identified any concerns with how the laundry was currently being processed, and reported the facility had processed laundry the same way for at least twenty years, and she had not been aware the process was incorrect.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide a clean, comfortable, homelike environment for residents on two (2) of three (3) hallways in the facility (Piney Woods Hall and Poplar Hall). Observation on 01/23/18 revealed the hallway on the Piney Woods Hall was observed to be dirty with multiple dried black areas throughout the hallway; resident room [ROOM NUMBER] was observed to have blackened dried spilled areas between the beds; Resident #22's room was observed to have a dried tan substance on the wall near the baseboard on the right side of the bed, and a dirty fall mat observed on the left side of the bed; Resident #31's room was observed to have a dried brown substance on the wall near the door, and dried black spilled areas at the foot of the bed and on the left side of the bed. The findings include: Review of the facility's policy titled Housekeeping, dated 01/01/2000, revealed all vertical surfaces would be spot cleaned daily. The policy stated all resident rooms would be deep cleaned on a monthly basis. In addition, the policy revealed all floors would be dust mopped, buildup removed, and damp mopped daily. 1. Observation of Resident #31's room on 01/23/18 at 11:27 AM revealed a dried brown substance was observed on the wall near the door. In addition, multiple food particles were on the floor with dried black areas which appeared to be from a spill at the foot and left side of Resident #31's bed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #31 to have a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident had severely impaired cognition and was therefore not interviewable. 2. Observation of Resident #22's room on 01/24/18 at 3:27 PM revealed a dried tan substance was observed near the baseboard on the wall by the right side of the resident's bed. In addition, a fall mat on the left side of the bed was observed to be dirty and in need of cleaning. Review of an annual MDS assessment dated [DATE] revealed the facility had assessed the resident to have a BIMS score of three (3) which indicated the resident had severely impaired cognition and was therefore not interviewable. 3. Observation of the Piney Woods Hall on 01/23/18 at 11:43 AM revealed the floor had multiple dried black areas, which appeared to be from multiple spills that had been walked over. Observation of the Piney Woods Hall on 01/23/18 at 12:31 PM revealed the hallway continued to be dirty with multiple blackened areas noted, and no observation of attempted cleaning. Interview conducted on 01/25/18 at 3:13 PM, with the Manager of the company that was contracted to provide housekeeping services in the facility, revealed all floors, walls, and resident rooms were cleaned daily. The Manager stated he was responsible for monitoring to ensure the facility remained clean. However, the Manager stated he was one of the two housekeeping staff members on duty daily. The Manager stated he had not identified any concerns with the facility not being clean. Interview with the Administrator on 01/25/18 at 12:03 PM revealed she made rounds daily to ensure that all floors, walls, and resident rooms were cleaned daily. The Administrator further revealed if she identified any area needing to be cleaned she addressed it immediately with the Manager of the company that was contracted to provide housekeeping services. The Administrator also revealed she had not identified any concerns with the facility not being clean.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to provide care in accordance with the comprehensive plan of care for four (4) of thirteen (13) sampled residents (Residents #2, #5, #6, and #11). Resident #2 had interventions in place to provide catheter care as ordered. Observation of catheter care on 11/02/16 at 10:30 AM revealed staff cleaned the resident's perineal area and then proceeded to clean the resident's catheter tubing with the same washcloth. Resident #5 had interventions in place for staff to check nails weekly and trim/clean as needed. Observation of a skin assessment on 11/02/16 at 9:55 AM revealed the resident had long, thick, yellow toenails. Resident #6 had interventions for treatment as ordered; however, observation of incontinence care on 11/0/16 at 5:30 PM revealed staff not changing their gloves and washing their hands after their gloves were soiled with bowel movement. Resident #11 had interventions for staff to provide catheter care per facility policy; however, observation of catheter care on 11/03/16 at 3:18 PM revealed staff placed the soiled washcloths in between the resident's legs while providing care. The findings include: Review of the facility policy, Care Plans - Comprehensive, dated 06/01/15, revealed an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . The policy did not address following the care plan. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 08/25/04 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired. Further review revealed the facility assessed the resident to require extensive assistance of two (2) staff persons for personal hygiene and toileting. Review of the Activities of Daily Living Self Care Deficit care plan dated 04/13/11 revealed an intervention to check nails weekly, and trim/clean nails as needed. Observation of a skin assessment on 11/02/16 at 9:55 AM revealed the resident had long, thick, yellow toenails. Interview with the Assistant Director of Nursing (ADON) performing the skin assessment revealed, I think the resident is seen by the podiatrist. He stated he had not provided nail care to the resident at any time. Interview with the Administrator on 11/02/16 at 1:41 PM revealed the resident was last seen by a podiatrist on 02/29/08. She stated the family had since refused podiatry services due to the podiatrist pulling some of the resident's toenails off. Interview with Certified Nurse Aide (CNA) #4 on 11/03/16 at 5:50 PM revealed they provided fingernail care but the resident's mother provides toenail care. She further stated that they got information related to the resident's care from the resident's care guide and that she looked at it daily. She stated the resident had an issue years ago related to a podiatrist pulling the resident's toenails off and the resident's mother had provided his/her toenail care since then. Further interview revealed the CNAs provide nail care to the residents that are not diabetic, and the nurses provide nail care to the residents that are diabetic. Interview with the resident's mother on 11/03/16 at 2:00 PM revealed she refused podiatry services for Resident #5 because in 2008 the resident was seen by a podiatrist and the podiatrist pulled a few of the resident's toenails off. She stated that she did not want the resident to be put through that again, so she had been providing the resident's toenail care until a few months ago when she became sick and could not visit as frequently. She further stated she had not looked at the resident's toenails in a while and did not know how long the resident's toenails were. Further interview revealed the facility had not readdressed the resident seeing a podiatrist since 2008. She stated she would be willing to allow the resident to be seen by a podiatrist again if the facility was serviced by a different podiatrist. Interview with the DON on 11/03/16 at 7:44 PM revealed she was not aware of any staff discussing podiatry services with Resident #5's family since 2008. She stated staff should look at the resident's care plan when they come back to the floor after being off from work or any time they have a question or if there was a change in the resident's condition. She further stated she had not identified any concerns with staff not following the resident's comprehensive care plan. Further interview revealed the family should have been educated and the podiatry services should have been offered again. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 10/15/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of the Comprehensive Care Plan dated 08/25/16 revealed the facility would provide catheter care as ordered. Observation of catheter care for Resident #2 on 11/02/16 at 10:30 AM revealed Certified Nurse Aide (CNA) #3 washed the perineal area and then, without changing the position of the washcloth, washed the catheter tubing. Observation further revealed after each use of a washcloth, CNA #3 placed the soiled washcloth between Resident #2's legs. When the catheter care was completed CNA #3 removed all the soiled washcloths by bringing them up and between Resident #2's legs touching the perineal area with the soiled washcloths. Interview with CNA #3 on 11/03/16 at 6:25 PM revealed she had been trained to either clean the catheter tubing with a clean washcloth or to change the position of the washcloth after cleaning the perineal area first. Further interview revealed the dirty washcloths should have been placed in a plastic bag after each use and not between the resident's legs. 3. Review of Resident #6's medical record revealed the facility admitted the resident on 05/08/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the facility assessed Resident #6 to have a BIMS score of 7, indicating the resident was severely cognitively impaired. Review of the Comprehensive Care Plan dated 05/26/15 revealed the facility would provide incontinence care as needed. Observation of incontinence care for Resident #6 on 11/01/16 at 5:30 PM revealed CNA #2, after washing Resident #6's buttocks from having a bowel movement, proceeded to wash his/her perineal area without washing her hands and changing gloves. Observation further revealed after each use of a washcloth during perineal care, CNA #2 placed the soiled washcloth between Resident #6's legs. When the perineal care was completed CNA #2 removed all the soiled washcloths by bringing them up and between Resident #6's legs touching the perineal area with the soiled washcloths. Interview with CNA #2 on 11/03/16 at 6:15 PM revealed she had been trained that if you did not have feces on your gloves after cleaning up a bowel movement then you did not have to change gloves before cleaning the perineal area. She further revealed she should have put the dirty washcloths in a plastic bag after each use and not between the resident's legs. 4. Review of Resident #11's medical record revealed the facility admitted the resident on 04/18/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the facility assessed Resident #11 to have a BIMS score of 15, indicating the resident was cognitively intact. Review of the Comprehensive Care Plan dated 05/01/15 revealed the facility would provide catheter care per policy. Observation of catheter care for Resident #11 on 11/03/16 at 3:18 PM revealed CNA #1 and CNA #3 placed gloves on to start catheter care without washing their hands. Observation further revealed after each use of a washcloth during perineal care, CNA #1 and CNA #3 placed the soiled washcloths between Resident #11's legs. When the perineal care was completed CNA #1 removed all the soiled washcloths by bringing them up and between Resident #11's legs touching the perineal area with the soiled washcloths. Interview with CNA #1 on 11/03/16 at 5:35 PM revealed she had been trained to always wash her hands before starting any kind of treatment on a resident. Further interview revealed the dirty washcloths should have been placed in a plastic bag after each use and not between the resident's legs. Interview with CNA #3 on 11/03/16 at 6:25 PM revealed she had been trained to always wash her hands before starting any kind of treatment on a resident due to infection control. Interview with the Staff Development Nurse on 11/03/16 at 7:45 PM revealed CNAs have been trained to use a clean washcloth when cleaning the catheter tubing. Further interview revealed after each use of a washcloth the soiled washcloth should be placed in a plastic trash bag. She revealed she conducted random spot checks on the CNAs during incontinence care and catheter care and had not identified any concerns. Interview with the Director of Nursing (DON) on 11/03/16 at 7:25 PM revealed the CNAs have been trained to always wash hands before starting any kind of treatments on residents and any time gloves were soiled. She further revealed the facility used audit tools on handwashing and random checks to ensure the staff was washing their hands. She revealed she had not identified any concerns.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure appropriate treatment and services were provided to prevent an infection of the urinary tract for four (4) of thirteen (13) sampled residents (Residents #2, #5, #6, and #11). Observation of indwelling urinary catheter care for Resident #2 revealed staff cleaned the resident's perineal area and then proceeded to clean the catheter tubing with the same washcloth. Observations of incontinence care for Resident #5 and Resident #6 revealed staff failed to change gloves and wash their hands as required during the provision of incontinence care. Observation of indwelling urinary catheter care for Resident #11 revealed staff placed soiled washcloths in between the resident's legs after use instead of in a soiled linen bag. Observations further revealed the soiled washcloths touched the resident's perineal area when they were removed from the bed. The findings include: Review of the facility policy, Catheterization Care, dated 07/29/16, revealed provide perineal hygiene using mild soap and warm water. Using a clean washcloth, clean catheter . Clean and dispose of used equipment . Review of the facility policy, Perineal Care, not dated, revealed perform hand hygiene and put on gloves, wash using gentle downward [MEDICAL CONDITION] from front to the back of the perineum to prevent intestinal organisms from contaminating the urethra or vagina . Avoid the anal area .use a clean section of washcloth for each stroke by folding each used section inward. Turn the patient on their side to expose the anal area, cleaning from front to back. Dispose of soiled articles in the appropriate receptacle. Remove and discard your gloves and perform hand hygiene. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 08/25/04 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired. Further review revealed the facility assessed the resident to require extensive assistance of two (2) staff persons for toileting. The facility also assessed the resident to always be incontinent of bowel and bladder. Observation of incontinence care on 11/02/16 at 1:54 PM revealed staff failed to use a clean section of washcloth for each area that was cleansed. Further observation revealed CNA #4 did not wash or sanitize her hands in between glove changes while providing incontinence care. Interview with CNA #4 on 11/03/16 at 5:50 PM revealed she should have removed her gloves and washed her hands after providing incontinence care to the resident. She stated she has been trained to remove her gloves, wash her hands, and put on clean gloves when going from dirty to clean with incontinence care. She further stated that she should have turned the washcloth and used clean areas each time she cleaned a different area during incontinence care. Interview with the Director of Nursing (DON) on 11/03/16 at 7:44 PM revealed that CNAs were trained on providing incontinence care, indwelling urinary catheter care, and proper hand washing and glove changes. She stated she made rounds daily to ensure that residents were receiving proper incontinence care and indwelling urinary catheter care. She further stated that the CNAs should have washed their hands and changed their gloves after providing incontinence care before repositioning the resident and touching the resident's bed control. Furthermore, she stated that the CNAs were not trained to place soiled washcloths between the resident's legs after use, that they were trained to place them in a soiled linen bag. She stated she had not identified any areas of concern with incontinence care, indwelling urinary catheter care, or hand washing and glove changing. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 10/15/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review of the annual MDS revealed the facility assessed Resident #2 to require extensive assistance with toileting. Review of the Comprehensive Care Plan dated 08/25/16 revealed the facility would provide catheter care as ordered. Observation of catheter care for Resident #2 on 11/02/16 at 10:30 AM revealed Certified Nurse Aide (CNA) #3 washed the catheter tubing after washing the perineal area without changing the position of the washcloth. Observation further revealed after each use of a washcloth, CNA #3 placed the dirty washcloth between Resident #2's legs. When the catheter care was completed CNA #3 removed all the dirty washcloths by bringing them up and between Resident #2's legs touching the perineal area with the soiled washcloths. Interview with CNA #3 on 11/03/16 at 6:25 PM revealed she had been trained to clean the catheter tubing with a clean washcloth or to change the position of the washcloth after cleaning the perineal area first. Further interview revealed the dirty washcloths should have been placed in the plastic bag lying on the resident's bed instead of between the resident's legs. 3. Review of Resident #6's medical record revealed the facility admitted the resident on 05/08/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the facility assessed Resident #6 to have a BIMS score of 7, indicating the resident was cognitively severely impaired. Further review of the quarterly MDS revealed the facility assessed Resident #6 to require extensive assistance with toileting. Review of the Comprehensive Care Plan dated 05/26/15 revealed the facility would provide incontinence care as needed. Observation of incontinence care for Resident #6 on 11/01/16 at 5:30 PM revealed CNA #2 cleaned Resident #6's buttocks that were soiled with feces and then cleaned Resident #6's perineal area without changing gloves and washing her hands. Observation further revealed after each use of a washcloth during perineal care, CNA #2 placed the dirty washcloth between Resident #6's legs. When the perineal care was completed CNA #2 removed all the dirty washcloths by bringing them up and between Resident #6's legs touching the perineal area with the soiled washcloths. Interview with CNA #2 on 11/03/16 at 6:15 PM revealed she had been trained that if your gloves were not soiled with feces, then you could use the same gloves to wash the perineal area. She further revealed she should have put the dirty washcloths in a plastic bag after each use and not between the resident's legs. 4. Review of Resident #11's medical record revealed the facility admitted the resident on 04/18/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the facility assessed Resident #11 to have a BIMS score of 15, indicating the resident was cognitively intact. Further review of the quarterly MDS revealed the facility assessed Resident #11 to require extensive assistance with toileting. Review of the Comprehensive Care Plan dated 05/01/15 revealed the facility would provide catheter care per policy. Observation of catheter care for Resident #11 on 11/03/16 at 3:18 PM revealed CNA #1 and CNA #3 placed gloves on to start catheter care without washing their hands. Observation further revealed after each use of a washcloth during perineal care, CNA #1 and CNA #3 placed the dirty washcloths between Resident #11's legs. When the perineal care was completed CNA #1 removed all the dirty washcloths by bringing them up and between Resident #11's legs touching the perineal area with the soiled washcloths. Interview with CNA #1 on 11/03/16 at 5:35 PM revealed she had been trained to always wash her hands before starting any kind of treatment on a resident. Further interview revealed the dirty washcloths should have been placed in a plastic bag after each use and not between the resident's legs. Interview with CNA #3 on 11/03/16 at 6:25 PM revealed she had been trained to always wash her hands before starting any kind of treatment on a resident due to infection control. Interview with the Staff Development Nurse on 11/03/16 at 7:45 PM revealed CNAs have been trained to use a clean washcloth when cleaning the catheter tubing. Further interview revealed after each use of a washcloth the dirty washcloth should be placed in a plastic trash bag. She revealed she had done random spot checks on the CNAs during incontinence care and catheter care and had not identified any concerns. Interview with the Director of Nursing (DON) on 11/03/16 at 7:25 PM revealed the CNAs have been trained to always wash hands before starting any kind of treatments on residents and any time gloves were soiled. She further revealed the facility uses audit tools on handwashing and random checks to ensure the staff was washing their hands. She revealed she had not identified any concerns.

Based on review of the facility policy, Menu Planning, record review, observation, and interview, it was determined the facility failed to prepare slurry bread (bread for puree consistency) as specified on the planned menu spreadsheet for five (5) residents requiring puree consistency food. The findings include: Review of the policy, Menu Planning, (revised 03/14/16) revealed the menus must be followed as written. Review of the menu spreadsheet for the noon meal on 11/01/16 revealed residents requiring puree consistency of food were to receive slurry bread. Observation of the tray line at the noon meal at 12:15 PM (CST) on 11/01/16 revealed slurry bread was not served to the residents requiring puree consistency. Interview with the cook (person that prepared the meal) at 12:15 PM on 11/01/16 revealed she had forgotten to prepare the slurry bread for the residents requiring puree consistency because the menus were new and she was not used to preparing the slurry bread.

Based on review of the facility policy, observation, and interview, it was determined the facility failed to serve palatable food to the facility residents at the noon meal on 11/01/16. Sliced potatoes were specified on the menu spreadsheet and a test tray and interviews with residents revealed the potatoes were not seasoned. The findings include: Review of the facility policy, Food Temperatures/Palatability, (dated 2014) revealed food should be served at the proper temperature to ensure food safety and palatability. Observation of the tray line at 12:15 PM on 11/01/16 revealed the sliced potatoes on the steam table had a bland appearance. The surveyor requested a test tray for the meat, sliced potatoes, and carrots. Results of the test tray revealed the sliced potatoes were not palatable. A dietary staff member assisted with the tasting of the test tray. The dietary employee agreed with the surveyor that the sliced potatoes were not palatable because the sliced potatoes did not have enough salt and margarine in them. Interview with five (5) alert residents in the group interview at 2:45 PM on 11/01/16 revealed the sliced potatoes they had for lunch were not palatable because they did not have enough seasoning.

Based on observation, interview, review of facility policy, and review of the 2013 Food and Drug Administration (FDA) Food Code revealed the facility failed to maintain the kitchen in a sanitary manner. Observations in the kitchen on 11/01/16 revealed the white microwave had food splashes on the inside, the can opener had a buildup of debris, and the plates were stored upright. The findings include: Review of the facility policy, Microwave Oven, (revised 09/03/15) revealed the microwave oven should be cleaned daily. Review of the facility policy, Can Opener, (revised 09/01/11) revealed the can opener was to be cleaned after each meal, and more frequently if needed. Review of the policy, Dish and Utensil Procedure, (revised 07/01/14) revealed plates shall be handled without contact with the inside surfaces. Review of the 2013 FDA Food Code Section 4-904.11 revealed cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip contact surface is prevented. Observation of the white microwave at 10:10 AM (CST) on 11/01/16 revealed numerous food splashes were on the inside of the microwave. Interview at 8:10 AM (CST) on 11/03/16 with a dietary employee revealed the microwave should be cleaned after every use. Observation of the can opener at 10:10 AM (CST) revealed the can opener blade contained a buildup of food debris. Interview at 10:10 AM (CST) on 11/01/16 with a dietary employee revealed the can opener should be cleaned every day, but stated the can opener had not been cleaned that day. Observation at 10:10 AM (CST) on 11/01/16 revealed the plates were stored upward with the inside surface of the plates exposed. Interview with a dietary employee at 10:10 AM (CST) on 11/01/16 revealed the plates were stored upright with the plate inside surfaces exposed and the dietary employee was unaware that they should be stored with the inside surface downward.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an effective infection control program and infection control practices for three (3) of thirteen (13) sampled residents (Residents #2, #5, and #6) and three (3) of four (4) unsampled residents (Residents A, D, and E) related to glove changes and handwashing during resident care and proper cleaning of the glucometer machine. The findings include: Review of the facility policy titled Standard Precautions, dated August 2007, revealed standard precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Further review of the standard precautions policy revealed hands shall be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such. Interview with the Director of Nursing (DON) on 11/03/16 at 4:10 PM revealed the facility did not have a policy on skin assessments. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 10/15/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review of the annual MDS revealed the facility assessed Resident #2 to require extensive assistance with toileting. Observation of a skin assessment for Resident #2 on 11/02/16 at 10:30 AM revealed the Assistant Director of Nursing (ADON) started a skin assessment at the feet of Resident #2 and then proceeded to the perineal area and then reached into a basin of dirty water and removed soiled washcloths from the basin of water, and continued to complete the skin assessment on the upper body, without washing his hands or changing gloves. Further observation revealed with the same soiled gloves the ADON assisted Certified Nurse Aide (CNA) #3 with repositioning Resident #2 by using the draw sheet. Interview with the ADON on 11/03/16 at 5:43 PM revealed he had not been trained that it mattered if he started at the feet first to do a skin assessment. He further revealed he should have washed his hands and changed gloves after doing the skin assessment on the perineal area and removing the soiled washcloths from the dirty water in the basin, before completing the skin assessment. Further interview revealed he should have washed his hands and changed gloves before assisting the CNA to reposition Resident #2. He revealed he understood the problem with cross-contamination. 2. Review of Resident #6's medical record revealed the facility admitted the resident on 05/08/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the facility assessed Resident #6 to have a BIMS score of 7, indicating the resident was severely cognitively impaired. Further review of the quarterly MDS revealed the facility assessed Resident #6 to require extensive assistance with toileting. Observation after incontinence care for Resident #6 on 11/01/16 at 5:30 PM revealed CNA #2 and CNA #3 repositioned Resident #6, by pulling him/her up using the draw sheet, without washing their hands and changing gloves after providing incontinence care. Interview with CNA #2 on 11/03/16 at 6:15 PM revealed she had not been trained to wash her hands or change gloves after providing incontinence care, before repositioning a resident with a draw sheet. She further revealed she should have for infection control purposes. Interview with CNA #3 on 11/03/16 at 6:25 PM revealed she had been trained to wash her hands and change gloves before starting any kind of treatment on residents. She further revealed she had been trained on infection control. Interview with the Staff Development Nurse on 11/03/16 at 7:45 PM revealed CNAs had been trained to wash their hands before starting any kind of treatment on residents and any time gloves were soiled. She further revealed staff was trained upon hire and annually. Further interview revealed spot checks are done randomly to ensure the staff was washing hands and using gloves. She had not identified any concerns. Interview with the Director of Nursing (DON) on 11/03/16 at 7:25 PM revealed the CNAs had been trained to always wash hands before starting any kind of treatments on residents and any time gloves were soiled. She further revealed the facility uses audit tools on handwashing and random checks to ensure the staff was washing their hands. She revealed she had not identified any concerns. 3. Review of Resident #5's medical record revealed the facility admitted the resident on 08/25/04 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired. Further review revealed the facility assessed the resident to require extensive assistance of two (2) staff persons for personal hygiene and toileting. The facility assessed the resident to always be incontinent of bowel and bladder. Review of the Comprehensive Care Plan dated 04/13/11 revealed an intervention to provide incontinence care after incontinence episodes. Observation of Resident #5's skin assessment on 11/02/16 at 9:55 AM by the Assistant Director of Nursing (ADON) revealed he started the assessment at the resident's head and then moved to the resident's feet. After assessing the resident's feet, he then moved to the resident's perineal area and continued to assess the resident's breast and touch the resident's back with the same gloved hands. After completing the full assessment he then removed his gloves and washed his hands prior to leaving the resident's room. Interview with the ADON on 11/03/16 at 5:43 PM revealed he should have assessed the resident's neck, ears, and shoulders as part of the skin assessment. He further revealed he should have washed his hands and changed gloves after doing the skin assessment on the perineal area, before completing the skin assessment. He revealed he understood the problem with cross-contamination. Observation of incontinence care for Resident #5 on 11/02/16 at 1:54 PM revealed staff failed to use a clean section of washcloth for each area that was cleansed. After providing incontinence care Certified Nurse Aide (CNA) #4 then applied the house barrier cream to the resident's buttocks and proceeded to reposition the resident with the same gloved hands. After repositioning the resident, CNA #4 then used the bed control to adjust the resident's bed with the same gloved hands. She then removed her gloves and washed her hands at the sink and proceeded to turn off the faucet with her bare hand and then dry her hands with a paper towel. Interview with CNA #4 on 11/03/16 at 5:50 PM revealed she should have removed her gloves and washed her hands after providing incontinence care to the resident. She further stated she should not have repositioned the resident in bed and then touched the resident's bed control with the gloves she was wearing for incontinence care. She stated she had been trained to remove her gloves, wash her hands, and put on clean gloves when going from dirty to clean with incontinence care. Interview with the Director of Nursing (DON) on 11/03/16 at 7:44 PM revealed that CNAs were trained on providing incontinence care, indwelling urinary catheter care, and proper hand washing and glove changes. She stated she made rounds daily to ensure that residents were receiving proper incontinence care and indwelling urinary catheter care. She further stated that the CNAs should have washed their hands and changed their gloves after providing incontinence care before repositioning the resident and touching the resident's bed control. She stated she had not identified any concerns related to hand washing and glove changing. Further interview with the DON revealed the ADON should have washed his hands and changed his gloves after assessing the resident's perineal area. She stated he had been trained to wash his hands and change his gloves after moving from a dirty area to a clean area. 4. Observations conducted during medication administration on 11/02/16, at 9: 20 AM revealed the ADON put on gloves without washing his hands and proceeded to administer medications to Resident A through the resident's gastrostomy tube (G/T). Interview with the ADON on 11/03/16 at 5:05 PM revealed he had been trained to wash his hands before and after doing resident care. The ADON stated he recalled failing to wash his hands prior to putting on gloves before giving the G/T medications. 5. Observations of an accu-check (blood sugar monitoring) conducted on 11/01/16 at 5:30 PM, revealed the Staff Development Coordinator (SDC) Nurse removed the glucometer from the medication cart drawer, obtained a lancet and alcohol swab, and took them into Resident D's room and obtained the resident's blood sugar level. The nurse then took the glucometer back to the medication cart, cleaned the glucometer with a bleach wipe, and laid the glucometer on top of the soiled medication cart to dry, and then placed the glucometer in the medication drawer. After the SDC Nurse administered Insulin coverage to Resident D, she then took the same glucometer (without cleaning it) and performed an accu-check on Resident E. Interview with the SDC Nurse on 11/03/16, at 5:45 PM revealed she had been trained to clean the glucometer before and after each use with a bleach wipe for 30 seconds and to air dry. The SDC Nurse stated she had never considered the top of the medication cart or drawer to be soiled or a dirty area. Interview with the DON on 11/03/16, at 7:25 PM revealed the glucometer was to be cleaned before and after each use with a bleach wipe. The DON stated the glucometer had always been stored in the top drawer of the medication cart.

Based on observation, interview, and record review, the facility failed to ensure privacy was provided for one (1) of thirteen (13) sampled residents (Resident #2) and one (1) of four (4) unsampled residents (Resident A) while care/services and/or treatment was being provided for the residents. The findings include: An interview conducted with the Director of Nurses (DON) on 11/03/16, at 9:00 AM, revealed the facility did not have a specific policy/procedure related to provision of privacy for residents when staff was providing care and services. 1. During the medication administration observation pass conducted on 11/02/16, at 9:20 AM (EST), the Assistant Director of Nursing (ADON) was observed to administer medications to Resident A per gastrostomy tube (G/T). When the nurse entered Resident A's room, the resident was in bed next to the window and the blinds were closed. At one point during the medication administration, another staff person came to the door and had a conversation with the ADON with the resident's door open and the curtain open leaving the resident exposed to possible other residents, staff, or visitors. The ADON failed to pull the curtain or to close the door to provide privacy while the G/T medications were administered to Resident A. Interview conducted with the ADON on 11/03/16, at 5:05 PM, revealed he had been trained to provide privacy for residents when providing care. The ADON stated he thought he pulled the curtain a little but should have pulled it all the way around the resident and closed the door to the room to completely provide privacy. Interview with the DON on 11/03/16, at 7:25 PM, revealed staff had been trained to pull the curtain and close the resident's door to provide privacy when providing care for a resident. The DON stated walk-through rounds were conducted randomly by administrative staff to monitor staff to ensure privacy was being provided and no problems had been identified. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 10/15/15 with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Observation of Resident #2 on 11/02/16, at 10:30 AM, revealed the resident was in bed and facility staff was providing wound care treatment to the buttocks, catheter care, and a skin assessment. Staff failed to keep the resident's skin covered between treatments allowing the resident's entire body from the waist down to be fully exposed during all the care. Interview with Certified Nurse Aide (CNA) #3 on 11/03/16 at 6:25 PM revealed she should have provided privacy to Resident #2 after providing catheter care. She further revealed she had been trained to always provide privacy while doing resident care. Interview with the ADON on 11/03/16 at 5:43 PM, revealed he had been trained to cover the resident as much as possible for privacy and dignity while providing care. He further revealed he was still in training and was very nervous being observed.

Based on interviews and record review it was determined the facility failed to promote care for residents in a manner that enhanced each resident's dignity for one (1) of thirteen (13) sampled residents (Resident #9). Interview with Resident #9 on 11/01/16 revealed the resident had experienced an episode of incontinence after facility staff failed to assist the resident to the bedside commode in a timely manner. The findings include: Interview with the Director of Nursing (DON) on 11/03/16 at 7:44 PM revealed the facility did not have a policy to address resident dignity. Review of the medical record for Resident #9 revealed the facility admitted the resident on 12/15/15 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment and the resident to be interviewable. Further review of the MDS revealed the facility assessed the resident to require extensive assistance of two (2) staff persons for toileting. Further review revealed the resident was assessed for frequent bladder and bowel incontinence. Interview with Resident #9 on 11/03/16 at 3:45 PM revealed on 11/02/16 after returning to his/her room at approximately 7:00 PM, the resident informed the two (2) Certified Nurse Aides (CNA #2 and CNA #6) that he/she needed to use the bedside commode. The resident stated they were already in his/her room providing care to his/her roommate. He/she stated the two (2) CNAs ignored the request and left the room. The resident stated he/she did not understand why they did not help since they were already in the room. Furthermore, the resident stated that due to the CNAs not assisting him/her to use the bedside commode he/she experienced an incontinence episode. He/she stated that it made him/her feel bad. The resident stated that he/she reported it to the morning shift CNA and that the Administrator and Social Services Director came and spoke to him/her about the incident and stated that it would not happen again. Interview with CNA #6 on 11/03/16 at 6:05 PM revealed she was not the CNA responsible for Resident #9's care. She stated that Resident #9 did tell her that he/she needed assistance to the bedside commode and she told the resident that she would be back to assist him/her but she got busy and did not come back to the resident's room. She further stated that she had been trained on promoting resident dignity and assisting residents with toileting. Interview with CNA #2 on 11/03/16 at 6:15 PM revealed that she was told by Resident #9 that he/she needed assistance getting to the bedside commode. She stated she told the resident she would be back to help him/her but got busy and did not come back until the resident was already in bed. She stated she should have helped the resident onto the bedside commode when the resident requested help but she was assisting someone else. She further stated she had been trained on assisting residents with toileting and with promoting dignity. Interview with the Director of Nursing (DON) on 11/03/16 at 7:44 PM revealed staff was trained all the time about answering call lights and providing continence/incontinence care. She stated if the CNAs were busy they should have gotten someone else to help the resident to the bedside commode. Further interview revealed she and the nurses conducted rounds multiple times a day to ensure the residents receive the required care. She further stated that due to staff not assisting the resident in a timely manner, and consequently the resident having an incontinence episode, the staff did not promote the dignity of Resident #9.

Based on observation, interview, and record review, it was determined the facility failed to accurately assess the resident's status for two (2) of thirteen (13) sampled residents (Resident #2 and Resident #11). Resident #2 and Resident #11 were observed to utilize a urinary catheter device. Review of the annual Minimum Data Set (MDS) assessment revealed the facility failed to assess the devices appropriately. The findings include: Interview with the MDS Coordinator on 11/03/16 at 5:05 PM revealed the facility uses the current Resident Assessment Instrument (RAI) guidelines and instructions when conducting comprehensive assessments for residents. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 10/15/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review of the MDS dated [DATE] revealed, under section H Bladder and Bowel, the facility assessed Resident #2 to have frequent incontinence of bladder. Review of the Comprehensive Care Plan dated 08/25/16 revealed the facility assessed Resident #2 to utilize an indwelling urinary catheter. Observation of Resident #2 during incontinence care on 11/02/16 at 10:30 AM revealed Resident #2 utilized an indwelling urinary catheter. 2. Review of Resident #11's medical record revealed the facility admitted the resident on 04/18/15 with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed the facility assessed Resident #11 to have a BIMS score of 15, indicating the resident was cognitively intact. Further review of the MDS dated [DATE] revealed, under section H Bladder and Bowel, the facility assessed Resident #11 to have occasional incontinence of bladder. Review of the Comprehensive Care Plan dated 05/01/15 revealed the facility assessed Resident #11 to utilize an indwelling urinary catheter. Observation of Resident #11 during incontinence care on 11/03/16 at 3:18 PM revealed Resident #11 utilized an indwelling urinary catheter. Interview with the MDS Coordinator on 11/03/16 at 5:05 PM revealed the Certified Nurse Aides (CNAs) utilized a kiosk system for documenting incontinence. She stated the CNAs did not have the option to document the use of a catheter, and could only document that the resident was continent or incontinent. The MDS Coordinator stated the information from the kiosk went directly to the MDS and could not be changed.

Based on observation, interview, record review, and facility policy review, the facility failed to review and revise the comprehensive care plan for two (2) of thirteen (13) sampled residents (Residents #1 and #7) when a change in condition occurred. Resident #1 had a physician's orders [REDACTED]. According to facility staff the resident was noncompliant and frequently removed the oxygen. Resident #7 had fall mats that were discontinued on 08/25/15. However, the comprehensive care plans for Residents #1 and #7 had not been reviewed/revised to reflect the changes in the residents' condition. The findings include: A review of the care plan policy (dated 06/01/15) revealed care plans would be revised by the nurse/interdisciplinary team as information about the resident and the resident's condition changed. 1. Resident #1 was observed on 11/01/16 at 12:50 PM, 1:35 PM, 3:00 PM, 3:25 PM, and 7:00 PM to be lying in bed. An oxygen concentrator was noted to be at the resident's bedside but was not in use. Resident #1 was again observed on 11/02/16 at 10:00 AM and 3:00 PM to be lying in bed with no oxygen in use. Interview with Resident #1 on 11/02/16, at 3:00 PM, revealed the resident stated he/she only used the oxygen at night and did not need the oxygen during the day. Review of the medical record revealed the facility admitted Resident #1 on 04/13/16 with [DIAGNOSES REDACTED]. Review of the quarterly comprehensive assessment dated [DATE], revealed the facility assessed the resident to use oxygen and to have a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident to have moderately impaired cognition. Review of the comprehensive care plan dated 04/20/16 and reviewed on 07/19/16, revealed the facility addressed the resident's breathing difficulty and implemented interventions to administer medications and oxygen as ordered. A review of the current November 2016 physician's orders [REDACTED]. Review of the November Treatment Administration Record (TAR) revealed that the nurses had initialed that the oxygen was administered to Resident #1 on 11/01/16 and on 11/02/16. Interview with RN #2 on 11/02/16, at 3:30 PM revealed she had applied the oxygen via nasal cannula to Resident #1 during the morning of 11/02/16. RN #2 stated the resident was noncompliant with using the oxygen and took it off during the night. RN #2 confirmed the resident only wanted to use the oxygen at night. The RN stated the nurse was responsible to revise the resident's care plan if the resident was noncompliant; however, she had not thought about doing it. Interview with the Staff Development Coordinator (SDC) on 11/02/16 at 5:45 PM revealed she was the nurse assigned to Resident #1 on 11/01/16. The SDC Nurse stated she also put the oxygen on Resident #1 on 11/01/16 because the resident's oxygen saturation level was down. The SDC Nurse stated the resident frequently took the oxygen off and the resident had been educated about the risks/benefits of using the oxygen. The SDC Nurse stated the staff nurses were responsible to revise the care plan when changes occurred in a resident's condition, but she had not thought about revising the care plan for Resident #1 because sometimes the resident left the oxygen on. The Director of Nursing (DON) confirmed in interview on 11/02/16, at 7:25 PM, that the nurses were responsible to update/revise the resident's care plan when they became aware of a change in the resident's condition. The DON stated the care plans were reviewed through the interdisciplinary care plan team and no problems had been identified. 2. Review of the medical record for Resident #7 revealed the facility admitted the resident on 08/04/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], and recent quarterly MDS dated [DATE], revealed the facility assessed Resident #7 to be free of falls since admission, entry/reentry, or prior assessment. Review of the Comprehensive Care Plan revealed the care plan was initiated on 08/15/15. The care plan included interventions regarding the resident's risk for falls related to prior History of Falls, Poor Safety Awareness, Poor Balance, Takes Medications with Potential for Side Effects, and Dementia. Interventions included Bed in Lowest Position with Fall Mat at Bedside. Review of the Fall Risk Evaluation completed on 08/08/15 revealed Resident #7 was assessed to be at risk for falls. Review of the Fall Risk Evaluation completed on 10/23/16 revealed Resident #7 was assessed to not be considered at risk for falls. Record review revealed a MD order to discontinue the intervention for the fall mat, dated 08/25/15. Review of the Comprehensive Care Plan revealed no evidence the intervention for the fall mat had been removed. Interview with Licensed Practical Nurse (LPN) #4 on 11/03/16 at 12:45 PM revealed the person who received an order was responsible for updating the Comprehensive Care Plan. Record review revealed an order to discontinue the fall mats was received on 08/25/15 by LPN #5. Telephone interview with LPN #5 on 11/03/16 at 3:07 PM revealed the nurse that received a new order was responsible to revise the care plan with the new order. When LPN #5 was questioned about Resident #7's fall mats, she stated the Director of Nursing (DON) or the Assistant DON were responsible to revise the care plan if an order was to discontinue treatment. Interview with the Administrator on 11/03/16 at 3:15 PM revealed when a new order was received the care plan should be updated to reflect the change by the nurse that takes the order. The Administrator further stated the facility conducted in-services on care plans with the nursing staff.