Every finding on record at Coldspring Transitional Care Center

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the environment remained free of accident hazards as much as possible for 2 of 37 sampled residents, Resident (R) 54 and R116. Observation of the shared bathroom for R54 and R116 on 06/23/2026 at 11:43 AM revealed a white powdery substance in an unlabeled medication cup sitting on the bathroom sink. The findings include: Review of the facility's policy titled, Fall and Accident Management, revision date 06/2019, revealed the facility would identify patients at risk of falls and other accidents with implementations placed and evaluated to reduce risk of injuries, falls or other accidents. The policy stated the facility would work to identify hazards and risks to decrease the risk of injury. Further review revealed the facility would evaluate, analyze, implement interventions, monitor for effectiveness, and modify when needed. The State Survey Agency (SSA) Surveyor requested from the Director of Nursing (DON) on 06/23/2026 at 4:33 PM a policy for medication administration. However, one was not provided by exit on 06/26/2026. The SSA Surveyor requested from the DON on 06/26/2026 at 11:23 AM any and all additional policies for accidents. She stated the only one was the one already given that was primarily for falls. Observation on 06/23/2026 at 11:43 AM revealed a shared bathroom in the resident room where R54 and R116 resided. In the shared bathroom there was a medication cup (30 milliliters) sitting on the bathroom sink with a white powdery substance inside unlabeled. The SSA Surveyor immediately informed Licensed Practical Nurse (LPN) 2, and she discarded the cup and substance. During an immediate interview with LPN2, she stated she did not know what the substance was or where it came from. She stated R116 had an order for an antifungal powder and that could have been it. She stated she had not left the cup in the bathroom that day or any other day. When asked why the cup should not have been left in the bathroom, she stated because no one knew what it contained, and a resident could eat it and possibly be harmed. 1. Review of R54's admission Record revealed the facility admitted the resident on 06/10/2024 with diagnoses to include multiple sclerosis, heart failure, and high blood pressure. Review of R54's active Order Set did not include any powders or crush medication order. 2. Review of R116's admission Record revealed the facility admitted the resident on 02/03/2025 with diagnoses to include stroke, diabetes, and depression. Review of R116's active Order Set revealed an order placed on 06/22/2026 for tolnaftate antifungal external powder 1% to be applied under breasts and abdominal fold topically every day and night shift for moisture associated skin disorder (MASD) for 14 days. Review of R116's June 2026 Treatment Administration Record [TAR] revealed the antifungal powder had been applied for the day shift dose on 06/23/2026, initialed by LPN2. During an interview with Unit Manager 2 on 06/25/2026 at 3:13 PM, she stated her tasks included managing the floor, helping the nurses when needed, and having huddles with the Nurse Practitioner (NP). She stated she and the staff did daily walk-throughs for safety of the residents and their rooms and addressed issues as needed. She stated, when asked about the medicine cup found in R54's and R116's shared bathroom, nothing had been found in the bathroom previously, and all the treatment carts and medication carts were locked. She stated her concern was that if a resident found the medicine cup, they could have ingested it, possibly causing harm. She stated her expectation was for staff administering medications to watch the resident take the medicine and apply all topicals. She stated she did not know what was in the cup. During an interview with LPN10 on 06/25/2026 at 6:21 PM, she stated she had provided care to R116 the night of 06/22/2026 and had not noticed any medicine cup sitting in R54's and R116's shared bathroom. She stated she had applied the antifungal powder to R116. She stated any confused resident could have entered that bathroom and ingested what was in the cup. She stated the facility provided training about not leaving medicine at the bedside. During an interview with the DON on 06/25/2026 at 8:45 AM, she stated her tasks included providing oversite of the nursing department, educating staff, and giving monthly in-services. When asked about finding the medication cup with the white powder in the shared bathroom, she stated it should not have happened. She stated she would be concerned about the safety of the residents and others in the building with that sitting out. She stated some of the residents were confused, and they could have gotten the cup and substance and ingested it. The DON stated staff was already doing daily walk-throughs to check all aspects of safety. She stated staff had been educated on not leaving items out, and she had no reports previously of any incidents where that occurred. During an interview with the Administrator on 06/25/2026 at 4:00 PM, he stated he had been the Administrator since 2018, and his tasks included oversite of the facility. He stated he was not clinical and relied on the DON for that side of operations. He stated his concern for having the substance found in the medicine cup in the shared bathroom was that any confused resident could have consumed it, and it could harm them.

Based on interview, record review, review of the facility's investigation, review of the nursing guidebook of professional standards, review of the Kentucky Board of Nursing (KBN) standards, and review of the facility's policies, the facility failed to ensure nursing services provided met professional standards of practice for 1 out of 12 sampled residents, Resident (R) 1.R1 was administered incorrect medications on 09/10/2025, which caused her to be sent to the hospital for further evaluation on 09/10/2025.Based on review of the facility's plan of correction (PoC) and validation through observation, interviews, and record reviews, the facility had implemented corrective actions with a compliance date of 09/18/2025, before survey entrance. Therefore, the deficient practice was past noncompliance.The findings include: Review of the facility's policy titled, Identification of the Resident Prior to Medication Administration, revised 12/2021, revealed, Prior to administering medication, the nurse/medication aide identifies the recipient of the medication by: asking the resident his/her name, if appropriate with diagnosis. Checking wristband. Comparing resident with picture in EMAR [electronic medication administration record]. If still in doubt, the nurse/medication aide must verify identity by conferring with facility staff member who is familiar with the resident.Review of the facility's policy titled, Administration Oral Medications, revised 11/2024, revealed, The medication name, dosage, and interval are to be read from the medication administration record. The policy also revealed, To assure administration accuracy, the nurse/medication aide cross checks the following reference points: physician's order, Medication administration record [MAR], and label on drug container.Review of the website, www.KBN.ky.gov revealed, Accountability and Responsibility of Nurses in accordance with KRS 314.021(2), nurses are responsible and accountable for making decisions that are based upon the individuals' educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Nursing practice should be consistent with the Kentucky Nursing Laws, established standards of practice, and be evidence based.Review of Mosby's Safe Medication Administration Guide, undated, from www.elsevier-elibrary.com, revealed, Always adhere to the 5 rights of medication administration when transcribing, preparing, administering, and documenting medications: Right patient, Right drug, Right route, Right dose, and Right time.Review of R1's incident investigation IDT [Interdisciplinary Team] Follow up Note, dated 09/11/2025, revealed the incident was reported and documented on 09/10/2025 at 6:45 AM. The note revealed, On the AM of 09/10/2025 resident received the following medications oxycodone-acetaminophen 5/325 mg [milligrams] one tablet [an opioid pain medication], clonazepam 0.5 mg one tablet [an anti-anxiety medication], nifedipine ER 30 mg one tablet [a cardiac medication], vitamin B12 1000 mcg [micrograms] one tablet, iron 325 mg one tablet, and omeprazole [a medication to reduce stomach acid] 40 mg one capsule. Resident's vitals were checked. Resident with altered mental status. Vital signs 148/90, pulse 62, respirations 20, temp 97.6 axillary, oxygen 88% room air. Oxygen applied, Narcan x 1. O2 sats increased to 96%. MD was notified with orders to send to ER [emergency room] for further eval [evaluation]. Son also notified. Resident was admitted to hospital r/t pneumonia and CHF.Review of R1's Face Sheet revealed the facility admitted R1 on 03/08/2021 with diagnoses which included Alzheimer's disease, chronic pain, anxiety, atrial fibrillation, and hypertension.Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/28/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, indicating intact cognition.During an interview on 10/21/2025 at 7:07 PM with Registered Nurse (RN) 1, she stated during morning medication administration, she was preparing medications for a different resident, R2, when R1, who was a couple of rooms down the hall, began yelling. She stated simultaneously another resident started yelling, and she went to check on R1 to make sure she was okay. She stated she had already pulled R2's medications and had them in a cup, so she placed them in her medication cart and locked it before walking away. She stated she then went to check on R1 who wanted her shoes on and her morning medications. She stated she helped R1 with her shoes and then gave R2's medications to R1 by mistake, since R1 was ready for her medications. She stated she realized what she had done right away and reported it. She stated she made the Director of Nursing (DON), Physician, and R1's son aware. She stated she obtained baseline vitals, and R1 was not as responsive to her. She stated, because of this, a dose of Narcan was given. She stated she received education, provided by the DON and Administrator. She stated she was observed administering medications correctly prior to her being allowed to return to work and administer medications unsupervised. She stated a plan of action was made to scan every medication. She stated, at the time R1 was yelling, she was safe. Therefore, RN1 stated she should have continued with R2's medication administration since they were already prepared. She also stated she should have made R1 wait until she was finished administering R2's medications.During an interview on 10/22/2025 at 11:21 AM with R1's representative, he stated the facility called him that morning and reported to him they had mistakenly given R1 the wrong medications. He stated they also told him R1 was being sent to the emergency room (ER) for further evaluation and monitoring. He stated he went to the ER, and his mother was tired, but she seemed okay. He stated R1 was very coherent. He stated R1 had never been given the wrong medications before, and he felt safe with R1 remaining in the facility.The facility provided an acceptable plan of correction (PoC) on 10/21/2025 alleging past non-compliance of the deficient practice and a date of compliance of 09/18/2025, with corrective actions as follows:Review of the Quality Assurance and Performance Improvement [QAPI] Plan of Correction [PoC], dated 09/12/2025, revealed the topic reviewed was medication errors. Corrective actions included assessing R1 on 09/10/2025, notifying the DON on 09/10/2025, notifying the physician and R1's son on 09/10/2025, review of R1's medical record, including medications administered on 09/10/2025. The PoC also revealed the DON completed a medication administration check-off and provided immediate education regarding the six rights of medication administration with RN1 on 09/12/2025. The DON completed medication administration audits with each licensed nurse working. The DON completed an audit of all medications carts to ensure medications were not pre-pulled, and there was no evidence of medications not administered per physician order, as well as reviewed the narcotic count sheets to ensure medications were administered as ordered, dated 09/10/2025. Head to toe assessments, including vital signs, were completed on all residents on the 2100 and 2400 Halls on 09/10/2025.Further review of the QAPI PoC, dated 09/12/2025, revealed measures to be put into place to ensure deficient practice did not recur included additional in-service education would be given to all licensed nurses by the DON by 09/12/2025. This would be monitored by a PI [Performance Improvement] Audit Worksheet, completed by the DON to verify residents' medications were administered per physician's orders. The PI was being completed by the DON daily for seven days, twice weekly for two weeks, weekly for two weeks, and then monthly. The results would be reviewed by the QAPI team. The Lifelong Learning Attendance Sheet revealed medication error education was given to all licensed nurses and medication aides to include medication policies; ensure medications were administered according to physician's orders; prepare only one resident's medications at a time and as soon as they were prepared; and administer medications according to the six rights (right resident, right medication, right dose, right time, right route, right documentation). Fifty-one signatures were on the sign-in sheet. The Medication Administration Observation revealed the DON observed RN1 administer 26 medications to a total of 13 different residents with zero errors on 09/12/2025. Review of the Quality/Continuity of Care PI Worksheet revealed audits were done on 09/12/2025, 09/13/2025, 09/14/2025, 09/15/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/19/2025, 09/20/2025, 09/21/2025, 09/25/2025, 09/26/2025, 09/30/2025, 10/01/2025, 10/03/2025, 10/04/2025, 10/07/2025, 10/10/2025, 10/17/2025, 10/18/2025, and 10/21/2025.The State Survey Agency (SSA) validated the facility's PoC for past noncompliance which determined the facility had corrected the deficient practice for F658 on 09/18/2025 as alleged.Record review of R1's incident report, internal investigation, and the medication administration record (MAR) revealed R1 was immediately assessed post incident by RN1, who noted altered mental status. RN1 notified all appropriate staff members as well as R1's son.The records of nine additional residents identified as potentially at risk to be affected were reviewed, R2, R3, R4, R6, R7, R8, R9, R10, and R11. This review identified no deficiencies.Observation of all eight medications carts on 10/21/2025, revealed no pre-pulled medications.During an interview on 10/21/2025 at 1:50 PM with Licensed Practical Nurse (LPN) 7, she stated she was new to the facility and had received education regarding medication administration and storage. She stated she had not had any errors to her knowledge, but if she discovered one, she was to access the resident, document the incident, and notify leadership.During an interview on 10/21/2025 at 3:27 PM with LPN1, he stated medications were in blister packs from the pharmacy and were never prepared for medication administration then placed in the cart. He stated he identified residents by scanning their bracelets, if they were wearing one, or by the picture in the facility's system. He stated he had received medication error education recently, and it was provided by the DON.During an interview on 10/21/2025 at 3:30 PM with Registered Nurse (RN) 2, she stated they were taught not to prepare resident medications and then place them back into the medication carts. She stated she had received education about medication administration recently by the DON.During an interview on 10/21/2025 at 3:31 PM with RN3, she stated medications were never pre-pulled and placed back into the medication carts. During an interview on 10/21/2025 at 3:34 PM with LPN2, he stated medications were administered as they were prepared. He stated he scanned the resident's bracelet to verify it was the correct resident. He stated he had received medication education within the past month. During an interview on 10/21/2025 at 3:37 PM with LPN3, she stated she never pre-pulled medications and had never witnessed that occurring in the facility. During an interview on 10/21/2025 at 3:40 PM with LPN4, he stated he had never pre-pulled medications, and he had received medication education recently. He stated his scanner on his computer was currently broken; however, information technology (IT) was aware. He stated IT was usually fast with fixing their equipment. He stated the other ways he could identify a resident was by their picture or asking another staff member who might be familiar with the resident.During an interview on 10/22/2025 at 9:02 AM with LPN5, she stated she never pre-pulled medications, and she administered medications to one resident at a time. She stated the DON had provided education regarding medication errors. During an interview on 10/22/2025 at 9:19 AM with LPN6, she stated if medications were not administered after being prepared, then staff was to dispose of them. During an interview on 10/22/2025 at 11:00 AM with the DON, she stated she expected all staff who administered medications to follow the facility's policies. She stated that was important for resident safety. She stated if a medication error did occur, she expected to be notified immediately.

Based on observation, interview, record review, and review of facility's policy, the facility failed to provide a nourishing snack at bedtime for 9 of 9 residents, Resident (R) 7, R22, R36, R66, R68, R76, R81, R91, and R94. On 05/13/2025 at 3:16 PM during the Resident Council meeting, all residents present stated the facility did not provide nourishing snacks for residents at bedtime. The findings include: Review of the facility's policy titled, [Facility] Health Care Management Nourishment Center, dated 06/2019, revealed the facility would have light refreshments/snacks available to residents between meals or over-night. Per the policy, the refreshments would be available to new residents arriving to the facility after the evening meal. Observation during the initial tour on 05/12/2025 between 6:14 PM and 10:07 PM revealed State Tested Nursing Aides (STNA) on the 1300 Unit and 1400 Unit were asking residents if they wanted ice but did not inquire to see if the residents needed snacks. During an interview on 05/13/2025 at 3:16 PM in the Resident Council meeting, all residents present (R7, R22, R36, R66, R68, R76, R81, R91, and R94) stated they had not been offered snacks at bed time. 1. Review of R7's admission Record revealed the facility admitted R7 on 12/06/2020 with admitting diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified; morbid (severe) obesity due to excess calories; and major depressive disorder recurrent, severe psychotic symptoms. Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/06/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating the resident was cognitively intact. During an interview on 05/13/2025 at 3:59 PM with R7 in the Resident Council meeting, she stated her blood sugar could be anywhere from 80 to 450 (normal 70 to 99), and she needed the snacks to help with the insulin and making sure her blood sugar did not get too low. 2. Review of R22's admission Record revealed the facility admitted R22 on 02/24/2020 with admitting diagnoses including hypertensive urgency, personal history of COVID-19, and type 2 diabetes mellitus with diabetic neuropathy unspecified. Review of R22's annual MDS, with an ARD of 02/24/2025, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, indicating the resident was cognitively intact. 3. Review of R36's admission Record revealed the facility admitted R36 on 02/09/2025 with admitting diagnoses of acute and chronic respiratory failure with hypoxia; other spondylosis with myelopathy, cervical region; and acute kidney failure, unspecified. Review of R36's admission MDS, with an ARD of 02/15/2025, revealed the facility assessed the resident as having a BIMS score of nine out of 15, indicating the resident had moderate cognitive impairment. 4. Review of R66's admission Record revealed the facility admitted R66 on 03/23/2025 with admitting diagnoses including heart failure, unspecified; atherosclerotic heart disease of native coronary artery without angina pectoris; and major depressive disorder, single episode, unspecified. Review of R66's admission MDS, with an ARD of 03/28/2025, revealed the facility assessed the resident as having a BIMS score of nine out of 15, indicating moderate cognitive impairment. 5. Review of R68's admission Record revealed the facility admitted R68 on 02/03/2025 with admitting diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; type 2 diabetes mellitus with hyperglycemia; and type 2 diabetes mellitus with ketoacidosis without coma. Review of R68's quarterly MDS, with an ARD of 05/09/2025, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, indicating intact cognition. During an interview on 05/13/2025 at 3:42 PM with R68 in the Resident Council meeting, she stated her blood sugar dropped to 75, and they had to get her some snacks because her vision was affected, she had a headache, and she had sweating. She stated she now kept snacks in her room because she never knew if staff would give out snacks at bedtime. She stated she needed to make sure she had food to keep her blood sugar from dropping with being on insulin. 6. Review of R76's admission Record revealed the facility admitted R76 on 02/16/2021 with admitting diagnoses including chronic obstructive pulmonary disease (COPD), unspecified; Sjogren's syndrome with keratoconjunctivitis; and type 2 diabetes mellitus without complications. Review of R76's annual MDS, with an ARD of 02/16/2025, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, indicating the resident was cognitively intact. 7. Review of R81's admission Record revealed the facility admitted R81 on 03/08/2021 with admitting diagnoses including COPD with (acute) exacerbation; acute respiratory failure with hypoxia; and acute respiratory failure with hypercapnia. Review of R81's annual MDS, with an ARD of 03/08/2025, revealed the facility assessed the resident as having a BIMS score of 12 out of 15, indicating the resident had moderate cognitive impairment. 8. Review of R91's admission Record revealed the facility admitted R91 on 11/22/2022 with admitting diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; major depressive disorder; and unspecified mental disorder due to known physiological condition. Review of R91's quarterly MDS, with an ARD of 03/22/2025, revealed the facility assessed the resident as having a BIMS score of eight out of 15, indicating the resident had moderate cognitive impairment. 9. Review of R94's admission Record revealed the facility admitted R94 on 12/31/2022 with admitting diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris; type 2 diabetes mellitus with diabetic neuropathy; and personal history of COVID-19. Review of R94's quarterly MDS, with an ARD of 01/06/2023, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 05/12/2025 at 8:14 PM with STNA15, she stated aides passed ice to residents during the evening and snacks if they requested them. During an interview on 05/15/2025 at 8:38 AM with STNA10, she stated during the day, residents went to the snack cart in the activities room and took what they wanted. She stated aides on night shift went around between 10:30 PM and 11:00 PM to pass ice and check on snacks. During an interview on 05/15/2025 at 9:20 AM with the Executive Chef, she stated staff provided snacks to the residents that were available 24 hours a day, seven days a week (24/7). She stated she and dietary staff were in charge of keeping the carts stocked every day. She stated the cart was organized for every diet for each resident and were audited daily. She stated nurse aides were responsible for taking carts around and offering snacks to the residents. She stated one resident took the cheesy peanut butter crackers, and the residents were upset about that. She stated dining rooms were opened 24 hours a day with drinks (coffee, tea, juice, other beverages). She stated there also were sandwiches available 24/7. She stated all the aides had to do was go to the kitchen and get them because they were pre-made. The Executive Chef stated she attended the Resident Council meetings, and residents were told aides could go and get sandwiches upon request. During an interview on 05/15/2025 at 4:42 PM with the Director of Nursing (DON), she stated it was her expectation that staff was to offer snacks to residents when they were passing ice between meals and at night. She stated there was a snack cart located in the activities room where residents could go and obtain snacks if they needed some. She stated staff was expected to check with residents who were unable to get snacks themselves and take them to residents. During an interview on 05/15/2025 at 5:01 PM with the Administrator, he stated it was his expectation staff was providing residents with snacks during the day and at bedtime.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 32 sampled residents, Resident (R) 122, in Transmission-Based Precaution (TBP) or Enhanced Barrier Precautions (EBP). 1. Observation and interview on 05/12/2025 revealed State Tested Nurse Aide (STNA) 2 provided direct care to R122 who was under EBP. The STNA did not don (put on) Personal Protective Equipment (PPE) before providing direct care. STNA2 was observed to exit R122's room wearing gloves while transporting trash to the dirty utility room. 2. Observation and interview on 05/12/2025 revealed Licensed Practical Nurse (LPN) 4 used a portable vital sign machine on R142 who was in EBP. The LPN did not clean and disinfect the vital sign machine after using it. Furthermore, the nurse left the shared equipment in the hallway and walked away, without returning to clean the machine during the observation. 3. Observation and interview on 05/12/2025 revealed STNA3 walked out of room [ROOM NUMBER] wearing gloves and holding a bag of contaminated trash. 4. Observation and interview on 05/12/2025 of the 2400 Hall revealed STNA3 removed a Hoyer lift (mechanical lift to transfer residents from surface to surface) from room [ROOM NUMBER]. The STNA took the lift to the shower room and immediately exited the room without cleaning and disinfecting the shared equipment. 5. Observation and interview on 05/12/2025 on the 2400 Hall revealed STNA4 and STNA5 transported a Hoyer lift down the hall. The STNAs took the lift to the shower room and immediately exited the room without cleaning and disinfecting the shared equipment. 6. Observation and interview on 05/14/2025 revealed STNA6 changed the linen on the bed without wearing appropriate PPE. No residents were present in the room at the time. 7. Observation on 05/13/2025 on the 2400 Hall revealed a medical provider exited a room wearing gloves. She removed her gloves as she continued to walk down the hall and as she entered the nurse's station. 8. Observation of the 200 Hall on 05/12/2025 revealed a box of clean gowns were stored on the floor outside of room [ROOM NUMBER], a TBP Droplet isolation room. The findings include: Review of the CDC Guidelines titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene (HH) should be performed immediately before providing resident care and after care was completed. It stated staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials. Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], revised September 2024, revealed the facility maintained an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Review of the facility's policy titled, Standard Precautions, revised September 2024, revealed standard precautions would be applied to all residents, regardless of diagnosis or infection status. It stated hand hygiene (HH) must be performed using soap and water or alcohol-based hand rubs (ABHR), especially when hands were visibly soiled or after contact with contaminated items. Per the policy, gloves should be removed before touching non-contaminated surfaces or other residents, and hands should be washed to prevent transferring microorganisms. Additionally, the policy stated shared equipment must be cleaned and disinfected before use on another resident. Review of the facility's policy titled, Transmission Based Precautions [TBP], revised April 2024, revealed TBPs should be used when caring for residents who were documented or suspected to have communicable diseases or infections that could be transmitted to others. The policy outlined Enhanced-Barrier Precautions (EBP) to reduce the transmission of specific multi-drug-resistant organisms (MDROs). It stated staff must wear a gown and gloves during high-contact care with residents, which included dressing, bathing, transferring, providing hygiene, changing linens and briefs, aiding with toileting, and caring for wounds. Review of the CDC signage Enhanced Barrier Precautions, posted in the facility, indicated for enhanced barrier precautions, everyone must clean their hands before entering and upon leaving a room. In addition, providers and staff were required to wear gloves and gowns during high-contact activities to reduce the risk of multidrug-resistant organism (MDRO) transmission. These high-contact activities included dressing, bathing, transferring patients, providing hygiene care, changing linens, changing briefs, and during device care or use. 1. Review of an admission Record, found in R122's electronic medical records (EMR), revealed the facility admitted R122 on 04/04/2025 with diagnoses that included critical illness myopathy (generalized weakness involving the muscles of the extremities, trunk, and respiration), dysphagia, and protein calorie malnutrition. Review of R122's admission Minimum Data Set [MDS], found in the EMR, with an Assessment Reference Date (ARD) of 04/10/2025, revealed a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Observation on the 1300 Hall on 05/12/2025 at 9:03 PM revealed STNA2 entered a room designated as under EBP. The STNA provided direct care to R122. STNA2 did not put on Personal Protective Equipment (PPE) before providing direct care. Additionally, STNA2 exited R122's room wearing gloves while transporting a clear plastic bag of trash to the dirty utility room. During an interview with STNA2 on 05/12/2025 at 9:10 PM, he stated R122 was not under any isolation precautions, and he did not have to wear a gown to provide direct care. When asked by the State Survey Agency (SSA) Surveyor what EBP was and when to use PPE, STNA2 was unable to explain the meaning of EBP. He stated he forgot to remove his gloves and perform hand hygiene before leaving the room. STNA2 stated he had received education on infection control upon hire and periodically through in-service training. He stated he was unaware that the facility's policy required staff to wear a gown and gloves while providing direct care to a resident in EBP. Furthermore, he stated it was important to perform hand hygiene before and after providing care to protect the residents and staff from spreading infection. During an interview with STNA1 on 05/12/2025 at 8:51 PM, she stated she only wore gowns for residents in droplet or contact isolation. STNA1 was unable to explain the necessity of following infection control guidelines for residents under EBP. She stated she had received training on infection control during her initial orientation and occasionally through ongoing in-service training. However, she stated she was not familiar with the facility's policy regarding the use of gowns and gloves when providing direct care to a resident under EBP. During an interview with R122 on 05/12/2025 at 9:13 PM, he stated STNA2 provided direct care but did not wear a gown. He stated he helped him with the bedpan. R122 stated most of the staff did not put on gowns when providing care. He stated he could not recall the last time someone wore a gown during bathing assistance, while providing care for his g-tube site, or when he was offered a bedpan. He stated he was aware of being in EBP and that PPE was in the bathroom, but he stated, Nobody wears it. 2. Observation of the 1300 Hall on 05/12/2025 at 8:48 PM revealed LPN4 exited room [ROOM NUMBER], an EBP room, with a portable vital sign machine. The LPN did not clean and disinfect the vital sign machine after using it. Furthermore, the nurse left the shared equipment in the hallway and walked away. Continued observation for 15 minutes revealed LPN4 did not return to clean the machine. During an attempted interview with LPN4 on 05/12/2025 at 8:48 PM, she stated she had to get something for a resident, but did not return. Efforts were made to locate LPN4, but she was unavailable for the interview. 3. Observation of the 2400 Hall on 05/12/2025 at 3:19 PM revealed STNA3 walked out of room [ROOM NUMBER] wearing gloves and holding a bag of contaminated trash. STNA3 walked to the dirty utility room down the hall and opened the door with her contaminated gloves. 4. Observation of the 2400 Hall on 05/12/2025 at 3:25 PM revealed STNA3 removed a Hoyer lift from room [ROOM NUMBER]. The STNA took the lift to the shower room and immediately exited the room without cleaning and disinfecting the shared equipment. During an interview with STNA3 on 05/12/2025 at 3:25 PM, she stated she should have removed PPE and performed HH before leaving the room. She stated gloves should not be worn in the hallway due to infection control concerns. STNA3 stated she wiped down the lift in the shower room. Additionally, she stated she received training on infection control during her initial orientation and periodically through ongoing in-service training. 5. Observation of the 2400 Hall on 05/13/2025 at 3:26 PM revealed STNA4 and STNA5 rolled a Hoyer lift down the hallway. They took the lift into the shower room and then exited immediately. During an interview with STNA4 and STNA5 on 05/13/2025 at 3:30 PM, both stated they did not clean and disinfect the lift prior to leaving the shower room. They stated shared equipment should be cleaned and sanitized with a Sani-wipe after each use and before it was stored. STNA4 stated that cleaning shared equipment was important to prevent the spread of infection from cross-contamination. Furthermore, both STNA4 and STNA5 stated they had received training on infection control during their initial orientation and continued to receive ongoing in-service training periodically. 6. Observation of room [ROOM NUMBER], an EBP room, on 05/14/2025 at 8:51 AM revealed STNA6 changed the linen on the bed without wearing appropriate PPE. No residents were present in the room at the time. During an interview with STNA6 on 05/14/2025 at 8:57 AM, she stated she did not wear PPE unless it was direct care. She stated she was informed that changing linens did not qualify as direct care. STNA6 further stated she was unaware if the CDC guidelines considered changing linen as direct care. She stated infection control signage was displayed inside the bathroom next to the PPE cart to guide staff on what to wear and when. Additionally, she stated she received training on infection control during her initial orientation and periodically through ongoing in-service training. 7. Observation on 05/13/2025 at 10:40 AM on the 2400 Hall revealed a physician exited a room wearing gloves. She removed her gloves as she continued to walk down the hall and as she entered the nurse's station. The SSA Surveyor attempted to interview the physician immediately after the observation on 05/13/2025 at 10:40 AM. However, she was no longer at the nurses' station, and staff stated she was no longer in the facility. 8. Observation of the 2300 Hall on 05/12/2025 at 8:37 PM revealed PPE was not stored in a sanitary manner. Several bagged gowns and an opened box containing gowns were on the floor outside of room [ROOM NUMBER] next to the PPE cart. There were two boxes of gloves sitting on top of the PPE cart. room [ROOM NUMBER] was designated as a TBP droplet isolation room. During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 05/13/2025 at 11:00 AM, she stated the facility adhered to the CDC's guidelines and followed the facility's infection prevention and control policies (IPCP). She stated all EBP rooms had signs on the doors leading into the room if shared or on the bathroom door, if a single room. She stated she checked all EBP rooms the morning of 05/12/2025 to ensure that PPE and signage was available. She stated PPE should be kept off the floor in the PPE cart. The IP/SDC stated gowns and gloves must be worn whenever staff entered an EBP room if they were providing high-level of care. She stated all staff needed to remove gloves and perform HH before leaving a resident's room. According to the IP/SDC, all staff members received education related to IPCP. During additional interview with the IP/SDC on 05/14/2025 at 4:28 PM, she stated she was unsure why staff did not follow isolation precautions despite having been educated on the importance of observing the signs posted on doors. She stated all staff was trained upon hire in the use of PPE and isolation precautions, including EBP. She stated medical providers should follow facility policy to ensure a safe environment for all residents. The IP/SDC stated it was her expectation that all staff adhered to the facility's policies and procedures to help prevent the spread of infections. She stated it was important for the health and safety of the residents. During an interview with the Director of Nursing (DON) on 05/14/2025 at 4:32 PM, she stated all staff underwent orientation upon hire and trained with a preceptor until capable of working independently, which typically took about two weeks. She stated all staff continued to receive IPCP training through online courses and in-service education. The DON further stated that once training was complete, the facility expected staff to adhere to CDC guidelines concerning TBP and EBPs. She stated nursing leadership, including the DON, Assistant DON (ADON), and Unit Managers (UM), observed staff performance; however, there were no formal IPCP audits in place. She stated if a breach in IPCP protocols occurred, nursing leadership would provide initial education, and if patterns of non-compliance continued, counseling would follow. During the continued interview with the DON on 05/14/2025 at 4:32 PM, she stated the cleaning and disinfection of shared equipment occurred as needed. The DON stated the Hoyer lift should be wiped down before and after being used. Additionally, she stated it was her expectation for staff, providers, and vendors to adhere to both CDC guidelines and the facility's IPCP. The DON stated following IPCP guidelines was critical to preventing the spread of infections and outbreaks of disease. During an interview with the Administrator on 05/14/2025 at 4:45 PM, he stated it was his expectation that staff followed IPCP guidelines. He stated all staff was responsible for ensuring IPCP practices were adhered to. He stated it was important to prevent the spread of infection and disease and to ensure the safety of the residents.

Based on observation, interview, and facility policy review, the facility failed to provide a homelike environment free of odors for 1 of 8 hallways, the 2100 Hall, with a census of 15 residents. The findings include: Review of the facility's policy titled, Environmental Services- Homelike Environment, dated 01/2025, revealed the facility was to provide a clean, odor free facility. Observations on 05/12/2025 at 6:55 PM and 8:27 PM, 05/13/2025 at 3:38 PM and 4:16 PM, and 05/14/2025 at 10:31 AM, revealed a strong urine smell in the 2100 hall, particularly concentrated around Resident (R) 79's room. Continued observation on 05/15/2025 at 10:58 AM revealed the odor of urine was still present, although not as strong as the previous days. In an interview on 05/12/2025 at 6:57 PM, R79 stated he spilled a full urinal by accident earlier that day, and it was a while before staff cleaned it up. He explained staff had not emptied his urinal after the last time he used it, and he did not realize that it had urine in it when he first picked it up. In an interview on 05/15/2025 at 11:05 AM, State Tested Nurse Aide (STNA) 19 stated the urine odor was persistent outside R79's room due to spillage from urinals. She stated the process for odor management was for nursing staff to clean the urine and tell housekeeping when they noticed a spill or lingering odor. STNA19 stated she frequently noticed a urine smell in this part of the hall, but it was not as bad during the interview as it was on prior days. In an interview on 05/15/2025 at 11:15 AM, Housekeeper 1 stated she had already mopped, changed the linens, and cleaned the bathroom for R79's room. Housekeeper 1 stated she could still smell the urine outside the room. Observation on 05/15/2025 at 11:18 AM revealed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) exited R79's room. In an immediate interview, the DON stated she came with the Housekeeping Manager to clean after a staff member alerted them to the urine smell noted in the hallway. She stated they did additional cleaning to attempt to eliminate the odor and did note improvement after the additional cleaning. The DON stated the urine odor was a frequent problem in that area because R79 and his roommate both used urinals that spilled sometimes and would take off their briefs and leave them in the floor. In an interview on 05/15/2025 at 2:50 PM, the Housekeeping Manager stated the process for controlling urine odors was for nursing staff to clean up the worst of the urine spill, then notify a member of the housekeeping staff to mop the floor. She stated the housekeeping staff performed deep cleanings on R79's floor twice per week, including on 05/14/2025. The Housekeeping Manager stated it was important for the facility to be free from odors because urine odors created an unpleasant environment for residents. In an interview on 05/15/2025 at 2:54 PM, the Regional Housekeeping Manager stated she inspected R79's room and found no visibly soiled areas. She stated she believed housekeeping had done everything they could to clean the area. Per interview, the Regional Housekeeping Manager stated the floor needed to be replaced because the odor was now likely in the glue and under the floor, where additional cleanings would not address the issue. In continued interview, the Regional Housekeeping Manager stated it was important to combat odor in the facility to have a clean, homelike environment. She further stated cleaning up urine was important to prevent infections from spreading through the facility's environment. In an interview on 05/15/2025 at 6:44 PM, the Administrator stated his expectations for staff was for them to make note of any odor and come back to see if the odor lingered 30 minutes later. He further stated if the odor lingered, he expected staff to notify housekeeping to perform extra cleaning of the area. Per interview, the Administrator stated it was important to manage odors in the facility because it was the resident's home, and the facility wanted to have a good environment for residents. In continued interview, the Administrator stated for R79's room in particular, he was aware of a lingering odor outside that room. He stated he believed, due to the persistent nature of the odor, the frequently spilled urine could have soaked into the glue of the flooring and the floor would need to be replaced.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set [MDS] assessments were correct for 1 of 32 sampled residents, Resident (R) 45. The findings include: Review of R45's admission Record revealed the facility admitted the resident on 11/19/2022 with admission diagnoses including Parkinson's disease, Alzheimer's disease, and protein-calorie malnutrition. Review of R45's Comprehensive Care Plan (CCP), not dated, revealed the facility assessed the resident as having a self-care deficit related to range of motion limitations and contractures of her knees. Further review revealed interventions including use of a Broda chair (special adaptive wheelchair), use of a Hoyer lift (mechanical lift to transfer the resident from surface to surface), and assisting with positioning to help maintain proper body alignment. Review of R45's quarterly MDS, with an Assessment Reference Date (ARD) of 03/07/2025, and the quarterly MDS, with an ARD of 05/08/2025, revealed the facility coded R45 as having no impairment in functional range of motion in her upper extremities, including her wrists and hands. Further review revealed the facility coded no impairment in range of motion to R45's lower extremities, including her hips and knees. Observation on 05/14/2025 at 4:51 PM revealed R45 had bilateral contractures of her knees, which could not be extended during perineal care or during bed to chair transfer. Further observation revealed R45 had contractures to her left hand. Continued observation revealed a sign in the resident's room, showing how to apply a brace to the left-hand contractures, as well as the brace lying on top of a side table in the resident's room. In an interview on 05/15/2025 at 4:12 PM, Minimum Data Set (MDS) Nurse 1 stated her process for completing an MDS assessment was to look at nursing assessments and the resident's care plan to know how to code the resident's functional and mobility status. In further interview, MDS Nurse 1 stated she sometimes went to a resident's room to fill out an interview section, but she mostly retrieved information from the resident's medical record. In an interview on 05/15/2025 at 3:46 PM, the MDS Coordinator stated the process for completing the MDS section on mobility status was driven by information from the therapy department. She further stated she had taken care of R45 and remembered she had knee contractures. When shown the MDS assessments that marked No to limitations in joints, the MDS Coordinator stated the nurse who filled out the forms picked the wrong box, or did not understand the question. She stated it was her expectation that MDS assessments be completed accurately to reflect the resident's actual mobility status. In an interview on 05/15/2025 at 4:48 PM, the Director of Nursing (DON) stated it was her expectation that MDS assessments be completed accurately. She further stated the facility's process for MDS assessments related to mobility was to get information from therapy, as well as for the MDS nurses to physically assess a resident they were not familiar with to ensure accuracy of the assessment. The DON stated the information MDS Nurse 1 entered on R45's most recent assessments was incorrect, as a result of a mistake by MDS Nurse 1. In an interview on 05/15/2025 at 6:44 PM, the Administrator stated he was not clinical personnel, so he did not know every aspect of the MDS assessment process. He further stated he expected the assessments to be as accurate as possible, given the large number of components to the assessment. Per interview, he did not know the cause of the error on R45's two assessments that were incorrect.

Based on observation, interview, and review of facility's Policy, it was determined the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Observations on 01/28/2020, 01/29/2020, 01/30/2020, and 01/31/2020, revealed the 1200 Unit Hallway had a strong odor of urine. The findings include: Review of the facility's Policy titled, Guidelines to Good Housekeeping - Environmental Services Nursing Department, dated 02/28/03, revealed it was the policy of the facility to provide guidelines specific for cleaning duties to provide an optimum environment for the staff, residents, and visitors. Continued review revealed the procedure for cleaning included for the resident lavatory to be sprayed with an EPA approved disinfectant and wiped with a damp cloth, clean the inside surfaces of the bowl, rinse the cloth under the faucet and rinse the inner surfaces of the bowl and wash and rinse the outer surfaces of the bowl with a damp cloth. Review of the facility's Policy titled, Soiled Linen and Disposables, dated 03/2008, revealed all soiled linen and disposable items were to be bagged before being removed from the area of use and then placed in the appropriate receptacles. All soiled linen and disposable items used for resident care will be bagged as it is removed from the resident's bed. If heavy soiling is present, it is suggested to double bag the linen before removal. Review of the facility policy titled, Health Care Management: Soiled Laundry, dated 02/2003, revealed soiled laundry should be handled as little as possible and with minimum agitation to prevent self-contamination as well as contaminating the air. Review of the facility form titled Environmental Services-Room Checklist dated 01/27/2020 to 02/02/2020 for resident room [ROOM NUMBER] revealed daily cleaning for the toilet, bathroom sink, and floors was completed; however, the wall tile in bathroom and the trash cans were documented as only being cleaned on 01/28/2020 and 02/02/2020. Observations of the 1200 Unit, on 01/28/2020 at 4:25 PM, 01/29/2020 at 8:40 AM, 3:53 PM, 01/30/2020 at 11:45 AM, 3:45 PM and 01/31/2020 at 8:30 AM and 10:53 AM, revealed a strong odor of urine in the hallway. Continued observations revealed the odor continued into room [ROOM NUMBER]. Resident #43, residing in room [ROOM NUMBER], was not available for interview. Resident #167, residing in room [ROOM NUMBER], was not interviewable. Review of the medical record revealed the facility admitted Resident #66 on 05/02/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed the resident as having a brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Interview with Resident #66, on 01/31/2020 at 2:30 PM, revealed he/she resides on the 1200 Unit hall. Continued interview revealed the hallway does continually smell of urine. Further interview revealed housekeeping does try to address the problem of the odor and it does makes the smell more bearable; however, the odor is still there. Review of the medical record revealed the facility admitted Resident #26 on 06/28/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/29/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Interview with Resident #26, on 01/31/2020 at 2:35 PM, revealed he/she does reside on the 1200 Unit hall. Continued interview revealed the hallway smells like urine. Per interview, housekeeping does try to clean; however, this does not remove the urine odor. Interview with Housekeeper #1, on 01/31/2020 at 1:15 PM, revealed there was a urine odor on the 1200 unit hall. Per interview, resident room [ROOM NUMBER] has had special cleaning due to the odor of urine. Per interview spray bleach and deodorizer are used to clean the resident's recliner, bed, and bathroom. Continued interview revealed the possible source of the urine odor could be soiled clothing. Per interview, soiled clothing should be double bagged; however, nursing staff does not always double bag the soiled clothing and this could lead to an increased urine odor. Per interview, she double bags the soiled clothing when she is cleaning the room. Interview with Housekeeper #2, on 01/31/2020 at 1:20 PM, revealed she cleans the bed, chairs, and deodorizes the floor. She also makes sure the soiled laundry doubled bagged because that could be a source of the odor. Interview with Director of Housekeeping, on 01/31/2020 at 1:30 PM, revealed the facility did identify the continuous urine odor. Per interview, the facility has changed the mattress in the resident's room, they mop the floor thoroughly and try to double bag the resident's soiled clothing. Further interview revealed the resident's recliner chair is cleaned daily; however, they may need to replace the recliner to help eliminate the odor. Interview with State Registered Nursing Assistant (SRNA) #3 assigned to the 1200 Unit hall, on 01/31/2020 at 1:25 PM, revealed the 1200 Unit hall did smell of urine. Continued interview revealed the hallway has smelled of urine for so long, she has gotten used to the smell. Per interview she thought the odor originated in room [ROOM NUMBER]. She stated the resident in room [ROOM NUMBER] would often miss the urinal when urinating. Per interview, she does provides a new urinal to the resident and she tries to keep the urinal clean with soap and water. Further interview revealed she double bags the resident's soiled clothing to decrease the odor; however, the strong odor remains through out the whole hall. Interview with Director of Nursing (DON), on 01/31/2020 at 2:35 PM, revealed there was a urine smell on the 1200 unit. Per interview the odor has been determined to originate from resident room [ROOM NUMBER]. Continued interview revealed resident room [ROOM NUMBER] was cleaned several times a day. Per interview, Resident #43 resides in room [ROOM NUMBER] and can be aggressive toward staff in changing clothes and with peri care. She stated, all soiled clothes were doubled bagged for the laundry. Further interview revealed Resident #167 who resides in this room is not checked and changed at night to keep him/her calm. Staff try to re-approach to assist with changing clothes often during the day. Interview with Administrator, on 01/31/2020 at 2:45 PM, revealed there was a continual urine odor in the hallway. Per interview, the continual urine odor was not a sanitary and comfortable environment and the facility was trying to address the odor by cleaning the mattress and the floor of the resident's room.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to implement the Comprehensive Person-Centered Care Plan for each resident to assist in attaining or maintaining the residents' highest practicable quality of life for one (1) of twenty-six (26) sampled residents, (Resident #109). Resident #109 had a Vascular Access Catheter for [MEDICAL TREATMENT] on the left upper chest at the [MEDICATION NAME] region due to previous [MEDICAL TREATMENT] due to End Stage [MEDICAL CONDITION]. The Vascular Access was exposed and did not have a wound covering/dressing in place. The findings include: Review of facility's Care Planning Policy, dated 01/2019, revealed the facility will provide resident centered care aiming to provide individualized Comprehensive/Interdisciplinary Care Plans for each resident. The care plan is developed to guide the resident in reaching their maximum functional level -while encompassing a holistic approach. The facility's objective is to assist the resident in meeting their personal goals, with optimal functioning level and a more fulfilled enhanced quality of life. Each discipline is responsible for implementing and providing input on any interventions to assist the resident in achieving their goals and desired outcomes. Care Plans are updated as needed following the Resident Assessment Instrument (RAI) manual and according to the changing needs of the resident. Review of Resident #109's clinical record revealed the facility admitted the resident on 09/29/19 with [DIAGNOSES REDACTED]. Review of Resident #109's Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/2019, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating the resident is cognitively intact. Further review revealed the facility assessed the resident to have had [MEDICAL TREATMENT]. Review of Resident #109's Physician order [REDACTED].#109 had [DIAGNOSES REDACTED]. Continued review revealed a physician's orders [REDACTED]. Further review revealed a physician's orders [REDACTED].#109 to Hospice for a terminal [DIAGNOSES REDACTED]. On 01/29/2020, a physician's orders [REDACTED]. Review of Resident #109's Comprehensive Care Plan, revised 01/22/2020, and revealed the resident had the potential for infection related to the presence of a Vascular Access Catheter at the left upper chest related to previous [MEDICAL TREATMENT] due to End Stage [MEDICAL CONDITION]. Continued review revealed the resident was admitted to Hospice on the 01/08/2020 and was no longer receiving [MEDICAL TREATMENT] only comfort measures. Per the Comprehensive Care Plan, the goal for resident #109 was for the Vascular Access Catheter to be free of signs and symptoms of infection through the review date of 04/27/2020. Interventions included: to change the dressing to the Vascular Access site per Clinician orders, to educate the resident on precautions to prevent contamination of the insertion site, keep the clinician and resident/responsible party updated with any changes, and to monitor the Vascular site every shift for evidence of redness, warmth, inflammation, and tenderness. Observation of Resident #109, on 01/29/2020 at 9:23 AM, revealed Resident #109 had a Vascular Access Catheter (used for [MEDICAL TREATMENT]) located at the left [MEDICATION NAME]/chest area which was exposed without a dressing in place. Continue observation revealed the resident was lying in the bed with the head of the bed up approximately thirty-five (35) degree and was holding the covers to his/her chest area. The upper chest/left [MEDICATION NAME] area was exposed and visible. Further observation revealed there was no dressing on the large lumen vascular access site. The resident was calling out for hot chocolate and a drink. Resident #109 had a somber affect and was moaning a bit. He/She put the call light on requested hot chocolate and a fruit drink. Several minutes later the aide entered the room handing the resident a hot chocolate beverage and a glass with a pink beverage, which was placed at the bedside. The resident then tipped over the hot chocolate on the blankets during the interview. At the end of the interview the aides came in and changed the covers. Interview with Licensed Practical Nurse (LPN) #1, on 01/30/2020 at 11:30 AM, revealed she was assigned to Resident #109 on 01/29/2020. Per interview, Resident #109 was no longer receiving [MEDICAL TREATMENT] due to his/her hospice status. LPN #1 stated, after shift report was completed on 01/29/2020, she looked in on resident #109 to ensure the resident was alright, then started her medication administration. Continued interview revealed at the first observation of resident #109, LPN #1 did not notice the resident's dressing or if the dressing was still in place and stated the aide noticed it was not in place when she went to check on the resident at about 9:20 AM. Further interview revealed LPN #1 was aware the resident's vascular access site should be covered at all times per the care plan and the Physician orders [REDACTED]. LPN #1 stated, she should have checked the resident's vascular access site at the time rounds were made initially on 01/29/2020. Interview with the Unit Manager of Hallway 2400, on 01/31/2020 at 3:30 PM, revealed resident #109 should have had a dressing maintained on his/her vascular access site at the left [MEDICATION NAME]/left chest even though the resident was no longer receiving [MEDICAL TREATMENT] per physician's orders [REDACTED]. The dressing should be clean, dry, and intact. Further interview revealed during the assessment, the nurse would observe the site for signs and symptoms of infection. If the dressing was not intact, then a new dressing would be applied. The physician or the nurse practitioner should be notified if there are any adverse signs or symptoms. Interview with the Assistant Director of Nursing (ADON), on 01/31/20 at 03:51 PM, revealed Resident #109 should have had a dressing on their vascular access site per the physician's orders [REDACTED]. Per interview, the nurses are trained on hire and as needed on patient care procedures and that would include physician orders [REDACTED]. Continued interview revealed if the dressing was loose or came completely off it would be his expectation that the nurse would replace the dressing immediately. Further interview revealed since Resident #109 was no longer receiving [MEDICAL TREATMENT] the nurses should follow the physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 01/31/2020 at 3:59 PM, revealed the vascular access site should be monitored by the nurse every day and night shift per the physician's orders [REDACTED].#109 is on Hospice and would no longer be receiving [MEDICAL TREATMENT] through the vascular access. Continued interview revealed the nurse should have assessed the site when she was passing medications. She stated it would be her expectation for the nurse to follow the physician's orders [REDACTED]. The nurses are training in all areas of care including following the resident's care plan. Interview with the Administrator, on 01/31/2020 at 4:16 PM, revealed he would expect the nurses to follow the protocols, including the physician's orders [REDACTED]. He stated it would be his expectation that the nurse follows the care plan policy to maintain a resident's health and well-being. Continued interview revealed the Unit Manager would be the nurse's direct supervisor to ensure proper procedures were followed including implementing the care plan. He stated, through experience as an Administrator, he was aware that the purpose of maintaining a dressing on a vascular access site was for infection prevention and control to prevent illness. Per interview, the facility's staff are provided training on a regular basis including assessment of the resident and implementing and following the care plan.

Based on interview and record review, it was determined the facility failed to ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities for one (1) of twenty-six (26) sampled residents (Resident #53). An Audiology (hearing) evaluation performed by Three Sixty (360) Care, on 03/05/2019, determined Resident #53 would benefit from hearing aids to help his/her hearing loss. The recommendation was sent to the attending physician for approval on 03/05/2019. The facility received signed approval from the attending physician on 03/11/2019. However, there was no documented evidence the facility followed through with assisting Resident #53 in making follow up appointments with Three Sixty (360) Care. Consequently, Resident #53 did not receive hearing aids as recommended. The findings include: A post-survey phone interview, with the Administrator, on 02/07/2020 at 11:15 AM, revealed the facility does not have a policy regarding hearing exams. Record review revealed the facility admitted Resident #53 on 08/29/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed Resident #53 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicates the resident is cognitively intact. Further MDS review revealed Resident #53 was assessed as having adequate hearing, meaning no difficulty in normal conversation, social interactions, or listening to television. Review of Resident #53's Comprehensive Care Plan, admitted on [DATE], revealed he/she has an Activities of Daily Living (ADL) deficit related to the disease process of [MEDICAL CONDITION], Impaired Mobility, Impaired Mobility, Impaired Balance, Pain, and Contractures. However, there is no documented evidence hearing impairment was identified. Review of Resident #53's physician's orders [REDACTED].#53 may be seen by Audiologist, Dentist, Nurse Practitioner, Optometrist, Podiatrist, Psychiatrist, Wound Nurse, Respiratory Therapist to evaluate, adjust, and treat delivery method of oxygen. Review of an Audiology Visit for a Hearing Examination, dated 03/05/19, revealed Resident #53 was seen by an Audiology (hearing) Specialist for a hearing exam because he/she was complaining of hearing loss and tinnitus. A Comprehensive Hearing Test was performed. Results revealed a moderate to severe sensorineural hearing loss bilaterally with fair speech discrimination. Continued review revealed, it was determined the resident would benefit from hearing aids. The next step would be to get the recommendation to the attending physician for approval, and then the hearing aids would be made. Interview with Resident #53, on 01/30/2020 at 2:47 PM, revealed he/she was tested for hearing problems as he/she was having difficulty with hearing. Per the interview, he/she stated he/she had a hearing exam approximately a year ago and based on that exam, he/she was supposed to get hearing aids. He/she further stated that was over a year ago and he/she has not heard anything further about the hearing aids. Additionally, he/she stated when he/she inquired about the hearing aids to staff, no one seems to know anything about the hearing aids, or provides him/her with an update. Per interview, the resident continued to have difficulty hearing. Interview with the MDS Coordinator, on 01/31/2020 at 4:27 PM, revealed she bases the Minimum Data Set (MDS) hearing assessment on the resident's overall interview and particularly on the resident's pain interview. During that interview for the Quarterly MDS assessment, dated 01/24/2020, Resident #53 was assessed as not hearing impaired. Interview with the Social Worker, on 01/31/2020 at 10:30 AM, regarding hearing aids for Resident #53 revealed in (MONTH) she was notified of the recommendation for hearing aids, but was unsure the status of the hearing aids, but would check. Additionally, she stated the facility utilizes the services of 360 Care for Audiology and Podiatry. Consents are normally sent back through the Medical Records department, but due to changes in the Medical Records department, the follow-up could have been overlooked. She further stated she would check and get back with me. She did not return for further interview, instead, she sent the facility's educator to explain what happened with the hearing aids follow up. Interview with the facility's Educator, on 01/31/2020 at 11:24 AM, revealed the Audiologist (health-care professionals who evaluate, diagnose, treat, and manage hearing loss, tinnitus, and balance disorders) saw the Resident on 03/05/2019 and recommended a hearing aid evaluation for hearing loss. To continue with the evaluation and subsequent hearing aids, required the attending physician's approval. The facility sent to the physician the hearing aid statement on 03/05/2019 and approval was sent back to the facility on [DATE]; however, the approval document was not sent to the hearing specialists to proceed with the hearing aids. Interview with the Director of Nursing (DON), on 01/31/2020 at 1:30 PM, revealed the facility failed to get the approval for hearing aids from the attending physician to the Audiologist to proceed with the hearing aids. Additionally, she expects consults to be followed up and followed through with as indicated. Interview with the facility Administrator, on 01/31/2020 at 1:40 PM, revealed he talks to Resident #53 frequently. He/she has never brought his/her hearing concerns, or hearing aids up to administration. He stated the facility follows relevant federal guidelines to ensure the residents' audiology, dental, vision and podiatry needs are met as needed. Further, he stated that Three Sixty (360) Care provides Audiology, Dental, Vision and Podiatry needs of residents in the facility. He expects the Medical Records department to handle all aspects of 360 services, to include making follow up appointments as indicated. Additionally, an appointment was made on 01/31/2020 for Resident #53 to see the Audiologist on 02/03/2020 for hearing aids follow-up.

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe sanitary and comfortable environment to help prevent the development and transmission of communicable diseases infections for one (1) of twenty-six (26) sampled residents (Resident #109) Observation on 01/29/2020 during the initial screening interview revealed Resident #109 had a vascular access catheter located at the left clavicle-chest area which was exposed without a dressing in place. This access had been utilized for [MEDICAL TREATMENT]. The findings include: Review of the facility's Policy, titled Infection Prevention and Control (IPCP), revised 01/2020, revealed the tended purpose of the facility's infection control policy was to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Continued review revealed all personnel would be trained on the infection control policies and practices upon hire and periodically thereafter. Review of the facility's Policy, titled [MEDICAL TREATMENT] Coordination and Resident Monitoring, undated, revealed the purpose of the facility's [MEDICAL TREATMENT] policy was the resident who receives [MEDICAL TREATMENT] will be monitored on-going for signs and symptoms of adverse effects. Continued review revealed the nurse will monitor the vascular access site pre and post [MEDICAL TREATMENT] session and as needed per the Plan of Care and communicate with the physician as needed. Review of the facility's Policy, titled Infection Control-Dressings- Dry/Clean, revised 04/2017, revealed the purpose of the facility's infection control-dressing policy was to provide guidelines for the application of dry, clean dressings. The nurse will review the Care Plan, verify there is a physician's orders [REDACTED]. Per the policy, it should be documented in the resident's medical record the date and time the dressing was changed, wound appearance, name and title of the individual changing the dressing, all assessment data, how the resident tolerated the procedure, any problems or complaints, if the resident refused the treatment and the reason why and the signature and title of the person recording the data. Review of Resident #109's clinical record revealed the facility admitted the resident on 09/29/19 with [DIAGNOSES REDACTED]. Review of Resident #109's Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident to have had [MEDICAL TREATMENT]. Review of the Physician order [REDACTED].#109, dated (MONTH) 31, 2020 revealed Resident #109 had [DIAGNOSES REDACTED]. An order dated 12/07/2020 revealed nurses were to check the left upper chest for placement of clean/dry dressing to catheter (vascular access) for [MEDICAL TREATMENT], change if soiled. A physician's orders [REDACTED].#109 to Hospice for a terminal [DIAGNOSES REDACTED]. On 01/29/2020 a physician's orders [REDACTED]. Observation of Resident #109, on 01/29/2020 at 9:23 AM, revealed the resident had a vascular access catheter (used for [MEDICAL TREATMENT]) located at the left [MEDICATION NAME]/chest area which was exposed and without a dressing in place. Continued observation revealed the resident was lying in the bed with the head of the bed up approximately thirty-five (35) degree and was holding the covers to his/her chest area. The upper chest/left [MEDICATION NAME] area was exposed and visible. Further observation revealed there was no dressing on the large lumen vascular access site. Resident #109 had a somber affect and was moaning a bit. He/She put the call light on requested hot chocolate and a fruit drink. Several minutes later the aide entered the room, handing the resident a hot chocolate beverage and a glass with a pink beverage, which was placed at the bedside. The resident then tipped over the hot chocolate on the blankets during the interview. Interview with Licensed Practical Nurse (LPN) #1, on 01/30/2020 at 11:30 AM, revealed she was the nurse assigned to Resident #109 on 01/29/2020. Continued interview revealed the resident was no longer receiving [MEDICAL TREATMENT] due to his/her hospice status. Per interview, after shift report was completed on 01/29/2020 at 7:00 AM, she looked in on resident #109 to ensure the resident was alright, then started her medication administration. Continued interview revealed at first observation of resident #109, LPN #1 did not notice the resident's dressing or if it were still in place and stated the aide noticed the dressing was not in place when she went to check on the resident at about 9:20 AM. Further interview revealed she was aware the vascular access site should be covered at all times per the resident's care plan and physician orders. Additionally, the care plan and physician orders [REDACTED]. Per interview, prior to the resident discontinuing [MEDICAL TREATMENT], the [MEDICAL TREATMENT] Clinic changed the access site dressing on Monday, Wednesday and Fridays. Continued interview revealed the rationale for an intact dressing would be to prevent infection. The dressing would prevent anything from getting in or out of the resident's access site. LPN #1 stated, she should have checked the resident's vascular access site at the time she made her initial rounds. Interview with the Unit Manager of Hallway 2400, on 01/31/2020 at 3:30 PM, revealed resident #109 should have had a dressing maintained on her vascular access site at the left [MEDICATION NAME]/left chest even though the resident was no longer receiving [MEDICAL TREATMENT] per physician's orders [REDACTED]. The nurse should also assess the site for signs and symptoms of infection if the dressing was not intact, then apply a new dressing. If necessary the physician or the nurse practitioner should be notified if there are any adverse signs or symptoms. Continued interview revealed the importance of maintain a dressing over the site was to prevent infection. She stated nurses have had training for infection control and training with monthly nursing meetings to address infection control. Our Assistant Director of Nursing (ADON) normally does the training. Interview with the Assistant Director of Nursing (ADON), on 01/31/20 at 03:51 PM, revealed Resident #109 should have had a dressing on his/her vascular access site per the physician's orders [REDACTED]. Continued interview revealed if the dressing was loose or came completely off it would be his expectation the nurse would replace the dressing immediately. He stated the nurse should, at that time, assess the site for signs and symptoms of infection. Further interview revealed the resident's dressing was to provide a safety barrier to prevent an infection. The nurses receive skills training for dressing changes and infection control. Further interview revealed, normally the [MEDICAL TREATMENT] clinic does vascular access site dressings three times a week but it is also our responsibility to monitor those dressings even when they go to [MEDICAL TREATMENT]. Since Resident #109 was no longer receiving [MEDICAL TREATMENT], the nurses should follow the physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 01/31/2020 at 3:59 PM, revealed the vascular access site should be monitored by the nurse every day and night shift per the physician's orders [REDACTED].#109 was on Hospice and would no longer be receiving [MEDICAL TREATMENT] through the vascular access. Further interview revealed the nurse should have assessed the site when she was passing medications. Continued interview revealed if the dressing was not intact a new dressing should have been applied. A dressing should be maintained on a vascular access site to prevent infections. Per interview, the access resident #109 has at the [MEDICATION NAME] area goes straight to the heart. Further interview revealed the nurses have received training for dressing changes and infection control. The staff would be trained upon hire and with yearly skills check-offs or as needed. If something comes up and a staff member is uncertain, they are re-trained. Interview with the facility Administrator, on 01/31/2020 at 4:16 PM, revealed he would expect the nurses to follow the protocols for dressings and vascular access sites which was to maintain a dressing for infection control per the facility policy. Per interview, the Unit Manager would be the nurse's direct supervisor to ensure proper procedures were followed. He stated through experience as an Administrator, I am aware the purpose of maintaining a dressing on a vascular access site was for infection prevention and control to prevent illness. Our staff are provided training by our ADON for infection control.

Based on observation, interview and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation on 01/16/18, revealed three (3) medication carts had boxes of foiled packages of [MEDICATION NAME]/[MEDICATION NAME] nebulizer vials. The foiled packages were open and expired, or were open and not marked with an open date. The findings include: Review of the facility Medication storage Policy, dated 8/2018, revealed once a medication is opened the facility should follow manufacturer/supplier guidelines with respect to expiration dates related to opened medications. Continued review revealed facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Further review of the Policy, revealed medications and biologicals should not be retained longer than recommended by manufacturer or supplier. Review of the Manufacturer's Recommendations for [MEDICATION NAME]/[MEDICATION NAME] nebulizer vials, revealed once the foiled packaging was open, discard after fourteen (14) days. Observation on 01/16/18 at 12:00 PM, on the HealthCare One (1) Unit 1200 Hall medication cart, revealed one (1) open box of foiled packages of [MEDICATION NAME]/[MEDICATION NAME] 0.5 mg/3 mg nebulizer vials. The foiled packages of vials were open and marked with an open date of 12/13/18, indicating the medication was expired. Observation on 01/16/18 at 12:10 PM, on the Healthcare One (1) Unit 1100 Hall medication cart, revealed three (3) open boxes of foiled packages of [MEDICATION NAME]/[MEDICATION NAME] 0.5 milligram (mg)/3 mg nebulizer vials. The foiled packages of vials were open and not marked with an open date. Observation on 01/16/18 at 12:15 PM, on the Healthcare One (1) Unit 1400 Hall medication cart, revealed two (2) open boxes of foiled packages of [MEDICATION NAME]/[MEDICATION NAME] 0.5 milligram (mg)/3 mg nebulizer vials. The foiled packages of vials were open and were not marked with an open date. This medication cart also contained three (3) boxes of foiled packages of [MEDICATION NAME]/[MEDICATION NAME] 0.5 milligram (mg)/3 mg nebulizer vials, with the foiled packages inside the boxes opened, with an open date of 11/06/18, indicating the medication was expired. Interview with the Director of Nursing (DON), on 1/17/19 at 5:15 PM, revealed staff was to follow facility policy related to medication storage for the safety of the residents. Per interview, staff was to date medications as they were opened, and discard expired medications. Interview with the Administrator, on 1/17/19 at 5:25, revealed it was his expectation for all nursing staff to follow the facility policy related to storage and labeling of medication. Per interview, he relied on the DON to ensure the policy was followed as he was not a clinical person. The Administrator reviewed the facility policy, and stated it was his expectation for staff to date medications once opened and discard medication when expired. Per interview, this is important for the safety of the residents.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for one (1) of thirty-three (33) sampled residents (Resident #1). Although Resident #1 sustained falls on 11/04/18, 12/08/18, and 12/10/18, and record review revealed interventions were implemented after the falls; there was no documented evidence the Comprehensive Care Plan (CCP) was revised with these interventions. Also, physician's orders [REDACTED]. The findings include: Review of the facility's Policy titled Advance Care Planning, revised 12/2017, revealed it was the facility's policy that situations needing investigation and/or follow up are conducted timely. However, the Policy did not address revision of the Care Plan. Review of the facility's Fall and Accident Management Policy, revised 05/2016, revealed when a resident falls the nurse will assess the resident for any injuries, implement interventions to prevent further incidents, and update the resident's Care Plan. Review of Resident #1's medical record revealed the facility admitted the resident on 12/08/17 and readmitted the resident on 01/09/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) of a three (3) out of fifteen (15) indicating severe cognitive impairment. Additional review revealed the facility assessed the resident as having no falls since admission or prior assessment. Review of the Comprehensive Care Plan (CCP), initiated 09/01/18, revealed Resident #1 was at high risk for falls related to a [DIAGNOSES REDACTED]. The goal revealed the resident's risk for falls/injuries would be reduced. There were several interventions including assist with transfers/mobility/repositioning /toileting as needed; keep floors free from spills and/or clutter; adequate light; call light within reach, frequently used items in reach; footwear in place to allow stability when standing; monitor for side effects of medication; notify Physician/Responsible Party with any falls or changes; and obtain and monitor labs/diagnostic tests as ordered and encourage activities. Review of the Progress Note, dated 11/04/18, revealed Resident #1 sustained a fall on 11/04/18, and was found by staff on his/her back in his/her closet lying in a puddle of urine, naked from the waist down. Per the Note, the resident had a history of [REDACTED]. until the resident could be assisted to bed. Review of Resident #1's Interdisciplinary Team (IDT) Follow-up Note dated 11/07/18, related to the fall on 11/04/18, revealed the IDT met to discuss the fall. Per the Note, the resident refused his/her medications before the fall, and had a history of [REDACTED]. The Note revealed Resident #1 was sent out of the facility for assessment by Behavioral Health. Continued review of Resident #1's Comprehensive Care Plan (CCP), initiated 09/01/18, revealed there was no documented evidence the CCP was revised after Resident #1's fall on 11/04/18 to indicate the resident sustained [REDACTED]. Additionally, there was no documented evidence the CCP was revised with interventions to have a State Registered Nurse Aide (SRNA) supervise the resident or have the resident sit at the nurse's station until the resident could be assisted to bed as per the Progress Note dated 11/04/18 or to undergo a psychiatric assessment as per the IDT Note dated 11/07/18. Review of the Progress Note, dated 12/08/18, revealed Resident #1 sustained a fall on 12/08/18. Per the Note, staff found Resident #1 sitting on the floor beside his/her wheelchair outside the nurse's station, and the resident had been exhibiting behaviors prior to the fall. The Note further revealed a new intervention of supplying Resident #1 with washrags to fold when agitated to distract him/her was implemented. Review of Resident #1's IDT Follow-Up Note dated 12/10/18, revealed the IDT met to discuss the fall which occurred on 12/08/18. Per the Note, Resident #1 had increased behaviors prior to the fall. The IDT determined Resident #1 should undergo a psychiatric evaluation related to the behaviors. Further review of Resident #1's Comprehensive Care Plan (CCP) initiated 09/01/18, revealed there was no documented evidence the CCP was updated to indicate the resident had an actual fall on 12/18/18. Also, there was no documented evidence the interventions to supply the resident with washrags to fold when agitated to distract him/her as per the Progress Note dated 12/08/18 or interventions for a psychiatric evaluation as per the IDT Follow Up Note dated 1210/18. Review of the Progress Notes dated 12/10/18, revealed Resident #1 sustained a fall, and was found on the floor of his/her room lying in feces. Per the Note, the resident was also noted to be combative with staff when staff was attempting to assess him/her after the fall. Continued review of the Note, revealed a new intervention was implemented to have the resident's family called to sit with him/her in order to have Resident #1 on one on one (1:1) care. Further review of the Note, revealed Resident #1 underwent a psychiatric evaluation. Review of Resident #1's IDT Follow-Up Note, dated 01/17/19, related to the fall the resident sustained [REDACTED].#1 returned to the facility post acute inpatient psychiatric stay. Prior to hospitalization Resident #1 was noted on the floor of his/her room with feces scattered about. The Note stated the resident had an acute psychotic episode and physical behaviors at the time of the fall. Per the Note, the Immediate intervention per the charge nurse was appropriate for 1:1 care. and the resident was secured and kept safe until acute care transport arrived. IDT determined the immediate intervention to have Resident #1's family come to the facility in order to have Resident #1 on one on one (1:1) care was an appropriate intervention. Review of Resident #1's Comprehensive Care Plan (CCP) initiated 09/01/18, revealed there was no documented evidence the CCP was revised after Resident #1's fall on 12/10/18 to indicate the resident has sustained an actual fall. In addition there was no documented evidence the CCP was revised with interventions to have Resident #1 on one on one (1:1) care, or sent for an inpatient psychiatric stay. Review of physician's orders [REDACTED]. Interview on 1/17/19 at 4:11 PM, with Registered Nurse (RN) #2, revealed Resident #1 sustained several falls due to his/her dementia and lack of safety awareness. She stated when Resident #1 sustained a fall, a new intervention was immediately implemented to prevent further falls, and IDT evaluated the immediate intervention to determine if it was appropriate and then added any further interventions to the CCP. Interview on 01/17/19 at 4:55 PM, with the Director of Nursing (DON), revealed it was her expectation staff revise the Care Plan with new interventions immediately after a fall. The DON stated, IDT met after each resident's fall to evaluate if the immediate intervention implemented after the fall was appropriate and also discussed if further interventions needed to be implemented. Per interview, the CCP should also be revised with interventions deemed appropriate to prevent further falls per the IDT. The DON also acknowledged the CCP should be revised with new physician's orders [REDACTED]. Interview on 1/17/19 at 4:55 PM, with the Administrator, revealed it was his expectation staff implement interventions and revise the resident's Care Plan with these interventions after a resident sustains a fall.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition to post-discharge care, and the reduction of factors leading to preventable readmissions for one (1) out of six (6) sampled residents (Resident #4). The facility discharged Resident #4 from the facility with Home Health Therapy and Nursing Services on [DATE]. However, the Home Health Agency did not receive the orders for Physical Therapy, Occupational Therapy or Nursing Services until [DATE], after the resident was seen by his/her Primary Care Physician. The findings include: Review of the facility's Discharge Planning Policy, revised (MONTH) (YEAR), revealed when a resident's discharge was anticipated, the facility would develop and implement a discharge plan that focused on the residents discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventative readmissions. Continued review revealed, for transfer or discharge to post-acute providers, residents who transferred to another skilled nursing facility (SNF), or who were discharged to a home health agency (HHA), inpatient rehabilitation facility (IRF), or long term care hospital (LTCH), the facility would assist residents and their representatives in selecting a post-acute care provider by using data that was relevant and applicable to the residents goals of care and treatment preferences, including but not limited to, SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to extent data was available. Further review revealed, information provided to the receiving provider must include a minimum of the following: a) contact information of the practitioner responsible for the care of the resident, b) resident representative information including contact information, c) Advance Directive information, d) all special instructions or precautions for ongoing care, as appropriate, e) comprehensive care plan goals and f) all other necessary information, including a copy of the resident's discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. Additional review revealed, when discharging the resident into the community, the facility would document any referrals to local contact agencies or other appropriate entities made for this purpose. Review of Resident #4's Admission Record revealed, the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident # 4's Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility had assessed the resident as having an active discharge plan already occurring for the resident to return to the community. Review of Resident #4's Comprehensive Care Plan, dated [DATE], revealed no documented evidence the residents Discharge Planning Process had been implemented. Review of Resident #4's Physician Orders, dated [DATE], revealed an order had been obtained to discharge the resident home with home health to follow the resident for Physical Therapy (PT) and Occupational Therapy (OT). Review of Resident #4's Progress Note, dated [DATE], entered by the Social Worker (SW), revealed Resident #4 was to be discharge to home on [DATE] with the resident's spouse to transport at 3:30 PM. Both Spouse and the resident were notified. Continued review revealed, Resident #4 did not require durable medical equipment: however, did require home health care. Review of the Discharge Summary Plan, dated [DATE], completed by the SW, revealed the resident was discharged home with home health care. Continued review revealed, a referral was made for the resident to receive Home Health Therapy and Home Health Nursing. Review of Resident #4's Medical Record revealed, no documented evidence a Home Health Care Agency had been notified by email, fax, or by a HHA representative pick up, of the PT and OT referral for home health services. Interview with Resident #4's spouse, on [DATE] at 3:30 PM, revealed the resident was discharged from the facility on [DATE] with orders for Home Health services. Per interview, the spouse called the HHA, on [DATE], to find out when the agency would be coming to start Physical Therapy. Continued interview revealed, the spouse was informed the agency had not received a referral from the facility for Resident #4 to receive home health services. The spouse stated, he/she called the facility and asked them to send the home health orders so the resident could start therapy. Per interview, the spouse could not remember who he/she spoke to at the facility. Further interview revealed, the HHA contacted the spouse on [DATE] and informed him/her the home health orders sent by the facility on [DATE] had expired and not valid. Continued interview revealed, due to the expired orders, the resident would need to be seen by his/her physician and a new order obtained before home health services could be initiated. Ongoing interview revealed, the resident was seen by the physician on [DATE] and an order was obtained for Home Health Therapy. Interview with the HHA Director of Clinical Service (DCS), on [DATE] at 12:37 PM, revealed the agency received a call from Resident #4's spouse, on [DATE], to inquire when therapy services would be started. The DCS stated, the agency had not received an order from the facility for Resident #4 to receive services. The DCS stated, the agency received a referral for Resident #4 for home health nursing and home health therapy on [DATE] that was dated [DATE]. Per phone interview, the [DATE] order was expired and the agency could not admit the resident to services until the resident had been seen by his/her primary care physician (PCP) and a new order was obtained. The DCS stated, the resident was seen by his/her PCP on [DATE] and an order was obtained to initiate services and the resident was admitted to the HHA on [DATE]. Interview with the SW, on [DATE] at 1:20 PM, revealed she had been employed by the facility for three (3) years and her role was to participate in Discharge Planning, Care Conferences, conduct MDS Assessments, and to help with assistance for transportation for long term care (LTC) residents. Continued interview with the SW revealed, when a discharge order was received, the nursing staff entered the discharge order into Point Click Care (PCC). After the order was generated, the SW would email the HHA with the date the resident was leaving the facility. Per interview with the SW, the HHA representatives were in the facility a couple of times a week to do marketing and when the representative was in the facility, they would just pick the referral up. Continued interview with the SW revealed, she did not have a system in place to track when a referral had been sent to, or received by the referral agency, and she did not document in the resident's record who she had made contact with at the agency when the referral had been made. Further interview with the SW revealed, she could not remember Resident #4 specifically, and in looking back through her emails for [DATE], she could not find email confirmation that she had contacted the HHA with the therapy referral. Per interview, she did not have a fax confirmation nor did she document who she spoke to or date and time she spoke with the HHA and she should document that information. Additional interview with the SW revealed, it would be important to document the name, contact date, and time the referral had been made to verify it was done, and it was important for the orders to get to the agency so that the resident had continuity of care and to ensure services were provided in a timely manner. Per interview, the sooner the services were provided, the sooner the interventions could be in place for the resident. Interview with the Administrator, on [DATE] at 2:00 PM, revealed the HHA representative was usually in the facility a couple of times a week and when they were in the facility they picked up the referral orders. Continued interview revealed, she expected the staff to call them and let them know they had an order if the representative had not been in the facility to pick the order up. Per interview, the SW or designee would be responsible for calling with the orders to the HHA and ensuring the orders had been received. Further interview revealed, the SW or designee should document the contact person on the discharge summary. Additional interview revealed, it was important to make sure the information was documented to ensure there was contact with the agency for the resident's wellness and continuity of care. Per interview, her expectation was for staff to follow the facility's Discharge Planning Policy.

Based on observations, interviews, and review of the facility's policies it was determined the facility failed to follow standard and transmission-based precautions to prevent the spread of infections for one (1) of twenty-eight (28) residents. Observation of the administration of a central line flush, on 01/31/2017, revealed staff failed to wash their hands and don gloves prior to performing the procedure. The findings include: Review of the policy, Access Devices: Central Venous Catheter (CVC), PICC Line (Peripherally Inserted Central Catheter), dated June 2017, revealed staff were to verify orders, wash hands, assemble equipment and supplies on a clean surface, don gloves, and assess access site. Review of the policy titled, Hand Hygiene, dated April 2017, revealed staff were expected to wear gloves when contact with blood or other potentially infectious materials could occur. Continued review revealed, all team members of the facility would follow hand hygiene guidelines to reduce the incidence of health care associated infections. Observation of Licensed Practical Nurse (LPN) #1, on 01/31/18 at 9:17 AM, revealed during the administration of a central line flush, LPN #1 failed to wash her hands or donning gloves prior to decontaminating the access port for administration of the flush for a Peripherally Inserted Central Catheter . Interview with LPN #1, on 02/01/2018 at 12:55 PM, revealed she was IV (Intravenous) certified. She stated she did not receive specific education regarding the procedure to access a PICC line during orientation; however, she was aware there was a policy regarding accessing central lines. Continued interview revealed, the process for the procedure was prior to accessing of a peripherally inserted central catheter (PICC) line, staff were to wash their hands, scrub the hub of the access port, and assess placement of the central catheter line prior to administering the flush. She further stated she should have washed her hands prior to the procedure and she probably should wear gloves. Interview with the Infection Preventionist, on 02/01/2018 at 08:17 AM, revealed her expectation was for nursing staff to wash their hands and don gloves prior to accessing a central line. Continued interview revealed, this was for the prevention of infections in residents. Interview of the Unit Manager, on 02/01/2018 at 09:43 AM, revealed her expectation for nursing staff was to wash their hands, don gloves, and check positioning of the central line access device prior to administering a flush to a central line. She further stated these expectations were for the protection of staff from blood borne exposures and for the prevention of infection in residents. Interview with the Director of Nursing, on 02/01/2018 at 11:15 AM, revealed her expectation was for nursing staff to use hand hygiene, don gloves, and scrub the port prior to accessing a central line. She stated the purpose of the process was to prevent infection in residents and protect the staff from blood borne pathogen exposures.

Based on observation, interview, record review, Center for Disease Control (CDC) Recommendations and Reports and review of facility Policy, it was determined the facility failed to provide services to meet professional standards of quality for one (1) of seven (7) sampled residents (Resident #5). According to facility Policy, Peripherally Inserted Central Line (PICC) dressings were to be changed every seven (7) days; however, observation on 6/14/17, revealed Resident #5's PICC line dressing was dated 05/31/17. Further observation revealed the dressing was not changed until 06/15/17, which was eight (8) days after the dressing should have been changed. The finding's include: Review of the facility Access Devices: Central Venous Catheter (CVC), Peripherally Inserted Central Catheter (PICC) Policy, revised August 2016, revealed PICC line dressings should be changed every seven (7) days. Review of the Center for Disease Control (CDC) Recommendations and Reports dated 08/09/02, revealed PICC line dressings should be changed every seven (7) days; or when the dressing became damp, loosened, or soiled; or when inspection of the site was necessary. Review of Resident #5's medical record revealed the facility admitted the resident on 06/13/16. Further review revealed the resident's [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed the resident as having active [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the most current physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) dated June 2017, revealed an intervention to change the PICC line dressing and needleless connector every week. Per the MAR, the intervention for the dressing change was initialed on 6/01/17 and 06/08/17, indicating the dressing change had been performed. However, observation of Resident #5 on 06/14/17 at 2:40 PM, revealed the PICC line dressing on the resident's right arm was dated 5/31/17, and the right side of the occlusive dressing appeared to be peeling. Further observation of Resident #5, on 6/14/17 at 4:15 PM, revealed the PICC line dressing on the resident's right arm was dated 5/31/17, and the right side of the dressing was noted to be loose and not adhering to the skin. Additional observation of Resident #5, on 6/15/17 at 9:30 AM, revealed the resident's PICC line dressing was dated 6/15/17-1:00 AM; however, record review of the Medication Administration Record dated 6/15/17, revealed the PICC line dressing was not signed to indicate the dressing had been performed. Interview on 6/15/17 at 11:45 PM, with Licensed Practical Nurse (LPN) #2, revealed she signed Resident #5's MAR to indicate she had performed the PICC line dressing change on 06/01/17. However, she stated after she signed the MAR, she realized the dressing was just changed on 5/31/17, and therefore the dressing did not yet need to be changed. Further interview revealed LPN #2 did not change the resident's PICC line dressing on 06/01/17, but she forgot to correct the MAR and error out the dressing change to indicate the dressing change was not performed on that date. Interview with LPN #1, on 6/15/17 at 12:10 PM, revealed she signed the MAR to indicate she had performed Resident #5's PICC line dressing change on 06/08/17; however, she stated she did not perform the dressing change on that date. Further interview revealed it was her understanding a Registered Nurse (RN) must do the PICC line dressing change so her process was to sign off on the MAR as though the dressing change had been performed, then tell the RN on duty that the dressing needed to be changed. She further stated she thought she told the Second Floor Unit Manager/RN that Resident #5's PICC line dressing needed to be changed on 6/08/17. However, LPN #1 stated she did not follow up to ensure the dressing was changed. Per interview, LPN #1 was aware PICC line dressings were to be changed every seven (7) days. Interview with RN #1, on 6/15/17 at 1:45 PM, revealed she changed the PICC line dressing for Resident #5 on 06/15/17 at 1:00 AM. She further stated she did not look at the old dressing fully as she did not turn on all the lights and could not verify the date on the old dressing. However, she stated she was told in report by the Unit Manager that evening to change the dressing as it was dated 05/31/17. She further stated she failed to document that she had performed the dressing change on the MAR on 06/15/17. RN #1 further stated she had not performed the PICC line dressing change with best practices and should have performed the dressing change with full visualization of the site. Interview with the Second Floor Unit Manager, on 06/15/17 at 2:15 PM, revealed facility policy was to have PICC line dressings changed every seven (7) days as per the Policy. Per interview, the LPN's were to let the RN's know when the PICC line dressing's needed to be changed; however, she did not remember being asked to change Resident #5's PICC line dressing on 06/08/17. Further interview revealed documentation of the dressing change should be completed on the MAR by the nurse who actually changed the dressing. The Unit Manager further stated, when the nurse signed off on the MAR, this was acknowledgement the treatment order was completed by the nurse. Per interview, it was her expectation that staff follow facility Policy related to PICC line dressings and document accurately on the MAR. Interview with the Director of Nursing (DON), on 06/15/17 at 3:00 PM, revealed per facility policy, both LPN's and RN's were to perform PICC line dressing changes and the facility educated staff annually related to this with check off competencies. Further interview revealed it was her expectation for all nurses to follow facility policies related to PICC line dressing changes to prevent risk of infection, as well as ensure the PICC line was secure. Per interview, the nurse who performs the PICC line dressing change should document their initials to indicate the dressing change was performed on the MAR after the procedure. Interview with the Administrator, on 06/15/17 at 2:50 PM, revealed it was her expectation for staff to follow facility policy in regards to PICC line dressing changes to ensure residents received proper care to the intravenous (IV) sites. Continued interview revealed it was important to document the dressing changes accurately in order for staff to be aware of the next date in which the dressing change was to be performed.

Based on observation, interview, and record review, Center for Disease Control recommendations, and review of facility Policy, it was determined the facility failed to maintain complete and accurately documented medical records for one (1) of seven (7) sampled residents (Resident #5). Resident #5's Medication Administration Record (MAR) dated June 2017, revealed the intervention to change the Peripherally Inserted Central Line (PICC) dressing was signed off to indicate the dressing was changed on 06/01/17 and 06/08/17; however, interviews with staff revealed the residents's PICC line dressing was not changed on those dates. In addition, observation of Resident #5's PICC line dressing on 06/15/17 revealed it was dated as changed on 6/15/17 at 1:00 AM; however, review of the MAR, dated June 2017, revealed the intervention for the dressing change was not signed off on that date to indicate the dressing had been changed. The finding's include: Review of Resident #5's clinical record revealed the facility admitted the resident on 06/13/16. Continued review revealed the resident's [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #5 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #5's physician's orders [REDACTED]. Review of the most current physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) dated June 2017, revealed an intervention to change the PICC line dressing and needleless connector every week. Per the MAR, the intervention for the PICC line dressing change was initialed on 6/01/17 and 06/08/17, to indicate the dressing change had been performed. However, observation of Resident #5 on 06/14/17 at 2:40 PM, revealed the PICC line dressing on the resident's right arm was dated 5/31/17, and the right side of the occlusive dressing appeared to be peeling away from the skin. Additionally, observation of Resident #5 on 6/14/17 at 4:15 PM, revealed the PICC line dressing on the resident's right arm was dated 5/31/17, and the right side of the dressing was noted to be loose and not adhering to the skin. Further observation of Resident #5 on 6/15/17 at 9:30 AM, revealed the resident's PICC line dressing was dated 6/15/17-1:00 AM; however, record review of the Medication Administration Record dated 6/15/17, revealed the PICC line dressing was not signed to indicate the dressing had been performed on that date. Interview on 6/15/17 at 11:45 PM, with Licensed Practical Nurse (LPN) #2, revealed she signed/initialed Resident #5's MAR indicating she had performed the PICC line dressing change on 06/01/17. However, further interview revealed after she signed the MAR, she realized the dressing was just changed on 5/31/17, and therefore the dressing did not yet need to be changed. Per interview, LPN #2 did not change the resident's PICC line dressing on 06/01/17, but did not correct the MAR and error out the dressing change to indicate the dressing change was not performed on that date. Interview with LPN #1, on 6/15/17 at 12:10 PM, revealed she signed/initialed the MAR to indicate she had performed Resident #5's PICC line dressing change on 06/08/17. However, she stated she did not perform the dressing change on that date. Per interview, it was her understanding a Registered Nurse (RN) must do the PICC line dressing change so her process was to sign off on the MAR as though the dressing change had been performed, then tell the RN on duty that the dressing needed to be changed. LPN #1 further stated she thought she told the Second Floor Unit Manager/RN that Resident #5's PICC line dressing needed to be changed on 6/08/17. However, LPN #1 revealed she did not follow up to ensure the dressing was changed. Interview with RN #1, on 6/15/17 at 1:45 PM, revealed she changed the PICC line dressing for Resident #5 on 06/15/17 at 1:00 AM. Per interview, she did not look at the old dressing fully as she did not turn on all the lights and could not verify the date on the old dressing. However, she stated she was told in report by the Unit Manager the evening of 06/15/17 to change the dressing as it was dated 05/31/17. Further interview revealed she failed to document that she had performed the dressing change on the MAR on 06/15/17. RN #1 stated she should have signed the MAR after performing the dressing change for the PICC line. Interview with the Second Floor Unit Manager, on 06/15/17 at 2:15 PM, revealed the LPN's were to let the RN's know when the PICC line dressing's needed to be changed; however, she did not remember being asked to change Resident #5's PICC line dressing on 06/08/17. Continued interview revealed documentation of the dressing change should be completed on the MAR by the nurse who actually changed the dressing. The Unit Manager revealed, when the nurse signed their initials on the MAR next to a treatment intervention, this was acknowledgement the treatment order was completed by the nurse. Further interview, revealed it was her expectation that staff document dressing changes accurately on the MAR. Interview with the Director of Nursing (DON), on 06/15/17 at 3:00 PM, revealed all documentation on the MARS was to be complete and accurate. Per interview, the nurse who performs the PICC line dressing change should document their initials to indicate the dressing change was performed on the MAR after the procedure. Continued interview revealed it was important to maintain an accurate medical record in order for staff to safely provide care for the residents. Interview with the Administrator, on 06/15/17 at 2:50 PM, revealed it was important for the PICC line dressing changes to be documented accurately in order for staff to know when the next dressing was due. She further stated it was her expectation for staff to document accurately in the medical record.

Based on interview, record review, and review of facility's policies and procedures and the facility's staff schedule, it was determined the facility failed to provide sufficient nursing staff to provide needed care to residents for their highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for seven (7) of nine (9) sampled residents. (Residents #1, #2, #4, #5, #6, #7, #8, and #9). Interviews with Residents #1, #2, #4, #5, #6, #7, #8, and #9 revealed the facility was not staffed sufficiently to answer their call lights in a timely manner to provide care as outlined in their care plans. The findings include: Review of the Resident Census and Conditions of Residents (Form CMS-672), completed by the facility on 03/14/17, revealed the facility had one hundred fifteen (115) residents on the start of the abbreviated survey. Continued review of the form revealed of the 115 residents, the facility assessed one-hundred six (106) residents as needing the assistance of one or two staff with transfers and five (5) residents being totally dependent. The facility only assessed four (4) residents as independent with transfers. Further review of the form revealed of the 115 residents, the facility assessed ninety-eight (98) residents as needing the assistance of one or two staff with toilet use and fourteen (14) being totally dependent on staff for toileting use. The facility only assessed three (3) residents as being independent with toilet use. Review of the facility's policy, Nursing Staffing Protocol, revised 03/13, revealed the facility provided sufficient nursing staff on a 24-hour basis to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by the resident assessment and individual plans of care. Review of the facility's policy, Call Lights, revised 08/16, revealed all requests are to be answered courteously and in a timely manner. Interview with the Director of Nursing (DON), on 03/14/17 at 4:30 PM, revealed the facility's audits, related call light response times, were part of the facility's Quality Improvement; therefor, she would not allow the surveyor to review the audits. Review of the facility's policy Urinary Incontinence Management, revised 03/16, revealed a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Continued review of the policy revealed toileting should be offered to incontinent residents on a consistent basis with the goal to keep the resident dry. Review of the facility's Resident Council Meeting Minutes, dated 12/14/16, revealed one resident complained of staff turning off the call light and not assisting him/her in the bathroom. Review of the facility's Resident Council Meeting Minutes, dated 01/11/17, revealed a resident's comment about staffing was that sometimes staffing is better than other times in regards to having enough staff available to receive care without waiting a long time. Another resident commented sometimes has to wait for pain medications. Review of the facility's Resident Council Meeting Minutes, dated 02/07/17, revealed one resident complained of having to wait twenty-five (25) minutes for staff to answer the call light. Another resident complained of not having enough staff and night shift was the worst. Interview with the Activities Director, on 03/16/17 at 2:00 PM, revealed the Resident Council Meeting concerns/complaints were reported to both the Director of Nursing (DON) and the Administrator. The Activity Director stated the March Resident Council Meeting was held on 03/10/17 and the concern of staff responding to call lights was brought up again; however, the minutes from that meeting were not available for review at that time. Interview with the Ombudsman, on 03/15/17 at 8:10 AM, revealed she had talked with the DON the previous week regarding staff responding to call lights. The Ombudsman stated the DON had stated the facility was short-staffed and did not know what she could do regarding the response time. Additional interview with the Ombudsman, on 03/15/17 at 10:15 AM, revealed her office had received sixteen (16) complaints regarding the staffing level at the facility and staff' slow or delayed response to call lights since the beginning of the year. The Ombudsman stated these complaints had come from residents, family members of residents, and a local physician who was concerned after hearing several of his patients, both former residents and/or family members, complaining about the lack of staff at the facility. 1. Record review revealed the facility admitted Resident #1 originally on 01/13/17 and with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident for Brief Interview for Mental Status (BIMS) as a fifteen (15) out of fifteen (15), indicating Resident #1 as being cognitively intact. Continued review of the MDS revealed the facility assessed the resident as needing the support of two plus persons for physical assist for bed mobility and transfers as well as toilet use. Further review of the MDS revealed the facility assessed the resident as being occasionally incontinent of bladder. Review of the Comprehensive Care Plan (CCP), dated 02/07/17 for Resident #1 revealed the facility care planned the resident for having Activities of Daily Living (ADL) self-care performance deficit related to Disease Process of [MEDICAL CONDITION] (MS). Continued review revealed the facility care planned the resident have needing extensive assistance of one (1) staff for Bed Mobility, with a date initiated of 02/14/17. Continued review revealed the facility assessed the resident of needing Extensive Assistance of One to two (1-2) staff for Toileting, with an initiation dote of 02/07/17, and needing Extensive Assistance of two (2) staff for Transfers, with date initiated on 02/07/17. Continued review revealed Resident #1 had a CCP, dated 02/07/17 for alteration in comfort related to the disease process of MS. Intervention included administering pain medication as need and to anticipate the resident's need for pain relief. Interview with Resident #1, on 03/15/17 at 3:15 PM, revealed it usually took staff ten (10) to fifteen (15) minutes to answer his/her call light but sometimes it took thirty (30) minutes to one (1) hour for staff to respond to the call light. Resident #1 stated he/she had to wait for over an hour to receive pain medications. Resident #1 further stated on two (2) different occasions, the resident was incontinent and had soiled the bed. Resident #1 stated it took staff an hour on one occasion to have the urine soaked linens, which he/she was laying in, changed. Resident #1 further stated it took about an hour and half before staff could assist him/her to change the linens the other time. 2. Record review revealed the facility admitted Resident #2 on 09/23/16 with [DIAGNOSES REDACTED]. Review of Resident #2's five (5) day MDS, dated [DATE], revealed the facility assessed the resident with a BIMS of a fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS revealed the facility assessed Resident #2 to be a two (2) plus person physical assist for transfers and one (1) person physical assist for toilet use. Further review revealed the facility assessed Resident #2 as being occasionally incontinent of bladder and always continent of bowel. Review of Resident #2's Care Plan, dated 09/23/16 revealed the facility assessed the resident to have an ADL self-care performance deficit related to Impaired Mobility and Pain with date initiated of 09/23/16. Continued review of the Care Plan revealed interventions of Mobility and Toilet Use as Extensive Assistance of one (1) staff and Transfers as Extensive Assistance of two (2) staff. Interview with Resident #2, on 03/13/17 at 11:40 AM, revealed staff do not answer the call lights in a reasonable time frame, stating usually the staff would answer anywhere from 15 to 30 minutes and if the call light was on during meals, staff never would come. Resident #2 stated on one occasion, he/she had waited over an hour for assistance to go to the restroom but ended up soiling himself/herself and had to ask a housekeeper for assistance. Resident #2 further stated it took staff over two (2) hours to administer pain medications requested on one occasion. The resident reported on one (1) occasion he/she needed assistance to toilet and because staff would not respond to the call bell for one (1) hour and forty-five (45) minutes, he/she was incontinent of urine, which made him/her feel horrible. Resident #2 stated he/she never cried about anything as much as he/she did with the poor care and service provided by the facility. 3. Record review revealed the facility admitted Resident #4 on 01/21/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident as needing one (1) person physical assist for Bed Mobility, Transfers, and Toileting. Further review revealed the resident to have an indwelling catheter and always continent of bowel. Review of Resident #4's CCP, dated 01/21/17 revealed the facility assessed the resident to be at risk for falls related to History of Falls, Side Effects of Medications and Unaware of Safety needs. Continued review revealed the facility placed interventions of assist with transfers/mobility/repositioning/toileting as needed with date initiated of 01/21/17. Further review of the CCP revealed the facility assessed the resident as having the Potential for alteration in comfort related to Arthritis, Fibro-Myalgia, and Generalized Pain initiated on 01/21/17. The facility placed interventions in place of administer pain medications as indicated and to anticipate the resident's need for pain relief with both initiated on 01/21/17. Interview with Resident #4, on 3/15/17 at 8:45 AM, revealed the resident had trouble getting staff to answer the call bells in a timely manner. The resident stated according to Therapy the resident was not supposed to get up without assistance but the resident had waited so long to have someone help him/her on Monday (03/13/17) morning that the resident got up by him/herself and went to the bathroom, although the resident was afraid he/she was going to fall, because the resident did not want to be incontinent and could not wait any longer for assistance. When the resident returned to the bed, the resident laid a towel on the bed because the resident was afraid he/she had not been able to clean him/herself properly and did not want to get the bed linens dirty. The resident stated when the SRNA did come to help him/her and was told about the towel the SRNA asked the resident if he/she wanted the towel removed, but did not check the resident for cleanliness. The resident stated he/she waited 30 minutes from the time of ringing the call bell to getting up to go to bathroom unassisted. Observation and interview with Resident #4, on 3/15/2017 at 1:35 PM, revealed the resident rang the call bell at 1:20 PM and had requested pain medication. The resident's sibling was in room with resident. The resident stated someone answered the call light and the resident told staff he/she would like a pain pill and the staff stated they would tell the nurse. The resident believed it was an SRNA but did not remember her name. At 1:45 on 3/15/2017, interview with Resident #4 revealed he/she had not received the pain medication. The resident stated he/she rang call bell again at 1:40 PM and a different facility employee came in and answered light but the resident did not know the name of worker but the resident believed it was an SRNA. The employee told the resident she would tell the nurse the resident was requesting medication. At 2:45 PM, on 03/15/2017, Resident #4 reported he/she had received pain medication after ringing her call bell again at 2:30 PM and requesting the pain medication a third time. Interview with resident's sibling, who was visiting at the time of the incident, corroborated the resident's story and sequence of events. Resident #4 stated at times he/she has had to wait so long for assistance that the resident started calling out and yelling for help in an attempt to get someone to help him/her and answer the call light. Review of the Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 revealed that medication ([MEDICATION NAME] 10mg) was given to the resident at 2:36 PM, after she was informed by the MDS nurse, who had answered the call bell while on the unit, that the patient needed medication. LPN #2 denied knowledge of patient requesting medication for one hour and sixteen minutes today. Interview with nurse stated that she gave medications as soon as she was aware that resident needed them; however, an hour wait for pain medications would be too long. 4. Record review revealed the facility admitted Resident #6 on 03/18/15, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of a fifteen (15) out of fifteen (15), indicating Resident #6 was cognitively intact. Continued review of the MDS revealed the facility assessed the resident as needing one (1) person physical assist for Bed Mobility and Transfers as well as toilet use. Further review revealed the facility assessed Resident #6 as being continent of Bladder and Bowel. Review of the CCP for Resident #6 revealed the facility care planned the resident for having Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility, Impaired Balance, and Limited ROM (range of motion) and the facility assessed the resident as needing Supervision of one (1) staff for transfers, date initiated 12/29/15, and limited assistance of one (1) staff for toilet use, with date initiated of 11/15/16. Interview with Resident #6, on 03/15/17 at 3:40 PM, revealed after breakfast this morning (03/15/17), the resident had taken self to the bathroom and used to call light to call for assistance. Resident #6 stated he/she waited over thirty (30) but no staff answered so the resident attempted to provide self-hygiene care after having a bowel movement even though the resident had limited ROM in the dominant arm. Resident #6 further stated when he/she received a shower later in the day, the staff assisting the resident noticed the resident still had stool on his/her person from the previous bowel movement when the resident had to perform self-hygiene. Resident #6 stated he/she was very embarrassed by the situation. Resident #6 stated he/she felt the facility did not have enough staff at all times to respond timely to the call lights. Interview with SRNA #4, on 03/16/17 at 10:35 AM, revealed she had assisted Resident #6 with a shower on 03/15/17. SRNA #4 stated Resident #6 still had stool on his/her person after attempting to provide self-hygiene care. SRNA #4 stated Resident #6 had stated he/she had turned on the call light but nobody came. SRNA #4 stated Resident #6 was embarrassed by the incident. 5. Record Review revealed the facility admitted Resident #7 on 01/24/17 with [DIAGNOSES REDACTED]. Review of Resident #7's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of a fifteen (15) out of fifteen (15), indicating Resident #7 was cognitively intact. Continued review of the MDS revealed the facility assessed the resident as needing two (2) plus persons physical assist for Bed Mobility and Transfers and as needing one (1) person physical assist for toilet use. Further review revealed the facility assessed Resident #7 as being always incontinent of bladder. Review of the CCP, dated 01/24/17, for Resident #7 revealed the facility care planned the resident for having Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility and Impaired Balance and assessed for needing Extensive Assistance of one (1) staff for Toilet Use and Extensive Assistance of two (2) staff for Bed Mobility and Transfers. Interview with Resident #7, on 03/15/17 at 8:10 AM, revealed it took thirty (30) to forty-five (45) minutes for staff to answer the call light then will take another 30 to 45 minutes for staff to come back and provide the care requested. Additional interview with Resident #7, on 03/15/17 at 3:10 PM, revealed whenever the resident used the call light, it would take staff at least 30 to 45 minutes to respond. Resident #7 stated sometimes he/she used the call light for toileting needs or to request some cold water. Resident #7 further stated on many occasions the resident would soil self having to wait on staff to respond to the call light. Resident #7 stated he/she felt the facility was not being staffed correctly to care for the residents' needs. 6. Record review revealed the facility admitted Resident #8 on 12/08/14 with [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS as fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident to have one (1) person physical assist for Bed Mobility, Transfers, and Toilet Use. Further review revealed the facility assessed Resident #8 to have an indwelling catheter and always continent of bowel. Review of Resident #8's CCP revealed the facility assessed the resident to have an ADL self-care performance deficit related to Impaired Mobility, Impaired Balance, and Pain. Continue review revealed the facility developed interventions of limited assistance by two (2) staff for Bed Mobility initiated on 02/15/16 and limited assistance by one (1) staff for Transfers and Toilet Use with both initiated on 03/22/16. Interview with Resident #8, on 3/15/17 at 1:45 PM revealed he/she had to wait five (5) to ten (10) minutes to have call bells answered on a good day, but that it was not unusual to have to wait thirty (30) minutes to have call light answered. The resident stated that it seemed worse on evenings and nights to get call bell answered. The resident stated the facility was having staffing issues and it had been getting worse since Christmas. The resident stated that one night recently there were no SRNAs on night shift at all. Further interview revealed that the resident is supposed to get a shower three (3) times a week but it didn't always happen and he/she felt that this may also be do to staffing shortages or issues. The resident further stated he/she had difficulty getting anyone to change the linens on his/her bed and had to ask before they would do this task. The resident believed that linen was supposed to be changed on shower days. Resident #8 stated they are sometimes short on linens. Resident #8 stated that on 3/14/17 during the AM shift he/she had to wait thirty (30) minutes for the call light to be answered for assistance with hygiene needs. 7. Record Review revealed the facility readmitted Resident #9 on 02/11/17 with [DIAGNOSES REDACTED]. Review of Resident #9's Significant Change MDS, dated [DATE], revealed the facility assessed the resident's BIMS as fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to need two (2) plus persons physical assist for Bed Mobility, Transfers, and Toilet Use. Further review of the MDS reviewed the facility assessed the resident to have an indwelling catheter and frequently incontinent of bowel. Review of Resident #9's CCP revealed the facility assessed the resident to have an ADL self-care performance deficit related to Impaired Mobility and Right Above the Knee Amputation. Continued review revealed the facility developed interventions of extensive assistance by two (2) staff for Bed Mobility and Toilet Use, initiated on 10/17/16 and total dependence by two (2) staff for transfers initiated on 10/17/16. Interview with Resident #9, on 03/15/2017 at 4:45 PM revealed that at times the SRNAs would come into his/her room and shut off the call light and not provide care, then leave the room. Further interview revealed the resident had difficulty getting his/her pain medications on time. The resident stated the pain medications were available every two (2) hours but stated if you have difficulty getting the call bells answered in a timely manner it will also make getting the medications late. The resident did state this was worse on the evening and night shifts. Continued interview with Resident #9, on 03/16/2017 at 9:00 AM, revealed on 03/14/17, during 11-7 shift at approximately 1:00 AM, the resident waited over one hour for his/her call bell to be answered and stated he/she was having trouble breathing as he/she was positioned, so the resident was lying partially on his/her side and could not get straightened out and this was restricting his/her breathing. Interview with SRNA #3, on 03/14/17 at 2:36 PM revealed the facility did not always have adequate staffing to meet resident needs. SRNA #3 stated at times lack of staffing affects how long it took to answer call lights and to help residents with care. Addition interview with SRNA #3, on 03/15/17 at 3:30 PM, revealed night shift stripped the beds of the people who needed changes of linen for the day, then she would make the beds up with new linen. She further stated that she was not sure how often that bed linen was changed, she thought it may be every two (2) to three (3) days or twice a week. Continued interview SRNA #3 revealed she thought most call bells should be answered within a few minutes and that if a resident had to wait thirty minutes for it to be answered, it was too long. Interview with SRNA #1, on 03/15/17 at 9:20 AM, revealed the staff could answer the call lights most of the time in a timely manner but the facility had been short staff lately and not always able to answer in a timely manner. Interview with SRNA #2, on 03/15/17 at 4:40 PM, revealed the facility did not have enough staff to meet the care needs of the residents. SRNA #2 stated the staff was not able to answer the call lights in a timely manner. SRNA #2 continued to state staff was not able to change linens as they should be changed. SRNA #2 further stated staff was not able to provide for the residents' highest well-being as outlined by the residents' care plans. Interview with LPN #1, on 03/15/17 at 4:45 PM, revealed the facility did not have enough staff to provide care to the residents according to their care plans. LPN #1 stated later this evening there would only be two (2) nurses and one (1) SRNA to care for the residents on the second floor, which was fifty-four (54) residents. LPN #1 further stated staff was unable to answer call lights in a timely manner. LPN #1 explained if several call lights went off, staff would try to answer those needing only one (1) staff assistance before providing care to the residents needing two (2) staff assistance causing those residents to wait a longer time period before staff was able to provide care. Additional interview with LPN #1, on 03/16/17 at 1:45 PM, revealed the facility was short staffed and that it did affect resident care. She stated the Director of Nursing and Assistant Director of Nursing only come out to help on the floor if there weren't any SRNA's and if a nurse called in, they did not help at all. She further stated that turn over had been high since September. She stated that employees get pulled to other units or floors without orientation and work short all the time. She stated that they do not have enough nurses or SRNA's to meet the residents' needs. Review of the staffing schedule for 03/14/15, revealed there were only two (2) nurses and one (1) SRNA to provide care to fifty-four (54) residents on the second floor of the facility from 10:00 PM to 7:00 AM. The staffing schedule for 03/15/17 was unavailable. Interview with the DON, on 03/16/17 at 5:20 PM, revealed her expectation was for all staff of the facility to answer residents' call light in a timely manner. The DON stated her definition of timely would be within fifteen (15) minutes for a regular call lights and within ten (10) minutes for the emergency/bathroom call lights. The DON further stated she felt the staff was able to answer the call lights in a timely manner and was able to provide care according to the residents' care plans. Interview with the Administrator, on 03/16/17 at 5:30 PM, revealed her expectation was for staff to answer residents' call lights within a timely manner. The Administrator defined a timely manner as within 15 minutes. The Administrator stated any time over 15 minutes would have to be investigated to examine trends. The Administrator further stated she felt the facility has sufficient staff to respond to call lights in a timely manner and to provide care according to the care plans.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develope and inital care plan based on the assessed needs of the resident upon admissionfor one (1)of nine (9) sampled residents (Resident #2). Resident #2 was admitted to the facility on [DATE] with a Physician's order for a Continuous Passive Motion (CPM), which is a treatment for [REDACTED]. The findings include: Review of the facility Policy titled, Care planning dated November 2016, revealed a nursing admission comprehensive assessment will be completed upon admission/readmission. The facility states the care plan will need to be in place within 48 hrs of admission. Review of facility's standard of practice Lippincott Manual of Nursing Practice Ninth Edition, appropriate care of the resident is adhering to the facility's policy and procedures, documenting appropriate information in the medical record, and following physician's order's. Care plans are to establish goals or expected outcomes and should be specific, measurable, patient focused and should include a time frame. The care plan should identify interventions as appropriate for goal attainment, should be detailed to provide continuity of care. Record review revealed the facility admitted Resident #2's on 09/23/16 with [DIAGNOSES REDACTED]. Review of the five (5) day Minimum Data set (MDS) Assessment, dated 9/29/16 revealed the facility assessed the resident to have a Brief Interview for Mental Status Score (BIMS) of fourteen (14) indicating the resident was independent with cognition skills for daily living. Further review of the MDS, revealed the facility assessed the resident to require extensive two (2) person assist with transfers and bed mobility and extensive one (1)person assist with locomotion, dressing, toileting and bathing. Review of the admission Physician's orders, dated 09/23/16, revealed an order for [REDACTED]. Interview with Resident #2, on 03/13/17 at 11:40 AM, revealed he/she was not happy with the quality of care provided by the facility for the seven (7) day he/she was there. The resident stated the CPM treatment was not performed as ordered on several different occasions. Resident #2 stated this was an ongoing problem the entire week as he/she knew this treatment was of great importance for a full recovery from surgery. The resident further stated he/she told the nursing staff about missing the treatments, but it did no good. Continued interview with Resident #2, revealed Ice therapy was not performed twice a day while he/she was in the facility. Further interview revealed he/she would use the call bell for assistance for toileting and staff would not respond. The resident reported on one (1) occasion he/she needed assistance to toilet and because staff would not respond to the call bell for one (1) hour and forty-five (45) minutes, he/she was incontinent of urine, which made him/her feel horrible. The resident further stated, discharge on 09/29/16 was not a planned discharged , but he/she was so unhappy with the care provided that he/she wanted to go home as soon as possible, even though therapy services after surgery was still needed. She stated she had to go home without all the equipment ordered for discharge related to being so unhappy with the care and services provided by the facility. Resident #2 further stated he/she had to leave without a walker, medications in place for discharge, or raised toilet seat available at home. Resident #2 stated he/she never cried about anything as much as he/she did with the poor care and service provided by the facility. Interview with MDS coordinator, on 03/16/2017 at 4:00 PM revealed that she did check Physician's orders when writing care plans but not all of them were put in the care plan. She stated she may or may not put assistive devices or therapies such as a CPM machine on the initial care plan because they have twenty-one days to do a comprehensive care plan. Interview with Director of Nursing (DON), on 3/16/17 at 5:10 PM revealed it would be her expectation that staff should follow the policy for care plans. The DON stated that treatment as ordered intervention oin the initial care plan would address the CPM machine treatment. Interview with Administrator, on 3/16/17 at 5:20 PM revealed it would be her expectation that staff follow the policy for care plans.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed provide or arrange services as outlined by the comprehensive care plan for two (2) of nine (9) sampled residents. (Resident #4 and Resident #6). Resident #4 and Resident #6 were care planned for assistance with toileting but staff did not assist the residents according to their care plans. The findings include: Review of the facility's policy Care planning dated 11/16, revealed the facility will provide resident/patient centered care aiming to provide individualized Comprehensive/Interdisciplinary Care Plans for each resident. Continued review revealed a care plan was developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level while encompassing a holistic approach including medical, nursing, psycho-social, nutritional, activities, therapy, spiritual and educational interventions. Further review revealed a nursing admission comprehensive assessment will be completed upon admission/readmission. The facility states the care plan will need to be in place within 48 hrs of admission. 1. Record review revealed the facility admitted Resident #4 on 01/21/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment, dated 03/04/17, revealed the facility assessed the resident's Brief Interview of Mental Status (BIMS) score to be 15 out of 15, indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident as needing one (1) person physical assist for Bed Mobility, Transfers, and Toileting. Further review revealed the resident to have an indwelling catheter and always continent of bowel. Review of Resident #4's Comprehensive Care Plan (CCP), dated 01/21/17, revealed the facility identified the resident to be at risk for falls related to a history of falls, side effects of medications and being unaware of safety needs. Continued review revealed the facility placed interventions of assist with transfers/mobility/repositioning/toileting as needed with date initiated of 01/21/17. Further review of the CCP revealed the facility identified the resident as having the potential for alteration in comfort related to Arthritis, Fibro-Myalgia, and Generalized Pain initiated on 01/21/17. The facility placed interventions in place to administer pain medications as indicated and to anticipate the resident's need for pain relief with both initiated on 01/21/17. Interview with Resident #4, on 3/15/17 at 8:45 AM revealed the resident had trouble getting staff to answer call bells in a timely manner and stated that per therapy he/she was not supposed to get up without assistance. Resident #4 stated he/she waited so long to have someone help them on Monday (03/13/17) morning that he/she got up by himself/herself and went to the bathroom, although he/she was afraid of falling, because he/she did not want to be incontinent and could not wait any longer for assistance. When the resident returned to bed he/she laid a towel on the bed because he/she was afraid that he/she had not been able to clean themselves properly and did not want to get the bed linens dirty. Resident #4 stated when the State Registered Nursing Assistant (SRNA) did come to help and the resident told the SRNA about the towel the SRNA ask the resident if he/she wanted the towel removed but did not check the resident for cleanliness. The resident stated that he/she waited 30 minutes from time of ringing the call bell to getting up to go to bathroom on their own. 2. Record review revealed the facility admitted Resident #6 on 03/18/15, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of a fifteen (15) out of fifteen (15), indicating Resident #6 was cognitively intact. Continued review of the MDS revealed the facility assessed the resident as needing one person physical assist for Bed Mobility and Transfers as well as toilet use. Further review revealed the facility assessed Resident #6 as being continent of Bladder and Bowel. Review of the Comprehensive Care Plan (CCP) for Resident #6, dated 12/29/15, revealed the facility care planned the resident for having Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility, Impaired Balance, and Limited ROM (range of motion) and the facility assessed the resident as needing supervision of one (1) staff for transfers, and limited assistance of one (1) staff for toilet use. Interview with Resident #6, on 03/15/17 at 3:40 PM, revealed after breakfast this morning (03/15/17), the resident had taken themselves to the bathroom and used to call light to call for assistance. Resident #6 stated he/she waited over thirty (30) but no staff answered so the resident attempted to provide self-hygiene care after having a bowel movement even though the resident had limited ROM in the dominant arm. Resident #6 further stated when he/she received a shower later in the day, the staff assisting the resident noticed the resident still had stool on his/her person from the previous bowel movement when the resident had to perform self-hygiene. Resident #6 stated he/she was very embarrassed by the situation. Resident #6 stated he/she felt the facility did not have enough staff at all times to respond timely to the call lights. Interview with SRNA #4, on 03/16/17 at 10:35 AM, revealed she had assisted Resident #6 with a shower on 03/15/17. SRNA #4 stated Resident #6 still had stool on his/her person after attempting to provide self-hygiene care. SRNA #4 stated Resident #6 had stated he/she had turned on the call light but nobody came. SRNA #4 stated Resident #6 was embarrassed by the incident. Interview with SRNA #3, on 03/14/17 at 2:36 PM revealed the facility did not always have adequate staffing to meet resident needs. SRNA #3 stated that at times lack of staffing affected how long it took to answer call lights and to help residents with care. Interview with the Director of Nursing (DON), on 03/16/17 at 5:20 PM, revealed her expectation was for all staff of the facility to answer residents' call light in a timely manner. The DON stated her definition of timely would be within fifteen (15) minutes for a regular call light and within ten (10) minutes for the emergency/bathroom call lights. The DON further stated she felt the staff was able to answer the call lights in a timely manner and was able to provide care according to the residents' care plans. Interview with the Administrator, on 03/16/17 at 5:30 PM, revealed her expectation was for staff to answer residents' call lights within a timely manner. The Administrator defined a timely manner as within fifteen (15) minutes. The Administrator stated any time over fifteen (15) minutes would have to be investigated to examine trends. The Administrator further stated she felt the facility had sufficient staff to respond to call lights in a timely manner and to provide care according to the care plans.

Based on interview, record review and review of facility policy, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (1) of nine (9) samples residents (Resident #2). Resident #2 was ordered to receive Continuous Passive Motion (CPM), which is a treatment for [REDACTED].#2 did not receive the treatment as ordered. The findings include: Interview with the Director of Nursing (DON), on 03/16/17 at 4:30 PM, revealed the facility utilized Lippincott Manual as their guide for professional standards of practice. Review of the facility's standard of practice Lippincott Manual of Nursing Practice Ninth Edition, revealed appropriate care of the resident was adhering to the facility's policy and procedures, documenting appropriate information in the medical record, and following physician's orders [REDACTED]. Record review revealed the facility admitted Resident #2's on 09/23/16 with [DIAGNOSES REDACTED]. Review of the five (5) day Minimum Data set (MDS) Assessment, dated 9/29/16 revealed the facility assessed the resident to have a Brief Interview for Mental Status Score (BIMS) of fourteen (14) indicating the resident was independent with cognition skills for daily living. Further review of the MDS, revealed the facility assessed the resident to require extensive two (2) person assist with transfers and bed mobility and extensive one (1)person assist with locomotion, dressing, toileting and bathing. Review of the admission physician's orders [REDACTED]. Review of Resident #2's Initial Care Plan, revealed no documented evidence the facility developed a plan of care upon admission related to the physician's orders [REDACTED]. Interview with Resident #2, on 03/13/17 at 11:40 AM, revealed he/she was not happy with the quality of care provided by the facility for the seven (7) day he/she was there. The resident stated the CPM treatment was not performed as ordered on several different occasions. Resident #2 stated this was an ongoing problem the entire week as he/she knew this treatment was of great importance for a full recovery from surgery. The resident further stated he/she told the nursing staff about missing the treatments, but it did no good. Continued interview with Resident #2, revealed Ice therapy was not performed twice a day while he/she was in the facility. Further interview revealed he/she would use the call bell for assistance for toileting and staff would not respond. The resident reported on one (1) occasion he/she needed assistance to toilet and because staff would not respond to the call bell for one (1) hour and forty-five (45) minutes, he/she was incontinent of urine, which made him/her feel horrible. The resident further stated, discharge on 09/29/16 was not a planned discharged , but he/she was so unhappy with the care provided that he/she wanted to go home as soon as possible, even though therapy services after surgery was still needed. She stated she had to go home without all the equipment ordered for discharge related to being so unhappy with the care and services provided by the facility. Resident #2 further stated he/she had to leave without a walker, medications in place for discharge, or raised toilet seat available at home. Resident #2 stated he/she never cried about anything as much as he/she did with the poor care and service provided by the facility. Interview with the Director of Nursing (DON), on 03/15/17 at 1:30 PM, revealed the order for the CPM therapy and the Ice therapy was the responsibility of nursing. She stated nursing would be responsible for performing those two (2) treatments and documenting the treatment on the Treatment Administration Record (TAR). Review of the TAR for Resident #2, revealed no documented evidence the CPM treatment was completed on 09/28/16 at 6:00 AM and 09/29/16 at 6:00 AM, as the TAR was not initialed by the nurse on those dates to indicate the resident had received the treatment. Interview with Licensed Practical Nurse (LPN) #1, on 3/16/17 at 3:15 PM, revealed blank spaces in the TAR could mean the care was not provided. Further interview revealed it was the facility's policy to document when care was provided such as treatments for residents. Further interview with the DON, on 3/16/17 at 5:10 PM, revealed it was her expectation that staff provide treatment to each resident as ordered by the Physician and document the treatment appropriately. Interview with the Administrator, on 3/16/17 at 5:20 PM, revealed it was her expectation that staff physician's orders [REDACTED].