Every finding on record at Driftwood Nursing Center

Based on interview, record review, and facility policy review, the facility failed to transmit resident assessments to the Centers for Medicare and Medicaid Services (CMS) within (14) days of completion for two (2) of (2) sampled residents (Residents #23 and #95), with the potential to affect all (14) residents who triggered for a late Resident Assessment.Findings include:A review of the facility's MDS (Minimum Data Set ) Policy, revised 1/10/24, revealed, .Standard.I. The CMS Long-Term Care Facility Resident Assessment Instrument User's Manual is the primary source of information for completion of an MDS assessment. II. Timing, scheduling, and completion of MDS assessments and entry and discharge reporting will be carried out per the guidelines set forth in the Long-Term Care Facility Resident Assessment Instrument User's Manual version 3.0. IX Transmission of MDS.Comprehensive assessments must be transmitted electronically within fourteen (14) days of the care plan completion date. All other MDS assessments must be submitted within (14) days of the MDS completion date.Resident #23A record review of the admission Record revealed the facility admitted Resident #23 on 11/3/17 with diagnoses including Legal Blindness.A record review of the facility's IQIES Report MDS 3.0 Final Validation Report revealed the Submission Date/Time: 01/26/2026 with Message: Record Submitted Late: The submission date is more than 14 days.Resident #95A record review of the admission Record revealed the facility admitted Resident #95 on 9/6/25 with diagnoses including anxiety disorder.A record review of the facility's IQIES Report MDS 3.0 Final Validation Report revealed the Submission Date/Time: 01/26/2026 with Message: Record Submitted Late: The submission date is more than 14 days.On 1/29/26 at 12:00 PM, during an interview, Registered Nurse (RN) #2 and RN #3, both MDS Nurses, confirmed the resident assessments for Residents #23 and #95 were completed but transmitted late. They explained they were unable to transmit the assessments timely due to additional responsibilities, including floor nursing coverage and staffing duties during the holiday period.On 1/29/26 at 12:30 PM, during an interview, the former Director of Nursing (DON) and the current DON stated their expectation was for all MDS assessments to be transmitted in accordance with CMS guidelines. They reported changes were implemented to remove staffing and the DON responsibilities from MDS nurses to allow timely completion and transmission of assessments.On 1/29/26 at 1:00 PM, during an interview, the Administrator stated she expected all MDS assessments to be transmitted in compliance with CMS requirements. She confirmed she became aware of the late MDS transmissions following a case mix review and reported MDS nurses had been utilized for floor coverage. She stated changes were being made to improve MDS timeliness and oversight.

Based on interview, record review, and facility policy review, the facility failed to provide the specific reason and basis for a hospital transfer in plain language for one (1) of two (2) residents sampled for hospitalization. Resident #54.Findings include:A review of the facility's policy, Transfer and Discharge (including AMA) (Against Medical Advice ) date implemented 02/05/2025, revealed, .Definitions: . 'Transfer and Discharge' includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. Policy Explanation and Compliance Guidelines: . 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge.A record review of the admission Record revealed the facility admitted Resident #54 on 12/3/25 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Progress Notes revealed Resident #54 had a Nurse's Note, effective 1/6/26 at 9:51 AM, for .Transferring resident to ER (Emergency Room) for evaluation of AMS (Altered Mental Status) .A record review of the Notice of Resident Transfer or Discharge notification with an effective date of 1/6/26 at 10:43 AM revealed Resident #54 was being transferred and the reason for transfer/discharge was listed as AMS. There was no further clarification or listing in plain language.On 1/27/26 at 3:10 PM, during an interview with the Unit Coordinator, she reported Resident #54 was sent to the emergency room and did not return to the facility. She reported she was responsible for mailing the Notice of Resident Transfer or Discharge notifications to the responsible representative (RR). She reported she was aware the notice must include the required information, including the specific reason in the language and manner the RR can understand. She reviewed Resident #54's Notice of Resident Transfer or Discharge notification and confirmed the reason for transfer or discharge was documented as AMS, which she explained meant altered mental status, and the reason was not explained in a language or manner they would understand. She reported the reason was documented as AMS in error and she knew to include the specific reason.On 1/28/26 at 3:00 PM, during an interview with the Administrator, she reported she was informed for the issue with the reason of transfer documentation for Resident #54. She reported she expected the forms to be completed accurately according to federal guidelines.

Based on observation, interview, and facility policy review, the facility failed to maintain infection prevention and control practices by allowing a resident meal tray to be stored in a biohazard room for one (1) of two (2) observations. Findings include:A record review of the facility's policy, Infection Prevention and Control Policy Program, dated 2/1/25, revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary.environment.On 01/28/2026 at 9:21 AM, during an observation with Housekeeper/Maintenance #1, there was a biohazard room on the north wing near the nurse's station. The room was marked with a biohazard logo and secured with keypad entry. Inside the room, there was a resident food tray that was placed beneath posted signage indicating food and utensils were not to be placed in the room. The tray contained a meal preference ticket identifying Resident #35 and indicated a dinner meal dated 1/27/2026. Housekeeping/Maintenance Staff #1 confirmed the tray should not have been in the biohazard room and stated he was unaware it had been left there and did not know who placed it there.On 01/28/2026 at 2:15 PM, in an interview with Infection Preventionist/Registered Nurse (RN) #1, she stated staff are trained during orientation and ongoing infection control education not to place food trays or utensils in biohazard rooms and that trays are to be returned directly to the kitchen. RN#1 stated this expectation is included in new-hire orientation and quarterly infection control and safety education.On 01/29/2026 at 10:40 AM, North Hall Charge Nurse/Licensed Practical Nurse (LPN) #1 stated staff are trained to return all meal trays to the kitchen but reported that second-shift staff frequently place trays in the biohazard room instead of returning them to the dietary department. LPN #1 stated she checks the biohazard room daily for trays and confirmed staff is aware that trays are not to be placed in the room. On 01/29/2026 at 11:00 AM, Dietary Department (DD) #1/Dietary Manager, stated that dietary staff leave the kitchen at 8:00 PM and the dietary department door is locked at that time while the dining hall remains open. He stated nursing staff have a key for access after-hours, and he was unsure where staff placed meal trays after dietary staff leave for the day.On 01/29/2026 at 11:05 AM, DD #2 stated the dietary department door is locked after kitchen staff leave and nursing staff may return trays to the dietary window for collection and washing the next morning.On 01/29/2026 at 11:30 AM, during a follow-up interview and observation with RN#1 and Housekeeping/Maintenance Staff #1, the biohazard room was confirmed to contain soiled linens and was restricted by keypad entry. Both confirmed the room was not accessible to residents or visitors and that the tray would have been placed in the room by facility staff.On 01/29/2026 at 1:11 PM, the Administrator stated staff are expected to return all dirty trays and dishes to the dietary department and that trays are not to be placed in biohazard rooms because it created an infection control concern and pest risk.

Based on observation and staff interview, the facility failed to ensure food temperatures were tested under sanitary conditions for one (1) of four (4) kitchen observations. Findings Include: During an observation of food temperature readings for the lunch meal on 10/30/24 at 11:45 AM in the kitchen area, the cook was observed using a thermometer to check the temperature of the macaroni and cheese. After testing the temperature, the cook wiped the thermometer on a clean towel. The same thermometer was then used to test the baked chicken, green peas, pureed chicken, and mashed potatoes, with the cook wiping the thermometer on the same towel after each test without sanitizing it. During an interview on 10/31/24 at 09:00 AM, the cook stated she had been cooking at the facility for six (6) months and had been cleaning the thermometer with a clean, dry towel during that time. She was uncertain if she had been specifically trained on sanitizing the thermometer, mentioning that numerous in-services were conducted, but she could not recall specific sanitation training. The cook further stated that she was informed by the Dietary Manager (DM) that failing to sanitize the thermometer could lead to cross-contamination and risk residents becoming ill. During an interview on 10/31/24 at 09:30 AM, the DM confirmed that the cook failed to sanitize the thermometer between food items. She stated that the cook was trained to dip the thermometer in a sanitation solution and dry it after each test. However, she acknowledged that no official in-service documentation was available, as training was often conducted informally through verbal instructions. During an interview on 10/31/24 at 10:00 AM, the Registered Dietitian stated that staff are instructed to sanitize thermometers by dipping them in a sanitizing solution and drying them between each food item. She confirmed that the cook should have sanitized the thermometer after testing each item. During an interview on 10/31/24 at 2:30 PM, the Administrator expressed an expectation that kitchen staff sanitize thermometers between food items to prevent cross-contamination.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to use enhanced barrier precautions (EBP) by not wearing the appropriate personal protective equipment (PPE) during catheter care for one (1) of four (4) residents reviewed for catheter care. (Resident #87) Findings Include: A review of the facility's policy titled Enhanced Barrier Precautions, dated 05/01/24, revealed, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: 'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities . Policy Explanation and Compliance Guidelines .2. Initiation of Enhanced Barrier Precautions .b. an order for enhanced barrier precautions will be obtained for residents with any of the following .i .indwelling medical devices (e.g .urinary catheters . During an observation on 10/28/24 at 3:11 PM, Resident #87 was observed lying in bed and had an indwelling catheter drainage bag attached to the bed. There was a yellow dot present near the name of the resident on the outside of the resident's room. During an interview on 10/29/24 at 8:45 AM, Registered Nurse (RN) #1 explained that a yellow dot next to a resident's name in the hallway signifies that the resident is on EBP and explained that residents with openings such as wounds and catheters are on EBP and all staff have been in-serviced accordingly. At 1:50 PM on 10/30/24, Certified Nurse Aide (CNA) #1 and CNA #2 were observed providing catheter care to Resident #87, and did not wear a gown during the care. During an interview on 10/31/24 at 9:10 AM, RN #1 explained that all staff are expected to follow EBP by wearing a gown and gloves while providing care. She noted that PPE supplies are stored in a closet on each hall and are readily available to staff. During an interview on 10/31/24 at 9:50 AM, CNA #1 confirmed that a yellow dot next to a resident's name indicates EBP and that PPE, including gowns, must be worn while providing care. She admitted that she did not wear a gown during catheter care on 10/30/24 and stated that she just got nervous. She confirmed that PPE is available in the closet on the hall. During an interview on 10/31/24 at 11:20 AM, the Director of Nursing (DON) confirmed that enhanced barrier policies are in place and that all staff have been educated on these precautions. She emphasized her expectation that staff always adhere to EBP. At 12:10 PM on 10/31/24, during an interview with CNA #2, he admitted that he did not wear a gown while assisting with catheter care for Resident #87 on 10/30/24. He acknowledged being aware of EBP but stated he was focused on care and forgot to apply PPE. A record review of the Admission Record revealed the facility admitted Resident #87 on 09/14/24 with diagnoses including Cerebral Infarction. A record review of the Order Summary Report with active orders as of 10/30/24, revealed Resident # 87 had a physician order, dated 9/23/24 for a urinary catheter.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was clinically indicated for one (1) of four (4) residents observed with catheters. (Resident #87) Findings Include: A review of the facility's Appropriate Use of Indwelling Catheters Policy, dated 03/01/17, revealed: .An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization is necessary. Policy Explanation and Compliance Guidelines .4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary .6. Documentation to support decision-making will be included in the medical record, including but not limited to: a. Clinical or medical conditions demonstrating the need for an indwelling catheter. b. Assessment of incontinence .d. Services provided to restore normal bladder function to the extent possible .7. Indwelling urinary catheters will be used on a short-term basis . During an observation on 10/29/24 at 11:00 AM, Resident #87 was observed lying in bed and had an indwelling catheter drainage bag on the side of the bed. A record review of the Admission Record revealed the facility admitted Resident #87 on 09/14/24 with diagnoses including Cerebral Infarction. A record review of the Order Summary Report with active orders as of 10/30/24, revealed Resident # 87 had a physician order, dated 9/23/24 for a urinary catheter. A record review of the Progress Notes, dated 09/20/24 at 11:46 AM, revealed Resident #87 had a Nurse's Note indicating .Foley (type of indwelling catheter) cath (catheter) patent and draining clear yellow urine into drainage bag . This was the first documentation in the medical record which indicated Resident #87 had an indwelling catheter. Further review of the medical record revealed there was no documentation to explain when or why an indwelling catheter was placed for Resident #87. On 10/31/24 at 10:30 AM, during an interview with Licensed Practical Nurse (LPN) #2, she stated that she updated physician orders daily and recalled putting in the catheter orders for Resident #87 on 09/23/24 based on a charge nurse's request. However, she did not recall the diagnosis used for the catheter and suggested that the charge nurse may have provided the reason, though she was not certain. At 10:50 AM on 10/31/24, during an interview with LPN #1, she confirmed Resident #87 did not have an indwelling catheter when he was admitted by the facility. She explained that she had been off and when she returned to work, she noted Resident #87 had a catheter, and asked LPN #2 to enter the orders, though no diagnosis was given for the catheter. Upon reviewing the progress notes, she found documentation indicating a Urinalysis was collected on 09/20/24, suggesting the catheter placement occurred around that time, but confirmed there was no documentation specifying the reason for insertion. During an interview on 10/31/24 at 11:20 AM, the Director of Nursing (DON) confirmed Resident #87 did not have a sufficient diagnosis for an indwelling catheter. She had investigated the catheter's origin, suspecting an agency nurse placed it. The DON noted the lack of documentation regarding when or why the catheter was inserted and emphasized her expectation that staff document any changes in resident care and adhere to facility policies. At 11:45 AM on 10/31/24, during an interview with the facility's Nurse Practitioner (NP), she acknowledged awareness of the catheter issue with Resident #87. She explained that the nurse had contacted an on-call doctor, not her, about the catheter placement. She confirmed that urinary retention does not justify the use of an indwelling catheter.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from misappropriation when facility staff used a resident's credit card to purchase goods or services without the consent or authorization of the resident for one (1) of five (5) sampled residents, Resident #1. Based on the facility's implementation of corrective actions, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) as of 6/29/24, prior to the SA's entrance on 8/19/24. Findings Include: A review of the facility's policy, Abuse Neglect and Exploitation, dated 10/01/22, revealed that .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent .exploitation of resident property .Definitions .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .Prevention of Abuse Neglect and Exploitation .The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves .addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . A record review of the Facility Investigation Summary revealed that Registered Nurse (RN) #1 and the Administrator received a report from the RR for Resident #1 on 6/24/24 that there were suspicious charges on the resident's credit card statements. The Administrator obtained the credit card from the resident and locked it up securely. The Administrator reviewed the resident's credit card statements with the Resident and her RR and determined that there were $330.10 in suspicious charges to a local spa, nail salon, and restaurants. Detective #1 with the local police department responded on 7/25/24 and notified the Administrator that Certified Nursing Assistant (CNA) #1 had been arrested and that subpoenaed information on the CNA's personal cell phone revealed that she had a photograph of the resident's credit card saved on the phone. The Summary included reimbursement of all monies fraudulently charged on Resident #1's credit card. A record review of the Admission Record for Resident #1 revealed that the facility admitted the resident on 2/28/24, and she had current diagnoses including Diabetes and Atrial Fibrillation. A record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 7/22/24 revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated no cognitive impairment. A record review of the personnel file for CNA #1 revealed the CNA was hired at the facility on 4/22/24, and her employment at the facility was terminated on 6/21/24, three (3) days prior to the discovery of suspicious charges on Resident #1's credit card. CNA #1's personnel file included no disciplinary actions prior to the termination of employment effective on 6/21/24, documentation of a background record found no violations that prevented her from working with residents served by a nursing home, and an Orientation Checklist dated 4/22/24 signed by the CNA, indicating that she had received information that included Resident Rights and Abuse, Neglect, and Exploitation Prevention and Protection and acknowledged complete understanding and agreement to comply accordingly. A record review of Historical Employee Clocking and Schedules from 4/17/24 to 8/19/24 for CNA #1 revealed that 6/05/24 was the last day the CNA clocked in for duty at the facility. On 8/19/24 at 10:00 AM, during an interview, Resident #1 revealed that her son (and RR) was her power of attorney and received and paid her bills. She said that she was shocked to find that her credit card had charges at a local spa, nail salon, and restaurants in May 2024. She said, It never dawned on me that anyone would do such a thing. She said that she never gave her card to anyone and always kept it in her purse in her room. She reported that she watched a home shopping channel on television and used the card for purchases from the program. She said that she had not been to a spa, nail salon, or out to any restaurants in May 2024. She said she had not given her card to anyone to use for any purpose. She said she remembered CNA #1 and had thought that she was a sweet girl. She reported that she never had any suspicion that her credit card had been compromised, photographed, or used without her authorization. Regarding the response of the facility, Resident #1 stated, I feel like they took care of it correctly. She stated that she had received reimbursement for all unauthorized charges. She denied feeling unsafe at the facility or fear of future misappropriation of property. She said she felt safe at the facility and that her belongings were secure and that everything had been taken care of. On 8/19/24 at 11:42 AM, during a telephone interview, the Resident Representative (RR) for Resident #1 stated that he had notified RN #1 and the Administrator on 6/24/24 after a review of Resident #1's credit card statements for May and June of 2024 revealed suspicious charges. He said he provided copies of the resident's credit card statements, which included charges at a local spa, nail salon, and restaurants during the resident's residence at the facility. He said that the Administrator contacted him on 7/25/24 and reported that CNA #1 had been identified as the person who had used Resident #1's credit card without authorization. He stated that Resident #1 had received restitution for all fraudulent charges. On 8/20/24 at 12:20 PM, during a telephone interview, Detective #1 confirmed that he had spoken with the Administrator and confirmed that Resident #1 was a vulnerable adult who resided at the facility and that CNA #1 had been employed at the facility in direct care from 4/22/24 through 6/05/24. He confirmed that the Administrator had reported an allegation of misappropriation of resident property on 6/24/24. He explained that the investigation led to the discovery that CNA #1 had pictures of Resident #1's credit card on her personal cell phone. Detective #1 said that CNA #1 had a prior arrest for similar charges involving a vulnerable adult, not a resident at the facility, days before being arrested for making unauthorized charges using Resident #1's credit card. The detective said that no police report was available until the investigation was concluded and that he was still investigating information discovered on CNA #1's cell phone regarding individuals who did not reside at the facility. He said he did not have the arrest date, and no court date had been set at the time of the interview. On 8/20/24 at 3:10 PM, during an interview, the Director of Nurses (DON) stated that the facility had provided in-service training regarding Resident Rights and Abuse, Neglect, and Misappropriation of Property after the event and usually completes this type of in-service at least monthly. The in-service included instructions that residents' belongings be respected and protected and that any allegations or signs/symptoms of abuse, neglect, or misappropriation of resident property be reported immediately to a supervisor, DON, or Administrator. A record review of the Quality Assurance and Improvement (QAPI) Committee Meeting Minutes dated 6/28/24 with attached sign-in sheets revealed that during the meeting attended by the facility Medical Director, Administrator, DON, and Infection Preventionist, the committee reviewed the incident and related policies and procedures and made no recommendations for changes. On 8/20/24 at 3:25 PM, during an interview, the Administrator stated that a mandatory in-service titled Abuse, Neglect and Misappropriation Prevention and Protection was provided by the facility to all facility staff on 6/25/24 and 6/26/24 and was completed on 6/26/24. The notifications were made to the SA, Attorney Generals Office (AGO), and local law enforcement. The Administrator also stated other residents were interviewed to make there were no other victims of misappropriation by CNA #1. On 8/2024, the SA validated through record reviews and interviews that the facility investigated the allegation of misappropriation when it was made by the RR, CNA #1 had voluntarily terminated her employment at the facility prior to the allegation being made, the appropriate agencies were notified timely, in-services were conducted for all staff, and a QAPI was held on 6/28/24 to review the incident. The SA determined that corrective actions were completed on 6/28/24 and the facility was in compliance effective 6/29/24, prior to the SA entrance on 8/19/24.

Based on staff interviews, record review, and the facility policy review, the facility failed to develop appropriate interventions for a cognitively impaired resident after a fall to prevent reoccurrence for one (1) of three (3) sampled residents. Resident #1 Findings include: A record review of the facility's policy Fall Risk Assessment with revised date 01/05/24 revealed . It is the policy of this facility to provide an environment that is free from accidents and hazards .Policy Explanation and Compliance Guidelines: . 4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident . A record review of the Witnessed Fall Report dated 05/15/24 revealed Resident #1 had a fall in the hallway. When the staff asked Resident #1 what had happened, he indicated that he did not know. A record review of the Witnessed Fall Report dated 05/23/24 revealed Resident #1 had a fall in his room. The resident's roommate stated that the resident was trying to get in the bed. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/24 revealed Resident #1's cognitive skills for daily decision making were moderately impaired. Record review of the care plan with an initiation date of 10/31/23 revealed Problem Falls: At risk for falls r/t (related to) .cognitive impairment Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .date initiated 5/20/2024 .Educate resident/family/caregivers about safety reminders and what to do if a fall occurs. Date initiated 5/24/24 . The care plan indicated Resident #1 had a witnessed fall out to the wheelchair on 5/15/24 and another witnessed fall on 5/23/24 transferring from the wheelchair to bed unassisted. At 12:10 PM on 06/27/24, during an interview with the Director of Nursing (DON), she confirmed Resident #1 was severely cognitively impaired and had memory loss. She explained he did not say many words but would answer yes and no questions. She stated she did not think Resident #1 could remember to use the call light or remember safety education provided to him. The DON reviewed Resident #1's care plan and confirmed after the resident's fall on 05/15/24 the intervention that was developed was to keep the call light within reach and encourage the resident to use it. The DON confirmed that was not appropriate for Resident #1 because of his cognitive impairment. She also confirmed the intervention initiated on 05/24/23 after the resident's second fall that was developed was to educate the resident about safety reminders and confirmed that was also not appropriate. She stated she expected care plan interventions to reflect the resident's individual needs and the care plan nurse to develop interventions that are appropriate for residents. On 06/27/24 at 12:35 PM, during an interview with Registered Nurse (RN) #1, she stated she was responsible for developing care plan interventions after a resident had a fall. She confirmed care plan interventions for Resident #1 included safety education and to encourage the resident to use the call light. She confirmed Resident #1 had memory problems and was oriented only to person. Resident #1 could not remember things and if his call light was in reach, he was cognitively impaired and would not know or remember how to use it. On 06/27/24 at 4:30 PM, during an interview with the Administrator, she explained the facility discussed falls and interventions daily and she expected the care plan nurse to add appropriate interventions to resident care plans to prevent future falls. A record review of the Admission Record revealed the facility admitted Resident #1 on 07/19/2022 with diagnoses that included Hemiplegia and Hemiparesis.

Based on staff interviews, record reviews, and facility policy review, the facility failed to transmit Minimum Data Set (MDS) Assessments by their target date, for 19 of 24 residents reviewed for MDS assessments. Resident #1, #2, #4, #17, #25, #32, #36, #37, #62, #65, #69, #72, #74, #78, #79, #83, #86, #93, and #104. Findings include: Review of the Memorial Driftwood Nursing Center MDS Policy with a revision date of 06/30/2019 revealed, Standard: .IX. Transmission of MDS .All MDS will be transmitted .i. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan completion date .ii. All other MDS assessments must be submitted within 14 days of the MDS completion date . Record review of MDS Assessments on 2/27/23, revealed the following: 1. The quarterly assessment for Resident #1 with a target date of 1/23/23, and the discharge MDS with a target date of 1/24/23, had not been transmitted. 2. The quarterly assessment for Resident # 2, with a target date of 1/20/23, had not been transmitted. 3. The quarterly assessment for Resident #4, with a target date of 1/2/23, had not been transmitted. 4. The quarterly assessment for Resident #17, with a target date of 1/25/23, had not been transmitted. 5. The yearly assessment for Resident #25, with a target date of 1/20/23, had not been submitted. 6. The quarterly assessment for Resident #32, with a target date of 1/13/23, had not been transmitted. 7. The quarterly assessment for Resident #36, with a target date of 1/18/23, had not been transmitted. 8. The annual assessment for Resident #37, with a target date of 1/16/23, had not been transmitted. 9. The quarterly assessment for Resident #62, with a target date of 1/10/23, had not been transmitted. 10. The quarterly assessment for Resident #65, with a target date of 1/11/23, had not been transmitted. 11. The quarterly assessment for Resident #69, with a target date of 1/22/23, had not been transmitted. 12. The quarterly assessment for Resident #72, with a target date of 1/10/23, had not been transmitted. 13. The annual assessment for Resident #74, with a target date of 1/12/23, had not been transmitted. 14. The quarterly assessment for Resident #78, with a target date of 1/17/23, had not been transmitted. 15. The quarterly assessment for Resident #79, with a target date of 1/24/23, had not been transmitted. 16. The quarterly assessment for Resident #83, with a target date of 1/13/23, had not been transmitted. 17. The quarterly assessment for Resident #86, with a target date of 1/17/23, had not been transmitted. 18. The Resident quarterly assessment for Resident #93, with a target date of 1/18/23, had not been transmitted. 19. The quarterly assessment for resident #104, with a target date of 1/23/23, had not been transmitted. An interview on 3/1/23, at 3:30 PM, with the Registered Nurse/MDS Coordinator and RN #1, revealed they are responsible for transmitting MDS assessments. They confirmed that they had completed the assessments but had not had enough uninterrupted time in their office to input the assessments and transmit them. The MDS-RN Coordinator revealed that she had notified the Corporate Administrator that they were behind in their MDS responsibilities. In an interview on 3/1/23, at 3:50 PM, with the Corporate Administrator, she confirmed that in January, the MDS-RN Coordinator had made her aware that they were behind in their work. She stated that the MDS nurses admitted that they had many times left their office to assist some of the lesser experienced nurses during the time the facility had been without a Director of Nurses (DON). The Corporate Administrator revealed that she had not put anything in place to ensure the MDS staff were provided the time that they needed to complete their responsibilities. She confirmed that the purpose of the MDS assessments is for case mix and if not done, it could lead to issues related to resident care and proper funding. During an interview on 3/1/23 at 4:12 PM, with the Administrator, she revealed that she knew that the MDS staff had been behind in their work in January, however, she was unaware that they were currently behind. The Administrator admitted that during the time the facility was without a DON, the MDS nurses had assisted as needed, but that the facility had not been short staffed enough to require the MDS nurses to have to do anything that would prevent them from doing their job. The Administrator stated the purpose of the MDS assessments is to determine the care needed for the residents and ensure payment. 37415 41680 44804 46013

Based on interviews, record review and facility policy review, the facility failed to ensure a resident had ready and reasonable access to personal funds for one (1) of 24 sampled residents, Resident #68 Findings include: A review of the facility's policy, (Proper Name of Facility) - Resident Personal Funds, implemented on 2/1/22, revealed the policy did not contain information regarding ready and reasonable access to personal funds for residents. On 02/27/23 at 11:39 AM, in an interview with Resident #68, he stated that he cannot get money from his personal funds on the weekend because the office staff is not at the facility on weekends. On 03/02/23 at 10:42 AM, in an interview with the Administrative Assistant (AA), she stated she is responsible for the residents' personal trust fund accounts. She said that the Activities Director (AD) also has access to $85 and will issue personal funds to the residents. The AA stated that she works Monday through Friday, from 8:00 AM until 4:30 PM and the AD works on the weekends at times. On 03/02/23 at 10:50 AM, in an interview with the AD, she confirmed that she has $85.00 to issue to residents and that she and the AA are the only staff who have access to the residents' personal fund account. She also confirmed that she works one weekend a month. She explained that the residents know to ask for any money they may need for the weekend by Friday of each week because there is no one at the facility to give the residents money. On 03/02/23 at 11:36 AM, in an interview with the AA, she confirmed that no other staff have access to resident personal funds on weekends and that resident ask for any money they may need for the weekend by Friday. On 03/02/23 at 1:12 PM, in an interview with the Administrator, she stated that residents are supposed to have access to their money on weekends and she was unaware that they did not. She explained that the facility has Management staff at the facility seven (7) days a week. On 03/02/23 at 1:20 PM, in an interview with the Corporate Administrator, she confirmed that weekend management does not have access to see if residents have money available in their personal fund account. Record review of the Face Sheet revealed the facility admitted Resident #68 on 8/03/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/22 revealed Resident #68 had Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately Impaired. Record review of the Trust Fund Trial Balance report revealed Resident #68 had a personal trust account at the facility. Record review of the Trust Fund Transaction List with transaction dates from 2/1/23 through 2/28/23 revealed that no resident trust fund transactions took place on a weekend for February 2023.

Based on staff and resident interviews, record review and facility policy review the facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) Level II for one (1) of three (3) PASRRs reviewed. Resident #6 Findings include: Record review of the facility policy titled, (Proper Name of Facility)-Resident Assessment in Coordination with PASRR Program with a revision date of 02/01/2019 revealed, .Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .a. ii. Positive Level I Screen-necessitates a PASRR Level II evaluation prior to admission. b. PASRR Level II-a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD (Mental Disorder) , ID (Intellectual Disorder) or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs . An interview on 2/28/23 at 2:30 PM, with Social Services (SS) #1, revealed she could not find the completed PASRR Level II for Resident #6, but she had called the Qualified Independent Contractor (QIC) and spoke with a Representative. She revealed that the QIC Representative implied that the PASRR Level II had been completed and she would fax a copy to the facility. She said that once the facility receives a written notice for a need for a Level II, the QIC will call them to set up the assessment via a telephone call. An interview on 3/1/23 at 9:30 AM, with SS #1, revealed that Resident #6 should have had a PASRR Level II completed in June of 2022. The QIC did call to complete the Level II at some point, but the resident was in the hospital and SS #1 did not follow up once the resident returned to the facility to ensure the Level II was completed. She confirmed that the resident had a diagnosis of Schizophrenia on admission and the purpose of a PASRR Level II is to get the guidance from the QIC regarding specific care for the resident. She revealed that the resident not having his PASRR Level II completed could have caused the resident's care to be lacking, because the facility would not have known if there were any additional services recommended. An interview on 3/1/23 at 10:25 AM, with the Director of Nurses (DON), confirmed that Resident #6 had a diagnosis of Paranoid Schizophrenia and Post Traumatic Stress Disorder (PTSD). She confirmed that if the resident needed a PASRR Level II screening, then the resident should have had it done. She confirmed that if the resident had not had the PASRR Level II then a lot of things could have happened, such as behaviors that could have affected the resident or other resident's and the resident would not have received the services that were recommended based on the PASRR Level II assessment. An interview on 3/1/23 at 2:15 PM, with the Administrator, revealed the purpose of the PASSR is to determine if the residents are appropriate for nursing home placement. She revealed that a PASRR Level II is used to determine any special services that the resident may need based on their diagnosis. She revealed that if the resident had a diagnosis of Paranoid Schizophrenia and PTSD and did not get a PASRR Level II, then the resident might have missed some needed services. Record review of the Face Sheet revealed the facility admitted Resident #6 on 3/23/22 and he had medical diagnoses that included Paranoid Schizophrenia, Anxiety Disorder, Unspecified, and Post-Traumatic Stress Disorder, Unspecified. Record review of the Pre-Admission Screen (PAS) for Resident #6, dated 03/22/22, revealed the PAS was completed by hospital staff prior to admission to the facility and did not indicate the resident had a medical diagnosis of a mental illness. Record review of the Pre-Admission Screen which was electronically submitted on 05/30/2022 after admission to the facility, revealed Resident #6 had a major mental illness. Record review of a notice from the QIC revealed, Notice of Need for Level II PASRR Screen with a Review Date of 6/3/22, which indicated Resident #6 required a Level II evaluation. Record review of a notice from the QIC revealed, Notice of Need for Level II PASRR Screen with a Review Date of 2/28/23, which indicated Resident #6 required a Level II evaluation. This document was faxed by the QIC on 2/28/23 after the inquiry by SS #1.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure one (1) of five (5) residents reviewed were protected from misappropriation of resident property. Resident #2. Findings include: Record review of the facility policy titled Abuse, Neglect and Exploitation Policy, dated 1/14/17, revealed, Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. On 1/21/21, at 8:30 AM, the State Agency (SA) entered the facility to investigate a self-reported incident. The facility reported Certified Nursing Assistant (CNA) #6 took Resident # 2's bank card and took money out of the resident's account. Review of the facility's investigation revealed Resident #2 reported on 10/23/20 he had loaned CNA #6 $300 dollars. On 8/27/20, CNA #6 took Resident # 2's bank card to the bank and got $300 dollars out of his account and never paid him back. Review of the Automated Teller Machine receipt of withdrawals from his account revealed on 8/27/20 two separate withdrawals were made. One for $100.99 and the second for $200.99, in addition to bank fees for the withdrawals totaling $5.00. Resident #2 reported the incident to the nurse on 10/23/20. Upon completion of the investigation, the facility was not able to determine if the claim from Resident #2 was substantiated. On 1/21/21, at 9:15 AM, in an interview with Resident #2, he stated he did not have anything missing. He stated he did have a bank card and he keep it in his lock box. When he was asked if any staff used his bank card he replied, I know I learned my lesson I am not allowed to ask anybody to use my bank card to get me anything. I am just supposed to go through Social Services or the Activity person. He stated he did get his $300 and he did not have any concerns. On 1/21/21, an interview with the Administrator at 9:43 AM, revealed Resident #2 told the night nurse in October that CNA #6 had taken three hundred dollars out of his account and had not paid it back. He did not report the incident until October. The facility reimbursed Resident #2 his money back plus bank fees. He had on his phone where money was taken out of his account on 8/27/2020. CNA #6 was suspended 10/23/20, pending investigation and was terminated for using the residents bank card. The SA was provided a copy of the Cash Receipt to Resident #2 from the facility dated 10/23/20 for $307.00, where he was reimbursed. The Administrator stated beginning 10/23/20, all staff were in-serviced about staff using resident's bank cards and a Resident Council Meeting was called to discuss the facility policy on not loaning money to staff. In an interview with the Activity Director on 1/21/21, at 10:51 AM, she stated sometimes Resident #2 has a hard time remembering things, so he puts notes in his phone. We have had a meeting with him and explained to him only the Social Services and I can go and buy him things. He likes to keep his bank card because he likes to order pizza. He is alert enough to keep his card in his lock box. On 1/21/21, at 1:02 PM, an interview with Social Services revealed Resident #2 use to make allegation about his son owing him money. He now has an alert on his phone so when there is a bank transaction it will alert him. He sometimes has his bank card in his lock box in his room. He does take it out a lot and will take it to the vending machine to get snacks. Social Services stated they are always going to the store to get him snacks. He is always trying to get the staff to go get him things, so he does not have to do it for himself. She stated he wants to keep his bank card. In an interview on 1/21/21, at 2:12 PM, with CNA #6, revealed Resident #2 gave her the bank card and pin to go to the bank and get him some money. CNA #6 stated she got him 300 dollars like he asked. She stated she came right back and gave him the money and his bank card. She said she was trying to help him out. He was always asking staff to take his card to the snack machine and to get him money. CNA #6 stated she was just trying to help him out and she takes care of her residents. On 1/21/21, at 2:26 PM, in an interview with Resident #3 revealed he was Resident #2's roommate when he asked CNA #6 to take his bank card and go to the bank and get money for him. Resident #3 stated Resident #2 gave CNA #6 his pin number for his bank account. I was there when CNA #6 gave the money and bank card back. I was not sure how much money he had asked for. CNA #6 was one of the better CNA's and I hope she did not get in trouble. Resident #6 was always asking the staff to go to the bank and get him money or to take his bank card to the vending machine to get him some snacks. Resident #2 did not report it for several weeks and then he told the night nurse some made up story. Record review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Record review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Staff were in-service regarding abuse on 10/23/20. Record review of the Resident Council Minutes from 10/23/20, conducted by Social Services and the Activity Director, revealed a discussion on not giving loans, payment, gifts, etcetera to the staff and who to contact if they needed personal items bought for them.

Based on observations, staff interview, and facility policy review, the facility failed to follow proper safe/sanitation practices to reheat food to the proper serving temperature of at least 165 degrees, prior to serving; and to prevent contamination of food by not cleaning the thermometer in between checking each food item on the steamtable for one (1) of three (3) kitchen observations, which had the potential to affect all residents in the facility who received a food tray. Findings Include: A Review of the facility policy, titled Resource: Taking Accurate Temperatures, dated 2013, revealed the digital thermometer is usually battery powered, takes only a few seconds to register the temperature, and the sensor is near the tip of the probe. To take temperatures, clean, rinsed, sanitized and air-dried thermometer that is the metal stem type is needed. Should the thermometer have a tube type cover, it must be sanitized as indicated for the thermometer. To take hot food temperatures, insert the thermometer at a 45 degree angle to the middle of the food item, taking care not to touch the container or bone if applicable. Wait for the thermometer to rise to the maximum temperature from the food item, and immediately clean and sanitize. A review of the facility policy, titled, Food Temperatures, dated 2013, revealed all hot foods must be cooked to appropriate temperatures, held, and served at a temperature of at least 135 degrees. Take temperatures often to monitor for safe food holding temperature ranges at or above 135 degrees for hot foods. Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking. Hot food items may not fall below 135 degrees after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees and reheated to at least 165 degrees prior to serving. A review of the facility policy titled, Resources, Critical Temperatures for safe Food Handling, dated 2013, revealed to reheat left-over foods one (1) time. During an observation or steam table temperatures, on 1/14/19 at 11:31 AM, taken by Dietary Staff Member (DSM) #2/Cook, with the Dietary Manager (DM) and DSM #3 present, revealed DSM #2 allowed the plastic handle on the thermometer to touch the food while checking the temperature for all of the food items. The ham temperature was 130.8 degrees. Four (4) minutes after reheating the ham in the steam oven, DSM #3 stated the temperature was 149 degrees. DSM #3 put several pieces of ham in a pot on the stove for about three (3) minutes and placed the ham on a regular plate. The temperature of the ham at that time was 160 degrees. During an interview on 01/16/19 at 9:57 AM, with the DM confirmed DSM #2 failed to prevent the possible spread of food bourne illness by placing the thermometer plastic handle in the food. The DM stated that DSM #2 has been trained to put the thermometer one (1) to two (2) inches in the food; the staff member should not allow the handle to go into the food. DM #1 confirmed DSM #3 failed to follow the facility policy by rewarming the food twice and serving the ham at less than 165 degrees or greater. An interview on 01/16/19 at 10:11 AM, with DSM #3/Assistant Manager, confirmed the ham was reheated twice and that the temperature did not reach 165 degrees or greater. DSM #3 stated that he should have left the ham in the oven until the temperature reached 165 degrees or above. During an interview on 01/16/19 at 10:14 AM, the Administrator confirmed since DSM #2 placed the thermometer handle in the food, policy was not followed. The Administrator stated that DSM #3 failed to follow the facility policy by reheating the food twice and not allowing the ham to reach a temperature of 165 degrees or greater. A review of the facility Record of In-service Training and Attendance Form, dated 1/13/19, revealed DSM #2 was trained to wipe the Thermometer between testing each item of food and trained in safe food preparation, which included cooking internal temperatures: Poultry 165, ground meats 155, fish and other meats 145 and eggs 145 degrees.

Based on observation, interview, record review and policy review, the facility failed to prevent cross contamination when providing catheter care, for one (1) of three (3) resident catheter care observations, Resident #74. Findings include: A review of the facility's policy titled (Facility Name) Care Policy, dated 3/1/17, revealed it is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infection. On 1/15/19 at 9:13 AM, an observation of catheter care for Resident #74, provided by Certified Nursing Assistant (CNA) #3, revealed he washed his hands, applied clean gloves, filled a basin with soapy water and filled another basin with clear water and turned the water off with these same gloved hands. CNA #3 then emptied the catheter drainage bag with the same gloved hands. CNA #3 washed his hands and applied clean gloves, then pulled Resident #74's covers back and with the same gloved hands, CNA #3 provided perineal care to Resident #74, washing the penial area, while holding the catheter near the penis area. On 1/16/19 at 8:00 AM, an interview with CNA #3 revealed, Yes, there is a problem with using the same gloved hands to pull Resident #74's covers back and begin catheter care. CNA #3 confirmed that was a cross contamination issue. On 1/16/19 at 8:15 AM, an interview with the Director of Nursing (DON), revealed there was a problem with using the same gloved hands to pull Resident #74's covers back and then immediately begin catheter care using those same gloved hands; that is cross contamination. On 1/16/19 at 11:25 AM, an interview with RN #3 revealed there is a problem with using the same gloved hands to pull covers back and begin catheter care. RN #3 stated CNA #3 should have changed his gloves, because he went from dirty to clean when he provided the catheter care for Resident #74. A review of the facility's Face Sheet revealed, the facility admitted Resident #74 on 4/19/16, with [DIAGNOSES REDACTED].

Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to ensure the resident had a securing device for the catheter tubing for one (1) of three (3) residents for catheter care observations, Resident #4. Findings include: A review of the facility's policy for (Facility Name) Catheter Care Policy dated 3/1/17, revealed, it is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infection. Review of the Society of Urological Nurses and Associates Clinical Practice Guidelines, Care of the Patient with an Indwelling Catheter, (YEAR), revealed: Secure the catheter to either the patient's thigh or the abdomen. This helps to decrease the risk of bleeding, trauma, meatal necrosis, an bladder spasms from pressure and traction. Review of the facility's Incontinent Care/Foley Catheter Care Checklist, not dated, revealed the Foley catheter care procedures included checking for the leg strap. A review of the facility Physician order [REDACTED].#4 had orders for a 16 French Indwelling Foley catheter related to [MEDICAL CONDITION], initiated 5/22/2018, and to provide catheter care per facility policy. An observation of catheter care with Certified Nursing Assistant (CNA) #1, on 01/15/19 at 10:00 AM, revealed Resident #4 did not have a catheter strap and/or securing device to anchor the catheter tubing. In an interview, on 01/15/19 at 10:05 AM, CNA #1 confirmed Resident #4 did not have a catheter strap/securing device in place or in the room. CNA #1 stated she had not provided catheter care for the resident today and that the night shift must have removed the catheter strap after care was provided. CNA #1 said the resident needed the strap to prevent trauma and to keep the catheter from coming out. In an interview on 01/16/19 at 9:24 AM, Registered Nurse (RN) #1 confirmed the facility policy was not followed if Resident #4 did not have a catheter strap in place. An interview on 01/16/19 at 10:35 AM, with the Director of Nursing (DON), confirmed the staff did not follow the facility policy by making sure Resident #4 had a catheter strap on all times to keep the catheter from coming out and/or causing trauma to the meatus. A review of the facility's face sheet revealed the facility admitted Resident #4 on 9/19/2017, with [DIAGNOSES REDACTED]. A review of Resident #4's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/07/2018, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had mild cognitive impairment.

Based on staff interview, record review, and facility policy review, the facility failed to revise the comprehensive care plan related to catheter care, to include a securing device for the catheter, for one (1) of three (3) catheter care observations. Resident #4. Findings Include: A review of the facility's Care Plan Policy, dated 2/1/17, revealed, the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of the Society of Urological Nurses and Associates Clinical Practice Guidelines, Care of the Patient with an Indwelling Catheter, (YEAR), revealed: Secure the catheter to either the patient's thigh or the abdomen. This helps to decrease the risk of bleeding, trauma, meatal necrosis, an bladder spasms from pressure and traction. Review of the facility's Incontinent Care/Foley Catheter Care Checklist, not dated, revealed the Foley catheter care procedures included checking for the leg strap. A review of the Comprehensive Care Plan for Resident #4 revealed the Care plan was updated on 3/19/2018, to insert a 16 French indwelling catheter and to provide catheter care per facility policy. The care plan failed to include the use of a catheter strap and/or securing device to secure the catheter tubing. Observation of catheter care on 01/15/19 at 10:00 AM, with Certified Nursing Assistant (CNA) #1, revealed Resident #4 had a Foley catheter, but did not have a catheter strap or securing device in place. In an interview on 01/15/19 at 10:05 AM, CNA #1 confirmed Resident #4 did not have a catheter strap. CNA #1 also confirmed the strap was not in the bed or room. CNA #1 also stated that the night shift must have removed the catheter strap after care was provided. CNA #1 said the resident needed the strap to prevent trauma and to keep the catheter from coming out. During an interview on 01/16/19 at 9:35 AM, Registered Nurse (RN) #2 said she thought the catheter strap was documented as an intervention on the care plan. RN #2 said the catheter strap should have been documented on the care plan. During an interview on 01/16/19 10:35 AM, the Director of Nursing (DON) stated she thought the catheter strap was an intervention on the care plan. A review of the facility's face sheet revealed the facility admitted Resident #4 on 9/19/2017, with [DIAGNOSES REDACTED]. A review of Resident #4's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/07/2018, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to follow the care plan to provide catheter care in a manner to prevent Urinary Tract Infections [MEDICAL CONDITION] for Resident #2, for one (1) of three (3) catheter care observations. Findings include: The facility's policy, Baseline Care Plan Policy, dated 1/1/19, noted it is the facility's policy to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Care plans are developed with the intended purpose of staff being informed on how to properly meet the resident's needs and provide daily care. The facility's policy, Catheter Care Policy, dated 3/1/17, noted catheter care will be performed every shift and as needed by the Certified Nursing Assistant (CNA). The policy also noted for catheter care for the male resident to gently grasp the penis and draw the foreskin back if applicable. Then using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Review of Resident #2's plan of care, initiated 9/19/19, noted an Indwelling Catheter, with a listed approach to provide catheter care per facility policy. In an observation of Foley catheter care, on 3/25/19 at 1:25 PM, Certified Nursing Assistant (CNA) #1 wiped Resident #2's catheter with a soapy cloth five (5) times, using the same area of the wash cloth, then changed to a new part of the wash cloth and wiped four (4) times, using the same area of the cloth. With a clean wet rinse cloth, CNA #1 wiped 11 times around the urinary meatus, downward, using the same area of the cloth. CNA #1 was careful to not wipe the same area of skin surface twice but used the same area of the cloth multiple times. Interview with CNA #1 on 3/25/19 at 1:50 PM, revealed she nodded her head Yes, when asked if she remembered using the same area of the wash cloth, but stated, I thought I did it OK. CNA #1 also confirmed having recent in-service for catheter care, use of the leg straps, following the care plan, and infection control. CNA #1 had no concerns with wiping multiple times with the same area of the cloth. In an interview with CNA #2 on 3/25/19 at 1:52 PM, she responded she would have covered the resident with a sheet in between the wash and the rinse. When asked if she would have done anything differently. CNA #2 denied having any concerns with the catheter care observation as provided by CNA #1. CNA #2 also confirmed recent in-services on infection control, catheter care, use of the leg strap, and following the care plan. CNA #2 did not identify any concerns with CNA #1 using the same area of the cloth to wipe multiple times. In an interview on 3/26/19 at 1:10 PM, the Director of Nursing (DON) confirmed the facility had recent in-services on catheter care, use of the leg strap for catheters, and infection control practices. The DON confirmed if a CNA wiped multiple times, using the same area of the cloth, then that would not be correct catheter care and would not be following the resident's plan of care. The Face Sheet documented the facility admitted Resident #2 on 9/19/17, with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/17/18, revealed Resident #2 scored an 8 on the Brief Interview for Mental Status, which indicated moderate cognitive impairment. The MDS documented the resident had a Foley Catheter and had indicated a UTI in the past 30 days.

Based on observation, interview, record review, and facility policy review, the facility failed to follow the care plan to provide catheter care in a manner to prevent Urinary Tract Infections [MEDICAL CONDITION] for Resident #2, for one (1) of three (3) catheter care observations. Findings include: The facility's policy, Baseline Care Plan Policy, dated 1/1/19, noted it is the facility's policy to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Care plans are developed with the intended purpose of staff being informed on how to properly meet the resident's needs and provide daily care. The facility's policy, Catheter Care Policy, dated 3/1/17, noted catheter care will be performed every shift and as needed by the Certified Nursing Assistant (CNA). The policy also noted for catheter care for the male resident to gently grasp the penis and draw the foreskin back if applicable. Then using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Review of Resident #2's plan of care, initiated 9/19/19, noted an Indwelling Catheter, with a listed approach to provide catheter care per facility policy. In an observation of Foley catheter care, on 3/25/19 at 1:25 PM, Certified Nursing Assistant (CNA) #1 wiped Resident #2's catheter with a soapy cloth five (5) times, using the same area of the wash cloth, then changed to a new part of the wash cloth and wiped four (4) times, using the same area of the cloth. With a clean wet rinse cloth, CNA #1 wiped 11 times around the urinary meatus, downward, using the same area of the cloth. CNA #1 was careful to not wipe the same area of skin surface twice but used the same area of the cloth multiple times. Interview with CNA #1 on 3/25/19 at 1:50 PM, revealed she nodded her head Yes, when asked if she remembered using the same area of the wash cloth, but stated, I thought I did it OK. CNA #1 also confirmed having recent in-service for catheter care, use of the leg straps, following the care plan, and infection control. CNA #1 had no concerns with wiping multiple times with the same area of the cloth. In an interview with CNA #2 on 3/25/19 at 1:52 PM, she responded she would have covered the resident with a sheet in between the wash and the rinse. When asked if she would have done anything differently. CNA #2 denied having any concerns with the catheter care observation as provided by CNA #1. CNA #2 also confirmed recent in-services on infection control, catheter care, use of the leg strap, and following the care plan. CNA #2 did not identify any concerns with CNA #1 using the same area of the cloth to wipe multiple times. In an interview on 3/26/19 at 1:10 PM, the Director of Nursing (DON) confirmed the facility had recent in-services on catheter care, use of the leg strap for catheters, and infection control practices. The DON confirmed if a CNA wiped multiple times, using the same area of the cloth, then that would not be correct catheter care and would not be following the resident's plan of care. The Face Sheet documented the facility admitted Resident #2 on 9/19/17, with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/17/18, revealed Resident #2 scored an 8 on the Brief Interview for Mental Status, which indicated moderate cognitive impairment. The MDS documented the resident had a Foley Catheter and had indicated a UTI in the past 30 days.

Based on staff interview, record review, and facility policy review, the facility failed to complete the comprehensive Minimum Data Set (MDS) for a resident with a significant change, and admission to Hospice in a timely manner, for one (1) of 29 MDS assessments reviewed. Resident #8. Findings include: A review of the facility's policy titled (Facility Name) MDS Policy, dated 2/1/17, revealed federal regulations require that the assessment reflects the resident's status. Timing, scheduling, and completion of MDS assessments will be carried out per the guidelines set forth in the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual for Version 3.0. Review of the RAI User's Manual for Version 3.0, revealed a significant change MDS must be completed by the 14th calendar day after the significant change has been determined. On 1/14/19 at 3:25 PM, an interview with the Director of Nursing (DON) revealed the Social Service Director (SSD) is designated as the Hospice Coordinator. The DON also stated when there was a change in Resident #8's condition, the facility notified Hospice. A review of the physician orders, dated 10/2/17, revealed Resident #8 was admitted to Hospice on 10/2/17, with a [DIAGNOSES REDACTED]. Review of a Significant Change in Status Assessment (SCSA) MDS (for Hospice), revealed an Assessment Reference Date (ARD) of 10/17/17, which was 16 days from the change of status, which included admission to Hospice. The comprehensive care plan with an onset date of 10/2/17, included interventions for Hospice. On 1/16/19 at 10:14 AM, an interview with Registered Nurse (RN) #2, revealed she completed a SCSA and revised the comprehensive care plan when a resident is admitted to Hospice. RN #2 stated the SCSA should have been completed within 14 days after Resident #8 had gone on Hospice, however, RN #2 confirmed the SCSA was not done within 14 days, and was missed by two (2) days. RN #2 also stated she used the Resident Assessment Instrument (RAI) Manual for a guideline to code the MDS assessment. On 1/16/19 at 11:32 AM, an interview with the DON revealed she would expect the MDS to be completed on time. A review of the facility's Face Sheet revealed, the facility admitted Resident #8 on 3/1/13, with a [DIAGNOSES REDACTED].

Based on record review, staff and Resident interviews and facility policy review, the facility failed to thoroughly investigate, document, and report an allegation of sexual abuse/misconduct to the State Agency and the Attorney General's office within 24 hours for one (1) of four (4) residents reviewed, Resident #1. Findings include: Review of the facility policy entitled Abuse, Neglect or Exploitation Policy, which was undated, revealed, A written complaint will be: Filed by a staff member assisting the person making the complaint; Turn in to the Administrator and/or DON (Director of Nursing). Also, Reporting: The complaint must be reported to: State Department of Health, Medicaid Fraud Control Unit (Attorney General) by phone 1. With-in 24 hours of discovery; In writing 1. With-in 72 hours of discovery . Included in the policy was Action: Any employee suspected of abuse, neglect, or exploitation shall be placed on suspension; Shall remain on suspension until 1. A complete investigation has been conducted. Review of the policy entitled Resident's Free from Abuse Policy, which was undated, revealed, Facility Responsibility; To report the allegation as well as the outcome of the investigation to the appropriate authorities . Review of the Complaint to the State Agency (SA) received from staff of (Name) [MEDICAL TREATMENT] Unit, revealed, on 12/21/16, Resident #1 reported to the [MEDICAL TREATMENT] staff she was tired of the driver, Transportation #1. When asked for details about the statement, Resident #1 stated she was not going to f**k Transportation #1 anymore, that he had pulled the van over and F**ked her under a bridge and she was tired of it. The complaint documented that the resident didn't want to come to [MEDICAL TREATMENT] anymore because Transportation #1 takes her other places prior to coming to [MEDICAL TREATMENT] and takes her clothes off. The report documented that other staff at the [MEDICAL TREATMENT] Unit recalled Resident #1 had told them the week prior of Transportation #1 having sexual relations with her. The report documented that the Director of Nursing (DON) was notified of the allegations by Resident #1, who acknowledged the resident had been making similar statements concerning the same and they were handling it at the facility. Review of the facility Incident/Accident Reports and Grievances revealed there had been no documentation of the allegation of sexual abuse for Resident #1. There was also no final report written by the facility of the allegation. There was no documented evidence that the allegation of sexual abuse/misconduct was reported to the appropriate state agencies. Review of the Departmental (Nurses') Notes for, 12/21/16 and 12/28/16, revealed there was no mention on either date of an allegation of sexual abuse, nor was there evidence of a body audit having been completed. Review of a Licensed Social Worker's note, dated 12/30/16 at 4:50 PM, revealed that he had been informed by staff that Resident #1 had reported the Transportation aide for sexual misconduct. Interview, on 01/10/17 at 4:15 PM, with the facility's Administrator, Director of Nursing (DON) and Assistant Administrator revealed the DON had been notified by the [MEDICAL TREATMENT] Unit that Resident #1 had stated she would have been there earlier, but Transportation #1 Van Driver was busy taking her clothes off. The DON also stated Resident #1 was never examined by a Physician, since she has a boyfriend who she goes out on pass with, and may return from pass to tell staff about sexual activity with boyfriend. Interview, on 01/11/17 at 8:30 AM, with the Administrator, revealed she had typed a time line on 01/10/17 of the allegation of sexual abuse. The Administrator also stated she was on vacation when the allegation was received from the [MEDICAL TREATMENT] Unit of sexual abuse. The Administrator stated the facility had received verbal statements when the allegation occurred (12/21/16), but the written statements were not obtained until 01/11/17. The Administrator confirmed review of the facility's Incident and Accident Report Log revealed there was no entry for the allegation of sexual abuse. Interview, on 01/11/17 at 9:15 AM, with Transportation #1, revealed he always had another staff member present when Resident #1 was transported to [MEDICAL TREATMENT], but would, on occasion, transport Resident #1 back to the facility with no other staff member present. Transportation #1 was unsure of the date the allegation was discussed with him, but stated the Assistant Administrator told him the Administrator said Resident #1 had an allegation of rape against him, which he denied. Transportation #1 stated he does not transport Resident #1 anymore, but that he was never suspended. Interview, on 01/11/17 at 9:50 AM, with Transportation #2, revealed she was with Transportation #1 when Resident #1 was transported to [MEDICAL TREATMENT] on 12/28/16, and there was no inappropriate contact between them that morning. Transportation #2 confirmed the statement by herself,which addressed the allegation (written on 01/11/17). Interview, on 01/11/17 at 10:15 AM, with the DON, revealed she confirmed her written statement, dated 1/10/17, that the [MEDICAL TREATMENT] Clinical Supervisor contacted her mid afternoon on 12/28/16, and reported Resident #1 had remarked that Transportation #1 had been taking her (Resident #1's) clothes off. The DON stated she went straight to the Assistant Administrator and reported the allegation, who then initiated the investigation. The DON also stated she did not write a statement or receive a statement from the [MEDICAL TREATMENT] Unit, and did not know if the family of Resident #1 was ever notified of the allegation. Interview, on 01/11/7 at 10:15 AM, with Activities #1, revealed the facility had interviewed her on the date of the allegation (12/28/16 per facility), and she had completed a written statement on 01/11/17. She confirmed on 12/28/16 she had accompanied Transportation #1 when Resident #1 was returned to the facility after [MEDICAL TREATMENT]. Interview, on 01/11/17 at 10:40 AM, with Social Services #1, revealed he had spoken with Resident #1 on the day of the alleged sexual abuse after he was told Transportation #1 was attempting to take the Resident's clothes off. Social Services #1 stated Resident #1 had no recollection of the allegation when he spoke with her. Social Services #1 stated he reported the interview to the Assistant Administrator. Interview, on 01/11/17 at 3:30 PM, with [MEDICAL TREATMENT] Employee #2, revealed she had written a statement, dated 12/29/16 of the allegation (which she stated occurred 12/21/16) against Transportation #1 by Resident #1. [MEDICAL TREATMENT] #2 stated she hated Transportation #1, and stated she wasn't going to have sexual relations with anybody. Review of [MEDICAL TREATMENT] Employee #2's written statement, dated 12/29/16, revealed Resident #1 was very angry and said that (Transportation #1) had pulled the van over and had sexual relations with her under a bridge and she was tired of it. She didn't like it and she wanted it to stop. [MEDICAL TREATMENT] Employee #2 then asked Resident #1 if Transportation #1 always touched her and tried to have sex with her? She (Resident #1) said, Yes he does, that he had told her that she has good p**** and then she said that she don't want to have sex with him anymore. Interview, on 01/11/17 at 3:50 PM, with [MEDICAL TREATMENT] Employee #3, revealed she had heard Resident #1 complain about Transportation #1 sexually abusing her (Resident #1). Also, Employee #3 documented a statement that Resident #1 complained that Transportation #1 would pull over under a bridge and have sexual relations with her, and that she was tired of it. Interview, on 01/11/17 at 4:10 PM, with [MEDICAL TREATMENT] Employee #4, revealed she recalled Resident #1 making allegations of sexual abuse in 12/16 (unsure of date), and stated, It was like two (2) seconds later she (Resident #1) said I don't know what you are talking about (when asked about allegation). In interview, on 01/11/17 at 4:20 PM, [MEDICAL TREATMENT] Employee #1 confirmed she had notified the SA on 12/30/16, regarding the allegation of sexual abuse for Resident #1, and the written report followed on 01/06/17. She stated she had never been aware of Resident #1 being late for an appointment at [MEDICAL TREATMENT]. [MEDICAL TREATMENT] Employee #1 also stated she had attempted to notify Resident #1's Responsible Party (RP) on the day of the incident, and was unable to do so. [MEDICAL TREATMENT] employee #1 also stated the RP returned the call a couple of days later and stated if Resident #1 said it, it probably happened. Interview, on 01/01/17 at 9:45 AM, with the Assistant Administrator, revealed she confirmed her statement about the sexual abuse allegation for Resident #1 was written 01/11/17. The Assistant Administrator stated that [MEDICAL TREATMENT] Employee #1 had called on 12/28/16 with an allegation that Transport #1 had sexually assaulted Resident #1. The Assistant Administrator stated after finding out about the allegation she talked with Transportation #1, per phone, who denied the allegation, and stated he had been accompanied by Transportation #2 on the trip to [MEDICAL TREATMENT]. The Assistant Administrator then arranged for Activities #1 to accompany Transportation #1 when Resident #1 was returned from [MEDICAL TREATMENT]. The Assistant Administrator stated Transportation #1's schedule was then changed to days Resident #1 was not transported to [MEDICAL TREATMENT]. The Assistant Administrator also stated she did not interview Transportation #2 the day the allegation occurred to confirm Transportation #1 had not been alone with Resident #1. The Assistant Administrator stated the Administrator was on vacation the day of the allegation, but there had been phone conversations to update the Administrator on the allegation. The Assistant Administrator stated it was the Administrator's responsibility to decide if an allegation was reported to the SA and was completed. Interview, on 01/12/17 at 10:50 AM, with the DON revealed when a report of abuse is received, the facility would first protect the resident. The incident would then be reported to the Administrator and investigated. The DON also stated she would not let the employee work with the resident involved, and the employee would not be allowed to return to work until the investigation had been completed. The DON stated she was notified by [MEDICAL TREATMENT] (of the allegation) and reported to the Assistant Administrator. The DON also stated Transportation employees were under Administration, so the DON would not have been responsible for suspending the employee for an allegation of abuse. The DON stated the facility would get written statements as well as interviews, and the Administrator was responsible for the final decision regarding abuse. Interview, on 01/12/17 at 11:15 AM, with the Administrator, revealed she confirmed the information in her statement dated 01/10/17, regarding the allegation of sexual abuse for Resident #1. The Administrator stated that the Assistant Administrator informed her of the allegation of sexual misconduct/abuse that day (date reported). The Administrator stated the Social Services employee interviewed Resident #1 on 12/29/16, which was the day after the allegation of sexual abuse. The Administrator also stated the incident had not been reported to the SA since the facility did not substantiate the allegation. The Administrator also confirmed, in general, the first action the facility would take would be to protect the resident and the employee would be suspended until the investigation was completed. The next thing the facility would do would be to review the resident's record and any written or verbal statements. The Administrator stated an allegation would be reported within 24 hours to the SA if the allegation was substantiated. The Administrator also confirmed prior to the allegation, at times there would have been only one (1) staff member to accompany Resident #1 from [MEDICAL TREATMENT]. The Administrator also confirmed the facility usually obtains written statements, but at times only verbal statements are obtained. There was no documented evidence that Transportation #1 was suspending pending an investigation after the allegation of sexual abuse. There was no documented evidence that a thorough and documented investigation was completed nor the allegation reported to the state agencies as required. Interview, on 01/12/17 at 12:50 PM, with the Assistant Administrator, revealed Resident #1 is confused at times, and it would have been possible for the Resident to have been confused about the date or time of the allegation. The Assistant Administrator also stated it is up to the facility's discretion whether to complete a Grievance, and an Accident/Incident Report is completed when there are physical findings. There was no documented evidence that the facility completed a physical body audit on Resident #1 to determine if there were physical injuries during the time of the allegation (12/21/16-12/28/16). Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on 09/02/16, with diagnoses, which included Metabolic [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder and End Stage [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/07/16, revealed the Resident scored 9 of 15 on the Brief Interview for Mental Status (BIMS) which indicated she had moderate cognitive impairment.

CI MS #9122 Based on observation, interview, record review and document review, the facility failed to follow the Resident's plan of care for one (1) of four (4) residents in the sample (Resident #1) to prevent injury from falls. A Nurse Aide failed to raise the side rail on the bed, which was indicated in the Resident's plan of care. This failure allowed Resident #1 to fall to the floor, sustaining an intracerebral hemorrhage as well as a bruise to the face. Findings Include: Resident #1, date of birth 1/28/26, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medications included Risperdal twice a day, Diovan, Metoprolol, Synthroid, Namenda and Celexa daily, Trazodone daily, and Cogentin twice a day. Assessments dated 9/3/10 and 2/24/11 reflected long and short-term memory problems, communication problems and difficulty with cognitive decision-making. Assistance was needed for transfer and ambulation, for eating and dressing. A care plan dated 12/7/10 reflected a need for limited to extensive assistance related to impaired cognition, gait disturbance, poor balance and decreased mobility. One of the approaches added 2/17/11 was for use of padded side rails. A nurse's note dated 3/2/11 at 0040 indicated the nurse was called to the room by a CNA and found Resident #1 lying on the left side on the floor beside the bed on top of blankets. The side rail was down and the personal body alarm was still pinned to the back of the nightgown. The resident's head was lying on the floor beside the bedside table and blood was noted in both nostrils, a clump of hair was noted on the handle of the lower drawer of the bedside table and blood was noted on the floor under the resident's head. The resident was sent to the hospital and had a CT of the head and spine. At 0400 the hospital notified the facility that they were sending the resident back due to no bruising of the brain but with an abrasion above the left eyebrow and having a black eye. At 0630 on 3/2/11 a nurse's note reflected that Resident #1 was sent back to the hospital. After rechecking the scan, it was believed the resident had a brain bleed. A history and physical reflected a small area of 1 cm hematoma in the vermis of the cerebellum, requiring the services of neurology for observation. Interview with the Director of Nursing (DON) on 3/22/11 at 10:30 a.m. revealed that the CNA was no longer at the facility due to failure to raise both side rails of the bed. She had interviewed the CNA who stated that she had seen the resident in bed "about" 11 p.m. on rounds and failed to notice the side rail was down. She said the personal body alarm (PBA) was in place but when she went back at 12:40 a.m. on 3/2/11 she had found the resident on the floor with the PBA still attached, but not sounding. Interview with the CNA by phone at 11:15 a.m. on 3/22/11 revealed that she saw the resident about 11:20 a.m. on 3/1/11 and made sure the PBA was attached, but that she failed to note that side rails were not elevated. She stated that when she went back at "about" 12:40 a.m. on 3/2/11 the resident was on the floor with the PBA still hooked to her gown but not sounding. She stated that maybe it didn't pull hard enough for it to go off (the alarm was attached to the side rail which was in the down position, closer to the floor.). The CNA stated that they fired me because I failed to put the side rail up but I didn't notice it. She stated that she had been trained to look at care plans but forgot to notice the side rail. The facility had self-reported this incident on 3/7/11 after an investigation. Their investigative report reflected that the resident had self-transferred from the bed and fell , hit head on the bedside table and fell to the floor. Neuro checks were implemented until transfer to the hospital for evaluation and treatment. Review of the in-service presented on 1/7/11 reflects that the CNA attended a training session on Abuse/Neglect and review of CNA care plans. This training included a need to review changes including interventions put in place so falls do not occur with the resident. There was a statement that the CNA must read the care plan prior to providing care for the resident. That if you do not and an injury happens with the resident, this can be seen as neglect.