Every finding on record at Gibson Health Opco LLC

Based on observations, staff interviews, and review of the facility's policy titled Hand Hygiene, the facility failed to ensure medications were handled using appropriate infection control practices to prevent contamination for one of four residents (R) observed during a medication pass (R47). In addition, the facility failed to ensure proper hand hygiene procedures were followed to prevent the spread of infection for one resident (R4) observed for wound care. These deficient practices increased the risk of contamination, placing residents at risk for infection and adverse outcomes.Findings include:Review of the facility's policy titled Hand Hygiene, last reviewed 10/01/2023, revealed the Policy Explanation and Compliance Guidelines section included . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.1. Observation on 04/15/2026 at 8:53 AM revealed Registered Nurse (RN) AA performing a medication pass for R47. She prepared R47's 9:00 AM medications and nutritional supplement and took them to R47's room. Further observation revealed that R47 refused the medications. Continued observation revealed that RN AA then returned to the medication cart and, using ungloved hands, removed Colace 100 mg and two vitamin B12 tablets from the medication cup and placed them back into the floor stock bottles. The remaining medications were set aside, and she stated they would be discarded properly and taken to the Director of Nursing (DON) office for disposal. In an interview conducted immediately following the medication pass, the surveyor asked RN AA whether it was appropriate to handle medications with bare hands and return them to the floor stock bottle. RN AA acknowledged that this was not appropriate and stated the medications should have been discarded in the same manner as the prescription medications.2. Observation on 04/15/2026 at 10:52 AM, a dressing change to a stage 3 wound on the left first distal toe was observed for R4, performed by wound nurse, Licensed Practical Nurse (LPN) BB. The nurse was observed using personal protective equipment (PPE) appropriately. She performed hand hygiene prior to donning (putting on) gloves and removed the old dressing. After removing the dressing, she removed her soiled gloves, donned a new pair without performing hand hygiene, and continued the dressing change. Upon completion of the dressing change, the surveyor asked LPN BB whether hand hygiene should have been performed after removing soiled gloves. She stated that it should have been performed prior to donning clean gloves.In an interview on 04/15/2026 at 11:15 AM, the DON stated that staff are expected to perform frequent hand hygiene and follow proper infection control practices. He emphasized that medications should not be handled with bare hands to prevent contamination and ensure resident safety, and that medications returned to floor stock containers should have been discarded with the rest. The DON further stated the facility does not have a specific policy addressing this practice, but it is considered standard practice not to handle medications with bare hands. The DON further stated that best practice is to perform hand hygiene before donning gloves and after removing them, including before donning a new pair, as gloves are not a substitute for hand hygiene.

Based on staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop and implement a comprehensive person-centered care plan that addressed the care and treatment for one of one Resident (R) (R318) reviewed with an indwelling catheter. The deficient practice had the potential to increase the risks of infections. Findings include: Review of the undated facility's policy titled Comprehensive Care Plan under the Policy statement revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of clinical records revealed, R318 was admitted with diagnoses that included, but not limited to, hyperosmolality and hypernatremia, dehydration, essential hypertension, adult failure to thrive, retention of urine, pressure ulcer of sacral region (stage 3), pressure-induced deep tissue damage of right heel, muscle weakness (generalized), and urinary tract infection. Review of the Order Audit Report dated 2/24/2025 revealed, R318 has orders for a [Name] Catheter18 Fr [French], 10cc [cubic centimeters] bulb every day shift every 30 days for Urinary retention. Change [Name] AND as needed for Urinary retention. May change as needed for occlusion or accidental removal. Review of the care plan dated 11/30/2023, revealed R318 has a urinary catheter due to urinary retention and is totally incontinent of bowels. The resident is at risk for complications such as UTIs (urinary tract infections) and skin breakdown due to incontinence. Intervention included but not limited to Provide pericare after each incontinent episode. However, there were no care plan areas that addressed catheter care and treatment. Interview on 2/27/2025 at 2:27 pm with Certified Nursing Assistant (CNA) FF revealed, she was unsure what catheter care meant. She stated the area was cleaned during catheter changes (every 30 days). Interview on 2/26/2025 at 2:35 pm with Licensed Practical Nurse (LPN) CC revealed that the policy was to perform catheter care at each catheter bag change (monthly) or as needed. LPN CC confirmed there was no evidence of documentation that catheter care was performed since 9/19/2024. Interview on 2/27/2025 at 3:25 pm with the Director of Nursing (DON) confirmed there was no documentation in the EMR that catheter care had been performed for R318. Cross Reference F684

Based on observations, staff interviews, and review of the facility's policy titled Insulin Pen, and review of the manufacturer's instructions titled Instructions for use [Name] Pen Pen-injector (Insulin Lispro) injection, to ensure care and services were provided in accordance with accepted professional standards for one of four residents (R) (R368) observed during medication administration. Specifically, the facility failed to prime the insulin pen prior to use for R368. This deficient practice had the potential to affect the resident's blood glucose level and have a negative impact on the resident's quality of life. Findings include: Review of the facility's policy titled Insulin Pen, revised 4/16/2024, under the Policy Explanation and Compliance Guidelines revealed, 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir .11. Procedure . h. Prime the insulin pen: (i) Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Review of the manufacturer's Instructions for use [Name] Pen Pen-injector (Insulin Lispro) injection under the section titled Priming your Pen revealed, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Review of R368's orders dated 2/25/2025 revealed, [Name] Kwik-Pen Subcutaneous Solution Pen Injector 100 unit/ml (milliliter) (Insulin Lispro), inject as per sliding scale. During observation of medication administration on 2/26/2025 at 11:32 am with Licensed Practical Nurse (LPN) AA who was observed performing a blood sugar check without concerns and subsequently administering four (4) units of insulin subcutaneously for a blood sugar level of 243. LPN AA retrieved the R368's insulin pen, attached a disposable, single-use insulin needle, and dialed the administration dose to 4 units as per doctors ordered. LPN AA then entered the R368's room and administered the insulin to R368 without priming the needle to remove air and to ensure an accurate insulin dose. During an interview on 2/26/2025 at 11:35 am with LPN AA revealed that she usually primes the insulin pen but admitted that she was nervous and forgot to do so today. During an interview on 2/26/ 2025 at 1:30 pm with the Director of Nursing (DON) revealed, there were two perspectives on whether insulin pens need to be primed-some believe priming is necessary, while others consider it unnecessary. The DON agreed to double check for it in their policies.

Based on staff interviews, record review, and review of the facility's policy titled, Catheter Care Policy, the facility failed to ensure one of one Resident (R) (R318) with an indwelling catheter received treatment and care in accordance with professional standards of practice. The deficient practice had the potential to increase the risks of infections. Findings include: Review of the facility's policy titled, Catheter Care Policy, revised 11/1/2023 under the Policy statement revealed, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheter care are in use. Under the section titled, Policy Explanation revealed, 1. Catheter care will be performed every shift and as needed by nursing personnel. Review of R318's Electronic Medical Record (EMR) revealed, diagnoses that included, but not limited to retention of urine, pressure ulcer of sacral region (stage 3), pressure-induced deep tissue damage of right heel, muscle weakness (generalized), and urinary tract infection (UTI). Review of R318's Order Audit Report dated 2/24/2025 revealed, an order for a [Name] Catheter18 Fr [French], 10cc [cubic centimeters] bulb every day shift every 30 days for Urinary retention. Change [Foley] AND as needed for Urinary retention. May change as needed for occlusion or accidental removal. However, there were no orders to address catheter care every shift. Review of the EMR for Treatment Administration Records (TAR) revealed a lack of documentation for catheter care and cleaning for R318 during October 2024, November 2024, and December 2024. Interview on 2/27/2025 at 2:27 pm with Certified Nursing Assistant (CNA) FF revealed, she was unsure what catheter care meant. She stated the area was cleaned during catheter changes (every 30 days). Interview on 2/26/2025 at 2:35 pm with Licensed Practical Nurse (LPN) CC initially stated she needed to reference the policy, then stated she expected catheter care to be performed when the catheter was changed monthly. She revealed that the policy was to perform catheter care at each catheter bag change (monthly) or as needed. LPN CC confirmed there was no evidence of documentation that catheter care was performed since 9/19/2024. Interview on 2/27/2025 at 3:25 pm with the Director of Nursing (DON) confirmed there was no documentation in the EMR that catheter care had been performed for R318. He continued that the staff had not been documenting catheter care in the EMR and they would begin immediately. He stated the policy was to perform catheter care once monthly or as needed. When asked about concern of her UTI's the DON stated, that the resident was on a prophylactic antibiotic and the catheter care policy was followed.

Based on observation, record review, review of the facility Skilled Inpatient Services Assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility Skilled Inpatient Services Assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. R#10 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that that she had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severely impaired cognition. Review of an electronic treatment administration record (eTAR) for R#10 revealed that she had a treatment order with a start date of 9/2/21 for custom order every five days day shift clean pressure ulcer on right heel with NS, blot dry, apply skin barrier wipe to peri-wound, apply polymem non-adhesive foam to site and cover with adhesive bandage. There was another treatment order with a start date of 11/9/21 for adhesive bandage every 5 days day shift clean pressure ulcer on right heel with normal saline, blot dry, apply skin barrier wipe to periwound, apply polymem and cover with non-adhesive foam dressing and wrap with kerlix every 5 days. On 11/4/21 there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that there was a dressing change on 1/30/22 per the eTAR dated 1/30/22 through 2/2/22. Review of the Wound Report dated 1/25/22 - 2/1/22 revealed that R#10 had a 1.0 centimeter (cm) by 0.5 cm by 3 cm Stage III pressure ulcer on her right heel, and a 2.0 cm by 1.0 cm x 0 cm Arterial Ischemic Ulcer to her right little toe. Interview on 2/2/22 at 8:31 a.m. with the Treatment Nurse revealed R#10 has a pressure ulcer on her right heel stage II, facility acquired from several years ago. She stated R#10 has very poor circulation. Treatment nurse stated the wound has gotten smaller, but it has not completely healed. She stated the wound is cleaned with normal saline, pat dry, put skin barrier wrap around it and foam dressing and wrap with kerlix every five days. She stated the area to R#10 right little toe has an arterial ischemic area. She stated the area is cleaned with normal saline, skin barrier wipe, and foam dressing every five days. She stated she thinks the nurse changed the dressing on the 1/30/22 or 1/31/22. Informed treatment nurse that the dressing to R#10 right little toe had a date of 1/25/22. Treatment Nurse stated she was not aware of it. She stated there are times when R#10 refuses, but she is not sure if R#10 refused or not. Treatment Nurse also stated if R#10 refuses treatment she will attempt to go in later and see if she can change her mind. Treatment Nurse further stated that she could not honestly tell surveyor when she last changed R#10's dressing. She stated when she does not do treatments the nurses are in charge of dressing changes. She stated the resident's skin is assessed weekly. Treatment Nurse stated R#10 's treatment is effective because the area has not worsened. She stated it is slowly getting smaller, but it's been there for several years. Wound observation on 2/2/22 at 10:15 a.m.Treatment Nurse who confirmed dressing to right little toe had a date of 1/25/22. Treatment nurse stated that she will probably need to change the order to as needed (prn). When the Treatment Nurse was questioned on how the nurses would know when to change the dressing if the order was changed, she stated she would not change the order. She stated she only had the order because the toe was rubbing up against and sticking to the boot. Treatment nurse stated the Nurse Practitioner is a certified wound nurse and she comes in to look at the wounds sometimes. Interview with the Director of Nursing (DON) on 2/2/22 at 12:44 p.m. revealed the Treatment Nurse is responsible for dressing changes. She stated if the Treatment Nurse is not on the medication cart as a staff nurse, she is responsible but if she is on the cart the charge nurses are responsible for doing their wound treatments. DON stated the Treatment Nurse did not work at the facility on 1/30/22 or 1/31/22. She stated the Treatment Nurse worked on 2/1/22 in her role as the Treatment Nurse on 2/1/22. DON further reported the Treatment Nurse should have changed the dressing to R#10 right little toe. She stated the nurses know when the Treatment Nurse is not in the building, they are responsible for doing the treatment. Further interview with the DON revealed that she looks at wounds if residents have a wound on admission, and she looks at wounds weekly but on no particular day. She stated if it worsens, she looks at it again, she stated if it is improving, she looks at it periodically. DON stated she was not aware that R#10 had a dressing to her right little toe dated 1/25/22. DON stated the dressing on the toe is more likely for preventive to keep the toe from rubbing against something, she stated it is more like a comfort. DON also stated the dressing should have been changed yesterday. She stated nobody goes back and check to make sure dressings are changed every day. DON stated no one would not know if dressings were not being done unless someone goes and looks at the dressings every day. DON further stated she expected the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident (R) #41 was admitted to facility on 4/18/19 with diagnosis's which include but not limited to [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] disease affecting left non-dominant side, acute respiratory failure with [CONDITION(S)], -[CONDITION(S)], unspecified organism, Metabolic [CONDITION(S)], Acidosis, -Acute kidney failure, Unspecified severe protein-calorie malnutrition, Pressure ulcer of sacral region and Pressure ulcer of left heel. Interview on 2/2/22 at 8:46 a.m. with Treatment Nurse who stated R#41 was admitted to facility with a Stage 4 sacral wound and DTI to right heel. She further stated that resident is being followed at a wound clinic. Treatment Nurse stated that the sacral wound treatment is daily, and Dakin's moistened gauze and foam dressing is applied daily. She furthered stated R#41's wound is improving and is now a Stage 2 with improved undermining. Treatment Nurse also stated that there are no signs of infection to the wound. R#41 also has a Deep Tissue Injury (DTI) to the right heel, which is painted with [MEDICATION(S)] every other day. The Treatment Nurse stated that resident has a low air loss mattress, wedges, and boots on while in bed as pressure relieving interventions. She further stated she is responsible for completing and documenting the skin assessments weekly. Treatment Nurse further stated that she does not consistently follow up with the staff at the wound care clinic to ensure a collaboration of wound care for R#41. Record review revealed R#41's wound care orders as follow: 1- clean sacral pressure ulcer to sacrum with normal saline, blot dry, use skin barrier wipes to peri wound, place fluffed moistened Dakin's gauze in wound bed and cover with foam dressing daily. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] During observation of wound treatment on 2/2/22 at 11:16 a.m. with Treatment Nurse, sacral wound dressing, soiled, and saturated with a date of 1/29/22. Treatment Nurse verified the date on the dressing and acknowledged that the daily treatment had not been done since 1/29/22. Treatment Nurse further stated that she does not work on weekends and the charge nurses are responsible for doing treatments over the weekends. She also confirmed that she worked 1/31/22 and 2/1/22 and did not do the treatment. Treatment Nurse stated R#41 treatment was not complete on 2/1/22 because resident was transferred to hospital before she had the opportunity to do the treatment. She further stated that she was not at work when he returned and that she did not communicate with the charge nurse to do treatment upon return. Further observation of feet, R#41 feet were observed to be on the bed and not offloaded with boots, pillow, or offloading device. Interview on 2/2/22 at 11: 55 a.m. with DON. DON stated that it is her expectation that wound care for all residents with wounds is done as ordered each day to promote wound healing. She further stated that the treatment nurse is responsible for doing wound treatments during the week and that the charge nurses complete wound treatments on the weekends. DON stated she was not aware that treatments were not being done. Interview 2/2/22 at 12:32 p.m. with Licensed Practical Nurse (LPN), DD stated that charge nurses are responsible for completing treatments on the weekends and during the week if the treatment nurse does not work. Typically, the treatment nurse works Monday thru Friday. She further stated that the nurses know when the treatment nurse is not working, and charge nurses complete the treatments according to the electronic treatment record. Observation 2/2/22 at 2:36 p.m. Certified Nursing Assistant (CNA) EE pulled covers back for surveyor to visualize R#41's feet. Pillow observed under calf. CNA EE verified that both of resident's heels were on the bed and not offloaded. Interview 2/2/22 at 3:42 p.m. with RN BB. He stated that he did complete the treatment on 1/29/22 but did not have the opportunity to do the treatment on 1/30/22. RN BB further stated that he was aware that the treatment is a daily treatment, but he had too much to do that day and did not get to it. Review of R#41's electronic treatment administration record (eTAR) revealed that treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN BB and DON viewed the eTAR and verified that treatments were not documented on record.

Based on record review, staff interview, and review of facility policy titled Abuse Prohibition the facility failed to ensure residents were protected from verbal abuse. This affected one Resident (R#154) of four facility reported incidents reviewed. Findings include: Review of facility Abuse Prohibition policy (2020) revealed under intent; It is the intent of this center to actively preserve each patient's right to be fee from mistreatment, neglect, abuse, or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Review of R#154 medical record revealed resident was admitted to facility on 2/4/21 and discharged from the facility on 6/17/21 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] for R#154 revealed Section C (Cognitive Patterns) Brief Interview of Mental Status (BIMS) score 14 indicating resident was cognitively intact and able to make needs known to staff. Continued review of MDS also revealed no indicators for mood or behaviors in sections D (Mood) and Section E (Behaviors) identified during the assessment period. Review of Facility Reported Incident Form dated 4/15/21 documented type of abuse as staff to resident. Details of incident included R#154 stated the Certified Nursing Assistant (CNA) entered her room using a loud voiced tone and spoke to her in an inappropriate manner. Documentation revealed that CNA was immediately suspended, family and physician were notified. Further review of facility documentation also revealed that after investigation of incident which included interviewing of staff and residents, the CNA that was involved in the allegation was terminated and reported to the licensure board. Interview with Administrator on 2/3/21 at 4:45 p.m. revealed the incident with R#154 was reported to her by R#154s' family after overhearing the conversation, while on the phone with resident, when the CNA entered resident's room. The CNA was immediately suspended pending investigation. Further interview also revealed that R#154 did have a history of reporting false allegations toward staff. However, after interviewing cognitive residents that resided on the A-hall and C-hall where the CNA was assigned, it was determined that there had been other incidents of the CNA speaking inappropriately to residents and it was determined that the CNA would be terminated from the facility. The Administrator also revealed all staff had been in-serviced on abuse and reporting of abuse.

Based on observation, record review, and staff interview, the facility failed to implement the comprehensive care plan related to catheter tubing placement for one resident (R#20) of 12 resident care plans reviewed. Findings Include: Observation of R#20 Foley catheter on 2/3/22 at 8:10 a.m. revealed catheter was noted hanging on resident side rail at the head of the bed during observation. Review of R#20 medical record revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medical Data Set (MDS) Admission Assessment date 11/25/21 revealed Section C (Cognitive Patterns) C0500 revealed BIM's score 99 indicating resident has cognitive deficit, Section G (Functional Abilities) revealed resident requires extensive assistance with bed mobility, transfers, dressing, and locomotion on and off the unit which includes staff assistance. Section H (Bladder and Bowel) H0100 indicated resident did have indwelling catheter present. Review of R#20 care plan dated 11/23/21 revealed under interventions: Keep catheter tubing placed below level of bladder, secure catheter tubing. Interview with Licensed Practical Nurse (LPN) AA on 2/3/22 at 8:15 a.m. confirmed R#20 Foley catheter was attached to the resident's side rail at the head of the bed without a privacy bag. Further interview also revealed that resident's catheter should be positioned below the bladder in a privacy bag, and tubing unkinked to encourage proper flow of urine. Interview with Director of Nursing (DON) on 2/3/22 at 9:00 a.m. revealed it is the expectation for all nursing staff to follow the residents plan of care, and to ensure that residents with catheters have a privacy bag and that their tubing is positioned properly.

Based on observations, interviews, record review, and review of the facility document titled, Foley Catheter Care, the facility failed to ensure that a Foley Catheter was placed in a privacy bag and was properly positioned for one of one resident (R#20) that had an indwelling Foley catheter. Findings include: Observation of R#20 Foley catheter on 2/1/22 at 12:05 p.m. revealed cloudy urine with sediment noted in tubing, with no privacy bag, which was visible from resident's door. Observation of R#20 Foley catheter on 2/3/22 at 8:10 a.m. revealed catheter was noted hanging on resident side rail at the head of the bed, there was no privacy bag noted during observation. Review of facility document titled Foley Catheter Care (dated 2020) revealed Intent: To promote, comfort and decrease risk of infection for patients with an indwelling catheter and is performed daily and PRN for soiling. Please see Lippincott Nursing Procedure Manual for additional information on how to complete procedure. Review of the Lippincott Nursing Procedure Manual did not provide any directives related to privacy bag usage. However, the manual stated to keep the catheter and drainage tubing free from kinks to allow the free flow of urine and keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder. Review of R#20 medical record revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) Admission Assessment date 11/25/21 revealed Section C (Cognitive Patterns) revealed Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment, Section G (Functional Abilities) revealed resident is dependent on staff related to toileting needs and requires extensive assistance with bed mobility, transfers, and dressing, and Section H (Bladder and Bowel) indicated indwelling catheter present. Interview with Licensed Practical Nurse (LPN) AA on 2/3/22 at 8:15 a.m. who confirmed R#20's Foley catheter was attached to the side rail at the head of the bed without a privacy bag. LPN AA acknowledged that R#20's catheter should be positioned below the bladder in a privacy bag, and tubing should be unkinked to encourage proper flow of urine. Interview with Director of Nursing (DON) on 2/3/22 at 9:00 a.m. revealed residents with Foley catheters should have two privacy bags one for their wheelchair and one for the bed. DON further revealed that at no time should a catheter be positioned above the resident's bladder and the tubbing should be positioned in a way to promote urine flow. It is the expectation for all nursing staff to follow the resident's plan of care and ensure that residents with catheters have a privacy bag and that their tubing is positioned properly. Continued interview also revealed that there is not a written policy for catheter care, but staff should follow guidelines as directed in the Lippincott Nursing Procedure Manuel that is located at the nursing station. Cross reference F656

Based on staff interview, record review and policy titled Skilled Inpatient Services Immunization of Patients, the facility failed to provide evidence that residents were offered the Pneumococcal vaccine for two residents (R#20 and R#36) of five sampled residents reviewed for immunizations. Findings include: Review of the facility Skilled Inpatient Services Immunization of Patients copyrighted 2020 revealed: It is a policy of this that all patients receive immunizations and vaccinations that aid in preventing infectious diseases unless medically contraindicated or otherwise ordered by the patient's attending physician or the facility's medical director. Upon admission to the facility, permission must be obtained from the patient (or representative) to administer pneumococcal vaccine if there is no documented history of vaccination and influenza vaccine annually (in the fall), unless contraindicated. 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. 1. R#20 admitted to the facility on [DATE]. Review of R#20's Annual MDS assessment dated [DATE] revealed a BIMS score of 99. Section O revealed the Pneumococcal vaccine was not up to date and had not been received because it had not been offered. Review of facility Pneumonia Vaccine report printed 2/3/22 revealed there was no documented evidence that R#20 received a Pneumococcal vaccine. 2.Review of R#36 clinical records revealed she was admitted to the facility on [DATE]. Review of R#36's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated an intact cognition. Review of the Admission MDS assessment dated [DATE] and Quarterly MDS assessment dated [DATE] Section O revealed the Pneumococcal vaccine was not up to date and had not been received because it had not been offered. Interview on 2/2/22 at 5:10 p.m. with R#36 who revealed she was not offered the Pneumococcal vaccine, she stated she does not want to receive the Pneumococcal vaccine. Review of facility Pneumonia Vaccine report printed 2/3/22 revealed there was no documented evidence that R#36 received a Pneumococcal vaccine. Interview with Director of Nursing (DON) on 2/3/22 at 9:45 a.m. revealed she along with the Assistant Director of Nursing (ADON) obtained consent for the Pneumococcal vaccine from R#36 on 2/2/22. DON stated they asked R#36 if she wanted to receive the Pneumococcal vaccine and she stated yes. DON stated she did not see a consent for R#36. Further interview with the DON revealed there was no consent form for R#20. DON stated the Infection Control Preventionist (ICP) called the family of R#20 on 2/3/22 to obtain consent. She stated since the ICP called the family she was responsible for signing the consent form. DON stated that ICP was out with COVID, but she came to the facility to sign the consent form. DON confirmed there was no consent forms for pneumococcal vaccine for R#20 and there was no consent form for pneumococcal vaccine for R#36. Interview with Assistant Director of Nursing (ADON) on 2/3/22 at 10:40 AM revealed she was collecting the information that was requested by the surveyors when she did not see a consent form for R#20, she stated she called the ICP to ask her where the consent form was. She stated the ICP stated she did not have a consent form for R#20, but she would call the family to obtain consent. ADON stated ICP stated family wanted Resident #20 to receive the pneumococcal vaccine. ADON confirmed that prior to 2/2/22 there was no consent form for R#20 and R#20 was not offered the pneumococcal vaccine. She stated consent forms are done on admission and they also get them yearly. ADON reported R#36 was not offered the pneumonia vaccine prior to yesterday. ADON stated she along with the DON asked R#36 if she wanted the pneumonia vaccine and she stated she did. ADON stated the pneumonia vaccine was not given because it was not available in the facility and had be ordered from the pharmacy.

Based on record review, review of facility policy titled Pharmacy Services Medication Administration-General, and staff interviews, the facility failed to assure that physician's orders [REDACTED].#13) of 33 sampled residents. Findings include: Review of the electronic medical record (EMR) for R#13 revealed [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. There was also an order [REDACTED].>Further review of the EMR revealed [MEDICATION NAME] was received on the following: 1. On 8/9/19, R#13 weighed 216.2 pounds. 2. On 8/15/19, R#13 weighed 215.4 pounds. 3. On 8/16/19, R#13 is documented as loss of one pound. 4. On 8/24/19, R#13 weighed 216.3 pounds. 5. On 8/28/19 and 8/29/19, R#13 weighed 215.3 pounds. 6. On 9/1/19, R#13 weighed 211.9 pounds. 7. On 9/4/19, R#13 weighed 216.6 pounds. 8. On 9/19/19, there was no weight documented for R#13. During interview on 9/26/19 at 10:59 a.m. with Licensed Practical Nurse (LPN) AA, who confirmed that medications should be given as written. LPN AA reported that she is unsure why R#13 was given medication when the weight was under 217 pounds. She further reported that she would not have given the medication if she was not able to determine the resident's weight. LPN AA reviewed [MEDICATION NAME] administration for (MONTH) 2019 and (MONTH) 2019 and confirmed medications were provided on identified dates when weight was under 217 pounds. Interview on 9/26/19 at 11:24 a.m. with the Director of Nursing (DON) who reported that her expectation is that medications should be administered as ordered by the Physician. If there is anything else identified, the physician should be notified for guidance. Staff can ask another nurse or come to her for guidance on the order. During interview on 9/26/19 at 12:34 p.m. with R#13's primary Physician it was reported that 217 pounds is the baseline weight for R#13 and that is what he uses to gage how much weight gain resident has per day. The Physician reported that it would not hurt resident to get the medication at 216.6 pounds as it is so clinically close to the 217 pounds. He also reported that he would prefer resident to not get the [MEDICATION NAME] at weights under 217 but if received R#13 would not be clinically hurt. The Physician went on to report that he had never clarified with staff related to what to do if they were unable to get a weight for the resident. However, he reported that staff could always call if there were any questions or if something needed clarification. Review of the undated facility policy titled Pharmacy Services, Medication Administration-General revealed: 2. Medications are administered in accordance with written orders of the attending physician.

Based on observation, record review and resident and staff interview, the facility failed to ensure that residents were consistently monitored for possible injury from unsafe hot water temperatures on three (3) of three (3) halls (A, B, C halls) and for two (2) of three (3) common shower rooms.( A and B halls). The sample size was 56 residents. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 6/26/17 was 85 residents. On 6/28/17, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 6/28/17 at 1:41 p.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 6/26/17, when unsafe hot water temperatures were identified and there was no indication that on-going consistent monitoring of the residents was conducted to ensure their safety from injuries related to unsafe hot water temperatures. The facility immediately submitted a Credible Allegation of Compliance (AoC) on 6/29/17 related to the immediate jeopardy. The immediate jeopardy continued through 6/29/17, and was removed on 6/30/17. The immediate jeopardy is outlined as follows: Unsafe hot water temperatures were identified on 6/26/17 beginning at 3:12 p.m. on the C Hall (adjoining bathrooms for resident rooms C 5/7, C6/8, C10/12 and the common shower room) and A hall (adjoining bathroom for resident room A2/4 and verified with the Maintenance Supervisor (MS) using the facility thermometer. The MS adjusted the hot water temperatures at the water tanks at 3:35 p.m. The Administrator was notified of the unsafe hot water temperatures on 6/26/17 at 3:40 p.m. On 6/26/17 beginning at 5:03 p.m., hot water temperatures for the identified resident rooms and common shower room were below 114 degrees (°) Fahrenheit (F). On 6/26/17 at 6:55 p.m., the Administrator stated that hot water temperatures would be checked hourly in the resident bathrooms that were identified as having unsafe hot water temperatures and a lock was placed on the C Hall common shower room. On 6/27/17 at 8:29 a.m., the plumber was in the facility and working on the hot water temperatures. Hot water temperatures were obtained with the MS using the facility thermometer at that time. Unsafe hot water temperatures ranged from 120.4° F to 122.2° F for the adjoining bathrooms for resident rooms C6/8, C5/7 and C1/3. On 6/27/17 beginning at 12:50 p.m., unsafe hot water temperatures were obtained using the surveyor's thermometer for the C Hall resident bathrooms and common shower and ranged between 130.7° F and 139.5° F; for the A Hall resident rooms and common shower and ranged between 130° F and 134° F; and the B hall resident rooms and common shower room using the MS thermometer and ranged between 122.2°F and 132.3° F. Review of the Water Temperature Log for 6/26/17 at 7:00 p.m. to 6/27/17 at 8:00 a.m. revealed that the last documented hot water temperatures at 8:00 a.m. were between 104.3° and 109° F. However, there was no indication that staff had continued to monitor resident bathrooms and common showers from 6/27/17 at 8:29 a.m. to 6/27/17 at 12:50 p.m. when unsafe hot water temperatures were identified on all three (3) halls. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.25 Quality of Care, Free of Accident Hazards/supervision/devices (F323, S/S:L), and 483.70 Effective Administration/Resident Well-Being (F490, S/S: L). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care, Free of Accident Hazards/supervision/devices (F323, S/S: L). An acceptable Credible Allegation of Compliance (AoC) was received on 6/29/17. Based on observations, record reviews, interviews as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/30/17. The facility remained out of compliance at a lower scope and severity at F323 S/S: F and F490 S/S: F, while the facility continued management level staff oversight of the monitoring for unsafe hot water temperatures. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (PoC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing the monitoring for unsafe hot water temperatures. Findings include: On 6/26/17 between 3:02 p.m. and 3:10 p.m., unsafe hot water temperatures were obtained for the adjoining bathrooms for following resident rooms using the surveyor's thermometer: C5 (2 residents who do not use the bathroom and are totally dependent) and C7 (new admission, dependent on staff to use the bathroom) was 125.4° F; C2 (1 resident who cannot use the bathroom) and C4 (total dependent residents who do not use the bathroom) was 126.6° F; C6 (residents who are total care) and C8 (residents are total care) was 124.9° F, and; C10 (residents are total care) and C12 (2 residents who use the bathroom independently) was 125.2° F. Interview and observation on 6/26/17 at 3:12 p.m., with the MS revealed that he tried to keep the temperatures in the resident bathrooms and common showers between 105-106° F. He obtained unsafe hot water temperatures using the facility digital thermometer for the following resident bathrooms and common showers: On 6/26/17 at 3:12 p.m., the adjoining bathroom for rooms C5 and C7 was 122.7° F; On 6/26/17 at 3:17 p.m., the adjoining bathroom for rooms C6 and C8 was 122.4° F; On 6/26/17 at 3:20 p.m., the adjoining bathroom for rooms C10 and C2 was 124.0° F; On 6/26/17 at 3:25 p.m. C hall Common Bath was 122.4° F, and; On 6/26/17 at 3:30 p.m., the adjoining bathroom for rooms A2 and A4 was 121.1° F. On 6/26/17 at 3:35 p.m., the boiler and water heater were assessed and the gauge for both read 118° F. The MS stated at that time that he would decrease the water tank temperature. On 6/26/17 at 3:40 p.m., the Administrator and Director of Nursing (DON) were notified of the unsafe hot water temperatures. The administrator stated at that time that none of the residents had been burned. Interview with Certified Nursing Assistant (CNA) OO on 6/26/17 at 4:40 p.m. revealed that the only residents who were physically able to toilet themselves on C hall were R#86 (C 12-1, uses the bathroom independently, BIMs Score of 12), R#82 (C12-3, uses the bathroom independently, BIMs score of 15) and R#27 (room C10-2 uses the bathroom independently, alert and oriented, nonverbal but able to respond appropriately to yes and no questions). Continued interview revealed that she had not been notified by the residents of any complaints about unsafe hot water temperatures. Interviews with R#86 (room C12-1) and R#82 (room C12-3) on 6/26/17 at 4:50 p.m. revealed that they had not had any unsafe hot water temperatures in their bathroom and that they knew how to adjust the hot and cold water faucets to obtain comfortable temperatures. Interview with R#27 (room C10-2) on 6/26/17 at 4:52 p.m. revealed that he had not had any unsafe hot water temperatures and that he knew how to adjust the hot and cold water faucets to obtain comfortable temperatures. Interview with CNA PP on 6/26/17 at 4:55 p.m. revealed that none of the residents shower themselves and that staff are always present to assist with showers. Interview with CNA AA on 6/26/17 at 5:00 p.m. revealed that she had not heard any complaints from residents about unsafe hot water temperatures. She stated that if she had been notified she would have told her nurse who would tell the MS. Review of the facility Weekly Water Temps and Equipment Instructions revealed that water temperature will be taken at least one time per week on each wing using a different room each time and that all patient care areas should be 100 to 110° F. On 6/26/17 at 6:00 p.m., the MS stated that he checked the hot water temperature in one room per hall per week as per facility policy. Continued interview revealed that he did not check the hot water temperatures in the common bathrooms unless there was an unsafe hot water temperature in a resident bathroom. Review of the Weekly Water Temps and Equipment Log for June 2017 revealed that on 6/23/17 the bathroom for A1 and A3 was 104° F; the bathroom for B12 was 106° F and the bathroom for C6 and C8 was 105° F. Continued review of the Weekly Water Temps and Equipment Log since 1/27/17 revealed that there were no hot water temperatures in resident bathrooms above 107.3° F. On 6/26/17 at 6:55 p.m. all resident bathrooms on the C hall and the bathroom for A2 and A4 were below 115° F and the MS had placed a lock on the C hall common bath. The Administrator stated at that time that hot water temperatures would be checked every hour in the affected resident rooms and that staff would be in-serviced to call the MS if hot water temperatures were above 115° F. On 6/27/17 at 8:29 a.m., the plumber from Company #1 was in the facility and working on the water heaters. Unsafe hot water temperatures were obtained with the MS using the facility thermometer in the resident bathrooms for the following rooms and common baths: On 6/27/17 at 8:29 a.m., C hall common bath (locked) was 124.1° F; On 6/27/17 at 8:34 a.m., the adjoining bathroom for C6 and C8 (3 totally dependent residents) was 120.4° F; On 6/27/17 at 8:39 a.m., the adjoining bathroom for C5 (1 totally dependent resident) and C7 (1 resident who does not use the bathroom) was 121.3° F, and On 6/27/17 at 8:41 a.m., the adjoining bathroom for C1 (3 residents who do not use the bathroom independently) and C3 (2 totally dependent residents) was 122.2° F. On 6/27/17 at 8:45 a.m., the surveyor requested the MS to notify the surveyor after the plumber from Company #1 had resolved the unsafe hot water temperature issues so that hot water temperatures could be rechecked. On 6/27/17 at 10:25 a.m., monitoring forms for hot water temperature checks from the previous night were provided by the Administrator. Review revealed that staff obtained temperatures from 7:00 p.m. on 6/26/17 to 8:00 a.m. on 6/27/17. The documented temperatures were between 104.3° and 109° F. On 6/27/17 beginning at 12:50 p.m. unsafe hot water temperatures were obtained using the surveyor's thermometer because the MS was busy with the Fire Marshall, as follows: On 6/27/17 at 12:50 p.m., the adjoining bathroom for rooms C2 and C4 (a total of 5 dependent residents) was 135.5° F; On 6/27/17 at 12:53 p.m. the adjoining bathroom for rooms C6 (3 dependent residents) and C8 (3 dependent residents) was 130.7° F; On 6/27/17 at 12:55 p.m., the adjoining bathroom for rooms C10 (3 residents of which 2 are independent) and C12 (2 independent residents) was 139.5° F; On 6/27/17 at 12:59 p.m., the adjoining bathroom for rooms C5 and C7 was 133.4° F; On 6/27/17 at 1:03 p.m., the adjoining bathroom for rooms C1 and C3 was 136.1° F; On 6/27/17 at 1:05 p.m., the C hall common shower was 135.5° F; On 6/27/17 at 1:09 p.m., the adjoining bathroom for rooms A2 and A4 (dependent residents) was 134° F; On 6/27/17 at 1:12 p.m. the adjoining bathroom for rooms A6 and A8 was 131.3° F (resident in room A8-3 is independent); On 6/27/17 at 1:15 p.m., A hall common shower was 131.8° F; On 6/27/17 at 1:19 p.m., the bathroom for room A10 was 130° F (dependent residents); On 6/27/17 at 1: 21 p.m., the adjoining bathroom for rooms A12 and A14 was 133.6° F (5 independent residents); On 6/27/17 at 1: 24 p.m., the bathroom for room A13 was 133.4° F (1 independent resident); On 6/27/17 at 1:28 p.m. the bathroom for room A3 was 133.2° F (1 independent residents), and; On 6/27/17 at 1:33 p.m., the bathroom for room A1 was 133.4° F (dependent residents). On 6/27/17 at 1:45 p.m., the Administrator was notified of the unsafe hot water temperatures on A and C halls and stated that she was unaware of the unsafe hot water temperatures. She stated at that time that someone was supposed to check the hot water temperatures before the plumber left to ensure they were safe. She stated that all the residents who were provided morning showers should have had showers before 8:00 a.m. and that none of the residents had been burned to her knowledge. On 6/27/17 beginning at 1:51 p.m. B hall hot water temperatures were obtained with the MS using the facility thermometer: On 6/27/17 at 1:51 p.m., the bathroom for room B2 was 132.3° F; On 6/27/17 at 1:56 p.m., the adjoining bathroom for rooms B1 and B3 was 128.5° F; On 6/27/17 at 1:59 p.m., the bathroom for room B4 was 126.9° F; On 6/27/17 at 2:01 p.m., the bathroom for room B6 was 126.0° F; On 6/27/17 at 2:04 p.m., the adjoining bathroom for rooms B5 and B7 was 126.0° F; On 6/27/17 at 2:08 p.m., the bathroom for room B8 was 127° F; On 6/27/17 at 2:10 p.m., the adjoining bathroom for rooms B9 and B11 was 122.4° F; On 6/27/17 at 2:12 p.m., the B hall common shower was 126.0° F; On 6/27/17 at 2:16 p.m., the bathroom for room B10 was 122.7° F; On 6/27/17 at 2:18 p.m., the bathroom for room B12 was 122.4° F, and; On 6/27/17 at 2:20 p.m., the adjoining bathroom for rooms B13 and B15 was 122.2° F. On 6/27/17 at 2:00 p.m., the MS stated that he did not get a chance to check the hot water temperatures to ensure they were safe before the plumber left between 10:30 a.m. and 11:00 a.m. because the Fire Marshall arrived to the facility. On 6/27/17 at 2:30 p.m., the MS turned off the hot water to resident bathrooms rooms and common bathrooms. On 6/27/17 at 4:19 p.m., Plumbing Company #1 who had been called back to the facility, stated that the water system did not have a circulating loop and will therefore have a variation in temperatures. Continued interview revealed that the attic was probably 170° F and that was where the water pipes were located. Further interview revealed that the system was worked on last month to reduce the pressure and that in turn affected the mixing valves that allowed the mixing of cold and hot water. Interview with the Administrator on 6/27/17 at 4:40 p.m., revealed that the remaining two common showers would be locked. Continued interview revealed that staff would be in-serviced that no baths/showers were to be given tonight or in the morning until hot water temperatures were safe. Further interview revealed that one (1) hour temperature monitoring would be done in all resident bathrooms indefinitely. On 6/27/17 at 6:57 p.m., the surveyor was rechecking hot water temperatures with the MS. The B hall shower room was unlocked and CNA II was providing a shower for a resident at that time. Interview with CNA II at that time revealed that she had not been notified that residents were not supposed to be provided a shower because of unsafe hot water temperatures. Continued interview revealed that she adjusted the shower water temperature and tested the water temperature on her arm to see if safe and comfortable prior to showering the resident. On 6/27/17 at 8:00 p.m., all three shower rooms were locked. The Administrator stated at that time that no showers would be provided to the residents tonight or in the morning. Continued interview revealed that the CNAs would provide bed baths and set up washbasins for residents who wanted bed baths. Further interview revealed that the nurse was responsible for ensuring safe water temperatures by checking the temperatures with a thermometer. Review of the Water temp log for 6/27/17 at 8:00 p.m. to 6/28/17 at 8:00 a.m. revealed that the hot water temperatures in the resident bathrooms were between 103 and 110° F. On 6/28/17 at 1:41 p.m., the Administrator and DON were notified of IJ related to facility failure to monitor resident safety from 6/27/17 at 8:29 a.m. when unsafe hot water temperatures were identified on C hall resident bathrooms to 6/27/17 at 12:50 p.m. when unsafe hot water temperatures had increased and were identified in resident bathrooms on all three (3) halls. Interview on 6/28/17 at 4:42 p.m., Plumber, from Plumbing Company 2, a new plumber, called by the facility to address the unsafe hot water issues revealed that work was done approximately 3 weeks ago to decrease the water pressure. Continued interview revealed that the water line was cut to put in a valve which released debris to the tempering valve on the cold water side and prevented the cold water from mixing with the hot water. Further interview revealed that he had removed the debris and opened up the valve and that the unsafe hot water temperature issues should be resolved. The facility implemented the following actions to remove the immediate jeopardy: 1. On 6/26/2017 at approximately 2:45 pm the MS was notified of water temperatures on C halls 2 rooms (C6 and C8, C10 and C12) and A Hall 2 rooms (A2 and A4) and the common bathroom on C hall recorded temperatures were 114-120° F. The MS immediately adjusted the water temperatures and continued to check water temperature on the identified rooms and began random checks on unidentified rooms to include shower rooms and common areas. 2. Temperature decreased to around 118° F and random water temperatures were started by MS. Random checks continued until approximately 4:00 p.m. with the surveyor in attendance approximately every hour. The MS was able to get temperatures with adjustments throughout the day down to the 112-114 ° F. 3. Company 1 was notified of temperature ranges consistently ranging above 110° F. Company 1 notified the center of being unable to come to facility until 6/27/2017 in the morning. 4. At 6:00 a.m. Water temperature was documented at 105-109° F with exception of C hall common bathroom it was continuing reading above 110° F. 5. Immediately placed a lock on the C hall common bathroom 6. At 5:00 p.m. staff in-service was started on conducting every hour water temperature checks, notify MS, Administrator and DON if temperatures were documented 110° F or greater. 7. At 6:00 p.m. water temperature log begun. Documented water temperatures on A and C halls every hour until and continued throughout all 3 shifts. All recorded temps were ranging between 105°-109° F. 8. On 6/27/2017 at approximately 8:30 a.m. Company 1 plumber arrived and changed the mixing valve and readjusted the pressure reducer and the mixing valve. 9. At 11:00 a.m. company 1 plumber confirmed that water temperature were in appropriate range of 104°-109.3° F. The Plumber remained at the facility working with MS until 11:00 a.m. and upon his departure he confirmed with DON that he had corrected the problem and had completed a round of temperature auditing and they were all under 110° F temperature range. 10. At 11:30 a.m. the MS made rounds and temperatures was between 105°F and 109° F. 11. At 12:45 p.m. the MS began rounding with the state surveyors and checking water temperatures and identified that the temperatures on all three halls were ranging from 110° F or greater and he immediately turned off hot water supply to building. 12. Immediately called Company 1 to inform him that water temperatures were ranging above 110° F. 13. At 1:30 p.m. company 1 returned call to the facility, notified of temperature ranges and company 1 instructed the MS via telephone how to readjust mixing valves. 14. The MS immediately adjusted the water temperatures and began water temperature checks. 15. The common Shower rooms on A and B was placed out of order with signs on the doors. 16. Staff re-educated on no showers and every hour water testing had begun and to notify MS, Administrator and DON of temperature greater than 110° F. 17. At 4:00 p.m. Company 1 returned to the facility and company 1 adjusted the mixing valve. Company 1 and MS checked water temperature together every hour until 6:00 p.m. Temperature reading range from 108° to 111° F. 18. At 6:00 p.m. staff was re-educated on continuous hour water temperature checks in all residents' room and no showers to be performed. Bed bath may be given by testing the temperature of the water on back of arm as well as offering resident to test for comfort until notified by the MS, Administrator and DON. 19. At 6:15 p.m. new locks were placed on A-Hall and B-Hall common bathrooms. 20. Temperature log documentation started continuously. All temperature after 24 remained between 105° to 109° F. 21. On 6/28/2017 Facility staff continues to perform every hour water temperatures. Company 2 arrived at 10:00 a.m. and corrected water temperature issues by cleaning out debris from mixing valve and remained in the facility until 5 p.m. to ensure all water temperatures ranged in 110° F or less range. 22. Company 2 recommendations were to upgrade water temperature system. Parts to perform the upgrade were ordered on [DATE]. 23. Facility continues to perform every hour water temperatures and document on temperature log and temperatures are reading 101° to 104° F range consistently. 24. Potential for Affecting Residents: All residents who have the ability to obtain water from the water supply have the potential to be affected. 25. Systematic Changes: New Contract plumber was called. Company 2 Plumber arrived at facility at 10:00 a.m. and resolved issue. We will continue to perform hourly checks for the remainder of the week. We have ordered upgraded water equipment and Company 2 Plumbing will come and replace and complete audit on water system. 26. Administrators will Contact Company 2 Quarterly to complete preventive maintenance on water valves. 27. Water Temperature checks will be performed at a more frequent schedule. The new scheduled for performing water temperatures will be performed weekly on all rooms and common baths for 4 weeks then the water temperature will be checked monthly on all rooms and common baths. Water temperatures on all rooms monthly will be reviewed by the Administrator to ensure temperatures are between 100° to 110° F. 28. Administrator provided education to the MS on new schedule for testing the water temperatures. 29. 80% of associates will be in serviced on safe water temperatures, this includes water testing, notifying MS, Administrator, and DON if temperatures are greater than 110° F by 06/30/2017. 30. The remaining associates will be in serviced service on safe water temperatures, this includes water testing, notifying MS, Administrator, and DON if temperatures are greater than 110° F before starting their next shift. 31. Any non-compliant areas will be reviewed in QAPI Process Monthly and as needed. The State Survey Agency (SSA) validated the facility's AoC as follows: 1. On 6/26/17 at 3:35 p.m., the boiler and water heater were assessed and the gauge for both read 118° F. The MS stated at that time that he would decrease the water tank temperature. 2. Review of the temperature logs confirmed that there was no water greater than 120°F and the temperatures were checked hourly. On 6/26/17 at 6:55 p.m. all resident bathrooms on the C hall and the bathroom for A2 and A4 were below 115° F and the MS had placed a lock on the C hall common bath. The Administrator stated at that time that hot water temperatures would be checked every hour in the affected resident rooms and that staff would be in-serviced to call the MS if hot water temperatures were above 115° F. 3. On 6/27/17 at 8:29 a.m., the plumber from Company 1 was in the facility and working on the water heaters 4. On 6/26/17 at 6:55 p.m. all resident bathrooms on the C hall and the bathroom for A2 and A4 were below 115° F and the MS had placed a lock on the C hall common bath. The Administrator stated at that time that hot water temperatures would be checked every hour in the affected resident rooms and that staff would be in-serviced to call the MS if hot water temperatures were above 115° F. 5. Observation on 6/27/17 at 8:00 p.m., all three shower rooms were locked. 6. Review of the in-service sign in sheets and the in-service materials confirmed that the staff education was completed including to notify the MS, Administrator and the DON. 7. Review of the temperature logs confirmed that there was no water greater than 120°F and the temperatures were checked hourly. 8, 9, 10. On 6/27/17 at 4:19 p.m., the Plumber, from Plumbing Company 1 who had been called back to the facility, stated that the water system did not have a circulating loop and will therefore have a variation in temperatures. Continued interview revealed that the attic was probably 170° F and that was where the water pipes were located. Further interview revealed that the system was worked on last month to reduce the pressure and that in turn affected the mixing valves that allowed the mixing of cold and hot water. Review of the temperature logs confirmed that there was no water greater than 120°F and the temperatures were checked hourly. 11, 12, 13, 14, 15. On 6/27/17 at 2:30 p.m., the MS turned off the hot water to resident bathrooms rooms and common bathrooms. Interview with the Administrator on 6/27/17 at 4:40 p.m., revealed that the remaining two common showers would be locked. Continued interview revealed that staff would be in-serviced that no baths/showers were to be given tonight or in the morning until hot water temperatures were safe. Further interview revealed that one (1) hour temperature monitoring would be done in all resident bathrooms indefinitely. On 6/27/17 at 6:57 p.m., the surveyor was rechecking hot water temperatures with the MS. The B hall shower room was unlocked and CNA II was providing a shower for a resident at that time. Interview with CNA II at that time revealed that she had not been notified that residents were not supposed to be provided a shower because of unsafe hot water temperatures. Continued interview revealed that she adjusted the shower water temperature and tested the water temperature on her arm to see if safe and comfortable prior to showering the resident. 16-17. Interviews conducted on 6/28/17 revealed the following staff confirmed they had attended an in-serviced related to hot water temperatures and were able to state acceptable hot water temperatures and who to notify if the water temperatures are too hot: At 2:55 p.m., with CNA NN, at 3:00 p.m. with CNA II, at 3:05 p.m. with CNA MM, at 5:50 p.m. with CNAs FF, GG and LPN HH. On 6-30-17 at 8:42 a.m. with CNA TT, at 8:50 a.m. with CNAs UU, and VV. 18. An interview with the Administrator on 6/27/17 at 6:00 p.m. revealed that no showers would be provided to the residents tonight or in the morning. Continued interview revealed that the CNAs would provide bed baths and set up washbasins for residents who wanted bed baths. Further interview revealed that the nurse was responsible for ensuring safe water temperatures by checking the temperatures with a thermometer. 19. Confirmation by the surveyor, on 6/27/17 at 6:15 p.m. that locks were added to the shower room doors on A and B hall. 20-21. Review of the hourly water temperature log on 6/28/17 at 8:00 a.m., 6/29/17 at 12:00 noon and on 6/30/17 at 9:00 a.m. revealed that all water temperatures were recorded as below 110 degrees F. 22-23. An interview with the Administrator and the MS on 6/28/17 at 4:42 p.m. revealed that the Plumber from Company two had found the cause for the water temperature problem, corrected it and suggested an upgrade to the system. Further interview with the Administrator confirmed the new parts had been ordered per the order form and the facility would now be utilizing the services of Plumbing Company 2 moving forward. 24. The following residents were interviewed related to hot water use, and/or the potential to be burned: On 6/28/17 at 2:15 p.m. with R#74, at 2:20 p.m. with R#4, at 2:25 p.m. with R#73, at 2:27 p.m. with R#95, at 2:30 p.m. with R#26 and R#43, at 2:34 p.m. with R#61, at 2:46 p.m. with R#80, at 2:47 p.m. with R#71, at 2:50 p.m. with R#90, at 2:53 p.m. with R#93, at 4:14 p.m. with R#79 and R#43, at 4:25 p.m. with R#100 and on 6/29/17 at 8:20 a.m. with R#21, at 8:31 a.m. with R#85 and at 8:33 a.m. with R#84.

Based on observation, interview and review of policies and procedures, the facility failed to ensure that safe water temperatures were maintained on three (3) of three (3) halls including resident rooms and common shower rooms. This failure had the potential to affect all residents in the facility. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 6/26/17 was 85 residents. The sample was 56. On 6/28/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 6/28/17 at 1:41 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/26/17. The immediate jeopardy continued through 6/29/17, and was removed on 6/30/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 6/29/17. The immediate jeopardy is outlined as follows: On 6/26/17 at between 3:02 p.m. and 3:10 p.m. water temperatures 118 degrees F and 124.9 degrees F. On 6/26/17 at 3:40 p.m. the Administrator and Don were notified of hot water temperatures and it was reported that no residents had been burned. Temperatures were checked again at 5:03 p.m. and temperatures checked were under 115 degrees F. Temperatures were checked again on 6/27/17 between 1:51 p.m. and 2:25 p.m. with temperatures ranging between 118.2 degrees and 132.3 degrees F. The excessive hot water temperatures affected three of three halls. The facility is now conducting hourly temperature checks of all resident bathrooms and the common shower rooms on each hall has been locked. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.25(d)(1)(2) (n)(1)- (3), Free of Accident Hazards/supervision/devices (F323, S/S: L) and 42 C.F.R. 483.70, Effective Administration/resident Well-Being (F490, S/S: L). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(1)(2) (n)(1)- (3), Free of Accident Hazards/supervision/devices (F323, S/S: L). A Credible Allegation of Compliance was received on June 29, 2017. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on June 30, 2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued monitoring of hot water temperatures in residents bathrooms. On 6/26/17 Company 1 plumber notified the facility that he would not be able to come to the facility until the morning of 6/27/17. As a result the common shower bathroom on hall C was locked and staffed were educated that if water temperatures were greater than 110 degrees F to notify Maintenance, the Administrator, and the DON. Company 1 plumber was present at the facility on 6/27/17 from 8:30 a.m. until 11 a.m. and readjust the mixing valve and pressure reducer. However, when water temperatures were tested at 12:45 p.m. with the Maintenance Supervisor and surveyors temperatures remained over 120 degrees in residents' rooms. The Maintenance Supervisor adjusted the mixing valve and began checking water temperatures. Shower room C remained locked and out of order signs were placed on the doors for the shower rooms on A and B halls. Staff were educated again on 6/27/17 regarding water temperatures and no showers are to be performed for residents. On 6/28/17 hourly monitoring of water temperatures continue and Company 2 plumber present at facility and suggested a water temperature system upgrade. Review of temperature logs did not reveal any water temperatures over 110 degrees F. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of education received related to safe water temperatures. Findings include: Interview on 6/30/17 at 2:00 p.m. with the Administrator who reported that prior to surveyors entering the facility there was no indication that there was an issue with safe water temperatures. The Administrator reported that once water temperatures were identified as an issue a plumber was called in to remedy the situation. The Administrator reported that the first plumber, from Plumbing Company 1, assured them that the issue was fixed but it was not so the decision to bring in a second plumber was made. Once the second plumber, from Plumbing Company 2, arrived he identified that the mixing valves had clogs and he cleaned them. It was also suggested that an upgraded system be purchased and the parts have been ordered. The upgrade to the system should be completed by the end of next week. The facility implemented the following actions to remove the immediate jeopardy: 1. On 6/26/2017 at approximately 2:45 pm the MS was notified of water temperatures on C halls 2 rooms (C6 and C8, C10 and C12) and A Hall 2 rooms (A2 and A4) and the common bathroom on C hall recorded temperatures were 114-120° F. The MS immediately adjusted the water temperatures and continued to check water temperature on the identified rooms and began random checks on unidentified rooms to include shower rooms and common areas. 2. Temperature decreased to around 118° F and random water temperatures were started by MS. Random checks continued until approximately 4:00 p.m. with the surveyor in attendance approximately every hour. The MS was able to get temperatures with adjustments throughout the day down to the 112-114 ° F. 3. Company 1 was notified of temperature ranges consistently ranging above 110° F. Company 1 notified the center of being unable to come to facility until 6/27/2017 in the morning. 4. At 6:00 a.m. Water temperature was documented at 105-109° F with exception of C hall common bathroom it was continuing reading above 110° F. 5. Immediately placed a lock on the C hall common bathroom 6. At 5:00 p.m. staff in-service was started on conducting every hour water temperature checks, notify MS, Administrator and DON if temperatures were documented 110° F or greater. 7. At 6:00 p.m. water temperature log begun. Documented water temperatures on A and C halls every hour until and continued throughout all 3 shifts. All recorded temps were ranging between 105°-109° F. 8. On 6/27/2017 at approximately 8:30 a.m. Company 1 plumber arrived and changed the mixing valve and readjusted the pressure reducer and the mixing valve. 9. At 11:00 a.m. company 1 plumber confirmed that water temperature were in appropriate range of 104°-109.3° F. The Plumber remained at the facility working with MS until 11:00 a.m. and upon his departure he confirmed with DON that he had corrected the problem and had completed a round of temperature auditing and they were all under 110° F temperature range. 10. At 11:30 a.m. the MS made rounds and temperatures was between 105°F and 109° F. 11. At 12:45 p.m. the MS began rounding with the state surveyors and checking water temperatures and identified that the temperatures on all three halls were ranging from 110° F or greater and he immediately turned off hot water supply to building. 12. Immediately called Company 1 to inform him that water temperatures were ranging above 110° F. 13. At 1:30 p.m. company 1 returned call to the facility, notified of temperature ranges and company 1 instructed the MS via telephone how to readjust mixing valves. 14. The MS immediately adjusted the water temperatures and began water temperature checks. 15. The common Shower rooms on A and B was placed out of order with signs on the doors. 16. Staff re-educated on no showers and every hour water testing had begun and to notify MS, Administrator and DON of temperature greater than 110° F. 17. At 4:00 p.m. Company 1 returned to the facility and company 1 adjusted the mixing valve. Company 1 and MS checked water temperature together every hour until 6:00 p.m. Temperature reading range from 108° to 111° F. 18. At 6:00 p.m. staff was re-educated on continuous hour water temperature checks in all residents' room and no showers to be performed. Bed bath may be given by testing the temperature of the water on back of arm as well as offering resident to test for comfort until notified by the MS, Administrator and DON. 19. At 6:15 p.m. new locks were placed on A-Hall and B-Hall common bathrooms. 20. Temperature log documentation started continuously. All temperature after 24 remained between 105° to 109° F. 21. On 6/28/2017 Facility staff continues to perform every hour water temperatures. Company 2 arrived at 10:00 a.m. and corrected water temperature issues by cleaning out debris from mixing valve and remained in the facility until 5 p.m. to ensure all water temperatures ranged in 110° F or less range. 22. Company 2 recommendations were to upgrade water temperature system. Parts to perform the upgrade were ordered on [DATE]. 23. Facility continues to perform every hour water temperatures and document on temperature log and temperatures are reading 101° to 104° F range consistently. 24. Potential for Affecting Residents: All residents who have the ability to obtain water from the water supply have the potential to be affected. 25. Systematic Changes: New Contract plumber was called. Company 2 Plumber arrived at facility at 10:00 a.m. and resolved issue. We will continue to perform hourly checks for the remainder of the week. We have ordered upgraded water equipment and Company 2 Plumbing will come and replace and complete audit on water system. 26. Administrators will Contact Company 2 Quarterly to complete preventive maintenance on water valves. 27. Water Temperature checks will be performed at a more frequent schedule. The new scheduled for performing water temperatures will be performed weekly on all rooms and common baths for 4 weeks then the water temperature will be checked monthly on all rooms and common baths. Water temperatures on all rooms monthly will be reviewed by the Administrator to ensure temperatures are between 100° to 110° F. 28. Administrator provided education to the MS on new schedule for testing the water temperatures. 29. 80% of associates will be in serviced on safe water temperatures, this includes water testing, notifying MS, Administrator, and DON if temperatures are greater than 110° F by 06/30/2017. 30. The remaining associates will be in serviced service on safe water temperatures, this includes water testing, notifying MS, Administrator, and DON if temperatures are greater than 110° F before starting their next shift. 31. Any non-compliant areas will be reviewed in QAPI Process Monthly and as needed. The State Survey Agency (SSA) validated the facility's AoC as follows: 1. On 6/26/17 at 3:35 p.m., the boiler and water heater were assessed and the gauge for both read 118° F. The MS stated at that time that he would decrease the water tank temperature. 2. Review of the temperature logs confirmed that there was no water greater than 120°F and the temperatures were checked hourly. On 6/26/17 at 6:55 p.m. all resident bathrooms on the C hall and the bathroom for A2 and A4 were below 115° F and the MS had placed a lock on the C hall common bath. The Administrator stated at that time that hot water temperatures would be checked every hour in the affected resident rooms and that staff would be in-serviced to call the MS if hot water temperatures were above 115° F. 3. On 6/27/17 at 8:29 a.m., the plumber from Company 1 was in the facility and working on the water heaters 4. On 6/26/17 at 6:55 p.m. all resident bathrooms on the C hall and the bathroom for A2 and A4 were below 115° F and the MS had placed a lock on the C hall common bath. The Administrator stated at that time that hot water temperatures would be checked every hour in the affected resident rooms and that staff would be in-serviced to call the MS if hot water temperatures were above 115° F. 5. Observation on 6/27/17 at 8:00 p.m., all three shower rooms were locked. 6. Review of the in-service sign in sheets and the in-service materials confirmed that the staff education was completed including to notify the MS, Administrator and the DON. 7. Review of the temperature logs confirmed that there was no water greater than 120°F and the temperatures were checked hourly. 8, 9, 10. On 6/27/17 at 4:19 p.m., the Plumber, from Plumbing Company 1 who had been called back to the facility, stated that the water system did not have a circulating loop and will therefore have a variation in temperatures. Continued interview revealed that the attic was probably 170° F and that was where the water pipes were located. Further interview revealed that the system was worked on last month to reduce the pressure and that in turn affected the mixing valves that allowed the mixing of cold and hot water. Review of the temperature logs confirmed that there was no water greater than 120°F and the temperatures were checked hourly. 11, 12, 13, 14, 15. On 6/27/17 at 2:30 p.m., the MS turned off the hot water to resident bathrooms rooms and common bathrooms. Interview with the Administrator on 6/27/17 at 4:40 p.m., revealed that the remaining two common showers would be locked. Continued interview revealed that staff would be in-serviced that no baths/showers were to be given tonight or in the morning until hot water temperatures were safe. Further interview revealed that one (1) hour temperature monitoring would be done in all resident bathrooms indefinitely. On 6/27/17 at 6:57 p.m., the surveyor was rechecking hot water temperatures with the MS. The B hall shower room was unlocked and CNA II was providing a shower for a resident at that time. Interview with CNA II at that time revealed that she had not been notified that residents were not supposed to be provided a shower because of unsafe hot water temperatures. Continued interview revealed that she adjusted the shower water temperature and tested the water temperature on her arm to see if safe and comfortable prior to showering the resident. 16-17. Interviews conducted on 6/28/17 revealed the following staff confirmed they had attended an in-serviced related to hot water temperatures and were able to state acceptable hot water temperatures and who to notify if the water temperatures are too hot: At 2:55 p.m., with CNA NN, at 3:00 p.m. with CNA II, at 3:05 p.m. with CNA MM, at 5:50 p.m. with CNAs FF, GG and LPN HH. On 6-30-17 at 8:42 a.m. with CNA TT, at 8:50 a.m. with CNAs UU, and VV. 18. An interview with the Administrator on 6/27/17 at 6:00 p.m. revealed that no showers would be provided to the residents tonight or in the morning. Continued interview revealed that the CNAs would provide bed baths and set up washbasins for residents who wanted bed baths. Further interview revealed that the nurse was responsible for ensuring safe water temperatures by checking the temperatures with a thermometer. 19. Confirmation by the surveyor, on 6/27/17 at 6:15 p.m. that locks were added to the shower room doors on A and B hall. 20-21. Review of the hourly water temperature log on 6/28/17 at 8:00 a.m., 6/29/17 at 12:00 noon and on 6/30/17 at 9:00 a.m. revealed that all water temperatures were recorded as below 110 degrees F. 22-23. An interview with the Administrator and the MS on 6/28/17 at 4:42 p.m. revealed that the Plumber from Company two had found the cause for the water temperature problem, corrected it and suggested an upgrade to the system. Further interview with the Administrator confirmed the new parts had been ordered per the order form and the facility would now be utilizing the services of Plumbing Company 2 moving forward. 24. The following residents were interviewed related to hot water use, and/or the potential to be burned: On 6/28/17 at 2:15 p.m. with R#74, at 2:20 p.m. with R#4, at 2:25 p.m. with R#73, at 2:27 p.m. with R#95, at 2:30 p.m. with R#26 and R#43, at 2:34 p.m. with R#61, at 2:46 p.m. with R#80, at 2:47 p.m. with R#71, at 2:50 p.m. with R#90, at 2:53 p.m. with R#93, at 4:14 p.m. with R#79 and R#43, at 4:25 p.m. with R#100 and on 6/29/17 at 8:20 a.m. with R#21, at 8:31 a.m. with R#85 and at 8:33 a.m. with R#84.

Based on observation, clinical record review, staff interview, and facility in-service training record review, the facility failed to provide visual privacy during the provision of incontinence care for three (3) residents ("A", "C", and "D") of four (4) sampled residents. Findings include: 1. Record review for Resident "A" revealed an Admission Minimum Data Set (MDS) assessment of 03/30/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident "A" had a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating that the resident was cognitively intact. During an observation conducted on 09/30/2014 at 10:10 a.m. while Certified Nursing Assistant (CNA) "BB" provided incontinence care to Resident "A", the resident was observed lying naked in the bed; however, the privacy curtains had been pulled only one-half (1/2) way around the bed, allowing Resident "A" to be seen, and thus exposed, upon entering the room. During interview on 09/30/2014 at 11:40 a.m. with CNA "BB", CNA "BB" acknowledged that she had not completely closed the privacy curtains when she provided care to Resident "A". 2. Resident "C"'s 07/17/2014 Quarterly MDS assessment documented in Section C - Cognitive Patterns a BIMS Summary Score of 10, indicating the resident to have moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. During an observation conducted on 09/30/2014 at 10:25 a.m. while CNA "FF" and CNA "GG" provided incontinence care to Resident "C", the resident had been undressed was observed lying naked in the bed. The privacy curtains, however, were not closed completely, having been pulled only one-half (1/2) way around the bed. Thus, Resident "C" could be seen, and was therefore exposed, upon entering the room. During an interview conducted on 09/30/2014 at 11:45 a.m. with CNA "GG", CNA "GG" stated that sometimes as she was providing care, privacy curtains get pulled back when as she goes back and forth. CNA "GG" acknowledged that the privacy curtain was not pulled completely around the bed as she provided care to Resident "C". Cross refer to F441 for more information regarding Resident "C". 3. Resident "D"'s Admission MDS assessment of 08/11/2014 documented in Section C - Cognitive Patterns that the resident had a BIMS Summary Score of 10, indicating moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. During an observation conducted on 09/30/2014 at 10:30 a.m., CNA "DD" provided incontinence care to Resident "D", after having undressed the resident. During this observation, Resident "D" was observed lying in the bed and was completely naked, but the privacy curtains were pulled only one-half (1/2) way around the bed. Resident "D" could be seen, and was therefore exposed, upon entering the room. During interview conducted on 09/30/2014 at 11:15 a.m. with CNA "DD", the CNA acknowledged that she did not close the privacy curtain completely while providing incontinence care to Resident "D". CNA "DD" also acknowledged that residents should be covered during incontinent care, but acknowledged she did not cover the resident. Cross refer to F315 for more information regarding Resident "D". Review of facility in-service training records revealed the facility had conducted in-service training with CNA staff, consisting of Steps I, II, and III, regarding incontinence care/handwashing. During a post-survey Quality Assurance interview with the Administrator conducted on 11/05/2014 at 11:39 a.m., the Administrator stated that this in-service training provided to the CNA staff concerning incontinence care had also included the provision of privacy during care and the importance of pulling the privacy curtains during care. Review of the in-service training record revealed the following: - CNA "BB" (who provided care to Resident "A" as referenced above) had attended Step I of this training on 08/08/2014, and Steps II and III on 08/25/2014; - CNA "DD" (who provided care to Resident "D" as referenced above) had attended Step I of the training on 08/08/2014, and Steps II and III on 08/26/2014; - CNA "FF" (who provided care to Resident "C" as referenced above) had attended Step I of this training on 08/24/2014, Step II on 08/26/2014, and Step III on 08/27/2014; - CNA "GG" (who had provided care to Resident "C" as referenced above) had attended Steps I and II of the training on 08/26/2014, and Step III on 08/27/2014.

Based on observation, staff interview, and clinical record review, the facility failed to ensure that care was provided in accordance with the Plan of Care, related to the provision of incontinence care in a manner to address the risk of urinary tract infections, for one (1) resident ("D") who was incontinent of bladder and bowel and had a history of [REDACTED]. Findings include: Resident "D"'s Admission Minimum Data Set assessment of 08/11/2014 documented [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented Resident "D" as always incontinent of urine and bladder during the look-back period. Review of Resident "D"'s Plan of Care revealed a Problem/Strength dated 08/22/2014 which identified that the resident was completely incontinent of bowel and bladder. This Problem/Strength also identified that Resident "D" was at risk for developing urinary tract infections due to her incontinence and also due to a history of urinary tract infection development. Interventions to address Resident "D"'s incontinence and risk of urinary tract infection development included for staff to provide incontinence care as needed by the resident. During a 09/30/2014, 10:30 a.m. observation, Certified Nursing Assistant (CNA) "DD" dampened a clean washcloth in a bath basin, removed feces from Resident "D"'s perineal/vaginal area, then rinsed the washcloth soiled with feces in the water in the bath basin. However, CNA "DD" then obtained a clean washcloth which she dampened in the water in the basin which was contaminated with feces, and then again wiped Resident "D"'s perineal/vaginal area with this contaminated washcloth, thus contaminating the resident's previously cleaned perineal/vaginal area with this contaminated cloth. During interview on 09/30/2014 at 11:15 a.m., CNA "DD" acknowledged she had used a contaminated washcloth to provide incontinence care to Resident "D". Based on the above, despite Resident "D" being incontinent of bowel/bladder and having a history of urinary tract infections, despite the Plan of Care identifying Resident "D"'s incontinence and identifying the resident to be at high risk of developing urinary tract infections, and despite the Plan of Care thus specifying as an Intervention that staff provided the needed incontinence care to prevent infections, CNA "DD" utilized a soiled washcloth to provide incontinence care to this resident. Cross refer to F315 for more information regarding Resident "D".

Based on observation, staff interview, clinical record review, and facility in-service training record review, the facility failed to ensure that one (1) resident ("D") who was incontinent of bladder and bowel received incontinence care in a manner to prevent urinary tract infections, on the total survey sample of four (4) residents. Findings include: Record review for Resident "D" revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/11/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel of this MDS documented that Resident "D" was always incontinent of urine and of bladder during the look-back period. During an observation of Resident "D" conducted on 09/30/2014 at 10:30 a.m., the resident had been incontinent of feces. Certified Nursing Assistant (CNA) "DD" obtained a clean washcloth, dampened the washcloth with clean water from the bath basin, and removed feces from the resident's perineal/vaginal area utilizing a front-to-back motion. CNA "DD" rinsed the washcloth soiled with feces in the clean water contained in the bath basin, thus contaminating the water. CNA "DD" then obtained a clean washcloth, dampened this clean washcloth in the now-contaminated water in the bath basin, and continued to wipe the previously cleaned area of Resident "D"'s perineal/vaginal area with this washcloth dampened with contaminated water. CNA "DD" then changed her gloves, placed a clean brief on Resident "D", and placed a clean gown on the resident. During an interview conducted on 09/30/2014 at 11:15 a.m., CNA "DD" acknowledged that she had used the contaminated water in which she had rinsed the fecal-soiled washcloth to dampen the washcloth to continue to provide incontinence care to Resident "D". During an interview conducted on 09/30/2014 at 9:45 a.m. with the Infection Control/Staff Development Nurse, this nurse stated that the facility had provided training to CNA staff regarding on incontinence care. Review of facility in-service training records revealed that on 08/08/2014, supervisory staff had observed CNA "DD" during the provision of incontinence/peri-care, and that on 08/26/2014, CNA "DD" had both viewed a video related to peri-care and handwashing and had been checked off on peri-care and handwashing during in-service training.

Based on observation and staff interview, the facility failed to store personal care items in a sanitary manner in seven (7) bathrooms on three (3) of three (3) halls, and failed to wash or sanitize hands between residents during one (1) of two (2)meal observations on one (1) of three (3)halls. Findings include: 1. Observations on 7/21/14 at 12:25 p.m. revealed in the bathroom in room B2, an unlabeled denture cup, an unlabeled comb and brush on a shelf above the sink and an unlabeled and uncovered wash basin and bedpan in the bath tub. Continued observations revealed unlabeled personal items on the shelf in the bathroom over the sink in room C1. Interview on 7-23-14 at 10:00 a.m. with the Interim Infection Control Nurse, confirmed that the above items remained unlabeled and uncovered as on the observation on 7-21-14 at 12:25 p.m. Continued interview revealed that her expectation was that the wash basin would be stored in a plastic bag in the resident's night table and that the denture cup, comb and brush would be labeled with the resident's name and also stored in the night stand. Further interview revealed that the personal items should be labeled and stored in the resident's night stand after use. 2. Observation during the lunch meal on the A Hall on 7-21-14 at 12:25 p.m. revealed one (1) certified nursing assistant (CNA) "BB" serving trays from the meal cart. The CNA pushed her hair out of the way, took a tray from the cart and served it to the resident without washing or sanitizing her hands. Continued observation revealed the same CNA picked something up off the floor, discarded the object, took a tray from the cart and served it to the resident without washing or sanitizing her hands. Interview on 7-23-14 at 9:40 a.m. with the Interim Infection Control Nurse, revealed that a handwashing inservice is given to new hires and at least twice a year and as needed. 3. Observations on the A Hall on 7/21/14 beginning at 12:01 p.m. and on 7/22/14 at 9:15 a.m. revealed the following concerns related to storage of resident personal care items:: -In Room A-7, there was an unlabeled bath basin and hairbrush in the bathroom shared by two residents. -In Room A-9, there was an unlabeled bath basin, hairbrush, denture cup containing one denture plate, and toothbrush, which was lying directly on top of the shelf over the sink. This bathroom was shared by two residents. -In Room A-10, there were three bath basins nested inside of each other on top of the toilet tank cover in the bathroom. Only one of the three basins was labeled with the resident's name. In addition, there was an unlabeled denture cup on the shelf over the sink. This bathroom was shared by two residents. -In Room A-14, there were two bagged bedpans in the bathroom that was shared by five residents. One bedpan was labeled, but had been stored with a brown material along the seating surface of the bedpan. The other bedpan was not labeled. During observations in the same bathrooms on 07/23/14 at 7:52 a.m., the above concerns were noted again, with the exception of the following: -In Room A-9, there was an unlabeled bath basin and toothbrush, which was lying directly on top of the shelf over the sink. (the hairbrush and denture cup were not seen). During interview with Licensed Practical Nurse (LPN) "AA" on 07/23/14 at 10:00 a.m., she stated that she would expect staff to bag bath basins and bedpans and place them in the resident's nightstand, and that items such as toothbrushes, hairbrushes and denture cups should also be placed in the nightstands. During observation with LPN "AA" at this time in the above bathrooms, she verified the observations made at 7:52 a.m., with the exception of the following: -Room A-10: There were two (instead of three) unlabeled bath basins in a plastic bag on top of the toilet tank cover, and an unlabeled denture cup on the shelf above the sink.

Based on observation, clinical record review, staff interview, and facility in-service training record review, the facility failed to ensure that staff provided direct resident care, during the provision of incontinence care, in a manner to prevent the spread of infection for one (1) resident ("C") from a total survey sample of four (4) residents. Findings include: Record review for Resident "C" revealed a Quarterly Minimum Data Set assessment of 07/17/2014 in which Section I - Active [DIAGNOSES REDACTED]. During an observation of Resident "C" (who resided in a semi-private room and had a roommate) conducted on 09/30/2014 at 10:25 a.m., Certified Nursing Assistants (CNAs) "FF" and "GG" provided incontinence care for the resident. CNA "FF", who was wearing gloves, removed Resident's "C"'s gown which was wet with urine and placed the wet gown on top of the bed covers, instead of in a plastic bag present in the room. CNA "FF" then removed Resident "C"'s incontinence brief which was wet with urine and placed the wet brief on the floor, instead of bagging the wet brief. CNA "FF" and CNA "GG" then provided incontinence care to Resident "C", cleaning her peri-area in a front-to-back motion. However, CNA "FF" then, without changing the soiled gloves, left the resident's room out into the hallway and returned with a clean gown and clean bed linen. After returning to the room, CNA "FF" and CNA "GG" then changed gloves, and CNA "FF" and CNA "GG" placed another incontinence pad on Resident "C" and placed the clean gown on the resident. It was at that point when the CNAs obtained the wet gown lying on the bed cover and the wet brief lying on the floor and placed these items in a plastic bag. During an interview conducted on 09/30/2014 at 11:30 a.m., CNA "FF" acknowledged that she did not change her soiled gloves prior to leaving the room to obtain supplies, and acknowledged she had failed to place Resident "C"'s wet gown and wet incontinence brief in a bag. CNA "FF" further stated that she had received training regarding incontinence care, hand sanitization, and the handling of soiled linen. During an interview with CNA "GG" conducted on 09/30/2014 at 11:45 a.m., CNA "GG" acknowledged she had been trained to placed soiled items of linen in a plastic bag. Review of facility in-service training records revealed that on 08/24/2014 and 08/28/2014, CNA "FF" and CNA "GG", respectively, had been observed by supervisory staff during the provision of incontinence/peri-care. Further review of this facility in-service training record revealed that on 08/26/2014, CNA "FF" and CNA "GG" had both viewed a video related to peri-care and handwashing and had been checked off on peri-care and handwashing. During interview conducted on 09/30/2014 at 9:45 a.m., the Infection Control/Staff Development Nurse acknowledged that CNA staff had received training which included hand care and sanitizing hands.

Based on observation, clinical record review, staff interview, and facility in-service training record review, the facility failed to provide visual privacy during the provision of incontinence care for three (3) residents (A, C, and D) of four (4) sampled residents. Findings include: 1. Record review for Resident A revealed an Admission Minimum Data Set (MDS) assessment of 03/30/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident A had a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating that the resident was cognitively intact. During an observation conducted on 09/30/2014 at 10:10 a.m. while Certified Nursing Assistant (CNA) BB provided incontinence care to Resident A, the resident was observed lying naked in the bed; however, the privacy curtains had been pulled only one-half (1/2) way around the bed, allowing Resident A to be seen, and thus exposed, upon entering the room. During interview on 09/30/2014 at 11:40 a.m. with CNA BB, CNA BB acknowledged that she had not completely closed the privacy curtains when she provided care to Resident A. 2. Resident C's 07/17/2014 Quarterly MDS assessment documented in Section C - Cognitive Patterns a BIMS Summary Score of 10, indicating the resident to have moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. During an observation conducted on 09/30/2014 at 10:25 a.m. while CNA FF and CNA GG provided incontinence care to Resident C, the resident had been undressed was observed lying naked in the bed. The privacy curtains, however, were not closed completely, having been pulled only one-half (1/2) way around the bed. Thus, Resident C could be seen, and was therefore exposed, upon entering the room. During an interview conducted on 09/30/2014 at 11:45 a.m. with CNA GG, CNA GG stated that sometimes as she was providing care, privacy curtains get pulled back when as she goes back and forth. CNA GG acknowledged that the privacy curtain was not pulled completely around the bed as she provided care to Resident C. Cross refer to F441 for more information regarding Resident C. 3. Resident D's Admission MDS assessment of 08/11/2014 documented in Section C - Cognitive Patterns that the resident had a BIMS Summary Score of 10, indicating moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. During an observation conducted on 09/30/2014 at 10:30 a.m., CNA DD provided incontinence care to Resident D, after having undressed the resident. During this observation, Resident D was observed lying in the bed and was completely naked, but the privacy curtains were pulled only one-half (1/2) way around the bed. Resident D could be seen, and was therefore exposed, upon entering the room. During interview conducted on 09/30/2014 at 11:15 a.m. with CNA DD, the CNA acknowledged that she did not close the privacy curtain completely while providing incontinence care to Resident D. CNA DD also acknowledged that residents should be covered during incontinent care, but acknowledged she did not cover the resident. Cross refer to F315 for more information regarding Resident D. Review of facility in-service training records revealed the facility had conducted in-service training with CNA staff, consisting of Steps I, II, and III, regarding incontinence care/handwashing. During a post-survey Quality Assurance interview with the Administrator conducted on 11/05/2014 at 11:39 a.m., the Administrator stated that this in-service training provided to the CNA staff concerning incontinence care had also included the provision of privacy during care and the importance of pulling the privacy curtains during care. Review of the in-service training record revealed the following: - CNA BB (who provided care to Resident A as referenced above) had attended Step I of this training on 08/08/2014, and Steps II and III on 08/25/2014; - CNA DD (who provided care to Resident D as referenced above) had attended Step I of the training on 08/08/2014, and Steps II and III on 08/26/2014; - CNA FF (who provided care to Resident C as referenced above) had attended Step I of this training on 08/24/2014, Step II on 08/26/2014, and Step III on 08/27/2014; - CNA GG (who had provided care to Resident C as referenced above) had attended Steps I and II of the training on 08/26/2014, and Step III on 08/27/2014.

Based on observation, staff interview, and clinical record review, the facility failed to ensure that care was provided in accordance with the Plan of Care, related to the provision of incontinence care in a manner to address the risk of urinary tract infections, for one (1) resident (D) who was incontinent of bladder and bowel and had a history of [REDACTED]. Findings include: Resident D's Admission Minimum Data Set assessment of 08/11/2014 documented [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented Resident D as always incontinent of urine and bladder during the look-back period. Review of Resident D's Plan of Care revealed a Problem/Strength dated 08/22/2014 which identified that the resident was completely incontinent of bowel and bladder. This Problem/Strength also identified that Resident D was at risk for developing urinary tract infections due to her incontinence and also due to a history of urinary tract infection development. Interventions to address Resident D's incontinence and risk of urinary tract infection development included for staff to provide incontinence care as needed by the resident. During a 09/30/2014, 10:30 a.m. observation, Certified Nursing Assistant (CNA) DD dampened a clean washcloth in a bath basin, removed feces from Resident D's perineal/vaginal area, then rinsed the washcloth soiled with feces in the water in the bath basin. However, CNA DD then obtained a clean washcloth which she dampened in the water in the basin which was contaminated with feces, and then again wiped Resident D's perineal/vaginal area with this contaminated washcloth, thus contaminating the resident's previously cleaned perineal/vaginal area with this contaminated cloth. During interview on 09/30/2014 at 11:15 a.m., CNA DD acknowledged she had used a contaminated washcloth to provide incontinence care to Resident D. Based on the above, despite Resident D being incontinent of bowel/bladder and having a history of urinary tract infections, despite the Plan of Care identifying Resident D's incontinence and identifying the resident to be at high risk of developing urinary tract infections, and despite the Plan of Care thus specifying as an Intervention that staff provided the needed incontinence care to prevent infections, CNA DD utilized a soiled washcloth to provide incontinence care to this resident. Cross refer to F315 for more information regarding Resident D.

Based on observation, staff interview, clinical record review, and facility in-service training record review, the facility failed to ensure that one (1) resident (D) who was incontinent of bladder and bowel received incontinence care in a manner to prevent urinary tract infections, on the total survey sample of four (4) residents. Findings include: Record review for Resident D revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/11/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel of this MDS documented that Resident D was always incontinent of urine and of bladder during the look-back period. During an observation of Resident D conducted on 09/30/2014 at 10:30 a.m., the resident had been incontinent of feces. Certified Nursing Assistant (CNA) DD obtained a clean washcloth, dampened the washcloth with clean water from the bath basin, and removed feces from the resident's perineal/vaginal area utilizing a front-to-back motion. CNA DD rinsed the washcloth soiled with feces in the clean water contained in the bath basin, thus contaminating the water. CNA DD then obtained a clean washcloth, dampened this clean washcloth in the now-contaminated water in the bath basin, and continued to wipe the previously cleaned area of Resident D's perineal/vaginal area with this washcloth dampened with contaminated water. CNA DD then changed her gloves, placed a clean brief on Resident D, and placed a clean gown on the resident. During an interview conducted on 09/30/2014 at 11:15 a.m., CNA DD acknowledged that she had used the contaminated water in which she had rinsed the fecal-soiled washcloth to dampen the washcloth to continue to provide incontinence care to Resident D. During an interview conducted on 09/30/2014 at 9:45 a.m. with the Infection Control/Staff Development Nurse, this nurse stated that the facility had provided training to CNA staff regarding on incontinence care. Review of facility in-service training records revealed that on 08/08/2014, supervisory staff had observed CNA DD during the provision of incontinence/peri-care, and that on 08/26/2014, CNA DD had both viewed a video related to peri-care and handwashing and had been checked off on peri-care and handwashing during in-service training.