Every finding on record at Greenbriar Nursing Center

Based on record review, interview, and facility policy review, the facility failed to revise care plans to accurately reflect residents' infection control status for two (2) of three (3) residents reviewed for infection control. Resident #1 and Resident #3Findings include:A review of the facility's policy, Care Plan Revisions Upon Status Change, dated November 2024, revealed, .to provide a consistent process for reviewing and revising the care plan. Policy Guidelines.1. care plan will be reviewed, and revised as necessary. 2. Procedure for.revising the care plan.d.care plan will be updated with the new or modified interventions. f.Care plans will be modified as needed. h.to ensure care plans have been updated to reflect current resident needs.Resident #1A record review of Resident #1's Care Plan Detail revealed an individual care plan with focus Resident has active diagnosis ESBL (Extended-Spectrum Beta-Lactamase) UTI (Urinary Tract Infection) dated 4/26/26. The goal revealed Resident's symptoms will be managed and ESBL will be resolved. The Interventions/Tasks revealed interventions including all meals to be served on disposable dishes using disposable utensils and cups. Discard into isolation trash can in room upon completion of meal, all staff to maintain standard contact isolation precautions, all staff to wear gloves and gown upon entering room and when caring for the resident, and keep PPE (Personal Protective Equipment) which will include gowns and gloves near resident's room.A record review of the admission Record revealed the facility admitted Resident #1 on 4/2/23 with the diagnoses including Acute on chronic diastolic (congestive) heart failure, urinary tract infection, and extended spectrum beta lactamase (ESBL) Resistance.A record review of the Discharge return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/14/26 revealed Resident #1's short term memory was okay and her cognitive skills with daily decision making was coded as modified independence.A record review of the Order Summary Report with active orders as of 5/26/26, revealed there was no physician's order for isolation precautions for Resident #1.A record review of the Medication Administration Record (MAR) for May 2026 revealed staff documented that Resident #1 was on Contact Precautions for ESBL in urine every shift until 5/8/26. Further review revealed the start date of the contact precautions was 4/28/26.Resident #3A record review of Resident #3's Care Plan Detail revealed an individual care plan with focus Resident has active diagnosis of VRE (Vancomycin-Resistant Enterococci) UTI dated 5/12/26. The goal revealed resident's symptoms will be managed and VRE will be resolved. The intervention/tasks revealed interventions including, All meals to be served in room on disposable dishes using disposable utensils and cups. Discard into isolation trash can in room upon completion of meal, all staff to maintain standard contact isolation precautions, all staff to wear gloves and gown upon entering room and when caring for the resident, and keep PPE which will include gowns and gloves near resident's room.A record review of the admission Record revealed the facility admitted Resident #3 on 12/26/23 with diagnoses including chronic obstructive pulmonary disease, unspecified, malignant neoplasm of lower lobe, right bronchus or lung, and urinary tract infection, site not specified.A record review of the Annual MDS with an ARD of 2/13/26 revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 14 indicating her cognition was intact. A record review of the Order Summary Report with active orders as of 5/26/26, revealed no order for isolation precautions.A record review of the MAR for May 2026 revealed that staff documented that Resident #3 was on Contact Isolation Precautions for Vancomycin-Resistant Enterococcus (VRE) (urine) every shift for transmission-based precautions for 8 days. The start date of contact isolation precautions began on 5/15/26 and ended on .On 5/26/26 at 2:13 PM, during an interview with Care Plan Nurse #1, she stated the care plan nurse is responsible for revising resident care plans. She reported that when isolation precautions are ordered, the intervention is added to the resident's care plan. She further explained that when isolation precautions are discontinued, the care plan focus is removed from the care plan. She confirmed the care plans for Resident #1 and Resident #3 had not been revised after the isolation orders were discontinued. On 5/26/26 at 2:29 PM in an interview with the Director of Nursing (DON), she reported the Care Plan nurse is responsible for revising the care plan with new and discontinued orders. She stated the care plan not being updated timely could interfere with resident care. She confirmed the care plan should have been revised for Resident #1 and Resident #3.On 5/26/26 at 2:43 PM in an interview with the Administrator she stated the care plan nurse is responsible for revising the care plan. She stated it is her expectation for the care plan to be updated in an accurate and timely manner.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from accident hazards during bed mobility when a Certified Nursing Aide (CNA) performed a linen and brief change without the required two (2) person assistance, in which Resident #1 fell from the bed and sustained a proximal humeral fracture (a break in the upper arm bone near the shoulder) for one (1) of three (3) residents reviewed for accidents.Findings include:A record review of the facility's investigation, undated, revealed that on 2/11/2026, at approximately 10:05 PM, CNA #1 was providing in-bed care to Resident #1, including a linen and brief change. During care, Resident #1 rolled to assist. She subsequently rolled too far and exited the bed, landing on the floor. A record review of the Incident Witness Statement, dated 2/11/26 and signed by CNA #1 revealed a Narrative if incident if witnessed which indicated the CNA was changing the resident and went to pull the sheet from under her and the resident rolled and fell. The CNA documented, .the brief was already on her, and I also tried to reach over and keep her from falling and she wasn't able to hold herself up even after grabbing the rail.A record review of the admission Record revealed the facility admitted Resident #1 on 7/14/25 with diagnoses including hypertension with an additional diagnosis added on 2/14/26 of other displaced fracture of upper end of left humerus, subsequent encounter for fracture with routine healing.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated she was cognitively intact. A review of Section GG revealed Resident #1 required substantial/maximal assistance for rolling left and right in bed.A record review of the Kardex Report as of 2/11/26 revealed Resident #1 required (2) staff to turn and reposition in bed.A record review of the XR (X-Ray) Shoulder Complete Left (Routine), dated 2/11/26, revealed, History: Shoulder injury from fall out of bed, and the impression indicated Resident #1 had a proximal humeral fracture.A record review of the Disciplinary Conference, dated 2/12/26, revealed CNA #1 received an infraction for failing to follow the resident's plan of care.During an observation and interview on 3/18/26 at 8:49 AM, Resident #1explained that during a linen change on 2/11/26, the CNA rolled her onto her side and removed the bed pad, causing her to begin falling from the bed. The resident reported she attempted to stop herself, and the CNA attempted to catch her, but she continued to fall and landed on her left side. The resident reported the CNA left the room to obtain assistance, and nursing staff came to assess her before she was transported to the hospital. An observation of the room revealed the bed was at an average height.During an interview with Certified Nursing Aide (CNA) #1 on 3/18/26 at 10:51 AM, she explained she was performing a linen and brief change alone. She stated she rolled the resident to provide care and remove soiled linens when the resident fell from the bed. She explained CNAs have access to a Kardex system that identifies care needs and that staff are expected to review it daily. She reported she was unsure how many staff were required for bed mobility at that time. She confirmed she participated in a disciplinary conference and in-service following the incident.During an interview with the Director of Nursing (DON) on 3/19/26 at 9:45 AM, she explained the resident fell from the bed during a linen change when the CNA did not follow the Kardex requiring (2) staff for bed mobility. She stated staff are expected to review the Kardex daily for updated care needs. She explained that following the incident, monitoring was implemented to ensure staff review the Kardex, with results reviewed in Quality Assurance and Performance Improvement (QAPI) and interdisciplinary meetings.Review of the facility's Corrective Action Plan, dated 2/12/26, revealed the President, Director of Nursing (DON), and Administrator spoke to the injured resident's family members. The President, DON, and Administrator interviewed Certified Nursing Aide (CNA) #1, Licensed Practical Nurse (LPN) #1, LPN #2, and LPN #3. A one-to-one (1:1) in-service and disciplinary conference was conducted with LPN #2 related to calling the DON for any falls or hospital transfers, and an in-service and disciplinary conference was completed by the DON. A one-to-one (1:1) in-service was conducted with LPN #1 related to calling the DON for any falls or hospital transfers and completing incident reports, and the in-service was completed by the DON. A one-to-one (1:1) in-service and disciplinary conference was conducted with CNA #1 related to following the plan of care, bed mobility, making an occupied bed, and incontinence care, with return demonstration completed with the DON. The plan further revealed no nursing staff were allowed to work until they were in-serviced on following the care plan, and in-services were completed by the Administrator, Chief Nursing Officer, and DON. A Quality Assurance and Performance Improvement (QAPI) meeting was held via telephone with the medical director and QAPI team members, during which policy was reviewed and no changes were made. The plan revealed the Lead CNA or DON would monitor care at least three (3) times weekly for compliance with care plans related to activities of daily living (ADL) care, the interdisciplinary team would meet weekly to discuss outcomes of observations for six (6) weeks, and observations would be reported to QAPI for two (2) months.Based on implementation of the facility's corrective actions on 2/12/2026, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 2/13/2026Validation:The SA validated on 3/19/2026, through interview and record review, that all corrective actions had been implemented as of 2/12/2026, and the facility was in compliance on 2/13/2026, prior to the SA's entrance on 3/18/2026.

Based on interview and record review, the facility failed to implement the comprehensive person-centered care plan requiring two (2) staff to assist with bed mobility, when staff provided care without the required assistance, resulting in the resident falling from the bed and sustaining a proximal humeral fracture (a break in the upper arm bone near the shoulder) for one (1) of three (3) sampled residents (Resident #1) .Findings include:A record review of the Care Plan Report revealed Resident #1 had a focus of an ADL (activities of daily living) self-care performance deficit with interventions initiated on 7/14/25 that included, BED MOBILITY: The resident requires x (times) 2 staff to turn and reposition in bed.A record review of the facility's investigation revealed that on 2/11/26 at 10:05 PM, Certified Nursing Aide (CNA) #1 was providing in-bed care to Resident #1, including a linen and brief change. During care, the resident rolled to assist and subsequently rolled too far, exiting the bed and landing on the floor.A record review of the Incident Witness Statement, dated 2/11/26, signed by CNA #1, revealed a Narrative if incident if witnessed, which indicated the CNA was changing the resident and went to pull the sheet from under her when the resident rolled and fell. The CNA documented, .the brief was already on her, and I also tried to reach over and keep her from falling and she was not able to hold herself up even after grabbing the rail.A record review of the admission Record revealed the facility admitted Resident #1 on 7/14/25 with diagnoses including hypertension with an additional diagnosis added on 2/14/26 of other displaced fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact. A review of Section GG revealed Resident #1 required substantial/maximal assistance for rolling left and right in bed.A record review of the XR (X-Ray) Shoulder Complete Left (Routine), dated 2/11/26, revealed, History: Shoulder injury from fall out of bed, and the impression indicated Resident #1 had a proximal humeral fracture (a break in the upper arm bone near the shoulder).A record review of the Disciplinary Conference, dated 2/12/26, revealed CNA #1 received an infraction for failing to follow the resident's plan of care.On 3/18/26 at 8:49 AM, during an interview with Resident #1, the resident explained CNA #1 was changing her bed linens alone on 2/11/26 when she fell from the bed.On 3/18/26 at 10:51 AM, during an interview with CNA #1, she confirmed she was the only staff member present while providing care. She explained she rolled the resident to remove soiled linens and replace them with clean linens when the resident fell from the bed.On 3/19/26 at 9:30 AM, during an interview with Registered Nurse (RN) #1, Care Plan Nurse, she explained that upon admission, she collaborates with nursing staff, CNAs, therapy, and dietary to assess resident needs and develop care plans. She stated she observes care to identify resident-specific needs and updates care plans quarterly, annually, and as needed.On 3/19/26 at 9:45 AM, during an interview with the Director of Nursing (DON), she explained Resident #1 had a person-centered care plan requiring (2) staff for bed mobility. She confirmed the CNA did not follow the care plan. She stated staff are expected to review the Kardex daily for updated care needs.Review of the facility's Corrective Action Plan, dated 2/12/26, revealed the President, Director of Nursing (DON), and Administrator spoke to the injured resident's family members. The President, DON, and Administrator interviewed Certified Nursing Aide (CNA) #1, Licensed Practical Nurse (LPN) #1, LPN #2, and LPN #3. A one-to-one (1:1) in-service and disciplinary conference was conducted with LPN #2 related to calling the DON for any falls or hospital transfers, and an in-service and disciplinary conference was completed by the DON. A one-to-one (1:1) in-service was conducted with LPN #1 related to calling the DON for any falls or hospital transfers and completing incident reports, and the in-service was completed by the DON. A one-to-one (1:1) in-service and disciplinary conference was conducted with CNA #1 related to following the plan of care, bed mobility, making an occupied bed, and incontinence care, with return demonstration completed with the DON. The plan further revealed no nursing staff were allowed to work until they were in-serviced on following the care plan, and in-services were completed by the Administrator, Chief Nursing Officer, and DON. A Quality Assurance and Performance Improvement (QAPI) meeting was held via telephone with the medical director and QAPI team members, during which policy was reviewed and no changes were made. The plan revealed the Lead CNA or DON would monitor care at least three (3) times weekly for compliance with care plans related to activities of daily living (ADL) care, the interdisciplinary team would meet weekly to discuss outcomes of observations for six (6) weeks, and observations would be reported to QAPI for two (2) months.Based on implementation of the facility's corrective actions on 2/12/2026, the deficient practice was determined to be Past Non-Compliance (PNC), and the facility was in compliance effective 2/13/2026Validation:The SA validated on 3/19/2026, through interview and record review, that all corrective actions had been implemented as of 2/12/2026, and the facility was in compliance on 2/13/2026, prior to the SA's entrance on 3/18/2026.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment as evidenced by adequate clean linens and washcloths were unavailable for resident care for one (1) of two (2) survey days.Findings include:A review of the facility's policy, Resident Rights, revised February 2023, revealed, .The resident has the right to a dignified existence.8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including.treatment and supports for daily living safely .On 2/9/26 at 10:50 AM, during an observation and interview with the facility owner, linen closets, supply closets, and nurses' station supply rooms were observed. The linen closet on Beach Avenue Hall was observed to contain no towels, washcloths, fitted sheets, blankets, or bed linen pads. Only one item was observed in the linen closet. The owner reported the closets would be filled once laundry staff made rounds.On 2/9/26 at 12:21 PM, during an interview, Certified Nursing Aide (CNA) #1 reported wipes were implemented to prevent staff from running out of washcloths. CNA #1 reported that normally each morning staff were without washcloths and towels and the CNA had reported the concern to the charge nurse, Director of Nursing (DON), and Administrator.On 2/9/26 at 12:29 PM, during an interview, CNA #2 reported towels, washcloths, and bed sheets were normally restocked daily at approximately 9:00 AM. She reported there had been linen shortages daily for the previous three (3) days and she reported the concern to the charge nurse. She explained that some residents used wipes instead of towels due to the shortage.On 2/9/26 at 12:47 PM, during an interview, CNA #3 reported that within the last seven (7) days, on (2) occasions, she did not have washcloths and towels available to prepare residents for breakfast. She reported she used a pillowcase or wipes to wash a resident's face or provide perineal care after a bowel movement due to the shortage. She reported she informed the charge nurse, who then informed the DON. She reported delays in receiving washcloths delayed completion of resident care. She reported linen closets were normally restocked around 8:30 AM and required additional restocking after lunch.On 2/9/26 at 1:38 PM, during an interview, the Housekeeping Supervisor reported linen closets were refilled (3) times daily, with the last refill occurring at approximately 3:00 PM. She reported there was no overnight laundry shift and laundry staff left at approximately 5:00 PM. She reported the department had been short staffed for approximately (2) months.On 2/9/26 at 1:51 PM, during an interview, Resident #1 reported linen shortages occurred daily and he believed there was a high turnover rate in the laundry department. He reported his bed was often made later in the day or after lunch due to linen shortages and reported that at night there were no bed pads or linens available.On 2/10/26 at 9:05 AM, during an interview, the DON reported staff had reported linen shortages. She reported linens were sometimes hidden in resident rooms. She explained additional linens were ordered and wipes were implemented due to linen shortages. She reported staff were educated during in-service training regarding not discarding stained linens. She stated linens were ordered weekly and the facility purchased additional towels to accommodate shortages.On 2/10/26 at 11:30 AM, during an interview, the Administrator reported that when linens were being replenished or used frequently, she conducted random checks. She explained there had been reports of washcloth shortages and wipes were implemented to prevent depletion and that she came into the facility at 4:00 AM to wash linens because there were no towels available for residents. Linen shortages were discussed during the January skills fair, and the issue had been present for at least six (6) weeks. She reported she believed staff were discarding heavily soiled linens instead of sending them to laundry for cleaning and confirmed there had been an ongoing linen shortage.A record review of daily linen issue sheets dated 2/6/26, 2/7/26, 2/8/26, and 2/9/26 revealed all linen closets were noted to be low on the morning shift at the time of inventory.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure perineal care was provided in a manner to prevent the possible spread of infection when a Certified Nurse Aide (CNA) failed to perform hand hygiene during care for one (1) of four (4) residents observed for care, Resident #22. Findings included: A review of the facility's Hand Hygiene Policy, dated 8/23, revealed, .The facility considers hand hygiene the primary means to prevent the spread of infections. All staff will perform proper hand hygiene procedures to prevent the spread of infection .Policy Guidelines .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 . On 6/12/25 at 10:34 AM, during an observation of perineal care provided by Certified Nurse Aide (CNA) #2, she began to assist Resident #22 and then stated, I need some help. She removed her gloves and exited the room without performing hand hygiene. She returned, did not perform hand hygiene but applied gloves and continued care. After completing care, she removed her gloves and applied a new pair before applying a clean brief, but did not perform hand hygiene before donning (putting on) the gloves. On 6/12/25 at 10:59 AM, during an interview with lead CNA #1, she confirmed CNA #2 did not perform hand hygiene several times after removing gloves and that hand hygiene should be performed each time staff enter or exit a room and between glove changes during perineal care. On 6/12/25 at 11:21 AM, during an interview with CNA #2, she admitted she did not perform hand hygiene each time she removed gloves or reentered the room. On 6/12/25 at 12:57 PM, during an interview with the Director of Nursing (DON), she stated CNA #2 should have performed hand hygiene when entering and exiting the room and between glove changes. On 6/12/25 at 3:29 PM, during an interview with Registered Nurse (RN) #1, the facility's Infection Preventionist, she stated CNA #2 should have washed her hands and donned clean gloves each time she entered or exited the room. She confirmed that Resident #22 could develop an infection from lapses in hand hygiene. A record review of Resident #22's admission Record revealed the facility admitted her on 6/25/19 with diagnoses including Unspecified Dementia. A record review of Resident #22's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/25 revealed her cognition was severely impaired.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to provide Percutaneous Endoscopic Gastrostomy (PEG) care in a manner to prevent the possible spread of infection during an annual recertification survey on 2/8/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of four deficiencies cited. F880. Findings include: Record review of the facility's QAPI Change Process Policy (undated) revealed, .The facility has established and utilized a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained or modified as needed . Record review of the Provider History Profile revealed the facility received a citation for F880-Infection Control. Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 2/8/2024, revealed the facility received a citation for F880, .Based on observation, staff interview, record review, and facility policy review, the facility failed to provide peg tube care and catheter care in a manner to prevent the possible spread of infection . During the current recertification survey, the facility failed to ensure perineal care was provided in a manner to prevent the possible spread of infection. On June 12, 2025, at 4:15 PM in an interview, the Administrator stated that corrective actions taken after the survey on 2/8/24 included in-service training for staff on the care and cleaning of catheter sites and PEG tube feeding sites.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain privacy during the provision of perineal care for one (1) of four (4) residents observed for care, Resident #22. Findings included: A review of the facility's policy titled Resident Rights, dated 2/2023, revealed, The resident has the right to a dignified existence .7. Privacy and confidentiality. The resident has a right to personal privacy . On 6/12/25 at 10:34 AM, during an observation of perineal care provided by Certified Nurse Aide (CNA) #2, the CNA left the resident exposed while she exited the room to get assistance. Resident #22 remained exposed and was pulling at her shirt in an attempt to cover her private area. CNA #2 returned with CNA #1, then later left the room again to retrieve additional towels, once again leaving Resident #22 exposed. The resident continued to pull her shirt down while waiting. On 6/12/25 at 10:59 AM, during an interview with lead CNA #1, she confirmed Resident #22 was left exposed and stated it was a dignity issue. She noted that the resident appeared embarrassed by being exposed. On 6/12/25 at 11:21 AM, during an interview with CNA #2, she confirmed she left the resident exposed twice when she exited the room. She acknowledged that she should have covered the resident and stated it was a dignity issue. On 6/12/25 at 12:57 PM, during an interview with the Director of Nursing (DON), she stated CNA #2 should have covered Resident #22 as much as possible during perineal care and when leaving the room to retrieve supplies. She confirmed it was a dignity issue to leave a resident exposed. A record review of Resident #22's admission Record revealed the facility admitted her on 6/25/19 with diagnoses including Unspecified Dementia. A record review of Resident #22's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/25 revealed her cognition was severely impaired.

Based on observation, interview, and record review, and facility policy review the facility failed to ensure the protection of privacy and confidentiality of resident care information when clinical instructions were posted in public view without safeguards for one (1) of eighteen (18) sampled residents, Resident #78. Findings included: A review of the facility's policy Resident Rights, dated 02/2023, revealed, .7. Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of his or her . medical records .a. Personal privacy includes .medical treatment .b. The resident has a right to secure and confidential personal and medical records . On 6/10/25 at 12:32 PM, during an observation, a sign indicating NPO (Nothing by Mouth) was observed posted on the outside of Resident #78's door, in plain view from the hallway. On 6/12/25 at 8:45 AM, during an interview with the Director of Nursing (DON), she stated the signage was posted so staff would know the resident was not to be given anything by mouth. She also stated she was unsure if the resident's family was aware that the sign had been placed on the door. On 6/12/25 at 8:49 AM, during an interview with Resident #78, she stated she had not been asked for permission for the sign to be posted and did not recall being asked about placing the sign on the door. On 6/12/25 at 9:09 AM, during an interview with Certified Nurse Aide (CNA) #1, she stated that CNAs could access residents' care information, including NPO status, via the Kardex and through documentation in the electronic health records system. On 6/12/25 at 10:45 AM, during a follow-up interview with the DON, she acknowledged that staff members from departments such as Physical Therapy and Dietary sometimes answer call lights. She stated all staff have access to residents' chart information. She also acknowledged that visitors and family members walking through the hallway could see the NPO sign posted on Resident #78's door, which contained care information that should have remained confidential. On 6/12/25 at 11:32 AM, during a phone interview with Resident #78's Resident Representative (RR), he stated no one asked him for permission to place a sign on the resident's door. He stated the resident had been transferred from another facility with an NPO order, and everyone understood that she should not be fed anything by mouth. A record review of the Profile revealed the facility admitted Resident #78 on 4/17/25 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side. A record review of the Order Details revealed a physician's order, dated 6/4/25, which indicated Resident #78 received enteral feedings. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/25 revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated her cognition was moderately impaired.

Based on staff interview, record review, and facility policy review, the facility failed to report an allegation of sexual abuse within two (2) hours, as required, when Resident #1 verbalized she was sexually abused for one (1) of three (3) sampled residents. Findings included: A review of the facility's, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation Policy, revised in August 2023, revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment .immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations with prescribed timeframes . Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation . Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency hotline . A record review of the Admission Record revealed the facility admitted Resident #1 on 09/13/2024 with diagnoses including Dementia and Alzheimer's Disease. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/23/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated her cognition was severely impaired. A record review of the facility's investigation of the alleged sexual abuse revealed that on 11/01/2024 at approximately 11:50 PM, Resident #1 exited her room with a bowel movement on her body and stated, There is so much blood, she raped me, there is so much blood. A record review of the local hospital Admission Note dated 11/02/2024 at 9:07 AM revealed, .she was yelling she was raped. On 11/12/2024 at 10:25 AM, during an interview, the Administrator stated that on 11/02/2024 at 1:18 AM, Resident #1 complained of rectal bleeding and was sent to the local emergency department. On 11/06/2024, the Administrator received a call from the case manager at the hospital reporting that a complaint would be submitted to the State Agency (SA) and the Attorney General regarding an allegation of rape at the facility. Upon receiving this information, the Administrator initiated an investigation and discovered that on 11/02/2024 at approximately 1:18 AM, Resident #1 walked out of her room with feces and blood and stated she must have been raped. The investigation revealed that Licensed Practical Nurse (LPN) #1 and Certified Nurse Assistants (CNAs) #1 and #2 were aware of the allegation on 11/02/2024 but did not report it to the Administrator or Director of Nursing (DON). The facility began their investigation on 11/06/2024 and was unable to substantiate that abuse occurred. The Administrator confirmed the facility's policy requires reporting allegations of rape to the SA, local police, and Attorney General within two (2) hours of the allegation. The facility's administration did not report the allegation on 11/02/2024 because they were unaware of the situation until 11/06/2024. On 11/12/2024 at 1:21 PM, during an interview, the DON confirmed that during the facility's investigation, there were three (3) staff members who stated that Resident #1, following a bowel movement with bleeding on 11/2/24, felt as if she was raped. The DON stated the facility was not aware of the allegation on 11/02/2024 because none of the staff informed the administration. The DON emphasized that staff should have notified her or the Administrator immediately to ensure reporting to the SA, local police, and Attorney General within two (2) hours. On 11/12/2024 at 2:20 PM, during an interview, LPN #1 confirmed that on 11/02/2024 at approximately 1:30 AM, Resident #1 appeared confused, walked out of her room with bowel and blood observed, and stated, with all this blood, I must have been raped. LPN #1 confirmed the Nurse Practitioner was notified about the bleeding, but admitted the Administrator or DON was not notified that Resident #1 said she had been raped because LPN #1 believed there was no basis for the allegation. A record review of CNA #1's witness statement revealed, .resident did not want anyone to touch her and stated rape. A record review of CNA #2's witness statement revealed, .she was saying it was so much blood and something about rape.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide peg tube care (Resident #29) and catheter care (Resident #61) in a manner to prevent the possible spread of infection for two (2) of five (5) resident care observations. Findings Include: Review of the facility's Gastrostomy Site Care Policy, dated 10/23, revealed, Policy: It is the policy of this facility to perform gastrostomy site care as ordered. Policy Guidelines .14. Using soap and water/wound cleanser gently clean the area around the tube and continue in an outward circular fashion, ensuring that under the bolster is cleaned . Review of the facility's Hand Hygiene Policy, dated 8/23, revealed, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .Policy Guidelines .6. Additional considerations: 1. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves . Resident #29 On 02/07/24 at 3:02 PM, during an observation of Percutaneous Endoscopic Gastrostomy (peg) tube care by Licensed Practical Nurse (LPN) #1 for Resident #29, she cleaned the peg tube insertion site using one (1) gauze, circling the site three (3) times. She did not rotate the gauze or use a new gauze with each circle around the peg tube insertion site. On 02/07/24 at 3:14 PM, in an interview with LPN #1, she confirmed she should have rotated the gauze or changed the gauze with each circle and her actions could have caused the resident to acquire an infection. Record review of the Admission Record revealed the facility admitted Resident #29 on 12/09/23 with current diagnoses including Aphasia following Cerebral Infarction. Record review of the Order Summary Report revealed Resident #29 had a Physician's Order, dated 12/11/23, to .Complete tube site care q (every) day and PRN (as needed). Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/23 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident was severely cognitive impaired. Resident #61 On 2/08/24 at 8:33 AM, an observation of catheter care for Resident #61 completed by Certified Nursing Aide (CNA) #1 revealed CNA #1 washed her hands and applied clean gloves. She filled the wash basin with water and turned the water off while wearing the same gloves. CNA #1 touched the water faucet handle, doorknobs, and the resident's bed linen while wearing the same gloves and did not discard and apply a new clean pair of gloves before providing catheter care. On 02/08/24 at 8:55 AM, in an interview with CNA #1, she stated she should have changed her gloves and applied a new pair of clean gloves before beginning catheter care because the resident could acquire an infection. Record review of the Admission Record revealed the facility admitted Resident #61 on 3/20/23 with current diagnoses including Retention of Urine and Benign Prostatic Hyperplasia. Record review of the Order Summary Report, revealed Resident #61 had a Physician's Order, dated 3/20/23, for Foley cath (catheter) care every shift. Review of the Quarterly MDS with an ARD of 12/5/24 revealed Resident #61 had a BIMS score of 5 which indicated he was severely cognitively Impaired. On 02/08/24 at 10:56 AM, in an interview with the DON, she confirmed CNA #1 should have prepared the wash basin and gathered supplies first and washed her hands and applied clean gloves before initiating catheter care for Resident #61. She stated there was a potential to introduce bacteria to the resident by not conducting catheter care with clean gloves. The DON stated LPN #1 should have gone around the peg tube site once per gauze or swab for Resident #29. She should have discarded it and got a new one to clean the site.

Based on observation, interview and record review, the facility failed to maintain a comfortable room temperature levels of 71 degrees to 81 degrees Fahrenheit (F) for two (2) of 18 sampled residents. Resident #13 and Resident #9 Findings include: A review of the facility's Safe and Homelike Environment Policy dated Apr (April) 23 revealed Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . Policy Guidelines: 7. The facility will maintain comfortable and safe temperature levels . Resident #13 On 02/05/24 at 12:53 PM, during an observation and interview with Resident #13, the resident complained the room temperature was too cold for him. He stated had had complained to all the staff about the room temperature, but nothing had been done. There was no unit or thermostat in the room for the resident to be able to adjust the temperature. On 02/08/24 at 9:52 AM, during a phone interview with Resident #13's wife, she explained the resident had complained about the room temperature being cold. She stated that she made staff aware, including the Administrator and the owner, and was told the system was being worked on. A record review of the Admission Record revealed the facility admitted Resident #13 on 05/28/21 with current diagnoses including Heart Failure. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/23, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. Resident #9 On 02/06/24 at 9:35 AM, during Resident Council Meeting, Resident #9 reported her room stays cold all the time, and that her hallway was also cold. A record review of the Admission Record revealed the facility admitted Resident #9 on 02/14/17 with the current diagnoses including Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side. Record review of the Annual MDS with an ARD of 11/09/23 revealed Resident #9 had a BIMS score of 13, which indicated she was cognitively intact. At 4:35 PM on 02/07/24, during an interview with the Administrator, she explained some residents had requested the facility to turn up the thermostat in the building and in their rooms. She reported the heating units are in the attic and the thermostat controls are located throughout the facility. She confirmed that there were some thermostats located in resident rooms and all thermostats were set on 72 degrees or higher. On 02/08/24 at 10:20 AM, during an observation and interview with Maintenance #1, he explained that Resident #9 and Resident #13's room temperature were controlled by a thermostat located in another resident's room (room [ROOM NUMBER]). Upon entering room [ROOM NUMBER], the thermostat was set on 68 degrees F and was on cool. The resident in room [ROOM NUMBER] stated that she had gotten hot during the night and had to turn on the air conditioner. She confirmed she adjusted the thermostat as she needed. Maintenance #1 confirmed residents have complained about being cold and that the thermostat in room [ROOM NUMBER] was not locked to prevent the resident from adjusting the temperature that affected other resident rooms. At 10:30 AM on 02/08/24, an observation of Resident #13's room (room [ROOM NUMBER]) with Maintenance #1, revealed the room temperature was 68 degrees when measured using a thermometer. Resident #9's room (room [ROOM NUMBER]) was 66 degrees initially, but when the thermometer was held near the vent in the ceiling, the thermometer reading increased to 69.4 degrees F. On 02/08/24 1:40 PM, during an interview with Administrator, she confirmed the thermostat in room [ROOM NUMBER] controls the temperatures for Rooms #16 through #21. She stated that she locked the thermostat in room [ROOM NUMBER] and turned the unit to auto, so it would turn off and on. She explained the owner had been working on the thermostats since June 2023 to remove thermostats from resident rooms. She explained that she expected all resident rooms to have a comfortable temperature from 71 degrees F and higher.

Based on observation, interviews, record review, and the facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to restraints for two (2) of 18 sampled residents. Resident #30 and Resident #36 Findings Include: A review of the facility's MDS 3.0 Completion Policy, dated October 2023, revealed, Policy Statement: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .Policy Guidelines .4. Care Plan Team Responsibility for Completion go MDS Sections .a. ii. Persons completing .the assessment must attest to the accuracy of the section they completed . Resident #30 During an observation on 2/5/24 at 1:35 PM, Resident #30 was observed to have one full length bedrail on one side of the bed and 1/4 (quarter) length side rail on the other. He stated that he requested the long bedrail to be up at night, and he kept it down during the day to make it easier to get out of the bed. A record review of the Admission Record revealed the facility admitted Resident #30 on 10/11/2023 and he had current diagnoses including Chronic obstructive pulmonary disease (COPD) and Type 2 Diabetes Mellitus A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 11/30/23 revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Review of Section P - Restraints revealed Resident #30 had bed rails coded as Used Daily. Resident #36 During an observation on 2/5/24 at 1:00 PM, Resident #36 was not in his room, however, there were 1/4 length side rails observed to both sides of the bed. A review of the Admission Record revealed the facility admitted Resident #36 on 1/6/2021 and he had current diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. A record review of the Comprehensive MDS with an ARD of 11/30/23 revealed Resident #36 had a BIMS score of 6, which indicated severe cognitive impairment. A review of Section P - Restraints revealed Resident #36 had bed rails codes as Used Daily. During an interview on 02/08/24 at 3:00 PM, with Licensed Practical Nurse (LPN) #2/ MDS nurse revealed that the 1/4 length bedrail on Resident #30 and Resident #36 were coded as a restraint on the MDS because she was trained that if a resident cannot lower the bedrail on their own, then it was to be coded as a restraint. LPN #2 revealed the 1/4 length bedrails are used as an enabler for Resident #30 and Resident #36. On 02/08/2024 at 3:50 PM, an interview with the Director of Nursing (DON) and Administrator revealed she was aware there was an MDS discrepancy regarding restraints and acknowledged the siderails for Resident #30 and Resident #36 were not a restraint but were used as an enabler. She stated that she had a meeting with the MDS nurse and the Administrator regarding bed rails and coding the MDS. The Administrator stated that she expected the MDS to be coded accurately. 48181

Based on observation, staff interviews, record review and facility policy review the facility failed to follow the care plan related to catheter/incontinent care and failed to develop an approach for securing a catheter tube for two (2) of 19 care plans reviewed, Resident #35 and Resident #117. Findings Include: Record review of the facility's policy, Comprehensive Care Plans, dated September 2018, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified assessment in the resident's comprehensive assessment. Resident #35 On 11/3/21 at 9:55 AM. an observation of catheter care by Certified Nursing Assistant #3 (CNA) and assisted by CNA #4 revealed CNA #3 did not change gloves after setting up supplies. She used gloved hands to close the curtain and did not change gloves and continued with care. CNA #3 did peri care before starting catheter care. She began care by cleaning the right groin, the left groin and then labia without folding the towel or using a clean towel. She then dried the groin areas and labia without clean towel or rotating the towel. CNA #3 did not change gloves throughout the care. She wiped the catheter tubing from insertion to the bag without folding the towel. On 11/4/21 at 9:16 AM, an in interview with CNA #4 stated that she assisted CNA #3. She stated that CNA #3 did not rotate the towels during care. She stated that CNA #3's actions could cause the resident to get a urinary tract infection. She stated she observed CNA #3 not changing gloves and rotating towels during care. On 11/4/21 at 10:00 AM, in a phone interview with CNA #4, stated her actions could have caused the resident to get sick. She stated the resident could have gotten a bacterial infection. She stated that she should have changed gloves and that the gloves had germs on them. She stated she spread germs by not changing gloves. She stated she was trying to make sure the whole thing was clean. She stated she started orientation and did a check off sheet on care. She stated she could not remember if the check off sheet had catheter care or peri care on it. She stated she was trying to make sure the whole tubing was clean. On 11/4/21 at 11:45 AM, in an interview with Director of Nursing (DON) stated CNA #3 should have never wiped the resident without folding the towel. She stated CNA #3 should have used a clean area of the towel for each area cleaned. She stated she should have changed her gloves. She stated CNA #3 could have caused Resident #35 to have a Urinary Tract Infection. On 11/4/21 at 2:10 PM, in an interview with Registered Nurse #1 (RN)/ Infection Control Nurse stated CNA #3 should not have completed care without changing gloves. She stated the resident can get a Urinary Tract Infection. She stated the resident can get any kind of infection. She stated it could make the resident sick. She stated sometimes an infection is not noticed until resident gets septic, especially the elderly. She stated if a resident gets septic, they could die. Record review of Resident #35 Comprehensive Care Plan dated 5/6/21, revealed, Focus: High risk for infection r/t (related to) F/C (foley catheter) .Intervention: .Clean foley with soap and water qs (every shift). Record review of In-service Sign-In Sheet on hand hygiene dated 5/24/21 and 10/22/21, revealed the signature of CNA #4. Resident #117 Record Review of Resident #117 Comprehensive Care Plan, dated 10/26/21, revealed Focus: High risk for infection r/t (related to) F/C (Foley Catheter). The Care plan does not address the securing device to prevent tension/trauma to the meatus and or infection. During an observation on 11/03/21 at 11:14 AM of incontinent care with Certified Nursing Assistant (CNA) #1 and (CNA) #2 revealed the CNA's Resident #117 had a securing device that was dislodged and was not secured to the residents leg to prevent trauma. No one addressed the securing device that was not connected to the residents leg. Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 were also present. During an observation on 11/3/21 at 2:30 PM reveal Resident #117 was sitting up in wheelchair without a securing device connected to the residents leg to prevent tugging on the meatus. The catheter tubing was dangling. The catheter bag was connected to the right side of the wheelchair. During an interview on 11/03/21 at 02:47 PM, with CNA #1 confirmed the resident's catheter was not secured to the resident's leg. CNA #1 said this could cause trauma to the meatus and cause the catheter to come out or infection. CNA #1 said it is the CNA's responsibility to tell the nurse if the resident's leg strap or securing device has come off the Resident's leg. CNA #1 said she didn't realize the securing device was not connected to the resident. CNA #1 confirmed the resident has been sitting in the wheelchair all day with the catheter unsecured to the residents leg. During an interview on 11/03/21 at 03:11 PM, with CNA #2 confirmed she failed to notify the nurse that Resident #117's catheter tubing was not secured while she was providing care. CNA #2 confirmed by pulling on the catheter could cause trauma to the meatus/bladder and or urinary tract infections ([CONDITION(S)]). During an interview on 11/3/21 at 3:15 PM, with LPN #1 confirmed she failed to secure Resident #117 catheter tubing. LPN #1 confirmed that pulling on the catheter could cause trauma to the meatus and can cause infections. During an interview on 11/3/21 at 3:20 PM with RN #1 confirm she failed to secure Resident #117 catheter tubing while providing care and did not notice the resident's catheter was not secured to her leg. RN #1 said if the tubing is not secure it could cause trauma to the meatus, and or infection. RN #1 confirmed the resident has been sitting in wheelchair all day with the catheter tubing unsecured. During an interview on 11/04/21 at 2:30 PM, with the Director of Nursing (DON) said the CNAs are trained to notify the nurse and the nurses are trained to secure the tubing to prevent tension. The DON confirmed CNA #1, CNA #2, LPN #1 and RN #1 could have caused trauma to the meatus/urethra and/or infections. Record review of the Admission Record revealed Resident #117 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/21 revealed Resident#117 had a Brief Interview for Mental Status (BIMS) of 15 that indicted #117 is cognitively intact. On 11/4/21 at 2:25 PM in an interview with RN #3/ Care Plan nurse stated she expects the staff to follow the care plan. She stated by them not following the care plan the resident can get an infection. Review of the facility, CNA Competency Based Orientation, dated 9/10/21 revealed Certified Nursing Assistant (CNA) #2 was educated on the care of residents with catheters. Review of the facility, CNA Competency Based Orientation, dated 4/16//21 revealed Certified Nursing Assistant (CNA) #1 was educated on the care of residents with catheters. Review of the facility, Nursing Competency Based Orientation, dated 9/11/21 revealed Licensed Practical Nurse (LPN) #1 was educated on the care of residents with catheters. Review of the facility checklist, dated 10/25/21 revealed Registered Nurse #1 was educated on the care of residents with catheters.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to prevent the possible spread of infection while providing incontinent care for two (2) of three (3) observations. Resident #35 and Resident #45. Findings Include: Record review of the facility's policy, Hand Hygiene Policy, dated March 2020, revealed, Policy: The purpose of this policy is to provide guidelines for proper hand hygiene to prevent spread of infection to other personnel, residents, and visitors. Policy Guidelines: All facility personnel must perform hand hygiene for at least 20 seconds under the following conditions: .8. Before handling clean or soiled dressings/linens/etc. 9. Before performing resident care procedures .11. After handling soiled dressings/linen, contaminated equipment, etc. 12. After contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin. 13. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. Record review of the facility's, Standard Precaution Policy, dated March 2020, revealed, Policy: Standard precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status .Gloves: j. Change gloves, as necessary, during the care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one) .l. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, .wash hands immediately to avoid transfer of microorganisms to other residents or environments. The facility policy, Perineal Care Policy, dated October 2018 revealed, Policy: It is the practice of the facility to provide perineal care to all incontinent residents during routine baths and as needed in order to promote cleanliness and comfort, prevent infections to the extent possible, and prevent and assess for skin breakdown .13. Females: d. Cleanse perineum by wiping in direction from front to back and repeat on opposite side using separate section of washcloth or new disposable wipe. c. Cleanse the labia folds by gently separating labia and wiping in a downward direction from pubic area toward rectum. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke . Resident #35 On 11/3/21 at 9:55 AM, an observation of peri care/catheter care with Certified Nursing Assistant (CNA) #3 and assisted by CNA #4 revealed CNA #3 did not change gloves after setting up supplies. She closed the privacy curtain and did not change her gloves. She continued care with the same gloves. CNA #3 did peri care before starting catheter care. She began the care by cleaning the right groin, the left groin and then the labia without rotating the towel to a different area or using a clean towel. She then dried the groin areas and labia with a clean towel. She did not rotate the drying towel to a different area between sites. CNA #3 did not change gloves throughout the care. She wiped the catheter tubing from the insertion site to the drainage bag without rotating or folding the towel to a different area. On 11/4/21 at 9;16 AM, interview with CNA #4 stated that she assisted CNA #3. She stated that CNA #3 did not rotate the towels during care. She stated that CNA #3 actions could cause the resident to get a Urinary Tract Infection. She stated she observed CNA #3 not changing gloves and contaminating the catheter tubing by wiping from the insertion site to the drainage bag. On 11/4/21 at 10:00 AM, in a phone interview with CNA #3 she stated her actions could have caused the resident to get sick. She stated the resident could have gotten a bacterial infection. She stated that she should have changed gloves because the gloves had germs on them. She stated she spread germs by not changing gloves. She stated she wiped all the way to the drainage bag because she was trying to make sure the whole thing was clean. She stated she started orientation and did a check off sheet on care. She stated she could not remember if the check off sheet had catheter care or peri care on it. She stated she was trying to make sure the whole tubing was clean. On 11/4/21 at 11:45 AM, in an interview with the Director of Nursing (DON) stated CNA #3 should have never wiped the resident without folding the towel. She stated CNA #3 should have folded the towel or used a clean towel between sites and should have changed her gloves. She stated the resident can get a [CONDITION(S)] or skin infection. She stated CNA #3 spread germs by cleaning the tubing from the insertion site to the drainage bag. On 11/4/21 at 2:10 PM, in an interview with Registered Nurse #1 (RN)/ Infection Control Nurse stated CNA #3 should have not completed care without changing her gloves. She stated the resident could get a Urinary Tract Infection. She stated it could make the resident sick. She stated sometimes an infection is not noticed until the resident gets septic. especially with the elderly. She stated if a resident gets septic, they could die. Record review of the Admission Record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's Order Summary Report for active orders as of 11/4/21 revealed foley catheter care using soap and water every shift. Record review of Resident #35's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/21 revealed a Brief Interview of Mental Status (BIMS) score of 99 indicating Resident #35 was unable to complete the interview. Record review of CNA #3's Competency Based Orientation, with a start date of 10/22/21 and end date of 10/25/21, revealed CNA #3's signature was on the orientation form. CNA #3 initials were noted on the competency for care of resident with a catheter and hand hygiene. Resident #44 On 11/3/21 at 2:22 PM, during an observation of peri care by Certified Nursing Assistant #4 (CNA) and assisted by CNA #5 revealed CNA #4 opened a drawer in Resident #44's room with gloves on to get briefs. She did not change gloves after getting a brief out of the drawer. CNA#4 raised the head of the bed using the remote and provided peri care for Resident #44 without changing gloves. She removed the gloves and sanitized her hands. CNA #4 applied clean gloves and opened a drawer to get out skin protectant. She applied protectant to the resident's buttocks. CNA #4 picked up two clear bags off the resident's bed. One bag contained dirty towels. The second bag contained a soiled incontinent pad and a soiled brief and placed them on the floor. She then picked the bags up off the floor and placed them on the resident's bed. On 11/4/21 at 9:16 AM, in an interview with CNA #4 revealed by putting the bags on the floor then placing the bags on the resident's bed, she cross contaminated the resident's bed. She stated the resident can get sick. She stated she should not have opened the drawer with gloved hands and continued care without changing gloves. She stated she should have made sure she had all supplies before beginning care. She stated her actions can cause the resident to get an infection. On 11/4/21 at 11:55 AM, in an interview with the Director of Nursing (DON), she stated CNA #4 should have never placed any items on the floor. She stated she should have not placed the items on the bed after placing them on the floor. She stated by the CNA placing items from the floor to the bed everything that was on the floor was put on the resident's bed. She stated she could introduce the resident to bacteria and spread it all over. She stated by CNA #4 not changing gloves and sanitizing her hands she spread germs from the gloves to the Resident. She stated it is a possibility the resident could get an infection. Record review of the Admission Record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS with an ARD of 9/17/21, revealed that the resident required extensive assistance with toileting and Section C revealed a BIMS score of 00 section indicating severe cognitive impairment. Record review of CNA #4's signature on the In-service Records dated 10/22/21 and 5/24/21 on the topic of hand hygiene.

Based on staff interviews and record review, the facility failed to ensure two (2) of two (2) sampled residents received written notice of transfer to the hospital. Resident # 23 and Resident # 67. Findings include: Resident #23 During an interview on 11/03/21 at 08:50 AM, with the Administrator, stated on admission the family signs a bed hold policy and when a resident is transferred to the hospital the nurse will fill out the form. The form is sent with the resident to the hospital. The family gets the sheet when the resident arrives at the hospital. The Administrator confirmed the facility does not mail letters to the family/representatives explaining why the resident was transferred to the hospital. The Administrator said the facility emails the resident representative when the resident is sent to the hospital. The Administrator also confirmed the facility did not have a Transfer Policy. On 11/03/21 at 4:00 PM, during a phone interview with Resident #23's Representative, she explained at the time her mother was transferred to the hospital in August, the facility did call to inform her of the transfer, but the facility did not send her a letter or email regarding transfer. Record review of Progress Notes revealed Resident #23 was sent to hospital on August 10, 2021. Record review of Resident #23's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/2021 revealed Resident #23 was discharged with return anticipated and the type of discharge was unplanned to an acute hospital. Section C of the MDS for staff assessment of cognitive patterns revealed Resident #23 had memory problems and cognitive skills are severely impaired and at the time of the discharge Resident #23 had altered level of consciousness. Record review of Resident #23's Admission Record revealed the facility admitted Resident #23 on 03/03/2021 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67 During an interview on 11/04/21 at 10:41 AM, with Registered Nurse (RN) #3 confirmed the resident was sent to the hospital on 7/9/21. RN #3 revealed Resident #67 was discharged home on 8/7/21 with (Name of Local Hospice). Record review of the Admission Record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07//09/21 revealed Resident #67 had a Brief Interview for Mental Status (BIMS) of 3 that indicted #67 has severe cognitive impairment.

Based on observation, staff and resident interviews, the facility failed to ensure food was served at a palatable and satisfactory temperature for five (5) of twelve (12) residents interviewed in Resident Council. (Residents #16, #26, #38, #42, and #53) Finding Include: On 11/02/21 at 2:00 PM, during Resident Council meeting, residents complained of receiving cold food if they decide to eat in their rooms and not in the dining area. The residents explained that all three meals have been served cold in their rooms. Residents explained they have talked about food being cold in previous resident council meetings and have made the Social Worker aware of the cold food. At 3:00 PM on 11/02/21, during an interview with Social Worker, she explained she does attend the resident council meetings monthly at the request of the residents and takes the meeting minutes. She confirmed the residents did have complaints about the food being served cold. On 11/03/21 12:00 PM State Survey Agency (SSA) observed Dietary #2 and Dietary #3 preparing hall lunch trays for the residents in the rooms. Dietary #2 explained the second cart is the cart that goes to the last hall and the last residents to be served in their room. SSA requested a tray to be fixed for SSA and placed on the last cart as the last tray served. SSA tray completed at 12:10 PM by Dietary #3 and the tray was placed in the insulated delivery cart which trays are placed inside the cart, with the doors closed, and await to be taken to the residents. At 12:15 PM, the insulated tray delivery carts leave the kitchen and go to the dining area and are left. SSA ask dietary #2 after cart leaves the kitchen who transports the carts with trays to the hall and the residents, she explained the aides from the hall will pick up the delivery carts and then takes the cart and delivers the trays to the residents in their room. At 12:20 PM no aides noticed to pick up delivery carts from the dining area. SSA observed Registered Dietician (RD) started to push the delivery cart down the hallway toward rooms. SSA asked the RD does she normally push the carts to the floor, she explained she always tries to help, but mostly does the dining observations in the dining room. The last tray off the delivery cart was delivered to room 45 and then the SSA tray was handed to the SSA at 12:30 PM. Two SSA tasted all food items on the tray, including rice, chicken teriyaki, oriental mixed vegetables, and vegetable egg roll. The oriental mixed vegetables were lukewarm, and the white rice and chicken teriyaki were cold to the taste and cold to the touch. On 11/03/2 at12:35 PM the Administrator was notified of the cold food served on the tray. The Administrator explained she is sorry for the cold food and will notify the Dietary Manager. On 11/03/21 at 12:45 PM, in an interview with the Dietary Manager, she explained she is sorry about the lunch tray. On 11/03/21 at 1:00 PM during an interview with Dietary #2, she explained she knew the food would be cold due to it took too long for Dietary #3 to serve the trays, close the door on the insulated tray delivery cart, and get the cart out of the kitchen. She explained this does happen frequently. At 2:30 PM on 11/04/21 interview with Resident #16, she explained her breakfast is served cold. On 11/04/21 interview with Resident #26 at 2:40 PM, she explained she tries to eat in the dining room for all meals now due to meals were always cold when served in her room. At 2:50 PM on 11/04/2021 during an interview with Resident #38, she explained all three meals have been served cold to her in her room. At 3:00 PM during an interview with Resident # 42 on 11/04/21, she explained her meals have been served cold to her in her room, so she tries to eat lunch in the dining room but does eat dinner in her room at times. On 11/04/21 at 3:10 PM during an interview with Resident #53, he explained is always served cold for all meals. On 11/04/21 at 3:30 PM during an interview with the Administrator, when ask for a food policy on serving food, she explained the facility does not have a policy regarding the temperature of food when served to residents. Resident #16 Record review of Resident #16's Admission Record revealed the facility admitted Resident #16 on 02/17/2020 with the diagnosis of Type 2 diabetes mellitus. Record review of Resident #16's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/221 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Resident #26 Record review of Resident #26's Admission Record revealed the facility admitted Resident #26 on 09/05/2019 with the diagnosis of Type 2 Diabetes mellitus. Record review of Resident #26's Annual MDS 08/17/2021 revealed Resident #26 had a BIMS score of 15, which indicated cognitively intact. Resident #38 Record review of Resident #38's Admission Record revealed the facility admitted Resident #38 on 03/05/21 with the diagnosis of Fracture of second vertebra with delayed healing. Record review of Resident #38's Quarterly MDS with ARD of 09/08/2021 revealed Resident #38 had a BIMS score of 15, which indicated cognitively intact. Resident #42 Record review of Resident #42's Admission Record revealed the facility admitted Resident #42 on 03/19/2015 with the diagnosis of [CONDITION(S)]. Record review of Resident #42's Quarterly MDS with ARD of 09/14/2021 revealed Resident #42 had a BIMS score of 15, which indicated cognitively intact. Resident #53 Record review of Resident #53's Admission Record revealed the facility admitted Resident #53 on 10/07/2020 with the diagnosis of [CONDITION(S)] Heart Disease of native artery. Record review of Resident #53's Annual MDS with ARD of 09/28/2021 revealed Resident #53 had a BIMS score of 15, which indicated Resident #53 is cognitively intact.

Based on observation, staff interviews, record review and facility policy review the facility failed to provide catheter/incontinent care in a manner to prevent infection and trauma to the meatus during catheter/incontinent care for two (2) of three (3) catheter care observations Resident #35 and Resident #117. Findings include: The facility policy, Catheter Care Policy, dated October 2018 revealed, Policy: The purpose of this procedure is to prevent catheter-associated urinary tract infections .Policy Explanation and Compliance Guidelines: 9 .Wipe from front to back with a clean cloth moistened with water and perineal cleanser (soap). Use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter . The facility policy, Perineal Care Policy, dated October 2018 revealed, Policy: It is the practice of the facility to provide perineal care to all incontinent residents during routine baths and as needed in order to promote cleanliness and comfort, prevent infections to the extent possible, and prevent and assess for skin breakdown .13. Females: d. Cleanse perineum by wiping in direction from front to back and repeat on opposite side using separate section of washcloth or new disposable wipe. c. Cleanse the labia folds by gently separating labia and wiping in a downward direction from pubic area toward rectum. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke . Resident #35 On 11/3/21 at 9:55 AM, an observation of catheter care being completed by Certified Nursing Assistant #3 (CNA) and assisted by CNA #4. During incontinent care CNA #3 cleaned the groin area and labia using the same area of the towel without rotationg sites on the towel. She wiped the catheter tubing from the insertion site to the drainage bag without rotating or folding the towel to a different area. On 11/4/21 at 9:16 AM, in an interview with CNA #4, she stated that she assisted CNA #3. She stated that CNA #3 did not rotate the towels during care. She stated that CNA #3's actions could cause the resident to get a urinary tract infection ([CONDITION(S)]). On 11/4/21 at 10:00 AM, in a phone interview with CNA #3, stated her actions could have caused the resident to get sick. She stated the resident could have gotten a bacterial infection. She stated she was trying to make sure the whole thing was clean. She stated she started orientation and did a check off sheet on resident care. She stated she could not remember if the check off sheet had catheter care or peri care on it. On 11/4/21 at 11:45 AM, in an interview with Director of Nursing (DON) stated CNA #3 should have never wiped the resident without folding the towel. She stated CNA #3 should have used the towel in a different area. She stated the resident can get [CONDITION(S)] or skin infection. She stated the CNA should have folded towel or changed the towel. She stated CNA #3 spread germs by cleaning the catheter tubing from the insertion site to the drainage bag. On 11/4/21 at 2:10 PM, in an interview with Registered Nurse #1 (RN)/ Infection Control Nurse, she stated the resident can get a Urinary Tract Infection. She stated the CNA's actions can cause all kinds of harm and the resident can get any kind of infection. She stated it could make the resident sick. She stated sometimes an infection is not noticed until a resident gets septic, especially the elderly. She stated if a resident gets septic, they could die. Record review of the Admission Record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #35's Order Summary Report for active orders as of 11/4/21 revealed foley catheter care using soap and water every shift. Record review of Resident #35 discharge Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 10/24/21 revealed a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete interview. Record review of Resident #35 Comprehensive Care Plan dated 5/6/21, revealed, Focus: High risk for infection r/t (related to) F/C (foley catheter) .Intervention: .Clean foley with soap and water qs (every shift). Record review of CNA #3 Competency Based Orientation, start date of 10/22/21 and end date of 10/25/21, revealed CNA #3's signature on orientation and CNA #3's initials on competency for care of resident with a catheter and hand hygiene. Resident #117 During an observation on 11/03/21 at 11:14 AM, of incontinent care with CNA #1 and CNA #2 revealed Resident #117 had a catheter securing device that was not secure to her leg. The securing device was dislodged and was not secured to the residents leg to prevent possible trauma. No one addressed the securing device that was not connected to the residents leg. Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 were present. During an observation on 11/3/21 at 2:30 PM, revealed Resident #117 was sitting up in her wheelchair without a catheter securing device connected to the resident's leg to prevent tugging on the meatus. The catheter tubing was dangling. The catheter bag was connected to the right side of the wheelchair. During an interview on 11/03/21 at 02:47 PM, with CNA #1 confirmed the resident's catheter was not secured to the resident's leg. CNA #1 said this could cause trauma to the meatus and cause the catheter to come out or infection. CNA #1 said it is the CNA's responsibility to tell the nurse if the resident's leg strap or securing device has come off the Resident's leg. CNA #1 said she didn't realize the securing device was not connected to the resident. CNA #1 confirmed the resident has been sitting in the wheelchair all day with the catheter unsecured to the her leg. During an interview on 11/03/21 at 03:11 PM, with CNA #2 confirmed she failed to notify the nurse that Resident #117's catheter tubing was not secured while she was providing care. CNA #2 confirmed by pulling on the catheter could cause trauma to the meatus/bladder and or urinary tract infections ([CONDITION(S)]). During an interview on 11/3/21 at 3:15 PM, with LPN #1 confirmed she failed to secure Resident #117 catheter tubing. LPN #1 confirmed that pulling on the catheter could cause trauma to the meatus and can cause infections. During an interview on 11/3/21 at 3:20 PM, with RN #1 confirmed she failed to secure Resident #117's catheter tubing while providing care and did not notice the resident's catheter was not secured to her leg. RN #1 said if the tubing is not secure it could cause trauma to the meatus and/or infection. RN #1 confirmed the resident has been sitting in the wheelchair all day with the catheter tubing unsecured. During an interview on 11/04/21 at 2:30 PM, with the Director of Nursing (DON) said the CNAs are trained to notify the nurse and the nurses are trained to secure the tubing to prevent tension. The DON confirmed CNA #1, CNA #2, LPN #1 and RN #1 could have caused trauma to the meatus/urethra and/or infections. Record review of the Admission Record revealed Resident #117 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/21 revealed Resident#117 had a Brief Interview for Mental Status (BIMS) of 15 that indicted she is cognitively intact. Review of the facility, CNA Competency Based Orientation, dated 9/10/21 revealed Certified Nursing Assistant (CNA) #2 was educated on the care of residents with catheters. Review of the facility, CNA Competency Based Orientation, dated 4/16/21 revealed Certified Nursing Assistant (CNA) #1 was educated on the care of residents with catheters. Review of the facility, Nursing Competency Based Orientation, dated 9/11/21, revealed Licensed Practical Nurse (LPN) #1 was educated on the care of residents with catheters. Review of the facility checklist, dated 10/25/21 revealed Registered Nurse #1 was educated on the care of residents with catheters.

CI MS # Based on interview, record review, and policy review, the facility failed to prevent a significant medication error for Resident #1, one (1) of five (5) residents reviewed for medication errors. Resident #1 received 20 mg of [MEDICATION NAME] by mouth instead of the ordered dose of 4 mg of [MEDICATION NAME]. The resident had no negative effects related to the medication error. Findings include: Review of the facility's Medication Errors Policy, dated (MONTH) (YEAR), revealed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Review of a physician's orders [REDACTED]. Review of a medication discrepancy report, dated [DATE], revealed a medication error was reported for Resident #1. The order was supposed to be for [MEDICATION NAME] 20 mg/5 ml-1 ml PO every 2 hours for pain as needed (4 mg) and the resident was administered [MEDICATION NAME] 20 mg/1 ml (20 mg) PO at 9:54 AM, and again at 11:36 AM. The report documented Resident #1 was monitored closely, vitals remained stable, and [MEDICATION NAME] (narcotic antagonist) was ordered, but not given (kept on hand). The report documented the pharmacy did not provide the correct medication/labeling and staff were educated on the medication error policy. Review of Nurse's Notes, dated [DATE], revealed Resident #1 complained of abdominal and leg pain, with [MEDICATION NAME] (pain medication) not sufficiently relieving the pain, so on [DATE], nurses' notes reflected the Nurse Practitioner (NP) ordered [MEDICATION NAME] (20 mg/5 ml-1 ml every 2 hours) for pain and [MEDICATION NAME] for anxiety. During an interview, on [DATE] at 9:10 AM, the Nurse Practitioner (NP) stated that Resident #1 was not urinating, evidence of a urinary tract infection [MEDICAL CONDITION], and her kidneys were shutting down. The NP stated that she ordered [MEDICATION NAME] on [DATE], for severe pain and met with the family. She stated the family wanted Do Not Resuscitate (DNR) orders and wanted only comfort measures. She stated the next day Resident #1 was thrashing around and moaning, so she (NP) wrote an order for [REDACTED].#1 was still in excruciating pain, so she ordered a second dose, which relieved the pain and vital signs remained stable. She stated after the 2nd dose, they discovered the medication error; 20 mg was given, not the four (4) mg per order. She said the family was in the room and they were informed of the error as well as informing the Medical Director and the Pharmacist. She stated the family did not want the error reported. The NP stated family said it stopped her pain, and that's what they wanted. The NP said she ordered [MEDICATION NAME], which was available, but it wasn't used, because the resident's vital signs were stable for the next five (5) hours. She said she came back about 3:30 PM, and met with staff to determine how the medication error happened. She stated the Pharmacist accepted the blame; said he should have caught the problem before giving the code to the [NAME] kit (emergency kit). She said Hospice came in and ordered five (5) mg of [MEDICATION NAME] every four (4) hours as needed for pain. The NP added that Resident #1 ceased breathing at 12:26 AM on [DATE], however, it wasn't related to the [MEDICATION NAME] error. Interview with the Director of Nursing (DON) at 9:30 AM on [DATE], revealed when she was notified of Resident #1's continued pain and the need for more [MEDICATION NAME], the pharmacist had them FAX over a copy of a written order for the drug, then he gave the code to open the E-kit. She stated she met with the family and they were distraught with Resident #1's continuing pain, and her daughter said, She just wants to die. The DON stated staff administered one (1) ml of [MEDICATION NAME], or 20 mg, and an hour later the resident was still rolling around and moaning, so a second dose was administered per the NP order. The DON stated the resident's pain was relieved and she started snoring. The DON stated there were 14 family members present and they were relieved. She said they had an order for [REDACTED]. The DON stated the family refused further treatment for [REDACTED]. The DON stated they pulled the multi-dose [MEDICATION NAME] and only had the single dose [MEDICATION NAME] now. The DON said Resident #1's physician reported Resident #1 died of kidney failure, untreated UTI, [MEDICAL CONDITION]. The Pharmacist was interviewed by telephone at 10:30 AM on [DATE]. He stated it was his fault for the [MEDICATION NAME] medication error; he released the code. He said he failed to look closely at the order, and stated, I screwed up. The Pharmacist stated the dose Resident #1 got was not out of the ordinary, that it is not rare, and that a higher dose of [MEDICATION NAME] was often given. He said Resident #1 was never in any danger from that dosage. He said there were four (4) other residents in the facility being given [MEDICATION NAME] and there were all checked and had no mediation errors. During an interview on [DATE] at 12:00 Noon, the RN Hospice Nurse Manager related that the dosage Resident #1 was given was a usual order; that residents can be given up to 20 mg per hour for unrelieved pain. She said it was evident the first dose did not relieve the resident's pain, and a second dose was given about an hour later, which made her comfortable, but in no way contributed to her death. At 2:00 PM, on [DATE], Resident #1's Grandson (son of the RP) returned a call and praised the care for his grandmother by the facility. He stated he was there at the time his Mother (RP) discussed the UTI; that she did not want Resident #1 treated for [REDACTED]. He said the facility kept them informed; they were told about the medication error and family asked them not to call and report the error. Resident #1 was admitted to the facility on [DATE], from a local hospital after surgery for [REDACTED].

Based on observation, interview, and record review, the facility failed to revise the care plans for one (1) of 21 sampled residents, Resident #14. Resident #14's care plan was not updated to include interventions for a known unsafe behavior. Findings include: Record review of the facility's policy titled, Comprehensive Care Plans, dated (MONTH) (YEAR), revealed the comprehensive care plan would be reviewed and revised by the team after each comprehensive and quarterly MDS assessment. The comprehensive care plan would use the objectives to monitor the resident's progress. Resident #43 Resident #43's Care Plan, located in the EM and dated 02/11/19, indicated, High risk for altered moods, behaviors, anxiety, and entering other residents' rooms. The Care Plan did not document issues with unsafe acts by Resident #43, such as thinking a bottle of soap was water to drink and there were no new interventions to address this activity. The 01/18/19 Nurse's Note documented: This nurse in resident's room making rounds when resident came out of bathroom. Resident had a bottle that had soap in it, in her hands twisting the lid back on it. This nurse asked resident what she was doing with the bottle. Resident stated, It's my water bottle to drink. This nurse explained to resident that it is a soap bottle, and not a good idea to drink out of it. This nurse asked resident if she drank anything from the bottle. Resident stated, No. This nurse showed resident her water pitcher/cup and told her there is water in it and if she needed more to let staff know. Resident got upset and started to cry and stated, Why do I always do things like this. This nurse consoled resident and was able to calm her down and took her to the dining room. Resident on antibiotic for Urinary Tract Infection. Confusion noted. During an interview with the Registered Nurse (RN) #17 MDS/CP Coordinator, on 03/06/19 at 8:54 AM, she stated each team member was responsible for revising a care plan when indicated. The MDS Coordinator said she was not aware of the 01/18/19 incident with the soap; the incident was not discussed at the care plan meeting in (MONTH) 2019, and therefore, she did not revise Resident #43's care plan. During interview on 03/06/19, with the Director of Nurses (DON) at 9:46 AM, she acknowledged Resident #43's current care plan did not reflect the potential for issues with soap etc. and did not have interventions to ensure Resident #43's safety. During an interview with Licensed Practical Nurse (LPN) #22, on 03/07/19 at 2:36 PM, she stated Resident #43 had Dementia and confusion. LPN #22 stated she observed Resident #43 twisting the cover back on a bottle of soap that had a pump on it. LPN #22 stated there was no resident name on the bottle and she had no idea where Resident #43 obtained the soap bottle. LPN #22 stated Resident #43 told her she was filling up her water bottle. LPN #22 stated when asked, Resident #43 told her she did not drink anything from the soap bottle and she took the soap bottle from Resident #43. LPN #22 stated she documented the incident in the nurse's note and notified the certified nurse aides on the unit regarding the incident. LPN #22 stated Resident #43 had no adverse effects. LPN #22 stated she notified the oncoming nurse. LPN #22 stated she did not revise Resident #43's care plan. The Profile found in Resident #43's EMR, indicated Resident #43 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #43's annual MDS, with an ARD of 10/26/18, indicated the resident had a BIMS score of 5 out of 15, which indicated severe cognitive impairment. Resident #43 required supervision and assistance with mobility and set up help with eating. During interview with RN #17/MDS/CP Coordinator, on 03/07/19 at 2:30 PM, she stated she expected care plans and interventions to be developed as resident needs were identified.

Based on observation, record review, and interview, the facility failed to implement comprehensive care plan interventions for two (2) of the 21 sampled residents, Resident #14 and Resident #42, whose care plans were reviewed. Resident #42 had a care plan for indwelling urinary catheter care that was to be done every shift and the care plan was not consistently implemented. Resident #14 had a care plan for nail care to be provided, which was not implemented. Findings include: Record review of the facility's policy titled, Comprehensive Care Plans, dated (MONTH) (YEAR), revealed the policy of the facility was to develop and implement a comprehensive person-centered care plan for each resident that was consistent with residents' rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were outlined in the resident's comprehensive assessment. Review of the Policy Explanation and Compliance Guideline revealed the care plan process would include an assessment of the resident's strengths, needs, personal, and cultural aspects to develop measurable objectives and timeframes. The comprehensive care plan would be developed within seven (7) days of the completion of the Minimum Data Set (MDS). Triggered areas on the MDS and other factors identified by the interdisciplinary team would also be addressed in the care plan. The guidelines further revealed the comprehensive care plan would describe the services that would be provided to attain or maintain the resident's highest physical, mental, and psychosocial well-being. Further review revealed the comprehensive care plan would be reviewed and revised by the team after each comprehensive and quarterly MDS assessment. The comprehensive care plan would use the objectives to monitor the resident's progress. Interview with the Administrator on 03/07/19 at 2:15 PM revealed the facility did not have a specific policy on implementation of the care plan interventions. Resident #42 Review of the Comprehensive Care Plan for Resident #42, undated, revealed a problem for being at high risk for infection which was related to an indwelling urinary catheter and urine retention. One (1) of the interventions directed the staff to wash the indwelling urinary catheter with soap and water every shift and as needed. Observation of Resident #42 on 03/04/19 at 8:40 AM, revealed he was in his room lying on the bed. An indwelling urinary catheter was draining to bedside drainage and the urine was medium yellow with no sediment. Interview on 03/06/19 at 10:58 AM, with Resident #42, revealed the staff may have cleaned the catheter tubing when he was first admitted but, the tubing had not been cleaned since then. Interview on 03/06/19 at 11:00 AM, with Registered Nurse (RN) 5, revealed the nurses and the Certified Nursing Assistants (CNA's) both perform catheter care. The CNA's mark in the kiosk (a remote computer station) that the catheter care was done, and the nurses document on the Treatment Administration Record (TAR) showing catheter care had been completed. RN #5 further revealed the CNA's could also just tell the nurse catheter care was completed. RN #5 stated if the documentation on the TAR was blank then that meant the catheter care had not been performed as ordered. Record review of the (MONTH) 2019 TAR revealed 13 blanks for day shift which indicated catheter care may not have been performed. Record review of the (MONTH) 2019 TAR, revealed blanks on (MONTH) 1, 2019 and (MONTH) 5, 2019, which indicated catheter care may not have been done. During interview with Resident #42 on 03/07/19 at 9:20 AM, after observation of catheter care, the resident stated the staff had not done catheter care since he was admitted . He stated they may have flushed the catheter, but they had not cleaned it before. Interview on 03/07/19 at 9:45 AM, with CNA #9, who provided care to Resident #42 that day, revealed the CNA's do catheter care every two (2) hours, however she stated Resident #42 did not have a catheter. CNA #9 revealed she had not been in to provide care to Resident #42 since she had come on the shift at 7:00 AM. Observation further revealed CNA #9 reviewed the care plan in the kiosk, twice, and still stated Resident #42 did not have a catheter, even though the care plan had a problem listed for catheters. CNA #9 stated the area for peri care was where they documented a check which indicated the peri care and catheter care had been completed. Interview with CNA #9 revealed she had not looked at Resident #42's care plan that morning. Interview on 03/07/19 at 10:03 AM, with RN #2/Quality Assurance (QA) Nurse/Infection Preventionist (IP), revealed it would be anyone's guess as to whether the catheter care was done in (MONTH) 2019, on the dates where the documentation was not signed as completed. She further revealed the failure to do catheter care for Resident #42 put him more at risk for infection. Interview with RN #17/Minimum Data Set (MDS)/Care Plan (CP) Coordinator, on 03/07/19 at 2:00 PM, revealed Resident #42 had a care plan for catheter care and the care plan should be followed. She further revealed she expected the care plan to be updated each time something happened with a resident. RN #17/MDS/CP Coordinator stated if a resident developed a pressure sore, then a care plan should be developed for the pressure sore and interventions should be implemented. Review of the Admission Sheet revealed Resident #42 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #42's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/19, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #42 had an indwelling urinary catheter. Resident #14 Review of the 12/21/19 Certified Nursing Assistant (CNA) Plan of Care, noted: Daily cleaning and weekly trim of nails. Observations on 03/04/19 at 10:00 AM and 3:30 PM, on 03/05/19 at 9:30 AM and 4:00 PM, and on 03/06/19 at 10:00 AM and 2:53 PM, revealed Resident #14 was lying in her bed and had dark brown material under her finger nails. During an observation on 03/06/19 at 10:00 AM, with CNA #16, Resident #14 was lying in bed and CNA #16 confirmed Resident #14 had dirty nails that required a trim and cleaning. During an interview on 03/06/19 with CNA #16 at 10:12 AM, she stated she was assigned to Resident #14 on 03/05/19 and 03/06/19. CNA #16 stated that although she provided personal care to Resident #14 on 03/05/19 and 03/06/19, and the resident was compliant with personal care, she did not trim or clean Resident #14's nails. Observations and interviews on 03/06/19 at 11:35 AM, with the Director of Nurses (DON), and at 3:53 PM with the Administrator, confirmed Resident #14 was lying in her bed with brown material under her nails. The Profile found in Resident #14's electronic medical record (EMR), indicated Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #14's significant change MDS assessment, with an ARD of 12/26/18, indicated Resident #14's Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated Resident #14 had moderate cognitive impairment, required assistance of one (1) to two (2) staff members for personal care, and had no behaviors related to rejection of care. During an interview with the RN #17/MDS/CP Coordinator, on 03/06/19 at 8:54 PM, she stated Resident #14 had a decline in mental status since the (MONTH) (YEAR) MDS assessment. RN #17/MDS/CP Coordinator stated she was not able to complete the BIMS on Resident #14 on 03/06/19, related to Resident #14's confusion.