Every finding on record at Gulf Pointe Plaza

Based on observations, record reviews and interviews, the facility failed to provide a safe, sanitary, and comfortable environment for one resident (resident #1) of six residents reviewed for environment. The facility failed to ensure that Resident's #1-bedroom closet was free from mold.This failure could place the resident at risk for illness or hospitalization. Findings Included:A record review of Resident #1 admission Record dated 08/14/26 revealed he was a [AGE] year old male admitted on [DATE] with diagnosis of Peripheral Autonomic Neuropathy (a disorder where the peripheral nerves that control involuntary body functions become damaged); Parkinson's Disease (disorder in which the brain nerve cells die or stop working) and Muscle Weakness (a reduced capacity of your muscles to exert force).A Review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 6. A BIMS score of 6 indicates severe cognitive impairment. An observation on 08/14/26 at 12:00 p.m. Resident's #1 closet located in his bedroom was noted to have a black fuzzy substance approximately 18 inches in diameter on the ceiling. An observation on 08/14/26 at 12:10 p.m. of randomly selected resident's bedrooms #109, #114, # 12, #301, #412 and # 415 the absence of black fuzzy substance was noted.In record review of the facility's maintenance log dated July 2026 resident's bedroom [ROOM NUMBER] had been noted to be treated for a black fuzzy substance on July 28, 2026. In an interview with Resident #1 on 08/14/26 at 12:10 p.m. Resident #1 stated he was unaware there was mold in the closet. He stated he had just recently moved into room [ROOM NUMBER]. Resident #1 denied having any symptoms of mold exposure including sneezing, coughing, nasal congestion, runny nose, itchy eyes or postnasal drip. In an interview on 08/14/26 at 12:12 p.m. the Maintenance Director stated he treated room [ROOM NUMBER] for mold while the resident was out of his bedroom. He stated he became aware of the mold issue while reviewing the July 2026 maintenance log. He stated he did the initial treatment on July 28, 2026, using a combination of bleach and water. The Maintenance Director stated he mixed 2-3 capfuls of bleach with 16 oz of water. He stated he sprayed the mixture on the mold and wiped it with a wet towel. The Maintenance Director stated he reinspected the room again on 08/11/26 and observed the mold had regrown in room [ROOM NUMBER] but only on the edges of the ceiling, not the whole ceiling like before. He stated he treated the mold with the same combination of bleach and water. The Maintenance Director stated the facility now uses a mold killer that goes into the paint. He stated the facility did not have a policy for treating mold and that he had done a google engine search to find out how to treat the mold. He stated he reported the mold to the Facility Administrator on July 28, 2026. The Maintenance Director stated the DON and ADON were also made aware of the black fuzzy substance in room [ROOM NUMBER] on July 28, 2027. In an interview on 08/14/26 at 12:30 p.m. the DON stated all issues and concerns including mold were reported on the maintenance log. She stated maintenance staff entered the room when resident was out of his room and treated the mold. The DON stated the resident was not relocated as the mold was never an infestation. She stated the resident was allowed to return to this room once his room had been treated. She stated the resident had not had any illness related to mold exposure. In an interview on 08/14/26 at 12:45 p.m. the Administrator stated he had made rounds with the Maintenance Director on 07/28/26 to observe room [ROOM NUMBER] which had been reported to have had mold, and the room did not meet his expectations. He stated his observations in room [ROOM NUMBER] conducted on 08/11/26 met his expectations. The Administrator stated the Maintenance Director reviewed the maintenance log and wrote down on the maintenance log mold was corrected. He stated the Maintenance Director did not indicate on the maintenance log what was used to treat the mold, if the treatment was effective, if he followed up or if the mold reoccurred. The Administrator stated the facility had no policy for managing mold, but he had escalated the issue to his corporate office

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 10 residents (Resident #18, Resident #57, and Resident #22) reviewed for respiratory care. 1. The facility failed to ensure Resident #18's oxygen was administered at the correct setting on 03/08/2026 as ordered by the physician. 2. The facility failed to ensure Resident #57's oxygen was administered at the correct setting on 03/08/2026 as ordered by the physician. 3. The facility failed to post an oxygen sign outside of the room indicating Resident #57 received oxygen on 03/08/2026 4. The facility failed to ensure Resident #22's oxygen was administered at the correct setting on 03/08/2026 as ordered by the physician. 5. The facility failed to ensure Resident #22's oxygen tubing was connected to humidification. These failures could place residents who receive oxygen at an increased risk of respiratory complications, decreased quality of care, and a risk of fire hazard. The findings included: 1. Record review of Resident #18's face sheet dated 3/8/26 reflected the resident was a 96 -year-old female with an admission date of 4/13/24 and an initial admission date of 4/12/22. Resident #18 had the following diagnosis: chronic obstructive pulmonary disease, (a progressive, chronic inflammatory lung disease that causes obstructed airflow, making it difficult to breathe), acute (sudden) and chronic (over time) respiratory failure (a condition where the lungs cannot adequately supply oxygen to the blood or remove carbon dioxide causing severe shortness of breath, confusion, and cyanosis (bluish skin)) with hypoxia (a condition where the tissues and organs in the body do not receive adequate oxygen), and dementia (a range of progressive neurological disorder that cause a decline in memory, language, problem-solving, and other thinking abilities). Record review of Resident #18's Quarterly MDS assessment, dated 1/17/26, reflected the resident had a BIMS score of 00 which suggests severe cognitive impairment. Self-care assessment reflected Resident #18 required substantial/maximal assistance with personal hygiene, putting on/taking off footwear, shower/bathe self, and toileting hygiene. She required partial/moderate assistance with oral hygiene and lower body dressing. She required supervision or touching assistance with eating and upper body dressing. Health conditions included shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring). Special treatments, procedures, and programs reflected resident received oxygen therapy. Record review of Resident #18s undated care plan reflected the resident had oxygen Therapy r/t COPD. Date Initiated: 1/28/26. Interventions included: Give medications as ordered by physician. Date initiated: 1/28/26. oxygen settings: O2 via nasal cannula/mask at 2L as needed for O2 sats below 90% or SOB. Record review of the Doctor's Order Entry dated 2/24/26 reflected Resident #18 was prescribed O2 at 2 L/minute via NC continuous every shift for SOB. During an observation on 3/8/26 at 1:05 p.m. Resident #18 was observed in her room asleep in bed with head of bed elevated, she was receiving O2 at 4.5 liters via nasal cannula. Resident #18 was not in any distress. 2. Record review of Resident #57's face sheet dated 03/10/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #57's pertinent diagnoses included Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), Picks Disease (a progressive and degenerative brain disease which usually affects people under 65's behavior, and sometimes it disrupts the ability to speak or understand others), and Aphasia (a communication disorder which affects a person's ability to process and formulate language, and it could impact various aspects of communication, including speaking, understanding, reading, and writing). Resident #57's face sheet also reflected an Advanced Directive status of DNR. Record review of Resident #57's Quarterly MDS assessment dated [DATE] revealed a BIMS was not conducted as Resident #57 was rarely or never understood. MDS also revealed Resident #57 had no speech and was rarely or never understood. Section O revealed Resident #57 was on oxygen therapy. Record review of Resident #57's care plan revealed there was no specific care plan for oxygen. There was, however, a care plan initiated 03/07/2026 for respiratory infection with the intervention for oxygen therapy as ordered by the physician. Record review of Resident #57's active physician orders dated 03/03/2026 revealed an order for oxygen via nasal cannula at 2 liters per minute continuously. In an observation on 03/08/2026 at 12:00 PM, Resident #57's oxygen concentrator was set at 2.5 liters per minute and there was no red sign outside of her door noting oxygen in use. 3. Record review of Resident #22's face sheet dated 03/10/2026 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with a re-admission on [DATE]. Resident #22's pertinent diagnosis included Acute Respiratory Failure with Hypoxia (a life-threatening condition characterized by inadequate oxygenation of the blood, requiring immediate medical intervention). Record review of Resident #22's Quarterly MDS assessment dated [DATE] revealed BIMS of 01, severely impaired cognition. The MDS also revealed Resident #22 was on oxygen therapy and had Respiratory Failure. Record review of Resident #22's care plan initiated 11/25/2025, and revised 01/22/2026, revealed a care plan for oxygen therapy related to ineffective gas exchange. Interventions included oxygen via nasal cannula at 3 liters continuously. Record review of Resident #22's active physician orders dated 12/27/2025 revealed an order for oxygen via Nasal Cannula at 3 liters per minute continuously. In an observation on 03/08/2026 at 11:57 AM, Resident #22's oxygen concentrator was set at 3.5 liters per minute and the oxygen tubing was not connected to the humidification bottle on the oxygen concentrator. The humidification bottle was on the concentrator with separate tubing hanging from it, but Resident #22's nasal cannula tubing was hooked directly into the oxygen concentrator. During an interview on 3/8/26 at 2:11 p.m. LVN A said she was the nurse assigned to Resident #18. She said the nurses were in charge of resident's oxygen settings. LVN A said she checked the O2 settings every shift, first thing in the morning. LVN A said the O2 flow rate was at the same setting when she arrived this morning at 6 a.m., she had not touched it. LVN A checked Resident #18's O2 sats this morning and she was ok. She said Resident #18's O2 sats were at 93% at around 7:30 a.m LVN A re-checked Resident #18's O2 saturations at 2:16 p.m., and they were at 97%. LVN A said she recalled Hospice stated the resident's oxygen flow rate could go up to 5 liters. LVN A said the orders from hospice and the orders on PCC should probably be the same. LVN A said she should follow MD orders. LVN A said she was not sure what could happen if a resident received too much oxygen. LVN A said a resident would become confused with hypoxia, so would become the opposite of hypoxic. LVN A said she did not recall what too much oxygen did because she never had that situation. During an interview on 3/9/26 at 4:20 p.m., RN B said the nurses were in charge of oxygen settings. RN B said she checked O2 flow rate settings upon start of every shift. RN B said she also checked the flow rate when a resident got up to wheelchair to ensure the flow rate was accurate, then would check the flow rate periodically or as needed after. RN B said an MD order was required to administer O2, unless oxygen was given for an emergency. RN B said if a resident must continue on O2, she must get an MD order. RN B said in an emergency, they would also increase the oxygen flow rate a resident was already receiving by .5 increments until the saturation rates were above the MD orders requested, then they would decrease the O2 flow rate back to the original MD order. RN B said if the oxygen cannot be decreased to baseline flow rate, she must call MD for new orders to increase the flow rate. RN B said a resident with COPD who received more oxygen than prescribed could have an adverse effect. RN B said if a resident was given more O2 than needed, it could cause O2 toxicity and symptoms that were not the resident's normal. In an interview on 3/10/2026 at 1:40 PM, the ADON stated residents on oxygen should have the red sign outside of their room warning oxygen was being utilized in the room to help prevent any injuries. He also stated the setting on the oxygen concentrator should match whatever the order for oxygen stated. The ADON stated the charge nurses were the ones who typically set or adjusted the settings on the oxygen concentrators, and the charge nurses should have checked each shift to verify the settings were correct. In an interview on 3/10/2026 at 2:09 PM, the DON stated when residents were on oxygen, they should have the red oxygen sign outside on their door warning oxygen was being utilized in the room. She state it was nursing judgement to place a resident on oxygen if needed, but the nurse must follow up with an MD to obtain the order. The DON stated the settings on the oxygen concentrator should match whatever was in the oxygen order, and the charge nurses were the ones who typically set or adjusted the settings on the oxygen concentrators, as well as verified each shift the settings were correct, but sometimes therapy would adjust the settings depending on how the resident tolerated therapy. The DON stated if a resident was getting more or less oxygen than what was ordered, it would not be considered therapeutic. She also stated if a resident was not getting enough oxygen they could end up with an altered mental status and poor perfusion (process by which blood delivers oxygen to tissues and organs). Record review of the facility's Oxygen Administration policy, revised October 2010, revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. Equipment and Supplies: 3. Humidifier Bottle 4. No Smoking / Oxygen in Use sign. Steps in the Procedure: 2. Place an Oxygen in use sign on the outside of the room entrance door. 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 14. Periodically recheck water level in humidifying jar.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation.The facility failed to properly label and date open, shelf stable food.The facility failed to dispose of expired shelf stable and refrigerated food.The facility failed to ensure containers and bags of food were sealed appropriately. The facility failed to ensure behind the ice machine and under the sink were clean.The facility failed to ensure all dry and/or shelf stable foods were labeled with received by, opened, and use by dates.The facility failed to ensure pans were free from dents and dings, as well as from having the Teflon scraped off.The facility failed to ensure there were no chemicals stored in the kitchen or serving area.The facility failed to ensure no staff items were being stored in the kitchen refrigerators. These failures could have placed residents at risk of ingesting foreign objects as well as possible foodborne illnesses.The findings included:Observations and initial tour of the kitchen on 03/08/2026 at 11:05 AM revealed the following:*Behind the ice machine and under the sink (dishwasher area) there was a large amount of dirt, debris, and grime built up.Refrigerator: *A small, individual container of open and used milk with no opened or use by dates on them.*Individual bottles of water belonging to the staff.*Multiple bags of bread on the bread cart with no received by, opened, or use by dates on them. In the walk-in cooler there were tortillas on the shelf wrapped in plastic wrap with the date 02/09/2026 written on them. There was a mixture of a food item in a bowl in the walk-in cooler which was half-covered and dated 03/01/2026. Walk-in cooler:*Opened waffles wrapped in plastic with a use by date of 02/27/2026. *A bag of a thick, white substance, wrapped in plastic wrap, with the date 02/28/2026 written on it. *A bag of opened bread with the date 02/22/2026 written on it. *A bag of shredded lettuce with a use by date of 03/06/2026.*Multiple bags of open cheese which were not sealed. There was also a bag of cheese which had been opened and used, but the use by date was 02/10/2026.*Multiple trays with cups of covered juice with no use by date or time on them or the trays. There was, however, a sticker at the top of the juice cart with 8 dates written on it. *A bag of English Muffins with a use by date of 03/06/2026. Further observation revealed in the kitchen serving area, there was a bottle of bleach sitting on top of cereal dispensing containers. There were also pans noted with scrapes, dings and scratches. In an interview on 03/09/2026 at 2:12 PM, the FSD stated the filters, floors, counters, walls, equipment and sinks were cleaned daily. She stated behind the ice machine was a difficult area to reach because it was not mobile, so it tended to get dirtier. She also stated the area under the sink next to the dishwasher was so dirty because it was where the previous dishwasher sat, so it had a lot of build-up behind it, but she had been working on getting it cleaned. The FSD stated food should be labeled with a received by date, opened date, and a use by date, and if it was not dated or sealed appropriately, it should be discarded because it could make the residents sick. The FSD stated she and the kitchen staff were allowed to keep personal items in the kitchen refrigerator as long as they were sealed and dated, and she thought it was what the policy said as well. The FSD also stated she knew the kitchen staff were not supposed to cook with pans which dinged or scraped so badly the Teflon was coming off because it could end up in the residents' food and make them sick. In an interview on 03/09/2026 at 3:05 PM, the RD stated she was not aware of how dirty it was behind the ice machine, but she would look into it. She also stated food should be labeled with a received by date, opened date, and a use by date, and if it was not dated or sealed appropriately, it should be discarded because it could make the residents sick. She stated the cups with juice in them should either have the cups dated, or the trays the cups sat on should be dated. She stated the bread dates were kept on a log on a sheet of paper, but she was not sure how someone inspecting the bread would be able to tell a specific loaf of bread on the bread cart went with the date written on the log. The RD also stated she knew the kitchen staff were not supposed to cook with pans which were dinged or scraped because it could end up in the residents' food and make them sick.In an interview on 03/10/2026 at 3:10 PM, the Adm stated if food was expired or left open it should be discarded, as well as staff should not keep personal items in the kitchen refrigerator because they had a staff refrigerator in the breakroom. Record review of the facility's Food Receiving and Storage Policy, no date noted, revealed 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 6. Dry foods stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 13. D. Beverages must be dated when opened and discarded after twenty-four hours. 14. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storeroom for food or food preparation equipment and utensils. 15. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage.

Based on interview and record review the facility failed to ensure residents had the right to be fully informed in advance about the risks or benefits of any proposed treatment that may affect the resident's well-being for 2 of 6 (Resident #7 and Resident #10) residents reviewed for psychotropic medication consents. 1. The facility failed to obtain a signed informed consent for Resident #7's Divalproex (a medication used to treat seizures, but could also be used to treat anxiety [intense, excessive and persistent worry and fear about everyday situations], depression [a mood disorder which caused a persistent feeling of sadness and loss of interest], schizophrenia [a severe mental disorder which affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking], and bipolar disorder [a mental health condition characterized by extreme mood swings which include emotional highs and lows]). 2. The facility failed to obtain a signed informed consent for Resident #10's Depakote (a medication used to treat seizures, but could also be used to treat anxiety [intense, excessive and persistent worry and fear about everyday situations], depression [a mood disorder which caused a persistent feeling of sadness and loss of interest], schizophrenia [a severe mental disorder which affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking], and bipolar disorder [a mental health condition characterized by extreme mood swings which include emotional highs and lows]) and Gabapentin (a medication used to prevent and control partial seizures, but could also be used to treat anxiety [intense, excessive and persistent worry and fear about everyday situations], and depression [a mood disorder which caused a persistent feeling of sadness and loss of interest]). These failures could place residents at risk to receive psychotropic medications without consent or knowledge of the possible side effects of the medications. The findings included: 1. Record review of Resident #7's face sheet revealed a [AGE] year-old female with an original admission date on 06/27/2018, and a current admission date on 07/16/2025. Pertinent diagnosis included Schizoaffective Disorder, Bipolar Type (a mental health condition which was marked by a mix of schizophrenia symptoms to include hallucinations, delusions, and a change in or elevated level of mood and energy). Record review of Resident #7's Quarterly MDS dated [DATE] revealed a BIMS score of 06, which indicated severely impaired cognition. Section D for Mood was not conducted as Resident #7 was rarely or never understood. Section I revealed active diagnoses of Depression and Schizophrenia (a severe mental disorder which affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking). Record review of Resident #7's care plan, initiated 10/05/2018 and revised 11/17/2021, revealed Resident #7 took mood stabilizing medications with potential for complications. The target behavior was paranoia with delusions. Interventions included obtain consents for medication and monitor and document for behavior every shift. Record review of Resident #7's active physician orders revealed an order started 07/17/2025 for Divalproex 125mg, give 4 capsules by mouth two times daily for Paranoid Disorder. Record review on Resident #7's consents reflected a previous consent for Depakote (Divalproex), dated 06/27/2018, to treat mood disorder with psychotic features. This consent was originally signed by a registered nurse and Resident #7 on 06/27/2018. 2. Record review of Resident #10's admission record reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, depressive type (mental health problem characterized by thinking and behavior problems and sadness), deaf non-speaking, and other recurrent depressive disorders (various, less specific, non-psychotic, chronic, or situational forms of repeated, significant, and often disabling, low-mood episodes). Record review of Resident #10's quarterly MDS dated [DATE] reflected a BIMS was not able to be completed and her cognitive skills for daily decision-making score was a 3 which indicated she rarely or never made decisions. Her MDS also indicated Resident #10 was taking an antipsychotic, an antidepressant, and an anticonvulsant. Record review of Resident #10's care plan dated 08/14/18 reflected a focus of a mood disorder with the use of Depakote and a targeted behavior of refusal of care initiated on 04/24/25. Interventions included consult with pharmacy, MD to consider reduction when clinically appropriate and monitor target behavior/symptoms and document, initiated on 04/24/25. Record review of Resident #10's physician order summary report on 03/10/26 reflected the following orders: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125mg. Give 2 capsules by mouth two times a day for Mood disorder. 2-caps = 250mg. Start date: 05/22/25. Gabapentin Oral Tablet 100mg. Give 1 tablet by mouth in the evening for mood disorder. Start date: 03/05/26. Record review of Resident #10's previous orders reflected the following orders for Depakote and Gabapentin: Depakote Oral Tablet Delayed Release 125mg. Give 1 tablet by mouth 1 time a day related to schizoaffective disorder, depressive type that started on 01/09/24 and was discontinued on 05/06/24. Depakote Oral Tablet Delayed Release 125mg. Give 1 tablet by mouth every day and evening shift related to schizoaffective disorder, depressive type that started on 05/06/24 and was discontinued on 07/29/24. Depakote Oral Tablet Delayed Release 250mg. Give 1 tablet by mouth 2 times a day for mood disorder that started on 07/29/24 and was discontinued on 05/22/25. Gabapentin Oral Tablet 100mg. Give 1 tablet by mouth in the evening for restlessness/mood that started on 06/26/25 and was discontinued on 01/15/26. Gabapentin Oral Tablet 100mg. Give 1 tablet by mouth in the evening for restlessness due to chronic pain that started on 01/16/26 and was discontinued on 03/05/26. Record review of Resident #10's miscellaneous forms reflected no consent forms for the use of Depakote or Gabapentin. An interview with Resident #10 was not possible due to her diagnoses of deafness and blindness. An unsuccessful attempt was made to contact Resident #10's RP on 03/10/26 at 3:03 pm. In an interview on 3/10/2026 at 1:40 PM, the ADON stated medications, such Depakote, being utilized as psychotropics or antipsychotic behaviors, required a consent form. He stated even if the medication was typically used to treat another condition but was being utilized in lieu of or as an adjunct to other psychotropic medications, there would need to be a consent obtained so the resident or the RP was informed of what the medication was for and the possible side effects. He also stated consent would need to be done when a new medication was started, if the medication dosage changed, or if the medication had previously been stopped and restarted. He stated the charge nurse that received the order for a new psychotropic medication was responsible for obtaining the consent, and he and the DON checked to ensure the consent was done. He stated it was important to get consents so the resident/RP would understand the reason, possible side effects, and goals of treatment for each psychotropic medication that was used. In an interview on 3/10/2026 at 2:09 PM, the DON stated medication consents should be obtained for psychotropics and/or antipsychotics, but not for other medications being utilized in lieu of psychotropics or antipsychotics. The DON also stated they utilized other medications at times, such as anxiolytics or anti-seizure medications as psychotropics, not as antipsychotics, but these medications did not require a consent. She stated antipsychotic medication would be used to treat more aggressive things such as psychosis or Schizophrenia. The DON stated if a psychotropic was new, changed, or had been stopped and restarted with longer than a day in between, there would need to be a new consent signed. She stated consents were important so residents and their families knew about the medication being utilized or any changes to it, and without a signed consent the facility was giving treatment in which a resident or family had not consented to, and this would be a resident's rights issue. The DON stated it was the charge nurse's responsibility to obtain the medication consent, or whomever got the order could have also gotten the consent. She also stated Valproic Acid (commonly known as Depakote) levels were not needed or drawn unless the medication was being utilized for seizures. Record review of the facility's Psychotropic Medication policy, revised February 2025, revealed 1. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Informed Consent or Refusal: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative to obtain documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); d. the resident's/representative's right to accept or decline the treatment. Gradual Dose Reduction: 3. Categories of medications which affect brain activity such as antihistamines, anti-cholinergic medications, and central nervous system medication are not prescribed or administered for psychotropic medication unless there is documented clinical indication consistent with clinical standard of practice. A. if such medication is prescribed or administered as a substitute for psychotropic medication, and there is documented clinical rationale, the medication is monitored and managed as a psychotropic medication.

Based on interview and record review, the facility failed to ensure residents had the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (Resident #57) of 5 residents reviewed for Advance Directives. The facility failed to ensure Resident #57's OOH-DNR was completed. The OOH-DNR form did not have the resident or RP signature. This failure could affect residents who have implemented Advance Directives and established their choice to not be resuscitated to a risk of receiving CPR and being resuscitated against their wishes. The findings included: Record review of Resident #57's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #57's diagnoses included Alzheimer's Disease (a progressive disorder which is the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes) and Picks Disease (a progressive and degenerative brain disease which usually affects people under 65's behavior, and sometimes it disrupts the ability to speak or understand others). Resident #57's face sheet also reflected an Advanced Directive status of DNR. Record review of Resident #57's Quarterly MDS assessment dated [DATE] revealed the BIMS was not conducted as Resident #57 was rarely or never understood. The MDS also revealed Resident #57 had problems with short-term and long-term memory recall, and daily decision making was severely impaired. Resident #57 had limited range of motion in all extremities. Record review of Resident #57's care plan initiated [DATE] revealed a code status of OOH-DNR. Interventions dated [DATE] included a copy of the OOH-DNR wouldass be kept in the resident's medical chart and readily available for all to see and the IDT would review code status with Resident #57 and/or the RP during the plan of care meeting. Staff were to verify the code status in Resident #57's medical chart with sudden changes in condition.Record review of Resident #57's active physician order revised [DATE] revealed an order for DNR. Record review of Resident #57's OOH-DNR form dated [DATE] revealed the form was signed in section C. Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication, was signed by an adult child. The OOH-DNR revealed section F. of the form was not completed by the Resident/Guardian/Agent/Proxy/Relative signature, in which all persons who had signed above section F (to include section C) also needed to sign in section F. In an interview on [DATE] at 1:40 PM, the ADON stated OOH-DNR should be signed in section F. by the physician, two witnesses, and the resident or the RP, and it had not been signed properly or appropriately it was considered invalid. In an interview on [DATE] at 2:09 PM, the DON stated the DNR or OOH-DNR form was discussed upon admission then signed by all parties, to include the physician, two witnesses, the resident or the resident's RP. The DON also stated all parties which signed above section F. should have signed in section F. The DON stated if the OOH-DNR was not completed properly it was not considered valid, and a resident could have received CPR when their wish was to not be resuscitated. Record review of the facility's Do Not Resuscitate policy, revised 2017, revealed the The facility will not use cardiopulmonary resuscitation and related emergency measure to maintain life functions on a resident when there is a Do Not Resuscitated Order in effect. 2. A Do Not Resuscitate order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate) . The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately for 1 of 4 medication carts (100 Hall Nurse Med-Cart) reviewed for storage.The facility failed to ensure the 100 Hall Nurse Med-Cart was locked and secured.This failure could have placed residents at risk of gaining access to unlocked medications which were not prescribed to them and could have caused them harm.The findings included:An observation on 01/20/2026 at 3:47 PM of the 100 Hall Nurse Med-Cart parked at the nurses' station revealed an unlocked medication cart. The lock on the cart was popped out, and all drawers except the narcotic drawer were able to be accessed. There was no staff observed at the cart, but there were multiple residents sitting out in the front lobby close to where the cart was parked. In an interview on 01/20/2026 at 3:48 PM LVN-A stated 100 Hall Nurse Med-Cart was hers, and she had not realized she had not locked the med-cart back after counting medications with the off-going nurse. LVN-A stated she knew she was not supposed to leave her med-cart unlocked when she walked away because if left unlocked, residents could have gotten into the med-cart and taken medications which had not belonged to them, which could have caused them harm. She stated she had been in-serviced on this previously, but she could not recall when the in-service was.In an interview on 01/20/2026 at 4:36 PM, the DON stated nurses should not leave their medication carts unlocked because residents could have gained access to medications which did not belong to them, and this could have caused the residents harm. She stated the nurses have been in-serviced previously over locking their medication carts. In an interview on 01/21/2026 at 5:25 PM the Administrator stated according to their policy, medication carts should be locked when not in use so residents did not gain access to medications which could have caused them harm, and the nurses had been educated and in-serviced on this topic.Record review of the facility's Storage of Medications policy, no date available, revealed 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use.

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure LVN A's medication cart on hall 400 and MAR contained an accurate count and record for Resident #1's liquid Morphine (a narcotic used to treat pain). This failure could place residents at risk for drug diversion and/or a delay in medication administration, as well as risk of not having allegations investigated or timely. Findings included:Record review of Resident #1's face sheet dated 04/19/25 revealed a [AGE] year-old female with an admission date of 04/19/25. Diagnoses included Warnicke's Encephalopathy (a brain disorder caused by a severe deficiency of thiamine (vitamin B1), Alzheimer's, Chronic Respiratory Failure (advanced lung disease which makes it progressively harder to breathe over time and can lead to sudden flare-ups), Cirrhosis (advanced liver disease characterized by the formation of scar tissue over time that can lead to liver failure), Depression, and Malignant Neoplasm of the Vulva (Cancer of the groin/vagina). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 04, indicating severe cognitive impairment. She was dependent on staff for toileting, showering, footwear, and positioning. She required substantial assistance with dressing and personal hygiene. She required supervision with eating and oral hygiene. She was always incontinent of bladder and bowel. Her pain scale averaged 4 out of 10. Record review of Resident #1's physician orders start date 06/18/25 revealed Morphine Sulfate (Concentrate) Oral Solution 20mg/ml. Give 1 ml by mouth every 2 hours as needed for severe pain rated 7-10. Record review of Resident #1's Individual Drug Administration Record revealed the Morphine count signed by LVN A on 09/13/25 at 9:30 am was 2ml. The next column had the sequence of 1ml remaining, and it was crossed through with LVN A's signature and written, Bottle is empty left in drawer. Record review of Resident #1's Individual Drug Administration Record revealed the Morphine count signed by LVN C on 10/02/25 at 11:25 pm was 49ml. The next column had a sequence of 39 ml remaining and was signed by LVN D. Record review of the PIR dated 10/20/25 revealed an incorrect narcotic count of Resident #1's Morphine 100mg/5ml on 10/19/25 at 10:00 pm. The controlled medication count revealed 5 ml were missing. The incorrect count was identified when the on-coming LVN B counted with the off-going LVN A. According to the PIR, both LVN A and LVN B stated the count was correct the previous night when on-coming LVN B counted with off-going LVN A. Both nurses were suspended pending investigation, with LVN A ultimately being terminated. During an observation on 10/30/25 at 8:25 AM revealed that off-going LVN E and on-coming LVN D were counting controlled medications whereas LVN D would actually count the medications, but LVN E just looked to verify the count on the controlled medication sheet was correct. LVN E was not actually watching LVN D count the medications, and LVN E was not actually looking at the sheet to verify it was correct. In an interview with LVN E on 10/30/25 at 8:35 am, she said she was just doing what everyone else was when it came to counting the narcotics. She said she did not think it was the right way to do it. She said the accuracy of narcotic counts was important because it was something that could go missing, and the residents might not get their pain controlled. She said she did not know why she never brought it up (the way the narcotics were counted) to anyone.Observation and interview with Resident #1 on 10/30/25 at 8:45 am revealed a well-kept female on oxygen. She was awake and oriented. She was on a pressure-reducing air mattress. She said the doctor changed her pain medications last week, and she was no longer taking the liquid morphine every 2 hours, but now an extended-release morphine pill every 12 hours, and was due at 9:00 am. She said those were not working very well. She said she also got oxycodone scheduled every 6 hours and had a fentanyl patch. (100mcg). She said her pain scale right now was a 7 or 8 (up from her usual 5). She said she was on hospice, and they came in three times a week for showers. She said she tolerated her showers without her oxygen. She said she was on hospice and took strong pain medication because she had a groin wound from cancer. She said her pain was not out of control, but she wished she could have the liquid morphine again because it worked well for her. In an interview with the DON and DR on 10/30/25 at 8:55 am regarding the resident's pain level. The DR said to the DON to get her on whatever works best for her without knocking her out. He said the fentanyl was not really working for her. He said he did not know how she was still alive with that horrible wound she has. The DON said they were getting the liquid morphine in 120ml vials, and the missing 5 ml's was so random and everyone freaked out over it, meaning it was difficult to think about a nurse stealing morphine from a hospice patient. Interview and record review with the DON on 10/30/25 at 10:05 am, the Narcotic count sheet dated 10/15/25-10/19/25 revealed a count of 11 ml's on 10/19/25 at 4:15 am by LVN B. At 4:30 am, the count was 10 ml by LVN A. She said LVN A was not in the building at 4:30 am because she worked the 6 am- 10 pm shift. The next entry was at 6:30 am on 10/19/25, signed by LVN C for 1 ml, and the count showed 4 ml. Then 3 ml at 10:00 am, 2 ml at 1:00 pm, 1 ml at 4:00 pm, and 0 ml at 9:15 am. She said an empty bottle of morphine was found (by unknown) in a trash can at the nurse's station on 10/19/25, and assumed it was the one referred to on the narcotic count sheet signed by LVN A. She said the empty bottle was not retrieved. She said it was against the policy to throw empty bottles or medication cards of narcotics in the trash. She said they had to go into the destruction bin. Record review of Resident #1's Individual Control Drug Record for Morphine 100mg/5ml Give 0.25 to 1 ml PO (by mouth) Q (every) 2hrs for pain/SOB (shortness of breath) Rx #2057026 Date Dispensed 08/25/25 revealed on 10/19/25, LVN A administered 1 ml to Resident #1 at 4:30 am, 6:30 am, 10:00 am, 1:00 pm, 4:00 pm and 9:15 pm. Record review of LVN A's time sheet revealed on 10/19/25, she clocked in at 5:47 am and clocked out at 10:02 pm. Record review of Resident #1's MAR for October 2025 revealed on 10/19/25 at 4:15 am, LVN C administered 1 ml of liquid morphine, and the remaining count was 11 ml. At 6:15 am, 10:00 am, 1:38 pm, and 9:35 pm, LVN A administered 1 ml of liquid morphine, and the remaining count was 1 ml. At 11:41 pm, LVN C administered 1 ml of liquid morphine to Resident #1, and the remaining count was 0 ml remaining.Record review of the DON's interview with LVN A dated 10/20/25 revealed she did not know why she would have signed out a dose of medication at 4:40 am when she was not in the building, she did not know and could not explain why the liquid morphine for Resident #1 went from 10 ml's to 4 ml's, and stated she did give medications that were not documented and she frequently signed out medications on the narcotic count sheet and not in the electronic health record. She was aware of the policy because she had been counseled before for not immediately charting when giving narcotics. She did not know why she did not report a possible drug diversion, but left the building after her shift. Record review of LVN B's written and signed statement dated 10/19/25 at 9:55 pm, she stated she counted narcotics with LVN A on the 400 hall, who told her Resident #1 was out of liquid morphine and hospice had been called and could not deliver any more until 10/20/25. LVN A also told her she obtained a one-time dose of oxycodone if needed through the night while waiting for the morphine. LVN B stated she realized Resident #1 had 11 ml's left in the bottle when she left from her previous shift the night before, and Resident #1 should have had at least 3 or more doses left. At this point, the DON was notified, and an empty liquid morphine bottle was found in a trash can on the 400 hall. Record review of LVN F's handwritten and signed statement dated 10/20/25 revealed she and LVN B had been discussing erratic behaviors of LVN A, in that she had allowed a hospice patient (Resident #1) to run out of morphine before she called for a refill. She wrote, she and LVN B double checked the narcotic sign out sheets and noticed the liquid morphine for Resident #1 had gone from 10 ml to 4 ml, and LVN B found an empty bottle of liquid morphine in the 400 hall trash can. The DON was notified at this time. LVN's A, C, and F were not available for interview after multiple attempts beginning on 10/30/25 at 9:00 am to 5:30 pm. Messages and a callback number were left. LVN B was unavailable for interview due to she was out of the country on a cruise.In an interview with LVN D on 10/30/25 at 2:42 pm, she said she did not know what happened when she wrote in 39 ml instead of 49 ml on the narcotic drug count sheet dated 10/03/25 at 6:45 am. She said 10 ml missing was a lot of morphine to be missing. She said she could not explain it. She said the process was to pay better attention and make sure they (nurses) were reading the bottle right. She said LVN C was the name on the narcotic shift count sheet prior to hers when the mistake was made. She said she could not explain why the count sheet was timed at 6:45 am, then again at 6:45 am when 10:15 am was written in, crossed out, written again, along with 6:45 on 10/03/25. She said her urine sample was not going to be positive. She said they (herself and LVN C) should have looked at the bottle and read the label before they counted at shift change. She said she should have looked at the syringe closer when she drew it up. She said narcotic sheets and counts were important because that was how they knew if something was missing. She said morphine belonged to the patients. She said the nurses had in-services on narcotics, but did not know when the last time was. Then she said the last one was about 2 weeks ago, that covered the right count on the carts, right patient, right dose, right amount in the bottle. She said the nurses were not provided with a policy at the in-service. She said if she found a discrepancy, she would take it to the DON immediately. She said she had never found a discrepancy here or ever, that she could recall. She said she did not know how someone could take a resident's pain medication. She said the facility had enough checks and balances for this not to happen. She said she was afraid she was going to lose her job, and she had been a nurse for 35 years. In an interview with the DON on 10/30/25 at 5:30 pm, she said the process for counting narcotics was for the nurses to count at the beginning and end of every shift, and if a nurse had to leave the floor or building. She said if there was a discrepancy identified and the nurses were unable to reconcile the count sheet, they were to stop, not sign the sheets, and notify the DON. She said she was responsible for accurate narcotic counts, as well as destruction. She said she would investigate the situation, such as if something was missed or overlooked. She said if she could not resolve the issue, the ADM would be notified, and an investigation would ensue. She said for any narcotic discrepancy, nurses would be drug tested on the spot if they were still in the building, and as soon as they could be reached otherwise. She said all staff in-services were and would be conducted. She said monitoring the actual counts of the narcotics and audits were and would be done for all carts and possibly an ad hoc QAPI. She said the individual control drug record sheet headings were missing information such as quantity received, or physician name, the Rx number, or the date dispensed. She said there was nowhere to initial the headings, and she was going to change that. She said it would be harmful to residents if their pain control were inadequate because of misappropriation of their narcotics. She said LVN's A, B, C, D, E, and F were all drug tested and all were negative. Interview with the ADM on 10/30/2025 at 5:45 pm, he said the DON was responsible for the nurses, and he became involved when the situation with narcotics could not be rectified. He said LVN A was drug tested, and the results were negative, but she was terminated because she had violated several policies. He said the DON found several instances where LVN A's times on Resident #1's MAR did not match her times of administration on the individual control drug record, where the morphine was actually counted. He said LVN A was terminated on 10/20/25.Record review of LVN A's personnel file revealed a medication discrepancy report for LVN A dated 10/18/25-10/19/25 for Morphine 100mg/5ml given x4 over 2 days and not documented in Resident #1's electronic chart. 5ml of Morphine was not accounted for. LVN A was written up, counseled, and suspended. A medication discrepancy report for LVN A dated 10/20/25 for violation dates 10/18/25 and 10/19/25 revealed the nurse gave morphine to Resident #1, documented on the narcotic sheet but did not document in the electronic health record on 10/18/25 x2 and 10/19/25 x2. LVN A did not report a potential drug diversion. LVN A declined to give a statement. LVN A was suspended pending investigation. The report was signed by LVN A. LVN A was terminated on 10/20/25. Record review of a liquid morphine audit dated 10/21/25 for the six residents prescribed liquid morphine revealed that only Resident #1 had a discrepancy. Record review of all medication cart audits dated 10/20/25 revealed no discrepancies with all narcotics. Record review of all narcotic count sheets checked for anomalies dated 10/21/25, 10/22/25, and 10/23/25 revealed no anomalies. Record review of all staff in-services dated 10/20/25-Abuse and Neglect, Drug Diversion, accurate shift counts, patterns of residents who only have pain complaints on a certain shift or with a certain staff member, complaints of increased pain at the start of a shift with documentation of pain medication administered at the end of the previous shift, multiple errors/disposed of meds on narcotic sign out sheet, be aware of suspicious activity, behavior, or impairment, report immediately, Always do a narcotic count at shift change, count all meds in the narc box every time, verify all items-do not assume the count is correct, once you sign off for that cart, you are responsible, make sure no signatures, dates, or times are missing. Record review of the facility policy dated April 2007, titled Controlled Substances, stated, The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. 4. If the count is correct, a control sheet must be made for each substance. Do not enter more than one prescription per page. This record must contain c. Quantity received, h. date and time received. i. time of administration.

Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 of 8 residents (Resident #47) reviewed for advanced directives. The facility failed to revise orders for Resident #47's code status from full code to DNR after his return from the hospital to correctly reflect the resident's wishes. The resident had a signed DNR form from 2019, but also had an active order for full code. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. The findings included: Record Review of Resident #47's face sheet dated [DATE] revealed a [AGE] year-old male with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnosis included Vascular Dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain). Record review of Resident #47's Comprehensive MDS assessment section C, cognitive patterns, dated [DATE] revealed a BIMS score of 11 (moderate impairment). Record review of Resident #47's care plan revealed the problem [Resident #47] has a code status of: OOH-DNR initiated on [DATE]. Interventions listed to treat the problem were as follows: - A copy of the OOH-DNR will be kept in the Resident medical chart readily available for all to see initiated on [DATE]. - In the event that the Resident arrests no efforts to resuscitate will be provided in accordance with the Resident wishes initiated on [DATE]. - Staff will honor and respect Resident wish to be a DNR status initiated on [DATE]. Record review of Resident #47's order summary dated [DATE] revealed an active order titled CPR - Full Code initiated on [DATE] by RN E. Further record review showed a discontinued order titled DNR'' placed on [DATE] and discontinued on [DATE]. Record review of the form titled OUT-OF-HOPSITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER revealed the form was completed and signed by Resident #47, two witnesses, and his physician on [DATE]. During an interview with Resident #47 on [DATE] at 9:46 AM, Resident #47 stated he wanted the facility to do everything they could do to save him in the case his heart stopped beating. Resident #47 stated he wanted the staff to perform CPR on him if he needed it. During an interview with CNA B on [DATE] at 9:26 AM, CNA B stated CNA's were not trained to do CPR in the facility. CNA B stated if she saw a resident that needed CPR, she would yell for a nurse immediately. CNA B stated Resident #47's room was in the 100 hall. CNA B stated almost every resident in the 100 hall was a DNR. CNA B stated in the instance they were not sure if a resident was a DNR or not, the nurses would find out the answer in the computer system or in the binder at the nurse's station. During an interview with LVN A on [DATE] at 10:00 AM, LVN A stated she was the current nurse for the 100 hall. LVN A stated she was trained to do CPR. LVN A stated most of the residents on the 100 hall was a DNR. LVN A stated she would always double check the records before performing CPR on a resident. LVN A stated there was a binder at the nurse's station that contained whether a resident was a DNR or full code. LVN A stated RN E worked in medical records and updated the binder when it was necessary. LVN A stated Resident #47 was a DNR. During an observation on [DATE] at 10:09 AM, LVN A showed this surveyor the advanced directives binder located at the nurses station. LVN A turned to the page containing Resident #47's signed DNR from [DATE]. During an interview with the DON on [DATE] at 10:12 AM, the DON stated if a resident were able to tell us if they wanted to be a full code or DNR then we would listen. The DON stated if residents were not able to make that choice, then the RP, doctor, and family would get together to make the best decision for the resident. The DON stated it could be difficult interpreting whether a resident could make the decision on their own if they wanted to be a full code or DNR. The DON stated she thought Resident #47 was cognitively aware enough to decide on his own if he wanted to be a full code or DNR. The DON stated she expected nurses to double check the advance directives book or the resident's chart before they administered CPR to the resident. The DON stated Resident #47 was a DNR. The DON stated when a resident was discharged to the hospital all active orders were discontinued. The DON stated Resident #47's DNR order was discontinued on [DATE]. The DON stated when they came back, all their new orders were put in, including a code status. The DON stated Resident #47's chart currently showed he was a full code. The DON stated Resident #47 was recently hospitalized on [DATE] from a fall he had in the shower. The DON stated the resident was in the hospital for a few weeks and returned to the facility on [DATE]. The DON stated if the code status was not correct then a nurse could start CPR on someone who was a DNR or not start CPR on someone who was a full code. During an interview with RN E on [DATE] at 10:25 AM, RN E stated when a resident came back from the hospital, the receiving nurse would put new orders into the resident's chart. RN E stated if the resident had a DNR before they went to the hospital, then when they came back they would maintain the same DNR status. RN E stated Resident #47 was a DNR. RN E stated she did not remember putting the Full Code order in the chart of Resident #47 on [DATE]. RN E stated she thought Resident #47 was cognitively aware enough to make the decision on whether he wanted to be a full code or DNR. RN E stated if a nurse looked in a resident's chart and saw that they were a full code, they might perform CPR on Resident #47 despite them having a signed DNR. During an interview with the ADON on [DATE] at 1:31 PM, the ADON stated on discharge, all orders for the discharged resident were discontinued. The ADON stated the admitting nurse would put orders into the system once the resident returned from the hospital. The ADON stated the hospital paperwork usually did not contain the resident's code status. The ADON stated the admitting nurse could verify the resident's code status by asking the resident or the resident's RP. The ADON stated he spoke to Resident #47 at approximately 11:00 AM on [DATE] about his code status, and the resident stated he wanted to be a full code. The ADON stated he explained the difference between full code and DNR to the resident and the resident acknowledged comprehension of the difference. The ADON stated they had a morning meeting with nurse managers every weekday to go over new orders from the previous day. The ADON stated if the resident's code status was not consistent across all platforms, they could perform CPR on a resident with a DNR or vice versa. Record review of the facility policy titled Advance Directives revised [DATE], revealed the following: 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #7) reviewed for care plans in that: The Facility failed to ensure that Resident #7's care plan was revised, updated and individualized with interventions and goals to address Resident #7's urinary incontinence. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns. Findings included: Record review face sheet, on 12/18/2024 at 3:17 PM, revealed Resident #7 was a [AGE] year-old-female with an original admitted [DATE], and a current admitted [DATE]. Record review of medical diagnoses revealed Resident #7 had Essential Primary Hypertension with onset of 8/28/2024. Record review of care plan initiated 9/03/24 revealed Resident #7 was on diuretic therapy related to hypertension, and goals include having moist mucous membranes and adequate urine output. There are no individualized or personalized focuses, goals or interventions related to urinary incontinence included in Resident #7's care plan, such as, need for frequent brief checks and changes, need for frequent clothing checks or changes, need for a toileting or bowel and bladder program. Record review of physician's orders revealed order for Furosemide 20 mg started 9/03/2024 and Tamsulosin 0.4 mg started 9/03/2024. Record review of progress note dated 12/12/24 revealed Resident #7 had constant complaints of urinary incontinence and bowel movements. Observation on 12/17/24 at 1:01 PM revealed a slight smell of urine and Resident #7 consistently looking at and feeling of her clothes to see if they were damp with urine. In an interview with Resident #7, on 7/17/24 at 1:00 PM, she stated she used to use a walker but spends all her time in a wheelchair now because her legs have gotten weaker, and she has had some falls. She stated due to being in the wheelchair, the falls, and the weakness in her legs, she needs more assistance than she used to. She stated she can no longer get herself up and to the bathroom, and this is why she wears briefs, but because of the water pill, she stated she stayed wet constantly, and it takes staff too long to answer call lights sometimes. She felt like she cannot go anywhere, including physical therapy because she was constantly soaked in urine. In an interview with LVN - A, on 12/18/2024 at 1:18 PM, she stated she is not sure why Resident #7's frequent urination and constant wetness is not care planned, but they will adjust the care plan to reflect individualized and personalized focuses, goals and outcomes. She stated she was not sure why the other approaches to this resident's issues with constant urination are not approached in the care plan, such as a toileting program, increased changing of the brief, monitoring for wetness of clothes, changing prior to activities. She stated resident has complained many times about her frequent urination and being wet frequently. She stated the MDS nurse typically updates the care plan, but she was out, but the ADON or any of the nurses can typically update the care plan, and she will discuss individualizing and personalizing this care plan. In an interview with the ADON, on 12/18/24 at 1:30 PM, he stated he was not sure why Resident #7's care plan was not individualized, or why there are not any personal goals for this resident for her increased and frequent incontinence. He stated the MDS nurse, the DON, Medical Records, and the nurse managers typically update the care plans, and they should have updated and personalized in this care plan, and they will work on getting it fixed. In an interview with the DON, on 12/19/24 at 7:50 AM, she stated Resident #7 had never previously complained about being soaked in urine or feeling like she has urine all over her until this week, so that was when she (the DON) addressed it. In an interview with CNA - B, on 12/19/24 at 9:06 AM, she stated Resident #7 has complained about frequent urination and bowel movements a lot, but she had never heard her complain about not wanting to leave room due to urination, but she always stated she wanted or needed to return back to her room quickly due to urination and needing to be changed. Record review of the facility's Care Plan Policy revised December 2016 revealed the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 7 medication carts (Overflow cart) reviewed for storage. The facility failed to keep the overflow cart locked when not in use. This failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm. Findings included: During an observation at 7:15 AM on 12/17/24, this surveyor pulled the top drawer of the overflow medication cart and it opened. The overflow medication cart was unlocked with no employee nearby. During an interview with CMA C at 7:16 AM on 12/17/24, CMA C stated she was not aware the medication cart was unlocked until she saw the drawer open. CMA C stated she arrived at the facility this morning at around 5:45 AM. CMA C stated the cart that was left unlocked was the overflow cart where they store extra medications for residents. CMA C stated she had not used the overflow cart yet since she arrived that morning. CMA C stated she did not know who left the medication cart unlocked. CMA C stated the medication carts should not be left unlocked when unattended. CMA C stated somebody could open the unlocked medication cart and use medication, possibly leading to adverse reactions. During an interview with RN E at 7:20 AM on 12/17/24, RN E stated she arrived this morning at 7:16 AM. RN E stated she did not know who left the medication cart unlocked. RN E stated medication carts should be locked whenever they were not in use. RN E stated anybody could open the unlocked medication cart to access other resident's medications. During an interview with LVN D at 12:41 PM on 12/19/24, LVN D stated she administered PRN medications and scheduled medications to residents. LVN D stated medication carts were supposed to be locked when not in use. LVN D stated if she saw an unlocked cart not in use, she would lock it. LVN D stated she would notify whoever's cart it was and the DON that the medication cart was left unlocked. LVN D stated any resident would be able to go into an unlocked medication cart and take medicine that was not theirs. During an interview with the DON on 1:57 PM on 12/19/24, the DON stated medication carts should be locked and the screen should be on lock mode when not in use. The DON stated if she saw an unlocked cart not in use, she would lock it and figure out whose cart it was. The DON stated she had been working at the facility for approximately 5 years. The DON stated she had seen medication carts unlocked when not in use about once per year since she had been working at the facility. The DON stated someone could have accessed medications from an unlocked cart who should not have access to those medications. Record review of the facility policy titled Security of Medication Cart revised April 2007, revealed the following: 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards as is possible for 1 of 1 central supply room reviewed for the environment. The facility failed to maintain and assure the central supply room was locked at all times. This failure could place residents at risk of living in an unsafe environment. The findings include: Observation of the central supply room door on 12/17/24 at 8:25 AM revealed the door was unlocked and easily opened. There was a key to the lock hanging on the wall just outside of the door. There was a sign on the door that read, Staff Only Do Not Enter. In the room were 12 closed boxes and one open box of disposable razors. There were 6 boxes of loose nail clippers, and 1 large box full of multiple individual bottles of liquid soap. The items were in cubby type shelves located from the floor to approximately waist high. Observation of the central supply room door on 12/18/24 at 9:18 AM revealed the door was unlocked and easily opened. There was one can of spray lubricant, the same boxes of nail clippers, and the same large box full of multiple individual bottles of liquid soap on the same shelves. In an interview with CNA F on 12/18/24 at 09:20 AM, she said the central supply room should be locked at all times and did not know why it was not. She demonstrated the locking mechanism on the door was difficult to engage and said she would put in a maintenance order for it. She would not say how long the locking mechanism was not working. She said she did not know if the spray lubricant was supposed to be in the central supply room. She said if a resident handled it, they could be harmed by the spray; it could get in their eyes and on their hands. She said she did not see anything else that might be harmful. In an interview with the DON on 12/18/24 at 4:13 PM, she said the central supply room should be locked at all times. She said there was a key on the wall just outside the door. She said there was also a sign on the door for only staff to enter. She said maintenance put a new self-locking handle on the door today. She said there were harmful items such as razors, liquid soap, and spray lubricant in the central supply room. She said the spray lubricant was definitely not supposed to be in there. She said the residents could not have razors or disposable razors of their own because they could harm themselves or others. She said the open box of disposable razors was removed yesterday because the door lock was difficult to manage. She said she had to use the key to unlock the central supply room weekly for ordering purposes and she was unaware it had not been locked. She said herself, the ADM and the MS were responsible for the safety of the central supply room. She said all staff were responsible for keeping the central supply room locked at all times. In an interview with the MS on 12/18/24 at 4:30 PM, he said the central supply room should be locked at all times. He said he replaced the lock today. He said he utilized the central supply room around 3 times a week and he always locked the door. He said he had tried to get the staff to keep it locked by telling them whenever he found it unlocked, which was frequently. He said the residents would push the door open if they saw someone in there and ask for things such as tissues or lotion, etc. He said mostly the liquids like lotion, and disposable razors and just about anything in the central supply room could be harmful to the residents. He said the (loaded) shelves could fall on them if a resident tried to balance themselves with it or tried to reach for something. He said he used the lubricating spray last week and he forgot he put it on the shelf in the central supply room. He said he mostly used the lubricating spray on resident's wheelchairs in his office when they were not using them, like during a nap. He said the central supply room now had a self-locking door handle. He said he would bring it up (the new door handle and locking the central supply room) in the next (daily) morning meeting where all managers attended. He said himself, the ADM and the DON were responsible for the safety of the central supply room. He said all staff were responsible for keeping the central supply room locked at all times. In an interview with CNA B on 12/19/24 at 9:05 AM, she said she had worked at the facility for eleven or twelve years. She said the central supply room door was not locked all the time-it depended on who was working. She said she had never seen a resident in there or attempt to go in there. She said the door should be locked all the time. She said there were harmful materials in there such as bath soap, shaving cream, nail clippers, disposable razors, and for infection control.She said the door was locked when she got here at 6:30 am today. She said she was happy it was locked. In an interview with the ADM on 12/19/24 at 9:26 AM, he said the central supply room should be locked at all times. He said the central supply room had lock on it, but it was difficult to manage, so it was replaced yesterday to one that automatically locked. He said residents should not be in there taking things at will. He said he did not go in there often-mostly to make sure boxes were not stacked too high. He said the door had been locked when he went in there in August. He said he did not know if there were any items that could harm residents in the central supply room. He said the MS and the DON were responsible for the safety of the central supply room, but he was ultimately responsible. He said all staff were responsible for keeping the central supply room locked at all times. Policies for storage of resident items and hazardous materials was requested. Record review of the facility policy revised November 2009, titled Receipt and Storage of Supplies and Equipment: 6. All supplies and equipment must be stored in accordance with the manufacturer's recommendations. 7. Hazardous/toxic materials must be properly stored and labeled in accordance with current regulations. 8. It shall be the purchasing agent's responsibility to assure that proper storage procedures are maintained. Record review of the facility policy revised December 2009, titled Storage Areas, Maintenance: Policy Statement-Maintenance storage areas shall be maintained in a clean and safe manner.

Based on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for the facility reviewed for infection control. The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread. This deficient practice place the facility residents at risk for airborne infections. The findings included: An interview on 09/27/23 at 10:28 AM with the Maintenance Director revealed he did not know what Legionnaire's was. He stated he had been working at this facility for three and a half years. The Maintenance Director stated the facility water is on city water and that he visually inspects water. The Maintenance Director stated to his knowledge, there was no system to monitor effectiveness of control measures. He stated that he had no training upon hire. He was also unaware of the facility policy, Legionella Water Management Program. An interview on 09/27/23 at 10:45 AM with Infectious Preventionist DON revealed there have not been any cases of residents with Legionellosis. An interview on 9/27/23 at 1:20 PM with the Administrator, stated there was no system in place to measure testing protocols or to intervene when control limits were not met. He stated that he was waiting on corporate to set up meeting to find out what they will be implementing regarding Legionella. Administrator was aware that the Maintenance Director was not knowledgeable about the disease Legionella. He did not have a map indicating where Legionella and other opportunistic waterborne pathogens can grow and spread. A record review of the facility's Legionella Water Management Program Policy Interpretation and Implementation revised 09/2022 indicated the water management program included the following elements: 5. b. A detailed description and diagram of the water system in the facility, including the following: 1. Receiving 2. Cold water distribution 3. Heating 4. Hot water distribution 5. Waste 5. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices such as CPAP machines, hydrotherapy equipment etc. 5. d. The identification of situations that can lead to Legionella growth, such as: 1. Construction 2. Water main breaks 3. Changes in municipal water quality 4. The presence of biofilm, scale, or sediments 5. Water temperature fluctuations 6. Water pressure changes 7. Water stagnation 8. Inadequate disinfection 5. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants) f. The control limits or parameters that are acceptable and that are monitored g. A diagram of where the control measures are in place h. A system to monitor control limits and the effectiveness of control measures i. A plan for when control limits are not met or not effective j. Documentation of the program

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments on 1 of 5 medication carts reviewed for storage of drugs. Nurses' Medication Cart was left unattended, unlocked and medication cart keys left in medication cart lock by nurse's station area. This deficient practice could affect residents who have medications on the Nurses' Medication Cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. Findings included: Observation on 09/25/23 at 1:45 PM revealed a medication cart was left unlocked, unattended and medication cart keys left in medication cart lock by nurse's station. There was one resident about 5 to 10 feet away from cart and one nurse located at the nurses station out of view of the unlocked medication cart. This surveyor opened the top drawer recognizing the cart being unlocked. Multiple medications in bulk bottles and blister packs were easily assessable for removable. The DON walked by approximately 5 to 10 minutes later and was made aware of the situation and paged RN A over the intercom to come to the nurse's station. When RN A came out of resident's room, he took ownership of the medication cart and acknowledged it being unlocked and unattended. Interview on 9/25/2023 at 3:20 PM with DON stated, medication carts should be locked at all times and RN A must have gotten distracted from locking it. DON stated it was important to keep medication cart locked at all times due to anyone being able to open it and get medications not prescribed to them. DON stated that the keys to medication carts should always be with the nurse responsible for that medication cart and in-servicing on unlocked medication carts would began immediately. Interview on 09/27/2023 at 2:00 PM., with RN A stated it was a rare circumstance to leave medication cart unlocked with keys left in it. RN A stated he was called to change a resident and was in a hurry. RN A stated it was important to not leave the keys on the medication cart because of the different types of medication including narcotics it stores and could be a safety issue. RN A stated if the keys are left on the medication cart a myriad of things could happen for example, a resident, visitor, or staff member can gain access to the meds in the cart. Record review of the Facility's Medication Carts and Supplies for Administering Medication policy and procedure states; #1. The Medication cart is locked at all times when not in use. #2. Do not leave the medication cart unlocked or unattended in the resident care areas.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated, for three Residents (R #1, R #2 and R #3) of five residents reviewed for abuse/neglect. The facility did not thoroughly investigate an incident of possible neglect of R #1, R #2 and R #3. There was no documentation of any interviews with the Charge Nurses or residents regarding the allegation of neglect. This failure could place residents at risk for abuse/neglect. The findings were: 1.) Resident #1 Review of R #1's Face Sheet dated [DATE] revealed a [AGE] year-old female initially admitted on [DATE], with [DIAGNOSES REDACTED]. Review of R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1: -had unclear speech -usually made herself understood and usually understood others -had severely impaired cognitive skills -extensive assistance of one-person for bed mobility, transfer, walk in room, and locomotion on unit. -extensive assistance of one-person physical assist for dressing, toilet use, and personal hygiene. -was always incontinent of bowel and bladder. Review of R #1's Care Plan dated [DATE] indicated R #1 had impaired cognitive function and impaired thought processes related to (r/t) Dementia. Goal - R #1 will develop skills to cope with cognitive decline and maintain safety by the review date. R #1 uses antianxiety medications. At risk for side effects. Interventions - R #1 Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Antianxiety Side Effects 1=sedation/drowsiness 2=increased falls/dizziness 3=[MEDICAL CONDITION] 4=agitation 5=blurred vision R #1 had an actual fall with No injury, related to: poor communication/comprehension, psychoactive drug use, Unrealistic sense of physical abilities, unsteady gait, bilateral extremity weakness. Dated Initiated: [DATE] Goal - R #1 Will not sustain fall with injury through review date. Interventions R #1 Continue interventions on the at risk plan. Document/report to doctor as needed x [AGE] hours post fall sign and symptoms: pain, bruises, change in mental status, sleepiness, inability to maintain posture, agitation. Review of R #1's Progress Notes completed by LVN B dated [DATE] at 02:23 AM- CNA alerted nurse to residents' room. R #1 noted lying on the floor in front of her recliner with w/c (wheel chair) overturned on top of her w/c moved off R #1. ROM (range of motion) x 4 extremities noted without difficulty no skin tears no bruising noted. R #1 unable to give a description of what happend. RP Review of R #1's Progress Notes completed by LVN C Review of R #1's Progress Notes completed by LVN C dated [DATE] at 10:40 PM had received result from Right Hip X-ray. Impression: Acute Right [MEDICAL CONDITION] at the Intertrochanteric of the Right Femur. Diffuse [CONDITION] is present. On [DATE] at 10:45 PM LVN notified Doctor and he ordered to transfer resident to local hospital ER for evaluation and treatment. On [DATE] at 11:45 PM, R.P. notified by LVN of X-ray results and of orders to transfer R #1 to hospital ER. 2.) Resident #2 Review of R #2's Face Sheet dated [DATE] revealed a [AGE] year old female Original admitted date [DATE], Initial admitted [DATE], and readmitted on [DATE]. Diagnoses: [REDACTED]. Review of R #2's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #2: -had clear speech -understood and usually understood others -had severely impaired cognitive skills -extensive assistance of two +person for bed mobility, transfer, and locomotion on unit. -extensive assistance of two +person physical assist for dressing, toilet use, and personal hygiene. And total dependence for bathing. -was always incontinent of bowel. Review of R #2's Care Plan dated [DATE] revealed R #2 is High risk for falls related to balance problem, impaired balance, incontinence, and vision problem. -Be sure call light is within reach and encourage to use it for assistance as needed R #2 Care Plan (Dated [DATE]) had an actual fall with No Injury related to poor balance, Unrealistic sense of physical abilities. Revision [DATE] Goal -Will not sustain fall with injury Interventions - Reinforce need to call for assistance and use call bell. -Continue interventions on the at risk plan -PT/OT (Physical Therapy/Occupational Therapy) screen for strength and mobility - Resident (R #2) refused therapy, PT tighten brakes on w/c, resident return demonstration and verbalized understanding of importance of locking W/C R #2 Care Plan (Dated [DATE]) revealed R #2 had an actual fall with No Injury, related to: poor balance, unsteady gait, confusion, poor vision -Anticipate and meet needs. -Encourage eyeglasses are on when out of bed. R #2 Care Plan (Dated [DATE]) revealed R #2 had an actual fall with serious injury related to: poor balance, unrealistic sense of physical abilities, and unsteady gait - transferring self from w/c to bed without assist -([DATE]) R #2 was transferred to ER (emergency room ) for eval and treat (admitted for Fracture of Right Knee) -Encourage an earlier bedtime with assist of staff -Reinforce need to call for assistance R # 2 Care Plan (Dated [DATE]) had deficit in memory, judgement, decision making and thought process related to: Dementia Observed R #2 on [DATE] at 1:46 PM - R #2 was in her room sleeping while sitting in her wheel chair. Roommate was awake while sitting in her wheel chair was non-interviewable and couldn't responded to questions asked. R #2 awaken and didn't respond to questions asked how she was doing from her fall. Resident is also non-interviewable. Observed room clean and no foul odors with call light on her bed, not in reach of R #2 while sitting in wheel chair. No fall mats noted by her bed. Observed regular mattress on R #2's bed. Observed R #2 wearing her eye glasses. R #2's room was located down the end of 400 hall not visible from the nurse's station. 3.) Resident #3 Review of R #3 Face Sheet dated [DATE] reveled R #3 an [AGE] year old female Original admitted on [DATE], Initially admitted on [DATE], and admitted [DATE] with Diagnoses: [REDACTED]. (Surgical Incision to Right Hip from fall not listed on Face Sheet) Review of R #3's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #3: -had clear speech -understood and usually understood others -had severely impaired cognitive skills -extensive assistance of one person for bed mobility, transfer, and walk in room. -limited assistance of one person physical assist for dressing, and -extensive assistance of one person for toilet use, and personal hygiene, and bathing. -was always continent of bowel and occasional incontinent of bladder. Review of R #3's Care Plan dated [DATE] revealed R #3 had an actual fall with major injury related to poor balance, Unrealistic sense of physical abilities, unsteady gait -Ambulating to Bathroom with walker, shoes not no properly Interventions (Date Initiated [DATE]) -Have family bring proper fitting footwear for ambulation. Assist with putting shoes on correctly before ambulation. -Monitor R #3; assist with toileting when she wakes in AM. Encourage and reinforce call light use. R #3 (Date Initiated [DATE]) requires anti-anxiety medication. At risk for side effects - [MEDICATION NAME] Behavior; Restlessness -Give anti-anxiety medication ordered by physician. Observe/document side effects: -Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, dizziness, lightheadedness . R #3 Fall Investigation work sheet dated [DATE] revealed under - Fall Information - resident walked to bathroom using assistive Device; rolling walker. Under witness information documented - Unwitnessed Fall Under - Injuries documented Injury to Right Elbow, skin tear and Right Hip Pain. Under Medical Changes - documented Diagnosis - Possible Right Hip/Right Femur Fracture. Under Environmental documented - Ill-fitting footwear; Resident (R #3) here for 5 day hospice respite care. Under Conclusion/Root Cause documented - Ill-fitting shoes; Resident (R #3) forgetful to use call bell for assist unaware of safety issue; Resident (R #3) admitted for 5 day hospice respite stay; Resident to return home at end of stay. R #3 - Head to toe assessment complete; complained of right hip pain . During an interview with Administrator on [DATE] at 10:30 AM, upon initial entrance of the facility Administrator was asked for a copy of documentation of investigations for unwitnessed falls for R #1, R #2, R #3 which were provided to the state. Administrator provided surveyor with Form 3613- A for all three residents. Administrator stated that reports provided to surveyor was completed and that was everything she had sent in to the State. Administrator said, Did it not print everything. Administrator said he would provide the in-services. Administrator stated no changes regarding fall with injury had been made, and two of the residents were still in the hospital. After observation noted R #1 had expired in the hospital from complications post-surgical. R #2 was residing at the facility in the 400 hall. And R #3 was on 100 hall. During an interview with DON on [DATE] at 10:45 AM, provided surveyor with what the nursing does after a post fall documentation and what is going to be done for the resident when returned from the hospital. DON continued to state, If the resident doesn't return from the hospital, well there is no reason to change anything. DON said R #1 had returned from the hospital post-surgical but had respiratory distress and was transferred to hospital and was put on life support. And DON said she did not know what had happen to R #1 after that. During interview on [DATE] at 4:00PM - Administrator stated she felt she did a thorough investigation, but she didn't provide all the information to surveyor because she never gives it to the surveyor unless they ask for it. Administrator stated she had sent a copy of everything already to state. The adminstrator provided surveyor a copy of provider investigation report HHSC form 3613-A and inservice training copies. Surveyor reviewed what was provided for R #1's fall. The provider investigation report did not have any documentation that R#1 had been interviewed. Record review of the Facility policy on Preventing Resident Abuse dated 2001 Med-Pass, Inc. (Revised [DATE]) documented, Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The individual conducting the investigation will, as minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; . c. Interview the person(s) reporting the incident' e. Interview the resident's (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other resident to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location; b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process; .

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for two Resident (R#1, R #2) of five residents reviewed for falls. The facility did not provide the type and amount of supervision necessary to prevent R #1 and R #2 from falling multiple times. This failure could place residents with high risk for falls at risk for additional falls and injuries. The findings included: 1.) Resident #1 Review of R #1's Face Sheet dated 12/12/19 revealed a [AGE] year-old female initially admitted on [DATE], with [DIAGNOSES REDACTED]. Review of R #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1: -had unclear speech -usually made herself understood and usually understood others -had severely impaired cognitive skills -extensive assistance of one-person for bed mobility, transfer, walk in room, and locomotion on unit. -extensive assistance of one-person physical assist for dressing, toilet use, and personal hygiene. -was always incontinent of bowel and bladder. Review of R #1's Care Plan dated 9/18/19 revealed: R #1 - had impaired cognitive function/impaired thought processes related to Dementia. - Uses antianxiety medication at risk for side effects. [MEDICATION NAME] Monitor/document side effects and effectiveness. Antianxiety side effects 1= sedation/drowsiness 2= increased falls/dizziness 3= [MEDICAL CONDITION] 4= agitation 5=blurred vision . Review of R #1's Progress notes dated 11/07/19 documented, New order for [MEDICATION NAME] 1 mg 1 PO (oral) BID (Twice a Day) for ongoing behaviors that resident is displaying ie (is exhibiting): rummaging through drawers and not making sense when she talks, talking to people that are not present, seeing things that are not in room, hoarding trash in drawers. Per medical history, resident responded well to this medication for these behaviors. Review of R #1's Progress notes dated 11/08/19 at 2:18 AM LVN B documented, CNA altered nurse to Residents (R #1) room Resident noted lying on the floor in front of her recliner with w/c (wheel chair) overturned on top of her (R #1) moved off of resident. ROM (range of motion) x4 extremities noted without difficulty no skin tears no bruising noted Resident unable to give a description of what happened family called, and Dr. faxed notifications will monitor neurological checks per facility protocol as fall was unwitnessed. Review of R #1's Progress notes dated 11/08/19 at 9:30 PM LVN D documented, Continue follow up with neuros for fall. Continue to note confusion, No bruising or abrasions noted. Resident (R #1) was complaining of pain to her right hip. Orders were received for R #1 to get X-Ray of Right Hip. Review of R #1's Progress notes dated 11/08/19 at 10:40 PM LVN C documented, Received result from Rt. (right) hip X-Ray. Impression: Acute right [MEDICAL CONDITION] at the intertrochanteric of the right femur. At 10:45 PM Dr. was notified and orders to transfer resident to local hospital for evaluation and treatment. Review of R #1's Falls Investigation Worksheet dated 12/11/19 documented under Environmental - Cords Conclusion/Root Cause - Resident sitting up in her recliner and wanted to go to her bed she (R #1) attempted to reach her w/c (wheel chair) attempting to transfer adlib. She (R #1) is forgetful and confused does not request assist of recall to use her c/b (call bell). New onset of behavioral symptoms; Resident (R #1) was on [MEDICATION NAME] 1mg BID prior to hospitalization in September per MHMR (Mental Health Mental [MEDICAL CONDITION]). Pending Psych evaluation. Call don't fall sign placed for resident to see when sitting in recliner. 2.) Resident #2 Review of R #2's Face Sheet dated 12/12/19 revealed a [AGE] year old female Original admitted date 06/05/14, Initial admitted [DATE], and readmitted on [DATE]. Diagnoses: [REDACTED]. Review of R #2's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #2: -had clear speech -understood and usually understood others -had severely impaired cognitive skills -extensive assistance of two +person for bed mobility, transfer, and locomotion on unit. -extensive assistance of two +person physical assist for dressing, toilet use, and personal hygiene. And total dependence for bathing. -was always incontinent of bowel. Review of R #2's Care Plan dated 12/08/19 revealed R #2 is High risk for falls related to balance problem, impaired balance, incontinence, and vision problem. -Be sure call light is within reach and encourage to use it for assistance as needed R #2 Care Plan (Dated 11/12/18) had an actual fall with No Injury related to poor balance, Unrealistic sense of physical abilities. Revision 12/08/19 Goal -Will not sustain fall with injury Interventions - Reinforce need to call for assistance and use call bell. -Continue interventions on the at risk plan -PT/OT (Physical Therapy/Occupational Therapy) screen for strength and mobility - Resident (R #2) refused therapy, PT tighten brakes on w/c, resident return demonstration and verbalized understanding of importance of locking W/C R #2 Care Plan (Dated 9/26/19) revealed R #2 had an actual fall with No Injury, related to: poor balance, unsteady gait, confusion, poor vision -Anticipate and meet needs. -Encourage eyeglasses are on when out of bed. R #2 Care Plan (Dated 10/30/19) revealed R #2 had an actual fall with serious injury related to: poor balance, unrealistic sense of physical abilities, and unsteady gait - transferring self from w/c to bed without assist -(10/30/19) R #2 was transferred to ER (emergency room ) for eval and treat (admitted for Fracture of Right Knee) -Encourage an earlier bedtime with assist of staff -Reinforce need to call for assistance R # 2 Care Plan (Dated 12/08/19) had deficit in memory, judgement, decision making and thought process related to: Dementia Observed R #2 on 12/12/19 at 1:46 PM - R #2 was in her room sleeping while sitting in her wheel chair. Roommate was awake while sitting in her wheel chair was non-interviewable and couldn't responded to questions asked. R #2 awaken and didn't respond to questions asked how she was doing from her fall. Resident is also non-interviewable. Observed room clean and no foul odors with call light on her bed, not in reach of R #2 while sitting in wheel chair. No fall mats noted by her bed. Observed regular mattress on R #2's bed. Observed R #2 wearing her eye glasses. R #2's room was located down the end of 400 hall not visible from the nurse's station. Interview with Administrator. on 12/11/19 at 10:30 AM, informed surveyor that no changes had been made since residents fall with injury and two of the residents were still in the hospital. Interviewed DON on 12/11/19 at 10:45 AM - DON stated, If resident doesn't return from the hospital, well there's no reason to change anything. Interviewed DON on 12/12/19 at 10:02 AM - said R #1 had returned from the hospital post-surgical but had respiratory distress and was put on life support but DON said she did not know what happed to R #1 after that. Interview with DON on 12/13/19 at 3:24 PM - Stated she believed R #2 with a BI[CONDITION] 01 (Severely Impaired Cognition) understood when P/T demonstrated and returned demonstration of using brakes on wheel chair. DON said that R #2 refused therapy. DON denied any changes since residents fall. DON said R #2 knows to use her call light. DON was asked that during an observation noted call light was lying on the bed while resident was sitting in wheel chair away from the bed, DON stated, that would have been after P/T. Interviewed with MDS Coordinator on 12/13/19 at 3:10 PM said, For residents that are fall risks, Fall Prevention Patient specific, we have measures, we have therapy as it should be patient specific. I can't say we do anything different we have those measures in place for care specific for each resident.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs, for two residents (R #65 and R #67) of eighteen residents reviewed for care plans. 1. Resident #65's comprehensive care plan did not address the use of an antipsychotic medication ([MEDICATION NAME]) or the [DIAGNOSES REDACTED]. 2. Resident #67's comprehensive care plan did not address her hospitalization to have fluid removed from her lungs and did not address physical and psychological effects of her chronic diarrhea. This deficient practice could affect residents who reside at the facility and could result in improper delivery of care. The findings included: 1.) R #65 R #65 undated facesheet documented an [AGE] year old male was admitted [DATE] with the [DIAGNOSES REDACTED]. Record review of R #65's, 06/2019 Consolidated physician's orders [REDACTED]. Record review of R #65's comprehensive care plan from 06/03/19 revealed the [DIAGNOSES REDACTED]. Record review of R #65's Psychiatric Consulting Services Progress Note dated 04/13/2019, revealed the [DIAGNOSES REDACTED]. Record review of R #65's Medication Administration Record [REDACTED]. During an interview on 06/27/19 at 11:10 a.m., Licesened Vocational Nurse (LVN) A, stated the reason the [MEDICAL CONDITION] Disorder and the antipsychotic medication- Zeprexa was not addressed on the current comprehensive care plan was because it was resolved on 6/5/19. LVN A, stated she was not aware of the new order for [MEDICATION NAME] dated 06/07/19 and acknowledged it had not been addressed in R #65's care plan. An interview was attempted on 06/27/19 at 3:45 p.m. with R #65, but he was unable to answer questions appropriately due to his cognitive deficit. 2.) R #67 Review of R #67's undated admission record revealed a [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview with R #67 on 06/25/19 at 10:19 AM, she stated she was having issues with diarrhea on a daily basis. R # 67 stated she was receiving medication daily and it seemed to help. R #67 also indicated that she was unable to attend activities due to the diarrhea but was participating in therapy. R #67 indicated that the diarrhea was especially disturbing to her since she never knew when it was going to happen. R #67 stated that frequently she had diarrhea after she ate. R #67 mentioned that she had gone back to the hospital about a week ago to have fluid drained from her lungs. During an interview with Charge Nurse LVN G on 06/27/19 at 11:46 AM, the issue of R #67's diarrhea was discussed. LVN G stated that this was a common result of the type of intestinal surgery that she had. LVN G stated that R #67 was getting medication to help it but the issue would not resolve completely for possibly several months. A record review of the Nurses Notes in the Medical Record dated 06/16/19 confirmed she went back to the hospital on [DATE] and returned on 06/16/19. During that time she had 1700 ml of fluid drained from her lungs. Record review of the undated Comprehensive Care plan with an admission date of [DATE] did not reveal a plan for addressing the physical and psychological care needs related to the diarrhea or the [MEDICAL CONDITION] which had the potential to cause the fluid overload. The Comprehensive Care Plan with an admission date of [DATE] included the following Focus Areas and Interventions: A) Focus: Inability to control bowel movements AEB (As Evidenced By): Usually Incontinent R/T (Related to) impaired mobility, S/P (status [REDACTED].>Interventions: Offer bedpan PRN (As Needed); Offer to assist to B/R (bathroom) on rounds; Provide incontinence care as needed during rounds (No interventions were offered to address the psychological impact of the diarrhea.) B) Focus: (R #67) has the potential for fluid volume deficit r/t (Related to) Admit DX (No explanation of Admit DX was provided) Interventions: Instruct resident and family of importance of fluid intake; Observe urine output for signs of dehydration: concentrated urine, strong odor; Obtain and monitor lab work: BUN (Blood Urea Nitrogen) creatinine. Report results to MD and follow up as indicated; RD (Registered Dietician) to eval and make recommendations as needed; Report to MD PRN (As Needed) for s/sx (Signs/Symptoms) of dehydration: decreased urine output, cracked lips, increased pulse, fever, dizziness, thirst, fatigue/weakness and poor skin tugor. During an interview on 06/27/19 at 1:48 PM with LVN A, she verified the fluid overload and physical and psychological effects of diarrhea had not been addressed in the Comprehensive Care Plans. Review of the facility's (MONTH) (YEAR) Comprehensive Person-Centered Care Plan Policy and Procedure documented A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: . b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . i. Reflect the resident's expressed wishes regarding care and treatment goals .

Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for two residents (R #63 and R #67) of 18 residents whose care plans were reviewed, in that: 1) R #63's comprehensive care plan was not reviewed or revised after the quarterly minimum data set (MDS) assessment on [DATE] to include R #63's current code status of Do Not Resuscitate (DNR), instead of Full Code. 2) R #67's comprehensive care plan did not address her hospitalization to have fluid removed from her lungs, did not address physical and psychological effects of her chronic diarrhea and was not individualized to address the complexities of her medical diagnoses. This failure could place residents at risk for inadequate care and services. The findings included: 1.) R #63: R #63's Face Sheet dated [DATE] documented an [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #63's Face Sheet revealed the advanced directives section identified R #63 as a DNR (Do Not Resuscitate). R #63's Out of Hospital DNR Order dated [DATE] revealed the order was signed and executed [DATE] by R #63's responsible party/power of attorney. R #63's Quarterly Minimum (MDS) data set [DATE] documented R #63: -had a brief interview of mental status score of 6- severely impaired cognition -was totally dependent on staff for bed mobility, dressing, toilet use, and personal hygiene -was always incontinent of bladder and bowel -was at risk of developing pressure ulcers/injuries -did not have one or more unhealed pressure ulcers/injuries, other skin problems: skin tear R #63's Person-Centered Comprehensive Care Plan revised [DATE] documented (R #63) has a code status of Full Code/CPR (Cardiopulmonary Resuscitation) .Interventions: IDT (Interdisciplinary Team) to review code status with resident and/or RP (responsible party) during the plan of care meeting; If the resident arrests, CPR will be performed, 911 called; Staff to verify Code Status in the resident's chart with sudden changes in condition such as cardiac/respiratory arrest; Staff will honor and respect resident wishes to be a Full Code/CPR. R #63's (MONTH) (YEAR) Consolidated physician's orders [REDACTED]. Interview with Licensed Vocational Nurse (LVN)/MDS Coordinator A on [DATE] at 01:30 PM revealed she was responsible for creating and updating all resident care plans. The surveyor brought to LVN A's attention of R #63's care plan, revised [DATE], that documented advance directives/code status of full code, instead of DNR as ordered by the physician. LVN A confirmed the plan and code status was incorrect and said the plan was not revised because I just missed it. Well, it is important to make sure the plan is correct and reflected the resident's current status to ensure the correct care is provided and so our entire team had the same information and knowledge on how to care for the resident. 2.) R #67: Review of R #67's undated admission record documented a [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview with R #67 on [DATE] at 10:19 AM, she stated she was having issues with diarrhea on a daily basis. Resident #67 stated she was receiving medication daily and it seemed to help. R #67 also indicated that she was unable to attend activities due to the diarrhea but was participating in therapy. R #67 indicated that the diarrhea was especially disturbing to her since she never knew when it was going to happen. R #67 stated that frequently she had diarrhea after she ate. R #67 also mentioned that she had gone back to the hospital about a week ago to have fluid drained from her lungs. During an interview with Charge Nurse LVN G on [DATE] at 11:46 AM, she stated chronic diarrhea was a common result of the type of intestinal surgery that R #67 had. LVN G stated that R #67 was getting medication to help it but the issue would not resolve completely for possibly several months. A record review of the Nurses Notes dated [DATE] in the Medical Record confirmed she went to the hospital on [DATE] and returned on [DATE]. During that time she had 1700 ml of fluid drained from her lungs. Record review of the Baseline Care Plan dated [DATE] as well as the Comprehensive Care plan with an admission date of [DATE] did not reveal a plan for addressing the physical and psychological care needs related to the diarrhea, the fluid overload or the [MEDICAL CONDITION]. Review of R #67's History & Physical dated [DATE], revealed: Having mild pain. No nausea vomiting but positive for multiple diarrhea stools. He ordered testing on the stools on [DATE]. Review of lab results for R #67, received on [DATE] indicated: Result: [DATE] - Abundant Pseudomonas aeruginosa. Record Review of R #67's clinical record revealed an order for [REDACTED]. During an interview on [DATE] at 1:48 PM with LVN A, she verified that the comprehensive care plan for R #67 had not been revised to include the fluid overload and did not address the chronic diarrhea or the infection that was detected in the lab results. Review of the facility's (MONTH) (YEAR) Comprehensive Person-Centered Care Plan Policy and Procedure documented A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: . b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . i. Reflect the resident's expressed wishes regarding care and treatment goals .

Based on observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to prevent, recognize, and control the onset and spread of infection by not following appropriate droplet precautions for one of one residents reviewed for droplet precautions (R #277) by: 1. CNA (Certified Nurse Aide) AM entered R #277's isolation room without donning a gown or gloves and only used a mask. 2. COTA (Certified Occupational Therapy Assistant) was treating R #277 in his room wearing only a gown and gloves but no mask or face shield. These deficient practices could place other residents and staff at risk for infection by not adhering to the facility policy for Isolation - Initiating Transmission-Based Precautions. The findings were: During initial rounds with residents on 06/24/19 at 3:30 PM, an isolation cart was observed outside of the room for R #277. A sign was also posted on the door that read See Nurse before Entering. CNA AM was asked if resident was awake. CNA AM donned a mask and stated that this was the only PPE (Personal Protective Equipment) needed. CNA AM then proceeded to enter the room and ask resident if he was willing to be interviewed. Interview with the charge nurse, LVN G, on 06/24/19 at 3;30 PM, confirmed resident was on droplet precautions for pseudomonas [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) so appropriate PPE was donned by surveyor which included a mask. Review of R #277's admission record revealed an [AGE] year old male was admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of the lab report dated 06/13/19 for R #277 revealed a sputum culture was taken to test for infection. Record Review of Skilled Nurses Notes dated 06/16/19 indicate he was placed on isolation for droplet precautions due [MEDICAL CONDITIONS]-Resistant Staphylococcus Aureus) and pseudomonas aeruginosa of the sputum. Further review revealed this information was not placed on the baseline care plan and had not been placed on a comprehensive care plan as of 06/27/19. Interview on 06/26/19 at 2:30 PM with the PT (Physical Therapist) revealed that droplet precautions were followed when the therapy team entered the room to treat R #277. PT stated that this included a gown, gloves, mask and face shield since they are in close contact with resident. All of their equipment also remains in the room. Interview on 06/26/19 at 2:54 PM with CNA I revealed she had been caring for R #277 since his admission. CNA I stated he was not on isolation precautions when he first arrived at the facility. CNA I stated she was told about the necessary precautions during shift report. CNA I was then able to describe the appropriate procedure for donning and doffing PPE to wear in the resident's room and washing hands prior to exiting the room. Interview on 06/27/19 at 11:46 AM with LVN G revealed that R #277 was placed on isolation as soon as labs were received. LVN G stated according to their isolation protocol, all individuals entering the room should don a gown, mask and gloves. LVN G stated she had to educate his family about the requirements. LVN G stated this information was also communicated to staff during shift report. LVN G also stated that she took another sputum culture today and it will go to the lab in the morning. If R #277 is clear, he would be discharged home this weekend. During a visit with R #277 on 06/28/19 at 10:17 AM, COTA (Certified Occupational Therapy Assistant) was observed working with resident in his room wearing only a gown and gloves. R #277 stated he planned to go home this weekend if his sputum test was clear but at this time, however, he had not been cleared. R #277 was confined to his room during his stay due to the infection present. During an nterview with COTA on 06/28/19 at 11:00 AM, she stated she had not been told about the droplet precautions so was not aware that she needed a mask. COTA provided a paper that she had been given listing what therapy was needed for R #277. A review of this paper revealed that droplet precautions were not on it. COTA stated she had just started working with R #277 this week. During an interview with the DON and ADON on 06/28/19 at 10:50 AM. they stated that Droplet Precautions should be followed in the case of R #277 by everyone since this could spread the infection. The DON stated they have a sign on the door that applies to all people prior to entrance to the room to stop and see charge nurse before going in the room so appropriate PPE can be worn into the room according to the type of precautions needed such as Droplet Precautions, Airborne Precautions or Contact Precautions. In the case of R #277, the ADON stated a mask, gown and gloves were required due to the droplet precautions that could spread the infection if the resident coughed or sneezed. Isolation - Initiating Transmission-Based Precautions policy for the facility revealed: Policy Statement Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact precautions, Droplet Precautions, or Airborne Precautions. Policy Interpretation and Implementation 5. When Transmission-Based Precautions are implemented, the Infection control Coordinator (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained in or near the resident's room so that everyone entering the room can access what they need. b. Post the appropriate notice on the room entrance door so that all personnel will be aware of precautions, or be aware that they must first see nurse to obtain additional information about the situation before entering the room. This facility's process for notification A sign on the front of the door indicating to see the nurse before entering. c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate iner, are placed in or near the resident's room; d. Please necessary equipment and supplies in the room that will be needed during the period of Transmission-Based Precautions; e. Be sure that an adequate supply of antiseptic soap and paper towels is maintained in the room during the isolation period; and f. Explain to the resident (or representative) the reason(s) for the precautions.

Based on observation, interview, and record review, the facility failed to make an attempt to use appropriate alternatives and assess the resident for risk of entrapment from bedrails prior to installation or review the risk and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for two residents (R #25, and R #31), of 15 residents reviewed for side rails, in that: The facility did not obtain an assessment or consent for the use of bed side rails for R #25 and R #31 prior to installation. This failure could put residents with side rails at risk for injuries. The findings included: 1.) R #25 R #25's Face Sheet dated 06/25/19 documented an [AGE] year-old female admitted [DATE] with the [DIAGNOSES REDACTED]. R #25's Quarterly Minimum (MDS) data set [DATE] revealed R #25: -had a brief interview of mental status score of 8- moderately impaired cognition -was totally dependent on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene -Physical Restraints: Used in bed: bed rail not used. Observation of R #25 on 06/24/19 at 03:44 PM revealed R #25 had one fourth bed side rail on each side of the bed, in a raised position. Review of R #25's (MONTH) 2019 Consolidated physician's orders [REDACTED]. R #25's Comprehensive Person-Centered Care Plan dated 06/21/19 revealed the plan did not address the use or need of half size side rails. Review of R #25's electronic clinical record revealed no consent for the use of bed side rails was found. Review of R #25's electronic clinical records of assessments/reports revealed there was no assessment for the use of bed side rails, risk of entrapment or alternatives attempted prior to the use of bed rails. 2.) R #31 R #31's Face Sheet dated 06/27/19 revealed an [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. R #31's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #31: -had a brief interview of mental status score of 2 - severe cognitive impairment -was totally dependent on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene R #31's Comprehensive Care Plan dated 05/17/19 documented Impaired physical mobility as evidenced by: Bed Mobility -extensive to total dependence x 2 staff Transfers - extensive to total dependence x 2 staff Walking - not applicable Locomotion - extensive to total dependence x 1 staff related to cognitive deficit Dx (diagnosis): Dementia, impaired balance, weakness ·1/2 S/R (side rail) x1 for T&P (turn and position). Observation of R #31 on 06/24/19 at 02:54 PM revealed she had one half bed side rail on each side of the bed, in a raised position. During an attempted interview with R #31 on 06/24/19 at 3:00 PM, when asked if she used the side rails, R #31 responded: Yea, I got them, I don't know where it came from but that's okay. Review of R #31's (MONTH) 2019 Consolidated physician's orders [REDACTED]. Review of R #31's electronic clinical record revealed no consent for the use of bed side rails was found. Review of R #31's electronic clinical records revealed there was no assessment for the use of bed side rails for risk of entrapment or alternatives attempted prior to the use of bed side rails. In an interview with the Director of Nurses (DON) and the Administrator on 06/27/19 at 10:15 AM, they confirmed the facility only completed a Physical Restraint Evaluation for the use of restraints. The DON said the use of bed side rails was not considered a restraint if the rails did not inhibit the residents movement or activity. The DON and the Administrator verified the facility had not completed a side rail assessment or obtained a consent for the use of side rails from any resident. The DON said she had not been aware of having to obtain an assessment, physician's orders [REDACTED]. Further interview with the DON on 06/27/19 at 01:33 PM revealed she reviewed her Standard of Care meeting notes and the use of bed side rails was noted to be an issue on 05/23/19. The DON explained at that time multiple bed side rails in the facility were removed but not 100%. The DON said she was currently working on obtaining assessments and consents for all the residents currently using bed side rails. The DON confirmed the facility did not assess or obtain consents, prior to today, for the all residents currently using bed side rails. The DON verified no resident had a consent or assessment for the use of bed side rails prior to 06/27/19. The facility's (MONTH) 2007 Bed Safety Policy and Procedure documented 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part as our regular bed safety program to identify risks and problems including potential entrapment . e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment . 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident or the resident's legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative . 8. Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Use of bed side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails

Based on record review and interview, the facility failed to develop a base line care plan that included the instructions needed to provide effective and person-centered care of the resident, for two residents (R#277 and R#67) of two residents reviewed for base line care plans. 1.) The facility did not develop and revise a baseline care plan that addressed the requirement for droplet precautions on Resident #277. 2.) The facility did not develop a base line care plan that addressed R #67's chronic diarrhea and her re-hospitalization to treat a fluid overload in her lungs. This deficient practice could place residents and staff at risk for transmission of infections and for not having their care needs met. The findings were: 1.) R #277: Review of R #277's admission record revealed an [AGE] year old male was admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of R #277's Baseline Care plan dated 06/11/19 and electronically signed by LVN AR did not indicate any respiratory issues under the section titled [MEDICAL CONDITION] Disease/URI (Upper Respiratory Infection). Review of the lab report dated 06/13/19 for R #277 revealed a sputum culture was taken to test for infection. Record Review of Skilled Nurses Notes dated 06/16/19 indicate he was placed on isolation for droplet precautions due [MEDICAL CONDITIONS]-Resistant Staphylococcus Aureus) and pseudomonas aeruginosa of the sputum. Further review revealed this information was not placed on the baseline care plan and had not been placed on a comprehensive care plan as of 06/27/19. 2.) R #67: Review of R #67's undated admission record revealed a [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview with R #67 on 06/25/19 at 10:19 AM, she stated she was having issues with diarrhea on a daily basis. Resident # 67 stated she was receiving medication daily and it seemed to help. She also indicated that she was unable to attend activities due to the diarrhea but was participating in therapy. R #67 mentioned that she had gone back to the hospital about a week ago to have fluid drained from her lungs. She indicated that the diarrhea was especially disturbing to her since she never knew when it was going to happen. She stated that frequently she had diarrhea after she ate. During an interview with Charge Nurse LVN G on 06/27/19 at 11:46 AM, the issue of R #67's diarrhea was discussed. LVN G stated that this was a common result of the type of intestinal surgery that she had. LVN G stated that she was getting medication to help it but the issue would not resolve completely for possibly several months. Record review of the Nurses Notes in the Medical Record dated 06/16/19 confirmed R #67 went back to the hospital on [DATE] and returned on 06/16/19. During that time she had 1700 ml of fluid drained from her lungs. Record review of the Baseline Care Plan dated 06/04/19 and the Comprehensive Care plan with an admission date of [DATE] did not reveal a plan for addressing the physical and psychological care needs related to the diarrhea or the fluid overload. During an interview on 06/27/19 at 1:48 PM with LVN A, she verified that the baseline care plan had not been revised to include the isolation precautions and the comprehensive care plan had not been completed as of the time of this interview for R #277. She also verified that the fluid overload and diarrhea had not been addressed in either the Baseline or Comprehensive Care Plans for R #67.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two Residents (R #2 and R #3) of six Residents reviewed for indwelling urinary catheters. -The Administrator failed to supervise the Director of Nurses (DON) and ensure the facility's neglect policy was implemented. -The DON failed to supervise the staff to ensure the nurses were actually assessing and documenting the results of indwelling urinary catheter monitoring. -R #3 had a urethral tear. The facility did not assess R #3's catheter-urethral junction every day as ordered by the Physician. -R #2 had an indwelling urinary catheter (a tube inserted into the bladder to enable urination). The facility did not assess R #2 or put interventions into place when R #2 developed a tear to his urethra. The underside of R #2's penis had no tissue from the meatus to the top of R #2's scrotum. These failures placed the six residents with indwelling urinary catheters at risk of not receiving proper assessments and care and services required to prevent delay in treatment, complications, or possible harm. Findings were: R #3 R #3's Face Sheet dated 10/13/14 revealed R #3 was a [AGE] year old male admitted to the facility 04/21/14 with initial admission date of [DATE] and the following Diagnoses: [REDACTED]. R #3's most current Care Plan revision, dated 05/13/14 revealed, "...has a Indwelling Catheter: Skin Breakdown ...Will be/remain free from catheter-related trauma through review date ...Change catheter 16 French 10 cc balloon (every) month and (as needed) ...Check tubing for kinks each shift, apply leg strap at all times ..." R #3's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #3 was understood by others, usually understood others and had no behaviorial symptoms. R #3 required extensive assistance with bed mobility, dressing, eating, and transfers with assistance of one person. R #3 had an indwelling urinary catheter and was frequently incontinent of bowel. R #3's consolidated Physician order [REDACTED]. -"(Indwelling urinary) catheter 18 (French) 30 (centimeter) bulb, change every 30 days on NIGHT shift and (as needed) every night shift starting on the 15th and ending on the 15th for [MEDICAL CONDITION] DEPENDENT TO DRAINAGE" and, -"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." Review of R #3's 12/2014 and 01/2015 Medication Administration Record [REDACTED]"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." R #3's Nurse's Notes dated 01/15/15 at 11:00 a.m. revealed: "While changing catheter- Nurse noticed meatus appeared to have torn. Bright red blood present upon removal of catheter. Significant amount of blood noted. Was able to reinsert catheter. MD (Medical Doctor) notified. (No) signs of infection noted at this site. Will continue to monitor." R #3's Nurse's Notes dated 01/16/15 at 3:30 a.m. revealed: "... (Indwelling urinary catheter) patent and draining yellowish urine via gravity. Penis at insertion site with slit to urethra, cleansed with warm water and soap, scant amount bright red blood and greenish drainage, tender to touch ..." R #3's Nurse's Notes dated 01/16/15 at 5:00 p.m. revealed: "...Spoke to (MD "D"), stated (MD "G") will come and evaluate coccyx wound and penile tear on Monday/Tuesday (01/19/15 or 01/20/15) ..." R #3's Nurse's Notes dated 01/17/15 at 8:00 p.m. revealed: "...Penile tear free from blood/drainage." Review of R #3's Nurse's Notes after 01/17/15 at 8:00 p.m. revealed there was no further documentation staff assessed R #3's penile tear. Review of Nurse's Notes dated 12/2014 through 01/14/15 revealed no documentation staff assessed R #3's catheter-urethral junction. On 01/21/15 at 9:10 a.m., during a wound care observation with Registered Nurse (RN) "E", R #3 had approximately a 1 cm (centimeter) tear to his urethra. RN "E" said MD "G" was supposed to come to the facility this week to evaluate R #3's wound and urethral tear but since MD "G" would not be able to come to the facility, R #3 would be sent out to the hospital today. R #3 had a leg strap in place. RN "E" did not know how R #3's urethral tear occurred and said R #3 wiggles around in his bed a lot. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/21/15 at 6:10 p.m. interview with the DON revealed the nurses only document in the nurses notes if something was different or wrong with a resident. On 01/22/15 at 11:35 a.m., interview with Licensed Vocational Nurse (LVN) "F" revealed there was no evidence in R #3's record that indicated the nurses documented every shift regarding R #3's catheter-urethral junction. This meant the assessments were not done. LVN "F" said the documentation should have been done on a TAR. R #2 R #2's Face Sheet dated 01/20/15 revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #2's MDS dated [DATE] revealed R #2: -Made himself understood, -Sometimes understood others, -Had severely impaired cognition (never/rarely made decisions), -Was totally dependent on one staff person for bed mobility, transfers, dressing and personal hygiene, -Was totally dependent on two staff persons for toileting, -Had an indwelling urinary catheter and, -Was frequently incontinent of bowel. R #2's current "Order Summary Report" dated 12/29/14 revealed the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." Observation of R #2's indwelling urinary catheter care on 01/21/15 at 9:55 a.m. revealed the underside of R #2's penis was missing from his meatus to the top of his scrotum. R #2's indwelling urinary catheter was inserted into the opening of his urethra that began at the top of R #2's scrotum. R #2 did not respond to investigator's questions. On 01/21/15 at 4:25 p.m., Certified Nurse Aide (CNA) "A" stated R #2 had a history of [REDACTED]. CNA "A" stated in April 2014 on unknown dates, R #2's urethra developed "tears" due to R #2 pulling on his indwelling urinary catheter. CNA "A" stated this occurred on "more than one" occasion and R #2 "had bigger tears each time he pulled on it." CNA "A" stated she reported this to unknown nurses each time it occurred. On 01/22/15 at 1:15 p.m., CNA "B" stated she told an unknown nurse on "two separate" occasions in April 2014 on unknown dates that R #2's urethra had developed tears. CNA "B" stated, "The first time it was already tore. It (the tear) was approximately one centimeter (long). The second time, it (the tear) was approximately one centimeter longer (than the first time)." CNA "B" stated she did not know how the tears occurred to R #2's urethra. R #2's Care Plans dated 03/07/13 and updated on 03/12/14 and 07/15/14 did not reflect R #2 pulled on his indwelling urinary catheter or had a damaged penis. R #2's April 2014 "Order Summary Report" included the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." R #2's TAR dated April 2014 revealed the following order: -" ...Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift ...." Staff documented by initialing and handwriting "O" from 04/01/14 through 04/30/14. R #2's Nurses Notes revealed no entries were documented from 01/26/14 through 04/03/14. The following dates revealed no documentation R #2 was pulling on his catheter or the condition of R #2's penis, in sequence: -04/04/14, -04/07/14, -04/09/14 and, -04/10/14. There was no other documentation between 04/04/14 through 04/10/14. R #2's Nurses Notes revealed: -Dated 04/15/14 at 12:40 p.m.: "Indwelling (urinary catheter) in place. Urinary meatus noted with (a) tear/erosion to underlying tip. Strong foul odor, scant (amount) of yellowish drainage (with) visible redness surrounding area (and) scrotum ... Faxed (MD "D") ..." -Dated 04/15/14 at 6:30 p.m.: " ... (MD "D") in facility and assessed area to penis ... Order to culture and set-up (appointment with) urologist ... Meatus (with) tear, reddened - thick yellow (drainage with) foul odor noted ..." R #2's physician progress notes [REDACTED].#2) on 04/15/14 due to tear on meatus from (indwelling urinary catheter) ... Drainage from open area per nursing staff ... Penis 3-4 (centimeters) laceration to underside of penis ... (Culture and sensitivity) done ..." R #2's Nurses Notes dated 04/16/14 at 1:45 p.m. revealed MD "D" ordered an antibiotic for R #2's penile drainage. On 01/21/15 at 12:10 p.m., Family Member (FM) "AA" stated on 04/15/14, the facility notified FM "AA" of R #2's urethral tear. FM "AA" stated R #2 was seen by a urologist in April 2014. FM "AA" stated the urologist "said we could fix it (R #2's urethral tear) or leave it. (The urologist said) it wouldn't hurt anything ... We decided to leave it the way it was." On 01/22/15 at 3:00 p.m., MD "D" stated on 04/15/14, facility staff notified him R #2 had a tear to his penis due to R #2 "pulling" on his indwelling urinary catheter. MD "D" stated the facility did not notify him prior to 04/15/14 when R #2 had developed a tear to his penis or when R #2 was pulling on his catheter. MD "D" stated the current condition of R #2's penis was due to urethral tears. MD "D" stated R #2 was assessed by a urologist in April 2014. MD "D" stated the urologist recommended to keep R #2's indwelling urinary catheter in his urethra and not insert a suprapubic urinary catheter. On 01/22/15 at 2:25 p.m., LVN "C" stated she provided care to R #2 in April 2014. LVN "C" stated she assessed R #2's catheter-urethral junction each day she worked in April 2014. LVN "C" stated, "I don't remember seeing any tears" prior to 04/15/14 when she assessed R #2. LVN "C" confirmed she initialed and wrote an "O" on R #2's TAR dated April 2014 on the days she worked. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/22/15 at 3:35 p.m., the Administrator stated, "If the nurses are documenting they gave care then they should have done it." The Administrator stated, "Inservices, continuity of care, making rounds, talking to families ... (and) morning meetings" were the procedures in place to ensure the nursing needs of residents were being met. The Administrator stated she monitored staff and the DON by auditing charts, "Quality Indicators", and routine competency checks by the "ADON (Assistant Director of Nurses)." Investigator asked the Administrator how the Substandard Quality of Care came about. The Administrator stated, "I am not a doctor or a nurse to say." On 01/22/15 at 4:00 p.m., the DON stated staff were trained for indwelling urinary catheter care. Investigator asked the DON how the Substandard Quality of Care came about. The DON said, "I don't know... It is common to have erosion" with a "regular" indwelling urinary catheter. The DON stated she was not aware the nurses were not doing the catheter-urethral assessments. According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Indwelling Urinary Catheter Care and Removal, pages 374-377, " ... Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling ... Don't pull on the catheter ... Pulling can injure the urethra ... Record ... the condition of the perineum and urinary meatus ..." The facility's Urinary Catheter Care Policy dated April 2010 indicated: " ... Complications 1. Observe the resident for complications associated with urinary catheters ...." The facility's "Recognizing Signs and Symptoms of Abuse/Neglect" Policy dated December 2006 indicated: " ... Our facility will not condone any form of resident abuse or neglect ... 2. 'Neglect' is defines as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect ... b. Signs of/Actual Physical Neglect: ... Inadequate provision of care ..." The facility's Centers for Medicare and Medicaid Services Form CMS-672 dated 01/20/15 revealed six residents with indwelling urinary catheters. Throughout the survey and during the exit conference on 01/22/15 at 6:00 p.m., the facility was given the opportunity to provide additional information related to effective administration. As of exit, the facility provided no further information.

Based on observation, interview and record review, the facility failed to implement their policy and procedures that prohibit neglect for two Residents (R #2 and R #3) of six Residents reviewed for indwelling urinary catheters. R #3 had a urethral tear. The facility did not assess R #3's catheter-urethral junction every day as ordered by the Physician. R #2 had an indwelling urinary catheter (a tube inserted into the bladder to enable urination). The facility did not assess R #2 or put interventions into place when R #2 developed a tear to his urethra. The underside of R #2's penis had no tissue from the meatus to the top of R #2's scrotum. These failures placed the six residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, or possible harm. Findings were: R #3 R #3's Face Sheet dated 10/13/14 revealed R #3 was a [AGE] year old male admitted to the facility 04/21/14 with initial admission date of [DATE] and the following Diagnoses: [REDACTED]. R #3's most current Care Plan revision, dated 05/13/14 revealed, "...has a Indwelling Catheter: Skin Breakdown ...Will be/remain free from catheter-related trauma through review date ...Change catheter 16 French 10 cc balloon (every) month and (as needed) ...Check tubing for kinks each shift, apply leg strap at all times ..." R #3's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #3 was understood by others, usually understood others and had no behaviorial symptoms. R #3 required extensive assistance with bed mobility, dressing, eating, and transfers with assistance of one person. R #3 had an indwelling urinary catheter and was frequently incontinent of bowel. R #3's consolidated Physician order [REDACTED]. -"(Indwelling urinary) catheter 18 (French) 30 (centimeter) bulb, change every 30 days on NIGHT shift and (as needed) every night shift starting on the 15th and ending on the 15th for [MEDICAL CONDITION] DEPENDENT TO DRAINAGE" and, -"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." Review of R #3's 12/2014 and 01/2015 Medication Administration Record [REDACTED]"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." R #3's Nurse's Notes dated 01/15/15 at 11:00 a.m. revealed: "While changing catheter- Nurse noticed meatus appeared to have torn. Bright red blood present upon removal of catheter. Significant amount of blood noted. Was able to reinsert catheter. MD (Medical Doctor) notified. (No) signs of infection noted at this site. Will continue to monitor." R #3's Nurse's Notes dated 01/16/15 at 3:30 a.m. revealed: "... (Indwelling urinary catheter) patent and draining yellowish urine via gravity. Penis at insertion site with slit to urethra, cleansed with warm water and soap, scant amount bright red blood and greenish drainage, tender to touch ..." R #3's Nurse's Notes dated 01/16/15 at 5:00 p.m. revealed: "...Spoke to (MD "D"), stated (MD "G") will come and evaluate coccyx wound and penile tear on Monday/Tuesday (01/19/15 or 01/20/15) ..." R #3's Nurse's Notes dated 01/17/15 at 8:00 p.m. revealed: "...Penile tear free from blood/drainage." Review of R #3's Nurse's Notes after 01/17/15 at 8:00 p.m. revealed there was no further documentation staff assessed R #3's penile tear. Review of Nurse's Notes dated 12/2014 through 01/14/15 revealed no documentation staff assessed R #3's catheter-urethral junction. On 01/21/15 at 9:10 a.m., during a wound care observation with Registered Nurse (RN) "E", R #3 had approximately a 1 cm (centimeter) tear to his urethra. RN "E" said MD "G" was supposed to come to the facility this week to evaluate R #3's wound and urethral tear but since MD "G" would not be able to come to the facility, R #3 would be sent out to the hospital today. R #3 had a leg strap in place. RN "E" did not know how R #3's urethral tear occurred and said R #3 wiggles around in his bed a lot. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/21/15 at 6:10 p.m. interview with the Director of Nurses (DON) revealed the nurses only document in the nurses notes if something was different or wrong with a resident. On 01/22/15 at 11:35 a.m., interview with Licensed Vocational Nurse (LVN) "F" revealed there was no evidence in R #3's record that indicated the nurses documented every shift regarding R #3's catheter-urethral junction. This meant the assessments were not done. LVN "F" said the documentation should have been done on a TAR. R #2 R #2's Face Sheet dated 01/20/15 revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #2's MDS dated [DATE] revealed R #2: -Made himself understood, -Sometimes understood others, -Had severely impaired cognition (never/rarely made decisions), -Was totally dependent on one staff person for bed mobility, transfers, dressing and personal hygiene, -Was totally dependent on two staff persons for toileting, -Had an indwelling urinary catheter and, -Was frequently incontinent of bowel. R #2's current "Order Summary Report" dated 12/29/14 revealed the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." Observation of R #2's indwelling urinary catheter care on 01/21/15 at 9:55 a.m. revealed the underside of R #2's penis was missing from his meatus to the top of his scrotum. R #2's indwelling urinary catheter was inserted into the opening of his urethra that began at the top of R #2's scrotum. R #2 did not respond to investigator's questions. On 01/21/15 at 4:25 p.m., Certified Nurse Aide (CNA) "A" stated R #2 had a history of [REDACTED]. CNA "A" stated in April 2014 on unknown dates, R #2's urethra developed "tears" due to R #2 pulling on his indwelling urinary catheter. CNA "A" stated this occurred on "more than one" occasion and R #2 "had bigger tears each time he pulled on it." CNA "A" stated she reported this to unknown nurses each time it occurred. On 01/22/15 at 1:15 p.m., CNA "B" stated she told an unknown nurse on "two separate" occasions in April 2014 on unknown dates that R #2's urethra had developed tears. CNA "B" stated, "The first time it was already tore. It (the tear) was approximately one centimeter (long). The second time, it (the tear) was approximately one centimeter longer (than the first time)." CNA "B" stated she did not know how the tears occurred to R #2's urethra. R #2's Care Plans dated 03/07/13 and updated on 03/12/14 and 07/15/14 did not reflect R #2 pulled on his indwelling urinary catheter or had a damaged penis. R #2's April 2014 "Order Summary Report" included the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." R #2's TAR dated April 2014 revealed the following order: -" ...Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift ...." Staff documented by initialing and handwriting "O" from 04/01/14 through 04/30/14. R #2's Nurses Notes revealed no entries were documented from 01/26/14 through 04/03/14. The following dates revealed no documentation R #2 was pulling on his catheter or the condition of R #2's penis, in sequence: -04/04/14, -04/07/14, -04/09/14 and, -04/10/14. There was no other documentation between 04/04/14 through 04/10/14. R #2's Nurses Notes revealed: -Dated 04/15/14 at 12:40 p.m.: "Indwelling (urinary catheter) in place. Urinary meatus noted with (a) tear/erosion to underlying tip. Strong foul odor, scant (amount) of yellowish drainage (with) visible redness surrounding area (and) scrotum ... Faxed (MD "D") ..." -Dated 04/15/14 at 6:30 p.m.: " ... (MD "D") in facility and assessed area to penis ... Order to culture and set-up (appointment with) urologist ... Meatus (with) tear, reddened - thick yellow (drainage with) foul odor noted ..." R #2's physician progress notes [REDACTED].#2) on 04/15/14 due to tear on meatus from (indwelling urinary catheter) ... Drainage from open area per nursing staff ... Penis 3-4 (centimeters) laceration to underside of penis ... (Culture and sensitivity) done ..." R #2's Nurses Notes dated 04/16/14 at 1:45 p.m. revealed MD "D" ordered an antibiotic for R #2's penile drainage. On 01/21/15 at 12:10 p.m., Family Member (FM) "AA" stated on 04/15/14, the facility notified FM "AA" of R #2's urethral tear. FM "AA" stated R #2 was seen by a urologist in April 2014. FM "AA" stated the urologist "said we could fix it (R #2's urethral tear) or leave it. (The urologist said) it wouldn't hurt anything ... We decided to leave it the way it was." On 01/22/15 at 3:00 p.m., MD "D" stated on 04/15/14, facility staff notified him R #2 had a tear to his penis due to R #2 "pulling" on his indwelling urinary catheter. MD "D" stated the facility did not notify him prior to 04/15/14 when R #2 had developed a tear to his penis or when R #2 was pulling on his catheter. MD "D" stated the current condition of R #2's penis was due to urethral tears. MD "D" stated R #2 was assessed by a urologist in April 2014. MD "D" stated the urologist recommended to keep R #2's indwelling urinary catheter in his urethra and not insert a suprapubic urinary catheter. On 01/22/15 at 2:25 p.m., LVN "C" stated she provided care to R #2 in April 2014. LVN "C" stated she assessed R #2's catheter-urethral junction each day she worked in April 2014. LVN "C" stated, "I don't remember seeing any tears" prior to 04/15/14 when she assessed R #2. LVN "C" confirmed she initialed and wrote an "O" on R #2's TAR dated April 2014 on the days she worked. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/22/15 at 3:35 p.m., the Administrator stated, "If the nurses are documenting they gave care then they should have done it." On 01/22/15 at 4:00 p.m., the DON stated "it is common to have erosion" with a "regular" indwelling urinary catheter. The DON stated she was not aware the nurses were not doing the catheter-urethral assessments. The facility's "Recognizing Signs and Symptoms of Abuse/Neglect" Policy dated December 2006 indicated: " ... Our facility will not condone any form of resident abuse or neglect ... 2. 'Neglect' is defines as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect ... b. Signs of/Actual Physical Neglect: ... Inadequate provision of care ..." According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Indwelling Urinary Catheter Care and Removal, pages 374-377, " ... Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling ... Don't pull on the catheter ... Pulling can injure the urethra ... Record ... the condition of the perineum and urinary meatus ..." The facility's Urinary Catheter Care Policy dated April 2010 indicated: " ... Complications 1. Observe the resident for complications associated with urinary catheters ...." The facility's Centers for Medicare and Medicaid Services Form CMS-672 dated 01/20/15 revealed six residents with indwelling urinary catheters. Throughout the survey and during the exit conference on 01/22/15 at 6:00 p.m., the facility was given the opportunity to provide additional information related to indwelling urinary catheters and neglect. As of exit, the facility provided no further information.

Based on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters received appropriate treatment and services to prevent urinary tract infections for two Residents (R #2 and R #3) of six Residents reviewed for indwelling urinary catheter care. R #3 had a urethral tear. The facility did not assess R #3's catheter-urethral junction every day as ordered by the Physician. R #2 had an indwelling urinary catheter (a tube inserted into the bladder to enable urination). The facility did not assess R #2 or put interventions into place when R #2 developed a tear to his urethra. The underside of R #2's penis had no tissue from the meatus to the top of R #2's scrotum. These failures placed the six residents with indwelling urinary catheters at risk of not receiving proper assessments and care and services required to prevent delay in treatment, complications, or possible harm. Findings were: R #3 R #3's Face Sheet dated 10/13/14 revealed R #3 was a [AGE] year old male admitted to the facility 04/21/14 with initial admission date of [DATE] and the following Diagnoses: [REDACTED]. R #3's most current Care Plan revision, dated 05/13/14 revealed, "...has a Indwelling Catheter: Skin Breakdown ...Will be/remain free from catheter-related trauma through review date ...Change catheter 16 French 10 cc balloon (every) month and (as needed) ...Check tubing for kinks each shift, apply leg strap at all times ..." R #3's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #3 was understood by others, usually understood others and had no behaviorial symptoms. R #3 required extensive assistance with bed mobility, dressing, eating, and transfers with assistance of one person. R #3 had an indwelling urinary catheter and was frequently incontinent of bowel. R #3's consolidated Physician order [REDACTED]. -"(Indwelling urinary) catheter 18 (French) 30 (centimeter) bulb, change every 30 days on NIGHT shift and (as needed) every night shift starting on the 15th and ending on the 15th for [MEDICAL CONDITION] DEPENDENT TO DRAINAGE" and, -"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." Review of R #3's 12/2014 and 01/2015 Medication Administration Record [REDACTED]"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." R #3's Nurse's Notes dated 01/15/15 at 11:00 a.m. revealed: "While changing catheter- Nurse noticed meatus appeared to have torn. Bright red blood present upon removal of catheter. Significant amount of blood noted. Was able to reinsert catheter. MD (Medical Doctor) notified. (No) signs of infection noted at this site. Will continue to monitor." R #3's Nurse's Notes dated 01/16/15 at 3:30 a.m. revealed: "... (Indwelling urinary catheter) patent and draining yellowish urine via gravity. Penis at insertion site with slit to urethra, cleansed with warm water and soap, scant amount bright red blood and greenish drainage, tender to touch ..." R #3's Nurse's Notes dated 01/16/15 at 5:00 p.m. revealed: "...Spoke to (MD "D"), stated (MD "G") will come and evaluate coccyx wound and penile tear on Monday/Tuesday (01/19/15 or 01/20/15) ..." R #3's Nurse's Notes dated 01/17/15 at 8:00 p.m. revealed: "...Penile tear free from blood/drainage." Review of R #3's Nurse's Notes after 01/17/15 at 8:00 p.m. revealed there was no further documentation staff assessed R #3's penile tear. Review of Nurse's Notes dated 12/2014 through 01/14/15 revealed no documentation staff assessed R #3's catheter-urethral junction. On 01/21/15 at 9:10 a.m., during a wound care observation with Registered Nurse (RN) "E", R #3 had approximately a 1 cm (centimeter) tear to his urethra. RN "E" said MD "G" was supposed to come to the facility this week to evaluate R #3's wound and urethral tear but since MD "G" would not be able to come to the facility, R #3 would be sent out to the hospital today. R #3 had a leg strap in place. RN "E" did not know how R #3's urethral tear occurred and said R #3 wiggles around in his bed a lot. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/21/15 at 6:10 p.m. interview with the Director of Nurses (DON) revealed the nurses only document in the nurses notes if something was different or wrong with a resident. On 01/22/15 at 11:35 a.m., interview with Licensed Vocational Nurse (LVN) "F" revealed there was no evidence in R #3's record that indicated the nurses documented every shift regarding R #3's catheter-urethral junction. This meant the assessments were not done. LVN "F" said the documentation should have been done on a TAR. R #2 R #2's Face Sheet dated 01/20/15 revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #2's MDS dated [DATE] revealed R #2: -Made himself understood, -Sometimes understood others, -Had severely impaired cognition (never/rarely made decisions), -Was totally dependent on one staff person for bed mobility, transfers, dressing and personal hygiene, -Was totally dependent on two staff persons for toileting, -Had an indwelling urinary catheter and, -Was frequently incontinent of bowel. R #2's current "Order Summary Report" dated 12/29/14 revealed the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." Observation of R #2's indwelling urinary catheter care on 01/21/15 at 9:55 a.m. revealed the underside of R #2's penis was missing from his meatus to the top of his scrotum. R #2's indwelling urinary catheter was inserted into the opening of his urethra that began at the top of R #2's scrotum. R #2 did not respond to investigator's questions. On 01/21/15 at 4:25 p.m., Certified Nurse Aide (CNA) "A" stated R #2 had a history of [REDACTED]. CNA "A" stated in April 2014 on unknown dates, R #2's urethra developed "tears" due to R #2 pulling on his indwelling urinary catheter. CNA "A" stated this occurred on "more than one" occasion and R #2 "had bigger tears each time he pulled on it." CNA "A" stated she reported this to unknown nurses each time it occurred. On 01/22/15 at 1:15 p.m., CNA "B" stated she told an unknown nurse on "two separate" occasions in April 2014 on unknown dates that R #2's urethra had developed tears. CNA "B" stated, "The first time it was already tore. It (the tear) was approximately one centimeter (long). The second time, it (the tear) was approximately one centimeter longer (than the first time)." CNA "B" stated she did not know how the tears occurred to R #2's urethra. R #2's Care Plans dated 03/07/13 and updated on 03/12/14 and 07/15/14 did not reflect R #2 pulled on his indwelling urinary catheter or had a damaged penis. R #2's April 2014 "Order Summary Report" included the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." R #2's TAR dated April 2014 revealed the following order: -" ...Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift ...." Staff documented by initialing and handwriting "O" from 04/01/14 through 04/30/14. R #2's Nurses Notes revealed no entries were documented from 01/26/14 through 04/03/14. The following dates revealed no documentation R #2 was pulling on his catheter or the condition of R #2's penis, in sequence: -04/04/14, -04/07/14, -04/09/14 and, -04/10/14. There was no other documentation between 04/04/14 through 04/10/14. R #2's Nurses Notes revealed: -Dated 04/15/14 at 12:40 p.m.: "Indwelling (urinary catheter) in place. Urinary meatus noted with (a) tear/erosion to underlying tip. Strong foul odor, scant (amount) of yellowish drainage (with) visible redness surrounding area (and) scrotum ... Faxed (MD "D") ..." -Dated 04/15/14 at 6:30 p.m.: " ... (MD "D") in facility and assessed area to penis ... Order to culture and set-up (appointment with) urologist ... Meatus (with) tear, reddened - thick yellow (drainage with) foul odor noted ..." R #2's physician progress notes [REDACTED].#2) on 04/15/14 due to tear on meatus from (indwelling urinary catheter) ... Drainage from open area per nursing staff ... Penis 3-4 (centimeters) laceration to underside of penis ... (Culture and sensitivity) done ..." R #2's Nurses Notes dated 04/16/14 at 1:45 p.m. revealed MD "D" ordered an antibiotic for R #2's penile drainage. On 01/21/15 at 12:10 p.m., Family Member (FM) "AA" stated on 04/15/14, the facility notified FM "AA" of R #2's urethral tear. FM "AA" stated R #2 was seen by a urologist in April 2014. FM "AA" stated the urologist "said we could fix it (R #2's urethral tear) or leave it. (The urologist said) it wouldn't hurt anything ... We decided to leave it the way it was." On 01/22/15 at 3:00 p.m., MD "D" stated on 04/15/14, facility staff notified him R #2 had a tear to his penis due to R #2 "pulling" on his indwelling urinary catheter. MD "D" stated the facility did not notify him prior to 04/15/14 when R #2 had developed a tear to his penis or when R #2 was pulling on his catheter. MD "D" stated the current condition of R #2's penis was due to urethral tears. MD "D" stated R #2 was assessed by a urologist in April 2014. MD "D" stated the urologist recommended to keep R #2's indwelling urinary catheter in his urethra and not insert a suprapubic urinary catheter. On 01/22/15 at 2:25 p.m., LVN "C" stated she provided care to R #2 in April 2014. LVN "C" stated she assessed R #2's catheter-urethral junction each day she worked in April 2014. LVN "C" stated, "I don't remember seeing any tears" prior to 04/15/14 when she assessed R #2. LVN "C" confirmed she initialed and wrote an "O" on R #2's TAR dated April 2014 on the days she worked. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/22/15 at 3:35 p.m., the Administrator stated, "If the nurses are documenting they gave care then they should have done it." On 01/22/15 at 4:00 p.m., the DON stated "it is common to have erosion" with a "regular" indwelling urinary catheter. The DON stated she was not aware the nurses were not doing the catheter-urethral assessments. According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Indwelling Urinary Catheter Care and Removal, pages 374-377, " ... Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling ... Don't pull on the catheter ... Pulling can injure the urethra ... Record ... the condition of the perineum and urinary meatus ..." The facility's Urinary Catheter Care Policy dated April 2010 indicated: " ... Complications 1. Observe the resident for complications associated with urinary catheters ...." The facility's Centers for Medicare and Medicaid Services Form CMS-672 dated 01/20/15 revealed six residents with indwelling urinary catheters. Throughout the survey and during the exit conference on 01/22/15 at 6:00 p.m., the facility was given the opportunity to provide additional information related to indwelling urinary catheters. As of exit, the facility provided no further information.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain the highest practicable physical, mental and psychological well-being for two Residents (R #2 and R #3) of six Residents reviewed for indwelling urinary catheters. R #3 had a urethral tear. The facility did not assess R #3's catheter-urethral junction every day as ordered by the Physician. R #2 had an indwelling urinary catheter (a tube inserted into the bladder to enable urination). The facility did not assess R #2 or put interventions into place when R #2 developed a tear to his urethra. The underside of R #2's penis had no tissue from the meatus to the top of R #2's scrotum. These failures placed the six residents with indwelling urinary catheters at risk of not receiving proper assessments and care and services required to prevent delay in treatment, complications, or possible harm. Findings were: R #3 R #3's Face Sheet dated 10/13/14 revealed R #3 was a [AGE] year old male admitted to the facility 04/21/14 with initial admission date of [DATE] and the following Diagnoses: [REDACTED]. R #3's most current Care Plan revision, dated 05/13/14 revealed, "...has a Indwelling Catheter: Skin Breakdown ...Will be/remain free from catheter-related trauma through review date ...Change catheter 16 French 10 cc balloon (every) month and (as needed) ...Check tubing for kinks each shift, apply leg strap at all times ..." R #3's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #3 was understood by others, usually understood others and had no behaviorial symptoms. R #3 required extensive assistance with bed mobility, dressing, eating, and transfers with assistance of one person. R #3 had an indwelling urinary catheter and was frequently incontinent of bowel. R #3's consolidated Physician order [REDACTED]. -"(Indwelling urinary) catheter 18 (French) 30 (centimeter) bulb, change every 30 days on NIGHT shift and (as needed) every night shift starting on the 15th and ending on the 15th for [MEDICAL CONDITION] DEPENDENT TO DRAINAGE" and, -"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." Review of R #3's 12/2014 and 01/2015 Medication Administration Record [REDACTED]"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." R #3's Nurse's Notes dated 01/15/15 at 11:00 a.m. revealed: "While changing catheter- Nurse noticed meatus appeared to have torn. Bright red blood present upon removal of catheter. Significant amount of blood noted. Was able to reinsert catheter. MD (Medical Doctor) notified. (No) signs of infection noted at this site. Will continue to monitor." R #3's Nurse's Notes dated 01/16/15 at 3:30 a.m. revealed: "... (Indwelling urinary catheter) patent and draining yellowish urine via gravity. Penis at insertion site with slit to urethra, cleansed with warm water and soap, scant amount bright red blood and greenish drainage, tender to touch ..." R #3's Nurse's Notes dated 01/16/15 at 5:00 p.m. revealed: "...Spoke to (MD "D"), stated (MD "G") will come and evaluate coccyx wound and penile tear on Monday/Tuesday (01/19/15 or 01/20/15) ..." R #3's Nurse's Notes dated 01/17/15 at 8:00 p.m. revealed: "...Penile tear free from blood/drainage." Review of R #3's Nurse's Notes after 01/17/15 at 8:00 p.m. revealed there was no further documentation staff assessed R #3's penile tear. Review of Nurse's Notes dated 12/2014 through 01/14/15 revealed no documentation staff assessed R #3's catheter-urethral junction. On 01/21/15 at 9:10 a.m., during a wound care observation with Registered Nurse (RN) "E", R #3 had approximately a 1 cm (centimeter) tear to his urethra. RN "E" said MD "G" was supposed to come to the facility this week to evaluate R #3's wound and urethral tear but since MD "G" would not be able to come to the facility, R #3 would be sent out to the hospital today. R #3 had a leg strap in place. RN "E" did not know how R #3's urethral tear occurred and said R #3 wiggles around in his bed a lot. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/21/15 at 6:10 p.m. interview with the Director of Nurses (DON) revealed the nurses only document in the nurses notes if something was different or wrong with a resident. On 01/22/15 at 11:35 a.m., interview with Licensed Vocational Nurse (LVN) "F" revealed there was no evidence in R #3's record that indicated the nurses documented every shift regarding R #3's catheter-urethral junction. This meant the assessments were not done. LVN "F" said the documentation should have been done on a TAR. R #2 R #2's Face Sheet dated 01/20/15 revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #2's MDS dated [DATE] revealed R #2: -Made himself understood, -Sometimes understood others, -Had severely impaired cognition (never/rarely made decisions), -Was totally dependent on one staff person for bed mobility, transfers, dressing and personal hygiene, -Was totally dependent on two staff persons for toileting, -Had an indwelling urinary catheter and, -Was frequently incontinent of bowel. R #2's current "Order Summary Report" dated 12/29/14 revealed the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." Observation of R #2's indwelling urinary catheter care on 01/21/15 at 9:55 a.m. revealed the underside of R #2's penis was missing from his meatus to the top of his scrotum. R #2's indwelling urinary catheter was inserted into the opening of his urethra that began at the top of R #2's scrotum. R #2 did not respond to investigator's questions. On 01/21/15 at 4:25 p.m., Certified Nurse Aide (CNA) "A" stated R #2 had a history of [REDACTED]. CNA "A" stated in April 2014 on unknown dates, R #2's urethra developed "tears" due to R #2 pulling on his indwelling urinary catheter. CNA "A" stated this occurred on "more than one" occasion and R #2 "had bigger tears each time he pulled on it." CNA "A" stated she reported this to unknown nurses each time it occurred. On 01/22/15 at 1:15 p.m., CNA "B" stated she told an unknown nurse on "two separate" occasions in April 2014 on unknown dates that R #2's urethra had developed tears. CNA "B" stated, "The first time it was already tore. It (the tear) was approximately one centimeter (long). The second time, it (the tear) was approximately one centimeter longer (than the first time)." CNA "B" stated she did not know how the tears occurred to R #2's urethra. R #2's Care Plans dated 03/07/13 and updated on 03/12/14 and 07/15/14 did not reflect R #2 pulled on his indwelling urinary catheter or had a damaged penis. R #2's April 2014 "Order Summary Report" included the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." R #2's TAR dated April 2014 revealed the following order: -" ...Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift ...." Staff documented by initialing and handwriting "O" from 04/01/14 through 04/30/14. R #2's Nurses Notes revealed no entries were documented from 01/26/14 through 04/03/14. The following dates revealed no documentation R #2 was pulling on his catheter or the condition of R #2's penis, in sequence: -04/04/14, -04/07/14, -04/09/14 and, -04/10/14. There was no other documentation between 04/04/14 through 04/10/14. R #2's Nurses Notes revealed: -Dated 04/15/14 at 12:40 p.m.: "Indwelling (urinary catheter) in place. Urinary meatus noted with (a) tear/erosion to underlying tip. Strong foul odor, scant (amount) of yellowish drainage (with) visible redness surrounding area (and) scrotum ... Faxed (MD "D") ..." -Dated 04/15/14 at 6:30 p.m.: " ... (MD "D") in facility and assessed area to penis ... Order to culture and set-up (appointment with) urologist ... Meatus (with) tear, reddened - thick yellow (drainage with) foul odor noted ..." R #2's physician progress notes [REDACTED].#2) on 04/15/14 due to tear on meatus from (indwelling urinary catheter) ... Drainage from open area per nursing staff ... Penis 3-4 (centimeters) laceration to underside of penis ... (Culture and sensitivity) done ..." R #2's Nurses Notes dated 04/16/14 at 1:45 p.m. revealed MD "D" ordered an antibiotic for R #2's penile drainage. On 01/21/15 at 12:10 p.m., Family Member (FM) "AA" stated on 04/15/14, the facility notified FM "AA" of R #2's urethral tear. FM "AA" stated R #2 was seen by a urologist in April 2014. FM "AA" stated the urologist "said we could fix it (R #2's urethral tear) or leave it. (The urologist said) it wouldn't hurt anything ... We decided to leave it the way it was." On 01/22/15 at 3:00 p.m., MD "D" stated on 04/15/14, facility staff notified him R #2 had a tear to his penis due to R #2 "pulling" on his indwelling urinary catheter. MD "D" stated the facility did not notify him prior to 04/15/14 when R #2 had developed a tear to his penis or when R #2 was pulling on his catheter. MD "D" stated the current condition of R #2's penis was due to urethral tears. MD "D" stated R #2 was assessed by a urologist in April 2014. MD "D" stated the urologist recommended to keep R #2's indwelling urinary catheter in his urethra and not insert a suprapubic urinary catheter. On 01/22/15 at 2:25 p.m., LVN "C" stated she provided care to R #2 in April 2014. LVN "C" stated she assessed R #2's catheter-urethral junction each day she worked in April 2014. LVN "C" stated, "I don't remember seeing any tears" prior to 04/15/14 when she assessed R #2. LVN "C" confirmed she initialed and wrote an "O" on R #2's TAR dated April 2014 on the days she worked. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/22/15 at 3:35 p.m., the Administrator stated, "If the nurses are documenting they gave care then they should have done it." On 01/22/15 at 4:00 p.m., the DON stated "it is common to have erosion" with a "regular" indwelling urinary catheter. The DON stated she was not aware the nurses were not doing the catheter-urethral assessments. According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Indwelling Urinary Catheter Care and Removal, pages 374-377, " ... Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling ... Don't pull on the catheter ... Pulling can injure the urethra ... Record ... the condition of the perineum and urinary meatus ..." The facility's Urinary Catheter Care Policy dated April 2010 indicated: " ... Complications 1. Observe the resident for complications associated with urinary catheters ...." The facility's Centers for Medicare and Medicaid Services Form CMS-672 dated 01/20/15 revealed six residents with indwelling urinary catheters. Throughout the survey and during the exit conference on 01/22/15 at 6:00 p.m., the facility was given the opportunity to provide additional information related to necessary care and services for indwelling urinary catheters. As of exit, the facility provided no further information.

Based on observation, interview, and record review the facility failed to ensure services provided met professional standards of quality for four Residents (R #3, R #2, R #7 and R #19) of 19 Residents reviewed for professional standards. R #3 had a urethral tear. The facility did not assess R #3's catheter-urethral junction every day as ordered by the Physician. R #2 had an indwelling urinary catheter (a tube inserted into the bladder to enable urination). The facility did not assess R #2 or put interventions into place when R #2 developed a tear to his urethra. The underside of R #2's penis had no tissue from the meatus to the top of R #2's scrotum. Registered Nurse (RN) "E" and Licensed Vocational Nurse (LVN) "C" did not pull up the strap on portable oxygen equipment resulting in a false reading of empty for R #7 and R #19. These failures could affect 10 residents receiving portable oxygen therapy and six residents with indwelling urinary catheters by placing them at risk of not receiving proper assessments and care and services required to prevent delay in treatment, complications, or possible harm. The findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; ...(D) Accurately and completely report and document: (i) the clients status including signs and symptoms; (ii) nursing care rendered; ...(v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client ' s status; ...(H) Make reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; ... (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications ;...(O) Implement measures to prevent exposure to infectious pathogens and communicable conditions;...(U) Supervise nursing care provided by others for whom the nurse is professionally responsible; ..." According to the facility's undated "How to Fill a Liquid Portable (oxygen tank)" Posting in the oxygen room revealed: "Lift the strap nearest to the gauge to read the fullness of the Portable on (the oxygen tank) ..." The facility's Policy and Procedure entitled " Catheter Care, Urinary" dated April 2010 indicated: " ...Complications ...1. Observe the resident for complications associated with urinary catheters ... " R #3 R #3's Face Sheet dated 10/13/14 revealed R #3 was a [AGE] year old male admitted to the facility 04/21/14 with initial admission date of [DATE] and the following Diagnoses: [REDACTED]. R #3's most current Care Plan revision, dated 05/13/14 revealed, "...has a Indwelling Catheter: Skin Breakdown ...Will be/remain free from catheter-related trauma through review date ...Change catheter 16 French 10 cc balloon (every) month and (as needed) ...Check tubing for kinks each shift, apply leg strap at all times ..." R #3's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #3 was understood by others, usually understood others and had no behaviorial symptoms. R #3 required extensive assistance with bed mobility, dressing, eating, and transfers with assistance of one person. R #3 had an indwelling urinary catheter and was frequently incontinent of bowel. R #3's consolidated Physician order [REDACTED]. -"(Indwelling urinary) catheter 18 (French) 30 (centimeter) bulb, change every 30 days on NIGHT shift and (as needed) every night shift starting on the 15th and ending on the 15th for [MEDICAL CONDITION] DEPENDENT TO DRAINAGE" and, -"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." Review of R #3's 12/2014 and 01/2015 Medication Administration Record [REDACTED]"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." R #3's Nurse's Notes dated 01/15/15 at 11:00 a.m. revealed: "While changing catheter- Nurse noticed meatus appeared to have torn. Bright red blood present upon removal of catheter. Significant amount of blood noted. Was able to reinsert catheter. MD (Medical Doctor) notified. (No) signs of infection noted at this site. Will continue to monitor." R #3's Nurse's Notes dated 01/16/15 at 3:30 a.m. revealed: "... (Indwelling urinary catheter) patent and draining yellowish urine via gravity. Penis at insertion site with slit to urethra, cleansed with warm water and soap, scant amount bright red blood and greenish drainage, tender to touch ..." R #3's Nurse's Notes dated 01/16/15 at 5:00 p.m. revealed: "...Spoke to (MD "D"), stated (MD "G") will come and evaluate coccyx wound and penile tear on Monday/Tuesday (01/19/15 or 01/20/15) ..." R #3's Nurse's Notes dated 01/17/15 at 8:00 p.m. revealed: "...Penile tear free from blood/drainage." Review of R #3's Nurse's Notes after 01/17/15 at 8:00 p.m. revealed there was no further documentation staff assessed R #3's penile tear. Review of Nurse's Notes dated 12/2014 through 01/14/15 revealed no documentation staff assessed R #3's catheter-urethral junction. On 01/21/15 at 9:10 a.m., during a wound care observation with RN "E", R #3 had approximately a 1 cm (centimeter) tear to his urethra. RN "E" said MD "G" was supposed to come to the facility this week to evaluate R #3's wound and urethral tear but since MD "G" would not be able to come to the facility, R #3 would be sent out to the hospital today. R #3 had a leg strap in place. RN "E" did not know how R #3's urethral tear occurred and said R #3 wiggles around in his bed a lot. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/21/15 at 6:10 p.m. interview with the Director of Nurses (DON) revealed the nurses only document in the nurses notes if something was different or wrong with a resident. On 01/22/15 at 11:35 a.m., interview with LVN "F" revealed there was no evidence in R #3's record that indicated the nurses documented every shift regarding R #3's catheter-urethral junction. This meant the assessments were not done. LVN "F" said the documentation should have been done on a TAR. R #2 R #2's Face Sheet dated 01/20/15 revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #2's MDS dated [DATE] revealed R #2: -Made himself understood, -Sometimes understood others, -Had severely impaired cognition (never/rarely made decisions), -Was totally dependent on one staff person for bed mobility, transfers, dressing and personal hygiene, -Was totally dependent on two staff persons for toileting, -Had an indwelling urinary catheter and, -Was frequently incontinent of bowel. R #2's current "Order Summary Report" dated 12/29/14 revealed the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." Observation of R #2's indwelling urinary catheter care on 01/21/15 at 9:55 a.m. revealed the underside of R #2's penis was missing from his meatus to the top of his scrotum. R #2's indwelling urinary catheter was inserted into the opening of his urethra that began at the top of R #2's scrotum. R #2 did not respond to investigator's questions. On 01/21/15 at 4:25 p.m., Certified Nurse Aide (CNA) "A" stated R #2 had a history of [REDACTED]. CNA "A" stated in April 2014 on unknown dates, R #2's urethra developed "tears" due to R #2 pulling on his indwelling urinary catheter. CNA "A" stated this occurred on "more than one" occasion and R #2 "had bigger tears each time he pulled on it." CNA "A" stated she reported this to unknown nurses each time it occurred. On 01/22/15 at 1:15 p.m., CNA "B" stated she told an unknown nurse on "two separate" occasions in April 2014 on unknown dates that R #2's urethra had developed tears. CNA "B" stated, "The first time it was already tore. It (the tear) was approximately one centimeter (long). The second time, it (the tear) was approximately one centimeter longer (than the first time)." CNA "B" stated she did not know how the tears occurred to R #2's urethra. R #2's Care Plans dated 03/07/13 and updated on 03/12/14 and 07/15/14 did not reflect R #2 pulled on his indwelling urinary catheter or had a damaged penis. R #2's April 2014 "Order Summary Report" included the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." R #2's TAR dated April 2014 revealed the following order: -" ...Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift ...." Staff documented by initialing and handwriting "O" from 04/01/14 through 04/30/14. R #2's Nurses Notes revealed no entries were documented from 01/26/14 through 04/03/14. The following dates revealed no documentation R #2 was pulling on his catheter or the condition of R #2's penis, in sequence: -04/04/14, -04/07/14, -04/09/14 and, -04/10/14. There was no other documentation between 04/04/14 through 04/10/14. R #2's Nurses Notes revealed: -Dated 04/15/14 at 12:40 p.m.: "Indwelling (urinary catheter) in place. Urinary meatus noted with (a) tear/erosion to underlying tip. Strong foul odor, scant (amount) of yellowish drainage (with) visible redness surrounding area (and) scrotum ... Faxed (MD "D") ..." -Dated 04/15/14 at 6:30 p.m.: " ... (MD "D") in facility and assessed area to penis ... Order to culture and set-up (appointment with) urologist ... Meatus (with) tear, reddened - thick yellow (drainage with) foul odor noted ..." R #2's physician progress notes [REDACTED].#2) on 04/15/14 due to tear on meatus from (indwelling urinary catheter) ... Drainage from open area per nursing staff ... Penis 3-4 (centimeters) laceration to underside of penis ... (Culture and sensitivity) done ..." R #2's Nurses Notes dated 04/16/14 at 1:45 p.m. revealed MD "D" ordered an antibiotic for R #2's penile drainage. On 01/21/15 at 12:10 p.m., Family Member (FM) "AA" stated on 04/15/14, the facility notified FM "AA" of R #2's urethral tear. FM "AA" stated R #2 was seen by a urologist in April 2014. FM "AA" stated the urologist "said we could fix it (R #2's urethral tear) or leave it. (The urologist said) it wouldn't hurt anything ... We decided to leave it the way it was." On 01/22/15 at 3:00 p.m., MD "D" stated on 04/15/14, facility staff notified him R #2 had a tear to his penis due to R #2 "pulling" on his indwelling urinary catheter. MD "D" stated the facility did not notify him prior to 04/15/14 when R #2 had developed a tear to his penis or when R #2 was pulling on his catheter. MD "D" stated the current condition of R #2's penis was due to urethral tears. MD "D" stated R #2 was assessed by a urologist in April 2014. MD "D" stated the urologist recommended to keep R #2's indwelling urinary catheter in his urethra and not insert a suprapubic urinary catheter. On 01/22/15 at 2:25 p.m., LVN "C" stated she provided care to R #2 in April 2014. LVN "C" stated she assessed R #2's catheter-urethral junction each day she worked in April 2014. LVN "C" stated, "I don't remember seeing any tears" prior to 04/15/14 when she assessed R #2. LVN "C" confirmed she initialed and wrote an "O" on R #2's TAR dated April 2014 on the days she worked. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/22/15 at 3:35 p.m., the Administrator stated, "If the nurses are documenting they gave care then they should have done it." On 01/22/15 at 4:00 p.m., the DON stated "it is common to have erosion" with a "regular" indwelling urinary catheter. The DON stated she was not aware the nurses were not doing the catheter-urethral assessments. R #7 R #7's Face Sheet dated 01/22/15 revealed R #7 was an [AGE] year old female admitted to the facility on [DATE] with initial admission on 12/29/07 and the following Diagnoses: [REDACTED]. R #7's consolidated Physician order [REDACTED]. -"Monitor O2 tank/concentrator (every) shift for proper functioning every shift", and -"O2 at (2 liters per minute) via (Nasal Cannula) for O2 (Saturation less than) 90% (as needed) every shift for shortness of breath." R #7's reentry MDS dated [DATE] revealed R #7 was admitted from an acute hospital. Review of R #7's most current Care Plans dated 10/16/14 revealed there were no care plans to address R #7's oxygen needs. On 01/21/15 at 12:20 p.m. surveyor observation revealed R #7 sitting at a dining room table with a portable oxygen tank attached to the back of R #7's wheelchair. Surveyor observed the oxygen dial was in the red, which indicated the oxygen tank was empty. Surveyor asked RN "E" what the dial reading was. RN "E" said it was on empty but she had just filled the resident's portable oxygen tank earlier in the morning. RN "E" said, "I will go and fill the tank again, the gauge must not be working." RN "E" said by looking at the dial on the O2 tank she would not know how much oxygen was in the tank. RN "E" disconnected the oxygen tubing from the tank and said she could feel air coming out of the tank by checking the tank with her hand. RN "E" said R #7 was to have oxygen at 2 liters per minute at meal time. On 01/21/15 at 12:25 p.m. RN "E" returned to the dining room and said that she had filled the tank but the dial on the tank still indicated the tank was empty. RN "E" said she had called the oxygen company several times in the past to come fix the broken dials on the oxygen tanks but had not received a response. R #19 R #19's Face Sheet dated 01/22/15 revealed R #19 was a [AGE] year old male admitted to the facility on [DATE] with initial admission on 04/01/14 and the following Diagnoses: [REDACTED]. R #19's consolidated Physician order [REDACTED]. -"Monitor O2 tank/concentrator (every) shift for proper functioning every shift", -"O2 at (2 liters per minute) via (Nasal Cannula) continuously as needed" and, -"O2 (saturation every) shift and (as needed)." R #19's Quarterly MDS dated [DATE] revealed R #19 usually understood others and was usually understood by others. R #19 was severely cognitively impaired (never/rarely understood others). R #19 required extensive assistance with bed mobility, dressing, bathing and transfers with assistance of one person. R #19 received oxygen therapy. Review of R #19's most current Care Plans dated 04/22/14 revealed there were no care plans to address R #19's oxygen needs. On 01/21/15 at 12:15 p.m., observation revealed R #19 sitting at a dining room table with a portable oxygen tank attached to the back of R #19's wheelchair. Surveyor observed the oxygen dial was in the red, which indicated the oxygen tank was empty. Surveyor asked LVN "C" what the dial on red meant. LVN "C" said it was on empty but she had just filled the resident's portable oxygen tank earlier in the morning. LVN "C" said, "I will go and fill the tank again, the gauge must not be working." LVN "C" said R #19 was to have continuous oxygen at 2 liters per minute. On 01/21/15 at 12:22 p.m., interview with the DON revealed she was aware R #19's portable oxygen tank gauge was not displaying accurate oxygen volume readings. On 01/21/15 at 3:35 p.m., interview with the DON revealed R #7 and R #19 did not have broken gauges as the nurses had thought, but the nurses were not properly reading the gauges according to the instructions from the oxygen company that supplied the portable tanks. The DON said the directions on the portable oxygen tanks was posted on the oxygen room wall. According to the facility list provided on 01/22/15, 10 residents received portable oxygen therapy. The facility's Centers for Medicare and Medicaid Services Form CMS-672 dated 01/20/15 revealed six residents with indwelling urinary catheters. Throughout the survey and during the exit conference on 01/22/15 at 6:00 p.m., the facility was given the opportunity to provide additional information related to professional standards. As of exit, the facility provided no further information.

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for two Residents (R #2 and R #3) of six Residents reviewed for indwelling urinary catheters. R #3 had a urethral tear. The facility did not assess R #3's catheter-urethral junction every day as ordered by the Physician. R #2 had an indwelling urinary catheter (a tube inserted into the bladder to enable urination). The facility did not assess R #2 or put interventions into place when R #2 developed a tear to his urethra. The underside of R #2's penis had no tissue from the meatus to the top of R #2's scrotum. These failures placed the six residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, or possible harm. Findings were: The facility's "Recognizing Signs and Symptoms of Abuse/Neglect" Policy dated December 2006 indicated: " ... Our facility will not condone any form of resident abuse or neglect ... 2. 'Neglect' is defines as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect ... b. Signs of/Actual Physical Neglect: ... Inadequate provision of care ..." R #3 R #3's Face Sheet dated 10/13/14 revealed R #3 was a [AGE] year old male admitted to the facility 04/21/14 with initial admission date of [DATE] and the following Diagnoses: [REDACTED]. R #3's most current Care Plan revision, dated 05/13/14 revealed, "...has a Indwelling Catheter: Skin Breakdown ...Will be/remain free from catheter-related trauma through review date ...Change catheter 16 French 10 cc balloon (every) month and (as needed) ...Check tubing for kinks each shift, apply leg strap at all times ..." R #3's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #3 was understood by others, usually understood others and had no behaviorial symptoms. R #3 required extensive assistance with bed mobility, dressing, eating, and transfers with assistance of one person. R #3 had an indwelling urinary catheter and was frequently incontinent of bowel. R #3's consolidated Physician order [REDACTED]. -"(Indwelling urinary) catheter 18 (French) 30 (centimeter) bulb, change every 30 days on NIGHT shift and (as needed) every night shift starting on the 15th and ending on the 15th for [MEDICAL CONDITION] DEPENDENT TO DRAINAGE" and, -"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." Review of R #3's 12/2014 and 01/2015 Medication Administration Record [REDACTED]"Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities." R #3's Nurse's Notes dated 01/15/15 at 11:00 a.m. revealed: "While changing catheter- Nurse noticed meatus appeared to have torn. Bright red blood present upon removal of catheter. Significant amount of blood noted. Was able to reinsert catheter. MD (Medical Doctor) notified. (No) signs of infection noted at this site. Will continue to monitor." R #3's Nurse's Notes dated 01/16/15 at 3:30 a.m. revealed: "... (Indwelling urinary catheter) patent and draining yellowish urine via gravity. Penis at insertion site with slit to urethra, cleansed with warm water and soap, scant amount bright red blood and greenish drainage, tender to touch ..." R #3's Nurse's Notes dated 01/16/15 at 5:00 p.m. revealed: "...Spoke to (MD "D"), stated (MD "G") will come and evaluate coccyx wound and penile tear on Monday/Tuesday (01/19/15 or 01/20/15) ..." R #3's Nurse's Notes dated 01/17/15 at 8:00 p.m. revealed: "...Penile tear free from blood/drainage." Review of R #3's Nurse's Notes after 01/17/15 at 8:00 p.m. revealed there was no further documentation staff assessed R #3's penile tear. Review of Nurse's Notes dated 12/2014 through 01/14/15 revealed no documentation staff assessed R #3's catheter-urethral junction. On 01/21/15 at 9:10 a.m., during a wound care observation with Registered Nurse (RN) "E", R #3 had approximately a 1 cm (centimeter) tear to his urethra. RN "E" said MD "G" was supposed to come to the facility this week to evaluate R #3's wound and urethral tear but since MD "G" would not be able to come to the facility, R #3 would be sent out to the hospital today. R #3 had a leg strap in place. RN "E" did not know how R #3's urethral tear occurred and said R #3 wiggles around in his bed a lot. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/21/15 at 6:10 p.m. interview with the Director of Nurses (DON) revealed the nurses only document in the nurses notes if something was different or wrong with a resident. On 01/22/15 at 11:35 a.m., interview with Licensed Vocational Nurse (LVN) "F" revealed there was no evidence in R #3's record that indicated the nurses documented every shift regarding R #3's catheter-urethral junction. This meant the assessments were not done. LVN "F" said the documentation should have been done on a TAR. R #2 R #2's Face Sheet dated 01/20/15 revealed an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #2's MDS dated [DATE] revealed R #2: -Made himself understood, -Sometimes understood others, -Had severely impaired cognition (never/rarely made decisions), -Was totally dependent on one staff person for bed mobility, transfers, dressing and personal hygiene, -Was totally dependent on two staff persons for toileting, -Had an indwelling urinary catheter and, -Was frequently incontinent of bowel. R #2's current "Order Summary Report" dated 12/29/14 revealed the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." Observation of R #2's indwelling urinary catheter care on 01/21/15 at 9:55 a.m. revealed the underside of R #2's penis was missing from his meatus to the top of his scrotum. R #2's indwelling urinary catheter was inserted into the opening of his urethra that began at the top of R #2's scrotum. R #2 did not respond to investigator's questions. On 01/21/15 at 4:25 p.m., Certified Nurse Aide (CNA) "A" stated R #2 had a history of [REDACTED]. CNA "A" stated in April 2014 on unknown dates, R #2's urethra developed "tears" due to R #2 pulling on his indwelling urinary catheter. CNA "A" stated this occurred on "more than one" occasion and R #2 "had bigger tears each time he pulled on it." CNA "A" stated she reported this to unknown nurses each time it occurred. On 01/22/15 at 1:15 p.m., CNA "B" stated she told an unknown nurse on "two separate" occasions in April 2014 on unknown dates that R #2's urethra had developed tears. CNA "B" stated, "The first time it was already tore. It (the tear) was approximately one centimeter (long). The second time, it (the tear) was approximately one centimeter longer (than the first time)." CNA "B" stated she did not know how the tears occurred to R #2's urethra. R #2's Care Plans dated 03/07/13 and updated on 03/12/14 and 07/15/14 did not reflect R #2 pulled on his indwelling urinary catheter or had a damaged penis. R #2's April 2014 "Order Summary Report" included the following orders: -Change R #2's indwelling urinary catheter every 30 days and as needed, -Provide R #2 with indwelling urinary catheter care every shift and as needed, and -"Monitor (R #2's) catheter-urethral junction" every shift and "document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift." R #2's TAR dated April 2014 revealed the following order: -" ...Monitor catheter-urethral junction (every) shift and document as follows: D-drainage R-redness I-irritation C-crusting P-pain O-no abnormalities every shift ...." Staff documented by initialing and handwriting "O" from 04/01/14 through 04/30/14. R #2's Nurses Notes revealed no entries were documented from 01/26/14 through 04/03/14. The following dates revealed no documentation R #2 was pulling on his catheter or the condition of R #2's penis, in sequence: -04/04/14, -04/07/14, -04/09/14 and, -04/10/14. There was no other documentation between 04/04/14 through 04/10/14. R #2's Nurses Notes revealed: -Dated 04/15/14 at 12:40 p.m.: "Indwelling (urinary catheter) in place. Urinary meatus noted with (a) tear/erosion to underlying tip. Strong foul odor, scant (amount) of yellowish drainage (with) visible redness surrounding area (and) scrotum ... Faxed (MD "D") ..." -Dated 04/15/14 at 6:30 p.m.: " ... (MD "D") in facility and assessed area to penis ... Order to culture and set-up (appointment with) urologist ... Meatus (with) tear, reddened - thick yellow (drainage with) foul odor noted ..." R #2's physician progress notes [REDACTED].#2) on 04/15/14 due to tear on meatus from (indwelling urinary catheter) ... Drainage from open area per nursing staff ... Penis 3-4 (centimeters) laceration to underside of penis ... (Culture and sensitivity) done ..." R #2's Nurses Notes dated 04/16/14 at 1:45 p.m. revealed MD "D" ordered an antibiotic for R #2's penile drainage. On 01/21/15 at 12:10 p.m., Family Member (FM) "AA" stated on 04/15/14, the facility notified FM "AA" of R #2's urethral tear. FM "AA" stated R #2 was seen by a urologist in April 2014. FM "AA" stated the urologist "said we could fix it (R #2's urethral tear) or leave it. (The urologist said) it wouldn't hurt anything ... We decided to leave it the way it was." On 01/22/15 at 3:00 p.m., MD "D" stated on 04/15/14, facility staff notified him R #2 had a tear to his penis due to R #2 "pulling" on his indwelling urinary catheter. MD "D" stated the facility did not notify him prior to 04/15/14 when R #2 had developed a tear to his penis or when R #2 was pulling on his catheter. MD "D" stated the current condition of R #2's penis was due to urethral tears. MD "D" stated R #2 was assessed by a urologist in April 2014. MD "D" stated the urologist recommended to keep R #2's indwelling urinary catheter in his urethra and not insert a suprapubic urinary catheter. On 01/22/15 at 2:25 p.m., LVN "C" stated she provided care to R #2 in April 2014. LVN "C" stated she assessed R #2's catheter-urethral junction each day she worked in April 2014. LVN "C" stated, "I don't remember seeing any tears" prior to 04/15/14 when she assessed R #2. LVN "C" confirmed she initialed and wrote an "O" on R #2's TAR dated April 2014 on the days she worked. On 01/22/15 at 3:15 p.m., RN "E" stated she did not assess residents' catheter-urethral junctions "unless there was a problem" because "the CNAs provide indwelling urinary catheter care and notify (us) if there is a problem." On 01/22/15 at 3:35 p.m., the Administrator stated, "If the nurses are documenting they gave care then they should have done it." On 01/22/15 at 4:00 p.m., the DON stated "it is common to have erosion" with a "regular" indwelling urinary catheter. The DON stated she was not aware the nurses were not doing the catheter-urethral assessments. According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Indwelling Urinary Catheter Care and Removal, pages 374-377, " ... Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling ... Don't pull on the catheter ... Pulling can injure the urethra ... Record ... the condition of the perineum and urinary meatus ..." The facility's Urinary Catheter Care Policy dated April 2010 indicated: " ... Complications 1. Observe the resident for complications associated with urinary catheters ...." The facility's Centers for Medicare and Medicaid Services Form CMS-672 dated 01/20/15 revealed six residents with indwelling urinary catheters. Throughout the survey and during the exit conference on 01/22/15 at 6:00 p.m., the facility was given the opportunity to provide additional information related to indwelling urinary catheters and neglect. As of exit, the facility provided no further information.

Based on observation, record review and interview, the facility failed to ensure that one of three residents, Resident (R#6) reviewed for pressure ulcers, received services to promote pressure ulcer healing. R#6 had a pressure ulcer identified on admission 12/01/11 and treatment was not implemented until 12/15/11 after surveyor's intervention. The failure to provide services to promote healing to pressure ulcers could delay healing for all three residents listed as having pressure ulcers. The findings were: Admission Nursing Evaluation dated 12/01/11 indicated R#6's had a Stage II pressure ulcer to coccyx had a [MEDICATION NAME] in place and would be removed in 2 days because the hospital had just applied the dressing. R#6's Daily Skilled Nurse's Notes dated from 12/01/11 to 12/14/11 did not indicate any entries regarding skin issues. Review of the 200 Hall 24 hour report dated 12/01/11 to 12/14/11, did not reveal any skin issues for R#6. On 12/14/11 at 11:20 a.m., surveyor accompanied by Certified Nurse Aide (CNA) "D" went into R#6's room. CNA "D" performed incontinent care to R#6. When R#6's buttocks were exposed, surveyor and CNA "D" observed two open wounds to the right buttocks. On 12/15/11 at 10:10 a.m., surveyor accompanied by Licensed Vocational Nurse (LVN) "E", LVN "F" and the Director of Nurses (DON) went into R# 6's room. Responsible Party (RP) "G" was seated in R#6's room. LVN "E" measured the two open wounds on R#6's right buttocks. Wound #1 measured 2.4 cm X 3.3 cm. Wound #1 had no drainage, no odor and a small amount of yellow slough. Wound #2 measured 1.0 cm X 1.9 cm. Wound #2 had no drainage, no odor and no slough. LVN "E" brought the treatment book for review. Surveyor and LVN "E" could not find a current treatment for [REDACTED]. During an interview with the DON on 12/15/11 at 10:15 a.m., the DON said "I did not know R#6 had a pressure ulcer, it was not reported to me. The treatment nurse will call R#6's physician and get an order for [REDACTED]. During an interview with LVN "E" on 12/15/11 at 10:27 a.m., LVN "E" stated she assessed R#6 on admission and discovered he had Stage II (partial thickness tissue loss) pressure ulcer to the (R) buttocks. LVN "E" said "I was supposed to assess R#6's pressure ulcer, I did not measure the pressure ulcer or inform the physician. During an interview with LVN "F" on 12/15/11 at approximately 10:28 a.m., LVN "F stated R#6 was admitted to the facility with a [MEDICATION NAME] dressing to the coccyx. ([MEDICATION NAME] is a skin dressing for the treatment of [REDACTED]. During another interview with the DON on 12/15/11 at 1:05 p.m., the DON stated all nurse managers made skin rounds on all residents and documented the results on weekly skin assessment forms. The results were without new findings. During an interview with LVN "H" on 12/15/11 at 1:37 p.m., LVN "H" stated skin assessments were done weekly. LVN "H" stated charge nurses should assess residents on admission and report abnormal findings to the physician and responsible parties. During an interview with LVN "C" dated 12/15/11 at 1:52 p.m., LVN "C" stated she worked with the facility for approximately 6 months and she knew skin checks were done weekly. She also stated she knew if a resident had a new pressure ulcer, she knew to assess, stage, measure and to notify the physician and the RP. R#6's Braden Scale for Predicting Pressure Sore Risk dated 12/01/11 indicated R#6 at high risk for pressure ulcer development. Review of Facility's Clinical Protocol- Pressure Ulcers/ Skin Breakdown Nursing Services Policy and Procedure Manual (C) 2005 MED-PASS, Inc (Revised April 2007) Assessment and Recognition: 2. The nurse shall assess and document/report the following: b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic issue. On 12/13/11, the DON provided surveyor with the names of three residents currently with pressure ulcers.R#6 was not listed. On 12/15/11, LVN "E" provided surveyor with the names of three residents currently with pressure ulcers. R#6 was not listed. At the exit conference on 12/15/11 at 4:15 p.m. the facility was given the opportunity to provide any additional information regarding the pressure ulcer issue and none was provided.

Based on observation, record review and interview, the facility failed to provide care services in accordance with the facility's policy to prevent neglect and avoid harm to one of four residents (R#6) reviewed for pressure ulcers. The facility failed to address the pressure ulcer and treatment to promote healing to R#6 buttocks until surveyor intervention on 12/14/11. The failure to recognize and treat pressure ulcers to promote healing could affect all residents who were at high risk of developing pressure ulcers. The findings were: Admission Nursing Evaluation dated 12/01/11 indicated R#6's had a Stage II pressure ulcer to coccyx had a [MEDICATION NAME] in place and would be removed in 2 days because the hospital had just applied the dressing. R#6's Daily Skilled Nurse's Notes dated from 12/01/11 to 12/14/11 did not indicate any entries regarding skin issues. Review of the 200 Hall 24 hour report dated 12/01/11 to 12/14/11, did not reveal any skin issues for R#6. On 12/14/11 at 11:20 a.m., surveyor accompanied by Certified Nurse Aide (CNA) "D" went into R#6's room. CNA "D" performed incontinent care to R#6. When R#6's buttocks were exposed, surveyor and CNA "D" observed two open wounds to the right buttocks. On 12/15/11 at 10:10 a.m., surveyor accompanied by Licensed Vocational Nurse (LVN) "E", LVN "F" and the Director of Nurses (DON) went into R# 6's room. Responsible Party (RP) "G" was seated in R#6's room. LVN "E" measured the two open wounds on R#6's right buttocks. Wound #1 measured 2.4 cm X 3.3 cm. Wound #1 had no drainage, no odor and a small amount of yellow slough. Wound #2 measured 1.0 cm X 1.9 cm. Wound #2 had no drainage, no odor and no slough. LVN "E" brought the treatment book for review. Surveyor and LVN "E" could not find a current treatment for [REDACTED]. During an interview with the DON on 12/15/11 at 10:15 a.m., the DON said "I did not know R#6 had a pressure ulcer, it was not reported to me. The treatment nurse will call R#6's physician and get an order for [REDACTED]. During an interview with LVN "E" on 12/15/11 at 10:27 a.m., LVN "E" stated she assessed R#6 on admission and discovered he had Stage II (partial thickness tissue loss) pressure ulcer to the (R) buttocks. LVN "E" said "I was supposed to assess R#6's pressure ulcer, I did not measure the pressure ulcer or inform the physician. During an interview with LVN "F" on 12/15/11 at approximately 10:28 a.m., LVN "F stated R#6 was admitted to the facility with a [MEDICATION NAME] dressing to the coccyx. ([MEDICATION NAME] is a skin dressing for the treatment of [REDACTED]. During another interview with the DON on 12/15/11 at 1:05 p.m., the DON stated all nurse managers made skin rounds on all residents and documented the results on weekly skin assessment forms. The results were without new findings. During an interview with LVN "H" on 12/15/11 at 1:37 p.m., LVN "H" stated skin assessments were done weekly. LVN "H" stated charge nurses should assess residents on admission and report abnormal findings to the physician and responsible parties. During an interview with LVN "C" dated 12/15/11 at 1:52 p.m., LVN "C" stated she worked with the facility for approximately 6 months and she knew skin checks were done weekly. She also stated she knew if a resident had a new pressure ulcer, she knew to assess, stage, measure and to notify the physician and the RP. R#6's Braden Scale for Predicting Pressure Sore Risk dated 12/01/11 indicated R#6 at high risk for pressure ulcer development. Review of Facility's Clinical Protocol- Pressure Ulcers/ Skin Breakdown Nursing Services Policy and Procedure Manual (C) 2005 MED-PASS, Inc (Revised April 2007) Assessment and Recognition: 2. The nurse shall assess and document/report the following: b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic issue. On 12/13/11, the DON provided surveyor with the names of three residents currently with pressure ulcers. R#6 was not listed. On 12/15/11, LVN "E" provided surveyor with the names of three residents currently with pressure ulcers. R#6 was not listed. At the exit conference on 12/15/11 at 4:15 p.m. the facility was given the opportunity to provide any additional information regarding the pressure ulcer issue and none was provided.