Every finding on record at Hattiesburg Health & Rehab Center

Based on observation, interview, and facility policy review, the facility failed to ensure residents' rights to a comfortable living environment by not ensuring comfortable room and water temperatures for residents across three (3) of four (4) halls in the facility, Halls A, B, and C.Findings include:A review of the facility's policy, Quality of Life - Homelike Environment, revised 5/2017, revealed, .Residents are to be provided with a.comfortable and homelike environment.Policy Interpretation and Implementation.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.h. Comfortable and safe temperatures (71 degrees Fahrenheit - 81 degrees Fahrenheit).A review of the facility's Resident Rights, undated, revealed, 1) A dignified and comfortable living environment.On 12/9/25 at 1:35 PM, during a Resident Council meeting, multiple residents reported concerns regarding room temperatures being cold while outside temperatures were in the low 30s. Resident #18 reported he informed maintenance that his room was cold and stated the room temperature did not improve following his request. Residents #138, #36, #93, #54, and #1 also reported that the temperatures in their rooms were cold. The residents also reported concerns that water temperatures in resident rooms and shower rooms were uncomfortable, stating that that the hot water felt cold.On 12/10/25 at 8:10 AM, during an interview, the Social Services Director reported she had received concerns from residents related to room temperatures and water temperatures and submitted work orders through the facility's electronic maintenance request system.On 12/10/25 at 8:33 AM, during an observation and interview, the Maintenance Director assessed room temperatures with an infrared thermometer and water temperatures with a digital thermometer on three halls identified through resident complaints. At 8:36 AM, the temperature in Room A8 (Resident #36) measured 69 degrees Fahrenheit (F) and the water temperature was 68 degrees F. At 8:44 AM, the temperature in Room B22 (Resident #1) measured 65.5 degrees F and the water temperature was 86F. At 8:48 AM, the temperature in Room B2 (Resident #138) measured 70 degrees F and the water temperature was 93 degrees F. At 8:49 AM, the temperature in Room B13 (Resident #54) measured 77 degrees F and the water temperature was 84 degrees F. At 8:55 AM, the temperature in Room B16 (Resident #93) measured 85 degrees F and the water temperature was 99.8 degrees F. At 8:57 AM, the water temperature in Room B11 measured 69.2 degrees F. The Maintenance Director reported that water required several minutes of running before reaching the temperatures measured.On 12/10/25 at 2:00 PM, during observation, the Maintenance Director rechecked room temperatures. Room A8 measured 65 degrees F. Room B2 measured 84 degrees F. Room B13 measured 88 degrees F. Room B16 measured 91 degrees F.On 12/10/25 at 2:08 PM, during an observation in the C-South shower room, the water temperature reached 100 degrees Fahrenheit after four minutes of continuous running.On 12/11/25 at 2:48 PM, during an interview, the Administrator reported the facility operates a tankless hot water system and acknowledged that water must travel through the system before reaching resident rooms. He stated his expectation was for residents to experience a consistent and comfortable living environment.

Based on staff interview, record review, and facility policy review, the facility failed to ensure that a resident's diagnosis of a major mental illness was accurately identified on the Pre-admission Screening and Resident Review (PASRR) at the time of admission for one (1) of twenty-nine (29) sampled residents, Resident #11.Findings include:A review of the facility's policy admission Criteria revised December 2016, revealed . Our facility will admit only those residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation 1. The objectives of our admission criteria policy are to: . e. assure that the facility receives appropriate medical . records . 8. Nursing and medical needs of individuals with mental disorders . will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review Program (PASARR) to the extent practicable.A record review of the facility's PASRR Completion Policy , undated, revealed The Center will a make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. PRACTICE GUIDELINES: 1. Center Administrator will designate either the Admissions Director or Social Worker to make sure that the PASSRR and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which might constitute an SMI (Serious Mental Illness) or ID (Intellectual Disability), the PASRR must be completed prior to admission. If the resident is deemed hospital exempted that must be clearly documented in the transfer documents prior to admission from the acute care facility.A record review of the admission Record revealed the facility admitted Resident #11 on 6/30/22 with diagnoses including Bipolar Disorder, with an onset date of 2/26/25.A record review of the Pre-admission Screening, dated 6/30/22, revealed Resident #11 had no diagnosis of Alzheimer's Disease, Dementia, or major mental illness identified at the time of admission. Further review revealed documentation that the resident was taking or had a history of taking psychotropic medications.A record review of electronic hospital records revealed Resident #11 had a Problem of Bipolar disorder that was Noted on 12/25/2014 and Updated on 4/23/25.A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/2025 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated he was cognitively intact. A review of Section I revealed he had no diagnoses of Dementia or Alzheimer's, however, the MDS indicated he had diagnoses including Psychiatric/Mood Disorders of Anxiety, Depression, and Bipolar Disorder.On 12/11/25 at 11:10 AM, during an interview with the Director of Nursing (DON) and a concurrent record review of Resident #11's Problem List with last review dated 9/25/25, she explained that the resident had a diagnosis of Bipolar Disorder, with a documented onset date of 12/25/14. She confirmed there was no diagnosis of Dementia or Alzheimer's Disease that would qualify the resident for a Level II PASRR exemption and that the PAS screening was completed inaccurately on admission dated 6/30/22. She reported that the staff member responsible for completing the PAS screening at that time was from Social Services but was no longer employed at the facility.On 12/11/25 at 2:00 PM, during an interview with Social Services, she confirmed she completes PAS screenings for all new admissions. She explained she gathers information from referral packets, electronic medical records, verbal information from the referring facility, and information obtained from families.On 12/11/25 at 3:48 PM, during an interview with the Administrator, he reported that he expects the staff member completing PAS screenings to complete them accurately and to identify any concerns to assure the facility can meet the resident's care needs.

Based on interviews, record review, and facility policy review, the facility failed to provide complete and timely written transfer notices for six (6) of six (6) residents reviewed for hospitalizations (Residents #1, #9, #10, #12, #14, and #15). The facility did not include a clear, resident-specific reason for why each resident was sent to the hospital. Written notices were provided late for five (5) residents (Residents #1, #10, #12, and #15), and the Responsible Representative for one (1) resident (Resident #14) did not receive a written notification of the transfer at all.Findings include: A review of the facility's policy, Transfer or Discharge Notice revised November 2023, revealed, .Policy Interpretation and Implementation.4. Under the following circumstances, the notice is given as soon as it is practical but before the transfer or discharge.d. An immediate transfer or discharge is required by the resident's urgen medical needs.5. The resident and representative will be notified in writing of the following information: a. The specific reason for the transfer or discharge. Resident #1 A record review of the admission Record revealed the facility initially admitted Resident #1 on 1/12/2024 and she had current diagnoses including Hemiplegia and Hemiparesis. A record review of the Order Recap Report revealed Resident #1 had a Physician's Order, dated 10/19/25 to send to (proper name of acute hospital) ER (Emergency Room) for eval (evaluation) and tx (treatment). A record review of the Notice of Resident Transfer or Discharge, dated 10/20/25, for Resident #1 indicated the reason as The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. It did not specify the reason for the transfer and was dated one (1) day after the transfer. Resident #9 A record review of the admission Record revealed the facility admitted Resident #9 on 05/24/2025 and she had diagnoses including End Stage Renal Disease. A record review of the Telephone/Verbal Order Signatures Details document revealed Resident #9 had a Physician's Order, dated 12/02/25 for order to send resident to (proper name of acute hospital) ER r/t (related to) respiratory distress. A record review of the Notice of Resident Transfer or Discharge, dated 12/2/25 for Resident #9 indicated, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. It did not specify the reason for the transfer. Resident #10 A record review of the admission Record revealed the facility initially admitted Resident #10 on 4/28/2017 and he had current diagnoses including Hemiplegia and Hemiparesis. A record review of the Order Recap Report revealed Resident #10 had a Physician's Order, dated 10/08/25 to .Send to (proper name of acute hospital) for evaluation . A record review of the Notice of Resident Transfer or Discharge, dated 10/21/25 for Resident #10 indicated, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. It did not specify the reason for the transfer and was dated 13 days after the resident was transferred to the hospital. Resident #12 A record review of the admission Record revealed the facility initially admitted Resident #12 on 10/10/24 with current diagnoses including Atrial Fibrillation. A record review of the Telephone/Verbal Order Signature Details document revealed Resident #12 had a Physician's Order, dated 09/30/25 for order to send to (proper name of acute hospital) r/t decreased O2 (oxygen) saturations and concern for possible blood clot . A record review of the Notice of Resident Transfer or Discharge, dated 10/6/25, for Resident #12 indicated, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. It did not specify the reason for the transfer and was dated seven (7) days after the resident was transferred to the hospital. Resident #14 A record review of the admission Record revealed the facility admitted Resident #14 on 11/9/2025 and he had current diagnoses including Chronic Atrial Fibrillation. A record review of the Order Recap Report revealed Resident #14 had a Physician's Order, dated 12/01/25 to send resident out to (proper name of acute hospital) ER for critical labs. A record review of the Notice of Resident Transfer or Discharge for Resident #14 indicated, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. It did not specify the reason for the transfer and was dated ten (10) days after the date of the transfer. On 12/11/2025 at 8:01 AM, during a phone interview with the Responsible Representative (RR), he explained that he did not receive written notification of the transfer for Resident #14's hospitalization on 12/1/2025. He stated the facility had called him to inform him of the transfer, but he did not receive anything in writing. Resident #15 A record review of the admission Record revealed the facility admitted Resident #15 on 06/02/2025 and he had current diagnoses including Personal History of Transient Ischemic Attack. A record review of the Telephone/Verbal Order Signature Details document revealed Resident #12 had a Physician's Order, dated 10/25/25 to send to out to hospital. A record review of the Notice of Resident Transfer or Discharge, dated 10/28/25, for Resident #15 indicated, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. It did not specify the reason for the transfer and was dated three (3) days after the date of the transfer. On 12/10/2025 at 2:42 PM, in an interview with the Director of Social Services (DSS), she confirmed that she was responsible for filling in the Notice of Resident Transfer or Discharge form and mailing it to the RR when a resident is transferred to the hospital. The Director of Social Services stated she does not list a reason for the transfer to hospital because the nurse will explain the reason over the phone. The DSS acknowledged that this leaves the RR without clear information regarding the transfer. The DSS stated she will begin writing the reason that the resident was sent to the hospital from now on. On 12/11/2025 at 1:02 PM, in an interview with the Director of Nursing (DON), she acknowledged the facility's hospital transfer form did not include a reason for hospitalization for Resident #14 and that the notice was not mailed to the RR. She stated the purpose of including this information is to ensure the RR is informed. The DON explained she expected the Social Services Director to complete the area with the symptoms charted and ensure the information was sent to the family and mailed to every RR. She stated she will suggest to the Administrator that staff follow up by phone a few days after mailing the notices to confirm they were received. On 12/11/2025 at 1:18 PM, in an interview with the Administrator, he acknowledged there was no reason for hospitalization documented on the transfer forms, including Resident #14's form that was not provided to the RR. He stated the reason for the RR to receive written notification with the reason for hospitalization is to support transparency. The Administrator stated his expectation was that the Social Services Director provide a specific reason for hospitalization and mail the forms in a timely manner.

Based on record review, staff interview, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status regarding hospice services for one (1) of 52 sampled residents. Resident #99 Findings include: A review of the facility's policy Minimum Data Set (MDS) Assessments, revised 09/2019, revealed . Resident assessments will be conducted to assist in developing person-centered care plans. This facility follows Resident Assessment Instrument (RAI) manual from the Centers for Medicare and Medicaid Services (CMS) for all Residents regardless of payer source . The RAI process requires: a. The assessment accurately reflects the Resident's status . A record review of the Order Summary Report with active orders as of 09/24/24 revealed a Physician's Order, dated 11/28/23, to admit Resident #99 to hospice services. A record review of the Admission Record revealed the facility admitted Resident #99 on 04/18/22 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia and Polyneuropathy. A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 09/02/24 revealed in Section O Special Treatments, Procedures, and Programs under K1 Hospice Care was not selected for Resident #99. On 09/26/24 at 8:35 AM, during an interview with the Licensed Practical Nurse (LPN) #, 1 she revealed herself and the MDS team are responsible for completing different sections of the MDS and each individual is responsible for their own accuracy. She confirmed Resident #99 is currently on Hospice care and has been for almost one (1) year. the LPN who completed Section O of Resident #99's MDS assessment was not working today. She confirmed section O Hospice on the recent Quarterly MDS was not marked and was not accurate. At 9:10 AM on 09/26/24, during an interview with Registered Nurse (RN)#1/MDS nurse, she explained each person on the MDS team was responsible for ensuring MDS assessments are accurate and reflect the resident's condition. She confirmed that Resident #99 was currently on hospice services, however, the Quarterly MDS inaccurately indicated he was not on hospice services. At 10:10 AM on 09/26/24, during an interview with the Administrator, he explained he expected the MDS team to code each residents assessments accurately and to the follow the RAI manual and the facility's policy for any assistance needed.

Based on record review, staff interview, and facility policy review, the facility failed to transmit MDS assessments within 14 days of completion for (10) of (52) sampled residents. (Resident #3, Resident #48, Resident #52, Resident #54, Resident #81, Resident #96, Resident #98, Resident #102, Resident #116, and Resident # 134). Findings include: Review of the facility's policy, Minimum Data Set (MDS) Assessment, revised 9/2019, revealed, .The facility follows Resident Assessment Instrument (RAI) manual from Centers of Medicare and Medicaid services (CMS) for all Residents .Assessment Timing (will follow the RAI manual guidelines) . Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2019 revealed . Transmitting Data: . Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days) .All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Resident # 3: A record review of the Admission Record revealed the facility admitted Resident #3 on 4/19/24 with diagnoses that included Type 2 Diabetes and Bradycardia. A record review of Resident #3'sDischarge MDS with an Assessment Reference Date (ARD) of 4/24/24 revealed Section Z0500B was dated 05/08/24. A record review of the facility's Final Validation Report revealed the assessment had been submitted on 9/25/24. Resident #3 had a target date of 04/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #48: A record review of the Admission Record revealed the facility admitted Resident #48 on 5/15/14 with diagnoses including Anoxic Brain Damage. A record review of Resident #48's Quarterly MDS revealed an ARD of 8/13/2024 and Section Z0500B revealed a date of 8/20/24. Record review of the facility's Final Validation Report revealed the assessment target date of 08/13/24 had been submitted on 9/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #52: A record review of the Admission Record revealed the facility admitted Resident #52 on 10/16/2020 with diagnoses including Heart Disease. A record review of the Quarterly MDS with an ARD of 8/15/2024 revealed Section Z0500B was dated 8/21/24. A record review of the Final Validation Report revealed the assessment target date of 08/15/24 had been submitted on 9/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS Resident #54: A record review of the Admission Record revealed the facility admitted Resident #54 3/18/24 with the diagnoses including Type 2 Diabetes Mellitus. A record review of the Discharge MDS with an ARD of 06/19/24 revealed Section Z0500B was dated 07/03/24. A record review of the facility's Final Validation Report revealed Resident #54 Discharge Assessment with target date of 06/19/24 was transmitted on 09/25/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #81 A record review of the facility's Admission Record revealed the facility admitted Resident #81 on 6/5/18 with diagnoses including Acute and Chronic Respiratory Failure. A record review of Resident #81's Quarterly MDS with an ARD of 8/6/2024 revealed Section Z0500B was dated 8/20/24. Record review of the facility's Final Validation Report revealed a target date of 08/6/24 was transmitted on 09/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #96 A record review of the Admission Record revealed the facility admitted Resident #96 on 1/23/2020 with diagnoses including Unspecified Dementia and Type 2 Diabetes. A record review of the Quarterly MDS with an ARD of 8/15/24 revealed Section Z0500B was dated 8/22/24. A record review of the facility's Final Validation Report revealed a target date of 08/15/24 and was transmitted on 09/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #98 A record review of the Admission Record revealed the facility admitted Resident #98 on 5/18/23 with a diagnosis of Cerebral Palsy. A record review of the Quarterly MDS with an ARD of 8/12/2024 revealed Section Z0500B was dated 08/20/24. A record review of the facility's Final Validation Report revealed a target date of 08/12/24 and was transmitted on 09/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident # 102 Record review of Admission Record revealed the facility admitted Resident #102 on 08/24/23 with diagnoses including Unspecified Convulsions. A record review of the Discharge MDS with an ARD of 05/31/24 revealed Section Z0500B was dated 06/14/24. A record review of the facility's Final Validation Report revealed target date of 05/31/24 and was transmitted on 9/25/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #116 A record review of the Admission Record revealed the facility admitted Resident #116 on 3/22/22 with diagnoses including Hemiplegia. A record review of Quarterly MDS with an ARD of 8/12/2024 revealed Section Z0500B was dated 08/20/2024. A record review of the Final Validation Report for Resident #116 revealed the MDS transmission had a Target Date of 8/12/2024 and was transmitted on 9/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident # 134 A record review of the Admission Record revealed the facility admitted Resident #134 on 05/02/24 with diagnoses including Hemiplegia and Hemiparesis Disease. A record review of the Discharge MDS with an ARD of 05/19/24 revealed Section Z0500B was dated 05/31/24. A record review of the facility's Final Validation Report revealed a target date of 5/19/24 was submitted on 9/25/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. On 09/25/24 at 1:56 PM, during an interview with the Licensed Practical Nurse (LPN) # 1, she revealed she and the team were responsible for completing and transmitting MDS assessments. She explained the facility recently had an update in their Electric Medical Record (EMR) system which had caused delays in the submission of the MDS. On 09/26/24 at 8:12 AM, in an interview with the Director of Nursing (DON) she explained she was not aware that MDS Assessments were not transmitted timely, and confirmed it was the responsibility of the LPN/ MDS Coordinator to transmit the assessments. The DON stated she expected the MDS to be transmitted timely. On 09/26/24 at 10:32 AM, during an interview with the Administrator, he explained the MDS staff are responsible for completing and transmitting MDS assessments timely. He was unaware there were late MDS transmissions. He stated that timely submission was important for federal reporting and reimbursement processes.

Based on observation, interview and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to a food item not labeled, a scoop stored in a dry bin container, a food item not refrigerated, and an opened food item not discarded after the Best Before date for one (1) of two (2) kitchen observations. Findings include: A review of the facility's policy, Food Receiving and Storage, Revised October 2017, revealed, Foods shall be .stored in a manner that complies with safe food handling practices .6. All foods will be labeled with open date at the time of unsealing .9. All foods stored in the refrigerator or freezer will be .labeled and dated . On 09/23/24 at 10:12 AM, an observation and interview with the Dietary Manager (DM) revealed Freezer #1 had one (1) Styrofoam cup of a frozen substance with no date or label, that the DM was unable to identify the contents. An observation of the pantry revealed one (1) opened bag of dried cranberries with a Best Before date of 7/17/24. There was one (1) opened bottle of lime juice with a facility date of 6/17/24 and the manufactures label instructed to refrigerate after opening. There was a large bin of cornmeal in which the scoop was stored in the corn meal and not in a designated area. The DM stated the dried cranberries should have been discarded and the lime juice should have been stored in the refrigerator. The DM also confirmed the scoop should not have been stored in the corn meal bin. The DM stated the staff are in-serviced every 2 weeks on food safety. On 09/25/24 at 1:21 PM, an interview with the Administrator revealed he was made aware by staff that the lime juice was not stored properly, and a scoop was stored in the corn meal bin.

Based on interviews, record review, and facility policy review, the facility failed to protect a resident (Resident #1) from sexual abuse by another resident (Resident #2) for one (1) of four (4) sampled residents. Resident #1 The facility's failure to provide adequate supervision and monitoring allowed Resident #2 to be in his room with his pants unzipped and penis exposed with Resident #1, who was a cognitively impaired and vulnerable person, in his bed with her clothing pulled down exposing her genital area. This placed Resident #1 and other vulnerable residents in a situation likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 12/21/23 when Resident #2 exhibited inappropriate sexual behaviors. The facility Administrator was notified of the IJ and Substandard Quality of Care (SQC) on 1/3/24 at 5:10 PM and was provided an IJ Template. Based on the facility's implementation of corrective actions on 12/22/23, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 12/23/23, prior to the SA's entrance on 1/2/24. Findings Include: A review of the facility's policy, Abuse and Neglect-Clinical Protocol, revised July 2017, revealed, .1. Abuse is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes .sexual abuse .3. Sexual abuse is defined .as non-consensual sexual contact of any type with a resident . A record review of the facility's investigation revealed on 12/22/23 at 9:22 AM, Resident #1 was observed lying on Resident #2's bed with her pants partially pulled down. Resident #2 was lying over Resident #1 with pants on, zipper of jeans unzipped. The residents were immediately separated and assessed. Resident #1 was transferred to a local hospital, and Resident #2 was transferred to a behavioral health unit. On 1/2/24 at 9:52 AM, during an interview with the Administrator, he confirmed Resident #1 was found to be in Resident #2's bed with her pants pulled down, and Resident #2 was on top of the resident with his pants unzipped. After observing the video surveillance, the administrator revealed that Resident #1 was in Resident #2's room for seven (7) minutes and 30 seconds with the door open. The Administrator stated Resident #1 had a history of roaming and wandering the memory care unit. The Administrator also confirmed that Resident #2 was admitted on [DATE], but on 12/21/23, he was touching himself and was being treated for hypersexuality before the incident occurred on 12/22/23. During a phone interview on 1/2/24 at 10:56 AM, with Resident #1's Resident Representative (RR), he confirmed the facility notified him that his wife was found in a resident room, in the bed with her pants pulled down. The other resident was lying on top of her with his penis exposed. Following the incident, his wife was brought to the local hospital for an evaluation. The RR stated his wife has Dementia, that she is unable to speak, and always roams the unit. He confirmed that before her Dementia diagnosis, Resident #1 was modest and would not expose herself to anyone in that way. The RR stated she was not being watched and that the facility was aware of her roaming into rooms. During an interview on 1/2/24 at 11:31 AM, the Assistant Director of Nurses (ADON) #2 stated on 12/22/23 at 9:30 AM, she was summoned to Resident #2's room by Certified Nurse Aide (CNA) #1. She observed Resident #1 lying on her back in the resident's bed, with her pants pulled down to her knees with Resident #2 on top of her with his penis exposed. The ADON immediately separated the residents, and both were examined. Resident #1 was transferred to a local hospital, and Resident #2 was transferred to a behavioral health unit. The ADON confirmed on 12/21/23 that Resident #2 demonstrated hypersexual behavior consisting of pulling his penis out of his pants and trying to touch nursing staff with his penis. The physician was notified of his behavior on 12/21/23 and new orders were received to administer Geodon 10 milligrams (MG) for two (2) doses and Provera 10 MG by mouth daily. She explained that Resident #1 always roamed and wandered in the hallways and into other resident rooms and required frequent redirections. She stated that before this incident, Resident #1 had never exposed herself to staff or other residents. On 1/2/24 at 12:30 PM, an interview with the Medical Director revealed that he was aware that on 12/21/23, Resident #2 had hypersexual behavior, which included masturbation and fondling of his genitalia. On 12/21/23, his nurse practitioner prescribed Geodon and Provera for his hypersexual behavior with interventions to re-direct. On 1/2/24 at 12:37 PM, an interview with the Licensed Masters Social Worker (LMSW) confirmed Resident #1 wandered, paced, and ambulated throughout the unit and required supervision and redirection frequently. Resident #2 was admitted on [DATE] and had no signs of being hypersexual or exposing himself. During an interview on 1/2/24 at 1:08 PM, CNA #1 confirmed on 12/22/23, while making rounds, he observed Resident #1 to be in Resident #2's room. She was positioned in his bed with her pants pulled down below her knees, exposing her genitalia. Resident #2 was positioned on the top of her with his pants on, but his penis was exposed and pulled out of his pants. He immediately notified the nurse and separated the residents. CNA #1 explained that Resident #1 had roamed the hallways, walked into other residents' rooms, and required frequent redirection since she was admitted to the facility. On 1/3/24 at 11:16 AM, in an interview with CNA #2, she stated that Resident #1 walked throughout the unit all day and hugged the staff. Resident #1 required supervision because she would enter other residents' rooms and must be redirected frequently throughout the shift. She stated on 12/22/23, while serving breakfast, she entered Resident #2's room and his privacy curtain was closed. He was masturbating and his penis was exposed. Resident #2 told her to come closer, let me hold you. CNA #2 reported the incident to ADON #2. On 1/3/24 at 12:02 PM, an interview with Psychiatric /Nurse Practitioner revealed Resident #1 was rubbing up against other residents inappropriately and rocking her body on other staff, residents, and visitors. She explained that Resident #1 required frequent supervision. During an interview on 1/4/24 at 11:58 AM, Registered Nurse (RN) #1 revealed that while she was performing a body audit on Resident #2 on 12/21/23, he was rubbing her on her mid-back. After she redirected him, he stopped. Then, as she was performing the body audit on his front side, he grabbed her around her neck. RN #1 called out for assistance and License Practical Nurse (LPN) #1 and CNA #3 entered and observed the resident touching himself and masturbating. They redirected him, and then he stopped. She explained that Resident #1 roamed the unit all day and required supervision from staff. On 1/4/24 at 12:12 PM, an interview with CNA #3 confirmed that on 12/21/23, both LPN #1 and herself were requested to Resident #2's room by RN #1, and they observed Resident #2 trying to touch RN #1 with his exposed penis. They all re-directed Resident #2, and he stopped. She explained that Resident #1 continuously ambulated through the locked unit and would go into other resident rooms. On 1/4/24 at 12:30 PM, an interview with LPN #1 revealed that on 12/21/23 she heard RN #1 calling for assistance in Resident #2's room. Resident #2 was exposing himself and masturbating in front of all three staff that were present, and they all re-directed him. Following the incident, the physician, and Director of Nurses (DON) were notified and the facility received new medication orders for Resident #2. During an interview on 1/4/23 at 2:00 PM, the DON confirmed that on 12/21/23, when Resident #2 was having his hypersexual activities, the facility should have put more interventions in place to protect the residents and provided increased supervision to all residents in the memory care unit. Resident #1 A record review of the Face Sheet revealed the facility admitted Resident #1 on 8/24/23 with diagnoses that included Alzheimer's disease. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/30/23, revealed Resident #1 required a staff interview to assess cognition, and she was rarely/never understood. A record review of the Emergency Department Encounter, dated 12/22/23, revealed, .Patient was apparently found in bed naked at her nursing home with another individual. The husband is unsure as to what happened .Patient has advanced Alzheimer's and cannot consent . Resident #2 A record review of the Face Sheet revealed the facility admitted Resident #2 on 12/20/23 with diagnoses that included Psychosis and Schizophrenia. A record review of the Progress Notes for Resident #2, signed by the Medical Director on 1/3/24, revealed, .Since coming into the facility he has been noted to have hypersexual behavior which includes masturbation and fondling of his genitalia. Per pharmacist recommendations, we initiated Geodon 10 mg .Provera 10 mg .on 12/21/23 . A record review of Resident #2's, Departmental Notes, revealed on 12/21/23 at 11:35 AM, . resident pulled his penis out and tried to touch the nurse and staff . Signed by: LPN #1. A record review of Resident #2 Departmental Notes revealed on 12/22/23 at 10:21 AM, .Wandering resident entered the resident's room, CNA summoned RN to the room, lying on top of other resident unclothed; nurse and CNA separated the residents, one on one initiated with the resident. Resident was seen masturbating by staff earlier this shift, while giving resident his medication, resident reached for nurse's private area . Signed by: ADON #2. The facility submitted the following Corrective Action Plan on 1/4/24: Based on the facility's implementation of corrective actions on 12/22/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected on 12/23/23, before the SA's entrance on 1/2/24. On 12/22/23, at 9:22 AM, resident #1 entered resident #2's room, where both residents were found in the same bed. Resident #1 was lying on bed with pants partially pulled down. Resident#2 over her with pants on, zipper of jeans unzipped. On 12/22/23 Administrator was notified of the incident on the memory care unit. On 1/3/24 at 5:10 PM the facility was placed in Immediate Jeopardy for F600, The facility failed to monitor and supervise Resident #2 with known inappropriate sexual behaviors to ensure other residents were free from abuse. On 12/22/23 at 9:29 AM, Resident #1 and Resident #2 were immediately separated and assessed for injury by staff nurse and Director of Nursing on 12/22/2023. Director of Nurses assessed for psycho-social and emotional concerns with no adverse outcomes. On 12/22/23 at 9:29 AM, Resident #2 placed one-on-one immediately until placement at behavioral health unit on 12/22/2023. On 12/22/23, at 10:30 AM (DON) notified Medical Director and Resident Representatives notified. On 12/22/23 at 10:00 AM (DON) initiated 100% body audits on all residents residing on the memory care unit to which no adverse findings were identified. On 12/22/23 (DON) notified the state dept of health, and attorney general's office, and police dept by 12/23/23. On 12/22/23, at 12:00 AM the (DON) initiated in-service on all staff regarding abuse prevention. On 12/22/23, the (DON) and Assessment nurse initiated interviewing residents residing on the memory care unit on 12/22/23 where no residents indicated any abuse or neglect concerns. On 12/22/23 at 12:30 PM, the Emergency Quality Assurance (QA) Committee meeting which includes Administrator, Medical Director, Director of Nurses/Infection Preventionist, Admission Nurse, Assistant Director of Nurses 1, Consultant Nurse 1, and Assistant Administrator was held 12/22/2023 to discuss interventions, abuse prevention policy and procedures including 12/22/23 incident. Any identified as requiring increased supervision and monitoring and interventions can include notify psych nurse practitioner, notifying family, offering alternative stimulation including diet, activity, and social and environmental interventions. On 12/22/23, at 12:00 PM care plan reviews were initiated on all residents residing on the memory care unit by Minimum Data Set Nurse and those identified updated immediately. The facility alleges all corrective actions were completed on 12/22/23 and Immediate Jeopardy removed on 12/23/23. The SA validated the facility's corrective actions on 1/5/24: On 1/5/24, the SA validated through interviews and record reviews, Resident #1 and Resident #2 were immediately separated and assessed for injury by staff nurse and Director of Nursing on 12/22/2023. Director of Nurses assessed for psycho-social and emotional concerns with no adverse outcomes. On 1/5/24, the SA validated through interviews and record reviews; on 12/22/23 at 9:29 AM, Resident #2 was placed one-on-one immediately until a placement at the behavioral health unit on 12/22/2023. On 1/5/24, the SA was validated through interviews and record reviews; on 12/22/23, at 10:30 AM (DON), the Medical Director and Resident Representatives were notified. On 1/5/24, the SA validated through interviews and record reviews; on 12/22/23 at 10:00 AM (DON), initiated 100% body audits on all residents residing in the memory care unit, to which no adverse findings were identified. On 1/5/24, the SA validated through interviews and record reviews, on 12/22/23 (DON) notified the state dept of health, and attorney general's office, and police dept by 12/23/23. On 1/5/24, the SA validated through interviews and record reviews on 12/22/23, at 12:00 PM the (DON) initiated in-service on all staff regarding abuse prevention. On 1/5/24, the SA validated through interviews and record reviews , on 12/22/23, the (DON) and Assessment nurse initiated interviewing residents residing on the memory care unit on 12/22/23 where no residents indicated any abuse or neglect concerns. On 1/5/24, the SA validated through interviews and record reviews, on 12/22/23 at 12:30 PM, the Emergency Quality Assurance (QA) Committee meeting which includes Administrator, Medical Director, Director of Nurses/Infection Preventionist, Admission Nurse, Assistant Director of Nurses 1, Consultant Nurse 1, and Assistant Administrator was held 12/22/2023 to discuss interventions, abuse prevention policy and procedures including 12/22/23 incident. Any identified as requiring increased supervision and monitoring and interventions can include notify psych nurse practitioner, notifying family, offering alternative stimulation including diet, activity, and social and environmental interventions. On 1/5/24, the SA validated through interviews and record reviews, on 12/22/23, at 12:00 PM care plan reviews were initiated on all residents residing on the memory care unit by Minimum Data Set Nurse and those identified updated immediately.

Based on interviews, record review and facility policy review the facility failed to provide written documentation when residents were transferred to the hospital for two (2) of four (4) residents reviewed for hospitalization s. Resident #72 and Resident #117. Findings Included: Record review of the facility's policy, titled Bed- Holds and Returns, dated March 2017 revealed .Policy Interpretation and Implementation .3. Prior to a transfer, if possible, written information will be given to the residents and the resident representatives that explains in detail .d. The details of the transfer (per the Notice of Transfer) . Resident #72 Record review of the Face Sheet revealed the facility admitted Resident #72 on 5/6/22 and she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 8/23/22 at 5:20 PM, which noted Resident #72 was transferred to the local hospital and the family was notified by phone. Record review of the Discharge MDS with an ARD of 9/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 9/23/22 at 3:44 PM, which noted Resident #72 was transferred to a behavioral unit and the family was notified by phone. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/8/22 revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. During an interview with Resident #72 on 10/12/22 at 4:47 PM, she stated that she has not received a anything from the Social Worker in writing about her hospitalization s. Resident #72 said if it was left in her room her daughter must have taken it home. Resident #72 said she has been having periods of confusion and her daughter has been handling her business. During an interview with Resident #72's daughter on 10/13/22 at 12:53 PM, she said she has not received a letter from the facility in writing about her mother going to the hospital. The daughter said the facility does notify her by phone when the resident is transferred to the hospital. Resident #117 Record review of the Face Sheet revealed the facility admitted Resident #117 on 6/6/22 and she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge MDS with an ARD or 6/7/22 revealed Resident #117 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 6/7/22 at 10:27 AM that noted Resident #117 was transferred to the local hospital via stretcher for respiratory distress and decreased level of consciousness. The family was notified by phone Record review of the Discharge MDS with an ARD of 6/27/22 revealed Resident #117 was discharged to an acute hospital. During an interview with the Director of Nursing (DON) on 10/12/22 at 1:30 PM, she stated that Resident #117 was transferred to the hospital directly from [CONDITION(S)] related to [CONDITION(S)] Flutter (abnormal heart rhythm) on 6/27/22. Record review of the Discharge Summary dated 6/27/22 from the local hospital revealed Resident #117 was transferred to the local hospital. Record review of the Discharge MDS with an ARD of 7/1/22 revealed Resident #117 was discharged to an acute hospital. Review of the Departmental Notes revealed a Nurses Note dated 7/1/22 at 12:33 PM, noted Resident #117 was transferred to a local hospital from the [CONDITION(S)] unit due to severe [CONDITION(S)] (increased heart rate) and chest pain. Record review of the Quarterly MDS with ARD of 9/12/22 revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 14, which indicated she was cognitively intact. During an interview on 10/11/22 at 02:15 PM, with the Resident #117's daughter, she said she has not received a letter from the facility letting her know her mother was sent to the hospital. During an interview with the Social Worker on 10/12/22 at 1:04 PM, she said she either mailed the written notification of transfer to the family or placed them at the bedside when the resident was transferred to the hospital. She stated that she did not keep a copy of the document to be placed in the residents' medical records because she did not know that she needed to keep a copy. During an interview with the Administrator on 10/13/22 at 1:00 PM, he said the Social Worker told him that she mailed the transfer letters to the families. The Social Worker also said she left the residents that are their own responsible party letters at their bedside.

Based on interviews, record review, and facility policy review the facility failed to provide written documentation records related to bed hold upon resident transfer to the hospital for two (2) of four (4) residents reviewed for hospitalization s. Resident #72 and Resident #117. Findings Included: Review of the facility's policy, titled Bed-Holds and Returns, dated March 2017 revealed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of bed-hold and return policy. Resident #72 Record review of the Face Sheet revealed the facility admitted Resident #72 on 5/6/22 and she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 8/23/22 at 5:20 PM, which noted Resident #72 was transferred to the local hospital and the family was notified by phone. Record review of the Discharge MDS with an ARD of 9/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 9/23/22 at 3:44 PM, which noted Resident #72 was transferred to a behavioral unit and the family was notified by phone. Record review of the Quarterly MDS with ARD of 8/8/22 revealed Resident #72 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated she was cognitively intact. On 10/12/22 at 4:47 PM, in an interview with Resident #72, she stated she has not received any letters from the Social Worker when she was transferred to the hospital. Resident #72 commented that if any paperwork was left in her room, then her daughter must have taken it home. She admitted that she has had periods of confusion and now her daughter handles her business for her. On 10/13/22 at 12:53 PM, in an interview with Resident #72's daughter, she stated that she has not received anything from the facility related to her mother going to the hospital. Resident #117 Record review of the Face Sheet revealed the facility admitted Resident #117 on 6/6/22 and she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) or 6/7/22 revealed Resident #117 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 6/7/22 at 10:27 AM that noted Resident #117 was transferred to the local hospital via stretcher for respiratory distress and decreased level of consciousness. The family was notified by phone Record review of the Discharge MDS with an ARD of 6/27/22 revealed Resident #117 was discharged to an acute hospital. On 10/22/22 at 1:20 PM, in an interview with the Director of Nursing (DON), she verified that on 6/27/22, Resident #117 was transferred to the hospital directly from the [CONDITION(S)] unit and not from the facility. She was sent to the hospital due to [CONDITION(S)] Flutter (abnormal heart rhythm). Record review of the Discharge Summary dated 6/27/22 from the local hospital revealed Resident #117 was transferred to the local hospital. Record review of the Discharge MDS with an ARD of 7/1/22 revealed Resident #117 was discharged to an acute hospital. Review of the Departmental Notes revealed a Nurses Note dated 7/1/22 at 12:33 PM, noted Resident #117 was transferred to a local hospital from the [CONDITION(S)] unit due to severe [CONDITION(S)] (increased heart rate) and chest pain. Record review of the Quarterly MDS with ARD of 9/12/22 revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 14, which indicated she was cognitively intact. During an interview on 10/11/22 at 02:15 PM with the Resident #112's daughter, she said she has not received a letter from the facility letting her know her mother was sent to the hospital. On 10/12/22 at 1:04 PM, in an interview with the Social Worker, she either mailed the bed hold notifications or placed them at the bedside when the resident was transferred to the hospital. She confirmed that she does not keep a copy of the bed hold letter that she sends to the resident or resident representative. She was unaware that she should retain a copy of the notification that was mailed. On 10/13/22 at 1:00 PM, in an interview with the Administrator, he stated that the Social Worker told him that she mailed the bed hold letters to the families or gives them to the resident when a resident transfers out of the facility.

Based on observation, interview, record review, and policy review, the facility failed to ensure residents were free from misappropriation for one (1) of six (6) residents reviewed for Abuse/Misappropriation, Residents #9. A Certified Nursing Assistant (CNA) accepted money from Resident #9. The facility also failed to protect Resident #16 from resident to resident abuse. Findings include: Review of the facility's Investigating Incidents of Theft and/or Misappropriation of Resident Property policy, dated (MONTH) (YEAR), revealed residents have the right to be free from theft and/or misappropriation of personal property. A review of the facility's Protection of Residents during Abusive Investigations policy, dated (MONTH) (YEAR), revealed: Our facility will protect residents from harm, reprisal, discrimination or coercion during investigations of abuse allegations. Resident #9 Review of a facility document, Employee Warning Report, dated 10/15/19, signed by CNA #1 and the Administrator, revealed CNA #1 accepted $10.00 on 10/9/19, from a resident (Resident #9). Upon notification of CNA #1 accepting money from a resident, CNA #1 was called in to meet with the Administrator and Director of Nursing (DON), prior to her work schedule. The $10.00 was immediately refunded to the resident by the facility. The document revealed CNA #1 was placed on Administrative suspension. Review of a written statement, dated 10/15/19, signed by CNA #1, revealed she knew it was against company policy to accept anything from residents. CNA #1 documented the resident (Resident #9) offered her money, she declined at first, and then ended up taking the money. She documented her intention was not to leave with the money, but to return it to the resident. She stated it slipped her mind, until she got home and realized she still had the money. CNA #1 documented, I know company policies is not to accept anything. My intentions was to take it back. I promise. During an interview, on 11/14/19 at 12:00 PM, the Administrator confirmed CNA #1 accepted $10.00 for her birthday from Resident #9. The Administrator stated CNA #1 she didn't want the resident to cry and think she was ungrateful when she gave it to her, and planned to bring the money back. The Administrator stated CNA #1 returned the money, which was given back to Resident #9. The Administrator stated he disciplined CNA #1 on 10/15/19, (documented in Personnel file), and probably should have fired her, but she had not had any discipline to that nature since her employment at the facility. The Administrator stated they suspended CNA #1 for approximately a week, without pay, until it was investigated properly, and also because it is the facility's policy not to accept gifts of any kind from any resident. During an interview, on 11/14/19 at 12:45 PM, with the Director of Nursing (DON) and review of the investigation, provided by the DON, the DON stated an investigation was initiated on 10/18/19, when CNA #1 allegedly received money from Resident #9. She stated the CNA was suspended, and allowed to return to work, after the investigation and advisement from the Attorney General's office, the incident would not be pursued as a crime. The DON confirmed CNA #1 accepted $10.00 from Resident #9. During an interview on 11/26/19 at 8:50 AM, Resident #9 revealed that she did give CNA #1 money for her birthday, because she wanted her to have it. Resident #9 stated the $10.00 was given back to her by the facility. Resident #9 stated she had never given CNA #1 anything before that day. Review of facility document titled In-service Training for Certified Nurse Aides (CNA) dated 6/13/19 revealed CNA #1 was in-serviced on abuse and neglect and exploitation of vulnerable adults. Resident #16 Review of an investigative report, dated 10/18/19, revealed on 10/15/19 at 4:30 PM, Resident #15 told the RN he had retrieved the remote from his roommate. The report documented Resident #16 was lying in his bed with a red area over his right eye brow. The report documented the RN Supervisor and the Physician's Assistant (PA) assessed both residents, with swelling and tenderness to Resident #16's right superior orbit of his eye; x-rays were negative for fracture. The report documented Resident #15 was assessed, with no injury, and was placed on 1:1 supervision until transport to the Geri-psych unit on 10/16/19 at 5:15 PM. A review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/30/19, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Record review of the Nurses Notes for Resident #15, dated 10/17/19, as a late entry for 10/15/19, by RN #1, revealed Resident #16 (Resident #15's roommate), told a CNA he was hit in the face by Resident #15 twice, because of a TV remote. The note documented the RN assessed both residents and Resident #15 was placed on 1:1 observation, until transported to the behavioral unit. The report documented Resident #15 admitted to hitting Resident #16 due to taking his remote. Record review of a facility document, Every Shift Monitoring, revealed Resident #15 was placed on 1:1 monitoring, beginning 10/15/19 at 5:00 PM, and the monitoring ended 10/16/19 at 6:00 PM. During an interview, on 11/18/19 at 1:37 PM, the Social Services Director (SSD) stated Resident #15 had been sent to the Geri-Psych unit twice before, for saying inappropriate things to staff members, but he had never been aggressive towards another resident until this happened with Resident #16.

Based on observation, record review, facility policy review, resident interview, and staff interview, the facility failed to follow the Comprehensive Care Plan related to [MEDICAL CONDITION] care for two (2) of three (3) residents observed for [MEDICAL CONDITION] care, Resident #22 and Resident #88, for nebulizer treatments for one (1) of two (2) resident nebulizer treatment observations, Resident #86, and for catheter care for one three (3) of five (5) residents observed for catheter care, Resident #7, Resident #88, and Resident #139. Finding include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), revealed it is the policy of this facility that 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. The facility policy also stated the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Resident #86 Review of Resident #86's Care Plan revealed a Focus problem, with an Onset Date of 05/20/2019, for the risk of respiratory distress and discomfort related to a [DIAGNOSES REDACTED]. The Care Plan revealed an Approach to this focused problem included the nebulizer treatment to be given as ordered; monitor for effectiveness; adverse side effects and document; report as needed. An observation, on 07/10/2019 at 9:30 AM, revealed Resident #86 was her room, lying in bed, with a nebulizer treatment in progress. Further observation revealed there was no staff present in the room, or nearby in the hallway. During an interview, on 07/10/2019 at 9:30 AM, with Resident #86, revealed she stated the nurse never stays in the room for the entire treatment time. Resident #86 stated, Sometimes when it is finished, I just take the mask off myself. During an interview, on 07/11/2019 at 3:44 PM, Licensed Practical Nurse (LPN) #2/ Transitional Care Nurse, stated he was supervising the morning of 07/10/2019. LPN #2 stated he was aware that Resident # 86 was receiving a nebulizer treatment, but he had left the room to go check on something and left the resident alone with a nebulizer treatment in progress. LPN #2 stated he was aware that a nurse should remain with the resident for the duration of the treatment to monitor response and effectiveness of the treatment. During a telephone interview, on 07/11/2019 at 4:26 PM, Licensed Practical Nurse (LPN) #1 revealed she was the nurse who started the nebulizer treatment for [REDACTED]. LPN #1 stated she got very busy preparing the rest of Resident #86's medications and did not stay with the resident for the duration of her nebulizer treatment. LPN #1 stated she knew it was the facility's policy for the nurse to stay with a resident during a nebulizer treatment until it's finished. During the interview, on 07/12/2019 at 10:07 AM, with Licensed Practical Nurse (LPN) #3/Care Plan Coordinator, it was confirmed there was a Focused problem on Resident #86's Care Plan regarding the resident being at risk for respiratory distress and discomfort, related to the [DIAGNOSES REDACTED]. LPN #3 also confirmed that an approach to this Focus problem was to provide nebulizer treatments as ordered, and monitor for effectiveness. LPN #3 stated the Care Plan had not been followed by the nurse administering the treatment, because she left the resident's room before the breathing treatment was done. During an interview, on 07/12/2019 at 10:19 AM, with the Director of Nursing (DON), it was confirmed the nurse should have stayed with the resident for the duration of the respiratory treatment. The DON stated that the correct way for administering nebulizer treatments is in the facility's policy for nebulizer treatments administration. The DON stated the nurse should have stayed with the resident. The DON stated Resident #86's Care Plan was not followed as what was intended for the administration of the nebulizer treatment. Review of the Face Sheet revealed Resident #86 was admitted by the facility, on 06/3/2015 and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #7 Review of the Comprehensive Care Plan revealed Resident #7 had a potential for complications related to the presence of a Suprapubic Catheter, related to a Stage 4 Pressure Ulcer to the sacrum, and a [DIAGNOSES REDACTED]. An observation, on 07/10/19 at 2:24 PM , revealed Resident #7 was provided catheter care by Certified Nursing Assistant (CNA) #2. CNA #2 washed her hands, applied gloves and applied soap to a wet wipe CNA #2 cleansed the right side of the catheter tubing, and cleaned the left side of catheter tubing with the same wipe. CNA #2 did not rotate the wipe. CNA #2 rinsed the catheter tubing with a wet wipe without rotating the wipes. During an interview, on 07/10/19 at 3:46 PM, Registered Nurse (RN) #3/Staff Development Nurse revealed the CNAs are trained upon hire and annually on the appropriate way to provide catheter care in a manner to prevent infection. During an interview, on 07/10/19 at 3:49 PM, the Director of Nursing (DON) revealed CNA #2 should have rotated the wipe during catheter care. The DON said the staff was trained annually how to provide catheter care. During an interview, on 07/11/19 at 9:42 AM, CNA #2 confirmed the she failed to rotate the wipes during Resident #7's catheter care. CNA #2 said she was nervous and did not realize she didn't rotate or change the wipes. During an interview, on 07/12/19 at 3:19 PM, LPN #3 revealed she expected the staff to provide catheter care according to the standards of practice and to follow the care plan. Review of the Face Sheet revealed the facility admitted Resident #7, on 01/29/201), with [DIAGNOSES REDACTED]. Review of Resident #7 Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/2/2019, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was cognitively impaired. Resident #139 Record Review of the Care Plan revealed Resident #139 was at risk for a Urinary Tract Infection related to the presence of an indwelling catheter for the [DIAGNOSES REDACTED]. An observation, on 07/10/19 at 2:30 PM, revealed CNA #1 provided Resident #139's catheter/peri care. CNA #1 washed her hands, applied gloves and cleaned the catheter tubing with wet wipes. No concerns were noted. CNA #1 left the room to get more wipes. On her return to the room, CNA #1 placed the wipes on the table without a surface barrier. CNA #1 did not wash her hands, and then placed gloves on her hands. CNA #1 wiped the shaft of the penis three times and dried the shaft of the penis. CNA #1 did not clean the head of the penis. During an interview, on 07/10/19 at 2:31 PM, RN #3/Staff Development Nurse said the staff was trained upon hire and annually to clean the head of the penis while performing catheter and peri care. RN #3 said CNA #1 should have cleaned the head of the penis by pulling the skin back, and then wipe the right and left side in a circular motion with the wipe. During an interview, on 07/10/19 at 2:35 PM, the DON revealed CNA #1 should have cleaned the head of the penis to prevent infection. During an interview, on 07/11/19 at 9:26 AM, CNA #1 confirmed she forgot to wash the head of Resident #139's penis because she was in a hurry. CNA #1 also said she forgot to put down her barrier. During an interview, on 07/12/19 at 3:16 PM, LPN #3 revealed she expected the CNAs to follow the care plan to provide catheter care in a manner to prevent infection, A review of the facility's Face Sheet revealed the facility admitted Resident #139, on 06/03/2019, with [DIAGNOSES REDACTED]. A review of Resident #139's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2019, revealed Resident #139 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #22 Review of the Comprehensive Care Plan revealed a Problem/Need, dated 01/11/2019, for a [MEDICAL CONDITION] related to [MEDICAL CONDITION] with Encephalopathey. At risk for respiratory distress, decreased oxygen saturation (O2 sat). Goals included the resident would not experience acute [MEDICAL CONDITION]/distress with appropriate interventions next 90 days, 07/20/19. Interventions included: Provide [MEDICAL CONDITION] care as ordered (per protocol). Monitor oxygen sats every shift and as needed. On 07/10/19 at 11:42 AM, an observation revealed LPN #4 provided Resident #22's [MEDICAL CONDITION] care. LPN #4 washed her hands and applied the sterile gloves just like they were regular gloves. She removed the [MEDICAL CONDITION] dressing and inner cannula, washed her hands and applied clean gloves. She then cleaned around the [MEDICAL CONDITION] plate area and around the inner cannula with a sterile water moistened 4x4 using a back and forth motion x 6. She moistened a Q-tip with the sterile water and cleaned the inner cannula area in a back and forth motion multiple times and discarded the Q-tip. She retrieved another Q-tip, moistened it with sterile water and cleaned the inner cannula area in a back and forth motion and discarded it. She then moistened a 4x4 gauze with sterile water and cleaned the neck plate in a back and forth motion multiple times and discarded it. She washed her hands, applied clean gloves, and placed a new inner cannula. She discarded all of the used/soiled supplies. On 07/12/19 at 10:15 AM, an interview with LPN #4 revealed she should have wiped in one direction and thrown the 4x4 gauze and Q-tip away when providing the tracheotomy care to Resident #22. She also stated wiping in a back and forth motion would cause cross contamination. On 7/12/19 at 10:35 AM, an interview with the DON, revealed the nurse should not have gone from dirty to clean, because that is cross contamination and could cause an infection. She also stated the nurse should have maintained a sterile technique while handling the inner cannula. The DON also stated the oxygen sat should have been checked prior to the nurse providing [MEDICAL CONDITION] care. She stated she has never known of hyper-oxygenating the resident before providing [MEDICAL CONDITION] care. On 7/12/19 at 3:10 PM, an interview with LPN #3/MDS-Care Plan Nurse, revealed, she would expect the staff to do what the care plan states to do to take care of the resident. She also stated when the care plan indicates [MEDICAL CONDITION] care as ordered, she would expect the staff to provide care according to the facility protocol. Resident #88 [MEDICAL CONDITION] Care Review of Resident #88's Comprehensive Care Plan revealed a Problem/Need, dated 05/22/2019, for a [MEDICAL CONDITION] related to [MEDICAL CONDITIONS] with [MEDICAL CONDITION] and Hypercapnia. At risk for respiratory distress, decreased oxygen saturation. Interventions included: Provide [MEDICAL CONDITION] care as ordered (per protocol). On 07/09/19 at 10:50 AM, an observation revealed the Respiratory Therapist (RT) provided Resident #88's [MEDICAL CONDITION] care. The RT entered resident's room, set up his [MEDICAL CONDITION] care supplies on the bedside table without wiping the table off, or placing a surface barrier. The RT attempted to put on the sterile gloves that were in the [MEDICAL CONDITION] Care Tray Kit, but changed his mind and wrote the current date on the sterile water bottle. The RT organized his supplies, poured the sterile water into a clear plastic basin that he removed with the sterile gloves and other [MEDICAL CONDITION] supplies from the [MEDICAL CONDITION] Care Tray kit and placed the items on the barrier. He applied the sterile gloves that he had bought into the room with him, moistened a 4x4 gauze with the sterile water, and cleaned around the [MEDICAL CONDITION] neck plate x eight (8) in a back and forth motion using the same 4x4 gauze without rotating the gauze. He then retrieved another gauze, moistened it with the sterile water and cleaned around the [MEDICAL CONDITION] neck plate again using a back and forth motion x 10 and not rotating the 4x4 gauze. He removed the inner disposable cannula and changed his gloves. The RT cleaned around the [MEDICAL CONDITION] inner cannula area using a 4x4 moistened with sterile water wiping in a back and forth motion x six (6) and not rotating the gauze. He then used a Q-tip moistened with sterile water and cleaned around the [MEDICAL CONDITION] inner cannula area in a back and forth motion x 10. The RT retrieved another Q-tip, moistened it with sterile water, and cleaned again around the [MEDICAL CONDITION] inner cannula area using a back and forth motion x eight (8). He obtained a 4x4 gauze, moistened it with sterile water and wiped around the [MEDICAL CONDITION] inner cannula area in a back and forth motion x 4. He retrieved another 4x4 gauze, moistened it with sterile water and wiped around the [MEDICAL CONDITION] inner cannula area in a back and forth motion x eight (8) without rotating the gauze. He placed a new inner cannula in the [MEDICAL CONDITION] and disposed of the soiled supplies in the biohazard trash can in the resident's room. On 07/11/19 at 1:45 PM, an interview with the RT, revealed he probably should have washed his hands during glove changes. He also stated he did not have his bag and likes to have his soiled utility bag. The RT stated, he has an injury to his left smallest finger, so he could not wear the sterile gloves that were in the [MEDICAL CONDITION] kit. He stated because he knew this resident, he felt like he could provide [MEDICAL CONDITION] care to the resident on room air and did not need to pre-oxygenate the resident prior to providing [MEDICAL CONDITION] care. He also stated he had checked the O2 sat, but forgot to tell the surveyor. The RT stated you could contaminate the area by not rotating your gauze or throwing away your gauze after wiping one time. He stated he would have most definitely did things differently, such as letting the surveyor know that he had checked the O2 sat, he would pre-oxygenate before providing [MEDICAL CONDITION] care, and he would wipe once and discard the 4x4s and/or Q-tips. On 07/11/19 at 2:05 PM, an interview with Registered Nurse (RN) #1/Infection Control Nurse, revealed the RT should have wiped the area once and thrown the 4x4 gauze away and wiped with a circular motion with the Q-tip once, thrown it away, and got another one to wipe again. On 07/12/19 at 3:10 PM, an interview with Licensed Practical Nurse (LPN) #3/MDS-Care Plan Nurse, revealed she would expect the staff to do what the care plan states to do to take care of the resident. She also stated when the care plan indicates [MEDICAL CONDITION] care as ordered, she would expect the staff to provide care according to the facility protocol. On 07/10/19 at 8:36 AM, an interview with the Physician revealed, the resident coded as a result of [MEDICAL CONDITION], and had to receive the [MEDICAL CONDITION]. Review revealed, the Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/28/19, revealed the MDS was coded to include [MEDICAL CONDITION] care. The physician orders [REDACTED]. Change [MEDICAL CONDITION] tubing, oxygen delivery, mask, T-tube and oxygen humidifier bottles and tubing prn (as needed). Change [MEDICAL CONDITION] tubing, oxygen delivery, mask, T-tube and oxygen humidifier bottles and tubing prn. Oxygen sign on front and back or door. Check O2 sats prn notify MD if sats < (less than) 88%. Check O2 sats Q (every) shift, notify MD (Medical Doctor) if O2 sat is < 88%. Humidified O2 (oxygen) @ 2 liters [MEDICAL CONDITION] T-tube. Chest physiotherapy (CPT) or positive expiratory pressure (PEP) therapy prn airway clearance, prevent or treat atelectasis. [MEDICAL CONDITION] lavage with sterile normal saline per [MEDICAL CONDITION] per licensed nurse or Registered Respiratory Therapist. (MONTH) use 2-4 ML (two to four milliliters) 20% [MEDICATION NAME] nebulized or via instillation with [MEDICAL CONDITION] lavage Q 4 hrs prn.[MEDICAL CONDITION] (heat and moisture exchanger) applied [MEDICAL CONDITION] needed for humidification when out of bed (use only if resident's secretions are thick). EzPAP (positive airway pressure therapy) [MEDICAL CONDITION] 15 minutes prn lung expansion, airway clearance per licensed nurse or respiratory therapist. (MONTH) use 3 ML 7% NaCL(Sodium Chloride)/[MEDICATION NAME] 2 ML [MEDICATION NAME]. Mouth care every shift. Suction secretions from oral cavity prn. Notify MD [MEDICAL CONDITION] dislodged. Type and size of [MEDICAL CONDITION], #8 Shiley DCT. Document characteristics and amount of sputum secretions. Catheter Care Review of the Comprehensive Care Plan revealed a Problem/Need for potential complications related to the presence of an indwelling catheter due to a Unstagable Pressure Ulcer with eschar and slough to the coccyx. The Goals included there would be no signs and symptoms of a Urinary Tract Infection by the next review, 0820/19. The Interventions included: Catheter care evey shift and as needed per the facility's protocol. On 07/09/19 at 2:45 PM, an observation revealed Certified Nursing Assistants (CNAs) #3 and #4 provided Resident #88's catheter care. CNA #3 and #4 washed their hands. CNA #3 set a clean barrier and placed a package of wipes, clean brief, and a box of clean gloves on the barrier. CNA #1 retrieved a clean wipe from the the package and cleaned around the resident's penis head x four (4) using the same wipe, did not rotate the wipe. CNA #3 discarded that wipe, retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) using the same wipe without rotating the wipe again. CNA #3 discarded that wipe, and CNA #3 retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) times using the same wipe and without rotating the wipe. Both CNAs positioned the resident onto his left side to remove the soiled brief and pad. They then positioned the resident onto his right side to finish removing soiled brief and pad. The CNAs applied a clean brief and pad to the resident. The CNAs discarded all of the soiled items into the biohazard trash and placed the linens in a biohazard linen hamper in the resident's room. Neither CNA cleaned the catheter tubing. The CNAs repositioned the resident on his left side, placed the catheter drainage bag on the left side of the bed, ensured the catheter securing device was in place, covered the resident up, and washed their hands. On 07/10/19 at 9:15 AM, an observation revealed CNA #5 and #6 provided Resident #88's catheter care. CNA #5 set up her supplies; water basin, placed two clear trash bags on the foot of the resident's bed, a box of gloves, and a package of wipes. Both CNAs applied clean gloves, and CNA #5 removed several clean wipes from the package of wipes, and CNA #5 placed the wipes on the resident's bed. CNA #5 wet the washcloth with soap and water and wiped the resident's right groin area in a back and forth motion without rotating the washcloth. She then wiped the resident's left groin area in a back and forth motion multiple times. CNA #5 retrieved a wipe and anchored the resident's catheter tubing nearest the meatus, and wiped in an outward motion x four (4) in a back and forth motion and without rotating the wipe. She retrieved another wipe, and wiped the resident's catheter tubing in a back and forth motion x four (4), and without rotating the wipe. While using a dry towel, CNA #5 dried the area also using a back and forth motion four (4), and dried the catheter tubing again by patting around the catheter tubing and penis area x six (6) without rotating the dry towel. On 07/11/19 at 10:05 AM, an interview with CNA #5, revealed she should have wiped in a downward motion and should have rotated her washcloth. She also stated wiping in a back and forth motion is cross contamination and could cause an infection. On 07/11/19 at 10:15 AM, an interview with CNA #6, revealed she placed the wipes on the resident's bed, and could have used a barrier before sitting them on the resident's bed covers or placed them in the clean plastic bag. She also stated the wipes became contaminated by sitting them on the resident's bed covers. On 07/11/19 at 10:20 AM, an interview with Registered Nurse (RN) #4/Unit Manager, revealed the CNA should not have wiped in a back and forth motion. RN #4 stated the CNA should have wiped in a downward motion one time and discarded the wipe. Donna stated, if the CNA was using a towel, she should have rotated the towel. She also stated, it is not okay to wipe in a back and forth motion, because it introduces germs back up the catheter and into the bladder and could cause a Urinary Tract Infection. On 07/11/19 at 11:25 AM, an interview with CNA #3, revealed she should have rotated her wipe as she was cleaning the resident's penal area. She stated she should have made the wipe to fit around her hand like a glove so she could have rotated it. She also stated, she should have held the catheter tubing at the end near the penis and wiped away from the penis. On 07/11/19 at 11:35 AM, an interview with CNA #4, revealed when cleaning the catheter tubing the CNA should hold it at the end close to the penis and wipe away from the penis and throw the wipe away. On 07/11/19 at 2:05 PM, an interview with RN #1/Infection Control Nurse, revealed CNA #3 should have rotated or thrown that wipe away and obtained another one, and not use the same wipe. She also stated the CNA should have cleaned from the meatus area outward on the catheter tubing. On 07/11/19 at 2:10 PM, an interview with RN #1/Infection Control Nurse, revealed when CNA #6 placed the wipes that was pulled from the package on the resident's covers with no barrier present, that contaminated the wipes. She stated CNA #6 should have used a barrier. She also stated CNA #5 should have wiped once or only used one wipe and rotated that wipe and never clean in a back an forth motion. She also stated she should have wiped the catheter tubing once in an outward motion from the meatus area and thrown the wipe away and never wipe in a back and forth motion. On 07/12/19 at 10:45 AM, an interview with the DON, revealed the CNAs should not have gone from dirty to clean because they can introduce bacteria which could cause an infection. On 07/12/19 at 3:10 PM, an interview with LPN #3/MDS-Care Plan Nurse, revealed she would expect the staff to do what the care plan states to do to take care of the resident. She also stated when the care plan indicates catheter care as ordered, she would expect the staff to provide care according to the facility's protocol.

Based on record review, staff interview, and facility policy review, the facility failed to provide an accurate Preadmission Screening and Resident Review (PASARR) for one (1) of eight (8) residents reviewed for PASARR. Resident #76. Findings Include: Review of the facility's Admission Policy titled, Admission Criteria, revised (MONTH) (YEAR), revealed our facility will admit only those residents whose medical and nursing care needs can be met. Nursing and medical needs of individual with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review Program (PASSAR) to the extent practicable. Review of the PASSAR, dated 02/25/2019, revealed Resident #76 did not have a mental illness. The PASSAR also stated the resident did not have a recent history of mental Illness. This PASSAR was done prior to admission. Review of the Admission History and Physical upon admission, dated 02/21/2019, revealed the Resident #76 was admitted with a [DIAGNOSES REDACTED].#76 had some severe behavioral disturbances where he became very angry and agitated requiring an injection of [MEDICATION NAME]. It took several hours for the resident to become manageable. During an interview with the doctor, Resident#76 became agitated, yelling and then immediately apologized. the doctor said Resident #76 exhibited very spontaneous anger and agitation. Resident #76 had rapid speech, and was easily agitated. Resident #76 was ordered [MEDICATION NAME] twice a day. On 07/12/19 1:55 PM, an interview with Registered Nurse (RN) #2/Quality Assurance (QA) Nurse confirmed the PASSAR wasn't accurate upon admission. The facility did not send the resident's PASSAR to (Name of Healthcare Management Company) to be evaluated because the Level 1 was not done accurately.

Based on facility policy review, staff interview, and record review, the facility failed to code a Significant Change in Status Assessment (SCSA) on the Minimum Data Set (MDS) for one (1) of eight (8) residents reviewed for Preadmission Screening and Resident Review (PASARR), Resident #157. Findings include: Review of facility's policy, titled Resident Assessment Instrument, dated (MONTH) 2010, revealed: The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: Within fourteen days of the residents admission to the facility; When there has been a significant change in the residents condition; at least quarterly; and once every 12 months. All persons who have completed any portion of the Minimum Data Set (MDS) Resident Assessment Form must sign such document attesting to the accuracy of such information. Record review of the Face Sheet revealed Resident #157 was admitted by the facility on 04/28/17. Record review of the Pre-Admission Screening (PAS) Level I, dated 05/10/17,revealed no Level II criteria was required at this time. Record review of the Diagnosis/History Report for Resident #157, revealed a Change in condition with a new [DIAGNOSES REDACTED]. Record review of the (Name of Healthcare Management Services Company)'s Level II Change in Status Request (case number- 4), dated 02/27/19, revealed the need for a Level II assessment for the [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].#157 was ordered [MEDICATION NAME] 0.5 milligram (mg) one (1) tablet twice a day by mouth for Mood Disorder/Aggressive behavior. Record review of a document provided and signed by Registered Nurse #2/Quality Assurance (QA) Nurse, as well as signed by the facility's Administrator, revealed: Regarding case number- 4, personnel at (Name of Healthcare Services Company) stated that a case number was located in the system, but it had not been processed, though it had been several months since it was submitted. Personnel stated that she was unsure why Level I outcomes and /or Level II outcomes were not completed and could not further assist. I was transferred to Level II division or (Name of Healthcare Management Company), however personnel stated that there was no profile in the level II division of the company. I spoke with the Department of Mental Health (DMH) Summary Reviewer regarding case number and she stated that the (Name of Healthcare Management Company) would have to send her department and as of date case number is not there. Record review of the current physician's orders [REDACTED].#157, revealed [MEDICATION NAME] 0.5 mg tablet give one-half (1/2) tablet by mouth every morning ([MEDICAL CONDITION]); [MEDICATION NAME] 0.5 mg tablet (1) one by mouth at bed time ([MEDICAL CONDITION]). An interview, on 07/11/19 at 9:12 AM, with Registered Nurse (RN) #2/Quality Assurance (QA) Nurse, revealed that when she took the position in February, she did a wide spread audit of all charts and sent to (Name of Healthcare Management Company) those residents that were needing Level II assessments. RN #2 revealed Resident #157 was one of the residents that she found needing the Level II assessment. RN #2 revealed she felt the resident's change in status for the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. RN #2 revealed she sent Resident #157's need for a Level II to (Name of Healthcare Management Company) when she discovered that he had a change in status in (MONTH) and the Level II request had not been done. The Level II request was sent to (Name of Healthcare Management Company) on 02/27/19. It was an abnormal length of time before his was sent to (Name of Healthcare Management Company). An interview, on 07/11/19 at 9:15 AM, with Licensed Practical Nurse (LPN)#3/Minimum Data Set (MDS) Coordinator, revealed she had just started in the MDS position not too long ago, but she remembered that they went way back and did a clean sweep to see who didn't have a Level II or a change of status. LPN #3 revealed she felt like the resident's change of status just fell through the crack because that is an abnormal length of time before it was discovered and reported. An interview, on 07/11/19 at 5:54 PM, with RN #2/QA Nurse, revealed she called (Name of Healthcare Management Company) for the resident's status on the Level II request sent 02/27/19, and was told by an (Name of Healthcare Management Company) employee that the resident had not had a Level II performed as of yet. She stated the lady at the company told her they were behind, and his paperwork was still in a pile to be processed. An interview, on 07/12/19 at 9:25 AM, with the facility's Administrator, revealed the facility realized in (MONTH) they had several people who had not received a Level II assessment and several that requests had been sent to the (Name of Healthcare Management Company) with no visit from management company for some of these. He stated there were numerous requests sent at the same time and day by RN #2/QA Nurse, requesting these assessments. The Administrator revealed there should have been a process to follow up on the requests, but there wasn't a process really in place since the healthcare management company usually comes quickly for the assessments. He stated he knew (Name of the Healthcare Management Company) was behind because they had even come on weekends before to do assessments. After they realized there was a problem, in February, the facility then took the problem to the Quality Assurance team to be placed on their QA list. The Administrator stated the facility now has a process in place to follow up with the healthcare management company's requests. The process is the Transitional Care Nurse will do the Level I requests on Admission, and then the MDS Nurse will pick up if there is a change of status and file a request with the healthcare management company. The Administrator stated he was going to add a log for the healthcare management company requests so they could better follow along with the process of who has received the Level II assessments, and who had not yet received the assessment. An interview, on 07/12/19 at 11:39 AM, with the Director of Nursing (DON) revealed at the time that Resident #157 had a change in status, with a new [DIAGNOSES REDACTED].

Based on observation, record review, facility policy review, resident interview, and staff interview, the facility failed to provide [MEDICAL CONDITION] care in a manner to prevent cross contamination for two (2) of three (3) residents observed for [MEDICAL CONDITION] care, (Resident #22 and Resident #88) and failed to provide nebulizer treatment under staff supervision for one (1) of two (2) resident nebulizer treatment observations. (Resident #86) Findings include Review of the facility's policy titled, Administering Medications Though a Small Volume (Handheld) Nebulizer, dated (MONTH) 2010, revealed it is the policy of this facility that the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into resident's airway. The facility policy stated that one of the steps in the procedure was to remain with the resident for the treatment. Resident #86 During an observation, on 07/10/2019 at 9:30 AM, revealed Resident #86 was in her room, lying in bed, with a nebulizer treatment in progress. Further observation revealed there was no staff or nurse present in the room, or nearby in the hallway. Review of Resident #86's medical record documentation titled, physician's orders [REDACTED]. Review of Resident #86's medical record documentation titled, E-Mar (Electronic Medication Administration Record), revealed that one (1) vial containing 0.25 milligrams (mg) of the medication [MEDICATION NAME] (a steroid) to be suspended in a Two (2) milliliters (ml) of saline solution, given via a Nebulizer was administered on 7/10/2019 at 9:30 AM, by Licensed Practical Nurse (LPN) #1. During an interview, on 7/10/2019 at 9:30 AM, with Resident #86, she stated the nurse never stays in the room for the entire treatment time. Resident #86 stated, sometimes when it is finished, I just take the mask off myself. An interview, on 07/11/2019 at 3:44 PM, revealed License Practical Nurse (LPN) #2/ Transitional Care Nurse, stated he was supervising the morning of 07/10/2019. LPN #2 said he was aware Resident # 86 was receiving a nebulizer treatment, but he had left the room to go check on something and left the resident alone with a nebulizer treatment in progress. LPN #2 stated he was aware that a nurse should remain with the resident for the duration of the treatment to monitor response and effectiveness of the treatment. A telephone interview, on 07/11/2019 at 4:26 PM, with Licensed Practical Nurse (LPN) #1, revealed she was the nurse who started the nebulizer treatment for [REDACTED]. LPN #1 stated she got very busy preparing the rest of Resident #86's medications and did not stay with the resident for the duration of her nebulizer treatment. LPN #1 said she knew it was the facility's policy for the nurse to stay with a resident during a nebulizer treatment until it was finished. An interview, on 07/12/2019 at 10:19 AM, with the Director of Nursing (DON), confirmed that the nurse should have stayed with the resident for the duration of the nebulizer treatment. The DON stated that the correct way for administering nebulizer treatments is in the facility's policy for nebulizer treatments administration. The DON said the nurse should have stayed with the resident Review of the Face Sheet revealed Resident #86 was admitted by the facility on 06/3/2015 and readmitted the resident on 12/15/2015, with [DIAGNOSES REDACTED]. Resident #22 On 07/10/19 11:42 AM, an observation revealed Licensed Practical Nurse (LPN) #4 provided Resident #22's [MEDICAL CONDITION] care. LPN #4 washed her hands and applied the sterile gloves just like they were regular gloves. She removed the [MEDICAL CONDITION] dressing and inner cannula. LPN #4 washed her hands and applied clean gloves. She then cleaned around the [MEDICAL CONDITION] plate area and around the inner cannula with a sterile water moistened 4x4 using a back and forth motion x six (6). She moistened a Q-tip with the sterile water and cleaned the inner cannula area in a back and forth motion multiple times and discarded the Q-tip. LPN #4 retrieved another Q-tip, moistened it with sterile water and cleaned the inner cannula area in a back and forth motion and discarded it. She then moistened a 4x4 gauze with sterile water and cleaned the neck plate wiping it in a back and forth motion multiple times and discarded it. She washed her hands, applied clean gloves, and placed a new inner cannula. She discarded all the soiled supplies. On 07/12/19 10:15 AM, an interview with LPN #4, revealed she should have wiped in one direction and thrown the 4x4 gauze and Q-tip away while providing tracheotomy care to Resident #22. She also stated wiping in a back and forth motion would cause cross contamination. On 7/12/19 at 10:35 AM, during an interview with the Director of Nursing (DON), the DON revealed LPN #4 should not have gone from dirty to clean, because that is cross contamination and could cause an infection. She also stated the nurse should have maintained a sterile technique with handling the inner cannula Resident #88 On 7/9/19 at 10:50 AM, an observation revealed the Respiratory Therapist (RT) entered the resident's room to provide Resident #88's [MEDICAL CONDITION] care. The RT set up his supplies. He attempted to put on the sterile gloves that were in the packet but changed his mind and wrote the current date on the sterile water bottle. He organized his supplies, poured the sterile water into a clear plastic basin that he removed the sterile gloves and other [MEDICAL CONDITION] supplies from the [MEDICAL CONDITION] Care Tray kit and placed the items on the barrier. He applied the sterile gloves that he had bought into the room with him, moistened a 4x4 gauze with the sterile water, and cleaned around the [MEDICAL CONDITION] neck plate x eight (8) in a back and forth motion using the same 4x4 gauze without rotating the gauze. He then retrieved another gauze, moistened it with the sterile water and cleaned around the [MEDICAL CONDITION] neck plate again using a back and forth motion x 10, and did not rotate the 4x4 gauze. He removed the inner disposable cannula and changed his gloves. The RT cleaned around the [MEDICAL CONDITION] inner cannula area using a 4x4 moistened gauze with sterile water wiping in a back and forth motion x six (6) and again did not rotate the gauze. He then used a Q-tip moistened with sterile water and cleaned around the [MEDICAL CONDITION] inner cannula area in a back and forth motion x 10. The RT retrieved another Q-tip, moistened it with sterile water, and cleaned again around the [MEDICAL CONDITION] inner cannula area using a back and forth motion x eight (8). He obtained a 4x4 gauze, moistened it with sterile water and wiped around the [MEDICAL CONDITION] inner cannula area in a back and forth motion x four (4). He retrieved another 4x4 gauze, moistened it with sterile water and wiped around the [MEDICAL CONDITION] inner cannula area in a back and forth motion x eight (8) without rotating the gauze. He placed a new inner cannula in the [MEDICAL CONDITION] and disposed of the soiled supplies in the biohazard trash can in the resident's room. On 7/11/19 at 1:45 PM an interview with the RT, revealed, he probably should have washed his hands during glove changes. He also stated he did not have his bag and likes to have his soiled utility bag. The RT stated, he has an injury to his left smallest finger, so he could not wear the sterile gloves that were in the [MEDICAL CONDITION] kit. He stated because he knew Resident #88, he felt like he could provide [MEDICAL CONDITION] care to the resident on room air and did not need to pre-oxygenate the resident prior to providing [MEDICAL CONDITION] care. He also stated he had checked the O2 sat but forgot to tell the surveyor. The RT stated he could contaminate the area by not rotating the gauze or throwing away the gauze after wiping one time. He stated he would have most definitely done things differently, such as letting the surveyor know that he had checked the 2 sat, he would pre-oxygenate before providing O [MEDICAL CONDITION] care, and he would wipe once and discard the 4x4s and/or Q-tips. On 7/11/19 at 2:05 PM an interview with Registered Nurse (RN) #1/Infection Control Nurse revealed, the RT should have wiped the area once and thrown the 4x4 gauze away and wiped with a circular motion with the Q-tip once, thrown it away, and gotten another one to wipe again. An interview, on 07/10/19 8:36 AM with the Doctor revealed, the resident coded as a result of [MEDICAL CONDITION] and had to receive the [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Change [MEDICAL CONDITION] tubing, oxygen delivery, mask, T-tube ([MEDICAL CONDITION]) and oxygen humidifier bottles and tubing prn. Change [MEDICAL CONDITION] tubing, oxygen delivery, mask, T-tube and oxygen humidifier bottles and tubing prn. Oxygen sign on front and back of door. Check O2 sats (oxygen saturations) prn notify MD if sats < (less than) 88% (percent). Check O2 sats Q (every) shift, notify MD (Medical Doctor) if O2 sat is < 88%. Humidified O2 @ (at) 2 liters [MEDICAL CONDITION] T-tube. Chest physiotherapy (CPT) or positive expiratory pressure (PEP) therapy prn airway clearance, prevent or treat atelectasis. [MEDICAL CONDITION] lavage with sterile normal saline per [MEDICAL CONDITION] per licensed nurse or Registered Respiratory Therapist. (MONTH) use 2-4 ML (milliliters) 20% [MEDICATION NAME] nebulized or via instillation with [MEDICAL CONDITION] lavage Q 4 hrs prn. [MEDICAL CONDITION] HME (heat and moisture exchanger) applied to [MEDICAL CONDITION] as needed for humidification when out of bed (use only if resident's secretions are thick). EzPAP (positive airway pressure therapy) via (by) [MEDICAL CONDITION] x15 minutes prn lung expansion, airway clearance per licensed nurse or respiratory therapist. (MONTH) use 3 ML 7% NaCL/[MEDICATION NAME] (sodium chloride/dual nebulizer) 2 ML [MEDICATION NAME]. Mouth care every shift. Suction secretions from oral cavity prn. Notify MD if [MEDICAL CONDITION] is dislodged. Type and size of [MEDICAL CONDITION], #8 Shiley DCT (disposable cuff tube). Document characteristics and amount of sputum secretions. A review of the Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/28/19, revealed the MDS was coded to include [MEDICAL CONDITION] care.

Based on observations, record review, staff interview, and facility policy review, the facility failed to provide catheter/perineal care in a manner to prevent the possible spread of infection for four of six (4 of 6) catheter care observations, for Resident #7, Resident #88, Resident #89 and Resident #139. Findings include: Review of the facility's policy titled, Catheter Care, Urinary, dated (MONTH) 2014, revealed it is the policy of this facility that the purpose of this procedure is to prevent catheter-associated Urinary Tract Infections [MEDICAL CONDITION]. The policy also stated under the general guidelines, that when maintaining unobstructed urine flow, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Further review of the policy revealed to prevent catheter-associated Urinary Tract Infections the Steps included in the procedure for a male resident: Use a washcloth with warm water and soap/or cleansing wipe to cleanse around the meatus. Cleanse the glans using circular [MEDICAL CONDITION] from the meatus outward. Change the position of the washcloth/wipe with each stroke. With a clean wash cloth, if used, rinse with warm water using the above technique. Return foreskin to normal position. Use clean washcloth with warm water and soap/or cleansing wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward. Resident #89 During the initial tour of the facility, on 07/09/2019 at 10:30 AM, it was observed, from the hallway Resident #89's catheter tubing was laying over the top of her bed's side rail, thus it was above the level of her bladder. It was observed that Resident #89's side rail on her bed was in an upright position. During a follow-up observation, on 07/09/2019 at 12:15 PM, it was observed that Resident #89's catheter tubing was still laying across the top of the bed's side rail, which was still in an upright position. Review of Resident #89's medical records document titled New physician's orders [REDACTED]. During an interview, on 07/09/2019 at 12:18 PM, Licensed Practical Nurse (LPN) #1, revealed the catheter tubing should not be hanging over the bed's side rail, because it was above the level of Resident #89's bladder. LPN #1 stated that if the catheter tubing was higher than the bladder, it would cause the urine to back up into the resident's bladder causing a Urinary Tract Infection [MEDICAL CONDITION]. During an interview, on 07/09/2019 at 3:11 PM, Registered Nurse (RN) #1/ Infection Control Officer, confirmed the catheter tubing should not be over the bed's side rail, above the level of Resident #89's bladder. RN #1 stated the Certified Nursing Assistants (CNA) know better. RN #1 stated they must have forgotten to re-position the catheter after giving her a bath. RN#1 also stated it could have been the hospice CNA. Review of the Face Sheet revealed Resident #89 was admitted by the facility, on 08/15/2014, with [DIAGNOSES REDACTED]. Resident #7 Record review of the facility's training titled, CNA (Certified Nursing Assistant) Performance And Skills Evaluation revealed the Certified Nursing Assistants (CNAs) were in-serviced 12/06/2018, 02/14/2019 and 04/15/2019 on providing appropriate catheter care. An observation, on 07/10/19 at 2:24 PM, revealed CAN #2 provided Resident #7's catheter care. CNA #2 washed her hands and applied gloves. CNA #2 applied soap to the wet wipe, and cleansed the right side of the catheter tubing, and then cleansed the left side of the catheter tubing with the same wipe. CNA #2 did not rotate the wipe. CNA #2 rinsed the catheter tubing with a wet wipe without rotating the wipes. During an interview, on 07/10/19 at 3:46 PM, Registered Nurse (RN) #3/Staff Development Nurse revealed the CNAs are trained upon hire and annually on the appropriate way to provide catheter care in a manner to prevent infection. During an interview, on 07/10/19 at 3:49 PM, the Director of Nursing (DON) revealed CNA #2 should have rotated the wipe during the catheter care. The DON said the staff was trained annually how to provide catheter care. An interview, on 07/11/19 at 9:42 AM, CNA #2 confirmed the she failed to rotate the wipes during the catheter care. CNA #2 said she was nervous and did not realize she didn't rotate or change the wipes. Review of the Face Sheet revealed the facility admitted Resident #7, on 01/29/2018, with diagnoses, which included [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION] and Stage 4 Pressure Ulcers. A review of Resident #7's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/2/2019, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was cognitively impaired. Resident #139 An observation, on 07/10/19 at 2:30 PM, revealed Resident #139's catheter/peri care was provided by CNA #1. CNA #1 washed her hands, applied gloves, and then began to clean the catheter tubing with wet wipes. No concerns were noted. CNA #1 left the room to get more wipes. CNA #1 returned to the room and placed the wipes on the table without a barrier. CNA #1 did not wash her hands, placed gloves on her hand and wiped the shaft of the resident's penis three times and dried the shaft of the penis. CNA #1 did not clean the head of the penis. During an interview, on 07/10/19 at 2:31 PM, RN #3 Staff Development Nurse said the staff was trained upon hire and annually to clean the head of the penis while performing catheter and peri care. RN #3 said CNA #1 should have cleaned the head of the penis by pulling the skin back, and wipe the right and left side in a circular motion with the wipe. During an interview, on 07/10/19 at 2:35 PM, with the DON revealed CNA #1 should have cleaned the head of the penis to prevent infection. During an interview, on 07/11/19 at 9:26 AM, CNA #1 confirmed she forgot to wash the head of Resident #139's penis because she was in a hurry. CNA #1 also said she forgot to put down her barrier. A review of the Face Sheet revealed the facility admitted Resident #139, on 06/03/2019, with [DIAGNOSES REDACTED]. A review of Resident #139 Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2019, revealed Resident #139 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #88 On 07/09/19 at 2:45 PM, an observation revealed Certified Nursing Assistants (CNAs) #3 and #4 provided Resident #88's catheter care. CNA #3 and #4 washed their hands. CNA #3 set a clean barrier and placed a package of wipes, clean brief, and a box of clean gloves on the barrier. CNA #1 retrieved a clean wipe from the the package and cleaned around the resident's penis head x four (4) using the same wipe, did not rotate the wipe. CNA #3 discarded that wipe, retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) using the same wipe without rotating the wipe again. CNA #3 discarded that wipe, and CNA #3 retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) times using the same wipe and without rotating the wipe. Both CNAs positioned the resident onto his left side to remove the soiled brief and pad. They then positioned the resident onto his right side to finish removing soiled brief and pad. The CNAs applied a clean brief and pad to the resident. The CNAs discarded all of the soiled items into the biohazard trash and placed the linens in a biohazard linen hamper in the resident's room. Neither CNA cleaned the catheter tubing. The CNAs repositioned the resident on his left side, placed the catheter drainage bag on the left side of the bed, ensured the catheter securing device was in place, covered the resident up, and washed their hands. On 07/10/19 at 9:15 AM, an observation revealed CNA #5 and #6 provided Resident #88's catheter care. CNA #5 set up her supplies; water basin, placed two clear trash bags on the foot of the resident's bed, a box of gloves, and a package of wipes. Both CNAs applied clean gloves, and CNA #5 removed several clean wipes from the package of wipes, and CNA #5 placed the wipes on the resident's bed. CNA #5 wet the washcloth with soap and water and wiped the resident's right groin area in a back and forth motion without rotating the washcloth. She then wiped the resident's left groin area in a back and forth motion multiple times. CNA #5 retrieved a wipe and anchored the resident's catheter tubing nearest the meatus and wiped in an outward motion x four (4) in a back and forth motion and without rotating the wipe. She retrieved another wipe and wiped the resident's catheter tubing in a back and forth motion x four (4), and without rotating the wipe. While using a dry towel, CNA #5 dried the area also using a back and forth motion four (4), and dried the catheter tubing again by patting around the catheter tubing and penis area x six (6) without rotating the dry towel. On 07/11/19 at 10:05 AM, an interview with CNA #5, revealed she should have wiped in a downward motion and should have rotated her washcloth. She also stated wiping in a back and forth motion is cross contamination and could cause an infection. On 07/11/19 at 10:15 AM, an interview with CNA #6, revealed she placed the wipes on the resident's bed, and could have used a barrier before sitting them on the resident's bed covers or placed them in the clean plastic bag. She also stated the wipes became contaminated by sitting them on the resident's bed covers. On 07/11/19 at 10:20 AM, an interview with Registered Nurse (RN) #4/Unit Manager, revealed the CNA should not have wiped in a back and forth motion. RN #4 stated the CNA should have wiped in a downward motion one time and discarded the wipe. Donna stated, if the CNA was using a towel, she should have rotated the towel. She also stated, it is not okay to wipe in a back and forth motion, because it introduces germs back up the catheter and into the bladder and could cause a Urinary Tract Infection. On 07/11/19 at 11:25 AM, an interview with CNA #3, revealed she should have rotated her wipe as she was cleaning the resident's penal area. She stated she should have made the wipe to fit around her hand like a glove so she could have rotated it. She also stated, she should have held the catheter tubing at the end near the penis and wiped away from the penis. On 07/11/19 at 11:35 AM, an interview with CNA #4, revealed when cleaning the catheter tubing the CNA should hold it at the end close to the penis and wipe away from the penis and throw the wipe away. On 07/11/19 at 2:05 PM, an interview with RN #1/Infection Control Nurse, revealed CNA #3 should have rotated or thrown that wipe away and obtained another one, and not use the same wipe. She also stated the CNA should have cleaned from the meatus area outward on the catheter tubing. On 07/11/19 at 2:10 PM, an interview with RN #1/Infection Control Nurse, revealed when CNA #6 placed the wipes that was pulled from the package on the resident's covers with no barrier present, that contaminated the wipes. She stated CNA #6 should have used a barrier. She also stated CNA #5 should have wiped once or only used one wipe and rotated that wipe and never clean in a back and forth motion. She also stated she should have wiped the catheter tubing once in an outward motion from the meatus area and thrown the wipe away and never wipe in a back and forth motion. On 07/12/19 at 10:45 AM, an interview with the DON, revealed the CNAs should not have gone from dirty to clean because they can introduce bacteria which could cause an infection.

Based on observation, staff interview, record review, and facility policy review, the facility failed to clean the drip pan under the stove burners in a timely manner to prevent the potential for fire, for one (1) of three (3) days Kitchen observations. Findings Include: Review of the facility's policy titled, Cleaning Instructions Range and Griddle Ovens, with an originated date of 09/04, revealed it is the facility's policy that the equipment shall be maintained in a clean and sanitary condition. Empty the broiler grease pan daily, or whenever it is 1/2 full. The drip shield, grids and grease pan/trough should be washed with a mild grease dissolving solution. Scrub the broiler chamber and body front frequently to reduce smoking. Review of the Cleaning Schedule revealed the back stove was scheduled to be cleaned on 07/02/2019. The schedule was not signed by the Cook. An observation of the Kitchen, on 07/10/19 at 10:42 AM, revealed the back stove drip pan had a large amt of thick black carbon build up. The Cook immediately removed the pan and cleaned it. During an interview, on 07/10/19 at 12:46 PM, the Dietary Manager revealed the Cook did not clean the stove the day it was due because they were short of staff. The Cook said she did not get a chance to clean the stove. The Dietary Manager said the stove could catch on fire if it's not cleaned in a timely manner.

Based on observation, staff interview, record review, and facility policy review, the facility failed to revise Resident #89's Comprehensive Care Plan for the use of a Foley Catheter for one (1) of 37 resident care plans reviewed. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), revealed that it is the policy of this facility that 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. The facility policy stated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. During the initial tour of the facility, on 07/09/2019 at 10:30 AM, it was observed, from the hallway Resident #89's catheter tubing was laying over the top of her bed's side rail, thus it was above the level of her bladder. It was observed that Resident #89's side rail on her bed was in an upright position. During a follow-up observation, on 07/09/2019 at 12:15 PM, it was observed that Resident #89's catheter tubing was still laying across the top of the bed's side rail, which was still in an upright position. Review of Resident #89's medical record document titled, Care Plan, revealed the Care Plan had not been revised to include upon the resident's return from the hospital, on 06/13/2019, she now had an indwelling Foley catheter. During an interview, on 07/09/2019 at 12:18 PM, Licensed Practical Nurse (LPN) #1, revealed the catheter tubing should not be hanging over the bed's side rail, because it was above the level of Resident #89's bladder. LPN #1 stated that if the catheter tubing was higher than the bladder, it would cause the urine to back up into the resident's bladder causing a Urinary Tract Infection [MEDICAL CONDITION]. During an interview, on 07/09/2019 at 3:11 PM, Registered Nurse (RN) #1/ Infection Control Officer, confirmed the catheter tubing should not be over the bed's side rail, above the level of Resident #89's bladder. RN #1 stated the Certified Nursing Assistants (CNA) know better. RN #1 stated they must have forgotten to re-position the catheter after giving her a bath. RN#1 also stated it could have been the hospice CNA. During an interview, on 07/12/2019 at 10:07 AM, Licensed Practical Nurse (LPN) #3/ Care Plan Coordinator, revealed the Care Plan, in regards to Resident #89's indwelling catheter, had not been revised when Resident #89 returned from the hospital on [DATE]. During an interview, on 07/12/2019 at 10:19 AM, the Director of Nursing (DON), confirmed Resident #89's Care Plan had not been updated and revised. The DON stated it should have been revised to reflect the resident's status change, regarding the use of a Foley catheter. Review of the Face Sheet revealed Resident #89 was admitted by the facility, on 08/15/2014, with [DIAGNOSES REDACTED].

Based on facility policy review, staff interview, and record review, the facility failed to identify the need for a Level II referral in a timely manner for one (1) of eight (8) residents reviewed for Level II review. Resident #157. Findings include: Review of facility's policy titled, Admission Criteria, dated (MONTH) (YEAR), revealed: The objective of our admissions criteria policy is to admit residents who can be cared for adequately by the facility; Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review Program (PASARR) to the extent practicable. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State Mental Health Agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires a level of services provided by the facility. Review of the Minimum Data Set (MDS) Summary Report, dated 07/11/19 for Resident #157, revealed no significant change for the [DIAGNOSES REDACTED]. An interview, on 07/12/19 at 11:39 AM, with the Director of Nursing (DON) revealed, at the time that Resident #157 had a change in status with a new [DIAGNOSES REDACTED]. An interview, on 07/12/19 2:20 PM, with Licensed Practical Nurse (LPN) #3/MDS Coordinator, revealed, The resident should have had a significant change after he received the [DIAGNOSES REDACTED]. Him having a new [DIAGNOSES REDACTED].

Based on observation, record review , facility policy review, and staff interview, the facility failed to revise pressure wound care plan to address reporting missing, soiled, or dislodged wound dressings for one (1) of 34 care plans reviewed, Residents #89. Findings include: A review of the facility's policy titled Goals and Objectives, Care Plans dated (MONTH) 2011, goals and objectives are reviewed and/or revised when the desired outcome has not been achieved. Resident #89 Review of Resident #89 Care Plan revealed a Problem/Need, dated 3/29/18, for the potential for skin breakdown or pressure ulcers due to decreased mobility, and incontinent of bowel and bladder. Actual Staff III to coccyx. Review of the Approaches revealed no intervention to address missing, soiled, or dislodged wound dressings. An observation, on 05/21/2018 at 11:07 AM, of Resident #89's wound care provided by Registered Nurse (RN) #3/Treatment (Tx) Nurse, revealed when the residents brief was removed by RN #3, Resident #89 did not have a dressing on the wound identified as a stage three (3) sacral pressure ulcer. During an interview, on 05/21/2018 at 11:12 AM, with RN #3/Tx Nurse Nurse, she confirmed the dressing for the sacral wound was missing. RN #3 stated no one had reported to her that the dressing had come off. RN #3 also stated she would have expected someone to report the missing dressing as soon as it came off. During an interview, on 05/21/2018 11:13 AM, with RN #4/ Dementia Care Unit Manager, she stated the dressing has been known to come off during perineal care and during bathing. RN #4 also stated the Certified Nursing Assistants (CNAs) are trained to report to a nurse if at any time a dressing is missing or comes off during care. RN #4 confirmed that when a dressing comes off, it should be reported as soon as possible to prevent possible infection. RN #4 stated that the CNAs should know the importance of reporting when any dressing comes off. During an interview, on 05/21/2018 at 11:35 AM, with CNA #3, it was revealed the dressing on Resident # 89's sacral wound had come off during the bathing task. CNA #3 stated that she was providing care, at 5:30 AM on 05/21/2018, and noticed the dressing was dislodged. CNA #3 stated that it came off when she removed the brief. CNA#3 also stated that it was her intention to report it to the treatment nurse or another nurse, but she got busy and forgot. An interview, on 05/23/2018 3:10 PM, with Registered Nurse (RN) #6/Minimum Data Set (MDS) Coordinator, confirmed reporting a missing, dislodged, or soiled dressing should be a part of the resident's care plan. RN #6 stated the Certified Nursing Assistants (CNAs) should be trained to report this to the nurses. RN #6 also stated the care plan department was working on all the care plans to make them better. RN #6 confirmed that reporting a missing, dislodged, or soiled dressing was not on Resident # 89's care plan. During an interview, on 05/24/2018 08:55 AM, with the Director of Nursing (DON), it was revealed reporting missing, dislodged, or soiled wound dressings should be a part of a resident's care plan objectives. The DON stated that this helps prevent the wound from getting worse. A review of the Face Sheet revealed Resident #89 was admitted by the facility, on 09/01/2015, with [DIAGNOSES REDACTED]. Review of Resident # 89's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/29/2018, revealed the resident's Brief Interview of Mental Status (BIMS) score indicated severe impaired cognition

Based on observation, record review, facility policy review, and staff interview, the facility failed to promote the healing of pressure ulcers for one of five (1 of 5) residents reviewed with pressure ulcers, Resident #89. Findings include: A review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol undated revealed: The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorbtive, etc.), and application of topical agents. The policy however did not address the events of dressings becoming dislodged, missing, or soiled. An observation, on 05/21/2018 at 11:07 AM, revealed Registered Nurse (RN) #3 removed Resident #89's brief to find there was no dressing on the wound identified as a stage three (3) sacral pressure ulcer. A review of the facility's wound care report titled, Wound and Skin Status Report, dated 05/10/2018, revealed Resident #89 had a facility acquired pressure ulcer with an onset date of 04/20/2017. The facility's wound and skin report revealed treatments for a daily, and an as needed wound care with use of a [MEDICATION NAME] dressing. A review of Resident # 89's (MONTH) (YEAR) Physician Orders, revealed an order, on 01/05/2018, for a wound care treatment related to a Stage Three (3) pressure ulcer to the coccyx. The treatment order stated the wound was to be cleansed with normal saline, pat dry, apply [MEDICATION NAME] or equivalent to wound bed, cover with silicone border foam, and change daily and as needed. During an interview, on 05/21/2018 at 11:12 AM, with RN #3/Treatment Nurse, it was confirmed the dressing for the sacral wound was missing. RN #3 stated no one had reported to her the dressing had come off. RN #3 also stated she would have expected someone to report the missing dressing as soon as it came off. During an interview, on 05/21/2018 11:13 AM, with RN #4/Dementia Care Unit Manager, it was confirmed the dressing for the sacral wound was missing. RN #4 stated the dressing has been known to come off during perineal care and during bathing. RN #4 also stated that the Certified Nursing Assistants (CNAs) are trained to report to a nurse if at any time a dressing is missing or comes off during care. RN #4 stated when a dressing comes off, it should be reported as soon as possible to prevent possible infection. RN #4 stated the CNAs should know the importance of reporting when any dressing comes off, and that maybe an in service is needed to remind them about how important it is to report it. RN #4 also stated no one had reported to her Resident #89's wound dressing was missing, or that it had come off this morning. An interview, on 05/21/2018 at 11:35 AM, with CNA #3, revealed the dressing on Resident #89's sacral wound had come off during the bathing task. CNA #3 stated she was providing care at 5:30 AM on 05/21/2018, and noticed the dressing was dislodged. CNA #3 stated it came off when she removed the brief. CNA #3 also stated it was her intention to report it to the treatment nurse or another nurse, but she got busy and forgot. An interview, on 05/23/2018 10:55 AM, with CNA #4 stated if a dressing for a wound is missing, soiled, or coming off, the CNA is to report it to nursing as soon as possible. CNA #4 stated if the dressing is missing, soiled, or coming off, the wound could get worse or get an infection. An interview, on 05/23/2018 at 11:15 AM, with Licensed Practical Nurse (LPN) #1, confirmed if a dressing was missing, soiled, or dislodged, the expectation would be that it is reported to a nurse as soon as possible. LPN #1 stated it should be reported so it can be redressed to prevent the wound from becoming contaminated, or get infected. During an interview, on 05/23/2018 at 2:05 PM, with the Director of Nursing (DON), it was confirmed when a wound dressing is missing, soiled, or coming off, the CNA is to report the status of the wound dressing to nursing as soon as possible. The DON stated when a wound is left uncovered, it is at risk for an infection. The DON also stated the as needed order covers the times that the dressing would need to be replaced, such as when the dressing is missing, soiled, or dislodged. The DON stated there was no actual facility policy that covers the reporting of missing, soiled, or dislodged dressing on wounds. A review of the Face Sheet revealed Resident #89 was admitted by the facility, on 09/01/2015, with [DIAGNOSES REDACTED]. A review of Resident # 89's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/29/2018, revealed a Brief Interview of Mental Status (BIMS) score indicating severe impaired cognition.