Every finding on record at Heartland Villa Nursing And Rehabilitation Center

Based on interview, record review and review of the facility's policy, the facility failed to ensure residents received prompt assessment and care for 1 of 3 sampled residents, Resident #2 (R2). On [DATE] at 8:30 PM, staff heard R2 yelling out and when Certified Nursing Assistant (CNA) 5 entered the resident's room she found R2 sitting on the floor near the foot of the bed. Staff lifted R2 from the floor and placed the resident on the bed. However, the facility failed to ensure nursing neurological (neuro) assessments and change in condition assessments (CIC) were completed for R2 after the unwitnessed fall. At approximately 12:00 AM (about 3.5 hours after the fall), R2 was screaming and yelling out with pain stating, call the ambulance, my legs are broke. R2 was sent to the emergency room (ER) for evaluation where it was determined she had a left impacted femur fracture, a thoracic compression fracture, and a traumatic subdural bleed with a midline shift. The hospital admitted R2 to its intensive care unit (ICU). On [DATE], R2 was admitted to hospice care and expired on [DATE]. The State Survey Agency (SSA) determined the deficient practice had been corrected on [DATE], prior to the initiation of the investigation. Deficient practice was determined to be Past Noncompliance. The findings include: Review of the facility's policy titled, Documentation and Charting Policy, dated [DATE], revealed services provided to a resident and/or any changes in the resident's medical or mental condition were to be documented in the resident's medical record as applicable. The documentation should include incidents, accidents, and changes in the resident's condition. Review of the facility's policy titled, Falls Policy, dated [DATE], revealed the intent of the policy was to ensure the facility provided an environment that was as free from accident hazards as possible, over which the facility had control to prevent avoidable falls/accidents. Continued policy review revealed all residents were to have a fall risk assessment upon admission, quarterly, annually, and with a significant change of condition to identify risk for falls. Review of the facility's policy titled, Neuro-Check Policy, with a review date of [DATE] (reviewed after R2's fall with no changes made), revealed the policy was to provide timely and consistent neurological (neuro) assessments for residents who had experienced a head injury, fall or other neurological concern to ensure prompt detection and response to changes in the resident's condition. Continued review revealed a neuro-check must be conducted as soon as possible after an event such as an unwitnessed fall, a witnessed fall in which a head injury, or other incident necessitating neurological evaluation. Per policy review, the assessment was to include an evaluation of the resident's level of consciousness (LOC), pupillary response, limb movement, and overall orientation. Continued review of the facility's, Neuro-Check Policy, dated [DATE], revealed a licensed nurse was to perform neuro-checks, unless a physician ordered the neuro-checks to end sooner or be continued for longer. Per the policy, the following sequence of neuro-checks was to be performed: 1. Perform neuro-checks every 15 minutes times 4 (x 4) for one hour, 2. Then every 30 minutes x 2 for one hour, 3. Then every 1 hour x 4 for 4 hours, 4. Then every 4 hours x 4 for a total of 16 hours. Further review of the facility's, Neuro-Check Policy, revealed licensed staff were to document each neuro-check, noting the time, the findings, and any significant changes. Review further revealed any changes in a resident's condition must be reported to the physician for further direction. Review of the facility's Neuro-Check Guidelines with a review date of [DATE] (dated after R2's fall), revealed for the initial assessment, the facility was to conduct a full neuro assessment as soon as possible after an event or incident in which the resident had an unwitnessed fall or a witnessed fall with observation of the resident hitting their head or any head injury. Per the review, staff were to document all neuro-checks and record the time and results of each neuro-check including any changes in the resident's condition. Further review revealed staff were also to ensure any new symptoms were reported to the physician. Review of R2's closed record revealed an Admission Face Sheet found in the resident's electronic medical record (EMR). Review of the Admission Face Sheet revealed the facility admitted R2 on [DATE], with diagnoses that included Alzheimer's Disease with late-onset, pathological fracture pelvic and history of falls. Review of R2's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five out of 15. This score indicated R2 was severely cognitively impaired. Continued MDS review revealed the facility also assessed R2 to be dependent on staff for bed mobility, transfers, and ambulation. Review of the MDS, revealed the facility assessed R2 as dependent on staff in walking 10 feet. The facility assessed R2 to use a wheelchair for mobility. Review of R2's Fall Risk Score, dated [DATE] revealed the facility assessed the resident to have a fall risk score of 16, which indicated she was considered a high risk for falls. Review of the facility's, Fall Incident Report, dated [DATE] at 8:30 PM, documented by Registered Nurse (RN) 1, revealed R2 had sustained an unwitnessed fall on [DATE] at approximately 8:30 PM (indicating the RN immediately completed the Report). Per review, Resident sitting on buttock with legs under her, and had been wearing pajama pants with footwear in place. Continued review revealed R2 was alert and oriented times one; her wheelchair was at the foot of her bed; and the resident was attempting to scoot herself on the floor. Further review revealed the facility assessed R2 with no injuries noted, and no signs or symptoms or complaints of pain voiced. Additional review revealed R2 was assisted to stand and ambulate a few steps back to her bed by CNA 5 and RN 1. The review revealed R2 tolerated the transfer well. However, there was no documented evidence indicating RN 1 completed the CIC and initiated the neuro-checks, nor obtained R2's vital signs or assessed her range of motion (ROM). Review of the Progress Note for R2 dated [DATE] at 9:35 PM, documented by RN 1 revealed the resident had been found on the floor on her buttocks, with no injuries or complaints of (c/o) pain. Per review, R2 was stating, get me up. Continued review revealed the Note had been struck through on [DATE] and noted as a late entry. Further review revealed no documentation noting RN 1 completed a Change of Condition (CIC) note, that was to be completed with any medical change. In addition, the facility failed to initiate neuro-checks after the resident's unwitnessed fall. Review of R2's Progress Note, dated [DATE] at 2:10 PM, documented by RN 1 and entered as a late entry for [DATE], revealed the nurse had been called to R2's room by CNA 5 because the resident was on the floor. Continued review revealed R2 was agitated and yelling, put me to bed. Per review, RN 1 noted her assessment of R2 which revealed the resident was sitting on her legs scooting towards the bed, wearing pj (pajama) pants and socks. Further review revealed R2 was able to stand up to get back in bed with the assist of two staff members. Additional review revealed RN 1 assessed R2 to have no abnormalities, and no pain voiced. CNA 5 and the RN assisted R2 to lie on her bed and made her comfortable, with her call light in reach, bed alarm on, and low bed in place. Review of the facility's, Acute Change in Condition (CIC) note dated [DATE] at 2:21 AM, revealed Resident is exhibiting an acute change in condition and was yelling out and complaining of severe pain to her left hip/leg and Tylenol was not effective. Per review, R2 had a fall on [DATE] at approximately 8:00 PM. Continued review revealed Date first observed: [DATE]. Things that make condition worse: touching. Record review revealed R2's vital signs dated [DATE] at 2:25 AM, revealed a blood pressure (B/P) reading of ,d+[DATE]; temperature 97.3; pulse 75 and respirations 20. NEED MEASURE, AND MAYBE NORMS FOR HER Further review of the CIC note revealed R2's pain was new and the description of her pain was left hip/leg pain. Per review of the Neuro evaluation of the CIC note revealed no changes observed with the Summary of Observation/Evaluation documented as R2 had a fall on [DATE] evening at approximately 8:00 PM, but showed no signs of pain at that time. Review further revealed at approximately 1:00 AM, R2 had been lying on her bed and began yelling out in pain to her left hip/leg, and was yelling call the ambulance. Additional review revealed the physician was notified and a new order was received to sent R2 to the ER for evaluation and treatment. Review of the Hospital History and Physical Note, dated [DATE] revealed admitting diagnoses included; a traumatic right side cerebral hemorrhage with unknown loss of consciousness, compression fracture of T1 vertebrae, and a closed non-displaced impacted fracture of the left femur initial encounter. The resident was admitted to the intensive care unit with a diagnosis of intracranial hemorrhage. Review of the Physician's Note dated [DATE], revealed, meeting on [DATE] with patient's son and daughter at bedside. Patient's prognoses remains very guarded, patient remains in significant discomfort on physical restraints, nasogastric (NG) tube in place. She has severe dementia and cannot communicate her needs. Family wants to transition her care to comfort only. We will discontinue tube feeds and physical restraints and will continue end-of-life care. Hospice was consulted. In interview on [DATE] at 10:46 AM, Licensed Practical Nurse (LPN) 1 stated on [DATE], in the report she received from LPN 2, R2 had fallen the night before and had been sent to the ER. She stated RN 1 had not completed a CIC note, nor initiated neuro-checks for R2 after the resident's fall. LPN 1 explained that the facility completed neuro-checks on a paper form, which were never started for R2. However, they should have been. She stated she informed the Director of Nursing (DON) of that information. The LPN stated there was a falls binder at the desk that instructed staff on how to handle residents' falls. In interview on [DATE] at 4:18 PM, CNA 5 stated she had been charting at the nurse's station on [DATE], when she heard R2 yelling out. She stated she went to R2's room and found the resident sitting on the floor and she immediately informed RN 1. The CNA stated RN1 made sure R2 had no injuries while the resident was still lying on the floor. CNA5 stated she and RN 1 lifted R2 from up off the floor, by getting the resident up under the arms and lifted her up and put her in the bed. Per the CNA, R2 had not complained of pain. She stated R2's feet were not touching the floor enough for her to bear weight. She stated she had not seen RN 1 further assess R2 after that, nor obtain the resident's vital signs or perform ROM (range of motion). In interview on [DATE] at 7:17 AM, LPN 2 stated she arrived to work on [DATE] at 10:00 PM, and R2 had been at the nurse's station sitting in her wheelchair and had been calm and in no distress. She stated she received in report from RN 1 that R2 had experienced a fall. LPN 2 stated she was not aware that a CIC had not been completed until she started charting and realized there was not an assessment for her to follow up on. The LPN stated she checked on R2 several times and completed neuro-checks of the resident; however, she had not documented the neuro-checks on the facility's form, nor in the resident's medical record. She stated the form for R2's neuro-checks had not been started and she had not started one either. The LPN stated she had completed a CIC when R2 started yelling out and complaining of pain. Per LPN 2, she administered Tylenol which had not been effective, so she notified the Medical Director who ordered an in-house x-ray. She stated she notified R2's daughter who did not want to wait on the in-house x-ray, so she called the Medical Director back and received an order to send R2 out (to the ER). LPN 2 explained when a resident sustained a fall, an incident report was to be completed, which triggered a Change in condition assessment to be completed and documentation the medical record. She further stated unwitnessed falls should have neuro-checks initiated. In interview on [DATE] at 3:07 PM, RN 1 stated she had worked at the facility for about a year and had been a nurse for almost [AGE] years. She stated she had been working on [DATE], when CNA 5 made her aware R2 had been found on the floor. RN 1 stated she went to R2's room and assessed the resident for injuries. She stated R2 had no complaints and she and CNA 5 picked the resident up and sat her in her chair. RN 1 stated R2 stood on her legs without pain and slept the rest of her shift. In continued interview RN 1 stated the CIC documentation had been completed by LPN 2 and the LPN should have started the neuro-checks when she saw they had not been completed. She stated she had not completed a CIC which had been an oversight on her part. The RN stated that night ([DATE]) had been a busy night; however, she should have completed a CIC assessment and initiated neuro-checks following R2's unwitnessed fall. In interview on [DATE] at 3:07 PM, RN 1 stated the next day on [DATE], she received a call from the Assistant Director of Nursing (ADON) to come to the facility and complete documentation as her initial note lacked documentation. RN 1 stated she wrote a progress note and included more information in her late entry note. She stated she received disciplinary action and education related to the facility's falls process and documentation. In interview on [DATE] at 12:13 PM, the former Assistant Director of Nursing (ADON) stated in the early morning hours of [DATE], (she could not recall the specific time) LPN 2 notified her of R2's fall and that the resident was being sent to the ER. The ADON stated she was also told that RN 1 failed to complete a CIC assessment for R2 and failed to initiate neuro-checks for the resident after the unwitnessed fall. She stated she called RN 1 and requested the nurse come to the facility to complete her documentation as it had been lacking. The ADON further reported RN 1 should have completed the CIC assessment and initiated neuro-checks of R2 as per the facility's policy. In an interview with the Medical Director on [DATE] at 5:17 PM, he stated that he was made aware of R2s fall but could not recall the time or which nurse made him aware. He stated he expected the facility to follow policies and document when a resident has a fall or a change in condition and to initiate neuro assessment,s if applicable. In interview on [DATE] at 2:08 PM, the Director of Nursing (DON) stated she had been the DON since [DATE] and was still learning her role. She stated the nurses called her when a resident had a fall. She explained she had a missed call from RN 1 on [DATE] around 10:00 PM. The DON stated she was made aware of R2's fall when she arrived to work on [DATE]. She stated she had been told by the ADON that RN 1 failed to initiate neuro-checks or complete a CIC assessment when R2 experienced the unwitnessed fall. Per the DON, the ADON called RN 1 and had her come to the facility and complete her documentation, to change her note and add information regarding the fall. She stated when a resident sustained a fall, she expected the nurse to perform a head-to-toe assessment to check for injuries. The DON stated the head-to-toe assessment was to include obtaining the resident's vital signs, checking their ROM (range of motion), and initiating neuro-checks as per the facility's policy. She stated an incident report and Change in Condition assessment(s) should also be completed, and the resident's family and physician notified. The DON further stated the Neuro-Check Policy had only been reviewed and no changes had been made to the policy. In interview on [DATE] at 2:19 PM, the Administrator stated he had been the Administrator since [DATE], and he was still learning his role. The Administrator stated the DON and ADON made him aware of R2's fall and told him the Change in Condition assessment was incomplete. He stated he was not clinical but expected staff to follow the facility's policy and protocols related to care provided to residents. The Administrator further stated the Neuro-Check Policy had only been reviewed and no changes had been made to the policy.

Based on observation, interview, and record review, the facility failed to maintain dignity for one (Resident (R) 10) of 13 sampled residents. R10, who had a urinary catheter, was not provided a dignity cover for the urine drainage bag, leaving the bag visible to others. The findings include: Review of an admission record revealed the facility admitted R10 on 08/14/2024 with diagnoses including chronic kidney disease. Review of an Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2024, revealed the facility assessed R10 to have a Brief Interview for Mental Status (BIMS) score of 15/15, indicating she was cognitively intact. Per the MDS, the resident had an indwelling catheter, required assistance with dressing, and had no documented behaviors or refusal of care. Review of a Comprehensive care plan, dated 08/15/2024, revealed R10 required an indwelling foley catheter due to a diagnosis of a neurogenic bladder. The care plan included an intervention that the facility would provide a privacy bag as the resident would allow. Observation of R10, on 09/05/2024 at 9:50 AM, revealed the resident was in bed in her room. R10's urinary catheter was secured to her bedside. There was no dignity cover in place on the urine drainage bag. The door to the resident's room was open, and the uncovered drainage bag, which contained urine, was visible from the hallway. During an interview with R10 on 09/05/2024 at 9:50 AM, she stated, I don't like that other people can see my urine. During an interview with Certified Nursing Assistant (CNA) 2, she stated R10's catheter should have been covered. CNA2, who was the aide responsible for the resident's care that morning, stated a catheter bag should always be covered because it was a privacy issue for the resident. Further interview revealed CNA2 had not identified that there was no privacy cover in place, and the urine drainage bag was not covered until after surveyor intervention. During an interview with CNA4 on 09/05/2024 at 6:20 PM, she stated catheters should always be covered but she did not know the reason as to why they should have a cover. During an interview with Licensed Practical Nurse (LPN) 3 on 09/05/2024 at 6:02 PM, she stated it was important for catheters to remain covered due to privacy. LPN3 further stated someone walking down the hallway could visualize the resident's urine and it was a dignity issue. During an interview with the Director of Nursing (DON) on 09/06/2024 at 3:07 PM, she stated she expected a dignity cover to always be on a catheter bag. The DON stated if staff noticed a dignity cover was not in place, they should replace it immediately. The DON further stated it was important to provide privacy for the residents and for the residents to feel comfortable. During an interview with the Administrator on 09/06/2024 at 3:21 PM, she stated she expected dignity covers to be in place unless the resident did not want it.

Based on interview, record review, and review of facility policy and procedures, it was determined the facility failed to protect one (1) of how many sampled residents from abuse (Resident #1). On 06/19/2020, State Registered Nurse Aide (SRNA) #1 was overheard by the Assistant Director of Nursing (ADON) yelling at Resident #1 while in the bathroom. A small red area was also noted on the resident's right forearm. The findings include: Review of facility policy, titled, Abuse Prohibition, last revised 07/01/19, revealed the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, injury or mental anguish. Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Record review revealed the facility admitted Resident #1 on 10/21/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment, dated 04/07/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Interview with the ADON, on 10/28/2020 at 10:16 AM, and the review of her written statement revealed she was standing at the nurses station and heard yelling from the adjacent bathroom. The ADON stated she went closer to the bathroom, and heard SRNA #1 yell to Resident #1, You're lucky I don't break your neck. The ADON revealed she immediately took over the care of the resident and the SRNA was sent to the Administrators office. She stated the resident told her she hurt me and when she assessed the resident she found a red area on the resident's right forearm with a bruise starting to form. She stated SRNA #1 was suspended pending the outcome of the investigation and was escorted to the time clock and out of the facility. Review of Resident #1's Skin assessment completed on 06/19/2020 after the incident in the bathroom, revealed a reddened area on the right forearm measuring two centimeters (cm) by one point five cm (2 cm x 1.5 cm) in size. Interview with LPN #2, on 10/28/2020 at 10:34 AM, and review of her written statement dated 06/19/2020 revealed she was at the treatment cart talking to the ADON. She stated SRNA #1 was in the shower room with Resident #1 and she was heard the SRNA talking loudly to the resident. She revealed while enroute to the shower room, she heard the SRNA say, you can't use that bathroom (talking about the bathroom in the resident's room). LPN #2 stated the ADON went into the bathroom and SRNA #1 came out of the bathroom and went straight up front. She further revealed the resident stated the SRNA had hurt his/her arm. Interview with LPN #1, on 10/28/2020 at 10:26 AM, revealed she was standing outside the bathroom talking to a coworker when she heard yelling in the bathroom. She stated she could not understand what was said but she did hear yelling. Interview with SRNA #1, on 10/28/2020 at 11:03 AM, and review of her written statement dated 06/19/2020 revealed Resident #1 wanted to go to the bathroom in his/her room but she took the resident to the bathroom up front as it had a toilet that was not as low to the floor as the toilet in the resident's room. The SRNA stated that she was speaking in a loud voice in order for the resident to hear her as the resident was hard of hearing and it was necessary to speak louder for the resident to be able to hear what was being said. She revealed she was taking the resident out of his/her bathroom while the resident was holding on to another resident's wheelchair and the resident must have hit his/her arm on the other wheelchair causing the bruise. She stated that she was sorry and that she had no intention of causing harm to the resident. She stated the ADON entered the front bathroom and she was sent to the Administrators office. She reports that she did not care for any other residents after leaving the bathroom as instructed by the ADON and she was suspended after talking with the Administrative team. She revealed she was escorted to the time clock and out of the building. Interview with the Chief Executive Director (Administrator) on 10/28/2020 at 9:17 AM, revealed the facility investigated the allegation, determined it was substantiated, and terminated SRNA #1. *** The facility implemented the following actions to correct the deficient practice: 1. SRNA #1 was suspended on 06/19/2020 immediately after the incident by the Administrator and ADON. The SRNA was terminated from employment on 06/26/2020 by the Administrator, the Chief Nurse Executive (CNO) and the Workforce Specialist. 2. Interviews with interviewable residents (BIMS of eight {8} and above were conducted on 06/22/2020 by CNO related to abuse with no concerns identified. 3. Skin assessments were conducted by the ADON and LPN #1 on non-interviewable residents (BIMS scores of below eight {8}) on 06/19/2020 for signs of abuse with no concerns identified. 4. Interviews with all staff was conducted on 06/19/20 - 06/24/2020 by the ADON to determine if had any knowledge of abuse in the facility with no concerns identified. 5. Abuse education and post tests were provided to all staff on 06/25/2020 at 6:30 AM and 1:00 PM by the Administrator. 6. Audits to observe seven to ten (7-10) residents every shift for signs of abuse were started on 06/25/ 0. Audits will contine until facility in compliance. 7. A Quality Assurance Process Improvement (QAPI) meeting was held on 06/22/2020 to discuss the incident and again on 07/01/2020 with the Medical Director's involvement. **The State Survey Agency validated the corrective action taken by the facility as follows 1. Review of the personnel record for SRNA #1 revealed she was suspended on 06/19/2020 and terminated via telephone on 06/26/2020 at 1:50 PM by DON and the Human Resources staff. 2. Review of interview logs revealed all residents were interviewed on 06/24/2020 about the care they received in the facility and if they had ever been abused with no concerns identified. 3. Review of resident skin assessment sheets dated 06/19/2020 revealed all non-interviewable residents were observed for signs of abuse with no concerns identified. 4. Review of questionnaires revealed all staff were interviewed on 06/22/2020 and 06/23/2020 to find out if the staff had ever witnessed a staff member abusing a resident and were also questioned as to what they should do if abuse was seen or suspected. Interviews on 10/28/20 with the ADON at 10:16 AM, LPN #1 at 10:26 AM, LPN #2 at 10:34 AM, SRNA #2 at 11:24 AM, SRNA #3 at 11:27 AM, Administrator at 11:39 AM, Workforce Specialist at 11:44 AM, SRNA #4 at 11:55 AM, Dietary Manager at 12:06 PM , Medication Technician (MT) #1 at 12:37 PM and RN #1 at 1:03 PM revealed they were interviewed related to if aware of any abuse in facility and if knew what to do if abuse was seen or suspected. 5. Review of an Abuse education sign in sheet revealed education was provided on 06/25/2020 at 6:30 AM and 1:00 PM by the Administrator to all staff about the Abuse Prohibition policy. Interviews on 10/28/20 with the ADON at 10:16 AM, LPN #1 at 10:26 AM, LPN #2 at 10:34 AM, SRNA #2 at 11:24 AM, SRNA #3 at 11:27 AM, Administrator at 11:39 AM, Workforce Specialist at 11:44 AM, SRNA #4 at 11:55 AM, Dietary Manager at 12:06 PM , Medication Technician (MT) #1 at 12:37 PM and RN #1 at 1:03 PM revealed they were educated on abuse. 6. Review of the Log book revealed seven to ten (7-10) residents were observed every shift for signs of abuse from 06/25/2020 to 10/28/2020 with no concerns identified. 7. Review of QAPI minutes for 06/22/2020 and 07/01/2020 revealed meeting were held to discuss the allegation of abuse. In attendance were the Medical Director, the ADON, the Workforce Specialist, the Administrator, the MDS Coordinator and Medical Records Specialist.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to implement interventions for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned for wound care treatments as ordered, which was to apply hydrogel to coccyx and dressing every three (3) days and as needed; however, there was no documented evidence wound care was provided to Resident #1's wound from 05/28/2020-06/02/2020 as scheduled (05/30/2020), or as needed. The findings include: Review of the facility's policy titled, Person Centered Care Plan, last revised 07/01/19, revealed the center must develop and implement a baseline person-centered care plan for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Further review of the policy revealed the interdisciplinary team will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. Record review revealed the facility admitted Resident #1 on 10/04/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/06/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Review of Resident #1's Weekly Skin Integrity Report, dated 05/27/2020, revealed the resident had an intact, red area to his/her coccyx, measuring two (2) centimeters (cm) in length by one (1) in width and was assessed to be incontinence related. Review of the Resident #1's Comprehensive Care Plan for Resident #1 was at risk for skin breakdown, dated 05/27/2020, revealed an intervention to complete treatments as ordered. Review of the May 2020 Treatment Administration Record (TAR) revealed to apply hydrogel to coccyx and dressing every three (3) days and as needed, every evening shift for moisture-associated skin damage. Review of the May 2020 Treatment Administration Record (TAR) revealed a treatment was completed on 05/27/2020 (day treatment order was received); however, further review of the May and June 2020 TAR's revealed there was no documented evidence the treatment order was completed on 05/30/2020 (scheduled treatment) or as needed through 06/02/2020, when the resident was sent to the hospital. Review of Resident #1's emergency room Report, dated 06/02/2020, revealed Resident #1 had a deep tissue injury (DTI) and excoriation, fifty (50) percent purple, fifty percent red to his/her coccyx, which measured seven (7) cm in length by eight (8) cm in width and 0.1 cm depth. Interview with Registered Nurse (RN) #1 on 06/11/2020 at 8:26 AM, revealed she failed to initial Resident #1's 05/27/2020 wound care on the TAR. She stated she thought she did the dressing change to Resident #1's coccyx but could not recall what the wound looked like or what treatment she applied. RN #1 further revealed if the TAR was not initialed someone could assume the care was not provided. She stated she should have followed Resident #1's care plan related to wound care orders. Interview with the Director of Nursing (DON), on 06/11/2020 at 11:45 AM, revealed all nursing staff should follow resident care plans when providing care.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of three (3) sampled residents, received care to promote healing (Resident #1). Resident #1 was identified to have skin breakdown (red area, two (2) centimeters (cm) by one (1) cm) on 05/27/2020 with a treatment put in place to apply hydrogel to coccyx and dressing every three (3) days and as needed. A treatment was conducted on 05/27/2020; however, there was no evidence the treatment was completed three (3) days later (05/30/2020) or as needed from 05/28/2020-06/02/2020. Resident #1 was sent to the hospital on [DATE] and the wound had worsened (Deep Tissue Injury {DTI} measuring seven {7} cm by eight {8} cm by 0.1 cm). The findings include: Review of the facility's policy titled, Skin Integrity Management, last revised 01/31/2020, revealed the implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continuously observes and monitors patients for changes and implements revisions to the plan of care as needed. Further review of the policy revealed practice standards for staff are to perform daily monitoring of wounds or dressings for presence of complications or declines and document. Record review revealed the facility admitted Resident #1 on 10/04/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/06/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Further review of the MDS assessment revealed Resident #1 had no skin breakdown/pressure ulcers. Review of Resident #1's Weekly Skin Integrity Report, dated 05/27/2020, revealed the resident had an intact, red area on his/her coccyx, measuring two (2) cm in length by one (1) cm in width and was assessed to be incontinence related. Review of the Resident #1's Comprehensive Care Plan for Resident #1 was at risk for skin breakdown, dated 05/27/2020, revealed an intervention to complete treatments as ordered. Review of Resident #1's Physician Order, dated 05/27/2020, revealed an order to apply hydrogel to coccyx and dressing every three (3) days and as needed, every evening shift for moisture-associated skin damage. Review of the May 2020 TAR revealed the first treatment was completed on 05/27/2020. Further review of the May and June 2020 TAR's revealed there was no documented evidence licensed staff completed a treatment to the wound on 05/30/2020 (next scheduled dressing change) or as needed from 05/28/2020 - 06/02/3030 (seven (7) days). Review of Resident #1's emergency room Report, dated 06/02/2020, revealed Resident #1 had a deep tissue injury (DTI) and excoriation, fifty (50) percent purple, fifty percent red to his/her coccyx, which measured seven (7) cm in length by eight (8) cm in width and 0.1 cm depth. Interview with Registered Nurse (RN) #1 on 06/11/2020 at 8:26 AM, revealed she failed to initial Resident #1's wound care on the TAR. She stated she thought she did the dressing change to Resident #1's coccyx but could not recall what the wound looked like or what treatment she applied. RN #1 further stated if the TAR was not initialed someone could assume the care was not provided and she should have followed Resident #1's care plan related to wound care orders. Interviews on 06/11/2020 with Certified Nursing Assistant (CNA) #1 at 9:50 AM, CNA #2 at 10:00 AM, and CNA #3 at 10:24 AM, revealed the CNA's worked on 05/30/2020 and did not witness or assist Registered Nurse (RN) #1 with Resident #1's dressing change during their shift. Interview with the Director of Nursing (DON), on 06/11/2020 at 11:45 AM, revealed nursing staff should document on the TAR and take credit for their work. She stated if the TAR was not initialed another nurse could assume the care was not provided. The DON further revealed if a nurse could not complete a task she should have made the next shift aware.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to implement the care plan for one (1) of three (3) sampled residents according to professional standards of practice (Resident #1). Resident #1 was care planned for staff to provide wound care as ordered; however, the staff failed to provide the wound care according to professional standards of practice when she failed to wash hands prior to wound care and after the removal of gloves, failed to clean table prior to placing barrier with supplies, brought box of supplies into room with resident on isolation precautions, and cleansed across buttock and over stage II coccyx wound contaminating the wound. The findings include: Review of the facility policy titled, Person Centered Care Plan, last revised 07/01/19 revealed the facility must develop and implement a person-centered care plan for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Record review revealed the facility admitted Resident #1 on 05/24/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan for at Risk for Skin Breakdown, related to limited mobility and incontinence of bowel and bladder, surgical wound left BKA, and Stage II Pressure Ulcer to Coccyx revealed interventions to provide Preventative Z-Guard to coccyx, and provide wound care per order. However, observation of wound care on 08/07/19 at 1:05 PM revealed the Assistant Director of Nursing (ADON) did not provide wound care per professional standards of practice as evidenced by not cleaning the over bed table prior to placing a barrier down followed by the wound supplies, not washing her hands prior to starting the procedure and between glove changes, bringing the box of dressing supplies into the room of a resident on isolation precautions, and when she cleaned the resident's buttocks from the rectum upward over the Stage II Coccyx Pressure Ulcer, spreading stool over the wound. In addition, Certified Nurse Aide (CNA) #1 placed the residents stump down on the bed contaminating the wound and the ADON failed to clean the wound. Interview with CNA #1 revealed she should not have placed the Left BKA stump down on the barrier on the bed as this contaminated the wound the ADON had just cleaned. Interview with the ADON on 08/07/19 at 1:40 PM revealed she should have followed the Care Plan by providing wound care correctly. She stated the resident stump wound was contaminated when the CNA placed the stump back on the bed after she cleansed the wound, and she failed to reclean it; and, she contaminated the Stage II wound coccyx wound when she cleaned across rectum on to the coccyx wound. She also revealed she should have washed her hands between glove changes. Interview with the Director of Nursing (DON) on 08/07/19 at 2:10 revealed she expected all nursing staff to follow Comprehensive Care plans. She revealed, That would just be good nursing knowledge and care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide pressure ulcer wound care consistent with professional standards of practice to prevent infection for one (1) of three (3) sampled residents (Resident #1). The findings include: Review of facility policy titled, Wound Dressings, last revised 11/28/17, revealed wound dressings are performed using aseptic technique. The purpose is to decrease the risk of wound contamination and cross-contamination during dressing changes. The procedure revealed to use personal protective equipment as indicated, clean over-bed table, position the area to be treated, and cleanse hands. If the resident has multiple wounds, treat the less contaminated wound first. If a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves. Remove the contaminated dressing. Wash hands and apply gloves. Cleanse or irrigate wound as ordered. Apply clean dressing and secure. Remove gloves and discard according to infection control procedure. Cleanse hands. Review of the facility policy titled, Contact Precautions, last revised 06/15/19, revealed staff must use barrier precautions when entering the room. Change gloves and gowns during care if gloves/gowns come in direct contact with infections material. Record review revealed the facility admitted Resident #1 on 05/24/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan for at Risk for Skin Breakdown, related to limited mobility, incontinence of bowel and bladder, surgical wound left BKA, and Stage II Pressure Ulcer to Coccyx revealed interventions to provide Preventative Z-Guard to coccyx, and provide wound care per order. Review of the Weekly Skin assessment dated [DATE] revealed a 2.5 by 2.5 by 0.0 centimeter (cm) Stage II Pressure Ulcer to Coccyx. Review of Resident #1's August 2019 Physician Orders revealed to Apply Z-Guard to Buttocks every shift and as needed. Apply Baza Antifungal Cream to Coccyx topically two times a day, and Wet to Dry dressing changes to Left BKA stump two times a week. Observation of wound care on 08/07/19 at 1:05 PM with the Assistant Director of Nursing (ADON) and Certified Nurse Aide (CNA) #1 revealed the ADON did not follow the Wound Care Policy as written as evidenced by attempting to apply a clean dressing to the Left BKA wound that was contaminated by MRSA first and then the wound care of the Stage II Coccyx Pressure Ulcer second. Both the ADON and CNA #1 did not remove their personal protective isolation gowns that they wore during wound care to the BKA, prior to providing pressure ulcer care . In addition, the ADON failed to clean the over bed table prior to placing a barrier down followed by the wound supplies and did not wash her hands prior to the start of the procedure and between glove changes. In addition, observation of wound care of the coccyx, revealed the ADON cleaned the buttocks from the rectum upward over the wound and spread stool over the wound, contaminating the wound. Interview with the ADON on 08/07/19 at 1:40 PM revealed she should have followed the facility policies as written by giving correct wound care to Resident #1. She stated during wound care to coccyx, she contaminated the wound by cleaning across rectum onto the coccyx wound. She also revealed she should have washed her hands between glove changes. Interview with the Director of Nursing (DON) on 08/07/19 at 2:10 revealed she expected all nursing staff to follow the facility policies on pressure ulcer care, contact precautions and Physician orders as written. She revealed, That would just be good nursing knowledge and care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation revealed staff used poor wound care technique and poor hand washing technique while caring for a resident with an infectious disease. The findings include: Review of the facility policy titled, Hand Hygiene, last revised 11/28/17, revealed adherence to hand hygiene practices is maintained by all personnel. This includes hand washing with soap and water when hands are visibly soiled and after exposure to known or suspected infections. The purpose is to improve hand hygiene practices and reduce the transmission of pathogenic microorganisms. The process revealed to perform hand hygiene before patient care, before an aseptic procedure, after contact with blood or other body fluids, even if gloves are worn, after patient care, and after contact with the patient's environment. Review of the facility policy titled, Contact Precautions, last revised 06/15/19, revealed staff must use barrier precautions when entering the room. Change gloves and gowns during care if gloves/gowns come in direct contact with infections material. Review of facility policy titled, Wound Dressings, last revised 11/28/17, revealed wound dressings are performed using aseptic technique. The purpose is to decrease the risk of wound contamination and cross-contamination during dressing changes. The procedure revealed to use personal protective equipment as indicated, clean over-bed table, position the area to be treated, and cleanse hands. If the resident has multiple wounds, treat the less contaminated wound first. If a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves. Remove the contaminated dressing. Wash hands and apply gloves. Cleanse or irrigate wound as ordered. Apply clean dressing and secure. Remove gloves and discard according to infection control procedure. Cleanse hands. Observation of Resident #1's wound care on 08/07/19 at 1:05 PM with the Assistant Director of Nursing (ADON) and Certified Nurse Aide (CNA) #1 revealed she did not follow the hand care and contact precaution policies as evidenced by contaminating the wound while applying a clean dressing to the Left Below Knee Amputation (BKA) wound that was contaminated with [CONDITION(S)] Resistant Staphlococcus Aureus (MRSA), and then providing wound care of the Stage II Coccyx Pressure Ulcer second. In addition, the ADON and CNA #1 did not remove their personal protective isolation gowns they wore during wound care to the BKA. The ADON did not wash her hands prior to the start of the procedure and did not wash her hands between glove changes. She also brought a box of dressing supplies into the room with the resident on isolation precautions. Interview with the ADON on 08/07/19 at 1:40 PM revealed she should have followed the facility policies as written by giving correct wound care. She stated she should have washed her hands between glove changes. She also revealed the wound care to the coccyx should have been completed first prior to the wound care to the Left BKA with MRSA. She also revealed the dirty isolation gowns used during the Left BKA care should have been discarded prior to starting the care of the pressure ulcer. Interview with the Director of Nursing (DON) on 08/07/19 at 2:10 revealed she expected all nursing staff to follow the facility policies on wound care, contact precautions and Physician orders as written. She revealed, That would just be good nursing knowledge and care. She also revealed she would re-educate the nursing staff on wound care and contact precautions.

Based on observation, interview, facility policy/audit review, and review of the facility Census and Condition, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 08/28/18, revealed a visibly soiled manual can opener, hand sanitation issues and inappropriate handling of food for the residents' lunch meal. Review of the facility Census and Condition, dated 08/28/18, revealed forty-three (43) of forty-three (43) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Cleaning Standards, last revised 06/15/18, revealed the purpose of this policy is to ensure all food service equipment and areas are clean and sanitary. Observation of the kitchen on 08/28/18 at 10:34 AM, revealed the kitchen's manual can opener was visibly soiled with a build up of yellowish brown crusty material all over the cutting edge and the area surrounding the cutting edge. 2. Review of facility policy titled, Hand Washing, last revised 06/15/18, revealed hand washing is performed frequently and using correct hand washing technique. It further states hand washing is performed after touching bare parts of the body other than clean hands and exposed portions of arms and when moving from one task to the other. Observation of lunch trayline set up on 08/28/18 at 11:38 AM, revealed Cook #1 touching inside of bowls with bare fingers and side of plates residents eat off of after wiping sweat off of his face with his hands. 3. Review of the facility policy titled, Food Handling, last revised 08/08/18, revealed foods are stored, prepared and served in a safe sanitary manner. Observation of lunch trayline at 08/28/18 on 11:43 AM, revealed Cook #1 placed buns against his shirt on three (3) separate occasions while cutting the buns open and prior to placing the buns on plates for residents' lunch meal. Interview with Dietary Manager on 08/28/18 at 2:20 PM, revealed she expected the manual can opener to be cleaned, washed and sanitized after each use and run through the dishwasher every shift. She stated she expected staff to ensure their hands are cleaned prior to handling any clean dishes that are going to be used for the residents. She revealed she expected Cook #1 to not handle any foods in a manner that potentially caused an infection control issue such as placing the buns against his shirt.

Based on interview, and review of the Skilled Nursing Facility Beneficiary Protections Notifications it was determined the facility failed to ensure the appropriate and required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was issued to one (1) of twelve (12) sampled residents residents/beneficiaries when Medicare covered services were ending (Resident #34). Review of Resident #34's Medicare Discharge, revealed the facility did not issue a SNFABN CMS Form . The findings include: Interview with the Business Office Manager on 08/30/18 at 1:26 PM, revealed the facility did not have a specific policy for issuing the SNFABN and the facility follows the federal regulations/guidelines. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #34 from Medicare Part 'A' services with the last covered day being 03/05/18; however, the resident still had benefit days that were not exhausted. Further review of this Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide an SNFABN form CMS- . Interview with the Business Office Manager on 08/28/18 at 1:35 PM, revealed she expected the facility to initiate the SNFABN per the federal guidelines. She stated the Clinical Reimbursement Coordinator (CRC) is responsible to initiate the SNFABN's for the facility. Interview with the CRC on 08/28/18 at 1:42 PM, revealed the SNFABN for Resident #34 was missed and not done. She stated she was expected to provide the SNFABN as per federal requirements.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to revise the care plan for one (1) of twelve (12) sampled Residents (Resident #39). On 06/01/18, Resident #39 fell in his/her room; however, there was no documented evidence the comprehensive care plan was updated with the corrective action or new intervention. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised 03/01/18, revealed care plans are to be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Record review revealed the facility admitted Resident #39 on 11/13/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/10/18, revealed the facility assessed Resident #39's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Further review of the MDS revealed the resident was also assessed to require extensive assistance with one person assist with bed mobility, transfers, toileting and personal hygiene; and he/she is mobile with wheelchair with supervision. The resident also was assessed to have limited range of motion to the left lower extremity and was not steady when moving seated to standing and/or surface to surface but was able to stabilize without human assistance. There was no indication on the MDS that the resident had behaviors. Review of the facility provided Fall Investigation Report revealed Resident #39 fell on [DATE] at 6:20 PM with no injuries. The report indicated the resident did not lock wheel chair and was attempting to transfer without assist and the wheel chair slid from under (him/her). The Root Cause for the fall was resident impulsiveness with the corrective action/interventions being Monitor resident to prevent transfers without assistance. Review of the Comprehensive Care Plan initiated on 11/22/17 and revised on 08/13/18 revealed no documented evidence that impulsiveness was a risk factor contributing to falls. In addition, there was no documented evidence of an intervention placed on the care plan to address the 06/01/18 fall. In addition, there was no documented evidence the facility was monitoring the resident for impulsive behaviors. Interview with Resident #39 on 08/29/18 at 9:12 AM revealed he/she fell on [DATE]. Resident #39 stated the bedside mat causes him/her to fall because the wheelchair wheels hit the mat, and the wheelchair tips over. Interview with the MDS Coordinator on 08/29/18 at 2:12 PM revealed she updates the care plans. She stated she was in the process of updating all care plans, and Resident #39's care plans had not been updated even though the quarterly MDS assessment was completed on 08/10/18. She revealed the care plans are updated in the computer and the care plans in the computer are the latest ones. Interview with the Director of Nursing (DON) on 08/29/18 at 2:24 PM revealed there was no actual order that says monitor on a routine basis, even though monitoring for falls is a nursing intervention. She stated, we monitor the resident for seventy-two (72) hours, post fall and that is documented; however, monitoring after that is done with routine rounds, but it is not documented anywhere. The DON revealed the charge nurse initiates an immediate intervention and then the fall is reviewed by the Interdisciplinary team (IDT) and the care plans are updated by an appointed clinical administrative team member during the IDT meeting. The DON stated she expected the care plans to be updated with any new interventions in a timely manner. Interview with the Administrator on 08/30/18 at 8:59 AM revealed she expected the floor nurse to update the care plans with new intervention and it is the responsibility of the IDT to follow up to make sure that was done. The Administrator stated the care plans should be updated with each new intervention and accurately.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of twelve (12) sampled residents received an accurate assessment reflective of the resident's status (Resident #39). Resident #39 fell on [DATE], however, the fall was not reflected on the Quarterly Minimum Data Set (MDS) assessment dated [DATE]. In addition, the MDS indicated the resident had a restraint, but he/she did not. Further, the resident had an order dated 02/23/18 for [MEDICATION NAME], an antipsychotic medication; however, in the Antipsychotic Medication Review section of the MDS, it was coded that antipsychotic medications were not received. The findings include: Review of the RAI Manual, Version 3.0 User Manual, Section J, Health Conditions, states: · Code 0, no: if the resident has not had any fall since the last assessment. · Code 1, yes: if the resident has fallen since the last assessment. Further, the MDS Manual, Section N, Medication Received, states: · Antipsychotic: Record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period. Additionally, the MDS Manual, Section P, Restraints and Alarms, states: · Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. · Code 1, used less than daily: if the item met the definition and was used less than daily. · Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. Record review revealed the facility admitted Resident #39 on 11/13/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 08/10/18, revealed the facility assessment Resident # 39's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Further review of the Quarterly MDS Assessment, dated 08/10/18, revealed physical restraints, bed rails, were being used daily for Resident #39; however, observation on 08/28/18 at 1:23 PM revealed bilateral 1/4 side rails, bed side floor mats and a low bed were in use with no restraint identified. In addition, interview with Resident #39 on 08/29/18 at 09:22 AM revealed he/she used the side rails for positioning and moving around in bed and restraints were not being used on him/her. Further review revealed a Comprehensive Care Plan initiated on 11/22/17 and last revised on 08/13/18 revealed resident utilized 1/4 side rails for bed positioning and mobility with no restraints identified. In addition, review of the Quarterly MDS, Section J-Health Conditions, dated 08/10/18, revealed the resident had not fallen since prior assessment and the Antipsychotic Medication Review section revealed it was coded 0 indicating antipsychotics were not received. However, review of a Fall Investigation revealed Resident #39 fell on [DATE] and review of the (MONTH) (YEAR) physician's orders [REDACTED]. Interview with the MDS Coordinator on 08/29/18 at 3:17 PM revealed the 08/10/18 Quarterly MDS should have been coded to reflect Resident #39's fall. She stated it was not coded due to human error. She revealed certain areas are auto populated into the current MDS and she does double check the auto populated information. She stated the fall should have been coded on the MDS but she overlooked it. The MDS Coordinator also stated the resident has bilateral side rails and for some reason restraint was triggered. She further stated the MDS was coded incorrectly and she would do a correction. Interview with the Director of Nursing (DON) on 08/29/18 at 2:37 PM revealed she is unfamiliar with the MDS process and does not have a process in place to monitor the accuracy of the assessments. She stated she expected the MDS to be coded correctly and these were not. Interview with the Administrator on 08/30/18 at 8:59 AM revealed the facility uses the RAI Manual for reference when completing MDS assessments. She stated she expected the MDS's to be coded correctly and updated as needed.

Based on observation, interview, and review of the facility policy and procedure, it was determined the facility failed to ensure food was stored and prepared under sanitary conditions related to food in the refrigerator opened and not dated when it was opened. In addition, the facility meat slicer was visibly soiled and it had a rusty blade. Review of the Census and Condition Report, dated 11/06/16, revealed thirty-nine (39) of thirty-nine (39) residents received their meals from the kitchen. The findings include: 1. Review of the facility policy and procedure titled, Refrigerated/Frozen Storage, last revised 10/01/15, revealed all foods stored in the refrigerator should be labeled with name of product, date received, and use by date, once opened. Observation and tour of the kitchen, on 11/06/16 at 10:20 AM, revealed the following opened and undated items were in the refrigerator. There was one (1) pack of sliced ham not sealed and not dated; one (1) half roll of bologna was half wrapped in foil with areas open to air and not dated; and, one (1) plastic container of sliced cheese open to air with no lid or covering and not dated. Interview with the Dietary Manager, on 11/06/16 at 11:45 AM, revealed the normal procedures for any item open in the refrigerator was it must be sealed completely; and, labeled and dated as to when it was opened. 2. Review of facility policy and procedure titled, Cleaning Procedure, not dated, revealed when cleaning the Slicer staff should give special attention to the blade on both sides, the corners, handles, connections, underneath rolled rims, receiving tray and the area between the chute and the tray along with the cord. Further observation on 11/07/16 at 9:10 AM revealed the slicer was visibly soiled with food particles all over the slicer and the slicer blade was rusty with food particles on it. Further interview with the Dietary Manager on 11/07/16 at 9:30 AM, revealed she expected the slicer to be cleaned after each use and she further stated it was unacceptable to have a rusty blade on the slicer and a new blade would need to be ordered. She stated she was responsible to ensure foods were stored properly in the refrigerator and the meat slicer was clean and in good repair. Interview with the Administrator on 11/07/16 at 2:23 PM, revealed she expected staff to follow facility policy and procedure.

Based on interview, record review and review of the facility policy, it is determined the facility failed to provide, or obtain from an outside resource, routine dental services to meet the needs of one (1) of ten (10) sampled residents, (Resident #6) and five (5) unsampled residents (Residents A, B, C, D, and E). The findings include: Review of the facilities policy statement titled Consultant Agreement and Responsibilities dated 09/01/13, revealed in the event a Genesis Health Care Center does not employ the services of a qualified professional person to render a specific service, dental, arrangements for such a service are provided by the outside resource. Record review of the facility's Dental Tracking Form, dated 11/06/16, revealed six (6) residents (Resident #6, and Unsampled Resident A, B, C, D, and E) had not been seen by a dentist within a year's timeframe and there was not any documented refusal to see the dentist noted for those six (6) residents. One (1) had been seen on 10/12/15 and five (5) were seen on 08/31/15. Record review revealed the facility admitted Resident #6 on 05/10/13 with diagnoses, which included [MEDICAL CONDITION], Dysphagia, Cognitive Deficit, and [MEDICAL CONDITION]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/31/16, revealed the facility assessed Resident #6's cognition to be moderately impaired Review of Resident #6's Comprehensive Care Plan, initiated 04/01/15, revealed the Resident exhibits or is at risk for oral health or dental problems as evidenced by broken, loose, and carious teeth. Interview with Resident #6, by the Social Service Department, on 11/07/16 at 11:07 AM, revealed he/she did not have any current mouth pain or dental concerns. Resident #6 stated he/she did not want to go to the dentist at this time. However, further review of the facility Dental Tracking form revealed there was no documentation of the resident refusing to go to the dentist prior to this interview. Review of the Interviewable list provided by the facility on 11/06/16, revealed Unsampled Resident E was interviewable. Further review of the list revealed Unsampled Residents A, B, C, and D were not on the list of interviewable residents. Interview with Unsampled Resident E, on 11/07/16 at 1:55 PM, revealed he/she needed to see a dentist due to he/she had a front tooth that needed to come out and had needed to for a while because he/she had been experiencing pain with the tooth. Interview with the Social Service Director on 11/07/16 at 2:10 PM revealed she expected every resident to be seem by a dentist annually. She stated she was responsible for scheduling the residents to be seen by a dentist annually; however, she had failed to schedule Resident #6, and Unsampled Resident A, B, C, D, and E for their annual visit this year. Interview with the Administrator on 11/07/16 at 2:25 PM revealed the facility certainly needed to make sure all residents get the opportunity to have an annual dental exam and the facility should have a formal system of decline in place.

Based on interview, record review, review of the facility's investigation, and facility policy and procedure review it was determined the facility failed to have an effective system to ensure the facility's written policy and procedures were followed related to the investigation of alleged violation of abuse for one (1) of three (3) sampled residents (Resident #1). On 04/30/15, Resident #1 accused Certified Nursing Assistant (CNA) #1 of going into his/her room and grabbing his/her hands and shaking them. Review of the facility's investigation revealed skin assessments for non-interviewable residents were completed prior to the allegation or after the investigation was completed, and there was no evidence a skin assessments were conducted at the time the abuse allegation was made to identify if there were any symptom of abuse/neglect to include psychosocial. Refer to F225 The findings include: Review of the facility policy and procedure titled:" OPS310-KY Abuse Prohibition-State of Kentucky", effective date 07/01/13, revealed the facility will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents. The facility should identify possible incidents or allegations which need investigation and conduct an investigation of incidents and allegations. Further review of the policy revealed when the information was received concerning a report of suspected abuse or alleged abuse, mistreatment, neglect, or exploitation, the Administrator or designee should initiate an investigation within 24 hours of an allegation of abuse that focuses on : whether abuse or neglect occurred and to what extent; and clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. Record review revealed the facility readmitted Resident #1 on 04/27/14 with [DIAGNOSES REDACTED]. Review of the residents quarterly Minimum Data Set (MDS) assessment, dated 04/17/15, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of "09", indicating the resident was interviewable. Interview with Resident #1, on 05/12/15 at 10:00 AM, and review of the facility investigation, not dated, and interview with the DON, on 05/13/15, revealed Resident #1 reported on 04/30/15 a Nurse Aide came into his/her room mad, bad mouthed him/her and grabbed his/her hands and shook them which caused him/her pain. Further review of the facility investigation revealed there was documented evidence the facility reviewed routine skin assessments and shower sheets completed 04/27/15-05/08/15; however, there was no documented evidence skin assessments for signs and symptoms of abuse to include psychosocial were conducted on non-interviewable residents by licensed staff at the time of the allegation to focus and to ensure no abuse had occurred per the facility policy. Interview with Administrator, on 05/13/15 at 11:00 AM, revealed the facility always monitored for potential of abuse and screened for injury of unknown origin. She stated the skin assessment was negative for the resident in the complaint but if bruise had been identified and was unexplained they would have completed skin assessments on all the other residents, or if any of the interviewable residents had voiced a concern then they would have gone down that path.

Based on observation, interview, record review and review of the facility's investigation, and policy and procedure, it was determined the facility failed to conduct a thorough investigation related to an abuse allegation for one (1) of three (3) sampled residents (Resident #1). Resident #1 alleged Certified Nursing Assistant (CNA) #1 came into the resident's room and grabbed him/her by the hands and shook them. The facility failed to have documented evidence they assessed residents that were not interviewable during the investigation to determine if there were any signs and symptoms of abuse to include psychosocial. Review of the facility's investigation revealed skin assessments for non-interviewable residents were completed prior to the allegation or after the investigation was completed and there was no evidence a skin assessment was conducted at the time the abuse allegation was made. The findings include: Review of the facility policy and procedure titled, "OPS310-KY Abuse Prohibition-State of Kentucky", dated 07/01/13, revealed the facility should prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: screening of potential hires; training of employees (both new employees and ongoing training for all employees); prevention of occurrences; identification of possible incidents or allegations which need investigation; investigation of incidents and allegations; protection of patients during investigation; and reporting of incidents, investigations, and center response to the results of their investigations. Section six (6) states upon receiving information concerning a report of suspected abuse or alleged abuse, mistreatment, neglect, or exploitation, the Administrator or designee will perform the following: (Section 6.6 ) Initiate an investigation within 24 hours of an allegation of abuse that focuses on : whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. Record review revealed the facility readmitted Resident #1 on 04/27/14 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment , dated 04/17/15, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of "09", indicating the resident was interviewable. Interview with Resident #1 on 05/12/15 at 10:00 AM, revealed the incident with the Nurse Aide had been taken care of. Resident #1 stated the Nurse Aide came in his/her room mad because the wedge pillow was not at his/her side and bad mouthed the resident when the resident said something back to her. Resident #1 revealed the Nurse Aide got mad and grabbed his/her hands and started shaking them. The resident stated the Nurse Aide hurt his/her hand and arm and there was another girl with her and she reported it. Resident #1 revealed he/she was not afraid of the Nurse Aide and the Nurse Aide had not been back in the room since that night. Resident #1 stated the facility checked him/her out to make sure there were no injuries and the resident declined a skin assessment. Review of the facility's Investigation, not dated, revealed there was no documented evidence skin assessments for signs and symptoms of abuse were conducted by licensed staff on non-interviewable residents related to the allegation of abuse. There was some documented evidence that weekly skin assessments and shower sheets, date 04/27/15 through 05/08/15 were reviewed. Interview with Director of Nursing (DON) on 5/12/15 at 3:00 PM, revealed the resident reported the incident to staff the morning of 04/30/15 and an investigation was immediately started. The DON stated she interviewed the resident and asked a nurse to complete a full skin assessment on the resident and then notified the residents spouse, medical provider and administrator. The DON revealed the Nurse Aide that the resident alleged had hurt him/her was not in the building at that time. The DON stated the Social Services Director interviewed all the residents with a BIMS of eight (8) or greater and all staff were interviewed related to the allegation and no one had any concerns with the care provided by the Nurse Aide in question. The DON revealed no formal skin assessments were completed on the non-interviewable residents at the time of the investigation. She stated the residents' skin assessments and weekly bath and skin reports completed by the nursing assistants were reviewed for all the non-interviewable residents related to injury of unknown origin and no concerns were noted. The DON further revealed CNA #1 had been reassigned to work on another hallway; received a final written warning; and, had been completing customer service education this week with her along with reeducation on abuse and neglect that all the employees had received. Interview with Administrator, on 05/13/15 at 11:00 AM, revealed the facility would use the residents' Activity of Daily Living (ADL's) to determine if a skin assessment was needed and the facility always monitored for potential of abuse and screened for injury of unknown origin. The Administrator stated the skin assessment was negative for the resident in the complaint; however, if a bruise had occurred and was unexplained then they would have completed skin assessments on all the other residents, or if any of the interviewable residents had voiced a concern then they would have gone down that path.

Based on observation, interview, and review of the facility's policy/procedure, it was determined the facility failed to ensure each resident received reasonable accommodation of needs as evidenced by the failure to honor dietary dislikes for four (4) unsampled residents (Residents B, C, D, and E). A review of the facility's Census and Condition, dated 08/19/14, revealed the facility's census was forty-two (42) and there were no residents who received tube feedings. The findings include: Review of the facility's policy/procedure titled "Food Preferences", last revised 05/05/13, revealed the facility should update resident food preferences at a minimum of quarterly. Food and Nutrition service employees should carefully read tray tickets during meal service, serve preferences, and offer substitutions for disliked items. 1. Observation during the lunch meal, on 08/19/14 at 12:20 PM revealed Resident D received California Blend (blend of cauliflower, carrots, and broccoli). Review of Resident D's dietary card revealed Resident D disliked broccoli. Interview with Resident D, on 08/19/14 at 3:00 PM, revealed he/she nodded "yes" when asked if he/she regularly received disliked food items during meals. 2. Observation during the lunch meal, on 08/20/14 at 12:15 PM revealed Resident C's plate contained carrots. Review of the Resident C's dietary card revealed Resident C disliked carrots. Further observation revealed Certified Nurse Aide (CNA) #1 fed Resident C a bite of carrots, Resident C nodded head "no" and stated "that is not good". Interview with CNA #1, on 08/20/14 at 12:45 PM, revealed he/she should have compared dietary cards against what the resident received and obtained a substitute if the resident received a food he/she disliked. 3. Observation during the lunch meal, on 08/20/14 at 12:15 PM, revealed Resident B received greens. Review of Resident B's dietary card revealed Resident B disliked greens. Interview with Resident B, on 08/20/14 at 08:08 AM, revealed he/she regularly received disliked food items during meals. 4. Observation during the breakfast meal, on 08/20/14 at 7:55 AM, revealed Resident E received scrambled eggs. Review of Resident E's dietary card revealed Resident E disliked eggs at breakfast. Interview with Resident E, on 08/20/14 at 7:55 AM, revealed he/she regularly received eggs "every morning". Interview with the Dietary Manager (DM), on 08/20/14 at 1:45 PM, revealed food preference questionnaires were completed within seventy-two (72) hours of admission and dislikes were listed on a resident specific dietary card. The DM stated she expected staff to check the diet order, dislikes, and preferences against what was on the tray during meal service. The DM revealed there was always a substitute item available. Interview with the Director of Nursing (DON), on 08/21/14 at 10:45 AM, revealed he/she expected staff to check diet orders and honor food preferences. Interview with the Administrator, on 08/21/14 at 10:55 AM, revealed staff should "pay attention to dietary meal cards" and obtain a substitute if the resident received an item he/she did not like. The Administrator revealed staff should communicate discrepancies to dietary.

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to ensure proper incontinent care and appropriate hand washing and gloving technique during the performance of perineal (incontinence) care for one (1) of eleven (11) sampled residents (Resident # 6). The findings include: Review of the facility's Hand Hygiene policy, last revised 10/01/2013, revealed employees should wash hands with soap and water after removing gloves, before and after direct patient care, immediately after contact with blood, body fluids, or other potentially infectious materials and when hands are visibly soiled or contaminated. Record review revealed the facility admitted Resident #6 on 07/08/14 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) Assessment, dated 07/15/14, revealed the facility assessed Resident #6's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of "7" indicating the resident was not interviewable. Observation of perineal care, on 08/20/14 at 3:00 PM, revealed Certified Nurse Aide (CNA) #2 and CNA #4 assisted Resident #6 to the commode in the women's shower room and removed the resident's incontinent brief. Further observation revealed CNA #2 wiped stool from Resident #6 using wet wipes; then assisted the resident into a clean brief and touched the resident, gait belt and wheelchair without removing her gloves and washing her hands. Interview with CNA #2, on 08/20/14 at 3:30 PM, revealed she should have removed her gloves and washed her hands after cleaning stool and prior to touching Resident #6, the gait belt and the wheelchair. Interview with the Director of Nursing (DON), on 08/21/14 at 14:20 PM, revealed she expected staff to remove gloves and wash hands after providing perineal care and before touching the resident, gait belt and wheelchair.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure it was free of medication error rates of five (5) percent or greater involving one resident (A), not in the selected sample. There were two (2) errors out of thirty-four (34) opportunities to equal a five (5) percent medication error rate. The findings include: Review of the General Dose Preparation and Medication Administration policy/procedure, last revised 03/01/11, revealed to verify each time that the medication was the right drug at the right dose, the right route, at the right rate, at the right time for the right patient. Confirm that the Medication Administration Record [REDACTED]. Observation, on 08/20/14 at 8:00 AM, revealed Licensed Practical Nurse (LPN) #1 administered the following medication to Resident A: 1. [MEDICATION NAME] Propionate Suspension 50 micrograms (mcg), one (1) spray in each nostril. 2. [MEDICATION NAME] 2.5 mg tablet by mouth. Record review revealed Resident A was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 1. [MEDICATION NAME] Propionate Suspension 50 mcg two (2) sprays in both nostrils one (1) time a day for Allergic Rhinitis. 2. [MEDICATION NAME] tablet, give 5 mg by mouth one (1) time a day for Allergic Rhinitis Interview with LPN #1, on 08/20/14 at 10:40 AM, revealed the medication label did not match the MAR for both medications administered to Resident A. She should have compared the medication with the MAR indicated [REDACTED]. She revealed if there was a discrepancy, it should have been clarified before medication administration. Interview with the Director of Nursing, on 08/21/14 at 9:45 AM, revealed she expected staff to ensure the medication label matched the MAR prior to medication administration. She revealed if there was a discrepancy, the medication order should have been verified.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide appropriate care and services for an indwelling urinary catheter to prevent urinary tract infections for one (1) of eleven (11) sampled residents (Resident #1). The findings include: Review of the facility's policy "Catheter: Indwelling Urinary - Care of ", last revised 01/02/14, revealed staff should perform catheter care twice a day and PRN. For a male resident staff should wash area around catheter insertion site and then wash from the tip of the penis down to the body. Include the scrotum and skin folds around and underneath the scrotum. If male is uncircumcised, the foreskin must be retracted and cleaned. Return the foreskin to its original position once the penis is dry. In addition, staff should cleanse the proximal third of the catheter with soap and water, washing away from the insertion site and manipulating the catheter as little as possible, then rinse. Staff should secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. Record review revealed the facility admitted Resident #1 on 05/10/13 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 03/27/14, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of "3" indicating the resident was not interviewable. Review of Resident #1's Care Plan, last reviewed 08/01/14, revealed the resident required an indwelling catheter due to [MEDICAL CONDITION] secondary to [MEDICAL CONDITIONS]. Further review revealed interventions which included to keep catheter off floor, provide skin care after each incontinent episode and apply a moisture barrier. Observation of Resident #1's skin assessment conducted by Registered Nurse (RN) #1, on 08/19/14 at 3:05 PM, revealed stool was present and RN # 1 used wet wipes to remove the stool; then removed gloves, washed hands and donned new gloves. However, RN #1 did not provide urinary catheter care. Interview with RN #1, on 08/19/14 at 3:35 PM revealed he/she was "nervous and forgot" to provide urinary catheter care and he/she should have provided urinary catheter care. Interview with the Director of Nursing (DON), on 08/19/14 at 3:40 PM, revealed he/she expected staff to provide urinary catheter care every shift and whenever visible stool was present. Observation of Resident #1, on 08/20/14 at 9:05 AM and 2:30 PM, revealed the resident's urinary catheter bag was inside a dignity bag touching the floor. Observation at 1:30 PM, revealed the urinary catheter bag was inside a dignity bag, lying on the floor with the bedside table wheel on top of the dignity bag. Interview with Certified Nurse Aide (CNA) #5, on 08/21/14 at 10:40 AM, revealed the urinary catheter bag or dignity bag should not be touching the floor. Interview with DON, on 08/21/14 at 10:55 AM, revealed the urinary catheter bag and/or dignity bag should be anchored below bladder level and never touching the floor.