Every finding on record at Hendrick Skilled Nursing Facility

Based on observation, interview and record review 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 for 1 of 3 staff (CNA-A) reviewed for infection control procedures. 1. The facility failed to ensure CNA-A performed proper hand hygiene while performing resident transfer, foley care and incontinent care.2. The facility failed to ensure CNA-A followed EBP during foley catheter care.3. The facility failed to ensure staff were notified of EBP for Resident #10 and failed to have a disposable gown readily accessible to staff outside of Resident #10's room. These failures could place residents at risk for the transmission of communicable diseases.Findings include:Record review of Resident #10's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE].Record review of Resident #10's history and physical, dated 10/1/2025, reflected she was admitted to a hospital on 9/5/2025, after heart catheterization. She was diagnosed with a UTI during the hospital stay on 9/8/2025. Further review reflected the foley catheter was kept in place postoperatively and she was admitted to skilled nursing to continue therapy.Record review of Resident #10's physician orders, dated 10/1/2025, reflected an order, dated 9/18/2025, for follow up appointment with outpatient urology clinic on 10/8/2025 for a trial of void to remove foley catheter. An order, dated 9/19/2025, reflected Indwelling Urinary Catheter Care Orders - Peri Care, using peri care wipes, to be performed on patient every 12 hours, outside of daily bathing, while foley catheter is in place in accordance with policy. Record review of Resident #10's care plan, dated 10/1/2025, reflected Indwelling Catheter Problems/Needs: Potential for urinary tract infection.Resident will: Increase fluid intake to 8 glasses per day.; Show no sign of urinary tract infection.; Be free of urinary tract pain.; Receive no injury secondary to catheter manipulation.; Receive no injury secondary to catheter removal by resident.Personalized Care.Indwelling Catheter Problems/Needs: Potential for urinary tract infection.give perineal care when resident is incontinent.Record review of Resident #10's comprehensive admission MDS, dated [DATE] , reflected a BIMS score of 13, which indicated Resident #10 was cognitively intact. Further review of the MDS, bladder section indicated Resident #10 had an indwelling catheter.Record review of CNA-A's computer-based training record reflected she passed training on infection prevention on 2/6/2025, had passed training on preventing catheter-associated urinary tract infections on 2/6/2025, and passed training on CAUTI - post insertions foley care system for CAUTI prevention on 2/5/2025.During an observation and interview on 9/30/2025 at 1:19 p.m., revealed CNA-A knocked on Resident #10's door and entered the room. There was no EBP sign outside of the room or on the door and were no gowns available on or around Resident #10's door. Resident #10 was sitting in a recliner to the right of the bed with her legs elevated. CNA-A used ABHR on her hands and put on gloves. Resident #10 agreed with getting in bed for foley catheter care. CNA-A took the foley catheter bag from the right of the recliner and secured it to Resident #10's walker. CNA-A grabbed a gait belt and placed it around Resident #10's abdomen and assisted Resident #10 to a standing position. Resident #10 ambulated using a walker to the right side of her bed and sat on the edge of the bed. The privacy curtain was pulled closed by a visitor in Resident #10's room who stood between the door and the privacy curtain. CNA-A grabbed the two pillows from the recliner and placed them at the head of Resident #10's bed before she assisted Resident #10 with raising her legs into the bed. Resident #10 was lying in bed on a draw sheet and CNA-A moved to the left side of the bed and pulled on the draw sheet to straighten Resident #10 in the bed. CNA-A moved back to the right side of the bed and placed the catheter bag from the walker to the right side of the bed. CNA-A lifted Resident #10's right leg to get the catheter tubing out from underneath it and lowered her leg onto the bed. CNA-A then moved the peri care wipes kit to bedside and moved the trash can to the right of the bed. CNA-A told Resident #10 what to expect from the procedure and then opened the peri wipe kit after lowering the front of Resident #10's brief exposing the foley catheter tube. CNA-A took one wipe from the kit and wiped the foley catheter tubing starting at Resident #10's skin and wiped away from her body. The wipe was disposed into a lined trash can. CNA-A got another wipe from the peri care kit and wiped the right side of the labia then another wipe was used to wipe the left side of labia. Those wipes were disposed of into a lined trash can. CNA-A used the last 2 wipes in the peri care kit to wipe Resident #10's skin from the front (right behind catheter exit site) to the back (rectal area) and both were disposed of into the lined trash can after use. CNA-A stated the brief was soiled and needed to be changed so she went to the area on the other side of the privacy curtain to get incontinent wipes and a clean brief. CNA-A instructed Resident #10 to roll to her left side, and she used the incontinent wipes to clean the gluteal skin disposing of the wipes into a lined trash can after use. CNA-A removed the used brief from under Resident #10 and disposed into the lined trash can. CNA-A placed a clean brief under Resident #10 and asked her to roll onto her back. The clean brief was brought through Resident #10's legs and secured with tabs by CNA-A. CNA-A dated the sticker on the peri care kit with a marker and placed the sticker on the foley catheter bag. CNA-A observed there was urine in the catheter bag and stated she would empty it. CNA-A disposed of the empty peri care kit into the lined trash can. CNA-A went into the restroom and grabbed a urinal. CNA-A emptied the urine from foley catheter bag into the urinal and placed the bag back into the privacy bag on the right side of the bed. CNA-A took the urinal into the restroom and dumped the urine into the toilet then flushed the toilet. CNA-A hung the urinal on the bar in the restroom and exited the restroom. CNA-A used the bed control to adjust Resident #10's bed and handed the control to Resident #10. CNA-A moved the trash can back to the side of the room and took off her gloves for the first time since putting them on after entering Resident #10's room. CNA-A used ABHR on her hands and she removed the trash liner from trash can. CNA-A exited the room with the trash inside of the liner and walked to room behind the nurses' station and put into a larger lined trash bin. Hand hygiene was performed. CNA-A stated she thought she should have replaced her gloves during resident care and would have to ask her supervisor about how to perform hand hygiene during catheter care. She stated she may need a refresher on hand hygiene. She stated not changing gloves and performing hand hygiene at correct times during catheter care could cause CAUTIs.During an interview on 9/30/2025 at 1:53 p.m., RN-B stated gloves should be changed when moving from a contaminated to clean area. RN-B stated she felt CNA-A needed more education on hand hygiene. RN-B stated she did not know CNA-A's training history or how long she had been a CNA. RN-B stated the educators monitored CNAs performed hand hygiene as needed but was unsure of how often the CNAs were monitored. She stated not performing hand hygiene when appropriate could cause infections. During an interview on 9/30/2025 at 2:10 p.m., the DON stated she expected employees to perform hand hygiene and replace gloves when going from one task to another as during foley catheter care. She stated staff were responsible for performing hand hygiene when needed. She stated hand hygiene was needed to prevent infections. She stated the educators monitored staff performed hand hygiene appropriately. She stated there was annual training on hand hygiene instructed by the educators. She stated she had no knowledge of EBP regulation for individuals with indwelling devices.During a follow-up interview on 10/1/2025 at 8:11 a.m., the DON requested information about EBP in long term care. She stated she knew about contact precautions, but she was unable to locate information about EBP in long term care. She stated in acute care, enhanced barrier was for COVID patients. During an interview on 10/1/2025 at 9:29 a.m., the IP stated she expected staff to sanitize hands and change gloves in between tasks and after contact with urine. She stated she anticipated gloves and gowns to be used in wound care but would not expect gowns to be used in foley catheter care. She did not answer if she had known about EBP in long term care but stated there would not be a splash of fluids with catheter care so a gown would not be needed. She stated staff were trained upon hire and annually on hand hygiene. She stated direct care staff had to do a hand hygiene skills check-off prior to being allowed to work with residents . She stated there were also secret shoppers (secret employees that observed staff members for skills then sent a report of what was observed good and bad to the IP) who were responsible for randomly picking direct care staff to perform hand hygiene check off. She stated the DON had a list of secret shoppers. The IP stated she got a report from the secret shoppers after check-off was completed and would check to see if CNA-A had checked off with the secret shopper in the past. She stated the DON was responsible for making sure direct care staff were performing hand hygiene appropriately. She stated the risk to residents from staff not performing hand hygiene appropriately during catheter care could be getting a facility acquired infection or spreading infection from the resident to other residents. During a follow-up interview on 10/1/2025 at 11:09 a.m., the IP stated there was no evidence CNA-A had not been randomly selected by secret staff to observe hand hygiene skill (secret shoppers) since she had been employed at the facility. During a follow-up interview on 10/2/2025 at 9:41 a.m., the DON stated there was no policy for EBP during care for residents with an indwelling device. She stated she could provide policy for contact, droplet, and airborne precautions but none for EBP for indwelling device .Record review of the facility's policy titled Handwashing, Hand Antisepsis and Glove Use, 4.4739 revised on 3/26/2019, reflected: Hand Hygiene 1. Each employee will wash his/her hands at the following times: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids.2. In addition, all employees with patient contact will decontaminate their hands with the hospital approved alcohol-based hand rub when the hands are not visibly soiled in clinical situations. Note: Alternately wash hands with the hospital approved antimicrobial soap and water in these clinical situations. A. Before having direct contact with patients.D. After contact with a patient's intact skin (e.g., when taking a pulse or lifting a patient). E, After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. F. When moving from a contaminated-body site to a clean-body site during patient care. G. After contact with inanimate objects in the immediate vicinity of the patient. H. After removing gloves. Glove Use 1. Employees will wear gloves in accordance with isolation guidelines and the Exposure Control-Bloodborne Pathogen Standard. 2. Employees will wear gloves when performing any procedures on a patient that could possible expose them to potentially infective material.4. Employees will wear gloves when performing the following nonpatient contact procedures: Cleaning up spills of blood or body fluids Cleaning contaminated equipment Cleaning sanitation facilities Handling contaminated trash, linens, or other potentially contaminated equipment or materials.7. Employees will change gloves and cleanse their hands between patients and between procedures with the potential of cross contaminating the same patient from one site to another (i.e. foley care and trach care ).

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity for one (Resident #107) of three residents reviewed for rights, in that: The facility failed to ensure Resident #107's ostomy drainage bag was placed in a privacy bag while performing physical therapy in the facility's hallway area. Ostomy (an opening (stoma) from an area inside the body to the outside). This failure could place residents with catheters at risk for embarrassment and reduced self-esteem. The findings included: Review of Resident #107's electronic record on 9/5/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of incarcerated hernia. (An incarcerated hernia is a type of hernia in which a part of the small bowel protrudes into the groin area and cannot be pushed back in). Record review of Resident #107's care plan dated 09/01/24 indicated in part: Patient would like to be able to use regular colostomy after recovery. Will be free from trauma to site and infection. Patient to have less leakage from ostomy. Record review of Resident #107's MDS dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Bladder and bowel: Ostomy checked yes. During an observation on 09/04/24 at 10:42 AM, Resident #107 was being assisted by PTA A with ambulating in the hallway with the use of the resident's walker. The resident's ostomy drainage bag was seen hanging on the walker and not covered with a privacy bag exposing the bowel movements in the drainage bag. There were other resident's seen in the hallway as well as several visitors. During an interview on 09/05/24 at 3:02 PM, Resident #107 said she was aware of her ostomy bag not being covered while out in the hallway. The resident said she did not mind it being uncovered. The resident said it did not make any difference to her if it was covered or not and that the facility staff had not asked her if they could cover it. During an interview on 09/05/24 at 3:07 PM, RN B said whenever a resident that used for example a urinary catheter bag they would make sure it was kept below the resident's waist to prevent back flow of the urine when being transferred out of bed. RN B said if the resident came out of their room they would also place a linen bag over the catheter bag for privacy. RN B was made aware of Resident #107 observed in the hall with her drainage bag uncovered. RN B said as far as she knew Resident #107 had not asked for a privacy bag nor had she asked the resident if she would like one. RN B said she did not think it was a privacy issues if Resident #107's drainage bag was uncovered while out in the hallway even if other residents and visitors were there unless Resident #107 said so. During an interview on 09/05/24 at 3:25 PM, PTA A said Resident #107 did not use a cover on her drainage bag. PTA A said Are we supposed to use a cover on the drainage bag ?. PTA A said the resident had never requested one be used and as far as he knew Resident #107 was fine with the bag not covered when walking in the hallway. During an interview on 09/05/24 at 3:32 PM, the DON was made aware of the observation of Resident #107 ambulating in the hallway with her ostomy drainage bag uncovered. The DON said the drainage bags were usually not covered as it was a skilled facility. The DON said Resident #107 had not voiced that she wanted her drainage bag covered. The DON said if the resident complained about the bag not being covered then they would offer to cover it. Record review of the facility's document titled Patient rights and responsibilities and dated 12/5/2023 indicated in part: Patients are entitled to dignified and respectful care regardless of age, race, color, national origin, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression.

Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 (Resident #59) of 3 residents reviewed for infection control. The facility failed to ensure: PTA B cleaned the counter prior to setting up a barrier for setting up wound care supplies for Resident #59. PTA B used a non-permeable barrier when setting up wound care supplies for Resident #59. PT A cleaned scissors between dirty procedure and clean procedure during wound care for Resident #59. PT A used the same scissors after cutting off Resident #59's dirty [NAME]-boot dressing (plaster dressing used to squeeze fluid out of a closed wound) to cut his clean [NAME]-boot dressing. These failures could place resident's at risk for cross contamination and the spread of infection. The findings included: Review of Resident #59's electronic record on 9/5/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including debility and septic discitis of the thoracic region (spine infection). Resident #59 was still in his MDS Assessment period. Review of Resident #59's care plan dated 8/23/24 revealed: Problem/ Need Problems: hospitalization abscess to leg Resident will exhibit: Be free from infection during hospital stay; verbalize how to prevent disease. Interventions: Teach patient about handwashing; assess every shift for signs and symptoms of infection; monitor vital signs and lab values; administer medication/ antibiotics as ordered; notify physician of any abnormal values; reinforce hygiene behavior; teach patient signs and symptoms of infection. Wound #1 Right Antero-lateral leg/Venous Ulcer WDL (closed or open, chronic wound that occurs when the veins don't return blood to the heart properly. Resident #59's wounds were closed and seeped fluid) within defined limits, except ulceration, venous, no drainage, dressing in place Review of Resident #59's Order Summary documented Rehab Services: wound care treatment orders: Order date 8/26/24 active. Observation on 9/4/24 at 10:07 a.m., PT A entered Resident #59's room to do wound care. PT A sanitized his hands with alcohol based hand rub (ABHR) and donned gloves. Then after surveyor entered the room, PTA B entered the room and moved Resident #59's belongings to the side and placed a folded towel on the counter without sanitizing the counter and set up the wound care supplies. PT A cut off Resident #59's [NAME]-boot dressing (plaster soaked dressing that compresses as it dries) with a pair of clean scissors. PT A took off the gloves, sanitized hands with ABHR and donned a new pair of gloves. He took measurements of Resident #59's wounds. PT A then applied lotion to Resident #59's leg, then he applied a new [NAME]-boot dressing. When PT A got to the top of Resident #59's calf, PT A used the same, uncleaned scissors to cut the remainder of the [NAME]-boot dressing off. PT A put gauze over the [NAME]-boot dressing, the kerlix (self-adhesive gauze), and put a tube covering over it and left with no hand hygiene. Interview on 9/5/24 at 1:01 p.m., PT A stated he knocked on Resident #59's door, asked about any issues, asked about pain, a student came in to set up supplies and they started the treatment. PT A said Resident #59 had the [NAME]-boot to treat edema. PT A said PTA B was the tech and she moved Resident #59's clothes and put down a clean towel. PT A stated the procedure was clean not sterile so as far as they knew a clean towel was enough. PT A said no one had talked to the PT department about using a non-permeable barrier when setting up wound care. PT A stated after the scissors were used they were considered dirty but they were used for the same resident. PT A said the facility policy was they could use the same instruments. Surveyor requested the policy. PT A stated he did not think it was a formal policy just a facility practice. Interview on 9/5/24 at 1:30 p.m., the ICP stated the expectation for wound care was staff wear the proper PPE which would be gown and gloves. The ICP said she thought a chuck (absorbent pad with plastic on one side to prevent leaks) which was disposable would be acceptable for wound care. The ICP stated she was not sure what the policy stated. The ICP stated once the dressing was cut off the scissors were considered dirty, and the facility did have a spray the PT could have used to clean them. The ICP said hand hygiene was expected before donning PPE, in between glove changes, after touching patient surroundings, and when exiting the room. In an interview on 9/5/24 at 2:21 p.m., the DON stated clean technique could be completed with a towel because the resident was the only person in the room. At this time PT A brought the mandatory in-services by the facility and infection control was completed 2/6/24. In an interview on 09/05/24 at 3:33 p.m., the DON said they did not have a specific policy for wound care.

Based on interview and record review, the facility failed to develop a baseline care plan with necessary information within 48 hours of the resident ' s admission for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for baseline care plans. The facility failed to include physician orders for medications and diets in Resident #101, Resident #51, and Resident #103 ' s baseline care plan. This failure placed residents at risk of not receiving continuity of care and communication among nursing staff and residents as well as increased risk of resident safety and safeguard against adverse events that are most likely to occur after admission. Findings included: Resident #101 Review of Resident #101 ' s patient profile revealed Resident #101 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of right hip fracture. Review of Resident #101 ' s admission assessment dated [DATE] revealed BIMS of 15, indicating resident was cognitively intact. Review of Resident #101 ' s physician orders dated 07/19/2023 revealed resident was prescribed Aspirin 325mg two times per day with breakfast and supper, atorvastatin 40mg at bedtime, levothyroxine 137mg before breakfast, multivitamin 1 tablet daily, Prednisolone ophthalmic drops four times per day to right eye, paroxetine 20mg daily, MiraLAX 1 packet daily, as needed sliding scale insulin for blood glucose above 200, 1800 ADA Carbohydrate Control diet, and Glucerna Vanilla shakes twice a day. Review of Resident #101 ' s baseline care plan dated 07/20/2023 revealed no evidence of focus, objectives or interventions for Aspirin 325mg two times per day with breakfast and supper, atorvastatin 40mg at bedtime, levothyroxine 137mg before breakfast, multivitamin 1 tablet daily, Prednisolone ophthalmic drops four times per day to right eye, paroxetine 20mg daily, MiraLAX 1 packet daily, as needed sliding scale insulin for blood glucose above 200, 1800 ADA Carbohydrate Control diet, and Glucerna Vanilla shakes twice a day. During an interview on 07/25/2023 at 10:05 am, Resident #101 stated she did not remember participating in care plan meetings. Resident #51 Review of Resident #51 ' s patient profile revealed Resident #51 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of [NAME] fracture of proximal end of left tibia (fracture left lower leg). Review of Resident #51 ' s admission assessment dated [DATE] revealed BIMS of 13, indicating resident was cognitively intact. Review of Resident #51 ' s physician orders dated 07/18/2023 revealed resident was prescribed ascorbic acid 200mg daily, Aspirin 81mg 2 times per day with meals, furosemide 40mg daily, losartan 25mg daily, Multivitamin Vitamin B Complex with C and Folic Acid daily, MiraLAX 1 packet daily, heel protectors, and Ensure Enlive Shakes two times per day. Review of Resident #51 ' s baseline care plan dated 07/19/2023 revealed no evidence of focus, objectives or interventions for ascorbic acid 200mg daily, Aspirin 81mg 2 times per day with meals, furosemide 40mg daily, losartan 25mg daily, Multivitamin Vitamin B Complex with C and Folic Acid daily, MiraLAX 1 packet daily, heel protectors, and Ensure Enlive Shakes two times per day. During an interview on 07/25/2023 at 10:14 am, Resident #51 stated not knowing anything about care plans. Resident #103 Review of Resident #103 ' s patient profile revealed Resident #103 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of fracture of left ulna (fracture of left upper arm). Review of Resident #103 ' s admission assessment dated [DATE] revealed BIMS of 14, indicating resident was cognitively intact. Review of Resident #103 ' s physician orders dated 07/21/2023 revealed resident was prescribed amiodarone 100mg daily, apixaban 2.5mg two times per day, celecoxib 200mg two times per day, losartan 100mg daily, metoprolol succinate XL 50mg daily, probenecid 500mg two times per day, rosuvastatin 20mg at bedtime, regular diet, and Ensure Enlive shakes two times a day. Review of Resident #103 ' s baseline care plan dated 07/22/2023 revealed no evidence of focus, objectives or interventions for amiodarone 100mg daily, apixaban 2.5mg two times per day, celecoxib 200mg two times per day, losartan 100mg daily, metoprolol succinate XL 50mg daily, probenecid 500mg two times per day, rosuvastatin 20mg at bedtime, regular diet, and Ensure Enlive shakes two times a day. During an interview on 07/25/2023 at 1:29 pm, Resident #103 stated she had not been informed of care plans. During an interview on 07/26/2023 3:44 pm, the DON stated the facility had no policy or procedures on baseline care plans. She stated that the facility follows Texas Administrative Code for baseline care plans. DON stated that each discipline creates their portion of the baseline care plan upon the resident ' s admission. Review of Texas Administrative Code 554.802(a) https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=26&pt=1&ch=554&rl=802 accessed 07/28/2023 revealed: (a) Baseline care plans. (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: (A) be developed within 48 hours of a resident's admission; (B) include the minimum healthcare information necessary to properly care for a resident, including: (i) initial goals based on admission orders; (ii) physician orders; (iii) dietary orders; (iv) therapy services; (v) social services; and (vi) PASRR recommendation, if applicable. 44722 48883

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for dignity. The facility did not ensure nursing staff entered Resident #101, Resident #51, and Resident #103 ' s rooms with permission prior to administering medications and providing ADL care. This failure could place residents at risk for decreased quality of life and quality of care. Findings included: Resident #101 Review of Resident #101 ' s patient profile undated revealed Resident #101 was [AGE] year old female who was admitted to the facility on [DATE] with diagnosis of right hip fracture. Review of Resident #101 ' s admission assessment dated [DATE] revealed BIMS of 15, indicating resident was cognitively intact. During an observation on 07/25/2023 at 1:47 pm, LVN-A entered Resident #101 ' s room without asking permission prior to entering to administer medications. During an observation on 07/26/2023 at 8:47 am, LVN-B entered Resident #101 ' s room without asking permission prior to entering to administer medications. Resident #51 Review of Resident #51 ' s patient profile revealed Resident #51 was [AGE] year old female who was admitted to the facility on [DATE] with diagnosis of [NAME] fracture of proximal end of left tibia (fracture left lower leg). Review of Resident #51 ' s admission assessment dated [DATE] revealed BIMS of 13, indicating resident was cognitively intact. During an observation on 07/25/2023 at 10:58 am, LVN-A and RN-A knocked on resident ' s room and entered without asking resident permission to enter. During an interview on 07/26/2023 at 8:02 am, Resident #51 stated that nurses knocked on the door and say hello but never ask permission prior to entering the room. Resident #103 Review of Resident #103 ' s patient profile revealed Resident #103 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of fracture of left ulna (fracture of left upper arm). Review of Resident #103 ' s admission assessment dated [DATE] revealed BIMS of 14, indicating resident was cognitively intact. During an observation on 07/26/2023 at 8:58 am, LVN-B entered Resident #103 ' s room without asking permission prior to entering to administer medications. During an interview on 07/26/2023 at 3:40 pm, DON stated that facility staff were trained in the acronym of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You). Staff are not trained to ask permission prior to entering resident ' s room. The DON also stated the facility did not have a policy or procedure regarding asking permission prior to entering a resident ' s room.

Based on observation, interviews, and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The facility name, the current census, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift(Registered nurses, Licensed practical nurses or licensed vocational nurses or Certified nurse aides) for 1 of 1 Staffing Log reviewed for nursing services. The facility failed to ensure the Direct Care Nursing/Staff Daily Log dated July 25, 2023, was completed with the facility name, current census, and the total number of hours worked and the actual hours worked by the RN and the LVN. This failure could place residents, their families, and visitors at risk of not having the staffing information readily accessible for review, residents and visitors are not able to know how many staff are currently working to provide care on all shifts. Findings Included: Observation on 07/25/2023 at 10:58 AM on the wall across from the nurse's station revealed a dry erase board with the date and names of charge nurse and nurse. There was no evidence of the facility's name, resident census or the number of hours or the actual hours worked by licensed staff providing direct care. During an interview on 07/25/2023 at 11:05 AM the DON stated the nurses staffing was posted on the dry erase board on the wall across from the nurses' station. The DON stated she followed what the TAC required for posting. The DON stated she did not know why she did not have the facility's name, resident census or the number of hours or the actual hours worked by licensed staff providing direct care written on on the board. The DON stated she must have overlooked the part about the facility name, the census and the nursing hours. Review of facility provided document titled Required Postings | Texas Health and Human Services dated 06/15/23 revealed F732/N1518-1520 and N1932 - Nursing Staffing Information 42 CFR Section 483.35(g) and 26 TAC Section 554.1001(b)(1)-(2) and Section 554.1921(e)(13) - An NF must conspicuously and prominently post the following information, in a clear and readable format and a prominent place readily accessible and available to residents, employees, and visitors, in accordance with Section 554.1921(e): On a daily basis: Facility name Current date Resident census Specific shifts for the day At the beginning of each shift, the total number of hours and actual time of day to be worked by the following licensed and unlicensed nursing staff, including relief personnel directly responsible for resident care: Registered nurses (RNs) Licensed vocational nurses (LVNs) Certified nurse aides (CNAs) In addition, the licensed NF must make the information required to be posted available to the public upon request.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey of the facility reviewed for resident rights. The facility failed to ensure the most recent survey results was posted for residents, family members, and visitors to review. The failure placed residents and their family members and representatives at risk for violation of the right to review the findings from State surveys and investigations conducted in the facility without asking to review the reports. Findings included: During an initial observation on 07/25/2023 at 7:45 am, the last survey results could not be located. Review of facility's survey history revealed last re-certification survey occurred on 09/18/2019. During an interview on 07/26/2023 at 3:45 pm, the DON stated she was not aware survey results had to be posted. DON stated that the facility followed required postings from https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings. Review of facility provided document titled Required Postings | Texas Health and Human Services dated 06/15/23 revealed F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results 42 CFR Section 483.10(g)(11) - An NF must: Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 07/26/2023 revealed: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results 42 CFR Section 483.10(g)(11) - An NF must: Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Review of website https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 07/26/2023 revealed: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results 42 CFR Section 483.10(g)(11) - An NF must: Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 07/26/2023 revealed: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results 42 CFR Section 483.10(g)(11) - An NF must: Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS . The facility failed to submit staffing information to CMS for FY Quarter 2 2023 (January 1- March 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Record review of the facility's Staffing Data Report for FY Quarter 2 2023 (January 1- March 31) revealed the facility triggered for Failed to Submit Data for the Quarter and One Star Staffing Rating. During an interview on 07/26/2023at 12:20 PM, the DON stated her expectation was that the facility followed CMS guidelines . The DON stated during the 2nd Quarter, they did not have residents and was not aware of who would have been responsible for reporting the staffing information.

Based on record review and interview the facility failed to establish and maintain an infection prevention and control program that includes when and to whom possible incidents of communicable disease or infections should be reported. The facility failed to immediately report 1 of 1 staff (Nurse A) who was COVID 19 positive to HHSC. This failure could affect any staff or resident of the facility by increasing the risk of infection. The findings included: Review of a Patient Under Investigation (PUI) form dated 06/03/20 revealed Nurse A, was tested on [DATE] with positive results returned on 05/30/20. Nurse A was asymptomatic. In an interview with the Nurse Manager on 06/05/20 at 2:11 PM, she stated that the Skilled Nursing Facility was temporarily closed and that the last resident was discharged on [DATE]. That resident tested negative on the date of discharge and all staff had been wearing full protective gear for a full week prior and wearing masks before that. She said she was notified that Nurse A was positive for COVID 19 on 05/30/20. The last night Nurse A worked was 05/29/20. The Nurse Manager said she had been waiting for all of the pending staff results to be returned before reporting to HHSC. In a telephone interview with the hospital Wellness Director on 06/05/20 at 2:16 PM, she said that Nurse had been off for the weekend (May 30 and 31st) when the results came back and she was notified to be on self-quarantine until 06/06/20. She said that she had notified the local health department on 05/30/20. In an interview with the Director on 06/05/20 at 2:19 PM and 2:24 PM, she said that all staff had started wearing N95 masks on the 19th or 20th of May and that all staff were screened on entry with their temperature checked. She said the facility followed the hospital policy on reporting. In an interview with the Vice president of Quality and Patient Safety on 06/05/20 at 2:24 PM, she said a line list was sent daily to the local health department and the PUI form was sent within a few days. In an interview with the Nurse Manager on 06/05/20 at 3:15 PM, she said that she was aware of the COVID response plan for skilled nursing facilities, but that she had just been waiting for all the results to be in before reporting. Review of the . Health System policy Reporting of Legally Reportable Diseases dated 03/18/19 revealed the following: Purpose: . Medical Center will maintain appropriate mechanisms for the internal reporting of suspected legally reportable disease and for the external reporting of confirmed reportable diseases as defined (sic) the laws of the State of Texas. Policy: 5. All patients diagnosed as having any legally reportable disease will be reported to the appropriate state or local health agency by the Infection Prevention Office in the timeframe's prescribed by the laws of the State of Texas. Review of the State of Texas COVID-19 Response for Nursing Facilities version 3.1 (6/2/20) revealed the following: 6. To Do's for Nursing Facilities: Report a confirmed COVID-19 case to the local health department or DSHS and to HHSC . Upon the first positive test result of a NF staff member or resident, the facility shall work with local health authorities, DSHS, and HHSC to coordinate testing of all NF staff and residents.

Based on observation, interview and record review the facility failed to prepare, store, distribute and serve food under sanitary conditions for one of one kitchens. The facility failed to ensure: a) general kitchen areas were free of trash, dirt and debris; and b) prepare, store, distribute and serve food under sanitary conditions. This failure placed 12 out of 13 residents at risk for exposure to cross contamination resulting in the potential for food borne illness. Findings include: Observation of the kitchen during initial tour on 02/02/16 at 11:10 a.m. revealed unlabeled and undated items: · In the walk-in refrigerator there was six trays of breaded meat and one tray of stuffed green peppers located on the food cart that was unlabeled and not dated: the food cart was covered with a plastic drape over the entire cart; however there was a three foot tear on the side of the plastic cover leaving the trays exposed. · In the walk-in Refrigerator, there was a container of ham that was not labeled or dated. There was a container of bacon that was not labeled, dated, or covered. Observation of the kitchen 02/03/2016 at 2:10 p.m., One extra-large round cooking pan and one extra- large rectangle cooking pan and five cast iron skillets; the bottoms were covered with encrusted grease deposits and other soil accumulations. · There was debris on the stainless steel shelves under the warmer ovens. · Two Tray carts were soiled with food debris. · Deep Fry grease vats full of fried debris. · Grill covered with baked on debri. · Oven beside plate warmer, (meat cooking) dripping brown colored liquid out of the bottom of oven onto the floor. · Refrigerator (holding) bottom shelf with food debris. · Dry Storage - Cornmeal, rice, and bread crumb bin ' s; lids dirty with food debris. Observation on 2/2/16 at 12:00 p.m. of the serving tray lines revealed the following: · The Tray Line Cook, while wearing gloves, took a cloth out of a sanitizing cleaning solution. She ringed out the excess solution and wiped up the work area. She placed the cleaning rag back into the solution. She used the spray pan coating on the flat grill then she reached into the refrigerated compartment under the flat grill and picked up a handful of ham bits and laid them onto the grill. She went to the refrigerator to get cheese. She picked up a spatula and stirred the ham on the grill. She then picked up a handful of cheese and mixed it with the ham (no measuring devices were observed being used). She plated and covered the food while using the same soiled gloves she used while handling the wiping cloth with the sanitizing cleaning solution. · The Tray Line Hot Foods Server was observed wearing gloves. She picked up a blue cleaning cloth off of the floor and threw it onto a rolling food cart. She went back to the serving line, picked up a hamburger bun without changing gloves. She reached into a container and picked up a bundle of sliced cheese. She pulled off one slice of cheese and placed it on the hamburger bun. She placed the bundle of cheese back into the container. She never changed gloves after she handled the discarded cleaning rag. · Tray Line Cold Foods Server was observed plating salads, sandwiches, and special orders wearing gloves. No tongs were being used. She handled all the food with her gloved hands. Review of the temperature logs on 2/2/16 at 1:45 p.m. revealed the following days and times that the food temperatures were not taken: January 2016 01/01/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) 01/02/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) 01/03/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) 01/04/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) 01/11/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) 01/14/16 Dinner (4:30 p.m.) 01/16/16 Dinner (4:30 p.m.) 01/19/16 Dinner (4:30 p.m.) 01/20/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) 01/21/16 Dinner (4:30 p.m.) 01/22/16 Dinner (4:30 p.m.) 01/23/16 Dinner (4:30 p.m.) 01/24/16 Dinner (4:30 p.m.) 01/25/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) 01/26/16 Dinner (4:30 p.m.) 01/27/16 Breakfast (6:30 a.m., 8:30 a.m.) Lunch (10:30 a.m., 12:30 p.m.) Dinner (4:30 p.m.) 01/28/16 Dinner (4:30 p.m.) 01/29/16 Dinner (4:30 p.m.) FEBRUARY 2016 02/01/16 Dinner (4:30 p.m.) In an interview on 02/02/2016 at 2:30 p.m., the Food Service Director (FSD) stated all foods on carts in the refrigerator should have been labeled, dated and covered properly. He said that the tray line servers should change their gloves and wash their hands after using a cleaning cloth. He said that the tray line servers are supposed to use measuring devices for items in the refrigerated food compartment under the flat grill. He said that they are supposed to be taking temperatures of the tray line every two hours and document in the log book. He did not know why temperatures were not taken consistently in January 2016. In an interview on 2/3/16 at 2:10 p.m. with the Tray Line Foods Server she said that she should have changed her gloves after she used the cleaning cloth. She said that they never use measuring devices for food items in the refrigerated compartment in under the flat grill. She said they just pick up the food items with their gloves. Review of the policy titled Storage undated revealed the following: All food and supplies must be stored accordingly to approved storage methods. Purpose: To conserve the quality of the food supply during storage. Storage of Perishable Foods: Store all perishable foods in an appropriate fashion at appropriate temperatures to ensure freshness and quality of the product . 2. Cover all refrigerated food and dated while in storage . Review of the policy titled Food Temperatures undated revealed the following: Policy: All food is to be prepared, held and served within the appropriate ranges set forth in the ARA Food Handling/Sanitation Manual. Purpose: To provide highest quality of food, prevent the growth of undesirable microorganisms and other food spoilage and to maintain the aesthetic values of food. Procedure: All production and service personnel are to have thermometers available to them. Temperatures are to be taken prior to the start of the line and corrected if necessary, before service begins. Temperatures are to be recorded and taken randomly throughout the meal service . Food Contact Surfaces; Review of the Texas Food Establishment Rules (TFER) Effective date: October 2015, §228.113. Cleaning of Equipment and Utensils. page 107 states (1) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (2) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (3) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . Gloves for Single Use; Review of the TFER, p. 56 §228.68(e)(1) revealed If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Labeling; Review of the Federal Food and Drug Administration (FDA) Food Code 2009 guidelines revealed; .Packaged food shall be labeled as specified in law, including 21 CFR 101, Food Labeling, 9 CFR 317, Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N, Labeling and Containers, and as specified under subsection (c)(7) and (8) of this section .(1) Food labels .(A) Food packaged in a food establishment, shall be labeled as specified in law, including 21 CFR 101, Food Labeling, 9 CFR 317, Labeling, Marking Devices, and Containers, and 9 CFR 381, Subpart N, Labeling and Containers.(B) Label information shall include: (i) the common name of the food, or absent a common name, an adequately descriptive identity statement . Management Duties (Temperatures); Review of the TFER, p. 22 §228.34 (4), Duties. Revealed employees are effectively cleaning their hands by routinely monitoring the employees ' hand washing; (7) employees are properly cooking time/temperature controlled for safety (TSC) food, being particularly careful in cooking those foods known to cause foodborne illness and death, such as eggs and comminuted meats, through daily oversight of the employees ' routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated . (12) .employees are preventing cross-contamination of ready-to-eat food with bare hands by properly using suitable utensils such as deli-tissue, spatulas, tongs, single-use gloves, or dispensing equipment . The facility's CMS 672 dated 2/2/16 revealed a census of 13, one resident receiving tube feeding's, the remaining 12 residents received their meals from the kitchen.

Based on record review and interview the facility failed to complete a quarterly assessment on time for 1 of 8 residents (Resident #4) reviewed for assessments. The facility failed to complete Resident #4's quarterly Minimum Data Set (MDS) Assessment in July 2015, October 2015, and January 2016. This facility failure could result in a failure to update the care plan with needed interventions resulting in inappropriate or incomplete care and services. This failure could affect any of the 13 residents who lived in the facility. Findings include: Record review of Resident #4's Record of admitted d 04/15/15 revealed he was an [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's most recent Minimum Data Set Assessment revealed it to be completed upon admission 04/22/15. In an interview on 02/03/16 at 4:50 p.m. the MDS Coordinator said that she was responsible for completing the MDS assessments timely. She said that Resident #4 should have had a quarterly MDS assessment completed in July 2015, October 2015, and January 2016. She confirmed that there were no quarterly MDS assessments completed on Resident #4. She said that she did not do quarterly MDS assessments on Resident #4 because he did not have a payor source. She said that Resident ' s usually do not stay on the Skilled Nursing Unit long enough to complete quarterly assessments. She said that she is focused on the Prospective Payment System (PPS) assessments and just forgot about the requirement for quarterly MDS assessments. The CMS 672 dated 02/02/16 revealed a census of 13.

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 Certified Nurse Aides (CNA's) were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1of 5 resident's (Residents # 5) reviewed for incontinent care. The facility failed to ensure: CNA B changed her gloves or washed her hands after providing incontinent care for Resident # 5 and before adjusting his clothing and straightening the bedding. This deficient practice could affect any of the 5 residents who were frequently incontinent of bladder and/or 3 residents who were frequently incontinent of bowel resulting in cross contamination and risk for bacteria into the urinary tract causing infection. The findings included: Observation of incontinent care for Resident #5 on 02/03/16 at 12:50 p.m. revealed the following; CNA A closed the door, explained to the resident what they were going to do. CNA A and CNA B washed their hands and donned gloves. CNA A and CNA B assisted Resident #5 from the chair to the bed using a gait belt, positioning resident on his back. CNA A and CNA B removed their gloves, used alcohol gel and donned clean gloves. CNA A and CNA B removed Resident #5 ' s soiled brief. CNA B cleaned Resident #5's urethral area using disposable pre-moistened wipes cleaned the resident's front including the penis and scrotum. CNA A and CNA B assisted Resident #5 to his side. CNA B using a disposable pre-moistened wipe cleaned the remaining area including the rectum and the buttocks. CNA B applied the clean brief. CNA A and CNA B repositioned Resident #5 onto his back and adjusted his brief and his gown. CNA B then straightened Resident #5's bed linens and adjusted the head of the resident's bed. CNA B did not change her gloves or wash her hands before she applied the clean brief, adjusted the residents gown, and bed linens. In an interview on 02/03/16 at 1:00 p.m. CNA B said that she forgot to change her gloves after she finished incontinent care. She said that she should have washed her hands and applied clean gloves before she applied the clean brief, and adjusted the resident ' s clothes and bed linens. She said that she had been taught properly, but she was nervous and just forgot. In an interview with the DON on 02/03/16 at 3:44 p.m. revealed that CNA B was a new CNA but she had done very well in her competency skills. She said that an in-service would be provided regarding incontinent care and they would stress the importance of changing gloves and hand washing to prevent cross contamination. Record review of the facility provided Hand washing and Hand Antisepsis policy dated 04/13 revealed, Policy Statement: Thorough hand washing or hand hygiene will be practiced by all employees for the protection of their own health and to prevent the transmission of infection. The recommendations from the Center for Disease Control; and Prevention Guidelines for Hand Hygiene in Health-Care settings will be used for guidance. Rules; 1. Each employee will wash his/her hands at the following times: a.When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids. b.Before eating and after using a restroom. c.If contact with spores (e.g. [DIAGNOSES REDACTED]icile or Bacillus anthracis) is likely to have occurred. 2. In addition all employees with patient contact will decontaminate their hands with the hospital approved alcohol-based hand rub when the hands are not visible soiled in the following clinical situations. Note: Alternately wash hands with the hospital approves antimicrobial soap and water in these clinical conditions: a. Before having direct contact with patients, . e. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. f. When moving from a contaminated-body site to a clean body site during patient care. h. After removing gloves. Review of Texas Nurse Aide Skills Exam dated 07/01/2005 revealed, Procedural Guideline #7-Hand-washing. A. Purpose: To remove germs from hands and prevent the spread of infection. 2. Hand-washing should be done at the following times: b. Before and after caring for each resident. c. Before applying gloves and after removing gloves. e. After contact with blood, body fluids and contaminated items. f. Whenever hands are obviously soiled. CMS 672 dated 02/02/16 revealed 5 residents frequently incontinent of bladder and 3 residents frequently incontinent of bowel.

Based on observation, interview and record review the facility failed to prepare, store, distribute and serve food under sanitary conditions. The facility failed to ensure: a) general kitchen areas were free of trash, dirt and debris; and b) prepare, store, distribute and serve food under sanitary conditions. This failure placed 17 out of 18 residents at risk for exposure to cross contamination resulting in the potential for food borne illness. Findings include: Observation of the kitchen during initial tour on 1/15/13 at 6:40 a.m. revealed unlabeled and undated items: ? In the walk-in refrigerator there was an entire shelf of food located on the food cart that was unlabeled and not dated: The items included the following: Roast beef, pickles, tomatoes, cheese, onions, croutons, chicken, ham, turkey, lettuce, potato salad, carrots, broccoli, and snap beans. ? In the walk-in refrigerator there was a pan with partially thawed turkey, located on the second shelf of the food cart with green beans located on the bottom shelf of the same food cart, both items were unlabeled and neither item was dated. ? In the walk-in Refrigerator, there were two small salad bowls and a container of mushrooms that were not labeled, dated or covered. ? Five of twenty two milk cartons had expired on 1/13/2013, which were all mixed together in the milk crate , no sign or notice that these expired milk cartons should have been discarded. ? One container of chicken, one container of celery and one container of tomatoes were located on the food cart , they were not labeled or dated. ? Two layers of uncooked bacon were not labeled, dated or covered on the food cart. ? Two serving pans of cooked bacon, not covered, labeled or dated, were sitting on top of uncovered, uncooked bacon on two separate shelves on the food cart, also not labeled or dated. ? A large plastic bottle of Caesar salad and Creamy French salad dressing was soiled with salad dressing running down the side of the jar. ? Unidentified red substance on the floor in the upper left hand corner of the walk in cooler (Between food racks) In an interview on 1/15/2013 at 7:00 a.m., the Front Line Manager stated all foods on cart should have been labeled, he stated they were leftovers from the night before, he further stated all these foods will be discarded. Observation of the walk in freezer 1/15/2013 at 7:30 a.m., chicken, frozen turkey patties, green beans, triple chocolate peanut butter cookies all in boxes with plastic bags that were open to air, none were dated. (Plastic bags were not freezer type bags.) ? One box of rolls was open torn tape and paper lying in the box touching the food. In an interview on 1/15/13 at 7:15 a.m. the Chef Manager stated that the food was to be put in freezer-safe bags, labeled and dated when opened from the original containers. Observation of the kitchen 1/15/2013 at 7:45 a.m., One Muffin tin, two steaming pans, three cast iron skillets, one small frying pan, and two white measuring cups were all dirty with food debris. ? Two mixing stands crusty with rust on bottom of stands ? There was debris on the floor under the pots and pan rack. ? Two Tray carts, covered with plastic were soiled with food debris. ? Two unused food racks blocking the door to the electrical room,(sign said specifically, do not block door) the floor was dirty with lots of debris, dirty rags, and dirty gloves. There was an empty root beer bottle sitting the floor and a discarded carry out container sitting on top of a breaker box. ? One gallon container of Plastic Roof Cement, which read "Caution combustible, keep away from flame ", was sitting in the floor of the electrical room. On 1/16/13 at 1:30 p.m. in an interview with the Chef Manager and the Front Line Manager, they agreed that all foods should be sealed, labeled, and dated. They provided a policy and procedure for food storage and handling which states; Prepared products are properly stored, Proof of Compliance, and Purpose. QA Number: CE.05.03 - Level 1, Operational Quality, dated 07/06/2010. Prepared products are stored according to food safety and storage standards (cooked foods over raw, seafood over beef, beef over poultry. etc.). All prepared foods are properly sealed, with a label containing product name, date prepared, and discard date per HACCP principles. Purpose: To ensure that unused prepared products/menu items are safely stored in the right container, in the correct location, at the right temperature, and with the proper labeling. The following Food & Sanitation Outcome is achieved in this Activity. Food items are prepared to ensure food quality and safety standards are met. The facility's CMS 672 revealed a census of 18, one resident receiving tube feeding ' s, the remaining 17 residents received their meals from the kitchen.

Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate of less than five percent. The medication error rate was 10% involving two RNs (RN B and D) of three RNs and one LVN observed and two residents (Residents #1 and #2) of six reviewed for medication administration during the medication pass. There were six errors out of 55 opportunities. a. Resident #1 received five different eye drops to his left eye without leaving five minutes between each resulting in four errors. b. Resident #2 received Potassium Chloride Extended Release without food. c. Resident #2 did not receive Calcium [MEDICATION NAME] within the scheduled time. These failures could place 12 residents assigned to RN A and D at risk for not receiving the intended therapeutic benefits from their medications and a decline in health status The findings included: 1. Record review of Resident #1's "Patient Record" revealed a [AGE] year old male who was admitted on [DATE] after a motor vehicle accident. Record review of Resident #1's "Pediatric Consultation" dated 01/11/13 revealed he was status [REDACTED]. Record review of Resident #1's physician's orders [REDACTED]. "[MEDICATION NAME] 14 mg/ml ophthalmic, give one drop left eye every four hours. Leave 5 minutes or more between drops. Prednisonlone Acetate 2% Ophthalmic, one drop left eye every four hours. Leave 5 minutes or more between drops. [MEDICATION NAME] 2% Ophthalmic, one drop left eye two times per day. Leave 5 minutes or more between drops. Dorzolamide + [MEDICATION NAME] 2%-0.5%, one drop left eye every four hours. Leave 5 minutes or more between drops. Moxifloxacin 0.5% Ophthalmic, one drop left eye every three hours. Leave 5 minutes or more between drops." Observation on 01/15/13 at 8:55 a.m. during routine medication pass revealed RN D gave Resident #1 the following eye drops in his left eye in the order listed and one immediately after the next without waiting 5 minutes between drops. First-Gentak ([MEDICATION NAME] 14 mg/ml) ophthalmic, one drop in his left eye, Second-Prednisonlone Acetate 2% Ophthalmic, one drop in his left eye, Third-[MEDICATION NAME] 2% Ophthalmic, one drop in his left eye, Fourth-Dorzolamide + [MEDICATION NAME] 2%-0.5%, one drop in his left eye, and Fifth-Vigomox (Moxifloxacin) 0.5% Ophthalmic, one drop in his left eye. In an interview on 01/15/13 at 3:30 p.m. RN D said that she had not waited 5 minutes between each eye drop that she had administered to Resident #1. RN D said that Resident #1's computerized Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RN D reviewed the original physician orders [REDACTED]. RN D said that she had not researched the eye drops to determine the recommended spacing between the eye drops. In an interview on 01/15/13 at 01/17/13 at 8:30 a.m. Pharmacist A said that when the pharmacy received the scanned physician's order [REDACTED]. "[MEDICATION NAME] Opthalmic - Antibiotic used to treat eye infections. If you are to use more than one drop in the same eye, wait at least 5 minutes before instilling the next drop." Source dated 01/23/13: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 9.html> "Prednisonlone Acetate 2% Ophthalmic - indicated for the treatment of [REDACTED].rxlist.com/script/main/art.asp?articlekey=3979> of the eye ...If you use more than one drop in the same eye, wait about 5 minutes before putting in the next drop." Source dated 01/23/13: <http://www.rxlist.com/pred-forte-drug/patient-how-to-take.htm> "[MEDICATION NAME] Ophthalmic - used to relieve pain caused by swelling and inflammation of the eye... If you are to use more than one drop in the same eye, wait at least 5 minutes before instilling the next drop." Source dated 01/23/13: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 7.html> "Dorzolamide + [MEDICATION NAME] 2%-0.5% - used in treatment of [REDACTED]." Source dated 01/23/13: <http://www.drugs.com/uk/dorzolamide-[MEDICATION NAME]-eye-drops-spc- .html> "Moxifloxacin ([MEDICATION NAME]) - Antibiotic used for eye infections ...wait at least five minutes before applying the other medications." Source dated 01/23/13: <http://www.medicinenet.com/moxifloxacin-ophthalmic/article.htm> 2. Record review of Resident #2's "Patient Record" revealed a [AGE] year old female who was admitted on [DATE] for post fall pain control. Record review of Resident #2's "History and Physical" dated 12/20/12 revealed [DIAGNOSES REDACTED]. Record review of Resident #2's Physican's Orders 01/08/13 revealed the following orders: Potassium Chloride ER Capsule 20 meq. by mouth two times per day. Calcium [MEDICATION NAME] one tablet by mouth three times per day. Observation on 01/15/13 at 10:15 a.m. during routine medication pass revealed RN B gave Resident #2 two capsules of Potassium Chloride extended release 10 meq. at 10:15 a.m. Resident #2 had not eaten breakfast and no food was offered with the medication. Resident #2 did not receive the physician ordered calcium [MEDICATION NAME] scheduled for 9:00 a.m. In an interview on 01/15/13 at 10:00 a.m. RN B said that there was no Calcium [MEDICATION NAME] in the Pyxis? MedStation (automated medication dispensing cabinet). RN B said that she would send a request to the pharmacy which she did now electronically from the Pyxis MedStation. Record review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] In an interview on 01/15/13 at 01/17/13 at 8:30 a.m. Pharmacist A said that calcium [MEDICATION NAME] was routinely stocked on all Pyxis? MedStation. She said they have a system in place to alert the pharmacy to refill the medications when the Pyxis? MedStation was empty of a medication, however, sometimes they get behind due to the workload. Pharmacist A said that the calcium [MEDICATION NAME] vendor was not sending the medication using the bubblepack method and they were having to bubblepack the calcium [MEDICATION NAME] in the pharmacy which delayed getting the medication to the floor's Pyxis? MedStation. Pharmacist A said that the pharmacy does not routinely put the instructions that Potassium chloride should be taken with food. She said that the old system automatically put the instructions to take potassium chloride with food but the current one did not so each person would have to manually put these instructions in the system. "Potassium chloride- used to prevent or to treat low blood levels of potassium ...Take potassium chloride with food or just after a meal." Source dated 01/12/13: <http://www.drugs.com/potassium_chloride.html> "Calcium [MEDICATION NAME]- used to prevent and to treat calcium deficiencies." Source dated 01/22/13: <http://www.drugs.com/mtm/calcium-[MEDICATION NAME].html> Record review of facility provided Nursing Policy (Index 5.0316) dated 11/13/12 revealed, "Subject: Medications - Standardized Medication Times Purpose: To provide access to standardized medication administration times ensuring that the patient receives appropriate dosing in a 24-hour period. RULES: ....5. Scheduled medications may be administered within 1 hour prior or 1 hour after scheduled medication times. Medication given outside this window would constitute a medication error ... Standard Medication Administration Guidelines - Three times a day 0900, 1500, and 2100" Record review of posted nurse assignment schedule dated 01/15/13 revealed RN A was assigned to give medications to six residents and RN D was assigned to give medications to six residents.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 6 residents (Residents' #1 and #2) reviewed for medication administration during the medication pass. a. Resident #1 received five different eye drops to his left eye without leaving five minutes between each resulting in four errors. b. Resident #2 received Potassium Chloride Extended Release without food. c. Resident #2 did not receive Calcium Citrate within the scheduled time. These failures could place 12 residents assigned to RN A and D at risk for not receiving the intended therapeutic benefits from their medications and a decline in health status The findings included: 1. Record review of Resident #1's "Patient Record" revealed a [AGE] year old male who was admitted on [DATE] after a motor vehicle accident. Record review of Resident #1's "Pediatric Consultation" dated 01/11/13 revealed he was status [REDACTED]. Record review of Resident #1's physician's orders [REDACTED]. "Gentamycin 14 mg/ml ophthalmic, give one drop left eye every four hours. Leave 5 minutes or more between drops. Prednisonlone Acetate 2% Ophthalmic, one drop left eye every four hours. Leave 5 minutes or more between drops. Atropine 2% Ophthalmic, one drop left eye two times per day. Leave 5 minutes or more between drops. Dorzolamide + Timolol 2%-0.5%, one drop left eye every four hours. Leave 5 minutes or more between drops. Moxifloxacin 0.5% Ophthalmic, one drop left eye every three hours. Leave 5 minutes or more between drops." Observation on 01/15/13 at 8:55 a.m. during routine medication pass revealed RN D gave Resident #1 the following eye drops in his left eye in the order listed and one immediately after the next without waiting 5 minutes between drops. First-Gentak (Gentamycin 14 mg/ml) ophthalmic, one drop in his left eye, Second-Prednisonlone Acetate 2% Ophthalmic, one drop in his left eye, Third-Atropine 2% Ophthalmic, one drop in his left eye, Fourth-Dorzolamide + Timolol 2%-0.5%, one drop in his left eye, and Fifth-Vigomox (Moxifloxacin) 0.5% Ophthalmic, one drop in his left eye. In an interview on 01/15/13 at 3:30 p.m. RN D said that she had not waited 5 minutes between each eye drop that she had administered to Resident #1. RN D said that Resident #1's computerized Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RN D reviewed the original physician orders [REDACTED]. RN D said that she had not researched the eye drops to determine the recommended spacing between the eye drops. In an interview on 01/15/13 at 01/17/13 at 8:30 a.m. Pharmacist A said that when the pharmacy received the scanned physician's order [REDACTED]. "Gentamycin Opthalmic - Antibiotic used to treat eye infections. If you are to use more than one drop in the same eye, wait at least 5 minutes before instilling the next drop." Source dated 01/23/13: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 9.html> "Prednisonlone Acetate 2% Ophthalmic - indicated for the treatment of [REDACTED].rxlist.com/script/main/art.asp?articlekey=3979> of the eye ...If you use more than one drop in the same eye, wait about 5 minutes before putting in the next drop." Source dated 01/23/13: <http://www.rxlist.com/pred-forte-drug/patient-how-to-take.htm> "Atropine Ophthalmic - used to relieve pain caused by swelling and inflammation of the eye ... If you are to use more than one drop in the same eye, wait at least 5 minutes before instilling the next drop." Source dated 01/23/13: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 7.html> "Dorzolamide + Timolol 2%-0.5% - used in treatment of [REDACTED]." Source dated 01/23/13: <http://www.drugs.com/uk/dorzolamide-timolol-eye-drops-spc- .html> "Moxifloxacin (Vigamox) - Antibiotic used for eye infections ...wait at least five minutes before applying the other medications." Source dated 01/23/13: <http://www.medicinenet.com/moxifloxacin-ophthalmic/article.htm> 2. Record review of Resident #2's "Patient Record" revealed a [AGE] year old female who was admitted on [DATE] for post fall pain control. Record review of Resident #2's "History and Physical" dated 12/20/12 revealed [DIAGNOSES REDACTED]. Record review of Resident #2's Physican's Orders 01/08/13 revealed the following orders: Potassium Chloride ER Capsule 20 meq. by mouth two times per day. Calcium citrate one tablet by mouth three times per day. Observation on 01/15/13 at 10:15 a.m. during routine medication pass revealed RN B gave Resident #2 two capsules of Potassium Chloride extended release 10 meq. at 10:15 a.m. Resident #2 had not eaten breakfast and no food was offered with the medication. Resident #2 did not receive the physician ordered calcium citrate scheduled for 9:00 a.m. In an interview on 01/15/13 at 10:00 a.m. RN B said that there was no Calcium Citrate in the Pyxis? MedStation (automated medication dispensing cabinet). RN B said that she would send a request to the pharmacy which she did now electronically from the Pyxis MedStation. Record review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] In an interview on 01/15/13 at 01/17/13 at 8:30 a.m. Pharmacist A said that calcium citrate was routinely stocked on all Pyxis? MedStation. She said they have a system in place to alert the pharmacy to refill the medications when the Pyxis? MedStation was empty of a medication, however, sometimes they get behind due to the workload. Pharmacist A said that the calcium citrate vendor was not sending the medication using the bubblepack method and they were having to bubblepack the calcium citrate in the pharmacy which delayed getting the medication to the floor ' s Pyxis? MedStation. Pharmacist A said that the pharmacy does not routinely put the instructions that Potassium chloride should be taken with food. She said that the old system automatically put the instructions to take potassium chloride with food but the current one did not so each person would have to manually put these instructions in the system. "Potassium chloride- used to prevent or to treat low blood levels of potassium ...Take potassium chloride with food or just after a meal." Source dated 01/12/13: <http://www.drugs.com/potassium_chloride.html> "Calcium citrate- used to prevent and to treat calcium deficiencies." Source dated 01/22/13: <http://www.drugs.com/mtm/calcium-citrate.html> Record review of facility provided "Instillation of Eye Medications" page 582, undated, revealed, "....9.If additional eyedrops are ordered, wait 30 seconds between each drop to allow time for absorption of medication." Record review of facility provided Nursing Policy (Index 5.0316) dated 11/13/12 revealed, "Subject: Medications - Standardized Medication Times Purpose: To provide access to standardized medication administration times ensuring that the patient receives appropriate dosing in a 24-hour period. RULES: ....5. Scheduled medications may be administered within 1 hour prior or 1 hour after scheduled medication times. Medication given outside this window would constitute a medication error ... Standard Medication Administration Guidelines - Three times a day 0900, 1500, and 2100" Record review of posted nurse assignment schedule dated 01/15/13 revealed RN A was assigned to give medications to six residents and RN D was assigned to give medications to six residents.

Based on interviews and record reviews the facility failed to develop the comprehensive plan of care for six (Resident #1, 2, 3, 4, 5, 7) of 8 sampled residents. The facility failed to: a. develop a plan of care for Resident #1 related to nutrition, hydration, pressure sore, ADL dependence, bladder/bowel incontinence, physical therapy, occupational therapy, speech therapy, risk for infection, risk for blot clots, and complications related to his eye injury. b. develop a plan of care for Resident #2 related to nutrition, constipation, mental status, skin integrity, [MEDICAL CONDITION], PT/OT, oxygen, power port used to administer IV medications, ADL assistance, fall risk, history of depression and use of [MEDICATION NAME] and HTN c. develop a plan of care for Resident #3 related to infection and use of IV antibiotics, weakness and fall risk, oxygen use, double lumen PICC line, pain, use of psychoactive medications, PT/OT, assistance with ADLs and history of HTN, [MEDICAL CONDITION] and [MEDICAL CONDITION] d. develop a plan of care for Resident #4 related to her fall and identified increased risk for falls, implementation of chair/bed alarm, skin tears with one of these resulting in the need for a wound VAC (vacuum-assisted drainage to remove blood or serous fluid from a wound), stage 1 pressure ulcer, use of coagulation therapy, and ADL care. This failure could affect any of the 18 residents in the facility that do not get a plan of care developed to meet their needs, by placing them at risk of not receiving the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Findings include: 1. Record review of Resident #1's Patient Record (undated) revealed he was a [AGE] year old male admitted to the facility on [DATE]. Record review of Resident #1's History and Physical dictated 12/17/12 revealed he was in a motor vehicle accident and suffered multiple fractures to his face, a laceration to his back, multiple cuts to his face, rupture of his left eye, severe cut to the left ear and a [MEDICAL CONDITION]. Record review of Resident #1's Pediatric Consultation dictated 01/11/13 revealed he was one month post motor vehicle accident where he suffered a [MEDICAL CONDITION], severe laceration to the left side of his face and head, and rupture of his left eye. Resident #1 had a [MEDICAL CONDITION] (a hole cut in the trachea for artificial airway) and gastrostomy (surgical opening for feeding tube). Observation on 01/16/13 at 9:30 a.m. revealed Resident #1 resting in bed, a black patch over his left eye, [MEDICAL CONDITION] to throat, the head of the bed elevated, a catheter bag hanging to the lower part of his bed, and his mother at his bedside. In an interview on 01/15/12 at 12:00 p.m. Resident #1's mother said he was a "normal" teenager prior to the accident. She described Resident #1 as a happy, healthy, very active teenager enjoying the normal challenges of high school. She said immediately after the accident, Resident #1 suffered brain trauma and has been unresponsive. She said he has improved since the accident, but was completely dependent on the staff for needs. She said he had a feeding tube for his nutritional needs. She said he could not walk or talk. She said he was receiving extensive physical therapy. Record review of Resident #1's physician's orders [REDACTED]. [MEDICATION NAME] with [MEDICATION NAME] 120mg/10mg every three hours as needed for pain Dorzolamide + [MEDICATION NAME] 2%-0.5%, one drop to left eye, two times a day (used to lower the pressure in the eye) [MEDICATION NAME] 30mg, subcutaneous injection two times a day (used to prevent blood clots) [MEDICATION NAME] 10mg, oral two times a day (used to treat heartburn) [MEDICATION NAME] Acetate 0.12%, one drop to left eye, six times a day (used to treat eye inflammation) [MEDICATION NAME] 1% Ophthalmic, one drop to left eye, two times a day (used to relieve pain caused by swelling and inflammations of the eye) [MEDICATION NAME] 14mg/ml Ophthalmic, one drop to left eye, six times a day (antibiotic for the eye) Moxifloxacin 0.5% Ophthalmic, one drop to the left eye, every three hours (antibiotic for the eye) Sequential Compression Device (used to prevent blood clots in the legs) [MEDICAL CONDITION] Care every 12 hours Vital 1.5 Cal, one can every four hours (tube feeding formula) Flush peg tube (feeding tube) every six hours with 200 ml of water with each feeding Elevate the head of the bed at 45 degrees for feedings and two hours after Up to chair four times a day as tolerated Chest Physiotherapy every 12 hours (used to mobilize or loosen secretions in the lungs) Physical Therapy Occupational Therapy Speech Therapy Record review of Resident #1's Plan of Care dated 01/10/13 revealed the following problems: Impaired Physical Mobility Impaired Skin Integrity Impaired Verbal Communication Altered Mental Status Impaired Airway Clearance Knowledge Deficit Ineffective Coping: Family Altered Comfort: Pain Record review of Resident#1's Assessment and Cares dated 01/14/13 revealed the following: Cognitive/Perceptual/Neuro: Level of Consciousness: unresponsive Speech: unable to speak Motor Response: withdraws Pupil Accomodation: Right- Absent Glasgow Coma Scale: 9 Respiratory: Airway: size 6 Shiley Nutrition: Diet/Nutrition: NPO (nothing by mouth) Tube Feeding Gastrointestinal: Fecal Incontinence PEG (percutaneous endoscopic gastrostomy) Tube [MEDICAL CONDITION]: Incontinence External Catheter Applied, Skin Care Provided Musculoskeletal: active range of motion severely impaired Skin: healing lacerations, small pressure ulcer [MEDICAL CONDITION] right side Braden Score: 12 In an interview on 01/17/13 at 10:20 a.m. RN E confirmed she was the primary care nurse for Resident #1. She explained each shift it was the primary care nurse's responsibility to update the care plan. She stated the nurses were limited to only update with the problems available in the computer system. She explained the computer program did not allow for any free hand typing. RN E confirmed Resident #1 did not have Care Plans to meet all of his assessed needs. She said bladder/bowel incontinence, nutrition, hydration, total dependency on ADL Care, complications related to his eye injury, potential for infection, pressure sore, physical therapy, occupational therapy, speech therapy, risk for infection, and risk for blot clots were all care concerns identified for Resident #1 that could have been care planned. 2. In an interview during initial tour on 01/15/2013 at 7:00 a.m., LVN A said that Resident #2 was admitted post fall with fractures to back and pain control. LVN A said that Resident #2 was pretty much bedbound and required assist x 2 when getting up. She said that Resident #2 was receiving PT/OT and [MEDICAL CONDITION] therapy. LVN A said that Resident #2 had a foley catheter. She said that Resident #2 was alert but confused, had depression and received [MEDICATION NAME]. LVN A said that Resident #2 had pain and received [MEDICATION NAME] every 12 hours. LVN A said that Resident #2 had a stage I to buttocks and both heels. LVN A said that Resident #2 was a risk for falls, required assistance x1 with ADLs and used oxygen prn. Observation during initial tour revealed a fall risk sign on Resident #2's door. Record Review of Resident #2's Patient Record revealed a [AGE] year old female admitted on [DATE]. Record Review of Resident #2's History and Physical dictated 12/20/2012 revealed the following Diagnoses: [REDACTED]. Record Review of Resident #2's Patient Orders revealed the following orders: [MEDICATION NAME] (medication given for depression) 20 mg daily [MEDICATION NAME] injectable (medication given for agitation or muscle spasm) 5 mg IV every 4 hours prn [MEDICATION NAME] injectable (medication given for pain) 6-8 mg IV every 2 hours prn Bedrest with bathroom privileges Indwelling Foley catheter Beclomethasone (inhaled corticosteroid used to treat asthma) Inhaler 80 mg give 2 puffs twice daily O2 by TDP OT treatment PT treatment [MEDICAL CONDITION] consult and treatment Record Review of Resident #2's Plan of Care dated 01/14/2013 revealed the following problems: Altered comfort: nausea/vomiting Altered comfort: Pain Altered urinary elimination Impaired physical mobility Potential for injury Record Review of Resident #2's Admission Profile dated 01/08/2013 revealed: Under section general information, treatment prior to arrival- oxygen; intravenous medication Under section Pain Assessment- complains of pain/discomfort Under section Current Health and Illness- [MEDICAL CONDITION] treatment Under section past Medical/Surgical History- cancer, depression, Hypertension Under section Cardiac- hypertension Under section Gastrointestinal/[MEDICAL CONDITION]- patient unable to void after most recent catheter removal Under section Skin- stage I to buttocks and heels Record Review of Resident #2's Assessment and Cares dated 01/15/2013 revealed the following: Safety- Fall risk score: 70 Cognitive/Perceptual/neuro- Level of Consciousness: confused, lethargic/somnolent Orientation: reorient to time, situation and place Speech: slurred Skin- Location/stage: left and right buttock and heels stage I Access/ Monitoring Devices- Vascular access port Location and type: right single lumen powerport (under the skin IV access for administering IV medications) [MEDICAL CONDITION]- GU voiding characteristics: foley Musculoskeletal- Extremity movement: upper and lower extremities with moderate impairment Ambulation: assistive equipment and person Transferring: Assistive equipment and person Toileting: assistive equipment and toileting Bathing: assistive person Dressing: assistive person Nutrition- Intake: 0% Observation on 01/15/2013 at 10:00 a.m. revealed Resident #2 in bed with RN B in room with her to assess. Resident was lethargic, confused with slightly slurred speech. Resident #2 had a foley to gravity draining at bedside. Her breakfast is on the overbed table untouched. Resident #2 was wearing O2 at 2 LPM via N/C. Resident #2 moans when ever she is moved. RN B and CNA A turned and repositioned Resident #2. Resident #2's buttocks and heels noted to be pink and blanched In an interview on 01/15/2013 at 10:50 a.m., RN A reviewed Resident #2's oral nutritional intake for past few days and documentation revealed that Resident #2's intake had been between 0 and 25%. RN A said that Resident #2 eats better when her spouse brings food into her but that altered nutrition should be added to Resident #2's care plan "since she is consistently not eating well" . RN A said that Resident #2's mental status has declined and that the doctor is trying to rule out or confirm brain metastasis from the resident ' [MEDICAL CONDITION]. RN A said that altered mental status should be added to Resident #2's care plan. RN A said that the powerport (under the skin IV access for administering IV medications) usually is not care planned but impaired skin integrity could be added since Resident #2 has a stage I to her buttocks and heels. When questioned about the type and amount of ADL assistance that Resident #2 requires, RN A said that the nurses put that information in the clinical summary. She said that Resident #2's fall risk is captured under the impaired mobility and that fall risk is not care planned separately. RN A did agree that potential for constipation exists for Resident #2 due to routine narcotic use due to pain. RN A said that the care plan process is still fairly new, been using it about a year, and that the nurses are still trying to figure out exactly how to do the care plans and how to manipulate through the system to address all of the residents problems. 3. In an interview during initial tour on 01/15/2013 at 6:50 a.m., LVN A said that Resident #3 was admitted for dehydration and failure to thrive. LVN A said that Resident #3 was alert and oriented but forgetful. LVN A said that Resident #3 was ambulatory with standby assistance x 1 with a walker, continent of bowel and bladder and required assistance x 1 with ADLs. LVN A said that Resident #3 was weak and was receiving PT and OT. LVN A said that Resident #3 was receiving IV antibiotics and used oxygen. She said that Resident #3 was on an AHA diet and could feed herself. LVN A said that Resident #3 receives Clonopine but had no behaviors and received [MEDICATION NAME] prn for pain. Observation revealed a fall risk sign noted on Resident #3's door. LVN A said that Resident #3 was a risk for falls due to weakness. Record Review of Resident #3's Patient Record revealed a [AGE] year old female admitted to the facility on [DATE]. Record Review of Resident #3's History and Physical dictated 01/04/2013 revealed the following Diagnoses: [REDACTED]. Record Review of resident #3's Patient Orders revealed the following: [MEDICATION NAME]+ [MEDICATION NAME] 325- 7.5 mg 1 tablet 3 times a day prn for moderate pain (4-7). [MEDICATION NAME] (medication used to treat hypertension) 5 mg daily [MEDICATION NAME] (medication used to treat panic disorders and certain types of [MEDICAL CONDITION]) 0.5 mg at bedtime HepLock flush 300 units every 12 hours [MEDICATION NAME] 15 mg at bedtime prn for [MEDICAL CONDITION] [MEDICATION NAME] (an antibiotic) 2 Gm IVPB every 24 hours Dressing change for PICC weekly per central line dressing protocol Diet: AHA O2 at 2 LPM by TDP OT treatment PT treatment Record Review of Resident #3's Care Plan revealed the following problems Fluid volume deficit Altered nutritional status Record Review of Resident #3's Admission Profile dated 01/09/2013 revealed the following: Under section current treatment being received- physical therapy; PT/OT under section past medical/ surgical history- [MEDICAL CONDITIONS] and Hypertension. Under section Current Level of Functioning- Ambulation- assistive equipment and person Transferring- assistive equipment and person Toileting- assistive equipment and person Bathing- assistive person Dressing- assistive person under safety Record Review of Resident #3's Assessment and Cares dated 01/15/2013 revealed: Under safety a fall risk score of 60. Under Access/Monitoring Devices- Right double lumen PICC line Under Musculoskeletal- extremity movement bilateral upper and lower mildly impaired Ambulation- assistive equipment and person Transferring- assistive equipment and person Toileting- assistive equipment and person Bathing- assistive person Dressing- assistive person Observation on 01/15/2013 revealed Resident #3 sitting on side of the bed. She had just finished eating her breakfast. She was wearing O2 via N/C at 2 LPM. A double lumen access was seen hanging from under the right sleeve of her gown. While visiting with the resident, she had to toilet. CNA A came to the room to assist the resident with toileting. Resident #3 was able to stand from the side of her bed and ambulated to the bathroom with a walker with stand by assistance from the CNA. In an interview on 01/15/13 at 10:40 a.m., RN A said that the nurse who admits the resident to the floor initiates the care plan. She said that the resident ' s primary nurse can and should go into the care plan and add problems or resolve problems as it pertains to the residents care. RN A said that the nurses can look at and address the care plan every shift. RN A said that "Resident #3's care plan definitely should have included the antibiotic since she is still on it." RN A looked at the medications that Resident #3 had received for pain since her admission and RN A said that "yes pain should have been addressed since she has been getting her pain medication." RN A agreed that Resident #3 was identified as a risk for falls due to weakness and that her weakness/ impaired mobility should have been addressed on the care plan. When questioned about Resident #3's use of oxygen, RN A looked at a chest x-ray for Resident #3 and said yes she had a pleural effusion so we could have care planned impaired gas exchange. RN A said that there was not a place on the care plan to address the resident ' s ADL care or assistance needed. When questioned about Resident #3's orders for [MEDICATION NAME] and [MEDICATION NAME] (both are psychoactive meds), RN A said that she would not necessarily care plan those medications unless the medications impaired the resident in some way such as confusion. RN A said that the peripheral lines, IV sites or mediports are never care planned to her knowledge. 4. In an interview during initial tour on 01/15/13 at 6:40 a.m. RN C said that Resident #4 was admitted for pneumonia and [MEDICAL CONDITION], was doing well and almost ready to be discharged and had a fall in the bathroom resulting in a skin tear to her left calf area. RN C said that the skin tear on her left calf was being treated by physical therapy and she would be receiving a wound VAC today. (Vacuum-assisted closure is a sophisticated development of a standard surgical procedure-the use of vacuum-assisted drainage to remove blood or serous fluid from a wound.). RN C said Resident #4 was alert, oriented, and required assistance of one staff for ambulation with a walker. Record review of Resident #4's "Patient Record" revealed an [AGE] year old female who was admitted on [DATE] for pneumonia and [MEDICAL CONDITION]. Record review of Resident #4's "History and Physical" dated 12/26/12 revealed [DIAGNOSES REDACTED]. Record review of Resident #4's only MDS revealed she was admitted on [DATE] from acute hospital and assessment reference date was 12/31/12. Record review of Resident #4's Patient Orders revealed the following orders: Aspirin [MEDICATION NAME] coated 81 mg by mouth daily dated 12/24/12 [MEDICATION NAME] ([MEDICATION NAME]) injectable 40 mg subcutaneous everyday 12/24/12 Wound care treatment dated 01/01/13 Wound care treatment - Physical therapy - change dressing daily with wet to dry dated 01/11/13 Wound Care - Physical therapy-VAC, Try to place wound vac to left lower extremity wound dated 01/15/13 Record review of Resident #4's "Plan of Care" dated 12/24/12 (admission) revealed: "Problem #1-Anxiety Problem #2-Impaired Physical Mobility Problem #3-Impaired airway clearance Problem #4-Impaired skin integrity " This plan of care had not been updated since admission. Record Review of Resident #4's Admission Profile dated 12/24/12revealed: Cardiac: Hypertension Gastrointestinal/[MEDICAL CONDITION]: constipation Current Level of Functioning: Ambulation (3) assistive equipment and person Transferring (3) assistive equipment and person Toileting (3) assistive equipment and person Bathing (2) assistive person Dressing (2) assistive person Eating (0) independent Skin: Bruising Hematological: Bruises easily Record review of Resident #4's "Event Detail History with all Tasks" dated 12/31/12 at 5:00 a.m. revealed: "Patient stated turned to sit on toilet and lost her footing, fell into shower stall ....Skin tear was sustained from the fall on the left lower leg ...Patient education provided to patient regarding fall precautions. ..Patient now high fall risk and bed and chair alarm will be implemented ....Patient did sustain a small hematoma to left upper eye. Patient on anticoagulant therapy " Record Review of Resident #4's Assessment and Cares dated 01/14/13 revealed the following: "Skin Stage 1 to left buttocks Braden score 17 - assess skin more frequently for pressure damage, as the patient may not be able to report pain Body location: Right arm, dressing dry, unable to visualize wound base Body location: Left shoulder, dressing intact, [MEDICATION NAME] thin, unable to visualize wound base Body location: Left arm, dressing intact, unable to visualize wound base Body location: Left calf, dressing dry, intact, wound base per physical therapist. Safety Fall Risk Score: 65 High fall risk score of over 50 on the Morse fall scale: Instruct patient to call for assistance prior to getting out of bed. Use treaded socks/slippers. Instruct patient to exit bed on stronger side. Fall precaution sign on patient door. Assist to bathroom. Bed/chair alarms in use." There was no care plan related to her increased risk for falls. Record Review of Resident #4's Assessment and Cares dated 01/16/13 revealed the following: "Skin Left upper calf - drain/device insertion site - dressing intact, small amount serosanquineous drainage, vacuum assisted closure continuous therapy at lower intensity setting". Observation on 01/16/13 at 1:15 pm. revealed LVN B assessed Resident #4's skin and dressings. Observed a dressing on the back of her right shoulder (dated 01/10/13) was dry and intact, dressing on left elbow area (dated 01/15/13) was dry and intact. Observed the left lower leg was wrapped with gauze which was dry and intact. LVN B said that the gauze on her left lower leg was covering the wound VAC that was applied yesterday by physical therapy. Observed a stage 1 pressure ulcer to her left buttocks. Observed bruising that started above her left eyebrow extended left to her hairline and down the right side of her face to her jaw line. This bruising was a very light bluish-brown in color. There was no care plan related to Resident #4's complications related to the skin tear and need for a wound VAC. In an interview on 01/16/13 at 1:15 p.m. Resident #4 said that the skin tears and bump and bruising above her left eyebrow was caused by a fall in the bathroom. 5. Record Review of Resident # 5 ' s Patient Record revealed a [AGE] year old female admitted on [DATE]. Record Review of Resident # 5 ' s History and Physical dictated 1/3/2013 revealed the following Diagnosis: [REDACTED]. Weight loss, Hypoxic Record Review of resident #5 ' s Patient Orders revealed the following: [MEDICATION NAME] E 4.25% D5 with Lytes, Intravenous continuous at 75 ml/hr. [MEDICATION NAME] 100 mg. oral 2 times per day Klonopin 1 mg oral 2 times per day Lovnox 30 ml Subcutaneous daily [MEDICATION NAME] LA tablet 600 mg oral every 12 hours [MEDICATION NAME] 400 mg, Oral 2 times per day after meals [MEDICATION NAME], 1 packet Oral daily [MEDICATION NAME] 88mcg, Oral before breakfast daily [MEDICATION NAME] XL 30 mg Oral, Daily Pantoprazole injectable, 40 mg Intravenous daily (Dilute with 10 ml NS and give over 2 minutes. [MEDICATION NAME] 20g/30 ml, Oral 2 times per day [MEDICATION NAME] Tablet 0 mg Oral after breakfast [MEDICATION NAME] 3252 mg, orally every 4 hours PRN for Mild Pain (1-3) or Temp >101 [MEDICATION NAME] Rectal. 10 mg, Rectal 2 times per day PRN for no BM [MEDICATION NAME] 0.1 mg, Oral every 4 hours PRN for SBP150 mmHg or DBP>90 mmHg [MEDICATION NAME] 0.5 mg IV every 8 hours PRN Magnesium [MEDICATION NAME] 30 ml, Oral PRN for Constipation [MEDICATION NAME] 12.5 mg IV every 4 hours PRN for Nausea/vomiting [MEDICATION NAME] + [MEDICATION NAME] 325mg/5mg, Give 1 tablet Oral every 4 hours PRN for Moderate Pain (4-7), Special Instructions: Max 4 grams / 24 hr. from all sources of [MEDICATION NAME]. Monitor for possible allergic reaction Activity - 2 times per day, up in chair; Out of bed with assistance Intake & Output, Strict - Every 12 hours Vital signs - Every 8 Hours Weight Daily Anti-Embolism Stockings, Knee Length Indwelling Foley Catheter to Gravity Diet High Protein High Calorie - Mechanically Altered/Ground Ensure Clinical Strength - Oral 1bottle three times per day [MEDICATION NAME] Inhalation, Give 2.5 mg Inhalation 4 times per day Bi-level Positive Airway Pressure ([MEDICAL CONDITION]) - Daily, Instructions O2 per TDO [MEDICAL CONDITION] 8/4 cm H2o as necessary to maintain Saturation greater than or = to 92% PRN for low 02 sats. [MEDICATION NAME] Inhalation, Give 0.5 mg Inhalation 2 times per day [MEDICATION NAME] 0.5 mg/2.5 ml Inhalation, Give 2.5 ml Inhalation 4 times per day. O2 by TDP Consult Dietician Consult OT PT Treatment Record Review of Resident # 5 ' s Care Plan dated 1/13/2013 revealed the following problems: Impaired Gas Exchange Altered Urinary Elimination Altered nutritional status Record Review of Resident # 5 ' s Admission Profile dated 01/10/2013 revealed: Under section general information, treatment prior to arrival -antibiotic within 24 hours; intravenous. Under section Current Health and illness; had pneumonia. Under section past medical/ surgical history- [MEDICAL CONDITION]; GERD; Hypertension, Kidney Disease, Cholecystectomy, Hysterectomy, Abdominal scar tissue removal. Record Review of Resident # 5 ' s Assessment and Cares dated 01/14/2013 revealed: Safety, fall risk score 60 Access Monitoring Device, Peripheral IV, IV dressing, daily evaluation; IV device patency placement Nutrition, Intake 25%, High Protein High Calorie; tray set-up [MEDICAL CONDITION]; indwelling double lumen catheter, Size 16 Fr., drainage bag to dependent drainage. Sleep/Rest, Pt. appears very tired; her eyes closed as she talks Peripheral Neurovascular: Antiembolic Interventions: ambulation promoted; anticoagulant adjustment; positioning; active ROM performed; passive ROM performed; compression stockings on. Musculoskeletal; Transferring- assistive equipment and person Toileting- assistive equipment and person Bathing- Assistive person Dressing- Assistive person Eating - Assistive person Under section Current Level of Functioning-Musculoskeletal, dated 1/17/13 Ambulation- Active level of assistance: w/1-person assist Positioning: w/ 1 person assist Under Musculoskeletal- full active movement of all extremities Under Skin assessment dated [DATE] Assess skin more frequently for pressure damage, as the patient may not be able to report pain Activity: Limit sitting to one hour or less Mobility: Turn & reposition every 2 hours or sooner if at risk (30 degrees lateral only). Use positioning aids as needed i.e., pillows, wedges, foot drop etc. Nutrition: Consult dietician (Supplements, calorie count, nutritional assessment, etc.) Consider patient food preferences; encourage eating if allowed, Encourage fluids (2000 cc/24 hrs.) If medical condition allows. Friction & Shear: Use draw sheet, Consider PT referral if indicated for transfers Location /Stage: Coccyx Stage I, Pressure Ulcer Appearance, reddened Hygiene care: Linen change, perineal care Coping: Observe Emotional State: Calm, cooperative Observation on 1/15/2013 a 2:00 p. m. revealed resident #5 lying in bed resting, she had just completed Physical Therapy, she was wearing O2 at 6 LPM per NC, her head of bed was elevated to a sitting position, she had a neck pillow in place, she had a peripheral IV in her left arm infusing Clenimix at 75 c/hr., she also had an indwelling Foley catheter with drainage bag to dependent drainage. Resident #5 stated that she was getting up in the bedside chair twice a day for about an hour, that she was wearing TED hose but she asked them to remove them because they were too tight. She stated they changed her position every couple of hours, and she stated she did not have any pressure sores at this time. In an interview 01/17/2013 at 8:50 a.m. with RN C she stated the computer program they have available to them does not have very many options to utilize when care planning, she stated that they are not allowed to hand write anything in the clinical record. She stated they are working on revising the program to be more units specific to meet the needs for the patients on the skilled unit regarding the care plan process. She stated it is a very time consuming process due to all the people that are involved. She also stated that if she was allowed she would include care plans; problems and interventions that were specific to the residents such as Resident #5, she would include: IV site, Falls, Ted Hose, ALD ' s, Depression, Strict I/O, Foley catheter, pressure ulcers, incontinence, and Activities. 6. Record Review of Resident #7 ' s Patient Record revealed an [AGE] year old female admitted on [DATE]. Record Review of Resident # 7 ' s History and Physical dictated 1/4/2013 revealed the following Diagnosis: [REDACTED]., [MEDICAL CONDITION], Hypertension, Goiter, Urinary Tract Infection. Record Review of resident #7 ' s Patient Orders revealed the following: [MEDICATION NAME] 650 mg, orally every 3 hours PN for mild pain or temperature greater than 101F [MEDICATION NAME] Rectal 650 mg Rectal every 4 hours PRN for Mild Pain (1-3) or Temp > 101 [MEDICATION NAME] 0.25 mg, Oral Every 8 hours PRN for Anxiety Aluminum [MEDICATION NAME] + [MEDICATION NAME] 200 mg. give 30 ml Oral Every 2 hours PRN for indigestion [MEDICATION NAME] 1 [MEDICATION NAME] Oral Every 1 hour PRN for throat discomfort [MEDICATION NAME] 10 mg Oral at Bedtime PRN constipation [MEDICATION NAME] 5 mg Rectal Daily PN constipation Fat [MEDICATION NAME] 20% IVPB 500 ml IVPB every 1 week infuse over 8 hours Magnesium [MEDICATION NAME] 8% 30 ml orally every 2 Hours PRN constipation [MEDICATION NAME] injectable 5 mg IV every 1 hour PRN for pain [MEDICATION NAME] Injectable 2 mg IV every 1 hour PRN for moderate Pain (4-7) [MEDICATION NAME] Injectable 6 mg IV every 1 hour PRN for severe pain (8-10) [MEDICATION NAME] Injectable 4 mg IV every 1 hour PRN for moderate pain (4-7) [MEDICATION NAME] Injectable 3 mg IV every 1 hour PRM for Severe Pain (8-10) [MEDICATION NAME] Injectable 12.5 mg IV every 4 hours PRN for Nausea/Vomiting Sodium Chloride 0.9% Flush Injectable 10 ml flushes every 12 hours Special instruction to each port [MEDICATION NAME] + [MEDICATION NAME] 8mg - 10 mg Give 5 ml every 8 hours PRN for cough Pantoprazole Injectable 40 mg IV every 12 hours [MEDICATION NAME] 0.1 mg/24 hr. [MEDICATION NAME] every week [MEDICATION NAME] Injectable 60 mg Subcutaneous Daily Dressing change for PICC weekly per central line dressing change Intake & Output, Strict No B/P, Injection, Venipuncture - Right, Upper Arm Vital signs every 4 hours Diet Soft - Easy to digest O2 by TDP Consult Dietician (regarding protein supplements) Consul Social Services / Case Management/ IP Hospice to possible transition to NH at a later date Consult Physical Therapy for evaluation and treat, Wound care Record Review of Resident # 7 ' s Admission Profile dated 01/10/2013 revealed the following: Under section general information, treatment prior to arrival - intravenous medication. Under section Current Health and Illness: not eating, weakness, inability to care for self. Under section past Medical/Surgical History-GERD, [MEDICAL CONDITION]; Hypertension, goiter. Under section Gastrointestinal/[MEDICAL CONDITION] -GERD; nausea, vomiting Under section Musculoskeletal-muscular weakness; gait, unsteady Under section Level of Functioning; Ambulation (3) assistive equipment and person Transferring (3) assistive equipment and person Toileting (3) assistive equipment and person Bathing (3) assistive equipment and person Dressing (2) assistive person Eating (2) assistive person Under section Mental Health; anxiety disorder Record Review of Resident #7 ' s Care Plan dated 1/13/2013 revealed the following problems: Altered Nutritional Status Impaired Skin Integrity Altered Comfort Record Review of Resident #7 ' s Assessment and Cares dated 01/14/2013 revealed: Safety, fall risk score 35 Fall precaution wristband, fall precaution on front of patient chart, fall precaution sign on patient door. Access/Monitoring Device; Picc Line, double lumen Nutrition; mechanical/dental sot, tray set up Incontinent Musculoskeletal, joint tenderness, back Extremity movement; Lower extremities, bilateral, active ROM mildly impaired Activity/Level of Assistance: HOD up 30-45 degrees; w/ 1-person assist; right side. Skin; Pressure Ulcer Stage III, coccyx, limit siting to 1 hour Turn and position every 2 hours or sooner, Use draw sheet, Keep HOB lower than 30 degrees Place minimal linen on bed, limit sitting to 1 hour Sensory perception slightly limited Mobility; movement/control of body movement slightly limited Nutrition, probable inadequate consider patient food preferences, encourage eating, and encourage fluids (2000 cc/24 hrs.) Assessment and Cares dated 1/15/2013Cognitive/Perceptual/Neuro; Level of consciousness; confused at times Musculoskeletal; Activity level of assistance; Positioning: HOB up 30-45 degrees; w/2 person assist. Skin; Hygiene care; bedtime care; incontinence; per patient w/1 assist In an interview 01/17/2013 at 8:50 a.m. with RN

Based on observation, interview and record review the facility failed to conduct a comprehensive assessment within 14 days after admission on 1 of 8 residents (Resident #4) reviewed. Resident #4 did not have an admission MDS (was due by 01/07/13). This failure placed four residents who had been admitted for at least 14 days at risk for not having their needs assessed with [REDACTED]. The findings included: Record review of Resident #4's "Patient Record" revealed an [AGE] year old female who was admitted on [DATE] for pneumonia and [MEDICAL CONDITION]. Record review of Resident #4's "History and Physical" dated 12/26/12 revealed [DIAGNOSES REDACTED]. Record review of Resident #4's only MDS revealed she was admitted on [DATE] from acute hospital and assessment reference date was 12/31/12. In an interview on 01/15/13 at 3:10 p.m. the MDS Coordinator said that she had not completed the Admission MDS (due on or before 14 days after admission which would be 01/07/13) for Resident #4. The MDS Coordinator said that she had selected another assessment reference date (from 12/31/12 to 01/10/13) and that Resident #4's MDS was not due by 14 days of admission because she was using her grace days. Record review of facility provided "MDS and Assessment Forms" dated 09/28/12 revealed, "...MDS (admission assessment) should be completed by day 14 ..." Record review of CMS RAI Version 3.0 Manual chapter 2, page 2-19, dated April 2012 reads, in part... "The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission .... ?Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being. This means it is imperative for nursing homes to assess a resident upon the individual's admission. The IDT may choose to start and complete the Admission comprehensive assessment at any time prior to the end of day 14..." Record review of "Patient Tracking" form dated 01/15/13 revealed four residents had been admitted for over 14 days.

Based on interviews and record reviews the facility failed to develop the comprehensive plan of care for three (Resident #1, #2,and #5 ) of 8 sampled residents. The facility failed to: a) develop a plan of care for Resident #1 related to high blood pressure, infection, assistance required for activities of daily living, pressure ulcer, and anticoagulant therapy b) develop a plan of care for Resident #2 related to low blood volume, high blood pressure, diabetes, infection, depression, blood disorder, nutrition and communication. c) develop a plan of care for Resident #5 related to the use of an indwelling catheter, nausea/comfort, nutritional status, oxygen use, anxiety, and the use of a central line for antibiotics. This failure could affect any of the 14 residents in the facility that do not get a plan of care developed to meet their needs, by placing them at risk of not receiving the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. The findings included: 1. Observation on 11/09/11 at 9:10 a.m. during initial tour RN B identified Resident #1 as alert and interviewable. RN B said Resident #1 was in the facility because she [MEDICAL CONDITION] after a surgery. RN B described Resident #1 as having a terrible infection requiring multiple antibiotics, non-weight bearing to her left lower extremity, having a wound on her back being treated by wound care, and having pain requiring medication frequently. Record review of Resident 1's Patient Record revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS dated [DATE] revealed: ? Active Diagnoses: [REDACTED]. ? Activities of Daily Living Assistance: Bed mobility- extensive assistance of two or more persons Transfer- extensive assistance of two or more persons Dressing- extensive assistance of two or more persons Bathing- physical help in part of bathing activity of two or more persons ? Functional Limitation in Range of Motion: Lower Extremity impairment on one side ? Bladder and Bowel: Indwelling catheter ? Health Conditions: Pain On scheduled pain medication regimen Received PRN (as needed) pain medication Received non-medication intervention for pain Vocal complaints of pain Indicators of pain observed daily Shortness of Breath Shortness of breath or trouble breathing with exertion Problem Conditions Fever ? Skin Conditions At Risk for developing pressure ulcers As having an unhealed pressure ulcer at stage 2 or higher As having a Stage 2 pressure ulcer upon admission Surgical wound ? Medications Injections Anticoagulant ? Special Treatment Occupational Therapy Physical Therapy Respiratory Therapy ? Care Area Assessment Summary identified the following areas: ADL Function/Rehabilitation Potential Urinary Incontinence and Indwelling Catheter Falls Nutritional Status Dehydration/ Fluid Maintenance Pressure Ulcer Pain Return to Community Referral Record review of Resident #1's Care Plan dated 10/27/11-11/09/11 revealed the following areas identified: ? Altered Comfort: Pain ? Potential for Injury ? Altered Urinary Elimination Record review of Resident #1's Assessment and Cares dated 10/25/11 revealed ability to void without difficulty, no abnormalities, able to empty bladder. In an interview on 11/10/11 at 9:20 a.m. the Nurse Manager said problems identified from the initial assessment should be added to the care plan by the admitting RN within 24 hours of admission. She explained that during each shift it is the direct care nurse's responsibility to update the care plan. She said care plan meetings are conducted weekly and updated during the meeting. She explained the facility recently obtained a new computer program and the care plans were not available during the last meeting on 11/08/11 to update them. In an interview on 11/10/11 at 10:00 a.m. LVN B said she was currently Resident #1's direct care nurse for that shift. She said care plans are on the computer. She explained the facility recently received a new computer program and she did not really know how to update the care plans. LVN B said she felt the computer care plans were not working well. LVN B reviewed Resident #1's care plan and said nutrition, infection, therapy, and wound care were all areas that needed to be added to the care plan. 2.Observation on 11/09/11 at 8:44 a.m. during initial tour LVN B identified Resident #2 as alert and interviewable. LVN B said Resident #2 was in the facility because she had [MEDICAL CONDITION] and right neck [MEDICAL CONDITION] that developed after a laryngectomy with [MEDICAL CONDITION] (removal of the larynx with placement of a surgically created hole through the front of the neck). LVN B described Resident #2 as having an infection requiring antibiotics and having pain requiring medication frequently. She stated that pain control for Resident #2 " had been an issue " . Record review of Resident #2's admission face sheet dated 10/07/11 revealed a [AGE] year old female admitted to the facility with a [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed: Active Diagnoses: [REDACTED]. ? Health Conditions: Pain On scheduled pain medication regimen Received PRN (as needed) pain medication Received non-medication intervention for pain Non-verbal complaints of pain Vocal complaints of pain Facial expression Indicators of pain observed daily Shortness of Breath Shortness of breath or trouble breathing with exertion Problem Conditions Vomiting Swallowing/Nutritional Status Complaints of difficulty or pain with swallowing Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months-Yes, not on physician-prescribed weight-loss regimen Parental/IV feeding Feeding Tube Mechanically Altered Diet Percent of Intake by Artificial Route-51% or more. Average fluid intake per day by IV or feeding tube-501cc/day (cubic centimeters) or more Medications Injections Medications received: antidepressant ? Special Treatment [MEDICAL CONDITION] Respiratory treatments: Oxygen therapy [MEDICAL CONDITION] care Other IV medications ? Care Area Assessment Summary identified the following areas: Communication ADL Functional/Rehabilitation Potential Falls Nutritional Status Feeding Tube Dehydration/Fluid Maintenance Pressure Ulcer Pain Record review of Resident #2's care plan dated 10/30/11 revealed the following: ? Altered comfort: Nausea/vomiting ? Infection ? Pain Record review of Resident #2's Physician orders [REDACTED]. Record review of physician's orders [REDACTED]." Record review of Resident #2's physician's orders [REDACTED].#2's PICC (Peripherally inserted central catheter). Record review of "Pharmacy Medication Review Note" dated 11/08/11 stated "...the current pharmacotherapy used for...depression and appetite decline may be suboptimally effective...currently taking [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (an appetite stimulant)...recommendation would be...day one d/c (discontinue) [MEDICATION NAME] three d/c [MEDICATION NAME], start [MEDICATION NAME] (a medication to assist with depression and appetite) 7.5 milligrams..." Record review of Physician order [REDACTED]. In an interview on 11/10/11 at 9:00 a.m., Resident #2 wrote (resident is non-verbal due to having an airway opening in her neck that prevents her from speaking) that she was taken off [MEDICATION NAME] and took [MEDICATION NAME] for her nerves but had difficulty swallowing and a poor appetite. In an interview on 11/10/11 at 10:15 a.m. the NM confirmed that Resident #2's care plan should have included nutrition, IV's and depression. In an interview with LVN B on 11/10/11 at 10:10 a.m. she stated Resident #2's care plan should have included depression, nutrition and skin. She confirmed Resident #2 could not talk and had to write out her needs. LVN B said she felt the computer care plans were not working well. Observation on 11/10/11 at 9:00 a.m. revealed Resident #2 lying in bed with I.V. fluids infusing via a pump into her right upper chest wall. An artificial opening was observed in her neck for breathing with oxygen being administered via a mist into the opening. 3. Record review of Resident #5's admission record revealed a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's "Infectious Disease Consultation" dated 11/07/11 revealed medical history of [REDACTED]. Record review of Resident #5's physician's orders [REDACTED]. However there were orders for oxygen, blood glucose monitoring, [MEDICATION NAME] flush for the intravenous line, and an antibiotic ([MEDICATION NAME]) for an infection in her lungs Observation on 11/09/11 at 9:00 a.m. during initial tour RN B Identified Resident #5 as alert and interviewable. RN B identified Resident #5 as having a urinary catheter in use. A urinary drainage bag was noted to bed hanging from the underside of her bed. The output was dark and amber in color. RN B said Resident #5 had urine cultures pending. Resident #5 had oxygen being delivered by a nasal cannula. Observation on 11/09/11 at 11:45 a.m. revealed Resident #5 in her room in her bed. Resident #5 was awake and alert. She had a urinary catheter bag hanging on the right side of her bed with dark amber urine in the collection bag. She had oxygen being delivered by a nasal cannula and an antibiotic being administered through an intravenous line (catheter placed in a vein). In an interview on 11/09/11 at 1:00 p.m. Resident #5 said that she was nauseous and had taken some medication to alleviate the nausea. In an interview on 11/09/11 at 1:15 p.m. Resident #5 said that lunch had arrived but she was unable to eat because of the nausea. Observation on 11/10/11 at 9:15 a.m. revealed Resident #5 in her room in her bed. Resident #5 was awake and alert. She had a urinary catheter bag hanging on the right side of her bed with dark amber urine in the collection bag. Record review of Resident #5's "Urine Culture" dated 11/08/11 revealed, "60,000 CFU(colony forming units)/ml (milliliter) which indicated an infection. Record review of Resident #5's "Long Term Care Nutritional Assessment" dated 11/04/11 revealed a weight of 118 pounds, a low blood [MEDICATION NAME] (decreased protein stores), increased protein needs due [MEDICAL CONDITION], and follow up weekly due to moderately compromised. Record review of Resident #5's computer based "Plan of Care" revealed only two identified problems; Activity intolerance and Altered Comfort: pain." There were no other problems identified. In an interview on 11/09/11 at 3:10 p.m. RN A said after reviewing Resident #5's computed based "Plan of Care" said that it was not complete. RN A said that she would have added urinary elimination related to the use of the urinary catheter, nausea/comfort due to her experiencing nausea, nutritional status, anxiety, and use of the central intravenous line relating to receiving antibiotics for pneumonia. In an interview on 11/10/11 at 10:20 a.m. the NM provided a copy of the computer based, "Plan of Care" for Resident #5 that included only two identified problems. There was no plan of care for the use the urinary catheter or oxygen, nausea, nutritional status, anxiety, glucose monitoring, or use of the central intravenous line. 4. Record review of the facility provided, "Resident Census and Conditions of Residents" dated 11/09/11 revealed a census of 14 residents.

Based on observation, interviews, and record reviews the facility failed to ensure three (Resident's #3 , #4 and #5) of 3 resident's clinical condition demonstrated that urinary catherization was medically necessary as evidence by: a) Resident #3 had continuous bladder irrigation with a urinary catheter without a documented medical need. b) Resident #4 had a urinary catheter but did not have a clinical [DIAGNOSES REDACTED]. c) Resident #5 had a urinary catheter but did not have an existing physician's orders [REDACTED]. This deficient practice could affect 3 residents identified by the facility as having urinary catheters. This failure could result in increase in urinary tract infections and failure to restore as much normal bladder function as possible. The findings included: 1. Record review of Resident #3's Patient Record revealed she was a [AGE] year old female admitted to the facility 11/07/11 with diagnoses including [MEDICAL CONDITION] and metastatic [MEDICAL CONDITION]. In an observation on 11/09/11 at 8:45 a.m. during initial tour RN B Identified Resident #3 as alert and interviewable. Continuous bladder irrigation was observed connected to Resident #3 and draining in a bag connected to the lower portion of her bed. The output was clear in color, without any bleeding. RN B did not know why Resident #3 was receiving continuous bladder irrigation (CBI). Record review of Resident #3's physician's orders [REDACTED]. No [DIAGNOSES REDACTED]. Continuous bladder irrigation is used to prevent urinary bladder obstruction by flushing small blood clots out of the bladder with a continuous flow of fluid. Source dated 11/14/11: <a href="http://medical-dictionary.thefreedictionary.com/continuous+bladder+irrigation">continuous bladder irrigation</a> In an interview on 11/09/11 at 1:30 p.m. LVN A said she was the direct care nurse for Resident #3. She said she was unsure why Resident #3 was receiving continuous bladder irrigation. She said Resident #3's urine had been clear since she started taking care of her at 7:00 a.m. In an interview on 11/09/11 at 2:30 p.m. RN C stated she was the charge nurse for the unit. She said she did not know why Resident #3 had continuous bladder irrigation in place. She stated she would call the urology doctor to ask if it was needed. In an interview on 11/10/11 at 9:40 a.m. Resident #3 said she lived at her private home independently with home health aides visiting daily. Resident #3 said she came to the hospital via ambulance on 10/25/11. She said she was continent of urine prior to her hospitalization . She said the continuous bladder irrigation was placed on 11/02/11 when she went to surgery for [REDACTED]. In an interview on 10/10/11 at 11:40 a.m. RN C said she attempted to call Resident #3's physician regarding the continuous bladder irrigation, but had not received any response. She said Resident #3 was still receiving the continuous bladder irrigation. Record review of Resident #3's physician's order [REDACTED]. Record review of Resident #3's Progress Notes dated 11/10/11 revealed the urology doctor had seen her and noted the urine has remained clear and the catheter could be removed. In an interview on 11/10/11 at 2:10 p.m. the Nurse Manager said she was unsure why she was receiving the continuous bladder irrigation. She said Resident #3's continuous bladder irrigation should have been addressed upon admission. 2. Observation on 11/09/11 at 8:44 a.m. on initial tour revealed Resident #4 sitting up in bed. A urinary collection bag was hanging at the lower end of the bed. In an interview on 11/09/11 at 10:46 a.m., Resident #4 stated she had had a catheter since she was admitted to the hospital but did not know why. In an interview on 11/09/11 at10:47 a.m. RN B confirmed Resident #4 had a urinary catheter but did not provide medical reasoning for it. In an interview on 11/09/11 at 1:40 p.m., the NM stated she did not know why Resident #4 had a catheter. After reviewing Resident #4's record, she confirmed there was no [DIAGNOSES REDACTED]. In a telephone interview on 11/09/11 at 4:25 p.m., Resident #4's daughter stated the catheter was placed when Resident #4 was admitted to the hospital. She stated Resident #4 was weak when she was admitted and received intravenous diuretics (medications to remove access fluid from the body) at that time. She stated no attempts had been made to remove it. Record review of Resident #4's Patient Record dated 10/18/11 revealed a [AGE] year old female admitted to the facility 10/18/11 with a [DIAGNOSES REDACTED]. Record review of Resident #4's admission orders . No [DIAGNOSES REDACTED]. 3. Record review of Resident #5's admission record revealed a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's "Infectious Disease Consultation" dated 11/07/11 revealed medical history of [REDACTED]. Record review of Resident #5's physician's orders [REDACTED]. Observation on 11/09/11 at 9:00 a.m. during initial tour RN B Identified Resident #5 as alert and interviewable. RN B identified Resident #5 as having a urinary catheter in use. A urinary drainage bag was noted to bed hanging from the underside of her bed. The output was dark and amber in color. RN B said Resident #5 had urine cultures pending. Observation on 11/09/11 at 11:45 a.m. revealed Resident #5 in her room in her bed. Resident #5 was awake and alert. She had a urinary catheter bag hanging on the right side of her bed with dark amber urine in the collection bag. Observation on 11/10/11 at 9:15 a.m. revealed Resident #5 in her room in her bed. Resident #5 was awake and alert. She had a urinary catheter bag hanging on the right side of her bed with dark amber urine in the collection bag. In an interview on 11/10/11 at 9:15 a.m. Resident #5 said that she did not know why she had a Foley catheter. In an interview on 11/09/11 at 3:10 p.m. RN A said that she did not know why Resident #5 had a Foley catheter but thought maybe because of her weakened condition, and diagnoses of [MEDICAL CONDITIONS]. RN A said that Resident #5 got very tired and it was hard for her to get up to the restroom. RN A reviewed Resident #5's clinical records and said that she could not find a physician's orders [REDACTED]. Record review of Resident #5's "Urine Culture" dated 11/08/11 revealed, "60,000 CFU(colony forming units)/ml (milliliter) which indicated an infection. Record review of Resident #5's physician "Progress Notes" dated 11/09/11 revealed that the resident had a urinary tract infection. In an interview on 11/10/11 at 10:20 a.m. the NM said that she could not find a physicians order for Resident #5's urinary catheter and she did not know exactly why she had a urinary catheter. The NM said that they had not tried to discontinue the urinary catheter since her admission on 11/03/11. Record review of the facility provided Nursing Policy on "Urinary Tract Infection Prevention-Catheter Associated" dated 06/03/11 revealed the following: "1. Indwelling urinary catheters should be inserted per physicians order and left in place only as long as medically indicated .... 6. When a urinary catheter is inserted, the projected date of removal will be written on the communication board in order to be made available to the physician. The projected date of removal is approximately forty-eight hours after insertions. Unless the physician has written an order with justification to maintain the Foley catheter, it will be removed within 48 hours. 7 ... Assess the need for the urinary catheter drainage daily." 4. Record review of the facility provided, "Resident Census and Conditions of Residents" dated 11/09/11 revealed three resident with catheters which were all present on admission.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with a plan of care in that 3 (Resident's #3 , #4 and #5) of 3 residents with urinary catheters did not have plans of care related to the catheters. a) Resident #3 had continuous bladder irrigation with a urinary catheter without a documented medical need or a plan of care. b) Resident #4 had a urinary catheter with no clinical [DIAGNOSES REDACTED]. c) Resident #5 had a urinary catheter but did not have an existing physician's orders [REDACTED]. This deficient practice could affect 3 residents identified by the facility as having urinary catheters. This failure could result in increase in urinary tract infections and failure to restore as much normal bladder function as possible. The findings included: 1. Record review of Resident #3's Patient Record revealed she was a [AGE] year old female admitted to the facility 11/07/11 with diagnoses including [MEDICAL CONDITION] and metastatic [MEDICAL CONDITION]. In an observation on 11/09/11 at 8:45 a.m. during initial tour RN B Identified Resident #3 as alert and interviewable. Continuous bladder irrigation was observed connected to Resident #3 and draining in a bag connected to the lower portion of her bed. The output was clear in color, without any bleeding. RN B did not know why Resident #3 was receiving continuous bladder irrigation (CBI). Record review of Resident #3's physician's orders [REDACTED]. No [DIAGNOSES REDACTED]. Continuous bladder irrigation is used to prevent urinary bladder obstruction by flushing small blood clots out of the bladder with a continuous flow of fluid. Source dated 11/14/11: <a href="http://medical-dictionary.thefreedictionary.com/continuous+bladder+irrigation">continuous bladder irrigation</a> In an interview on 11/09/11 at 1:30 p.m. LVN A said she was the direct care nurse for Resident #3. She said she was unsure why Resident #3 was receiving continuous bladder irrigation. She said Resident #3's urine had been clear since she started taking care of her at 7:00 a.m. In an interview on 11/09/11 at 2:30 p.m. RN C stated she was the charge nurse for the unit. She said she did not know why Resident #3 had continuous bladder irrigation in place. She stated she would call the urology doctor to ask if it was needed. In an interview on 11/10/11 at 9:40 a.m. Resident #3 said she lived at her private home independently with home health aides visiting daily. Resident #3 said she came to the hospital via ambulance on 10/25/11. She said she was continent of urine prior to her hospitalization . She said the continuous bladder irrigation was placed on 11/02/11 when she went to surgery for [REDACTED]. In an interview on 10/10/11 at 11:40 a.m. RN C said she attempted to call Resident #3's physician regarding the continuous bladder irrigation, but had not received any response. She said Resident #3 was still receiving the continuous bladder irrigation. Record review of Resident #3's physician's order [REDACTED]. Record review of Resident #3's Progress Notes dated 11/10/11 revealed the urology doctor had seen her and noted the urine has remained clear and the catheter could be removed. In an interview on 11/10/11 at 2:10 p.m. the Nurse Manager said she was unsure why she was receiving the continuous bladder irrigation. She said Resident #3's continuous bladder irrigation should have been addressed upon admission. 2. Observation on 11/09/11 at 8:44 a.m. on initial tour revealed Resident #4 sitting up in bed. A urinary collection bag was hanging at the lower end of the bed. In an interview on 11/09/11 at 10:46 a.m., Resident #4 stated she had had a catheter since she was admitted to the hospital but did not know why. In an interview on 11/09/11 at10:47 a.m. RN B confirmed Resident #4 had a urinary catheter but did not provide medical reasoning for it. In an interview on 11/09/11 at 1:40 p.m., the NM stated she did not know why Resident #4 had a catheter. After reviewing Resident #4's record, she confirmed there was no [DIAGNOSES REDACTED]. In a telephone interview on 11/09/11 at 4:25 p.m., Resident #4's daughter stated the catheter was placed when Resident #4 was admitted to the hospital. She stated Resident #4 was weak when she was admitted and received intravenous diuretics (medications to remove access fluid from the body) at that time. She stated no attempts had been made to remove it. Record review of Resident #4's Patient Record dated 10/18/11 revealed a [AGE] year old female admitted to the facility 10/18/11 with a [DIAGNOSES REDACTED]. Record review of Resident #4's admission orders . No [DIAGNOSES REDACTED]. Record reveiw of Resident #4's "Plan of Care" dated 10/28/11 revealed a goal for "...Altered Urinary Elimination-Voids on Own: In Progress..." Record reveiw of Resident #4's MDS dated [DATE] revealed an indwelling catheter. 3. Record review of Resident #5's admission record revealed a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's "Infectious Disease Consultation" dated 11/07/11 revealed medical history of [REDACTED]. Record review of Resident #5's physician's orders [REDACTED]. Observation on 11/09/11 at 9:00 a.m. during initial tour RN B Identified Resident #5 as alert and interviewable. RN B identified Resident #5 as having a urinary catheter in use. A urinary drainage bag was noted to bed hanging from the underside of her bed. The output was dark and amber in color. RN B said Resident #5 had urine cultures pending. Observation on 11/09/11 at 11:45 a.m. revealed Resident #5 in her room in her bed. Resident #5 was awake and alert. She had a urinary catheter bag hanging on the right side of her bed with dark amber urine in the collection bag. Observation on 11/10/11 at 9:15 a.m. revealed Resident #5 in her room in her bed. Resident #5 was awake and alert. She had a urinary catheter bag hanging on the right side of her bed with dark amber urine in the collection bag. In an interview on 11/10/11 at 9:15 a.m. Resident #5 said that she did not know why she had a Foley catheter. In an interview on 11/09/11 at 3:10 p.m. RN A said that she did not know why Resident #5 had a Foley catheter but thought maybe because of her weakened condition, and diagnoses of [MEDICAL CONDITIONS]. RN A said that Resident #5 got very tired and it was hard for her to get up to the restroom. RN A reviewed Resident #5's clinical records and said that she could not find a physician's orders [REDACTED]. Record review of Resident #5's "Urine Culture" dated 11/08/11 revealed, "60,000 CFU(colony forming units)/ml (milliliter) which indicated an infection. Record review of Resident #5's physician "Progress Notes" dated 11/09/11 revealed that the resident had a urinary tract infection. In an interview on 11/10/11 at 10:20 a.m. the NM said that she could not find a physicians order for Resident #5's urinary catheter and she did not know exactly why she had a urinary catheter. The NM said that they had not tried to discontinue the urinary catheter since her admission on 11/03/11. Record review of Resident #5's computer based "Plan of Care" revealed only two identified problems; Activity intolerance and Altered Comfort: pain." There were no other problems identified. Record review of the facility provided Nursing Policy on "Urinary Tract Infection Prevention-Catheter Associated" dated 06/03/11 revealed the following: "1. Indwelling urinary catheters should be inserted per physicians order and left in place only as long as medically indicated .... 6. When a urinary catheter is inserted, the projected date of removal will be written on the communication board in order to be made available to the physician. The projected date of removal is approximately forty-eight hours after insertions. Unless the physician has written an order with justification to maintain the Foley catheter, it will be removed within 48 hours. 7 ... Assess the need for the urinary catheter drainage daily." 4. Record review of the facility provided, "Resident Census and Conditions of Residents" dated 11/09/11 revealed three resident with catheters which were all present on admission.