Every finding on record at Piney Grove Nursing and Rehabilitation Center

Based on observations, and resident and staff interviews, the facility failed to maintain Packaged Terminal Air Conditioner (PTAC) units in good condition in 8 of 26 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Room#109, room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed for a comfortable, safe, and homelike environment. The findings included: An observation of room [ROOM NUMBER] on 1/20/26 at 9:50 AM revealed 4 out of 5 slats on the PTAC unit contained a patchy black, irregularly shaped residue that covered 50% of the surface of left side of each slat. room [ROOM NUMBER] was occupied by 2 residents. An observation of room [ROOM NUMBER] on 1/20/26 at 9:58 AM revealed 5 out of 5 PTAC unit slats contained a patchy black, raised residue that covered 75% of the entire surface of each slat and the internal surface behind the vent slats. room [ROOM NUMBER] was occupied by 2 residents. On 1/20/26 at 10:15 AM an observation of room [ROOM NUMBER] revealed 4 out of 5 PTAC unit slats contained a patchy black, raised residue that covered 25% of the surface on left side of each slat. room [ROOM NUMBER] was occupied by 2 residents. An observation of Room# 106 on 1/20/26 at 10:32 AM revealed the base of the internal surface behind the slats contained brown, white and black particles that covered 75% of the area. room [ROOM NUMBER] was occupied by 2 residents. An observation of room [ROOM NUMBER] on 1/20/26 at 10:53 AM revealed the base of the internal surface behind the slats contained brown, white, and black particles that covered 50% of the area. room [ROOM NUMBER] was occupied by 2 residents. An observation of room [ROOM NUMBER] on 1/20/26 at 10:57 AM revealed 5 out of 5 PTAC unit slats contained a patchy, raised black residue that covered 50% of the surface of each slat. room [ROOM NUMBER] was occupied by 2 residents. An observation of room [ROOM NUMBER] on 1/20/26 at 11:12 AM revealed 5 out of 5 PTAC unit slats contained a patchy black, raised residue that covered 25 % of the entire surface of each slat. The base of the internal surface behind the vent slats was 75% covered with brown and black particles. room [ROOM NUMBER] was occupied by 2 residents. An observation of room [ROOM NUMBER] with 2 residents on 1/20/26 at 11:29 AM revealed 5 out of 5 PTAC unit slats contained a patchy black, raised residue that covered 50% of the entire surface of each slat. room [ROOM NUMBER] was occupied by 2 residents. An interview was conducted with the Director of Maintenance on 1/22/26 from 12:12 PM-12:42 PM. During this time, an observation was conducted with the Director of Maintenance of room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] and the issues observed on 1/20/26 remained. The Director of Maintenance stated staff were to report any damage/issues through the electronic tracking system. He shared he received immediate notification of staff reported issues on his phone app work order system once staff have entered a work order request. He stated he had not received notification of the PTAC issues in these rooms. The Director of Maintenance stated room rounds are done monthly with the corporate consultant to identify major repairs. He stated he inspected each room in the facility once a week to determine if repairs were needed but looked at the PTAC units only when a monthly filter change was scheduled. He stated that he was unaware of the PTAC concerns for Resident Rooms #101, #102, #103, #106, #107, #109, #110, and #115 but the residue on the slats appeared to be caused by condensation produced by the units and then dust particles adhered and dried. He stated the particle build up on the base behind the slats was most likely from housekeeping when floors are clean floors particles fly into the register. He further stated cleaning of this area of the register was the responsibility of housekeeping; maintenance was only responsible for changing out the filters, which were done monthly. Housekeeping does the outside of the units, we do the inside. The Director of Maintenance was unable to describe a routine inspection or cleaning schedule for the affected areas of the PTAC units located in resident rooms. An interview and observations of room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] was conducted with the Director of Housekeeping on 1/22/26 PM from 12:54 PM-1:14 PM. She stated housekeeping touched all low and high touch areas in each room daily. This included the PTAC units but only the perimeter area. She stated monthly a deep clean was completed in each room and at that time she audited the completion of the task. When asked if she considered the unit slats and the base behind the slats inside or outside of the unit, she stated outside and that would fall to Maintenance. The Housekeeping Director was unable to describe a routine inspection or cleaning schedule for the affected areas of the PTAC units located in resident rooms. She stated that she was unaware of the concerns for the PTAC units for resident rooms #101, #102,#103, #106, #107,#109, #110, and #115. The Administrator was interviewed on 1/22/26 at 3:50 PM. He stated it was unacceptable to have dirty PTAC units in resident rooms. He stated it was the responsibility of the Maintenance Department to clean the base behind the slats and housekeeping to clean the slats during daily room cleaning, if needed. He stated he was unaware of this issue and did not know why Housekeeping and Maintenance Departments were unaware of who was responsible for cleaning each section of the PTAC units.

Based on record review and interviews with residents, staff, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to protect a resident's right to be free from misappropriation of controlled medications for 1 of 3 residents reviewed for misappropriation of resident's property (Resident # 17). As a result of not getting her pain medication, Resident #17 had an increase in her pain of a level 8 on a scale of 1 to 10 which was increased from her usual pain level of 0 to 3 when getting her medication as prescribed. Resident #17 described the pain as constant aching and throbbing pain in her right hip and throbbing pain in her mouth. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident Property Policy, last revised on [DATE], revealed in part the facility would do whatever is in its control to prevent misappropriation of resident's property. Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. The physician's order dated [DATE] revealed Resident #17 had an order to receive one table of oxycodone-Acetaminophen oral tablet ,d+[DATE] milligrams (mg) (oxycodone with acetaminophen) or Percocet (a type of opioid analgesic consisted of oxycodone/acetaminophen that acted on the central nervous system to relieve pain) by mouth three times a day for pain. The medication was scheduled to be given at 8:00 AM, 2:00 PM and 8:00 PM. A Packing Slip dated [DATE] from the Pharmacy revealed Oxycodone/Acetaminophen tablets ,d+[DATE] mg tablets, 90 tablets were received for Resident #17 and signed for by Agency Nurse #1. The declining narcotic count sheets indicated Resident #17 had 2 sheets for a total of 60 tablets instead of 3 sheets for a total of 90 tablets as received and signed for by Agency Nurse #1 on [DATE]. The sheets had been altered at the top indicating there were 2 sheets (1 of 2 sheets and 2 of 2 sheets) received instead of 3 sheets (1 of 3 sheets, 2 of 3 sheets and 3 of 3 sheets) as indicated from the pharmacy at the top of the sheet as well as the packing slip from the pharmacy indicating 90 tablets with 3 sheets received. The declining narcotic count sheets indicated the last dose given was on [DATE] at 8:00 PM. There was no page 3, and 30 tablets were unaccounted for, for Resident #17. A telephone interview on [DATE] at 9:56 AM with Agency Nurse #1 who had signed for Resident #17's medications on [DATE] revealed she could not recall signing for the medications but stated if her signature was on the document then she had signed them in. She stated she did not remember how many tablets there were or how many declining count sheets there were attached to the medications. Nurse #1 further stated she did not recall altering the declining count sheets to say 1 of 2 sheets and 2 of 2 sheets instead of 1 of 3, 2 of 3 and 3 of 3 sheets from the pharmacy. She denied knowing anything about one of the sheets and one of the cards of medication going missing. Nurse #1 denied taking the medications and sheet and denied knowing anything about anyone else taking the medications or sheet. Review of Resident Council Meeting Minutes dated [DATE] revealed during the meeting when residents were asked about New Business concerns, Resident #17 stated in the meeting that she had not received her pain medications for 4 days. The MAR for [DATE] revealed Resident #17 had not received her medication the following dates and times: - [DATE]:00 AM, 2:00 PM and 8:00 PM - [DATE]:00 AM, 2:00 PM and 8:00 PM - [DATE]:00 AM, 2:00 PM and 8:00 PM - [DATE]:00 AM, 2:00 PM and 8:00 PM - [DATE]:00 AM and 2:00 PM for a total of 14 doses missed. Review of Resident #17's significant change MDS dated [DATE] revealed she was cognitively intact and received scheduled pain medication and no as needed pain medication. The assessment also revealed the resident had almost constant pain at a level of 10 out of ,d+[DATE]. An interview on [DATE] at 10:03 AM with Resident #17 revealed she had gone over 4 ,d+[DATE] days the first of August without receiving her pain medication as ordered. She stated during that time she had an increase in her pain level to an 8 on a scale of ,d+[DATE], instead of her usual pain level of ,d+[DATE] with her medication. Resident #17 described a constant aching and throbbing pain in her right hip and constant pain in her joints due to arthritis. Additionally, Resident #17 stated she had three teeth extracted during this time which further increased her pain and described her mouth pain as a throbbing pain in her mouth. She stated the staff (couldn't remember names) kept telling her it was on order and had not come from the pharmacy and said one nurse (couldn't remember name) finally told her it was too soon to refill her prescription for her pain medication. Resident #17 said they didn't offer her any other medication or treatment for her pain during those 4 ,d+[DATE] days she went without her scheduled pain medication. A telephone interview on [DATE] at 12:12 PM with the Pharmacy Manager stated on [DATE] 90 tablets and 3 medication sheets were sent to the facility for Resident #17. The Pharmacy Manager stated they had received a new electronic script on [DATE] for Resident #17 but it was too early to refill because the [DATE] order should have lasted until [DATE]. She further stated on [DATE] they received another electronic script, and it was still too early to refill the medication so on [DATE] they received approval from Unit Manager #2 to refill the medication and to bill the facility and send the medication out on special delivery. The Pharmacy Manager explained the medication had gone out on the afternoon of [DATE] to the facility and that usually their medication runs occurred during the night hours. She further explained that 90 tablets had been sent to the facility for Resident #17 along with 3 narcotic declining count records. Review of an invoice from the Pharmacy dated [DATE] revealed on [DATE] 90 pills were sent to the facility and billed to the facility for Resident #17. A telephone interview on [DATE] at 2:42 PM with the former Director of Nursing (DON) revealed she had been the interim DON at the facility in August of 2024. She stated no one had reported to her that any resident was missing Percocet or any other medications. The former DON further stated she remembered vaguely that someone had run out of their pain medication but said she had been told it was because the physician had increased the dosage of medication not that there were medications missing. She indicated she did not authorize any medications being paid for by the facility while there and no one had told her that narcotics were missing while she was interim DON at the facility. An interview on [DATE] at 4:35 PM with the Medical Director (MD) revealed she was not aware of missing medications for Resident #17 until just before this interview. She stated she was familiar with Resident #17 and her chronic pain and her concern with her not receiving her pain medication for over 4 days would have been her increased intensity in her pain. The MD further stated it seemed as though someone with access had diverted the medications belonging to Resident #17 and she would be mindful in the future of requests for refilling narcotic medications early. A telephone interview on [DATE] at 2:04 PM with the Nurse Practitioner (NP) revealed she was not aware that Resident #17 was missing medications or that she had completely ran out of her medications. The NP stated it seemed as though someone had diverted her pain medication, and she would pay better attention to early requests for narcotic medication refills. A telephone interview on [DATE] at 2:46 PM with the Consultant Pharmacist revealed they did monthly controlled substance inspections at the facility and looked in the books to ensure the count on the declining sheets matched the card count. She stated they looked at the carts and medication rooms for dates on medications, expired meds, and ensure medications were being stored appropriately. The Consultant Pharmacist further stated they might find a missed signature from time to time on medication sheets but had not noticed any medication sheets being altered or missing or missing cards of medication. She indicated it was unlikely they would have found an error such as this on their cart and medication room inspections because they spot checked the carts and medication rooms and this error would have been hard to identify with their current process. The Consulting Pharmacist further indicated an error like this should have been reported to the Medical Director and the pharmacy and should have been documented they were notified. An interview on [DATE] at 6:10 PM with the Director of Nursing (DON) revealed it was the expectation of the DON that resident's medications were not taken and unaccounted for and that residents received their medications as ordered by the providers. The DON stated she had been through all the files and was not able to locate the 3rd declining count sheet received on [DATE] for Resident #17. She further stated they could only assume the medications and sheet had been taken by one of the nurses with access to the medications and sheet.

Based on record review and interviews with residents, staff, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to ensure a resident's pain was assessed and that she received her pain medication to treat acute throbbing mouth pain from teeth being extracted and chronic constant aching and throbbing pain in her right hip for 1 of 3 residents reviewed for pain management (Resident #17). As a result of the resident not getting her pain medication as prescribed, her pain level increased to an 8 on a scale of 1 to 10 when her usual pain level was 0 to 3 when taking her pain medication as prescribed three times a day. The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. The physician's order dated 10/25/23 revealed Resident #17 had an order to receive one tablet of oxycodone-Acetaminophen oral tablet 5-325 milligrams (mg) (a type of opioid analgesic consisted of oxycodone/acetaminophen that acted on the central nervous system to relieve pain) by mouth three times a day for pain. The medication was scheduled to be given at 8:00 AM, 2:00 PM and 8:00 PM. Review of Resident #17's Nurse Practitioner progress note dated 07/01/24, Resident #17's arthritis was described as polyosteoarthrits of multiple joints including right hip, left hip, bilateral knees and shoulders. According to the note the resident was being followed by the local pain clinic for assistance in managing her pain. Resident #17's topical pain patch was changed from as needed to scheduled one time a day to help with pain. Review of the physician's orders for August 2024 revealed Resident #17 was on the following medications for pain in addition to the oxycodone-acetaminophen oral tablet 5-325 mg by mouth three times a day: - Salonpas Pain Relieving External Patch 4% (Lidocaine) apply to right hip topically one time a day for hip pain with a start date of 07/02/24. Patch scheduled for 9:00 AM - Acetaminophen oral tablet give 1000 mg by mouth two times a day for chronic pain give as an alternating dose with oxycodone/acetaminophen with start date of 10/18/23. Tablets scheduled at 11:00 AM and 5:00 PM. - Diclofenac sodium external gel 1% (topical) apply 2 grams to left and right hip for arthritic pain two times daily. Scheduled for day and evening. - Diclofenac sodium external gel 1% (topical) apply 2 grams to right shoulder for arthritic pain two times daily. Scheduled for day and evening. Review of a dental care note dated 08/01/24 for Resident #17 she had three teeth extracted on 08/01/24 at 12:46 PM. Teeth #9, #10, and #11 were extracted under local anesthetic and sutures placed for closure that would dissolve in 5 days. Resident #17 was given antibiotics prior to the dental appointment but no pain medication was administered. Review of Resident Council Meeting minutes dated 08/19/24 revealed during the meeting when residents were asked about New Business concerns, Resident #17 stated that she had not received her pain medications for 4 days the beginning of August 2024. The Medication Administration Record (MAR) for August 2024 revealed Resident #17 had not received her medication of oxycodone-acetaminophen 5-325 mg one tablet by mouth at 8:00 AM, 2:00 PM and 8:00 PM the following dates and times, the blocks on the MAR for these dates and times was blank and there was no indication of what her pain level was on these dates and times: - August 1 8:00 AM, 2:00 PM and 8:00 PM - August 2 8:00 AM, 2:00 PM and 8:00 PM - August 3 8:00 AM, 2:00 PM and 8:00 PM - August 4 8:00 AM, 2:00 PM and 8:00 PM - August 5 8:00 AM and 2:00 PM for a total of 14 doses missed Continued review of the MAR revealed on the following dates and times, Nurse #3 had taken care of Resident #17 and had not administered her Percocet and there was no indication of what her pain level was on these dates and times: - August 1 at 8:00 AM and 2:00 PM - August 3 at 8:00 AM, 2:00 PM and 8:00 PM - August 4 at 8:00 AM and 2:00 PM A telephone interview was attempted with Nurse #3; however, the number had been disconnected and Nurse #3 was no longer employed through the agency. Continued review of the MAR revealed on August 1 and August 2 at 8:00 PM Medication Aide (MA) #2 had taken care of Resident #17 and had not administered her Percocet on those days and times and there was no indication of what her pain level was on those dates and times. An interview on 10/10/24 at 3:31 PM with MA #2 revealed she did not recall the evening she cared for Resident #17 but stated usually if there were no medications available for a resident, she reported it to the nurse supervising her and the nurse would contact the pharmacy or the physician for orders. MA #2 stated if it was not signed out then she had not given the medication. She further stated she could not recall if the resident had complained of pain with not getting her narcotic medication. Continued review of the MAR revealed on the following dates and times, Nurse #2 had taken care of Resident #17 and had not administered her Percocet on those dates and times and there was no indication of what her pain level was on those dates and times: - August 2 at 8:00 AM and 2:00 PM - August 5 at 8:00 AM and 2:00 PM A telephone interview on 10/10/24 at 4:00 PM with Nurse #2 revealed she couldn't recall the specifics but stated generally if a resident does not have their medication, she typically contacted the pharmacy and then if a script was needed, she would contact the Nurse Practitioner to send an electronic script to the pharmacy for the medication. Nurse #2 stated she couldn't recall if they had oxycodone with acetaminophen in their narcotic Emergency Kit but stated she felt like if they had she would have given it from the Emergency Kit. She further stated she could not recall if the resident had complained of pain with not getting her narcotic medication and could not recall if she had complained of mouth pain from having her teeth extracted. Continued review of the MAR revealed on August 4 at 8:00 PM Nurse #4 had taken care of Resident #17 and had not administered her Percocet on that day and time and there was no indication of what her pain level was at that time or if she had any acute mouth pain from her teeth being extracted. A telephone interview was attempted several times with Nurse #4 without success. Continued review of the MAR revealed on August 5 at 8:00 PM when Resident #17 received her pain medication her pain level was 8 on a scale of 1-10. The Emergency Medication Kit for Controlled Substances revealed there were no Percocet in the kit at the facility available to administer to residents. Review of the nursing progress notes revealed the following: - 08/02/24 at 11:54 PM resident verbalized she's in constant pain in her right hip at a level of 10 for the last 5 days and level 8 while talking with this nurse. - 08/03/24 at 03:56 AM resident awake at intervals tonight. Inquired about pain medications and informed it was on order and awaiting pharmacy to send it. A telephone interview was attempted several times with Nurse #7 who wrote the above progress notes without success. Review of Resident #17's significant change MDS dated [DATE] revealed she was cognitively intact and received scheduled pain medication but no as needed (prn) pain medication. The assessment also revealed the resident had almost constant pain at a level of 10 out of 1-10. Review of Resident #17's care plan last revised on 09/14/24 revealed a focus area for chronic pain related to impaired mobility, leukemia, diabetes mellitus, type II, arthritis and coronary artery disease. The interventions included in part, administering pain medication as per MD orders and note effectiveness, and notify physician if pain management is not effective. An interview on 10/10/24 at 10:03 AM with Resident #17 revealed she had gone several days, like over 4 days without receiving her pain medication as ordered. She stated during that time she had an increase in her pain level to an 8 instead of a 0 to 3 with her medication. She described having a constant aching, throbbing pain in her right hip and aching pains throughout her body due to arthritis in her joints. Resident #17 also described a throbbing pain in her mouth due to her teeth being extracted and being without her pain medication. She stated the staff (couldn't remember names) kept telling her it was on order and had not come from the pharmacy and one nurse (couldn't remember name) finally told her it was too soon to refill her prescription for her pain medication. Resident #17 said they didn't offer her any other medication or treatment for her pain during those 4 1/2 days she went without her scheduled pain medication. The resident further said it made it difficult without her pain medication to get up during the day and found herself lying back down and sleeping more during the day and then having trouble sleeping at night. Resident #17 indicated she had not been offered ice or heat to help with her constant pain and had used her topical Biofreeze (topical pain relief product that uses menthol to soothe minor muscle and joint pain), patch and topical gel but none of them really helped the pain she had like her pain medication. A telephone interview on 10/10/24 at 12:12 PM with the Pharmacy providing medications to the facility revealed during a conversation with the Pharmacy Manager that on 07/11/24 90 tablets were sent to the facility for Resident #17. The Pharmacy Manager stated they had received a new electronic script on 08/02/24 and 08/04/24 for Resident #17 but it was too early to refill because the 07/11/24 order should have lasted until 08/10/24. Then on 08/05/24 they received an approval from Unit Manager #2 to refill the medication and to bill the facility and send the medication out on special delivery. The Pharmacy Manager explained the medication had gone out on the afternoon of 08/05/24 to the facility. An interview on 10/10/24 at 4:35 PM with the Medical Director (MD) revealed she was not aware that Resident #17 had missed 14 consecutive doses or her narcotic medication for chronic pain until just before this interview. She stated she was familiar with Resident #17 and her chronic pain and the acute pain she had suffered getting her teeth pulled during this time and her concern with the resident not receiving her pain medication for over 4 days would have been her increased intensity in her pain. The MD further stated the facility staff should have told the Nurse Practitioner that she was out of her pain medication so she could have given orders for something else in the meantime while awaiting her medication from the pharmacy. The MD indicated it should have been made clear to the Nurse Practitioner that the resident was completely out of her medications and not that she just needed a refill script. The MD further indicated Resident #17 should have had her medication to keep her pain at a level that was manageable. A telephone interview with the Nurse Practitioner (NP) caring for Resident #17 revealed she was unaware the resident had gone over 4 days in a row without her pain medication and had missed 14 consecutive doses. She stated she tried to stay on top of ordering her medications due to her chronic pain but said she had not been notified that she was completely out or had not received her medications for over 4 days. The NP stated she was surprised the resident had not mentioned it to her unless she just didn't see her during that time. She further stated her concern with Resident #17 not receiving her medications for that period would have been the increase in intensity of her pain because of the chronic nature of her pain and the acute pain she suffered getting her teeth extracted. The NP stated she should not be going that long without her medicine and that she would have expected the nursing staff to have called her and told her she was out of her medicine and not just that she needed a refill prescription. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) and Administrator revealed it was the expectation of the DON that resident's pain medications were administered as ordered by the providers. The DON further stated the nurses should have made it clear to the Nurse Practitioner that Resident #17 was out of her pain medication so the NP could have ordered additional medication to relieve the resident's acute pain from her teeth being extracted and chronic pain she was suffering in her hip and other joints.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide the resident's preference of showers for 3 of 3 residents reviewed for choices (Resident #17, Resident #189 and Resident #64). The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. Resident #17's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required substantial to maximal assistance with showering and bathing. The assessment also revealed Resident #17 had no rejection of care behaviors and according to the assessment, it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The shower schedule for the middle hall revealed Resident #17 was scheduled for showers on Tuesday and Friday on 1st shift (7:00 AM to 3:00PM). The documentation of showers in the electronic medical record for Resident #17 for 08/13/24 through 10/11/24 revealed she received showers as scheduled on 08/13/24, 08/16/24, 08/20/24, 08/27/24, 09/03/24, 09/10/24, 09/17/24, 09/20/24, and 09/24/24. On the other days she was scheduled for showers the following was documented: Friday 08/23/24 no shower provided Friday 08/30/24 partial bath provided Friday 09/06/24 no shower provided Friday 09/13/24 no shower provided Friday 09/27/24 no shower provided Tuesday 10/01/24 no shower provided Friday 10/04/24 no shower provided Tuesday 10/08/24 no shower provided Friday 10/11/24 no shower provided An observation and interview on 10/08/24 at 9:23 AM revealed Resident #17 sitting up in her wheelchair and dressed for the day. The Resident's skin was visibly dry and flaky. Resident #17 stated she was not getting her showers two times a week as scheduled and stated she preferred to take showers because the hot water felt good to her arthritis. Resident #17 further stated she had not refused any of her showers and had not been offered showers two times per week, every week and had sometimes gone two weeks without a shower. On 10/10/24 at 4:00 PM a Resident Council Meeting was held, and Resident #17 was in attendance and again she and others complained about not getting showers during the meeting. She stated that she was not getting her showers two times per week as scheduled. A telephone interview was attempted several times with agency NA #13 who cared for Resident #17 on 08/23/24 during the 7:00 AM to 3:00 PM shift with voicemail messages left for return call with no response. A telephone interview on 10/11/24 at 3:55 PM with agency NA #8 revealed she had cared for Resident #17 on 08/30/24 during the 7:00 AM to 3:00 PM shift. She stated she usually tried to give all her showers or bed baths but said sometimes their schedule changed during their shift and showers sometimes got missed. Agency NA #8 further stated the scheduled changed frequently and it was difficult to keep up with showers when changes were made mid-day. A telephone interview on 10/10/24 at 12:07 PM with Agency Nurse Aide (NA) #3 revealed she had cared for Resident #17 on 09/06/24 during the 7:00 AM to 3:00 PM shift. She stated she couldn't remember why she had not given Resident #17 a shower on that day but said sometimes their assignments were changed during the shift and residents may have missed their showers. Agency NA #3 stated she usually gave all her showers and bed baths unless the schedule was changed and said that happened a lot because staff worked different hours. She further stated the staff worked 4, 8, 12 and 16-hour shifts. A telephone interview was attempted several times with agency NA #12 who cared for Resident #17 on 09/13/24 and 10/11/24 during the 7:00 AM to 3:00 PM shift with voicemail messages left for return call with no response. An interview on 10/11/24 at 4:42 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #17 was not receiving her showers as scheduled. She stated the NAs should be reporting not getting showers done to the nurse or to her so they could have adjusted the schedule to accommodate the residents. Unit Manager #2 further stated she could have moved NAs around or added them to an assignment to get the resident showers done if she had been told they were not done. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their bed baths or showers as scheduled. She stated the NAs should report to the nurses or unit managers any residents refusing care or who didn't receive their bed bath or shower as scheduled so they could be accommodated on the next shift or next day. The DON further stated there were changes sometimes to the schedule because they had staff working 4, 8, 12 and 16-hour shifts. She indicated they were trying to cover the schedule with agency staff as they hired their own staff, and it was difficult with using so many agencies to get dependable staff to cover the schedule. The DON further indicated they needed to interview the residents and make sure their preferences were documented correctly. 2. Resident #64 was admitted to the facility on [DATE] with diagnoses which included hemiparesis due to cerebrovascular accident (CVA) or stroke. Resident #64's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired and required partial to moderate assistance with showering and bathing. The assessment also revealed Resident #64 had no rejection of care behaviors and according to the assessment, it was somewhat important to the resident to choose between a tub bath, shower, bed bath or sponge bath. The shower schedule for the middle hall revealed Resident #64 was scheduled for showers on Wednesday and Saturday on 2nd shift (3:00 PM to 11:00 PM). The documentation of showers in the electronic medical record for Resident #64 for 08/05/24 through 10/09/24 revealed she received showers on 08/20/24 which was not a scheduled shower day (Tuesday), 09/04/24, 09/11/24, 10/02/24 and 10/07/24 which was not a scheduled shower day (Monday). On the other days she was scheduled for showers the following was documented: Wednesday 08/07/24 partial bath provided Saturday 08/10/24 partial bath provided Wednesday 08/14/24 no shower provided Saturday 08/17/24 complete bed bath Wednesday 08/21/24 no shower provided Saturday 08/24/24 no shower provided Wednesday 08/28/24 partial bath provided Saturday 08/31/24 complete bed bath provided Saturday 09/07/24 no shower provided Saturday 09/14/24 complete bed bath provided Wednesday 09/18/24 no shower provided Saturday 09/21/24 complete bed bath provided Wednesday 09/25/24 no shower provided Saturday 09/28/24 partial bath provided Saturday 10/05/24 no shower provided Wednesday 10/09/24 no shower provided An observation and interview on 10/07/24 at 3:30 PM with Resident #64 revealed her lying in bed and said she had a shower today but prior to that it had been a while since she had one. Resident #64 stated she only got one shower about every 2 weeks and would like to get 2 showers a week as scheduled. She further stated she preferred a shower because the warm water felt good to her, and she felt cleaner after a shower than when she received a bed bath. A telephone interview was attempted several times with Nurse Aide (NA) #6 who cared for Resident #64 on 08/14/24 and 08/28/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. A telephone interview on 10/10/24 at 11:22 AM with agency NA #4 revealed she had cared for Resident #64 on 08/21/24 (along with agency NA #5), 08/31/24, and 09/18/24 during the 3:00 PM to 11:00 PM shift. She stated she usually tried to get all her showers done but sometimes their assignments changed 2 hours into the shift, and she may have been switched to other residents and not gotten her shower done before the assignment changed. Agency NA #4 stated there seemed to be a scheduling problem at the facility because assignments were constantly being changed during the shift. A telephone interview on 10/10/24 at 11:50 AM with agency NA #5 who cared for Resident #64 on 08/21/24 (along with agency NA #4), and 09/25/24 during the 3:00 PM to 11:00 PM shift revealed if they were fully staffed, she was able to get her showers done on 2nd shift but if not, she was not able to get all the showers done as scheduled. She stated there were times that staff would just not show up for their shift and would not call and that left them short and on those shifts it was difficult to get all the showers done. An interview on 10/11/24 at 4:42 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #64 was not receiving her showers as scheduled. She stated the NAs should be reporting not getting showers done to the nurse or to her so they could have adjusted the schedule to accommodate the residents. Unit Manager #2 further stated she could have moved NAs around or added them to an assignment to get the resident showers done if she had been told they were not done. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their showers as scheduled. She stated the NAs should report to the nurses or unit managers any residents refusing care or who didn't receive their shower as scheduled so they could be accommodated on the next shift or next day. The DON further stated there were changes sometimes to the schedule because they had staff working 4-, 8-, 12- and 16-hour shifts. She indicated they were trying to cover the schedule with agency staff as they hired their own staff, and it was difficult with using so many agencies to get dependable staff to cover the schedule. The DON further indicated they needed to interview the residents and make sure their preferences were documented correctly. 3. Resident #189 was admitted to the facility on [DATE] with diagnoses which included hemiplegia due to cerebrovascular accident (CVA) or stroke. Resident #189's annual Minimum Data Set (MDS) dated [DATE] revealed it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. Resident #189's quarterly MDS dated [DATE] revealed she was moderately cognitively impaired but could make her needs known and required setup with showering and bathing. The assessment also revealed Resident #189 had no rejection of care behaviors. The shower schedule for the middle hall revealed Resident #189 was scheduled for showers on Monday and Thursday on 2nd shift (3:00 PM to 11:00 PM). The documentation of showers in the electronic medical record for Resident #189 for 08/05/24 through 09/05/24 revealed she received no showers as scheduled during this time. On the days she was scheduled for showers the following was documented: Monday 08/05/24 no shower provided Thursday 08/08/24 no shower provided Monday 08/12/24 complete bed bath provided Thursday 08/15/24 no shower provided Monday 08/19/24 no shower provided Thursday 08/22/24 partial bath provided Monday 08/26/24 partial bath provided Thursday 08/29/24 partial bath provided Monday 09/02/24 complete bed bath provided Thursday 09/05/24 no shower provided Documentation for 09/06/24 through 10/09/24 was not provided for this resident. An observation and interview on 10/07/24 at 12:38 PM with Resident #189 revealed her sitting up in her wheelchair in her room dressed for the day. The Resident's skin that was visibly dry and flaky. Resident #189 stated she was not getting her showers two times a week as scheduled and stated she preferred to take showers because the hot water felt good to her, and she felt cleaner after a shower and getting her hair washed. A telephone interview was attempted several times with Nurse Aide (NA) #6 who cared for Resident #189 on 08/08/24, 08/12/24 and 08/26/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. A telephone interview on 10/10/24 at 12:07 PM with Agency NA #3 revealed she had cared for Resident #189 on 08/05/24 and 09/05/24 during the 3:00 PM to 11:00 PM shift. She stated she couldn't remember why she had not given Resident #189 a shower on those days but said sometimes their assignments were changed during the shift and residents may have missed their showers. Agency NA #3 stated she usually gave all her showers and bed baths unless the schedule was changed and said that happened a lot because staff worked different hours. She further stated the staff worked 4, 8, 12 and 16-hour shifts. A telephone interview on 10/10/24 at 11:57 AM with agency Nurse Aide (NA) #2 revealed she had cared for Resident #189 on 08/19/24 during the 3:00 PM to 11:00 PM shift. She stated she was not sure why she had not given Resident #189 a shower on that day but said sometimes their assignments were changed during the shift. She further stated it could have been that she originally had the resident and then was reassigned to another set of residents. Agency NA #2 indicated she always tried to give her showers and if she was not able to it was because the assignments were changed or there was not enough time during her shift to get it done. She also indicated there were times when staff called out or didn't show up and there was not enough time in the shift to give showers because of the increased workload. A telephone interview on 10/10/24 at 11:22 AM with Agency NA #4 revealed she had cared for Resident #189 on 08/22/24 during the 3:00 PM to 11:00 PM shift. She stated she usually tried to get all her showers done but sometimes their assignments changed 2 hours into the shift, and she may have been switched to other residents and not gotten her shower done before the assignment changed. Agency NA #4 stated there seemed to be a scheduling problem at the facility because assignments were constantly being changed during the shift. A telephone interview was attempted several times with agency NA #15 who cared for Resident #189 on 08/29/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. A telephone interview was attempted several times with agency NA #7 who cared for Resident #189 on 09/02/24 during the 3:00 PM to 11:00 PM shift with voicemail messages left for return call with no response. An interview on 10/11/24 at 4:42 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #189 was not receiving her showers as scheduled. She stated the NAs should be reporting not getting showers done to the nurse or to her so they could have adjusted the schedule to accommodate the residents. Unit Manager #2 further stated she could have moved NAs around or added them to an assignment to get the resident showers done if she had been told they were not done. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their preferred showers as scheduled. She stated the NAs should report to the nurses or unit managers any residents refusing care or who didn't receive their shower as scheduled so they could be accommodated on the next shift or next day. The DON further stated there were changes sometimes to the schedule because they had staff working 4-, 8-, 12- and 16-hour shifts. She indicated they were trying to cover the schedule with agency staff as they hired their own staff, and it was difficult with using so many agencies to get dependable staff to cover the schedule. The DON further indicated they needed to interview the residents and make sure their preferences were documented correctly.

Based on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 6 of 10 months reviewed (January 2024, March 2024, April 2024, June 2024, July 2024, and August 2024). Findings included: Review of the Resident Council Minutes for the period 09/25/23 through 09/20/24 revealed the following: a. The Resident Council meeting minutes dated 01/31/24 revealed under New Business there were noted resident concerns about not receiving showers, staff turning off call lights and not providing care, ice not being passed daily, and better customer service. b. The minutes from the Resident Council meeting held on 02/16/24 were not available for review. c. The Resident Council meeting minutes dated 03/22/24 revealed the section for old business noted resident concerns with showers not being given or in a timely manner, staff turning off call lights and not answering them, and better customer service. There was no indication of the facility's response to these concerns listed under old business. Under New Business there were noted residents were unhappy with certain pictures being taken down, nursing assistants being disrespectful, not changing sheets, or making resident beds, not picking up trays or telling residents their names, and not receiving showers on time. d. The Resident Council meeting minutes dated 04/19/24 revealed no indication that the minutes from the Resident Council meeting held on 03/22/24 were read, approved, revised and/or resolved. Further review revealed the section for old business noted residents were unhappy with certain pictures being taken down, nursing assistants being disrespectful and not changing their sheets or making their beds, not picking up their trays, not telling residents their names, and not receiving showers on time. There was no indication of the facility's response to these concerns. Under New Business there were noted resident concerns with showers, staff not picking up resident trays, wipes not being replaced in resident rooms, resident beds not being made, 3rd shift staff turning off call lights and not coming back in a timely manner for care, and dietary not providing correct utensils. e. The minutes from the Resident Council meeting held on 05/19/24 were not available for review. f. The Resident Council meeting minutes dated 06/21/24 revealed section for old business noted about showers given on time and call lights answered in a timely manner. There was also no indication of the facility's response to concerns voiced during the 05/19/24 resident council meeting. g. The Resident Council meeting minutes dated 07/19/24 revealed no indication that the minutes from the Resident Council meeting held on 06/21/24 were read, approved, revised and/or resolved. Further review revealed the section for old business noted no improvements to prior complaints. Under New Business there was noted resident concerns of housekeeping throwing away cups with herbs in them and giving plants too much water, nursing assistants were changing air conditioning temperatures in resident rooms and residents were cold, dietary concerns of correct food for diets, receiving utensils on tray, ice cream being served melted, and facility staff not being friendly. h. The Resident Council meeting minutes dated 08/19/24 revealed no indication that the minutes from the Resident Council meeting held on 07/19/24 were read, approved, revised and/or resolved. Further review revealed, the section for old business noted the complaints that were staff related have somewhat improved. Under New Business there was noted resident concerns of medications being passed late, resident not receiving their pain medication for 4 days, nursing assistants talking too much, resident bed linens not being changed more than once a month and their beds not being made daily, and missing clothing items. A Resident Council group interview was conducted on 10/09/24 at 4:00 PM. During the interview, Residents #3, #17, #38, #45, #57, and #66, who attend Resident Council meetings regularly, all stated they felt facility staff did not really address their concerns or suggestions because the only response they typically received from staff, if they received one at all, was we are working on it, it has been addressed, or we spoke with staff but never any satisfactory resolution and some of the issues continued to happen. Resident #45, who was the Resident Council President, added they understood some of the concerns they voiced couldn't be fixed right away but it would be nice to receive some form of communication back as to what was being done. The residents all agreed they would like to know they were being heard and receive feedback from the administration on the efforts that had been made or attempted to resolve their concerns and/or suggestions. During an interview on 10/09/24 at 4:45 PM, the Activity Director (AD) confirmed she attended and recorded the minutes for the Resident Council monthly meetings. The AD explained she had been told by the previous Administrator that when residents voiced concerns and/or suggestions during the monthly meetings, to write them under new business on the Resident Council minutes and inform him or the previous Director of Nursing (DON) of the concerns and they would look into them. She stated she never received an actual response back from the previous Administrator or the previous DON as to how the concerns had been resolved other than being told it had been addressed or they were working on it. She revealed most of the same concerns were mentioned during the meetings each month and she continued to document those concerns in the Resident Council minutes and inform the current Administrator and DON. The AD stated the previous DON attended some of the Resident Council meetings prior to her leaving and during those meetings the residents addressed their concerns with nursing staff directly to her. The previous DON stated she would take care of those concerns but never informed the AD if or how those concerns were addressed or resolved. The AD revealed moving forward she would prefer to write any concerns or suggestions from Resident Council meetings on a grievance form so she could have some form of a paper trail showing the concerns had been reviewed and were being addressed. A telephone interview with the previous Director of Nursing (DON) on 10/10/24 at 11:11 AM revealed she had been employed at the facility from April 2024 until the first week of September 2024. She stated during her employment at the facility she had attended Resident Council meetings but could not recall which dates she had attended, or any specific resident concerns or resolutions discussed during the meetings. The former Administrator was unable to be interviewed. During an interview on 10/11/24 at 4:30 PM, the current Administrator revealed he began his employment at the facility around the middle of August 2024. He stated that he could not speak to the process of former Administration, but his preference would be for the AD to complete grievance forms for any concerns/suggestions brought up during Resident Council meetings. The Administrator revealed once the grievance forms from Resident Council meetings were completed, they would be given to him as he was the grievance officer and he would distribute them out to the responsible departments for their review. He stated once the grievances were resolved, the departments would write out their resolution on the grievance form and those would be distributed back to the AD for review at the following Resident Council meeting. He also stated that moving forward with this process would help with making sure any grievances or suggestions from Resident Council were being addressed and the departments responsible were being held accountable.

Based on record review and staff interviews, the facility failed to notify the Regional Ombudsman when residents discharged or transferred from the facility for 6 of 6 months (April 2024, May 2024, June 2024, July 2024, August 2024, and September 2024). Findings included: Review of the facility's Admission/Discharge report for the period 04/01/24 to 09/30/24 revealed there were 149 residents who were discharged home, transferred to the hospital, or transferred to another nursing facility. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) revealed since starting her employment in October 2023, she had not sent notifications to the Regional Ombudsman when residents discharged or transferred from the facility and wasn't aware that she needed to do so. During an interview on 10/09/24 at 10:16 AM, the Administrator revealed he had spoken with the SW and she had not been contacting the Regional Ombudsman to notify them of any resident discharges or transfers. The Administrator stated both he and the SW had no excuse as to why notifications were not sent to the Regional Ombudsman but they should be done anytime a resident discharged or transferred from the facility and there would be a process moving forward.

Based on record review and resident, family and staff interviews, the facility failed to have a discharge planning process in place that incorporated the resident in the development of a discharge care plan that addressed the resident's discharge goals and post-discharge needs for residents who wished to discharge to the community for 3 of 4 sampled residents (Residents #82, #13 and #137). Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included gout (type of arthritis that causes severe pain, swelling, redness and tenderness in joints), hypertension, severe protein-calorie malnutrition, and osteoarthritis of knee. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition with a discharge goal to return to the community. The MDS noted an active discharge plan was in place for Resident #82. The Social Service admission assessment dated [DATE] noted Resident #82's discharge goal was to return to the community. Review of Resident #82's comprehensive care plan, last reviewed/revised 10/09/24, revealed no discharge care plan. During an interview on 10/07/24 at 4:18 PM, Resident #82 expressed his goal was to return home as soon as he was able. Resident #82 revealed that since being admitted to the facility, he did not recall having a discussion with facility staff regarding his discharge goals, plans or rehab progress. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) explained when residents were first admitted to the facility, she met with the resident and/or Responsible Party (RP) to introduce herself, complete the initial assessment and then held a 72-hour care plan meeting with the resident/RP to discuss their goals. The SW stated after the initial 72-hour care plan meeting, she tried to visit with the resident weekly but didn't document the conversations. The SW stated she had not developed a discharge care plan for Resident #82 or any other resident. She stated care plans were completed by the MDS Coordinator. During an interview on 10/09/24 at 12:20 PM, the MDS Coordinator explained the development of a resident's comprehensive care plan was an Interdisciplinary Team effort and discharge care plans normally fell on the SW to complete. The MDS Coordinator stated she had not developed or completed any resident's discharge care plan. During an interview on 10/09/24 at 3:50 PM and follow-up interview on 10/11/24 at 5:52 PM, the Administrator stated for residents who admitted to the facility for short-term rehab, the discharge planning process should begin upon admission, updated based on the resident's progress and remain ongoing until the resident discharged . In addition, he expected the initial care plan meeting to be held with the resident/RP within 72-hours to discuss the resident's overall goals. The Administrator explained that a discharge care plan should be developed as part of the discharge planning process that incorporated the resident's goals and wishes and updated based on the resident's therapy progress, goals and care needs. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (breakdown of muscle tissue), hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition with a discharge goal to return to the community. The MDS noted an active discharge plan was in place for Resident #13. Review of Resident #13's comprehensive care plan, last reviewed/revised 08/26/24, revealed no discharge care plan. During an interview on 10/07/24 at 12:28 PM, Resident #13 stated he wanted to return home but was not sure when that would be. Resident #13 stated no one at the facility has talked with him about his discharge goal, plans or needs. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) explained when residents were first admitted to the facility, she met with the resident and/or Responsible Party (RP) to introduce herself, complete the initial assessment and then held a 72-hour care plan meeting with the resident/RP to discuss their goals. The SW stated after the initial 72-hour care plan meeting, she tried to visit with the resident weekly but didn't document the conversations. The SW stated she had not developed a discharge care plan for Resident #13 or any other resident. She stated care plans were completed by the MDS Coordinator. During an interview on 10/09/24 at 12:20 PM, the MDS Coordinator explained the development of a resident's comprehensive care plan was an Interdisciplinary Team effort and discharge care plans normally fell on the SW to complete. The MDS Coordinator stated she had not developed or completed any resident's discharge care plan. During an interview on 10/09/24 at 3:50 PM and follow-up interview on 10/11/24 at 5:52 PM, the Administrator stated for residents who admitted to the facility for short-term rehab, the discharge planning process should begin upon admission, updated based on the resident's progress and remain ongoing until the resident discharged . In addition, he expected the initial care plan meeting to be held with the resident/RP within 72-hours to discuss the resident's overall goals. The Administrator explained that a discharge care plan should be developed as part of the discharge planning process that incorporated the resident's goals and wishes and updated based on the resident's therapy progress, goals and care needs. 3. Resident #137 was admitted to the facility on [DATE] with diagnoses that included right pubis fracture (one of the bones in the pelvis), multiple myeloma (cancer of the plasma cells) and chronic pain. The Nursing Admission Assessment completed on 09/27/24 revealed that Resident #137 was able to communicate her needs and be understood. Resident #137 required supervision or touching assistance with eating and substantial/maximal assistance with all other self-care tasks, bed mobility and transfers. The Social Service admission assessment dated [DATE] noted Resident #137's discharge goal was to return to the community. An interview was conducted with Resident #137 and her family member on 10/07/24 at 3:50 PM. Both Resident #137 and her family member stated that her goal was to receive therapy services and discharge home as soon as possible. Both Resident #137 and the family member expressed that staff had not met with them to discuss Resident #137's discharge goals, plans or treatment needs. Both Resident #137 and the family member stated the only discussion they have had with staff thus far was regarding her insurance right after Resident #137 first admitted to the facility. An interview was conducted with Resident #137's Responsible Party (RP) on 10/09/24 at 9:25 AM with Resident #137 and her family member present. The RP stated no one had met with him or Resident #137 to discuss her discharge plans and voiced frustration over the lack of communication regarding Resident #137's therapy progress. The RP stated he received a call from facility staff about a week ago and a care plan meeting was scheduled for 10/24/24 which would be almost a month since she was admitted to the facility. The RP explained Resident #137's rehab stay was covered for the first 20 days and starting day 21, she would have to start paying a copay and they had planned on her returning home before that. During an interview on 10/09/24 at 12:03 PM, the Social Worker (SW) explained when residents were first admitted to the facility, she met with the resident and/or RP to introduce herself, complete the initial assessment and then held a 72-hour care plan meeting with the resident/RP to discuss their goals. The SW stated she did not conduct a 72-hour care plan with Resident #137 or her RP and was not sure what happened, it just fell through the cracks. The SW stated she had not developed a discharge care plan for Resident #137 or any other resident. During an interview on 10/09/24 at 3:50 PM and follow-up interview on 10/11/24 at 5:52 PM, the Administrator stated for residents who admitted to the facility for short-term rehab, the discharge planning process should begin upon admission, updated based on the resident's progress and remain ongoing until the resident discharged . In addition, he expected the initial care plan meeting to be held with the resident/RP within 72-hours to discuss the resident's overall goals. The Administrator explained that a discharge care plan should be developed as part of the discharge planning process that incorporated the resident's goals and wishes and updated based on the resident's therapy progress, goals and care needs.

Based on record reviews and staff interviews, the facility failed to maintain accurate Treatment Administration Records (TAR) for 1 of 4 residents reviewed for pressure ulcers (Resident #238). The findings include: a. Review of Resident #238's medical record revealed a physician order dated 02/17/2024 to cleanse sacral pressure ulcer with wound cleanser and pat dry then apply non-adhesive pad then cover with foam dressing every day and as needed. Review of Resident #238's 02/2024 TAR revealed there was no documentation on 02/27/2024 to indicate the treatment was completed as ordered. An interview was conducted with former Wound Nurse #1 on 10/09/2024 at 7:01 AM who was assigned to perform pressure ulcer treatments on 02/27/2024. Wound Nurse #1 explained that she remembered Resident #238 and when she performed the Resident's admission skin assessment on 02/16/2024 the Resident had a stage II pressure ulcer on her sacrum. Wound Nurse #1 reported she worked Monday through Friday, but she was also responsible to take call which meant if she was called into work during the week after her first shift, she was scheduled off the following day and the pressure ulcer treatments were left up to the nurse on the hall to perform. Wound Nurse #1 stated she could not verify whether 02/27/2024 was one of those days she was off or whether she forgot to initial for the treatment. She indicated it was possible that she overlooked initialing it. Review of Resident #238's 03/2024 TAR revealed there was no documentation on 03/15/2024, 03/20/2024, 03/25/2024 and 03/29/2024 to indicate the treatment was completed as ordered. An interview was conducted with former Wound Nurse #1 on 10/09/2024 at 7:01 AM who was assigned to perform pressure ulcer treatments on 03/15/2024. Wound Nurse #1 explained that she could not confirm whether she was scheduled to perform the treatments on 03/15/2024 and stated it was possible she forgot to initial for the treatment. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 03/20/2024 and 03/29/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. The facility was unable to identify the initials of the nurse who worked the hall on 03/25/2024 first shift in order to obtain an interview. Review of Resident #238's 04/2024 TAR revealed there was no documentation on 04/10/2024 to indicate the treatment was completed as ordered. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 04/10/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. b. Review of Resident #238's medical record revealed a physician order dated 04/24/2024 to cleanse sacral pressure ulcer with wound cleanser and apply crushed metronidazole (antibiotic) and collagenase ointment (used to debride) then cover with a silver fortified dressing and an island dressing every day. Review of Resident #238's 04/2024 TAR revealed there was no documentation on 04/25/2024 to indicate the treatment was completed as ordered. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 04/25/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. c. Review of Resident #238's medical record revealed a physician order dated 05/03/2024 to cleanse sacral pressure ulcer with wound cleanser and apply calcium alginate and cover with dry dressing every day. Review of Resident #238's TAR for 05/2024 revealed there was no documentation that indicated the treatment was completed on 05/09/2024. An interview was conducted with Nurse #8 on 10/10/2024 at 2:31 PM who worked on 05/09/2024 first shift. Nurse #8 explained she vaguely remembered Resident #238 and did not recall whether she performed the pressure ulcer treatment or not. An interview was conducted with the Director of Nursing (DON) on 10/11/2024 at 11:28 AM. The DON explained that if it is not documented, then it was not done because when staff initialed for the treatment it indicated the treatment was done. She indicated if the treatment was not completed for whatever reason, then there should be documentation to support the reason why the treatment was not done.

Based on observations, record reviews, and resident and staff interviews, the facility failed to implement infection control policies and procedures when the Wound Nurse did not follow the procedure for dressing change for a wound (Resident #25). In addition, Nurse Aide (NA) #11 failed to remove soiled gloves and perform hand hygiene after incontinence care and before she touched the resident, bed linens and the bed control (Resident #25), the Wound Nurse did not follow enhanced barrier precautions (EPB) while applying stabilizing devices to indwelling catheters for two residents (Resident #60 and Resident #63), Nurse #9, failed to follow enhanced barrier precautions while administering intravenous antibiotics into a central venous catheter (Resident #139) and NA #1 did not follow EPB when providing catheter care (Resident #63). The deficient practice occurred for 4 of 5 staff observed for infection control practices (Wound Nurse, Nurse Aide (NA) #11, Nurse #9, and NA #1). The findings included: 1. Review of the facility's policy and procedure on clean dressings last revised on 10/31/18 revealed the following procedure: - Provide for clean field on overbed table by using wax paper, paper towel, etc. - Place clean supplies on the clean field. - Place trash receptacle within easy reach. - [NAME] gloves, remove, and dispose of old dressing in the trash receptacle. - Cleanse the wound. Cleanse from the inside working out. If additional cleaning is needed, use another 4 x 4 gauze. Never use the same 4 x 4. - Discard sponges used for cleaning the wound in the trash receptacle/bag. - Remove and dispose gloves in trash receptacle/bag. - Wash your hands. - [NAME] clean gloves. Apply clean dressing. - Secure dressing with tape. - Date and initial the dressing. - Remove and dispose of gloves in trash receptacle/bag. - Wash hands. - Remove supplies and trash from the resident's room. - Dispose of removed trash properly. An observation of wound care was made on 10/09/24 at 09:50 AM. The Wound Nurse washed his hands with soap and water, donned a clean gown and gloves and placed a barrier down on the overbed table that had not been cleaned. After placing all the supplies on the barrier, he doffed his gloves, sanitized his hands, and donned clean gloves. He assisted Nurse Aide (NA) #11 with turning Resident #25 on his side and the resident had a large amount of stool between his buttock cheeks and there were smears of stool on the brief underneath the resident. The Wound Nurse removed the old dressing and discarded the dressing in the trash bag. He doffed his gloves, sanitized his hands, and donned new gloves and cleaned the outer portion of the wound with normal saline (NS). He then proceeded to clean the wound bed with NS. He doffed his gloves, sanitized his hands, and donned new gloves and proceeded to apply an antifungal and a corticosteroid cream to the outer edges of the wound. The Wound Nurse then applied moisture barrier cream (used to treat minor skin irritations) to the wound edges and peri wound area. He doffed his gloves, sanitized his hands and donned clean gloves and applied a hydrogel that helps maintain a moist wound environment conducive to healing to the wound bed and packed it with a solution-soaked gauze used to prevent and treat infection. As the Wound Nurse was packing the solution-soaked gauze in the wound the end of the gauze fell out of the wound onto the stool smeared brief and the Wound Nurse proceeded to pack it back into the wound. The Wound Nurse applied the bordered gauze dressing to the wound and Resident #25 was turned onto his back. An interview on 10/09/24 at 11:41 AM with the Wound Nurse revealed he had been doing wound care at the facility for 4 months and did all the wound care in the building both pressure and non-pressure wounds. He stated he had forgotten to clean the overbed table prior to placing his wax paper down and he forgot to put a clean chuck pad under Resident #25 prior to providing the wound care. The Wound Nurse further stated he realized that he should have tossed the gauze when it fell out of the wound onto the resident's brief but was nervous about being observed and just continued with the wound care. An interview on 10/11/24 at 6:34 PM with the Director of Nursing (DON) who was also the Infection Preventionist revealed it was her expectation for the Wound Nurse to follow infection control guidelines and wound care guidelines while providing wound care. She stated they were auditing staff to ensure they were following infection control guidelines and procedures and said she would be adding the Wound Nurse and wound care to the auditing tool. The DON/IP further stated she thought the Wound Nurse was nervous about being observed doing wound care. 2. Review of the facility's policy on Handwashing revised 04/2023, indicated personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. The policy read in part: Personnel should wash their hands: - After contact with blood, bodily fluids, secretions, excretions, & equipment or articles contaminated by them. - After removing gloves before performing procedures in which a normally sterile part of the body is entered. - Before and after touching wounds. - When otherwise indicated to avoid transfer of microorganisms to other residents and environments. - When indicated between tasks and procedures to prevent cross contamination of different body sites. An alcohol-based hand sanitizer may be used for handwashing unless the hands are visibly soiled. The hands should be free of dirt and organic material when using an alcohol-based hand sanitizer. The hands should be washed with soap and water after exposure to blood or body fluids. An observation of incontinence care was made on 10/09/24 at 10:13 AM and revealed Nurse Aide (NA) #11 wearing a gown and gloves proceeded to clean stool from Resident #25's buttocks and made sure he was thoroughly clean. With the same gloves on, she adjusted the resident in bed, touching his linens and pillow under his legs and bed controls. She then touched his catheter bag, clean pants and pushed his catheter bag through his pants. In the meantime, his top sheet had fallen on the floor behind his bed, and she walked behind the bed and lifted the sheet up off the floor and placed it on his bed. After getting his pants pulled up on him, she placed the sheet that had fallen on the floor over the resident and then touched his bed controls again with the same gloves to put his bed in low position. NA #11 doffed her gown and gloves without sanitizing her hands and put on a single glove, collected the trash bag and left the room. An interview on 10/09/24 at 3:12 PM with NA #11 revealed she had only taken care of Resident #25 a couple of times. NA #11 stated she realized after she left the room that she should have doffed her gloves after cleaning the resident, sanitized her hands and donned clean gloves prior to touching him and anything in his environment. She further stated she was nervous about being observed providing care and just forgot to change her gloves. NA #11 indicated she should have gotten the resident a clean sheet as well since his had fallen onto the floor. An interview on 10/11/24 at 6:34 PM with the Director of Nursing/Infection Preventionist (DON/IP) revealed she expected all staff to follow the infection control procedures and guidelines when providing incontinence care and any care to residents. She stated she would be providing additional education to the NAs on infection control procedures and guidelines and would likely be monitoring them to ensure they are following the guidelines while providing care to the residents. The DON/IP further stated they would provide additional one on one training as the need was identified. 37280 3. Review of the facility's policy on Enhanced Barrier Precautions (EBP) revised 06/14/24, indicated EBP are used in conjunction with Standard Precautions to reduce the risk of Multi Drug Resistant Organism (MDRO) transmission during high-contact resident care activities. Includes use of both gown and gloves. EBP are meant to be in place for the duration of the resident's stay or until resolution of a wound or discontinuation of an indwelling medical device. Review of the facility's policy on Handwashing revised 04/2023, indicated personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. Personnel should wash their hands: After contact with blood, bodily fluids, secretions, excretions, & equipment or articles contaminated by them. After removing gloves before performing procedures in which a normally sterile part of the body is entered. a. On 10/08/25 at 10:15 AM an observation was made of Nurse #9 who went into Resident #139's room to administer an intravenous (IV) antibiotic through a central venous catheter (CVC, a long flexible tube inserted into a vein in the neck, chest, arm or groin that leads to the large vein which empties into the heart). Posted on the Resident's door was a sign for Enhanced Barrier Precautions that indicated all healthcare personnel should don gloves and gowns when providing care of high contact resident care activities that included device care or use including central lines. Nurse #9 applied gloves and gathered the IV antibiotic, normal saline flush syringe and alcohol pads before she entered Resident #139's room. The Nurse proceeded to sanitize the catheter tip and flushed the normal saline into the CVC before she connected the IV antibiotic to the catheter. b. An observation was made on 10/08/24 at 11:20 AM of Nurse #9 disconnecting Resident #139's IV antibiotic from her central venous catheter. The Nurse sanitized her hands and donned gloves and gathered a normal saline syringe and alcohol pads before she went into the Resident's room. Nurse #9 sanitized the catheter tip then removed the IV antibiotic and flushed the normal saline then sanitized the catheter tip a second time. An interview was conducted with Nurse #9 on 10/08/24 at 2:39 PM. While standing outside of Resident #139's door the Nurse was asked to explain the EBP sign posted on the Resident's door. Nurse #9 explained that Resident #139 had multiple wounds on her coccyx and heels and had to be under EBP. The Nurse was asked if having a central venous catheter warranted being under EBP and Nurse #9 stated no. The Nurse was asked to read the sign, and she then stated yes, I guess it does. Nurse #9 stated she usually wore the gown, but she had not worn the gown with Resident #139. When asked why not, the Nurse stated she really had no reason to offer. An interview was conducted with the Weekend Supervisor on 10/08/24 at 3:11 PM. The Supervisor explained she had only been employed by the facility for three weeks and was still learning her duties. She continued to explain that if Resident #139 had a CVC, then Nurse #9 should have followed the EBP sign on the door. She indicated Nurse #9 might need further education on infection control. c. On 10/08/24 at 10:42 AM an observation was made of Nurse Aide (NA) #1 and Medication Aide (MA) #1 going into Resident #63's room to provide urinary catheter care. It was noted that there was no Enhanced Barrier Precaution sign or Personal Protective Equipment (PPE) posted on the Resident's door. The two staff donned gloves but did not don gowns. After the MA noticed Resident #63 did not have a stabilizing device in place for his urinary catheter, she removed her gloves and left the room to inform the Wound Nurse about the Resident needing a stabilizing device. The MA never returned to the room. In the meantime, NA #1 emptied Resident #63's catheter bag and disposed of the urine in the commode. NA #1 then removed her gloves and without sanitizing or washing her hands she donned another pair of gloves. At this time the Wound Nurse entered the room wearing only gloves and proceeded to attach the stabilizing device on Resident #63's left thigh. The Wound Nurse removed his gloves, washed his hands and left the room. NA #1 then proceeded to perform catheter care on the Resident and when she was finished, she removed her gloves and washed her hands before she left the Resident's room. An observation was made on 10/08/24 at 3:00 PM of the Enhanced Barrier Precaution sign and PPE tower was posted on Resident #63's door. An interview was conducted with NA #1 on 10/08/24 at 3:02 PM as she stood outside Resident #63's door. NA #1 explained she had been at the facility for about 6 months and received infection control training when she was hired. When asked how she knew if a resident was on any kind of infection control precaution, she responded the precaution sign should be posted on the door. The NA pointed at the EBP sign on Resident #63's door and stated that sign was not on the Resident's door earlier when she rendered care to him because if the sign had been on the door, she would have donned the appropriate PPE meaning a gown as well as the gloves because the Resident had a catheter. The NA was asked if she should have done anything different during the morning care of Resident #63 the NA explained she should have washed her hands after she emptied his urinary bag and removed her gloves and before she donned another pair of gloves. An interview was conducted with the Weekend Supervisor on 10/08/24 at 3:11 PM. The Supervisor explained that anytime you remove gloves you should wash your hands before donning more gloves so NA #1 should have washed or sanitized her hands after she removed her gloves and before she donned new gloves. She stated a resident who had a urinary catheter should be on EBP which indicated to use the PPE of gown and gloves. The Supervisor reported she did not know who was responsible for posting the precaution signs and PPE, but the Director of Nursing was responsible for the infection control program. On 10/08/24 at 3:48 PM during an interview with the Medical Supply Clerk, she explained that she posted the EBP sign and PPE on Resident #63's door earlier that afternoon and was asked to post them by Nurse #10. During an interview with the Wound Nurse on 10/08/24 at 4:29 PM the Nurse explained that he had only been doing the wound treatments for a few months. When asked about if Resident #63 was on EBP he stated he could not remember if the precaution sign was on the door, but he should have worn a gown and gloves because the Resident had a urinary catheter. When asked what he wore when he applied the stabilizing device to Resident #63 the Wound Nurse explained he only wore gloves and not the gown because he was told if the reason you were coming in contact with the resident did not last longer than 15 minutes then you did not have to wear the gown. The Wound Nurse implied he was told that by the Director of Nursing. An interview was conducted with Nurse #10 on 10/08/24 at 7:47 PM who explained that she just started back to work at the facility that week. The Nurse stated she was asked by the Director of Nursing earlier in the afternoon (10/08/24) to have the Medical Supply Clerk post the EBP sign and PPE on Resident #63's door. d. An observation was made of the Wound Nurse applying a stabilizing device for Resident #60's indwelling urinary catheter on 10/08/24 at 4:24 PM. The door was open to the Resident's room which had an EBP sign posted, and the PPE tower mounted on the Resident's door. The Wound Nurse was noted to be wearing gloves and no gown during the procedure. An interview was conducted with the Wound Nurse on 10/08/24 at 4:29 PM. The Wound Nurse was asked about what kind of precautions was posted on Resident #60's door and he replied EBP which meant he should have worn gloves and a gown. When asked why he did not wear a gown the Nurse explained that he was told that if the reason he was coming in contact with the resident did not last longer than 15 minutes then you did not have to wear a gown. The Wound Nurse implied he was told that by the Director of Nursing. During an interview with the Director of Nursing (DON) who was also the Infection Preventionist on 10/08/24 at 4:50 PM the DON explained that she had only been employed at the facility for about 4 weeks and had not yet put any new systems into place regarding infection control nor had she conducted any education on infection control. The DON remarked that you would think that Nurse #9 wound follow the directions of the EBP sign posted on Resident #139's door before she administered medication to Resident #139's CVC. She reported that she conducted an audit for the precaution signs and found that Resident #63 had an indwelling urinary catheter and did not have an EBP sign or PPE posted on his door, so she instructed Nurse #10 to have a sign placed on the Resident's door. The DON stated she did not have a routine monitoring for handwashing but indicated NA #1 should have washed her hands after she removed her gloves and before she donned new gloves after she emptied Resident #63's catheter. She stated both NA #1 and the Wound Nurse should have worn a gown when they worked with Resident #63 and Resident #60 because the residents had an indwelling urinary catheter. The DON voiced that she did not inform the Wound Nurse that if the encounter with the resident lasted no longer than 15 minutes then they did not have to wear gowns that the Wound Nurse must be getting it confused with COVID contact time. She stated it looked like she would need to educate on infection control sooner than later.

Based on record review and interviews with resident, staff, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to notify the NP and MD that a resident was completely out of her narcotic pain medication resulting in her missing 14 consecutive doses for 4 1/2 days for 1 of 3 residents reviewed for notification (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included debility, arthritis, and chronic pain. The physician's order dated 10/25/23 revealed Resident #17 had an order to receive one tablet of oxycodone-Acetaminophen oral tablet 5-325 milligrams (mg) (oxycodone with acetaminophen) or Percocet (a type of opioid analgesic consisted of oxycodone/acetaminophen that acted on the central nervous system to relieve pain) by mouth three times a day for pain. The medication was scheduled to be given at 8:00 AM, 2:00 PM and 8:00 PM. The Medication Administration Record (MAR) for August 2024 revealed Resident #17 had not received her medication the following dates and times: - August 1 8:00 AM, 2:00 PM and 8:00 PM - August 2 8:00 AM, 2:00 PM and 8:00 PM - August 3 8:00 AM, 2:00 PM and 8:00 PM - August 4 8:00 AM, 2:00 PM and 8:00 PM - August 5 8:00 AM and 2:00 PM for a total of 14 doses missed. The August 2024 MAR revealed on the following dates and times, Agency Nurse #3 had taken care of Resident #17 and had not administered her Percocet: - August 1 at 8:00 AM and 2:00 PM - August 3 at 8:00 AM, 2:00 PM and 8:00 PM - August 4 at 8:00 AM and 2:00 PM A telephone interview was attempted with Agency Nurse #3 on 10/10/24 at 3:15 PM; however, the number had been disconnected and Nurse #3 was no longer employed through the Agency. The August 2024 MAR revealed on the following dates and times, Nurse #2 had taken care of Resident #17 and had not administered her Percocet: - August 2 at 8:00 AM and 2:00 PM - August 5 at 8:00 AM and 2:00 PM A telephone interview on 10/10/24 at 4:00 PM with Nurse #2 revealed she couldn't recall the specifics but said generally if a resident does not have their medication, she typically contacts the pharmacy and then if a script was needed, she contacted the NP to send an electronic script to the pharmacy for the medication. Nurse #2 stated she couldn't recall if they had oxycodone with acetaminophen in their narcotic Emergency Kit but stated she felt like if they had she would have given it from the Emergency Kit. She further stated she could not recall notifying the NP or MD that the resident was completely out of her pain medication. The August 2024 MAR revealed on August 4 at 8:00 PM Agency Nurse #4 had taken care of Resident #17 and had not administered her Percocet on that day and time. A telephone interview was attempted several times with Agency Nurse #4 without success. Review of Resident #17's significant change MDS dated [DATE] revealed she was cognitively intact and received scheduled pain medication and no as needed pain medication. The assessment also revealed the resident had almost constant pain at a level of 10 out of 1-10. An interview on 10/10/24 at 10:03 AM with Resident #17 revealed she had gone 4 1/2 days the first of August without receiving her pain medication as ordered. She stated during that time she had an increase in her pain level to an 8 on a scale of 1-10, instead of her usual pain level of 0 to 3 with her pain medication. She stated the staff (couldn't remember names) kept telling her it was on order and had not come from the pharmacy and said one nurse (couldn't remember name) finally told her it was too soon to refill her prescription for her pain medication. An interview on 10/10/24 at 4:35 PM with the MD revealed she was not aware Resident #17 had completely ran out of her pain medication. The MD stated she or the NP should have been notified the resident was completely out of her pain medication so they could have ordered pain medication to cover her while awaiting her order from the pharmacy. She further stated she was familiar with Resident #17 and her chronic pain and her concern with her not receiving her pain medication for over 4 days would have been her increased intensity in pain. A telephone interview on 10/11/24 at 2:04 PM with the NP revealed she was not aware that Resident #17 had completely ran out of her pain medication. The NP stated had she known she could have ordered additional pain medication and potentially other modalities such as heat to help with her pain. The NP further stated her concern with Resident #17 not receiving her pain medication would have been her increased intensity in pain making it difficult to get the pain back under control. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed it her expectation that residents received their medications as ordered by the providers. The DON stated the nurses or Unit Manager #2 should have contacted the NP or MD to obtain orders for pain medication and utilized other modalities such as heat to assist the resident in managing her pain.

Based on record review, residents and staff interviews, the facility failed to invite residents to participate and provide input in care planning for 2 of 3 sampled residents (Residents #82 and #13). Findings included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included gout (type of arthritis that causes severe pain, swelling, redness and tenderness in joints), hypertension, severe protein-calorie malnutrition, and osteoarthritis of knee. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition. Review of Resident #82's electronic medical record revealed no evidence he was invited to attend a care plan meeting to discuss and provide input regarding his plan of care following the completion of the admission MDS assessment dated [DATE]. Review of the facility's Care Plan Meeting Schedules for the period August 2024 - October 2024 revealed a care plan meeting with Resident #82 was not listed on the schedules. During an interview on 10/07/24 at 4:18 PM, Resident #82 did not recall being invited to participate in any care plan meetings since being admitted to the facility. During interviews on 10/09/24 at 12:02 PM and 10/10/14 at 10:27 AM, the Social Worker (SW) verified a care plan meeting had not been held with Resident #82 following the completion of his admission MDS assessment dated [DATE]. The SW explained when she started her employment in October 2023, the previous SW had not wanted to train her and there was a lot that she did not know or was trained to do. The SW explained at the time, she really didn't have a process for ensuring care plan meetings were scheduled which resulted in care plan meetings falling through the cracks. She stated now, the process was for the receptionist to schedule the meeting and the SW would keep track of the meetings on a monthly calendar and facilitate the care plan meeting. The SW stated that sometimes the families of residents did not want the resident to attend the meeting so she did not invite the resident at the families' request. The SW stated she was unaware that residents should be invited and provided the opportunity participate in their care plan meeting but she would make sure she invited residents going forward. During an interview on 10/11/24 at 5:52 PM, the Administrator stated the SW was responsible for keeping track of the care plan meeting schedule and he expected the initial care plan meeting to be conducted within 72-hours of a resident's admission to the facility and then completed quarterly. The Administrator stated the care plan meetings should be conducted with the entire Interdisciplinary Team (IDT) present to provide information related to the resident's progress with each discipline. If the IDT member was not able to attend the care plan meeting, he expected the IDT member to provide the information to the SW for her to review with the resident and/or their representatives during the care plan meeting. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (breakdown of muscle tissue), hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. Review of Resident #13's electronic medical record revealed no evidence he was invited to attend a care plan meeting to discuss and provide input regarding his plan of care following the completion of the admission MDS assessment dated [DATE]. Review of the facility's Care Plan Meeting Schedules for the period August 2024 - October 2024 revealed no care plan meeting was scheduled for Resident #13 until October 24, 2024. During an interview on 10/07/24 at 12:28 PM, Resident #13 stated that he had not been invited to participate in any care plan meetings since being admitted to the facility. During interviews on 10/09/24 at 12:02 PM and 10/10/14 at 10:27 AM, the Social Worker (SW) verified a care plan meeting had not been held with Resident #13 following the completion of his admission MDS assessment dated [DATE]. The SW explained when she started her employment in October 2023, the previous SW had not wanted to train her and there was a lot that she did not know or was trained to do. The SW explained at the time, she really didn't have a process for ensuring care plan meetings were scheduled which resulted in care plan meetings falling through the cracks. She stated now, the process was for the receptionist to schedule the meeting and the SW would keep track of the meetings on a monthly calendar and facilitate the care plan meeting. The SW stated that sometimes the families of residents did not want the resident to attend the meeting so she did not invite the resident at the families' request. The SW stated she was unaware that residents should be invited and provided the opportunity participate in their care plan meeting but she would make sure she invited residents going forward. During an interview on 10/11/24 at 5:52 PM, the Administrator stated the SW was responsible for keeping track of the care plan meeting schedule and he expected the initial care plan meeting to be conducted within 72-hours of a resident's admission to the facility and then completed quarterly. The Administrator stated the care plan meetings should be conducted with the entire Interdisciplinary Team (IDT) present to provide information related to the resident's progress with each discipline. If the IDT member was not able to attend the care plan meeting, he expected the IDT member to provide the information to the SW for her to review with the resident and/or their representatives during the care plan meeting.

Based on observations, record review, and resident, family member, and staff interviews, the facility failed to clean and trim nails on both hands of a dependent resident and failed to shave chin hairs on a dependent resident for 1 of 3 dependent residents reviewed for activities of daily living (Resident #43). The findings included: Resident #43 was readmitted on [DATE]. Her diagnoses included diabetes mellitus type II, osteoporosis, and dementia. Resident #43's Care Area Assessment for activities of daily living (ADL) dated 07/14/24 revealed she needed assistance from staff with all activities of daily living due to her diagnoses of dementia, hemiplegia following a stroke affecting her left non-dominant side and osteoporosis. Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired but was able to make her needs known. The assessment also revealed Resident #43 required substantial to maximal assistance with showering and bathing and required partial to moderate assistance with personal hygiene. The resident had no behaviors of rejection of care. Review of Resident #43's care plan last revised on 10/05/24 revealed she had a focus area for requiring assistance with activities of daily living (ADL) related to left sided hemiplegia from previous stroke. The interventions included in part, bed mobility required substantial to maximal assistance, showers/bathing required substantial to maximal assistance and personal hygiene required partial to moderate assistance from staff. An observation on 10/07/24 at 3:43 PM revealed Resident #43 resting in her bed eating crackers with her nails noted to be 1/4 inch beyond the end of her fingers with brown debris under all the nails on both her hands. Resident #43 was also noted to have visible white chin hairs that were 1/4 inch long on her chin. An interview with the resident revealed she did not like her nails to be long and would like for them to be trimmed and cleaned on both hands and said she didn't like having chin hairs and would like for someone to trim them off her chin for her. Resident #43 stated her family member usually had to trim her nails and the chin hair off her chin because the staff at the facility didn't offer to do it for her. She further stated her family member had not been able to come to the facility to visit her because she had fallen and broken her arm. A telephone interview on 10/11/24 at 3:55 PM with Agency Nurse Aide (NA) #8 revealed she had taken care of Resident #43 on 10/07/24 during the 7:00 AM to 3:00 PM shift and had given her a complete bed bath. Agency NA #8 stated she knew Resident #8 had long nails, but she was not used to taking care of her, so she didn't trim her nails. She further stated she had not reported to Unit Manager #2 that her nails were long and needed trimming. Agency NA #8 said she did not usually trim chin hairs on women and said she had not asked Resident #43 if she wanted her chin hairs trimmed and had not reported to Unit Manager #2 that her chin hairs needed to be trimmed. She indicated she was not aware she was expected to trim chin hairs on women. An observation on 10/08/24 at 4:32 PM revealed Resident #43 resting in her bed and her nails were still long with brown debris under them and she still had visible white chin hairs on her chin. She stated she had received a bed bath on 10/07/24 but her nails had not been trimmed and she had not had her chin hairs shaved during her bath. Review of the shower schedule revealed Resident #43 was scheduled for showers/bed baths on Monday and Thursday on 2nd shift (3:00 PM to 11:00 PM). An interview on 10/09/24 at 3:15 PM with Nurse Aide (NA) #11 revealed she had taken care of Resident #43 on 10/08/24 and 10/09/24 during the 7:00 AM to 3:00 PM shift and stated she had not noticed Resident #43's nails being long or being dirty on both her hands. NA #11 stated she had not given her a bath on the days she had cared for her and had not paid attention to her nails or the hair on her chin. She stated usually resident's nails are trimmed and they are shaved on their shower days, and she had not provided Resident #43's shower when she cared for her on 10/08/24 and 10/09/24. NA #11 further stated she believed Resident #43 was diabetic and her nails would have to be trimmed by the nurse but said she had not reported her nails needing to be trimmed to Unit Manager #2. An observation on 10/09/24 at 3:03 PM revealed Resident #43 lying in bed with her family member at her bedside. Her nails were trimmed and cleaned, and her chin hairs had been shaved. The family member stated she had trimmed and cleaned the brown debris from under Resident #43's nails and shaved her chin hairs because the staff at the facility would not do it even though she had requested the resident's nails to be trimmed and kept clean and her chin hairs shaved from her face. The family member further stated she had not been able to visit for 3 weeks because she had fallen and broken her arm and had to heal herself. She indicated to her knowledge the facility staff had never offered to trim Resident #43's nails or shave the chin hairs from her face, so she tried to do it, but it had been difficult today with her broken arm. An interview on 10/10/24 at 2:54 PM with Unit Manager #2 revealed she was not aware, and no one had told her that Resident #43's nails were long and needed to be trimmed. She stated her nails would have to be trimmed by a nurse since she was diabetic but the NAs caring for her should keep them clean and they shouldn't have brown debris under the nails. Unit Manager #2 further stated that shaving residents both male and female was part of their routine when giving residents bed baths or showers and said Resident #43 should have been shaved on Monday when she received her bed bath. She indicated she was not aware the resident's family member had requested the resident be shaved and her fingernails trimmed but said it should be part of her routine ADL care and her family member should not have to trim her fingernails or shave her chin hairs. She further indicated that should be done by the facility staff. An interview on 10/11/24 at 6:10 PM with the Director of Nursing (DON) revealed she expected residents to have their nails trimmed and cleaned and be shaved as part of their bed bath or shower. She stated the NAs should report to the nurses or Unit Managers any diabetic residents with nails that needed to be trimmed, and they should be trimming the other resident's nails. The DON further stated all residents that wanted to be shaved male or female should be shaved as part of their ADL care.

Based on observations, record review, resident and staff interviews the facility failed to apply compression wraps daily per the physician's order for 1 of 1 resident (Resident #57) reviewed for edema (swelling). Findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included lymphedema (chronic condition that causes swelling, most often in the arms or legs, due to a buildup of lymph fluid). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. She required substantial/maximum staff assistance with lower body dressing and received application of nonsurgical dressings other than to feet. It was further noted that Resident #57 had not rejected care during the MDS assessment reference period. An active physician's order dated 08/23/24 for Resident #57 read in part, apply compression garments (wraps) in the morning daily for 8 to 12 hours. Remove at night and elevate legs. Every shift for lymphedema of bilateral lower extremities. Review of the staff progress notes for October 2024 revealed no entries related to Resident #57 refusing application of the compression wraps. An observation and interview was conducted with Resident #57 on 10/07/24 at 4:08 PM. Resident #57 was sitting up in her motorized wheelchair, there was swelling noticed to both lower legs and she had no compression wraps applied. A rolling walker was placed at the end of Resident #57's bed and lying on the seat of were two compression wraps. Resident #57 stated she was supposed to wear the compression wraps on her lower legs due to edema and never refused to have them applied. Resident #57 explained she couldn't put them on herself and staff did not consistently apply them for her. Resident #57 stated staff did not apply the compression wraps on Thursday (10/3/24) or Friday (10/04/24) and had yet to apply them today (10/07/24). Review of Resident #57's Treatment Administration Record (TAR) for October 2024 revealed the compression wraps were initialed as applied daily except for 10/03/24 and 10/04/24. Further review revealed Nurse #5 initialed the TAR as applying the compression wraps on 10/07/24. During an interview on 10/11/24 at 10:04 AM, the Wound Nurse revealed he worked the medication cart on 10/03/24 when he was on-call and could not recall if he had offered to apply Resident #57's compression wraps. He stated if he had, it would not have been until late in the afternoon. The Wound Nurse stated Resident #57 had told him that her compression wraps were not applied last Thursday (10/03/24) or Friday (10/04/25) and typically didn't get applied when he or the weekend Wound Nurse were not working. During a telephone interview on 10/11/24 at 12:54 PM, Nurse #5 revealed she had offered to apply Resident #57's compression wraps on 10/04/24 but she had refused. Nurse #5 stated she had meant to document the refusal on Resident #57's TAR but she must have got distracted and forgot. During a telephone interview on 10/11/24 at 1:43 PM, Nurse #6 revealed she was assigned to do treatments on 10/07/24 but did not have Resident #57 on her list of treatments completed that day. Nurse #5 confirmed it was her initials that were noted on Resident #57's TAR for 10/07/24 and explained it was initialed as completed by mistake because she did not apply Resident #57's compression wraps that day. During an interview on 10/11/24 at 4:25 PM, the Director of Nursing (DON) stated Resident #57 did not typically refuse to have her compression wraps applied by staff, she might delay having them put on until after her shower but not refuse completely. The DON was unaware Resident #57's compression wraps were not applied by staff on 10/3/24, 10/04/24 or 10/07/24. She stated she would expect for the physician order to be followed and if the treatment nurse was not doing treatments, hall nurses were responsible for checking the TAR and completing treatments.

Based on observations, record review, resident and staff interviews the facility failed to secure an indwelling urinary catheter tubing to prevent tension or trauma for 1 of 3 residents reviewed for urinary catheter (Resident #63). The finding include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (enlarged prostate which can cause urinary obstruction). The admission Minimum Data Set assessment dated [DATE] revealed Resident #63's cognition was moderately impaired and had an indwelling urinary catheter. Review of Resident #63's care plan revised 07/10/24 that addressed the use of an indwelling urinary catheter related to benign prostatic hyperplasia. The goal that he would be free of urinary tract infections would be attained by utilizing interventions that include following catheter care policies and procedures and abiding by enhanced barrier precautions. Review of Resident #63's physician order dated 08/20/24 indicated indwelling urinary catheter due to benign prostatic hyperplasia. On 10/07/24 at 12:56 PM during an observation and interview with Resident #63 while sitting up in his wheelchair, the Resident wore pants, and the catheter tubing was threaded down his left pant leg and the catheter bag was contained in a catheter bag holder which was hooked to the wheelchair bars. When the Resident was asked if the catheter tubing had a stabilizing device attached to his leg to prevent pulling on the tubing he replied, sometimes but not now, I don't always have one. On 10/08/24 at 10:42 AM Nurse Aide (NA) #1 and Medication Aide (MA) #1 was in Resident #63's room to provide morning care. Before providing catheter care it was noted that there was no stabilizing device in place to prevent pulling or trauma related to the catheter. The MA located the Wound Nurse who came into the Resident's room and applied a sure lock tape on the Resident's left thigh and secured the catheter tubing during the observation. During interviews with the Wound Nurse and MA #1 on 10/08/24 at 10:42 AM the MA explained that sometimes the staff remove it when they give him a shower and when the MA was asked if Resident #63 had a shower that morning the MA indicated he had not. The MA and Wound Nurse stated there should be a stabilizing device in place for every indwelling urinary catheter. An interview was conducted with the Director of Nursing (DON) on 10/11/24 at 10:11 AM. The DON explained that every catheter should have a stabilizing device in place to prevent trauma caused by pulling on the catheter tubing.

Based on observation, staff interviews and record review, the facility failed to provide a dignified dining experience by standing while providing assistance with feeding for 1 of 5 residents (Resident #123) reviewed for assistance with dining. Findings included: Resident #123 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set assessment dated [DATE] was in progress. The assessment revealed Resident #123 had severely impaired cognition. The baseline care plan dated 2/15/22 indicated the resident needed assistance with eating. On 2/21/22 at 12:40 PM Resident #123 was observed in her bed in an upright seated position. She was being fed by Nurse Aide (NA) #1. The meal tray was located on the overbed table at the foot of the resident's bed. NA #1 was observed as she walked to the foot of Resident #123's bed, scooped up a serving of food, then walked back to the head of the bed where the resident was, stood above eye level of Resident #123 and fed her. NA #1 then returned to the meal tray and obtained another scoop of food and walked back to the resident and fed her. NA #1 continued to walk back and forth with each bite of food and stood above eye level of Resident #123 for the duration of the meal while she fed the resident. At 12:58 PM Resident #123 indicated she was finished eating and NA #1 removed the lunch tray from the overbed table and exited the room. An interview was completed with NA #1 on 2/21/22 at 12:59 PM, during which she stated Resident #123 had confusion and needed to be fed her meal. She said she typically stood up when she fed residents, including Resident #123. NA #1 shared the facility hadn't specifically educated staff whether they should be seated or stand when they fed a resident. The Staff Development Coordinator (SDC) was interviewed on 2/24/22 at 9:10 AM. She explained staff were to be seated in a chair when they fed a resident. She stated staff positioning during meals was covered in the nurse aide skills training. The SDC added NA #1 was from a nurse staffing agency and although the SDC hadn't done skills training with the nurse aide, she expected agency staff to know the right things to do with resident care. During an interview with the Administrator on 2/24/22 at 2:43 PM, she said NA #1 was new to the facility and did not know why she stood when she fed Resident #123. She explained staff were to be seated when they provided assistance to a resident during meals.

Based on observation, resident and staff interviews, and record reviews the facility failed to provide activities based on individual interest to include 1:1 activities for 1 of 1 sampled for activities (Resident # 59). Findings included: Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had cognitive impairment for decision making and required extensive assistance of staff for activities of daily living with transfers, locomotion, bed mobility and dressing. A review of the comprehensive care plan dated 2/18/2022 revealed a focused area for activities that read, Resident #59 can make his own choice of whether or not he would like to participate in group activities. Resident #59 will participate in 1:1 activity with the activities staff a couple of times a week to engage in mental stimulation. Resident #59 will be able to identify at least 2 activities that he would like to participate in whether it be in the room, 1:1 or out of the room. If he can identify 1:1 activities that he would like then he will be offered those a couple of times a week. Interventions included: Arrange for the activity aide to visit and encourage Resident #59 to observe or participate in an activity out of the room so that he can be social with other residents. Assist Resident #59 in planning his own leisure time activities and remind him that his wife comes to visit which will help with his being mentally stimulated and engage in conversation. Sustain contact with Resident #59 by visiting in the room frequently and remind him that 1:1 activities are also an option. An observation was conducted of Resident #59 on 2/21/22 at 10:18 AM lying in bed with his eyes shut, without a book, magazine, or music. There was no item for entertainment on the nightstand. An interview was conducted with Resident #59 on 2/21/22 at 10:29 AM and he stated he gets bored sitting in this room. An observation was conducted on 2/22/22 at 3:23 PM of Resident #59 and he was lying in bed with no books, magazines, or items for entertainment, staring at the wardrobe with no music and no television. An observation was conducted on 2/23/22 at 11:19 AM of Resident #59 lying in bed sleeping. An interview was conducted on 2/23/2022 at 2:11 PM with the Activities Director and she revealed that she had been out of the facility from 2/15/2022 through 2/21/2022 and during this time the Assistant Activities Director was managing all activities programs and the one-on-one activities that took place in the facility. She revealed that documentation of one-on-one activities had not been completed during the past few months. An interview was conducted on 2/23/2022 at 2:31 PM with the Assistant Activities Director and she revealed she managed the activities that had been conducted from 2/15/2021 through 2/23/2022 and these activities did not include any one-on-one activities with Resident #59. She added that she had not documented any one-on-one activities for any residents for the last few months. An interview was conducted with the Administrator on 2/23/2022 at 2:54 PM and she revealed she was unaware Resident #59 had not received 1:1 activities over the last week, per his care plan, and she planned to meet with the Activities Director to provide education regarding 1:1 documentation and participation and this would be conducted immediately.

Based on resident and staff interviews and record review, the facility failed to honor a resident's choice and provide showers as scheduled for 1 of 2 residents (Resident #40) reviewed for choices. Findings included: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Patient Admission Data form which was completed upon Resident #40's admission to the facility on [DATE] revealed the resident's preference of baths or showers at home was showers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had moderately impaired cognition. She was dependent on staff for bathing. Resident #40's care plan updated 9/13/19 revealed a problem of activities of daily living (ADL)/personal care. An intervention included one person extensive physical assistance with bathing. The facility's shower schedule revealed Resident #40 was scheduled for showers on Wednesdays and Saturdays during the 7:00 AM-3:00 PM shift. Further review of the medical record documentation revealed Resident #40 received a shower on 9/25/19 (Wednesday) and 10/9/19 (Wednesday). No shower was documented to have been provided on Saturday, 9/28/19 or Saturday, 10/12/19. On 10/22/19 at 9:17 AM an interview was completed with Resident #40 during which she stated she was supposed to get a shower twice a week (Wednesday and Saturday) but typically only received a shower on Wednesdays. Resident #40 added she wasn't sure why a shower was not given to her on Saturdays but indicated she wanted a shower twice a week. ADL documentation on 9/28/19 revealed Nurse Aide (NA) #1 provided personal care to Resident #40. On 10/24/19 at 1:41 PM an interview was completed with NA #1. She stated she was not assigned to Resident #40 on 9/28/19 and was unable to state why a shower was not given. She explained she documented ADLs in the electronic medical record (EMR) on behalf of an agency NA who was unable to access the EMR system. An interview on 10/25/19 at 1:10 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed they were unable to determine which NA worked with Resident #40 on 9/28/19. ADL documentation on 10/12/19 revealed NA #2 provided personal care to Resident #40. On 10/25/19 at 9:59 AM an interview with NA #2 revealed although she documented ADLs in the EMR, she had not provided care to Resident #40 on 10/12/19. She indicated there was an agency NA who worked on the hall that Saturday. Attempts to interview the agency NA who worked with Resident #40 on 10/12/19 were unsuccessful. During a follow up interview with Resident #40 on 10/25/19 at 11:38 AM she expressed that she would not refuse a shower if the staff offered one to her. She said she received showers on Wednesdays but showers were not offered to her on Saturdays. Resident #40 indicated she liked the showers and reported that it made her feel good. A continuation of the interview with the DON on 10/25/19 at 1:10 PM revealed she was unsure why Resident #40 had not received showers on Saturdays. She said she had observed that staff gave showers to residents on the weekends. The DON explained there was a NA information book located at the nurse's desk that informed staff which residents needed showers on a particular day/shift. The DON confirmed that Resident #40 was scheduled for showers on Wednesdays and Saturdays and expected each NA provide a shower to their resident on the scheduled shower day.

Based on observations, resident, staff and transport driver interviews and record review, the facility failed to maintain appropriate temperatures of protein-based sandwiches that were transported with residents to the [MEDICAL TREATMENT] center for 1 of 1 resident (Resident #66) reviewed for [MEDICAL TREATMENT]. Findings included: Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact and received [MEDICAL TREATMENT]. During a tour of the kitchen on 10/22/19 at 6:13 AM an observation of the reach in refrigerator revealed three gallon size plastic bags. Each bag contained a sandwich (two chicken salad sandwiches and one pimento cheese sandwich), two juices, a container of applesauce and a package of cookies. An interview with the Cook revealed the plastic bags contained prepared lunches that were sent with the [MEDICAL TREATMENT] residents when they went to the [MEDICAL TREATMENT] center. On 10/22/19 at 9:56 AM an interview was completed with Resident #66 during which she stated she went to [MEDICAL TREATMENT] on Mondays and Fridays. She indicated she typically left the facility around 10:45 AM and returned by 4:30 PM. Resident #66 said the facility provided her with a bagged lunch that she took to the [MEDICAL TREATMENT] center. The lunch typically consisted of a protein-based sandwich such as pimento cheese, chicken salad, ham or turkey, juice, applesauce and a package of crackers or cookies. The resident revealed the lunch was provided in a gallon size plastic bag and was not transported in any type of cooler. She further stated the [MEDICAL TREATMENT] center had not provided a refrigerator or cooler for the lunch to be kept in, rather, Resident #66 carried the plastic bag with her belongings on the van ride to the [MEDICAL TREATMENT] center and then placed the bag on a side table in the [MEDICAL TREATMENT] treatment room. During an interview with Nurse #2 on 10/23/19 at 3:51 PM, she explained that a lunch was sent with Resident #66 when she went to [MEDICAL TREATMENT]. She said either the nurse or nurse aide (NA) picked up the lunch from the kitchen and gave it to the resident prior to leaving the facility. An observation of Resident #66 on 10/25/19 at 10:41 AM revealed the resident had received a lunch meal that was to be taken to [MEDICAL TREATMENT]. Medication Aide #1 handed the lunch to the resident. The lunch was in a gallon size plastic bag and contained a turkey sandwich, two apple juices, a package of lemon cookies, a single serve cup of applesauce and a packet of mayonnaise. Upon receipt of the lunch, Resident #66 placed the plastic bag inside a plastic basin with some personal belongings. The resident indicated she kept the lunch with her on the ride to the [MEDICAL TREATMENT] center and said, Sometimes I'll eat it after [MEDICAL TREATMENT]. An interview with Medication Aide #1 on 10/25/19 at 10:45 AM revealed the kitchen pre-packed the lunches for [MEDICAL TREATMENT] and gave them to nursing staff to distribute to residents. On 10/25/19 at 10:50 AM an observation was made of Resident #66 being placed onto the van for transport to [MEDICAL TREATMENT]. The plastic bag that contained the lunch was in the resident's plastic basin which was held by Resident #66. The Transport Driver was interviewed on 10/25/19 at 10:55 AM. He provided transportation to the [MEDICAL TREATMENT] center and reported he was not responsible for the resident's lunches. He explained the lunches were kept with each individual resident on the ride to the [MEDICAL TREATMENT] center and typically the resident held the lunch or it was placed in a pocket behind their wheelchair. On 10/25/19 at 2:59 PM an interview was completed with the Dietary Manager. She stated the kitchen prepared lunches that were sent with residents who went to [MEDICAL TREATMENT]. She reported the protein-based sandwich that was included in the bagged lunch was typically either turkey, chicken salad, ham, pimento cheese or peanut butter and jelly. The Dietary Manager explained the lunch was placed in a plastic bag and sent with a resident to the [MEDICAL TREATMENT] center. She verified the temperature of the sandwich should be at 41 degrees or below and added she didn't know how the temperature of the sandwich was maintained once it left the kitchen but thought the temperature rose once it left the refrigerator. She further indicated the facility had insulated bags/coolers but they had not been used for the [MEDICAL TREATMENT] lunches since she had worked at the facility, rather, a plastic bag was used. She said the best way to maintain the temperature of the sandwich was to use a cooler. The Dietary Manager acknowledged the facility was responsible to ensure food was transported in a manner that was safe and that meals were served at the proper temperature. An interview with the Administrator on 10/25/19 at 4:10 PM revealed she expected the temperature of the lunch meal be maintained in a manner that was safe for residents to eat when at the [MEDICAL TREATMENT] center.

Based on observations, record review and staff and physician interviews, the facility failed to ensure repositioning techniques were followed when repositioning a resident in his wheelchair by pulling him under his arms for 1 of 3 sampled residents (Resident #1) reviewed for supervision to prevent accidents. The failure to properly reposition Resident #1 resulted in Resident #1 sustaining a large hematoma (an abnormal collection of blood), experiencing blood loss and severe bruising to his chest. Resident #1 was sent to the hospital on [DATE] and diagnosed with [REDACTED]. Resident #1 returned to the facility on [DATE]. Immediate jeopardy began on 1/22/19 when nursing assistant (NA) #1 repositioned Resident #1 up in his wheelchair by pulling him under his arms which resulted in injury. Immediate Jeopardy was removed on 2/14/19 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) for the facility to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's care plan, updated on 12/19/18, revealed Resident #1 required assistance of one person to maintain maximum function of self-sufficiency for transferring from one position to another related to: unsteady gait. The care plan goal was for Resident #1 to receive the necessary physical assistance to transfer. Interventions included: assistance of one person, two if fatigued. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had moderately impaired cognition and required extensive assistance with one person for bed mobility and transfers and utilized a wheelchair. Resident #1 had limitation in range of motion on his right and left sides. A review of a progress note by the physician dated 1/23/19 revealed, Seen for acute visit due to bruise on left chest and slight cough. Patient described bruise on his chest to be result of a tug of him by nursing staff. Noted a large non elevated bruise of the right axillary fossa. There is noted a deep bruise right axilla. The bruise in right axilla had not changed however there was a significant elevated soft mass over the entire right pectoralis major, was a bleeding mass, was soft and non-fluctuant, view of the extensive amount of [MEDICAL CONDITION] noted and the fact that it had developed within 24 hours since my initial evaluation of him, Doppler and stat labs ordered. An interview with the facility physician on 2/13/19 at approximately 10:30 AM revealed he examined Resident #1 on 1/22/19 for increased confusion and ordered a chest x-ray and a urinalysis. He stated he did not see any swelling or bruising to Resident #1's right chest area that day but examined him again on 1/23/19 and observed the large swollen area and bruising and ordered a Doppler study and a complete blood count. The physician stated invasive intervention would not be considered due to the risk for infection and Resident #1's cardiac status and [DIAGNOSES REDACTED]. An interview on 2/13/19 at 10:40 AM with Nurse #1 who rounds with the physician stated the physician saw Resident #1 on 1/22/19 for increased confusion and there was no bruising. When the physician saw Resident #1 on 1/23/19, there was swelling and bruising to the right chest area. She stated the nurses were monitoring and applying ice to the area. A record review revealed a physician's orders [REDACTED]. A record review revealed a physician's orders [REDACTED]. A review of the chest x ray results revealed interval development of right perihilar and bibasilar infiltrates since 11/22/2018 called to physician assistant, new orders received and initiated for [MEDICATION NAME] 875 milligrams by mouth for 10 days, [MEDICATION NAME] 1 cap by mouth daily for 21 days, [MEDICATION NAME] 600 milligrams by mouth and nebulizer treatments as needed. A review of the Doppler results done on 1/23/19 revealed fluid collection 9.65 x 5.71 x 5.46 centimeters -differential included organizing hematoma, cyst or abscess. A review of the complete blood count results dated 1/23/19 revealed a hemoglobin level of 12.9. A review of a progress note by the nurse practitioner dated 1/24/19 revealed she saw Resident #1 for follow up on hematoma formation to right upper chest. The progress note revealed the right upper chest had a raised, firm area, extending from the sternum to under the arm pit with some yellowing and light bruising to area. A dark echymotic area on right rib cage was noted. The results of the compete blood count and Doppler ultrasound results were reviewed. A statement by nurse aide (NA) #1 dated 1/25/19 taken by the Director of Nursing (DON) via telephone revealed NA#1 had been assigned to care for Resident #1 on 1/22/19 and she asked Restorative Aide #1 to help her pull Resident #1 up in the chair. The statement revealed Restorative Aide #1 came to assist her and NA #1 pulled Resident #1 up in the chair by pulling him under his arm. An interview on 2/13/19 at 1:13 PM with NA #1 revealed she was assigned to Resident #1 on 1/22/19 on first shift (7AM -3PM). She stated when she went into Resident #1 ' s room on 1/22/19 in the morning to transfer him from the bed to the wheelchair, she got him to sit on the side of the bed because he was able to stand and pivot. NA #1 stated that she transferred Resident #1 from his bed to his wheelchair without any assistance. She stated Resident #1 was sliding down in his wheelchair so she asked Restorative Aide #1 to assist her to reposition him. She stated she couldn't remember if she pulled Resident #1 up under his arms to reposition him in his wheelchair. She recalled that she did not have a gait belt. She stated she did not remember seeing any swelling or bruising on Resident #1's body. A review of a statement by Restorative Aide #1 on 1/25/19 revealed she was asked by NA #1 to assist her to pull up Resident #1 on 1/22/19 in his wheelchair. She entered the room to assist and observed NA #1 pulling Resident #1 back in the wheelchair with her arm under his left arm. She stated she instructed NA #1 not to do that. An interview on 2/13/19 at 1:30 PM with Restorative Aide #1. She stated on 1/22/19, she entered Resident #1's room after NA #1 asked for help to pull Resident #1 up in his wheelchair. She observed Resident #1 sliding down in his wheelchair and assisted NA #1 to pull him up in his wheel chair. She stated she got to the left side toward the back of Resident #1 and pulled him up by the back of his pants. She assumed NA #1 would do the same thing on the other side of the resident, but when she looked up, she observed NA #1 pulling Resident #1 up under his arms. She told NA #1 that was wrong and they were never supposed to lift residents under their arms. She did not observe any swelling or bruising on Resident #1. Record review revealed no documentation of bruising or swelling for Resident #1 until 1/25/19. On 1/25/19 a nurse ' s note was written indicating a family member was visiting and was concerned about the swelling and bruising on Resident #1. An interview on 2/14/19 at 2:17 PM with Nurse #2 revealed she was the nurse assigned to Resident #1 on 1/26/19 when the resident was sent to the hospital. She stated she couldn't remember exactly what happened or why she sent him to the hospital, but she recalled he was in a lot of pain in his shoulder. A physicians order dated 1/26/19 revealed Resident #1 was sent to the Emergency Department for pain and increased swelling and bruising on right chest and right side per family request. A review of the hospital discharge summary dated 1/30/19 revealed Resident #1 presented to the emergency department after son noted swelling to the chest wall that occurred 3 days ago. Resident #1 was in [MEDICAL CONDITION] with heart rate of 150, complaining of chest wall pain and shoulder pain. Hemoglobin was down 4 grams from baseline on admission and stabilized at 8.9. He remained hemodynamically stable. He received [MEDICATION NAME] iron and will discharge on iron supplement with follow up as an outpatient. Troponin is elevated but not consistent with ischemia and most likely related to trauma. An attempt to interview the hospital physician on 2/14/19 at 1:32 PM was unsuccessful. An interview on 2/14/19 at approximately 11:00 AM with Physical Therapist (PT) #1 revealed he was very familiar with Resident #1 and had worked with him often. He stated prior to Resident #1 going to the hospital on [DATE], he had variable levels of functioning and could some days stand and pivot with stand by assistance, and other days required more hands on assistance. PT #1 stated Resident #1 could be resistant to getting out of bed and needed encouragement and Resident #1 had chronic right shoulder pain and needed to be encouraged and reminded to lay on his back or left side. He stated it was important for staff to explain what they were doing and give Resident #1 time to process things as he did have impaired cognition. PT#1 stated staff should utilize gait belts to transfer residents to prevent injury. An observation of Resident #1 on 2/13/19 at 10:45 AM revealed Resident #1 lying in bed on back with eyes open. There was swelling observed to Resident #1's right chest and bruising in various stages of healing observed to Resident #1's chest at midline, toward axilla and on right side. The resident was unable to state how the bruising and swelling on his chest occurred. An interview on 2/13/19 at 1:35 PM with the director of nursing (DON) revealed the Administrator told her about the bruising on 1/25/19 and she began an investigation. She interviewed NA #1 and Restorative Aide #1 and it was determined that the swelling and bruising on Resident #1's chest occurred from the improper transfer/repositioning A follow up interview with the DON on 2/14/19 revealed she didn't remember when she was informed about the swelling and bruising. She stated it was never acceptable to transfer a resident by pulling them under their arms and all staff should have a gait belt and use gait belts to transfer residents properly to prevent injuries. An initial interview on 2/13/19 at 1:40 PM with the Administrator revealed she became aware of the swelling and bruising to Resident #1 on 1/25/19 when a family member called her concerned about it. She stated she talked to the family member about the swelling and bruising and the investigation into how it occurred. A follow up interview with the Administrator on 2/14/19 revealed she knew about bruising on the 24th because she made notes about it in her planner on that day and Resident #1 was discussed in team meeting. On 2/14/19 at 1:00 PM, the facility's Administrator and Corporate Nurse were informed of the Immediate Jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 2/15/19 at 11:06 AM. The allegation of immediate jeopardy removal was as follows: How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 1/22/19 resident # 1 was transferred by certified nursing assistant #1 without use of gait belt, using resident's chest and arms to assist due to failure to follow transfer procedure as a result of knowledge deficit. On 1/22/19 resident # 1 received a chest x-ray in facility for cough. On 1/23/19 abnormal chest x-ray results of interval development of right perihilar and bibasilar infiltrates since 11/22/2018 called to physician assistant, new orders received and initiated for [MEDICATION NAME] 875 mg x 10 days, [MEDICATION NAME] 1 cap daily x 21 days, [MEDICATION NAME] 600 mg PO and Neb treatment ordered as needed. On 1/23/19 resident # 1 was discussed by the clinical team (DON, ADON, MDS, administrator, Therapy) during morning meeting (Cardinal IDT) for change in condition related to cough, and antibiotics. Physician note from 1/23/19 indicating the bruise not available at time of review. On 1/23/19 resident # 1 was seen by physician, medical director, in facility for follow-up to abnormal chest x-ray. Progress note reflected resident to also have bruise on left chest. New order received for ultrasound of chest area, CBC, Vitamin B-12, Vitamin D, and BMP. Progress note for visit not received by facility until 1/24/19. On 1/24/19 resident # 1 was discussed by the clinical team (DON, ADON, MDS, administrator, Therapy) during morning meeting (Cardinal IDT) for abnormal chest x-ray, diet downgrade, and hematoma (bruise). During Cardinal IDT, administrator instructed director of nursing and assistant director of nursing to start interviewing staff to determine cause of hematoma (bruise). On 1/24/19 director of nursing and assistant director of nursing began contacting staff for interviews related to bruising on resident #1. On 1/25/19 director of nursing and assistant director of nursing obtained statements from two certified nursing assistants that indicated resident #1 was not transferred according to transfer procedure. On 1/25/19 resident #1 was discussed by director of nursing, assistant director of nursing, and therapy manager regarding change in transfer ability. Discussion resulted in a resident being changed to a 2 person mechanical lift until therapy services could evaluate formally. On 1/25/19 resident #1's care plan was updated to reflect change in transfer technique to 2 person mechanical lift by the minimum data set nurse. Residents care plan includes the care guide (ICSP) which communicates to nursing staff including certified nursing assistants and agency staff a resident's transfer technique. On 1/26/19 resident # 1 was sent to emergency room for evaluation of increased size of bruising, swelling and pain on left side of chest. On 1/29/19 certified nursing assistant # 1 was provided in-service training by assistant director of nursing on transfers and gait belt use which included residents in a chair and poor position, return demonstration of resident transfer completed. Nursing assistant # 1 was provided with gait belt. Extra gait belts are available at nurse's stations and staff facilitator office. On 1/30/19 resident #1 was readmitted to facility from acute care hospital. On 1/31/19 resident was evaluated and added to caseload for physical, speech, and occupational therapy for treatment as appropriate, including change in transfer ability. As a result of the therapy evaluation resident was picked up by therapy services for physical, occupational, and speech services on 1/31/19. Therapy goals include resident will be 1 person assistance with bed mobility, transfer stand- pivot, resident will have a tolerable pain level with range of movement. On 1/29/19 the interdisciplinary team (DON, ADON, administrator, and therapy) utilized investigation and the 5 whys to determine the root cause of the resident injury was staff failure to follow procedure related transfers due to knowledge deficit. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 1/29/19 the director of nursing (DON) and assistant director of nursing (ADON) completed an audit of resident care guides for all residents currently in facility for proper transfer status based on each resident's current status. All care guides were correct with no negative findings noted. This audit was documented on a census. On 1/29/19 the DON and ADON completed transfer observations of all residents currently in the facility to ensure transfer observed was completed per care guide. No negative findings noted. This audit was documented on a census. On 1/29/19, the ADON initiated in-service for 100% of licensed nurses, and nursing assistants, including agency staff and certified nursing assistant #1, on appropriate transfers with and without gait belt, including not repositioning residents using arms, use of draw sheet when gait belt not appropriate and resident in bed, and gait belt use. This in-service was added to new staff orientation, including agency staff. In-service 100% complete with all nursing staff (CNAs, licensed nurses, and agency staff) on 2/14/19. To ensure in-service is effective beginning 2/13/19 the DON, and/or ADON will complete random audits of 5 resident transfers 5 times weekly, to include all halls, all shifts, and agency staff, for transfer observation. The audit will be completed by observing the transfer and ensuring transfer technique is correct based on the resident care plan and facility procedure including correct use of gait belt when gait belt use is appropriate. The audit will be documented on the transfer audit tool. On 1/29/19 the interdisciplinary team discussed any other resident incidents or occurrences related to resident transfer technique. No other issues noted. What measures will be put into place or systemic changes made to ensure the deficient practice will not occur: On 1/29/19, the ADON initiated in-service for 100% of licensed nurses, and nursing assistants, including agency staff and certified nursing assistant #1, on appropriate transfers with and without gait belt, including not repositioning residents using arms, use of draw sheet when gait belt not appropriate, and gait belt use. This in-service was added to new staff orientation, including agency staff. In-service was 100% complete with all nursing staff (CNAs, licensed nurses, and agency staff) on 2/14/19. To ensure in-service is effective beginning 2/13/19 the DON, and/or ADON will complete random audits of 5 resident transfers 5 times weekly, to include all halls, all shifts, and agency staff, for transfer observation. The audit will be completed by observing the transfer and ensuring transfer technique is correct based on the resident care plan and facility procedure including use of gait belt when appropriate. The audit will be documented on the transfer audit tool. Gait belts are provided to nursing staff during orientation and are also available at nursing stations, and staff development. On 2/14/19 the DON, and/or ADON began reviewing all progress notes entered for any resident (all residents) 5x weekly (to include all shifts, all halls) x 12 weeks to ensure new skin areas, including bruising have been followed up on and investigated if needed. This audit will be documented on the skin audit tool. This audit will ensure any bruising has been investigated timely when appropriate. On 2/14/19 the DON, ADON, and/or MDS nurse will review P[NAME] skin alerts 5x weekly(to include all shifts, all halls) x 12 weeks to ensure skin alerts, including bruising, have been followed up on and investigated if needed. This audit will be documented on the skin audit tool. This audit will ensure any bruising has been investigated timely when appropriate. The performance improvement plan was discussed and approved by the quality assurance performance improvement (QAPI) committee on 1/28/19. The medical director was made aware of the plan on 1/28/19 and is in agreement with plan. How the facility plans to monitor its performance to make sure solutions are sustained. Beginning 1/28/19, the facility increased communication in the form of: verbal communication to nursing staff by in-service and daily interdisciplinary team (IDT) meetings, written education, and audit forms to ensure the facility provides residents with supervision to prevent accidents by providing safe transfers. The IDT, QAPI committee will continue to monitor the facility to identify other factors contributing to failure to supervise to prevent accidents. Beginning 1/28/19, the DON, and ADON will present the in-service comments, supervision observations, and audit trends to the IDT weekly as needed and monthly QAPI committee for six months. The IDT and QAPI committee will focus on improving residents' safety through prevention of accidents, including resident transfers. The administrator and/or DON will present the recommendations of the daily IDT and monthly QAPI committee to the quarterly QAPI committee for additional recommendations for monitoring and continued compliance. The administrator will be responsible for implementing this plan of removal of immediate jeopardy to ensure any issues of failure to provide supervision to prevent accidents will be addressed through additional root cause analysis, process correction, training, and monitoring. Piney Grove Nursing and Rehabilitation alleged removal of IJ as of 2/14/19. The facility's credible allegation of Immediate Jeopardy removal was validated on 2/15/19 at 1:30 PM. The validation was evidenced by interviews with both licensed and non-licensed nursing staff on gait belt use and when not to use, where to locate them not positioning under arms and using draw sheet when appropriate. Review of on-going inservice records revealing licensed and non-licensed staff were in-serviced on gait belt use and when not to use, where to locate them not positioning under arms and using draw sheet when appropriate. Review of Resident #1's updated care plan and care guide reflecting change in transfer status. Review of on-going audits, documented review of audit of all residents to ensure care guides correct and transfer status correct.

Based on observation, record review and staff and physician interviews, the facility failed to ensure an agency nursing assistant was trained and competent before allowing the nursing assistant to work for 1 of 3 (NA #1) agency nursing assistants reviewed. The failure to ensure NA #1 was trained and competent resulted in an improper transfer and repositioning of Resident #1 when NA #1 lifted Resident #1 under his arms to reposition Resident #1 in his wheelchair, resulting in injury. Resident #1 sustained a large hematoma (an abnormal collection of blood), experiencing blood loss and severe bruising to his chest. Resident #1 was sent to the hospital on [DATE] and diagnosed with [REDACTED]. Resident #1 returned to the facility on [DATE]. Immediate jeopardy began on 1/22/19 when nursing assistant (NA) #1 repositioned Resident #1 up in his wheelchair by pulling him under his arms which resulted in injury. Immediate Jeopardy was removed on 2/14/19 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) for the facility to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's care plan, updated on 12/19/18, Resident #1 required assistance of one person to maintain maximum function of self-sufficiency for transferring from one position to another related to: unsteady gait, [MEDICAL CONDITION]. The care plan goal was for Resident #1 to receive the necessary physical assistance to transfer. Interventions included: assistance of one person, two if fatigued. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had moderately impaired cognition and required extensive assistance with one person for bed mobility and transfers and utilized a wheelchair. Resident #1 had limitation in range of motion on his right and left sides. A review of a progress note by the physician dated 1/23/19. Seen for acute visit due to bruise on left chest and slight cough. Patient described bruise on his chest to be result of a tug of him by nursing staff. Noted a large non elevated bruise of the right axillary fossa. There is noted a deep bruise right axilla. The bruise in right axilla had not changed however there was a significant elevated soft mass over the entire right pectoralis major, was a bleeding mass, was soft and non-fluctuant view of the extensive amount of [MEDICAL CONDITION] noted and the fact that it had developed within 24 hours since my initial evaluation of him, Doppler and stat labs ordered. A review of the Doppler results done on 1/23/19 revealed fluid collection 9.65 x 5.71 x 5.46 centimeters -differential included organizing hematoma, cyst or abscess. A statement by nurse aide (NA) #1 dated 1/25/19 taken by the Director of Nursing (DON) via telephone revealed NA#1 had been assigned to Resident #1 on 1/22/19 on the 7AM - 3 PM shift and she asked Restorative Aide #1 to help her pull Resident #1 up in the chair. The statement revealed Restorative Aide #1 came to assist her and NA #1 pulled Resident #1 up by pulling him under his arm. An interview on 2/13/19 at 1:13 PM with NA #1 revealed she was assigned to Resident #1 on 1/22/19 on first shift (7AM -3PM). She stated when she went into Resident #1's room on 1/22/19 in the morning to transfer him from the bed to the wheelchair, she got him to sit on the side of the bed because he was able to stand and pivot. NA #1 stated that she transferred Resident #1 from his bed to his wheelchair without any assistance. She stated Resident #1 was sliding down in his wheelchair so she asked Restorative Aide #1 to assist her to reposition him. She stated she couldn't remember if she pulled Resident #1 up under his arms to reposition him in his wheelchair. She recalled that she did not have a gait belt. She stated she did not remember seeing any swelling or bruising on Resident #1's body. A review of a statement by Restorative Aide #1 on 1/25/19 revealed she was asked by NA #1 to assist her to pull up Resident #1 on 1/22/19 in his wheelchair. She entered the room to assist and observed NA #1 pulling Resident #1 back in the wheelchair with her arm under his left arm. She stated she instructed NA #1 not to do that. An interview on 2/13/19 at 1:30 PM with Restorative Aide #1. She stated on 1/22/19, she entered Resident #1's room after NA #1 asked for help to pull Resident #1 up in his wheelchair. She observed Resident #1 sliding down in his wheelchair and assisted NA #1 to pull him up in his wheel chair. She stated she got to the left side toward the back of Resident #1 and pulled him up by the back of his pants. She assumed NA #1 would do the same thing on the other side of the resident, but when she looked up, she observed NA #1 pulling Resident #1 up under his arms. She told NA #1 that was wrong and they were never supposed to lift residents under their arms. She did not observe any swelling or bruising on Resident #1. A physicians order dated 1/26/19 revealed Resident #1 was sent to the Emergency Department for pain and increased swelling and bruising on right chest and right side per family request. A review of the hospital discharge summary dated 1/30/19 revealed Resident #1 presented to the emergency department after a family member noted swelling to the chest wall that occurred 3 days ago. Resident #1 was in [MEDICAL CONDITION] with heart rate of 150, complaining of chest wall pain and shoulder pain. Hemoglobin (responsible for transporting oxygen in the blood; normal range 13.5 - 17.5) was down 4 grams from baseline on admission and stabilized at 8.9. He remained hemodynamically stable. He received [MEDICATION NAME] iron and will discharge on iron supplement with follow up as an outpatient. Troponin level (a laboratory test to differentiate between [MEDICAL CONDITION] infarction and unstable [MEDICAL CONDITION]) is elevated but not consistent with ischemia (reduced blood flow) and most likely related to trauma. An interview on 2/14/19 at approximately 11:00 AM with Physical Therapist (PT) #1 revealed staff should utilize gait belts to transfer residents to prevent injury. An observation of Resident #1 on 2/13/19 at 10:45 AM revealed Resident #1 lying in bed on back with eyes open. There was swelling observed to Resident #1's right chest and bruising in various stages of healing observed to Resident #1's chest at midline, toward axilla and on right side. The resident was unable to state how the bruising and swelling on his chest occurred. An interview on 2/14/19 at 8:50 AM with the Staff Development Coordinator revealed orientation for new hires included a video about transfers and lifting. It included information about using gait belts for transfers and she stated every staff member should receive one during orientation and have it with them at all times when working. She stated there was an orientation for agency staff as well with a check list that included a review of the safe resident handling and movement policy which stated staff will follow the movement and handling safety interventions/procedures for each resident as individually determined through the admission/re-entry admission process, including, use approved resident handling aids, i.e. gait belts, in accordance with instructions and training. An interview on 2/14/19 at 10:02 AM with NA #1 revealed the only orientation she received when she started working at the facility was orientation on the time clock. She stated she never watched a video about transfers and lifting. An interview on 2/14/19 at 2:30 PM with the Assistant Director of Nursing revealed NA #1's orientation checklist wasn't completed. She stated she called NA #1 on the phone on 2/14/19 and completed the orientation checklist. Positioning/repositioning wasn't completed. On 2/14/19 at 1:00 PM, the facility's Administrator and Corporate Nurse were informed of the Immediate Jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 2/14/19. The allegation of immediate jeopardy removal was as follows: How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 1/22/19 resident # 1 was transferred by certified nursing assistant #1 without use of gait belt, using resident's chest and arms to assist due to failure to follow procedure. On 1/23/19 resident # 1 was noted to have bruise on left chest. On 1/26/19 resident # 1 was sent to emergency room for evaluation of increased size of bruising, swelling and pain on left side of chest. On 1/26/19 resident # 1 was admitted to acute care hospital from emergency room . On 1/29/19 certified nursing assistant # 1 was provided in-service training by assistant director of nursing on transfers and gait belt use. On 1/26/19 resident # 1 was admitted to acute care hospital from emergency room with primary [DIAGNOSES REDACTED]. On 1/30/19 resident #1 was readmitted to facility from acute care hospital. On 1/29/19 the interdisciplinary team (DON, ADON, administrator, and therapy) utilized investigation and the 5 whys to determine the root cause of the resident injury was staff failure to follow procedure related to transfers due to knowledge deficit. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 1/29/19, the ADON initiated in-service for 100% of licensed nurses, and nursing assistants, including agency staff and certified nursing assistant #1, on appropriate transfers, not repositioning residents using arms, and gait belt use. In-service was completed on 2/14/19. This in-service was added to new staff orientation, including agency staff. Return demonstration competency will be accomplished through audits as outlined below. Beginning 1/29/19 the DON, and/or ADON will complete random audits of resident transfers 5 times weekly x 12 weeks. The audit will be completed by observing the transfer and ensure transfer technique is correct based on the resident care plan and facility procedure. This audit will ensure staff is competent in transfer procedure. The audit will be documented on the transfer audit tool. On 1/29/19 the interdisciplinary team discussed any other resident incidents or occurrences related to resident transfer technique. No other issues noted. What measures will be put into place or systemic changes made to ensure the deficient practice will not occur: On 1/29/19, the staff facilitator (SF) initiated in-service for 100% of licensed nurses, nursing assistants, including agency staff, on appropriate transfers and gait belt use. In-service completed on 2/14/19. This in-service was added to new staff orientation, including agency staff. Yearly proactive education for licensed nurses, and nursing assistants, including agency staff, will occur starting in 2019 with this training and will be scheduled yearly thereafter. This in-service will ensure licensed nurses and certified nursing assistants, including agency, are aware of the expectations related to safe transfers and gait belt use. This will ensure staff are competent related to resident transfers. The performance improvement plan was discussed and approved by the quality assurance performance improvement (QAPI) committee on 1/28/19. The medical director was made aware of the plan on 1/28/19 and is in agreement with plan. How the facility plans to monitor its performance to make sure solutions are sustained. Beginning 1/28/19, the facility increased communication in the form of: verbal communication by in-service to nursing staff by the DON, ADON, and/or staff facilitator and daily interdisciplinary team (IDT) meetings, written education, and audit forms to ensure the facility provides residents with supervision to prevent accidents by providing safe transfers. The IDT, QAPI committee will continue to monitor the facility to identify other factors contributing staff competency including with resident transfers. Beginning 1/28/19, the DON, and ADON will present the in-service comments, supervision observations, and audit trends to the IDT weekly as needed and monthly QAPI committee for six months. The IDT and QAPI committee will focus on improving staff competency, including with resident transfers. The administrator and/or DON will present the recommendations of the daily IDT and monthly QAPI committee to the quarterly QAPI committee for additional recommendations for monitoring and continued compliance. The administrator will be responsible for implementing this plan of immediate jeopardy removal to ensure any issues of staff competency will be addressed through additional root cause analysis, process correction, training, and monitoring. Piney Grove Nursing and Rehabilitation alleges removal of IJ as of 2/14/19. The facility's credible allegation of Immediate Jeopardy removal was validated on 2/15/19 at 1:30 PM. The validation was evidenced by interviews with both licensed and non-licensed nursing staff on gait belt use and when not to use, where to locate them not positioning under arms and using draw sheet when appropriate. Review of on-going in-service records revealing licensed and non-licensed staff were in-serviced on gait belt use and when not to use, where to locate them not positioning under arms and using draw sheet when appropriate. Review of Resident #1's updated care plan and care guide reflecting change in transfer status. Review of on-going audits, documented review of audit of all residents to ensure care guides correct and transfer status correct.

Based on observations, record review and interviews with residents, family members and facility staff, the facility failed to secure smoking materials per the facility's Smoking Policy and failed to intervene and remove a resident from his room that was observed with smoke in it for 1 of 3 (Resident #315) residents reviewed for smoking. The failure to ensure smoking materials were secured resulted in Resident #315, who required continuous oxygen, receiving first [MEDICAL CONDITION] his hands and face and could have caused an adverse outcome to other residents residing in the facility. Findings included: Resident #315 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Smoking Policy dated 2/1/18 section Smoking Materials: All resident smoking materials are maintained in a secured area and are accessible only through the assistance of the facility's staff. These measures are necessary to ensure the safety of the facility's smoking and non-smoking residents. Residents and/or visitors may not provide smoking materials at any time to other residents. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #315 was independent with ambulation, cognitively intact and had no behaviors. A review of the care plan dated 7/16/18 revealed Resident #315 was an independent and safe smoker with a goal to continue smoking safely in designated areas through next review. Interventions included: assist resident in obtaining smoking materials from secured storage area upon request, evaluate resident's continued ability to smoke safely on a consistent and regular basis, observe for potential violations of the smoking policy, oxygen removal prior to smoking per physicians order, resident may smoke at times of own choice in designated smoking areas, resident may smoke independently without supervision, upon return of smoking materials by resident, ensure materials are placed in secured storage area. A smoking assessment was completed on 7/11/18 that deemed Resident #315 to be a safe smoker. A review of an incident report dated 9/30/18 revealed NA #2 reported smelling smoke in room and resident had blister on lip. Per resident, he was burning the hems on his clothes. The physician was notified and an order was given to apply petroleum jelly to the affected areas. Cigarettes and lighter were removed from the residents room, the resident was informed of the smoking policy. The resident's sister was notified and the Director of Nursing (DON) was called. A statement given by NA #2 revealed she was walking up the middle hall and smelled smoke. She opened the door and the room was full of smoke and went to tell the charge nurse. A phone interview on 10/17/18 at 7:15 PM with NA #2 revealed on the evening of 9/30/18 at about 9:30 PM, she was walking by Resident 315's room and smelled smoke. She stated she opened the door and saw smoke and a flame from a lighter. She stated that she immediately went to the front hall to get the charge nurse. A statement given by Nurse #1 revealed on 9/29/18 NA #2 came on the front hall to tell him she smelled smoke coming from Resident #315's room. He went to the room and asked Resident #315 if he was smoking cigarettes. Resident #315 stated no, he said he was burning the hems off his pants leg, but he was wearing shorts. Resident #315 stated he burned his lip, chin and left palm. Nurse #1 called the DON, and the physician and was given a verbal order to apply petroleum jelly to the areas and monitor. A nurses note dated 9/29/18 at 9:22 PM by Nurse #1 revealed NA #2 came to get the nurse because she smelled smoke coming from Resident #315's room. The resident stated he was burning the hems from his pants legs although he wasn't wearing pants. The nurse instructed the resident to give him his lighter. The nurse called the Director of Nursing (DON) to inform her of the situation and was instructed to remove the cigarettes and lighter. An interview on 10/18/18 at 7:30 AM with Nurse #1 revealed the resident's cigarettes and lighters were kept at the nurse's station and the residents asked the nurses when they wanted to smoke. He was unaware Resident #315 had cigarettes in his room. On 9/30/18 he went to the room after NA #2 came to get him because she smelled smoke, he asked Resident #315 was he smoking and the resident stated no, he was burning hems off of his pants. Nurse #1 observed a burned area to his bottom lip, chin and left palm. He called the DON and the physician and was instructed to apply petroleum jelly to the areas and monitor. He removed cigarettes and lighter from the room. A nurse's note dated 9/30/18 at 8:40 AM by Nurse #2 revealed she followed up on Resident #315'[MEDICAL CONDITION] his left hand and face. The physician, Hospice representative and family were notified and the physician gave a telephone order to send the resident to the emergency department. The administrative staff on duty notified the Administrator. Nurse #2 provided education about smoking rules, non-compliance and dangers of smoking with oxygen on. The resident stated he was sorry and didn't want to hurt anyone. An observation on 10/15/18 at 11:31 AM of room [ROOM NUMBER]B (Resident #315's room) revealed NA #1 sitting outside of the door. The door was open and Resident #315 was sitting on the side of his bed with his guitar in his lap. An interview on 10/15/18 at 11:31 AM with NA #1 revealed Resident #315 was on 1:1 observation because he did something he wasn't supposed to. An observation on 10/15/18 at 11:32 AM of Resident #315 in his room revealed oxygen at 4 liters per minute in use. The resident had a scabbed area to his chin, left hand and upper lip. An interview on 10/15/18 at 11:32 AM with Resident #315 revealed he had a little accident. He stated he was smoking in his room with his oxygen on and when he lit the lighter, it ignited. He stated he obtained the cigarettes and the lighter from the store and had a couple of packs in his room and a lighter. He revealed the he was sorry and would never do it again. An interview on 10/17/18 at 1:51 PM with Nurse #3 revealed all of the smokers in the facility are safe to smoke independently, but they keep their cigarettes and lighters locked in the medication cart and the residents ask for them when they want to smoke. She revealed Resident #315 would either turn on his call bell or come out into the hall to request a cigarette. An interview on 10/18/18 at 8:45 AM with Medication Aid #1 revealed that before the incident Resident #315 would call out or come out into hallway to get a cigarette. She stated that he would bring them back when he came back in but sometimes needed reminding. A phone interview on 10/18/18 at 9:02 AM with Resident #315's family member revealed she would bring the resident cigarettes at times and not leave them with the nurse. She stated she wasn't aware they kept the cigarettes locked up until a couple of weeks ago. An interview on 10/18/18 at 9:30 AM with the Administrator revealed prior to this incident, Resident #315 was assessed and able to smoke independently. She revealed the cigarettes and lighters were kept at the nurse's station for all smokers. She indicated that the resident's sister may have brought cigarettes in to the resident, but her expectation was the smoking policy be followed. The Administrator provided the Plan of Correction on 10/18/18 at 3:54 PM Plan of Correction: On 9/29/18, the smoking materials in the resident's possession were removed from the room. The resident was educated that he was not allowed to smoke in the facility and around combustible material such as his oxygen. Root cause was the resident did not return his cigarettes and lighter to the nurse due to his non-compliance with the smoking policy. Upon reentry to the facility from a local hospital on [DATE], the Administrator educated the resident and the sister who was present on the smoking policy and informed them the resident was now a supervised smoker and would require on 1:1 sitter at all times as long as resident remains in the facility. He was assessed and determined that he was a supervised smoker. His care plan was updated to reflect current status by the MDS coordinator. On 9/30/18, the MDS nurse, the hall nurse and the medication aide checked all resident rooms for any smoking materials and/or lighters or sources of ignition. The 100% check of resident rooms revealed one other resident, who was in the hospital, had cigarettes and a lighter in her room. The cigarettes and lighter were removed from the room. On 9/30/18, all present smokers were assessed by the MDS nurse and determined to be safe smokers. During the assessment, it was determined that a monthly assessment for independent smokers had not been completed per policy by the MDS coordinator. On 9/30/18, smokers were provided with education on the smoking policy by licensed nurse. This education is documented in the smoking assessment section B. On 9/30/18, the staff facilitator initiated an in-service on the smoking policy, which included a section on smoking materials and that smoking is prohibited inside the facility and in any areas where flammable liquids, combustible gases or oxygen are in use or stored, for 100% staff (all departments, nurses, medication aides, nursing assistants, contracted staff, agency staff). The in-service included what staff are to do if they smell or see smoke. Also included in the in-service was monthly assessments for independent smokers and quarterly for supervised smokers. The in-service was completed on 10/4/18. Beginning 10/4/18, the staff facilitator will cover the smoking policy in new employee orientation, including agency staff. On 9/30/18, the MDS coordinator completed a smoking evaluation on all residents who smoke to determine if they are a safe smoker or require supervision. Beginning 9/30/18, the admissions coordinator, social worker and/or nurse will review the smoking policy with all newly admitted residents. Also beginning 9/30/18, the admissions coordinator, social worker and/or nurse will complete a smoking assessment on all newly admitted residents that smoke to determine if they are a safe smoker or require supervision. With each smoking assessment the resident will be provided with re-education on the smoking policy. This will be documented on the smoking assessment section B. Beginning 9/30/18, the interdisciplinary team (IDT) committee members will review all new resident admissions. The review will include the review of the smoking policy and smoking assessments if the resident smokes. The IDT committee will perform the review the next business day after the resident's admission. Admission assessments will be reviewed by the IDT to ensure completion of all assessments, including the smoking assessment. The results of the IDT review will be brought before the Quality Assurance and Performance Improvement (QAPI) team to review for any further interventions and/or monitoring. A QAPI meeting was held on Friday 10/5/18 to review the plan of correction for smoking in the room with oxygen. Meeting also reviewed resident involved had a lighter and cigarettes in room, non-compliant with smoking policy. The DON and/or the Assistant Director of Nursing (ADON) will review each new admission including smoking assessment within 72 hours of completion to ensure education was provided to resident and/or resident representative per smoking policy, the care plan is appropriate related to smoking using Admission Audit Tool. The Administrator will review this audit weekly using the Admission Audit Tool. The DON and/or the ADON will review each resident that smokes monthly to ensure smoking assessments are current per policy, resident and/or representative education per smoking policy and the care plan is appropriate related to smoking using the Smoking Audit Tool. The administrator will review the Smoking Audit Tool monthly to ensure smoking assessments are current per policy, resident and/or representative education per policy and the care plan is appropriate related to smoking using the Smoking Audit Tool. The MDS nurse, DON and/or Weekend Manager on duty will audit three resident rooms daily 5 times per week for 12 weeks to ensure no smoking paraphernalia is in resident's rooms. Any negative findings will be immediately addressed by auditor and appropriate resident specific interventions put into place. This audit will be documented on the Smoking Materials in Room Audit Tool. The Administrator will review audit tools weekly. The facility will ensure that independent smokers return their cigarettes and lighters with the Smoking Materials in Room Audit tool and the completed Monthly Smoking Assessment including education on the smoking policy. The smoking policy education that will be provided will include returning cigarettes and lighters to the nurse. The Administrator will be responsible for implementing the acceptable plan of correction. The plan of correction was verified on 10/18/18 as evidenced by: Review of smoking assessments for the three residents in the facility that smoked dated 9/30/18. All three assessed as safe smokers and educated on smoking policy and care plans updated. Resident #315 assessed upon reentry to the facility on [DATE], educated and deemed unsafe to smoke without supervision. Care plan updated on 10/1/18. Review of documentation by Administrator on 10/10/18 in Resident #315's electronic record on education of smoking policy of Resident #315 and family member. Review of new admissions since 9/30/18 indicated no new admissions that smoked. Review of all staff in-service sign in sheets for in-service titled Smoking Policy dated 9/30/18 by the staff facilitator and on 10/1/18 by the Administrator. Review of Smoking Materials in room audit tool completed for 10/1/18 through 10/18/18.

Based on record review, staff and physician interviews the facility failed to report the lab results for one of two sampled residents on [MEDICATION NAME] (Resident #1). Resident #1 had lab monitoring three times a week due to use of [MEDICATION NAME] (blood thinner) in addition to an antibiotic. The resident had lab results from 1/3/17 that were elevated and not reported to the physician. Resident #1 had two falls with head injury on 1/4/17 resulting in an emergency transport to the hospital. The resident was diagnosed with [REDACTED]. Immediate Jeopardy began on 1/3/17 when the facility staff failed to obtain the PT/INR results for Resident #1 and report the results to the physician. The PT/INR was high and would have required physician evaluation. Resident #1 had two falls on 1/4/17 and sustained head injuries which resulted in an emergency transport to the hospital. The hospital [DIAGNOSES REDACTED].#1 was not responding, and one pupil was fixed which indicated [MEDICAL CONDITION]. The immediate jeopardy was removed on 1/13/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedure for obtaining lab results, reviewing the lab results and contacting the physician. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. [MEDICATION NAME] (antibiotic) 1 gram each day via the midline catheter. The orders included lab work for PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) to be obtained on Monday, Wednesday and Friday while on the antibiotic therapy. Review of the Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had moderate impairment of long and short term memory. Review of the care plan dated 12/27/16 included the use of [MEDICATION NAME] due to prosthetic heart valve. The approaches included to obtain lab work as ordered and to inform the physician of abnormal lab results. Review of Resident #1 ' s orders for dosing the [MEDICATION NAME] for a therapeutic dose for a person with a prosthetic heart valve was an INR of 2.5 to 3.5. The lab results and physician orders [REDACTED]. -The INR dated 12/21/16 was 4.7 (high). The physician was notified and orders were given to hold the medication for 12/21 and 12/22 and then restart it at a lower dose of 2 mg on 12/25. -The INR dated 12/23/14 was 2.5 (in therapeutic range) the physician was notified with no changes in the dose. -The INR dated 12/28/16 was 3.4 (in therapeutic range) and the MD was notified and said to continue the same dose. The INR dated 1/3/17 was 4.9 (high) and there was no notification to the physician or nurse practitioner. Review of the Medication Administration Record [REDACTED]. Record review revealed Resident #1 had a fall on 1/4/17, at 5:30 AM. There were no injuries assessed as occurring with the fall at 5:30 AM. The resident was found on the floor beside the nurse ' s desk and had fallen while ambulating. Resident #1 also had a second fall (exact time unknown) during the morning of 1/4/17 in his room. He was found on the floor, on his right side and was bleeding from the back of his head. The bleeding was controlled with a pressure dressing. The nurse called for emergency transport to the hospital. Review of the hospital records dated 1/4/17 revealed he had a subdural hematoma and was transported to a local hospice care facility. The hospital admission record dated 1/4/17 indicated resident was not responding and one pupil was fixed and did not react to light and one pupil was dilated and did not respond to light. Interview with the primary physician on 1/11/17 at 1:35 PM revealed the Nurse Practitioner (NP) took call from 12/28/16 through 1/2/17 because she was out of town during that timeframe. She explained she was back at work on 1/3/17. Her expectation would have been for the facility to call either her or the NP. Further interview revealed it may have been when the resident had fallen on 1/4/17 that she was notified. If she had been called, the 5:00 PM dose on 1/3/17 would have been held if the INR was above 4.0 and a lower dose could be ordered if it was under 4.0. When asked if bleeding could occur with the lab value of an INR 4.0 she explained, not spontaneous, but with trauma it could occur. Interview with the primary physcian on 1/11/17 at 2:20 PM revealed she spoke with her NP, and she had not been notified of the lab results. Further interview revealed had either the physician or the NP been called, orders would have been given to hold the [MEDICATION NAME] dose, usually for 2 days, then recheck the PT/INR. During the interview the primary physician explained she had requested the facility to have the faxed paper results as well as the computer transmitted results that were to be directly in Resident #1 ' s electronic chart. The Nurse practitioner was unavailable for interview. Interview with the Director of Nursing (DON) on 1/11/17 at 1:47 PM revealed if the resident had a PICC (percutaneous indwelling central catheter) the nurse would draw the lab work. If the result was high, the lab would call the nurse and fax the results to the nurse. Further interview revealed the lab results could be reviewed in the electronic chart under lab reports. The nurse was to document when the lab results were received. Interview with the QA nurse (Quality Assurance) on 1/11/17 at 2:21 PM revealed the lab would not call the facilityfor a high lab result. The process for calling the facility was for Critical lab values. The lab results were automatically faxed to the facility at the nurse's station. The nurse would check on their shift for labs and call the physician as indicated. The physician would need to be notified of Resident #1's lab results on the same day the results come in on the Fax. When the resident had the second fall, she asked the nurse what were the latest PT/INR results. The nurse did not know and the QA nurse obtained the results from the fax machine. The results were faxed to the facility on [DATE] at 2:23 PM. The QA nurse had notified the physician of the lab results and resident's condition after the second fall on 1/4/17. Interview with the QA nurse on 1/11/17 at 2:30 PM revealed this was a new system of obtaining lab results which had been in place for a couple of months. The contracted lab inter-faced with the facility ' s electronic residents ' records. The lab results were to be under a specific tab for review by the nurse and the physician. Due to the new system, the primary physician wanted the facility to keep obtaining the results by paper fax in addition to the computer record. The QA nurse was not able to retreive the lab results for Resident #1 in the electronic record for review during the interview. The QA nurse stated the nurses were to check both the fax machine and the computer for lab reports. The lab results for the 1/3/17 PT/INR for Resident #1 were provided by the medical records staff member on 1/11/17 when requested during the survey. Interview with nurse #2, who worked 7:00 AM to 7:00 PM on 1/3/17 and 1/4/7 was conducted by phone on 1/12/17 at 9:57 AM. During the interview, she explained the PT/INR was to be drawn on Monday, Wednesday and Friday. She was not aware it had been obtained on Tuesday and was not checking for the results. The lab results were faxed to the facility and also in the computer. The computer system for obtaining the lab results was a new system and was not working. She would not have known to check for the lab results unless it had been reported to her in the shift to shift report. The Medication Administration Record [REDACTED]. A new order should have been written if it was changed. She did not routinely check the room with the lab fax machine. Nurse #2 explained everyone was to check, but one person was not assigned to check for lab faxes. On 1/12/17 at 1:30 PM, the administrator was notified of the immediate Jeopardy. The administrator provided the following credible allegation of compliance on 1/13/17 at 1:20 PM: 1. Residents found to have been affected by the deficient practice. On 1/3/17, the physician was not notified of a PT/INR of 4.9 (high) for Resident #1. The physician was notified on 1/4/17 after residents second fall with head trauma by Quality Assurance Nurse. On 1/4/17, at 10:30 AM Resident #1 was transferred to emergency room for evaluation post fall with hematoma on back of head and skin tear on right arm which were noted at 8 am, and a laceration to head with all bleeding controlled by pressure dressing prior to transport to emergency room . Resident #1 fell twice the morning of 1/4/17. Resident did not return to the facility. On 1/11/17, for the DON, QI nurse and staff facilitator who were involved in the deficient practice, the corporate facility consultant reviewed the deficient practice of not monitoring Resident #1 ' s [MEDICATION NAME] labs draws and lab results. The corporate facility consultant then in-serviced the DON, QI nurse, and staff facilitator on completing the [MEDICATION NAME] Audit as PT/INRs are drawn, results received, and new orders obtained, and Quality Improvement Action Team Laboratory Monitoring including laboratory monitoring tool as laboratory results are received and specimens are drawn. On 1/11/17, the corporate facility consultant also in-serviced the DON on how to match lab results to residents to ensure results are posted timely to the resident electronic medical record. 2. Address how the corrective actions will be accomplished for those residents having the potential to be affected by the same deficient practice. On 1/12/17, the corporate facility consultant completed a 100% audit of residents on [MEDICATION NAME] to ensure the last PT/INR was drawn according to the physician's order [REDACTED]. The [MEDICATION NAME] audit was documented on the [MEDICATION NAME] Audit tool. The audit resulted in no negative findings for Resident #2, labs were drawn as ordered and communicated to the physician timely with new order received and processed. On 1/12/17, the corporate facility consultant completed an audit of all laboratory orders for the past 30 days to ensure laboratory samples were drawn, received, and communicated to physician in a timely manner, including PT/INRs. The audit of all laboratory results will be completed by 1/13/17. This audit will be documented on the Quality Improvement Action Team Laboratory Audit form. On 1/12/17, the DON initiated a 100% in-service of all nurses and nursing assistants on basic teaching of [MEDICATION NAME], it ' s side effects, the importance of monitoring, how it is monitored, how the dosing depends on the lab results, the importance of fall prevention, assistance with personal care, and monitoring medications and foods. The in-service will be completed by 1/20/17, no nurse or nursing assistant will be allowed to work until this in-service is completed. The staff facilitator or DON will provide the [MEDICATION NAME] in-service to new nurses and nursing assistants during orientation. On 1/11/17 the corporate facility consultant and corporate clinical director worked with the DON, QI nurse, and staff facilitator to perform a root cause analysis of why the physician was not notified of the 4.9 INR result on 1/3/2017. The outcome of the root cause analysis determined: (1) why was the physician not notified of the 4.9 INR on 1/3/2017? Because the DON, QI nurse, and staff facilitator did not inform the physician. (2) Why did the DON, QI nurse, and staff facilitator not inform the physician of the 4.9 INR result on 1/3/17? Because they were not aware of the lab result. (3) Why were the DON, QI nurse, and staff facilitator not aware of the lab result? Because the lab result was on the table in the lab computer room. (4) Why was the lab result on the table in the lab computer room? Because the DON, QI nurse, and staff facilitator did not know to look for the lab result. (5) Why did the DON, QI nurse, and staff facilitator not know to look for the lab result? Because the QI nurse was not at work, the staff facilitator did not know the lab had been drawn and results should be back, and the DON did not know the lab had been drawn and results should be back. (6) Why did the staff facilitator and DON not know that the lab had been drawn and results should be back? Because the QI nurse, staff facilitator, and DON were not using the [MEDICATION NAME] log, and Quality Assurance Laboratory Tracking Log were not being completed as labs were drawn. There was no need to change the process but to first identify a back up to the QI nurse and address weekend/holiday coverage. Second, the integration of laboratory results into the electronic health record, allows the physician or nurse practitioners to mark lab results as reviewed onsite or remotely. The facility DON remains responsible for ensuring the overall lab process is completed. On 1/13/2017 the corporate facility consultant and corporate clinical director in-serviced the DON, QI nurse, and staff facilitator that the QI nurse will be responsible for daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. When the QI nurse is not in the facility the staff facilitator will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. On Saturday and Sunday the weekend RN supervisor will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. The [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tools will be kept lab computer room in labeled binders for 24 hour 7 day a week access. The completed [MEDICATION NAME] Audit and Quality Assurance Action Team Laboratory Monitoring tools will be reviewed for: resident name, lab ordered, type of lab, physician order [REDACTED]. 3. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur. On 1/13/2017 the corporate facility consultant and corporate clinical director in-serviced the DON, QI nurse, and staff facilitator that the QI nurse will be responsible for daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. When the QI nurse is not in the facility the staff facilitator will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. On Saturday and Sunday the weekend RN supervisor will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. The [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tools will be kept lab computer room in labeled binders for 24 hour 7 day a week access. The completed [MEDICATION NAME] Audit and Quality Assurance Action Team Laboratory Monitoring tools will be reviewed for: resident name, lab ordered, type of lab, physician order [REDACTED]. On 1/12/17, the DON completed the Laboratory Process in-service for all nurses on all shifts (nurses draw labs when there is an order for [REDACTED]. in following up for results and notification of physician. The Laboratory Process also includes the DON ' s responsibility to review laboratory results 5 times weekly and follow up with hall nurses to ensure physician notification occurs and Medical Record ' s responsibility to ensure the physician/nurse practitioner has marked the laboratory result as reviewed in electronic medical record. The staff facilitator or DON will in-service all newly hired nurses during new employee orientation. On 1/12/17, the DON, QI nurse, staff facilitator, and weekend supervisor began completing the [MEDICATION NAME] Audit tool as PT/INRs are drawn, results received, and new orders obtained, and Quality Improvement Laboratory Monitoring tool as laboratory results are received and specimens are drawn. The [MEDICATION NAME] Audit tool and Quality Improvement Laboratory Monitoring tool aids in documenting: date of audit, resident ' s name, lab type, date lab results are received, date lab results are marked as reviewed, date physician is notified date physician responded, any new orders, date of responsible party notification, comments, DON signature, DON review date, administrator signature, and administrator review date. The [MEDICATION NAME] Audit tool and Quality Improvement Laboratory Monitoring tool will be kept in labeled binders and maintained in the lab computer room which is accessible 24 hours a day 7 days a week. On 1/12/17 the DON in-serviced the physician/medical director and nurse practitioners on the Point-Click-Care Electronic Medical Record System. The DON in-serviced the physician and nurse practitioners on the process for reviewing laboratory results and marking laboratory results as reviewed in the Point Click Care electronic medical record. All new laboratory results are listed as un-reviewed in the electronic medical record until marked as reviewed by a medical professional. All un-reviewed laboratory results are easily accessible to the physician and nurse practitioners on the Point-Click-Care dashboard. Laboratory results are integrated with the electronic medical record and transmitted into the electronic medical record from the laboratory services provider immediately as results are available. Since laboratory results are integrated into the electronic medical record, the physician or nurse practitioners look in the electronic medical record for laboratory results instead of paper copies of results. Since the DON trained the physician, the physician has requested to review only the electronic medical record results. The facility DON is responsible for ensuring the physician and/or nurse practitioners find and review each lab result. Point Click Care screen shot handouts were provided to the physician and nurse practitioners for future reference. The physician and nurse practitioners have remote access to Point Click Care. The validation of the credible allegation was completed on 1/13/17 at 3:00 M by doing the following: In-service training material and records were reviewed and included the topics in the allegation of compliance. The Current list of nurse employees was reviewed for completion of the training. Interviews were conducted with administrative nursing staff and floor staff for verification of the in-service training and their understanding of the material. The Administrative staff understood their role in monitoring lab results and training new employees. The floor staff explained the procedure for checking for lab results and follow up with contacting the physician. The primary physician was interviewed and explained she had received training on the computer to access the lab results for her residents. The NP had been trained by the physician on the computer access. Five medical records (hard charts and electronic charts) of residents with orders for lab work were reviewed. The paper faxed results were initialed by the physician and the electronic record had been reviewed by the physician. One resident in the facility was on [MEDICATION NAME] with current lab results reviewed by the physician. Audits were reviewed and included verification that all residents' lab results had been received and reviewed by the physician. The physician had been notified of all abnormal lab results. The [MEDICATION NAME] audit notebook was reviewed with the current resident on [MEDICATION NAME] listed with the lab results, the date and physician notification. The lab book was reviewed with the lab work that was due for each day under the date tab. Interviews with the floor nurses and the administration nurses revealed they were aware of the notebooks and how to use them.

Based on record review, staff and physician interviews the facility failed to monitor the [MEDICATION NAME] as ordered by the physician for 1 of 2 residents, Resident #1 reviewed for anticoagulant therapy. The PT/INR ([MEDICATION NAME] time/International Normalization Ratio) was above the therapeutic range. Resident #1 sustained a subdural hematoma and subsequently was admitted to hospice. The findings included: Immediate Jeopardy began on 1/3/17 when the facility staff failed to obtain the PT/INR results from the FAX system for Resident #1 and report the results to the physician. The PT/INR dated 1/3/7 was high (with an INR of 4.9) and the physician did not have the opportunity to evaluate the need for a [MEDICATION NAME] dose adjustment. Resident #1 had two falls on 1/4/17 and sustained head injuries which resulted in an emergency transport to the hospital. The hospital [DIAGNOSES REDACTED].#1 was admitted to hospice services. The immediate jeopardy was removed on 1/13/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedure for obtaining lab results, reviewing the lab results and contacting the physician. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. The goal range for treatment with [MEDICATION NAME] was 2.5 to 3.5 due to valve replacement. The orders included lab work for PT/INR ([MEDICATION NAME] Time/International Normalized Ratio used to determine the bleeding time to keep the blood thinned) to be obtained on Monday, Wednesday and Friday while on the antibiotic therapy. Resident #1 had orders for monitoring the [MEDICATION NAME] three times a week due to receiving an antibiotic [MEDICATION NAME] via a midline intravenous catheter. Due to the interactions of the two drugs, the antibiotic would prolong the effects of the [MEDICATION NAME]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had moderate impairment of long and short term memory, required extensive assistance with activities of daily living from one staff member, had behaviors of resisting care and physical aggression towards others. Review of the MDS revealed he had two falls without injury. Review of the care plan dated 12/27/16 included the use of [MEDICATION NAME] due to prosthetic heart valve. The approaches included to obtain lab work as ordered and to inform the physician of abnormal lab results. Review of Resident #1 ' s lab results revealed blood work was obtained on 12/21/16, 12/23/16, 12/28/16 and 1/3/17. Review of Resident #1 ' s orders for dosing the [MEDICATION NAME] for a therapeutic dose for a person with a prosthetic heart valve was an INR of 2.5 to 3.5. The lab results and physician orders [REDACTED]. -The INR dated Wednesday, 12/21/16 was 4.7 (high). The physician was notified and orders were given to hold the medication for 12/21 and 12/22 and then restart it at a lower dose of 2 mg on 12/25. -The INR dated Friday, 12/23/14 was 2.5 (in therapeutic range) the physician was notified with no changes in the dose. -The INR dated Wednesday, 12/28/16 was 3.4 (in therapeutic range) and the MD was notified and said to continue the same dose The INR dated Tuesday, 1/3/17 was 4.9 (high) and there was no notification to the physician or nurse practitioner. Was the facility drawing PT/INR results on Mondays? Review of the Medication Administration Record [REDACTED]. Review of the accident/incident report dated 1/4/17 at 5:30 AM and again sometime after 8:30 AM Resident #1 had fallen. There were no injuries assessed as occurring with the fall at 5:30 AM. The resident was found on the floor beside the nurse ' s desk and had fallen while ambulating. The second fall (exact time unknown) occurred in his room. He was found on the floor, on his right side and was bleeding from the back of his head. The bleeding was controlled with a pressure dressing. The nurse called for emergency transport to the hospital. Review of the emergency room admission history and physical dated 1/4/17 revealed Resident #1 was diagnosed with [REDACTED].#1 was not responding and one pupil was fixed and did not react to light and one pupil was dilated and did not react to light. Due to the inoperable subdural hematoma, the family agreed with comfort care. He was transported to a local hospice care facility. Interview with the primary physician on 1/11/17 at 1:35 PM revealed the Nurse Practioner (NP) took call from 12/28/16 through 1/2/17 because she was out of town during that timeframe. She explained she was back at work on 1/3/17. Her expectation would have been for the facility to call to either her or the NP. Further interview revealed it may have been when the resident had fallen on 1/4/17 that she was notified. If she had been called, the dose would have been held if the INR was above 4.0 and a lower dose could have been ordered if it was under 4.0. The primary physician stated spontaneous bleeding would not necessarily occur with an INR greater than 4.0, but with trauma it could. Interview with the primary physcian on 1/11/17 at 2:20 PM revealed she spoke with her NP, and she had not been notified of the lab results. Further interview revealed had either the physician or the NP been called, orders would have been given to hold the [MEDICATION NAME] dose, usually for 2 days, then recheck the PT/INR. During the interview the primary physician explained she had requested the facility to have the faxed paper results as well as the computer transmitted results that were to be directly in Resident #1 ' s electronic chart. Interview with the Director of Nursing (DON) on 1/11/17 at 1:47 PM revealed if the resident had a PICC (mildline intravenous catheter) the nurse would draw the blood for the PT/INR and send it to the laboratory. If the result was high, the lab would call and fax the results to the nurse. Further interview revealed the lab results could be reviewed in the electronic chart under lab reports. The nurse was to document when the lab results were received. Interview with the QA nurse (Quality Assurance) on 1/11/17 at 2:21 PM revealed the lab would not call the facility for a high lab result. The lab results were automatically faxed to the facility at the nurse's station. The nurse would check on their shift for labs and call the physician as indicated. The physician would need to be notified of Resident #1's lab results from 1/3/17. When the resident had the second fall, the physician asked the nurse what were the latest PT/INR results. The nurse did not know and the QA nurse obtained the results from the fax machine. The results were faxed to the facility on [DATE] at 2:23 PM. The QA nurse had notified the physician of the lab results and resident's condition after the second fall on 1/4/17. Interview with the QA nurse on 1/11/17 at 2:30 PM revealed this was a new system of obtaining lab results which had been in place for a couple of months. The primary physician wanted the facility to keep obtaining the results by paper fax in addition to the computer record. The QA nurse was not able to retrieve the lab results for Resident #1 in his electronic record for review. During the interview the QA nurse explained the lab did not draw the ordered PT/INR on Monday because it was a holiday. Interview with nurse #2 who worked 7-3 on 1/3/17 and 1/4/17 was conducted by phone on 1/12/17 at 9:57 AM. During the interview, she explained the PT/INR was to be drawn on a Monday, Wednesday and Friday schedule. She was not aware it had been obtained on Tuesday and was not checking for the results. The lab results were faxed to the facility and were also in the computer. The computer system for obtaining the lab results was a new system and it was not working. She would not have known to check for the lab results unless it had been reported to her the PT/INR had been drawn in the shift to shift report. The Medication Administration Record [REDACTED]. A new order should have been written if it was changed. She did not routinely check the room with the lab fax machine. Nurse #2 explained everyone was to check for lab results, and one person was not assigned to check for lab faxes. . On 1/12/17 at 1:30 PM, the administrator was notified of the immediate Jeopardy. The administrator provided the following credible allegation of compliance on 1/13/17 at 1:20 PM: 1. Residents found to have been affected by the deficient practice. On 1/3/17, the physician was not notified of a PT/INR of 4.9 (high) for Resident #1. The physician was notified on 1/4/17 after residents second fall with head trauma by Quality Assurance Nurse. On 1/4/17, at 10:30 AM Resident #1 was transferred to emergency room for evaluation post fall with hematoma on back of head and skin tear on right arm which were noted at 8 am, and a laceration to head with all bleeding controlled by pressure dressing prior to transport to emergency room . Resident #1 fell twice the morning of 1/4/17. Resident did not return to the facility. On 1/11/17, for the DON, QI nurse and staff facilitator who were involved in the deficient practice, the corporate facility consultant reviewed the deficient practice of not monitoring Resident #1 ' s [MEDICATION NAME] labs draws and lab results. The corporate facility consultant then in-serviced the DON, QI nurse, and staff facilitator on completing the [MEDICATION NAME] Audit as PT/INRs are drawn, results received, and new orders obtained, and Quality Improvement Action Team Laboratory Monitoring including laboratory monitoring tool as laboratory results are received and specimens are drawn. On 1/11/17, the corporate facility consultant also in-serviced the DON on how to match lab results to residents to ensure results are posted timely to the resident electronic medical record. 2. Address how the corrective actions will be accomplished for those residents having the potential to be affected by the same deficient practice. On 1/12/17, the corporate facility consultant completed a 100% audit of residents on [MEDICATION NAME] to ensure the last PT/INR was drawn according to the physician's order [REDACTED]. The [MEDICATION NAME] audit was documented on the [MEDICATION NAME] Audit tool. The audit resulted in no negative findings for Resident #2, labs were drawn as ordered and communicated to the physician timely with new order received and processed. On 1/12/17, the corporate facility consultant completed an audit of all laboratory orders for the past 30 days to ensure laboratory samples were drawn, received, and communicated to physician in a timely manner, including PT/INRs. The audit of all laboratory results will be completed by 1/13/17. This audit will be documented on the Quality Improvement Action Team Laboratory Audit form. On 1/12/17, the DON initiated a 100% in-service of all nurses and nursing assistants on basic teaching of [MEDICATION NAME], it ' s side effects, the importance of monitoring, how it is monitored, how the dosing depends on the lab results, the importance of fall prevention, assistance with personal care, and monitoring medications and foods. The in-service will be completed by 1/20/17, no nurse or nursing assistant will be allowed to work until this in-service is completed. The staff facilitator or DON will provide the [MEDICATION NAME] in-service to new nurses and nursing assistants during orientation. On 1/11/17 the corporate facility consultant and corporate clinical director worked with the DON, QI nurse, and staff facilitator to perform a root cause analysis of why the physician was not notified of the 4.9 INR result on 1/3/2017. The outcome of the root cause analysis determined: (1) why was the physician not notified of the 4.9 INR on 1/3/2017? Because the DON, QI nurse, and staff facilitator did not inform the physician. (2) Why did the DON, QI nurse, and staff facilitator not inform the physician of the 4.9 INR result on 1/3/17? Because they were not aware of the lab result. (3) Why were the DON, QI nurse, and staff facilitator not aware of the lab result? Because the lab result was on the table in the lab computer room. (4) Why was the lab result on the table in the lab computer room? Because the DON, QI nurse, and staff facilitator did not know to look for the lab result. (5) Why did the DON, QI nurse, and staff facilitator not know to look for the lab result? Because the QI nurse was not at work, the staff facilitator did not know the lab had been drawn and results should be back, and the DON did not know the lab had been drawn and results should be back. (6) Why did the staff facilitator and DON not know that the lab had been drawn and results should be back? Because the QI nurse, staff facilitator, and DON were not using the [MEDICATION NAME] log, and Quality Assurance Laboratory Tracking Log were not being completed as labs were drawn. There was no need to change the process but to first identify a back up to the QI nurse and address weekend/holiday coverage. Second, the integration of laboratory results into the electronic health record, allows the physician or nurse practitioners to mark lab results as reviewed onsite or remotely. The facility DON remains responsible for ensuring the overall lab process is completed. On 1/13/2017 the corporate facility consultant and corporate clinical director in-serviced the DON, QI nurse, and staff facilitator that the QI nurse will be responsible for daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. When the QI nurse is not in the facility the staff facilitator will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. On Saturday and Sunday the weekend RN supervisor will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. The [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tools will be kept lab computer room in labeled binders for 24 hour 7 day a week access. The completed [MEDICATION NAME] Audit and Quality Assurance Action Team Laboratory Monitoring tools will be reviewed for: resident name, lab ordered, type of lab, physician order [REDACTED]. 3. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur. On 1/13/2017 the corporate facility consultant and corporate clinical director in-serviced the DON, QI nurse, and staff facilitator that the QI nurse will be responsible for daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. When the QI nurse is not in the facility the staff facilitator will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. On Saturday and Sunday the weekend RN supervisor will be responsible for the daily monitoring and completion of the [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tool. The [MEDICATION NAME] Audit and Quality Improvement Action Team Laboratory Monitoring tools will be kept lab computer room in labeled binders for 24 hour 7 day a week access. The completed [MEDICATION NAME] Audit and Quality Assurance Action Team Laboratory Monitoring tools will be reviewed for: resident name, lab ordered, type of lab, physician order [REDACTED]. On 1/12/17, the DON completed the Laboratory Process in-service for all nurses on all shifts (nurses draw labs when there is an order for [REDACTED]. in following up for results and notification of physician. The Laboratory Process also includes the DON ' s responsibility to review laboratory results 5 times weekly and follow up with hall nurses to ensure physician notification occurs and Medical Record ' s responsibility to ensure the physician/nurse practitioner has marked the laboratory result as reviewed in electronic medical record. The staff facilitator or DON will in-service all newly hired nurses during new employee orientation. On 1/12/17, the DON, QI nurse, staff facilitator, and weekend supervisor began completing the [MEDICATION NAME] Audit tool as PT/INRs are drawn, results received, and new orders obtained, and Quality Improvement Laboratory Monitoring tool as laboratory results are received and specimens are drawn. The [MEDICATION NAME] Audit tool and Quality Improvement Laboratory Monitoring tool aids in documenting: date of audit, resident ' s name, lab type, date lab results are received, date lab results are marked as reviewed, date physician is notified date physician responded, any new orders, date of responsible party notification, comments, DON signature, DON review date, administrator signature, and administrator review date. The [MEDICATION NAME] Audit tool and Quality Improvement Laboratory Monitoring tool will be kept in labeled binders and maintained in the lab computer room which is accessible 24 hours a day 7 days a week. On 1/12/17 the DON in-serviced the physician/medical director and nurse practitioners on the Point-Click-Care Electronic Medical Record System. The DON in-serviced the physician and nurse practitioners on the process for reviewing laboratory results and marking laboratory results as reviewed in the Point Click Care electronic medical record. All new laboratory results are listed as un-reviewed in the electronic medical record until marked as reviewed by a medical professional. All un-reviewed laboratory results are easily accessible to the physician and nurse practitioners on the Point-Click-Care dashboard. Laboratory results are integrated with the electronic medical record and transmitted into the electronic medical record from the laboratory services provider immediately as results are available. Since laboratory results are integrated into the electronic medical record, the physician or nurse practitioners look in the electronic medical record for laboratory results instead of paper copies of results. Since the DON trained the physician, the physician has requested to review only the electronic medical record results. The facility DON is responsible for ensuring the physician and/or nurse practitioners find and review each lab result. Point Click Care screen shot handouts were provided to the physician and nurse practitioners for future reference. The physician and nurse practitioners have remote access to Point Click Care. The validation of the credible allegation was completed on 1/13/17 at 3:00 PM as follows: In-service training material and records were reviewed and included the topics in the allegation of compliance. The Current list of nurse employees was reviewed for completion of the training. Interviews were conducted with administrative nursing staff and floor staff for verification of the in-service training and their understanding of the material. The Administrative staff were able to provide feedback they understood their roles in monitoring lab results and training new employees. The floor staff explained the procedure for checking for lab results and follow up with contacting the physician. The primary physician was interviewed and explained she had received training on the computer to access the lab results for her residents. The NP had been trained by the physician on the computer access. Five medical records (hard charts and electronic charts) of residents with orders for lab work were reviewed. The paper faxed results were initialed by the physician and the electronic record had been reviewed by the physician. One resident in the facility was on [MEDICATION NAME] with current lab results reviewed by the physician. Audits were reviewed and included verification that all residents ' lab results had been received and reviewed by the physician. The physician had been notified of all abnormal lab results. The [MEDICATION NAME] audit notebook was reviewed with the current resident on [MEDICATION NAME] listed with the lab results, the date and physician notification. The lab book was reviewed with the lab work that was due for each day under the date tab. Interviews with the floor nurses and the administration nurses revealed they were aware of the notebooks and how to use them.

Based on observations, staff interviews, and record review the facility failed to prevent tension on an indwelling catheter for 1 of 1 resident. (Resident #131 Findings include: Resident #131 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A nurse's note , dated 3/11/10, revealed the resident's condom catheter was discontinued and an indwelling catheter was placed. The nurse noted "approx (approximately) 200 cc (cubic centiliters) cloudy urine returned." The treatment nurse was made aware of the placement of the indwelling catheter. A staff in-service, dated "3/31/10 - 4/2/10", listed the subject covered was "providing cath (catheter) care." Thirty staff members from 1st and 2nd shift attended the in-service. A sheet attached to the in-service, titled "Providing Catheter Care" included some of the following interventions; "12. Observe area around catheter for sores, crusts, redness, swelling, discolorization, and abnormal drainage. 15. Position catheter so that urine flows freely into drainage bag attached to bed frame. Tape to leg as directed." The "Flow sheet of Non-Ulcer Skin Conditions", dated 4/16/10, revealed the resident had no problems noted to his urinary meatus (the external orifice of the urethra, from which urine is ejected during urination). The drainage bag was noted to be positioned correctly and a leg strap was in place. Subsequent flow sheets dated 4/30/10, 5/7/10, 5/14/10, 5/22/10, 5/27/10, 6/4/10, and 6/11/10 revealed no problems were noted to the resident's urinary meatus. The drainage bag was positioned correctly and a leg strap was in place. The resident's most recent minimum data set (MDS), dated [DATE], revealed he had no memory problems. He was severely impaired in daily decision making skills. The resident "usually" understood verbal communication and was "sometimes" able to be understood when speaking. Resident #131 had no noted behaviors, such as resisting care. He required extensive assistance with the following activities of daily living (ADLs); bed mobility, locomotion on and off the unit, and eating. The resident was totally dependent on staff for transfers, dressing, toileting, and personal hygiene. Resident #131 was listed as having an indwelling catheter for urine elimination and incontinent of bowel. The "Flowsheet of Non-Ulcer Skin Conditions", dated 6/18/10, read in part, "Urinary meatus- laceration noted to rt (right) side of penis, very red in color." Under the comments section, "Clean with ns (normal saline) apply steri-strips wrap with (gauze bandage) monitor qd (everyday) for any changes, cleaned daily during adl care." A nurse's note, dated 6/19/10 at 7:46PM, reflected a "late entry" note. The note revealed the resident's penis was observed on 6/14/10. The penis was "slightly open at catheter site, area is not swollen or inflammed." A physician progress notes [REDACTED]. There was no signs of trauma, no bleeding, and a "small amount" of urine drainage was noted. The "Flowsheet of Non-Ulcer Skin Conditions", dated 6/25/10, revealed the resident's penis was "very red." The comments section read in part, "Clean with ns wrap with (pertoleum based) gauze qd and monitor cath (catheter) strap placement q shift." The physician's progress note, dated 6/28/10, read in part, "He's going to urology to f/u (follow up) on his penis, which was labeled/diagnosed as an "erosion." A verbal order, dated 6/28/10, read in part, "Refer to urology as planned." On 6/28/10, the "Wound/Ulcer Flowsheet" noted the resident had an open area measuring 3.5 x 2.0 x 1.0 cm (centimeters). The area type was listed as pressure. Under the stage section was "N/A" (not applicable).The wound bed appearance was described as "100% beefy red full thickness laceration." The peri-wound appearance was desribed as "[DIAGNOSES REDACTED]." The current treatment was listed as, "clean with ns apply (pertroleum based) gauze qd, check cath strap placement q shift." Under the comments section was a note that read, "laceration to penis very red with clear pus noted." Review of the Urological note dated 6/29/10, read in part, "There is ventral (on the lower surface) urethral erosion to the level of the coronal sulcus (the "groove" behind the corona which is the flared rim at the back of the glans). There is very mild penile [MEDICAL CONDITION]." The history section noted, "Recently at the nursing home upon (indwelling) catheter change he was noted to have enlargement of his urethral meatus. It is not causing any significant discomfort." The assessment section noted resident #131 had a [MEDICAL CONDITION] bladder and a ventral urethral erosion secondary to indwelling catheter. The plan section read in part, "Upon arrival in our office today the patient's (indwelling) catheter was noted to be on tension and this is likely the underlying etiology of his ventral urethral erosion. At this point we will use conservative measures including making sure his (indwelling) catheter is off tension. This may be accomplished by means of a leg strap or tape as needed to keep the catheter off tension." The "Report Of Consultation" , dated 6/29/10, read in part, "Discussed that there is no surgery to repair erosion. Discussed possibly placing SP (suprapubic) tube as alternative to urethral catheter, but would like to avoid surgery at this time. (Indwelling) catheter must (underlined) be kept off tension - tension/pressure is direct cause of urethral erosion - use leg strap or tape as needed to keep catheter off tension." The nurse's note , dated 6/30/10 at 5:07PM, revealed the resident's indwelling catheter had been replaced "without difficulty." The catheter strap was in place and the drainage bag was in the "proper location on bed frame." The nurse's note, dated 6/30/10 at 10:42PM, revealed the resident's indwelling catheter was noted to be "draining red bright blood." The catheter was removed and the resident "started to bleed from his penis." The resident was sent to the emergency room for evaluation and treatment. A nurse's note, dated 7/1/10 at 2:33PM, revealed the resident had returned to the facility that morning. The indwelling catheter was re-inserted by the hospital. The [DIAGNOSES REDACTED]." A physician progress notes [REDACTED]. The resident was brought back to the facility that day from the hospital. He was sent out for "gross hematuria" from the penis. He was found to have a urinary tract infection at the hospital as well as kidney stones. It was noted, "Resident (indwelling catheter) is to be kept off tension. Res (resident) now has a leg strap." The details section read in part, "Blood around head of penis- leg strap in place- red tinged urine in (indwelling catheter) bag- discomfort w/ (with) palpation of penis per resid (resident)." The "Wound/Ulcer Flowsheet", dated 7/12/10, noted an open area to the urethra/penis. The wound was described as "pressure" and the measurements were 2.5 x 1.5 x 1.0 cm. A small amount of bloody drainage with occasional pus was noted. The wound bed appearance was described as "100% beefy red full thickness laceration." The current treatment was, "clean with ns wrap erosion with (petroleum based) gauze." The comments section read, "cath strap and drainage bag placement checked q shift." A wound care observation was performed on 7/14/10 at 5:09 PM, with the wound care nurse. The wound care nurse stated the reason for the urethral erosion was "tension on the catheter." She indicated they (the staff) had witnessed the resident "pulling" on the catheter "at times." The wound nurse did not provide interventions other than the leg strap to decrease or prevent the resident from "pulling' on the catheter. The indwelling catheter tubing was secured to his left thigh. The drainage bag was secured to the side of the bed. There was an open area from the tip and down the right side of the penile shaft. The area was beefy red and open with urine leakage noted (visualized urine simultaneously come from around the wound and drain in the tubing). An observation of resident mechanical lift transfer was done on 7/15/10 at 7:17 AM. NA #1 and NA #3 were present. The resident's indwelling catheter tubing was secured to his left thigh. The catheter drainage bag was attached to the top bar (resident's right) of the mechanical lift. While moving the resident down into his chair the catheter drainage bag remained on the top bar, above the resident's head. As the resident was moved down the catheter tubing was stretched (the tension was visible) then the drainage bag snapped back down (due to stretching/tension). NA #1 stated she did not think the facility had "ever" showed them where to position the drainage bag. NA #1 went on to state the catheter bag "should have been at the bottom, so it would not cause tension." The resident was not able to give a clear answer if it hurt when the catheter tubing was pulled and the drainage bag snapped back. NA #3 stated she was new to the facility and another nursing assistant had showed her how to use the lift. During an interview, on 7/15/10 at 12:09PM, nursing assistant (NA) #1 indicated when the resident came in "his penis was fine." She was not sure when exactly the wound started on his penis but she thought it was "maybe a month ago and it continued to split." NA #1 stated there was pus and bleeding noted with the wound, but it looked better now. NA #1 indicated they were using a catheter strap to secure the tubing and she thought they put it on when he first came to the facility. She stated at first they just did routine care/cleaning of the catheter. NA #1 indicated it was second shift that picked up on the wound, "you had to pick up the catheter and look." She stated the wound nurse performed the wound treatment to the open area. NA #1 indicated the resident was not one to complain, for instance she had to "assume when he wants to lay down" because he wouldn't tell her. She stated the wound looked like it hurt, "that's a sensitive area." The resident did not want her to "mess with that too much (penis area)." NA #1 indicated she had not spoken to the nurse about pain related to the penis wound. During an interview on 7/15/10 at 5:23PM, the nursing consultant indicated they (the facility) were putting the urethral erosion on a non-pressure form. She had informed the facility they should be using the wound/pressure form and the area was to be measured so they could tell if it was getting better or worse.