Every finding on record at PruittHealth - Marietta

Based on observations and staff interviews, and review of the facility policy titled, Disposal of Medications, the facility failed to ensure expired medications were removed from active medication storage areas and unavailable for use in one of two medication rooms (first floor medication room) reviewed. This deficient practice had the potential to affect 51 residents receiving medications on the unit.Findings include:Review of the facility policy titled Disposal of medications revised 12/15/2026 indicated under Policy Statement: It is the policy of 'company name' Pharmacy Services that medications which have expired, been discontinued, or remain in the healthcare center after a patient/resident's discharge shall be removed from active stock and placed in disposal.Observation on 02/25/2026 at 10:30 AM of medication storage was conducted in the first-floor medication room and medication carts. During inspection of medication stock, the following expired medications were observed stored with active medications and available for administration:One container of lidocaine oral solution with a manufacturer's expiration date of 02/23/2026.Three IV (intravenous) bags of daptomycin with manufacturer expiration dates of 02/21/2026.Interview on 02/25/2026 at 10:45 AM with Licensed Practical Nurse (LPN) JJ revealed that medications are routinely checked for expiration; however, the nurse confirmed the expired medications remained in the medication room at the time of observation.Interview on 02/25/2026 at 10:49 AM with the acting Director of Nursing (DON) confirmed that expired medications were expected to be removed immediately upon expiration and either returned to the pharmacy or disposed of in accordance with facility policy.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure oxygen equipment was safely maintained and monitored for two of nine residents (R) (R70 and R83) reviewed for oxygen use. Specifically, the facility failed to remove an oxygen tank from a resident room that was unsecure and unattended (R70) and failed to date respiratory supplies and to keep an oxygen concentrator filter free of debris (R83). The deficient practices had the potential to create accident hazards, improper oxygen administration, and impaired oxygen delivery.Findings include:1. Review of the Electronic Health Record (EHR) for R70 revealed the resident was admitted with diagnoses including but not limited to Alzheimer's disease, unspecified dementia, Type 2 diabetes mellitus, generalized anxiety disorder, gastro-esophageal reflux disease, dysphagia, lymphedema, and repeated falls.Review of the Minimum Data Set (MDS) assessment dated [DATE] for R70 documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. A review of Section O (Special Treatments, Procedures, Programs) revealed the residents received Occupational Therapy, Physical Therapy, and Respiratory Therapy; however, oxygen (O2) therapy was not indicated.Review of physician orders for R70 revealed no physician order for oxygen therapy.Review R70's care plan revealed the care plan did not identify O2 therapy as a treatment and did not contain interventions related to O2 use or oxygen equipment.Observation and resident interview on 02/24/2026 at 10:59 AM revealed an unsecure and unattended O2 tank in the R70's room (room [ROOM NUMBER]). When asked if he used the O2 tank, R70 stated, No, take it with you.Observation on 02/25/2026 at 12:23 PM in R70's room (Room121) revealed an unsecure and unattended O2 tank present.Interview on 02/26/2026 at 9:02 AM with Licensed Practical Nurse (LPN) AA revealed R70 was not on O2 and was currently on hospice services. When asked if O2 tanks should be in residents' rooms when not in use, she stated she did not think so. LPN AA identified potential negative outcomes including a fire hazard and the possibility the tank could fall.Interview on 02/26/2026 at 9:16 AM with the Director of Nursing (DON) revealed if a resident did not have a physician order for O2 that R70 should not have O2 in the room. The DON identified potential negative outcomes including accident hazards related to the O2 tank being in the room unsecure and unattended, the possibility of someone placing O2 on the resident without an order, a medication error, and staff not recognizing O2 use due to lack of signage.Interview on 02/26/2026 at 9:23 AM with Regional Corporate Clinical Nurse (RCCN) II revealed R70 was not supposed to have an O2 tank in the room. She stated staff were expected to be observant for O2 tanks in resident rooms and remove them if the resident does not have an order, especially if there was no signage indicating O2 use. She identified a potential negative outcome including staff administering O2 without a physician order.2. Review of the EHR for R83 revealed a BIMS score of 1, indicating severe cognitive decline.Observation on 02/24/2026 at 11:51 AM, R83 was observed in his room receiving O2 via nasal cannula at 3 liters per minute delivered by O2 concentrator. The O2 concentrator was observed in operation; however, the external filter appeared visibly soiled with accumulated dust and debris. The nasal cannula was not dated. A nebulizer machine was present in the room; however, no date was observed on the nebulizer components/supplies.Observation on 02/25/2026 at 1:15 PM of R83 revealed R38 in his room receiving O2 via nasal cannula at 3 liters per minute delivered by an O2 concentrator. The O2 concentrator was in operation; however, the external filter remained visibly soiled with accumulated dust and debris. The nasal cannula remained undated.Observation on 02/26/2026 at 9:55 AM of R83 revealed that the resident had an O2 concentrator in the room. The external filter of the O2 concentrator appeared visibly soiled with accumulated dust and debris. A nasal cannula was observed in use; however, the cannula was not dated.Interview on 02/25/2026 at 02:10 PM with Licensed Practical Nurse (LPN) DD revealed when asked about O2 administration and management, she stated that, per her understanding, facility policy does not require O2 nasal cannulas to be dated. She further stated that nursing staff were responsible for cleaning the O2 concentrator, including the filter. She reported that O2 tubing was stored in plastic bags and was routinely changed weekly on Sunday nights by the night shift staff.Interview on 02/25/2026 at 3:00 PM with Registered Nurse (RN) GG, Case Mix Director revealed when asked about O2 administration practices, she stated that when a resident was receiving O2 therapy, an Oxygen in Use sign was placed on the resident's door in accordance with safety protocols. She further stated that nasal cannulas were typically stored in a plastic bag at the resident's bedside when not in use and were routinely changed weekly on Sunday nights. She further stated that, to her knowledge, facility policy did not require O2 nasal cannulas to be dated.Interview on 02/26/2026 at 10:20 AM with Regional Nurse (acting DON) confirmed that the O2 concentrator filter was dirty upon inspection. She stated that the concentrator was the responsibility of the hospice provider and indicated that the facility would notify the hospice unit regarding the equipment's condition for follow-up. She also affirmed that the facility policy did not require that O2 cannulas be dated.

Based on observations and staff interviews, the facility failed to ensure appropriate hand hygiene practices were performed during wound care treatment for one of six residents (R) (R6) with pressure ulcers. This deficient practice had the potential to increase the risk of transmission of infection. Findings include:Review of the electronic medical records (EMR) revealed R6 was admitted with diagnoses that included but not limited to Alzheimer's disease with late onset, severe dementia, paraplegia, peripheral vascular disease, underweight/low BMI (body mass index), dysphagia (difficulty swallowing), and Stage IV pressure ulcer of the sacral region.Review of the resident's care plan revealed: (Problem Start Date: 09/18/2025) reflected interventions intended to reduce risk of complications and infection, including: weekly wound assessments with measurements, treatment as ordered, use of a low-air-loss (LAL) mattress, use of positioning/off-loading devices (e.g., wedges/boots), keeping the resident clean and dry, keeping linens clean/dry/wrinkle free, enhanced barrier precautions, nutritional support/dietary involvement, and coordination/communication with hospice and the wound provider. Wound provider documentation dated 02/20/2026 described a sacral pressure injury clinically staged as Stage IV, with measurements documented and drainage described as mild serous with no odor and no peri-wound erythema, and the wound status noted as improving.Observation on 02/25/2026 at 9:05 AM of wound care for R6 performed by Licensed Practical Nurse (LPN) CC, Wound Care Nurse revealed R6 lying on a specialty mattress and was identified as severely impaired and dependent on staff for care. LPN CC donned (put on) gloves and removed the soiled dressing. After removing the soiled dressing, LPN CC removed her gloves and donned a new pair of gloves; however, hand hygiene was not performed between glove removal and application of new gloves. The wound was cleansed per treatment order. During the procedure, gloves were again removed and replaced; however, hand hygiene was not performed between glove changes. The wound dressing was then applied per the treatment protocol, the resident was repositioned, and the soiled dressing was removed from the room.Interview on 02/25/2026 at 9:20 AM with LPN CC CC revealed when asked about performing hand hygiene between glove changes, she stated she was unaware that hand hygiene was required between removing and donning a new pair of gloves during wound care.Interview on 02/25/2026 at 9:40 AM with Registered Nurse (RN) II, Corporate Nurse who was acting as the Director of Nursing (DON) confirmed that the expectation was for licensed nursing staff to perform hand hygiene between glove changes in accordance with infection control standards and facility policy.

Based on staff interviews, record reviews, and review of the facility policy titled Care Plans, the facility failed to develop a care plan for one resident (R)(R715) of 49 sampled related to amount of assistance needed to provide care during a transfer. Actual harm occured on 11/5/2024 when R715 was hit on the head by the mechanical lift swing when Certified Nursing Assistant (CNA) KK attempted a transfer alone. This resulted in bruising to the left eye of R715. Findings include: Review of the facility's policy titled, Care Plan dated 7/27/2023 documented It is the policy of the health center for each resident to have a person-centered care plan. (2) Care plan will be updated to reflect changes to approaches, as necessary, that result from significant changes in conditions or needs. (4) Care plans will be updated by nurses or any other interdisciplinary team member so that the care plan will reflect the resident's needs at any given moment. Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R715 had a Brief Interview of Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Further review in the MDS Section GG revealed upper extremity impairment on one side and lower extremity impairment on both sides, and dependent care for Activities of Daily Living (ADLs). Review of Progress Note dated 11/6/2024 documented Call to resident side in dinning [sic] hall. Upon walking noted a difference in facial area. Walked up to examine and there was a large area of discoloration on the left side of the resident's forehead. Review of statement written by CNA KK dated 11/8/2024 revealed that R715 was being assisted from chair to bed by using the Hoyer lift with no assistance from another CNA. When the strap was released the top of the lift swing hit R715 across the head. Review of the Physician's Order dated 11/6/2024 documented Bruise: Assess Neurological Status if affected area is on face/head/neck or cause of injury is unknown. During an interview on 1/16/2025 at 4:25 pm with the Director of Nursing (DON), it was confirmed that everybody is responsible for updating the care plan. The care plan should be updated when there is need or change that had been noticed with the residents. Staff are expected to be updated and follow the care plan as soon as possible. Interview on 1/16/2025 at 4:42 pm with the Administrator stated we will reeducate on how to pull the information from the electronic record and hold the staff accountable for following the care plan. Cross refer F689

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Occurrence Reduction Plan, the facility failed to provide adequate staff to prevent injuries while using a mechanical lift for one of 49 sampled residents (R) (R715). Actual harm occured on 11/5/2024 when R715 was hit on the head by the mechanical lift swing when Certified Nursing Assistant (CNA) KK attempted a transfer alone. This resulted in bruising to the left eye of R715. Findings included: A review of the facility's policy titled, Occurrence Reduction Plan, dated 1/29/2021 documented Reporting all occurrences of unknown origins to the Administrator or design immediately. Participating in investigations of unknown occurrences as outlined in the abuse prohibition policies. A review of the Electronic Medical Record (EMR) revealed that R715 was admitted to the facility on [DATE] with diagnoses that included primary cerebral ischemia (blood flow to the brain), osteoarthritis (breaks down joint bone and cartilage) contracture (left hand) (hardening of muscles) functional quadriplegia (loss of ability of all four limbs) lumbar region without neurogenic claudication (back and leg pain) spinal stenosis (weakness in arms and legs), and other lack of coordination. A review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R715 had a Brief Interview of Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Further review of the MDS Section GG revealed upper extremity impairment on one side and lower extremity impairment on both sides, and dependent care for Activities of Daily Living (ADLs). Review of Progress Note dated 11/6/2024 documented Call to resident side in dinning [sic] hall. Upon walking noted a difference in facial area. Walked up to examine and there was a large area of discoloration on the left side of the resident's forehead. A review of Observation Detail List Report dated 11/6/2024 at 8:40 pm indicated an alteration in the skin that consisted of a skin tear on the right arm and right leg. A review of CNA KK's written statement dated 11/8/2024 which she documented that she was assigned 11 residents and seven of the residents required assistance via a [NAME] lift. CNA KK reported that she was able to get assistance with six of her residents but there was no one available to assist her with the seventh resident. CNA KK then reported that she used the [NAME] lift to transfer the resident from the chair to the bed. It is during this time that the top of the lift swing bumped the resident in the head after it swiveled out of control after the strap was released. CNA KK reported that she did not see any signs of injury to the resident, and she proceeded to give the resident a bed bath. Later that morning CNA KK reported that she transferred the resident from bed to chair and the resident still did not have any visible injury to her head. A review of the Facility's Investigation dated 11/14/2024 documented Following a thorough investigation of the injury of unknown origin involving R715 the CNA KK statement, we were able to substantiate the resident was injured after R715 head was bumped by the Hoyer lift. During an interview on 1/16/2025 at 11:16 am the Assistant Director of Nursing (ADON) stated he is familiar with the incident on R715 but could not recall the event in detail. He stated he was the one who provided the in-service education on the usage of mechanical lifts after the incident. ADON revealed the education consisted of the proper use of the mechanical lifts, how many people should be present when doing mechanical lifts, the correct sling size and how to use it, and making sure the resident behaviors are appropriate at the time to carry out the safe transfer. He continued to state the training was demonstrated and the staff had to do a return demonstration. ADON further confirmed CNAs know how to work with residents regarding mobility. They are expected to look at it under ADL care area in the electronic health record (EHR) for functional abilities. During an interview on 1/16/2025 at 4:32 pm the Administrator and Senior Nurse Consultant (SNC) confirmed the facility's policy states there should be two people when transferring a resident with a mechanical lift. The Administrator stated all nursing staff are educated and checked off on proper usage of the mechanical lifts before working on the floor. They continued to state they have a process that involves random audits with mechanical lifts. SNC stated the Director of Nursing (DON) is responsible for overseeing monitoring for safe transfers. If the staff are not properly using the mechanical lifts on the residents, then that staff member will be suspended while an investigation is pending. Further, the Administrator confirmed she expected staff to follow the policy and training that have been provided.

Based on observations, resident interviews, and staff interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment as evidenced by wedged items in privacy curtain and dust build up in PTAC in room [ROOM NUMBER], a loose PTAC unit in room [ROOM NUMBER], peeling trim near the second floor shower room, substances on the floor/tile in the A-Hall shower room, black and black/brown substances in the ceiling of kitchen dish washing room and dry storage area. This deficient practice had the potential to jeopardize the health and safety of all 106 residents in the facility in three resident rooms, two of four shower rooms, and the kitchen. Findings include: Observation made on 1/14/2025 at 11:27 am in room [ROOM NUMBER] revealed a privacy curtain rail with a brown item wedged into the end of the railing and exposed insulating spray foam on the left wall of the PTAC unit. Observation made on 1/14/2025 at 11:55 am in room [ROOM NUMBER] revealed a loose PTAC unit. Observation made on 1/14/2025 at 12:01 pm in room [ROOM NUMBER] revealed dust buildup on filter of the PTAC unit. Observation made on 1/14/2025 at 12:12 pm the entrance of the B-Hall second-floor shower room and room [ROOM NUMBER] revealed peeling trim. Observation made on 1/15/2025 at 12:00 pm in the A-Hall first-floor shower room revealed orange substances on the floor of the shower room floor and ceiling vent. Observation made on 1/16/2025 at 4:30 pm in the A-Hall first-floor shower room revealed clusters of black substances between the tiles of the shower. Observation made on 1/16/2025 at 4:50 pm in the kitchen dish washing room revealed clusters of black substances on the ceiling and in the kitchen dry storage room there were brown and black substances on the ceiling vent. An interview with the resident council on 1/14/2025 at 3:08 pm revealed concerns about black substances in the A-hall shower room on the first floor. An interview and observation with the Maintenance Director on 1/16/2025 at 4:07 pm confirmed the missing part from the curtain rail, buildup on PTAC filter and exposed insulating foam spray in room [ROOM NUMBER], a loose PTAC filter in room [ROOM NUMBER], clusters of black substances on the ceiling in the kitchen dish room and in the kitchen pantry, substances in the first floor shower room ceiling, floor and tile. The Maintenance Director further confirmed the peeling trim near the second-floor shower room. He acknowledged that he was unaware of these concerns. He reported that he expected staff to identify concerns in resident rooms and around the facility and report them in the facility's electronic building management system. He further stated he is the only maintenance employee and has no assistants, so it is challenging to address all the concerns in the building right away. An interview with the Administrator on 1/16/2025 at 5:36 pm revealed she has been in the role since the end of July 2024. She stated that PTAC units should be checked and cleaned weekly and ceiling vents should be cleaned monthly. She further stated that there should be no negative outcomes since these concerns will be addressed immediately. A policy for the environment was requested but not provided.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to adhere to accepted standards of quality care by crushing medications that cannot be opened or crushed in one out of seven residents observed during a medication pass, and not measuring the correct dosage of Diclofenac ointment (nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain and inflammation) in one out of seven residents (R) (R12) who have diclofenac ointment ordered. This deficient practice could result in serious adverse effects, including an increased risk of medication side effects or reduced efficacy due to improper administration techniques. Findings include: A review of the facility policy Medication Administration: General Guidelines revised 4/10/2019 reveals that Medications are administered as prescribed. 2. Medications are administered in accordance with written orders of the attending physician .If a dose seems excessive considering the resident's age or condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. 21. Liquid dosage forms may be used whenever physically practical in place of solid tablets that would have to be crushed and especially for administration through enteral feeding tubes. The nurse checks with their provider pharmacy to determine if a liquid form is available and covered by the applicable payment program. The physician is contacted for a new order before changing the dosage, unless the physician has previously authorized that alternate dosage forms of the ordered drug may be used if necessary and appropriate. 22. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a patient/ resident has difficulty swallowing or is tube fed using the following guidelines: -long-acting or enteric-coated dosage forms should generally not be crushed and require a physician-specific order to do so. The physician must record in the medical records that the benefit of crushing the dosage form outweighs any potential risk. -The need for crushing medications is indicated on the patient/ resident paper MAR or e-MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during paper MAR or e-MAR reviews. R12 was admitted to the facility on [DATE] with diagnoses including, but not limited to old cerebral infraction, aphagia and dysphagia, pneumonia, gastroesophageal reflux disease, chronic pain syndrome, dysarthria and anarthria, and pain in left knee. A review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9, indicating the resident has moderate cognitive deficit. Section K, Swallowing/Nutrition Status, indicated the resident is on a mechanically altered diet. Section J indicates that the resident is experiencing pain. A review of the Orders dated 6/2/2021 reads: Resident gets medication crushed and takes them orally. Review of the Orders for diclofenac sodium gel [over-the-counter (OTC)] gel; 1%; amount. 4 grams (g); topical with a start date of 5/27/2022. Apply 4g to the left knee four times daily. Review of the Orders for potassium chloride capsule, extended release; 10 milliequivalent (mEq); amount 3 capsules; oral with a start date of 1/16/2025. Special Instructions: for hypokalemia. Do Not Crush. Ok to open capsule and pour in apple sauce. Review of the Orders for rivastigmine tartrate; 3 milligram (mg); 1 cap; oral with a start on 11/2/2023. Special Instructions: Do not crush. During the med pass conducted on 1/16/2025 at 8:45 am by a Licensed Practical Nurse (LPN) AA on a R12, it was observed that when administering medications to the resident, she crushed them finely and mixed them with water, stating that the resident could not swallow them. Upon reviewing the medications, some medications, such as extended-release potassium chloride capsules and rivastigmine tartrate capsules, were identified to not be opened or crushed, as indicated on the medication package and in the order. LPN AA agreed that she should have contacted the pharmacist or the doctor to explore alternative forms of the medications. When further observing the LPN AA administering Diclofenac gel to the resident, LPN AA was noted to squeeze an unmeasured amount of the ointment into a small medicine cup, locking the tube back into the med cart, and proceeded to the resident's room. When LPN AA was questioned about how she ensured she was administering the doctor-ordered 4 grams (g) of the gel, the LPN AA admitted she did not know how to measure it correctly. An interview with a Unit Manager (UM) for the first floor, LPN BB on 1/16/2024 at 12:00 pm revealed that if a resident cannot swallow a pill, they would call the pharmacy to clarify if a medication could be crushed, or if it could be changed to another form. She further reported that they would then reach out to the doctor to get it okayed by the MD. UM LPN BB reported that the correct way of measuring the diclofenac ointment is to squeeze the gel on a measuring card to ensure the correct dosage is administered. During an interview with UM LPN CC on 1/16/2025 at 12:05 pm she revealed that if a resident cannot swallow a medication, the nurse should first call the pharmacy to see whether the medication can be changed to another form. UM LPN CC reported the correct way of measuring and administering diclofenac ointment, was to just squeeze the gel into a small medication cup. UM LPN CC further reported that she would use somewhere around 5-15 ml but was unclear on the precise amount. When asked about using the measuring card that comes with the medication UM LPN CC revealed that she was unaware of the measuring card. During an interview with the Director of Nursing (DON) on 1/16/2025 at 12:50 pm, it was revealed that if a resident has problems swallowing medication and the extended-release capsule cannot be opened or crushed, they call the pharmacy and then a doctor to get it switched to another form, if possible. The DON then stated that they do not measure and administer it liberally when referring to the correct way of measuring diclofenac ointment. The DON acknowledged not being aware that the ointment comes with a measuring card and was not sure if there was a policy concerning this. During an interview on 1/16/2025 at 3:15 pm Pharmacist DD revealed that they write special instructions on the Medication Administration Record (MAR) if a medication cannot be crushed or if a capsule cannot be opened. She further stated that nurses often notice and inform the pharmacy services when a resident has difficulty swallowing. At this point the pharmacy would advise them if an alternative form is available. Nurses then return to the doctor to have the order changed. The DON further explained that when a resident is admitted to the facility, and their medications are entered, the staff are attentive for signs of dysphagia and notifying pharmacists. In such cases, alternative forms of medication are explored. For instance, potassium chloride (KCL) can be switched to a liquid form, and rivastigmine (Exelon) also comes in a transdermal form.

Based on observations, resident and staff interviews, and review of facility policy titled Transmission Based Isolation Precautions, the facility failed to maintain sanitary conditions for two of 50 sampled residents (R)(R23 and R3). Specifically, oxygen equipment (nasal cannula) was hung over the humidifier and touched the floor when not in use for R23 and the facility failed to use appropriate Personal Protection Equipment (PPE) for a resident R3 on Enhanced Barrier Precautions (EBP) of 50 sampled residents. This deficient practice could risk equipment contamination, increasing the likelihood of infections and health complications. Findings include: 1.A policy on maintaining oxygen supplies, such as nasal cannulas, under sanitary conditions was requested but not provided. A review of the Electronic Medical Record (EMR) revealed that R23 was admitted to the facility on [DATE] with diagnoses including, but not limited to intracerebral hemorrhage, pneumonia, nasal congestion, pulmonary nodule, acute respiratory failure with hypoxia, and COVID-19. A review of the recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R23 had a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. Further review of the MDS revealed that R23 received oxygen therapy. Review of the care plan dated 1/14/2025 for R23 revealed a problem: Resident needs nebulizer treatment/Oxygen (O2) use related to history of pneumonia, respiratory failure, COVID-19 with a goal that Resident will not exhibit signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) with approach: Monitor oxygen saturation via pulse oximetry as ordered/needed, administer nebulizer treatment/O2 as ordered. A review of the Physician Orders for R23 revealed an order dated 11/18/2024 for O2 at 2 liters (L) via nasal cannula (NC) as needed to keep O2 saturation (sat) above 95%. Change respiratory supplies weekly on Sundays. During an observation on 1/14/2025 at 12:04 pm in the resident's room, R23 was resting in bed. The oxygen concentrator was on, but the resident was not wearing the nasal cannula. The long tubing of the nasal cannula was connected to the concentrator, draped over it, tangled on top, and with portions touching the floor, rather than being stored hygienically in the bag attached to the concentrator. The resident stated that she does not use oxygen continuously, only as needed. During an observation on 1/15/2025 at 9:00 am R23 was resting in bed, asleep, and comfortable. The oxygen tubing was connected to the concentrator in the same manner as observed the previous day, not stored in a bag. During an observation and interview on 1/15/2025 at 11:00 am with the Assistant Director of Nursing (ADON) while in R23's room, ADON confirmed the O2 was not bagged. ADON reported that O2 tubing should be bagged when not in use and should not be placed on the floor or the concentrator. He stated that he would provide R23 with new tubing. 50878 2. A review of the Transmission Based Isolation Precautions policy, effective date 3/1/2019, section five, Enhance Barrier Precautions (EBP) revealed that Enhanced Barrier Precautions expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDROs) to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated when contact precautions do not otherwise apply, for nursing home residents with wounds and or indwelling devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Review of the electronic medical record for R3 was admitted to the facility on [DATE] following hospitalization . She was admitted to the facility with diagnoses that included but were not limited to the wound of right elbow, unstageable pressure ulcer of sacral region, stage II, Bacteremia, Unspecified fracture of lower end of left radius, and encounter for attention to gastrostomy. A review of the annual minimum data set (MDS) dated [DATE], revealed Section M which indicated R3 had a stage II pressure ulcer/injury on the sacrum, which was in place at admission to the facility. R3 also was being treated for a right elbow unstageable wound by off-site wound care provider. Review of the care plan revealed that R3 had an abrasion of unknown origin to left elbow at admission on 12/11/2024. Last review of care plan was 1/16/2024. Care plan last reviewed 1/16/2025 notes tube feeding creates risk for aspiration, weight loss and dehydration. Risks for MDRO due to this medical device. Review of the physician orders for R3 regarding wound care on elbow states effective R3 was placed on Enhanced Barrier Precautions effective 12/12/2024 due to wound with wound vac. Physician's orders for Gastrostomy bolus of Jevity 1.5 five times a day and to check for residual before feeding. If residual is greater than 100 mL, hold feeding and call MD for further orders. Check tube placement prior to med administration/flushes. During medication administration times, flush tube with 15 milliliters (mLs) water before and after medications and 5 mLs with each medication. On 1/15/2025 at 8:39 am, licensed practical nurse LPN LL, was observed sitting next to R3 reclasping percutaneous (peg) tube. He stated that he had just completed her bolus feeding. At the time of this observation no PPE was in use. It was noted that the room of R3 was not marked for EBP although the matrix indicated Stage II pressure ulcers and g-tube feeding. LPN LL left room with supplies remaining on the side table, formula bottle and syringe unlabeled. LPN LL continued his med pass to other residents. There was a cart for personal protective equipment available in the hallway however none was donned. On 1/16/2025 at 10:35 am, an interview with the Assistant Director of Health Services (ADHS) regarding TBP for R3, was shared by ADHS that the room was indeed not properly marked with EBP for g-tube and open wounds. ADHS noted that this would be corrected and by the end of shift, the room was properly marked for EBP.

Based on observations, record review, interviews, and review of the facility's policy, it was determined that the facility failed to ensure bed/side rails had been assessed for the risk of entrapment and only used bed/side rails after trying other alternatives for three of three residents (R) (R#15, R#46, and R#249). The facility also failed to obtain informed consent for the use of bed/side rails for two of three residents (R#15 and R#46) reviewed for bed/side rail use. Finding included: A review of the facility's policy titled Bed Rails last revised 2/1/18 indicated, Bed Rails (also referred to as side rails) are adjustable metal or rigid plastic bars that attach along the side of a patient's bed for the purpose of preventing a patient from falling out of the bed or for assisting a patient independently to turn or maneuver themselves in the bed. Bed rails are available in a variety of types, shapes, and sizes, ranging from full, to one-half, one-quarter, or one-eighth of a bed. Prior to installing or using bed rails on a patient's bed, the patient should be assessed by the admitting nursing and/or the interdisciplinary team (IDT) to determine whether the use of bed rails would constitute an enabler or a restraint for the patient. The patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not be limited to, the risk of entrapment. 1. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated R#15 had severely impaired cognitive skills for daily decision making. The resident required extensive to total assistance with all activities of daily living (ADLs). The MDS indicated bed rails were not used as a restraint. A review of R#15's care plan, last revised 8/23/22, revealed the use of bed/side rails was not care planned. A review of the Observation Detail List Report for restraint-adaptive equipment use indicated the observation date was 4/22/22 and completion date was 4/22/22. This form indicated R#15 did not have restraints or adaptive equipment in use. There was no mention of the side rails. Observations on 10/3/22 at 12:30 p.m. revealed R#15 had quarter side rails on both sides of the resident's bed. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The resident had quarter rails on their bed, not half rails). Further review of R#15's electronic health record (EHR) revealed no consent for the use of side rails describing the risks and benefits of use. The consent was requested from the facility on 10/4/22 and was not provided by the end of the survey. During an interview on 10/6/22 at 12:30 p.m. with Certified Nurse Aide (CNA) PP, he stated almost all of the beds had side rails and the residents used them for turning and repositioning. During an interview on 10/6/22 at 1:46 p.m. with Staff QQ, Maintenance Director, he stated all the beds except one, had rails and the rails were made to go on the beds. He stated they were checked monthly and was able to demonstrate how he checked the beds/rails for safety. During an interview on 10/6/22 at 2:44 p.m. with Licensed Practical Nurse (LPN) LL, he stated side rail assessments were done quarterly on the MDS schedule. He stated consents for side rails were obtained by the person doing the admission. He stated R#15 used their side rails for positioning. He stated the use of side rails should be care planned. During an interview on 10/6/22 at 2:58 p.m. with Registered Nurse (RN) NN, she stated side rail assessments were done quarterly and consents were obtained at admission. RN NN stated the rails were checked monthly by maintenance. During an interview on 10/6/22 at 6:48 p.m. with CNA UU, she stated R#15 used the side rails to hold themselves over during care. During an interview on 10/6/22 at 8:27 a.m. with CNA DD, she stated R#15 used the bed bars for positioning and assist with cares. During an interview on 10/7/22 at 9:23 a.m. with CNA TT, she stated R#15 used the side rails when they were being changed to be able to hold themselves over. 2. A review of the Resident Face Sheet indicated the facility admitted R#46 on 2/10/22 and was readmitted from the hospital on 5/23/22. A review of the quarterly MDS, dated [DATE], indicated R#46 had a BIMS score of 13, indicating the resident had no cognitive impairment. The resident required extensive to total assistance of one to two people for their ADLs. The MDS indicated bed rails were not used as a restraint. A review of R#46's care plan, last revised 8/23/22, revealed the use of bed/side rails was not care planned. Observations on 10/3/22 at 12:40 p.m. revealed R#46 had quarter side rails on both sides of the resident's bed. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (The resident had quarter rails on their bed, not half rails). A review of the Observation Detail List Report for restraint-adaptive equipment use indicated the observation date was 2/10/22 and completion date was 2/16/22. This form indicated R#46 did not have restraints or adaptive equipment in use. There was no mention of the side rails. A review of R#46's electronic EHR revealed no current assessment/reassessment for R#46's continued use of the side rails. Further review of R#46's EHR revealed no consent for the use of side rails describing the risks and benefits of use. The consent was requested from the facility on 10/4/22 and was not provided by the end of the survey. During an interview on 10/6/22 at 12:30 p.m. with CNA PP, he stated almost all the beds had side rails and the residents used them for turning and repositioning. During an interview on 10/6/22 at 1:46 p.m. with Staff QQ, Maintenance Director, he stated all the beds except one, had rails and the rails were made to go on the beds. He stated they were checked monthly and was able to demonstrate how he checked the beds/rails for safety. During an interview on 10/6/22 at 2:44 p.m. with LPN LL, he stated side rail assessments were done quarterly on the MDS schedule. He stated consents for side rails were obtained by the person doing the admission. He stated R#46 used their side rails for positioning. He stated the use of side rails should be care planned. During an interview on 10/6/22 at 2:58 p.m. with RN NN, she stated side rail assessments were done quarterly and consents were obtained at admission. RN NN stated the rails were checked monthly by maintenance. During an interview on 10/6/22 at 6:48 p.m. with can UU, she stated R#46 used the side rails to hold themselves over during care. During an interview on 10/6/22 at 8:27 a.m. CNA DD, she stated R#46 used the bed bars for positioning and assist with cares. During an interview on 10/7/22 at 9:23 a.m. with CNA TT, she stated R #46 used the side rails when they were being changed to be able to hold themselves over. 3. A review of the Resident Face Sheet indicated the facility admitted R#249 on 9/19/22. A review of the admission MDS, dated [DATE], indicated R#249 had a BIMS score of 15, indicating the resident had no cognitive impairment. The resident required extensive assistance of one to two people for their ADLs. The MDS indicated bed rails were not used as a restraint. A review of R#249's care plan, last revised 9/26/22, revealed the use of bed/side rails was not care planned. Observations on 10/3/22 at 11:55 a.m. revealed R#249 had quarter side rails on both sides of their bed. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Restraint-Adaptive Equipment Use form indicated the observation occurred on 9/19/22 but was recorded on 10/4/22. This form indicated R#249 did not have restraints or adaptive equipment in use. There was no mention of the side rails. During an interview on 10/6/22 at 12:30 p.m. with CNA PP, he stated almost all the beds had side rails and the residents used them for turning and repositioning. During an interview on 10/6/22 at 1:46 p.m. with Staff QQ, Maintenance Director, he stated all the beds except one, had rails and the rails were made to go on the beds. He stated they were checked monthly and was able to demonstrate how he checked the beds/rails for safety. During an interview on 10/6/22 at 2:44 p.m. with LPN LL, he stated side rail assessments were done quarterly on the MDS schedule. He stated consents for side rails were obtained by the person doing the admission. He stated R#249 used their side rails for positioning and to assist with standing up. He stated the use of side rails should be care planned. During an interview on 10/6/22 at 2:58 p.m. with RN NN, she stated side rail assessments were done quarterly and consents were obtained at admission. RN NN stated the rails were checked monthly by maintenance. During an interview on 10/6/22 at 6:48 p.m. with CNA UU, she stated R#249 used the side rails for positioning and to stand. During an interview on 10/6/22 at 8:27 a.m. with CNA DD, she stated R#249 used the bed bars for positioning and assist with cares. During an interview on 10/7/22 at 9:23 a.m. with CNA TT, she stated R#249 liked to have their side rails up all the time and she stated the resident would keep their call light and bed remote on the rail. During an interview on 10/7/22 at 9:59 a.m. with CNA EE, she stated all the residents had side rails and she would put them up if the resident requested. During an interview on 10/7/22 at 4:15 p.m. with the Director of Nursing Services, she stated that each resident had a restraint equipment device assessment done quarterly and annually and consents for the bed rails were to be obtained upon admission. During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated his goal was to take all the side rails off all the beds but if the resident needed them, then consent should be obtained as part of the admission assessment. He stated they would be getting consent from all residents that had side rails.

Based on observations, interviews, record review, and document review, it was determined the facility failed to have sufficient nursing staff to provide care for two of nine (R) (R#12 and R#293) reviewed for activities of daily living and one of four residents (R#56) who required daily wound care. Findings included: A review of the Facility Assessment for 2022 revealed the facility evaluated Staffing, Training, Services & Personnel for Overall Staffing, Staff Competencies, and Services. According to the assessment, for a sufficiency analysis summary indicated to Use and/or refer to: 1. Staffing and scheduling systems 2. Staff training and competency programs 3. A review of individual staff assignments and systems for coordination and continuity of care for residents withing and across staff assignments. An interview with the Administrator on 10/7/22 at 2:40 p.m. revealed the facility was staffed according to the census. According to the Administrator, when the resident census ran in the 90s, he liked to have four or five certified nursing assistants (CNAs) for each floor on the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts. During an interview on 10/7/22 at 1:53 p.m., the Director of Nursing (DON)/Registered Nurse (RN) BB and Senior Nurse Consultant (NC) WW stated she would like to see four CNAs scheduled on each floor for the first shift, three CNAs on each floor for second shift, and five to six CNAs for third shift. 1. A review of R#56's quarterly Admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. A review of the September 2022 Treatment Administration Record (TAR) indicated an order, with a start date of 9/9/22 and end date of 9/30/22, to cleanse the right dorsal proximal foot (top of the right foot closest to the leg) with wound cleanser, pat dry, pack with Dakin's 0.5% packing, cover with a 4 x 4 gauze, and secure with rolled gauze. Change three times weekly with frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 09/26/22, or 9/28/22. A review of the September 2022 TAR revealed an additional treatment order, start date of 9/9/22 and end date of 9/30/22, to cleanse the right ankle with wound cleanser. Pay dry. Apply [MEDICATION(S)] Blue and secure. Change three times a week with a frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 9/26/22, or 9/28/22. A review of Active [physician] Orders for R#56 revealed an order with a start date of 9/30/22, to cleanse the resident's right dorsal proximal foot (top of the right foot closest to the leg) and right malleolus of the anterior foot (the ankle bone on the inside of the foot) with wound cleanser, pat the areas dry, pack with Dakins 0.5% packing, cover with 4 x 4 pad, and secure with rolled gauze. An interview with R#56 on 10/3/22 at 11:32 a.m. revealed the resident thought the bandage was changed daily; however, observation revealed the bandage on the right foot was dated 9/30/22, three days prior. An interview with Wound Care Nurse OO on 10/3/22 at 10:26 a.m. revealed she was supposed to provide wound care for residents at least four days a week. However, she had not completed wound care consistently for the last couple of months because she had been reassigned to provide resident care due to staffing. She stated the facility needed more staff so she could provide wound care. During a follow-up interview on 10/4/22 at 12:05 p.m., Wound Care Nurse OO confirmed the last day she provided treatment to R#56's right foot was on 9/30/22. She stated she had to work as a staff nurse and was unsure whether the treatment was provided for the resident since 9/30/22. An interview with Licensed Practice Nurse (LPN) CC on 10/4/22 at 4:00 p.m. revealed she had mentioned to the DON that there was not enough staff and the DON told her that she would have to step up and help. LPN CC stated she told the DON that she had to administer residents' medications and would help the residents the best she could. However, she could not agree with the DON because she could not do her job and the duties of a CNA. According to LPN CC, the DON was working as a staff nurse and thought the DON had worked until 1:00 a.m. the previous night. LPN CC stated she and Wound Care Nurse OO worked as staff nurses on 10/3/22 because they did not have enough nurses; subsequently, Wound Care Nurse OO could not provide all wound care. She stated staff had been told the facility would not get agency staff because it cost the company too much money. An interview with RN NN on 10/5/22 at 3:49 p.m. revealed she thought wound care could be done better if they had more staff. An interview with DON BB and Senior Nurse Consultant WW on 10/7/22 at 2:39 p.m. revealed they were unaware of any concerns with wound care not being completed. The DON and Senior Nurse Consultant WW stated they had been short staffed like everywhere else. They stated they were trying of offer bonus/incentives to get more staff and had not been using agency staffing. They said that the wound care nurse had been pulled a lot to work as a staff nurse, but they thought the other nurses were providing wound care. They stated they expected staff nurses to complete wound care if Wound Care Nurse OO was not available. An interview with the Administrator on 10/7/22 at 2:11 p.m. revealed he was aware of the facility's staffing concerns but they did not hire agency staffing because corporate staff said it cost too much money. He was aware that due to staffing issues the DON and Wound Care Nurse OO had been working as floor nurses instead of their normal job duties. 2. A review of the Face Sheet indicated R#12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS dated [DATE] indicated R#12 had a BIMS of two, which indicated severe cognitive impairment. The assessment revealed R#12 required extensive assistance of one staff member for dressing, toileting, and personal hygiene. A review of R#12's care plan, revised 8/24/22, indicated the resident was at risk for a decline in activities of daily living (ADL) related to the resident's cognition and required staff assistance with ADLs. The facility developed an intervention that required staff to assist the resident with ADLs, including the assistance of one staff for toileting, incontinence care, dressing, bathing, and grooming. A review of a facility's Grievance/Complaint Form: Healthcare Centers, dated 7/6/22, indicated R#12's family member called to file a grievance in response to other family members who were very upset after visiting R#12 over the weekend (7/2/22-7/3/22) and finding the resident dirty, ungroomed, and in dirty clothes. The family member stated R#12 was always very well put together and conscious of [the resident's] appearance. The form indicated facility steps taken to investigate the grievance included showering R#12, clipping and cleaning the resident's nails, shaving, and changing R#12 into clean clothes. The form concluded, Grievance confirmed. A review of the Daily Census Report indicated the census on Saturday, 7/2/22, was 92 residents, and the census on Sunday, 7/3/22, was 93 residents. On 10/7/22 at 1:01 p.m., the surveyor and HR/Staffing personnel XX reviewed the Daily Nursing Staff Forms and the Export [NAME] Punch Audits, a log of employee time clock information, for 7/2/22 and 7/3/22. According to the staffing information, on 7/2/22 on the 7:00 a.m. to 3:00 p.m. shift, two CNAs worked on each of the two facility floors. On 7/2/22, on the 3:00 p.m. to 11:00 p.m. shift, for the first floor, one CNA worked the entire shift, and a second CNA reported to the first floor at 7:00 p.m. On the second floor, two CNAs worked until 7:00 p.m., one of the CNAs left at 7:00 p.m., leaving one CNA working. On 7/2/22, from 11:00 p.m. to 7:00 a.m., there were two CNAs on each floor. Further review of staffing information revealed on 7/3/22, there were two CNAs on each of the two facility floors from 7:00 a.m. to 3:00 p.m. On the 3:00 p.m. to 11:00 p.m. shift, one CNA worked the first floor, one CNA worked the entire 3:00 p.m. to 11:00 p.m. shift on the second floor, and two other CNAs working five hours total. Five CNAs worked on the 11:00 p.m. to 7:00 a.m. shift on 7/3/22. 3. A review of R#144's 5-Day scheduled, discharge MDS, dated [DATE], revealed the facility admitted the resident on 7/19/22 and discharged the resident on 7/23/22. The MDS revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#144 had a BIMS score of 15, indicating intact cognition. According to the MDS, R#144 was occasionally incontinent of bowel and bladder. The assessment further revealed R#144 required limited assistance from one staff member with bed mobility, transfers, personal hygiene, toileting, dressing, walking in the room, and locomotion on the unit. A review of a facility's Grievance/Complaint Form: Healthcare Centers, dated 7/20/22, indicated a family member found R#144 in urine. The grievance summary indicated the family member had arrived before the staff could get to the resident. On 10/7/22 at 10:44 a.m., an interview with R#144's family member revealed the resident was at the facility for rehabilitation, but the resident was found on day one soaked, sitting in [their] own urine. The family member stated R#144 needed help getting to the bathroom, and that was the very reason the resident went to the facility. The family member stated they got the resident out of the facility as soon as they could. It was unacceptable that someone did not assist the resident. On 10/7/22 at 1:01 p.m. a review of the Daily Nursing Staff Forms dated 7/20/22 and reconciliation of the Export [NAME] Punch Audits for 7/20/22, with HR/Staffing personnel XX revealed on 7/20/22, on the 7:00 a.m. to 3:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift, there were two CNAs on each floor. On 7/20/22, on the 11:00 p.m. to 7:00 a.m. shift, there were five CNAs in the facility. 4. A review of an anonymous complaint revealed on 2/6/22, the complainant visited the facility and found an unnamed resident in a mess. The complaint alleged only one CNA was working the floor. On 10/5/22 at 3:02 p.m., an interview with HR/Staffing personnel XX revealed she was responsible for making the staffing schedules. She stated staffing was determined by resident census. HR XX stated the census on 2/6/22 was 94. Referring to the Daily Nursing Staff Form, dated 2/6/22, HR XX stated that while she would have wanted three CNAs on each floor per shift, the facility had two CNAs on each floor per shift. A follow-up interview with HR XX on 10/7/22 at 1:46 p.m., revealed after reviewing the Export [NAME] Punch Audit dated 2/6/22, she confirmed that one of the CNAs listed on the Daily Nursing Staff Form dated 2/6/22 had called out from work and only one CNA worked on the second floor for the 7:00 a.m. to 3:00 p.m. shift. Continued interview on 10/5/22 at 3:02 p.m., HR XX stated three staff members (Restorative CNA AAA, Recreation/Activity Staff BBB, and Medical Records CCC) who primarily served in other roles were also certified and were at times pulled from their primary duties to fill staffing needs. However, a review of the Export [NAME] Punch Audit and the Daily Nursing Staff Form revealed no documented evidence the three staff members had worked as a CNA. During an interview on 10/5/22 at 2:44 p.m., CNA EEE stated the weekends were understaffed. CNA EEE stated more staff were needed so they could get to everyone. An interview with CNA DD on 10/6/22 at 2:10 p.m. revealed there were not enough staff to care for residents. She stated sometimes there were one or two CNAs to provide care for 50 residents. During an interview on 10/7/22 at 5:41 a.m., CNA DDD stated at times the resident load was too much. CNA DDD stated they usually started waking residents at 3:00 a.m. to begin providing morning care so there would be time to get it could get done. CNA DDD stated there were not enough staff during the week nor on weekends to provide resident care, and sometimes the care did not get done. An interview with CNA UU on 10/7/22 at 5:50 a.m. revealed at times the resident load was too much, and they had to wake residents early to get the morning care completed. During an interview on 10/7/22 at 6:08 a.m., CNA RR stated there were not enough staff during the week nor on the weekends, sometimes resulting in a lack of incontinent care and overall patient care. An interview with LPN CC on 10/5/22 at 4:00 p.m. revealed that the previous weekend (10/1/22-10/2/22), one CNA was responsible for caring for 50 residents. She stated they were always short staffed, and the DON was working as a staff nurse all the time. An interview with CNA FFF on 10/6/22 at 2:25 p.m. revealed she thought they needed to hire more staff because she felt like they could do a better job caring for residents if they had more CNAs and nurses. During an interview on 10/7/22 at 1:53 p.m., with the DON/ RN BB and Senior Nurse Consultant (NC) WW stated she would like to see four CNAs scheduled on each floor for the first shift, three CNAs on each floor for second shift, and five to six CNAs working third shift. The DON stated the census for the second floor on 2/6/22 was 46 and one CNA was not enough. The DON stated she would have liked to have had more staff to care for residents on 7/3/22 on the 3:00 p.m. to 11:00 p.m. shift and on 7/20/22. On 10/7/22 at 2:40 p.m., the Administrator stated the facility tried to meet and exceed the state requirements for staffing. The Administrator stated the facility was staffed according to the census. The Administrator stated the residents on the second floor of the facility had a higher acuity, which was considered when scheduling staff. Further interview with the Administrator revealed when the resident census ran in the 90s, he liked to have four or five CNAs on each floor for each of the 7:00 a.m. to 3:00 p.m. and 3:00 to 11:00 p.m. shifts. The Administrator did not comment about one CNA assigned to care for 46 residents, but stated staffing was an ongoing issue everywhere.

Based on observation, document review, and interviews, the facility failed to prohibit the Director of Nursing (DON) from serving as a charge nurse for eight of 18 days reviewed when the facility's census was greater than 60 residents and there was no staffing waiver in effect. Findings included: During an observation on 10/3/22 at 9:48 a.m., the DON was observed working a medication cart and administering mediations to residents. A review of a Census Daily Detail by Name Report: All Units for 10/3/22 indicated the census of the facility was 90 residents. During an interview on 10/5/22 at 3:07 p.m., the Human Resources (HR) Director, HR XX, stated when the DON worked on the floor, the DON did so as a charge nurse. HR XX stated that, as a charge nurse, the DON was responsible for a medication cart and the administration of medications to residents. HR XX reviewed Daily Nursing Staff Forms with the surveyor and confirmed the DON was scheduled and worked as a charge nurse on 9/20/22 during the 7:00 a.m. to 7:00 p.m. shift, on 9/21/22 during the 7:00 a.m. to 3:00 p.m. shift, on 9/26/22 during the 7:00 a.m. to 7:00 p.m. shift, on 9/27/22 during the 7:00 a.m. to 3:00 p.m. shift, on 9/29/22 during the 7:00 a.m. to 7:00 p.m. shift, and on 9/30/22 during the 7:00 a.m. to 7:00 p.m. shift. According to HR XX, the DON was scheduled as a charge nurse during the 7:00 a.m. to 7:00 p.m. shift on 10/3/22, but another nurse came into work and relieved the DON of that duty. Per HR XX, on 10/4/22, the DON worked a medication cart until another nurse relieved the DON of that duty. HR XX reported the DON was scheduled to work as a charge nurse because two nurses had been on vacation, one of which came back to work that day, on 10/5/22, and the other nurse resigned, which caused staffing issues. A review of a Census Daily Detail by Name Report: All Units report revealed on 9/20/22, the facility's census was 94 residents; on 9/21/22, the facility's census was 94 residents; on 9/26/22, the facility's census was 93 residents; on 9/27/22, the facility's census was 94 residents; on 9/29/22, the facility's census was 95 residents; on 9/30/22, the facility's census was 93 residents; and on 10/4/22, the facility's census was 90 residents. During an interview on 10/6/22 at 2:21 p.m., the DON reported the facility was short of staff and when there was no one available to cover the medication cart, she worked the medication cart as a charge nurse. During an interview on 10/6/22 at 2:39 p.m., the Administrator stated there was a shortage of staff everywhere, so the DON sometimes manned the medication cart when there was no one else to do so. The Administrator explained he had lost two nurses earlier in the year, and two more nurses had been on extended vacations. According to the Administrator, he had been offering incentives for staff, even out of his own pocket. The Administrator stated he tried to follow the regulations, but he also had to make sure the residents got their medications on time. During a follow-up interview on 10/7/22 at 4:54 p.m., the DON confirmed she had been scheduled as a charge nurse on 9/20/22, 9/21/22, 9/26/22, 9/27/22, 9/29/22, 9/30/22, 10/3/22, and 10/4/22.

Based on observations, interviews, record review, and document review, the facility failed to accommodate the needs of three of 48 sampled residents (R) (R#3, R#21, and R#52) related to providing a functional shower bed for use on the second floor of the facility, resulting in the residents failing to receive showers as preferred. Findings included: A review of a facility Daily Census Report dated 10/6/22 revealed five of 48 residents on the second floor desired a shower bed for bathing. 1. A review of R#3's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#3's Quarterly Minimum Data Set (MDS) Assessment, dated 9/24/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment indicated that R#3 had bilateral impairments in range of motion of the upper and lower extremities; R#3 was totally dependent on two or more people for bathing (how the resident took a full body bath/shower); and it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. A review of R#3's care plan, last dated 7/28/22, revealed the resident required staff assistance with activities of daily living (ADLs). The facility developed a care plan intervention directing staff to provide the resident physical assistance with ADLs. A review of R#3's Point of Care History from 9/7/22 to 10/4/22 revealed the resident received bed baths. There was no documented evidence that the resident received a shower. An interview with R#3 on 10/7/22 at 3:58 p.m. revealed the resident only received bed baths and had not had a shower for some time. R#3 said it would be nice to go to the shower room and take a shower. 2. A review of R#21's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#21's Annual MDS assessment dated [DATE], revealed the resident had a BIMS score of 15, indicating intact cognition. The assessment indicated R#21 had range of motion limitations to both lower extremities and was totally dependent on staff for bathing (how the resident took a full body bath/shower) and that it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. A review of R#21's care plan, last dated 9/20/22, revealed the resident required staff assistance with activities of daily living (ADLs). A review of R#21's Point of Care History from 9/13/22 to 10/7/22 revealed the resident received complete bed baths and there was no documented evidence the resident received a shower. An interview and observation of R#21 on 10/7/22 at 3:50 p.m. revealed the resident was lying in bed. Observation revealed the resident had bilateral leg amputations. R#21 stated he/she used a shower chair for showers, but noted it would be nice to use a shower bed. 3. A review of R#52's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#52's quarterly MDS dated [DATE], revealed the resident had a BIMS score of one, indicating severely impaired cognition. The assessment indicated the resident had lower extremity impairments in range of motion on both sides and was totally dependent on two or more people for bathing. A review of R#52's care plan dated 4/1/22, revealed the resident had a severe cognitive decline and was unable to complete most daily activities independently. The care plan indicated the resident was in hospice care for heart disease. The facility developed an intervention that directed staff to provide total assistance with showers. A review of R#52's Point of Care History from 9/8/22 to 10/4/22 revealed the staff provided a partial or complete bed bath and there was no documented evidence staff provided showers for the resident. An interview with Certified Nursing Assistant (CNA) ZZ on 10/6/22 at 2:25 p.m. revealed the shower bed for the second floor did not fit into the shower room. CNA ZZ stated they had shower chair; however, there were residents who were not able to sit up in the chair for a shower. An observation of a second-floor shower room revealed a shower chair and mechanical lifts were stored in the room. There was no shower bed observed in the shower room. An interview with Maintenance QQ on 10/6/22 at 3:03 p.m. revealed the facility had one shower bed that should fit in the shower stall on each floor. An observation with Maintenance QQ on 10/6/22 at 3:05 p.m. revealed the shower bed was too big to fit in the shower stall in the second-floor shower room. Maintenance QQ stated that until now he was unaware the shower bed would not fit in the shower room on the second floor. An interview with Senior Nurse Consultant WW and Director of Nursing (DON) BB on 10/7/22 at 2:39 p.m. revealed if residents could not shower in the reclining shower chair, they could take residents to another floor for a shower. An interview with Administrator AA on 10/7/22 at 2:11 p.m. revealed the facility purchased the shower bed approximately six months prior and the Administrator was unaware the shower bed did not fit in the shower stall on the second floor.

Based on record review, interviews and review of the facility's policy, the facility failed to prevent abuse for one of three sampled residents (R) (R#193) related to sexual abuse. Findings included: A review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 10/27/20 indicated Procedures: 1. Providers are to identify, correct, and intervene in situations in which abuse, neglect, mistreatment, or exploitation may occur. The assessment, care planning, and monitoring of patients with needs and behaviors that might lead to conflict or neglect, such as patients with a history of aggressive behaviors, patients who have behaviors such as entering other patients' rooms, patient with self-injurious behaviors, patients with communication disorders, and patients who require heavy nursing care or are totally dependent on staff. A review of the Facility Incident Report Form, dated 11/24/21, indicated the Administrator was informed by the Social Worker (SW) at 9:30 a.m. that the SW received a note from nursing staff that R#193 was seen performing a sexual act on R#195 the previous evening. The report indicated R#193's had a Brief Interview for Mental Status (BIMS) score was seven, indicating severe cognitive impairment, and R#195's had a BIMS of 15, indicating that R#195 was cognitively intact. The report indicated the residents were separated by staff once identified. The report indicated R#193 stated R#195 made them perform the act. The report indicated the Certified Nursing Assistant (CNA) that witnessed the act was unsure at first what to do and reported it to the nurse, who stopped the act. The report indicated the staff did not report to the Administrator immediately because the staff thought they were respecting the rights of two adults and assumed it was acceptable. The nurse left a note to the SW as a courtesy. The report indicated the Administrator interviewed R#195, who denied the incident. The Administrator informed R#195 they would be moved to a different floor and was given a 30-day notice of discharge. The report indicated that due to the eyewitness account of the resident, as well as three other staff members, the allegation was substantiated. R#195 was moved off the floor where R#193 lived, R#195 was placed on 30-minute observation when away from their room, and monitoring when moving through the facility for activities. R#195 was medicated appropriately, provided psychiatric services including psychotherapy, and was transferred to another facility on 12/3/21. The report indicated R#193 was provided psychiatric services, and the staff were educated on abuse, recognizing abuse, and reporting abuse, with a focus on sexual abuse. A review of the Resident Face Sheet revealed R#195 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/7/21, indicated R#195 had no cognitive impairment with a BIMS score of 15 out of 15. The resident required supervision with set up only for their activities of daily living (ADLs). A review of R#195's Care Plan, dated 10/11/21, indicated the resident exhibited inappropriate sexual behavior towards another resident and watched pornography on their cell phone. A review of the Resident Face Sheet indicated R#193 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly MDS Assessment, dated 10/8/21, indicated R#193 had moderate cognitive impairment with a BIMS score of seven out of 15, indicating the resident was severely cognitively impaired. The resident had a behavior of wandering that occurred daily. The resident required limited to extensive assistance for their ADLs. A review of the Care Plan, dated 8/31/21, indicated R#193 had the potential for presence of behavioral symptoms related to a history of aggressive behavior, care rejection, and dementia with behavioral disturbance. A review of R#195's social service Progress Note, dated 10/13/21, indicated SW FF spoke with R#195 about a report that the resident was in their room the previous night with another resident (R#193) with the door closed and lights out. The note indicated R#195 stated the residents were talking and were just friends. The note indicated the SW told R#195 the other resident had a different idea about their relationship, so R#195 told the SW they would be careful not to let it happen again. A review of R#195's Psychotherapy Progress Note, dated 10/15/21, written by Licensed Clinical Social Worker (LCSW) GG, an outside provider, indicated R#195 presented as fully alert and oriented. The note indicated R#195 used most of the session to talk about relationships with residents of the opposite sex and was encouraged to work on ways to avoid giving others mixed signals about their intentions. The note indicated the resident was encouraged to be clear in communication with healthy boundaries. A review of R#195's Psychotherapy Progress Note, dated 10/29/21, indicated R#195 continued to join in activities and to socialize with a resident of the opposite sex (R#31) with a goal of a cessation of episodes of sexualized behaviors that the peer found unsettling despite their stated affection for R#195 and wish to continue seeing them. The note indicated the facility social worker was updated and addressed the issues with both residents to clarify intentions and safe/healthy boundaries. A review of R#195's Psychiatry Follow Up Note, dated 11/2/21, written by Nurse Practitioner (NP) JJ, an outside provider, indicated R#195 had questionable behaviors displayed, evidenced by the increased online use of possible adult sites and some sexually suggestive verbalizations being made with no actual or specific acting out. The note indicated SW FF and staff reported the resident was overly sexual verbally at times with others. The note indicated the psychiatrist was to be notified if the sexualized behaviors worsened, and a trial of [MEDICATION(S)] (often used as a mood stabilizer) may be considered. The note indicated if the resident had increased behaviors, laboratory blood tests should be obtained, including [a gender specific hormone] level. A review of R#195's Psychotherapy Progress Note, dated 11/5/21, indicated R#195 reported enjoying sexual content on a social media platform and engaged in it often, sometimes for hours a day. The note indicated the resident used the platform to direct message people of the opposite sex to send sexy photos of themself. The note indicated the writer of the note had a discussion with the facility SW about R#195's relationship with a mentally competent peer (R#31) that had grown very attached to R#195 but stated they did not wish to have sexual encounters, despite calling R#195 their boy/girlfriend. The note indicated the discussion focused on making sure R#195 respected the other resident's wishes and boundaries and that their relationship was not sexual unless they both wanted it to be. The note indicated R#195 conveyed mixed feelings about the friend, acting sad when they stayed away but acting annoyed at times if they did not wish to engage. The note indicated the writer spoke with the facility SW about a goal of stopping behaviors that the friend reportedly found unsettling despite their stated affection for R#195 and wish to continue seeing them as a friend in either one of their rooms. A review of a nurse practitioner (NP) Resident Progress Note, dated 11/9/21, indicated R#195 was complaining of discharge from their sexual organ and showed the NP with no discharge noted. The note indicated a nurse had reported the resident had been watching porn on their phone and was having hypersexual behavior. The note indicated blood tests were ordered, including a [hormone] level. R#195 was to be evaluated for hypersexual behavior by a psychiatrist with follow-up by psychiatric services already seeing the resident. A review of a Psychotherapy Progress Note, dated 11/19/21, indicated R#195 talked about relationships with other residents and considered the resident a friend and not a romantic partner, even though they believed the other person was more serious and considered them a boy/girlfriend. The note indicated R#195 was encouraged to not lead the resident on to avoid causing misunderstandings and hurt feelings. A review of a NP Resident Progress Note, dated 11/23/21, indicated R#195 was seen by the psychiatrist for their hypersexual behavior, and adjustments were made to the resident's medications. The note indicated the psychiatrist's progress note was not available. The note indicated the resident was also seen by an outside psychotherapist that week. The note indicated the resident's lab results were negative and [hormone] level was normal. A review of R#195's nursing Progress Note, dated 11/24/21, indicated Licensed Practical Nurse (LPN) CC was called to the hallway on 11/23/21 at 8:30 p.m. by staff standing near R#195's room and told LPN CC to look in the room. The note indicated that when LPN CC looked in the room, she observed R#193 performing a sexual act on R#195. The note indicated LPN CC told the residents to stop and R#195 continued to stroke R#193's head, then R#193 stopped and went out of the room stating they were sorry, they did not want to do it, but R#195 made them do it. A review of R#195's SW Progress Note, dated 11/24/21, indicated it was reported to the SW upon their arrival to the facility that R#195 made another resident (R#193) perform oral sex on them the previous night (11/23/21). The note indicated the SW spoke with R#193 and they confirmed the act. R#193 stated they did not want to do it, but R#195 made them. A review of R#195's NP Resident Progress Note, dated 11/24/21, indicated they were notified by the facility Administrator that R#195 made a confused resident perform oral sex on them. The note indicated Psychiatrist II was notified and started R#195 on [MEDICATION(S)] 250 milligrams (mg) at 9:00 a.m. and 1:00 p.m. and 500 mg at bedtime. The note indicated Psychiatrist II discontinued the resident's [MEDICATION(S)] (used to treat mild to moderate confusion) and [MEDICATION(S)] (an antidepressant). The note indicated Psychiatrist II was notified of the most recent [hormone] levels and Psychiatrist II wanted to start the resident on Depo-[MEDICATION(S)] injections (decreases sexual drive). The note indicated the resident was sent to the emergency room for a mental health evaluation. A review of a nursing Resident Progress Note, dated 11/24/21, indicated R#195 was moved to room [ROOM NUMBER]. A review of a Nursing Progress Note, dated 11/25/21, indicated R#195 was on 30-minute checks until further notice. A review of a Psychotherapy Comprehensive Clinical Assessment, dated 11/30/21, indicated R#195 was referred to counseling services to assess their well-being following a sexual encounter with another resident. The assessment indicated per chart review R#195 was upset at the time of the incident and said the act was forced on them. A review of a social service Resident Progress Note, dated 12/2/21, indicated R#195 was given a transfer notice that day and would be transferring to another facility on 12/3/21. During a telephone interview on 10/6/22 at 12:10 p.m. with SW FF, they stated they had retired and no longer worked at the facility. SW FF stated as far as they could recall, the incident between R#193 and R#195 happened before Thanksgiving 2021 because it was a hard conversation to have with R#193's family at that time; the family did not want to do anything about the incident. SW FF stated that when he came into work, the incident was reported to him and he reported it to the Administrator, who told him to get statements. SW FF stated when he questioned R#193 that day, R#193 stated they had never done anything like that before, but R#195 made them do it. SW FF stated R#195 denied it. SW FF stated R#195 was always looking on their phone at porn. SW FF stated he spoke with R#195 about the incident on 10/13/21 and R#195 told him nothing happened. SW FF had no way of proving anything did or did not occur. SW FF stated R#193 had nothing to report when asked if anything happened. SW FF stated he could not recall who reported the 10/13/21 incident to him. During an interview on 10/6/22 at 11:55 a.m. with LPN CC, she stated the staff called her to R#195's room and stated R#193 was in the room. She stated she stopped them and asked R#193 what they were doing. She said R#193 told her R#195 made them do it and they had never done that kind of thing before. LPN CC stated she was told the following day by the Administrator that she should have reported it to him, the state, and police. She stated the other nurse told R#193 earlier in the shift that it was not appropriate for R#193 to go into R#195's room at that time of evening. She stated R#193 frequently went into R#195's room. During an interview on 10/6/22 at 1:28 p.m. with Psychiatrist II, she stated she usually gave [MEDICATION(S)] for elderly residents with hypersexual behaviors, and if it was not effective, then she would prescribe [MEDICATION(S)] weekly for 12 weeks. She stated [MEDICATION(S)] was a birth control shot that was used in the elderly to safely decrease hypersexual behaviors. She stated she wanted the resident's [hormone] level to be less than 50, but they would need to give the medications time to work. Psychiatrist II stated she only saw R#195 once. She stated she was told the resident was hypersexual and going around to residents' rooms propositioning them for sex. She stated she thought she ordered [MEDICATION(S)] for R#195 but was not sure without checking the chart. After review of the medical record, she stated R#195 was ordered both [MEDICATION(S)] and [MEDICATION(S)] due to the incident on 11/23/21. She stated R#195 was discharged to another facility and she never saw the resident again to be able to follow up. She stated she was unsure why she was contacted instead of the resident's normal provider. On 10/6/22 at 3:08 p.m., an attempt to contact Nurse Practitioner (NP) HH was made, and a message was left. There was no response from NP HH by the end of the survey. During an interview on 10/6/22 at 3:37 p.m. with LCSW GG stated R#193 was confused about the incident and thought R#195 was their spouse. LCSW GG stated she had no information to suggest R#193 had any previous sexual behaviors. She stated R#193 missed their spouse and seemed confused at times about who they thought other people were. During an interview on 10/6/22 at 8:27 p.m. with CNA DD, she stated she was walking by R#195's room and saw R#193 performing a sex act on R#195. She stated she turned around right away and went and got the nurse, who stopped it. She stated she did not report it because the nurse knew about it, but she would report it next time. She stated she was told they should have reported it right away. CNA DD stated R#193 said R#195 made them do it and they had never done that type of thing before. CNA DD stated she had never known of either resident doing anything like that before. She stated R#195 had never made any sexual comments to her. CNA DD stated R#193 would go into R#195's room and talk. She stated they would redirect R#193 out of the room and R#195 would tell staff it was okay. During an interview on 10/7/22 at 9:59 a.m. with CNA EE, she stated she only saw R#193's head in R#195's lap and did not see the actual act occur. CNA EE stated she told the nurse, and the nurse handled it. She stated she did not remember either resident saying anything. During an interview on 10/7/22 at 4:15 p.m. with the Director of Nursing Services (DNS) and Senior Nurse Consultant (SNC) WW, the DNS stated she became the DNS in April of 2022, so she was not part of the investigations. She stated she was informed of it afterwards. The SNC stated she was notified of the incident and stated R#195 was put on a medication to get their [hormone] levels in check and they were placed on every-30-minute checks until they were discharged . During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated he reported the incident between R#195 and R#193 as soon as he heard about it on 11/24/21. He also notified R#193's family. He stated he felt they took care of the situation quickly and appropriately. The Administrator stated the psychiatrist was notified and medications were started while placement in a more appropriate setting was being found. He stated the staff should report any incident when they found an issue. He stated he felt like the staff had a grasp on the education that was given on abuse. He stated he told the staff he would make the decision if a situation was abuse or not because he knew more about the residents' whole story than the staff may have knowledge of, such as BIMS and background.

Based on record reviews, interviews, facility document review, and review of the facility's policy, it was determined that the facility failed to report allegations of abuse for two of three residents (R) (R#31 and R#193) reviewed for abuse. Specifically, the facility failed to: -Ensure staff reported an incident of sexual abuse that occurred to R#193 in a timely manner; and -Ensure staff reported an allegation of sexual abuse that occurred to R#31 to the Administrator so an appropriate investigation could occur. Findings included: A review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 7/29/19, indicated, Procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegation of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within two hours after the allegation is made if the events upon which the allegation is based involved abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. 1. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated R#193 had severe cognitive impairment, with a BIMS score of seven out of 15. The resident had a behavior of wandering that occurred daily. The resident required limited to extensive assistance for their ADLs. A review of R#193's Care Plan, dated 8/31/21, indicated R#193 had the potential for presence of behavioral symptoms related to a history of aggressive behavior, care rejection, and dementia with behavioral disturbance. A review of the quarterly MDS, dated [DATE], indicated R#195 had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required supervision with set up only for their activities of daily living (ADLs). A review of R#195's Care Plan, dated 10/11/21, indicated the resident exhibited inappropriate sexual behavior towards another resident and watched pornography on their cell phone. A review of R#195's social service Progress Note, dated 11/24/21, indicated it was reported to the Social Worker (SW), upon their arrival to the facility, that R#195 made another resident (R#193) perform oral sex on them the previous night. The note indicated the SW spoke with R#193 and the resident confirmed the act. R#193 stated they did not want to do it, but R#195 made them. The note indicated R#193 stated they had never even done that with their spouse and asked for forgiveness. A review of R#195's nursing Progress Note, dated 11/24/21, indicated Licensed Practical Nurse (LPN) CC was called to the hallway on 11/23/221 at 8:30 p.m. by staff standing near R#195's room who told LPN CC to look in the room. When LPN CC looked in the room, she observed R#193 performing a sexual act on R#195. The note indicated LPN CC told the residents to stop, and R#195 continued to stroke R#193's head. R#193 stopped and went out of the room, stating they were sorry; they did not want to do it, but R#195 made them do it. During a telephone interview on 10/6/22 at 12:10 p.m. with SW FF, he stated he had retired and no longer worked at the facility. SW FF stated that as far as he could recall, the incident between R#193 and R#195 happened before Thanksgiving 2021 because it was a hard conversation to have with R#193's family at that time. R#193's family did not want to do anything about the incident. SW FF stated that when he came in to work on 11/24/21, the incident was reported to him and he reported it to the Administrator, who told him to get statements. During an interview on 10/6/22 at 11:55 a.m. with LPN CC, she stated the staff called her to R#195's room and stated R#193 was in the room. She stated she stopped them and asked R#193 what they were doing. She said R#193 told her R#195 made them do it and they had never done that before. LPN CC stated she was told the following day by the Administrator that she should have reported it to him, the state, and police. During an interview on 10/6/22 at 8:27 p.m. with CNA DD, she stated she was walking by R#195's room and saw R#193 performing a sex act on R#195. She stated she turned around right away and got the nurse, who stopped it. She stated she did not report it because the nurse knew about it, but she would report it next time. She stated she was told they should have reported it right away to the Administrator. During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated he reported the incident between R#195 and R#193 as soon as he heard about it on 11/24/21 and notified R#193's family. He stated he felt they took care of the situation quickly and appropriately. He stated the staff should report any issue like that when they found it. He stated he felt like the staff had a grasp on the education that was given on abuse after the incident. He stated he told the staff he would make the decision if a situation was abuse or not because he knew more about the residents' whole story than the staff may have knowledge of, such as BIMS score and background. 2. A review of the quarterly MDS, dated [DATE], indicated R#195 had no cognitive impairment, with a BIMS score of 15 out of 15. The resident required supervision with set up only for their ADLs. A review of R#195's Care Plan, dated 10/11/21, indicated the resident exhibited inappropriate sexual behavior towards another resident and watched pornography on their cell phone. A review of the annual MDS, dated [DATE], indicated R#31 had no cognitive impairment, with a BIMS score of 15 out of 15. The resident required supervision with set up with their ADLs. A review of R#31's Care Plan, dated 6/1/22, indicated R#31 had impaired understanding of health regimen maintenance and restrictions. A review of R#31's Progress Notes from September 2021 through December 2021 revealed no documentation of any interaction between R#31 and R#195. During a telephone interview on 10/6/22 at 12:10 p.m., SW FF stated he had retired and no longer worked at the facility. SW FF stated R#195 was always looking on the resident's phone at porn and would send pictures to R#31, their boyfriend/girlfriend. SW FF stated R#31 showed him (the SW) an inappropriate picture that R#195 had sent to R#31. SW FF stated he spoke to R#195 about not sending those types of pictures, and the resident stated they understood. During an interview on 10/6/22 at 11:55 a.m. with LPN CC, she stated R#195 had residents in their room including R#31, who was sort of their boyfriend/girlfriend. She stated R#31 was upset once, saying R#195 did something or told them something, but R#31 would not elaborate. During an interview on 10/6/22 at 3:37 p.m. with Licensed Clinical Social Worder (LCSW) GG (with the psychiatric services provided outside of the facility staff), she stated she had seen both R#195 and R#31. LCSW GG stated she was aware of the things going on with R#31, the boyfriend/girlfriend of R#195. She stated R#31 would get mad at R#195 for showing R#31 their private parts. She stated R#195 would not discuss any sexual urges, but R#31 would tell LCSW GG about it. LCSW GG stated she mentioned it to the facility social worker, and he told her R#195 and R#31 were both consenting adults and they could not interfere. During an interview on 10/7/22 at 4:49 p.m. with the Administrator, he stated the staff should report when they found an issue. He stated he felt like the staff had a grasp on the education that was given on abuse. He stated he told the staff he would make the decision if a situation was abuse or not because he knew more about the resident's whole story than the staff may have knowledge of, such as BIMS score and background.

Based on record review, facility policy review, and interviews, it was determined that the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurate upon admission for one of two residents (R) (R#34) reviewed for PASARR. Findings included: A review of the facility's policy titled, Admission Policy for Healthcare Centers, revised 1/4/21, revealed the Admissions Director will obtain a copy of state specific PASARR form. The state contractor for PASRR was contacted by phone for information related to the state's PASRR requirements. On 8/19/22 at 4:00 p.m., Licensed Professional Counselor and Supervisor with the state's contracted PASRR department was interviewed about the PASRR Level I Assessment Form, DMA-613. Regarding question 4, she stated if the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#34's History and Physical from a local hospital with a date of service 5/13/22 indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Resident Face Sheet indicated the facility admitted R#34 admitted from a local hospital with a primary/admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#34's admission Minimum Data Set (MDS), dated [DATE], revealed the resident was moderately impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of nine. The MDS indicated R#34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#34's Preadmission Screening/Resident Review Level I Assessment (Form DMA-16) dated 7/28/22, indicated R#34 did not have a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Question 4, on the form indicated, Does the individual have a Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? The facility indicated, No. An interview with the Administrator on 10/7/22 at 1:13 p.m. revealed the PASARR should be accurate. According to the Administrator, it was his impression that mental illness only had to be a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/7/22 at 1:15 p.m., Staff WW, the Senior Nurse Consultant, stated the PASARR was done at the hospital.

Based on record review, interviews, and review of the facility's policy, it was determined that the facility failed to ensure one of five residents (R) (R#15) reviewed for unnecessary medications received blood sugar monitoring and medications as ordered by the physician. Findings included: A review of the facility's policy titled, Medication Administration: Insulin Injections last reviewed 10/15/21, indicated, Record the results of blood glucose testing on the resident's Blood Glucose Monitoring form in the MAR [Medication Administration Record] and prepare any needed insulin according to the prescriber's orders. The policy further indicated, Document the dose administered and injection site location in the resident's MAR/EMAR [electronic MAR]. A review of the Resident Face Sheet indicated the facility admitted R#15 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R#15's quarterly Minimum Data Set (MDS), dated [DATE], indicated R#15 was severely impaired in cognitive skills for daily decision making with long and short-term memory problems according to the Staff Assessment for Mental Status. The MDS indicated R#15 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#15's Care Plan with a problem start date of 4/22/22, indicated R#15 was at risk for hyper/[CONDITION(S)] (high/low blood sugar) related to diabetes mellitus. The care plan had a goal for the resident to maintain appropriate blood glucose levels. The care plan interventions directed staff to monitor for signs of [CONDITION(S)] [a blood glucose reading of greater than 140 milligrams (mg)/deciliter (dl)] and monitor for signs of [CONDITION(S)] (a blood glucose reading of less than 60 mg/dl). A review of the active physician Orders for R#15 revealed that on 6/3/22 the resident was ordered to receive [MEDICATION(S)] Insulin 12 units subcutaneous twice a day at 9:00 a.m. and 5:00 p.m. and [MEDICATION(S)] Insulin per sliding scale subcutaneous before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. and at bedtime at 9:00 p.m. The orders directed staff to call the physician if R#15's blood sugar was less than 70 mg/dl or greater than 400 mg/dl, to administer 4 units of insulin if the resident's blood sugar was between 201-250 mg/dl, to administer 8 units if the resident's blood sugar was between 251-200 mg/dl, to administer 12 units if the resident's blood sugar was between 301 - 350 mg/dl, and to administer 16 units if the resident's blood sugar was between 351- 400 mg/dl. A review of R#15's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R#15's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R#15's October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/6/22 at 11:55 a.m., Licensed Practical Nurse (LPN) CC stated blank spaces on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/6/22 at 2:44 p.m., LPN LL stated there should not be blank spaces on the MAR. According to LPN LL, he was unsure why there were blank spaces on R#15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/6/22 at 2:58 p.m., Registered Nurse (RN) NN stated R#15 refused insulin at times, which RN NN noted should be documented as a refusal and not left as a blank space on the MAR. During an interview on 10/7/22 at 4:15 p.m., the Director of Nursing, RN BB, stated the expectation was for staff to check the resident's blood sugar and document the administration of insulin. During an interview on 10/7/22 at 4:49 p.m., the Administrator stated he expected medications to be administered and for documentation to be complete with no blank spaces on the MAR. According to the Administrator, if a medication was not administered, the physician should be notified, and the nurse should document the reason the medication was not administered.

Based on observations, interviews, and facility document review, it was determined the facility failed to provide wound care per physician's orders for one of three residents (R) (R#56) reviewed for pressure ulcers. Findings included: A review of a facility job description titled, LPN [Licensed Practical Nurse] Skin Integrity Coordinator, dated December 2016, revealed one key responsibility was performs wound care and/or treatments following physician orders using aseptic or sterile technique following orders and policy. A review of the Resident Face Sheet for R#56 revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#56's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. According to the MDS, the resident had an open lesion, other than ulcers, rashes, cuts. Skin and ulcer/injury treatments included the application of dressings to the feet (with or without topical medications. A review of R #56's care plan, dated 4/29/22, revealed the resident was at risk for frequent development of infection to the right foot related to old unresolved injury. The goal was for the resident to be free of infection to the foot. The facility developed an intervention to apply dressing as ordered by the resident's provider. A review of the September 2022 Treatment Administration Record (TAR) indicated an order, with a start date of 9/9/22 and end date of 9/30/22, to cleanse the right dorsal proximal foot (top of the right foot closest to the leg) with wound cleanser, pat dry, pack with Dakin's 0.5% packing, cover with a 4 x 4 gauze, and secure with rolled gauze. Change three times weekly with frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 9/26/22, or 9/28/22. A review of the September 2022 TAR revealed an additional treatment order, start date of 9/9/22 and end date of 9/30/22, to cleanse the right ankle with wound cleanser. Pay dry. Apply [MEDICATION(S)] Blue and secure. Change three times a week with a frequency on Monday, Wednesday, and Friday. The TAR indicated there was no documentation of the dressing change being performed on 9/19/22, 9/26/22, or 9/28/22. A review of a Progress Note Report dated 9/30/22 revealed the right dorsal proximal foot wound measured 0.8 centimeters (cm) long x 0.8 cm wide x 0.5 cm deep, with moderate, yellow serosanguinous drainage. The right anterior medial malleolus (the ankle bone on the inside of the foot) wound measured of 0.5 cm long x 0.5 cm wide x 0.5 cm deep and had mild, yellow serous drainage. A review of Active [physician] Orders for R#56 revealed an order with a start date of 9/30/22, to cleanse the resident's right dorsal proximal foot and right malleolus of the anterior foot with wound cleanser, pat the areas dry, pack with Dakin's 0.5% packing, cover with 4 x 4 pad, and secure with rolled gauze. The order indicated the dressing was to be changed daily. An observation and interview with R#56 on 10/3/22 at 11:30 a.m. revealed the bandage to R#56's right foot was dated 9/30/22, the time and staff initials were not legible. R#56 stated the resident believed the dressing was changed every day. An interview with Wound Care Nurse OO on 10/3/22 at 10:26 a.m. revealed she was responsible for providing resident wound care four days per week. However, due to staffing issues she was pulled to work as a staff nurse and could not consistently provide wound care. Wound Care Nurse OO stated the facility really needed more staff so she could provide wound care. An observation of R#56's wound care with Wound Care Nurse #OO on 10/4/22 at 1:30 p.m. revealed Wound Care Nurse OO confirmed the date on the bandage was 9/30/22 at 12:00 p.m. She confirmed she provided the wound care on 9/30/22 and wound care had not been provided since 9/30/22. A follow-up interview with Wound Care Nurse OO on 10/4/22 at 1:44 p.m. revealed the risk of not changing a bandage was infection. She stated nursing staff were responsible for providing wound care when she was not available and should have followed R#56's orders for wound care on 10/1/22 through 10/3/22 An interview with Licensed Practical Nurse (LPN) #CC on 10/4/22 at 4:00 p.m. revealed she was responsible to complete R#56's wound care on 10/3/22 but admitted it was not done. She knew if the wound care was not done it could put the resident as a high-risk for infection. An interview with Wound Care Nurse OO on 10/5/22 at 9:05 a.m. revealed she thought maybe the daily wound changes were getting overlooked because the nurses were too busy. A phone interview with Wound Care Physician Assistant III on 10/5/22 at 12:59 p.m. revealed she expected the staff to follow the wound orders. She said the potential risk of not doing the wound care would depend on the wound and the health of the patient, and she had no knowledge of the wound care not being done. An interview with Registered Nurse NN on 10/5/22 at 3:49 p.m. revealed the wound care nurse was supposed to provide wound care, but if the wound care nurse was unable, it was the nurse's responsibility. She said it was very important to provide wound care because if it was not done it could put the resident at high-risk for infection or [CONDITION(S)]. A phone interview with Nurse Practitioner (NP) JJJ on 10/6/22 at 7:37 p.m. revealed he expected staff to follow the orders, and the risk of not following the wound care orders could potentially cause infections, worse wounds, and even death. He was not aware that wound care was not being done. An interview with Administrator AA on 10/7/22 at 2:11 p.m. revealed he expected the staff to do the wound care and to follow the orders so the wounds would heal. He said the risk of not doing the wound care would be a decline, infection, and possibly hospitalization . The nurses were responsible for the wound care if the wound care nurse was not able to do them. An interview with Senior Nurse Consultant WW and Director of Nursing (DON) BB on 10/7/22 at 2:39 p.m. revealed Wound Care Nurse OO had worked on the floor as a floor nurse instead of the wound care nurse, but the nurses were responsible to do the wound care if she was not available. If the wound care was not being done as ordered, it could cause infection or unnecessary pain. They were not aware of any concerns with wound care not being done.

Based on observations, record review, interviews, and review of the facility's policy, it was determined that the facility failed to ensure two of 31 residents (R) (R#249 and R#15) reviewed had accurately documented medical records. Specifically, the facility failed to accurately document the correct amount of [MEDICATION(S)] (an anticoagulant) administered to R#249 and failed to accurately document the amount of water flush being administered to R#15. Findings included: A review of the facility's policy titled, Maintenance of Medical Records, dated 11/21/16, indicated, It is the policy of (the facility) and its affiliated entities (collectively, the Organization) to maintain a medical record for each patient/resident in the healthcare center/agency that is to be accurate, complete, and systematically organized. Further review of the policy revealed All reports and entries in the medical record are to be accurate and complete. 1. A review of the Resident Face Sheet indicated the facility admitted R#249 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), dated [DATE], indicated R#249 had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required extensive assistance of one to two people for the activities of daily living (ADLs). The MDS indicated R#249 took an anticoagulant medication seven out of seven days during the look-back period. A review of the care plan dated 10/3/22 indicated R#249 was at risk for abnormal bleeding or hemorrhage because of anticoagulation usage. Interventions included: -Administer anticoagulant as currently prescribed - see Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Educate on risk and benefits of anticoagulation use. -Monitor for and report to the physician signs and symptoms of abnormal bleeding and/or hemorrhage. -Schedule lab tests as ordered by the physician to monitor coagulation factors and report abnormal findings to the physician. A review of the Order History revealed Resident #249's orders included: -[MEDICATION(S)] (an anticoagulant) 4 milligrams (mg) one tablet orally once a day on Sunday, Monday, Tuesday, and Friday, ordered 9/19/22 and discontinued 10/4/22. -[MEDICATION(S)] 2.5 mg one tablet orally once a day on Wednesday, Thursday, and Saturday, ordered 9/29/22 and discontinued 10/4/22. A review of the October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] 2.5 mg was signed off by the nurses as being administered on 10/2/22, 10/3/22, and 10/4/22, along with the [MEDICATION(S)] 4 mg that was scheduled to be given on those days. During observations of medication administration by the nurses, it was determined that each resident had their medications pre-packaged by the pharmacy, and the nurses would not have been able to administer both the [MEDICATION(S)] 2.5 mg along with the [MEDICATION(S)] 4 mg on 10/2/22-10/4/22, even though it was documented that way, making the resident's record inaccurate. A review of the pharmacy delivery record for R#249 revealed the correct dose ordered by the physician and amount of [MEDICATION(S)] had been delivered to the facility in individual dated packages. This would have kept the nurses from being able to give the [MEDICATION(S)] 2.5 mg at the same time as the [MEDICATION(S)] 4 mg, indicating the documentation was incorrect and the resident's record was inaccurate. During an interview on 10/6/22 at 11:55 a.m., Licensed Practical Nurse (LPN) CC stated the nurses should not be documenting a medication was given if it was not prepped or given. During an interview on 10/6/22 at 2:44 a.m., LPN LL stated the computer system made the nurse prep the medications before they were given, and medications were pre-packaged. He stated the nurse should not sign off on a medication if it was not given. During an interview on 10/6/22 at 2:58 p.m., Registered Nurse (RN) NN stated medications were prepackaged by the pharmacy so it was difficult to have a medication error, but the nurses should not be signing off a medication or treatment if it was not given or done. During an interview on 10/7/22 at 4:15 p.m. with the Director of Nursing Services (DNS) and Senior Nurse Consultant (SNC) WW, the DNS stated that when a new order was received, it should be verified with the physician. Residents that are new admissions had two nurses verify the medications with the orders, had the physician verify, and then the pharmacy was to also verify. The SNC stated the nurse managers should be able to run a report to check for any new orders to be able to verify them; however, the DNS stated she did not have access to run those reports at that time. The SNC stated there was also a tab in the computer program that required the nurses to verify orders they had entered, but it only included discontinued orders or new orders, not changes in orders. The SNC stated the facility had identified areas of concern in Quality Assurance (QA) with documentation in the facility and had initiated a Performance Improvement Plan (PIP) for g-tube (gastrostomy tube) and medication administration documentation. She stated they were trying to identify barriers that were keeping the staff from completing documentation and were constantly reminding the staff to do their documentation by paging overhead. The DON stated the expectation was that all documentation be complete and accurate. During an interview on 10/7/22 at 4:49 p.m., the Administrator stated the staff should not be signing off on a medication or a treatment if they did not give it or do it. He stated the nurse managers should be monitoring for complete and accurate documentation. He stated the nurse that took the order was responsible for verifying it. 2. A review of the Resident Face Sheet indicated R#15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS, dated [DATE], indicated R#15 had severely impaired cognitive skills for daily decision making. The resident required extensive to total assistance with all ADLs. The MDS indicated the resident received 51% or more of their calories and 501 cubic centimeters (cc) a day or more of fluid from a feeding tube. A review of the Active Orders revealed R#15's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Both of those water flushes were being signed off as being received, indicating the resident would have been receiving 350 ml of water every four hours instead of the ordered 150 ml every four hours. Observations on 10/5/22 at 10:15 a.m. revealed R#15's pump was set to deliver 150 ml of water every four hours. During an interview on 10/6/22 at 2:58 p.m., RN NN stated nurses should not be signing off a medication or treatment if it was not given or done. During an interview on 10/7/22 at 12:34 p.m., LPN WWW stated she did not do the flushes for R#15; the machine did it. After reviewing R#15's physician orders, she stated the machine must be programmed to administer both flushes, but she was not sure. During an interview on 10/7/22 at 12:43 p.m., RN NN stated R#15 should not have two flush orders, and the machine would only deliver one flush. RN NN stated she was going to talk to the other nurse and get the order clarified. During an interview on 10/7/22 at 4:15 p.m. with the DNS and SNC WW, the DNS stated that when a new order was received, it should be verified with the physician. Residents that are new admissions had two nurses verify the medications with the orders, had the physician verify, and then the pharmacy was to also verify. The DNS stated the Registered Dietitian (RD) put the new order in for R#15's flush of 150 ml every four hours and did not discontinue the old order of 200 ml every four hours. She stated education would be provided to the RD. The SNC stated the nurse managers should be able to run a report to check for any new orders to be able to verify them; however, the DNS stated she did not have access to run those reports at that time. The SNC stated there was also a tab in the computer program that required the nurses to verify orders they had entered, but it only included discontinued orders or new orders, not changes in orders. The SNC stated the facility had identified areas of concern in QA with documentation in the facility and had initiated a PIP for g-tube and medication administration documentation. She stated they were trying to identify barriers that were keeping the staff from completing documentation and were constantly reminding the staff to do their documentation by paging overhead. The DON stated the expectation was that all documentation be complete and accurate. During an interview on 10/7/22 at 4:49 p.m., the Administrator stated the staff should not be signing off on a medication or a treatment if they did not give it or do it. He stated the nurse managers should be monitoring for complete and accurate documentation. He stated the nurse that took the order was responsible for verifying it.

Based on staff interview, record review and review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one resident (R#1) of 4 sampled residents. Findings include: During an interview on 2/25/2020 at 10:10 a.m., R#1 stated to this surveyor that he refused to allow Certified Nursing Assistant (CNA) AA in his room or allow her to touch him. He reported that he is legally blind and CNA AA was mean and rude to him. The resident angrily states that he is blind but CNA AA treated him like he was stupid. The resident further stated that he informed the Social Worker (SW) regarding how he was being treated and did not want CNA AA back in his room. An interview with the SW on 2/25/2020 at 11:30 a.m. revealed that she spoke with the R#1 on 2/24/2020 in which he reported to her that CNA AA was mean to him and did not want her to come back into his room or provide him any care. SW further stated that she completed a grievance report at that time and reported the incident to the Administrator. An interview on 2/25/2020 at 11:40 a.m. with the Administrator revealed that according to the report the facility became aware of the allegation on 2/24/2020. He further stated that he did not consider the incident as an allegation of abuse and therefore did not report the incident to the State agency. Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised on 4/26/2017, stated that mental abuse: includes but is not limited to humiliation, harassment, threats of punishment or deprivation. The suspected abuse will be reported within two hours to the State Survey Agency.

Based on observation, interview, record review, and facility policy review Lippincott indwelling urinary catheter care and management, the facility failed to provide appropriate indwelling urinary catheter care for one resident (R) #3, of three sampled residents. Findings include: Review of the facility policy for Indwelling urinary catheter (Foley) care and management revised 3/24/2017 indicated in the Implementation section to Provide routine hygiene for meatal care; note that cleaning the meatal area with antiseptic solutions isn't necessary. To avoid contaminating the urinary tract, always clean by wiping away from-never toward- the urinary meatus. Use soap and water or a perineal cleaner to clean the [MEDICAL CONDITION] area after each bowel movement. Avoid frequent and vigorous cleaning of the area. Review of the Quarterly Minimum Data Set (MDS) for R#3 dated 2/02/2020 revealed that his [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) indicated a score of 15 indicating the resident was cognitively intact. R#3 had an indwelling foley catheter on admission to the facility. Review of the Care Plan for R #3 dated 10/15/2019 revealed a care plan for an Indwelling Foley Catheter. Approaches included: Provide perineal care every day and PRN Report redness, swelling, discharge or urinary related odor to supervisor Follow aseptic technique with Cath insertion and irrigation Observe and report the change in color, odor, presence of cloudiness or sediment in urine to charge nurse Report complaints of pain/discomfort from cath to charge nurse Record intake and output as ordered Check Cath q (every) shift for patency, proper position of tubing and bag. Report Cath leakage to charge nurse. Review of the Medication Administration Record [REDACTED]. A review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating that he was cognitively intact. The resident required total care for all activities of daily living and had an indwelling urinary catheter upon admission. Review of the Physician's Orders for R #3 dated 12/5/2019 revealed orders for: May change indwelling foley cath monthly as needed for blockage, clogging, dislodgement, sedimentation, s/s (signs and symptoms) of bleeding, or infection. Catheter: Diagnosis, [MEDICAL CONDITION] bladder and pressure injury to the sacrum. Observation of Certified Nursing Assistant (CNA) BB a indwelling foley catheter care was provided to R #3 on 2/25/2020 at 10:40 a.m. revealed: 1. Failed to use warm water or a basin to provide catheter care 2. Using wet wipes he washed the base of the penis and top of the scrotum. 3. He failed to wash the meatus of the penis. 4. Failed to wipe down the catheter tubing. Interview with CNA BB conducted on 2/25/2020 at 10:45 a.m. revealed that he was last trained on catheter care was December 2019. He also revealed that it was ok to wet wipes while providing catheter care but did not have any explanation regarding washing the meatus or the catheter tubing. Interview with the Nurse Consultant on 2/26/2020 at 1:49 p.m. revealed that the Clinical Competent Coordinator (CCC), provides a skill check-off annually which includes catheter care. Review of a Skills Competency Checklist Form: CNA Annual for CNA BB dated 12/9/19 included catheter care. The skill checks off include Lippincott Procedure dated 3/24/2017 and included washing the meatus/catheter insertion site.